http://dx.doi.org/10.24016/2023.v9.284
ORIGINAL
ARTICLE
Suicide risk model
based on the interpersonal theory of suicide: evidence in three regions of
Mexico
Modelo de riesgo suicida basado en la teoría interpersonal del
suicidio: evidencia en tres regiones de México
Modesto Solis-Espinoza
1, Juan Manuel Mancilla-Díaz 1, Rosalía Vázquez-Arévalo 1
1 Facultad de
Estudios Superiores Iztacala, Universidad Nacional Autónoma de México,
Iztacala, Mexico.
* Correspondence: modesto333_3@hotmail.com.
Received: August 23, 2022 | Revised: November 14, 2022 | Accepted:
February 16, 2023 | Published online: February 23, 2023.
CITE IT AS:
Solis-Espinoza, M., Mancilla-Díaz, J., &
Vázquez-Arévalo, R. (2023). Suicide risk model based on the interpersonal theory of suicide:
evidence in three regions of Mexico. Interacciones, 9,
e284. http://dx.doi.org/10.24016/2023.v9.284
ABSTRACT
Background: Reports of suicidal behavior
have increased in Mexico for years. In order to develop a more adequate suicide
prevention strategy, it is necessary to understand its predictive factors, so
the purpose of this research was to propose a model of suicidal risk in young
people, taking into account one of the most current theories on the subject,
Joiner's interpersonal theory. Method: A non-probabilistic sample of young people with
suicidal ideation from three regions of Mexico was obtained by online survey
(N=411), with mean age of 17.89 years (SD. 1.2), 336 women (81.8%), and 75 men
(18.2%). Results: First, a multiple linear regression model was created
to predict suicidal risk based on thwarted belongingness and perceived burden
with 17% explained variance; then a second model was generated with the same
variables and including other factors associated with suicide such as
self-injury desires, impulsivity and suicide attempts, in addition to variables
associated with family conflicts, improving the explained variance to 34%.
Lastly, two properly adjusted structural equation models were obtained, one
focused on suicidal risk (R2=.21; RMSEA=.026; CFI=.99) and the other
on ideation (R2=.18; RMSEA=.070; CFI=.98). Conclusions: The main factors that
explain suicidal risk are depressive symptoms, perceived burden and desires for
self-injury. Further research on the effect of painful experiences as factors
that could predict suicide attempt is suggested.
Keywords: suicide, interpersonal theory, self-injury, thwarted
belongingness, perceived burdensomeness.
RESUMEN
Introducción: Los reportes de conducta suicida en México
han aumentado por años. Para desarrollar una estrategia más adecuada de
prevención del suicidio es necesario comprender sus factores predictores, por
lo que el propósito de la presente investigación fue proponer un modelo del
riesgo suicida en jóvenes tomando en cuenta una de las teorías más vigentes en
cuanto al tema, la teoría interpersonal de Joiner. Método: Se obtuvo por encuesta online una muestra no
probabilística de jóvenes con ideación suicida de tres regiones de México
(N=411), con una edad media de 17.89 años (DE. 1.2), 336 mujeres (81.8%) y 75
hombres (18.2%). Resultados: Primero se conformó
un modelo de regresión lineal múltiple para predecir riesgo suicida a partir
del sentido de pertenencia frustrado y la carga percibida con 17% de varianza
explicada; después se generó un segundo modelo con las mismas variables e
incluyendo otros factores asociados al suicidio como los deseos de autolesión,
impulsividad e intentos suicidas, además de variables asociadas a conflictos
familiares, mejorando la varianza explicada hasta un 34%. Por último, se
obtuvieron dos modelos de ecuaciones estructurales con ajuste adecuado, uno
enfocado en riesgo suicida (R2=.21; RMSEA=.026; CFI=.99) y otro en
la ideación (R2=.18; RMSEA=.070; CFI=.98). Conclusiones: Los principales factores que explican el
riesgo suicida son los síntomas depresivos, la carga percibida y los deseos de
autolesión, se sugiere seguir investigando sobre el efecto de experiencias
dolorosas como factores que podrían predecir el intento suicida.
