Assessing mental pain as a predictive factor of suicide risk in a clinical sample of patients with psychiatric disorders

Assessing mental pain as a predictive factor of suicide risk in a clinical sample of patients with psychiatric disorders

Giulia Lucca1, Paolo Quaroni2, Silvia Paparesta2, Luca Ceroni3, Camilla Callegari2, Marco Innamorati4, Maurizio Pompili4, Nicola Poloni5

1ASST Lariana, Como, Italy; 2Department of Medicine and Surgery, Section of Psychiatry, University of Insubria, Varese, Italy; 3University of Turin, licensed Psychologist; 4Department of Neuroscience, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Italy; 5Section of Psychiatry, University of Insubria, Como, Italy.

Summary. Background. Mental pain (psychache) is a key risk factor for suicide, surpassing traditional constructs like depression and anxiety. While its correlation with suicidal ideation is well-established, few studies have evaluated its predictive value for actual suicide attempts in clinical populations. This study aimed to evaluate whether mental pain predicts short-term suicide attempts in a clinical sample, and to assess its potential role as a screening tool in suicide prevention. Methods. A longitudinal study on 179 psychiatric outpatients recruited at the University Hospital of Varese between 2020 and 2022. At baseline, participants completed the Psychache Scale (PAS), Beck Hopelessness Scale (BHS), Beck Depression Inventory-II (BDI-II), and Columbia Suicide Severity Scale (C-SSRS), among others. Sociodemographic, clinical, and laboratory data were also collected. Suicide attempts were tracked over a 12-month follow-up. Binary logistic regression was used to identify predictors of suicide attempts. Results. Twenty-six patients attempted suicide during follow-up, with 24 cases occurring within the first 6 months. Higher scores on the PAS, BHS, BDI-II, and Columbia Severity Rating Scale (C-SSRS) were significantly associated with increased suicide risk. In logistic regression, the PAS emerged as an independent predictor: each point increase corresponded to a 3.8% rise in suicide attempt probability (p=0.015). The BDI-II showed the strongest model fit (R2=0.169). Unemployment and history of substance abuse were also significantly associated with increased risk. No significant associations were found with routine laboratory parameters. Conclusions. The PAS, alongside the BDI-II, BHS, and C-SSRS scales may serve as an effective tool for early suicide risk detection, especially in psychiatric and primary care settings. Mental pain appears to be a relevant short-term risk indicator, highlighting the need for targeted screening and prevention strategies. Further research should explore its application in general healthcare to enhance suicide prevention efforts.

Key words. Mental pain, psychache, suicide.

Valutazione del dolore mentale come fattore predittivo del rischio di suicidio in un campione clinico di pazienti con disturbi psichiatrici.

Riassunto. Introduzione. Il dolore mentale (psychache) è un fattore di rischio chiave per il suicidio, superando costrutti tradizionali come depressione e ansia. Sebbene la sua correlazione con l’ideazione suicidaria sia ben consolidata, pochi studi ne hanno valutato il valore predittivo per i tentativi di suicidio effettivi in popolazioni cliniche. Questo studio mira a valutare se il dolore mentale predica i tentativi di suicidio a breve termine in un campione clinico e a valutarne il potenziale ruolo come strumento di screening nella prevenzione del suicidio. Metodi. Studio longitudinale su 179 pazienti psichiatrici ambulatoriali reclutati presso l’Azienda Ospedaliero-Universitaria di Varese tra il 2020 e il 2022. All’inizio dello studio, i partecipanti hanno completato, tra le altre, la Psychache Scale (PAS), la Beck Hopelessness Scale (BHS), la Beck Depression Inventory-II (BDI-II) e la Columbia Suicide Severity Scale (C-SSRS). Sono stati raccolti anche dati sociodemografici, clinici e di laboratorio. I tentativi di suicidio sono stati monitorati per un follow-up a 12 mesi. La regressione logistica binaria è stata utilizzata per identificare i predittori dei tentativi di suicidio. Risultati. Ventisei pazienti hanno tentato il suicidio durante il follow-up, con 24 casi verificatisi entro i primi 6 mesi. Punteggi più elevati su PAS, BHS, BDI-II e C-SSRS erano significativamente associati a un aumento del rischio di suicidio. Nella regressione logistica, la PAS è emersa come un predittore indipendente: ogni punto di aumento corrispondeva a un aumento del 3,8% della probabilità di tentativo di suicidio (p=0,015). La BDI-II ha mostrato il più forte adattamento al modello (R2=0,169). Anche la disoccupazione e la storia di abuso di sostanze erano significativamente associate a un aumento del rischio. Non sono state trovate associazioni significative con i parametri di laboratorio di routine. Conclusioni. La PAS, insieme alle scale BDI-II, BHS e C-SSRS, può rappresentare uno strumento efficace per la rilevazione precoce del rischio di suicidio, soprattutto in ambito psichiatrico e di assistenza primaria. Il dolore mentale sembra essere un indicatore di rischio a breve termine rilevante, evidenziando la necessità di strategie mirate di screening e prevenzione. Ulteriori ricerche dovrebbero esplorarne l’applicazione nell’assistenza sanitaria generale per migliorare gli sforzi di prevenzione del suicidio.

