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International Journal of Nursing Studies Advances logoLink to International Journal of Nursing Studies Advances
. 2025 Apr 8;8:100325. doi: 10.1016/j.ijnsa.2025.100325

Psychological distress and suicidal ideation in patients with depressive disorders: the chain mediation of psychological resilience and neuroticism

Xueqing Wang a, Huafang Li a,b,⁎
PMCID: PMC12018043  PMID: 40276211

Highlights

  • •

    Suicidal ideation is an important part of the suicidal behavior of patients with depression.

  • •

    The relationship between psychological distress and suicidal ideation in depressed patients is mediated by psychological resilience.

  • •

    The relationship between psychological distress and suicidal ideation in depressed patients is mediated by neuroticism.

  • •

    Psychological resilience and neuroticism mediate the relationship between psychological distress and suicidal ideation in depressed patients.

Keywords: Psychological distress, Suicidal ideation, Psychological resilience, Neuroticism, Chain mediation, Depression

Abstract

Objective

Suicide in depressed patients has become a serious challenge in the field of public health. In-depth analyses of the relationship between psychological distress and suicidal ideation, as well as its intrinsic mechanisms, are of great clinical significance for the prevention of suicide in depressed patients. The objective of this study was twofold: firstly, to explore the intrinsic relationship between psychological distress and suicidal ideation in depth; and secondly, to further investigate the mediating roles of psychological resilience and neuroticism in this relationship.

Methods

In this study, a cross-sectional research design was employed to select 200 patients diagnosed with depression from a mental health centre in Shandong Province. This study utilised the abbreviated version of the Big Five Personality Inventory, the Simplified Scale of Psychological Resilience, the Suicidal Ideation Scale, and the Kessler Psychological Distress Scale to administer questionnaires to patients.

Results

Psychological distress has a direct predictive effect on suicidal ideation. In depressed patients, it also exerts an indirect effect on suicidal ideation via three pathways: the separate mediating effect of psychological resilience, the separate mediating effect of neuroticism, and the chain mediating effect of psychological resilience and neuroticism.

Conclusion

In conclusion, the results of this study elucidate the effect of psychological distress on suicidal ideation in depressed patients and its mechanism of action. Furthermore, they demonstrate the chain-mediated roles of psychological resilience and neuroticism in the relationship between psychological distress and suicidal ideation in depressed patients. Finally, they provide a new perspective for understanding suicidal ideation and preventing suicidal risk in depressed patients. Nevertheless, the present study was only able to measure the correlation between the variables; therefore, it is not yet possible to infer causality. In future, more precise prediction and intervention programmes for suicide risk in depressed patients can be explored in depth through longitudinal or experimental studies, etc.

1. Introduction

As indicated by the World Health Organization (2023), suicide has emerged as the fourth leading cause of mortality among individuals aged 15 to 29. Globally, approximately 700 thousand individuals die by suicide each year. Suicidal ideation represents a thought process in which an individual contemplates ending their own life, yet does not act upon it. It serves as a crucial precursor to suicidal behavior (Timpka et al., 2021). A cross-sectional study was conducted in the psychiatric department of a hospital in Lishui City (Chen and Shi, 2024), China, assessing in which 112 patients diagnosed with depression were assessed for suicidal ideation. The results revealed that 54.46 % of the patients reported experiencing suicidal ideation. Liu et al. (2024) conducted a questionnaire survey of 173 adolescents with depression who were admitted to a hospital in Henan Province. The findings indicated that all of the adolescent patients with depression in the sample exhibited moderate suicidal ideation. A cross-sectional survey of students from three medical schools in a foreign country found that 57.98 % of the 238 students who reported depression exhibited suicidal ideation (Pitanupong et al., 2024). Suicidal ideation is a common clinical manifestation in patients with depression and is often indicative of more serious clinical outcomes (Liu et al., 2023). Depressed patients with suicidal ideation have a poor response to antidepressant treatment and a long treatment duration, which imposes a significant burden on society and families (Szanto et al., 2003). Statistical evidence indicates that approximately 80 % of individuals who have died by suicide have previously expressed suicidal thoughts or intentions in one or more ways before taking suicidal action (Xiao, 2001). Consequently, the advent of suicidal ideation can have a markedly deleterious effect on patients suffering from depression, even in the absence of suicidal behavior. The high prevalence of suicidal ideation among patients with depression, and the subsequent adverse outcomes, pose a significant public health concern, necessitating prompt attention and effective interventions from all sectors of society.

