Suicide and Life-Threatening Behavior 1

© 2017 The American Association of Suicidology

DOI: 10.1111/sltb.12392

Implicit Association with Suicide as Measured

by the Suicide Affect Misattribution Procedure
(S-AMP) Predicts Suicide Ideation
RAYMOND P. TUCKER, PHD, LARICKA R. WINGATE, PHD, MELISSA BURKLEY, PHD, AND
TONY T. WELLS, PHD

The identification of indirect markers of suicide that do not rely on expli-

cit self-report of suicide ideation is vital, as research indicates that a significant
number of individuals who die by suicide do not discuss or explicitly deny
thoughts of suicide with a provider in their last health care interaction. The
current study tests whether a new measure of implicit association with suicide,
a modified version of the Affect Misattribution Procedure (AMP), predicts sui-
cide ideation in participants oversampled for the experience of suicide ideation.
Results indicated that implicit associations with suicide-related images were
positively correlated with levels of suicide ideation and predicted suicide idea-
tion when entered as a simultaneous predictor with symptoms of depression,
thwarted belongingness, and perceived burdensomeness. Implicit associations
with positive and negative images were unrelated to thoughts of suicide. The
modified version of the AMP may be a particularly useful indirect measure of
suicide ideation that can be easily included in suicide risk assessment paradigms
in clinical practice and research studies.

The suicide rate in the United States is at
its highest point in over a decade (Drapeau
& McIntosh, 2015). This increased suicide
rate is also reflected in worldwide data,
which suggests that the prevalence of sui-
cide has increased over the last 50 years
(World Health Organization, 2015). Suicide
risk assessment efforts rely heavily on the
self-disclosure of suicide ideation; unfortu-
nately, research suggests that thoughts of
suicide are not always communicated during
health care interactions. For example, the
vast majority (78%) of psychiatric inpatients
who died by suicide while in or shortly after
discharging from the hospital denied suicide
ideation in their last communication with a
provider (Busch, Fawcett, & Jacobs, 2003).
To assist in the prediction of suicide risk,
research has sought to investigate indirect
markers of suicide that do not rely on the
explicit self-report of suicide ideation.
A promising vein of this indirect mar-
ker research includes the use of computer-
ized behavioral tasks such as the Stroop task
(Stroop, 1935) and the Implicit Association
Test (IAT; Greenwald, McGhee, &
Schwartz, 1998). Cha, Najmi, Park, Finn,
and Nock (2010) demonstrated that an

