Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

The Mediating Effect of Psychache on the Relationship Between Psychological Strains and Suicidal Behaviors Among Chinese Hui and Han Medical Students:

The Mediating Effect of Psychache on the Relationship Between Psychological Strains and Suicidal... Psychological strain is associated with suicidal behavior; however, the way that psychological strain leads to suicidal behavior remains unclear. The current study examines the mediation effect of psychache on the relationship between psychological strain and suicidal behavior among Chinese Hui and Han medical students. A total of 1,696 enrolled medical students (974 Han and 722 Hui) were administered the Psychological Strain Scale (PSS), the Suicide Behavior Questionnaire-Revised (SBQ-R) scale, and the Psychache Scale. There were significant differences in the PSS between different ethnic groups. Correlation analysis showed that both psychological strain and psychache were positively correlated with suicidal behaviors, and the two predictive variables were also positively correlated. The mediation effect test procedure showed that the direct and indirect effects (mediator effect) of psychological strain on suicidal behaviors were significant. The findings indicate that psychological strain partially induced psychache in both two ethnicity groups, leading to suicidal behavior in Chinese medical college students. Keywords psychological strain, psychache, suicidal behavior, mediating effect, ethnic can identify their own psychological problems in time and Introduction receive counseling and treatment (Carla & Patrizia, 2018). Suicide has become a global social problem that cannot be Special training is needed to improve diagnostic skills and ignored. As of 2015, an estimated 788,000 people had died of competency in SI assessment, especially for medical stu- suicide, accounting for nearly 1.5% of the global death toll dents (Palmieri et al., 2008). SI is the early psychological and making suicide one of the top 20 causes of death (World activity of suicide attempts and suicides, with one in five Health Organization [WHO], 2017). Data from other coun- people attempting suicide before completing suicidal behav- tries show that suicide rates are also high in India, especially ior (Chang et al., 2011; Deisenhammer et al., 2009). among college students (Muttathu et al., 2013). China’s lat- Therefore, it is necessary to assess suicidal danger as a link est figures show 4.31 suicides per 100,000 urban residents to and component of suicide prevention (Xiao, 2001). In par- (Sha et al., 2018). Among the causes of death for Chinese ticular, it is important to detect the influencing factors of SI college students, suicide dropped from third place in 1990 to and maintain mental health among medical students. fourth place in 2016 (Xu et al., 2018). China’s suicide rate is Many medical students experience distress during med- significantly lower than the average. However, some poten- ical school. Medical students must go to the hospital for tial uptrends cannot be ignored (Parry, 2014). For example, practice and training, and this training process and envi- an increasing number of studies show that medical students ronment contribute to the deterioration of mental health in are at high risk of suicidal ideation (SI; Rotenstein et al., developing physicians (Brazeau et al., 2014). Edwin 2016; Sugawara et al., 2014). Medical students report higher rates of SI than do students of other majors in China (Zang Xi’an Jiaotong University, Xi’an, China et al., 2016); this is also the case for students in the United Ningxia Medical University, Yinchuan, China States (Dyrbye et al., 2008). Compared with the general pop- Zunyi Medical University, Zunyi, China ulation, heavy medical courses put more pressure on medical Corresponding Author: students (Castaldelli-Maia et al., 2019). In addition, this ZhiZhong Wang, Department of Epidemiology and Statistics, School of trend may be related to the attitude of medical students Public Health of Zunyi Medical University, Zunyi 563006, China. toward the suicide of patients and whether medical students Email: wzhzh_lion@126.com Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open Shneidman proposed the concept of psychache in 1953. He minority medical students because their ethnicity adversely defined psychache as “hurt, anguish, soreness, aching, affects their medical school experience (Dyrbye et al., 2007). psychological pain in the psyche, the mind.” Psychache is Furthermore, previous studies indicate that suicide rates tend a necessary condition for suicide to occur (Shneidman, to be lowest in Muslim countries, and in the Muslim commu- 1993) and a core factor of suicide susceptibility (Verrocchio nities, the Islam belief as a coping of life stress was inversely et al., 2016). When the perception of pain is unbearable, associated with suicide behaviors (Koenig, 2012). However, the cognitive level is lowered to the point that suicide is no study had examined the psychological strain theory among seen as the only way to block the unbearable flow of con- minority ethnicity population (like Hui in this study) in main- sciousness (Shneidman, 1984). Studies have consistently land China. In the path from psychological strain to suicidal related psychache to suicide risk (Maser et al., 2019). behavior, strain may be moderated by social factors such as Medical students experience considerable psychache due social integration and psychological factors such as personal- to various pressures in the training process, but they are ity traits (J. Zhang & Zhao, 2017). reluctant to seek help despite their health care needs. Based on these theories, the present study hypothesized Medical students both domestically and abroad experience the following: (a) psychache mediates the relationships substantial psychache. However, the concept of psychache between psychological strain and suicide in Chinese medi- has rarely been used to describe psychological distress and cal students and (b) the cultural differences between assess suicide risk in Chinese medical students. It is neces- Chinese Hui (most of them believe Islam) and Chinese Han sary to determine in a timely fashion whether medical stu- (most of them have no religion affiliation) students affect dents are experiencing psychache and to adopt interventions SI through the difference in psychological strain and psych- to prevent suicide. ache. This study suggests three innovations to research on Research shows that psychological strains (such as dif- this issue: (a) psychological factors play an important role ferential values strain and relative deprivation strain) are risk in suicidal behavior, but the mediating pathways through factors of suicide and significantly and positively affect SI (J. which psychological strain affects suicidal behavior are not Zhang & Zhao, 2017). The conceptualization of the strain sufficiently clear; (b) the suicide rate of medical students is theory of suicide is derived from and built on the previous increasing daily globally, but no studies have explored this work of Durkheim (1951), Merton (1957), Agnew (2006), relationship in Chinese medical students; and (c) the addi- and (J. Zhang & Lyu, 2014) and has been tested in the tion of ethnic medical students to the mediating effect of Chinese population (J. Zhang et al., 2013b). Psychological psychache between psychological strain and suicide strain can predict mental illness and suicidal behavior in both extends previous studies on this relationship. When indi- rural and urban youth (Sun et al., 2015) as well as among viduals, especially medical students, experience various stomach cancer patients and Chinese Americans. The types of pressure, psychological strain may increase the extreme solution in an acute and excruciating moment of risk of suicide through psychache. This study offers direc- psychological strain is suicide (J. Zhang et al., 2013a; X. tions for future work in this area and suggests ways to pre- Zhang et al., 2017b). A single stress is not a strain. A strain vent suicide among medical students. consists of at least two forces, or two stresses, that push a person in different directions (J. Zhang & Lyu, 2014). Four Method types of strain can predict suicide: (a) differential values occur when two conflicting social values compete in an indi- Participants and Procedure vidual’s life and are equally important, (b) aspiration versus reality means that an individual has impossible aspirations, Data were collected from a medical student sample selected (c) relative deprivation occurs when a person compares him- from Ningxia Medical University, which has 8,880 full-time self or herself negatively with others, and (d) deficient cop- students. A cluster sampling approach was undertaken to ing refers to the lack of ability to face crises in life (J. Zhang select the sample. Students registered in the same class (usu- et al., 2011). ally 35–45 students) were defined as a cluster. Then, 48 It is remarkable that suicide-related psychological vari- classes (n = 2,000) were selected from the school of clinical ables are associated with SI only through psychache medicine, the school of nursing, and the school of public (Montemarano et al., 2018). In the relation between psycho- health. And 1,696 participants who finished the full ques- logical strain and suicide, psychache may be a mediator. tionnaires were included in the final data analysis. The sam- Some studies have examined the mediating effect of psych- ple for this study consisted of 643 males (37.9%) and 1,053 ache on the relationship between risk factors (such as depres- females (62.1%), including Chinese Han (57.4%) and sion and hopelessness) and suicidal behavior (Sun et al., Chinese Hui (42.6%) students. The average age of the total 2015; J. Zhang et al., 2009). However, the mediating effect of participants was 21.7 years with standard deviation 2.4 psychache on the relationship between psychological strain (ranged from 18 to 30 years). and suicide has rarely been examined within the medical col- A questionnaire survey was conducted during November lege students. In addition, psychache is more common in 14 to 24, 2017. A research team was responsible to distribute Ha et al. 3 the questionnaires to students in university classrooms and to to examine differences in age, PPS scores, SBQ-R scores, collect the questionnaires back at that time. The anonymity of and psychache scores between Chinese Han and Chinese the respondents and the confidentiality of the collected infor- Hui students. A chi-square test was applied to examine the mation