Resilience To Suicidal Behaviour In Young Adults: A Cross-Sectional Study

Despite decades of research on suicide risk factors in young people, there has been no signi�cant improvement in our understanding of this phenomenon. This study adopts a positive deviance approach to identify the individuals with suicide resilience and to describe their associated psychological and sociodemographic pro�les. Australian young adults aged 18 to 25 years with suicidal thoughts (N=557) completed an online survey covering sociodemographic, mental health status, emotion regulatory and suicide-related domains. Latent class analysis was used to identify the individuals with suicide resilience. Predictors of suicide resilience were assessed using logistic regression models. Results suggested that one in ten (n=55) met criteria for suicide resilience. Factors that had a signi�cant association with suicide resilience included greater cognitive �exibility, greater self-ecacy in expressing positive affect, reduced use of digital technology and less self-harm and substance use as a response to emotional distress. This study identi�ed the factors that may protect young adults with suicidal thoughts from progressing to suicide attempts. Suicide prevention programs might be optimised by shifting from a decit-based to a strength-based approach through promoting cognitive �exibility, self-ecacy and reducing maladaptive coping.


Introduction
Suicide is a complex public health phenomenon that represents a leading cause of death for young adults aged between 18 and 25 years globally and in Australia 1 .Research in this eld has mostly focused on detecting the risk factors of suicide with a noticeable scarcity of studies on suicide resilience [2][3][4] .Shifting our attention to resilience to suicide and its related behaviour may help inform innovative suicide prevention strategies 5,6 .Developing strengths-based approaches can be an important new direction in developing interventions, as a focus on risks of suicide has not advanced our understanding of suicide or reduce suicide rates 7 .
Suicide resilience is generally acknowledged as both the ability and the dynamic process of maintaining psychological and physical health functioning under high levels of suicide risks 8,9 .The concept is largely derived from well-documented observations that the majority of high-risk individuals, e.g., those with depression 10 or suicidal thoughts 11 , do not develop suicidal behaviour.Most of the current studies on suicide resilience adopt the buffering hypothesis 8 to identify the psychological constructs that moderate the relationship between suicide risks and suicidal behaviour 12,13 .This approach, however, is often limited because it yields relatively small effect sizes (2%-5%) of the indicated interaction effects and inconsistent ndings across studies, while a person-centered approach by identifying resilient individuals demonstrates stability of resilience over time 14 .
Positive deviance (PD) is a person-centered research approach that is promising to disentangle the relationship between suicide risks and suicidal behaviour.This approach is gaining prominence in identifying and understanding individuals' exceptional performance under complex health situations 15- 17 .The PD approach is grounded on the premise that in each community there are certain individuals whose uncommon behaviour and strategies enable them to nd better solutions to the same problems than their peers 18 .It has been effectively implemented as a practical strategy to untangle complex health problems, such as child malnutrition 19 , safe sexual practices 20 , and weight control 21 .To our knowledge, the PD approach has not been implemented in suicide prevention.
In this study, we followed the general practice in PD research to rstly de ne the problem 22 .We aim to understand the factors that promote resilience to suicidal behaviour amongst young people with suicidal thoughts, as the transition from suicidal thoughts to behaviour is increasingly acknowledged as a signi cant predictor of suicide death in theories 23,24 and empirical literature 23,24 .
One area that warrants further investigation in the suicidal ideation to action framework is emotion regulation 25 .Although extensive research has indicated that emotion dysregulation is associated with suicidal thoughts and history of suicidal attempts after accounting for the symptoms of psychological disorders [26][27][28][29] , the relationship between emotion dysregulation and suicidal behaviour is complex.
On one hand, there is evidence that emotion dysregulation is closely related to increased risks of engaging in risky behaviour 30 , such as deliberate self-harm 31 and alcohol use 32 .These associations may be mediated by increased acquired capability for suicide, a proposed key factor in the transition from suicidal thoughts to attempts 33 .On the other hand, de cits in emotion regulation also indicate individuals' low ability to tolerate distress, as behaviour of emotionally dysregulated individuals is often motivated by their desire to escape from painful experiences 34 .Emotion dysregulation can thus serve to counter or lower acquired capability for suicide 35 .The inconsistent ndings may be related to different aspects of emotion regulation, such as the adoption of maladaptive emotion regulation strategies such as self-harm behaviour 36 , ability to switch between emotional regulation strategies in adaption to situations ( exibility) 37,38 , or con dence in the ability to cope with different stressors (self-e cacy) 39,40 .
Therefore, further investigation in the context of youth suicide prevention is required to better understand the roles of these related components of emotion regulation.
Therefore, this study seeks to, for the rst time, understand resilience to suicidal behaviour amongst young adults with suicidal thoughts via the positive deviance informed analytic approach.We hypothesized that young people with suicide resilience would be distinguished by more adaptive emotion regulation strategies, higher coping and cognitive exibility and higher self-e cacy in emotion regulation, after adjusting for constraints (i.e., risk factors of suicidal attempts).We expected that our results would improve our understanding of protective factors to optimise suicide prevention interventions and facilitate the transition from a de cit-based to a strength-based suicide prevention approach.Identifying psychological, social and behavioural pro les of young people who demonstrate positive deviance may indicate speci c therapeutic targets, thereby guiding the development of more effective treatment and prevention interventions for individuals with suicidal thoughts.