R AYMOND T UCKER , Oklahoma State Oklahoma State University, Stillwater, OK,

University, Stillwater, OK, and VA Puget
Sound Health Care System, Seattle, WA,
USA; LARICKA WINGATE, Department of Psy-
chology, Oklahoma State University, Stillwater,
OK, USA; MELISSA BURKLEY and TONY WELLS,
USA.
Address correspondence to Raymond
Tucker, Louisiana State University, 236 Audu-
bon Hall, Baton Rouge, LA 70803, USA;
E-mail: rtucker1@lsu.edu
2 S-AMP PREDICTS SUICIDE IDEATION
attention bias toward death/suicide-related
semantic stimuli (e.g., the words “death,”
“funeral,” and “suicide”) during an emotional
Stroop task was associated with both previ-
ous suicide attempts and the prevalence of
suicide attempts 6 months after the task was
completed. Similarly, Nock et al. (2010)
indicated that implicit associations with
death/suicide-related words tested with the
IAT were related to a history of suicide
attempts, as well as predicted the prevalence
of suicide attempts 6 months after participa-
tion. These two studies indicate the pro-
found promise of behavioral tasks that serve
as indirect means of assessing suicide risk.
Importantly, these tasks neither rely on the
self-report of suicidal intent nor do they rely
on observable behaviors directly associated
with suicide (such as attempts or self-injury).
The creation of additional indirect
markers of suicide, especially those measur-
ing implicit association with suicide, would
be beneficial. Ideally, indirect measures of
suicide should be highly mobile and easily
administered via multiple technological plat-
forms. Ease of implementation of these indi-
rect markers would allow for researchers and
clinicians to quickly and accurately assess
real-time suicide risk. The current investiga-
tion aimed to further this line of research
through the adaptation of the Affect Misat-
tribution Procedure (AMP; Payne, Cheng,
Govorun, & Stewart, 2005). The AMP uti-
lizes sequential priming techniques to assess
potential implicit attitudes toward semantic
or pictorial stimuli. In this task, participants
are asked to quickly judge the pleasantness of
an emotionally ambiguous stimulus (Chinese
pictograph), which is displayed to the partici-
pant following an emotionally valenced stim-
ulus (e.g., picture of a baby crying). Prior
research indicates that participants are likely
to label the Chinese pictograph as unpleas-
ant if it is preceded by an emotionally upset-
ting image. For example, a picture of a baby
crying tends to elicit an implicit negative
reaction which primes the participant to
evaluate the following emotionally ambigu-
ous stimuli (the Chinese pictograph) as
unpleasant.
An adapted version of the AMP may
be an important indirect measure of suicide
for several reasons. First, the AMP has been
shown to be highly reliable. In Payne
et al.’s (2005) initial validation of the AMP,
the procedure demonstrated good to excel-
lent internal consistency across six studies
(a = .81–.95). Following its initial validation
in 2005, adaptations of the AMP have
demonstrated adequate to excellent internal
consistency (Hofmann & Baumert, 2010;
Imhoff & Banse, 2011; Imhoff, Schmidt,
Bernhardt, Dierksmeier, & Banse, 2011;
Payne, Govorun, & Arbuckle, 2008). Addi-
tionally, the AMP has been shown to pre-
dict clinically relevant attitudes, personality
traits, and behaviors such as honor ideol-
ogy, self-concept, neuroticism, and alcohol
use (Imura, Burkley, & Brown, 2014;
Payne, Govorun, & Arbuckle, 2008; Sava
et al., 2012). Finally, meta-analyses compar-
ing the relationship between behavioral
measures and indirect measures of behavior
suggest stronger effect sizes for the AMP
as compared to the IAT (Cameron, Brown-
Iannuzzi, & Payne, 2012; Greenwald,
Poehlman, Uhlmann, & Banaji, 2009). The
AMP may also be a promising indirect mea-
sure of suicide risk as the task is easy to
implement and only takes approximately
5 minutes to complete (Payne & Lundberg,
2014). Additionally, the AMP measures
content of responses (i.e., affective reaction
to the Chinese Pictographs) instead of how
fast responses are made. Concerns about
real-time capture of reaction time data (e.g.,
accounting for an individual’s general pro-
cessing speed and ensuring accuracy of cap-
ture across different platforms) are
circumvented by utilizing the AMP.
In the current study we tested
whether levels of suicide ideation relate to
implicit associations with suicide measured
by a modified version of the AMP. We
tested whether implicit associations with
suicide, positive, neutral, and negative stim-
uli relate to self-reported suicide ideation.
It was hypothesized that suicide ideation
would be positively correlated with implicit
associations with suicide. We also tested
TUCKER ET AL.
whether implicit associations could predict
levels of suicide ideation and differentiate
those who were experiencing suicide idea-
tion and those who were not. Negative and
neutral stimuli were included in this
adapted version of the AMP to serve as
potential covariates and further clarify the
nature of found relationships.
METHOD
Participants
Participants were 138 students
(68.12% female, 31.88% male) from a large
state university who were oversampled for
suicide ideation. Participant ages ranged
from 18 to 33 years, with a mean age of
19.25 years. The majority of participants
(70.29%) self-identified as being Caucasian,
7.24% as American Indian/Alaska Native,
6.52% as Hispanic or Latino/Latina, 5.80%
as biracial, 5.72% as African American, and
1.45% as Asian American. Twenty-three
participants (16.67%) indicated experienc-
ing some level of suicide ideation during
the 2 weeks prior to participation and
37.50% of participants scored above the
clinical cutoff (≥ 16) on the Center for Epi-
demiologic Studies Depression Scale (Radl-
off, 1977). All participants received course
credit for their participation.
Materials
Suicide Affect Misattribution Procedure
(S-AMP). This computerized behavioral
task, administered via Direct RT version
2008 software (Jarvis, 2008), relies on the
affect misattribution process to assess impli-
cit associations. Four categories of primes
were utilized in the study: suicide (e.g.,
dead bodies reasonably presumed to be
caused by suicide via hanging, overdose, or
firearm), negative (e.g., inherently negative
images that do not depict death or suicide,
such as insects crawling on half-eaten food
items), neutral (e.g., a barstool or umbrella),
and positive (e.g., children laughing and
3
playing and nature pictures that include
flowers and blue skies). These images were
acquired from a previous peer-reviewed
study investigating startle response to
images related to pictorial stimuli (Smith,
Cukrowicz, Poindexter, Hobson, & Cohen,
2010). Smith et al. (2010) procured these
images from the Internet and the Interna-
tional Affective Picture System collection
(IAPS; Lang, Bradley, & Cuthbert, 1990).
The instructions for rating the Chinese pic-
tographs were altered to reflect an implicit
semantic association with presented stimuli
(identical to Sava et al., 2012) instead of an
implicit affective reaction. Specifically, par-
ticipants were asked to quickly rate how
suitable the Chinese pictograph would be if
it were printed on a personalized t-shirt,
using a 4-point rating scale associated with
keys on the keyboard: 2 = doesn’t fit me
well (d key), 1 = fits me a little (f key),
1 = moderately fits me (h key), and 2 = fits me
well (j key). Using these instructions, the
rating of the pictograph therefore serves as
a measure of how much the respondent
implicitly associates the prime category
(e.g., suicide) with their self-concept (Sava
et al., 2012).
All other instructions were identical to
Payne et al. (2005). Each participant com-
pleted 12 practice trials (images of scenery),
then 60 total target trials (15 trials per prime
category). Trials were presented in a ran-
dom order and each trial included a
novel Chinese pictograph. Each trial con-
sisted of a white fixation cross presented in
the middle of a blank black screen for
150 milliseconds followed by a blank
black screen (100 milliseconds), a prime
(150 milliseconds), a blank black screen
(100 milliseconds), a Chinese pictograph
(150 milliseconds), and then a black and
white static screen (mask) with response
instructions presented until a response was
made (Figure 1).
S-AMP responses were recoded from
the 2, 1, 1, 2 format to 1, 2, 3, 4 for the
purpose of study analyses. To quantify
implicit associations with suicide-related
stimuli, ratings of pictographs following
4 S-AMP PREDICTS SUICIDE IDEATION

