Edited by: Domenico De Berardis, Hospital “G. Mazzini”, Italy
Reviewed by: Angelo Compare, University of Bergamo, Italy; Alessandro Valchera, Casa di Cura Villa San Giuseppe, Italy
Specialty section: This article was submitted to Affective Disorders and Psychosomatic Research, a section of the journal Frontiers in Psychiatry
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Mental pain, defined as a subjective experience characterized by perception of strong negative feelings and changes in the self and its function, is no less real than other types of grief. Mental pain has been considered to be a distinct entity from depression. We have performed a systematic review analyzing the relationship between mental pain and suicide by providing a qualitative data synthesis of the studies.
We have conducted, in accordance with PRISMA guidelines, a systematic search for the literature in PubMed, Web Of Science, and Scopus. Search terms were “mental pain” “OR” “psychological pain” OR “psychache” combined with the Boolean “AND” operator with “suicid*.” In addition, a manual search of the literature, only including the term “psychache,” was performed on Google Scholar for further studies not yet identified.
Initial search identified 1450 citations. A total of 42 research reports met the predefined inclusion criteria and were analyzed. Mental pain was found to be a significant predictive factor of suicide risk, even in the absence of a diagnosed mental disorder. Specifically, mental pain is a stronger factor of vulnerability of suicidal ideation than depression.
Mental pain is a core clinical factor for understanding suicide, both in the context of mood disorders and independently from depression. Health care professionals need to be aware of the higher suicidal risk in patients reporting mental pain. In this regard, psychological assessment should include a clinimetric evaluation of mental pain in order to further detect its contribution to suicidal tendency.
The World Health Organization estimated 804,000 suicide deaths occurred worldwide in 2012, representing an annual global age-standardized suicide rate of 11.4 per 100,000 population (15.0 for males and 8.0 for females). For every completed suicide, there are many more people who attempt suicide every year (
The clinical link between psychological pain and suicide, as well as the concept of psychache as essential factor affecting suicidality, has been established with empirical research studies showing psychache’s full mediation effects on the suicide risk (
Despite the extensively reported data of the literature supporting the association between psychache and several dimensions of suicidality, such as suicide thoughts or ideation, suicide motivation and preparation, suicide attempt, and suicide act (
On this preliminary background, the aim of the current study is to provide a systematic review of original studies by focusing on the relationship (including associations or correlations, comparisons and differences, mediating roles, as well as contributions or predictions) between mental pain and the core suicidal clinical factors, namely ideation, attempt, and suicidal act.
In line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (
Papers were eligible for inclusion if they were original research reports in English language describing data on mental pain in relation to suicidal ideation, attempt, and behavior. We excluded peer-reviewed articles published prior to 1995, single case studies, reviews, meta-analyses, letters to the editor and commentaries, conference abstracts, books, and papers that were clearly irrelevant. Studies were discarded whether full text was not available. Results were not limited to chronological age of participants.
Due to the heterogeneity of study design, measures, and features of the samples, it was not possible to combine the results into a meta-analysis. Consequently, results have been described reporting data through a systematic review. Studies were categorized based on the sample recruited for the study, by summarizing and comparing significant information for each study.