Participants and procedure
Australian young adults aged between 18 and 25 years who experienced suicidal thoughts in the past year were recruited from Facebook and Instagram advertisements in February 2021.Other eligibility criteria include being uent in English, currently living in Australia, having no diagnosis of bipolar disorder or psychosis, and having no suicide attempt in the past 30 days.Informed consent was obtained from all participants.Eligible participants then lled in a Qualtrics online survey, including questions on sociodemographic (e.g., age, sex, socioeconomic status), mental and physical health conditions and status (e.g., suicidal thoughts and behaviour, depression, anxiety), emotion regulation and related constructs (e.g., coping exibility, cognitive exibility, regulatory emotional self-e cacy), and health service usage (e.g., help-seeking intentions).The participants were reimbursed for their participation by a draw to win one of three $30 e-gift vouchers.From the 2392 clicks on the Facebook and the Instagram advertisements, 725 participants completed the eligibility assessment, of which 658 (90.8%) were eligible, and 557 (84.7%) completed the variables of interest for the current study.No signi cant difference was found between the complete and incomplete responses on age and sex.The research was carried out in accordance with the latest version of the Declaration of Helsinki, and the study received ethics approval from the Human Research Ethics Committee at the University of New South Wales (HC200696).

Measures
Sociodemographic variables include date of birth, sex, sexual orientation, current living and relationship status, highest level of education completed, self-perceived socioeconomic status 41 , history of diagnosed mental illness and long-term physical health conditions, and current medication.
Mental and physical wellbeing measures include subjective mental wellbeing measured by the Short Warwick-Edinburgh Mental Well-Being Scale SWEMWBS; 42 .The scale consists of seven items assessing general mental wellbeing over the past two weeks.Total converted scores range from 7 to 35 with higher scores indicating higher levels of subjective mental well-being.This scale has demonstrated good reliability in the current study (Cronbach's α = 0.82).Physical wellbeing was measured by the EQ-VAS 43 , a visual analogue scale numbered from 0 (the worst health you can imagine) to 100 (the best health you can imagine) over the last two weeks.A higher score represents a perception of better physical health.
The severity of suicidal thoughts was assessed by the Suicidal Ideation Attributes Scale SIDAS; 44 , consisting of ve items related to frequency of suicidal thoughts, controllability, closeness to suicidal attempt, levels of distress and impact on daily functioning in the past month.Item two (controllability) is reverse scored.Total scale ranges from 0 to 50, with higher scores indicating more severe suicidal thoughts.The measure has shown internal consistency (Cronbach's α = 0.84) in the current study.History of suicide attempts was assessed by a question on a three-point Likert scale, ranging from "No, never (0)", "Yes, once (1)", to "Yes, more than once (2)" 45 .