The extant research on suicidal ideation primarily concentrates on the dimensions of negative life events, family environment, and individual psychological experience, and investigates their role in the genesis of suicidal ideation (Hu et al., 2023; Wu and Zhang, 2022). However, there is a paucity of studies that have delved deeply into the role of individual psychological distress in the developmental trajectory of suicidal ideation. Psychological distress can be defined as an adverse emotional state exhibited by an individual under the influence of multiple factors, including psychological, social, or spiritual dimensions (Arvidsdotter et al., 2016). It encompasses a range of symptoms associated with mental disorders, such as depression, anxiety, and stress, as well as somatic symptoms, including insomnia, headaches, and cognitive impairment (Zhu et al., 2022). The motivation-will integration model of suicide, as proposed in O'Connor et al. (2011), suggests that an individual's suicidal motivation may be influenced by the psychological distress they experience in their surrounding environment. This model further proposes that suicidal ideation may arise when an individual's psychological distress reaches a critical level, rendering them unable to cope effectively. The mediating effect of psychological distress between somatic multimorbidity and suicidal ideation in older adults was also demonstrated. Specifically, psychological distress was identified as a significant positive predictor of suicidal ideation in older adults (Jing et al., 2021). DeVylder et al. (2020) observed that in patients presenting with psychotic experiences, psychological distress was significantly associated with an increase in suicidal ideation. It is therefore imperative that further investigation be conducted into the relationship between psychological distress and suicidal ideation in depressed patients, with the aim of reducing and preventing suicidal ideation in this patient group.

The American Psychological Association defines psychological resilience, also known as resilience and toughness, as the process by which an individual adapts effectively and moderates well in the face of adversity, trauma, tragedy, threat, or other stress (Huang et al., 2014; Kutluturkan et al., 2016). Individuals who possess high psychological resilience are better equipped to adapt to and recover from challenging circumstances in a more efficient manner. They are also more likely to identify effective solutions and sustain a favorable state of psychological well-being. In their longitudinal study of predictors of psychological resilience, Wu et al. (2017) identified psychological distress as a risk factor for psychological resilience. In particular, the study found that the level of psychological resilience is significantly diminished when an individual is in a prolonged state of poor mood, due to multiple factors. Furthermore, psychological resilience significantly and negatively predicts suicidal ideation in depressed patients, and its high level state can effectively reduce suicidal ideation (Li et al., 2024).

Neuroticism is a personality trait characterised by the experience of negative emotions (Widiger and Oltmanns, 2017). It is a condition in which individuals are prone to adverse emotional reactions, including anxiety, depression and hostility in the face of stress. Furthermore, they exhibit emotional instability and low self-esteem (Vidal-Arenas et al., 2022). This reflects an individual's sensitivity to stress and the stability of their emotional regulation. It is an important predictor of depressive symptoms (Cloninger et al., 2006). Individuals exhibiting high levels of neuroticism tend to experience a greater prevalence of depressive moods, which in turn exacerbate depressive symptoms (Karreman et al., 2013) and significantly elevate the level of psychological distress observed in patients (Yusoff et al., 2021). Psychological distress has been demonstrated to positively predict neuroticism in critical care nurses. Those with high neuroticism, including emotional sensitivity, poor self-control, and introversion, are particularly prone to psychological distress (Yu et al., 2019). Additionally, high neuroticism is regarded as a potential risk factor for suicidal ideation in individuals with depressive disorders, with empirical evidence indicating a positive predictive association between the two (Gramstad et al., 2013).

The extant literature indicates that neuroticism is a significant predictor of psychological resilience. Individuals with high neuroticism are more likely to experience negative emotions, which impede the development of psychological resilience. Consequently, such patients exhibit significantly lower levels of psychological resilience than individuals with low neuroticism. Neuroticism has been identified as a negative predictor of psychological resilience (Kalisch et al., 2015) . Depressed patients with low psychological resilience are unable to effectively regulate their emotions and are more susceptible to experiencing negative emotions such as anxiety and depression. Such emotional states can also serve to exacerbate the manifestation of neuroticism. Accordingly, psychological resilience and neuroticism were incorporated into the same model from the perspective of individuals’ coping abilities and personality traits, respectively, with a view to exploring how psychological distress affects suicidal ideation by influencing the direction of the relationship between psychological resilience and neuroticism.

