For decades, suicide and its associated behaviours (SB) have been considered as priority problems in the health policies of many countries and the world (78). Despite this, we do not have adequate strategies to significantly reduce its incidence. This is explained by the complex nature of this behaviour, in which sociocultural, familial, biological, and psychological aspects concur. This is what many studies conducted in different countries over several decades consistently teach (1).

Today, despite our solid knowledge of the different variables associated with this behaviour, it has not been possible to generate interventions that allow us to anticipate SB (2). This is a limitation that includes the estimation of immediate and future behaviour. Given this, many authors have raised the need to study this behaviour using methods other than traditional ones (3, 4), in what some have described as a “paradigm shift.” An example of the limitations that traditional SB risk indicators face in order to anticipate these behaviours can be seen in studies that have explored the clinical utility of SB severity ranking scales. The available evidence does not support the clinical use of these scales (5, 6). Furthermore, there is considerable agreement regarding the uselessness and eventual risk of the use of scales and other clinical instruments in order to rank suicide risk in risk subjects (7–9).

SB is infrequent even in those patients whose clinical condition is frequently associated with risk factors. An example of this is the case of having a previous history of suicide attempts. While a prior suicide attempt is one of the best predictors of suicide risk, most of those who attempt suicide will die from another cause. This shows the importance of state variables in the risk of SB. When comparing depressive patients with and without SB, we can recognise a set of variables that, when presented simultaneously, could configure a risk state for SB (10). But we can also describe what the psychic experience that precedes the suicidal behaviour is like in order to identify a particular clinical condition in those who might have SB. The latter is what Shneidman proposed when underlining the crucial role that a specific psychic state has as the antecedent of all SB: “in most cases, suicide stems from psychological pain, and the psychache itself arises from frustrated psychological needs” (11). For this important author, all SB was preceded by a state that he defined as “psychache” (12). This term describes a state of intense disturbance that has also been defined as “mental pain” (MP), “psychological pain,” and “psychic pain” by different authors (13). For many, this state represents a way of responding to adversity and suffering that seems inevitable, and that is what would incline someone to end his/her life.

The role of psychache as a mediator between circumstances, risk factors, and suicidal behaviour has led several authors to recognise the central role that psychache plays in SB (14). Several scales have been developed to recognise and identify its severity (13, 15, 16). One of the most recent proposals is the incorporation of this dimension as part of the patient-reported outcomes (PRO) in treatment outcome studies (15). But there are two difficulties in this: firstly, the capacity in those who experience this state to understand it as MP, and secondly, the difficulty for clinicians to interpret the different aspects of the mental examination under the concept of MP.

Indeed, a particular problem of SB is the knowledge that the patient has of his/her own state. It is quite possible that psychache's own deep emotional distress and disturbance prevents many subjects from being able to understand their behaviour and decisions. For some, the latter forces patients to consider the possibility of suicidal behaviour, even if they do not express it explicitly (17). If this is the case, then those who evaluate patients with severe psychiatric problems should assess the general condition of the patient without restricting themselves exclusively to what the patient says when assessing the risk of SB. This clinical problem would allow us to understand those cases of subjects who consulted for a short time before committing suicide without manifesting ideation or death plans when being evaluated. In the latter cases, it is often thought that the subjects concealed their will, and although in many cases this could have been the case, it is possible that many of them were unaware of the state of risk in which they were.

Today we have several scales to assess the severity of MP and psychache that have been used in samples of very diverse groups of patients at risk of suicide (adolescents, students, the elderly, migrants, patients with a history of high-risk suicide attempts). As some point out, “mental pain provides the clinical threshold that is essential for determining the amount of distress that is worthy of clinical attention, in conjunction with diagnostic criteria. It may be a better specification of the criteria on ‘clinically significant distress' that frequently recurs in DSM IV” (13). On the other hand, this state would be a factor associated with suicide independent of the diagnosis. MP can be established progressively during the different stages of suicidal behaviour—ideation, attempt, and suicide—as a continuous phenomenon. The association of other factors with the state of MP could increase or decrease its intensity. Although these scales help to assess the severity of MP, it is not enough to recognise its existence and severity, since it is necessary to know for each subject what factors explain this state in her/him. The latter is what a good clinical interview should achieve by identifying what facts and factors promote this state in each individual subject (13). Research on suicidal behaviour has always tried to find what might prevent it. For some, the task should be broader, since the research should also be directed to identify aspects that could be a target for intervention: “Existing suicide prediction models which attempt to pinpoint the patients at highest suicide risk, do not tell us which suicide-focused treatments are right for which patient. This is the key clinical question critics of suicide risk screening have in mind when they say in-depth clinical assessments should focus on need for treatment rather than risk of suicide” (7). By establishing the determining factors of MP for each patient, we could then define interventions to mitigate the impact of this state according to highly individual needs.

