Suicide-related metacognitions in psychiatric inpatients admitted after suicide attempt or an acute suicidal crisis: a longitudinal mediation analysis

BACKGROUND: The metacognitive model of suicidality suggests that suicide-related metacognitions activate a Cognitive Attentional Syndrome (CAS)-including suicide-specific rumination, attentional fixation, and thought suppression-which may intensify and prolong suicidal ideation. While initial support has emerged from general population samples, longitudinal evidence in high-risk clinical populations remains lacking. METHODS: In a multicenter, prospective study, we examined model assumptions in a sample of 184 psychiatric inpatients (M = 37.5 years, 50% male), all admitted following a suicide attempt or severe suicidal crisis. Participants completed baseline assessments prior to discharge and engaged in a 3-week ecological momentary assessment (EMA) protocol measuring suicide-specific rumination, thought suppression, and suicidal intent up to four times daily. Past suicidal ideation and suicide-related metacognitions (positive and negative) were assessed using validated scales. RESULTS: Past suicidal ideation significantly predicted both positive and negative suicide-related metacognitions. These, in turn, prospectively predicted suicide-specific rumination but not thought suppression. Mediation analyses indicated that positive metacognitions mediated the relationship between past suicidal ideation and future suicide-specific rumination. Additionally, suicide-specific rumination-rather than thought suppression-mediated the relationship between suicide-related metacognitions and both intensity and frequency of suicidal intent during the EMA period. LIMITATIONS: Attentional fixation was not assessed. EMA compliance averaged 48.3%, and some measures were adapted from preliminary versions. CONCLUSIONS: Findings provide the first longitudinal support for the metacognitive model of suicidality in a clinical sample. Suicide-specific rumination and positive metacognitions may be important drivers of intensification and prolongation of suicidal ideation and suicidal intent formation in the high-risk post-discharge period.