The Roles of Attitudes Toward Suicide in Suicidal Ideation and Attempts among Chinese College Students: A Structural Equation Modeling Study

The Roles of Attitudes Toward Suicide in Suicidal Ideation and Attempts among Chinese College Students: A Structural Equation Modeling Study | 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 The Roles of Attitudes Toward Suicide in Suicidal Ideation and Attempts among Chinese College Students: A Structural Equation Modeling Study Shunyan Lyu, Zixuan Guo, Yanan Jiang, Yu Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4056776/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 Attitudes toward suicide are complex and multifaceted, and their predictive roles in suicidal ideation and suicide attempts are not well understood. Elaborating on attitudes toward suicide can help contribute to suicide prevention. The current study examined whether and how attitudes toward suicide are involved in the ideation-to-action framework of suicide among college students. A cross-sectional survey was administered to 1427 Chinese college students (mean age, 22.42 years), of whom 570 reported suicidal ideation. Participants completed questionnaires to assess their endorsed attitude toward suicide, stigmatized attitude toward suicide, self-stigma toward suicide, depression, suicidal ideation, and suicide attempts. Structural equation modeling revealed that the associations between the three types of attitudes, i.e., endorsed attitude, stigmatized attitude, and self-stigma, and suicidal ideation and suicide attempts were fully or partially mediated by depression. The results suggested that attitudes towards suicide significantly influence suicidal behaviors and future suicide prevention efforts should consider these influences. Figures Figure 1 Figure 2 1 Introduction Suicide, while not classified as a medical illness, remains a pressing public health concern (American Psychiatric Association [APA], 2013). It holds the unfortunate distinction of being the second leading cause of death among individuals aged 15 to 29 worldwide (WHO, 2019). In China, the suicide mortality rate for urban adolescents and young adults (15-24 years old) underwent a sudden surge in 2020, surpassing the levels observed in the preceding decade (National Health Commission of China, 2022). For young adult college students in China, a complex interaction of internal and external factors, encompassing mental health, family dynamics, negative life events, and the social environment, contributes to the risk of suicide (Huang & Saito, 2022; Jiang et al., 2018; Qiao et al., 2022). Previous research indicates that attitudes toward suicide can potentially serve as either protective or risk factors for suicide (Carpiniello & Pinna, 2017; Kawashima et al., 2020). The present study specifically delves into the examination of attitudes toward suicide and their influence on suicide behaviors among college students — a demographic group with an elevated risk of suicide. The findings of this research could contribute to a deeper insight into the role that attitudes play in suicidal ideation and inform suicide prevention strategies tailored to college students. The term "suicide" encompasses the act of intentionally ending one's own life (Posner et al., 2007; VandenBos, 2015). Heterogeneous definitions have been used to identify different stages of the spectrum of suicide in the past decades (Crosby, 2011; Harmer et al., 2021; Klonsky et al., 2016). For clarity and consistency, the current study adheres to the terminology and definitions proposed by Klonsky et al. (2016). Individuals experiencing suicidal thoughts are considered to have suicidal ideation, while those engaging in incomplete acts of self-harm are classified as having suicide attempts (Beck et al., 1975; VandenBos, 2015). It is crucial to distinguish between people having suicidal ideation and people having suicide attempts (Klonsky & May, 2014; Klonsky et al., 2017; Klonsky et al., 2018). Evidently, mental disorders are widely recognized as significant risk factors for suicide. Depression, in particular, has been extensively studied in the field of suicidology (Huang & Saito, 2022; Langhinrichsen-Rohling et al., 2009; Li et al., 2014; Kay et al., 2009). While depression alone may not be sufficient to determine the presence of suicidal ideation or differentiate between individuals with suicidal ideation and those with both suicidal ideation and suicide attempts (Klonsky & May, 2010; May & Klonsky, 2016; Klonsky et al., 2021), it remains a robust predictor of suicidal ideation (Brown et al., 2000; Cheng et al., 2021). Growing evidence suggests that depression plays a mediating role in the pathway from psychological distress to suicidal ideation and suicide attempts (Conejero et al., 2018; Wu et al., 2020). Consequently, depression stands as a reliable and robust factor in predicting suicidal ideation and attempts. On this basis, the present study proposed the 1 st hypothesis that depression would have a positive association with suicidal ideation and suicide attempts. In addition to depression, recent research has underscored the significance of attitudes toward suicide as a crucial factor influencing suicide (Kim & Park, 2014; Kodaka et al., 2011; Shneidman, 1993). Kawashima et al. (2020) elucidated that suicide beautification is negatively related to attitudes toward suicide prevention, while a positive association was observed between suicide stigma and suicide prevention initiatives. Similarly, tolerant and normalized attitudes toward suicide have been linked to an elevated risk of suicide attempts (McAuliffe et al., 2003). Psychometricians have developed several scales to effectively measure these and relative attitudes (Cwik et al., 2017; Domino et al., 1980; Kodaka et al., 2011; Renberg & Jacobsson, 2003). These scales categorize attitudes into distinct types, such as endorsed and stigmatized attitudes (Domino et al., 1982; Lee et al., 2007). Moreover, previous studies have investigated attitudes toward suicide and depression and found a significant association among the three constructs. Park et al. (2022) demonstrated that stronger attitudes toward suicide among Korean college students were a significant predictor of depression, which in turn was predictive of non-suicidal self-injury (NSSI), which is a recognized risk factor for suicidal ideation and attempts (Hou et al., 2022; Klonsky et al., 2014; You & Lin, 2015). Jiang et al. (2021) found that Chinese adolescents who perceived a negative attitude toward themselves from others were more likely to experience depression and NSSI. These findings collectively support the notion that attitudes toward suicide can serve as a reliable predictor of depression. The present study aims to further elucidate this relationship by examining two general types of attitudes alongside depression to gain a comprehensive understanding of their influence on suicidal ideation and attempts. For endorsed attitude toward suicide, previous studies have established a positive association between endorsed attitude and suicide attempts (Kawashima et al., 2020; McAuliffe et al., 2003). This association can be attributed to a complex interaction of cultural and social factors. From the cultural perspective, suicide is not blamed when it is committed for a good purpose in traditional Confucian societies, it would even be considered as one of the acceptable approaches (e.g., protecting virtue; Bunney et al., 2002; Fei, 2009, 2020; Zhang, 2009). Research has consistently demonstrated that individuals' endorsed attitude toward suicide plays a critical role in shaping suicide rates (Foo et al., 2014; Zhang, 2014; Zhang & Liu, 2012). From the social perspective, public media also serves as a salient influence on the formation of endorsed attitude toward suicide. Phillips (1974) proposed the concept of the "Werther effect," which suggests that media portrayals of suicide can induce imitation among susceptible individuals (Ha & Yang, 2021; Scherr & Reinemann, 2011). The rise of social media has amplified concerns about suicide contagion, a phenomenon driven by social learning mechanisms (Biddle, 2008; Choi & Noh, 2020; De Leo & Heller, 2008; Pirkis et al., 2006). Specifically, studies have shown that individuals may attempt suicide using methods they have previously observed through media exposure (Cheng et al., 2007). Moreover, mass media can disseminate a wealth of graphic and detailed information about suicide cases (Amitital & Apter, 2012; Liu et al., 2020; Luxton et al., 2012; Sedgwick, 2019), potentially strengthen one’s capability of suicide (Klonsky & May, 2014; Joiner, 2005; van Orden et al., 2010). In light of these factors, the strength of an individual's endorsed attitude toward suicide is strongly correlated with their susceptibility to suicidal behaviors (Batterham et al., 2013a; Lyu & Li, 2023; Kawashima et al., 2020). Based on the ideation-to-action framework as well as existing research on endorsed attitude, the current study proposed the 2 nd hypothesis that endorsed attitude toward suicide would have a directly positive relation with suicidal ideation and suicide attempts; and the 3 rd hypothesis that endorsed attitude toward suicide would have a positive relation with suicidal ideation and suicide attempts indirectly through depression (Fig.1). For stigmatized attitude toward suicide, studies on stigma emerged in the late 1890s and suggested that stigma is closely related to stereotyping, prejudice, and discrimination (Corrigan, et al., 2005; Link & Phelan, 2001; Major & O’Brien, 2005). As a social phenomenon, stigma exerts significant social influences. From the perspective of people who stigmatize others, Dovidio et al. (2000) proposed that stigmatizing attitude and behaviors can bolster individuals' self-esteem and social identity, serving as a means of justifying their own status quo (Zhang & Yu, 2007). Besides, in the field of suicidology, stigma is recognized as a major obstacle to suicide prevention (APA, 2022; Hom et al., 2015; Saxena et al., 2014). Suicidal behaviors and individuals who have attempted suicide or have family members who have committed suicide may be confronted with stigmatization from the public (Parker, 2014; Peters et al., 2016; Worden, 2018). Consequently, individuals with stronger stigmatized attitude toward suicide are less likely to engage in suicide attempts, as such attitudes may deter them from becoming part of the group they stigmatize. Our previous research also supports this c, demonstrating a negative association between individuals' stigmatized attitude toward suicide and their suicide behaviors (Lyu & Li, 2023). Therefore, the present study proposed the 4 th hypothesis that stigmatized attitude toward suicide would have a negative relation with suicidal ideation and suicide attempts; and the 5 th hypothesis that stigmatized attitude toward suicide would have a negative relation with suicidal ideation and suicide attempts indirectly through depression (Fig.1). Regarding the term of stigma, it can be broadly categorized into public stigma and self-stigma (Corrigan & Penn, 1999; Corrigan & Watson, 2002; Rüsch, Angermeyer, & Corrigan, 2005). Public stigma denotes the stigma held by others, and self-stigma represents the stigma held by people themselves (Corrigan, 2004; Corrigan et al., 2018; Guarneri et al., 2019; Kowalski & Peipert, 2019). Stigmatized attitude is considered a form of public stigma. Existing research has demonstrated that individuals can internalize public stigma, by leading to a process of agreement, application, and then acceptance of these negative perceptions (Corrigan & Rao, 2012; Livingston & Byod, 2010; Rimkeviciene et al., 2019). Self-stigma, the outcome of internalization, has been associated with heightened depressive symptoms (Aruta et al., 2021; Corrigan et al., 2019). Moreover, in both clinical samples and sexual minority groups, depression has been shown to mediate the association between stigma and suicide (Kaniuka, et al., 2019; Zeng et al., 2018). Hence, we proposed the 6 th hypothesis that self-stigma toward suicide would have a direct positive relation with suicidal ideation and suicide attempts; and the 7 th hypothesis that self-stigma toward suicide would have a positive relation with suicidal ideation and suicide attempts indirectly through depression (Fig.1). To test the hypotheses proposed above, we employed structural equation modeling (SEM) in three separate models to investigate whether and how attitudes toward suicide influence the ideation-to-action framework of suicide among college students. For this purpose, we recruited a sample of Chinese college students, both those with and without suicidal ideation, and administered questionnaires to assess their endorsed attitude, stigmatized attitude, self-stigma toward suicide, depression, suicidal ideation, and suicide attempts. (Please incorporate images when they enhance the content.) 