Palabras clave: suicidio, teoría interpersonal, autolesiones, carga percibida,
sentido de pertenencia frustrado.
BACKGROUND
The prevalence of suicides in Mexico has been on an upward trend for
approximately two decades (Fernández et al., 2016; National Institute of
Statistics, Geography and Informatics (2020, 2021), a fact that could be
exacerbated when considering the psychosocial effects of the pandemic of
COVID-19, the estimates that have been made in other countries such as the
United States, China, Bangladesh and the United Kingdom with people in a wide
range of ages (15-75 years), point to a prevalence of 11.5% with suicidal
ideation in the general population, a higher percentage than is usually
reported prior to the pandemic (Farooq et al., 2021).
The previous trend combines with what was recorded by the National
Survey of Health and Nutrition (ENSANUT) 2018, in which it refers that 5% of
the population over 10 years old has ever thought about committing suicide,
more specifically in the adolescent population (10 to 19 years old) 4% in men
and 7% in women, and in the young population (20 to 29 years old) 4% in men and
5% in women.
It has been analyzed that the impact of the pandemic on the suicide
spectrum can be economic, social and biological (Conejero
et al., 2020), with psychological consequences that could impact suicide rates
during the pandemic and even after (Sher, 2020), as has been verified in the
significant increase in the number of consultations due to suicide ideas and
attempts (Jerónimo et al., 2021), or in the increase
in mortality due to suicide, even in countries with a relatively small impact
of COVID -19 (Watanabe and Tanaka, 2022). With this panorama, it is necessary
to test models that explain suicidal risk, which allow guiding prevention and
clinical supported on theoretical empirical bases about suicide.
Along this line, some models have already been generated to predict
suicide in the Latin American context, such is the case of the contribution of
Toro et al. (2021), who created a cross-cultural model with a proven good fit
with Mexican and Colombian adult population, giving a special emphasis to the
explanation of suicidal risk from depression, despair and suicidal ideation.
On the other hand, a predictive model of suicidal ideation in Mexican
adolescents from Jalisco was also recently revealed (Reynoso et al., 2019),
which managed to explain 30.7% of the variance, having as predictor variables
in depressive symptoms, lack of family support and problems adjusting to school
in order of relevance.
After the COVID-19 pandemic, it is necessary to involve aspects such as
the case of despair about the future and changes in social reciprocity (Banergee et al., 2021), which is why the high explanatory
potential of the interpersonal theory of Joiner (2005), one of the most current
theories regarding the explanation of suicide that has been tested both in
clinical samples (Joiner et al., 2009) and in non-clinical ones (Becker et al.,
2020).
The theory of Joiner is based on the interaction of three variables, the
perceived burden (feeling like a burden to others), the thwarted belongingness
(not perceiving oneself as part of any group), and the acquired capacity for
suicide (absence of fear of dying and high pain tolerance), according to the
theory the first two variables will result in the desire to die (Van Orden et
al., 2010), however, the possibility and lethality of the attempt are
determined by the acquired capacity for suicide, which is explained by
habituation processes and the opposite process (Solomon, 1998), constant
painful experiences could make it less intimidating to try to commit suicide.
There are systematic reviews of the studies that test this theory,
yielding controversial results, for example Ma et al. (2016) point out that the
perceived burden influences suicidal ideation, that the perceived burden in the
interaction with the thwarted belongingness with suicidal ideation are modest,
while the relationship with suicidal capability has been low. In a more or less
similar way, Klonsky et al. (2016) found significant and robust associations
between thwarted belongingness and the perceived burden with suicidal ideation,
and acquired suicidality related to a greater number of suicide attempts,
although points out that the operational definition of suicidal capability
could be influencing so that larger effect sizes are not obtained.
Similarly, other studies partially support Joiner's (2005) postulates,
pointing out that it is necessary to continue exploring the interaction of its
main constructs with gender-specific effects and other psychological processes
(Cha et al., 2018); just as it has been mentioned that the perceived burden and
the thwarted belongingness influence suicidal ideation differently in their
interaction with other factors, underlining the importance of studying this
theory associated with other aspects of suicidal behavior (Espinosa-Salido et al., 2020).