were ensured for academic research, and we prom- differences in gender, one-child families, and economic sta- ised to follow the principle of voluntary participation. All tus between the two groups of students. Linear regression participants were asked to provide a written consent form, and correlations were used to analyze the relationships and this study was approved by the Institutional Review among variables. The mediation analyses were performed Board of Ningxia Medical University (No. 2017-171). using PROCESS (Hayes & Preacher, 2013). PROCESS estimates the direct effect and bias-corrected confidence intervals (CIs). A direct effect was considered not signifi- Measures cant when the CI included zero. In this case, it is a full Sociodemographic information was measured by a self- mediation effect. Structural equation modeling (SEM) report questionnaire, which included grade, gender, ethnic- analyses were used to explore the full mediating role of ity, number of siblings, self-rated physical condition (“1 = psychache in Hui students between deprivation strain and very bad,” “2 = bad,” “3 = normal,” “4 = good,” and “5 suicide behavior. = very good”), family economic status, and religious affili- ation. Ethnicity was categorized as “1 = Han” and “2 = Results minority.” The Psychological Strain Scale (PSS) was developed in As Table 1 shows, among the final 1,696 participants, there both English and Chinese. The original PSS was validated in were significant differences in economic status (t/χ = a sample of the Chinese population; it has been tested, and its 3.87, p < .001), PSS total scores (t/χ = 2.49, p = .013), reliability and validity have been demonstrated (X. Zhang and SBQ-R scores (t/χ = 1.19, p = .046) between the et al., 2012). The Cronbach’s alpha coefficient of the total Chinese Han sample and the Chinese Hui sample. Chinese PSS was .94 in the current study. The PSS comprises four Hui students had higher psychological strain scores than scales for value strain, aspiration strain, deprivation strain, Chinese Han students. Total PSS and the three dimensions and coping strain, each with 10 items. Each of the 40 items were significant (total PSS, p = .013; value strain, p = had five options, including 1 = never, not me at all; 2 = .006; aspiration strain, p = .036; deprivation strain, p = rarely, not me; 3 = maybe, not sure; 4 = often, like me; and .002). However, Chinese Hui students had a lower SBQ-R 5 = yes, strongly agree. The higher the total PSS score, the score than Chinese Han students. Other factors were insig- greater the strain (J. Zhang & Zhao, 2017). nificant, such as age, gender, one-child family, coping The Psychache Scale (Holden et al., 2001) is a 13-item strain, and psychache (p > .05). self-report scale to measure the degree of psychache using a Table 2 shows the correlations for the key variables in 5-point scale of “1 = never,” “2 = once in a while,” “3 = Chinese medical students. The results of correlation and sometimes,” “4 = many times,” and “5 = almost always.” regression analysis showed that psychological strain, psych- The higher the score, the higher the pain. Coefficient alpha ache, and SI were significantly positively correlated (p < .01). reliabilities of .92 and .95 have been reported for this scale Table 3 shows the mediating effect of psychache on the (Holden & Delisle, 2005). It was translated into Chinese by relationship between psychological strain and suicidal Yang and Chen, and found that the internal consistency reli- behavior in Chinese medical students, Chinese Han and ability of the scale was .90 (Yang & Chen, 2017), and it was Chinese Hui. The independent variable (X) is psychological .94 in this study. strain, the mediating variable (M) is psychache, and the The Suicide Behavior Questionnaire-Revised (SBQ-R) is dependent variable (Y) is suicidal behavior. In total, a, b, c, a four-item scale to assess different suicide behaviors: life- and c’ were all statistically significant in the equation and time SI and suicide attempts, the frequency of SI over the could be used to describe the relationship among the vari- past 12 months, threats of suicide attempt, and self-reported ables. The indirect effect (ab) of psychological strain on SI likelihood of suicidal behavior in the future (Osman et al., by the mediating effect of psychache was significant (p < 2001). The total score ranges from 3 to 18, with a higher .05, 95% CI = [0.014, 0.094]); the direct effect (c’) was sig- score indicating a higher risk of suicide and a positive cutoff nificant (p < .05, 95% CI = [0.005, 0.085]), except that the score of 7. Coefficient alpha reliabilities for the SBQ-R items effect of deprivation strain on SI was not significant (p = were .80 (Aloba et al., 2017) and .72 in the current study. .138, 95% CI = [−0.007, 0.047]) in Chinese Hui. Psychache partially mediated the effect between psycho- logical strain and suicidal behavior in Chinese medical stu- Statistical Analysis dents, with mean effects of 0.641 (value strain), 0.688 The Statistical Package for Social Sciences (SPSS) version (aspiration strain), 0.731 (deprivation strain), 0.637 (coping 23 was used for statistical analysis. Cronbach’s alpha coef- strain), and 0.623 (total PSS) in total sample. The mean ficients were used to evaluate the validity. A t test was used effect was 0.665 in Han students, with the value strain, 4 SAGE Open Table 1. Demographic and Psychopathological Characteristics of the Sample by Ethnicity. Variable Total (n = 1,696) Han (n = 974) Hui (n = 722) t/χ p value Age, M ± SD 21.7 ± 2.4 21.0 ± 1.5 22.8 ± 3.1 1.52 .129 Gender, n (%) 0.63 .526 Male 643 (37.9) 363 (37.3) 280 (38.80) Female 1,053 (62.1) 611 (62.7) 442 (61.20) One-child family, n (%) 1.13 .259 Yes 283 (16.7) 237 (24.30) 46 (6.40) No 1412 (83.3) 737 (75.70) 675 (93.50) Economic, n (%) 3.87 <.001 Bad 374 (22.10) 188 (19.4) 186 (25.8) Normal 1,188 (70.00) 693 (71.1) 495 (68.5) Good 134 (7.90) 93 (9.5) 41 (5.7) PSS, M ± SD 94.00 ± 21.68 92.87 ± 21.82 95.53 ± 21.42 2.49 .013 Value, M ± SD 24.90 ± 6.47 24.52 ± 6.32 25.40 ± 6.64 2.74 .006 Aspiration, M ± SD 23.84 ± 7.07 23.52 ± 7.03 24.25 ± 7.09 2.09 .036 Deprivation, M ± SD 22.65 ± 6.31 22.23 ± 6.27 23.22 ± 6.32 3.17 .002 Coping, M ± SD 22.62 ± 6.52 22.58 ± 6.66 22.66 ± 6.33 0.23 .812 Psychache, M ± SD 22.60 ± 8.83 22.62 ± 8.82 22.57 ± 8.84 0.12 .903 SBQ-R, M ± SD 4.51 ± 2.37 4.61 ± 2.39 4.38 ± 2.33 1.99 .046 Note. PSS = Psychological Strain Scale; SBQ-R = Suicide Behavior Questionnaire-Revised. Table 2. The Correlation Matrix Among the Predicted Variables. Variables 1 2 3 4 5 6 1.Value 1 2.Aspiration .605* 1 3.Deprivation .471* .664* 1 4.Coping .559* .568* .518* 1 5.Psychache .431* .448* .405* .521* 1 6.SBQ-R .271* .249* .209* .302* .423* 1 Note. SBQ-R = Suicide Behavior Questionnaire-Revised. *p < .01. Table 3. The Mediation Effect of Psychache on the Relationship Between Psychological Strains. Model 1 Model 2 Model 3 Path Estimate Lower Upper Estimate Lower Upper Estimate Lower Upper Effect M Value strain → psychache Total 0.066** 0.054 0.080 0.037** 0.020 0.055 0.103** 0.087 0.120 .641 → suicide behavior Han 0.074** 0.057 0.094 0.039** 0.016 0.062 0.113** 0.091 0.136 .655 Hui 0.056** 0.039 0.078 0.039** 0.013 0.065 0.095** 0.070 0.120 .589 Aspiration strain → psychache Total 0.063** 0.052 0.077 0.029** 0.013 0.045 0.092** 0.076 0.107 .688 → suicide behavior Han 0.068** 0.052 0.085 0.026* 0.005 0.046 0.093** 0.073 0.114 .731 Hui 0.056** 0.039 0.075 0.036** 0.011 0.061 0.092** 0.069 0.115 .609 Deprivation strain → psychache Total 0.065** 0.053 0.041 0.024** 0.007 0.041 0.088** 0.071 0.106 .731 → suicide behavior Han 0.071** 0.056 0.089 0.030* 0.007 0.053 0.101** 0.078 0.124 .703 Hui 0.056** 0.039 0.074 0.020 −0.007 0.047 0.076** 0.050 0.103 1.000 Coping strain → psychache Total 0.074** 0.060 0.090 0.042** 0.024 0.060 0.116** 0.100 0.132 .637 → suicide behavior Han 0.084** 0.065 0.106 0.031* 0.007 0.054 0.115** 0.093 0.136 .730 Hui 0.061** 0.043 0.082 0.057** 0.029 0.085 0.118** 0.093 0.144 .517 Psychological strain → Total 0.023** 0.019 0.029 0.014** 0.008 0.019 0.037** 0.032 0.042 .623 psychache → suicide behavior Han 0.025** 0.020 0.032 0.013** 0.006 0.045 0.038** 0.032 0.045 .658 Hui 0.020** 0.014 0.027 0.016** 0.008 0.025 0.036** 0.029 0.044 .556 Note. Model 1 = indirect effect (ab); Model 2 = direct effect (c’); Model 3 = total effect (c); Effect M = ab/c. *p < .05. **p < .01. Ha et al. 5 0.076* Deprivaon strain Suicide behavior (a) (a) Psychache Suicide behavior Deprivaon strain 0.109* 0.543* (b) Figure 1. Path coefficients in the full mediation model in the Hui students. The total effect. Complete mediation model. *p < .01. aspiration strain, deprivation strain, and coping strain were religion protects against SI (Rasic et al., 2011), suggesting 0.655, 0.727, 0.707, and 0.732, respectively. The effect of that certain traditional cultures have a buffer effect on psych- the other independent variable on the dependent variable ache (Fan et al., 2009; Stack, 2000a). Therefore, ethnic dif- was not completely achieved through the mediating effect ferences may dilute the effect of psychache on SI. of psychache. There was a difference between Chinese Han and Chinese However, the mediating effect of psychache between depri- Hui medical students’ scores in psychological strain (includ- vation strain and suicidal behavior was achieved among Hui ing value strain, aspiration strain, and deprivation strain). students. The path model is shown in Figure 1 and includes the The significant effect corroborates the impact of ethnicity on total effect (a) and complete mediation model (b). Based on psychological strain. There are four types of strains, and each the results, the model fit was acceptable: χ (df) = 2.1 (1), p = strain consists of at least two conflicting social facts. Value .146, goodness of fit index (GFI) = 0.998, root mean square strain involves a conflict of two or more values; this study error of approximation (RMSEA) = 0.039, Tucker–Lewis found that Hui students had higher PSS scores. As an ele- index (TLI) = 0.987, comparative fit index (CFI) = 0.996, χ ment of culture and as a social-cultural phenomenon, reli- / df = 2.1. The effect of the other independent variable on the gion is a source of change, difference, and contrast in various dependent variable was not completely achieved through the places (Khaki, 2020). Hui students believe in Islam because mediating effect of psychache. The mean effect was 0.547 in of their family environment and have their own traditional Hui students; value strain, aspiration strain, and coping strain culture and living habits. On one hand, they abide by the were 