Depressive Disorder and Suicidal Tendencies: Role of Psychological Pain and Health-Related Quality of Life

Abstract

With over 720,000 people dying by suicide each year and many more attempting it, suicide events have become a significant public health concern. Individuals with depressive disorders are particularly at risk, as suicide is one of the most common preventable causes of death in this group. The aim of this study was to examine the relationship between psychological pain, health-related quality of life, and suicidal tendencies among patients with depressive disorder. The study included 73 patients hospitalized in the psychiatric ward at a University Psychiatric Hospital. To assess the observed variables, a battery of questionnaires was administered, consisting of a sociodemographic questionnaire and validated instruments, including Suicide Screening Questionnaire—Self Rating (SSQ-SR), the 36-Item Short Form Health Survey (SF-36), and the Mee–Bunney Psychological Pain Assessment Scale (MBPPA). A significant association was found between psychological pain, health-related quality of life, and suicidal tendencies. Higher levels of psychological pain and greater impairment in physical, emotional, and social functioning were associated with a higher presence of risk factors for suicide. Psychological pain, emotional well-being, and physical functioning were significant predictors of suicidal tendencies in individuals with depressive disorders. The results of this study emphasize the importance of psychological pain and specific aspects of health-related quality of life in both the prevention and treatment of suicide.

1. Introduction

According to the World Health Organization [1], more than 700,000 people worldwide die by suicide each year, with the number of suicide attempts being up to 20 times higher. Suicide rates in the Republic of Croatia [2] are similar to those in other countries. Data from 2022 indicate that 529 people died by suicide, which is higher than the average rate within the European Union [2].

Mental illness appears to be one of the most consistent precursors to all stages of the suicidal process, from suicidal ideation to suicide attempt and death by suicide [3,4]. While suicidal behavior is associated with borderline personality disorder, substance use disorders, and schizophrenia, it is more common among individuals with affective disorders [3,5,6]. People with depressive disorders are a particularly vulnerable group, with suicide being one of the most common preventable causes of death [7,8]. According to a recent meta-analysis, the global prevalence of suicide attempts in patients with depressive disorders was as high as 31%, with a similar percentage of 27.5% for European countries [8,9]. Additionally, the estimated overall prevalence of suicidal ideation was up to 39%, with approximately 15% for suicidal plans and 53.1% for suicidal thoughts [10,11]. This incidence is somewhat higher among individuals diagnosed with depressive disorder who are hospitalized in psychiatric facilities, with suicidal thoughts reaching up to 66.4% and suicide attempts reaching up to 39.4% [12]. Although findings indicate that a substantial proportion of those who attempt or die by suicide suffer from depression, in most cases, individuals with depression primarily exhibit only suicidal ideation, without progression toward suicidal behavior [13]. This suggests that a diagnosis of depressive disorder alone is insufficient to explain the heterogeneity in suicide risk.

Previous studies, guided by the assumptions of the biopsychosocial model, have emphasized the necessity of conceptualizing suicide risk as the outcome of complex interactions among an individual’s biological, psychological, and social characteristics [14,15]. A family history of mental illnesses and family-related suicidal behavior has proven to be a significant predictor of suicidal events in people with depression [7]. Furthermore, prior self-harm and suicidal attempts are among the most prominent risk factors for suicide ideations and attempts, both in the general and clinical populations [16,17,18]. In the context of underlying risk factors, exposure to various forms of childhood maltreatment, such as sexual and physical abuse, have been associated with specific sub-types of self-injurious thoughts and behaviors [19,20]. Additionally, individuals exposed to emotional abuse and neglect are more likely to report suicidal thoughts and suicidal attempts [21]. However, while childhood traumas and a history of suicidal thoughts and behaviors are significant contributors to suicide risk, they alone are not sufficient predictors of suicidal acts [20,22].