The search of PubMed, Scopus, Web of Science, and Google Scholar databases provided a total of 1450 citations. Based both on inclusion and exclusion criteria, a total of 42 original research studies were identified and selected for inclusion in the systematic review, as reported in the flowchart displayed in Figure
Several studies conducted with mood disorder patients have shown significant associations between mental pain and suicidality (see Table
Study | Title | Aim | Sample information | Measure of mental pain | Measure of suicide |
---|---|---|---|---|---|
Berlim et al. ( |
Psychache and suicidality in adult mood disordered outpatients in Brazil | To assess the prediction that psychache (as derived by psychological quality of life) is associated with suicidality over and above depressive symptoms, hopelessness, interpersonal, and physical domains of quality of life | Sample size: 60 diagnosed depressed adult patients |
WHO-QOL psychological domain (6 items) | BDI suicidality item; MINI questions about suicidality |
Caceda et al. ( |
Impulsive choice and psychological pain in acutely suicidal depressed patients | To examine the relationship of psychological pain and choice impulsivity with acute suicidal behavior | Sample size: 82 participants divided into four groups; G1, suicide attempters (20); G2, suicide ideators (22); G3, depressed controls (20); G4, healthy controls (20) |
PAS | C-SSRS |
Huanhuan et al. ( |
Clarifying the role of psychological pain in the risks of suicidal ideation and suicidal acts among patients with major depressive episodes | To further investigate the role of psychological pain in suicidal ideation and suicidal acts among patients with major depressive episodes | Sample size: 111 depressed patients divided into two groups; G1, depressed patients with a history of suicide attempts (28); G2, depressed patients with no history of suicide attempts (83) |
TDPPS |
BSS |
Mee et al. ( |
Assessment of psychological pain in major depressive episodes | To evaluate, developing a brief measure of psychological pain, the role of psychological pain in suicide, and depression | Sample size: 168 participants divided into two groups; G1, major depressive episode patients (73); G2, non-psychiatric controls (95) |
MBPPAS | SBQ |
Meerwijk and Weiss ( |
Does suicidal desire moderate the association between frontal delta power and psychological pain? | To investigate the moderating effect of recent suicidal desire on the association between resting-state neurophysiological parameters and psychological pain | Sample size: 35 adults with a history of depression, divided into two groups |
PAS |
BSS |
Olié et al. ( |
Higher psychological pain during a major depressive episode may be a factor of vulnerability to suicidal ideation and act | To test the hypothesis that higher psychological pain during a major depressive episode may represent a trait of vulnerability to suicidal ideation and suicidal acts | Sample size: 210 patients divided into three groups; G1, recent suicide attempters (87); G2, former suicide attempters (61); G3, |
Three items assessing intensity of psychological pain currently and during the last 15 days (including usual and maximum) | Two items measuring intensity of suicidal ideation and frequency of suicidal ideation |
van Heeringen et al. ( |
The functional neuroanatomy of mental pain in depression | To evaluate neurofunctional aspects of mental pain related to suicidality | Sample size: 39 depressed patients divided into three groups; G1, 13 patients with low levels of mental pain; G2, 13 patients with medium levels of mental pain; G3, 13 patients with high levels of mental pain |
OMMP | Item 9 of the BDI assessing occurrence and severity of suicidal ideation |
Xie et al. ( |
Anhedonia and pain avoidance in the suicidal mind: behavioral evidence for motivational manifestations of suicidal ideation in patients with major depressive disorder | To provide empirical evidence for the relationship between anhedonia, psychological pain (i.e., pain avoidance), and suicidal ideation | Sample size: 60 participants divided into three groups; G1, high suicide ideation participants (27 depressed patients); G2, low suicide ideation participants (13 depressed patients); G3 healthy control participants (20) |
TDPPS |
BSS |
High levels of psychache during a major depression may represent a condition of vulnerability for suicidal ideation and act. Olié et al. (
In order to demonstrate the association between the degree of mental pain and changes in the cerebral blood flow in specific areas of the brain (i.e., right occipital cortex, left inferior temporal gyrus, right dorsolateral prefrontal cortex, and right inferior frontal gyrus, as well as left medulla at pontine levels) van Heeringen et al. (