0.586, 0.607, and 0.517, respectively. rules of Islam, which, as the traditional culture of their ethnic region, influences their family education and living habits (Guo & Fang, 2013); on the other hand, they adapt to the Discussion Confucian culture together with their Chinese Han class- This study explored the mediating effect of psychache mates. In addition, conflict between Muslim cultural values between psychological strain and suicidal behavior among and modern cultural values occurs when Chinese Hui choose Chinese medical students, including Chinese Hui and a medical profession (Calizaya-Gallegos et al., 2019). Hui Chinese Han people. All the proposed hypotheses were sup- students experience strain when these two conflicting values ported. First, the findings showed that there was a difference are equally important in their daily life. between Chinese Han and Chinese Hui medical students’ Value strain, aspiration strain, and deprivation strain scores on the SBQ-R. Chinese Hui had lower scores on the may not play equally important roles in SI. Aspiration SBQ-R. Chinese Hui must follow Islam, whereas Chinese strain is mainly a sense of the gap between reality and Han people do not have to believe in religion. Most Chinese hopes. Hui students’ higher scores may be linked to reli- Han people have no religion or take Confucian culture as the gious belief. In other studies, aspiration strain has been mainstream culture, and many religions coexist, such as found to be related to love-partner selection, job choice, Buddhism and Taoism. Therefore, different national cultures and gender (J. Zhang et al., 2009), but this relationship is exist among Chinese Hui and Chinese Han people. The find- unclear. Deprivation strain occurs when people from simi- ings are in line with previous studies that reported that the lar backgrounds lead better lives, as evidenced by income suicide rates of individuals with religious beliefs were lower inequality and distribution inequality. Chinese Hui stu- than those without (Breault, 1986; Stack, 1983) and that dents obtained higher scores in this area. Research shows a 6 SAGE Open strong link between deprivation strain and economic fac- Psychache played a full mediating role between depriva- tors (J. Zhang et al., 2018). According to our research, the tion strain and suicidal behavior in Hui students. This may economic conditions were poorer for Hui students than for not be entirely related to ethnicity. Some people believe that Han students. The occurrence of deprivation strain may a deprivation response is caused by economic risk factors, represent this difference. which are a better explanation for suicide (Stack, 2000b). The last factor in PSS is coping strain. People with poor According to our research, improving individuals’ economic coping skills will develop coping strain. It is difficult to level can effectively reduce the risk of suicide by reducing change one’s culture and social environment, and improving deprivation strain to reduce the level of psychache. In addi- coping strategies would be an effective way to reduce the tion, high self-esteem increases the sense of psychological risk of suicide (Li & Zhang, 2012). However, medical stu- imbalance and cannot be easily mediated; thus, individuals dents, whether Han or Hui, have poor coping skills to deal undergo so much psychological pain that they attempt sui- with problems in the social environment, which increases cide. Alternatively, when deprivation strain occurs, it their level of coping strain and risk of suicide. Research has increases life stress and the mediating effect of psychache. shown that social problem-solving is negatively correlated with suicide (Kwok & Shek, 2009). Generally, students with Practical Significance poor problem-solving confidence and an avoidant style are more likely to report SI (Abdollahi et al., 2016). For college Our findings have some implications. Suicidal behavior can students, the main source of pressure stems from interper- begin with psychological strain, which suggests a way to sonal relationships, including pressure related to family, prevent and intervene in suicide. A study found that SI and classmates, love, and teacher relationships (Hurst et al., suicidal behavior can be prevented or reduced by reducing or 2013). In addition, coping strain may be related to burnout avoiding psychological strain (J. Zhang et al., 2017a). when medical students face heavy academic work (Palupi & Psychache is caused by the interweaving of various psycho- Findyartini, 2019). Schools should establish courses to culti- logical strains. Due to the poor coping ability of medical stu- vate medical students’ coping skills in response to academic dents, they often develop cognitive conflicts, which lead to and social problems, such as active coping. The higher an suicidal thoughts. Measures should be taken to buffer the individual’s coping ability, the lower the individual’s coping psychache caused by psychological strain. First, schools can strain and the lower the risk of suicide. organize campaigns to teach students to espouse correct val- Second, the linear regression indicated that psychache and ues and determine their direction to strengthen their beliefs. psychological strain can be used to predict suicidal behavior. Second, students can establish achievable learning and living Psychache is the strongest statistical predictor of suicidality, goals instead of blindly comparing themselves with others. given Shneidman’s theory of psychache (Troister & Holden, Students should accept their differences and failures, be 2010). The findings are consistent with a study conducted aware of the distance between aspiration and reality, and among communities showing that the PSS scale can be keep trying. Third, excellent coping skills and a wide range applied in research to predict suicidal behavior (J. Zhang & of social support mechanisms can give a person the strength Lyu, 2014). Each scale of the PSS has a significant positive to face a variety of crises and negative situations. correlation with psychache. Future studies can further explore and confirm this relationship. Understanding and avoiding Limitations psychological strain can not only prevent suicide but also reduce psychache and control it within a tolerable range. The current study has several limitations. First, the data Third, the mediation effect test procedure found that applied in this study were not entirely representative of differ- psychache was predictive of suicidal behavior. After con- ent ethnic minorities in China. The influence of ethnicity on trolling for psychache, psychological strain was a signifi- psychological strain and suicidal behavior requires further cant predictor of suicidal behavior. Further analysis found study. Second, the variables included in the regression model that psychological strain could also predict suicidal behav- did not include all the potential predictors (e.g., family history ior by influencing psychache. The indirect effect of psych- of suicide or previous mental health status), which may lead ache is significant, which explains why psychache has a to an overestimation of the mediating effect of psychache. mediating effect between psychological strain and suicide. Finally, the cross-sectional design is not able to infer a causal Psychological strain significantly affects suicidal behavior. association between psychache and suicidal behavior. Therefore, psychache plays a partial mediating role in the prediction of suicidal behavior by psychological strain. Conclusion Based on our analysis of the demographic and psycho- pathological characteristics of the sampled college students The mediating effect of psychache is significant and par- of different ethnic minorities, we believe that one or several tial in the relationship between psychological strain and influencing factors can dilute the effect of psychological suicidal behavior. In Hui students, the mediating effect of strain or psychache, such as religious beliefs, economic sta- psychache between psychological strain and suicidal tus, purpose in life, and social support (Wang et al., 2016). behavior is complete. Ha et al. 7 Declaration of Conflicting Interests Chang, B., Gitlin, D., & Patel, R. (2011). The depressed patient and suicidal patient in the emergency department: Evidence-based The author(s) declared no potential conflicts of interest with respect management and treatment strategies. Emergency Medicine to the research, authorship, and/or publication of this article. Practice, 13(9), 1–23. Deisenhammer, E. A., Ing, C. M., Strauss, R., Kemmler, G., Funding Hinterhuber, H., & Weiss, E. M. (2009). The duration of the suicidal process: How much time is left for interven- The author(s) disclosed receipt of the following financial support for tion between consideration and accomplishment of a suicide the research, authorship, and/or publication of this article: This work attempt? Journal of Clinical Psychiatry, 70(1), 19–24. was supported by the CMB foundation project (16-254), and annual Durkheim, E. (1951). Suicide: A study in sociology. New York: project of philosophy and Social Sciences in Ningxia (project number: Free Press. 