Original Article
Exposure to suicide in the family and suicidal ideation in Portugal during the Covid-19 pandemic: The mediating role of unbearable psychache
Alexandra Medina Pereira,
Rui C. Campos,
Alexandra Medina Pereira
Department of Psychology, School of Social Sciences, University of Évora, Portugal
Search for more papers by this authorCorresponding Author
Rui C. Campos
Department of Psychology, School of Social Sciences, University of Évora, Portugal
Department of Psychology, School of Social Sciences and CIEP-UE, University of Évora, Portugal
Correspondence should be addressed to Rui C. Campos, Departamento de Psicologia, Universidade de Évora, Apartado 94, 7002-554 Évora, Portugal (email: [email protected]).
Search for more papers by this author
Alexandra Medina Pereira,
Rui C. Campos,
Alexandra Medina Pereira
Department of Psychology, School of Social Sciences, University of Évora, Portugal
Search for more papers by this authorCorresponding Author
Rui C. Campos
Department of Psychology, School of Social Sciences, University of Évora, Portugal
Department of Psychology, School of Social Sciences and CIEP-UE, University of Évora, Portugal
Correspondence should be addressed to Rui C. Campos, Departamento de Psicologia, Universidade de Évora, Apartado 94, 7002-554 Évora, Portugal (email: [email protected]).
Search for more papers by this authorAbstract
Objectives
This study tested the mediation effects of two facets of psychache – bearable and unbearable – in the relationship between exposure to suicide in the family and suicidal ideation in Portugal during the Covid-19 pandemic.
Methods
Two hundred and forty-four adults aged between 19 and 64 participated. Two groups were defined: one exposed to suicide in the family (n = 42) and a control group (n = 192).
Results
Path analysis using structural equation modelling tested a mediation model. Results demonstrated that unbearable psychache fully mediated the relationship between exposure to suicide and suicidal ideation, even when controlling for the mediation effects of depressive symptoms, the presence of a psychiatric diagnosis, and years of education.
Conclusions
These results suggest that rather than considering just the global experience of psychache in individuals exposed to suicide, researchers and clinicians should look to the presence of unbearable psychache given its contribution to suicidal ideation.
Practitioner points
- Unbearable psychache fully mediated the relationship between exposure to suicide in the family and suicidal ideation
- It is not the global experience of psychache that contributes to suicide ideation in individuals exposed to suicide in the family rather the presence of unbearable psychache
Conflict of interest
All authors declare no conflict of interest.
References
- Agerbo, E., Nordentoft, M., & Mortensen, P. B. (2002). Familial, psychiatric, and socioeconomic risk factors for suicide in young people: nested case-control study. BMJ, 325, 74. https://doi.org/10.1136/bmj.325.7355.74
- Almasi, K., Belso, N., Kapur, N., Webb, R., Cooper, J., Hadley, S., … Appleby, L. (2009). Risk factors for suicide in Hungary: a case-control study. BMC Psychiatry, 9(1). https://doi.org/10.1186/1471-244x-9-45
- Almeida, O. P., Draper, B., Snowdon, J., Lautenschlager, N. T., Pirkis, J., Byrne, G., … Pfaff, J. J. (2012). Factors associated with suicidal thoughts in a large community study of older adults. British Journal of Psychiatry, 201, 466–472. https://doi.org/10.1192/bjp.bp.112.110130
- Andriessen, K. (2009). Can postvention be prevention? Crisis, 30(1), 43–47. https://doi.org/10.1027/0227-5910.30.1.43
- Arria, A. M., O’Grady, K. E., Caldeira, K. M., Vincent, K. B., Wilcox, H. C., & Wish, E. W. (2009). Suicide ideation among college students: A multivariate analysis. Archives of Suicide Research, 13, 230–246. https://doi.org/10.1080/13811110903044351
- Baca-Garcia, E., Perez-Rodriguez, M. M., Oquendo, M. A., Keyes, K. M., Hasin, D. S., Grant, B. F., & Blanco, C. (2011). Estimating risk for suicide attempt: Are we asking the right questions? Passive suicidal ideation as a marker for suicidal behavior. Journal of Affective Disorders, 134, 327–332. https://doi.org/10.1016/j.jad.2011.06.026
- Barzilay, S., & Apter, A. (2014). Psychological models of suicide. Archives of Suicide Research, 18, 295–312. https://doi.org/10.1080/13811118.2013.824825