Parole chiave. Dolore mentale, psychache, suicidio.

Introduction

As of today, data from the WHO shows that in a year there are almost 700.000 suicides globally, whereas suicide attempt are 20 times more frequent1-3. Although suicide is a major public health problem and a leading cause of death, there is no definitive clinical indicator of future suicide behaviors. According to contemporary suicidology, the major risk factor for suicide is not represented by the psychiatric diagnosis but by the levels of psychological pain (psychache), described as an intolerable subjective experience that the person wishes to end by any means available, including physical death, and conceptualized as a perception of negative changes in the self and its functions that are accompanied by negative feelings4-8.

Recent findings have further supported the centrality of mental pain in suicide risk assessment. Blandizzi et al.9 provided a psychometric validation of the PAS using Mokken scaling in clinical samples, confirming its robust dimensional structure and clinical reliability. Campos et al.10 demonstrated that traditional tools such as the BDI-II and BHS, when used alone, may fail to detect individuals at imminent suicide risk, whereas measures of psychache offer significantly greater predictive power.

Several case-control studies comparing patients suffering from psychiatric disorders versus persons without a psychiatric diagnosis have highlighted a relationship between a history of suicide attempts and psychological pain, concluding that psychological pain is significantly correlated with both previous suicides and suicide attempts and with the presence of suicidal ideation11-14. In recent years, there has been growing attention to the role of individual factors, and among those, to mental pain in adverse life events response15,16 independently from psychiatric diagnosis and/or depressive symptoms5,17,18. The existing studies on this topic are mainly cross-sectional studies11,19,20. This model allows us to identify the correlation between levels of mental pain and a history of previous suicides and suicide attempts, or between levels of mental pain and current suicidal ideation but does not allow to understand whether the identified potential risk could translate results into a concrete attempt.

Furthermore, most of the papers refer to samples of patients with mood disorders, leaving out many of the diagnoses historically associated with suicide risk (e.g., personality disorders, substance abuse) and thus deviating from the clinical reality of psychiatric services21-24. The few prospective works conducted on this subject show that high levels of mental pain predict changes in suicidal ideation both in the short term (weeks, months) and in the long term (up to four years); however, these works12,25-28 are conducted on non-clinical samples (university students) and evaluate changes in ideation, but not actual complete suicides or suicidal attempts in the follow-up period29. Starting from the assumption that mental pain is a measurable construct through psychometric scales, this study aims to identify any correlation between mental pain levels and suicide or suicide attempt in the short term and, if so, to identify a psychometric tool in the context of suicide prevention20.

