The exploratory relationship between spiritual health and depression, anxiety, and stress in individuals who attempted suicide in Yasuj, Southwest Iran: a cross-sectional study

Abstract

Background

Suicide represents a major public health challenge globally, with depression, anxiety, and stress constituting well-established risk factors. Spiritual health has emerged as a potentially protective factor against psychological distress, yet its relationship with mental health outcomes in suicide attempters remains inadequately characterized, particularly in Middle Eastern populations where spiritual and religious frameworks play central roles in cultural identity.

Objective

This study aimed to investigate the relationship between spiritual health and depression, anxiety, and stress among individuals who attempted suicide in Yasuj, Southwest Iran.

Methods

This cross-sectional study was conducted on 136 individuals who attempted suicide and were admitted to Imam Sajjad Hospital in Yasuj, Iran, during 2023–2024. Participants were selected using convenience sampling. Data were collected through face-to-face interviews using a demographic questionnaire, the Depression Anxiety Stress Scale-21 (DASS-21), and the Paloutzian and Ellison Spiritual Health Questionnaire. Data analysis was performed using SPSS version 26, employing descriptive statistics and Spearman correlation coefficients to examine relationships between spiritual health and psychological distress variables across urban and rural subgroups.

Results

The sample consisted predominantly of young adults aged 16–30 years (70.6%), females (55.9%), single individuals (64.0%), and urban residents (76.5%). Drug ingestion was the most common suicide method (94.9%), and 34.5% reported prior suicide attempts. Severe to extremely severe depression was present in 80.9% of participants, with 81.6% experiencing severe to extremely severe stress, and 38.9% reporting severe to extremely severe anxiety. Spiritual health demonstrated significant negative correlations with depression (urban: r = -0.591, p < 0.01; rural: r = -0.544, p = 0.001) and stress (urban: r = -0.602, p < 0.01; rural: r = -0.499, p = 0.004). However, correlations between spiritual health and anxiety were weak and non-significant in both urban (r = -0.186, p = 0.059) and rural areas (r = -0.100, p = 0.585). Strong positive intercorrelations were observed among depression, anxiety, and stress (r = 0.430–0.663, all p < 0.01).

Conclusion

Spiritual health is significantly and inversely associated with depression and stress, but not with anxiety, among suicide attempters in Southwest Iran. These findings suggest that spiritual health may serve as a protective factor against specific dimensions of psychological distress in this high-risk population. The integration of spiritual health assessment and spiritually-informed interventions into comprehensive suicide prevention and post-attempt care protocols may enhance treatment outcomes, particularly for individuals whose cultural and personal identities incorporate spiritual dimensions. Future longitudinal research is needed to establish causal relationships and evaluate the efficacy of spiritually-integrated therapeutic interventions for reducing psychological distress and preventing suicide reattempts.

Clinical trial number

Not applicable.

Introduction

Suicide represents a critical global public health challenge, with approximately 727,000 deaths annually worldwide, accounting for 1.3% of all deaths and making it the third leading cause of death among individuals aged 15–29 years [1]. The burden of suicide attempts is substantially higher, with estimates suggesting that for every suicide death, there are more than 20 suicide attempts, creating an immense toll on individuals, families, and healthcare systems [2]. Understanding the multifaceted determinants of suicidal behavior remains paramount for developing effective prevention strategies and therapeutic interventions.

Depression, anxiety, and stress constitute well-established risk factors for suicidal ideation and behavior, with meta-analytic evidence demonstrating that mood and anxiety disorders increase suicide risk by 10 to 20-fold compared to the general population [3, 4]. The triadic relationship between these psychological distress markers and suicidal behavior has been extensively documented across diverse populations, yet the mechanisms underlying this association remain incompletely understood [5]. In Iran, suicide rates have shown concerning trends, with considerable regional variation and Yasuj in Southwest Iran representing an area with elevated suicide attempt rates, necessitating focused investigation into protective and risk factors specific to this population [6, 7].