- Berman, A. L. (2011). Estimating the population of survivors of suicide: Seeking an evidence base. Suicide and Life-Threatening Behavior, 41(1), 110–116. https://doi.org/10.1111/j.1943-278x.2010.00009.x
- Borges, G., Angst, J., Nock, M. K., Ruscio, A. M., & Kessler, R. C. (2008). Risk factors for the incidence and persistence of suicide-related outcomes: A 10-year follow-up study using the National Comorbidity Surveys. Journal of Affective Disorders, 105, 25–33. https://doi.org/10.1016/j.jad.2007.01.036
- Brás, M., Jesus, S., & Carmo, C. (2016). Fatores psicológicos de risco e protetores associados à ideação suicida em adolescentes. Psicologia, Saúde & Doenças, 17, 132–149. https://doi.org/10.15309/16psd170203
10.15309/16psd170203 Google Scholar
- Brezo, J., Paris, J., Tremblay, R., Vitaro, F., Hébert, M., & Turecki, G. (2007). Identifying correlates of suicide attempts in suicidal ideators: A population-based study. Psychological Medicine, 37, 1551–1562. https://doi.org/10.1017/S0033291707000803
- Brown, G. K., Beck, A. T., Steer, R. A., & Grisham, J. R. (2000). Risk factors for suicide in psychiatric outpatients: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 68, 371–377. https://doi.org/10.1037/0022-006x.68.3.371
- Campos, R. C., & Holden, R. R. (2020). Psychological pain and previous suicide attempts in young adults: Results with the Portuguese version of the Psychache Scale. Journal of Clinical Psychology, 76, 1965–1971. https://doi.org/10.1002/jclp.22973
- Campos, R. C., Holden, R. R., & Gomes, M. (2018). Assessing psychache as a suicide risk variable: Data with the Portuguese version of the psychache scale. Death Studies, 43, 527–533. https://doi.org/10.1080/07481187.2018.1493002
- Campos, R. C., Holden, R. R., & Lambert, C. E. (2019). Avoidance of psychological pain and suicidal ideation in community samples: Replication across two countries and two languages. Journal of Clinical Psychology, 75, 2160–2168. https://doi.org/10.1002/jclp.22837
- Campos, R., Holden, R., Laranjeira, P., Troister, T., Oliveira, A., Costa, F., … Fresca, N. (2016). Self-report depressive symptoms do not directly predict suicidality in nonclinical individuals: Contributions toward a more psychosocial approach to suicide risk. Death Studies, 40, 335–349. https://doi.org/10.1080/07481187.2016.1150920
- Campos, R. C., Holden, R. R., & Santos, S. (2017). Exposure to suicide in the family: Suicide risk and psychache in individuals who have lost a family member by suicide. Journal of Clinical Psychology, 74, 407–417. https://doi.org/10.1002/jclp.22518
- Campos, R. C., Holden, R. R., Spínola, J., Marques, D., & Santos, S. (2020). Exposure to suicide in the family: Suicidal ideation and unmet interpersonal needs in young adults who have lost a family member by suicide. The Journal of Nervous and Mental Disease, 208, 201–207. https://doi.org/10.1097/nmd.0000000000001106
- Carqueja, E. (2017). Luto: Um Processo Dinâmico. In: H. Salazar (Coord.), (Ed.), Intervenção psicológica em cuidados paliativos (pp. 57–87). Lisboa: Pactor.
- Cavanagh, J. T. O., Carson, A. J., Sharpe, M., & Lawrie, S. M. (2003). Psychological autopsy studies of suicide: A systematic review. Psychological Medicine, 33, 395–405. https://doi.org/10.1017/s0033291702006943
- Cerel, J., Maple, M., van de Venne, J., Moore, M., Flaherty, C., & Brown, M. (2016). Exposure to suicide in the community: Prevalence and correlates in one U.S. state. Public Health Reports, 131(1), 100–107. https://doi.org/10.1177/003335491613100116
- Conner, K. R., Duberstein, P. R., Conwell, Y., Seidlitz, L., & Caine, E. D. (2001). Psychological vulnerability to completed suicide: A review of empirical studies. Suicide and Life-Threatening Behavior, 31(4), 367–385. https://doi.org/10.1521/suli.31.4.367.22048
- Crosby, A. E., & Sacks, J. J. (2002). Exposure to suicide: Incidence and association with suicidal ideation and behavior: United States, 1994. Suicide and Life-Threatening Behavior, 32(3), 321–328. https://doi.org/10.1521/suli.32.3.321.22170
- De Leo, D., & Heller, T. (2008). Social modeling in the transmission of suicidality. Crisis: the Journal of Crisis's Intervention and Suicide. Prevention, 29(1), 11–19. https://doi.org/10.1027/0227-5910.29.1.11
- DeLisle, M., & Holden, R. R. (2004). Depression, hopelessness, and psychache as increasingly specific predictors of suicidal manifestations. Canadian Clinical Psychologist, 15, 7–10.