Another important issue is red flags that should alarm a clinician during a routine evaluation. Various indications in this regard are already available21, but these imply direct questions on the topic of suicide, which indicates that clinical suspicion is already present30. The indication regarding social, clinical or other factors that are unequivocally considered as alarm bells to investigate the topic of suicide in more depth, are still controversial. If previous suicidal attempts are recognized as a significant risk factor, the same attention is not paid to other factors31. In particular, the analysis of the literature revealed a lack of works exploring the correlation between suicidal risk and alterations in routine laboratory parameters. For this reason, we also included in the analyses the laboratory tests typically used in the clinical practice of emergency room visits or hospital admissions to highlight any correlations between their alterations and increased suicide risk.

Objectives

The primary purpose of this study is to identify a possible correlation between the level of mental pain, measured through the scales administered at the time of recruitment, and the risk of complete suicide or attempted suicide (AS) in the following 12 months to evaluate if the tools used in this work could be used as a screening method in the context of suicide prevention.

The secondary purpose is to deepen the correlation between socio-demographic, clinical, laboratory and psychometric variables with the suicidal risk in the short term to help the clinician identify people candidates for a targeted prevention path.

Materials and methods

Study design

This is a longitudinal study. A total of 179 patients were recruited between October 2020 and October 2022 through the administration of evaluation scales measuring levels of depression, anxiety, hopelessness, and mental pain. All patients were assessed in an outpatient setting, during scheduled visits to psychiatric services or follow-up consultations. The majority of assessments occurred during clinically stable phases, although no specific symptom severity threshold was required for inclusion.

Psychometric assessments

The following psychometric scales were used: Suicide Columbia Severity Rating Scale (C-SSRS)32; Hamilton Rating Scale for Anxiety (HAM-A)33; Hamilton Rating Scale for Depression (HAM-D)34; Psychache Scale (PAS)35; Mental Pain Questionnaire (OMMP)17; Beck Depression Inventory-II (BDI-II)36; Beck Hopelessness Scale (BHS)37. The C-SSRS scale was considered a control scale as it is a semi-structured interview that investigates suicidal ideation and behavior in depth. The other scales are all simple and quick tools to use and are all potentially suitable screening methods. In particular, three of these investigate traditional constructs such as anxiety and depression, and three constructs belonging to modern suicidology, hopelessness, and psychache.

Clinical and laboratory variables

Clinical, laboratory, and sociodemographic variables of the sample were also collected. The patients were recruited at the University Hospital of Varese (Azienda Socio-Sanitaria Territoriale Sette Laghi), during check-up visits at the psychiatric outpatient care services of Varese, Azzate, and Arcisate and at the outpatient clinic for anxiety and depression. The biological markers most frequently associated in the literature with major depression or suicide risk and typically analyzed as a screening at each hospital access were collected. No additional laboratory tests were required. The following laboratory tests were included in the assessment: white blood cell count, ESR (erythrocyte sedimentation rate), CRP (C-reactive Protein), total serum calcium, total cholesterol, and TSH (thyroid-stimulating hormone).

Recruitment criteria

Inclusion criteria were being over 18 years of age, the presence of a psychiatric illness diagnosed following the diagnostic criteria of the Statistical Diagnostic Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), and the signing of informed consent for the anonymous use of data for research purposes. Exclusion criteria included minor age and a cognitive or linguistic barrier that compromised the understanding of the study. Subjects suffering from major neuropsychiatric pathologies such as epilepsy, intellectual disabilities, or genetic syndromes with psychiatric correlates, as well as patients suffering from conditions that did not allow completing the evaluation, such as linguistic problems, severe dyslexia, or poor knowledge of the Italian language, were excluded from the study.

Ethical considerations

All personally sensitive information contained in the database used for this study was previously de-identified according to the Italian legislation (D.L. 196/2003, art. 110, 24 July 2008 art. 13). Since data were made anonymous and unidentifiable, the Provincial Health Ethical Review Board (Ethics Committee of Insubria – Azienda Socio Sanitaria Sette Laghi, Varese, Italy) confirmed before the beginning of the study that, as this was a longitudinal investigation, it did not require an approval process from the Board. The study was carried out in accordance with the Declaration of Helsinki (with amendments) and Good Clinical Practice.