18NXBSH03); the funder played no role in the study design and Dyrbye, L. N., Thomas, M. R., Eacker, A., Harper, W., Massie, F. publication. S. J., Power, D. V., Huschka, M., Novotny, P. J., Sloan, J. A., & Shanafelt, T. D. (2007). Race, ethnicity, and medical student ORCID iDs well-being in the United States. Archives of Internal Medicine, Lina Ha https://orcid.org/0000-0002-5981-8742 167(19), Article 2103. Dyrbye, L. N., Thomas, M. R., Massie, F. S., Power, D. V., Eacker, ZhiZhong Wang https://orcid.org/0000-0002-0612-3218 A., Harper, W., Durning, S., Moutier, C., Szydlo, D. W., Novotny, P. J., Sloan, J. A., & Shanafelt, T. D. (2008). Burnout References and suicidal ideation among U.S. medical students. Annals of Abdollahi, A., Talib, M. A., Yaacob, S. N., & Ismail, Z. (2016). Internal Medicine, 149(5), 334–341. Problem-solving skills and suicidal ideation among Malaysian Fan, Z. F., Yu, G. L., & Liu, C. H. (2009). Review of psychache college students: The mediating role of hopelessness. Academic research- focus on the psychache of the affected people in 5.12 Psychiatry, 40(2), 1–7. Wenchuan earthquake. Advances in Psychological Science, Agnew, R. (2006). Pressured into crime: An overview of general 17(3), 631–638. strain theory. Roxbury Publishing Company. Guo, H., & Fang, Q. Z. (2013). Chinese ethnic and religious theo- Aloba, O., Ojelege, O., & Aloba, T. (2017). The psychometric charac- ries and policies. Ningxia People’s Publishing House. teristics of the 4 item Suicidal Behaviors Questionnaire-Revised Hayes, A. F., & Preacher, K. J. (2013). Conditional process model- (SBQ-R) as a screening tool in a nonclinical sample of Nigerian ing: Using structural equation modeling to examine contingent University students. Asian Journal of Psychiatry, 26, 46–51. causal processes. In G. R. Hancock & R. O. Mueller (Eds.), Bartlett, J., & Fowler, K. (2019). Beyond the curriculum: a cross- Structural equation modeling: A second course (pp. 219–266). sectional study of medical student psychological distress, and IAP Information Age. health care needs, practices and barriers. Social Psychiatry Holden, R. R., & Delisle, M. M. (2005). Factor analysis of the and Psychiatrie Epidemiology. Advance online publication. Beck Scale for suicide ideation with female suicide attempters. doi:10.1007/s00127-019-01771-1 Assessment, 12(2), Article 231. Brazeau, C. M. L. R., Shanafelt, T., Durning, S. J., Massie, F. S., Holden, R. R., Mehta, K., Cunningham, E. J., & Mcleod, L. D. (2001). Eacker, A., Moutier, C., Satele, D. V., Sloan, J. F., & Dyrbye, Development and preliminary validation of a scale of psychache. L. N. (2014). Distress among matriculating medical students Canadian Journal of Behavioural Science, 33(4), 224–232. relative to the general population. Academic Medicine, 89(11), Hurst, C. S., Baranik, L. E., & Daniel, F. (2013). College student 1520–1525. stressors: A review of the qualitative research. Stress and Breault, K. D. (1986). Suicide in America: A test of Durkheim’s the- Health, 29(4), 275–285. ory of religious and family integration, 1933-1980. American Khaki, A. (2020). The Effect of Religion and Denomination on Journal of Sociology, 92(3), 628–656. Calmness in Residential Spaces Based on Islamic Teachings. Calizaya-Gallegos, C., Mayta-Tristán, P., Pereyra-Elías, R., José, Journal of Religion and Health. Advance online publication. M.-I. J., Avila-Figueroa, J., Benítez-Ortega, I., Cabrera- doi:10.1007/s10943-019-00973-w Enriquez, J., Calixto, O.-J., Cardozo-López, J. P., Grandez- Koenig, H. G. (2012). Religion, spirituality, and health: The Urbina, J. A., Moreno-Loaiza, O., Rodriguez, M. A., research and clinical implications. ISRN Psychiatry, 2012, Sepúlveda-Morales, R, Sierra-Avendaño, J. A., Carreño, F., Article 278730. Vásquez-García, G. R., Vasquez-Sullca, R. R., Yescas, G., & Kwok, S. Y., & Shek, D. T. (2009). Social problem solving, family Red-LIRHUS. (2019). Religious affiliation and the intention to functioning, and suicidal ideation among Chinese adolescents choose psychiatry as a specialty among physicians in training in Hong Kong. Adolescence, 44(174), Article 391. from 11 Latin American countries. Transcultural Psychiatry, Li, Z., & Zhang, J. (2012). Coping skills, mental disorders, and 56(6), 1237–1254. suicide among rural youths in China. Journal of Nervous and Carla, G., & Patrizia, Z. (2018). Medical students and suicide pre- Mental Disease, 200(10), 885–890. vention: Training, education, and personal risks. Frontiers in National Health Commission. (2018). China health statistical year- Psychology, 9, Article 452. book. Peking Union Medical College Press. Castaldelli-Maia, J. M., Lewis, T., Marques, D. S. N., Picon, F., Merton, R. K. (1957). Social theory and social structure. New Kadhum, M., Farrell, S. M., Molodynski, A., & Ventriglio, A. York: Free Press. (2019). Stressors, psychological distress, and mental health Maser, B., Danilewitz, M., Guérin, E., Findlay, L., & Frank, E. (2019). problems amongst Brazilian medical students. International Medical Student Psychological Distress and Mental Illness Review of Psychiatry, 31, 7–8. Relative to the General Population: A Canadian Cross-Sectional 8 SAGE Open Survey. Academic Medicine: Journal of the Association of Troister, T., & Holden, R. R. (2010). Comparing psychache, American Medical Colleges, 94(11), 1781–1791. depression, and hopelessness in their associations with Montemarano, V., Troister, T., Lambert, C. E., & Holden, R. R. suicidality: A test of Shneidman’s theory of suicide. (2018). A four-year longitudinal study examining psychache Personality and Individual Differences, 49(7), 689–693. and suicide ideation in elevated-risk undergraduates: A test of Verrocchio, M. C., Carrozzino, D., Marchetti, D., Andreasson, K., Shneidman’s model of suicidal behavior. Journal of Clinical Fulcheri, M., & Bech, P. (2016). Mental pain and suicide: A Psychology, 74(10), 1820–1832. systematic review of the literature. Frontiers in Psychiatry, Muttathu, K. C., Paul, S. S., Satya, R., Vinod, S., Suma, N., Priya, M., 7(1), 215–230. & Neethu, C. (2013). Adolescent suicide: Characterizing the need Wang, Z., Koenig, H. G., Ma, H., & Shohaib, S. A. (2016). Purpose and identifying the predictive factors for preventive consultation in life, social support and psychological distress in Chinese or hospitalization in a rural community setting. International university students. Journal of Religion and Health, 55(3), Journal of Adolescent Medicine and Health, 25(1), 81–86. 1055–1064. Osman, A., Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kopper, World Health Organization. (2017). Depression and other common B. A., & Burrios, F. X. (2001). The Suicidal Behaviors mental disorders: Global health estimates. Questionnaire-Revised (SBQ-R): Validation with clinical and Xiao, S. Y. (2001). Clinical assessment of suicide risk. Chinese nonclinical samples. Assessment, 8(4), Article 443. Medical Journal, 3(2), 87–90. Palmieri, G., Forghieri, M., Ferrari, S., Pingani, L., Coppola, P., Xu, R. B., Wen, B., Song, Y., Luo, D. M., Dong, Y. H., Dong, B., Colombini, N., Rigatelli, M., & Neimeyer, R. A. (2008). Suicide & Ma, J. (2018). Changes of China’s youth mortality rate and intervention skills in health professionals: A multidisciplinary major causes of death from 1990 to 2016. Chinese Journal of comparison. Archives of Suicide Research, 12(3), 232–237. Preventive Medicine, 52(8), Article 802. Palupi, R., & Findyartini, A. (2019). The relationship between gen- Yang, L., & Chen, W. (2017). Reliability and validity test of der and coping mechanisms with burnout events in first-year Chinese Version of Psychological Distress Scale in Chinese medical students. Korean Journal of Medical Education, 31(4), college students. Chinese Journal of Clinical Psychology, 331–342. 25(3), 475–478+583. Parry, J. (2014). Falling suicide rates in China mask emerging Zang, M. H., Wang, X., Wang, Y. J., Huang, X. L., & Wang, J. upward trends. BMJ Clinical Research, 349, Article g4486. (2016). Systematic evaluation of influencing factors of sui- Rasic, D., Kisely, S., & Langille, D. B. (2011). Protective associa- cidal ideation of medical students in mainland China. Chinese tions of importance of religion and frequency of service atten- Journal of School Health, 37(5), 711–715. dance with depression risk, suicidal behaviours and substance Zhang, J., Dong, N., Delprino, R., & Zhou, L. (2009). Psychological use in adolescents in Nova Scotia, Canada. Journal of Affective strains found from in-depth interviews with 105 Chinese Disorders, 132(3), 389–395. rural young suicides. Archives of Suicide Research, 13(2), Rotenstein, L. S., Ramos, M. A., Torre, M., Segal, J. B., & Mata, 185–194. D. A. (2016). Prevalence of depression, depressive symptoms, Zhang, J., Fang, L., Wu, Y. W., & Wieczorek, W. F. (2013a). and suicidal ideation among medical students: A system- Depression, anxiety, and suicidal ideation among Chinese atic review and meta-analysis. The Journal of the American Americans: A study of immigration-related factors. Journal of Medical Association, 316(21), Article 2214. Nervous and Mental Disease, 201(1), 17–22. Sha, F., Chang, Q., Law, Y. W., Hong, Q., & Yip, P. (2018). Suicide Zhang, J., Lester, D., Haines, J., Williams, C. L., & Ma, W. (2018). rates in China, 2004-2014: Comparing data from two sample- Identifying psychological strains in suicide notes. OMEGA- based mortality surveillance systems. BMC Public Health, Journal of Death and Dying, 2018(1): 003022281881146. 18(1), 239. doi:10.1186/s12889-018-5161-y Zhang, J., Liu, Y., & Sun, L. (2017a). Psychological strain and sui- Shneidman, E. S. (1984). Aphorisms of suicide and some implica- cidal ideation: A comparison between Chinese and US college tions for psychotherapy. American Journal of Psychotherapy, students. Psychiatry Research, 255, 256–262. 38(3), 319–328. Zhang, J., & Lyu, J. (2014). Reliability, validity and preliminary Shneidman, E. S. (1993). Commentary: Suicide as psychache. hypothesis tests for the English version of the Psychological Strain Journal of Nervous and Mental Disease, 181(3), 145–147. Scales (PSS). Journal of Affective Disorders, 164(1), 69–75. Stack, S. (1983). The effect of religious commitment on suicide: A Zhang, J., Tan, J., & Lester, D. (2013b). Psychological strains found cross-national analysis. Journal of Health and Social Behavior, in the suicides of 72 celebrities. Journal of Affective Disorders, 24(4), 362–374. 149(1–3), 230–234. Stack, S. (2000a). Suicide: A 15-year review of the sociological Zhang, J., Wieczorek, W. F., Conwell, Y., & Tu, X. M. (2011). literature. Part I: Cultural and economic factors. Suicide and Psychological strains and youth suicide in rural China. Social Life-Threatening Behavior, 30(2), 145–162. Science and Medicine, 72(12), 2003–2010. Stack, S. (2000b). Suicide: A 15-year review of the sociological lit- Zhang, J., & Zhao, Z. (2017). Psychological strain and suicidal ide- erature. Part II: Modernization and social integration perspec- ation among Chinese young people. International Journal of tives. Suicide and Life-Threatening Behavior, 30, 145–162. Asian Social Science, 7(6), 497–504. Sugawara, N., Hashimoto, K., Tanaka, O., Nakamura, K., & Yasui- Zhang, X., Wang, H., Xia, Y., Liu, X., & Jung, E. (2012). Stress, coping and suicide ideation in Chinese college students. Furukori, N. (2014). Parental bonding and attitudes toward sui- Journal of Adolescence, 35(3), 683–690. cide among medical college students in Japan. Neuropsychiatric Zhang, X., Zhang, J., Procter, N., Chen, X., Su, Y., Lou, F., & Cao, Disease and Treatment, 10, 2015–2020. F. (2017b). Suicidal ideation and psychological strain among Sun, L., Li, H., Zhang, J., & Wu, Q. (2015). Psychological strains patients diagnosed with stomach cancer: The mediation of and suicide intent: Results from a psychological autopsy study psychopathological factors. Journal of Nervous and Mental with Chinese rural young suicides. International Journal of Disease, 205(7), 550–557. Social Psychiatry, 61(7), 677–683. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png SAGE Open SAGE

