The Emergence of Suicidal Ideation: Testing the Three-Step Theory in Iranian Adolescents
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Abstract
Objective: Suicide is a global public health problem with significant adverse effects on individuals and society, especially among adolescents. Klonsky’s three-step theory (3ST) of suicide explains suicidal ideation through three factors, namely hopelessness, psychological pain, and connectedness in two steps. No study has investigated connectedness (step 2) in combination with psychological pain and hopelessness (step 1) in prediction of suicidal ideation among adolescents. Thus, we empirically tested the first two steps of the 3ST in a sample of Iranian adolescents.
Method: A total of 466 adolescents aged 12 to 20 years (356 females and 110 males) were recruited using convenience sampling. This cross-sectional study was conducted between September to November 2024. The participants completed self-report questionnaires on suicidal ideation, hopelessness, psychological pain, and connectedness. Hierarchical linear regression analysis was conducted to explore the impact of the interaction of hopelessness and psychological pain on suicidal ideation. In addition, we explored whether connectedness reduced the escalation of suicidal ideation in adolescents experiencing high psychological pain and hopelessness levels.
Results: The findings showed that the interaction of hopelessness and psychological pain accounted for 59% of the variance in suicidal ideation (P < 0.001). Connectedness was found as a protective factor for suicidal ideation in adolescents who experience high levels of both psychological pain and hopelessness (r = 0.24, P < 0.001).
Conclusion: These findings support the applicability of the first two steps of the 3ST for Iranian adolescents. Future research should examine all three steps of this theory in a clinical sample of adolescents.
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2. Mirahmadizadeh A, Rezaei F, Mokhtari AM, Gholamzadeh S, Baseri A. Epidemiology of suicide attempts and deaths: a population-based study in Fars, Iran (2011-16). J Public Health (Oxf). 2020;42(1):e1-e11.
3. Mirhashemi S, Motamedi MH, Mirhashemi AH, Taghipour H, Danial Z. Suicide in Iran. Lancet. 2016;387(10013):29.
4. Martínez-Alés G, Jiang T, Keyes KM, Gradus JL. The Recent Rise of Suicide Mortality in the United States. Annu Rev Public Health. 2022;43:99-116.
5. Miri M, Rezaeian M, Ghasemi SA. A systematic review on the prevalence and causes of suicide (thoughts and actions) in Iranian school and university students. Journal of Rafsanjan University of Medical Sciences. 2022;21(5):551-74.
6. Riera-Serra P, Navarra-Ventura G, Castro A, Gili M, Salazar-Cedillo A, Ricci-Cabello I, et al. Clinical predictors of suicidal ideation, suicide attempts and suicide death in depressive disorder: a systematic review and meta-analysis. Eur Arch Psychiatry Clin Neurosci. 2024;274(7):1543-63.
7. Witte TK, Fitzpatrick KK, Joiner TE, Jr., Schmidt NB. Variability in suicidal ideation: a better predictor of suicide attempts than intensity or duration of ideation? J Affect Disord. 2005;88(2):131-6.
8. Gelvez-Gafaro L-M, Medina-Duarte D-M, Villa-Belluci I-P, Rivera-Porras D, Bonilla-Cruz N-J. Psychosocial risk factors associated with suicide in youth and adolescents: A systematic review. Gac Med Caracas. 2022;130(3S).
9. Fonseca-Pedrero E, Al-Halabí S, Pérez-Albéniz A, Debbané M. Risk and Protective Factors in Adolescent Suicidal Behaviour: A Network Analysis. Int J Environ Res Public Health. 2022;19(3):1784.
10. Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, Lee S. Suicide and suicidal behavior. Epidemiol Rev. 2008;30(1):133-54.
11. Nock MK, Prinstein MJ. Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol. 2005;114(1):140-6.
12. Klonsky ED, Saffer BY, Bryan CJ. Ideation-to-action theories of suicide: a conceptual and empirical update. Curr Opin Psychol. 2018;22:38-43.
13. Klonsky ED, May AM, Saffer BY. Suicide, Suicide Attempts, and Suicidal Ideation. Annu Rev Clin Psychol. 2016;12:307-30.
