Abstract
Background
The aim of this study was to investigate the association between depression and suicidal ideation among attendees of a sexually transmitted diseases (STD) clinic in Shanghai, China, using an intertheoretical psychosocial framework.
Methods
We recruited 910 attendees from STD clinics for this cross-sectional study. We gathered data on sociodemographic factors, psychosocial variables, and suicidal ideation using a structured questionnaire that incorporated the PHQ-9, Defeat Scale, and Entrapment Scale. Logistic regression analysis was applied to examine the association between psychosocial variables and suicidal ideation. Furthermore, mediation analysis was conducted to explore the indirect effect of depression on suicidal ideation.
Results
The percentage of reported suicidal ideation among participants was 24.0%. Sex(OR = 0.645[0.474–0.879]), age(OR26 − 40=2.564[1.679–3.917], OR41 − 60=4.944[2.953–9.277], OR> 61=5.192[2.484–10.852]), highest educational level(ORhigh school=1.542[1.013–2.347]), current marital status(ORmarried=2.159[1.560–2.990], ORdivorced=2.148[1.063–4.340]), depression(OR = 0.810[0.781–0.840]), entrapment(OR = 0.928[0.916–0.940]), and defeat(OR = 0.927[0.913–0.941]) were significantly associated with suicidal ideation. The mediation role of entrapment was significant(indirect effect = 0.012, p < 0.001).
Conclusions
Our findings confirm the applicability of the Integrated Motivational-Volitional (IMV) model to the studied population. Importantly, entrapment emerged as a significant mediator in the relationship between depression and suicidal ideation among individuals attending STD clinics, highlighting its role in the pathway from depression to suicidal ideation. This underscores the need for tailored interventions addressing entrapment in this high-risk group to mitigate the risk of suicidal ideation.
Keywords: STD clinic attendees, Suicidal ideation, Integrated motivational-volitional model, Mediator, Depression, Entrapment
Background
Sexually transmitted infections (STI) have a substantial effect on patients’ physiological and psychological functioning. Individuals with STIs experience not only physical discomfort, but also moral stigma and discrimination, which may cause mental health problems such as depression [1, 2] and increase the risk of suicidal ideation [3]. Results from our previous study suggest that 25.0% of sexually transmitted disease (STD) clinic attendees in Shanghai experience suicidal ideation [4], indicating that more attention should be paid to the economic burden and social impact of suicide. Although mental and sexual health problems have historically been considered separate domains, and are often diagnosed and treated by different professionals in different healthcare facilities, recent events and research indicate that it is more appropriate to consider them interdependent disorders [5].
Several theoretical models have been proposed to explain the development of suicidal ideation, including the cry of pain hypothesis [6], the schematic appraisals model of suicide [7], and the integrated motivational-volitional (IMV) model of suicidal behavior, which posits that feelings of defeat and entrapment are the key drivers of suicidal ideation. Defeat has been defined as a sense of a failed social struggle, a loss or reduction of social rank [8] that may be directly related to interpersonal conflict but may also relate to perceptions of failure to attain social and material resources [9]. Entrapment has been defined as a desire to escape from the current situation while feeling that all escape routes are blocked [8]. STD clinic attendees who feel trapped by their condition and defeated by societal stigma and discrimination may experience entrapment and defeat because of assumptions inherent in traditional Chinese culture. Therefore, we generated a hypothesis based on the IMV model, namely, that entrapment and defeat may play a role in mediating the relationship between depression and suicidal ideation among STD clinic attendees.
In addition to understanding the psychological mechanisms underlying suicidal ideation, countering defeat and entrapment may be an important goal of therapeutic interventions from a clinical perspective. Thus, the study aim was to determine whether entrapment and defeat mediate the relationship between depression and suicidal ideation among STD clinic attendees in China.
Methods
Participants
Shanghai Skin Diseases Hospital is affiliated to Tong Ji University School of Medicine and is the only public hospital in Shanghai that specializes in STIs. All participants included in our research were receiving care from the STD clinics of two branches of the Shanghai Skin Diseases Hospital(Baode Road and Qiujiang Road, both in the Jingan District).
