Examining suicidal ideation through the Three-Step Theory: a focus on pain, hopelessness, and meaning in life in a Malaysian sample

Objectives: To investigate the roles of reasons for living (RFL) and meaning in life (MIL) in potentially promoting mental health and well-being and protecting against suicide ideation among community-residing older adults and to investigate the psychometric properties of the Reasons for Living Scale-Older Adult version (RFL-OA).Method: Of 173 older adults initially recruited into a longitudinal study on late-life suicide ideation, 109 completed the RFL-OA and measures of cognitive and physical functioning and positive and negative psychological factors at a two-year follow-up assessment. We tested a model in which RFL and MIL protect against suicide ideation, controlling for demographic and clinical factors. We also assessed the psychometric properties of the RFL-OA in community-residing older adults, investigating its internal consistency and its convergent (MIL, perceived social support, and life satisfaction), divergent (loneliness, depressive symptom severity, and suicide ideation), and discriminant validity (cognitive and physical functioning).Results: RFL-OA scores explained significant variance in suicide ideation, controlling for age, sex, depressive symptom severity, and loneliness. MIL explained significant unique variance in suicide ideation, controlling for these factors and RFL, and MIL significantly mediated the association between RFL and suicide ideation. Psychometric analyses indicated strong internal consistency (α = .94), convergent, divergent, and discriminant validity for the RFL-OA relative to positive and negative psychological factors and cognitive and physical functioning.Conclusion: These findings add to a growing body of literature suggesting merit in investigating positive psychological factors together with negative factors when assessing suicide risk and planning psychological services for older adults.

The three-step theory of suicide: Description, evidence, and some useful points of clarification

BackgroundChronic pain is a significant risk factor for suicidal ideation (SI) and suicidal behavior (SB), including a 20%-40% prevalence rate of SI, a prevalence between 5% and 14% of suicide attempts, and a doubled risk of death by suicide in patients with chronic pain compared to controls. In most studies, associations between chronic pain and suicidality are robust, even after adjusting for the effect of sociodemographics and psychiatric comorbidity, and particularly for depressive conditions. A number of specific conditions that can modulate suicidality risk in patients with chronic pain have been investigated, but there is a need for their more specific characterization. Numerous recent studies have shown that demoralization and meaning in life (MiL) constructs affect suicidality as risk and protective factors, respectively. These constructs have been mainly investigated in patients with somatic illness and in community-dwelling individuals who may present with SI or SB independently of a psychiatric diagnosis of depression. However, a paucity of studies investigated them in suicidal patients affected by chronic pain.ObjectiveThe primary objective of this project is to investigate the relationship between demoralization and MiL on SI risk in patients with chronic pain. The secondary objectives are (1) to test whether demoralization can occur independently of depression in patients with chronic pain and SI, (2) to examine whether the expected association between demoralization and SI may be explained by a sole dimension of demoralization: hopelessness, (3) to examine whether the presence of MiL, but not the search for MiL, is associated with less SI, and (4) to explore whether previously described MiL profiles (ie, high presence-high search, high presence-low search, moderate presence-moderate search, low presence-low search, and low presence-high search) emerge in our cohort.MethodsThis project is a single-center, observational, case-control study—the Demoralization and Meaning in Life (DEMiL) study—conducted by the Division of Clinical Pharmacology and Toxicology, the Multidisciplinary Pain Centre, and the Service of Liaison Psychiatry and Crisis Intervention at the Geneva University Hospitals. Self- and hetero-administered questionnaires were conducted among patients and controls, matched by age and gender. The Ethics Committee of the Canton of Geneva approved the scientific utilization of collected data (project No. 2017-02138; decision dated January 25, 2018). Data have been analyzed with SPSS, version 23.0, software (IBM Corp).ResultsFrom March 1, 2018, to November 30, 2019, 70 patients and 70 controls were enrolled. Statistical analyses are still in progress and are expected to be finalized in November 2020. To date, we did not observe any unfavorable event for which a causal relationship with the collection of health-related personal data could be ruled out. Results of this study are expected to form the basis for possible prevention and psychotherapeutic interventions oriented toward demoralization and MiL constructs for suicidal patients with chronic pain.ConclusionsThe interest in exploring demoralization and MiL in chronic pain patients with SI arises from the common clinical observation that experiencing chronic pain often requires a revision of one’s life goals and expectations. Hence, the impact of chronic pain is not limited to patients’ biopsychosocial functioning, but it affects the existential domain as well. The major clinical implications in suicidal patients with chronic pain consist in trying to (1) delineate a more precise and individualized suicide risk profile, (2) improve detection and prevention strategies by investigating SI also in individuals who do not present with a clinically diagnosed depression, and (3) enhance the panel of interventions by broadening supportive or psychotherapeutic actions, taking into consideration the existential condition of a person who suffers and strives to deal with his or her suffering.International Registered Report Identifier (IRRID)DERR1-10.2196/24882