Studies conducted with different clinical groups (e.g., suicidal patients and/or psychiatric patients) showed significant associations between mental pain and suicide (
Study | Title | Aim | Sample information | Measure of mental pain | Measure of suicide |
---|---|---|---|---|---|
Barak and Miron ( |
Writing characteristics of suicidal people on the internet: a psychological investigation of emerging social environments | To support, in Study 3, Shneidman’s original argument that there are specific themes that characterized suicidal people, such as unbearable emotional pain (and cognitive constriction), focusing on the content of online writers’ messages | Sample size: 64 online messages by 39 participants in the SAHAR suicidal support forum and by 24 participants in the sexual assault forum |
Leenaars’ (1996) thematic guide for predicting suicide | NA |
Campos and Holden ( |
Testing models relating rejection, depression, interpersonal needs, and psychache to suicide risk in non-clinical individuals | To evaluate a model of suicide risk based on the contribution of four psychological variables, parental rejection, depression, interpersonal need, and psychache | Sample size: 203 non-clinical participants |
PAS | SBQ-R |
Gould et al. ( |
An evaluation of crisis hotline outcomes part 2: suicidal callers | To determine, among other objectives, predictors (i.e., intent to die, psychological pain, hopelessness) of suicidality after the call to crisis services/hotlines | Sample size: 1085 suicidal callers |
Two items assessing psychological pain | Nine questions about suicidal thoughts, plans, and attempts |
Gvion et al. ( |
A proposed model of the development of suicidal ideations | To develop a model of suicide ideation in psychiatric patients and the general population taking into account the role of mental pain domain, aggressive-impulsive domain, communication difficulties domain, and life events | Sample size: 196 participants divided into three groups; G1, suicide attempters (92 psychiatric patients); G2, non-attempters (47 psychiatric patients); G3 controls (57 healthy subjects) |
OMMP | Item 9 of the BDI |
Gvion et al. ( |
Aggression–impulsivity, mental pain, and communication difficulties in medically serious and medically non-serious suicide attempters | To evaluate, among other objectives, the role of mental pain, depression, and hopelessness in differentiating suicide attempters from non-attempters | Sample size: 196 participants divided into four groups; G1, medically serious suicide attempters (43); G2, medically non-serious suicide attempters (49); G3, psychiatric control group (47); G4, healthy control group (57) |
OMMP | LRS |
Horesh et al. ( |
Medically serious versus non-serious suicide attempts: relationships of lethality and intent to clinical and interpersonal characteristics | To investigate, among other objectives, the relationship between mental pain and subjective/objective suicide intent in both medically serious and medically non-serious attempters | Sample size: 102 participants divided into two groups; G1, patients after a medically serious suicide attempt (35); G2, patients after a medically non-serious suicide attempt (67) |
OMMP | SIS |
Leenars et al. ( |
Suicide notes in alcoholism | To assess whether suicide notes of alcoholics differ from suicide notes of non-alcoholics in Leenars’ dimensions of suicide, including unbearable pain | Sample size: 16 suicide notes of alcoholics and matched suicide notes of non-alcoholics |
Suicide notes | Suicide notes |
Levi et al. ( |
Mental pain and its communication in medically serious suicide attempts: an “impossible situation” | To test the hypothesis that mental pain is a general risk factor for suicidal behavior (and communication difficulties are a particular risk factor for medically serious suicidal behavior) | Sample size: 173 subjects divided into three groups; G1, patients after a medically serious suicide attempt (35); G2, patients after a medically non-serious suicide attempt (67); G3 healthy controls (71) |
OMMP | LRS |
Levi-Belz et al. ( |
Attachment patterns in medically serious suicide attempts: the mediating role of self-disclosure and loneliness | To assess the contribution of attachment style to medical lethality of the suicidal attempt above and beyond mental pain (and the meditational role of communication difficulties in the relationship between attachment style and medically serious suicide attempt) | Sample size: 102 patients divided into two groups; G1, patients after a medically serious suicide attempt (35); G2, patients after a medically non-serious suicide attempt (67) |
Mental pain is only indirectly evaluated with measures of depression, hopelessness and negative life events, BDI, BHS, and LES, respectively | LRS |