The Mediating Effect of Psychache on the Relationship Between Psychological Strains and Suicidal Behaviors Among Chinese Hui and Han Medical Students:

Ha, Lina; Chang, Qingning; Wang, ZhiZhong
SAGE Open , Volume 10 (3): 1 – Jul 15, 2020
Download PDF
8 pages

Loading next page...
 
/lp/sage/the-mediating-effect-of-psychache-on-the-relationship-between-DvbAY8c20v

References (70)

Publisher
SAGE
Copyright
Copyright © 2022 by SAGE Publications Inc, unless otherwise noted. Manuscript content on this site is licensed under Creative Commons Licenses.
ISSN
2158-2440
eISSN
2158-2440
DOI
10.1177/2158244020942158
Publisher site
See Article on Publisher Site

Abstract

Psychological strain is associated with suicidal behavior; however, the way that psychological strain leads to suicidal behavior remains unclear. The current study examines the mediation effect of psychache on the relationship between psychological strain and suicidal behavior among Chinese Hui and Han medical students. A total of 1,696 enrolled medical students (974 Han and 722 Hui) were administered the Psychological Strain Scale (PSS), the Suicide Behavior Questionnaire-Revised (SBQ-R) scale, and the Psychache Scale. There were significant differences in the PSS between different ethnic groups. Correlation analysis showed that both psychological strain and psychache were positively correlated with suicidal behaviors, and the two predictive variables were also positively correlated. The mediation effect test procedure showed that the direct and indirect effects (mediator effect) of psychological strain on suicidal behaviors were significant. The findings indicate that psychological strain partially induced psychache in both two ethnicity groups, leading to suicidal behavior in Chinese medical college students. Keywords psychological strain, psychache, suicidal behavior, mediating effect, ethnic can identify their own psychological problems in time and Introduction receive counseling and treatment (Carla & Patrizia, 2018). Suicide has become a global social problem that cannot be Special training is needed to improve diagnostic skills and ignored. As of 2015, an estimated 788,000 people had died of competency in SI assessment, especially for medical stu- suicide, accounting for nearly 1.5% of the global death toll dents (Palmieri et al., 2008). SI is the early psychological and making suicide one of the top 20 causes of death (World activity of suicide attempts and suicides, with one in five Health Organization [WHO], 2017). Data from other coun- people attempting suicide before completing suicidal behav- tries show that suicide rates are also high in India, especially ior (Chang et al., 2011; Deisenhammer et al., 2009). among college students (Muttathu et al., 2013). China’s lat- Therefore, it is necessary to assess suicidal danger as a link est figures show 4.31 suicides per 100,000 urban residents to and component of suicide prevention (Xiao, 2001). In par- (Sha et al., 2018). Among the causes of death for Chinese ticular, it is important to detect the influencing factors of SI college students, suicide dropped from third place in 1990 to and maintain mental health among medical students. fourth place in 2016 (Xu et al., 2018). China’s suicide rate is Many medical students experience distress during med- significantly lower than the average. However, some poten- ical school. Medical students must go to the hospital for tial uptrends cannot be ignored (Parry, 2014). For example, practice and training, and this training process and envi- an increasing number of studies show that medical students ronment contribute to the deterioration of mental health in are at high risk of suicidal ideation (SI; Rotenstein et al., developing physicians (Brazeau et al., 2014). Edwin 2016; Sugawara et al., 2014). Medical students report higher rates of SI than do students of other majors in China (Zang Xi’an Jiaotong University, Xi’an, China et al., 2016); this is also the case for students in the United Ningxia Medical University, Yinchuan, China States (Dyrbye et al., 2008). Compared with the general pop- Zunyi Medical University, Zunyi, China ulation, heavy medical courses put more pressure on medical Corresponding Author: students (Castaldelli-Maia et al., 2019). In addition, this ZhiZhong Wang, Department of Epidemiology and Statistics, School of trend may be related to the attitude of medical students Public Health of Zunyi Medical University, Zunyi 563006, China. toward the suicide of patients and whether medical students Email: wzhzh_lion@126.com Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open Shneidman proposed the concept of psychache in 1953. He minority medical students because their ethnicity adversely defined psychache as “hurt, anguish, soreness, aching, affects their medical school experience (Dyrbye et al., 2007). psychological pain in the psyche, the mind.” Psychache is Furthermore, previous studies indicate that suicide rates tend a necessary condition for suicide to occur (Shneidman, to be lowest in Muslim countries, and in the Muslim commu- 1993) and a core factor of suicide susceptibility (Verrocchio nities, the Islam belief as a coping of life stress was inversely et al., 2016). When the perception of pain is unbearable, associated with suicide behaviors (Koenig, 2012). However, the cognitive level is lowered to the point that suicide is no study had examined the psychological strain theory among seen as the only way to block the unbearable flow of con- minority ethnicity population (like Hui in this study) in main- sciousness (Shneidman, 1984). Studies have consistently land China. In the path from psychological strain to suicidal related psychache to suicide risk (Maser et al., 2019). behavior, strain may be moderated by social factors such as Medical students experience considerable psychache due social integration and psychological factors such as personal- to various pressures in the training process, but they are ity traits (J. Zhang & Zhao, 2017). reluctant to seek help despite their health care needs. Based on these theories, the present study hypothesized Medical students both domestically and abroad experience the following: (a) psychache mediates the relationships substantial psychache. However, the concept of psychache between psychological strain and suicide in Chinese medi- has rarely been used to describe psychological distress and cal students and (b) the cultural differences between assess suicide risk in Chinese medical students. It is neces- Chinese Hui (most of them believe Islam) and Chinese Han sary to determine in a timely fashion whether medical stu- (most of them have no religion affiliation) students affect dents are experiencing psychache and to adopt interventions SI through the difference in psychological strain and psych- to prevent suicide. ache. This study suggests three innovations to research on Research shows that psychological strains (such as dif- this issue: (a) psychological factors play an important role ferential values strain and relative deprivation strain) are risk in suicidal behavior, but the mediating pathways through factors of suicide and significantly and positively affect SI (J. which psychological strain affects suicidal behavior are not Zhang & Zhao, 2017). The conceptualization of the strain sufficiently clear; (b) the suicide rate of medical students is theory of suicide is derived from and built on the previous increasing daily globally, but no studies have explored this work of Durkheim (1951), Merton (1957), Agnew (2006), relationship in Chinese medical students; and (c) the addi- and (J. Zhang & Lyu, 2014) and has been tested in the tion of ethnic medical students to the mediating effect of Chinese population (J. Zhang et al., 2013b). Psychological psychache between psychological strain and suicide strain can predict mental illness and suicidal behavior in both extends previous studies on this relationship. When indi- rural and urban youth (Sun et al., 2015) as well as among viduals, especially medical students, experience various stomach cancer patients and Chinese Americans. The types of pressure, psychological strain may increase the extreme solution in an acute and excruciating moment of risk of suicide through psychache. This study offers direc- psychological strain is suicide (J. Zhang et al., 2013a; X. tions for future work in this area and suggests ways to pre- Zhang et al., 2017b). A single stress is not a strain. A strain vent suicide among medical students. consists of at least two forces, or two stresses, that push a person in different directions (J. Zhang & Lyu, 2014). Four Method types of strain can predict suicide: (a) differential values occur when two conflicting social values compete in an indi- Participants and Procedure vidual’s life and are equally important, (b) aspiration versus reality means that an individual has impossible aspirations, Data were collected from a medical student sample selected (c) relative deprivation occurs when a person compares him- from Ningxia Medical University, which has 8,880 full-time self or herself negatively with others, and (d) deficient cop- students. A cluster sampling approach was undertaken to ing refers to the lack of ability to face crises in life (J. Zhang select the sample. Students registered in the same class (usu- et al., 2011). ally 35–45 students) were defined as a cluster. Then, 48 It is remarkable that suicide-related psychological vari- classes (n = 2,000) were selected from the school of clinical ables are associated with SI only through psychache medicine, the school of nursing, and the school of public (Montemarano et al., 2018). In the relation between psycho- health. And 1,696 participants who finished the full ques- logical strain and suicide, psychache may be a mediator. tionnaires were included in the final data analysis. The sam- Some studies have examined the mediating effect of psych- ple for this study consisted of 643 males (37.9%) and 1,053 ache on the relationship between risk factors (such as depres- females (62.1%), including Chinese Han (57.4%) and sion and hopelessness) and suicidal behavior (Sun et al., Chinese Hui (42.6%) students. The average age of the total 2015; J. Zhang et al., 2009). However, the mediating effect of participants was 21.7 years with standard deviation 2.4 psychache on the relationship between psychological strain (ranged from 18 to 30 years). and suicide has rarely been examined within the medical col- A questionnaire survey was conducted during November lege students. In addition, psychache is more common in 14 to 24, 2017. A research team was responsible to distribute Ha et al. 3 the questionnaires to students in university classrooms and to to examine differences in age, PPS scores, SBQ-R scores, collect