The Relationship Between Psychological Strain,Perceived Burdensomeness,Thwarted Belongingness,and Suicide Attempt Among College Students

1.BackgroundSuicide is one of the most important public health problems worldwide.According to Suicide Worldwide in 2019 reported by WHO,suicide is the fourth leading cause of death among people aged 15-29.At present,suicide is divided into three categories:suicidal ideation,suicide attempt and completed suicide.Suicide attempt is more dangerous than suicidal ideation and is the most reliable predictor of completed suicide.Although there is no national data on suicide attempt in China,a meta-analysis including 88,225 college students found that the prevalence of suicide attempt among college students in China was about 2.8%.It can be seen that suicide attempt of college students should be paid attention to.Based on the integration of sociological factors and psychopathological factors,Zhang Jie proposed the Strain Theory of Suicide(STS)to explain the psychological mechanism before the occurrence of suicidal behaviors.Psychological strain is different from a single stress,it includes at least two conflicting stresses.Therefore,psychological strain is more harmful to an individual’s health than stress alone.The Strain Theory of Suicide postulates that individuals with unresolved strain feel tortured and angry,that the outward release of anger is an act of violence against others,and that the inward release can lead to depression,anxiety,or suicide.There could be at least four types of psychological strain:value strain,aspiration strain,deprivation strain and coping strain.In addition,a suicide note study has found that perceived burdensomeness and thwarted belongingness were associated with psychological strain.Some studies have shown that perceived burdensomeness and thwarted belongingness were associated with suicide attempt.As two structures reflecting interpersonal function,perceived burdensomeness and thwarted belongingness may play a mediating role in the process of psychological strain increasing the risk of suicide attempt.At present,most of the research on the relationship between psychological strain and suicide focuses on the relationship between psychological strain and suicidal ideation or completed suicide.There are studies on the relationship between psychological strain and suicide attempt in rural population in China,but no studies on college students.The survey was based on a large sample of college students,thus expecting to provide a stable estimate of the prevalence of suicide attempt in this population.Then from the perspective of the psychological strain,we aimed to explore the influence factors of suicide attempt,and to testify the mediation roles of the perceived burdensomeness and thwarted belongingness in the association between psychological strain and attempted suicide,which provides the basis for the prevention of college students’ suicide attempt and puts forward some measures and suggestions,so as to make corresponding crisis intervention.2.Objectives(1)To understand the prevalence and related factors of suicide attempt among college students in China.(2)To analyze the association between psychological strain and suicide attempt which might enrich the STS.(3)To explore the mediating effects of perceived burdensomeness and thwarted belongingness between the psychological strain and suicide attempt.This can further promote the development of the STS.3 MethodsA cross-sectional study was conducted at seven universities in seven provinces in China from October 2017 to March 2018.A total of 13,387 students participated in the survey,and 11,473 valid questionnaires were finally obtained.The effective recovery of the questionnaire was 85.70%.Among them,4496(39.19%)were male and 6977(60.81%)were female,with an average age of(20.71±1.36)years,and(20.68±1.34)years,respectively.The questionnaires mainly included basic demographic information,Suicidal Behaviors Questionnaire-Revised,Psychological Strain Scale,The Short-Form Version of the Depression Anxiety Stress Scales,Rosenberg Self-esteem Scale,Interpersonal Needs Questionnaire,etc.The average time required to complete the questionnaire was 30 minutes.This study was approved by the Ethics Committee of Preventive Medicine,Shandong University.IBM SPSS Statistics 24.0(Online edition)and Mplus(version 7.4)were used for data processing and statistical analysis.Student’s test,F test,Chi-square test,Fisher exact test and rank-sum test were used to compare the characteristics between