According to Chu et al., (2017) there is a lack of studies that test the
interpersonal theory with validated instruments, in addition to recommending
the application with adolescents, understanding that there is a high number of
suicidal behaviors and they can last until death. Adulthood, which makes
special sense in light of the latest epidemiological reports (INEGI, 2021), in
which the age group with the highest suicide rate is the one of people between
18 and 29 years old, 10.7 deaths per 100,000 people.
Just as there are studies that have directly explored the interpersonal
theory of suicide, there are also studies that have reported data that could
appear to be evidence of Joiner's (2005) statements, such as have suffered
health damage due to violence implies a greater risk of suicide attempt
compared to those who have not (Valdéz-Santiago et
al., 2018), which could be related to the
acquired capacity for suicide due to habituation to painful experiences, in the
same way as with research on suicide and its link with behavior.
In another
study, those with a mild eating disorder score reported 1.5 times more likely
to attempt suicide, while those with moderate scores had 4.2 times more likely
to attempt suicide compared to those without eating psychopathology (Valdéz-Santiago et al., 2018). In turn, it has been
possible to distinguish between young people with suicidal ideation and
behavior based on exposure to self-harm among friends and/or relatives,
psychological disorders, and the use of cigarettes and drugs (except cannabis)
(Mars et al., 2019), findings that point in the same direction as that
postulated regarding the acquired capacity for suicide (Van Orden et al.,
2010), assuming that exposure to painful behaviors can facilitate a reduction
in fear towards them and therefore, a greater risk of attempting against one's
own life.
As a complementary way to what was proposed by Joiner
(2005), it has been proposed that in addition to the acquired capacity for
suicide, there are more variables that determine the passage from ideation to
suicide attempt, as in the case of self-destructive behaviors of others serving
as modeling and impulsivity among other variables (O´Connor & Kirtley, 2018).
Taking into account the above, factors associated with
relevant suicidal behavior in its prediction have been included in this project,
as is the case of self-injury (Serra et al., 2022), or the case of depressive
symptomatology (Melhem et al., 2019; Sandoval et al.,
2018). The objective was to propose a model of suicidal risk in young people
based on Joiner's interpersonal theory, in adolescents with suicidal ideation
from different regions of Mexico.
METHODS
Participants
A non-probabilistic sample was obtained from young
people with suicidal ideation (non-specific active suicidal thoughts) N=411
with an M=17.89 years (SD. 1.2), in an age range between 13 and 20 years old,
336 women (81.8%) and 75 men (18.2%), the participants came from cities in
three regions of Mexico, Mexico City (n=155) and State of Mexico (n=102),
“central zone”; Guadalajara (n=86) “western area”, and Tijuana (n=68),
“northern area”. Regarding schooling, 50.6% reported studying high school
level, 26.3% university, 5.6% reported secondary level and 17.5% reported not
studying at the time of their participation.
Instruments
General data: sociodemographic aspects such as age, schooling,
substance use, and relationship with family and school environment.
Plutchik's Suicide Risk Scale (Plutchik & Van Praag, 1989; adapted to Spanish by Rubio et al., 1998). It
consists of 15 items with yes/no answers, the sum of 6 affirmative answers
implies the presence of suicidal risk (Rubio et al., 1998). The modified version
of two items by Suárez-Colorado et al. (2019) was used. Internal consistency in
Mexicans has been Cronbach's Alpha of .74 (Santana-Campas
& Santoyo, 2018) and up to .84 (Solis-Espinoza, 2021).
Beck's Depression Inventory (BDI - II) (Beck et al., 1996; adapted for the Mexican
population by Jurado et al., 1998). It consists of 21 items that evaluate
depressive symptoms with a descriptive scale of four options, it has a high
reliability with Cronbach's alpha of .89 (Padrós
& Pintor, 2021).