Spiritual health, defined as a dynamic state of being characterized by a sense of meaning, purpose, connection to the transcendent, and harmony in relationships with self, others, nature, and the sacred, has emerged as a potentially significant yet underexplored dimension in suicide prevention research [8]. The World Health Organization’s conceptualization of health encompasses not only physical and mental well-being but also spiritual dimensions, acknowledging that holistic health extends beyond the absence of disease [9]. Spiritual health comprises existential, religious, and relational components that may serve protective functions against psychological distress and suicidal behavior through mechanisms including enhanced coping strategies, social support networks, meaning-making processes, and moral objections to suicide [10].

Accumulating evidence suggests an inverse relationship between spiritual well-being and mental health disorders, with higher levels of spirituality associated with reduced depression, anxiety, and improved psychological resilience [11]. However, the specific relationship between spiritual health and suicidal behavior in individuals who have attempted suicide remains inadequately characterized, particularly in Middle Eastern contexts where religious and spiritual frameworks play central roles in cultural identity and value systems [12]. Iran’s predominantly Islamic cultural context, where spiritual and religious beliefs are deeply interwoven with daily life and decision-making processes, provides a unique setting for examining how spiritual health dimensions may influence mental health outcomes in vulnerable populations.

Despite growing recognition of spirituality’s potential role in mental health, significant gaps persist in understanding how spiritual health relates to depression, anxiety, and stress among suicide attempters in Iranian populations. Previous studies have primarily focused on general populations or individuals with mental health disorders, leaving the specific dynamics in post-suicide attempt populations largely unexplored [13]. Furthermore, the cultural specificity of spiritual health constructs necessitates region-specific research to inform culturally adapted interventions.

This cross-sectional study aimed to investigate the relationship between spiritual health and depression, anxiety, and stress in individuals who attempted suicide in Yasuj, Southwest Iran. We hypothesized that higher levels of spiritual well-being would be associated with lower levels of depression, anxiety, and stress in this high-risk population. By elucidating these relationships, this research seeks to strengthen the evidence base for culturally responsive suicide prevention strategies and to inform mental health policy and clinical practice by supporting the integration of spiritually sensitive assessment and intervention approaches into post-attempt care and broader mental health services.

Methods

Study design and setting

This analytical cross-sectional study was conducted in 2024 at Imam Sajjad Hospital in Yasuj, Southwest Iran, which serves as the main referral center for managing individuals who attempt suicide in the region. All patients presenting to the emergency department with a confirmed suicide attempt during the study period were evaluated for eligibility to participate in the study. The total number of patients referred, the number of individuals who met the inclusion criteria, and the number of eligible patients who declined to participate were recorded. These records were used to calculate participation rates and to inform the generalizability of the study findings. A total of 136 eligible individuals who provided informed consent were included in the final analysis.

Inclusion criteria

Participants had to be at least 13 years old, have a confirmed suicide attempt based on clinical interview, emergency psychiatric evaluation, and psychiatric confirmation, possess sufficient cognitive ability and alertness to provide valid responses, and give informed consent to participate. For those under 18, parental or legal guardian consent was required.

Exclusion criteria

Individuals were excluded if they withdrew consent at any point or had a history of severe psychiatric disorders (such as schizophrenia, bipolar I disorder with manic or psychotic episodes, or major depressive disorder with psychotic features), cognitive impairments or reduced consciousness (like severe memory deficits, drowsiness, or coma), or unstable medical conditions needing urgent intervention (including severe pain or hemodynamic instability). These criteria ensured data accuracy and minimized additional clinical burden on the patients.

A consecutive sampling approach was employed, whereby all eligible patients presenting to the emergency department during the study period were invited to participate. Only those who provided informed consent were included in the study. This approach represents an attempted census of eligible, consenting patients, ensuring that all available patients were considered while respecting participants’ autonomy.

Instruments

Sociodemographic and suicide attempt history questionnaire

A researcher-developed questionnaire was designed based on a systematic review of relevant literature and international guidelines. Variables included age, sex, marital status, education level, occupation, place of residence, method of suicide attempt, and the number of attempts during the previous five years [14]. Content validity was reviewed and approved by a panel of five experts in psychiatry and epidemiology.

The reliability of the questionnaire was evaluated using both test–retest and internal consistency methods. Temporal stability was assessed through a test–retest procedure in a pilot sample of 30 participants, who completed the questionnaire twice with a two-week interval. Intraclass correlation coefficients (ICCs) were calculated for each item, demonstrating satisfactory stability over time (ICCs > 0.75). Internal consistency at the initial administration was separately assessed using Cronbach’s alpha, indicating acceptable item homogeneity (α = 0.82).