2 Methods and Materials 2.1 Participants Data from 1427 Chinese undergraduate and graduate students (61.32% females; age range, 18-31 years, M = 22.42, SD = 2.67) were analyzed. Of these students, 9.82% were freshmen, 23.51% sophomores, 37.37% junior students, and 29.30% senior students or postgraduates. The current cross-sectional study was reviewed and approved by the Research Ethics Committee of BNU-HKBU United International College (Ref. No. REC-2022-01). Phone numbers and email addresses of a few local and national crisis intervention agencies in major Chinese cities were provided to all participants. 2.2 Measures Endorsed and stigmatized attitudes were separately measured by the Glorification and Stigma subscales of the Stigma of Suicide Scale – Short Form (SOSS-SF; Batterham et al., 2013a). This 5-point Likert scale focuses on endorsement and stigmatized attitudes toward suicide, and each item is responded to by indicating numbers from 1 ( strongly disagree ) to 5 ( strongly agree ). The two dimensions were assessed by calculating the total scores of all items within each subscale. The higher scores denote a stronger endorsed or stigmatized attitude toward suicide. The two subscales used in this study were extracted from a revised version of the Chinese SOSS (12 items). The Cronbach’s α of this Chinese version scale in Chinese college students has been previously reported (Glorification, .77; Stigma, .72; Han et al., 2017). In the present study, Cronbach’s α values for the Glorification subscale and Stigma subscale were .72 and .85, respectively, demonstrating good internal consistency. Depression was measured by the Patient Health Questionnaire-9 (PHQ-9; Spitzer et al., 1999), a widely used tool for measuring depressive symptoms. This 9-item questionnaire focuses on depression symptoms in the past 2 weeks of individuals. Each item is scored on a 4-point Likert scale ranging from 0 ( not at all ) to 3 ( nearly every day ; Kroenke et al., 2001; Williams, 2009). Adding up all the items yields the total score, and a higher score means a higher level of depression. Acceptable reliability and validity coefficients of this scale among Chinese community samples have been previously reported (Cronbach’s α is above .86; Wang et al., 2014). The Cronbach’s α of the scale was .84 in the current sample, demonstrating good internal consistency. Suicidal ideation was measured by the Suicidal Ideation Attributes Scale (SIDAS; van Spijker, et al., 2014). This 5-item questionnaire assesses suicidal ideation in the past month using an 11-point Likert Scale by measuring the frequency of suicide thoughts [from 0 ( never ) to 10 ( always )], the degree to which the thoughts are uncontrollable [from 0 ( no control ) to 10 ( full control )], the closeness to suicide attempts [from 0 ( not close at all ) to 10 ( made an attempt )], the distress caused by the thoughts [from 0 ( not at all ) to 10 ( extremely )], and the interference with daily activities [from 0 ( not at all ) to 10 ( extremely )]. Adding up all the items yields the total score, and a higher score means a higher level of suicidal ideation. Participants with a total SIDAS score larger than 20 were indicated a high risk of suicidal behavior. Excellent reliability coefficients of this scale among Chinese college students have been previously reported (Cronbach’s α > .91; Han et al., 2017). The Cronbach’s α of the scale was .88 in the current sample, showing excellent internal consistency. Suicide attempts were measured by the Suicide Behaviors Questionnaire-Revised (SBQ-R; Osman, 2001). This 4-item questionnaire assesses suicidal attempts by measuring the lifetime suicide-related thoughts and attempts (from 1 to 4), the frequency of suicidal thoughts in the past year (from 1 to 5), the threats of attempting suicide (from 1 to 3), and the self-reported likelihood of suicide attempts (from 0 to 6). Adding up all the items yields the total SBQ-R score, and a higher score means a higher level of suicide attempts. Participants with a total SBQ-R score larger than 6 were indicated a high suicide risk. Acceptable reliability coefficients of this scale have been reported among Chinese college students (ρ = .79, ω = .075; Huen et al., 2022). In the current study, the Cronbach’s α was .72. Self-stigma toward suicide in the 570 participants who have suicidal ideation was further measured by the Self-blame subscale of the Personal Suicide Stigma Questionnaire (PSSQ; Rimkeviciene et al., 2019). This 7-item subscale focuses on self-stigma toward suicide, and each item is ranged from 1 ( never ) to 5 ( very often ). The subscale was scored by adding up all the items, and a higher score means stronger self-blame toward suicide. Acceptable reliability coefficients of this scale among an Australian community sample have been reported (Rimleviciene et al., 2021). In the current study, the subscale was first translated into Chinese by S.L. and then double-checked by Y.L. The Cronbach’s α was .90, showing excellent internal consistency. 2.3 Data Analysis All data analyses were conducted using JASP 0.17.1.0 (JASP Team) and Amos 27.0 (IBM Corp). Pearson correlation analyses were first conducted to examine the correlations among endorsed and stigmatized suicides, depression, suicidal ideation, and suicide attempts. Bootstrapping with 10,000 times replicates was used to determine a 95% confidence interval of correlation coefficients. A multicollinearity test was conducted and assessed with the variables of variance inflation factor (VIF < 5.00; Shrestha, 2020). No multicollinearity was found in the current sample. According to Efron and Tibshirani (1993), bootstrap procedures offer an empirical means for determining statistical significance that circumvents the need to assume normality. Therefore, bootstrapping was used to due with the possible non-normal distribution of the data. To test all hypotheses as well as the hypothesized model, we followed the suggestions by Anderson and Gerbing (1988). First, confirmatory factor analyses (CFAs) were conducted to confirm the measurement models for each scale had acceptable fits. Then the hypothesized relationships were tested with the structural models. Both measurement and structural models were performed with full-information maximum likelihood estimation. Bias-corrected nonparametric percentile bootstrap method was used to test the mediating effects. Statistical significance was determined with bias-corrected bootstrapping with 10,000 re-samples. For each estimate, 95% bootstrapped confidence intervals were also calculated, and a 95% confidence interval not including zero was deemed to be statistically significant. Four indexes were used to assess the goodness of fit of the models: the comparative fit index (CFI ≥ .90; Bentler, 1990); the incremental fit index (IFI ≥ .90; Bollen, 1989), the standardized root mean square residual (SRMR ≤ .10; Kline, 2005), and the root mean square error of approximation (RMSEA ≤ .10; Hair et al., 2019; Xia & Yang, 2019). As an index which highly sensitive to sample size, Chi-square test results were also reported but not used in assessing model fit because they tend to be statistically significant due to a large sample size (Keith, 2015). 3 Results 3.1 Sample Characteristics Among all 1427 college students, 8.76% of them ( N = 125) were identified as having a high risk of suicidal behaviour in the past 30 days (total SIDAS score ≥ 21; Li et al., 2014), 28.17% of participants ( N = 402) identified as having high suicide risk in the past 1 year (total SBQ-R score ≥ 7), 94.11% ( N = 1343) classified into the normal group (score of SBQ-R Item 1 ≤ 2), and 13.33% ( N = 84) classified into the suicide-risk group (the score of SBQ-R Item 1 ≥ 3; Osman et al., 2001). Table 1 provides the descriptive statistics and intercorrelations of all variables. The results showed all the correlations were statistically significant. Of the 570 participants with suicidal ideation (i.e., total SIDAS score ≥ 0), 21.93% of them ( N = 125) were identified as having a high risk of suicidal behavior in the past 30 days (Li et al., 2014), 60.18% of participants ( N = 343) identified as having high suicide risk in the past 1 year, 86.67% ( N = 494) classified into normal group, and 13.33% ( N = 76) classified into the suicide-risk group (Osman et al., 2001). Table 2 provides the descriptive statistics and intercorrelations of all variables. The results showed all the correlations were statistically significant. 3.2 Measurement models To test the models, observed indicators of the latent constructs were used. For each latent variable, all the items of the corresponding scale were used as observable variables. The measurement model of endorsed attitude showed a good fit with χ 2 /df = 8.132, CFI = .926, IFI = .926, SRMR = .050, RMSEA = .067, 90%CI = [.063, .070]. The measurement model of stigmatized attitude showed a good fit with χ 2 /df = 7.374, CFI = .927, IFI = .927, SRMR = .056, RMSEA = .067, 90%CI = [.064, .070]. The measurement model of self-stigma showed a good fit with χ 2 /df = 3.23, CFI = .915, IFI = .916, SRMR = .060, RMSEA = .063, 90%CI = [.058, .067]. All the observed variables were significantly loaded on their respective latent variables (all p s < .001; see Online Resource 1). The results of confirmatory factor analyses demonstrated that all the scales used formed adequate measurement models, and thus provided evidence for the construct validity of the measures. 