14. Klonsky ED, May AM. The three-step theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. Int J Cogn Ther. 2015;8(2):114-29.
15. Tsai M, Lari H, Saffy S, Klonsky ED. Examining the Three-Step Theory (3ST) of Suicide in a Prospective Study of Adult Psychiatric Inpatients. Behav Ther. 2021;52(3):673-85.
16. Dhingra K, Klonsky ED, Tapola V. An Empirical Test of the Three-Step Theory of Suicide in U.K. University Students. Suicide Life Threat Behav. 2019;49(2):478-87.
17. Yang L, Liu X, Chen W, Li L. A Test of the Three-Step Theory of Suicide among Chinese People: A Study Based on the Ideation-to-Action Framework. Arch Suicide Res. 2019;23(4):648-61.
18. Pachkowski MC, Hewitt PL, Klonsky ED. Examining suicidal desire through the lens of the three-step theory: A cross-sectional and longitudinal investigation in a community sample. J Consult Clin Psychol. 2021;89(1):1-10.
19. Kelly LM, Swenson LP, Wolff JC. Application of the Three-Step Ideation-to-Action Theory to Passive and Active Suicidal Ideation in College Students. Minerva Psychiatry. 2023;64(1):1-12.
20. Shepherd BF, Kelly LM, Brochu PM, Wolff JC, Swenson LP. An examination of theory-based suicidal ideation risk factors in college students with multiple marginalized identities. Am J Orthopsychiatry. 2023;93(2):107-19.
21. Schimanski I, Scarf D, Rapsey C, Treharne GJ, Mason A. Step by Step? Understanding Suicidal Thoughts and Behavior Among University Students in Aotearoa New Zealand: Utility of the Three–Step Theory of Suicide. Journal of College Student Mental Health. 2024:1-16.
22. Kann L, Kinchen S, Shanklin SL, Flint KH, Hawkins J, Harris WA, et al. Youth risk behavior surveillance—United States, 2013. Morbidity and Mortality Weekly Report: Surveillance Summaries. 2014;63(4):1-168.
23. Stewart SM, Eaddy M, Horton SE, Hughes J, Kennard B. The Validity of the Interpersonal Theory of Suicide in Adolescence: A Review. J Clin Child Adolesc Psychol. 2017;46(3):437-49.
24. Kirshenbaum JS, Pagliaccio D, Bitran A, Xu E, Auerbach RP. Why do adolescents attempt suicide? Insights from leading ideation-to-action suicide theories: a systematic review. Transl Psychiatry. 2024;14(1):266.
25. May AM, O'Brien KH, Liu RT, Klonsky ED. Descriptive and Psychometric Properties of the Inventory of Motivations for Suicide Attempts (IMSA) in an Inpatient Adolescent Sample. Arch Suicide Res. 2016;20(3):476-82.
26. Gunn JF, 3rd, Goldstein SE, Gager CT. A longitudinal examination of social connectedness and suicidal thoughts and behaviors among adolescents. Child Adolesc Ment Health. 2018;23(4):341-50.
27. Vasegh S, Ardestani SMS. Suicidal ideation, plans, and attempts in a sample of Iranian students: Prevalence and some new risk and protective factors. Journal of Muslim Mental Health. 2018;12(2).
28. Bazrafshan MR, Sharif F, Molazem Z, Mani A. Exploring the risk factors contributing to suicide attempt among adolescents: A qualitative study. Iran J Nurs Midwifery Res. 2016;21(1):93-9.
29. Sawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. The lancet child & adolescent health. 2018;2(3):223-8.
30. Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol. 1979;47(2):343-52.
31. Beck AT, Steer RA. Manual for the Beck scale for suicide ideation. San Antonio, TX: Psychological Corporation. 1991;63.
32. Esfahani M, Hashemi Y, Alavi K. Psychometric assessment of beck scale for suicidal ideation (BSSI) in general population in Tehran. Med J Islam Repub Iran. 2015;29:268.
33. Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol. 1974;42(6):861-5.
34. Dejkam K. Adaptability and standardization of Beck Hopelessness Scale with students of Islamic Azad University, Tehran Branch. Islamic Azad University, Tehran Branch; 2004: Dissertation.