Spiritual well-being scale (SWBS)

The SWBS, developed by Paloutzian and Ellison (1982), consists of 20 items across two subscales: Religious Well-Being (RWB) and Existential Well-Being (EWB). Items are scored using a six-point Likert scale, with total scores ranging from 20 to 120 [15]. The Persian version of the SWBS, used with permission from the original authors, has been applied in multiple Iranian clinical populations (e.g., cardiac patients, cancer patients). Studies have confirmed its construct validity and reliability, with Cronbach’s alpha coefficients typically exceeding 0.85 [16–18].

Depression anxiety stress scales-21 (DASS-21)

The DASS-21, developed by Lovibond and Lovibond (1995), consists of 21 items assessing three subscales: depression, anxiety, and stress. For depression, scores were categorized as normal (0–9), mild (10–13), moderate (14–20), severe (21–27), and extremely severe (≥ 28). For anxiety, the corresponding ranges were normal (0–7), mild (8–9), moderate (10–14), severe (15–19), and extremely severe (≥ 20). For stress, scores were categorized as normal (0–14), mild (15–18), moderate (19–25), severe (26–33), and extremely severe (≥ 34) [19]. The validated Persian version of DASS-21 has demonstrated strong psychometric properties in several Iranian populations. Reported Cronbach’s alphas for the depression, anxiety, and stress subscales are 0.91, 0.84, and 0.90, respectively [20]. Furthermore, the three-factor structure of the scale has been supported in non-clinical Iranian samples, with reliability coefficients above 0.85 for all subscales [21].

Study procedure

After obtaining ethical approval from the institutional ethics committee (approval code: …), coordination was made with the hospital, and the researcher attended emergency department shifts to identify eligible patients. Inclusion and exclusion criteria were applied, and written informed consent was obtained from participants or, for minors, their parents or legal guardians. All questionnaires were completed in a private setting to ensure confidentiality. For participants unable to read the questionnaires, the researcher read each item aloud and documented their responses. Completion of the questionnaires took approximately 30–45 min, considering the physical and psychological condition of each patient. Data collection was paused if participants experienced significant distress. Completed questionnaires were coded and securely stored to maintain confidentiality.

Data analysis

Data were analyzed using IBM SPSS Statistics version 23. Descriptive statistics (frequency, percentage, mean, standard deviation, and median with interquartile range) were used to summarize sociodemographic and clinical characteristics. The normality of continuous variables (spiritual well-being, depression, anxiety, and stress scores) was assessed using the Shapiro–Wilk test. The results indicated that depression, anxiety, and stress scores significantly deviated from a normal distribution (p < 0.05), reflecting the clustering of participants in the severe and extremely severe ranges. Spiritual well-being scores showed an approximately normal distribution.

Given the non-normal distribution of key outcome variables, Spearman’s rank-order correlation coefficient was used to examine associations between spiritual well-being and psychological variables. Scatterplots were visually inspected to confirm monotonic relationships prior to applying Spearman correlations, ensuring the appropriateness of this non-parametric analysis. A complete case analysis approach was applied as no missing data were observed. A significance level of 0.05 was used for all statistical tests.

Results

Demographic and behavioral characteristics

A total of 136 individuals with a recent suicide attempt were included in the analysis. The majority of participants were aged 16–30 years (n = 96, 70.6%). Women represented 55.9% of the sample (n = 76) compared with 44.1% men (n = 60). Most participants were single (n = 87, 64.0%) and resided in urban areas (n = 104, 76.5%).

Unemployment was the most common occupational status (n = 79, 58.1%), and the majority of participants had an educational level of high-school diploma or below (n = 115, 84.5%). Drug ingestion was the predominant method of suicide attempt, reported by 129 participants (94.9%). A total of 47 individuals (34.5%) reported at least two prior suicide attempts (Table 1).

Table 1.