3.3 Structural Models No latent variable exhibited multicollinearity issues in all the models, as all VIFs were below 5.00. Therefore, all the latent variables were included in the analysis of structural models. The structural model of endorsed attitude (Fig.2A), which is based on all college students, showed a good fit to the data with χ 2 /df = 8.132, CFI = .916, IFI = .916, SRMR = .058, RMSEA = .071, 90%CI = [.068, .074]. The structural model of stigmatized attitude (Fig.2B) also showed a good fit with χ 2 /df = 8.266, CFI = .916, IFI = .916; SRMR = .067; RMSEA = .071, 95%CI = [.068, .074]. The structural model of self-stigma (Fig.2C), which was based on the students with suicidal ideation, showed a good fit with χ 2 /df = 3.436, CFI = .907, IFI = .907; SRMR = .067; RMSEA = .065, 95%CI = [.061, .070]. Thus, all three models were used in the subsequent bootstrapping and invariance testing analyses. A bootstrap procedure recommended by Shrout and Bolger (2002) was used to examine the significant levels of indirect effects for the mediation models. The first step in this bootstrap procedure was to create 10,000 bootstrap samples from the two original data sets respectively ( N = 1427 and N = 570) by random sampling with replacement. The second step was to run the hypothesized structural models 10,000 times separately with these 10,000 bootstrap samples to yield 10,000 estimations of each path coefficient. The third step was to save the output of the 10,000 estimations of each path coefficient in the three models to calculate an estimate of the mediating or indirect effects. We calculated the mediating pathways from endorsed attitude, stigmatized attitude, or self-stigma, through depression to suicidal ideation for each of the three models (i.e., Panel A: endorsed attitude → depression → suicidal ideation; Panel B: stigmatized attitude → depression → suicidal ideation; Panel C: self-stigma → depression → suicidal ideation). The pathways were calculated by multiplying 10,000 pairs of the path coefficients. The results from 10,000 bootstrap samples showed that the 95% CI for these indirect effects did not include zero, indicating that these indirect effects were statistically significant, with the direct effect from endorsed attitude to suicidal ideation as the only exception (Table 3). For the model with endorse attitude in Panel A, there was a complete mediating effect from endorsed attitude to suicidal ideation through depression. For the model with stigmatized attitude in Panel B, there was a suppressing effect from endorsed attitude to suicidal ideation through depression (Cheung & Lau, 2008). Specifically, the influence of the indirect effect was opposite to the direct effect. For the model with self-stigma in Panel C, there is a partial mediation from self-stigma to suicidal ideation through depression, and its mediating effect accounted for 63.04% of the variance in the total effect. 4 Discussion Elucidating attitudes toward suicide is paramount to developing effective and efficient suicide prevention strategies (Kim & Park, 2014; Kodaka et al., 2011). Anchored in the ideation-to-action framework, this study delved into the interaction between attitudes toward suicide with suicidal ideation and attempts. The results across all three models corroborated the 1 st hypothesis, underscoring depression as a reliable and robust predictor of both suicidal ideation and attempts. This finding resonates with prior research among Chinese college students (Wu et al., 2020; Zhou et al., 2021). Furthermore, the results revealed that all three types of attitudes exerted significant influences on suicidal ideation and attempts, with depression serving as the mediating factor. The hypotheses were supported for all but the 2 nd and 4 th one. The present study revealed that depression fully mediates the association between endorsed attitude and suicidal ideation. The direct path between endorsed attitude and suicidal ideation was nonsignificant. Similar relations between endorsement and suicidal ideation have been observed in previous research among college students (Batterham et al., 2013a; Joe et al., 2007; Kawashima et al., 2020; Zemaitiene & Zaborskis, 2005). This finding can be interpreted by the notion that such attitude may normalize suicide, rendering it a more acceptable, attainable, and desirable option during a psychological crisis (Gibb et al., 2006; Lee et al., 2007). Individuals with endorsed attitude toward suicide are less likely to perceive suicide as a crisis, thereby diminishing the likelihood of help-seeking behaviors and intentions (McAuliffe et al., 2003). This decreased inclination, in turn, increases their vulnerability to the relatively high risk of suicide and makes them less accessible to professional intervention (Calear et al., 2014). Future studies could delve into the specific role of help-seeking and attitude toward it in suicide and explore how attitude toward help-seeking influence the pathway from endorsed attitude toward suicide to suicidal ideation and suicide attempts. Simultaneously, stigmatized attitude toward suicide hold considerable significance in the field of suicidology. The present study demonstrated a significant negative association between stigmatized attitude and suicidal ideation, which was fully mediated by depression. Notably, the direct path between stigmatized attitude and suicidal ideation was positive but suppressed by the indirect pathway. The bootstrapping test results further indicated that the indirect path accounted for a larger proportion of variance compared to the direct path. The mediated pathway can be explained by the potential of stigmatized attitude to increase help-seeking intentions, thereby reducing depression and suicide risk (Colucci & Minas, 2013; Dovidio et al., 2000; Downs & Eisenberg, 2012). On the other hand, the direct pathway may be attributable to stigma internalization (Corrigan et al., 2019). Given that internalization processes can be obstructed and only a portion of the participants exhibited self-stigma toward suicide, the association between stigmatized attitude and suicidal ideation was relatively weak in our sample ( N = 1427) (Dreier et al., 2023; Jung et al., 2017). Distinguished from stigmatized attitude as public stigma, self-stigma emerges from the internalization of these negative perceptions, leading to exacerbated depressive symptoms and potentially contributing to suicidal ideation (Aruta et al., 2021; Corrigan et al., 2019; Kaniuka et al., 2019; Zeng et al., 2018). The present study revealed direct and indirect associations between self-stigma and suicidal ideation. Notably, self-stigma toward suicide positively influenced suicide attempts in students with suicidal ideation, with depression and suicidal ideation partially mediating this relationship. Consistent with prior research, self-stigma among students with suicidal ideation was identified as a critical predictor for further suicidal thoughts (Lyu & Li, 2023; Rimkeviciene et al., 2015). A plausible explanation is that individuals with self-stigma may experience guilt and self-blame, increasing their susceptibility to poor mental well-being and suicide, rendering self-stigma a significant barrier to seeking professional intervention (Maclean et al., 2023; Saxena et al., 2014; Williams et al., 2003). Additionally, some studies suggest that negative public attitudes may accelerate suicide attempts in individuals with suicidal ideation (Carpiniello & Pinna, 2017; Worden, 2018). Therefore, self-stigma toward suicide may expedite the process of suicide in individuals with suicidal ideation. The current study yields important implications for suicide prevention strategies. Firstly, endorsed and stigmatized attitudes toward suicide are purported to function as accelerators and barriers to suicide among all college students (Downs & Eisenberg, 2012). Therefore, mitigating endorsed attitude toward suicide should be a central focus of overarching suicide prevention efforts. As suggested by Kawashima et al. (2020), the implementation of suicide education programs and the cultivation of public awareness can effectively enhance suicide literacy and advance suicide prevention initiatives (Batterham et al., 2013a; Bunney et al., 2002; Corrigan & Penn, 1999). Several countries have implemented administrative measures to address endorsed attitude toward suicide and alleviate the risk of social media-related copycat suicide (Amitai & Apter, 2012; Domaradzki, 2021; Fahey et al., 2018). Additionally, social media platforms can contribute to suicide prevention by providing professional support and fostering the development of interpersonal connections among users (Choi & Noh, 2020; Ha & Yang, 2021; Robinson et al., 2016). Secondly, self-stigma toward suicide is associated with an increased risk of suicide among students with suicidal ideation. Suicide prevention efforts should prioritize reducing self-stigma among these students. Considering that students with self-stigma toward suicide may be less inclined to proactively seek help, one potential approach is to encourage them to engage in regular professional counseling (Drum et al., 2009; Han et al., 2018; Vogel et al., 2007). Providing regular psychological assessments and counseling services can significantly improve personal mental health and reduce suicide risk (Teismann et al., 2018; Teismann, Brailovskaia, & Margraf, 2019). Inevitably, there are some limitations regarding the current study. Firstly, it did not differentiate between self-stigma subtypes, namely perceived stigma and internalized stigma (Corrigan & Penn, 1999; Livingston & Byod, 2010). As Corrigan et al. (2011) have asserted, assessing perceived stigma alone is insufficient to elucidate its impact. The detrimental effects of stigma are primarily driven by the internalization of stigma, also known as self-stigma (Corrigan et al., 2011). Future studies should gather data on perceived stigma and, based on this information and self-stigma, delve into the internalization process of stigma (Hanschmidt, 2016; Nicholas et al., 2022). Secondly, the data collection employed a cross-sectional design, with all data gathered at a single time point. However, given the reciprocal relationship between stigma and suicide, longitudinal data may be more effective in uncovering causal links (Carpiniello & Pinna, 2017). To enhance the understanding of suicidal ideation and suicide attempts, future studies could consider conducting multi-wave longitudinal research (Franklin et al., 2017; Maclean et al., 2023). 5 Conclusions This structural equation modeling study demonstrated that depression mediates the relationship between attitudes toward suicide and suicidal ideation and attempts. 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Review of Religious Research, 54 (1), 93-111. Zhou, S. J., Wang, L. L., Qi, M., Yang, X. J., Gao, L., Zhang, S. Y., ... & Chen, J. X. (2021). Depression, anxiety, and suicidal ideation in Chinese university students during the COVID-19 pandemic. Frontiers in psychology, 12, 669833. Tables Table 1 . Intercorrelations for All Variables in the Entire Group ( N = 1427). Variable 1. Endorsed Attitude 2. Stigmatized Attitude 3. Depression 4. Suicidal Ideation 5. Suicide Attempt 1 — 2 −.56 *** [−.60, −.53] — 3 −.27 *** [.22, .33] −.25 *** [−.30, −.20] — 4 −.22 *** [.16, .27] −.12 *** [−.17, −.07] −.59 *** [.55, .63] — 5 −.17 *** [.22, .32] −.25 *** [−.30, −.20] −.64 *** [.60, .67] −.77 *** [.74, .80] — M (SD) 2.13 (±.80) 3.06 (±1.01) 5.35 (±4.04) 4.93 (±8.24) 5.67 (±2.77) Confidence intervals (95%) based on 10000 bootstrap replicates. *** p < .001. Table 2 . Intercorrelations for All Variables in the Students with Suicidal Ideation ( N = 570). Variable 1. Endorsed Attitude 2. Stigmatized Attitude 3. Self-stigma 4. Depression 5. Suicidal Ideation 6. Suicide Attempt 1 — 2 −.53 *** [−.59, −.46] — 3 −.05 *** [−.14, .04] −.15 *** [.06, .24] — 4 −.22 *** [.14, .31] −.21 *** [−.29, −.13] −.33 *** [.26, .41] — 5 −.22 *** [.04, .21] −.02 *** [−.06, .10] −.33 *** [.26, .40] −.49 *** [.42, .55] — 6 −.17 *** [.22, .32] −.14 *** [−.22, −.06] −.32 *** [.24, .39] −.57 *** [.52, .62] −.66 *** [.61, .71] — M (SD) 2.35 (±.82) 2.84 (±.97) 21.60 (±6.71) 7.71 (±4.65) 12.21 (±8.95) 7.87 (±2.84) Confidence intervals (95%) based on 10000 bootstrap replicates. ** p < .01, *** p < .001. Table 3 . Bootstrap Analyses of the Magnitude and Statistical Significance of the Estimated Mediating Effects. Independent variable Effect β SE 95% CI Panel A ( N = 1427) Direct effect (Endorsed → Suicidal Ideation) −.003 .029 −.058, .055 Indirect effect (Endorsed → Depression → Suicidal Ideation) .257 .030 .200, .318 Total effect .254 .034 .188, .321 Panel B ( N = 1427) Direct effect (Stigmatized → Suicidal Ideation) .085 .023 .041, .129 Indirect effect (Stigmatized → Depression → Suicidal Ideation) −.217 .024 −.265, −.171 Total effect −.132 .030 −.190, −.074 Panel C ( N = 570) Direct effect (Self-Stigma → Suicidal Ideation) .136 .044 .050, .222 Indirect effect (Self-Stigma → Depression → Suicidal Ideation) .232 .032 .185, .314 Total effect .368 .039 .172, .297 Additional Declarations No competing interests reported. 