Imaging suicidal thoughts and behaviors: a comprehensive review of 2 decades of neuroimaging studies

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Schmaal, Lianne 
van Harmelen, Anne-Laura  ORCID logo
Chatzi, Vasiliki 
Lippard, Elizabeth T. C. 
Toenders, Yara J. 

Abstract: Identifying brain alterations that contribute to suicidal thoughts and behaviors (STBs) are important to develop more targeted and effective strategies to prevent suicide. In the last decade, and especially in the last 5 years, there has been exponential growth in the number of neuroimaging studies reporting structural and functional brain circuitry correlates of STBs. Within this narrative review, we conducted a comprehensive review of neuroimaging studies of STBs published to date and summarize the progress achieved on elucidating neurobiological substrates of STBs, with a focus on converging findings across studies. We review neuroimaging evidence across differing mental disorders for structural, functional, and molecular alterations in association with STBs, which converges particularly in regions of brain systems that subserve emotion and impulse regulation including the ventral prefrontal cortex (VPFC) and dorsal PFC (DPFC), insula and their mesial temporal, striatal and posterior connection sites, as well as in the connections between these brain areas. The reviewed literature suggests that impairments in medial and lateral VPFC regions and their connections may be important in the excessive negative and blunted positive internal states that can stimulate suicidal ideation, and that impairments in a DPFC and inferior frontal gyrus (IFG) system may be important in suicide attempt behaviors. A combination of VPFC and DPFC system disturbances may lead to very high risk circumstances in which suicidal ideation is converted to lethal actions via decreased top-down inhibition of behavior and/or maladaptive, inflexible decision-making and planning. The dorsal anterior cingulate cortex and insula may play important roles in switching between these VPFC and DPFC systems, which may contribute to the transition from suicide thoughts to behaviors. Future neuroimaging research of larger sample sizes, including global efforts, longitudinal designs, and careful consideration of developmental stages, and sex and gender, will facilitate more effectively targeted preventions and interventions to reduce loss of life to suicide.


Funder: American Foundation for Suicide Prevention (AFSP); doi:

Funder: Brain and Behavior Research Foundation (Brain & Behavior Research Foundation); doi:

Funder: MQ Brighter Futures Award MQBFC/2, International Bipolar Foundation, For the Love of Travis Foundation, Women's Health Research at Yale, John and Hope Furth Endowment

Funder: U.S. Department of Health & Human Services | NIH | National Institute of Mental Health (NIMH)

Funder: Brain and Behavior Research Foundation (Brain & Behavior Research Foundation)

Funder: Robert E. Leet and Clara Guthrie Patterson Trust (Robert E. Leet & Clara Guthrie Patterson Trust); doi:

Funder: U.S. Department of Veterans Affairs (Department of Veterans Affairs); doi:

Expert Review, /631/378, /692/53/2423, /59/36, /59/57, /59/78, expert-review
Journal Title
Molecular Psychiatry
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Nature Publishing Group UK
U.S. Department of Health & Human Services | NIH | National Institute of Mental Health (NIMH) (RC1MH088366, R01MH113230, R61MH111929, R01MH117601)
Royal Society (Dorothy Hodgkin Fellowship DH15017)