The aim of this study is to contribute to the accuracy of the understanding of MP in suicide risk through a qualitative review of 73 studies that present findings about the state and experience associated with MP in suicide risk. This information will help clinicians to guide the clinical interview to assess those areas of psychic life typically associated with MP. For this purpose, we have selected studies conducted to evaluate MP or Psychache following the same criteria used by the authors of a recent major review (14). Our findings seek to translate the information from many studies carried out in diverse populations into the clinic.

MP is a transdiagnostic construct which has been recognised as one of the most important proximal predictors of suicidal risk well beyond depression (14, 18, 19). “MP is also understood as “psychache” (20) and defined as an acute state of intense psychological pain associated with negative cognitive and emotional aspects of the self—i.e., thoughts of self-disappointment or inadequacies and feelings of guilt, anguish, fear, panic, angst, loneliness, and helplessness often accompanied by a sense of disconnection, loss, or incompleteness of the self (13, 21, 22).

Aspects that stand out in suicidal MPs are certain experiences of connectedness and impulsivity. On the one hand, connectedness would be associated with: feeling socially excluded; loneliness-even when apparently accompanied by others; not having mutual and satisfactory interpersonal relationships; perception of being a burden to others. This is linked [according to the Interpersonal Theory of Suicide proposed by Joiner (23)] to an acquired capacity to commit suicide. Impulsivity, on the other hand, MP would be related to the experience of out-of-control expressions of aggression, trait anger, risk-taking behaviours in the face of intolerable and impossible to communicate experiences in requesting help (24).

With regard to the above, a development of clinical interventions aimed at addressing connectedness and the management of reactive impulsivity would be especially beneficial for clinical interventions. This would be particularly useful in critical services such as psychiatric emergencies and in the case of pathologies usually associated with suicidal risk, such as depressive disorders, dependencies, psychotic disorders, eating disorders and personality dysfunctionalities (25, 26).

MP is viewed as stemming from the discrepancy between the ideal and the actual perception of oneself, accompanied by the awareness of one's role in the experience of emotional pain (13). This suffering would be found around a perception of the gap between what we want and what we can have. Along with the realisation of the existence of this gap, there is a certain impossibility of tolerating this gap. MP sufferers accept that the gap exists and are unable to intuit alternatives to find solutions besides death.

We agree with the literature demonstrating that the moment bordering on suicidal ideation and attempt is affected by a particular emotional transitory state and a personality style characterised by traits that lead to the activation of suicidal risk.

A psychological state is a construct defined as characteristic patterns of thinking, feeling, and behaving in a concrete situation at a specific moment in time; it is a transitory experience that can be affected by external events and by internal movements of the self. State variables such as depression, hopelessness, and anxiety have been shown to have a significant relationship with suicide risk (27).

Other factors include stable or enduring differences between individuals. Such long-term tendencies, sometimes referred to as traits, could be a wistful temperament, genetic predisposition, personality style (27), or characteristic patterns or tendencies of thinking, feeling, and behaving that generalise across similar situations, differ systematically between individuals, and remain rather stable across time (28). Self-destructiveness, poor impulse control, and antisocial behaviour are among the main suicide risk factors observed in suicidal patients with personality dysfunctions (29).

Our purpose through this comprehensive study is to pinpoint those factors most commonly associated with suicide risk, as shown by studies examining MP and suicide. Using this information, we propose clinical interventions that would allow us to reduce the state of MP.

We carried out a comprehensive review of scientific publications that studied the concept of mental pain, offering a high-quality data synthesis of the studies, according to the following search criteria:

This inquiry yielded 73 studies. The details are shown in Table 1. The heterogeneity of the resulting scientific articles in terms of methods and sample types made it impossible to gather criteria for quantitative analysis. Given the above, we performed a qualitative analysis in three successive steps:

In the next step of the analysis, the groupings obtained were assembled under concepts of abstraction, as shown below:

Grouping by similarity allowed us to guide the clinical reflection of these maladaptive ways of being with oneself and with others in order to select pertinent psychotherapeutic interventions for these conditions that are associated with suicidal risk. We discuss the clinical recommendations in the final section.

To visualise the words that emerged in the analysis, they were organised in proportion to the number of times they appeared in the revised texts. We extracted those words that appeared at least 10 times and presented them in word clouds. This criterion had the simple function of ensuring that the words were visible in the graph, as words with lower frequencies would be too small to be clearly seen.

For the diagramming, we used the free online program EdWordle, a tool that organises word clouds based on Wordle using concepts or groupings of words. The result graphically shows what is presented in a text according to the weight of the words as a whole (http://www.edwordle.net/).

The layout can be seen in Figures 1, 2 “Groupings of concepts of state in mental pain (diagnosis and psychological experience, respectively)” and in Figure 3 “Groupings of concepts of traits in mental pain.”

