From emotional invalidation to suicide risk: the role of depression and sense of coherence in a moderated mediation model

From emotional invalidation to suicide risk: the role of depression and sense of coherence in a moderated mediation model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From emotional invalidation to suicide risk: the role of depression and sense of coherence in a moderated mediation model Nicole Bungaro, Cecilia Blandizzi, Michela Balsamo, Anna Contardi, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6662755/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Depression is one of the most common psychiatric disorders associated with suicide risk. Several factors can influence the development of depressive symptoms and the emergence of pre-suicide mental states, including invalidating environments. Specifically, emotional invalidation is associated with both depression and increased suicide risk. However, protective factors, such as high levels of sense of coherence (SOC), may buffer against these negative effects by helping individuals process their experiences. The buffering role of SOC in the emergence of depression and suicide risk has not yet thoroughly investigated. Thus, this study aimed to: a) clarify whether depression could mediate the relationship between perceived emotional invalidation and suicide risk, measured as severity of mental states prodromic of suicide; and b) investigate whether SOC could moderate the pathway linking emotional invalidation, depression, and suicide risk. Methods: 399 adults (73% females; age 33.5±15.7) were recruited from the general Italian population. All participants were administered self-reported questionnaires assessing depression, sense of coherence, perceived invalidation of emotion, the presence of past suicide behaviours, and current pre-suicide mental states. Results: Higher suicide risk was strongly associated with depression (rho = 0.74) and SOC (rho = -0.73), and moderately with emotional invalidation (rho = 0.50) in the bivariate analyses. However, at the multivariate level, emotional invalidation was not significantly associated with suicide risk. The moderatedmediation model indicated that depressive symptoms partially mediated the relationship between perceived emotional invalidation and the severity of mental states prodromic of suicide, after controlling for the presence of past suicidal behaviours, explaining 36% of the common variance. Furthermore, a high level of SOC moderated the impact of emotional invalidation on depression. Conclusions: Invalidating environments may contribute to the development of emerging distress symptoms and increased suicide risk, particularly in individuals with limited coping resources. Promoting a strong sense of coherence could serve as a protective factor, helping individuals find meaning in their life and better cope with everyday stressors, thus limiting depressive states and reducing emerging suicidality. Perceived invalidation Suicide Sense of coherence Depression Distress symptoms. Figures Figure 1 1. Introduction It is recognized that the risk of suicide is a consequence of the interplay between predisposing (e.g., familiar and genetic factors, and early-life adversity) and precipitating factors (e.g., psychiatric disorders, psychological and environmental factors) [ 1 ]. Previous research evidenced that almost all psychiatric disorders have raised risk for suicide [ 2 ], with depressive syndromes being one of the most prevalent disorders present in suicide victims and attempters [ 3 ]. There are several potential factors that can influence the emergence of depression and other mental states precursor of suicide (e.g., suicide ideation, hopelessness, psychache, tunnel vision), such as having lived in invalidating environments [ 4 ]. In invalidating environment, family members may ignore, minimize or punish a child’s emotional experiences [ 5 ]. Emotional invalidation may also occur during adulthood, when a person perceives that significant people disconfirm or judge negatively his/her emotional experiences [ 6 ]. The invalidation of emotions has been linked to severe neuropsychiatric disorders, such as borderline personality disorder, and it may also act as a precursor to affective distress (i.e., depression, anxiety), conditions both strongly related to suicide [ 7 , 8 ]. Furthermore, emotional invalidation could be associated with difficulties in emotional regulation [ 9 ]. This association is central to Joiner’s Emotional Cascades Hypothesis [ 10 ], which addresses how invalidation intensifies challenges in coping with certain emotions among emotionally dysregulated individuals, who often have a history of suicide attempts [ 11 ]. A recent study suggested that emotional invalidation could help to discriminate people with and without suicide ideations and/or behaviours [ 12 ]. However, this relationship could be explaining and mediate by other variables, such as the presence of depressive symptoms [ 4 ]. The hypothesis that depression could mediate the association between emotional invalidation and suicide risk was investigated and confirmed in a recent study [ 13 ]. Moreover, Leahy and colleagues [ 14 ] found a negative correlation between emotional validation and depressive symptoms, suggesting that emotional validation could normalize depression and reduce feelings of shame and guilt, while emotional invalidation could worsen the difficulties in regulating one’s emotions and lead to the emergence of depressive feelings. Nevertheless, people could eventually develop abilities useful to cope and resist with stress, and reduce the risk to develop depression and other mental states prodromic of suicide when facing negative life events and invalidating environments. Sense of Coherence (SOC) is defined a global orientation that reflects an individual’s stable tendency to perceive the world as comprehensible, manageable, and meaningful [ 15 ]. Having high levels of coherence may allow individuals to integrate and balance both positive and negative experiences, promoting health and well-being [ 16 ]. Conversely, people low in sense of coherence could be more predisposed to develop depression [ 17 – 20 ] and an increased risk for suicide [ 21 – 24 ]. Therefore, SOC would appear to be a protective factor for depressive symptoms and suicide risk [ 25 ]. Indeed, a study explored the role of SOC in the relationship between emotional neglect and mental health outcomes in the adulthood, and found that higher levels of SOC moderated significantly this relationship and reduced the negative effects of early-life adversities [ 26 ]. Similarly, sense of coherence could also moderate the effects of emotional invalidation. As far as we know, no prior studies have investigated the moderating role of SOC in the pathway linking emotional invalidation to increased suicide risk via the emergence of depressive symptoms. Since the variability in how individuals perceive critical behaviours depends on several factors [ 5 ], addressing this gap could provide valuable insights into protective mechanisms that mitigate the impact of emotional invalidation on the development of depression and suicide risk. Recently, mental states prodromic of suicide have been taken to the centre of the scientific debate and newer constructs, such as the Suicide Crisis Syndrome (SCS) [ 27 ] and the Acute Suicidal Affective Disturbance (ASAD) [ 28 ], have been introduced and their importance increased. Mental states prodromic of suicide and the pre-suicidal mind have been investigated to increase our ability to assess suicide risk in the short term and to prevent suicide behaviours, capturing the true essence of suicide [ 29 ]. Thus, in the present study we investigated whether invalidation of emotions could be related to the presence of mental states prodromic of suicide and, if so, whether depression could explain at least partly this relationship by acting as a mediator. Additionally, we aimed to establish whether a strong sense of coherence could moderate the relationship between emotional invalidation and depression, and between emotional invalidation and the emergence of mental states prodromic of suicide. 2. Methods 2.1 Participants and procedure A cross-sectional study was conducted on a sample of 399 adults (73% females) incidentally recruited from the general Italian population, between April 2023 and December 2024. The mean age of the participants was 33.5 (SD = 15.7; range = 19–80) years (see Table 1 ). The inclusion criteria were age ≥ 18 years and the ability to complete the online assessment. Exclusion criterion were age < 18 years and the presence of any conditions that affect the ability to complete the assessment, including refusal of informed consent. The sample was recruited online, through advertisement on social media (e.g., facebook) and in university campuses. All participants voluntarily agreed to participate in the study, providing written informed consent. The assessment protocol was administered through Google Modules. Due to the anonymous nature of the survey, only minimal demographic data were collected. Participants' confidentiality was guaranteed, excluding the possibility for the participants to include in their responses any information other than those variables collected from the sociodemographic checklist and from questionnaires. Furthermore, Google Modules did not collect participants' email addresses or any other personal information. Before completing the assessment protocol, all participants were presented with a module explaining the study objectives, the rights of the individual according to the EU Regulation no. 2016/679 and Italian Personal Data Protection Code (D.Lgs. no. 196/2003), and information about emergency telephone numbers. At the end of this module, the participant had to select either the response “I read my rights according to the Italian Personal Data Protection Code, and I give my informed consent to participate in the study” or the response “I do not give my informed consent to participate in the study”, and to submit their response. The assessment protocol was presented only to those who provided their informed consent. An average of 15 min was requested to complete the assessment protocol. Each questionnaire was presented on a separate screen, and the participant was asked to submit each screen before being presented with the next questionnaire. Furthermore, responses to all the variables were mandatory, and no missing values were allowed. Participants had not received any payment or other compensation (i.e., academic credits) for their participation. The study was approved by the Ethics Committee of the European University of Rome (Rome, Italy) and was performed according to the Helsinki Declaration standards. 