Columbia Scale to Assess the
Seriousness of Suicidal Ideation (C-SSRS) (Posner et al., 2011; adapted to Spanish by Al-Halabí et al., 2016). It is a semi-structured interview
that evaluates: 1) severity of suicidal ideation with 5 types of ideation with
a 5-point ordinal scale (from 1=desire to die to 5=suicidal ideation with a
specific plan or intention), 2) intensity of ideation made up of ordinal scales
(frequency, duration, controllability, deterrence, and reason for ideation), 3)
suicidal behavior with a nominal scale of actual, interrupted, and aborted
attempts, preparatory acts, and nonsuicidal
self-destructive behavior, and 4) the lethality of suicidal ideation, suicidal
behavior, the scale has shown evidence of adequate discriminant validity and
sensitivity to change. Sensitivity to change: the reduction of one point in
item 3 of the Hamilton Depression Rating Scale implied 5.08 points fewer in the
severity of suicidal ideation and 13.51 points fewer in the intensity of
suicidal ideation. The intensity of suicidal ideation obtained a Cronbach's
alpha of .53, the factors of intensity of suicidal ideation explained 55.66% of
the variance (Al-Halabí et al., 2016).
Interpersonal Needs
Questionnaire (Van
Orden et al., 2008; adapted to Spanish by Ordoñez-Carrasco,
et al., 2018). Instrument developed to test Joiner's interpersonal theory of
suicide. There are 10 items on a Likert scale with 7 response options, from 1
(not very true for me) to 7 (very true for me). It has two subscales: perceived
burden with an alpha of .92 (feeling of being "a burden" for other
people) and thwarted belongingness with an alpha of .80 (feeling that one is
not part of anything) (Ordoñez-Carrasco, et al.,
2018).
Scale of acquired capacity
for suicide (lack of fear of dying) (Ribeiro et al., 2014; adapted by Trejo, 2018). 8-item
scale that estimates fearlessness to hurt oneself with 5 response options, from
1 (not at all like me) to 5 (very much like me). In the Mexican population, a
Cronbach's alpha of .76 has been reported (Trejo, 2018).
Self-harm risk questionnaire (CRA) (Solis & Gómez-Peresmitré,
2020). The self-injury frequency factor and the addictive effect of
self-injury/desire for self-injury were used, consisting of 9 dichotomous and
polytomous questions, with high internal consistency (alpha and omega = .94)
(Solis & Gómez-Peresmitré, 2020).
Plutchik's Impulsivity Scale (Plutchik & Van Praag, 1989; adaptation to Spanish by Rubio et al., 1998).
It consists of 15 items that measure impulsive behavior on a Likert-type scale
with 4 response options ranging from never to almost always. Adequate
reliability has been reported (Cronbach's alpha = .71) (Alcázar-Córcoles
et al., 2015).
Procedure
A web page created on GoogleForms
was distributed through social networks, in which the different instruments
were included; at the beginning, an informed consent was presented with the
description of the project, stating that participation would be voluntary and
the data would be used only for research purposes, later, each section of
general questions and the instruments were presented, one week after answering
the survey feedback and report of results were sent by email to each
participant, suggesting that they receive psychological support in cases where
there were indications of psychopathology (for example, high suicidal risk
score or active suicidal ideation), they were provided a list of public
psychological support centers to receive care and followed up on cases in which
they requested support and/or more information. The data collection was non-invasive
and the ethical criteria for research in psychology (SMP, 2007) were followed.
Analysis of data
Measures of central tendency of the variables were
obtained. Afterwards, the assumptions of variance homogeneity (Levene test) and normality (Kolmogorov-Smirnov) of the
sample were tested in order to perform the analysis of variance of one factor
(ANOVA), with the aim of looking for differences according to the region of the
participants. Although not all the variables obtained a normal distribution, some
authors point out that if this assumption is not drastically violated, the
ANOVA works adequately (Zar, 2010). Then multiple
linear regressions and structural equations were used to create models that
explained suicide risk, with the Generalized Least Squares estimator. For the
size of the sample, the recommendations of Vargas-Halabí
(2016). The cut-off points of the adjustment indices were considered: RMSEA≤.08
(Browne & Cudeck, 1993); GFI≥.90
; CFI≥ .95 (Lai, 2021); IFI≥.90 (Bollen,
1989). SPSS V.21 and AMOS V.21 were used.
Ethics topics
This project had the
approval of the Comité de ética de la Universidad Nacional Autónoma de
México - Facultad de Estudios Superiores Iztacala (no. 1417).