While the relevance of clinical variables in understanding the complex nature of suicidal thoughts and behavior is undeniable, the importance of psychosocial resources and an individual’s health status (psychological well-being and physical and social functioning) as modifiable factors is being increasingly recognized [23,24,25,26]. Negative emotions, such as sadness, burdensomeness, and hopelessness, are associated with an increased risk of suicidal ideation and suicide attempts in patients with depressive disorder [27,28]. Furthermore, increased negative affect significantly predicted the frequency of suicidal thoughts and suicide attempts over a one-month period [29]. These findings align with the three-step theory of suicide, which emphasizes that suicidal ideation emerges in response to hopelessness and pain, whether emotional or physical [30]. Fatigue, insomnia, and changes in appetite are among the most common symptoms of depression and can significantly affect physical health and daily functioning [31,32]. Several studies have shown that individuals with depressive disorder who experience poorer physical health, higher levels of physical pain, and a lower self-reported health status are at an increased risk of suicidal ideation and behavior [33,34]. Furthermore, a significant association was found between difficulties in performing daily activities and increased suicidal ideation [35]. A deterioration in physical functioning, which manifests itself in difficulty performing daily activities such as going to work, performing housework, or maintaining personal hygiene, can contribute to feelings of helplessness, despair, and dependence on others, thereby increasing the risk of suicide among individuals with depressive disorder [36,37,38].

Emotional and/or physical difficulties in individuals with depression can lead to social withdrawal, and these disruptions in social functioning may further heighten the risk of suicidality [24,25,39]. Previous studies have emphasized that reduced social participation and isolation contribute to the development and frequency of suicidal ideation [38,40]. The findings of Fukai et al. [41] indicate that men with a negative social health status are nearly five times more likely to experience suicidal thoughts than those with positive social health status. Therefore, when examining risk factors for suicidal ideation and attempts in people with depression, social functioning should also be considered.

In the context of examining the psychological factors that contribute to suicide risk, the importance of psychological pain is being increasingly recognized [4,42]. Psychological pain, i.e., mental pain or psychache, refers to the perception of negative changes in the self and its functioning, accompanied by intense negative emotions such as guilt, fear, failure, shame, and loneliness [43,44]. Psychological pain, while not a specific symptom of depression, has proven to be one of the most significant risk factors for suicidal ideation in individuals with depressive disorders [45,46]. It can exacerbate the severity of depressive symptoms, impair the ability to carry out daily tasks and responsibilities, and diminish social quality of life [47]. The significance of examining psychological pain is also reflected in theoretical models of suicide, such as Shneidman’s (1993) theory, which emphasizes psychache (i.e., mental or psychological pain) as the key motivator for suicide attempts [44]. Confronted with overwhelming negative emotions and possible limitations in daily functioning, people suffering from psychological pain may see no way out. Their suffering becomes unbearable as it stems from unmet fundamental psychological needs, leading them to perceive suicide as the only option [4,48]. Moreover, it has been established that psychological pain is significantly more intense in individuals who have attempted suicide than in those who have not, even when the level of depressive symptoms is similar between the two groups [47,49]. Despite its relevance, the severity of suicidality cannot be predicted solely by the level of psychological pain. Instead, it may result from the interaction of psychological, social, and biological risk factors (e.g., impaired physical health, difficulties in daily functioning) [49,50].

Given the complex nature of suicidal events and their high prevalence among individuals with depressive disorders, understanding and recognizing modifiable risk factors remains of great importance. Therefore, the present study aimed to investigate the relationship between different domains of health-related quality of life and suicidal tendencies in patients with depressive disorders. In addition, the role of psychological pain as one of the most important psychological risk factors for suicidal thoughts and behavior was examined.

2. Materials and Methods

2.1. Participants and Procedure

The study included 73 patients diagnosed with depressive disorder, of whom 24 (32.9%) were men and 49 (67.1%) were women. Participants were between the ages of 23 and 76 years, with an average age of 44 years (M = 44.55; with standard deviation (SD) = 13.19).