2.2 Measures A checklist assessing socio-demographic (i.e., age, sex, school attainment, marital status, and job status) and clinical variables (presence of self-reported psychiatric diagnosis, recent stressful life events, alcohol abuse in the past 12 months, and illicit drug or legal highs use in the past 12 months), and Italian versions of questionnaires assessing: perceived invalidation of emotions [ 6 ], depressive symptoms [ 30 ], sense of coherence [ 31 ], mental states prodromic of suicide, and past suicide behaviours [ 32 ] were administrated to all participants. Perceived Invalidation of Emotion Scale (PIES) [ 6 ]. The PIES is a 10-item self-report scale evaluating current (past month) perceived emotional invalidation, as a general environmental characteristic rather than nesting it within one or more particular relationships. Participants have to consider “how often others” respond to shared emotions in the described manner on a 5-point Likert scale (from 1 – “almost ever” , to 5 – “almost always” ). The psychometric properties of the PIES ware confirmed in others studies [e.g., 33,34]. Cronbach’s alpha in the present sample was 0.92 for the total score. Patient Health Questionnaire-9 (PHQ-9) [ 30 , 35 ]. The PHQ-9 is a nine-item self-report questionnaire that assesses the presence/severity of depressive symptoms during the past two weeks. Each item is rated on a 4-point Likert scale (from 0 – “ absent ”, to 3 – “ present nearly every day ”). If participants indicate the presence of any problems, they are requested to respond to an additional last item asking: “How difficult have these problems made it for you to do yours work, take care of things at home, or get along with other people?”, rated on 4 points (from “ none ” to “ extreme ”). The PHQ-9 has demonstrated good psychometric properties, including robust sensitivity and specificity [ 36 , 37 ]. The total score ranges from 0 to 27, with scores ≥ 10 suggesting moderate to severe depression. Cronbach’s alpha in the present sample was 0.91 for the total score. Sense of Coherence scale (SOC-13) [ 31 , 38 ]. The SOC-13 is a self-report questionnaire, derived from the original scale of 29 questions (SOC-29) [ 39 ], that assess the three dimensions of sense of coherence (comprehensibility, manageability and meaningfulness), rated on a 7-point Likert scale (from 1 – “ never have this feeling ”, to 7 – “ always have this feeling ”). For the purpose of the present study, we used the total score, which ranges from 13 to 91. The SOC-13 demonstrated satisfactory internal consistency [ 38 ]. Cronbach’s alpha in the present sample was 0.88. Suicidal Crisis Evaluation Scale (SCES) . The SCES is a 9-item self-measure, assessing nine cognitive variables characteristics of people at risk for suicide: suicide ideation (i.e., the presence of passive or active death thoughts), controllability of ideation (i.e., difficulty in controlling thoughts about death and suicide), mental pain (i.e., the presence of unbearable despair and psychological pain), pessimism (i.e., the belief that nothing good is possible in the future), tunnel vision (i.e., the tendency to focus on suicide the only solution possible for one’s own problems), overgeneral memory (i.e., the propensity to retrieve only negative memories), unbearability (i.e., the belief that one’s situation is unpleasant and it is hard/impossible to accept), Sense of Agency (i.e., the feeling of [loss of] control over one’s actions), perceived burdensomeness (i.e., the belief that we are a burden and one’s death will be beneficial for others). Items were devised by authors of the present study following an analysis of the literature and models that suggested precipitating mental states associated with suicide [ 40 – 43 ]. Each item consists of groups of statements reflecting the different presence of the variable. The participant has to select the statement that best represents how they felt at the worst moment in the last 3 months. Cronbach’s alpha in this sample was 0.84 for the total score. Suicidal History Self-Rating Screening Scale (SHSS) [ 32 ]. The SHSS is composed of 32 items that assess suicidal ideation (i.e., death wishes, active suicide ideation), suicide planning, and suicide behaviours (i.e., suicide attempts, interrupted or self-interrupted attempts, and preparatory acts) over the last 12 months and throughout lifetime except in the last 12 months. Participants have to respond to items on a 4-level Likert-type scale. This questionnaire was derived from the original 18-item version, and exhibited satisfactory reliability and validity in previous study [ 32 ]. In the present study, we used only items assessing suicide behaviours from the Lifetime schedule (SB_Life), which showed a satisfying reliability (Cronbach’s alpha = 0.95). 2.3 Statistical analysis All the analyses were performed with the Statistical Package for Social Sciences (SPSS v.25.0). The data were examined before conducting statistical analyses. No missing data were present in the dataset. A post-hoc power analysis [ 44 ] was conducted using the R package ‘ prw ’ [ 45 ]. Statistical power was determined as a function of the effect size (medium: f 2 = 0.15), significance level ( α = 0.05), sample size (N = 399), and the number of predictors and covariates (K = 6), resulting in a power of 0.999. Skewness and kurtosis indices were computed to assess the distribution shape of the size variables within the sample. Since not all investigated variables met the normality assumptions, the relationships between variables at the bivariate level were evaluated using Spearman's correlation coefficient (rho), which ranges from − 1 to + 1, with the following interpretations: correlations are considered strong when rho > 0.50, moderate when rho is between 0.30 and 0.50, weak when rho is between 0.10 and 0.30, and negligible or absent when rho < 0.10 [ 44 ]. All variables that were statistically significant in the bivariate analyses were incorporated into a generalized linear model (GLM) with suicide risk as the dependent variable. Odds ratios (OR) and their 95% confidence intervals (CI) were reported as measures of association. The likelihood ratio chi-square (χ²) test and its corresponding p-value were reported as measure of model fit. Multicollinearity was assessed using the tolerance index and the variance inflation factor (VIF); a VIF exceeding 10 and a tolerance value below 0.10 suggest potential multicollinearity issues [ 46 ]. Since perceived emotional invalidation was not associated with suicide risk in the GLM, and in line with the study hypothesis, we tested whether depression could mediate the relationship between emotional invalidation and suicide risk. Additionally, we evaluated whether the sense of coherence could moderate the relationship between the independent variable and the dependent variable, or between the independent variable and the mediator, while controlling for the presence of lifetime suicide behaviours. Moderated mediation analyses were conducted using the PROCESS macro (models no. 7 and 8), which employs ordinary least squares (OLS) regression to assess the conditional indirect effect, with a bias-corrected bootstrap procedure (5000 samples, 95% CI), examining whether the indirect effect varies across different values (low = – 1 DS; moderate = mean; high = + 1 DS), providing estimates that account for covariates [ 47 ]. All variables were transformed into z-scores to produce standardized regression coefficients, and statistical significance was established at p < 0.05 for all tests. 3. Results Sociodemographic characteristics of the sample are shown in Table 1 . Around 10% of the sample reported having received a psychiatric diagnosis in the past, and 79.2% reported having experienced stressful life events in the past 12 months. Mean scores for psychological measures are reported in Table 2 . Table 1 Sociodemographic characteristics (N = 399) Variable Number Percentage Sex Females 292 73.2 Males 103 25.8 Non binary 4 1.0 Age – Mean|SD 33.5 15.7 School attainment ≤ 8 years 6 1.5 13 years 169 42.4 16 years 92 23.1 ≥ 18 years 132 33.1 Marital status Single 229 57.4 Married 152 38.1 Divorced 14 3.5 Widow 4 1.0 Job status Unemployed 18 4.5 Employed 161 40.4 Retired 31 7.8 Students 189 47.4 Self-reported past psychiatric diagnosis 39 9.8 Stressful events in the past 12 months 316 79.2 Alcohol abuse in the past 12 months 104 26.1 Use of illicit drugs or legal highs in the past 12 months 66 16.5 Table 2 Mean scores for psychological questionnaires (N = 399) Variable Mean Standard Deviation (SD) Minimum/Maxium Skewness Curtosis SCES 4.79 4.23 0.00/22.00 1.41(SE = 0.12) 2.11(SE = 0.24) PHQ-9 6.24 6.16 0.00/28.00 1.16(SE = 0.12) 0.63(SE = 0.24) SOC-13 60.30 14.70 18.00/91.00 -0.21(SE = 0.12) -0.53(SE = 0.24) PIES 17.50 7.77 10.00/50.00 1.56(SE = 0.12) 2.05(SE = 0.24) SB_Life 4.59 4.01 3.00/23.00 2.79(SE = 0.12) 7.04(SE = 0.24) Note: SCES = Suicidal Crisis Evaluation Scale; PHQ-9 = Patient Health Questionnaire-9; SOC-13 = Sense of Coherence; PIES = Perceived Invalidation of Emotion Scale; SB_Life = Suicide Behaviours, lifetime schedule. SCES scores correlated strongly and positively with PHQ-9 scores (rho = 0.74; p < 0.001) and negatively with SOC-13 scores (rho = − 0.73; p < 0.001). SCES scores also correlated moderately and positively with PIES scores (rho = 0.50; p < 0.001) and weakly with SB_Life scores (rho = 0.23; p < 0.001) (see Table 3). Table 3. Spearman Bivariate Correlations SCES PHQ SOC PIES SB_Life SCES . 0.74 *** -0.73 *** 0.50 *** 0.24 *** PHQ-9 0.74 *** . -0.72 *** 0.52 *** 0.19 *** SOC-13 -0.73 *** -0.72 *** . -0.54 *** -0.26 *** PIES 0.50 *** 0.52 *** -0.54 *** . 0.17 *** SB_ Life 0.24 *** 0.19 *** -0.26 *** 0.17 *** . Note: SCES = Suicidal Crisis Evaluation Scale; PHQ-9 = Patient Health Questionnaire-9; SOC-13 = Sense of Coherence; PIES = Perceived Invalidation of Emotion Scale; SB_Life = Suicide Behaviours, lifetime schedule. * p < 0.05. ** p < 0.01. *** p < 0.001. The multivariate model with the SCES as the dependent variable (see Table 4 ) fitted the data well (the likelihood ratio χ² 6 = 4737.8; p < 0.001). SCES scores were significantly and positively associated with PHQ-9 severity (OR = 1.54; p < 0.001) and with SB_Life scores (OR = 1.24; p < 0.01), and negatively with SOC-13 scores (OR = 0.75; p < 0.001), while controlling for sex and age. SCES scores were not significantly associated with PIES scores (OR = 1.06; p = 0.09). Table 4 Generalized Linear Model (Criterion: SCES) Variables B SE Odds Ratios 95% Wald Confidence Interval for Odds Ratio Sign. Lower Upper Females -0.02 0.29 0.98 0.56 1.73 0.74 Age -0.01 0.01 1.00 0.97 1.01 0.68 PHQ-9 0.43 0.03 1.54 1.45 1.63 < 0.001 SOC-13 -0.29 0.01 0.75 0.73 0.77 < 0.001 PIES 0.06 0.02 1.06 1.02 1.10 0.09 SB_Life 0.21 0.03 1.23 1.16 1.31 < 0.01 Note: SCES = Suicidal Crisis Evaluation Scale; PHQ-9 = Patient Health Questionnaire-9; SOC-13 = Sense of Coherence; PIES = Perceived Invalidation of Emotion Scale; SB_Life = Suicide Behaviours, lifetime schedule. A moderated-mediation model with the sense of coherence moderating both the direct effect of perceived invalidation of emotions on suicide risk and the relationship between the independent variable (PIES) and the mediator (PHQ-9) (Model #8) indicated a no significant moderation of the direct effect (Test of highest order unconditional interaction p = 0.56). Thus, we analyzed a second model and calculated statistics with SOC-13 moderating only the relationship between the independent variable (PIES) and the mediator (PHQ-9) (Model #7) (see Fig. 1). SOC-13 moderated significantly the association between PIES scores and PHQ-9 severity (Test of highest order unconditional interaction p < 0.05; R 2 -change = 0.005), while controlling for the presence of lifetime suicidal behaviours (SB_Life). For low (– 1 DS: effect = 0.24, 95% CI = 0.16/0.32) and moderate (mean: effect = 0.17, 95% CI = 0.07/0.27) SOC-13 scores, the association between the independent variable and the mediator was significant (PIES ◊ PHQ-9), but not for high levels of SOC-13 (+ 1 DS: effect = 0.06, 95%CI = – 0.04/0.16). Moreover, depression partly mediated the association between perceived invalidation of emotions and suicide risk, accounting for approximately 36% of the total effect. Higher invalidation of emotions was also associated directly with more severe suicide risk (direct effect = 0.12, 95% CI = 0.05/0.20). The moderated mediation analyses are shown in Table 5. Table 5. Moderated mediation model B SE Odds Ratios t 95% Boot CI Lower Uppert Sign. PIES ◊ PHQ-9 0.11 0.06 1.12 3.48 0.074 0.266 < 0.01 PIES x SOC-13 ◊ PHQ-9 -0.07 0.03 0.93 -2.14 -0.139 -0.006 < 0.05 PHQ-9 ◊ SCES 0.61 0.04 1.84 16.16 0.539 0.688 < 0.001 (direct effect) PIES ◊ SCES 0.12 0.04 1.13 3.28 0.049 0.195 < 0.01 Conditional indirect effect for different levels of SOC-13: PIES ◊ PHQ-9 ◊ SCES Low (– 1 DS) 0.15 0.04 1.16 0.084 0.223 Mean 0.10 0.04 1.10 -0.034 0.174 High (+ 1 DS) 0.06 0.05 1.06 -0.044 0.156 Index of moderated mediation -0.04 0.03 0.96 -0.102 -0.003 Covariate: Suicide Behaviours, lifetime schedule. Note: PIES = Perceived Invalidation of Emotion Scale; PHQ-9 = Patient Health Questionnaire-9; SOC-13 = Sense of Coherence; SCES = Suicidal Crisis Evaluation Scale. 