the questionnaires back at that time. The anonymity of and psychache scores between Chinese Han and Chinese the respondents and the confidentiality of the collected infor- Hui students. A chi-square test was applied to examine the mation were ensured for academic research, and we prom- differences in gender, one-child families, and economic sta- ised to follow the principle of voluntary participation. All tus between the two groups of students. Linear regression participants were asked to provide a written consent form, and correlations were used to analyze the relationships and this study was approved by the Institutional Review among variables. The mediation analyses were performed Board of Ningxia Medical University (No. 2017-171). using PROCESS (Hayes & Preacher, 2013). PROCESS estimates the direct effect and bias-corrected confidence intervals (CIs). A direct effect was considered not signifi- Measures cant when the CI included zero. In this case, it is a full Sociodemographic information was measured by a self- mediation effect. Structural equation modeling (SEM) report questionnaire, which included grade, gender, ethnic- analyses were used to explore the full mediating role of ity, number of siblings, self-rated physical condition (“1 = psychache in Hui students between deprivation strain and very bad,” “2 = bad,” “3 = normal,” “4 = good,” and “5 suicide behavior. = very good”), family economic status, and religious affili- ation. Ethnicity was categorized as “1 = Han” and “2 = Results minority.” The Psychological Strain Scale (PSS) was developed in As Table 1 shows, among the final 1,696 participants, there both English and Chinese. The original PSS was validated in were significant differences in economic status (t/χ = a sample of the Chinese population; it has been tested, and its 3.87, p < .001), PSS total scores (t/χ = 2.49, p = .013), reliability and validity have been demonstrated (X. Zhang and SBQ-R scores (t/χ = 1.19, p = .046) between the et al., 2012). The Cronbach’s alpha coefficient of the total Chinese Han sample and the Chinese Hui sample. Chinese PSS was .94 in the current study. The PSS comprises four Hui students had higher psychological strain scores than scales for value strain, aspiration strain, deprivation strain, Chinese Han students. Total PSS and the three dimensions and coping strain, each with 10 items. Each of the 40 items were significant (total PSS, p = .013; value strain, p = had five options, including 1 = never, not me at all; 2 = .006; aspiration strain, p = .036; deprivation strain, p = rarely, not me; 3 = maybe, not sure; 4 = often, like me; and .002). However, Chinese Hui students had a lower SBQ-R 5 = yes, strongly agree. The higher the total PSS score, the score than Chinese Han students. Other factors were insig- greater the strain (J. Zhang & Zhao, 2017). nificant, such as age, gender, one-child family, coping The Psychache Scale (Holden et al., 2001) is a 13-item strain, and psychache (p > .05). self-report scale to measure the degree of psychache using a Table 2 shows the correlations for the key variables in 5-point scale of “1 = never,” “2 = once in a while,” “3 = Chinese medical students. The results of correlation and sometimes,” “4 = many times,” and “5 = almost always.” regression analysis showed that psychological strain, psych- The higher the score, the higher the pain. Coefficient alpha ache, and SI were significantly positively correlated (p < .01). reliabilities of .92 and .95 have been reported for this scale Table 3 shows the mediating effect of psychache on the (Holden & Delisle, 2005). It was translated into Chinese by relationship between psychological strain and suicidal Yang and Chen, and found that the internal consistency reli- behavior in Chinese medical students, Chinese Han and ability of the scale was .90 (Yang & Chen, 2017), and it was Chinese Hui. The independent variable (X) is psychological .94 in this study. strain, the mediating variable (M) is psychache, and the The Suicide Behavior Questionnaire-Revised (SBQ-R) is dependent variable (Y) is suicidal behavior. In total, a, b, c, a four-item scale to assess different suicide behaviors: life- and c’ were all statistically significant in the equation and time SI and suicide attempts, the frequency of SI over the could be used to describe the relationship among the vari- past 12 months, threats of suicide attempt, and self-reported ables. The indirect effect (ab) of psychological strain on SI likelihood of suicidal behavior in the future (Osman et al., by the mediating effect of psychache was significant (p < 2001). The total score ranges from 3 to 18, with a higher .05, 95% CI = [0.014, 0.094]); the direct effect (c’) was sig- score indicating a higher risk of suicide and a positive cutoff nificant (p < .05, 95% CI = [0.005, 0.085]), except that the score of 7. Coefficient alpha reliabilities for the SBQ-R items effect of deprivation strain on SI was not significant (p = were .80 (Aloba et al., 2017) and .72 in the current study. .138, 95% CI = [−0.007, 0.047]) in Chinese Hui. Psychache partially mediated the effect between psycho- logical strain and suicidal behavior in Chinese medical stu- Statistical Analysis dents, with mean effects of 0.641 (value strain), 0.688 The Statistical Package for Social Sciences (SPSS) version (aspiration strain), 0.731 (deprivation strain), 0.637 (coping 23 was used for statistical analysis. Cronbach’s alpha coef- strain), and 0.623 (total PSS) in total sample. The mean ficients were used to evaluate the validity. A t test was used effect was 0.665 in Han students, with the value strain, 4 SAGE Open Table 1. Demographic and Psychopathological Characteristics of the Sample by Ethnicity. Variable Total (n = 1,696) Han (n = 974) Hui (n = 722) t/χ p value Age, M ± SD 21.7 ± 2.4 21.0 ± 1.5 22.8 ± 3.1 1.52 .129 Gender, n (%) 0.63 .526 Male 643 (37.9) 363 (37.3) 280 (38.80) Female 1,053 (62.1) 611 (62.7) 442 (61.20) One-child family, n (%) 1.13 .259 Yes 283 (16.7) 237 (24.30) 46 (6.40) No 1412 (83.3) 737 (75.70) 675 (93.50) Economic, n (%) 3.87 <.001 Bad 374 (22.10) 188 (19.4) 186 (25.8) Normal 1,188 (70.00) 693 (71.1) 495 (68.5) Good 134 (7.90) 93 (9.5) 41 (5.7) PSS, M ± SD 94.00 ± 21.68 92.87 ± 21.82 95.53 ± 21.42 2.49 .013 Value, M ± SD 24.90 ± 6.47 24.52 ± 6.32 25.40 ± 6.64 2.74 .006 Aspiration, M ± SD 23.84 ± 7.07 23.52 ± 7.03 24.25 ± 7.09 2.09 .036 Deprivation, M ± SD 22.65 ± 6.31 22.23 ± 6.27 23.22 ± 6.32 3.17 .002 Coping, M ± SD 22.62 ± 6.52 22.58 ± 6.66 22.66 ± 6.33 0.23 .812 Psychache, M ± SD 22.60 ± 8.83 22.62 ± 8.82 22.57 ± 8.84 0.12 .903 SBQ-R, M ± SD 4.51 ± 2.37 4.61 ± 2.39 4.38 ± 2.33 1.99 .046 Note. PSS = Psychological Strain Scale; SBQ-R = Suicide Behavior Questionnaire-Revised. Table 2. The Correlation Matrix Among the Predicted Variables. Variables 1 2 3 4 5 6 1.Value 1 2.Aspiration .605* 1 3.Deprivation .471* .664* 1 4.Coping .559* .568* .518* 1 5.Psychache .431* .448* .405* .521* 1 6.SBQ-R .271* .249* .209* .302* .423* 1 Note. SBQ-R = Suicide Behavior Questionnaire-Revised. *p < .01. Table 3. The Mediation Effect of Psychache on the Relationship Between Psychological Strains. Model 1 Model 2 Model 3 Path Estimate Lower Upper Estimate Lower Upper Estimate Lower Upper Effect M Value strain → psychache Total 0.066** 0.054 0.080 0.037** 0.020 0.055 0.103** 0.087 0.120 .641 → suicide behavior Han 0.074** 0.057 0.094 0.039** 0.016 0.062 0.113** 0.091 0.136 .655 Hui 0.056** 0.039 0.078 0.039** 0.013 0.065 0.095** 0.070 0.120 .589 Aspiration strain → psychache Total 0.063** 0.052 0.077 0.029** 0.013 0.045 0.092** 0.076 0.107 .688 → suicide behavior Han 0.068** 0.052 0.085 0.026* 0.005 0.046 0.093** 0.073 0.114 .731 Hui 0.056** 0.039 0.075 0.036** 0.011 0.061 0.092** 0.069 0.115 .609 Deprivation strain → psychache Total 0.065** 0.053 0.041 0.024** 0.007 0.041 0.088** 0.071 0.106 .731 → suicide behavior Han 0.071** 0.056 0.089 0.030* 0.007 0.053 0.101** 0.078 0.124 .703 Hui 0.056** 0.039 0.074 0.020 −0.007 0.047 0.076** 0.050 0.103 1.000 Coping strain → psychache Total 0.074** 0.060 0.090 0.042** 0.024 0.060 0.116** 0.100 0.132 .637 → suicide behavior Han 0.084** 0.065 0.106 0.031* 0.007 0.054 0.115** 0.093 0.136 .730 Hui 0.061** 0.043 0.082 0.057** 0.029 0.085 0.118** 0.093 0.144 .517 Psychological strain → Total 0.023** 0.019 0.029 0.014** 0.008 0.019 0.037** 0.032 0.042 .623 psychache → suicide behavior Han 0.025** 0.020 0.032 0.013** 0.006 0.045 0.038** 0.032 0.045 .658 Hui 0.020** 0.014 0.027 0.016** 0.008 0.025 0.036** 0.029 0.044 .556 Note. Model 1 = indirect effect (ab); Model 2 = direct effect (c’); Model 3 = total effect (c); Effect M = ab/c. *p < .05. **p < .01. Ha et al. 5 0.076* Deprivaon strain Suicide behavior (a) (a) Psychache Suicide behavior Deprivaon strain 0.109* 0.543* (b) Figure 1. Path coefficients in the full mediation model in the Hui students. The total effect. Complete mediation model. *p < .01. aspiration strain, deprivation strain, and coping strain were religion protects against SI (Rasic et al., 2011), suggesting 0.655, 0.727, 0.707, and 0.732, respectively. The effect of that certain traditional cultures have a buffer effect on psych- the other independent variable on the dependent variable ache (Fan et al., 2009; Stack, 2000a). Therefore, ethnic dif- was not completely achieved through the mediating effect ferences may dilute the effect of psychache on SI. of psychache. There was a difference between Chinese Han and Chinese However, the mediating effect of psychache between depri- Hui medical students’ scores in psychological strain (includ- vation strain and suicidal behavior was achieved among Hui ing value strain, aspiration strain, and deprivation strain). students. The path model is shown in Figure 1 and includes the The significant effect corroborates the impact of ethnicity on total effect (a) and complete mediation model (b). Based on psychological strain. There are four types of strains, and each the results, the model fit was acceptable: χ (df) = 2.1 (1), p = strain consists of at least two conflicting social facts. Value .146, goodness of fit index (GFI) = 0.998, root mean square strain involves a conflict of two or more values; this study error of approximation (RMSEA) = 0.039, Tucker–Lewis found that Hui students had higher PSS scores. As an ele- index (TLI) = 0.987, comparative fit index (CFI) = 0.996, χ ment of culture and as a social-cultural phenomenon, reli- / df = 2.1. The effect of the other independent variable on the gion is a source of change, difference, and contrast in various dependent variable was not completely achieved through the places (Khaki, 2020). Hui students believe in Islam because mediating effect of psychache. The mean effect was 0.547 in of their family environment and have their own traditional Hui