The participants were recruited in person at the psychiatric ward of the University Psychiatric Hospital in Croatia’s Clinic for Affective Disorders, between March and May, 2024. Among approximately 105 patients present at the Clinic during the study period, 16 were being treated for a psychotic disorder or personality disorder, 13 had a primary diagnosis of an anxiety disorder with depressive components, and 3 declined to participate in the study. The remaining patients were diagnosed with a primary depressive disorder. Only those with an official diagnosis of depressive disorder were included in the study. The diagnosis was made by a psychiatrist at the Clinic where the study was conducted. Additionally, a validated instrument, the Patient Health Questionnaire-9 (PHQ-9), was used to assess the severity of the depressive disorder. Approximately 85% of participants scored above 10, which is regarded as the cut-off value for major depressive disorder [51]. To obtain a homogeneous sample, we did not include patients with specific psychotic disorders that could manifest with depressive symptoms during participant recruitment. Before completing the questionnaire, each participant provided written informed consent, confirming their understanding of the study’s purpose and procedures, along with their right to withdraw from the research at any time. Participation was entirely voluntary, and no monetary compensation was offered to the participants.

2.2. Instruments

Participants completed a battery of questionnaires, which included a sociodemographic questionnaire and validated measures for assessing suicidal tendencies, psychological pain, and health-related quality of life.

Sociodemographic questionnaire: A structured questionnaire was used to gather sociodemographic information from participants, such as age, gender, and marital/relationship status. Additionally, clinical information regarding the participants’ personal and family history of mental health problems was also collected, as well as previous tendencies towards suicidal behavior.

Suicide Screening Questionnaire—Self Rating (SSQ-SR [52]). The SSQ-SR is a validated instrument that measures various suicide risk factors and events. The first 20 items focus on the presence of stressful life events, social isolation, and negative mood, with participants responding on a 4-point scale (from 1—very untrue to 4—very true). The last 5 items examine the presence and timeframe of suicidal plans and behaviors, rated with 4-point scale (1—never, 2—more than 12 months ago, 3—2 to 12 months ago, to 4—within the past month). The total score is calculated as a linear combination of responses, and it ranges from 25 to 100. Considering the content of the items, in addition to the total score, it is possible to form results on two subscales: Mental Health and Environmental Factors (the first 20 items) and Active Suicidal Thoughts and Behaviors (the last 5 items). SSQ-SR demonstrated strong internal consistency (α = 0.96) and good concurrent validity in previous studies [52]. The Cronbach alpha for the current study (α = 0.86) also points to good reliability.

The 36-Item Short-Form Health Survey questionnaire (SF-36 [53]). The SF-36 is a widely used self-reported measure of health-related quality of life. The questionnaire consists of 36 items grouped into eight subscales that reflect different domains of life: (1) physical functioning (PF), (2) bodily pain (BP), (3) role limitations due to physical health problems (PHL), (4) role limitations due to personal or emotional problems (EHL), (5) emotional well-being (EWB), (6) social functioning (SF), (7) energy/fatigue (F), and (8) general health perceptions (GH). Responses for each item were transformed to fit a 0–100 range, with 0 being the lowest score and 100 being the highest score. The total score on the subscales is calculated as the average value of transformed responses, with a higher score indicating a better health status. The subscales show good internal consistency with Cronbach’s alpha above 0.78 [53] and above α = 0.89 in this study.

Mee–Bunney Psychological Pain Assessment Scale (MBPPAS [54]). The Mee–Bunney Psychological Pain Scale is a 10-item self-reported scale that measures the intensity and frequency of psychological pain during the last three months. Participants rate the statements on a 5-point scale. The total score on each subscale is calculated as a linear combination of responses, with a higher score indicating higher levels of psychological pain. The scale shows good internal consistency in studies that observed depressive patients with Cronbach’s alpha above 0.75 [54,55]. The scale’s reliability in this study, as measured by the Cronbach alpha coefficient, is 0.84.

2.3. Data Analysis

The data were analyzed using the IBM SPSS Statistics program (version 26). Before conducting the statistical analysis, the data were examined for outliers. Based on the z-score method, the data of three participants were excluded from further analysis, as their values exceeded three or more standard deviations from the mean for validated measures of health-related quality of life (above 3.5 SD). Given that some variables deviated from a normal distribution, to which the z-score is sensitive, Tukey’s method was additionally applied, confirming the presence of these three outliers [56]. Significance was set at p < 0.05.