Introduction: Suicide is one of the major public health concerns worldwide which has numerous negative consequences for individual and society. Aim: This study aimed to model the structural equations of suicide risk factors based on the three-step theory of suicide in individuals with the emotional disorders. Method: This was a descriptive study using structural equation modeling. The statistical population included all people with emotional disorders referring to psychiatric outpatient clinics of Razi Educational and Medical Center of Tabriz in 2020. 205 patients with emotional disorders were selected by purposive sampling method and, they answered the questionnaires of Suicide Ideation (STS), Suicide Attempt (SAS), Suicide Capacity (SCS), and Suicide Motivation Questionnaire (IMSA). Data were analyzed using Pearson SPSS correlation test version 23 and structural equation modeling. Results: The correlation coefficient results showed a significant relationship between pain, hopelessness, sense of connectedness, and suicide capacity with suicidal ideation and suicide attempt (P<0.05). The results of structural equation modeling showed that the indirect effect of hopelessness (0.234) and low connectedness (0.048) on suicide ideation via suicide capacity was significant. The results showed that the indirect effect of frustration (0.586) and low belonging (0.121) on suicide attempts via suicidal capacity was significant. Conclusion: Using a three-step model can be useful in rapid diagnosis and action to distinguish people with only suicide ideation or who are prone to suicide.

Worldwide, internet addiction and suicidal ideation have become serious issues in public health. However, little is known about the underlying mechanisms in the relationship between internet addiction and suicidal ideation. This study aimed to investigate the relationship between internet addiction and suicidal ideation, and the role of meaning in life (MIL) and social support in this relationship. A total of 714 (female= 53.78%; mean age = 18.29 years, SD = 0.68 years) completed internet addiction, suicidal ideation, MIL, and social support measures. Results from PROCESS Model analysis showed higher internet addiction to be associated with a higher risk for suicidal ideation. This association was fully mediated by MIL so that internet addiction predicts suicidal ideation by reducing MIL. Social support moderated the effect of loss of MIL on suicidal ideation; namely, a lower sense of MIL was associated with higher suicidal ideation at low levels of social support, while high social support eliminated the effect of meaninglessness on suicidal ideation among college students. These findings imply a need for intervention in order to prevent suicidal ideation in college students in the digital era.

A Global Call for Action to Prioritize Healthcare Worker Suicide Prevention During the COVID-19 Pandemic and Beyond.

BackgroundYoung adults in Hong Kong are subject to elevated psychological distress given the societal stressors such as civil unrest and COVID-19 pandemic and suicide is a leading cause of death among them. The present study aimed to evaluate the psychometric properties and measurement invariance of the 4-item Patient Health Questionnaire-4 (PHQ-4) as a brief measure of psychological distress and its associations with meaning in life and suicidal ideation (SI) in young adults.Materials and methodsA mobile survey recruited a large and random sample of 1,472 young adults (Mean age = 26.3 years, 51.8% males) in Hong Kong in 2021. The participants completed the PHQ-4 and Meaning in Life Questionnaire–short form (MLQ-SF) for presence of meaning in life (MIL), SI, COVID-19 impact, and exposure to suicide. Confirmatory factor analysis was conducted to examine the factorial validity, reliability, and measurement invariance of PHQ-4 and MLQ-SF across gender, age, and distress subgroups. Multigroup structural equation model evaluated and compared the direct and indirect effects of latent MIL factor on SI via latent PHQ-4 factor across distress groups.ResultsBoth MIL and PHQ-4 supported a 1-factor model with good composite reliability (Ω = 0.80–0.86) and strong factor loadings (λ = 0.65–0.88). Both factors showed scalar invariance across gender, age, and distress groups. MIL showed significant and negative indirect effects (αβ = −0.196, 95% CI = −0.254 to −0.144) on SI via PHQ-4. PHQ-4 showed a stronger mediating role between MIL and SI in the distress group (Δ = −0.146, 95% CI = −0.252 to −0.049) than the non-distress group. Higher MIL predicted higher likelihoods of help-seeking (Odds ratios = 1.46, 95% CI = 1.14–1.88).ConclusionThe present results support adequate psychometric properties in terms of factorial validity, reliability, convergent validity, and measurement invariance for the PHQ-4 in young adults in Hong Kong. The PHQ-4 demonstrated a substantial mediating role in the relationship between meaning in life and SI in the distress group. These findings support clinical relevance for using the PHQ-4 as a brief and valid measure of psychological distress in the Chinese context.