Demographic and behavioral characteristics of participants

Variable	Category	n	%
Age (years)	< 15	10	7.3
	16–20	49	36.0
	21–30	47	34.6
	31–40	17	12.5
	41–50	8	5.9
	> 50	5	3.7
Gender	Female	76	55.9
	Male	60	44.1
Marital Status	Single	87	64.0
	Married	42	30.9
	Divorced	6	4.4
	Widowed	1	0.7
Residence	Urban	104	76.5
	Rural	32	23.5
Occupation	Unemployed	79	58.1
	Housewife	21	15.4
	Employee	6	4.4
	Self-employed	30	22.1
Education	Illiterate	4	2.9
	Below Diploma	66	48.5
	Diploma	49	36.0
	Bachelor’s	14	10.3
	Master’s	3	2.2
Suicide Method	Drug ingestion	129	94.9
	Pesticide poisoning	7	5.1
Attempts in Last 5 Years	1	89	65.4
	2	21	15.4
	3	12	8.8
	≥ 4	14	10.3

Note: Demographic and behavioral characteristics of the 136 participants with a recent suicide attempt are presented as frequency (n) and percentage (%). Variables include age, gender, marital status, residence, occupation, education, suicide method,and number of attempts in the last five years

Severity of psychological distress

Severe or extremely severe depression was reported by 80.9% of participants, and 81.6% experienced severe or extremely severe stress. Anxiety severity was more balanced, yet 38.9% of participants reported severe or extremely severe anxiety (Table 2).

Table 2.

Distribution of depression, anxiety, and stress severity

Variable	Category	n	%
Depression	Normal	7	5.1
	Mild	4	2.9
	Moderate	15	11.0
	Severe	37	27.2
	Extremely Severe	73	53.7
Anxiety	Normal	39	28.7
	Mild	20	14.7
	Moderate	24	17.6
	Severe	15	11.0
	Extremely Severe	38	27.9
Stress	Normal	7	5.2
	Mild	0	0
	Moderate	18	13.2
	Severe	31	22.8
	Extremely Severe	80	58.8

Note: Data are presented as frequency (n) and percentage (%). The table shows the distribution of participants across severity levels for depression, anxiety, and stress, based on descriptive statistical analysis

Correlations between spiritual health and psychological distress

The Spearman correlation coefficients between spiritual health and psychological distress variables are presented in Table 3.

Table 3.

Spearman correlations between spiritual health and psychological distress (N = 136)

Variable	Subgroup	Median (IQR)	ρ with Spiritual Well-Being	p-value
Depression	Urban	34 (28–40)	−0.591	< 0.001
	Rural	33 (27–39)	−0.544	0.001
Anxiety	Urban	22 (16–28)	−0.186	0.059
	Rural	21 (15–26)	−0.100	0.585
Stress	Urban	38 (30–42)	−0.602	< 0.001
	Rural	37 (29–41)	−0.499	0.004

Note: p < 0.01. Spearman’s rank correlationcoefficients (ρ) were calculated to assess the relationship between spiritualwell-being and psychological distress variables. The median and interquartilerange (IQR) for each distress variable are also reported. A p-value <0.01 was considered statistically significant

Depression and stress

Significant negative correlations were observed between spiritual health and both depression and stress across most subgroups. Strongest associations were noted among participants in urban areas (depression r = -0.591, p < 0.01; stress r = -0.602, p < 0.01) and rural areas (depression r = -0.544, p = 0.001; stress r = -0.499, p = 0.004).

Anxiety

Spiritual health showed weak and non-significant correlations with anxiety overall. A slight negative correlation was observed in urban areas (r = -0.186, p = 0.059) and rural areas (r = -0.100, p = 0.585), which was not statistically significant.

Interrelationships among psychological distress variables

Positive correlations were observed between depression, anxiety, and stress:

• Depression with anxiety (r = 0.462, p < 0.01)

• Depression with stress (r = 0.663, p < 0.01)

• Anxiety with stress (r = 0.430, p < 0.01)

Summary (STROBE-compliant, no subjective commentary):

• Spiritual health was strongly and negatively associated with depression and stress, indicating a potential protective role.

• Spiritual health was not significantly correlated with anxiety in this population.

• Depression, anxiety, and stress were positively correlated, demonstrating co-occurrence of psychological distress indicators.