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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-4056776","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":277694553,"identity":"910f9af5-7d95-498a-a866-a276160cff1c","order_by":0,"name":"Shunyan Lyu","email":"","orcid":"","institution":"BNU-HKBU United International College","correspondingAuthor":false,"prefix":"","firstName":"Shunyan","middleName":"","lastName":"Lyu","suffix":""},{"id":277694554,"identity":"856849e1-103b-428b-a6b5-71bc47402e10","order_by":1,"name":"Zixuan Guo","email":"","orcid":"","institution":"University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Zixuan","middleName":"","lastName":"Guo","suffix":""},{"id":277694555,"identity":"1e5a51b9-0cda-4068-9908-c9b4619aafb1","order_by":2,"name":"Yanan Jiang","email":"","orcid":"","institution":"Macau University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Yanan","middleName":"","lastName":"Jiang","suffix":""},{"id":277694556,"identity":"31ba35e1-bf86-4906-8f51-abdf0f2b3a89","order_by":3,"name":"Yu Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAApUlEQVRIiWNgGAWjYFAC5oYDHxgkQCwDYrUwNhycQbIWZh4Ii0gtBjcSGw/btlnIM7A3b5NgqLlDlJaGw7ltEoYNPMfKJBiOPSNeSwKDRI6ZBGPDYSK1WIK0yL8hRQsj2BYeIrVInnnYcLDnnIRhG09asUXCMSK08B1PPvzhR1mdPD/74Y03PtQQoUXhAJTBBiISCGtgYJBvIEbVKBgFo2AUjGwAAPK3OPlFQF26AAAAAElFTkSuQmCC","orcid":"","institution":"BNU-HKBU United International College","correspondingAuthor":true,"prefix":"","firstName":"Yu","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-03-09 13:47:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4056776/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4056776/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52786292,"identity":"cd458f0b-04a7-424e-a758-253f88a2088b","added_by":"auto","created_at":"2024-03-15 18:49:52","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2304524,"visible":true,"origin":"","legend":"\u003cp\u003eHypothesized Structural Equation Models of the Present Study.\u003cstrong\u003e \u003c/strong\u003e− indicates a negative relation between latent variables. + indicates a positive relation between latent variables.\u003c/p\u003e","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4056776/v1/5aa6ab9681081d535ba12309.jpg"},{"id":52786396,"identity":"9815163c-19c8-432c-98b9-d43648e1c450","added_by":"auto","created_at":"2024-03-15 18:50:28","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2514756,"visible":true,"origin":"","legend":"\u003cp\u003eThe Results of the Structural Equation Models. The dashed line denotes the path coefficient was not significant. \u003csup\u003e**\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e \u0026lt; .01, \u003csup\u003e***\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e \u0026lt; .001.\u003c/p\u003e","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4056776/v1/69557df41856ee025355d823.jpg"},{"id":60579387,"identity":"f941e2c5-76a3-447b-9594-5c00a066b649","added_by":"auto","created_at":"2024-07-18 11:24:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1607073,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4056776/v1/80ceb609-381e-4a8f-ad3c-3f319c761f61.pdf"},{"id":52786417,"identity":"abfe03e4-ae31-4884-9342-c07d93003396","added_by":"auto","created_at":"2024-03-15 18:50:39","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20604,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryInformation.docx","url":"https://assets-eu.researchsquare.com/files/rs-4056776/v1/2a0d980c02829b632d8cc9d6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Roles of Attitudes Toward Suicide in Suicidal Ideation and Attempts among Chinese College Students: A Structural Equation Modeling Study","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eSuicide, while not classified as a medical illness, remains a pressing public health concern (American Psychiatric Association [APA], 2013). It holds the unfortunate distinction of being the second leading cause of death among individuals aged 15 to 29 worldwide (WHO, 2019). In China, the suicide mortality rate for urban adolescents and young adults (15-24 years old) underwent a sudden surge in 2020, surpassing the levels observed in the preceding decade (National Health Commission of China, 2022). For young adult college students in China, a complex interaction of internal and external factors, encompassing mental health, family dynamics, negative life events, and the social environment, contributes to the risk of suicide (Huang \u0026amp; Saito, 2022; Jiang et al., 2018; Qiao et al., 2022). Previous research indicates that attitudes toward suicide can potentially serve as either protective or risk factors for suicide (Carpiniello \u0026amp; Pinna, 2017; Kawashima et al., 2020). The present study specifically delves into the examination of attitudes toward suicide and their influence on suicide behaviors among college students \u0026mdash; a demographic group with an elevated risk of suicide. The findings of this research could contribute to a deeper insight into the role that attitudes play in suicidal ideation and inform suicide prevention strategies tailored to college students.\u003c/p\u003e\n\u003cp\u003eThe term \u0026quot;suicide\u0026quot; encompasses the act of intentionally ending one\u0026apos;s own life (Posner et al., 2007; VandenBos, 2015). Heterogeneous definitions have been used to identify different stages of the spectrum of suicide in the past decades (Crosby, 2011; Harmer et al., 2021; Klonsky et al., 2016). For clarity and consistency, the current study adheres to the terminology and definitions proposed by Klonsky et al. (2016). Individuals experiencing suicidal thoughts are considered to have suicidal ideation, while those engaging in incomplete acts of self-harm are classified as having suicide attempts (Beck et al., 1975; VandenBos, 2015). It is crucial to distinguish between people having suicidal ideation and people having suicide attempts (Klonsky \u0026amp; May, 2014; Klonsky et al., 2017; Klonsky et al., 2018).\u003c/p\u003e\n\u003cp\u003eEvidently, mental disorders are widely recognized as significant risk factors for suicide. Depression, in particular, has been extensively studied in the field of suicidology (Huang \u0026amp; Saito, 2022; Langhinrichsen-Rohling et al., 2009; Li et al., 2014; Kay et al., 2009). While depression alone may not be sufficient to determine the presence of suicidal ideation or differentiate between individuals with suicidal ideation and those with both suicidal ideation and suicide attempts (Klonsky \u0026amp; May, 2010; May \u0026amp; Klonsky, 2016; Klonsky et al., 2021), it remains a robust predictor of suicidal ideation (Brown et al., 2000; Cheng et al., 2021). Growing evidence suggests that depression plays a mediating role in the pathway from psychological distress to suicidal ideation and suicide attempts (Conejero et al., 2018; Wu et al., 2020). Consequently, depression stands as a reliable and robust factor in predicting suicidal ideation and attempts. On this basis, the present study proposed the 1\u003csup\u003est\u003c/sup\u003e hypothesis that depression would have a positive association with suicidal ideation and suicide attempts.\u003c/p\u003e\n\u003cp\u003eIn addition to depression, recent research has underscored the significance of attitudes toward suicide as a crucial factor influencing suicide (Kim \u0026amp; Park, 2014; Kodaka et al., 2011; Shneidman, 1993). Kawashima et al. (2020) elucidated that suicide beautification is negatively related to attitudes toward suicide prevention, while a positive association was observed between suicide stigma and suicide prevention initiatives. Similarly, tolerant and normalized attitudes toward suicide have been linked to an elevated risk of suicide attempts (McAuliffe et al., 2003). Psychometricians have developed several scales to effectively measure these and relative attitudes (Cwik et al., 2017; Domino et al., 1980; Kodaka et al., 2011; Renberg \u0026amp; Jacobsson, 2003). These scales categorize attitudes into distinct types, such as endorsed and stigmatized attitudes (Domino et al., 1982; Lee et al., 2007).\u003c/p\u003e\n\u003cp\u003eMoreover, previous studies have investigated attitudes toward suicide and depression and found a significant association among the three constructs. Park et al. (2022) demonstrated that stronger attitudes toward suicide among Korean college students were a significant predictor of depression, which in turn was predictive of non-suicidal self-injury (NSSI), which is a recognized risk factor for suicidal ideation and attempts (Hou et al., 2022; Klonsky et al., 2014; You \u0026amp; Lin, 2015). Jiang et al. (2021) found that Chinese adolescents who perceived a negative attitude toward themselves from others were more likely to experience depression and NSSI. These findings collectively support the notion that attitudes toward suicide can serve as a reliable predictor of depression. The present study aims to further elucidate this relationship by examining two general types of attitudes alongside depression to gain a comprehensive understanding of their influence on suicidal ideation and attempts.\u003c/p\u003e\n\u003cp\u003eFor endorsed attitude toward suicide, previous studies have established a positive association between endorsed attitude and suicide attempts (Kawashima et al., 2020; McAuliffe et al., 2003). This association can be attributed to a complex interaction of cultural and social factors. From the cultural perspective, suicide is not blamed when it is committed for a good purpose in traditional Confucian societies, it would even be considered as one of the acceptable approaches (e.g., protecting virtue; Bunney et al., 2002; Fei, 2009, 2020; Zhang, 2009). Research has consistently demonstrated that individuals\u0026apos; endorsed attitude toward suicide plays a critical role in shaping suicide rates (Foo et al., 2014; Zhang, 2014; Zhang \u0026amp; Liu, 2012).\u003c/p\u003e\n\u003cp\u003eFrom the social perspective, public media also serves as a salient influence on the formation of endorsed attitude toward suicide. Phillips (1974) proposed the concept of the \u0026quot;Werther effect,\u0026quot; which suggests that media portrayals of suicide can induce imitation among susceptible individuals (Ha \u0026amp; Yang, 2021; Scherr \u0026amp; Reinemann, 2011). The rise of social media has amplified concerns about suicide contagion, a phenomenon driven by social learning mechanisms (Biddle, 2008; Choi \u0026amp; Noh, 2020; De Leo \u0026amp; Heller, 2008; Pirkis et al., 2006). Specifically, studies have shown that individuals may attempt suicide using methods they have previously observed through media exposure (Cheng et al., 2007). Moreover, mass media can disseminate a wealth of graphic and detailed information about suicide cases (Amitital \u0026amp; Apter, 2012; Liu et al., 2020; Luxton et al., 2012; Sedgwick, 2019), potentially strengthen one\u0026rsquo;s capability of suicide (Klonsky \u0026amp; May, 2014; Joiner, 2005; van Orden et al., 2010). In light of these factors, the strength of an individual\u0026apos;s endorsed attitude toward suicide is strongly correlated with their susceptibility to suicidal behaviors (Batterham et al., 2013a; Lyu \u0026amp; Li, 2023; Kawashima et al., 2020).\u003c/p\u003e\n\u003cp\u003eBased on the ideation-to-action framework as well as existing research on endorsed attitude, the current study proposed the 2\u003csup\u003end\u003c/sup\u003e hypothesis that endorsed attitude toward suicide would have a directly positive relation with suicidal ideation and suicide attempts; and the 3\u003csup\u003erd\u003c/sup\u003e hypothesis that endorsed attitude toward suicide would have a positive relation with suicidal ideation and suicide attempts indirectly through depression (Fig.1).