Background and Objectives: Research on suicidal behavior (SB) has frequently focused more on risk factors than protective factors. Since the historic works of Viktor E. Frankl, who inquired how some Nazi concentration camps prisoners maintained their will to live though confronted with pervasive absurdity, Meaning in Life (MiL) has been interpreted as a potent resiliency factor. MiL then declined along a multitude of theoretical perspectives and was associated with various functioning domains of the individual. Surprising, few studies investigated the role of MiL on SB. We aimed to review and synthetize current literature on possible associations between MiL and SB, which included suicidal ideation (SI), suicidal attempts (SA), and completed suicide, focusing on two MiL constructs (the presence of MiL and search for MiL) from the Michael F. Steger’s recent conceptualization. Material andMethods: A systematic strategy following PRISMA guidelines was used to search for relevant articles in Pubmed/MEDLINE, Scopus, PsycINFO, and ScienceDirect (January 1980–February 2019) and yielded 172 articles, 37 of which met our inclusion criteria. Results: MiL emerged as a protective factor against SI, SA, and completed suicides, directly or through mediation/moderation models with other SB-related variables. When distinguishing the presence of MiL and the search for MiL, a consensual protective impact was described for the former. Data for the latter were less consistent but rather oriented towards a non-protective impact Conclusions: These findings could have clinical repercussions for SB prevention, in both suicide risk assessment refinement and psychotherapeutic interventions. Further research is needed to examine the dynamic interplay of the two constructs.

Effectiveness of narrative nursing on depression patients with suicide attempt: A preliminary randomized controlled trial.

BackgroundPatients with chronic pain have elevated risk of suicidal ideation and behavior, including suicide attempts and completed suicides. In most studies, associations between chronic pain and suicidal ideation/suicidal behavior are robust even after adjusting for the effect of sociodemographics and psychiatric comorbidity. However, to refine the risk profile of these patients, further exploration of other possible risk and protective factors is necessary.ObjectiveThere is a common clinical observation that experiencing chronic pain often requires a revision of life goals and expectations, and hence, it impacts the existential domain including one’s perception of the meaning in life (MiL). This study aimed to characterize the main domains that constitute the personal MiL, including the “presence of” and “search for” constructs, in a group of patients with chronic pain and suicidal ideation.MethodsSeventy participants were enlisted by ongoing recruitment through a larger project anchored in daily clinical practice at the Multidisciplinary Pain Center of the Geneva University Hospitals. It was an observational mixed method study. Data were recorded through both validated quantitative questionnaires and qualitative open-ended questions.ResultsThe total sample consisted of 70 patients. Responses to questionnaires showed a depressive episode in 68 (97%) patients and anxious disorders in 25 (36%) patients. With a score threshold for positive MiL of 24, the mean score for the “presence of” construct was 20.13 (SD 8.23), and 63% (44/70) of respondents had a score <24. The mean score for the “search for” construct was lower at 18.14 (SD 8.64), and 70% (49/70) of respondents had a score <24. The “presence of” and “search for” constructs were significantly positively correlated (R=0.402; P=.001). An open question addressed the “presence of” construct by inviting the respondents to cite domains they consider as providing meaning in their life at the present time. All patients responded to this question, citing one or more domains. The three main dimensions that emerged from content analysis of this qualitative section were as follows: the domain of relationships, the domain of personal activities, and pain and its consequences on MiL.ConclusionsThe study results provide insights into patients with chronic pain and suicidal ideation, including the domains that provide them with meaning in their lives and the impact of pain on these domains with regard to suicidal ideation. The main clinical implications concern both prevention and supportive/psychotherapeutic interventions. They are based on a narrative approach aiming to explore with the patients the content of their suffering and the MiL domains that they could identify to mitigate it, in order to restructure/reinforce these domains and thus possibly reduce suicidal ideation. Specifically, a focus on maintaining the domains of interpersonal relationships and personal activities can allow patients to ultimately escape the biopsychosocial vicious cycle of chronic pain–induced deep moral suffering.