1. Prime image

2. Chinese character

3. Mask

Please rate the Chinese

character
-2: -1: Fits 1: 2: Fits
Doesn’t me a little Moderately me well
fit me fits me
well

Figure 1. Pictorial representation of the suicide affect misattribution procedure (S-AMP).

Note: Suicide image depicted in this figure was not utilized in the current study. An image from the current study
was not included to protect the integrity of International Affective Picture System images, and the suicide images
retrieved from the Internet are highly graphic in nature.

suicide-related primes were summed to cre-
ate a “suicide S-AMP score,” with higher
values being related to more implicit associa-
tion with suicide-related stimuli. This was
repeated for negative (“negative S-AMP
score”), neutral (“neutral S-AMP score”),
and positive (“positive S-AMP score”)
primes. Suicide S-AMP and negative S-AMP
scores demonstrated good reliability (a = .88
and .83, respectively). Positive S-AMP scores
demonstrated adequate reliability (a = .75).
Neutral S-AMP scores demonstrated poor
reliability (a = .57).
Demographics Questionnaire. The
demographics questionnaire asked participants
general questions such as age, sex, and
ethnicity. A question assessing the ability
to read Chinese pictographs was added to
the demographics questionnaire, as data
from these participants would be excluded
from analyses to ensure the emotional
ambiguity of the Chinese pictographs pre-
sented during the S-AMP (Payne et al.,
2005).
Hopelessness Depressive Symptom Ques-
tionnaire–Suicidality Subscale (HDSQ-SS;
Metalsky & Joiner, 1997). The Suicidality
Subscale of the Hopelessness Depression
Symptom Questionnaire. The subscale was
designed to assess self-reported suicide idea-
tion, urges for suicide, and plans and prepa-
ration for suicide experienced in the previous
TUCKER ET AL.
2 weeks (Metalsky & Joiner, 1997). The
HDSQ-SS consists of four items rated on a
scale of 0–3, with the corresponding
responses varying depending on the ques-
tion. Higher scores indicate elevated levels of
suicide ideation. Internal consistency for
HDSQ-SS was excellent in the current study
(a = .92).
Center for Epidemiologic Studies Depres-
sion Scale (CES-D; Radloff, 1977). The
CES-D is a 20-item self-report measure of
depression symptoms experienced over the
previous 7 days. Responses are scored on a
4-point Likert-type scale ranging from 0
(rarely or none of the time—less than 1 day) to 3
(most or all of the time—5–7 days), with higher
scores indicating higher frequency and sever-
ity of depression symptoms. The CES-D
was chosen to be used in the current study as
the measure does not include an item that
assesses suicide ideation. As the CES-D was
used, in part, as a covariate of suicide idea-
tion in this investigation, the use of a depres-
sion symptom measure without an item
regarding suicidality was important. Lewin-
sohn, Seeley, Roberts, and Allen (1997) sug-
gest a clinical cutoff score of 16 that
demonstrates elevated risk for clinically sig-
nificant depression symptoms. Internal con-
sistency for the CES-D was excellent in the
current study (a = .93).
Interpersonal Needs Questionnaire-15
(INQ-15; Van Orden et al., 2012). The
INQ-15 is a self-report measure of current
feelings of thwarted belongingness (feelings
of social isolation and lack of reciprocal car-
ing from others) and perceived burdensome-
ness (belief that one’s existence strains
others). Thwarted belongingness and per-
ceived burdensomeness are central tenants of
the Interpersonal Theory of Suicide (Joiner,
2005) and have been shown to be strong cor-
relates of suicide ideation (Chu et al., 2017).
The INQ-15 was added to this study to fur-
ther test the predictive ability of S-AMP
scores in relation to important theory-based
predictors of suicide ideation. Nine items
comprise the thwarted belongingness sub-
scale of the measure contains and the other
six items of the INQ-15 assess perceptions of
5
burdensomeness. Responses are made on a 1
(not at all true for me) to 7 (very true for me)
Likert-type scale. Both the thwarted belong-
ingness and perceived burdensomeness sub-
scales demonstrated excellent internal
consistency in the current study (a = .92 and
a = .94, respectively).
Procedure
Suicide ideation was oversampled by
inviting anyone in the psychology student
subject pool who scored a one or above on
the HDSQ-SS screening questionnaire to
come into a research laboratory on campus
to participate in the study. Ten percent of
the subject pool who scored a zero on the
HDSQ-SS were also invited to sign up for
a time slot to participate.
As a counter balance, participants were
randomized into either one of two condi-
tions: completing study measures prior to
the S-AMP task or after. All participants
received a resource sheet at the end of partic-