4. Discussion The present study explored the link between perceived emotional invalidation, depression, and suicide risk, measured as severity of mental states prodromic of suicide in line with recent literature highlighting the critical role of the pre-suicidal mind in increasing the risk for suicide [ 29 ]. Specifically, the main objective was to investigate whether emotional invalidation was related to suicide risk and whether this relationship could be partly explained by the mediating role of depressive symptoms. Additionally, we examined whether a strong sense of coherence could buffer the impact of emotional invalidation on depression and suicide risk by acting as a moderator. Emotional invalidation was found to correlate positively with both depressive symptoms and suicide risk, consistent with prior research [ 8 ]. These findings provide empirical support for the hypothesis that emotional invalidation could serve as a precursor to the emergence of pre-suicide mental states, such as suicide ideation, loss of control, mental pain, and tunnel vision [ 48 – 51 ]. It is important to note that while emotional invalidation was correlated with mental states prodromic of suicide, it was not an independent predictor of suicide risk in the multivariate model. This prompted a moderated mediation analysis to investigate the underlying mechanisms that could explain this correlation. As hypothesized, moderated mediation model showed that part of the common variance (35.86%) between perceived invalidation and the severity of mental states prodromic of suicide was explained by depression, although a significant direct effect of perceived invalidation on suicide risk was also observed. Specifically, individuals who perceived higher levels of emotional invalidation were more likely to report increased depressive symptoms, which in turn were associated with a higher suicide risk, in line with earlier studies [ 12 , 13 ]. Our results suggest that depression could play a pivotal role in the association between emotional invalidation and the emergence of pre-suicide mental states. However, sense of coherence could mitigate the detrimental effects of emotional invalidation, offering a novel insight into the role of individual differences in emotional regulation and resilience in the context of suicide risk. Specifically, in individuals with high sense of coherence emotional invalidation was not predictive of depressive symptoms. This suggests that individuals with a weaker sense of coherence may be more vulnerable to the emotional consequences of invalidating environments, increasing their risk for depression and, potentially, suicide risk. These results are consistent with previous studies suggesting that lower sense of coherence could be associated with higher levels of depression and increased suicide risk [ 19 , 24 ]. In contrast, individuals with strong SOC may be better equipped to cope with emotional invalidation, thereby reducing their susceptibility to depression and mitigating the emergence of mental states prodromic of suicide. However, the direct effects of depression and emotional invalidation on suicide risk were not moderated by sense of coherence, and the detrimental effects of invalidating environments were not fully explained by depression. This suggests that other factors, such as pre-existing mental health conditions or poor distress tolerance, could contribute to the manifestation of pre-suicide mental states in the context of invalidating environments, and that these factors are able to act also in highly resilient individuals. For instance, the literature has demonstrated that invalidation could be associated with the presence of severe difficulties in emotional regulation, consistent with the emotional cascade hypothesis [ 49 ] and the biosocial model [ 52 ], which propose that emotional dysregulation arises in invalidating contexts. Specifically, several studies have examined how experiencing invalidation encourages emotional suppression, the use of aggressive behaviours, and other dysfunctional strategies to regulate negative emotions [ 9 , 53 – 55 ]. In turn, these strategies are linked to an increased suicide risk [ 56 , 57 ]. Thus, it is plausible to hypothesize that emotional dysregulation may mediate the relationship between emotional invalidation and the emergence of suicide risk. However, our study is not useful to verify this hypothesis. Similarly, Early Maladaptive Schemas (EMSs) could provide additional insights into the relationship between perceived invalidation and suicide risk [ 58 ]. EMSs are conceptualized as organized representations of an individual's past experiences that influence current perceptions, thoughts, and behaviours [ 59 ]. Individuals with dysfunctional EMSs could engage in dysfunctional relationships, potentially leading to distress, avoidance strategies, and self-sabotaging behaviours, which significantly impact the individual's behaviour and emotional functioning [ 60 ]. Future studies are needed to explore the complex interplay of these factors and their potential cumulative effects on suicide behaviours and pre-suicide mental states. Our findings reinforce the importance of early identification and intervention strategies for individuals at risk for suicide. This aligns with recent calls for a more nuanced understanding of the pre-suicidal mind and the development of targeted interventions aimed at addressing the specific affective and cognitive states that contribute to suicide risk [ 27 – 29 , 61 ]. Although the present findings are valuable, several limitations should be considered. For instance, the cross-sectional design of the study does not allow for causal inferences. Longitudinal studies are needed to clarify the temporal dynamics between emotional invalidation, depression, and suicide risk. Additionally, all data were collected through self-administered questionnaires. While self-report measures offer advantages (e.g., ease of administration, and the ability to capture participants’ subjective experience), they are also susceptible to biases, such as social desirability, cognitive distortion, and potential under- or over-reporting of suicide risk. Moreover, our sample was drawn from the general population and predominantly consisted of females, which could limit the generalizability of the findings, as gender differences may influence the outcomes. Additionally, since specific subgroups were not examined, caution is needed in generalizing the findings to individuals from diverse backgrounds. Future studies may wish to replicate these results with a more representative sample, including clinical populations, to enhance the external validity of the findings. 5. Conclusion The current study highlights the significant role of perceived emotional invalidation in the development of mental states prodromic of suicide in the general population, with depression acting as a key mediator. Sense of coherence emerges as a protective factor, suggesting that promoting a strong SOC may enhance individuals’ ability to find meaning in their lives and cope with daily stressors when exposed to invalidating environments, thereby reducing depressive states and suicide risk. Our findings emphasize the importance of considering individual differences in emotional resilience when designing suicide prevention strategies, particularly in the context of emotional invalidation and related mental health challenges. Abbreviations CI Confidence Interval EMS Early Maladaptive Schema GLM Generalized Linear Model OR Odd Ratio PHQ Patient Health Questionnaire PIES Perceived Invalidation of Emotion Scale SCES Suicidal Crisis Evaluation Scale SB_Life Suicidal Behaviour_Lifetime schedule SD Standard Deviation SE Standard Error SOC Sense of Coherence Declarations Ethics approval and consent to participate The present study was conducted under the guidance of the declaration of Helsinki and it was approved by local research ethic committee. Written informed consent was obtained from all participants prior to their inclusion in the study. Consent for publication Not applicable. Availability of data and material The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions NB: conceptualization, investigation, methodology, validation, formal analysis, data curation, visualization, and writing–original draft; CB: conceptualization, investigation, methodology, validation, formal analysis, data curation, and writing–original draft; MB: conceptualization, investigation, and writing–review & editing; AC: conceptualization, writing–review & editing, and supervision; LC: conceptualization, investigation, and writing–review & editing; ATL: conceptualization, and writing–review & editing; CA: conceptualization, and writing–review & editing; FDV: conceptualization, and writing–review & editing; RMQ: conceptualization, and writing–review & editing; MI: conceptualization, investigation, methodology, validation, data curation, writing–review & editing, and supervision. Acknowledgements The authors would like to thank all the participants in this study for their participation. 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The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. 10.1046/j.1525-1497.2001.016009606.x . Antonovsky A. The structure and properties of the sense of coherence scale. Social Sci Med. 1993;36(6):725–33. 10.1016/0277-9536(93)90033-Z . Innamorati M, Pompili M, Serafini G, Lester D, Erbuto D, Amore M, Tatarelli R, Girardi P. Psychometric Properties of the Suicidal History Self-Rating Screening Scale. Arch Suicide Res. 2011;15(1):87–92. 