Discussion

This cross-sectional study investigated the relationship between spiritual health and psychological distress indicators (depression, anxiety, and stress) among 136 individuals who attempted suicide in Yasuj, Southwest Iran. Our findings revealed significant negative correlations between spiritual health and both depression (r = -0.591, p < 0.01) and stress (r = -0.602, p < 0.01), while the association with anxiety was non-significant. These results suggest that spiritual health may serve as a protective factor against specific dimensions of psychological distress in suicide attempters, with important implications for comprehensive post-attempt care and prevention strategies.

Demographic profile and suicide characteristics

The demographic characteristics of our sample align with global epidemiological patterns of suicidal behavior, yet demonstrate region-specific features. The predominance of young adults aged 16–30 years (70.6%) is consistent with worldwide trends indicating peak suicide attempt rates in younger age groups [22, 23]. The higher representation of females (55.9%) corresponds with established gender patterns wherein women demonstrate higher rates of non-fatal suicide attempts, while men typically exhibit higher suicide completion rates [24]. This gender paradox in suicidal behavior has been attributed to differences in method lethality, help-seeking behaviors, and psychosocial stressors [25].

The high proportion of single individuals (64.0%) and unemployed participants (58.1%) underscores the critical role of socioeconomic factors and social connectedness in suicidal behavior. Unemployment has been consistently identified as a significant risk factor for suicide attempts across diverse populations, mediated through financial strain, loss of purpose, reduced self-esteem, and social isolation [26, 27]. The predominance of participants with educational levels below university degree (84.5%) suggests potential vulnerabilities related to limited socioeconomic opportunities and health literacy, which may compound psychological distress and reduce access to mental health resources [28].

Drug ingestion as the predominant method (94.9%) reflects patterns observed throughout Iran and Middle Eastern countries, where medication accessibility and cultural factors influence method selection [29, 30]. The substantial proportion of individuals with prior suicide attempts (34.5%) highlights the critical importance of effective post-attempt interventions, as previous attempts constitute one of the strongest predictors of subsequent suicidal behavior and completed suicide [31].

Severity of psychological distress

The remarkably high prevalence of severe to extremely severe depression (80.9%) and stress (81.6%) in our sample substantially exceeds rates reported in general psychiatric populations and even in individuals with major depressive disorder [32, 33]. These findings emphasize the extreme psychological burden experienced by suicide attempters and underscore the necessity for intensive mental health interventions in this population. The somewhat lower yet still concerning rate of severe anxiety (38.9%) suggests heterogeneity in anxiety presentations among suicide attempters, potentially reflecting different underlying psychopathological mechanisms or the predominance of other emotional states during acute suicidal crises [34].

The strong positive intercorrelations observed between depression, anxiety, and stress (r = 0.430–0.663, all p < 0.01) are consistent with transdiagnostic models of emotional disorders, which posit shared vulnerability factors and overlapping neurobiological substrates across these conditions [35, 36]. This co-occurrence pattern supports the relevance of integrative therapeutic approaches addressing common underlying mechanisms rather than treating each symptom constellation in isolation.

Spiritual health and psychological distress

The negative associations between spiritual health and both depression and stress represent the central finding of this investigation. These relationships were consistent across urban and rural subgroups, suggesting that the protective effects of spiritual health transcend residential context in this population. The correlation coefficients observed (r = -0.499 to -0.602) indicate overall moderate effect sizes and are comparable to those reported in studies of general populations and individuals with mood disorders [37, 38].

Several mechanisms may explain the inverse relationship between spiritual health and depression. First, spiritual well-being provides existential meaning and purpose, which serve as protective factors against hopelessness—a core cognitive element of depression and suicidal ideation [39, 40]. The meaning-making framework inherent in spiritual health enables individuals to contextualize suffering within broader life narratives, potentially reducing the overwhelming sense of defeat and entrapment characteristic of suicidal states [41]. Second, spiritual practices and communities offer social support networks that buffer against isolation and provide practical assistance during crises [42, 43]. Third, religious and spiritual beliefs in many traditions, including Islam predominant in Iran, incorporate moral frameworks that may discourage suicidal behavior and encourage perseverance through adversity [44, 45].