In order to further examine the interrelationships and intrinsic linkages among the four variables, the following hypotheses were formulated in this study:

  • 1: Psychological distress positively predicts suicidal ideation in depressed patients.

  • 2: Psychological resilience mediates the relationship between psychological distress and suicidal ideation in depressed patients.

  • 3: Neuroticism acts as a mediator between psychological distress and suicidal ideation in individuals with depressive disorders.

  • 4: Psychological resilience and neuroticism act as chain mediators in the relationship between psychological distress and suicidal ideation in depressed patients.

2. Research methods

2.1. Participants

2.1.1. Inclusion criteria

The study's inclusion criteria include: 1) Patients diagnosed with depression according to the International Classification of Diseases, 10th Edition (ICD-10) and meeting the diagnostic criteria for depressive episodes. 2) Subjects capable of independently completing questionnaires and communicating effectively. 3) Participants aged between 12 and 60 years. 4) Patients who have been fully informed of the study details and provided written consent.

2.1.2. Exclusion criteria

Patients will be excluded if they: 1) Have comorbid mental retardation, alcohol or other psychoactive substance abuse disorders. 2) Suffer from other serious physical diseases affecting the heart, liver, kidneys, etc., or organic brain diseases. 3) Have undergone a significant life event (e.g. the death of a loved one, a serious accident, etc.) within the six months before the study started. 4) Have undergone a psychotherapeutic or pharmacological intervention that is not in accordance with the standardised protocols within three months prior to study entry.

The diagnosis of depressed patients participating in this study was made by a team of psychiatrists from a mental health centre in Shandong province. Members of the team have considerable clinical experience and are familiar with the diagnostic criteria for depressive episodes in the International Classification of Diseases, 10th edition (ICD-10).The diagnostic process was based on a combination of structured interviews and clinical assessment. For cases where the diagnostic results were uncertain, an expert consultation was organised to ensure the accuracy of the results. At the time of participation in the study, all patients were receiving antidepressant medication and were in remission.

This study was reviewed and approved by the Ethics Committee of Shandong Mental Health Center. Informed consent for this study was obtained from all participants and their legal guardians.

2.1.3. Procedure

In this study, a convenience sampling method was employed to distribute questionnaires to 200 patients diagnosed with depression who were hospitalised in a mental health center in Shandong Province and met the inclusion criteria. To guarantee the precision and dependability of the data gathered, the returned questionnaires were subjected to rigorous screening and cleaning procedures. The logic of the relevant questions in the questionnaire was evaluated, and responses were classified as “random” if they were contradictory, lacked logical coherence, or showed little variability in their patterns. A questionnaire was deemed incomplete if >10 % of the total number of questions were absent or if three consecutive questions were unanswered. Questionnaires that exhibited random responses or lacked sufficient data were excluded from the study. Ultimately, 153 valid questionnaires (76.5 % of the total number distributed) were obtained.

2.2. Measurement

2.2.1. General demographic information

The researcher devised the instrument independently, according to the objectives of the study, taking into account variables such as gender, age, education, occupation and number of hospital admissions.

2.2.2. Neuroticism

In this study, a simplified version of the Big Five Personality Scale developed by John et al. (1991) was employed, comprising five dimensions: neuroticism, extraversion, openness, conscientiousness, and agreeableness, with a total of 44 items. The scale is rated on a five-point Likert scale, with patients assigned a score from one to five according to the degree of conformity with the description of each item in each question, ranging from strongly disagree to strongly agree. Zhou Jie's study (Zhou, 2010) has demonstrated that the Big Five personality scale exhibits satisfactory construct validity in the assessment of personality traits. The Cronbach's alpha coefficient for the scale in this study was 0.781.

2.2.3. Suicidal ideation

In this study, we employed the Self-rating Idea of Suicide Scale (SIOSS), a tool developed by Xia et al. (2002), which encompasses four dimensions: despair (items 2, 3, 4, 8, 11, 14, 16, 17, 19, 20, 23, and 26), optimism (items 1, 7, 10, 21, and 22), masking (items 6, 9, 13, 15, and 25), and sleep (items 5, 12, 18, and 24), with a total of 26 items. A score of 1 was assigned to a “yes” response and 0 to a “no” response for each item. The total score for suicidal ideation was calculated by adding the scores for the despair, optimism, and sleep dimensions (range: 0–21). A score of 12 was used as the threshold for initial screening of suicidal ideation. A subject was classified as having suicidal ideation if the total score was ≥12, and as not having suicidal ideation if the score was <12. The Cronbach's alpha coefficient for the SIOSS scale in this study was 0.574.