10.1080/13811118.2011.540471 . Brandão T, Brites R, Hipólito J, Nunes O. The perceived invalidation of emotion scale (PIES) in a Portuguese sample: A psychometric evaluation and an item response theory analysis. Curr Psychol. 2022;41(11):7657–65. 10.1007/s12144-020-01238-6 . Jeon ME, Kurtz AJ, Udupa NS, Gratz KL, Tull MT, Joiner TE. Measurement Invariance of the Perceived Invalidation of Emotion Scale: An Examination Across Race/Ethnicity, Gender, Sexual Orientation, and Intersection of Identities. Assessment. 2024;10731911241273386. 10.1177/10731911241273386 . Mazzotti E, Fassone G, Picardi A, Sagoni E, Ramieri L, Lega I, Camaioni D, Abeni D, Pasquini P. The patient health questionnaire (PHQ) for the screening of psychiatric disorders: A validation study versus the structured clinical interview for DSM-IV axis I (SCID-I). Ital J Psychopat. 2003;9(3):235–42. Cassin S, Sockalingam S, Hawa R, Wnuk S, Royal S, Taube-Schiff M, Okrainec A. Psychometric properties of the Patient Health Questionnaire (PHQ-9) as a depression screening tool for bariatric surgery candidates. Psychosom. 2013;54(4):352–8. 10.1016/j.psym.2012.08.010 . Beard C, Hsu KJ, Rifkin LS, Busch AB, Björgvinsson T. Validation of the PHQ-9 in a psychiatric sample. J Affect Dis. 2016;193:267–73. 10.1016/j.jad.2015.12.075 . Sardu C, Mereu A, Sotgiu A, Andrissi L, Jacobson MK, Contu P. Antonovsky’s sense of coherence scale: Cultural validation of SOC questionnaire and socio-demographic patterns in an Italian population. Clin Pract Epidemiol Ment Health: CP EMH. 2012;8:1–6. 10.2174/1745017901208010001 . Antonovsky A. Unraveling the mystery of health: How people manage stress and stay well. San Francisco. 1987; 175. Shneidman ES. The suicidal mind. Guilford Press; 1997. Wenzel A, Brown GK, Beck AT. Cognitive therapy for suicidal patients: Scientific and clinical applications. Am Psychol Ass. 2009. 10.1037/11862-000 . Klonsky ED, Pachkowski MC, Shahnaz A, May AM. The three-step theory of suicide: Description, evidence, and some useful points of clarification. Prev Med. 2021;152:106549. 10.1016/j.ypmed.2021.106549 . Pompili M. On mental pain and suicide risk in modern psychiatry. Ann Gen Psych. 2024;23(1):6. 10.1186/s12991-024-00490-5 . Cohen J. Statistical Power Analysis for the Behavioral Sciences. Routledge. 2013. 10.4324/9780203771587 . 0 ed.. Champely S, Ekstrom C, Dalgaard P, Gill J, Weibelzahl S, Anandkumar A. pwr: Basic Functions for Power Analysis. R package version 1.3-0. 2020. URL https://CRAN. R- project. org/package = pwr. Hair J, Black WC, Babin BJ, Anderson RE, Tatham RL. Multivariate Data Analysis. 6th, editor Upper Saddle River NJ. Prentice-Hall; 2010. Hayes AF. Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. Guilford; 2017. Neff KD. The science of self-compassion. In: Germer C, Siegel R, editors. Compassion and Wisdom in Psychotherapy. New York: Guilford Press; 2012. pp. 79–92. Selby EA, Yen S, Spirito A. (2013). Time Varying Prediction of Thoughts of Death and Suicidal Ideation in Adolescents: Weekly Ratings over 6-month Follow-Up. J of Clin Child & Adolescent Psychol. 2013; 42(4):481–495; 10.1080/15374416.2012.736356 Klonsky ED, May AM. The Three-Step Theory (3ST): A New Theory of Suicide Rooted in the Ideation-to-Action Framework. Int J Cognit Therapy. 2015;8(2):114–29. 10.1521/ijct.2015.8.2.114 . Cardona ND, Madigan RJ, Sauer-Zavala S. How minority stress becomes traumatic invalidation: An emotion-focused conceptualization of minority stress in sexual and gender minority people. Clin Psychol: Sci Pract. 2022;29(2):185–95. 10.1037/cps0000054 . Linehan M. Cognitive-behavioral treatment of borderline personality disorder. Guilford Press; 1993. Krause ED, Mendelson T, Lynch TR. Childhood emotional invalidation and adult psychological distress: The mediating role of emotional inhibition. Child Abuse Negl. 2003;27(2):199–213. 10.1016/S0145-2134(02)00536-7 . Cheavens JS, Rosenthal MZ, Daughters SB, Nowak J, Kosson D, Lynch TR, Lejuez CW. An analogue investigation of the relationships among perceived parental criticism, negative affect, and borderline personality disorder features: The role of thought suppression. Behav Res Therapy. 2005;43(2):257–68. 10.1016/j.brat.2004.01.006 . Herr NR, Jones AC, Cohn DM, Weber DM. The impact of validation and invalidation on aggression in individuals with emotion regulation difficulties. Personal Dis: Theory Res Treat. 2015;6(4):310–4. 10.1037/per0000129 . Rajappa K, Gallagher M, Miranda R. Emotion Dysregulation and Vulnerability to Suicidal Ideation and Attempts. Cogn Therapy Res. 2012;36(6):833–9. 10.1007/s10608-011-9419-2 . Rogier G, Chiorri C, Beomonte Zobel S, Muzi S, Pace CS, Cheung MWL, Velotti P. The multifaceted role of emotion regulation in suicidality: Systematic reviews and meta-analytic evidence. Psychol Bull. 2024;150(1):45–81. 10.1037/bul0000415 . Grażka A, Strzelecki D. Early maladaptive schemas and schema modes among people with histories of suicidality and the possibility of a universal pattern: A systematic review. Brain Sci. 2023;13(8):1216. 10.3390/brainsci13081216 . Young JE, Klosko JS, Weishaar ME. Schema therapy: A practitioner’s guide. Guilford Press; 2006. Dadomo H, Grecucci A, Giardini I, Ugolini E, Carmelita A, Panzeri M. Schema therapy for emotional dysregulation: Theoretical implication and clinical applications. Front in Psychol. 2016; 7:1987; 10.3389/fpsyg.2016.01987h Rudd MD. The Suicidal Mode: A Cognitive-Behavioral Model of Suicidality. Suicide & Life-Threat Behav. 2000; 30(1):18–33; 10.1111/j.1943-278X.2000.tb01062.x Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6662755","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":476499303,"identity":"1457a17b-2965-41c7-813f-f79f91d9a6d8","order_by":0,"name":"Nicole Bungaro","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYDACZiB+wHAAxDp4ILEBJMTYQFhLAlgLWwJMSyMBPXAtPAYHoObjt8acnfnhg4SKO4nb+dd8OPBwh00+PwNz+wN8Wiyb2YwNEs48S9w54+2GA4ln0ixnNhBwmMFhHjaJxLbDiRtunAVqaTtsAHQeMVr+gbSceQDU8p9YLQ1ALed7GIBaDhCjBeSXY8+MN9xgMwD6JdlAspmxcQZeLecPP3zwoeaO7AYg4+HPHXYG/OztDz7g04IAEglQBjNx6oGA/wDRSkfBKBgFo2CEAQADaFtTBAWSCQAAAABJRU5ErkJggg==","orcid":"","institution":"European University of Rome","correspondingAuthor":true,"prefix":"","firstName":"Nicole","middleName":"","lastName":"Bungaro","suffix":""},{"id":476499304,"identity":"0b32c5db-470a-4609-87a0-cf804a996a85","order_by":1,"name":"Cecilia Blandizzi","email":"","orcid":"","institution":"European University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Cecilia","middleName":"","lastName":"Blandizzi","suffix":""},{"id":476499305,"identity":"c64f86a2-85c6-4bcc-9207-8123ce7c3fbd","order_by":2,"name":"Michela Balsamo","email":"","orcid":"","institution":"“G. d’Annunzio” University of Chieti- Pescara","correspondingAuthor":false,"prefix":"","firstName":"Michela","middleName":"","lastName":"Balsamo","suffix":""},{"id":476499306,"identity":"8d19e8bd-2744-4fad-8939-5271d9e83f51","order_by":3,"name":"Anna Contardi","email":"","orcid":"","institution":"European University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Contardi","suffix":""},{"id":476499307,"identity":"80b73f9d-3ae0-4cb3-b5e2-a55883463ca6","order_by":4,"name":"Leonardo Carlucci","email":"","orcid":"","institution":"University of Foggia","correspondingAuthor":false,"prefix":"","firstName":"Leonardo","middleName":"","lastName":"Carlucci","suffix":""},{"id":476499308,"identity":"4d5f61ff-44ce-4053-b007-2ca089347854","order_by":5,"name":"Alejandro de la Torre-Luque","email":"","orcid":"","institution":"University of Madrid, CIBERSAM ISCIII","correspondingAuthor":false,"prefix":"","firstName":"Alejandro","middleName":"de la","lastName":"Torre-Luque","suffix":""},{"id":476499309,"identity":"869b0ebe-e78c-49cf-abf0-56b86c5ee485","order_by":6,"name":"Chiara Alessio","email":"","orcid":"","institution":"European University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Chiara","middleName":"","lastName":"Alessio","suffix":""},{"id":476499310,"identity":"59620035-8d76-47a3-b7ab-51b1fea29f2b","order_by":7,"name":"Francesco De Vincenzo","email":"","orcid":"","institution":"European University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Francesco","middleName":"","lastName":"De Vincenzo","suffix":""},{"id":476499311,"identity":"90b8251d-5875-4b0a-9059-d0100f5bd43b","order_by":8,"name":"Rossella Mattea Quinto","email":"","orcid":"","institution":"European University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Rossella","middleName":"Mattea","lastName":"Quinto","suffix":""},{"id":476499312,"identity":"f5b16ced-a146-4a98-814c-f375750b11e7","order_by":9,"name":"Marco Innamorati","email":"","orcid":"","institution":"European University of Rome","correspondingAuthor":false,"prefix":"","firstName":"Marco","middleName":"","lastName":"Innamorati","suffix":""}],"badges":[],"createdAt":"2025-05-14 09:38:28","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6662755/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6662755/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85646779,"identity":"7316ee74-d5d4-4391-b170-ab2bbb1a450a","added_by":"auto","created_at":"2025-06-30 08:43:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":24675,"visible":true,"origin":"","legend":"\u003cp\u003eModerated mediation model\u003c/p\u003e\n\u003cp\u003eSCES = Suicidal Crisis Evaluation Scale; PHQ-9 = Patient Health Questionnaire-9; SOC-13 = Sense of Coherence; PIES = Perceived Invalidation of Emotion Scale; SB_Life = Suicide Behaviours, Lifetime schedule.\u003c/p\u003e\n\u003cp\u003eOR are reported.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ep \u003c/em\u003e\u003csup\u003e*\u003c/sup\u003e\u0026lt; 0.05. \u003csup\u003e**\u003c/sup\u003e\u0026lt; 0.01. \u003csup\u003e***\u003c/sup\u003e\u0026lt; 0.001.