Levi-Belz et al. ( |
Mental pain, communication difficulties, and medically serious suicide attempts: a case-control study | To assess the role of mental pain and communication difficulties in medically serious suicide attempt | Sample size: 336 participants divided into four groups; G1, medically serious suicide attempters (78); G2, medically non-serious suicide attempters (116); G3, psychiatric control group (47); G4, healthy control group (95) |
OMMP | LRS |
Levinger and Holden ( |
Reliability and validation of the Hebrew Version of the Reasons for Attempting Suicide Questionnaire (RASQ-H) and its importance for mental pain | To evaluate, among other objectives, relationships of the RASQ-H with mental pain and the tolerance of mental pain | Sample size: 97 participants divided into three groups; G1, suicide attempter inpatients (42); G2, non-suicidal psychiatric inpatients (26); G3, non-clinical individuals (29) |
OMMP |
RASQ-H |
Levinger et al. ( |
The importance of mental pain and physical dissociation in youth suicidality | To assess whether physical dissociation can make a unique contribution to suicidal risk above and beyond the contributions of mental pain and low tolerance for that mental pain | Sample size: 123 young adults divided into three groups; G1, suicidal patients (42); G2, non-suicidal inpatients (36); G3 non-clinical group (45) |
OMMP |
MAST |
May et al. ( |
Descriptive and psychometric properties of the Inventory of Motivations for Suicide Attempts (IMSA) in an inpatient adolescent sample | To investigate, among other objectives, the motivations (e.g., psychache, hopelessness, and escape) adolescents endorsed for their suicide attempts | Sample size: 52 adolescent psychiatric inpatients who attempted suicide |
Psychache scale of the IMSA | Interview assessing lifetime suicide attempts |
Nahaliel et al. ( |
Mental pain as a mediator of suicidal tendency: a path analysis | To examine the mediating role of mental pain in the relationship between number of lifetime losses, self-destruction, and suicidal tendency | Sample size: 150 adults divided into three groups; G1, suicide attempt patients (50); G2, non-suicidal psychiatric patients (50); G3, healthy controls (50) |
OMMP | MAST |
Orbach et al. ( |
Mental pain and its relationship to suicidality and life meaning | To test, among other objectives, Shneidman’s proposition – on the relationship between mental pain and suicide – by comparing the mental pain of suicidal and non-suicidal individuals | Sample size: 91 subjects divided into three groups; G1, suicide attempters patients (32); G2, non-suicide attempters patients (29); G3 control participants (30) |
OMMP | MAST |
Pompili et al. ( |
Psychache and suicide: a preliminary investigation | To explore the usefulness of Shneidman’s measure of psychache using a sample of psychiatric patients. one specific objective was to address the association between PPAS score and current suicidal risk and suicidal history | Sample size: 88 psychiatric patients |
PPAS | Section about suicidal risk of the MINI integrated with Clinician’s opinion |
Reisch et al. ( |
An fMRI study on mental pain and suicidal behavior | To investigate the neural correlates of script-driven recall of mental pain plus suicide action | Sample size: 10 individuals who had attempted suicide 1 to 4 weeks prior to the interview |
OMMP |
Suicide action and suicide attempt sequences from narrative interviews |
Trakhtenbrot et al. ( |
Predictive value of psychological characteristics and suicide history on medical lethality of suicide attempts: a follow-up study of hospitalized patients | To test, among other assumptions, the hypothesis that mental pain, depression, and hopelessness are positively related to follow-up suicide attempt | Sample size: 153 subjects divided into three groups; G1, patients hospitalized for a medically serious suicide attempt (53); G2, patients hospitalized for a medically non-serious suicide attempt (64); G3, psychiatric control group (36) |
OMMP | Clinician assessment of suicide attempts, medical severity of the attempts, and medical severity of the follow-up attempt |
A recent research (
Levi et al. (
In order to further study the lethality of the suicide intent, as dichotomously conceptualized in its subjective vs. objective components, Horesh et al. (
The relationship between suicidal risk and mental pain was further evaluated in a study by Gould et al. (
Other studies investigated the mediational role of mental pain. Nahaliel et al. (
Mental pain seems to be a leading cause of suicide only when it is experienced as unbearable according to the cubic model of Shneidman (
A previous study from Levinger and Holden (
Finally, an fMRI study (
