(PS2-D77) Cognitive Inflexibility as a Potential Mechanism of Suicidal Thoughts and Behaviors: A Systematic Review

              Suicide is a major public health concern (e.g., Khazaei et al., 2017) that involves complicated decision-making processes (e.g., Gvion et al., 2015). However, studies examining decision-making and suicide have overly focused on identifying deficiencies and produced unfruitful results partly because individuals follow different decision-making processes (Qiu & Klonsky, 2021). In response, there has been a call to examine how maladaptive development of normal processes may influence suicidal thoughts and behaviors (STB; Millner et al., 2020). One such mechanism that may have promising value is cognitive flexibility, which refers to the ability to adapt cognitive/behavioral strategies based on environmental feedback (Lezak, 2004). Cognitive flexibility may be particularly relevant given its associations with higher level functions such as decision-making and problem-solving (Boog et al., 2014), and maladaptive behaviors such as rumination (Davis & Nolen-Hoeksema, 2000). Consequently, this review focused on examining the relationship between cognitive flexibility and STBs.

             The search, guided by the PRISMA guidelines, was conducted on two major databases (i.e., PsycINFO and PubMed) and included peer-reviewed articles from January 2000 to August 2021. Based on the two rounds of searches, 1,710 articles were identified, which were reduced to 1,356 after excluding 354 duplicates. An initial review of the abstracts warranted a full-text review of 145 articles of which 20 were identified to meet to the full inclusion criteria.

             Results were mixed in that 13 (65%) studies found significant differences on cognitive flexibility depending on the STB status, whereas 7 (35%) studies reported nonsignificant results. Cognitive inflexibility significantly distinguished individuals based on suicide attempt history, type of STB (i.e., ideation vs. attempt), and severity of the behavior (e.g., lethality and persistence). Such results were also supported in longitudinal designs. The most common tool for assessing cognitive flexibility was the Wisconsin Card Sorting Task (WCST: n=11; 55%), followed by the Trail Making Task (n=5; 20%), the Delis-Kaplan Executive Function System – Color-Word Interference Test (n=3; 15%), and a self-report measure – the Cognitive Flexibility Inventory (n=1; .5%). Nearly half of the studies that reported insignificant results used the WCST and the insignificant results may be partly due to the inconsistencies in its scoring (see Miles et al., 2021).

             The findings partly support the significance of cognitive flexibility as a potential mechanism in the development and progression of STBs, but also point to gaps in the literature. For example, the effects of cognitive flexibility may differ based on the context (e.g., Genet et al., 2013). It may be that cognitive inflexibility makes suicide a more viable option at times of distress, only when suicide is cognitively accessible via past experiences (O’Connor & Kirtley, 2018). Furthermore, the definition of cognitive flexibility requires clarification as the construct may overlap with related terms such as psychological flexibility.