RESULTS
Table 1 shows the comparisons (simple variance
analysis), the average, and the standard deviation of the main variables of the
study in the sample according to the entity of origin.
|
Table 1. Comparisons of variables related to
suicide according to the state of origin. |
||||||||||
|
Ciudad
de México (n= 155) |
Estado
de México (n=102) |
Jalisco
(n = 86) |
Tijuana
(n= 68) |
ANOVA |
||||||
|
Variable |
M |
SD |
M |
SD |
M |
SD |
M |
SD |
F |
η2 |
|
Suicidal risk |
25.67 |
1.92 |
25.62 |
2.06 |
26.32 |
1.73 |
25.76 |
2.05 |
2.56 |
0.010 |
|
Depressive symptoms |
52.89 |
11.75 |
54.46 |
10.66 |
55.31 |
8.01 |
54.02 |
10.79 |
1.05 |
0.008 |
|
Perceived burden |
29.83 |
10.47 |
30.29 |
10.86 |
31.08 |
10.59 |
28.55 |
10.78 |
0.75 |
0.005 |
|
Thwarted belongingness |
17.68 |
5.89 |
18.50 |
6.32 |
19.10 |
5.46 |
18.04 |
6.25 |
1.14 |
0.008 |
|
Impulsivity |
39.45 |
5.70 |
39.73 |
6.36 |
41.56 |
5.63 |
39.41 |
6.63 |
2.64* |
0.010 |
|
No fear of dying |
26.49 |
7.26 |
24.99 |
6.43 |
25.82 |
6.98 |
27.25 |
7.26 |
1.66 |
0.010 |
|
Desire to self-injury |
11.84 |
4.16 |
11.56 |
4.66 |
12.12 |
3.95 |
11.91 |
4.58 |
0.26 |
0.002 |
|
Suicidal attempts |
1.83 |
1.91 |
1.71 |
1.92 |
1.80 |
2.00 |
2.21 |
2.72 |
0.83 |
0.006 |
|
Intensity of suicidal ideation |
14.18 |
3.65 |
14.68 |
3.77 |
15.62 |
4.03 |
15.05 |
4.36 |
2.72* |
0.020 |
|
Family problems |
3.00 |
0.83 |
3.22 |
0.91 |
3.13 |
0.89 |
3.35 |
0.85 |
2.89* |
0.020 |
|
Note: sig. * p<.05 |
||||||||||
Upon concluding that most of the variables did not
differ significantly according to each subsample, and in the cases in which
there were differences, the effect size was small, the analyzes were performed
as a whole, as a single sample. Two models with multiple linear regression (see
Table 2) were hypothesized to test some postulates of the interpersonal theory
of suicide, predicting suicidal risk, a first model of the perceived burden and
thwarted belongingness was developed with 17% of explained variance. Being one
of the key factors within the interpersonal theory of suicide, the absence of
fear of dying was included in the regression models, however, it did not have a
significant effect. Subsequently, variables that could be associated with the
acquired capacity for suicide were added (previous suicide attempts,
impulsivity, the desire to self-injury, and family violence), and a variable
that could be associated with thwarted belongingness (quality of the family
relationship), the second model achieved an explained variance of 34%, with the
main predictors being the desire to harm oneself (β=.26), the perceived burden
(β=.17) and the number of suicide attempts (β=.19).