Several studies, conducted with university students, have demonstrated associations between psychache and a history of suicidal ideation (
Study | Title | Aim | Sample information | Measure of mental pain | Measure of suicide |
---|---|---|---|---|---|
Campos et al. ( |
Self-report depressive symptoms do not directly predict suicidality in non-clinical individuals: contributions toward a more psychosocial approach to suicide risk | To use a longitudinal design to test several hypotheses. Study 2 assessed the hypothesis that change in suicide ideation is associated with change in psychache after controlling for changes in depression and hopelessness. Study 3 tested the hypothesis that the combination of psychache and hopelessness fully mediated the relationship between depression and life-time suicidality, and that hopelessness related indirectly to life-time suicidality through psychache | Sample size: S2 90 undergraduate students having a history of suicidal ideation or suicide attempt; S3 280 university students |
PAS | BSS |
DeLisle and Holden ( |
Differentiating between depression, hopelessness, and psychache in university undergraduates | To measure the overlap between depression, hopelessness, and psychache constructs in predicting suicide risk | Sample size: 587 undergraduate students |
PAS | BSS |
Flamenbaum and Holden ( |
Psychache as a mediator in the relationship between perfectionism and suicidality | To assess whether psychache mediates the relationship between perfectionism and suicide | Sample size: 264 university students |
PAS | Five items assessing suicide history |
Holden et al. ( |
Development and preliminary validation of a scale of psychache | To assess psychometric properties of the Psychache Scale and its association with suicidal manifestations | Sample size: S1 = 294 university students; S2 = 211 university students |
PAS | RASQ |
Leenars and Lester ( |
A note on Shneidman’s Psychological Pain Assessment Scale | To explore validity and reliability of the PPAS as a correlate of suicidality | Sample size: 127 undergraduate students |
PPAS | Questions about prior suicidal ideation, prior suicide attempts, and lethality of prior attempts |
Lester ( |
Psychache, depression, and personality | To explore the correlation of psychache with a history of suicidal ideation and suicide attempts (and manic-depressive tendencies and temperament) | Sample size: 51 undergraduate students |
PPAS | Questions assessing history of suicidal ideation, and history of suicide attempts |
Troister |
A 5-month longitudinal study of psychache and suicide ideation: replication in general and high-risk university students | To evaluate whether psychache and suicidality are associated, and whether this association continues when other suicide-relevant variables of depression and hopelessness are controlled statistically | Sample size: 945 university students into two groups; G1, 683 general sample of participants; G2, 262 high-risk university students |
PAS | Five questions asked about lifetime suicide attempts |
Troister and Holden ( |
Factorial differentiation among depression, hopelessness, and psychache in statistically predicting suicidality | To evaluate the unique contributions of psychache, depression, and hopelessness in the prediction of suicide ideation | Sample size: 2,974 university students |
PAS | BSS |
Troister and Holden ( |
A two-year prospective study of psychache and its relationship to suicidality among high-risk undergraduates | To use a longitudinal design to investigate psychache contribution to suicidality in at-risk university students | Sample size: 41 at-risk university students |
PAS | BSS |
Troister et al. ( |
Comparing psychache, depression, and hopelessness in their associations with suicidality: a test of Shneidman’s theory of suicide | To test Shneidman’s theory of suicide by evaluating the contributions of psychache, depression, and hopelessness, to the statistical prediction of suicidality | Sample size: 1475 undergraduate students |
PAS | Five questions asked about lifetime suicide attempts |
You et al. ( |
Effects of life satisfaction and psychache on risk for suicidal behavior: a cross-sectional study based on data from Chinese undergraduates | To investigate the predictive power of life satisfaction and psychache on risks for suicidal ideation and suicide attempt in Chinese university students | Sample size: 5988 college students |
PAS | Two questions assessing suicidal ideation |
Flamenbaum and Holden (
When longitudinally evaluating the relationship between psychache and suicidality, Troister and Holden (
The relationship between mental pain and suicide was further addressed in special populations of prisoner, homeless, and soldiers (Table
Study | Title | Aim | Sample information | Measure of mental pain | Measure of suicide |