This cross-sectional study was conducted from June to December 2018 among STD clinic attendees. Patients who met the following criteria were invited to participate: (a) aged ≥ 18 years, (b) clinical diagnosis of an STD. Patients with the following characteristics were excluded: (a) reluctance to cooperate, (b) cognitive impairment and/or severe mental disorder caused by neurosyphilis, (c) unconsciousness, (d) serious audiovisual impairment or poor reading ability and/or inability to understand the study aims and contents.
Procedures
The details of the study procedure have been described previously [4, 10]. First, a cooperation agreement was signed by Shanghai Skin Disease Hospital and Shanghai Jiao Tong University School of Medicine. Outpatient doctors were responsible for recruiting and screening participants, and medical students were responsible for informed disclosure and investigation. On the days when our investigators were present, patients who visited either of the two branch institutes for STI treatment were considered as potential participants. Patients who met the inclusion criteria and who agreed to participate were included in this study.
All participants gave their informed consent before the investgations began, and were advised that they could ask questions at any time. Participants were also informed that if they wished, they could terminate the interviews at any time.
Measures
Sociodemographic variables
The sociodemographic variables measured comprised sex, age, highest educational level, current marital status, and diagnosis.
Lifetime suicidal ideation
Lifetime suicidal ideation was measured with one question: “Have you ever thought about suicide?” (1 = yes, 0 = no). A response of 1 indicated the presence of suicidal ideation [4, 11, 12].
Psychosocial variables
Depression was assessed with the Patient Health Questionnaire-9 (PHQ-9) [13], a concise screening tool where higher total scores indicate more severe depression. The Entrapment Scale (ES), consisting of 16 items [8], was employed to measure entrapment, with higher total scores reflecting a greater sense of entrapment. The 16 - item Defeat Scale (DS) [8] was used to evaluate participants’ level of defeat, where higher total scores correspond to higher levels of perceived defeat.
Statistical analysis
Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA) and JASP Version 0.16.3 (https://jasp-stats.org/). A descriptive statistical analysis was first conducted. Categorical variables were examined using a chi-square test, and continuous variables with a non-normal distribution were assessed via non-parametric tests. These tests compared the differences between groups with and without suicidal ideation. Then, Pearson’s product-moment correlation coefficients were used to examine the relationships between all psychosocial variables and suicidal ideation. Logistic regression analysis was used to test the regression relationship between psychosocial variables and suicidal ideation. A mediation model using JASP was constructed to interpret the relationship between depression and suicidal ideation among STD clinic attendees. The bootstrap method was implemented for the accuracy estimation using 1000 bootstraps.
Results
Sociodemographic and psychosocial characteristics
Sociodemographic characteristics of the participants are summarized in Table 1. A total of 910 STD clinic attendees were included. Participants had a mean age of 39.72 years and 48.1% were women. Most participants were married (61.8%), and were educated to college level or higher (52.6%). A total of 218 (24.0%) participants reported having had lifetime suicidal ideation.
Table 1.
