Emotion Regulation May Worsen Suicidal Thoughts Under Stress, Study Finds

Reflexive attempts to regulate emotions during stressful moments may inadvertently increase suicidal thoughts in individuals with depression, according to a study published in Biological Psychiatry: Cognitive Neuroscience and Neuroimaging. This groundbreaking research, which combines brain imaging and real-time assessments, offers new insights into how stress can influence suicide risk and highlights potential opportunities for improving interventions.

New Insights into Spontaneous Emotion Regulation

The study investigated the impact of emotion regulation strategies on depression and suicidal ideation through two innovative approaches: functional MRI (fMRI) imaging and ecological momentary assessment (EMA). A group of 82 participants with major depressive disorder underwent an fMRI task designed to measure "cognitive reappraisal," an emotion regulation strategy that involves reframing negative thoughts, while recalling distressing autobiographical memories.

Following the fMRI assessment, participants were monitored for a week using EMA, which involves repeated, real-time measurement of thoughts and emotions in everyday life. EMA allowed researchers to observe how participants’ responses to daily stressors influenced their mood and suicidal thoughts.

The study found that individuals who spontaneously activated neural markers of emotion regulation during the fMRI task were more likely to experience increased suicidal thoughts in response to daily stressors. However, participants who were explicitly guided to use cognitive reappraisal during the study showed more adaptive responses to stress. This suggests that reflexive engagement of emotion regulation may be counterproductive under unexpected stress, while intentional application of these strategies may help mitigate emotional distress.

Why These Findings Matter

Suicide rates in the United States have risen by approximately 37% since 2000, making it increasingly urgent to identify and address the factors contributing to acute suicide risk. Stressful life events are often the immediate triggers for suicidal acts, but understanding how individuals react to stress in real time has remained a challenge.

"To reverse this trend, we need to understand how suicide risk emerges in daily life, and specifically the biopsychosocial factors that may influence the ebb and flow of suicide risk," said senior investigator J. John Mann, MD, of the New York State Psychiatric Institute and Columbia University.

This study is among the first to link brain-based biomarkers of emotion regulation to real-world responses to stress. “Ecological momentary assessment allows us to observe how individuals suffering from depression react to stressful events in their daily lives, for example, with intensified suicidal thoughts and worsened mood,” explained co-first author Sarah Herzog, PhD. “This multimodal method promises to improve prediction of suicide risk in those vulnerable to suicide and perhaps aiding effective intervention of potentially life-threatening reactions to stress.”

Broader Implications for Suicide Prevention

The findings challenge the conventional understanding of emotion regulation as a universally beneficial strategy for managing stress. “Flexibility in emotion regulation is generally understood to be a marker of psychological health,” said Cameron S. Carter, MD, Editor-in-Chief of Biological Psychiatry: Cognitive Neuroscience and Neuroimaging. “However, in the current study, researchers found that reflexively engaging emotion regulation in the face of unexpected stressors may not be helpful or effective in all circumstances.”

Future research will likely explore how individuals can be trained to apply emotion regulation strategies more selectively and effectively based on context. Co-first author Noam Schneck, PhD, added, “The use of neural decoding allows us to identify mental processes that were previously elusive to capture, such as spontaneous emotion regulation. In future work, the decoder approach can be employed to better understand how emotion regulation is engaged spontaneously to modulate hour-to-hour, day-to-day experience, thereby influencing suicide risk in a fluctuating manner.”

By combining advanced brain imaging with real-world behavioral data, this study represents a major step forward in understanding the complex interplay between stress, depression, and suicide risk. It also highlights the legacy of senior author Barbara H. Stanley, MD, who was instrumental in designing this research before her passing in 2023.

Dr. Mann remarked, “It was Dr. Stanley’s idea that we employ ecological momentary assessment in the same depressed patients who completed the fMRI negative autobiographical memories task. It was that combination of research procedures that led to these remarkable findings.”

This study provides an important foundation for improving suicide risk prediction and developing interventions to address the role of stress and emotion regulation in at-risk individuals.