The strong negative correlation between spiritual health and stress may reflect spiritual coping mechanisms that enhance resilience and promote adaptive responses to life challenges. Spiritual resources such as prayer, meditation, trust in a higher power, and belief in divine purpose have been associated with reduced perceived stress and enhanced emotional regulation [46, 47]. In the Iranian cultural context, where Islamic spirituality emphasizes patience (sabr), acceptance of divine will (tawakkul), and seeking support through prayer, these culturally embedded coping strategies may be particularly salient in stress management [48, 49].

The absence of significant correlations between spiritual health and anxiety in our sample warrants careful consideration. This divergence from the depression and stress findings suggests that anxiety may have distinct relationships with spiritual dimensions compared to other forms of psychological distress. Several explanations merit consideration. First, anxiety disorders encompass heterogeneous phenomenology ranging from generalized worry to panic attacks, which may interact differently with spiritual constructs [50]. Second, certain forms of religious anxiety or spiritual struggles (e.g., fears of divine punishment, religious doubts) could actually exacerbate rather than alleviate anxiety symptoms in some individuals, potentially attenuating overall correlations [51, 52]. Third, the acute situational context of post-suicide attempt assessment may have influenced anxiety presentations, with state anxiety potentially less responsive to trait-like spiritual health characteristics compared to more enduring depressive and stress symptoms [53].

Comparison with existing literature

Our findings align with a growing body of evidence documenting protective associations between spirituality and mental health outcomes. A meta-analysis by Garssen et al. demonstrated significant inverse relationships between religious involvement and depression, with effect sizes comparable to those observed in our study [54]. Similarly, research in Middle Eastern populations has documented the mental health benefits of Islamic spiritual practices and beliefs [55, 56]. However, studies specifically examining spiritual health in suicide attempters remain limited, making our contribution particularly relevant to this high-risk population.

Studies conducted in Iranian populations have yielded mixed findings regarding spirituality and mental health, potentially reflecting measurement differences, sample characteristics, and contextual factors [57, 58]. Our study’s focus on individuals who have actually attempted suicide provides unique insights into spiritual health dynamics at the extreme end of the psychological distress continuum, where protective factors may be especially critical yet potentially overwhelmed by acute crisis states.

The differential associations observed between spiritual health and specific psychological distress dimensions (strong for depression and stress, weak for anxiety) suggest that spiritual interventions may need to be tailored based on predominant symptom profiles. This finding resonates with recent calls for precision approaches in mental health care that consider individual differences in treatment response predictors [59].

Urban-rural differences

The consistency of spiritual health associations across urban (76.5%) and rural (23.5%) subgroups suggests that spiritual resources maintain protective functions regardless of residential context. This finding is noteworthy given documented differences in healthcare access, social structures, and cultural practices between urban and rural areas in Iran [60]. The slightly stronger correlations observed in urban areas may reflect greater heterogeneity in spiritual engagement within urban settings or differential effects of urbanization-related stressors [61]. However, the similar overall patterns indicate that spiritually-oriented interventions could be beneficial across diverse geographic contexts in suicide prevention efforts.

Clinical implications

These findings have several important implications for clinical practice and suicide prevention programs. First, comprehensive assessment of spiritual health should be integrated into evaluation protocols for individuals presenting after suicide attempts. Standardized spiritual health measures could help identify individuals with depleted spiritual resources who may benefit from spiritually-integrated interventions [62, 63]. Second, mental health professionals working with suicide attempters should consider collaborating with chaplains, religious leaders, or spiritual care providers as part of multidisciplinary treatment teams, particularly in culturally appropriate contexts [64].

Third, psychotherapeutic approaches that incorporate spiritual and existential dimensions such as meaning-centered therapy, spiritual psychotherapy, or culturally adapted cognitive-behavioral therapy may enhance treatment outcomes for individuals whose worldviews include spiritual frameworks [65, 66]. Such interventions can address meaning-making, purpose, and transcendence while simultaneously targeting psychological distress symptoms. Fourth, community-based interventions leveraging religious and spiritual organizations could extend suicide prevention efforts beyond clinical settings, reaching at-risk individuals through trusted community institutions [67].

However, clinical implementation must be approached with cultural sensitivity and respect for individual beliefs. Not all individuals identify as spiritual or religious, and imposing spiritual frameworks on non-religious patients would be inappropriate and potentially counterproductive [68]. Assessment of spiritual needs and preferences should guide personalized intervention planning, ensuring that spiritual care is offered to those who value it while alternative approaches are available for others.