- DeLisle, M. M., & Holden, R. R. (2009). Differentiating between depression, hopelessness, and psychache in university undergraduates. Measurement and Evaluation in Counseling and Development, 42(1), 46–63. https://doi.org/10.1177/0748175609333562
- Dowling, N. M., Bolt, D. M., Deng, S., & Li, C. (2016). Measurement and control of bias in patient reported outcomes using multidimensional item response theory. BMC Medical Research Methodology, 16, 1–18. https://doi.org/10.1186/s12874-016-0161-z
- Ducasse, D., Holden, R. R., Boyer, L., Artéro, S., Calati, R., Guillaume, S., … Olié, E. (2018). Psychological pain in suicidality: A meta-analysis. Journal of Clinical Psychiatry, 79. https://doi.org/10.4088/JCP.16r10732
- Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., … Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 145, 187–232. https://doi.org/10.1037/bul0000084
- Gonçalves, B., & Fagulha, T. (2004). The Portuguese version of the Center for Epidemiologic Studies Depression Scale (CES-D). European Journal of Psychological Assessment, 20, 339–348. https://doi.org/10.1027/1015-5759.20.4.339
- Guerreiro, D. (2013). Glossário. In: J. C. Santos (Relator), A. Carvalho, B. Peixoto, C. B. Saraiva, D. Sampaio, F. Amaro, J. C. Santos, J. H. Santos, & N. Santos (eds), Plano nacional de prevenção do suicídio 2013-2017. Lisoba: Direção-Geral da Saúde.
- Hauser, D., Paolacci, G., & Chandler, J. (2018). Common concerns with MTurk as a participant pool: Evidence and solutions. In F. Kardes, P. Herr, & N. Schwarz (Eds), Handbook in research methods in consumer psychology.England, UK: Routledge.
10.31234/osf.io/uq45c Google Scholar
- Hedstrom, P., Liu, K.-Y., & Nordvik, M. K. (2008). Interaction domains and suicide: A population-based panel study of suicides in Stockholm, 1991–1999. Social Forces, 87, 713–740. https://doi.org/10.1353/sof.0.0130
- Holden, R. R., Mehta, K., Cunningham, E. J., & McLeod, L. D. (2001). Development and preliminary validation of a scale of psychache. Canadian Journal of Behavioural Science, 33, 224–232. https://doi.org/10.1037/h0087144
- Jacobs, D., Baldessarini, R., Conwell, Y., Fawcett, J., Horton, L., Meltzer, H., … Simon, R. I. (2010). Practice guidelines for the assessment and treatment of patients with suicidal behaviors. APA Practice Guidelines.
- Jordan, J. R. (2001). Is suicide bereavement different? A reassessment of the literature. Suicide and Life-Threatening Behaviour, 31(1), 91–102. https://doi.org/10.1521/suli.31.1.91.21310
- Jordan, J. R., & McGann, V. (2017). Clinical work with suicide loss survivors: Implications of the U.S. Postvention guidelines. Death Studies, 41, 659–672. https://doi.org/10.1080/07481187.2017.1335553
- Jordan, J. R., & McMenamy, J. (2004). Interventions for suicide survivors: A review of the literature. Suicide and life-threatening Behavior, 34(4), 337–349.