ipation that identified local and national
emergency services to aid those contemplat-
ing suicide (i.e., University Counseling Cen-
ter and Suicide Prevention Hotline). Also,
data collection was completed in the same
building as the campus’ Psychological Ser-
vices Center (PSC) and all participants were
asked if they would like to speak to an associ-
ate after participation.
Analytical Strategy
A participant’s data were considered
invalid and removed from study analyses if
the majority of their S-AMP ratings were
made under 350 milliseconds (premature
responses) or greater than 2000 milliseconds
(a nonspontaneous response). This is consis-
tent with the protocol utilized in Hofmann
and Baumert (2010). Additionally, participants
who responded to 90% or more of the
S-AMP trials with the same response were
eliminated to reduce concerns related to ran-
dom responding. As neutral S-AMP scores
demonstrated poor reliability, analyses were
not conducted with these scores.
6 S-AMP PREDICTS SUICIDE IDEATION
Bivariate correlations were conducted
to test for simple associations between
S-AMP scores, symptoms of depression, and
suicide ideation. A logistic regression was
conducted to determine whether S-AMP
scores predicted suicide ideation status.
Those not experiencing recent suicide idea-
tion (HDSQ-SS total score equal to
zero) were dummy coded with a “0,” and
those experiencing any level of suicide idea-
tion in the previous 2 weeks (HDSQ-SS
greater than or equal to one) were dummy
coded with a “1.” S-AMP scores that were
significant predictors of suicide ideation sta-
tus were entered into a separate logistic
regression equation with psychiatric and the-
ory-based correlates of suicide ideation
(symptoms of depression, thwarted belong-
ingness, and perceived burdensomeness) to
further clarify predictive ability of significant
S-AMP scores. Finally, a negative binomial
regression analysis was conducted to deter-
mine the relationship between S-AMP scores
and suicide ideation (not simply suicide idea-
tion status). Negative binomial regression
was chosen as suicide ideation demonstrated
positive skew and overdispersion. In this
analysis, S-AMP scores that were correlated
with suicide ideation were entered as a simul-
taneous predictor of suicide ideation with
symptoms of depression, thwarted belong-
ingness, and perceived burdensomeness.
RESULTS
Data Cleaning
No participants were excluded for the
ability to read Chinese pictographs. Twelve
participants were eliminated from study analy-
ses as the majority of their S-AMP responses
were made under 350 milliseconds. Upon fur-
ther evaluation of these potentially invalid data
points, 10 of these 12 participants responded
to over 90% of S-AMP trials with the same
association rating, further questioning the
validity of their data. The mean age of
excluded participants (M = 20.67, SD = 2.43)
did not differ in comparison with included
participants (M = 20.23, SD = 2.36; t(136) =
.28, p = .784). Ethnicity and gender of
excluded and included participants did not
statistically differ (v2 = .23, p = .630 and
v2 = 2.55, p = .768, respectively). None of the
excluded participants indicated experiencing
suicide ideation the 2 weeks before participa-
tion. This left an analyzed sample of 126 par-
ticipants (68.3% female, 70.6% Caucasian),
18.25% of which indicated experiencing sui-
cide ideation in the 2 weeks prior to participa-
tion.
General Associations Between Study
Variables
Means, standard deviations, scoring
ranges, skewness and kurtosis values, and
bivariate correlation coefficients of study vari-
ables are presented in Table 1. Suicide idea-
tion was positively related to suicide S-AMP
scores (with a small effect size), thwarted
belongingness and perceived burdensomeness
(with moderate effect sizes), and symptoms of
depression (with a large effect size). Suicide
ideation was unrelated to both negative and
positive S-AMP scores. Suicide S-AMP scores
were positively correlated with symptoms of
depression and thwarted belongingness with
small effect sizes, but were unrelated to per-
ceived burdensomeness.
Prediction of Suicide Ideation
In a significant logistic regression
analysis with all S-AMP scores predicting
suicide ideation status (v2(3) = 12.43,
p = .006, Cox & Snell R2 = 0.094, Nagelk-
erke R2 = 0.153, 82.5% correctly classified),
suicide S-AMP scores were significant posi-
tive predictors (b = .17, Wald = 7.92, p =
.005, Exp(B) = 1.19, 95% CI [1.05, 1.34]),
but positive and negative S-AMP scores were
not significant predictors (b = .03, Wald =
0.47, p = .491, Exp(B) = 1.03, 95% CI [0.95,
1.11] and b = .09, Wald = 2.40, p = .121,
Exp(B) = .91, 95% CI [0.82, 1.02], respec-
tively).
When suicide S-AMP scores were
entered in a logistic regression analysis with
 TUCKER
ET AL.