---|---|---|---|---|---|
Coohey et al. ( |
Sources of psychological pain and suicidal thoughts among homeless adults | To assess the association between several sources of psychological pain (i.e., drug problems, family relationship problems, social problems, psychiatric problems, past emotional abuse, past physical abuse, and past sexual abuse) and suicidal thoughts | Sample size: 457 homeless adults |
ASI questions on sources of psychological pain | ASI questions about current suicidal thoughts and past suicide attempts |
Mills et al. ( |
An evaluation of the Psychache Scale on an offender population | To test the hypothesis that the Psychache Scale is more strongly related to suicide indicators than measures of either depression or hopelessness in an offender population | Sample size: 136 inmates of a medium security prison |
PAS | DHS |
Patterson et al. ( |
Psychache and suicide ideation among men who Are homeless: a test of Shneidman’s model | To evaluate psychache as a stronger predictor of suicide among homeless | Sample size: 97 homeless |
PAS | BSS |
Pereira et al. ( |
Testing Shneidman’s model of suicidality in incarcerated offenders and in undergraduates | To evaluate psychache as a stronger predictor of suicide among offenders and undergraduates | Sample size: 233 participants divided into three groups; G1, incarcerated offenders (73); G2, male undergraduate students (80); G3, female undergraduate students (80) |
PAS | DHS |
Shelef et al. ( |
Emotional regulation of mental pain as moderator of suicidal ideation in military settings | To examine how mental pain and emotional regulation of mental pain contribute to suicide ideation. Additionally, it explores whether emotional regulation of mental pain moderates the relationship between mental pain and suicide ideation. | Sample size: 168 soldiers divided into three groups; G1, soldiers attempted suicide (58); G2, soldiers psychologically treated without a history of suicide attempt (58); G3 soldiers control group (50) |
OMMP |
SSI |
Two studies were founded in prisoner populations. Mills et al. (
Assessing the mental pain contribution to suicidality among homeless, a research study of Coohey et al. (
Meaningful results were recently reported by Shelef and Holden (
Intense negative emotions, such as guilt, shame, and hopelessness may become a generalized experience of unbearable mental pain, especially when there is no foreseeable change in the future. Consequently, individuals may seek to escape their “psychache” dying by suicide (
Associations between mental pain and suicidality were found in patients with mood disorders, in other clinical and non-clinical samples. High levels of mental pain may represent a condition of vulnerability to suicidal ideation, suicidal attempts, and suicide acts. When taking the clinical consequences of the research studies analyzing the relationship between psychache and suicide into consideration, the findings revealed the unique value of psychological pain in predicting suicidal behavior (i.e., ideation, attempts, and acts) when controlling for the effects of other variables (i.e., depression, hopelessness, aggression-impulsivity) potentially associated with suicidality (
Recent studies have examined the mediation role of mental pain, finding that this construct mediates both the relationship between self-destruction and suicidal tendency (
Longitudinal studies confirmed the critical role of mental pain in student populations, demonstrating that changes in suicide motivation and preparation were significantly associated with changes in psychache (
By supporting the evidence that psychological pain and its different dimensions (i.e., pain avoidance, emotional pain) play a central role in predicting suicide, the results of this review study could further underline the clinical relevance of psychache in prevention (i.e., early detection) as well as in treatment of suicide. In this regard, mental pain may represent, from a clinical point of view, an important therapeutic target, when considering that diminishing levels of psychache potentially means to decrease the risk of suicidal acts (
In conclusion, several measures have been developed to assess mental pain (
According to recent developments on clinical psychometrics (
Based on this background, it is highly meaningful to clinimetrically evaluate measurement aspects (i.e., construct validity) of the instruments in order to assess psychache in clinical setting.
All authors participated in the concept and writing of this manuscript. All authors approved the final version of the manuscript.
There are no potential conflicts of interest or any financial or personal relationships with other people or organizations that could inappropriately bias conduct and findings of this study.