Abstract : Objective: In
psychiatric literature, few original studies exist on the topic of
demoralization in suicide. In this review, we aim to identify original
studies on suicidal ideation (SI)/suicidal behavior (SB) and
demoralization in populations of community-dwellers and patients with
somatic or psychiatric disorders. Methods: We employed a systematic
approach that followed PRISMA guidelines, searching through four major
electronic databases (PubMed/MEDLINE, Scopus, Science Direct, and
PsychINFO) for relevant titles/abstracts published from January
1980–June 2021. We included original studies that explicitly mentioned
the investigation of a potential association between SI/SB and
demoralization. Results: A total of 18 studies met our inclusion
criteria. Their synthesis revealed that demoralization can be associated
with SI/SB in a wide range of populations (community dwellers, patients
with somatic or psychiatric disorders) and lead to significantly higher
suicide risk (odds ratios of >6 were encountered in community
dwellers experiencing financial hardship or isolation). Moreover,
demoralization alone (about half the patients who were demoralized did
not meet the criteria for an affective disorder nor were they clinically
depressed) or together with depression has been identified as a major
risk factor for SI/SB. Regarding the crucial issue of progression from
SI to SA, in the context of the “ideation-to-action” frame, some authors
found that the interaction of demoralization and over-arousal could be a
useful predictor for this progression, while others found that
depression alone was sufficient to differentiate attempters from
non-attempters or the interaction with shutdown (helplessness and low
positive emotions). Conclusion: These results emphasize the possibility
to identify demoralization as an independent risk factor for suicide. In
patients with psychiatric disorders, the association between
demoralization and SI/SB may be transnosographic. Overall, from the
clinical implications perspective, our findings highlight that: i.
Assessment of demoralization may contribute to a more comprehensive
suicide risk detection. This appears particularly relevant in Emergency
Departments (EDs) where heterogeneous population typologies are usually
admitted and a clinical diagnosis of depression is often difficult to be
defined. ii. Additionally, since meaninglessness is considered one of
the demoralization subcomponents, meaning-centered psychotherapeutic
approaches prove to be indicated and they can be initiated already at
the EDs upon first contact with the patient. Further studies are
necessary to confirm these findings.