groups.Univariate and multivariate Logistic regression analysis were used to analyze the influencing factors of suicide attempt among college students,as well as the association between psychological strain,perceived burdensomeness,thwarted belongingness and suicide attempt.Pearson correlation and Point-biserial correlation were used to analyze the correlation between variables.Finally,Mplus 7.4 was used to test the possible mediating effects of factors associated with suicide attempt based on bias-corrected nonparametric percentile method and 5000 Bootstrap sample.In this study,all reported P values were two-sided,and if P values were<0.05,the difference was statistically significant.4.Results4.1 Reliability of the used scalesThe reliability of the scales used in this study was tested.Results showed that the Cronbach’α coefficient of self-esteem scale was 0.65,and other scales were all above 0.70,which indicated that the reliability of scales used in this study was good and they had good internal consistency.4.2 Suicide attempt and characteristics of suicide attempt of college students4.2.1 Suicide attempt of college studentsOf the 11,473 college students included in the statistical analysis,2.02%(232)reported lifetime suicide attempt.Among male college students,94 reported lifetime suicide attempt,accounting for 2.09%;138 female students reported lifetime suicide attempt,accounting for 1.98%.The difference was not statistically significant(P=0.675).4.2.2 Demographic characteristics of attempted suicide among college studentsCollege students with and without suicide attempt differed statistically and significantly in household registration(χ2=5.36,P=0.021),whether from an only child family(χ2=6.23,P=0.013),self-rated physical health(χ2=24.31,P<0.001),self-rated academic results(χ2=28.59,P<0.001),self-rated economic status(χ2=6.52,P=0.038).And there was no significant difference between the two groups associated with gender(χ2=0.18,P=0.675),grade(χ2=8.48,P=0.067),race(χ2=0.17,P=0.921),whether from another province(χ2=0.74,P=0.391),whether to participate in school associations(χ2=1.99,P=0.159).4.2.3 Psychological characteristics of attempted suicide among college studentsCollege students with and without suicide attempt differed statistically and significantly in value strain(t=8.56,P<0.001),aspiration strain(t=8.69,P<0.001),deprivation strain(t=6.29,P<0.001),coping strain(t=9.74,P<0.001),psychological strain(t=10.15,P<0.001),perceived burdensomeness(t=8.43,P<0.001),thwarted belongingness(t=9.29,P<0.001),depressive symptoms(χ2=77.48,P<0.001)and self-esteem(χ2=39.12,P<0.001).4.3 Psychological strain,perceived burdensomeness and thwarted belongingness of college students with different characteristicsThe scores of value strain,aspiration strain,deprivation strain and psychological strain all differed statistically and significantly by gender,grade,race,household registration,whether from an only child family,self-rated physical health,self-rated academic results,self-rated economic status,whether to participate in school associations,depressive symptoms and selfesteem(Ps<0.05).And there was no significant difference in whether from another province(Ps>0.05).The score of coping strain differed statistically and significantly by grade,race,household registration,whether from an only child family,self-rated physical health,self-rated academic results,self-rated economic status,whether to participate in school associations,depressive symptoms and self-esteem(Ps<0.05).And there was no significant difference in gender and whether from another province(Ps>0.05).The score of perceived burdensomeness differed statistically and significantly by gender,grade,race,household registration,whether from an only child family,self-rated physical health,self-rated academic results,self-rated economic status,whether to participate in school associations,depressive symptoms and self-esteem(Ps<0.05).And there was no significant difference in whether from another province(Ps>0.05).The score of thwarted belongingness differed statistically and significantly by gender,grade,race,household registration,whether from another province,whether from an only child family,self-rated physical health,self-rated academic results,self-rated economic status,whether to participate in school associations,depressive symptoms and self-esteem(Ps<0.05).4.4 Analysis of the associated factors of suicide attempt among college studentsUnivariate Logistic regression showed that there was a positive association between students in the