|
Table 2. Multiple linear regression models for Suicidal
risk. |
||||||
|
Non-standardized coefficients |
Standardized coefficients |
|||||
|
|
|
β |
Error típ. |
β |
t |
p |
|
Model 1 |
(Constant) |
22.84 |
0.36 |
62.92 |
0.001 |
|
|
Perceived burdensomness |
0.07 |
0.01 |
0.38 |
8.47 |
0.001 |
|
|
|
Thwarted belongingness |
0.05 |
0.02 |
0.15 |
3.25 |
0.001 |
|
Model 2 |
(Constant) |
19.61 |
0.69 |
28.49 |
0.001 |
|
|
Perceived burdensomness |
0.03 |
0.01 |
0.18 |
3.86 |
0.001 |
|
|
Thwarted belongingness |
0.04 |
0.01 |
0.11 |
2.65 |
0.008 |
|
|
No fear
of dying |
-0.01 |
0.01 |
-0.05 |
-1.09 |
0.275 |
|
|
Domestic violence |
0.33 |
0.14 |
0.12 |
2.36 |
0.019 |
|
|
Impulsivity |
0.04 |
0.01 |
0.11 |
2.73 |
0.007 |
|
|
Desires of self-injury |
0.12 |
0.02 |
0.26 |
5.62 |
0.001 |
|
|
No. of
suicide attempts |
0.19 |
0.04 |
0.20 |
4.53 |
0.001 |
|
|
|
Family problems |
0.25 |
0.11 |
0.11 |
2.29 |
0.022 |
After the development of regression models, two models
were proposed using structural equations, considering some of the previous
results, taking the suicidal risk as the dependent variable in the first, and
the intensity of ideation second in the second (see Table 3). Figure 1 shows
the models.
|
Table 3. Goodness-of-fit indices of the models
(n=411). |
|||||||||
|
|
X2 |
df |
p |
RMSEA |
AIC |
R2 |
CFI |
GFI |
IFI |
|
Model 1.
Suicide risk prediction |
2.544 |
2 |
0.28 |
0.03 |
28.5 |
0.21 |
0.99 |
0.99 |
0.99 |
|
Model 2. Prediction of the intensity of
suicidal ideation |
3.003 |
1 |
0.083 |
0.07 |
21.0 |
0.18 |
0.98 |
0.99 |
0.98 |
|
Note: X2 = Chi
squared. df = Degrees of
freedom. CFI = Comparative fit index. TLI = Tucker-Lewis index. RMSEA = Root mean square error of
approximation. SRMR = Standardized root mean square residual. |
|||||||||
Figure 1. Path analysis.
Note: Model 1 = Suicide risk prediction. Model 2 =
Prediction of the intensity of suicidal ideation.
DISCUSSION
The objective of the study was to propose a model that
explains the suicidal risk in young people based on the principles of the
interpersonal theory of Joiner (2005), two multiple linear regression models
were carried out, one testing the hypothesis that the perceived burdens and the
thwarted belongingness would be associated with suicidal risk with 17% explained
variance and one in which the addition of other associated variables was tested
reaching 34% explained variance. Subsequently, two path analysis models with
acceptable adjustable indices were proposed, one taking suicide risk as a
variable to predict (R2=.21; RMSEA=.026; CFI=.99) and another
predicting the intensity of suicidal ideation (R2=.18, RMSEA=.070,
CFI=.98).
What was found in the multiple linear regression
models is consistent with one of the hypotheses proposed in the work of Van
Orden et al., (2010), in which it is pointed out that the variables of
perceived burden and thwarted belongingness can have an impact on their own
alone in the development of ideas about suicide, however, the effect seems
unequal, with the effect of the perceived burdensomeness (.38) being more than
the double that the thwarted belongingness (.14) on suicidal risk; this finding
could be explained by taking into account what was pointed out by Espinosa-Salido et al., (2020), both factors, despite being
interrelated and having proven to be good predictors of suicide attempts, have
also contributed to some predictive models independently and in interaction
with other variables. Another result that could be associated with the thwarted
belongingness is the relationship with the family, a factor added in the second
regression model that had a significant impact (Domestic violence β=.11; Family conflicts β=.11), from it could be hypothesized that a family
relationship considered "good" would serve as a protective factor against
suicide, insofar as this would reflect a sense of belonging with family
members.
In contrast to the first two elements of the
interpersonal theory of suicide, the effects of the absence of fear of dying
did not have a significant impact on the predictive models, similar to what was
reported by Becker, Foster and Luebbe (2020), who
found moderate to high correlations between suicidal risk with thwarted
belongingness (.41), with perceived burdensomeness (.52), with depressive
symptomatology (.55), and lower correlations with the absence of fear of dying
(.06).