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6662755/v1/952f291ee65d426c9fbf6a84.png"},{"id":100237261,"identity":"23191f09-9559-413b-b791-831047285cd0","added_by":"auto","created_at":"2026-01-14 12:41:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1128773,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6662755/v1/561730e3-2481-4bf3-a302-a6e70265fbd6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"From emotional invalidation to suicide risk: the role of depression and sense of coherence in a moderated mediation model","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eIt is recognized that the risk of suicide is a consequence of the interplay between predisposing (e.g., familiar and genetic factors, and early-life adversity) and precipitating factors (e.g., psychiatric disorders, psychological and environmental factors) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Previous research evidenced that almost all psychiatric disorders have raised risk for suicide [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], with depressive syndromes being one of the most prevalent disorders present in suicide victims and attempters [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. There are several potential factors that can influence the emergence of depression and other mental states precursor of suicide (e.g., suicide ideation, hopelessness, psychache, tunnel vision), such as having lived in invalidating environments [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn invalidating environment, family members may ignore, minimize or punish a child\u0026rsquo;s emotional experiences [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Emotional invalidation may also occur during adulthood, when a person perceives that significant people disconfirm or judge negatively his/her emotional experiences [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The invalidation of emotions has been linked to severe neuropsychiatric disorders, such as borderline personality disorder, and it may also act as a precursor to affective distress (i.e., depression, anxiety), conditions both strongly related to suicide [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, emotional invalidation could be associated with difficulties in emotional regulation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This association is central to Joiner\u0026rsquo;s Emotional Cascades Hypothesis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], which addresses how invalidation intensifies challenges in coping with certain emotions among emotionally dysregulated individuals, who often have a history of suicide attempts [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A recent study suggested that emotional invalidation could help to discriminate people with and without suicide ideations and/or behaviours [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, this relationship could be explaining and mediate by other variables, such as the presence of depressive symptoms [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The hypothesis that depression could mediate the association between emotional invalidation and suicide risk was investigated and confirmed in a recent study [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Moreover, Leahy and colleagues [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] found a negative correlation between emotional validation and depressive symptoms, suggesting that emotional validation could normalize depression and reduce feelings of shame and guilt, while emotional invalidation could worsen the difficulties in regulating one\u0026rsquo;s emotions and lead to the emergence of depressive feelings.\u003c/p\u003e \u003cp\u003eNevertheless, people could eventually develop abilities useful to cope and resist with stress, and reduce the risk to develop depression and other mental states prodromic of suicide when facing negative life events and invalidating environments. Sense of Coherence (SOC) is defined a global orientation that reflects an individual\u0026rsquo;s stable tendency to perceive the world as comprehensible, manageable, and meaningful [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Having high levels of coherence may allow individuals to integrate and balance both positive and negative experiences, promoting health and well-being [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Conversely, people low in sense of coherence could be more predisposed to develop depression [\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and an increased risk for suicide [\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Therefore, SOC would appear to be a protective factor for depressive symptoms and suicide risk [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Indeed, a study explored the role of SOC in the relationship between emotional neglect and mental health outcomes in the adulthood, and found that higher levels of SOC moderated significantly this relationship and reduced the negative effects of early-life adversities [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Similarly, sense of coherence could also moderate the effects of emotional invalidation. As far as we know, no prior studies have investigated the moderating role of SOC in the pathway linking emotional invalidation to increased suicide risk via the emergence of depressive symptoms. Since the variability in how individuals perceive critical behaviours depends on several factors [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], addressing this gap could provide valuable insights into protective mechanisms that mitigate the impact of emotional invalidation on the development of depression and suicide risk.\u003c/p\u003e \u003cp\u003eRecently, mental states prodromic of suicide have been taken to the centre of the scientific debate and newer constructs, such as the Suicide Crisis Syndrome (SCS) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and the Acute Suicidal Affective Disturbance (ASAD) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], have been introduced and their importance increased. Mental states prodromic of suicide and the pre-suicidal mind have been investigated to increase our ability to assess suicide risk in the short term and to prevent suicide behaviours, capturing the true essence of suicide [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, in the present study we investigated whether invalidation of emotions could be related to the presence of mental states prodromic of suicide and, if so, whether depression could explain at least partly this relationship by acting as a mediator. Additionally, we aimed to establish whether a strong sense of coherence could moderate the relationship between emotional invalidation and depression, and between emotional invalidation and the emergence of mental states prodromic of suicide.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Participants and procedure\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted on a sample of 399 adults (73% females) incidentally recruited from the general Italian population, between April 2023 and December 2024. The mean age of the participants was 33.5 (SD\u0026thinsp;=\u0026thinsp;15.7; range\u0026thinsp;=\u0026thinsp;19\u0026ndash;80) years (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe inclusion criteria were age\u0026thinsp;\u0026ge;\u0026thinsp;18 years and the ability to complete the online assessment. Exclusion criterion were age\u0026thinsp;\u0026lt;\u0026thinsp;18 years and the presence of any conditions that affect the ability to complete the assessment, including refusal of informed consent. The sample was recruited online, through advertisement on social media (e.g., facebook) and in university campuses.\u003c/p\u003e \u003cp\u003e All participants voluntarily agreed to participate in the study, providing written informed consent. The assessment protocol was administered through Google Modules. Due to the anonymous nature of the survey, only minimal demographic data were collected. Participants' confidentiality was guaranteed, excluding the possibility for the participants to include in their responses any information other than those variables collected from the sociodemographic checklist and from questionnaires. Furthermore, Google Modules did not collect participants' email addresses or any other personal information. Before completing the assessment protocol, all participants were presented with a module explaining the study objectives, the rights of the individual according to the EU Regulation no. 2016/679 and Italian Personal Data Protection Code (D.Lgs. no. 196/2003), and information about emergency telephone numbers. At the end of this module, the participant had to select either the response \u0026ldquo;I read my rights according to the Italian Personal Data Protection Code, and I give my informed consent to participate in the study\u0026rdquo; or the response \u0026ldquo;I do not give my informed consent to participate in the study\u0026rdquo;, and to submit their response. The assessment protocol was presented only to those who provided their informed consent. An average of 15 min was requested to complete the assessment protocol. Each questionnaire was presented on a separate screen, and the participant was asked to submit each screen before being presented with the next questionnaire. Furthermore, responses to all the variables were mandatory, and no missing values were allowed. Participants had not received any payment or other compensation (i.e., academic credits) for their participation. The study was approved by the Ethics Committee of the European University of Rome (Rome, Italy) and was performed according to the Helsinki Declaration standards.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Measures\u003c/h2\u003e \u003cp\u003eA checklist assessing socio-demographic (i.e., age, sex, school attainment, marital status, and job status) and clinical variables (presence of self-reported psychiatric diagnosis, recent stressful life events, alcohol abuse in the past 12 months, and illicit drug or legal highs use in the past 12 months), and Italian versions of questionnaires assessing: perceived invalidation of emotions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], depressive symptoms [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], sense of coherence [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], mental states prodromic of suicide, and past suicide behaviours [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] were administrated to all participants.\u003c/p\u003e \u003cp\u003e\u003cb\u003ePerceived Invalidation of Emotion Scale (PIES)\u003c/b\u003e [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The PIES is a 10-item self-report scale evaluating current (past month) perceived emotional invalidation, as a general environmental characteristic rather than nesting it within one or more particular relationships. Participants have to consider \u003cem\u003e\u0026ldquo;how often others\u0026rdquo;\u003c/em\u003e respond to shared emotions in the described manner on a 5-point Likert scale (from 1 \u0026ndash; \u003cem\u003e\u0026ldquo;almost ever\u0026rdquo;\u003c/em\u003e, to 5 \u0026ndash; \u003cem\u003e\u0026ldquo;almost always\u0026rdquo;\u003c/em\u003e). The psychometric properties of the PIES ware confirmed in others studies [e.g., 33,34]. Cronbach\u0026rsquo;s alpha in the present sample was 0.92 for the total score.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePatient Health Questionnaire-9 (PHQ-9)\u003c/b\u003e [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The PHQ-9 is a nine-item self-report questionnaire that assesses the presence/severity of depressive symptoms during the past two weeks. Each item is rated on a 4-point Likert scale (from 0 \u0026ndash; \u0026ldquo;\u003cem\u003eabsent\u003c/em\u003e\u0026rdquo;, to 3 \u0026ndash; \u0026ldquo;\u003cem\u003epresent nearly every day\u003c/em\u003e\u0026rdquo;). If participants indicate the presence of any problems, they are requested to respond to an additional last item asking: \u0026ldquo;How \u003cem\u003edifficult\u003c/em\u003e have these problems made it for you to do yours work, take care of things at home, or get along with other people?\u0026rdquo;, rated on 4 points (from \u0026ldquo;\u003cem\u003enone\u003c/em\u003e\u0026rdquo; to \u0026ldquo;\u003cem\u003eextreme\u003c/em\u003e\u0026rdquo;). The PHQ-9 has demonstrated good psychometric properties, including robust sensitivity and specificity [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The total score ranges from 0 to 27, with scores\u0026thinsp;\u0026ge;\u0026thinsp;10 suggesting moderate to severe depression. Cronbach\u0026rsquo;s alpha in the present sample was 0.91 for the total score.