\u003c/p\u003e\n\u003cp\u003eFor stigmatized attitude toward suicide, studies on stigma emerged in the late 1890s and suggested that stigma is closely related to stereotyping, prejudice, and discrimination (Corrigan, et al., 2005; Link \u0026amp; Phelan, 2001; Major \u0026amp; O\u0026rsquo;Brien, 2005). As a social phenomenon, stigma exerts significant social influences. From the perspective of people who stigmatize others, Dovidio et al. (2000) proposed that stigmatizing attitude and behaviors can bolster individuals\u0026apos; self-esteem and social identity, serving as a means of justifying their own status quo (Zhang \u0026amp; Yu, 2007). Besides, in the field of suicidology, stigma is recognized as a major obstacle to suicide prevention (APA, 2022; Hom et al., 2015; Saxena et al., 2014). Suicidal behaviors and individuals who have attempted suicide or have family members who have committed suicide may be confronted with stigmatization from the public (Parker, 2014; Peters et al., 2016; Worden, 2018). Consequently, individuals with stronger stigmatized attitude toward suicide are less likely to engage in suicide attempts, as such attitudes may deter them from becoming part of the group they stigmatize. Our previous research also supports this c, demonstrating a negative association between individuals\u0026apos; stigmatized attitude toward suicide and their suicide behaviors (Lyu \u0026amp; Li, 2023). Therefore, the present study proposed the 4\u003csup\u003eth\u003c/sup\u003e hypothesis that stigmatized attitude toward suicide would have a negative relation with suicidal ideation and suicide attempts; and the 5\u003csup\u003eth\u003c/sup\u003e hypothesis that stigmatized attitude toward suicide would have a negative relation with suicidal ideation and suicide attempts indirectly through depression (Fig.1).\u003c/p\u003e\n\u003cp\u003eRegarding the term of stigma, it can be broadly categorized into public stigma and self-stigma (Corrigan \u0026amp; Penn, 1999; Corrigan \u0026amp; Watson, 2002; R\u0026uuml;sch, Angermeyer, \u0026amp; Corrigan, 2005). Public stigma denotes the stigma held by others, and self-stigma represents the stigma held by people themselves (Corrigan, 2004; Corrigan et al., 2018; Guarneri et al., 2019; Kowalski \u0026amp; Peipert, 2019). Stigmatized attitude is considered a form of public stigma. Existing research has demonstrated that individuals can internalize public stigma, by leading to a process of agreement, application, and then acceptance of these negative perceptions (Corrigan \u0026amp; Rao, 2012; Livingston \u0026amp; Byod, 2010; Rimkeviciene et al., 2019). Self-stigma, the outcome of internalization, has been associated with heightened depressive symptoms (Aruta et al., 2021; Corrigan et al., 2019). Moreover, in both clinical samples and sexual minority groups, depression has been shown to mediate the association between stigma and suicide (Kaniuka, et al., 2019; Zeng et al., 2018). Hence, we proposed the 6\u003csup\u003eth\u003c/sup\u003e hypothesis that self-stigma toward suicide would have a direct positive relation with suicidal ideation and suicide attempts; and the 7\u003csup\u003eth\u003c/sup\u003e hypothesis that self-stigma toward suicide would have a positive relation with suicidal ideation and suicide attempts indirectly through depression (Fig.1).\u003c/p\u003e\n\u003cp\u003eTo test the hypotheses proposed above, we employed structural equation modeling (SEM) in three separate models to investigate whether and how attitudes toward suicide influence the ideation-to-action framework of suicide among college students. For this purpose, we recruited a sample of Chinese college students, both those with and without suicidal ideation, and administered questionnaires to assess their endorsed attitude, stigmatized attitude, self-stigma toward suicide, depression, suicidal ideation, and suicide attempts. (Please incorporate images when they enhance the content.)\u003c/p\u003e"},{"header":"2 Methods and Materials","content":"\u003cp\u003e\u003cstrong\u003e2.1 Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from 1427 Chinese undergraduate and graduate students (61.32% females; age range, 18-31 years, \u003cem\u003eM\u003c/em\u003e = 22.42, \u003cem\u003eSD\u003c/em\u003e = 2.67) were analyzed. Of these students, 9.82% were freshmen, 23.51% sophomores, 37.37% junior students, and 29.30% senior students or postgraduates. The current cross-sectional study was reviewed and approved by the Research Ethics Committee of BNU-HKBU United International College (Ref. No. REC-2022-01). Phone numbers and email addresses of a few local and national crisis intervention agencies in major Chinese cities were provided to all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEndorsed and stigmatized attitudes were separately measured by the Glorification and Stigma subscales of the Stigma of Suicide Scale \u0026ndash; Short Form (SOSS-SF; Batterham et al., 2013a). This 5-point Likert scale focuses on endorsement and stigmatized attitudes toward suicide, and each item is responded to by indicating numbers from 1 (\u003cem\u003estrongly disagree\u003c/em\u003e) to 5 (\u003cem\u003estrongly agree\u003c/em\u003e). The two dimensions were assessed by calculating the total scores of all items within each subscale. The higher scores denote a stronger endorsed or stigmatized attitude toward suicide. The two subscales used in this study were extracted from a revised version of the Chinese SOSS (12 items). The Cronbach\u0026rsquo;s \u0026alpha; of this Chinese version scale in Chinese college students has been previously reported (Glorification, .77; Stigma, .72; Han et al., 2017). In the present study, Cronbach\u0026rsquo;s \u0026alpha; values for the Glorification subscale and Stigma subscale were .72 and .85, respectively, demonstrating good internal consistency.\u003c/p\u003e\n\u003cp\u003eDepression was measured by the Patient Health Questionnaire-9 (PHQ-9; Spitzer et al., 1999), a widely used tool for measuring depressive symptoms. This 9-item questionnaire focuses on depression symptoms in the past 2 weeks of individuals. Each item is scored on a 4-point Likert scale ranging from 0 (\u003cem\u003enot at all\u003c/em\u003e) to 3 (\u003cem\u003enearly every day\u003c/em\u003e; Kroenke et al., 2001; Williams, 2009). Adding up all the items yields the total score, and a higher score means a higher level of depression. Acceptable reliability and validity coefficients of this scale among Chinese community samples have been previously reported (Cronbach\u0026rsquo;s \u0026alpha; is above .86; Wang et al., 2014). The Cronbach\u0026rsquo;s \u0026alpha; of the scale was .84 in the current sample, demonstrating good internal consistency.\u003c/p\u003e\n\u003cp\u003eSuicidal ideation was measured by the Suicidal Ideation Attributes Scale (SIDAS; van Spijker, et al., 2014). This 5-item questionnaire assesses suicidal ideation in the past month using an 11-point Likert Scale by measuring the frequency of suicide thoughts [from 0 (\u003cem\u003enever\u003c/em\u003e) to 10 (\u003cem\u003ealways\u003c/em\u003e)], the degree to which the thoughts are uncontrollable [from 0 (\u003cem\u003eno control\u003c/em\u003e) to 10 (\u003cem\u003efull control\u003c/em\u003e)], the closeness to suicide attempts [from 0 (\u003cem\u003enot close at all\u003c/em\u003e) to 10 (\u003cem\u003emade an attempt\u003c/em\u003e)], the distress caused by the thoughts [from 0 (\u003cem\u003enot at all\u003c/em\u003e) to 10 (\u003cem\u003eextremely\u003c/em\u003e)], and the interference with daily activities [from 0 (\u003cem\u003enot at all\u003c/em\u003e) to 10 (\u003cem\u003eextremely\u003c/em\u003e)]. Adding up all the items yields the total score, and a higher score means a higher level of suicidal ideation. Participants with a total SIDAS score larger than 20 were indicated a high risk of suicidal behavior. Excellent reliability coefficients of this scale among Chinese college students have been previously reported (Cronbach\u0026rsquo;s \u0026alpha; \u0026gt; .91; Han et al., 2017). The Cronbach\u0026rsquo;s \u0026alpha; of the scale was .88 in the current sample, showing excellent internal consistency.\u003c/p\u003e\n\u003cp\u003eSuicide attempts were measured by the Suicide Behaviors Questionnaire-Revised (SBQ-R; Osman, 2001). This 4-item questionnaire assesses suicidal attempts by measuring the lifetime suicide-related thoughts and attempts (from 1 to 4), the frequency of suicidal thoughts in the past year (from 1 to 5), the threats of attempting suicide (from 1 to 3), and the self-reported likelihood of suicide attempts (from 0 to 6). Adding up all the items yields the total SBQ-R score, and a higher score means a higher level of suicide attempts. Participants with a total SBQ-R score larger than 6 were indicated a high suicide risk. Acceptable reliability coefficients of this scale have been reported among Chinese college students (\u0026rho; = .79, \u0026omega; = .075; Huen et al., 2022). In the current study, the Cronbach\u0026rsquo;s \u0026alpha; was .72.\u003c/p\u003e\n\u003cp\u003eSelf-stigma toward suicide in the 570 participants who have suicidal ideation was further measured by the Self-blame subscale of the Personal Suicide Stigma Questionnaire (PSSQ; Rimkeviciene et al., 2019). This 7-item subscale focuses on self-stigma toward suicide, and each item is ranged from 1 (\u003cem\u003enever\u003c/em\u003e) to 5 (\u003cem\u003every often\u003c/em\u003e). The subscale was scored by adding up all the items, and a higher score means stronger self-blame toward suicide. Acceptable reliability coefficients of this scale among an Australian community sample have been reported (Rimleviciene et al., 2021). In the current study, the subscale was first translated into Chinese by S.L. and then double-checked by Y.L. The Cronbach\u0026rsquo;s \u0026alpha; was .90, showing excellent internal consistency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Data Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data analyses were conducted using JASP 0.17.1.0 (JASP Team) and Amos 27.0 (IBM Corp). Pearson correlation analyses were first conducted to examine the correlations among endorsed and stigmatized suicides, depression, suicidal ideation, and suicide attempts. Bootstrapping with 10,000 times replicates was used to determine a 95% confidence interval of correlation coefficients.\u0026nbsp;A multicollinearity test was conducted and assessed with the variables of variance inflation factor (VIF \u0026lt; 5.00; Shrestha, 2020). No multicollinearity was found in the current sample. According to Efron and Tibshirani (1993), bootstrap procedures offer an empirical means for determining statistical significance that circumvents the need to assume normality. Therefore, bootstrapping was used to due with the possible non-normal distribution of the data.\u003c/p\u003e\n\u003cp\u003eTo test all hypotheses as well as the hypothesized model, we followed the suggestions by Anderson and Gerbing (1988). First, confirmatory factor analyses (CFAs) were conducted to confirm the measurement models for each scale had acceptable fits. Then the hypothesized relationships were tested with the structural models. Both measurement and structural models were performed with full-information maximum likelihood estimation. Bias-corrected nonparametric percentile bootstrap method was used to test the mediating effects. Statistical significance was determined with bias-corrected bootstrapping with 10,000 re-samples. For each estimate, 95% bootstrapped confidence intervals were also calculated, and a 95% confidence interval not including zero was deemed to be statistically significant.\u003c/p\u003e\n\u003cp\u003eFour indexes were used to assess the goodness of fit of the models: the comparative fit index (CFI \u0026ge; .90; Bentler, 1990); the incremental fit index (IFI \u0026ge; .90; Bollen, 1989), the standardized root mean square residual (SRMR \u0026le; .10; Kline, 2005), and the root mean square error of approximation (RMSEA \u0026le; .10; Hair et al., 2019; Xia \u0026amp; Yang, 2019). As an index which highly sensitive to sample size, Chi-square test results were also reported but not used in assessing model fit because they tend to be statistically significant due to a large sample size (Keith, 2015).