Sociodemographic and psychosocial characteristics of STD clinic attendees in Shanghai
| Characteristics | Total(N = 910) | Suicidal Ideation（N = 218) | p | |
|---|---|---|---|---|
| Sex(%) | ||||
| Male | 438(48.1) | 87(39.91) | 0.005 | |
| Female | 472(51.9) | 131(60.09) | ||
| Age(%) | ||||
| < 25 | 113(12.4) | 52(23.85) | < 0.001 | |
| 26–40 | 481(52.9) | 120(55.05) | ||
| 41–60 | 238(26.2) | 35(16.06) | ||
| > 61 | 78(8.6) | 11(5.05) | ||
| Highest education level(%) | ||||
| Middle school and less | 229(5.1) | 66(30.28) | 0.019 | |
| Highschool | 202(22.2) | 35(16.06) | ||
| College degree or over | 479(52.6) | 117(53.67) | ||
| Current marital status(%) | ||||
| Unmarried(single) | 277(30.4) | 94(43.12) | < 0.001 | |
| Married | 562(61.8) | 108(49.54) | ||
| Divorced | 57(6.3) | 11(5.05) | ||
| Widowed | 14(1.5) | 5(2.29) | ||
| Diagnosis(%) | ||||
| Gonorrhea | 30(3.3) | 5(2.29) | 0.452 | |
| Syphilis | 365(40.1) | 82(37.61) | ||
| Genital warts | 361(39.7) | 96(44.04) | ||
| Genital herpes | 28(3.1) | 8(3.67) | ||
| HIV | 12(12.5) | 26(11.93) | ||
| Others | 114(1.3) | 1(0.46) | ||
| Depression(mean[SD]) | 15.19(5.39) | 10.54(6.05) | < 0.001 | |
| Entrapment(mean[SD]) | 28.12(13.30) | 22.32(14.71) | < 0.001 | |
| Defeat(mean[SD]) | 32.50(11.15) | 23.766(11.90) | < 0.001 | |
Scores on psychosocial characteristics are summarized in Table 1. All psychosocial problems measured were significantly associated with suicidal ideation (Table 2).
Table 2.
Relationships between psychosocial characteristics and suicidal ideation
| Psychosocial characteristics | Suicidal ideation | Depression | Entrapment | Defeat |
|---|---|---|---|---|
| Suicidal ideation | 1 | |||
| Depression | -0.444** | 1 | ||
| Entrapment | -0.412** | 0.714** | 1 | |
| Defeat | -0.354** | 0.603** | 0.738** | 1 |
*p < 0.05
**p < 0.01
Regression analysis
Table 3 presents the odd ratios (OR) for the associations between sociodemographic and psychosocial characteristics and suicidal ideation. The results showed that sex, age, highest educational level, current marital status, depression, entrapment, and defeat were significantly associated with suicidal ideation. However, following a multivariable logistic regression, only entrapment (OR = 0.962, 95% CI = 0.945–0.978) and depression (OR = 0.866, 95% CI = 0.827–0.907) remained significantly associated with suicidal ideation.
Table 3.
Regression model of suicidal ideation
| Variables | Wald Test | Odds Ratio | 95% Confidence interval | ||
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Sex | |||||
| Female | 7.708** | 0.645 | 0.474 | 0.879 | |
| Male | Ref. | Ref. | Ref. | Ref. | |
| Age | |||||
| 26–40 | 18.980** | 2.564 | 1.679 | 3.917 | |
| 41–60 | 36.954** | 4.944 | 2.953 | 8.277 | |
| > 61 | 19.180** | 5.192 | 2.484 | 10.852 | |
| < 25 | Ref. | Ref. | Ref. | Ref. | |
| Highest education level | |||||
| Highschool | 4.091* | 1.542 | 1.013 | 2.347 | |
| Middle school and less | 1.558 | 0.789 | 0.560 | 1.137 | |
| College degree or less | Ref. | Ref. | Ref. | Ref. | |
| Current marital status | |||||
| Married | 21.497** | 2.159 | 1.560 | 2.990 | |
| Divorced | 4.540* | 2.148 | 1.063 | 4.340 | |
| Widowed | 0.019 | 0.925 | 0.301 | 2.837 | |
| Unmarried(single) | Ref. | Ref. | Ref. | Ref. | |
| Diagnosis | |||||
| Syphilis | 0.537 | 0.690 | 0.256 | 1.860 | |
| Genital warts | 1.388 | 0.552 | 0.206 | 1.483 | |
| Genital herpes | 1.158 | 0.500 | 0.141 | 1.767 | |
| HIV | 0.525 | 0.677 | 0.236 | 1.944 | |
| Others | 0.467 | 2.200 | 0.229 | 21.090 | |
| Gonorrhea | Ref. | Ref. | Ref. | Ref. | |
| Depression | 126.927** | 0.810 | 0.781 | 0.840 | |
| Entrapment | 130.394** | 0.928 | 0.916 | 0.940 | |
| Defeat | 101.862** | 0.927 | 0.913 | 0.941 | |
| Model 1 a | |||||
| Depression | 37.820** | 0.868 | 0.830 | 0.908 | |
| Entrapment | 12.633** | 0.962 | 0.942 | 0.983 | |
| Defeat | 0.071 | 0.997 | 0.973 | 1.021 | |