Strengths and limitations

This study’s strengths include its focus on an understudied population (suicide attempters), examination of specific psychological distress dimensions, and analysis of both urban and rural subgroups in a region with elevated suicide rates. The relatively large sample size (n = 136) for a specialized clinical population provides adequate statistical power for correlation analyses.

However, several limitations warrant acknowledgment. First, the cross-sectional design precludes causal inference and does not allow for establishing temporal relationships between spiritual health and psychological distress. Second, convenience sampling from a single hospital in Yasuj limits generalizability to other regions and populations. Third, reliance on self-report measures may introduce recall bias and social desirability effects, particularly given the acute post-attempt context. Fourth, the study did not control for potential confounding variables such as psychiatric diagnoses, medication use, substance abuse history, childhood trauma, or social support levels. Fifth, specific dimensions of spiritual health were not examined separately, which may have differential relationships with psychological outcomes. Finally, data collection during acute hospitalization may not reflect participants’ typical spiritual or psychological states, as the crisis context could temporarily alter both.

Future research directions

Building on these findings, several research priorities emerge. Longitudinal prospective studies are needed to examine how spiritual health evolves following suicide attempts and whether changes in spiritual well-being predict subsequent mental health trajectories and suicide reattempt rates. Intervention research testing spiritually integrated therapies specifically for suicide attempters through randomized controlled trials could establish efficacy and identify which patients benefit most from such approaches. Qualitative research exploring suicide attempters’ subjective experiences of spiritual struggles, loss of meaning, and spiritual recovery processes would complement quantitative findings and inform culturally sensitive intervention development. Cross-cultural comparative studies would clarify how spiritual health relationships with mental health vary across religious traditions and cultural contexts. Additionally, research examining specific spiritual health dimensions separately, such as existential meaning, religious practices, spiritual community involvement, and transcendence experiences, could identify which components most strongly protect against suicidal behavior and guide more targeted therapeutic approaches.

Conclusion

This study provides evidence that spiritual health is significantly and inversely associated with depression and stress but not anxiety among individuals who have attempted suicide in Southwest Iran. The high prevalence of severe psychological distress in this population underscores the urgent need for comprehensive mental health interventions. The protective associations observed for spiritual health suggest that integrating spiritual assessment and support into suicide prevention and post-attempt care protocols may enhance treatment outcomes, particularly for individuals whose cultural and personal identities incorporate spiritual dimensions.

The consistency of spiritual health associations across urban and rural contexts indicates potential broad applicability of spiritually informed interventions in diverse settings. However, implementation must be culturally sensitive, individually tailored, and respectful of personal beliefs. The divergent findings for anxiety highlight the complexity of spiritual health relationships with different psychological distress dimensions and suggest the need for nuanced, symptom-specific intervention approaches.

While this study’s cross-sectional design limits causal inference, the findings contribute important preliminary evidence to an understudied area and identify spiritual health as a potentially modifiable protective factor warranting further investigation. As suicide prevention efforts increasingly recognize the importance of holistic care addressing biological, psychological, social, and spiritual dimensions of human experience, research clarifying spiritual health’s role in high-risk populations becomes ever more critical. Future longitudinal and intervention research will be essential for translating these correlational findings into evidence-based practices that reduce suffering and save lives among individuals vulnerable to suicidal behavior.

Author contributions

The authors confirm their contribution to the paper as follows: All authors were involved with the conception and study design. Study conception and design: MMJ, AK, LM, MM, MSN; data collection: AK, LM, MMJ, MM; analysis and interpretation of results: MMJ, LM; draft manuscript preparation and edit: MMJ, AK, LM, MSN. All authors critically reviewed the entire manuscript and approved the final submission.

Funding

There are no funding sources to be declared.

Data availability

All the relevant data are within the paper.

Declarations

Ethics approval and consent to participate

This research project was approved by the Research Ethics Committee of Yasuj University of Medical Sciences with registration number IR.YUMS.REC.1403.104. All study participants provided written informed consent, ensuring that they understood the details of the study and demonstrated the ability to make informed and voluntary decisions. All participants were aged 18 years or older and each provided consent personally. The research adhered strictly to ethical standards as outlined in the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.