\u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Sample Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong all 1427 college students, 8.76% of them (\u003cem\u003eN\u003c/em\u003e = 125) were identified as having a high risk of suicidal behaviour in the past 30 days (total SIDAS score \u0026ge; 21; Li et al., 2014), 28.17% of participants (\u003cem\u003eN\u003c/em\u003e = 402) identified as having high suicide risk in the past 1 year (total SBQ-R score \u0026ge; 7), 94.11% (\u003cem\u003eN\u003c/em\u003e = 1343) classified into the normal group (score of SBQ-R Item 1 \u0026le; 2), and 13.33% (\u003cem\u003eN\u0026nbsp;\u003c/em\u003e= 84) classified into the suicide-risk group (the score of SBQ-R Item 1 \u0026ge; 3; Osman et al., 2001). Table 1 provides the descriptive statistics and intercorrelations of all variables. The results showed all the correlations were statistically significant.\u003c/p\u003e\n\u003cp\u003eOf the 570 participants with suicidal ideation (i.e., total SIDAS score \u0026ge; 0), 21.93% of them (\u003cem\u003eN\u003c/em\u003e = 125) were identified as having a high risk of suicidal behavior in the past 30 days (Li et al., 2014), 60.18% of participants (\u003cem\u003eN\u003c/em\u003e = 343) identified as having high suicide risk in the past 1 year, 86.67% (\u003cem\u003eN\u003c/em\u003e = 494) classified into normal group, and 13.33% (\u003cem\u003eN\u003c/em\u003e = 76) classified into the suicide-risk group (Osman et al., 2001). Table 2 provides the descriptive statistics and intercorrelations of all variables. The results showed all the correlations were statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Measurement models\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo test the models, observed indicators of the latent constructs were used. For each latent variable, all the items of the corresponding scale were used as observable variables. The measurement model of endorsed attitude showed a good fit with \u0026chi;\u003csup\u003e2\u003c/sup\u003e/df = 8.132, CFI = .926, IFI = .926, SRMR = .050, RMSEA = .067, 90%CI = [.063, .070]. The measurement model of stigmatized attitude showed a good fit with \u0026chi;\u003csup\u003e2\u003c/sup\u003e/df = 7.374, CFI = .927, IFI = .927, SRMR = .056, RMSEA = .067, 90%CI = [.064, .070]. The measurement model of self-stigma showed a good fit with \u0026chi;\u003csup\u003e2\u003c/sup\u003e/df = 3.23, CFI = .915, IFI = .916, SRMR = .060, RMSEA = .063, 90%CI = [.058, .067]. All the observed variables were significantly loaded on their respective latent variables (all \u003cem\u003ep\u003c/em\u003es \u0026lt; .001; see Online Resource 1). The results of confirmatory factor analyses demonstrated that all the scales used formed adequate measurement models, and thus provided evidence for the construct validity of the measures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Structural Models\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo latent variable exhibited multicollinearity issues in all the models, as all VIFs were below 5.00. Therefore, all the latent variables were included in the analysis of structural models. The structural model of endorsed attitude (Fig.2A), which is based on all college students, showed a good fit to the data with \u0026chi;\u003csup\u003e2\u003c/sup\u003e/df = 8.132, CFI = .916, IFI = .916, SRMR = .058, RMSEA = .071, 90%CI = [.068, .074]. The structural model of stigmatized attitude (Fig.2B) also showed a good fit with \u0026chi;\u003csup\u003e2\u003c/sup\u003e/df = 8.266, CFI = .916, IFI = .916; SRMR = .067; RMSEA = .071, 95%CI = [.068, .074]. The structural model of self-stigma (Fig.2C), which was based on the students with suicidal ideation, showed a good fit with \u0026chi;\u003csup\u003e2\u003c/sup\u003e/df = 3.436, CFI = .907, IFI = .907; SRMR = .067; RMSEA = .065, 95%CI = [.061, .070]. Thus, all three models were used in the subsequent bootstrapping and invariance testing analyses.\u003c/p\u003e\n\u003cp\u003eA bootstrap procedure recommended by Shrout and Bolger (2002) was used to examine the significant levels of indirect effects for the mediation models. The first step in this bootstrap procedure was to create 10,000 bootstrap samples from the two original data sets respectively (\u003cem\u003eN\u003c/em\u003e = 1427 and \u003cem\u003eN\u003c/em\u003e = 570) by random sampling with replacement. The second step was to run the hypothesized structural models 10,000 times separately with these 10,000 bootstrap samples to yield 10,000 estimations of each path coefficient. The third step was to save the output of the 10,000 estimations of each path coefficient in the three models to calculate an estimate of the mediating or indirect effects.\u003c/p\u003e\n\u003cp\u003eWe calculated the mediating pathways from endorsed attitude, stigmatized attitude, or self-stigma, through depression to suicidal ideation for each of the three models (i.e., Panel A: endorsed attitude \u0026rarr; depression \u0026rarr; suicidal ideation; Panel B: stigmatized attitude \u0026rarr; depression \u0026rarr; suicidal ideation; Panel C: self-stigma \u0026rarr; depression \u0026rarr; suicidal ideation). The pathways were calculated by multiplying 10,000 pairs of the path coefficients. The results from 10,000 bootstrap samples showed that the 95% CI for these indirect effects did not include zero, indicating that these indirect effects were statistically significant, with the direct effect from endorsed attitude to suicidal ideation as the only exception (Table 3).\u003c/p\u003e\n\u003cp\u003eFor the model with endorse attitude in Panel A, there was a complete mediating effect from endorsed attitude to suicidal ideation through depression. For the model with stigmatized attitude in Panel B, there was a suppressing effect from endorsed attitude to suicidal ideation through depression (Cheung \u0026amp; Lau, 2008). Specifically, the influence of the indirect effect was opposite to the direct effect. For the model with self-stigma in Panel C, there is a partial mediation from self-stigma to suicidal ideation through depression, and its mediating effect accounted for 63.04% of the variance in the total effect.\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eElucidating attitudes toward suicide is paramount to developing effective and efficient suicide prevention strategies (Kim \u0026amp; Park, 2014; Kodaka et al., 2011). Anchored in the ideation-to-action framework, this study delved into the interaction between attitudes toward suicide with suicidal ideation and attempts. The results across all three models corroborated the 1\u003csup\u003est\u003c/sup\u003e hypothesis, underscoring depression as a reliable and robust predictor of both suicidal ideation and attempts. This finding resonates with prior research among Chinese college students (Wu et al., 2020; Zhou et al., 2021). Furthermore, the results revealed that all three types of attitudes exerted significant influences on suicidal ideation and attempts, with depression serving as the mediating factor. The hypotheses were supported for all but the 2\u003csup\u003end\u003c/sup\u003e and 4\u003csup\u003eth\u003c/sup\u003e one.\u003c/p\u003e\n\u003cp\u003eThe present study revealed that depression fully mediates the association between endorsed attitude and suicidal ideation. The direct path between endorsed attitude and suicidal ideation was nonsignificant. Similar relations between endorsement and suicidal ideation have been observed in previous research among college students (Batterham et al., 2013a; Joe et al., 2007; Kawashima et al., 2020; Zemaitiene \u0026amp; Zaborskis, 2005). This finding can be interpreted by the notion that such attitude may normalize suicide, rendering it a more acceptable, attainable, and desirable option during a psychological crisis (Gibb et al., 2006; Lee et al., 2007). Individuals with endorsed attitude toward suicide are less likely to perceive suicide as a crisis, thereby diminishing the likelihood of help-seeking behaviors and intentions (McAuliffe et al., 2003). This decreased inclination, in turn, increases their vulnerability to the relatively high risk of suicide and makes them less accessible to professional intervention (Calear et al., 2014). Future studies could delve into the specific role of help-seeking and attitude toward it in suicide and explore how attitude toward help-seeking influence the pathway from endorsed attitude toward suicide to suicidal ideation and suicide attempts.\u003c/p\u003e\n\u003cp\u003eSimultaneously, stigmatized attitude toward suicide hold considerable significance in the field of suicidology. The present study demonstrated a significant negative association between stigmatized attitude and suicidal ideation, which was fully mediated by depression. Notably, the direct path between stigmatized attitude and suicidal ideation was positive but suppressed by the indirect pathway. The bootstrapping test results further indicated that the indirect path accounted for a larger proportion of variance compared to the direct path. The mediated pathway can be explained by the potential of stigmatized attitude to increase help-seeking intentions, thereby reducing depression and suicide risk (Colucci \u0026amp; Minas, 2013; Dovidio et al., 2000; Downs \u0026amp; Eisenberg, 2012). On the other hand, the direct pathway may be attributable to stigma internalization (Corrigan et al., 2019). Given that internalization processes can be obstructed and only a portion of the participants exhibited self-stigma toward suicide, the association between stigmatized attitude and suicidal ideation was relatively weak in our sample (\u003cem\u003eN\u003c/em\u003e = 1427) (Dreier et al., 2023; Jung et al., 2017).\u003c/p\u003e\n\u003cp\u003eDistinguished from stigmatized attitude as public stigma, self-stigma emerges from the internalization of these negative perceptions, leading to exacerbated depressive symptoms and potentially contributing to suicidal ideation (Aruta et al., 2021; Corrigan et al., 2019; Kaniuka et al., 2019; Zeng et al., 2018). The present study revealed direct and indirect associations between self-stigma and suicidal ideation. Notably, self-stigma toward suicide positively influenced suicide attempts in students with suicidal ideation, with depression and suicidal ideation partially mediating this relationship. Consistent with prior research, self-stigma among students with suicidal ideation was identified as a critical predictor for further suicidal thoughts (Lyu \u0026amp; Li, 2023; Rimkeviciene et al., 2015). A plausible explanation is that individuals with self-stigma may experience guilt and self-blame, increasing their susceptibility to poor mental well-being and suicide, rendering self-stigma a significant barrier to seeking professional intervention (Maclean et al., 2023; Saxena et al., 2014; Williams et al., 2003). Additionally, some studies suggest that negative public attitudes may accelerate suicide attempts in individuals with suicidal ideation (Carpiniello \u0026amp; Pinna, 2017; Worden, 2018). Therefore, self-stigma toward suicide may expedite the process of suicide in individuals with suicidal ideation.