The Kolmogorov–Smirnov normality test identified deviations from the normality of distribution, which were somewhat expected considering that data were collected from a clinical sample. Descriptive statistics were conducted to determine the mean and standard deviations for observed continuous variables. For variables with asymmetric distributions, both the mean and median values are reported. Categorical sociodemographic and clinical variables, such as previous suicide attempts, are presented as frequencies.

Pearson’s r correlation analysis was used to determine the relationship between psychological pain, health-related quality of life, and suicidal tendencies. To examine the contribution of psychological pain and satisfaction with certain domains of life (physical, social, and emotional functioning) in the prediction of suicidal tendencies in patients with depressive disorder, hierarchical regression analysis was carried out. To determine whether hierarchical regression analysis was suitable for our data, indicators of multicollinearity and Mahalanobis and Cook distances were calculated.

2.4. Ethical Aspects

The study was approved by the Ethics Committee at the University of Zagreb Faculty of Croatian Studies (protocol code: 640-16/23-2/0001). Ethical approval was also obtained from the Ethics Committee of the University Psychiatric Hospital, where the research was conducted (protocol code: 01-856/24-4).

3. Results

This study included 73 patients from the Clinic for Affective Disorders. The majority were either married (39.7%) or in a romantic relationship (31.5%). Approximately 29% (N = 21) reported having a family member with a mental illness, most commonly a parent (80.9%). Furthermore, 17.8% (N = 13) of participants indicated that a family member had attempted suicide, with 38.5% (N = 5) of these attempts resulting in fatal outcomes. Regarding pharmacotherapy, 87% of participants were treated with SSRIs (such as Fluoxetine), while 13% were treated with SNRIs (such as Venlafaxine). Additional sample characteristics are presented in

Table 1. Sociodemographic characteristics of the participants (N = 73).

		N (%)
Relationship status	Married	29 (39.7)
	Co-habiting/unmarried	23 (31.5)
	Divorced	15 (20.6)
	Widow	6 (8.2)
Suicide attempt	Within the last month	1 (1.4)
	Within the last year	8 (11.0)
	More than a year ago	12 (16.4)
	No	52 (71.2)
Mental illness in family	Yes	21 (28.8)
	No	52 (71.2)
Suicide attempt in family	Yes—fatal	5 (6.8)
	Yes—non-fatal	8 (11.0)
	No	60 (82.2)

.

Table 2. Descriptive statistics for observed variables (N = 70).

	M (C)	SD	Min	Max	K-S
Physical functioning	68.79 (70)	21.55	5	100	0.113 *
Emotional well-being	41.89	14.19	8	72	0.09
Social functioning	39.29	20.33	0	87.5	0.17 **
Role limitations—physical health	26.07 (0.0)	35.9	0	100	0.29 **
Role limitations—emotional problems	1.9 (0.0)	7.8	0	33.3	0.54 **
Bodily pain	47.75	24.97	10	100	0.14 **
Fatigue	31.86	17.76	0	65	0.12 *
General health	41.79	13.93	15	80	0.12 *
Psychological pain	31.16	5.7	20	45	0.08
Suicidal tendencies	52.64	10.16	30	81	0.08
Mental health and environmental factors	43.67	8.05	24	60	0.07
Suicidal thoughts and behaviors subscale	8.97 (8.0)	3.52	6	23	0.19 **

* p < 0.05; ** p < 0.01; M, mean; C, median; SD, standard deviation; K-S, Kolmogorov–Smirnov statistics.

displays descriptive statistics for the observed variables, including the subscales of the health-related quality of life measure (SF-36), psychological pain, and suicidal events measure. When observing the average values on SF-36 subscales, it is noticeable that the participants achieved the lowest scores in the emotional and social domains. This indicates a greater presence of negative emotions, such as sadness and agitation, as well as more frequent difficulties in participating in social activities due to impaired physical health or emotional problems. There are also certain limitations in physical functioning, as participants reported moderate difficulties in carrying out daily activities, such as climbing stairs or completing household chores. In addition, they expressed slightly lower satisfaction with their general physical health and experienced moderate levels of physical pain. Lower values are also observed on the fatigue subscale, indicating the greater presence of exhaustion and a lack of energy. Participants in this study reported a moderate level of psychological pain, with similar values found in previous research involving individuals with major depressive disorder (MDD) [55,57]. A moderate level of suicidal tendencies is also evident among participants in this study. Observing the values on individual subscales of SSQ-SR, participants reported a moderate presence of mental health problems and environmental factors that are considered risk factors for suicide. Suicidal plans and attempts are less pronounced, which may be attributed to the specific characteristics of the sample.