2.2.4. Psychological resilience

In this study, the simplified version of the Connor-Davidson Resilience Scale (CD-RISC), as revised by Wang et al. (2010), was employed for the purpose of quantitatively assessing the level of psychological resilience among patients suffering from depression. The scale is unidimensional, comprising 10 items. A five-point Likert scale, ranging from 0 (never) to 4 (almost always), with the total score being the sum of the scores for each item. A higher total score indicates a higher level of psychological resilience. The Cronbach's alpha coefficient for the scale employed in this study was 0.847.

2.2.5. Depressive disorders

This study employed the Chinese version of the Kessler Psychological Distress Scale, originally developed by Kessler et al. (2002) and subsequently revised by Xu et al. (2005). The scale comprises 10 items, rated on a five-point scale ranging from 1 (almost never) to 5 (almost always). Total scores are calculated by summing the scores for each item, resulting in a total score ranging from 10 to 50. Total scores are used to classify mental health status into four categories: 10–15 points indicate good mental health, 16–21 points indicate average mental health, 22–29 points indicate poor mental health, and 30–50 points indicate very poor mental health. The Cronbach's alpha coefficient for the scale employed in this study was 0.911.

2.3. Statistical analyses

In this study, the statistical software SPSS 25.0 was employed for the descriptive statistical analysis of the data, with the mean ± standard deviation, and for the common method bias test. Furthermore, the Spearman's rank correlation analysis was used to explore the correlation between psychological distress, psychological resilience, neuroticism, and suicidal ideation. A chain mediation model was constructed with psychological distress as the independent variable X, psychological resilience and neuroticism as the mediator variables M1 and M2, respectively, and suicidal ideation as the dependent variable Y. The model is based on a chain mediation model with psychological resilience and neuroticism as the mediator variables. The chained mediation effect of the model was tested using the SPSS macro program PROCESS, prepared by Hayes. Based on the Bootstrap method (Bolin and Hayes, 2014), 95 % confidence intervals were calculated for 5000 repetitive samples, and significance tests for chained mediation effects were performed. A statistically significant result was deemed to be one where p < 0.05 or a bootstrap 95 % confidence interval that did not contain 0 was observed. In order to ascertain the adequacy of the sample size for this study, power analysis was conducted. The sample size was calculated using PASS 2021 software within the framework of multiple regression analysis, with the significance level (α) set at 0.05, the test efficacy set at 0.8, and the total number of samples to be recruited, assuming a 20 % dropout rate, calculated to be 92. The actual sample size of this study was 153, which was significantly higher than the calculated sample size to be recruited, and it was able to provide sufficient data to support the study and to ensure that the results of the present study had a high degree of reliability and stability.

3. Result

3.1. Basic characteristics of the research subjects

A total of 153 study participants were included in this study, of whom 70 (45.8 %) were males and 83 (54.2 %) were females. The age distribution ranged from 14 to 60 years, with a mean age of 31.06(SD = 13.808) years. The age distribution of the participants was as follows: 37.3 % were in the 14–20 age group, 19 % were in the 21–30 age group, 15 % were in the 31–40 age group, and 28.8 % were in the 40–60 age group. With regard to occupational composition, the participants could be classified as follows: 20.9 % were students, 37.3 % were employees, and 41.8 % were in other occupational categories. Please refer to Table 1 for further details.

Table 1.

General patient information.

Entry Item Frequency Percentage (%)
Gender Male 70 45.8
Female 83 54.2
Age (years) 14–20 57 37.3
21∼30 29 19
31∼40 23 15
40–60 44 28.8
Educational level High school and below 125 81.7
University 22 14.4
Postgraduate and above 6 3.9
Occupation Student 32 20.9
Employee 57 37.3
Other 64 41.8
Number of hospitalisations One time 117 76.5
Twice 18 11.8
Three times and above 18 11.8
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3.2. Common method bias test

To guarantee the precision and reliability of the findings, the Harman single factor method was employed in this study to assess the data for common method bias (Zhou and Long, 2004). A total of 18 characteristic factors exceeding 1 were extracted, and the variance explained by the largest common factor was 19.89 %, which was considerably below the critical value of 40 %. The results demonstrated the absence of a significant common method bias in the dataset under examination.