| Model 2 b | |||||
| Depression | 37.174** | 0.866 | 0.827 | 0.907 | |
| Age | |||||
| 26–40 | 8.523** | 2.078 | 1.272 | 3.396 | |
| 41–60 | 23.241** | 4.660 | 2.493 | 8.713 | |
| > 61 | 15.078** | 6.390 | 2.506 | 16.297 | |
| < 25 | Ref. | Ref. | Ref. | Ref. | |
| Entrapment | 19.908** | 0.962 | 0.945 | 0.978 | |
| Highest education level | |||||
| Highschool | 6.27* | 1.926 | 1.153 | 3.217 | |
| Middle school and less | 2.604 | 0.681 | 0.427 | 1.086 | |
| College degree or less | Ref. | Ref. | Ref. | Ref. | |
aMultivariable logistic regression included psychological variables
bMultivariable logistic regression included sociodemographic and psychological variables (using the forward stepwise method)
*p < 0.05
**p < 0.01
Mediation model
The results of the mediation model are shown in Table 4; Fig. 1. The total effects were 0.036 (p < 0.001), the direct effects were 0.024 (p < 0.001), and the total indirect effects were 0.012 (p < 0.001). The mediation role of entrapment was significant (indirect effect = 0.012, p < 0.001).
Table 4.
Mediating effect of entrapment and defeat on relationship between depression and suicidal ideation
| Estimate | Std. Error | z-value | p | 95% Confidence Interval | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Lower | Upper | |||||||||
| Direct effects | ||||||||||
| Depression | → | Suicidal Ideation | 0.024 | 0.003 | 7.062 | < 0.001 | 0.017 | 0.030 | ||
| Indirect effects | ||||||||||
| Depression | → | Entrapment | → | Suicidal Ideation | 0.012 | 0.003 | 4.043 | < 0.001 | 0.006 | 0.018 |
| Depression | → | Defeat | → | Suicidal Ideation | 0.001 | 0.002 | 0.201 | 0.840 | -0.004 | 0.005 |
| Total indirect effects | ||||||||||
| Depression | → | Suicidal Ideation | 0.012 | 0.002 | -5.1 | < 0.001 | 0.008 | 0.017 | ||
| Total effects | ||||||||||
| Depression | → | Suicidal Ideation | 0.036 | 0.002 | -15.363 | < 0.001 | 0.031 | 0.041 | ||
| Residual covariances | ||||||||||
| Entrapment | ↔ | Defeat | 49.013 | 3.119 | 15.713 | < 0.001 | 42.899 | 55.127 | ||
Fig. 1.
The serial multiple mediation of defeat and entrapment between depression and suicide ideation
Note: Path coefficients were shown in standardized regression. *p < 0.001
Discussion
Consistent with our previous study, the rate of suicidal ideation among STD clinic attendees was 24.0%. Consistent with other studies [14, 15], our research found that several psychosocial problems were associated with suicidal ideation. It should be noted that previous studies have reported suicidal ideation rates of 25.2% among oncology patients [16] and 20.0% among chronic pain patients [17]. Considering that such patients are usually regarded as having a high suicide risk, the results of the present study indicate that STD clinic attendees could be considered a high-risk group for suicidal ideation.
The results of the binary regression analysis showed that depression, entrapment, and defeat were significantly associated with suicidal ideation. Additionally, entrapment was found to be a positive mediator of the relationship between depression and suicidal ideation among STD clinic attendees. Despite widespread use of the IMV model in populations including university students [18] and Chinese adolescents [19], evidence that this model is applicable to STD clinic attendees remains lacking. Previous research has demonstrated that the IMV model effectively correlates defeat, entrapment and suicidal ideation among high-risk populations with suicidal ideation such as men who have sex with men and young adults [20, 21]. The present findings demonstrate that the IMV model is applicable to this population. Consistent with other research findings [22–25], our study once again finds the significant role of depression in suicidal ideation. Of course, this may also be because suicidal ideation is one of the additional criteria for diagnosing depression.