To determine the association between psychological pain, health-related quality of life, and suicidal tendencies, Pearson’s correlation analysis was conducted (

Table 3. Correlation analysis of the observed variables (N = 70).

	1	2	3	4	5	6	7	8	9	10	11
Suicidal tendencies (1)	-
Mental health and environmental factors (2)	0.95 **
Suicidal thoughts and behaviors (3)	0.71 **	0.46 **
Psychologicalpain (4)	0.52 **	0.58 **	0.17
Physical functioning (5)	−0.23 *	−0.25 *	−0.22	−0.22
Emotional well-being (6)	−0.61 **	−0.68 **	−0.23	−0.46 **	0.02
Social functioning (7)	−0.35 **	−0.38 **	−0.15	−0.39 **	0.04	0.42 **
Role limitations—physical health (8)	−0.19	−0.27 *	0.06	−0.24 *	0.43 **	0.18	0.15
Role limitations—emotional problems (9)	0.09	0.04	0.18	−0.21	−0.13	0.11	0.25 *	−0.01
Bodily pain (10)	−0.16	−0.15	−0.13	−0.31 *	0.52 **	−0.14	0.17	0.27 *	−0.02
Fatigue (11)	−0.58 **	−0.65 **	−0.19	−0.63 **	0.19	0.61 **	0.49 **	0.38 **	0.18	0.27 *
General health (12)	−0.32 **	−0.38 **	−0.06	−0.31 **	0.32 **	0.32 **	0.14	0.48 **	−0.12	0.12	0.41 **

* p < 0.05; ** p < 0.01.

). A significant negative correlation was found between certain aspects of health-related quality of life and suicidal tendencies, indicating that participants who report greater difficulties in social functioning and impaired emotional well-being tend to score higher on measures of suicidal risk and events, particularly on the Mental Health and Environmental Factors subscale. There was also a significant correlation between higher levels of fatigue and increased limitations in daily activities and an elevated risk of suicidal attempts. Moreover, participants who assessed their overall health as worse in comparison to others had higher scores for the suicidality measure. The active suicidal thoughts and behaviors subscale was not significantly associated with the other variables observed in the study, which may be due to the limited variability and low scores within the sample. Additionally, a significant moderate correlation was found between psychological pain and suicidal tendencies, indicating that participants experiencing greater psychological pain tended to score higher on the measure of suicidal tendencies and associated risk factors. A significant correlation was also observed between psychological pain and certain aspects of health-related quality of life, with higher levels of perceived psychological pain associated with greater fatigue and difficulties in social and emotional functioning, as well as impaired overall health.

In order to examine the contribution of psychological pain and health-related quality of life (SF-36) in explaining suicidal tendencies, hierarchical regression analysis was conducted. To confirm the suitability of conducting this analysis on our data, multicollinearity indicators, i.e., Variance Inflation Factor (VIF) and Tolerance, were calculated. Considering that the values of these indicators did not exceed critical thresholds (VIF < 10; Tolerance > 0.2), no violations of the multicollinearity assumption were identified. Furthermore, Cook distance values below 1 and Mahalanobis distance values under 15 suggest the absence of multivariate outliers in the analyzed data [58].

The first block included psychological pain, and the second block contained certain aspects of health-related quality of life, i.e., emotional well-being, social functioning, physical functioning, and general health perception. The regression analysis showed statistical significance for both blocks of predictors (FModel1 = 24.57; p < 0.001; FModel2 = 7.03; p < 0.001). All predictors included in the analysis explained 49% (R2adj = 45%; p < 0.001) of the variance in suicidal tendencies, with the first block (psychological pain) explaining 26.5% of the variance (R2adj = 25.5%; p < 0.001). Of the domains of health-related quality of life, satisfaction with emotional well-being was the most significant factor in explaining suicidal tendencies. Physical functioning was also found to be a significant predictor (

Table 4. Hierarchical regression analysis predicting suicidal tendencies in depressed patients (N = 70).