Follow-up and suicide attempt assessment

After 12 months from the date of recruitment, hospital and territorial databases and medical records were analyzed with the aim of identifying suicides or attempted suicides that occurred during the follow-up period. Complete suicides were considered, as well as suicidal attempts that led to access to the emergency room requiring observation for at least 24 hours, or subsequent hospitalization, or which were followed by an emergency therapeutic intervention. Attempts that did not lead to access to emergency services but were described as objectively anti-conservative by the referring clinicians and reported in the patient’s clinical documentation were also considered. The sample was then divided into two groups: with AS during follow-up (New-AS) and without AS at follow-up (No-new-AS). The two groups were then compared for tests, sociodemographic, and clinical variables. Psychometric scales were administered at the time of recruitment, which coincided with a clinical evaluation. Although symptom severity was not standardized across participants, most patients were assessed outside of acute decompensation episodes.

Statistical analysis

Statistical analyses were performed using the IBM® SPSS® Statistics Version 24 statistical package. The investigated variables are presented as the mean and standard deviation for continuous variables and as frequency and percentages for qualitative variables. Associations between qualitative variables were assessed using the Chi-square test and, when necessary, Fisher’s exact test. Binary logistic regression was used to evaluate the predictivity of a dependent variable concerning one or more independent variables. Quantitative variables were processed with the Kolmogorov-Smirnov test to evaluate normality; the non-parametric variables were then analyzed with the Mann-Whitney and Kruskal-Wallis tests. All tests were considered significant with p-value ≤ 0.05.

Results

Sample characteristics

The sample consists of 64 males and 114 females, totaling 178 patients. Most patients are between the ages of 30 and 69, with a higher percentage between 50 and 59 (23.5%). 74.3% of the sample is in polypharmacotherapy, including at least different categories (e.g., antidepressant and mood stabilizer or antidepressant and anxiolytics); 68.6% of the sample is in treatment with benzodiazepines. The most frequent psychiatric diagnosis was personality disorder (39.4%), followed by major depressive disorder (26.3%) and attachment disorder (12%). Most patients (75.9%) have no psychiatric comorbidities, while the most common comorbid conditions reported are major depressive disorder (6.3%) and substance use disorder (5.2%).

Suicide attempts during follow-up

During the follow-up period, 26 out of 179 subjects made an attempted suicide and, of these, 24 within 6 months. For all the variables investigated, the two groups of AS and non-AS patients were compared. The statistical analyses were carried out given the greater frequency of AS at 6 months from baseline.

Association between psychometric scales and suicide attempts

Regarding the first objective – the association between the administered psychometric scales and suicide attempts at 6 months – patients who attempted suicide during the follow-up period showed significantly higher scores on most scales. In particular, the BDI-II, PAS, BHS, and C-SSRS (both current and lifetime versions) reached statistical significance. These findings are summarized in figure 1 and table 1.

Binary logistic regression analyses were conducted to examine the predictive value of each scale. The BDI-II emerged as the strongest individual predictor, with an R2 Nagelkerke of 0.169 and an increase of 6.4% in suicide attempt probability for each additional point (p<0.01). The C-SSRS Current score also showed a robust predictive value (R2=0.115; +8.9% risk per point, p<0.01), followed by the C-SSRS Lifetime score (R2=0.096; +7.4%, p=0.02). The PAS was a significant but more modest predictor, with each point increase corresponding to a 3.8% higher risk (R2=0.061, p=0.015). The BHS also reached significance (R2=0.042, +8.1%, p=0.044), whereas the OMMP scale was not significantly different between groups at 6 months but showed predictive value in the regression model (R2=0.102, p=0.02) (table 2).

On the other hand, the HAM-A and HAM-D scales did not reach statistical significance and showed poor model fit (p=0.928 and 0.112, respectively), suggesting limited utility in predicting short-term suicide risk in this sample.

Sociodemographic, clinical, and laboratory risk factors

The second objective was the in-depth study of sociodemographic, clinical, and laboratory variables with suicidal risk to identify people to be candidates for a targeted prevention path. Regarding the socio-demographic variables, summarized in table 3, only employment status presents a statistically significant difference between AS and non-AS patients (p<0.01). Marital status appears protective compared to other conditions (unmarried, divorced, and widowed; p<0.05).