TABLE 1
Means, Standard Deviations, and Correlation Coefficients of Study Variables
Variable 1 2 3 4 5 6 7 8

1. Suicide S-AMP score —

2. Negative S-AMP score 0.85*** —
3. Positive S-AMP score 0.32*** 0.17 —
4. Suicide ideation 0.24** 0.16 0.09 —
5. Log transformed suicide ideation 0.25** 0.16 0.09 0.99*** —
6. Depression symptoms 0.19* 0.21* 0.02 0.52*** 0.54*** —
7. Thwarted belongingness 0.28** 0.27** 0.08 0.46*** 0.48*** 0.80*** —
8. Perceived burdensomeness 0.14 0.14 0.08 0.49*** 0.49*** 0.73*** 0.71*** —
M 31.70 33.02 45.21 0.55 0.64 13.71 21.40 9.78
SD 8.90 8.50 6.90 1.30 0.10 11.11 11.33 6.28
Minimum 16 15 22 0 0.60 0 9 6
Maximum 51 56 58 8 1.00 52 55 33
Possible range 15–60 15–60 15–60 0–12 — 0–60 9–63 6–42
Skewness 0.35 0.18 0.35 2.16 2.01 1.21 1.80 2.41
Kurtosis 0.92 0.61 .10 4.18 3.13 1.10 1.0 0.30

