How internalizing and externalizing symptoms related to suicidal ideation and suicide attempts in patients with obsessive-compulsive disorder? A network analysis study

This study aimed to evaluate the network structure of suicidality and its relation with internalizing and externalizing symptoms in patients with obsessive-compulsive disorder (OCD). A total of 754 patients with OCD were recruited. The mean age of all participants was 33.19, with a standard deviation of 10.65. Additionally, 43.9% of participants were female. We used the Scale for Suicide Ideation (SSI), Externalizing Spectrum Inventory–Brief Form (ESI-BF), Yale-Brown Obsessive-Compulsive Scale, and Inventory of Depression and Anxiety Symptoms-II (IDAS-II) to estimate the network structure. Patients were also questioned about their prior failed suicide attempts and categorized into groups based on their history of suicide attempts. We created Directed Acyclic Graphs (DAG) to examine potential causal paths and utilized Markov Random Fields (MRFs) to demonstrate predictive linkages. The MRFs revealed that impulsivity, impatience, urgency, panic symptoms, and age were directly related to suicide ideation severity in both groups. However, general depression was linked to suicide ideation only among patients without a history of suicide attempts. Additionally, traumatic intrusions were linked to suicide ideation only among patients with a history of suicide attempts. The DAG model predicted that suicide ideation causes externalizing symptoms, while internalizing symptoms predicted suicide ideation in both groups. These findings suggest that specific internalizing and externalizing symptoms in patients with or without a history of suicide attempts may contribute to suicidality. Thus, suicide attempt history, as well as internalizing and externalizing symptoms, should be carefully monitored in patients with OCD.