Highlighting psychological pain avoidance and decision‐making bias as key predictors of suicide attempt in major depressive disorder—A novel investigative approach using machine learning

Objective Predicting suicide is notoriously difficult and complex, but a serious public health issue. An innovative approach utilizing machine learning (ML) that incorporates features of psychological mechanisms and decision-making characteristics related to suicidality could create an improved model for identifying suicide risk in patients with major depressive disorder (MDD). Method Forty-four patients with MDD and past suicide attempts (MDD_SA, N = 44); 48 patients with MDD but without past suicide attempts (MDD_NS, N = 48-42 of whom with suicide ideation [MDD_SI, N = 42]), and healthy controls (HCs, N = 51) completed seven psychometric assessments including the Three-dimensional Psychological Pain Scale (TDPPS), and one behavioral assessment, the Balloon Analogue Risk Task (BART). Descriptive statistics, group comparisons, logistic regressions, and ML were used to explore and compare the groups and generate predictors of suicidal acts. Results MDD_SA and MDD_NS differed in TDPPS total score, pain arousal and avoidance subscale scores, suicidal ideation scores, and relevant decision-making indicators in BART. Logistic regression tests linked suicide attempts to psychological pain avoidance and a risk decision-making indicator. The resultant key ML model distinguished MDD_SA/MDD_NS with 88.2% accuracy. The model could also distinguish MDD_SA/MDD_SI with 81.25% accuracy. The ML model using hopelessness could classify MDD_SI/HC with 94.4% accuracy. Conclusion ML analyses showed that motivation to avoid intolerable psychological pain, coupled with impaired decision-making bias toward under-valuing life's worth are highly predictive of suicide attempts. Analyses also demonstrated that suicidal ideation and attempts differed in potential mechanisms, as suicidal ideation was more related to hopelessness. ML algorithms show useful promises as a predictive instrument.