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSense of Coherence scale (SOC-13)\u003c/b\u003e [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The SOC-13 is a self-report questionnaire, derived from the original scale of 29 questions (SOC-29) [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], that assess the three dimensions of sense of coherence (comprehensibility, manageability and meaningfulness), rated on a 7-point Likert scale (from 1 \u0026ndash; \u0026ldquo;\u003cem\u003enever have this feeling\u003c/em\u003e\u0026rdquo;, to 7 \u0026ndash; \u0026ldquo;\u003cem\u003ealways have this feeling\u003c/em\u003e\u0026rdquo;). For the purpose of the present study, we used the total score, which ranges from 13 to 91. The SOC-13 demonstrated satisfactory internal consistency [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Cronbach\u0026rsquo;s alpha in the present sample was 0.88.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSuicidal Crisis Evaluation Scale (SCES)\u003c/b\u003e. The SCES is a 9-item self-measure, assessing nine cognitive variables characteristics of people at risk for suicide: suicide ideation (i.e., the presence of passive or active death thoughts), controllability of ideation (i.e., difficulty in controlling thoughts about death and suicide), mental pain (i.e., the presence of unbearable despair and psychological pain), pessimism (i.e., the belief that nothing good is possible in the future), tunnel vision (i.e., the tendency to focus on suicide the only solution possible for one\u0026rsquo;s own problems), overgeneral memory (i.e., the propensity to retrieve only negative memories), unbearability (i.e., the belief that one\u0026rsquo;s situation is unpleasant and it is hard/impossible to accept), Sense of Agency (i.e., the feeling of [loss of] control over one\u0026rsquo;s actions), perceived burdensomeness (i.e., the belief that we are a burden and one\u0026rsquo;s death will be beneficial for others). Items were devised by authors of the present study following an analysis of the literature and models that suggested precipitating mental states associated with suicide [\u003cspan additionalcitationids=\"CR41 CR42\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Each item consists of groups of statements reflecting the different presence of the variable. The participant has to select the statement that best represents how they felt at the worst moment in the last 3 months. Cronbach\u0026rsquo;s alpha in this sample was 0.84 for the total score.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSuicidal History Self-Rating Screening Scale (SHSS)\u003c/b\u003e [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The SHSS is composed of 32 items that assess suicidal ideation (i.e., death wishes, active suicide ideation), suicide planning, and suicide behaviours (i.e., suicide attempts, interrupted or self-interrupted attempts, and preparatory acts) over the last 12 months and throughout lifetime except in the last 12 months. Participants have to respond to items on a 4-level Likert-type scale. This questionnaire was derived from the original 18-item version, and exhibited satisfactory reliability and validity in previous study [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In the present study, we used only items assessing suicide behaviours from the Lifetime schedule (SB_Life), which showed a satisfying reliability (Cronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.95).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAll the analyses were performed with the Statistical Package for Social Sciences (SPSS v.25.0). The data were examined before conducting statistical analyses. No missing data were present in the dataset. A post-hoc power analysis [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] was conducted using the R package \u0026lsquo;\u003cem\u003eprw\u003c/em\u003e\u0026rsquo; [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Statistical power was determined as a function of the effect size (medium: \u003cem\u003ef\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.15), significance level (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05), sample size (N\u0026thinsp;=\u0026thinsp;399), and the number of predictors and covariates (K\u0026thinsp;=\u0026thinsp;6), resulting in a power of 0.999. Skewness and kurtosis indices were computed to assess the distribution shape of the size variables within the sample. Since not all investigated variables met the normality assumptions, the relationships between variables at the bivariate level were evaluated using Spearman's correlation coefficient (rho), which ranges from \u0026minus;\u0026thinsp;1 to +\u0026thinsp;1, with the following interpretations: correlations are considered strong when rho\u0026thinsp;\u0026gt;\u0026thinsp;0.50, moderate when rho is between 0.30 and 0.50, weak when rho is between 0.10 and 0.30, and negligible or absent when rho\u0026thinsp;\u0026lt;\u0026thinsp;0.10 [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. All variables that were statistically significant in the bivariate analyses were incorporated into a generalized linear model (GLM) with suicide risk as the dependent variable. Odds ratios (OR) and their 95% confidence intervals (CI) were reported as measures of association. The likelihood ratio chi-square (χ\u0026sup2;) test and its corresponding p-value were reported as measure of model fit. Multicollinearity was assessed using the tolerance index and the variance inflation factor (VIF); a VIF exceeding 10 and a tolerance value below 0.10 suggest potential multicollinearity issues [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Since perceived emotional invalidation was not associated with suicide risk in the GLM, and in line with the study hypothesis, we tested whether depression could mediate the relationship between emotional invalidation and suicide risk. Additionally, we evaluated whether the sense of coherence could moderate the relationship between the independent variable and the dependent variable, or between the independent variable and the mediator, while controlling for the presence of lifetime suicide behaviours. Moderated mediation analyses were conducted using the PROCESS macro (models no. 7 and 8), which employs ordinary least squares (OLS) regression to assess the conditional indirect effect, with a bias-corrected bootstrap procedure (5000 samples, 95% CI), examining whether the indirect effect varies across different values (low = \u0026ndash; 1 DS; moderate\u0026thinsp;=\u0026thinsp;mean; high\u0026thinsp;=\u0026thinsp;+\u0026thinsp;1 DS), providing estimates that account for covariates [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. All variables were transformed into z-scores to produce standardized regression coefficients, and statistical significance was established at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all tests.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eSociodemographic characteristics of the sample are shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Around 10% of the sample reported having received a psychiatric diagnosis in the past, and 79.2% reported having experienced stressful life events in the past 12 months. Mean scores for psychological measures are reported in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSociodemographic characteristics (N\u0026thinsp;=\u0026thinsp;399)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e292\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e73.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon binary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e \u0026ndash; Mean|SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool attainment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;8 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWidow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eJob status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e161\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRetired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e189\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e47.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-reported past psychiatric diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStressful events in the past 12 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e79.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlcohol abuse in the past 12 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUse of illicit drugs or legal highs in the past 12 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMean scores for psychological questionnaires (N\u0026thinsp;=\u0026thinsp;399)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStandard Deviation (SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMinimum/Maxium\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSkewness\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCurtosis\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00/22.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41(SE\u0026thinsp;=\u0026thinsp;0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.11(SE\u0026thinsp;=\u0026thinsp;0.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHQ-9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.00/28.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.16(SE\u0026thinsp;=\u0026thinsp;0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63(SE\u0026thinsp;=\u0026thinsp;0.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSOC-13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.00/91.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.21(SE\u0026thinsp;=\u0026thinsp;0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.53(SE\u0026thinsp;=\u0026thinsp;0.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePIES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.00/50.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.56(SE\u0026thinsp;=\u0026thinsp;0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.05(SE\u0026thinsp;=\u0026thinsp;0.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSB_Life\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.00/23.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.79(SE\u0026thinsp;=\u0026thinsp;0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.04(SE\u0026thinsp;=\u0026thinsp;0.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003eNote: SCES\u0026thinsp;=\u0026thinsp;Suicidal Crisis Evaluation Scale; PHQ-9\u0026thinsp;=\u0026thinsp;Patient Health Questionnaire-9; SOC-13\u0026thinsp;=\u0026thinsp;Sense of Coherence; PIES\u0026thinsp;=\u0026thinsp;Perceived Invalidation of Emotion Scale; SB_Life\u0026thinsp;=\u0026thinsp;Suicide Behaviours, lifetime schedule.