3.3. Descriptive statistics and correlation analysis of variables

In this study, the variables were subjected to correlation analysis, and the results are presented in Table 2. The results of the correlation analyses indicated that there was a significant positive correlation between psychological distress, neuroticism, and suicidal ideation. Furthermore, psychological resilience was significantly negatively correlated with neuroticism and suicidal ideation, while neuroticism was significantly positively correlated with suicidal ideation.

Table 2.

Means, standard deviations, and analysis of related variables(N = 153).

Variable M±SD Analysis of related
PD PR N SI
PD 29.50±8.08 1
PR 17.79±6.25 -0.414** 1
N 27.59±5.87 0.424** -0.584** 1
SI 15.81±2.66 0.495** -0.530** 0.541** 1
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Notes: *P < 0.05, **P < 0.01, ***P < 0.001. PD=Psychological distress; PR= Psychological resilience; N= Neuroticism; SI= Suicidal ideation.

3.4. Analysis of the mediating effect of psychological resilience and neuroticism

In order to gain a deeper understanding of the mechanisms underlying psychological resilience and neuroticism in the relationship between psychological distress and suicidal ideation. This study employed the chain mediation model, utilising Model 6 (Chain Mediation Model) in the SPSS macro program PROCESS.

The results, as presented in Table 3, indicate that the total effect of psychological distress on suicidal ideation is positive and statistically significant (β = 0.275, P < 0.001), thereby supporting Hypothesis 1. Furthermore, psychological distress was found to negatively predict psychological resilience (β = -0.473, P < 0.001) and positively predict neuroticism (β = 0.294, P < 0.001). A negative prediction was observed between psychological resilience and neuroticism (β = -0.435, P < 0.001), as well as between psychological resilience and suicidal ideation (β = -0.235, P < 0.01). The results indicated that neuroticism had a positive predictive effect on suicidal ideation (β = 0.282, P < 0.01).

Table 3.

Regression analysis between variables.

Predictor variable PR
 N
 SI
Β t Β t Β t
PD -0.473 -6.604*** 0.294 4.091*** 0.275 3.697***
PR -0.435 -6.052*** -0.235 -2.993**
N 0.282 3.528**
R2 0.224 0.398 0.426
F 43.607 49.493 36.809
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The results of the mediation effect analysis are presented in Table 4. The specific effects are manifested in three pathways: the pathway of psychological distress → psychological resilience → suicidal ideation produces an indirect effect 1, with an effect size of 0.037. This result supports Hypothesis 2, as the pathway of psychological distress → neuroticism → suicidal ideation produces an indirect effect 2, with an effect size of 0.027. Similarly, the pathway of psychological distress → psychological resilience → neuroticism → suicidal ideation produced a chain-mediated effect 3 with an effect size of 0.019, which supports Hypothesis 4. Bootstrap 95 % confidence intervals for all three pathways were not found to contain 0, indicating that the three pathways produced indirect effects at a statistically significant level. The findings indicate that psychological distress can exert a direct influence on suicidal ideation, as well as through the respective chain-mediating effects of psychological resilience and neuroticism, and the chain mediating effects of psychological resilience and neuroticism. The mediating effect model and its corresponding coefficient values for each pathway are illustrated in Fig. 1.

Table 4.

Bootstrap analysis of significance tests for mediating effects.

Model Effect Effect ratio LLCI ULCI
Total indirect effect 0.083 47.70 % 0.052 0.118
PD→PR→SI 0.037 21.26 % 0.014 0.065
PD→N→SI 0.027 15.51 % 0.009 0.053
PD→PR→N→SI 0.019 10.91 % 0.007 0.035
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Note: LLCI = lower limit of the 95 % confidence interval, ULCI = upper limit of the 95 % confidence interval.

Fig. 1.

Fig 1

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The result of chain mediation model.