- Khan, M. M., Mahmud, S., Karim, M. S., Zaman, M., & Prince, M. (2008). Case–control study of suicide in Karachi, Pakistan. British Journal of Psychiatry, 193(05), 402–405. https://doi.org/10.1192/bjp.bp.107.042069
- Klonsky, E. D., May, A. M., & Saffer, B. Y. (2016). Suicide, suicide attempts, and suicidal ideation. Annual Review of Clinical Psychology, 12(1), 307–330. https://doi.org/10.1146/annurev-clinpsy-021815-093204
- Kõlves, K., Zhao, Q., Ross, V., Hawgood, J., Spence, S. H., & de Leo, D. (2018). Suicide and other sudden death bereavement of immediate family members: An analysis of grief reactions six-months after death. Journal of Affective Disorders, 243, 96–102. https://doi.org/10.1016/j.jad.2018.09.018
- Kuramoto, S. J., Stuart, E. A., Runenson, B., Lichtenstein, P. L., Långström, N., & Wilcox, H. C. (2010). Maternal or paternal suicide and offspring’s psychiatric and suicide-attempt hospitalization risk. Pediatrics, 126, 1026–1032. https://doi.org/10.1542/peds.2010-0974
- Luxton, D. D., Rudd, D., Reger, M. A., & Gahm, G. A. (2011). A psychometric study of the suicide ideation scale. Archives of Suicide Research, 15, 250–258. https://doi.org/10.1080/13811118.2011.589720
- Maple, M., Cerel, J., Sanford, R., Pearce, T., & Jordan, J. (2017). Is exposure to suicide beyond kin associated with risk for suicidal behavior? A systematic review of the evidence. Suicide and Life-Threatening Behavior, 47, 461–474. https://doi.org/10.1111/sltb.12308
- May, C. N., Overholser, J. C., Ridley, J., & Raymond, D. (2015). Passive suicidal ideation: A clinically relevant risk factor for suicide in treatment-seeking veterans. Illness, Crisis & Loss, 23, 261–277. https://doi.org/10.1177/1054137315585422
10.1177/1054137315585422 Google Scholar
- McMenamy, J. M., Jordan, J. R., & Mitchell, A. M. (2008). What do suicide survivors tell us they need? Results of a pilot study. Suicide and Life-Threatening Behavior, 38, 375–389. https://doi.org/10.1521/suli.2008.38.4.375
- Mitchell, A. M., Kim, Y., Prigerson, H. G., & Mortimer-Stephens, M. K. (2004). Complicated grief in survivors of suicide. Crisis, 25, 12–18. https://doi.org/10.1027/0227-5910.25.1.12
- Montemarano, V., Troister, T., Lambert, C. E., & Holden, R. R. (2018). A four-year longitudinal study examining psychache and suicide ideation in elevated-risk undergraduates: A test of Shneidman’s model of suicidal behavior. Journal of Clinical Psychology, 74, 1820–1832. https://doi.org/10.1002/jclp.22639
- National Institute of Health Ricardo Jorge (2020). Saúde mental em tempos de pandemia. Lisbon, Portugal: INSA.
- National Institute of Statistcis (2017). Causas de morte 2017. Lisboa, Portugal: INE.
- O’Connor, R. C., & Nock, M. K. (2014). The psychology of suicidal behavior. The Lancet Psychiatry, 1, 73–85. https://doi.org/10.1016/S2215-0366(14)70222-6
- Orbach, I., Mikulincer, M., Sirota, P., & Gilboa-Schechtman, E. (2003). Mental pain: A multidimensional operationalization and definition. Suicide and Life-Threatening Behavior, 33, 219–230. https://doi.org/10.1521/suli.33.3.219.23219
- Overholser, J. C., Braden, A., & Dieter, L. (2012). Understanding suicide risk: Identification of high-risk groups during high-risk times. Journal of Clinical Psychology, 68, 334–348. https://doi.org/10.1002/jclp.20859
- Pachkowski, M. C., May, A. M., Tsai, M., & Klonsky, E. D. (2019). A brief measure of unbearable psychache. Suicide and Life-Threatening Behavior, 49, 1721–1734. https://doi.org/10.1111/sltb.12556
- Qin, P., Agerbo, E., & Mortensen, P. B. (2003). Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: A national register–based study of all suicides in Denmark, 1981–1997. American Journal of Psychiatry, 160, 765–772. https://doi.org/10.1176/appi.ajp.160.4.765
- Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. https://doi.org/10.1177/014662167700100306
- Rostila, M., Saarela, J., & Kawachi, I. (2013). Suicide following the death of a sibling: a nationwide follow-up study from Sweden. British Medical Journal Open, 3, e002618. https://doi.org/10.1136/bmjopen-2013-002618
10.1136/bmjopen?2013?002618 Google Scholar
- Santos, S., Campos, R. C., & Tavares, S. (2015a). O impacto do suicídio nos familiares: Evidências atuais. Evidências, 1, 16–23.