35. Holden RR, Mehta K, Cunningham EJ, McLeod LD. Development and preliminary validation of a scale of psychache. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement. 2001;33(4):224.
36. Ordóñez-Carrasco JL, Cuadrado Guirado I, Rojas Tejada A. Scale of psychological pain: Spanish adaptation of the Psychache Scale in young adults. Rev Psiquiatr Salud Ment (Engl Ed). 2022;15(3):196-204.
37. Van Orden KA, Witte TK, Gordon KH, Bender TW, Joiner TE, Jr. Suicidal desire and the capability for suicide: tests of the interpersonal-psychological theory of suicidal behavior among adults. J Consult Clin Psychol. 2008;76(1):72-83.
38. Van Orden KA, Cukrowicz KC, Witte TK, Joiner TE. Thwarted belongingness and perceived burdensomeness: construct validity and psychometric properties of the Interpersonal Needs Questionnaire. Psychol Assess. 2012;24(1):197-215.
39. Amini-Tehrani M, Sadeghi R, Nasiri M, Jalali T, Zamanian H. Suicide-related interpersonal needs of young Iranian people: A preliminary validation of thwarted belongingness and perceived burdensomeness constructs. Clin Psychol Psychother. 2021;28(2):422-37.
40. Van Orden KA, Witte TK, Cukrowicz KC, Braithwaite SR, Selby EA, Joiner TE, Jr. The interpersonal theory of suicide. Psychol Rev. 2010;117(2):575-600.
41. Shneidman ES. Commentary: Suicide as psychache. J Nerv Ment Dis. 1993;181(3):145-7.
42. Flamenbaum R. Testing Shneidman's theory of suicide: Psychache as a prospective predictor of suicidality and comparison with hopelessness: Queen's University; 2009.
43. Shneidman ES. What do suicides have in common? Summary of the psychological approach. 1992.
44. Arbabi K, Yeh CJ, Sangkar PR. Exploring the Lived Experiences of Iranian Adolescents Exhibiting Suicidal Behavior and Ideation. Res Child Adolesc Psychopathol. 2025;53(6):891-904.
45. Joiner T, Rudd MD, Abramson LY, Alloy LB, Hogan ME, Whitehouse WG, et al. The hopelessness theory of suicidality. Suicide science: Expanding the boundaries. 2002:17-32.
46. Rudd MD, Joiner Jr TE, Jobes DA, King CA. The outpatient treatment of suicidality: An integration of science and recognition of its limitations. Professional Psychology: Research and Practice. 1999;30(5):437.
47. O’Connor RC. The integrated motivational-volitional model of suicidal behavior. Hogrefe Publishing; 2011.
2. Mirahmadizadeh A, Rezaei F, Mokhtari AM, Gholamzadeh S, Baseri A. Epidemiology of suicide attempts and deaths: a population-based study in Fars, Iran (2011-16). J Public Health (Oxf). 2020;42(1):e1-e11.
3. Mirhashemi S, Motamedi MH, Mirhashemi AH, Taghipour H, Danial Z. Suicide in Iran. Lancet. 2016;387(10013):29.
4. Martínez-Alés G, Jiang T, Keyes KM, Gradus JL. The Recent Rise of Suicide Mortality in the United States. Annu Rev Public Health. 2022;43:99-116.
5. Miri M, Rezaeian M, Ghasemi SA. A systematic review on the prevalence and causes of suicide (thoughts and actions) in Iranian school and university students. Journal of Rafsanjan University of Medical Sciences. 2022;21(5):551-74.
6. Riera-Serra P, Navarra-Ventura G, Castro A, Gili M, Salazar-Cedillo A, Ricci-Cabello I, et al. Clinical predictors of suicidal ideation, suicide attempts and suicide death in depressive disorder: a systematic review and meta-analysis. Eur Arch Psychiatry Clin Neurosci. 2024;274(7):1543-63.
7. Witte TK, Fitzpatrick KK, Joiner TE, Jr., Schmidt NB. Variability in suicidal ideation: a better predictor of suicide attempts than intensity or duration of ideation? J Affect Disord. 2005;88(2):131-6.
