From psychotic symptoms to suicide probability and depressive symptoms: the mediating role of hopelessness in schizophrenia spectrum disorders — evidence from covariate-adjusted structural equation modelling

Objective Suicide is a leading cause of premature mortality among individuals with schizophrenia spectrum disorders. Although depression and hopelessness are associated with suicidality, the underlying mechanisms remain unclear. This study examined whether hopelessness mediates the associations between psychotic symptoms and both suicide risk and depressive symptoms. Methods This cross-sectional study included 200 individuals with schizophrenia spectrum disorders (123 with schizophrenia and 77 with schizophreniform disorder). Psychotic symptoms and depressive symptoms were assessed using clinician-administered measures, whereas hopelessness and suicide risk were assessed using self-report measures. Structural equation modeling examined the mediating role of hopelessness while controlling for age, sex, years of education, age at illness onset, and history of suicide attempts. Results Hopelessness partially mediated the associations between psychotic symptoms and both suicide risk and depressive symptoms. The indirect effects remained significant after adjustment for demographic and clinical covariates. A history of suicide attempts was associated with higher hopelessness, depressive symptoms, and suicide risk, whereas higher educational attainment was associated with lower suicide risk. Conclusions Hopelessness appears to be an important cognitive-affective process associated with psychotic symptoms, suicide probability, and depressive symptoms beyond established demographic and clinical risk factors. Routine assessment of hopelessness may improve suicide risk identification and inform targeted interventions. Longitudinal studies are needed to confirm these findings.