4. Discussion

4.1. Relationship between psychological, psychological resilience, and suicidal ideation

The present study demonstrated that psychological resilience mediates the relationship between psychological distress and suicidal ideation, and that psychological distress is a significant predictor of suicidal ideation among individuals with depression, exerting a detrimental effect on psychological resilience. The persistence of psychological distress and negative emotions results in the continuous depletion of an individual's psychological resources, thereby reducing their capacity to cope with challenges and leading to a markedly diminished level of psychological resilience (Wu et al., 2017). Individuals with lower levels of psychological resilience frequently lack effective coping strategies and adequate coping abilities when confronted with challenges, making them more susceptible to adverse emotional states such as depression, anxiety, and stress. In turn, this elevates the likelihood of suicidal ideation (Li et al., 2024). In the context of the prevailing sample and research conditions, the model not only corroborates those reported in previous research but also provides further insight into the intricate relationship between psychological distress, psychological resilience, and suicidal ideation, without precluding the potential existence of other mediating and moderating variables. Consequently, the likelihood of suicidal ideation diminishes through the implementation of efficacious psychological interventions that assist patients in alleviating their psychological distress and enhancing their psychological resilience.

4.2. Relationship between psychological distress, neuroticism, and suicidal ideation

The present study showed that neuroticism serves as a mediator in the relationship between psychological distress and suicidal ideation. In other words, psychological distress indirectly predicts suicidal ideation in depressed patients through the mediating effect of neuroticism. Persistent psychological distress can lead to the development of hyper-neurotic traits in patients, which, in turn, exacerbates their suicidal ideation. Depression is characterised by long-term psychological distress, with negative emotions accumulating and recurring over time. This process strengthens the patient's cognitive responses and behavioral habits, leading to heightened sensitivity and more intense reactions to external stimuli. Consequently, neurotic tendencies are exacerbated (Yusoff et al., 2021; Yu et al., 2019) . The findings of the current study are consistent with those of previous research, which has shown that high neuroticism traits are a significant risk factor for suicidal ideation in patients with depression. (Gramstad et al., 2013). It is therefore recommended that special attention be paid to the development of neuroticism in depressed patients when implementing treatment plans. Through the use of targeted psychological interventions, patients can be assisted in reducing their neuroticism levels, which in turn can help to reduce the likelihood of suicidal ideation.

4.3. The role of psychological resilience and neuroticism in the relationship between psychological distress and suicidal ideation

The present study found that psychological distress can increase the development of suicidal ideation in depressed individuals by weakening psychological resilience, making individuals more likely to develop high levels of neuroticism, which in turn increases the development of suicidal ideation in depressed individuals. Long-term psychological distress has been demonstrated to impair the psychological resilience of depressed patients (Wu et al., 2017), thereby increasing the likelihood that they may lack effective coping strategies when facing problems and are more inclined to adopt negative coping styles. This further strengthens and maintains the negative effects of psychological distress and increases the risk of patients developing high neuroticism (Kalisch et al., 2015). High neuroticism represents a significant factor in the development of suicidal ideation, which may ultimately result in the manifestation of suicidal ideation (Chu et al., 2023). The present study not only revealed the intricate interplay between psychological distress, psychological resilience, neuroticism, and suicidal ideation, but also substantiated the mediating role of neuroticism in this complex network. This finding indicates that it is of particular importance for clinicians to assist depressed patients in alleviating psychological distress, while simultaneously enhancing their psychological resilience and reducing neuroticism, in order to mitigate the risk of suicidal ideation.

4.4. Cultural specificity and universality

The present study validated the chain-mediated roles of psychological resilience and neuroticism in psychological distress and suicidal ideation in depressed patients through modelling. It should be noted, however, that the results of this study were derived from a sample of depressed patients in a mental health centre in a region of China. Consequently, the expression of psychological resilience and suicidal ideation may manifest differently and exhibit distinct characteristics in different cultural contexts. In Chinese culture, collectivism, family values and respect for authority are of great importance. It may therefore be hypothesised that these values may influence the development of psychological resilience in individuals facing psychological distress. In some traditional Chinese cultures, the admonitions “I would rather die than give in” and “a man can be killed than humiliated” are often used to describe the attitudes of those who encounter difficulties or humiliations. These attitudes may influence many people and may be more susceptible to suicidal ideation (Ji and Li, 2020). Concurrently, the psychological mechanisms elucidated in this study are pervasive, as psychological distress, psychological resilience, and neuroticism—critical factors influencing suicidal ideation (O'Connor et al., 2011; Li et al., 2024; Gramstad et al., 2013)—may exert a pivotal role in disparate cultural contexts, albeit with distinctive manifestations that vary across diverse populations. In conclusion, the impact of cultural factors on the findings of this study must be given due consideration, and cross-cultural validation should be undertaken when applying the results of this study.

