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Imaging suicidal thoughts and behaviors: a comprehensive review of 2 decades of neuroimaging studies
Open accessAbstract
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.
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“These studies consistently implicate neural circuits involved in emotion regulation, impulse control, and decision-making.”
From Exploring the neurobiological markers of suicidal behaviors in pediatric population: a narrative review (2026) · cites this paper as [11]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Reduced serotonergic tone, compounded by diminished BDNF–TrkB signaling, then compromises plasticity in the frontolimbic circuits whose alterations are the most reproducible neuroimaging finding in suicidal youth (11–13, 28).”
From Exploring the neurobiological markers of suicidal behaviors in pediatric population: a narrative review (2026) · cites this paper as [11]
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“Several prior reviews have highlighted brain regions implicated in suicidal (32, 45–49) and non-suicidal behaviors (39, 50).”
From Neural correlates associated with suicide and nonsuicidal self-injury in youth (2021) · cites this paper as [32]
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“showing that alterations within the extended ventral prefrontal cortex (VPFC) system may potentiate suicidal thinking given prominent roles in negative self-referential thinking and rumination (33, 34).”
From Neural correlates associated with suicide and nonsuicidal self-injury in youth (2021) · cites this paper as [32]
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“Consistent with Schmaal and colleagues (32), youth STB research is characterized by alterations within prefrontal (53–55) and limbic (62, 75, 102, 103) systems whereby a compromised regulatory system may potentiate suicidal thinking, and perturbations in top-down and bottom-up connections may lead to suicidal behaviors.”
From Neural correlates associated with suicide and nonsuicidal self-injury in youth (2021) · cites this paper as [32]
In the citing paper
“Of particular note is that several studies implicate dysregulation of salience network structures including the insula and anterior cingulate with suicide risk, lending support to the hypothesis that these structures may be critically important in acute risk for suicide because of their role in switching between the other large-scale functional brain networks (80).”
From New methods for assessing rapid changes in suicide risk (2021) · cites this paper as [80]
In the citing paper
“A recent comprehensive review of structural and functional brain changes accompanying suicidal thoughts and behaviors implicated the ventral and dorsal prefrontal cortex systems and their connections with insula, anterior cingulate, mesial temporal structures, striatal, and posterior connection sites with suicide risk (80).”
From New methods for assessing rapid changes in suicide risk (2021) · cites this paper as [80]
In the citing paper
“Repeated and chronic stress may tax limbic systems that modulate arousal and approach behaviors, disrupt bottom-up and top-down connections, and potentially, facilitate the transition from ideation to behavior (32, 127).”
From Neural correlates associated with suicide and nonsuicidal self-injury in youth (2021) · cites this paper as [32]
In the citing paper
“Although neuroimaging studies of suicidal behavior and ideation disagree about details, the main features of dysfunctional neural circuitry (Figure 1) include 1) a relationship of enhanced negative affective and self-referential processing networks (ventromedial prefrontal cortex [vmPFC], medial orbitofrontal cortex [OFC], rostral anterior cingulate cortex [rACC], insula, and ventral striatum) to”
From A brain-centric model of suicidal behavior (2020) · cites this paper as [65]
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Metadata
- Authors
- Schmaal, L., van Harmelen, A.-L., Chatzi, V., Lippard, E. T. C., Toenders, Y. J., Averill, L. A., Mazure, C. M., & Blumberg, H. P.
- Affiliations
- The University of Melbourne (AU)
- University of Cambridge (GB)
- The University of Texas at Austin (US)
- United States Department of Veterans Affairs (US)
- Yale University (US)
- Corresponding author
- Blumberg, Hilary P.
- ORCID
- Venue
- Molecular Psychiatry
- Published
- 2019-12-02
- Volume
- 25
- Issue
- 2
- Pages
- 408-427
- ISSN
- 1359-4184 (ISSN-L)
- 1476-5578
- PMC
- PMC6974434
- OpenAlex
- W2990590397
- Cited by
- 373
- References
- 229
- Citations by year
- 2026: 62 · 2025: 67 · 2024: 55 · 2023: 48 · 2022: 57 · 2021: 55 · 2020: 25 · 2019: 2
- FWCI
- 5.50
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Molecular Psychiatry (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- EUR Research Repository (Erasmus University Rotterdam) (publishedVersion, cc-by)
- Leiden Repository (Leiden University) (submittedVersion, cc-by)
- EUR Research Repository (Erasmus University Rotterdam) (submittedVersion, cc-by)
- Minerva Access (University of Melbourne) (submittedVersion, cc-by)
- Apollo (University of Cambridge) (submittedVersion)
- Apollo (University of Cambridge) (submittedVersion, cc-by)
- Data Archiving and Networked Services (DANS) (submittedVersion, cc-by)
- Apollo
- Apollo (cc-by)
- Funders
- U.S. Department of Health & Human Services | NIH | National Institute of Mental Health (RC1MH088366, R01MH113230, R61MH111929, R01MH117601)
- American Foundation for Suicide Prevention
- Brain and Behavior Research Foundation
- 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
- Royal Society (Dorothy Hodgkin Fellowship DH15017)
- Robert E. Leet and Clara Guthrie Patterson Trust
- U.S. Department of Veterans Affairs
- Topics
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Life Sciences › Neuroscience › Cognitive Neuroscience › Neural and Behavioral Psychology Studies
- Life Sciences › Neuroscience › Cellular and Molecular Neuroscience › Neurotransmitter Receptor Influence on Behavior
- Keywords
- suicidal ideation, suicide attempts, suicide risk, ventral prefrontal cortex, dorsal prefrontal cortex, insula, dorsal anterior cingulate cortex, inferior frontal gyrus, emotion regulation, impulse control, top-down inhibition, decision-making, suicide prevention, brain circuits
- MeSH terms
- Mental Disorders, Brain, Emotions, Female, Gyrus Cinguli, Humans, Male, Suicide, Suicide, Attempted, Prefrontal Cortex, Suicidal Ideation, Neuroimaging
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