Virtual Reality Suicidal Decision Exposure: An Experimental Therapeutics Approach to Targeting Suicide Capability Mechanisms - Project Summary/Abstract To curb the rising rates of suicide, interventions that directly target the causal mechanisms for suicidal behaviors (SB; i.e., suicide capability) are needed. Virtual reality (VR) suicidal decision scenarios are a valid and safe proxy for SB among at-risk individuals and have enabled causal examinations of suicide capability mechanisms. Intriguingly, these studies, including our preliminary data (N = 63), show that exposure to VR suicidal decision scenarios may evoke clinically meaningful reductions in suicide risk via suicide capability mechanisms. These findings converge with mounting evidence for the effectiveness of VR-based exposure in treating numerous psychiatric disorders. We consider a putative suicide capability mechanism that can be safely therapeutically targeted using VR suicidal decision exposure: motivational relevance of the suicidal decision process that facilitates the development of non-threat associations (i.e., inhibitory learning) with suicide ideation (SI) and the reintegration of suicidal deterrents (i.e., negative consequences of SB; reasons for living). This aligns with recent electroencephalography (EEG) findings that suicide attempters, but not ideators, show decreased sustained reactivity to threat/violence, reflecting an ability to volitionally dampen fear-inducing aspects of SI (i.e., suicidal deterrents), temporarily increasing their ability to approach SB. Our pilot EEG data (N = 28 suicidal adults) show VR suicidal decision scenarios engage the target mechanism of motivational relevance. This K23 proposal will evaluate VR suicidal decision exposure as a mechanistic intervention for SB and is designed to make the next critical steps in intervention development: (1) provide preclinical evidence for the feasibility, acceptability, and safety of the intervention in a transdiagnostic sample of 100 adults with recent SI and 50% with a suicide attempt history; (2) test whether the intervention, relative to treatment as usual, effectively engages the proposed mechanistic targets (neural; increases in late-LPP to suicide-related images and fronto-central gamma during the VR decision scenarios) and behavioral indicators (subjective accessibility of suicidal deterrents; behavioral orientation toward death/life) both in lab and in daily life; and (3) test whether change in the mechanistic targets and behavioral indicators account for intervention-associated change in clinical outcomes related to SB. We will use a multi-method approach involving EEG, subjective and behavioral responses, ecological momentary assessment (EMA), and self-reports/interviews to assess changes pre-post the intervention. This K-award addresses crucial gaps in the candidate’s training and will prepare them to be a leader in suicide intervention science employing an experimental therapeutics approach. The candidate will receive advanced training from an expert mentorship team, including mentors Drs. Joiner, Siegle, and Scott and consultants Drs. Patrick and Krafty. Findings will inform future R-level studies focused on 1) intervention refinement and clinical translation and 2) integrative multi-method (neurophysiology, subjective, behavioral, EMA) approaches to further clarify suicide capability mechanisms and develop effective, mechanistically targeted, and scalable SB interventions.