	Model 1		Model 2
	β	t	β	t
Psychological pain	0.515 **	4.96	0.22 *	2.05
Emotional well-being	-	-	−0.48 **	−4.37
Social functioning	-	-	−0.05	−0.51
Physical functioning	-	-	−0.21 *	−2.12
General health	-	-	−0.03	−0.28
R	0.515 **		0.7 **
R2	0.265 **		0.49 **
R2adj.	0.255 **		0.45 **

* p < 0.05; ** p < 0.01; β (beta) = standardized coefficient; t = t-statistic.

).

4. Discussion

The findings of this study confirm a significant relationship between suicidal tendencies and specific aspects of health-related quality of life, particularly emotional well-being and physical functioning. A significant association was also found between psychological pain, i.e., intense negative emotions and changes in the self and its functioning, and suicidal tendencies.

Observing the measure of suicidality, participants in this study exhibited a moderate level of suicidal tendencies. This is particularly evident in the aspect of mental difficulties and environmental factors, such as exposure to violence and recurring failures in different aspects of life, as potential stressors for suicidality. The obtained values are consistent with a previous study conducted on clinical samples [52]. Participants, most of whom had an MDD diagnosis, exhibited a moderate level of psychological distress and environmental risk factors, along with a relatively low presence of active suicidal thoughts and behaviors [52]. The findings regarding lower scores on the Active Suicidal Thoughts and Behaviors subscale align with the results of this study, indicating a reduced occurrence of recent suicide plans and attempts among patients with depressive disorder. It is important to note that the sample of this study included only individuals with depressive disorders who were hospitalized in a psychiatric hospital, where they were likely to receive ongoing support and therapy as part of their treatment. Additionally, more than two-thirds of participants reported that they had never attempted suicide. Among participants who had attempted suicide at some point in their lives, only 12% had done so within the past year (N = 9). In this study, participants reported, on average, a moderate frequency and intensity of psychological pain (i.e., psychache), which aligns with findings from previous research conducted on patients with MDD [57]. Moderate levels of psychological pain were also observed among outpatients with MDD recruited from psychiatric clinics, with more than half of the participants reporting high levels of psychological pain [55].

Consistent with previous findings, a significant relationship has been established between psychological pain and suicidal tendencies. Higher levels of experienced psychological pain were associated with a greater frequency of suicidal ideation in patients with MDD [45,46,57,59]. This relationship remained significant even after controlling the severity of depressive symptomatology [60]. Depressed patients with suicidal ideation or those who have recently attempted suicide reported higher levels of psychological pain compared to nonsuicidal depressed patients who did not exhibit significant suicidal tendencies [61]. The importance of psychological pain in the context of suicide is further supported by evidence of its various dimensions, such as loss of control and emptiness, in case reports of individuals who died by euthanasia or assisted suicide [62]. Consistent with prior research, psychological pain was a significant predictor of suicidal tendencies among patients with depressive disorder included in this study. As psychological pain increases and becomes unbearable, the severity of depressive symptoms and suicidal ideation increases [46,63]. Patients that reported higher levels of psychological pain were more likely to report suicide events and suicide attempts at their 6-month follow-up [64]. In addition, participants in this study who reported higher levels of psychological pain had greater difficulties in social functioning, lower levels of energy, and impaired emotional well-being.

When observing the relationship between certain aspects of health-related quality of life and suicidal tendencies, the significant role of emotional well-being becomes apparent. A higher presence of negative emotions, such as moodiness, sadness, and agitation, was significantly associated with an increased suicidal tendency. Furthermore, emotional well-being proved to be the strongest predictor of suicidal tendencies among depressive patients included in this study. These results are in line with previous research that found a significant association between the level of sadness and suicidal thoughts [27]. Follow-up studies indicate that higher levels of agitation predict the frequency of suicidal thoughts over a four-week period [29]. The experience of overwhelming negative emotions was a recurring theme in the case records of patients who died by assisted suicide [62].