\u003c/p\u003e\n\u003cp\u003eThe current study yields important implications for suicide prevention strategies. Firstly, endorsed and stigmatized attitudes toward suicide are purported to function as accelerators and barriers to suicide among all college students (Downs \u0026amp; Eisenberg, 2012). Therefore, mitigating endorsed attitude toward suicide should be a central focus of overarching suicide prevention efforts. As suggested by Kawashima et al. (2020), the implementation of suicide education programs and the cultivation of public awareness can effectively enhance suicide literacy and advance suicide prevention initiatives (Batterham et al., 2013a; Bunney et al., 2002; Corrigan \u0026amp; Penn, 1999). Several countries have implemented administrative measures to address endorsed attitude toward suicide and alleviate the risk of social media-related copycat suicide (Amitai \u0026amp; Apter, 2012; Domaradzki, 2021; Fahey et al., 2018). Additionally, social media platforms can contribute to suicide prevention by providing professional support and fostering the development of interpersonal connections among users (Choi \u0026amp; Noh, 2020; Ha \u0026amp; Yang, 2021; Robinson et al., 2016). Secondly, self-stigma toward suicide is associated with an increased risk of suicide among students with suicidal ideation. Suicide prevention efforts should prioritize reducing self-stigma among these students. Considering that students with self-stigma toward suicide may be less inclined to proactively seek help, one potential approach is to encourage them to engage in regular professional counseling (Drum et al., 2009; Han et al., 2018; Vogel et al., 2007). Providing regular psychological assessments and counseling services can significantly improve personal mental health and reduce suicide risk (Teismann et al., 2018; Teismann, Brailovskaia, \u0026amp; Margraf, 2019).\u003c/p\u003e\n\u003cp\u003eInevitably, there are some limitations regarding the current study. Firstly, it did not differentiate between self-stigma subtypes, namely perceived stigma and internalized stigma (Corrigan \u0026amp; Penn, 1999; Livingston \u0026amp; Byod, 2010). As Corrigan et al. (2011) have asserted, assessing perceived stigma alone is insufficient to elucidate its impact. The detrimental effects of stigma are primarily driven by the internalization of stigma, also known as self-stigma (Corrigan et al., 2011). Future studies should gather data on perceived stigma and, based on this information and self-stigma, delve into the internalization process of stigma (Hanschmidt, 2016; Nicholas et al., 2022). Secondly, the data collection employed a cross-sectional design, with all data gathered at a single time point. However, given the reciprocal relationship between stigma and suicide, longitudinal data may be more effective in uncovering causal links (Carpiniello \u0026amp; Pinna, 2017). To enhance the understanding of suicidal ideation and suicide attempts, future studies could consider conducting multi-wave longitudinal research (Franklin et al., 2017; Maclean et al., 2023).\u003c/p\u003e"},{"header":"5 Conclusions","content":"\u003cp\u003eThis structural equation modeling study demonstrated that depression mediates the relationship between attitudes toward suicide and suicidal ideation and attempts. Specifically, endorsed attitude, stigmatized attitude, and self-stigma toward suicide all exerted indirect positive or negative effects on suicidal ideation and attempts through depression. These findings contribute to a deeper understanding of suicidal ideation and attempts and have implications for suicide prevention efforts. Future studies should further explore both public stigma and self-stigma to gain a better understanding of the internalized process of stigma toward suicide and its influence on suicidal ideation and attempts. Additionally, employing a multi-wave longitudinal design could provide stronger evidence for the relationships between these variables.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmerican Psychiatric Association. (2013). \u003cem\u003eDiagnostic and Statistical Manual of Mental Disorders\u003c/em\u003e (5th ed.). https://doi.org/10.1176/appi.books.9780890425596\u003c/li\u003e\n\u003cli\u003eAmerican Psychiatric Association. (2022). \u003cem\u003eSuicide Prevention\u003c/em\u003e. https://www.psychiatry.org/patients-families/suicide-prevention\u003c/li\u003e\n\u003cli\u003eAmitai, M., \u0026amp; Apter, A. 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World Health Organization.\u003c/li\u003e\n\u003cli\u003eScherr, S., \u0026amp; Reinemann, C. (2011). Belief in a Werther Effect: Third‐Person Effects in the Perceptions of Suicide Risk for Others and the Moderating Role of Depression. \u003cem\u003eSuicide and Life‐Threatening Behavior\u003c/em\u003e\u003cem\u003e, 41\u003c/em\u003e(6), 624-634.\u003c/li\u003e\n\u003cli\u003eSedgwick, R., Epstein, S., Dutta, R., \u0026amp; Ougrin, D. (2019). Social media, internet use and suicide attempts in adolescents. \u003cem\u003eCurrent opinion in psychiatry, 32\u003c/em\u003e(6), 534.\u003c/li\u003e\n\u003cli\u003eShneidman, E. S. (1993). \u003cem\u003eSuicide as psychache: A clinical approach to self-destructive behavior\u003c/em\u003e. Jason Aronson.\u003c/li\u003e\n\u003cli\u003eShrestha, N. (2020). Detecting multicollinearity in regression analysis. \u003cem\u003eAmerican Journal of Applied Mathematics and Statistics, 8\u003c/em\u003e(2), 39-42.\u003c/li\u003e\n\u003cli\u003eShrout, P. E., \u0026amp; Bolger, N. (2002). Mediation in experimental and nonexperimental studies: New procedures and recommendations. \u003cem\u003ePsychological Methods, 7\u003c/em\u003e(4), 422\u0026ndash;445.\u003c/li\u003e\n\u003cli\u003eTeismann, T., Forkmann, T., Brailovskaia, J., Siegmann, P., Glaesmer, H., \u0026amp; Margraf, J. (2018). Positive mental health moderates the association between depression and suicide ideation: A longitudinal study. \u003cem\u003eInternational Journal of Clinical and Health Psychology\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(1), 1-7.\u003c/li\u003e\n\u003cli\u003evan Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., \u0026amp; Joiner, T. E. (2010). The Interpersonal Theory of Suicide. \u003cem\u003ePsychological Review, 117\u003c/em\u003e(2), 575\u0026ndash;600.\u003c/li\u003e\n\u003cli\u003evan Spijker, B. A., Batterham, P. J., Calear, A. L., Farrer, L., Christensen, H., Reynolds, J., \u0026amp; Kerkhof, A. J. (2014). The Suicidal Ideation Attributes Scale (SIDAS): Community‐based validation study of a new scale for the measurement of suicidal ideation. \u003cem\u003eSuicide and Life‐Threatening Behavior, 44\u003c/em\u003e(4), 408-419.\u003c/li\u003e\n\u003cli\u003eVandenBos, G.R. (Ed.) (2015), \u003cem\u003eAPA Dictionary of Psychology\u003c/em\u003e. American Psychological Association.\u003c/li\u003e\n\u003cli\u003eVogel, D. L., Wade, N. G., \u0026amp; Hackler, A. H. (2007). Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes toward counseling. \u003cem\u003eJournal of counseling psychology\u003c/em\u003e, \u003cem\u003e54\u003c/em\u003e(1), 40.\u003c/li\u003e\n\u003cli\u003eWang, W., Bian, Q., Zhao, Y., Li, X., Wang, W., Du, J., ... \u0026amp; Zhao, M. (2014). Reliability and validity of the Chinese version of the Patient Health Questionnaire (PHQ-9) in the general population. \u003cem\u003eGeneral hospital psychiatry, 36\u003c/em\u003e(5), 539-544.\u003c/li\u003e\n\u003cli\u003eWilliams, D. R., Neighbors, H. W., \u0026amp; Jackson, J. S. (2003). Racial/ethnic discrimination and health: Findings from community studies. \u003cem\u003eAmerican journal of public health, 93\u003c/em\u003e(2), 200-208.\u003c/li\u003e\n\u003cli\u003eWilliams, R. T., Heinemann, A. W., Bode, R. K., Wilson, C. S., Fann, J. R., \u0026amp; Tate, D. G. (2009). Improving measurement properties of the Patient Health Questionnaire\u0026ndash;9 with rating scale analysis. \u003cem\u003eRehabilitation Psychology, 54\u003c/em\u003e(2), 198\u003c/li\u003e\n\u003cli\u003eWorden, J. W. (2018). Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner, (5\u003csup\u003eth\u003c/sup\u003e Ed.). Springer Publishing Company. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2019). \u003cem\u003eSuicide in the world: Global Health Estimates\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003eXia, Y., \u0026amp; Yang, Y. (2019). RMSEA, CFI, and TLI in structural equation modeling with ordered categorical data: The story they tell depends on the estimation methods. \u003cem\u003eBehavior Research Methods, 51\u003c/em\u003e(1), 409-428.\u003c/li\u003e\n\u003cli\u003eYou, J., \u0026amp; Lin, M. P. (2015). Predicting suicide attempts by time-varying frequency of nonsuicidal self-injury among Chinese community adolescents. \u003cem\u003eJournal of consulting and clinical psychology\u003c/em\u003e, \u003cem\u003e83\u003c/em\u003e(3), 524.\u003c/li\u003e\n\u003cli\u003eZemaitiene, N., \u0026amp; Zaborskis, A. (2005). Suicidal tendencies and attitude towards freedom to choose suicide among Lithuanian schoolchildren: results from three cross-sectional studies in 1994, 1998, and 2002. \u003cem\u003eBMC Public Health, 5\u003c/em\u003e(1), 83\u0026ndash;83.\u003c/li\u003e\n\u003cli\u003eZeng, C., Li, L., Hong, Y. A., Zhang, H., Babbitt, A. W., Liu, C., ... \u0026amp; Cai, W. (2018). A structural equation model of perceived and internalized stigma, depression, and suicidal status among people living with HIV/AIDS. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(1), 1-11.\u003c/li\u003e\n\u003cli\u003eZhang, B., \u0026amp; Yu, G. (2007). Stigma Phenomenon and Its Psychological Effects. \u003cem\u003eAdvances in Psychological Science, 15\u003c/em\u003e(6), 993-1001.\u003c/li\u003e\n\u003cli\u003eZhang, E. Y. (2009). Confucian Moral Views on Life and Death: Female Suicide in the Lien\u0026uuml;zhuan\u003cem\u003e. International Journal of Chinese \u0026amp; Comparative Philosophy of Medicine, 7\u003c/em\u003e(2), 67-86.\u003c/li\u003e\n\u003cli\u003eZhang, J. (2014). The gender ratio of Chinese suicide rates: an explanation in Confucianism. \u003cem\u003eSex Roles, 70\u003c/em\u003e(3), 146-154.\u003c/li\u003e\n\u003cli\u003eZhang, J., \u0026amp; Liu, E. Y. (2012). Confucianism and youth suicide in rural China. \u003cem\u003eReview of Religious Research, 54\u003c/em\u003e(1), 93-111.\u003c/li\u003e\n\u003cli\u003eZhou, S. J., Wang, L. L., Qi, M., Yang, X. J., Gao, L., Zhang, S. Y., ... \u0026amp; Chen, J. X. (2021). Depression, anxiety, and suicidal ideation in Chinese university students during the COVID-19 pandemic. Frontiers in psychology, 12, 669833.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eIntercorrelations for All Variables in the Entire Group (\u003cem\u003eN\u003c/em\u003e = 1427).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.643659711075442%\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e1. Endorsed Attitude\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e2. Stigmatized Attitude\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e3. Depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e4. Suicidal Ideation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e5. Suicide Attempt\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.643659711075442%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.643659711075442%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e\u0026minus;.56\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[\u0026minus;.60, \u0026minus;.53]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.643659711075442%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e\u0026minus;.27\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.22, .33]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e\u0026minus;.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[\u0026minus;.30, \u0026minus;.20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.643659711075442%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e\u0026minus;.22\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.16, .27]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e\u0026minus;.12\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[\u0026minus;.17, \u0026minus;.07]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026minus;.59\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.55, .63]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.643659711075442%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e\u0026minus;.17\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.22, .32]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e\u0026minus;.25\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[\u0026minus;.30, \u0026minus;.20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026minus;.64\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.60, .67]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026minus;.77\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.74, .80]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.643659711075442%\"\u003e\n \u003cp\u003eM (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e2.13 (\u0026plusmn;.