This study had several limitations. First, 910 STD clinic attendees were recruited from two different branches of representative study sites, however both branches are in the same city and thus the study does not qualify as a true multicenter research. Future research should take into account the fact that Shanghai is a metropolis that contains many migrants. Second, both newly diagnosed and returning patients were included in the study. There may be differences in the reasons why these two categories of patients have suicide ideation, thus leading to the need for different interventions. For example, newly diagnosed patients might have suicide ideation because they are temporarily unable to accept this reality. In contrast, returning patients may have suicide ideation due to the prolonged duration and suffering of the disease. In future studies, newly diagnosed cases should be selected to control for confounding bias. Finally, self-reports were used for all the psychosocial factors. Suicidal ideation was assessed using a self-report binary scale, which is quick and easy to administer and minimizes the burden on respondents who had already completed several scales in this study. However, that may lead to biased results. Therefore, multi-item assessments may be needed for further understand the relationship between entrapment and suicidal ideation.
Conclusions
In this study, we used a mediation model informed by the IMV model to demonstrate the severity of suicidal ideation in STD clinic attendees. The results increase the understanding of suicide risk among STD clinic attendees. These findings suggest that public health providers should consider not only patients’ treatment and psychological status when developing prevention and intervention policies, but should also take into account psychosocial variables that may be associated with suicide risk and thus pose a substantial risk to patients and society. The finding that entrapment may mediate the relationship between depression and suicidal ideation indicates that measures targeting both depression and entrapment may be effective in preventing suicide among STD clinic attendees. Additional studies are needed to further investigate the interaction between these factors and suicidal ideation, and to inform effective preventive measures.
Acknowledgements
We acknowledge all participants and interviewers involved in this research. We thank Diane Williams, PhD, from Liwen Bianji (Edanz) (www.liwenbianji.cn), for editing the English text of a draft of this manuscript.
Abbreviations
- STD
Sexually transmitted disease
- STI
Sexually transmitted infection
- IMV
Integrated motivational-volitional
- PHQ-9
Patient Health Questionnaire-9
- ES
Entrapment Scale
- DS
Defeat Scale
- CI
Confidence interval
- OR
Odds ratio
Author contributions
Conceptualization, Y.C.; Software, R.G.; formal analysis, R.G.; data curation, H.W.; writing– review and editing, R.G and Y.C; supervision, Y.N and Y.C. All authors have read and agreed to the published version of the manuscript.
Funding
This work was supported by the key discipline projects of Shanghai Three-Year Action Plan for Public Health under Grant (GWVI-11.1-29), National Key R&D Program of China (2020YFC2006400), and Yangtze River Delta Regional Leading Talents Research Project on Immunization (CSJP033). This work was supported by the key discipline projects of Shanghai Three-Year Action Plan for Public Health under Grant (GWVI–11.1–29), Key Project in Medical-Engineering Interdisciplinary Research at Shanghai Jiao Tong University (AF7320007, YG2025ZD29),Yangtze River Delta Regional Leading Talents Research Project on Immunization (CSJP033), Xuhui District Medical Research Project (SHXH202411), Medial Discipline Construction Program of Shanghai Pudong New Area Health Commission(the Key Discipline Program)(PWZzk2022–22), and Healthcare Management Research Division Shanghai Society of Integrative Medicine (2023–YYGL10).
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Shanghai Jiao Tong University School of Medicine Public Health and Nursing Ethics Committee (SJUPN-201702). Informed consent was obtained from all participants involved in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Yang Ni and Hantao Wu these two authors contribute equally to this study/work.
Contributor Information
Ruijie Gong, Email: cynthia-dt@sjtu.edu.cn.
Yong Cai, Email: caiyong202028@hotmail.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.