In another study (Schuler et al., 2021), although low
levels of suicidal ideation were associated with low suicide capacity, it was
emphasized that the acquired capacity for suicide did not show significant
variations over 90 days, suggesting that it is of a factor that tends to be
stable, so it would not be entirely clear how this aspect would be involved in
suicide prevention, even pointing out that genetic aspects and other variables
could influence suicidal ability.
Following the same trend, Wolford-Clevenger et al.,
(2020) confirmed the hypothesis of Van Orden et al., (2010) regarding the
association between the perceived burden and thwarted belongingness with
suicidal wishes, despite little support for the relationship with the acquired
capacity for suicide, from which it is suggested to consider new
conceptualizations of that construct in the measurement of the variables, such
as the proposal by Klonsky and May (2015) with two other variables that
contribute to the capacity to commit suicide: practical (knowledge and access
to lethal means to take one's life) and dispositional (genetic aspects such as
sensitivity to pain, fear of blood, fearless traits).
On the other hand, the results were consistent with
the studies that support the relationship between self-injury and suicidal
behavior, according to a review of studies that analyzed this association (Grandclerc et al., 2016), the authors point out that
self-injury has been linked to suicide from some theories as a
"gateway" in this continuum, it has also been addressed with the
theory of a "third variable" in which comorbidity with other relevant
factors between self-injury and suicide is assumed, and, Predominantly, it has
been associated in recent years with the acquired capacity for suicide,
habituation to pain and less fear of death.
The result obtained regarding self-injury seems to
coincide with that found by Burke et al., (2018), in which the frequency of
self-injury turned out to be a discriminating variable between groups with
suicidal ideation and different degrees of planning and intention to die,
similarly, other pain-provoking events such as the experience of childhood
emotional abuse, physical abuse and physical neglect, for which the authors
suggest considering them as factors to be evaluated when exploring the
transition from ideation to suicidal behavior. On the other hand, they did not
find a significant difference when comparing the groups with a scale of
acquired capacity for suicide, similar to what was obtained in the present
study, considering the number of suicide attempts and
family violence as painful experiences that facilitate suicidal capacity
independently of the absence of fear of dying.
Based on these results, it could be hypothesized that
the evaluation of the acquired capacity for suicide does not contribute as much
to the explanation of suicidal risk as the pain-provoking experiences do,
however, as a line of research to be developed, the effects of these events regardless
of the pain caused and if they generate less/greater fear of death. As an
example of this, the frequency of self-injury according to what is postulated
in the theories of ideation to action, would represent a means of habituation
to pain and therefore to suicide attempt, however, self-injury by concept is
associated with the attempt to regulate negative emotions (Gratz & Roemer,
2008; Wolff et al., 2020), from which it could be inferred that perhaps the
main effect on suicidal risk is not through pain tolerance, but from coping
style, emotional dysregulation and the events that have triggered the negative
emotions previously.
The first path model of this study may have
similarities with the "three-step" approach of Klonsky and May
(2015), in which the presence of pain and hopelessness, the lack of connection
and the suicidal capacity are considered determinants so that the attempt is
reached. In this study, depressive symptoms and perceived burdensomeness are
correlated factors (.59) that would play a role similar to that of pain and
hopelessness, with a direct influence on suicidal risk in the case of
depressive symptoms (β=.44) and as well as different effects on
the desire for self-injury and impulsivity, which is a variable that triggers
suicide attempts (O'Connor & Kirtley, 2018); both
factors associated with suicidal capability with direct influence on suicidal
risk (desires for self-injury β=.26; impulsivity β=.09). The second proposed model takes up some
elements and obtains a similar adjustment even without considering aspects
associated with the perceived burden or the social belonging of the
interpersonal theory of suicide.
Given the role played by the addictive effect of
self-injury/desire to self-harm in both models (β = .26 in the suicide risk model; β = .28 in the intensity of suicidal ideation model),
it is necessary to continue directing more research to this concept, facing the
positions that disassociate self-injury from suicide, considering different
associated aspects regardless of the habituation of pain (Joiner, 2005). At the
same time, it is recommended for future projects to develop different ways of
evaluating the acquired capacity for suicide and analyze in greater depth the
relevance that the absence of fear of dying might or might not have.
