Neural correlates of positive future-oriented thinking related to recent suicide attempts, suicidal ideation, and hopelessness in individuals with psychopathology

Suicide risk is high in individuals with mental illness and has been associated with deficits in positive future thinking. Whether abnormalities in positive future thinking can explain the propensity to engage in suicide attempts is unclear. Functional MRI-data and vividness ratings acquired during imagining self-relevant positive and neutral future events were compared between psychiatric patients who recently attempted suicide (SP, N = 23; median recency <1 month), psychiatric patient controls without attempts (PC, N = 22), and non-psychiatric controls (NPC, N = 23). Associations with suicidal ideation, hopelessness, and depressive severity scores were explored. No differences in vividness and brain activation during positive versus neutral imagination were observed between SP and PC, though both patient groups showed less vivid imagination and higher activation of fronto-opercular brain regions during both positive and neutral imagination than NPC. Hopelessness related more strongly to suicidal ideation in SP than in PC, and to lower activation in the medial orbitofrontal cortex (mOFC) and left frontopolar cortex during positive versus neutral imagination across patient groups. Mediation analyses revealed that the mOFC and left frontopolar cortex activation related to higher suicidal ideation via hopelessness, specifically in SP. Abnormalities in envisioning future events do not appear to explain the propensity for suicide attempts directly. Instead, hypoactivation of regions involved in reward and emotion processing when envisioning future events relates to higher suicidal ideation through its pertinence to hopelessness. This study provides evidence of the complex interplay between the neural underpinnings of future-oriented thinking and symptomatology underlying suicide.