students; value strain, aspiration strain, and coping strain culture and living habits. On one hand, they abide by the were 0.586, 0.607, and 0.517, respectively. rules of Islam, which, as the traditional culture of their ethnic region, influences their family education and living habits (Guo & Fang, 2013); on the other hand, they adapt to the Discussion Confucian culture together with their Chinese Han class- This study explored the mediating effect of psychache mates. In addition, conflict between Muslim cultural values between psychological strain and suicidal behavior among and modern cultural values occurs when Chinese Hui choose Chinese medical students, including Chinese Hui and a medical profession (Calizaya-Gallegos et al., 2019). Hui Chinese Han people. All the proposed hypotheses were sup- students experience strain when these two conflicting values ported. First, the findings showed that there was a difference are equally important in their daily life. between Chinese Han and Chinese Hui medical students’ Value strain, aspiration strain, and deprivation strain scores on the SBQ-R. Chinese Hui had lower scores on the may not play equally important roles in SI. Aspiration SBQ-R. Chinese Hui must follow Islam, whereas Chinese strain is mainly a sense of the gap between reality and Han people do not have to believe in religion. Most Chinese hopes. Hui students’ higher scores may be linked to reli- Han people have no religion or take Confucian culture as the gious belief. In other studies, aspiration strain has been mainstream culture, and many religions coexist, such as found to be related to love-partner selection, job choice, Buddhism and Taoism. Therefore, different national cultures and gender (J. Zhang et al., 2009), but this relationship is exist among Chinese Hui and Chinese Han people. The find- unclear. Deprivation strain occurs when people from simi- ings are in line with previous studies that reported that the lar backgrounds lead better lives, as evidenced by income suicide rates of individuals with religious beliefs were lower inequality and distribution inequality. Chinese Hui stu- than those without (Breault, 1986; Stack, 1983) and that dents obtained higher scores in this area. Research shows a 6 SAGE Open strong link between deprivation strain and economic fac- Psychache played a full mediating role between depriva- tors (J. Zhang et al., 2018). According to our research, the tion strain and suicidal behavior in Hui students. This may economic conditions were poorer for Hui students than for not be entirely related to ethnicity. Some people believe that Han students. The occurrence of deprivation strain may a deprivation response is caused by economic risk factors, represent this difference. which are a better explanation for suicide (Stack, 2000b). The last factor in PSS is coping strain. People with poor According to our research, improving individuals’ economic coping skills will develop coping strain. It is difficult to level can effectively reduce the risk of suicide by reducing change one’s culture and social environment, and improving deprivation strain to reduce the level of psychache. In addi- coping strategies would be an effective way to reduce the tion, high self-esteem increases the sense of psychological risk of suicide (Li & Zhang, 2012). However, medical stu- imbalance and cannot be easily mediated; thus, individuals dents, whether Han or Hui, have poor coping skills to deal undergo so much psychological pain that they attempt sui- with problems in the social environment, which increases cide. Alternatively, when deprivation strain occurs, it their level of coping strain and risk of suicide. Research has increases life stress and the mediating effect of psychache. shown that social problem-solving is negatively correlated with suicide (Kwok & Shek, 2009). Generally, students with Practical Significance poor problem-solving confidence and an avoidant style are more likely to report SI (Abdollahi et al., 2016). For college Our findings have some implications. Suicidal behavior can students, the main source of pressure stems from interper- begin with psychological strain, which suggests a way to sonal relationships, including pressure related to family, prevent and intervene in suicide. A study found that SI and classmates, love, and teacher relationships (Hurst et al., suicidal behavior can be prevented or reduced by reducing or 2013). In addition, coping strain may be related to burnout avoiding psychological strain (J. Zhang et al., 2017a). when medical students face heavy academic work (Palupi & Psychache is caused by the interweaving of various psycho- Findyartini, 2019). Schools should establish courses to culti- logical strains. Due to the poor coping ability of medical stu- vate medical students’ coping skills in response to academic dents, they often develop cognitive conflicts, which lead to and social problems, such as active coping. The higher an suicidal thoughts. Measures should be taken to buffer the individual’s coping ability, the lower the individual’s coping psychache caused by psychological strain. First, schools can strain and the lower the risk of suicide. organize campaigns to teach students to espouse correct val- Second, the linear regression indicated that psychache and ues and determine their direction to strengthen their beliefs. psychological strain can be used to predict suicidal behavior. Second, students can establish achievable learning and living Psychache is the strongest statistical predictor of suicidality, goals instead of blindly comparing themselves with others. given Shneidman’s theory of psychache (Troister & Holden, Students should accept their differences and failures, be 2010). The findings are consistent with a study conducted aware of the distance between aspiration and reality, and among communities showing that the PSS scale can be keep trying. Third, excellent coping skills and a wide range applied in research to predict suicidal behavior (J. Zhang & of social support mechanisms can give a person the strength Lyu, 2014). Each scale of the PSS has a significant positive to face a variety of crises and negative situations. correlation with psychache. Future studies can further explore and confirm this relationship. Understanding and avoiding Limitations psychological strain can not only prevent suicide but also reduce psychache and control it within a tolerable range. The current study has several limitations. First, the data Third, the mediation effect test procedure found that applied in this study were not entirely representative of differ- psychache was predictive of suicidal behavior. After con- ent ethnic minorities in China. The influence of ethnicity on trolling for psychache, psychological strain was a signifi- psychological strain and suicidal behavior requires further cant predictor of suicidal behavior. Further analysis found study. Second, the variables included in the regression model that psychological strain could also predict suicidal behav- did not include all the potential predictors (e.g., family history ior by influencing psychache. The indirect effect of psych- of suicide or previous mental health status), which may lead ache is significant, which explains why psychache has a to an overestimation of the mediating effect of psychache. mediating effect between psychological strain and suicide. Finally, the cross-sectional design is not able to infer a causal Psychological strain significantly affects suicidal behavior. association between psychache and suicidal behavior. Therefore, psychache plays a partial mediating role in the prediction of suicidal behavior by psychological strain. Conclusion Based on our analysis of the demographic and psycho- pathological characteristics of the sampled college students The mediating effect of psychache is significant and par- of different ethnic minorities, we believe that one or several tial in the relationship between psychological strain and influencing factors can dilute the effect of psychological suicidal behavior. In Hui students, the mediating effect of strain or psychache, such as religious beliefs, economic sta- psychache between psychological strain and suicidal tus, purpose in life, and social support (Wang et al., 2016). behavior is complete. Ha et al. 7 Declaration of Conflicting Interests Chang, B., Gitlin, D., & Patel, R. (2011). The depressed patient and suicidal patient in the emergency department: Evidence-based The author(s) declared no potential conflicts of interest with respect management and treatment strategies. Emergency Medicine to the research, authorship, and/or publication of this article. Practice, 13(9), 1–23. Deisenhammer, E. A., Ing, C. M., Strauss, R., Kemmler, G., Funding Hinterhuber, H., & Weiss, E. M. (2009). The duration of the suicidal process: How much time is left for interven- The author(s) disclosed receipt of the following financial support for tion between consideration and accomplishment of a suicide the research, authorship, and/or publication of this article: This work attempt? Journal of Clinical Psychiatry, 70(1), 19–24. was supported by the CMB foundation project (16-254), and annual Durkheim, E. (1951). Suicide: A study in sociology. New York: project of philosophy and Social Sciences in Ningxia (project number: Free Press. 