The authors of this article declare no conflict of interest.
Joiner’s Interpersonal-Psychological Theory of Suicide (IPTS) considers the interpersonal variables of low social belonging and the perception of being a burden on others as drivers of suicidal ideation. This study has sought to review the empirical evidence on this prediction. In all, 40 studies were found. The findings report a major mediator and moderator role of perceived burdensomeness (PB) and thwarted belongingness (TB) in the relationship between the propensity toward suicide and psychological, social, and environmental factors. As the theory predicts, expecting to find that the interaction of both of these variables would be more closely linked to suicidal ideation, this does not appear to have been fully supported, generally finding a greater significance when they were integrated into separate models. It seems that attributing other forms of relationship with suicide for the variables identified by Joiner would provide IPTS with greater empirical support.
La teoría interpersonal psicológica del suicidio de Joiner considera las variables interpersonales de baja pertenencia social y la percepción de ser una carga para los demás como impulsores de la ideación suicida. Este estudio revisa la evidencia empírica sobre esta predicción. En total, se han encontrado 40 estudios. Los hallazgos descubren un importante papel mediador y moderador de la carga percibida y la pertenencia frustrada en la relación entre la propensión al suicidio y los factores psicológicos, sociales y ambientales. Como predice la teoría, esperando encontrar que la interacción de ambas variables estaría más estrechamente ligada a la ideación suicida, esto no parece haber sido totalmente respaldado, encontrando generalmente una mayor significación cuando estas se integraron en modelos separados. Parece que atribuir otras formas de relación con el suicidio para las variables identificadas por Joiner proporcionaría a la teoría interpersonal psicológica del suicidio un mayor apoyo empírico.
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Criteria were following the PICO strategy for formulating clinical questions (
Participants/population: any type of population without specifications.
Intervention: evaluation of TB [thwarted belongingness] or/and PB [perceived burdensomeness] as mediating or moderating variables of any suicidal outcome.
Comparator(s)/control. No specific comparators were required.
Outcomes: statistical significance or not of the factor studied through TB or PB in the outcome, that is, the confidence intervals do not include zero (
Inclusion criteria for the articles were as follows: (1) the study includes the explicit terms “thwarted belongingness” or “perceived burdensomeness” as moderator or mediator variables; (2) the study includes a suicide construct as outcome; (3)there are statistical analyses of mediation or moderation on the study; (4) the study has been published as of 2005 for the analyses of indirect relationships.
No reviews, development texts, or clinical cases are included. Despite this, we included international studies. Finally, unpublished data was not included. In spite of the large body of research out there on the different statistical relationships between Joiner’s interpersonal theory concepts, we only decided to include studies with moderation and mediation data on the “thwarted belongingness” and “perceived burdensomeness” – since the purpose of this review was to respond to this type of relationship.
To find studies to include in this review, which started in November 28th 2017, we decided to use Scopus, PubMed, and Ebscohost as search systems, having access to databases such as Medline or APA PsycINFO. The controlled key terms used to search were: (Perceived Burdensomeness) OR (Thwarted Belongingness) OR (Interpersonal psychological theory) AND (Suicide).
The sum of studies of the three search systems after having inserted the key words were 776. Using citation management application Endnote version X7 the duplicates were deleted, leaving 414 articles for the first screening. Two independent reviewers (PES, MPO) proceeded to read the abstract by searching for the presence or not of indirect relations analysis; all items that were not quantitative studies were removed – like meta-analysis, qualitative studies or clinical case – with an agreement between the reviewers on the exclusion of studies; 115 articles were found for full-text reading. Each reviewer carried out the reading of the studies, according to the established inclusion and exclusion criteria, removing studies (i.e., investigated other variables of the theory, there were not analyses of indirect relationships between the variables proposed, or these analyses were given in other study variables), 3 articles were excluded for not access to full text, ending up with 40 articles. The review followed Prisma Statement and Checklist (
We were not able to do a meta-analysis due to insufficient available data on interaction effects and the heterogeneity of the studies and population (
A total of 40 articles with 46 studies were found with a mediation or moderation analysis of TB (thwarted belongingness) and/or PB (perceived burdensomeness) among psychological constructs and suicide risk (
Joiner’s IPTS [Interpersonal-Psychological Theory of Suicide] constructs have been studied in myriad samples, with a large number of these (34.78%) recruiting university students, military personnel, and veterans (13.4%); 15.21% of this sample is compiled with out- and inpatients, hospital admissions, or mental health sufferers. Three studies (6.52%) in this review noted different variables in Portuguese population, four studies (8.69%) in LGBT and LGB population, two (4.3%) in Afro-American population, and one in South Korean population, the same as in specific populations as practitioners of dominance, submission, and sadomasochism, child abuse, a past history of self-harm, substance abuse or obesity.