Among the main contributions of this study, in
contrast to other projects, is the type of sample used, since it is even a
community sample, the indicators obtained represent high levels of depressive
psychopathology and suicidal risk, with 65.9% of participants with a record of
suicide attempts, which has allowed predictive estimates to be made in a
population that actually has suicidal thoughts, and that thanks to the project
have received an assessment; although it was not the objective of this study,
it is worth mentioning that qualitative information was collected and various
questions and problems expressed by the participants were answered, both
specific problems and advice on seeking psychological support. In addition, the
models obtained seem to be valid in adolescents from different regions, as it
is verified that relevant factors of suicide did not differ significantly
beyond the possible cultural differences derived from the different social
environments.
Some authors (Chu et al., 2017) have pointed out that
smaller effect sizes are usually found when suicide research is not based
solely on the web, so it could be deduced that the privacy and anonymity of
social networks could be providing more reliable information, less susceptible to
effects of social desirability, in such a way those information gathering
strategies could be maintained in a virtual format even without the impediment
to carrying out face-to-face evaluations; In addition to the fact that some
preventive strategies have already been developed within virtuality, an example
of this has been focusing on social connectivity as a protection factor,
through the creation of safe environments in spaces such as Reddit (McAuliffe
et al., 2022).
Suicide is complex and multifactorial, so it requires
an approach that is not limited only to psychopathology, it is necessary that
prevention considers the socioeconomic and cultural context (Gómez-García et
al., 2022; Navarrete et al., 2019 ), in this sense, it is essential to prevent
suicide to move towards multidisciplinary approaches that are not only the
responsibility of public health instances, it is necessary to promote laws and
a legal framework that allows establishing solid strategies against suicide in
favor of mental health (Valdéz-Santiago et al.,
2021).
Public health implications
Although previous suicide attempts, among other
variables, are clearly identified as risk factors (Gómez, et al., 2019;
Wilkinson et al., 2011), there are other variables such as desires of
self-injury and perceived burdensomeness, which possibly need to be considered
more frequently when examining young people in risk. The relevance of this type
of study lies in the possibility of refining and promoting early prevention
strategies, with the support of current scientific findings, which implies
specifying clear action guidelines from mental health institutions.
Limitations
As a main limitation, it would be mentioned that given
the nature of a cross-sectional study, aspects related to the temporality and
stability of the variables studied could not be evaluated, in addition to the
fact that there was no other resource to corroborate or confirm the scores
obtained like an interview. In addition to the fact that an exhaustive
measurement of pain-provoking experiences or a direct evaluation was not
carried out to estimate objective tolerance to pain, which would be essential
in this line of research if the acquired capacity for suicide continues to be
studied. Finally, it is necessary to point out that the present study was
carried out under the conditions imposed by the COVID-19 pandemic, so it could
be assumed that there are important changes in terms of the responses given by
the participants, it will be up to future research to continue analyzing the
possible effects of confinement by the health emergency, as well as to compare
the models proposed in this study in other samples and under different
conditions.
ORCID
Modesto Solis Espinoza https://orcid.org/0000-0002-9043-4245
Juan Manuel Mancilla Díaz https://orcid.org/0000-0001-7259-3667
Rosalía Vázquez Arévalo https://orcid.org/0000-0001-6491-9639
AUTHORS' CONTRIBUTION
Modesto Solis Espinoza: conceptualization, methodology, formal analysis,
investigation, writing review & editing, funding acquisition.
Juan Manuel Mancilla Díaz: validation,
resources, supervision, funding acquisition.
Rosalía
Vázquez Arévalo: methodology, resources, supervision.
FUNDING SOURCE
This research was
supported by Universidad Nacional Autónoma de México
(Programa de Becas Posdoctorales en la UNAM).
CONFLICT OF INTERESTS
The authors declare
that there were no conflicts of interest.
ACKNOWLEDGMENTS
Not applicable.
REVIEW PROCESS
This study has been
reviewed by external peers in double-blind mode. The editor in charge was Jeff Huarcaya-Victoria. The review process is included as
supplementary material 1.
DATA AVAILABILITY STATEMENT
Not applicable.
DISCLAIMER
The authors are
responsible for all statements made in this article.
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