Previous studies on individuals with depressive disorders emphasize that impaired physical health serves as an additional risk factor for suicidality [65]. Findings from a large cohort of patients with MDD indicate that more severe somatic symptoms, such as physical pain and fatigue, are associated with a higher risk of suicidal ideation, suicide plans, and suicide attempts [12]. Depressed individuals who report poorer physical health and greater difficulties in performing daily activities, such as dressing and maintaining hygiene, exhibit a higher prevalence of suicidal ideation [66]. A significant relationship between physical functioning, fatigue, limitations in performing certain activities, and suicidal tendencies was observed in the participants of this study. In contrast to previous research [12,67], no significant relationship was found between physical pain and suicidal tendencies. Similarly to our findings, Pérez-Balaguer et al. [68] established that psychological pain was significantly associated with an increased risk of suicidal events, while no statistically significant associations were observed for varying intensities of physical pain [69]. Although the link between physical comorbidities and somatic symptoms, particularly pain, and an increased risk of suicidality is largely supported, the mechanisms underlying this relationship remain unclear. Racine [70] emphasizes that pain is often conceptualized in a one-dimensional manner, without accounting for factors such as its type, location, and duration. The lack of association between pain and suicidal thoughts and behaviors may be attributed to the increased pain tolerance among individuals who self-harm [28]. Furthermore, the increased risk of suicidal events among individuals experiencing pain may be due to its association with feelings of helplessness, burdensomeness, and a lack of belonging, which are strong predictors of suicidal behaviors, especially among individuals with depressive disorder [28]. The absence of a significant association between suicidal tendencies and physical pain in this study may be due to the characteristics of the sample, particularly the presence of certain physical comorbidities that were not examined. Furthermore, the study involved hospitalized patients receiving treatment, suggesting they likely had access to appropriate pharmacological therapy aimed at alleviating certain symptoms of depressive disorders, including pain.

There are some limitations of this study that should be considered when interpreting the findings. Due to the cross-sectional design, it was not possible to establish causal relationships between suicidality and other variables, such as psychological pain and health-related quality of life (QOL). Although the study was conducted in a specific clinical population, it is important to note that the results were obtained from a relatively small sample size, within a single public psychiatric hospital, specifically, the Clinic for Affective Disorders, which may, to some extent, impact the validity of the findings. Additionally, this study focused on patients who were hospitalized, meaning that the findings cannot be generalized to individuals with depressive disorders who are less clinically stable or in remission. It would be valuable to examine a group of individuals with depressive disorders attending daily hospitals, where they continue to receive support while being further integrated into society. To gain a more comprehensive understanding of health status as a risk factor for suicidal ideation and behavior, future studies should consider the presence and duration of physical comorbidities, the experience of somatic pain, and pain tolerance. Additional research is needed to explore the relationship between specific clinical variables, such as the type of depressive disorder, length of psychiatric hospitalization, duration of illness, and pharmacotherapy, and the observed psychosocial factors and suicidal tendencies in individuals with depressive disorders. Future research would also benefit from considering certain sociodemographic variables, such as educational level, personal income, and living conditions.

Despite these limitations, this research builds on previous studies by examining the role of specific risk factors in predicting suicidal tendencies in individuals with depressive disorders.

5. Conclusions

Given the high prevalence and recurrent rates of suicidal thoughts, plans, and behaviors in individuals with depressive disorders, identifying risk factors has become important in clinical practice and suicide interventions. The results of this study emphasize the importance of certain psychosocial variables and physical functioning in the treatment of individuals at risk for suicide thoughts and behavior. Improving the physical functionality of individuals with depressive disorders could help reduce feelings of burdensomeness and dependence on others, which may subsequently lower the risk for suicide events. Clinicians should consider the level of experienced psychological pain when assessing individuals with mental health difficulties, particularly in the context of evaluating suicide risk. Interventions that focus on emotion regulation may improve patients’ emotional well-being and help them cope more effectively with psychological pain, thereby reducing the risk of suicidal ideation and behavior in patients with depressive disorders after discharge from a psychiatric hospital.