5. Conclusion

The objective of this study was to examine the mediating role of psychological distress among the development of suicidal ideation in patients with depression. To this end, a chain mediation model was constructed. The findings of this study indicate that psychological distress is a direct predictor of suicidal ideation among depressed patients. Thereby, it suggests that psychological distress can serve as a direct cause of suicidal ideation in depressed patients, consistent with previous studies (Jing et al., 2021). The current study also demonstrates that psychological distress indirectly predicts suicidal ideation among depressed patients through the independent mediating roles of psychological resilience and neuroticism, as well as the chain-mediating role of the two. Furthermore, the findings of the study indicated that although a notable correlation was observed between the four variables, the strength of this correlation was moderate or low. The results suggest that psychological distress is a significant contributing factor, rather than the sole determinant, of suicidal ideation. Suicidal ideation is the result of a combination of factors, including psychological distress, psychological resilience, and neuroticism. While there is a link between these factors, it is not a particularly strong one.

In conclusion, the chain-mediated effects of psychological resilience and neuroticism in the relationship between psychological distress and suicidal ideation in depressed patients are consistent with the hypotheses proposed above. The mediating effect model constructed in this study builds upon previous research on the mechanisms of psychological distress and suicidal ideation formation and development, as well as the chain-mediated pathways of psychological resilience and neuroticism between psychological distress and suicidal ideation. It provides a theoretical framework for understanding the complex causes of suicidal ideation in depressed patients. The present study lends support to the central tenet of psychological resilience theory, namely that psychological resilience acts as a protective factor, attenuating the direct impact of psychological distress on suicidal ideation when individuals are confronted with psychological distress. The present study contributes to the existing research on neurotic personality traits by demonstrating that these traits can exacerbate the facilitating effects of psychological distress on suicidal ideation. This indicates that healthcare professionals must consider not only psychological distress and depressive symptoms in patients with depression, but also the level of psychological resilience and neurotic personality traits in order to implement more targeted psychological interventions. By improving psychological resilience and reducing neurotic traits, the risk of suicidal ideation in patients can be reduced.

6. Shortcomings and prospects of the study

It is important to note that this study is not without limitations. Firstly, the sample size of 200 depressed patients from a single mental health center is relatively small and may not be representative of the broader population. It would be beneficial for future studies to be conducted with multicenter, large samples and high quality. Secondly, this study employed a cross-sectional design, which enabled the measurement of the correlation between variables and ascertained the chain mediating role. It is conceivable that there exist additional mediating or moderating variables yet to be identified in the relationship between psychological distress and suicidal ideation. However, the findings cannot yet be interpreted in terms of cause and effect. It would be beneficial for future studies to adopt a longitudinal or experimental design in order to investigate the causal relationship between psychological distress and suicidal ideation. These studies could also incorporate other potential mediating or moderating variables into the model. Then, they can further refine the dynamic interaction process between the variables. The goal is to construct a more comprehensive and in - depth model of the influencing factors of suicidal ideation. Ultimately, by intervening or mediating these influencing factors, we can reduce the occurrence of suicidal ideation in depressed patients. This will lower the risk of suicide and safeguard the safety of patients.

Ethics declarations

This study was reviewed and approved by the Ethics Committee of Shandong Mental Health Center. Informed consent for this study was obtained from all participants and their legal guardians.

Data availability statement

Data will be made available on request.

CRediT authorship contribution statement

Xueqing Wang: Writing – review & editing, Writing – original draft, Methodology, Investigation, Data curation, Conceptualization. Huafang Li: Writing – review & editing, Supervision, Funding acquisition, Data curation.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

We express our heartfelt thanks to all the participants.

Footnotes

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ijnsa.2025.100325.

Appendix. Supplementary materials

mmc1.pdf (355.3KB, pdf)
mmc2.docx (808.7KB, docx)
mmc3.docx (29.8KB, docx)
mmc4.docx (156.2KB, docx)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

mmc1.pdf (355.3KB, pdf)
mmc2.docx (808.7KB, docx)
mmc3.docx (29.8KB, docx)
mmc4.docx (156.2KB, docx)

Data Availability Statement

Data will be made available on request.

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