18NXBSH03); the funder played no role in the study design and Dyrbye, L. N., Thomas, M. R., Eacker, A., Harper, W., Massie, F. publication. S. J., Power, D. V., Huschka, M., Novotny, P. J., Sloan, J. A., & Shanafelt, T. D. (2007). Race, ethnicity, and medical student ORCID iDs well-being in the United States. Archives of Internal Medicine, Lina Ha https://orcid.org/0000-0002-5981-8742 167(19), Article 2103. Dyrbye, L. N., Thomas, M. R., Massie, F. S., Power, D. V., Eacker, ZhiZhong Wang https://orcid.org/0000-0002-0612-3218 A., Harper, W., Durning, S., Moutier, C., Szydlo, D. W., Novotny, P. J., Sloan, J. A., & Shanafelt, T. D. (2008). Burnout References and suicidal ideation among U.S. medical students. Annals of Abdollahi, A., Talib, M. A., Yaacob, S. N., & Ismail, Z. (2016). Internal Medicine, 149(5), 334–341. Problem-solving skills and suicidal ideation among Malaysian Fan, Z. F., Yu, G. L., & Liu, C. H. (2009). Review of psychache college students: The mediating role of hopelessness. Academic research- focus on the psychache of the affected people in 5.12 Psychiatry, 40(2), 1–7. Wenchuan earthquake. Advances in Psychological Science, Agnew, R. (2006). Pressured into crime: An overview of general 17(3), 631–638. strain theory. Roxbury Publishing Company. Guo, H., & Fang, Q. Z. (2013). Chinese ethnic and religious theo- Aloba, O., Ojelege, O., & Aloba, T. (2017). The psychometric charac- ries and policies. Ningxia People’s Publishing House. teristics of the 4 item Suicidal Behaviors Questionnaire-Revised Hayes, A. F., & Preacher, K. J. (2013). Conditional process model- (SBQ-R) as a screening tool in a nonclinical sample of Nigerian ing: Using structural equation modeling to examine contingent University students. Asian Journal of Psychiatry, 26, 46–51. causal processes. In G. R. Hancock & R. O. Mueller (Eds.), Bartlett, J., & Fowler, K. (2019). Beyond the curriculum: a cross- Structural equation modeling: A second course (pp. 219–266). sectional study of medical student psychological distress, and IAP Information Age. health care needs, practices and barriers. Social Psychiatry Holden, R. R., & Delisle, M. M. (2005). Factor analysis of the and Psychiatrie Epidemiology. Advance online publication. Beck Scale for suicide ideation with female suicide attempters. doi:10.1007/s00127-019-01771-1 Assessment, 12(2), Article 231. Brazeau, C. M. L. R., Shanafelt, T., Durning, S. J., Massie, F. S., Holden, R. R., Mehta, K., Cunningham, E. J., & Mcleod, L. D. (2001). Eacker, A., Moutier, C., Satele, D. V., Sloan, J. F., & Dyrbye, Development and preliminary validation of a scale of psychache. L. N. (2014). Distress among matriculating medical students Canadian Journal of Behavioural Science, 33(4), 224–232. relative to the general population. Academic Medicine, 89(11), Hurst, C. S., Baranik, L. E., & Daniel, F. (2013). College student 1520–1525. stressors: A review of the qualitative research. Stress and Breault, K. D. (1986). Suicide in America: A test of Durkheim’s the- Health, 29(4), 275–285. ory of religious and family integration, 1933-1980. American Khaki, A. (2020). The Effect of Religion and Denomination on Journal of Sociology, 92(3), 628–656. Calmness in Residential Spaces Based on Islamic Teachings. Calizaya-Gallegos, C., Mayta-Tristán, P., Pereyra-Elías, R., José, Journal of Religion and Health. Advance online publication. M.-I. J., Avila-Figueroa, J., Benítez-Ortega, I., Cabrera- doi:10.1007/s10943-019-00973-w Enriquez, J., Calixto, O.-J., Cardozo-López, J. P., Grandez- Koenig, H. G. (2012). Religion, spirituality, and health: The Urbina, J. A., Moreno-Loaiza, O., Rodriguez, M. A., research and clinical implications. ISRN Psychiatry, 2012, Sepúlveda-Morales, R, Sierra-Avendaño, J. A., Carreño, F., Article 278730. Vásquez-García, G. R., Vasquez-Sullca, R. R., Yescas, G., & Kwok, S. Y., & Shek, D. T. (2009). Social problem solving, family Red-LIRHUS. (2019). Religious affiliation and the intention to functioning, and suicidal ideation among Chinese adolescents choose psychiatry as a specialty among physicians in training in Hong Kong. Adolescence, 44(174), Article 391. from 11 Latin American countries. Transcultural Psychiatry, Li, Z., & Zhang, J. (2012). Coping skills, mental disorders, and 56(6), 1237–1254. suicide among rural youths in China. Journal of Nervous and Carla, G., & Patrizia, Z. (2018). Medical students and suicide pre- Mental Disease, 200(10), 885–890. vention: Training, education, and personal risks. Frontiers in National Health Commission. (2018). China health statistical year- Psychology, 9, Article 452. book. Peking Union Medical College Press. Castaldelli-Maia, J. M., Lewis, T., Marques, D. S. N., Picon, F., Merton, R. K. (1957). Social theory and social structure. New Kadhum, M., Farrell, S. M., Molodynski, A., & Ventriglio, A. York: Free Press. (2019). Stressors, psychological distress, and mental health Maser, B., Danilewitz, M., Guérin, E., Findlay, L., & Frank, E. (2019). problems amongst Brazilian medical students. International Medical Student Psychological Distress and Mental Illness Review of Psychiatry, 31, 7–8. Relative to the General Population: A Canadian Cross-Sectional 8 SAGE Open Survey. Academic Medicine: Journal of the Association of Troister, T., & Holden, R. R. (2010). Comparing psychache, American Medical Colleges, 94(11), 1781–1791. depression, and hopelessness in their associations with Montemarano, V., Troister, T., Lambert, C. E., & Holden, R. R. suicidality: A test of Shneidman’s theory of suicide. (2018). A four-year longitudinal study examining psychache Personality and Individual Differences, 49(7), 689–693. and suicide ideation in elevated-risk undergraduates: A test of Verrocchio, M. C., Carrozzino, D., Marchetti, D., Andreasson, K., Shneidman’s model of suicidal behavior. Journal of Clinical Fulcheri, M., & Bech, P. (2016). Mental pain and suicide: A Psychology, 74(10), 1820–1832. systematic review of the literature. Frontiers in Psychiatry, Muttathu, K. C., Paul, S. S., Satya, R., Vinod, S., Suma, N., Priya, M., 7(1), 215–230. & Neethu, C. (2013). Adolescent suicide: Characterizing the need Wang, Z., Koenig, H. G., Ma, H., & Shohaib, S. A. (2016). Purpose and identifying the predictive factors for preventive consultation in life, social support and psychological distress in Chinese or hospitalization in a rural community setting. International university students. Journal of Religion and Health, 55(3), Journal of Adolescent Medicine and Health, 25(1), 81–86. 1055–1064. Osman, A., Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kopper, World Health Organization. (2017). Depression and other common B. A., & Burrios, F. X. (2001). The Suicidal Behaviors mental disorders: Global health estimates. Questionnaire-Revised (SBQ-R): Validation with clinical and Xiao, S. Y. (2001). Clinical assessment of suicide risk. Chinese nonclinical samples. Assessment, 8(4), Article 443. Medical Journal, 3(2), 87–90. Palmieri, G., Forghieri, M., Ferrari, S., Pingani, L., Coppola, P., Xu, R. B., Wen, B., Song, Y., Luo, D. M., Dong, Y. H., Dong, B., Colombini, N., Rigatelli, M., & Neimeyer, R. A. (2008). Suicide & Ma, J. (2018). Changes of China’s youth mortality rate and intervention skills in health professionals: A multidisciplinary major causes of death from 1990 to 2016. Chinese Journal of comparison. Archives of Suicide Research, 12(3), 232–237. Preventive Medicine, 52(8), Article 802. Palupi, R., & Findyartini, A. (2019). The relationship between gen- Yang, L., & Chen, W. (2017). Reliability and validity test of der and coping mechanisms with burnout events in first-year Chinese Version of Psychological Distress Scale in Chinese medical students. Korean Journal of Medical Education, 31(4), college students. Chinese Journal of Clinical Psychology, 331–342. 25(3), 475–478+583. Parry, J. (2014). Falling suicide rates in China mask emerging Zang, M. H., Wang, X., Wang, Y. J., Huang, X. L., & Wang, J. upward trends. BMJ Clinical Research, 349, Article g4486. (2016). Systematic evaluation of influencing factors of sui- Rasic, D., Kisely, S., & Langille, D. B. (2011). Protective associa- cidal ideation of medical students in mainland China. Chinese tions of importance of religion and frequency of service atten- Journal of School Health, 37(5), 711–715. dance with depression risk, suicidal behaviours and substance Zhang, J., Dong, N., Delprino, R., & Zhou, L. (2009). Psychological use in adolescents in Nova Scotia, Canada. Journal of Affective strains found from in-depth interviews with 105 Chinese Disorders, 132(3), 389–395. rural young suicides. Archives of Suicide Research, 13(2), Rotenstein, L. S., Ramos, M. A., Torre, M., Segal, J. B., & Mata, 185–194. D. A. (2016). Prevalence of depression, depressive symptoms, Zhang, J., Fang, L., Wu, Y. W., & Wieczorek, W. F. (2013a). and suicidal ideation among medical students: A system- Depression, anxiety, and suicidal ideation among Chinese atic review and meta-analysis. The Journal of the American Americans: A study of immigration-related factors. Journal of Medical Association, 316(21), Article 2214. Nervous and Mental Disease, 201(1), 17–22. Sha, F., Chang, Q., Law, Y. W., Hong, Q., & Yip, P. (2018). Suicide Zhang, J., Lester, D., Haines, J., Williams, C. L., & Ma, W. (2018). rates in China, 2004-2014: Comparing data from two sample- Identifying psychological strains in suicide notes. OMEGA- based mortality surveillance systems. BMC Public Health, Journal of Death and Dying, 2018(1): 003022281881146. 18(1), 239. doi:10.1186/s12889-018-5161-y Zhang, J., Liu, Y., & Sun, L. (2017a). Psychological strain and sui- Shneidman, E. S. (1984). Aphorisms of suicide and some implica- cidal ideation: A comparison between Chinese and US college tions for psychotherapy. American Journal of Psychotherapy, students. Psychiatry Research, 255, 256–262. 38(3), 319–328. Zhang, J., & Lyu, J. (2014). Reliability, validity and preliminary Shneidman, E. S. (1993). Commentary: Suicide as psychache. hypothesis tests for the English version of the Psychological Strain Journal of Nervous and Mental Disease, 181(3), 145–147. Scales (PSS). Journal of Affective Disorders, 164(1), 69–75. Stack, S. (1983). The effect of religious commitment on suicide: A Zhang, J., Tan, J., & Lester, D. (2013b). Psychological strains found cross-national analysis. Journal of Health and Social Behavior, in the suicides of 72 celebrities. Journal of Affective Disorders, 24(4), 362–374. 149(1–3), 230–234. Stack, S. (2000a). Suicide: A 15-year review of the sociological Zhang, J., Wieczorek, W. F., Conwell, Y., & Tu, X. M. (2011). literature. Part I: Cultural and economic factors. Suicide and Psychological strains and youth suicide in rural China. Social Life-Threatening Behavior, 30(2), 145–162. Science and Medicine, 72(12), 2003–2010. Stack, S. (2000b). Suicide: A 15-year review of the sociological lit- Zhang, J., & Zhao, Z. (2017). Psychological strain and suicidal ide- erature. Part II: Modernization and social integration perspec- ation among Chinese young people. International Journal of tives. Suicide and Life-Threatening Behavior, 30, 145–162. Asian Social Science, 7(6), 497–504. Sugawara, N., Hashimoto, K., Tanaka, O., Nakamura, K., & Yasui- Zhang, X., Wang, H., Xia, Y., Liu, X., & Jung, E. (2012). Stress, coping and suicide ideation in Chinese college students. Furukori, N. (2014). Parental bonding and attitudes toward sui- Journal of Adolescence, 35(3), 683–690. cide among medical college students in Japan. Neuropsychiatric Zhang, X., Zhang, J., Procter, N., Chen, X., Su, Y., Lou, F., & Cao, Disease and Treatment, 10, 2015–2020. F. (2017b). Suicidal ideation and psychological strain among Sun, L., Li, H., Zhang, J., & Wu, Q. (2015). Psychological strains patients diagnosed with stomach cancer: The mediation of and suicide intent: Results from a psychological autopsy study psychopathological factors. Journal of Nervous and Mental with Chinese rural young suicides. International Journal of Disease, 205(7), 550–557. Social Psychiatry, 61(7), 677–683.

Journal

SAGE Open – SAGE

Published: Jul 15, 2020

Keywords: psychological strain; psychache; suicidal behavior; mediating effect; ethnic

There are no references for this article.