- Santos, S., Campos, R. C., & Tavares, S. (2015b). Suicidal ideation and distress in family members bereaved by suicide in Portugal. Death Studies, 39, 332–341. https://doi.org/10.1080/07481187.2014.946626
- Santos, S., & Tavares, S. (2014). Sobreviventes. In C. B. Saraiva, B. Peixoto & D. Sampaio (Eds.), Suicídio e comportamentos autolesivos – dos conceitos à prática clínica (pp. 445–453). Lisboa, Portugal: Lidel.
- Santos, S., Tavares, S., & Campos, R. C. (2015c). Distress in Portuguese family members bereaved by suicide: An exploratory study. Journal of Loss and Trauma, 20, 267–280. https://doi.org/10.1080/15325024.2014.934618
- Shneidman, E. (1972). Foreward. In A. C. Cain (Ed.), Survivors of suicide (pp. ix–xi). Springfield, IL: Charles C. Thomas.
- Shneidman, E. (1993). Suicide as psychache: A clinical approach to self-destructive behavior. Lanham: Rowman & Littlefield Publishers Inc.
- Shneidman, E. (1996). The suicidal mind: Final thoughts and reflections. Oxford, UK: Oxford University Press.
- Shneidman, E. S. (1998). Further reflections on suicide and psychache. Suicide and Life-Threatening Behavior, 28, 245–250.
- Song, I. H., Kwon, S. W., & Kim, J. E. (2015). Association between suicidal ideation and exposure to suicide in social relationships among family, friend, and acquaintance survivors in South Korea. Suicide and Life-Threatening Behavior, 45, 376–390. https://doi.org/10.1111/sltb.12158
- Sveen, C. A., & Walby, F. A. (2008). Suicide survivors’ mental health and grief reactions: A systematic review of controlled studies. Suicide and Life-Threatening Behavior, 38(1), 13–29. https://doi.org/10.1521/suli.2008.38.1.13
- Sveticic, J., & De Leo, D. (2012). The hypothesis of a continuum in suicidality: a discussion on its validity and practical implications. Mental Illness, 4, 73–78. https://doi.org/10.4081/mi.2012.e15
10.4081/mi.2012.e15 Google Scholar
- Tal-Young, I., Iglewicz, A., Glorioso, D., Lanouette, N., Seay, K., Ilapakurti, M., & Zisook, S. (2012). Suicide bereavement and complicated grief. Dialogues in Clinical Neuroscience, 14, 177.
- Troister, T., D'Agata, M. T., & Holden, R. R. (2015). Suicide risk screening: Comparing the Beck Depression Inventory-II, Beck Hopelessness Scale, and Psychache Scale in undergraduates. Psychological Assessment, 27, 1500–1506. https://doi.org/10.1037/pas0000126
- Troister, T., & Holden, R. R. (2012). A two-year prospective study of psychache and its relationship to suicidality among high-risk undergraduates. Journal of Clinical Psychology, 68, 1019–1027. https://doi.org/10.1002/jclp.21869
- Verrocchio, M. C., Carrozzino, D., Marchetti, D., Andreasson, K., Fulcheri, M., & Bech, P. (2016). Mental pain and suicide: a systematic review of the literature. Frontiers in Psychiatry, 7, 108. https://doi.org/10.3389/fpsyt.2016.00108
- World Health Organization [WHO] (2014). Preventing suicide: A global imperative. Retrieved from: https://www.who.int/mental_health/suicide-prevention/exe_summary_english.pdf
- World Health Organization [WHO] (2019). Suicide. Geneva, Switzerland: WHO. Retrieved from: https://www.who.int/en/news-room/fact-sheets/detail/suicide
- Wrobleski, A. (2002). Suicide Survivors: A guide for those left behind. Minneapolis, MN: SAVE.
- Zhang, S., Tao, F., Wu, X., Tao, S., & Fang, J. (2016). Low health literacy and psychological symptoms potentially increase the risks of non-suicidal self-injury in Chinese middle school students. BMC Psychiatry, 16(1). https://doi.org/10.1186/s12888-016-1035-y
10.1186/s12888?016?1035?y Google Scholar