Almost all the studies are cross-sectional (89.1%). Only five studies (10.8%) took measures from the same population over different moments in time.
Quite a few of the studies have investigated whether TB and PB could act as mediators of the symptomology of specific disorders. In a study that identifies the symptomology of an eating disorder (
Numerous studies have linked depression and insomnia to suicide.
As regards insomnia, TB seems to play a mediating role in suicidal ideation and risk (
Substance abuse is another risk factor associated with suicidal behaviour. A study involving frequent users of cannabis (
Concerning social functioning, social anxiety impacts upon suicidal ideation through PB solely when there are also high levels of TB (
Regarding family-related constructs, a study based on the relationship between the style of maternal attachment in childhood and how this might be related to depressive thoughts in the future (
There are studies focussing on other issues of a social nature. For example, a sample of 348 university students revealed that the intensity of cyberbullying is related to suicidal ideation mediated by the PB variable and symptoms of depression (
A study of 816 transgender adults revealed that internalised transphobia, as well as future expectations, are associated with suicidal ideation through Joiner’s variables (
Other studies observing these interpersonal constructs with personality traits or emotions conclude that self-directed hostility, shame, and personality disorder traits – together with symptoms of depression – are related to different suicide variables – ideation, risk – through both interpersonal variables (
Hopelessness has also been studied with regard to suicide and these constructs. A study of 349 women (aged between 18 and 30) found a greater risk of suicidal ideation when they experience hopelessness toward the future together with high levels of PB and TB (
Findings of other reviews regarding the relationship between PB and TB in the suicide phenomenon are mixed and have so far provided partial support for Joiner’s IPTS (
The results of this review found that PB and TB play a major mediating role in the relationship between the propensity toward suicide and psychological, social, and environmental factors. The constructs found to be most widely studied seem to differ in terms of the variables’ influence. As the theory predicts, expecting to find that the interactions between both variables would be associated more frequently and more strongly with suicidal ideation does not appear to have been fully supported, finding a greater significance when these are integrated in separate models. For example, the research that studied the influence of TB and PB in the relationship between insomnia and a propensity toward suicide reports a greater influence by TB. In depressive symptomology, social constructs and personality traits record a greater indirect influence by PB.
The results have generally been mixed, with the indirect relationship on other constructs and the suicide risk through interpersonal variables being largely significant, and all the studies have found indirect associations for one or more of Joiner’s variables. These results might explain the partial support found in the relationship between PB and TB and suicide (
There are studies reporting that resilience factors have an indirect impact on interpersonal variables and the suicide risk (
The measures used for assessing the interpersonal variables have largely been INQ-15, followed by INQ-12, INQ-18, INQ-10 (
It is not only suicidal ideation that has been included as a outcome variable, as other studies evaluate other constructs – risk, conducts, suicidal behaviour, propensity towards suicide – which could encompass more aspects or facets other than suicide, with this being one of the study’s major limitations. On the other hand, the so-called “grey literature” has not been included in this review – only the published articles have been selected – so the studies published in this review may not be fully representative of the current literature. Another significant limitation is that information on other variables included in mediation models is not included. The review did not provide information on the total or partial mediation of interpersonal variables in the regression models. Authors (
To conclude, the results of this review reveal that it seems that the variables described by Joiner could have a type of indirect influence on other psychological constructs, TB appearing to have a minor influence on the relationship of other psychological factors (
The results of this review could hint at the influence of subjective perception of social environment on subjects with suicidal ideation. As far as the literature has been studied, there is a great influence on the part of IPTS variables, which helps us to better understand this phenomenon, where there are many factors and variables to consider. Knowing this, and if empirical evidence continues to support theories on suicide that include social variables as an essential part, then it would not hurt to include these, not only in clinical practice treatment programs, but also in suicide prevention programs.
Cite this article as: Espinosa-Salido, P., Perez Nieto, M. A., Baca-García, E., & Provencio Ortega, M. (2020). Systematic review of the indirect relationships of thwarted belongingness and perceived burdensomeness in suicide.
Funding: Funding for this study was provided by Centro de Enseñanza Universitaria SEK S.A., Calle Castillo de Alarcón, Urbanización Villafranca del Castillo.