BackgroundChronic pain is associated with an elevated risk of suicidal ideation (SI).ObjectiveWe aimed to examine if the presence or the search for Meaning in Life (MiL) are associated with less SI and explore whether MiL profiles emerge in our cohort. These profiles can be described as high presence–high search, high presence–low search, low presence–low search, and low presence–high search.MethodsIn this observational study, we recruited 70 patients who were referred to the Multidisciplinary Pain Center of the Geneva University Hospitals and who answered positively to question 9 on the Beck Depression Inventory, 2nd Edition, investigating SI. Patients who agreed to participate in the study were further investigated; they participated in a structured diagnostic interview to screen for psychiatric diagnoses. During this interview, they completed the Meaning in Life Questionnaire and the semistructured Scale for Suicide Ideation (SSI) to assess the characteristics and severity of SI.ResultsThere was a statistically significant correlation between the presence of MiL subscale and the SSI. These 2 scales had a negative and statistically highly significant correlation (R=–.667; P<.001). The results also showed a negative and statistically highly significant correlation between the score of the search for MiL and the SSI (R=–.456; P<.001). The results thus pointed to the presence of MiL as a potential protective factor against the severity of SI, while the search for MiL is also a possible resiliency factor, although to a lesser extent. The profile low presence–low search grouped the vast majority (47%) of the patients; in these patients, the mean SSI score was 14.36 (SD 5.86), much higher compared with that of the other subgroups.ConclusionsThis study’s results point to MiL as a concept of interest regarding devising psychotherapeutic interventions for chronic pain patients in order to reduce the suicidal risk and more accurately determine patients’ suffering.

Theory, research, and clinical practice suggest that perceptions of meaning in life (MIL) and purpose in life (PIL) may enhance mental health and well-being and protect against suicide risk among older adults. In this study, we investigated cross-sectional associations among MIL, PIL, and suicide ideation in community-residing older adults recruited into a longitudinal study of risk and resiliency to the onset and/or exacerbation of late-life depression and suicide ideation. A total of 173 adults, 65 years or older (M = 73.9, SD = 6.1, Range: 65–93 years) completed a demographics questionnaire and measures of suicide ideation and associated risk (depressive symptom severity and social hopelessness) and potential resiliency factors (MIL, PIL, and subjective well-being). Zero-order correlation coefficients supported hypothesized positive associations between suicide ideation and the risk factors and negative associations among suicide ideation, MIL, PIL, and subjective well-being. Results of a hierarchical multiple regression analysis indicated that MIL significantly protected against suicide ideation controlling for the risk factors and the additional resiliency factors, replicating and extending our previous findings among middle-aged clinical and heterogeneous older adult samples. MIL further interacted significantly with depressive symptom severity in protecting against suicide ideation; however, PIL did not. Study findings thus add to a growing body of literature suggesting that perceptions of MIL may play a critical role in conferring resiliency to contemplations of suicide among older adults.

Differential effects of state and trait social anhedonia on suicidal ideation at 3-months follow up

Despite the prominence of individuals presenting for therapy with suicidal thoughts and behaviors (STBs), there is little research available that examines how one or both members of a couple experience STBs when presenting for couple therapy. Thus, there is a prominent gap in the literature in understanding the types of STBs for both adult partners in a committed romantic relationship presenting for couple therapy, reducing clinicians' preparedness to address suicidality in this unique therapy modality. We applied the Three-Step Theory as a guiding framework to investigate the types of couples with suicidal risk that present to couple therapy. We used clinical data from the Marriage and Family Therapy Practice Research Network (n = 337 couples) to identify Dyadic Latent Profiles. We determined a three-profile model: Profile 1: Minimal Risk; Profile 2: Active and Passive Risk; and Profile 3: Both Passive Risk. However, nearly all predictors and covariates (e.g., biological sex, race, relationship duration, mental health treatment, pressure to attend therapy, and intimate partner violence) were not associated with profile membership. These results indicate that while most couples who attend couple therapy are unlikely to display elevated suicide risk, 7% of the sample (Profile 2) displayed active risk based on the Three-Step Theory of suicide. These findings aid clinicians in understanding that a small number of couples present an active risk. Results further encourage clinicians to assess STBs with continuous and not binary assessment questions.

The objectives of this study are as follows: (a) to analyze whether MIL at baseline moderates the association between ED psychopathology at baseline and borderline symptoms, hopelessness, and suicide ideation at follow-up and (b) to analyze whether MIL moderates the association between suicide ideation, hopelessness, and borderline symptoms at baseline and at the 7-month follow-up. The sample was composed of 300 participants with ED at baseline and 122 at the 7-month follow-up. The participants filled out the Purpose in Life, Eating Attitude Test, Borderline Symptoms List, Hopelessness Scale, and Suicide Ideation Scale. (a) MIL at baseline moderated the association between ED psychopathology at baseline and borderline symptoms, hopelessness, and suicide ideation at the follow-up; (b) MIL moderated the association between suicide ideation, hopelessness, and borderline symptoms at baseline and at the 7-month follow-up. MIL could be a relevant variable in the ED psychopathology.