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eSCES scores correlated strongly and positively with PHQ-9 scores (rho\u0026thinsp;=\u0026thinsp;0.74; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and negatively with SOC-13 scores (rho\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.73; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). SCES scores also correlated moderately and positively with PIES scores (rho\u0026thinsp;=\u0026thinsp;0.50; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and weakly with SB_Life scores (rho\u0026thinsp;=\u0026thinsp;0.23; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (see Table\u0026nbsp;3).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003eTable 3. Spearman Bivariate Correlations\u003c/div\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHQ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSOC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePIES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSB_Life\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.74\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.73\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHQ-9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.74\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.72\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.52\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.19\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSOC-13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.73\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.72\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.54\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.26\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePIES\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.52\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.54\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSB_ Life\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.19\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.26\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003eNote: SCES\u0026thinsp;=\u0026thinsp;Suicidal Crisis Evaluation Scale; PHQ-9\u0026thinsp;=\u0026thinsp;Patient Health Questionnaire-9; SOC-13\u0026thinsp;=\u0026thinsp;Sense of Coherence; PIES\u0026thinsp;=\u0026thinsp;Perceived Invalidation of Emotion Scale; SB_Life\u0026thinsp;=\u0026thinsp;Suicide Behaviours, lifetime schedule.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e*\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. \u003csup\u003e**\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01. \u003csup\u003e***\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe multivariate model with the SCES as the dependent variable (see Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e) fitted the data well (the likelihood ratio \u0026chi;\u0026sup2;\u003csub\u003e6\u003c/sub\u003e = 4737.8; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). SCES scores were significantly and positively associated with PHQ-9 severity (OR\u0026thinsp;=\u0026thinsp;1.54; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and with SB_Life scores (OR\u0026thinsp;=\u0026thinsp;1.24; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and negatively with SOC-13 scores (OR\u0026thinsp;=\u0026thinsp;0.75; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while controlling for sex and age. SCES scores were not significantly associated with PIES scores (OR\u0026thinsp;=\u0026thinsp;1.06; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.09).\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eGeneralized Linear Model (Criterion: SCES)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eOdds\u003c/p\u003e\n \u003cp\u003eRatios\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e95% Wald Confidence Interval for Odds Ratio\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSign.\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePHQ-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSOC-13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePIES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSB_Life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\"\u003e\n \u003cp\u003eNote: SCES\u0026thinsp;=\u0026thinsp;Suicidal Crisis Evaluation Scale; PHQ-9\u0026thinsp;=\u0026thinsp;Patient Health Questionnaire-9; SOC-13\u0026thinsp;=\u0026thinsp;Sense of Coherence; PIES\u0026thinsp;=\u0026thinsp;Perceived Invalidation of Emotion Scale; SB_Life\u0026thinsp;=\u0026thinsp;Suicide Behaviours, lifetime schedule.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eA moderated-mediation model with the sense of coherence moderating both the direct effect of perceived invalidation of emotions on suicide risk and the relationship between the independent variable (PIES) and the mediator (PHQ-9) (Model #8) indicated a no significant moderation of the direct effect (Test of highest order unconditional interaction \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.56). Thus, we analyzed a second model and calculated statistics with SOC-13 moderating only the relationship between the independent variable (PIES) and the mediator (PHQ-9) (Model #7) (see Fig. 1). SOC-13 moderated significantly the association between PIES scores and PHQ-9 severity (Test of highest order unconditional interaction \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; R\u003csup\u003e2\u003c/sup\u003e-change\u0026thinsp;=\u0026thinsp;0.005), while controlling for the presence of lifetime suicidal behaviours (SB_Life). For low (\u0026ndash; 1 DS: effect\u0026thinsp;=\u0026thinsp;0.24, 95% CI\u0026thinsp;=\u0026thinsp;0.16/0.32) and moderate (mean: effect\u0026thinsp;=\u0026thinsp;0.17, 95% CI\u0026thinsp;=\u0026thinsp;0.07/0.27) SOC-13 scores, the association between the independent variable and the mediator was significant (PIES \u0026loz; PHQ-9), but not for high levels of SOC-13 (+\u0026thinsp;1 DS: effect\u0026thinsp;=\u0026thinsp;0.06, 95%CI = \u0026ndash; 0.04/0.16). Moreover, depression partly mediated the association between perceived invalidation of emotions and suicide risk, accounting for approximately 36% of the total effect. Higher invalidation of emotions was also associated directly with more severe suicide risk (direct effect\u0026thinsp;=\u0026thinsp;0.12, 95% CI\u0026thinsp;=\u0026thinsp;0.05/0.20). The moderated mediation analyses are shown in Table\u0026nbsp;5.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv align=\"left\" class=\"colspec\"\u003eTable 5. Moderated mediation model\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tabb\" border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRatios\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% Boot\u003c/strong\u003e\u003cstrong\u003eCI\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLower Uppert\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSign.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePIES \u0026loz; PHQ-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.074\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePIES x SOC-13 \u0026loz; PHQ-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-2.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePHQ-9 \u0026loz; SCES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.539\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.688\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e(direct effect) PIES \u0026loz; SCES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eConditional indirect effect for different levels of SOC-13:\u003c/p\u003e\n \u003cp\u003ePIES \u0026loz; PHQ-9 \u0026loz; SCES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLow (\u0026ndash; 1 DS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.223\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHigh (+\u0026thinsp;1 DS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eIndex of moderated mediation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"8\"\u003e\n \u003cp\u003eCovariate: Suicide Behaviours, lifetime schedule.\u003c/p\u003e\n \u003cp\u003eNote: PIES\u0026thinsp;=\u0026thinsp;Perceived Invalidation of Emotion Scale; PHQ-9\u0026thinsp;=\u0026thinsp;Patient Health Questionnaire-9; SOC-13\u0026thinsp;=\u0026thinsp;Sense of Coherence; SCES\u0026thinsp;=\u0026thinsp;Suicidal Crisis Evaluation Scale.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"},{"header":"4. Discussion","content":"\u003cp\u003eThe present study explored the link between perceived emotional invalidation, depression, and suicide risk, measured as severity of mental states prodromic of suicide in line with recent literature highlighting the critical role of the pre-suicidal mind in increasing the risk for suicide [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Specifically, the main objective was to investigate whether emotional invalidation was related to suicide risk and whether this relationship could be partly explained by the mediating role of depressive symptoms. Additionally, we examined whether a strong sense of coherence could buffer the impact of emotional invalidation on depression and suicide risk by acting as a moderator.\u003c/p\u003e \u003cp\u003eEmotional invalidation was found to correlate positively with both depressive symptoms and suicide risk, consistent with prior research [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These findings provide empirical support for the hypothesis that emotional invalidation could serve as a precursor to the emergence of pre-suicide mental states, such as suicide ideation, loss of control, mental pain, and tunnel vision [\u003cspan additionalcitationids=\"CR49 CR50\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is important to note that while emotional invalidation was correlated with mental states prodromic of suicide, it was not an independent predictor of suicide risk in the multivariate model. This prompted a moderated mediation analysis to investigate the underlying mechanisms that could explain this correlation. As hypothesized, moderated mediation model showed that part of the common variance (35.86%) between perceived invalidation and the severity of mental states prodromic of suicide was explained by depression, although a significant direct effect of perceived invalidation on suicide risk was also observed. Specifically, individuals who perceived higher levels of emotional invalidation were more likely to report increased depressive symptoms, which in turn were associated with a higher suicide risk, in line with earlier studies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur results suggest that depression could play a pivotal role in the association between emotional invalidation and the emergence of pre-suicide mental states. However, sense of coherence could mitigate the detrimental effects of emotional invalidation, offering a novel insight into the role of individual differences in emotional regulation and resilience in the context of suicide risk. Specifically, in individuals with high sense of coherence emotional invalidation was not predictive of depressive symptoms. This suggests that individuals with a weaker sense of coherence may be more vulnerable to the emotional consequences of invalidating environments, increasing their risk for depression and, potentially, suicide risk. These results are consistent with previous studies suggesting that lower sense of coherence could be associated with higher levels of depression and increased suicide risk [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In contrast, individuals with strong SOC may be better equipped to cope with emotional invalidation, thereby reducing their susceptibility to depression and mitigating the emergence of mental states prodromic of suicide.