S-AMP, Suicide Affect Misattribution Procedure. ***p < .001, **p < .01, *p < .05.
7
8 S-AMP PREDICTS SUICIDE IDEATION
symptoms of depression, thwarted belong-
ingness, and perceived burdensomeness as
simultaneous predictors, S-AMP scores and
symptoms of depression were significant
positive predictors of suicide ideation status,
but thwarted belongingness and perceived
burdensomeness were not significant pre-
dictors (v2(6) = 44.82, p < .001, Cox &
Snell R2 = .299, Nagelkerke R2 = 0.488,
86.5% correctly classified, see Table 2).
See Table 3 for results of a negative
binomial regression analysis of suicide
S-AMP scores, symptoms of depression,
thwarted belongingness, and perceived bur-
densomeness as simultaneous predictors of
suicide ideation. The entire model signifi-
cantly predicted suicide ideation (v2(4) =
76.65, p < .001). Suicide S-AMP scores,
symptoms of depression, and perceived bur-
densomeness were significant positive pre-
dictors of suicide ideation, but thwarted
belongingness was not a significant predic-
tor (Table 3).
DISCUSSION
The aim of the present study was to
determine whether the S-AMP may be a
useful measure of implicit associations with
suicide and a potential indirect marker of
suicide risk. Study hypotheses were partially
supported as implicit associations with sui-
cide stimuli were positively correlated with
levels of suicide ideation and differentiated
participants who were recently experiencing
suicide ideation from those who were not.
These results indicate that the experience of
TABLE 2
Logistic Regression Analysis of S-AMP Scores, Symptoms, Thwarted Belongingness, and Perceived
Burdensomeness as Simultaneous Predictors of Suicide Ideation Status
Predictor b SE b
Suicide S-AMP .09 .04
Depression symptoms .09 .04
Thwarted belongingness .02 .04
Perceived burdensomeness .03 .06
S-AMP, Suicide Affect Misattribution Procedure.
recent suicide ideation (i.e., in the previous
2 weeks) may covary with people’s implicit
associations between suicide and the self-
concept. Such a result is consistent with
Nock et al.’s (2010) assertion that implicit
associations with death and suicide may
influence susceptibility to suicidal behavior.
Overall, this research is important because
it furthers the literature regarding implicit
associations with suicide as an indirect mea-
sure of suicide risk, an important avenue for
psychological research (NIMH, 2009).
It is also important to note that
implicit associations with negative stimuli
during the adapted AMP task were not cor-
related with suicide ideation or predictive of
suicide ideation status. This result is impor-
tant because if implicit associations with
suicide and negative stimuli demonstrated
equal relationships to suicide ideation, it
could be argued that negative implicit asso-
ciations generally relate to suicide ideation,
not suicide-specific implicit associations.
Instead, the results of the current study sug-
gest that it is implicit associations with sui-
cide, not negative stimuli in general, that
are related to suicide ideation.
Results of multivariate analyses indi-
cated that the implicit associations with sui-
cide may provide useful information
regarding the susceptibility to suicide idea-
tion in tandem with symptoms of depression,
thwarted belongingness, and perceived bur-
densomeness. When analyzed together,
implicit associations with suicide, symptoms
of depression, and perceptions of burden-
someness were all significant positive predic-
tors of suicide ideation. Additionally, implicit
Wald p Exp(B) 95% CI for Exp(B)
4.81 .028 1.09 1.01–1.18
5.30 .021 1.10 1.01–1.18
0.35 .556 1.02 0.95–1.01
0.30 .587 1.03 0.93–1.15
TUCKER ET AL.
TABLE 3
Negative Binomial Regression Analysis of S-AMP Scores, Symptoms, Thwarted Belongingness, and
Perceived Burdensomeness as Simultaneous Predictors of Suicide Ideation
Predictor b SE b
Suicide S-AMP .01 .00
Depression symptoms .01 .00
Thwarted belongingness .00 .00
Perceived burdensomeness .01 .00
S-AMP, Suicide Affect Misattribution Procedure.
associations with suicide and symptoms of
depression when analyzed together were both
positive predictors of suicide ideation status
(presence or absence in the previous
2 weeks). This suggests that the relationship
between implicit associations with suicide
and suicide ideation may not exclusively be
due to these important psychiatric and the-
ory-based predictors of suicide ideation. This
result is in line with the findings of Nock
et al. (2010) that demonstrated that implicit
association with death/suicide were related to
suicidal behavior above and beyond common
psychiatric symptoms associated with suicide.
This series of studies suggests that implicit
associations with suicide encompass a suscep-
tibility to suicide that may not be encapsu-
lated by commonly assessed self-report risk
factors. This indicates that the assessment of
implicit associations with suicide may be
important to advance the field’s understand-
ing and prediction of suicide.
It should be noted, however, that there
are conceptual concerns regarding the co-
varying of depression symptoms out of
suicide ideation (as well as thwarted belong-
ingness and perceived burdensomeness) in
the clinically meaningful prediction of sui-
cide ideation. In a recent study that investi-
gated the residuals of suicide ideation when
depression was covaried out, data depicted
that residuals left of suicide ideation lacked
core features of suicidality, including psycho-
logical pain, passive thoughts of death, and
depressive cognitions (Rogers et al., 2016).
The authors attest that research investigating
predictors of suicide may limit the clinical
relevance of study results by covarying such
9
Wald p Exp(B) 95% CI for Exp(B)
