When to quit: Calibration of voluntary persistence and attempted suicide in depression

Background People in a suicidal crisis feel forced to choose among coping, waiting passively, or attempting suicide. They must continually decide whether to persist in their efforts to cope or quit. One hypothesis is that suicidal behavior reflects a preference for immediate escape over longer-term prospects, but findings from delay discounting studies have been mixed. Importantly, these studies relied on hypothetical choices without real waiting and did not require people to re-evaluate ongoing actions as events unfolded. We examined (1) quitting vs. re-engagement after setbacks and (2) calibration of persistence in depression and attempted suicide. Methods Adults from a mid- to late-life depression cohort (N=277; 87 attempters, 59 ideators, 63 depressed non-suicidal, 68 controls) completed the Willingness-to-Wait task, in which brief persistence (∼3 s) maximized reward, whereas longer waits were counterproductive. Immediate quitting – taking the smaller reward without waiting – was modeled with multilevel logistic regression; quitting latency with Cox mixed-effects models. Exploratory analyses examined attempt lethality and age of first attempt. Sensitivity analyses accounted for impulsivity, cognition, and personality. Results All groups were more likely to quit immediately after losses than wins, but this difference was larger in attempters than in each comparison group. Once a wait began, attempters and depressed non-suicidal participants over-persisted relative to controls. Earlier age of first attempt, but not attempt lethality, was linked with stronger loss-triggered quitting and overpersistence. Findings were robust to confounds. Conclusions Depression was associated with maladaptive overpersistence, whereas a history of suicide attempts was additionally associated with loss-triggered disengagement. Dynamic tasks that separate re-engagement after failure from stopping decisions may help clarify decision processes relevant to suicidal behavior.