Differentiating Transdiagnostic Roles of Psychological Pain and Depression on Suicide Attempt in Major Depressive Disorder, Bipolar Disorder and Substance Use Disorder

This study aimed to expand the applicability of the three-dimensional psychological pain model for suicide prediction in clinical practice. A total of 548 psychiatric patients were recruited, of whom 56.9% had major depressive disorder, 28.5% bipolar disorder, 14.6% substance use disorder and 28.1% a history of suicide attempt (SA). Centrality measures and bridge factors were analyzed to map the close connections among psychological pain, severity of symptoms and SAs through network analysis. Joint profiles of psychological pain and depressive symptoms, and their associations with SA were also tested through latent profile and receiver operating characteristic curve analyses. Emotional and cognitive manifestations of depressive symptoms emerged as the top two most central nodes in each patient group. Importantly, pain avoidance showed the strongest direct and positive associations with SA, significantly surpassing depressive symptoms. Pain avoidance acted as the most prominent bridge variable with the highest bridge expected influence, mediating the relationship between depressive symptoms and SAs. Patients in the pain-avoidance and depressive symptoms class were approximately four times (OR = 3.47-4.63) as likely to report SA as those in the other two classes. Pain avoidance displayed superior performance (AUC = 0.77) than depressive symptoms in accurately identifying suicide attempters with these three psychiatric disorders. Compared to depression, pain avoidance is a more proximal trigger of SAs in patients with psychiatric disorders characterized by emotional and behavioural control deficits. Pain avoidance may bridge the gap between depressive symptoms and a risk of SA in such clinical populations.