4.32 .038 1.01 1.00–1.01
8.61 .003 1.01 1.00–1.01
0.00 .053 1.00 0.99–1.01
4.00 .046 1.01 1.00–1.02
important elements out of suicidality. This
concern is likely even more important to
raise in the current study as regression analy-
ses also incorporated thwarted belongingness
and perceived burdensomeness, both of
which demonstrated moderate sized correla-
tions with suicide ideation in the current
study. Thus, interpretations regarding the
relationship between the S-AMP and suicide
ideation should be made with results of uni-
variate and multivariate relationships in
mind.
Limitations
Results of this study should be inter-
preted with specific limitations in mind. The
effect size of the relationship between impli-
cit associations with suicide and suicide idea-
tion was relatively small. Future work should
seek to replicate study results in more clini-
cally severe samples to determine whether
effect sizes remain consistent. Additionally,
this research would allow for the investiga-
tion of whether implicit associations with
suicide relate to suicide attempts, an area of
study difficult to conduct in convenience
samples but vitally important for indirect
measures research. The cross-sectional nat-
ure of this study also limits the ability
to determine causal and prospective relation-
ships between implicit associations with
suicide and suicide ideation. Ideally, an indi-
rect marker of suicide should prospectively
predict suicide ideation to assist in the deter-
mination of suicide risk (e.g., Cha et al.,
2010; Nock et al., 2010), and thus, future
research utilizing the S-AMP should
10
incorporate prospective designs. This is par-
ticularly important as very few individuals
who experience suicide ideation make a sui-
cide attempt (Kessler, Borges, & Walters,
1999). An implicit measure that can prospec-
tively predict suicidal behavior may be of
higher clinical importance than an implicit
measure that only predicts the experience of
suicide ideation. Finally, the college student
sample used here not only limits generaliz-
ability of results to more clinically severe
samples, but also to more diverse popula-
tions. Results should be replicated in com-
munity samples to determine whether results
vary in samples comprised of higher percent-
ages of male participants and older and more
ethnically diverse individuals.
Implications
The current study has potentially
important implications for the assessment
and understanding of suicide risk. Contin-
ued work refining the S-AMP may demon-
strate that the computerized task can assist
both clinicians and researchers in the assess-
ment of suicide risk. Clients and partici-
pants may be motivated to conceal suicide
ideation and intent to avoid consequences
such as forced hospitalization (Denmark,
Hess, & Becker, 2012) and stigmatizing
attitudes associated with suicide (Sudak,
Maxim, & Carpenter, 2008). The S-AMP
does not rely on the explicit self-report of
suicide ideation or intent, which makes this
task a potentially beneficial addition to sui-
cide risk assessment. The S-AMP may be
particularly advantageous for suicide risk
REFERENCES
BURKLEY, M., BURKLEY, E., & BOCK, J.
(2016). AMP-LT: Development and evaluation of a
low-technology version of the affect misattribution
procedure. Unpublished manuscript.
BUSCH, K. A., FAWCETT, J., & JACOBS, D.
G. (2003). Clinical correlates of inpatient suicide.
Journal of Clinical Psychiatry, 64, 14–19.
CAMERON, C. D., BROWN-IANNUZZI, J. L.,
& PAYNE, B. K. (2012). Sequential priming
S-AMP PREDICTS SUICIDE IDEATION
assessment paradigms in clinical work and
research as this task is easy to administer
and complete. The S-AMP takes approxi-
mately 5 minutes to complete, is particu-
larly easy to score and interpret results, and
does not rely on reaction time as a metric
for risk. Because of these characteristics, the
S-AMP can easily be incorporated into real-
time risk assessment strategies utilizing vari-
ous mobile platforms, an important endea-
vor for future research (Davidson, Anestis,
& Gutierrez, 2016). Furthermore, like most
implicit measures, the S-AMP requires
computer equipment and software to
administer, but recently researchers have
developed a low-technology version of the
basic procedure that would increase the
likelihood that researchers will utilize the S-
AMP in the future (Burkley, Burkley, &
Bock, 2016).
The need for this research on the S-
AMP is timely as the development of an
implicit association with suicide is theorized
to be a potentially late stage in the progres-
sion along the suicide continuum from
thoughts of suicide to death by suicide (Nock
et al., 2010). Additionally, the death/suicide
IAT, which tests implicit associations with
suicide, has begun to be integrated into
research testing pertinent theories of suicidal
behavior and treatment studies specifically
targeting this implicit association (Price
et al., 2014; Tang, Wu, & Miao, 2013). The
current study provides an initial validation of
an additional measure of implicit association
with suicide that can be integrated in the
continued study of this new and important
element of suicide risk.
measures of implicit social cognition: A meta-
analysis of associations with behavior and explicit
attitudes. Personality and Social Psychology Review,
16, 330–350.
CHA, C. B., NAJMI, S., PARK, J. M., FINN,
C. T., & NOCK, M. K. (2010). Attentional bias
toward suicide-related stimuli predicts suicidal
behavior. Journal of Abnormal Psychology, 119,
616–622.
TUCKER ET AL.
CHU, C., STANLEY, I. H., HOM, M. A.,
BUCHMAN-SCHMITT, J. M., TUCKER, R. P.,
HAGAN, C. R., ET AL. (2017). The interpersonal
theory of suicide: A systemic review and meta-analysis