fifth year of college,self-rated poor and general physical health,value strain,aspiration strain,deprivation strain,coping strain,psychological strain,perceived burdensomeness,thwarted belongingness,depressive symptoms and suicide attempt(Ps<0.05);rural household registration,non-only child,self-rated general academic performance,medium and high self-esteem were negatively associated with suicide attempt(Ps<0.05).Multivariate Logistic regression of the relationship between the four dimensions of psychological strain,perceived burdensomeness,thwarted belongingness and suicide attempt showed that students in the fifth year of college(OR=3.31.95%CI:1.26-8.71),self-rated general physical health(OR=1.42,95%CI:1.06-1.89),coping strain(OR=1.05,95%CI:1.031.08),perceived burdensomeness(OR=1.04.95%CI:1.03-1.06),thwarted belongingness(OR=1.03,95%CI:1.01-1.05)and depressive symptoms(OR=1.45,95%CI:1.02-2.06)were positively associated with suicide attempt;self-rated general academic performance(OR=0.52,95%CI:0.38-0.71)and deprivation strain(OR=0.97,95%CI:0.94-0.99)were negatively associated with suicide attempt.Multivariate Logistic regression of the relationship between total psychological strain,perceived burdensomeness,thwarted belongingness and suicide attempt showed that students in the fifth year of college(OR=3.27,95%CI:1.25-8.55),self-rated general physical health(OR=1.45,95%CI:1.09-1.94).psychological strain(OR=1.01,95%CI:1.01-1.02),perceived burdensomeness(OR=1.04,95%CI:1.03-1.06).thwarted belongingness(OR=1.03,95%CI:1.01-1.05)and depressive symptoms(OR=1.52,95%CI:1.07-2.16)were positively associated with suicide attempt;self-rated general academic performance(OR=0.52,95%CI:0.38-0.71)was negatively associated with suicide attempt.4.5 Correlation analysis of psychological strain,perceived burdensomeness,thwarted belongingness and suicide attemptThe correlation coefficients of psychological strain with perceived burdensomeness.thwarted belongingness and suicide attempt were 0.367.0.344 and 0.094,and the correlation coefficients of perceived burdensomeness,thwarted belongingness and suicide attempt were 0.109 and 0.074,respectively.All the correlation coefficients were statistically significant(Ps<0.01).4.6 The mediating effect of perceived burdensomeness and thwarted belongingness on the relationship between psychological strain and suicide attemptResults showed that psychological strain(β=0.156,95%CI:0.083～0.227)had a significantly positive effect on suicide attempt.Perceived burdensomeness(β=0.147,95%CI:0.095～0.199)and thwarted belongingness(β=0.145,95%CI:0.068～0.225)had a significantly positive effect on suicide attempt.The Indirect effect of perceived burdensomeness on psychological strain and suicide attempt was 0.034(95%CI:0.022～0.047),and the mediating effect accounted for 15.67%of the total effect.Its 95%CI did not include 0,indicating that perceived burdensomeness had a significant mediating effect on psychological strain and suicide attempt.The indirect effect of thwarted belongingness on psychological strain and suicide attempt was 0.027(95%CI:0.013～0.042),and the mediating effect accounted for 12.44%of the total effect.Its 95%CI did not include 0,indicating that thwarted belongingness had a significant mediating effect on psychological strain and suicide attempt.The total indirect effect of perceived burdensomeness and thwarted belongingness on psychological strain and suicide attempt was 0.061(95%CI:0.042～0.080).and the total mediating effect accounted for 28.1 1%of the total effect.Its 95%CI did not include 0,indicating that perceived burdensomeness and thwarted belongingness had a significant total mediating effect on psychological strain and suicide attempt.5.Conclusions1.The reported rate of suicide attempt among college students was high,which was a social problem that couldn’t be ignored.2.Suicide attempt was associated with a wide range of factors.Grade,self-rated physical health,self-rated academic performance,psychological strain,perceived burdensomeness,thwarted belongingness and depressive symptoms were associated with suicide attempt in college students.3.Psychological strain was positively associated with suicide attempt.Among the four types of psychological strain,coping strain was positively associated with suicide attempt,while deprivation strain was negatively associated with suicide attempt.4.Perceived burdensomeness and thwarted belongingness partly mediated the relationship between psychological strain and suicide attempt,both with statistical significance.