Multiple pathways to suicide: A network analysis based on three components of psychological pain

Psychological pain is a multidimensional structure that has long been recognized as an important risk factor for suicidal ideation and behavior. The roles of interactions among psychological pain subfactors at different stages of suicidality remain unclear.

A relatively large sample of outpatients with major depressive disorder (N = 501) was recruited to complete the Three-Dimensional Psychological Pain Scale (TDPPS). Exploratory graphical analysis (EGA) was conducted to explore the factor structure of TDPPS, thereby ensuring that the psychological pain subfactor was measured accurately. Network analysis included all TDPPS items, depression, passive suicidal ideation (PSI), active suicidal ideation (ASI), and history of suicidal action (SA) to identify key loops of suicidality.

EGA disclosed a three-factor structure of TDPPS comprising cognitive, affective, and motivational factors. Network analysis revealed that items of motivational factors, but none of the items of cognitive and affective factors, were directly linked to PSI, ASI, and SA. Furthermore, three communities were identified by a "walktrap" algorithm. Depression and cognitive factor coalesced into a 'cognitive' community, affective factor constituted an 'affective' community, and motivational factor, PSI, ASI, and SA comprised a 'suicidal' community.

This study used a cross-sectional design that cannot provide information on causal relationships among variables in the network.

Psychological pain avoidance may be a direct driver of suicidality, and therefore its assessment and intervention in clinical practice is necessary.