of a decade of cross-national research. Manuscript
under review.
DAVIDSON, C. L., ANESTIS, M. D., &
GUTIERREZ, P. M. (2017). Ecological momentary
assessment is a neglected methodology in suici-
dology. Archives of Suicide Research, 21, 1–11.
DENMARK, A. B., HESS, E., & BECKER, M.
S. (2012). College students’ reasons for conceal-
ing suicidal ideation. Journal of College Student
Psychotherapy, 26, 83–98.
DRAPEAU, C. W., & MCINTOSH, J. L. (for
the American Association of Suicidology).
(2015). U.S.A. suicide 2013: Official final data.
Washington, DC: American Association of Suici-
dology. Retrieved January 22, 2015, from http://
www.suicidology.org.
GREENWALD, A. G., MCGHEE, D. E., &
SCHWARTZ, J. L. (1998). Measuring individual
differences in implicit cognition: The Implicit
Association Test. Journal of Personality and Social
Psychology, 74, 1464–1480.
GREENWALD, A. G., POEHLMAN, T. A.,
UHLMANN, E. L., & BANAJI, M. R. (2009). Under-
standing and using the Implicit Association Test:
III. Meta-analysis of predictive validity. Journal of
Personality and Social Psychology, 97, 17–41.
HOFMANN, W., & BAUMERT, A. (2010).
Immediate affect as a basis for intuitive moral
judgement: An adaptation of the affect misattri-
bution procedure. Cognition and Emotion, 24,
522–535.
IMHOFF, R., & BANSE, R. (2011). Implicit
and explicit attitudes toward ex-partners differ-
entially predict breakup adjustment. Personal
Relationships, 18, 427–438.
IMHOFF, R., SCHMIDT, A. F., BERNHARDT,
J., DIERKSMEIER, A., & BANSE, R. (2011). An
inkblot for sexual preference: A semantic variant
of the affect misattribution procedure. Cognition
and Emotion, 25, 676–690.
IMURA, M., BURKLEY, M., & BROWN, R.
(2014). Honor to the core: Measuring implicit
honor ideology endorsement. Personality and
Individual Differences, 59, 27–31.
JARVIS, B. (2008). MediaLab (Version 2008)
[Computer software]. New York, NY: Empirisoft
Corp.
JOINER, T. (2005). Why people die by suicide.
Cambridge, MA: Harvard University Press.
KESSLER, R. C., BORGES, G., & WALTERS,
E. E. (1999). Prevalence of and risk factors for
lifetime suicide attempts in the national comor-
bidity survey. Archives of General Psychiatry, 56,
617–626.
11
LANG, P. J., BRADLEY, M. M., & CUTH-
BERT, B. N. (1990). Emotion, attention, and the
startle reflex. Psychological Review, 97, 377–395.
LEWINSOHN, P. M., SEELEY, J. R., ROBERTS,
R. E., & ALLEN, N. B. (1997). Center for Epidemi-
ological Studies-Depression Scale (CES-D) as a
screening instrument for depression among com-
munity-residing older adults. Psychology and Aging,
12, 277–287.
METALSKY, G. I., & JOINER JR., T. E.,
(1997). The Hopelessness Depression Symptom
Questionnaire. Cognitive Therapy and Research,
21, 359–384.
National Institute of Mental Health. (2009).
The National Institute of Mental Health Strategic
Plan. Retrieved July 7, 2017, from http://www.
nimh.nih.
NOCK, M., PARK, J., FINN, C., DEIBERTO,
T., DOUR, H., & BANAJI, M. (2010). Measuring
the suicidal mind: Implicit cognitions predict sui-
cidal behavior. Psychological Science, 21, 511–517.
PAYNE, B. K., CHENG, C. M., GOVORUN,
O., & STEWART, B. (2005). An inkblot for atti-
tudes: Affect misattribution as implicit measure-
ment. Journal of Personality and Social Psychology,
89, 277–293.
PAYNE, B. K., GOVORUN, O., & ARBUCKLE,
N. L. (2008). Automatic attitudes and alcohol:
Does implicit liking predict drinking? Cognition
and Emotion, 22, 238–271.
PAYNE, K., & LUNDBERG, K. (2014). The
affect misattribution procedure: Ten years of evi-
dence on reliability, validity, and mechanisms.
Social and Personality Psychology Compass, 8, 672–686.
PRICE, R. B., IOSIFESCU, D. V., MURROUGH,
J. W., CHANG, L. C., AL JURDI, R. K., IQBAL, S.
Z., ET AL. (2014). Effects of ketamine on explicit
and implicit suicidal cognition: A randomized
controlled trial in treatment-resistant depression.
Depression and Anxiety, 31, 335–343.
RADLOFF, L. S. (1977). The CES-D scale:
A self-report depression scale for research in the
general population. Applied Psychological Measure-
ment, 1, 385–401.
ROGERS, M. L., STANLEY, I. H., HOM, M.
A., CHIURLIZA, B., PODLOGAR, M. C., & JOINER,
T. E. (2016). Conceptual and empirical scrutiny
of covarying depression out of suicidal ideation.
Assessment. E-pub ahead of print. https://doi.org/
10.1177/1073191116645907.
SAVA, F. A., MARICUTOIU, L. P., RUSU, S.,
MACSINGA, I., V^IRGA , D., CHENG, C. M., ET AL.
(2012). An inkblot for the implicit assessment of
personality: The semantic misattribution procedure.
European Journal of Personality, 26, 613–628.
SMITH, P. N., CUKROWICZ, K. C., POIN-
DEXTER, E. K., HOBSON, V., & COHEN, L. M.
(2010). The acquired capability for suicide: A
12
comparison of suicide attempters, suicide idea-
tors, and non-suicidal controls. Depression and
Anxiety, 27, 871–877.
STROOP, J. R. (1935). Studies of interfer-
ence in serial verbal reactions. Journal of Experi-
mental Psychology, 18, 643–662.
SUDAK, H., MAXIM, K., & CARPENTER, R.
(2008). Suicide and stigma: A review of the liter-
ature and personal reflections. Academic Psychia-
try, 32, 136–142.
TANG, J., WU, S., & MIAO, D. (2013).
Experimental test of escape theory: Accessibility
to implicit suicidal mind. Suicide and Life-Threa-
tening Behavior, 43, 347–355.
S-AMP PREDICTS SUICIDE IDEATION
VAN ORDEN, K. A., CUKROWICZ, K. C.,
WITTE, T. K., & JOINER, T. E. JR., (2012).
Thwarted belongingness and perceived burden-
someness: Construct validity and psychometric
properties of the Interpersonal Needs Question-
naire. Psychological Assessment, 24, 197.
World Health Organization. (2015). Sui-
cide fact sheet. Retrieved July 14, 2017, from
http://www.who.int/mediacentre/factsheets/fs398/
en/.
Manuscript Received: March 31, 2017
Revision Accepted: June 15, 2017