Regarding age, gender, education level, medical conditions, or family history of mental illness, no statistically significant association was found with suicide attempts. No statistically significant differences were observed for primary psychiatric diagnosis. The absence of comorbidities is associated with a lesser risk of suicide attempt (p<0.05), while the presence of substance abuse history increases the probability (p<0.01). A significant association was found between SA and antipsychotic therapy (p<0.05) and mood stabilizer therapy (p<0.05), while no significant association was found between antidepressant and anxiolytic therapy. As shown in table 3, previous suicidal attempts represent one of the main suicidal risk factors.

Laboratory markers and suicide risk

Regarding biological markers, it was impossible to compare the two groups, as the group that did not have access to the hospital (No-New AS group) did not have complete tests. The New-AS group was then compared with the expected values of the general population. No statistically significant indicators of suicide attempt were found. However, most patients showed altered biochemical results during the routine tests after the SA. In particular, for inflammation markers, 45% had high WBC, 45% had high ESR, and 37.5% had high CRP. 42.5% of the sample had a high cholesterol count, only 4.3% had high calcium, and 7.7% had high TSH (figure 2).

Discussion

Role of mental pain in suicide risk

This longitudinal study aimed to evaluate the role of mental pain in suicide risk and its interactions with other sociodemographic, clinical, laboratory, and psychometric factors to better understand the potential applicability of its measurement as a screening method in the context of suicide prevention. This study identified a correlation between high scores obtained on some psychometric scales and the real risk of carrying out an AS. In fact, total scores measured by the PAS, BDI-II, C-SSRS, and BHS scales were significantly higher in the group with an AS at follow-up than in those without, and the binary regression model made it possible to highlight how the score on these scales increases, the risk of AS also increases. Among these, however, only PAS, BDI-II, and BHS seem to have the characteristics of simplicity and speed of use, which make them applicable in the clinical context and also in contexts different from the psychiatric one, such as, for example, in general practitioners’ outpatient clinics or primary care.

These results reinforce the value of a combined assessment of affective symptoms and mental pain in clinical settings. Amore et al.38 found that depressive insight in psychotic patients can intensify psychache, suggesting that patients with greater awareness of their condition may experience more profound psychological suffering. This supports the clinical utility of jointly using PAS and BDI-II, especially in complex psychiatric profiles. Moreover, Mantenuto et al.39 described a case in which a suicide crisis led to the late diagnosis of autism spectrum disorder (ASD), highlighting how acute self-harming behaviors may reflect underlying diagnostic challenges. These findings underscore the importance of considering not only symptom severity, but also diagnostic complexity and subjective experience when assessing suicide risk.

Anxiety, depression, and psychometric tools

HAM-A and HAM-D scales did not seem to be related to suicide risk, despite various evidence showing that high levels of anxiety and depression are risk factors and that anxiety disorders are associated with an increase in suicide risk40. This discrepancy could be explained both in terms of diagnostic sampling, i.e., a prevalence of Panic Disorder, and intrinsic limitations of the evaluation tool. In fact, pathological anxiety is a complex phenomenon not adequately estimated, in its subjective dimensions and experience (therefore properly symptomatic), by a scale that focuses on the evaluation mainly of clinical signs (thus objectifiable). Regarding depressive symptoms, this study indicates that the BDI-II is suitable for detecting patients at risk of suicide, whereas the HAM-D scale is not. Several pieces of evidence show that depressive symptoms, especially if severe, are associated with high levels of mental pain41,42. This discrepancy between the two scales may be attributed to differences in patient phenotype (e.g., a greater perception of depression in patients with predominantly emotional symptoms compared to those with predominantly somatic or neurovegetative symptoms). The OMMP score was not significantly associated with new AS, although higher scores were found in that group. Moreover, it was significant when analyzed using a regression model. This was also found in the literature where a new form of the scale (OMMP-8) was found to be a more viable option, although more research should be completed before adoption43. The small sample size limited the results, making it impossible to use multivariate analysis of the data.