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.13804173354735%\"\u003e\n \u003cp\u003e3.06 (\u0026plusmn;1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e5.35 (\u0026plusmn;4.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e4.93 (\u0026plusmn;8.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.693418940609952%\"\u003e\n \u003cp\u003e5.67 (\u0026plusmn;2.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eConfidence intervals (95%) based on 10000 bootstrap replicates. \u003csup\u003e***\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e \u0026lt; .001.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eIntercorrelations for All Variables in the Students with Suicidal Ideation (\u003cem\u003eN\u003c/em\u003e = 570).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"677\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e1. Endorsed Attitude\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e2. Stigmatized Attitude\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e3. Self-stigma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e4. Depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e5. Suicidal Ideation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e6. Suicide Attempt\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.53\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[\u0026minus;.59, \u0026minus;.46]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.05\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[\u0026minus;.14, .04]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.15\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.06, .24]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.22\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.14, .31]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.21\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[\u0026minus;.29, \u0026minus;.13]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.33\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.26, .41]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.22\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.04, .21]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.02\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[\u0026minus;.06, .10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.33\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.26, .40]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.49\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.42, .55]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.17\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.22, .32]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.14\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[\u0026minus;.22, \u0026minus;.06]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.32\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.24, .39]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.57\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.52, .62]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026minus;.66\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e[.61, .71]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003eM (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e2.35 (\u0026plusmn;.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e2.84 (\u0026plusmn;.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e21.60 (\u0026plusmn;6.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e7.71 (\u0026plusmn;4.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e12.21 (\u0026plusmn;8.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003e7.87 (\u0026plusmn;2.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eConfidence intervals (95%) based on 10000 bootstrap replicates.\u0026nbsp;\u003csup\u003e**\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e \u0026lt; .01,\u0026nbsp;\u003csup\u003e***\u003c/sup\u003e \u003cem\u003ep\u003c/em\u003e \u0026lt; .001.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eBootstrap Analyses of the Magnitude and Statistical Significance of the Estimated Mediating Effects.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.248796147672552%\"\u003e\n \u003cp\u003eIndependent variable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"52.1669341894061%\"\u003e\n \u003cp\u003eEffect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\"\u003e\n \u003cp\u003e\u0026beta;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.741573033707865%\"\u003e\n \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.656500802568218%\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.248796147672552%\" rowspan=\"3\"\u003e\n \u003cp\u003ePanel A\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eN\u003c/em\u003e = 1427)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"52.1669341894061%\"\u003e\n \u003cp\u003eDirect effect (Endorsed\u0026nbsp;\u0026rarr; Suicidal Ideation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\"\u003e\n \u003cp\u003e\u0026minus;.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.741573033707865%\"\u003e\n \u003cp\u003e.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.656500802568218%\"\u003e\n \u003cp\u003e\u0026minus;.058, .055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.553030303030305%\"\u003e\n \u003cp\u003eIndirect effect (Endorsed\u0026nbsp;\u0026rarr; Depression \u0026rarr; Suicidal Ideation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.659090909090908%\"\u003e\n \u003cp\u003e.257\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.954545454545454%\"\u003e\n \u003cp\u003e.030\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.833333333333332%\"\u003e\n \u003cp\u003e.200, .318\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.553030303030305%\"\u003e\n \u003cp\u003eTotal effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.659090909090908%\"\u003e\n \u003cp\u003e.254\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.954545454545454%\"\u003e\n \u003cp\u003e.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.833333333333332%\"\u003e\n \u003cp\u003e.188, .321\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.248796147672552%\" rowspan=\"3\"\u003e\n \u003cp\u003ePanel B\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eN\u003c/em\u003e = 1427)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"52.1669341894061%\"\u003e\n \u003cp\u003eDirect effect (Stigmatized\u0026nbsp;\u0026rarr; Suicidal Ideation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\"\u003e\n \u003cp\u003e.085\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.741573033707865%\"\u003e\n \u003cp\u003e.023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.656500802568218%\"\u003e\n \u003cp\u003e.041, .129\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.553030303030305%\"\u003e\n \u003cp\u003eIndirect effect (Stigmatized\u0026nbsp;\u0026rarr; Depression \u0026rarr; Suicidal Ideation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.659090909090908%\"\u003e\n \u003cp\u003e\u0026minus;.217\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.954545454545454%\"\u003e\n \u003cp\u003e.024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.833333333333332%\"\u003e\n \u003cp\u003e\u0026minus;.265, \u0026minus;.171\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.553030303030305%\"\u003e\n \u003cp\u003eTotal effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.659090909090908%\"\u003e\n \u003cp\u003e\u0026minus;.132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.954545454545454%\"\u003e\n \u003cp\u003e.030\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.833333333333332%\"\u003e\n \u003cp\u003e\u0026minus;.190, \u0026minus;.074\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.248796147672552%\" rowspan=\"3\"\u003e\n \u003cp\u003ePanel C\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eN\u003c/em\u003e = 570)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"52.1669341894061%\"\u003e\n \u003cp\u003eDirect effect (Self-Stigma\u0026nbsp;\u0026rarr; Suicidal Ideation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.186195826645266%\"\u003e\n \u003cp\u003e.136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.741573033707865%\"\u003e\n \u003cp\u003e.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.656500802568218%\"\u003e\n \u003cp\u003e.050, .222\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.553030303030305%\"\u003e\n \u003cp\u003eIndirect effect (Self-Stigma\u0026nbsp;\u0026rarr; Depression \u0026rarr; Suicidal Ideation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.659090909090908%\"\u003e\n \u003cp\u003e.232\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.954545454545454%\"\u003e\n \u003cp\u003e.032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.833333333333332%\"\u003e\n \u003cp\u003e.185, .314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"61.553030303030305%\"\u003e\n \u003cp\u003eTotal effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.659090909090908%\"\u003e\n \u003cp\u003e.368\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.954545454545454%\"\u003e\n \u003cp\u003e.039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.833333333333332%\"\u003e\n \u003cp\u003e.172, .297\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"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":"","lastPublishedDoi":"10.21203/rs.3.rs-4056776/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4056776/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Attitudes toward suicide are complex and multifaceted, and their predictive roles in suicidal ideation and suicide attempts are not well understood. Elaborating on attitudes toward suicide can help contribute to suicide prevention. The current study examined whether and how attitudes toward suicide are involved in the ideation-to-action framework of suicide among college students. A cross-sectional survey was administered to 1427 Chinese college students (mean age, 22.42 years), of whom 570 reported suicidal ideation. Participants completed questionnaires to assess their endorsed attitude toward suicide, stigmatized attitude toward suicide, self-stigma toward suicide, depression, suicidal ideation, and suicide attempts. Structural equation modeling revealed that the associations between the three types of attitudes, i.e., endorsed attitude, stigmatized attitude, and self-stigma, and suicidal ideation and suicide attempts were fully or partially mediated by depression. The results suggested that attitudes towards suicide significantly influence suicidal behaviors and future suicide prevention efforts should consider these influences.","manuscriptTitle":"The Roles of Attitudes Toward Suicide in Suicidal Ideation and Attempts among Chinese College Students: A Structural Equation Modeling Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-15 18:40:28","doi":"10.21203/rs.3.rs-4056776/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":"66e37b37-f527-44f9-a6d4-7da7f832f562","owner":[],"postedDate":"March 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-18T11:16:43+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-15 18:40:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4056776","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4056776","identity":"rs-4056776","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}