\u003c/p\u003e \u003cp\u003eHowever, the direct effects of depression and emotional invalidation on suicide risk were not moderated by sense of coherence, and the detrimental effects of invalidating environments were not fully explained by depression. This suggests that other factors, such as pre-existing mental health conditions or poor distress tolerance, could contribute to the manifestation of pre-suicide mental states in the context of invalidating environments, and that these factors are able to act also in highly resilient individuals. For instance, the literature has demonstrated that invalidation could be associated with the presence of severe difficulties in emotional regulation, consistent with the emotional cascade hypothesis [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] and the biosocial model [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], which propose that emotional dysregulation arises in invalidating contexts. Specifically, several studies have examined how experiencing invalidation encourages emotional suppression, the use of aggressive behaviours, and other dysfunctional strategies to regulate negative emotions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. In turn, these strategies are linked to an increased suicide risk [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Thus, it is plausible to hypothesize that emotional dysregulation may mediate the relationship between emotional invalidation and the emergence of suicide risk. However, our study is not useful to verify this hypothesis. Similarly, Early Maladaptive Schemas (EMSs) could provide additional insights into the relationship between perceived invalidation and suicide risk [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. EMSs are conceptualized as organized representations of an individual's past experiences that influence current perceptions, thoughts, and behaviours [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Individuals with dysfunctional EMSs could engage in dysfunctional relationships, potentially leading to distress, avoidance strategies, and self-sabotaging behaviours, which significantly impact the individual's behaviour and emotional functioning [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Future studies are needed to explore the complex interplay of these factors and their potential cumulative effects on suicide behaviours and pre-suicide mental states.\u003c/p\u003e \u003cp\u003eOur findings reinforce the importance of early identification and intervention strategies for individuals at risk for suicide. This aligns with recent calls for a more nuanced understanding of the pre-suicidal mind and the development of targeted interventions aimed at addressing the specific affective and cognitive states that contribute to suicide risk [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the present findings are valuable, several limitations should be considered. For instance, the cross-sectional design of the study does not allow for causal inferences. Longitudinal studies are needed to clarify the temporal dynamics between emotional invalidation, depression, and suicide risk. Additionally, all data were collected through self-administered questionnaires. While self-report measures offer advantages (e.g., ease of administration, and the ability to capture participants\u0026rsquo; subjective experience), they are also susceptible to biases, such as social desirability, cognitive distortion, and potential under- or over-reporting of suicide risk. Moreover, our sample was drawn from the general population and predominantly consisted of females, which could limit the generalizability of the findings, as gender differences may influence the outcomes. Additionally, since specific subgroups were not examined, caution is needed in generalizing the findings to individuals from diverse backgrounds. Future studies may wish to replicate these results with a more representative sample, including clinical populations, to enhance the external validity of the findings.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe current study highlights the significant role of perceived emotional invalidation in the development of mental states prodromic of suicide in the general population, with depression acting as a key mediator. Sense of coherence emerges as a protective factor, suggesting that promoting a strong SOC may enhance individuals\u0026rsquo; ability to find meaning in their lives and cope with daily stressors when exposed to invalidating environments, thereby reducing depressive states and suicide risk. Our findings emphasize the importance of considering individual differences in emotional resilience when designing suicide prevention strategies, particularly in the context of emotional invalidation and related mental health challenges.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEarly Maladaptive Schema\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGLM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneralized Linear Model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdd Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient Health Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePIES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePerceived Invalidation of Emotion Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSCES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSuicidal Crisis Evaluation Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSB_Life\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSuicidal Behaviour_Lifetime schedule\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Error\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSOC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSense of Coherence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study was conducted under the guidance of the declaration of Helsinki and it was approved by local research ethic committee. Written informed consent was obtained from all participants prior to their inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNB: conceptualization, investigation, methodology, validation, formal analysis, data curation, visualization, and writing–original draft; CB: conceptualization, investigation, methodology, validation, formal analysis, data curation, and writing–original draft; MB: conceptualization, investigation, and writing–review \u0026amp; editing; AC: conceptualization, writing–review \u0026amp; editing, and supervision; LC: conceptualization, investigation, and writing–review \u0026amp; editing; ATL: conceptualization, and writing–review \u0026amp; editing; CA: conceptualization, and writing–review \u0026amp; editing; FDV: conceptualization, and writing–review \u0026amp; editing; RMQ: conceptualization, and writing–review \u0026amp; editing; MI: conceptualization, investigation, methodology, validation, data curation, writing–review \u0026amp; editing, and supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the participants in this study for their participation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTurecki G, Brent DA, Gunnell D, O\u0026rsquo;Connor RC, Oquendo MA, Pirkis J, Stanley BH. 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Suicide \u0026amp; Life-Threat Behav. 2000; 30(1):18\u0026ndash;33; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1943-278X.2000.tb01062.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1943-278X.2000.tb01062.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Perceived invalidation, Suicide, Sense of coherence, Depression, Distress symptoms.","lastPublishedDoi":"10.21203/rs.3.rs-6662755/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6662755/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Depression is one of the most common psychiatric disorders associated with suicide risk. Several factors can influence the development of depressive symptoms and the emergence of pre-suicide mental states, including invalidating environments. Specifically, emotional invalidation is associated with both depression and increased suicide risk. However, protective factors, such as high levels of sense of coherence (SOC), may buffer against these negative effects by helping individuals process their experiences. The buffering role of SOC in the emergence of depression and suicide risk has not yet thoroughly investigated. Thus, this study aimed to: a) clarify whether depression could mediate the relationship between perceived emotional invalidation and suicide risk, measured as severity of mental states prodromic of suicide; and b) investigate whether SOC could moderate the pathway linking emotional invalidation, depression, and suicide risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e 399 adults (73% females; age 33.5±15.7) were recruited from the general Italian population. All participants were administered self-reported questionnaires assessing depression, sense of coherence, perceived invalidation of emotion, the presence of past suicide behaviours, and current pre-suicide mental states.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eHigher suicide risk was strongly associated with depression (rho = 0.74) and SOC (rho =\u003cbr\u003e\n-0.73), and moderately with emotional invalidation (rho = 0.50) in the bivariate analyses. However, at the multivariate level, emotional invalidation was not significantly associated with suicide risk. The moderatedmediation model indicated that depressive symptoms partially mediated the relationship between perceived emotional invalidation and the severity of mental states prodromic of suicide, after controlling for the presence of past suicidal behaviours, explaining 36% of the common variance. Furthermore, a high level of SOC moderated the impact of emotional invalidation on depression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eInvalidating environments may contribute to the development of emerging distress symptoms and increased suicide risk, particularly in individuals with limited coping resources. Promoting a strong sense of coherence could serve as a protective factor, helping individuals find meaning in their life and better cope with everyday stressors, thus limiting depressive states and reducing emerging suicidality.\u003c/p\u003e","manuscriptTitle":"From emotional invalidation to suicide risk: the role of depression and sense of coherence in a moderated mediation model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-30 08:43:52","doi":"10.21203/rs.3.rs-6662755/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6f056cee-89ee-4fa2-84f2-adb3b004b62e","owner":[],"postedDate":"June 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-14T12:40:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-30 08:43:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6662755","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6662755","identity":"rs-6662755","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}