Sociodemographic, clinical, and laboratory risk factors

The second objective of the work was to delve deeper into the correlation between AS and sociodemographic, clinical, and laboratory risk factors to help the clinician identify people who would be candidates for a targeted prevention process. As regards sociodemographic and clinical data, our results seem to be in line with the literature, showing as risk factors for AS being unemployed or invalid, having a history of substance abuse, a disability, or having comorbidities and premedication31. This higher association can be explained both in terms of higher psychological stress related to loneliness, physical limitations, social isolation, and financial difficulties and in terms of greater epigenetic vulnerability, as shown by the increasing number of studies on individual variations in the stress response system44-46. Several pieces of evidence have demonstrated a correlation between inflammation and suicidal risk46,47. Works are emerging on alterations of other laboratory parameters with suicidal risk, such as cholesterol and triglycerides, vitamin D, or thyroid hormones, but there is still little clarity on the topic and data on routinely used tests are lacking48-51. For this reason, we included in our study the measurement of hormonal and inflammatory parameters such as white blood cell count, RCP, ESR, TSH, and calcium serum level. At the moment, our data are not supported by statistical significance, probably due to the small sample size. Still, alterations concerning the population average were observed in all the values considered. In particular, an increase in inflammatory indices (WBC, RCP, ESR) and a reduction in serum calcium were found, which are interesting to explore.

Suicide risk and mental pain

In the multifactorial understanding of suicide risk, psychiatric disorders are major but not exclusive contributors to such a risk. In the phenomenological perspective of the suicidal mind, mental or psychological pain, also called “psychache”, is a valid construct for describing a subjective experience of intolerable distress that the person wishes to end by any means available, including physical death. In the mind of the suicidal individual, ending their life would represent a voluntary act aimed not at death itself but at escaping from unbearable pain. Therefore, suicide prevention efforts are shifting towards early recognition and treatment of this pain so that the individual can see their quality of life improve and thus choose to live5. Although several studies have demonstrated a correlation between high levels of mental pain and suicidal ideation, it is still unclear whether the level of mental pain can be considered a predictor of suicidal behavior or effective suicide14. The importance of distinguishing between suicidal ideation and suicide attempts when assessing the usefulness of these scales in evaluating suicide risk lies in the fact that suicidal ideation alone, especially without planning, is not a valid surrogate for a complete suicide risk52.

Conclusions

The results of this study suggest that the scores obtained from BHS, BDI-II and PAS scales can be useful tools for psychiatrists who should be trained to identify suicide risk in patients early53,54, but also for primary care physicians to assess the suicidal risk of their patients directly in their ambulatory. This is particularly important since primary care physicians are often the first point of contact for patients seeking mental health care, and they may not have access to specialized psychiatric services or resources. By identifying patients at increased risk of suicide using these scales, primary care physicians can provide targeted prevention and treatment interventions and potentially reduce the risk of suicide in their patient population48-50. In this study, the suicide risk was also assessed over time, specifically in the 6 and 12 months following patient recruitment. While no clear association with mental pain scales was identified at 12 months, several scales (C-SSRS, BDI-II, BHS, PAS) were statistically significant at 6 months in detecting patients with a higher suicide risk. This can be interpreted as an important clinical finding, indicating that mental pain may be an indicator of suicide risk in the short term, thus providing a valuable first-line screening tool for patients who will then be referred to specialist care. The main objective to be achieved in the near future will be to extend the investigations to general medicine clinics to test the effective applicability of the tools that have proved to be promising in the present work in this context.

Conflicts of interest: MP has received lectures and advisory board honoraria or has engaged in clinical trial activities with Angelini Pharma, Allergan, Janssen, Lundbeck, Merck Sharp and Dohme, Otsuka, Rovi, Pfizer Inc, Fidia, Viatris, Recordati, Boehringer Ingelheim, Newron, GSK, and Teva, all of which are unrelated to this article.

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