Finally, in the discussion, we propose strategies to use these findings in such a way that they serve as a response to difficult circumstances, interpersonal adversities, and psychological suffering that seems inevitable and is intolerable. This can be oriented toward aspects such as

1) the clinical interview in the evaluation of patients with probable risk of suicide and

2) therapeutic interventions in different stages of the treatment of subjects with suicidal risk from the first clinical interview onwards (Figure 4).

The 73 studies reviewed had different characteristics, amongst which the following stand out:

The works included different methods and approaches. Most of them were done in adult samples. Not all studies detailed the sex and age of the patients, and some that obtained information from the internet were unable to establish the samples' demographic characteristics. There were 56 studies with quantitative methods, most of them comparing the results between different samples; 4 studies used qualitative analysis with smaller samples, and 2 studies used mixed methods. There were 4 reviews, 3 systematic reviews, 1 cross-sectional survey, and 2 studies that followed different methods. There were 2 studies in which a follow-up of close to 1 year was carried out. While most of the studies came from the United States, there were three Portuguese studies, two Canadian, and four Chinese. The reviewed studies are detailed in Table 1.

We analysed the information through an abstraction exercise that allowed us to classify different items in ordered groups under a common notion. The content analysis was structured based on the personality theory perspective of states and traits in suicidal mental pain. There are different factors that shape personality and can lead to dysfunctionalities in coping with areas of life: the genetic load that has been inherited from family biology; learning to deal problematically with emotions and interpersonal relationships in childhood; life events that cause prolonged stress; and traumatic childhood experiences, such as abuse, neglect, loss of caregivers, and bullying, among others. Dysfunctionalities can be increased or decreased, depending on history and context, leading to states of greater or lesser emotional well-being and impacting the relationship with oneself, interpersonal relationships, and quality of life (30).

The analysis provided a list of 607 variables, which an exercise of conceptual abstraction led us to group according to clinical criteria, differentiating those that are transitory from those that are relatively stable over time. The transient variables include the mental pain psychological states in suicide, and relatively stable variables include the mental pain psychological traits in suicide.

The purpose of this paper is to contribute to the accuracy of the understanding of MP in suicide risk. Through a qualitative review of content, we have found variables which can be grouped corresponding to clinical criteria, differentiating between transitory variables associated with a psychological state in suicidal MP, including diagnostic variables on the one hand and subjective experience variables on the other.

In addition, we found relatively stable personality traits in suicidal MP. Figure 3 shows the central elements of the evaluation of a patient who might be suffering from MP. Each of the factors is a reminder of the facts that are paramount in this task. We have collected the results of a number of studies to highlight those aspects that are most frequently observed in a clinical population. These facts can be assessed in the first interview and at different stages of the treatment after a suicide attempt. Our recommendations are based on the identification of mental pain as the event closest to suicidal action. One of the limitations of our study on SB is that the studies selected are those that include MP, which leaves out many very valuable papers conducted from different perspectives. We understand that the problem of suicide is extraordinarily complex, and therefore, when evaluating the experience of mental pain, we can recognise the manifestation of a diversity of facts in a similar state.

The main task for clinicians is to identify what contributes to encouraging or attenuating psychic pain in the subject's relationships with him/herself and with others. To reduce psychic pain, interventions must be directed at those factors that determine MP in everyone. The treatment of axis I disorders (DSM-V) is a priority and has been sufficiently described for each of the pathologies by means of various clinical guidelines and systematic reviews. We will review other state variables, such as hopelessness, unbearable suffering, loneliness, and psychological pain, when describing clinical strategies and the proper psychotherapeutic interventions.

The different groups of factors associated with suicide—namely personality and individual differences, cognitive factors, social factors, and adverse life events (1)—play roles in the different stages of this behaviour. According to the integrated motivational-volitional model proposed by O'Connor, SB has a pre-motivational phase that includes background factors and triggering events: diathesis, environment, and life events; a motivational phase, in which ideation and intention build up; and a volitional phase, where the behaviour is enacted. MP takes place in the motivational phase, in which diverse psychological factors might lead a subject to experience a feeling of humiliation and defeat, followed by a perception of entrapment that might lead him/her to conceive of SB as the only way to alleviate mental pain. It is in the motivational phase where the presence or absence of factors might show a risk or a protective role. It is within that phase—which has a limited time frame—that those interventions might play a critical role in helping someone to avoid SB. The myriad of possible factors that might be relevant to someone's actions obliges us to select the most relevant ones leading to MP in each individual case. There doesn't seem to be a better way to approach this clinical plight. To prevent the subject from acting, we must single out the sources of individual psychological distress, addressing individual needs to foster preventive strategies (32).

All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.

This work was funded by the Department of Psychiatry of the School of Medicine at the Pontificia Universidad Católica de Chile. The study received funding from ANID – Millennium Science Initiative Program/Millennium Institute for Research on Depression and Personality (MIDAP) ICS13_005.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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