8. Gelvez-Gafaro L-M, Medina-Duarte D-M, Villa-Belluci I-P, Rivera-Porras D, Bonilla-Cruz N-J. Psychosocial risk factors associated with suicide in youth and adolescents: A systematic review. Gac Med Caracas. 2022;130(3S).
9. Fonseca-Pedrero E, Al-Halabí S, Pérez-Albéniz A, Debbané M. Risk and Protective Factors in Adolescent Suicidal Behaviour: A Network Analysis. Int J Environ Res Public Health. 2022;19(3):1784.
10. Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, Lee S. Suicide and suicidal behavior. Epidemiol Rev. 2008;30(1):133-54.
11. Nock MK, Prinstein MJ. Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol. 2005;114(1):140-6.
12. Klonsky ED, Saffer BY, Bryan CJ. Ideation-to-action theories of suicide: a conceptual and empirical update. Curr Opin Psychol. 2018;22:38-43.
13. Klonsky ED, May AM, Saffer BY. Suicide, Suicide Attempts, and Suicidal Ideation. Annu Rev Clin Psychol. 2016;12:307-30.
14. Klonsky ED, May AM. The three-step theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. Int J Cogn Ther. 2015;8(2):114-29.
15. Tsai M, Lari H, Saffy S, Klonsky ED. Examining the Three-Step Theory (3ST) of Suicide in a Prospective Study of Adult Psychiatric Inpatients. Behav Ther. 2021;52(3):673-85.
16. Dhingra K, Klonsky ED, Tapola V. An Empirical Test of the Three-Step Theory of Suicide in U.K. University Students. Suicide Life Threat Behav. 2019;49(2):478-87.
17. Yang L, Liu X, Chen W, Li L. A Test of the Three-Step Theory of Suicide among Chinese People: A Study Based on the Ideation-to-Action Framework. Arch Suicide Res. 2019;23(4):648-61.
18. Pachkowski MC, Hewitt PL, Klonsky ED. Examining suicidal desire through the lens of the three-step theory: A cross-sectional and longitudinal investigation in a community sample. J Consult Clin Psychol. 2021;89(1):1-10.
19. Kelly LM, Swenson LP, Wolff JC. Application of the Three-Step Ideation-to-Action Theory to Passive and Active Suicidal Ideation in College Students. Minerva Psychiatry. 2023;64(1):1-12.
20. Shepherd BF, Kelly LM, Brochu PM, Wolff JC, Swenson LP. An examination of theory-based suicidal ideation risk factors in college students with multiple marginalized identities. Am J Orthopsychiatry. 2023;93(2):107-19.
21. Schimanski I, Scarf D, Rapsey C, Treharne GJ, Mason A. Step by Step? Understanding Suicidal Thoughts and Behavior Among University Students in Aotearoa New Zealand: Utility of the Three–Step Theory of Suicide. Journal of College Student Mental Health. 2024:1-16.
22. Kann L, Kinchen S, Shanklin SL, Flint KH, Hawkins J, Harris WA, et al. Youth risk behavior surveillance—United States, 2013. Morbidity and Mortality Weekly Report: Surveillance Summaries. 2014;63(4):1-168.
23. Stewart SM, Eaddy M, Horton SE, Hughes J, Kennard B. The Validity of the Interpersonal Theory of Suicide in Adolescence: A Review. J Clin Child Adolesc Psychol. 2017;46(3):437-49.
24. Kirshenbaum JS, Pagliaccio D, Bitran A, Xu E, Auerbach RP. Why do adolescents attempt suicide? Insights from leading ideation-to-action suicide theories: a systematic review. Transl Psychiatry. 2024;14(1):266.
25. May AM, O'Brien KH, Liu RT, Klonsky ED. Descriptive and Psychometric Properties of the Inventory of Motivations for Suicide Attempts (IMSA) in an Inpatient Adolescent Sample. Arch Suicide Res. 2016;20(3):476-82.
26. Gunn JF, 3rd, Goldstein SE, Gager CT. A longitudinal examination of social connectedness and suicidal thoughts and behaviors among adolescents. Child Adolesc Ment Health. 2018;23(4):341-50.
27. Vasegh S, Ardestani SMS. Suicidal ideation, plans, and attempts in a sample of Iranian students: Prevalence and some new risk and protective factors. Journal of Muslim Mental Health. 2018;12(2).
28. Bazrafshan MR, Sharif F, Molazem Z, Mani A. Exploring the risk factors contributing to suicide attempt among adolescents: A qualitative study. Iran J Nurs Midwifery Res. 2016;21(1):93-9.
29. Sawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. The lancet child & adolescent health. 2018;2(3):223-8.
30. Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol. 1979;47(2):343-52.
31. Beck AT, Steer RA. Manual for the Beck scale for suicide ideation. San Antonio, TX: Psychological Corporation. 1991;63.
32. Esfahani M, Hashemi Y, Alavi K. Psychometric assessment of beck scale for suicidal ideation (BSSI) in general population in Tehran. Med J Islam Repub Iran. 2015;29:268.
33. Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol. 1974;42(6):861-5.
34. Dejkam K. Adaptability and standardization of Beck Hopelessness Scale with students of Islamic Azad University, Tehran Branch. Islamic Azad University, Tehran Branch; 2004: Dissertation.
35. Holden RR, Mehta K, Cunningham EJ, McLeod LD. Development and preliminary validation of a scale of psychache. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement. 2001;33(4):224.
36. Ordóñez-Carrasco JL, Cuadrado Guirado I, Rojas Tejada A. Scale of psychological pain: Spanish adaptation of the Psychache Scale in young adults. Rev Psiquiatr Salud Ment (Engl Ed). 2022;15(3):196-204.
37. Van Orden KA, Witte TK, Gordon KH, Bender TW, Joiner TE, Jr. Suicidal desire and the capability for suicide: tests of the interpersonal-psychological theory of suicidal behavior among adults. J Consult Clin Psychol. 2008;76(1):72-83.
38. Van Orden KA, Cukrowicz KC, Witte TK, Joiner TE. Thwarted belongingness and perceived burdensomeness: construct validity and psychometric properties of the Interpersonal Needs Questionnaire. Psychol Assess. 2012;24(1):197-215.
39. Amini-Tehrani M, Sadeghi R, Nasiri M, Jalali T, Zamanian H. Suicide-related interpersonal needs of young Iranian people: A preliminary validation of thwarted belongingness and perceived burdensomeness constructs. Clin Psychol Psychother. 2021;28(2):422-37.
40. Van Orden KA, Witte TK, Cukrowicz KC, Braithwaite SR, Selby EA, Joiner TE, Jr. The interpersonal theory of suicide. Psychol Rev. 2010;117(2):575-600.
41. Shneidman ES. Commentary: Suicide as psychache. J Nerv Ment Dis. 1993;181(3):145-7.
42. Flamenbaum R. Testing Shneidman's theory of suicide: Psychache as a prospective predictor of suicidality and comparison with hopelessness: Queen's University; 2009.
43. Shneidman ES. What do suicides have in common? Summary of the psychological approach. 1992.
44. Arbabi K, Yeh CJ, Sangkar PR. Exploring the Lived Experiences of Iranian Adolescents Exhibiting Suicidal Behavior and Ideation. Res Child Adolesc Psychopathol. 2025;53(6):891-904.
45. Joiner T, Rudd MD, Abramson LY, Alloy LB, Hogan ME, Whitehouse WG, et al. The hopelessness theory of suicidality. Suicide science: Expanding the boundaries. 2002:17-32.
46. Rudd MD, Joiner Jr TE, Jobes DA, King CA. The outpatient treatment of suicidality: An integration of science and recognition of its limitations. Professional Psychology: Research and Practice. 1999;30(5):437.
47. O’Connor RC. The integrated motivational-volitional model of suicidal behavior. Hogrefe Publishing; 2011.
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How to Cite
1.
Khishe R, Sardarzehi R, Doosalivand H, Fayazmanesh H, Bastami M. The Emergence of Suicidal Ideation: Testing the Three-Step Theory in Iranian Adolescents. Iran J Psychiatry. 2025;:1-8.