Levels of depression and anxiety over the past two weeks were measured by the Patient Health Questionnaire-9 PHQ-9; 46 and the Generalized Anxiety Disorder-7 GAD-7; 47 , respectively, with higher scores re ecting more severe depression and anxiety.Both measures have shown good internal consistency (PHQ-9, Cronbach's α = 0.86) and (GAD-7, Cronbach's α = 0.88) in this study.The positive and negative affect was assessed by the International Positive and Negative Affect Schedule Short-form I-PANAS-SF; 48 .The scale has ten items assessing the frequency of positive affect (active, determined, attentive, inspired, and alert) and negative affect (afraid, nervous, upset, hostile, and ashamed) over the last two weeks on 5-point Likert scale, ranging from "Never (1)" to "Always ( 5)".This scale has shown acceptable consistency (Cronbach's α = 0.72 for positive affect and Cronbach's α = 0.68 for negative affect) in the current study.
Emotion regulation related measures include the 16-item Brief Di culties in Emotion Regulation Scale DERS-16; 49 evaluating emotion regulation di culties: emotional clarity, goals, impulsivity, strategies, and non-acceptance.Total score ranges from 16 to 80, with higher scores re ecting greater levels of emotion dysregulation.The DERS-16 has shown good internal consistency and in the current study (Cronbach's α = 0.91).
Levels of exibility were measured by the Coping Flexibility Scale CFS; 50  Self-e cacy in emotion regulation was measured by the Regulatory Emotional Self-e cacy Scale RESE; 52 .The scale is composed of 12 items that assess competence belief in regulating affects due to occurrence of positive or negative events.This scale assesses self-e cacy in three aspects of emotion regulation: expressing positive emotions, managing despondency-distress, and managing anger-irritation.Each aspect is measured by four items, with total scores of each subscale ranging from 4 to 20.All subscales have shown good internal consistency in this study, with Cronbach's α ranging from 0.71 to 0.80.
Cognitive and behavioural responses to emotional distress were measured by 18 questions assessing participants' likelihood to engage in the listed activities 53,54 using a four-point Likert scale, ranging from "Highly unlikely (1)" to "Highly likely (4)".The activities cover six aspects, including digital technology (i.e., watching TV or online videos, browsing social media, playing videogames or computer games), create arts (i.e., jigsaws, drawing or journaling), self-harm and substance use (i.e., using drug or alcohol, self-harm, thinking about death), exercise (i.e., anerobic exercise, aerobic exercise), self-transcendence (i.e., pray, mindfulness or mediation, challenging negative thoughts, doing randomly kind things to others), and selfcare (i.e., sleeping, taking a bath or long shower, playing with pets, massaging), with average scores of each aspect ranging from one to four.Higher scores indicate higher intentions to engage with the activities.

Statistical analysis
Latent class analysis (LCA) was used to identify the positive deviant (PD) cases.LCA is a mixture modelling technique that classi es a seemingly heterogeneous sample into a discrete number of subgroups ('classes'), focusing on the similarities and differences across individuals 55 .Whereas LCA is typically seen as a data-driven approach where the best tting model is chosen based on statistical consideration, theoretical and practical insights can also be used to optimise the model 56 .In this study, the latent class analysis was performed based on three constructs: subjective mental wellbeing measured by the SWEMWBS, physical wellbeing measured by the EQ-VAS, and existence of self-reported lifetime suicidal attempts.These constructs were chosen to identify the PD individuals who maintained high levels of wellbeing and had not attempted suicide to investigate the resilient factors to suicidal behaviour.A 2-class, 3-class, 4-class, and 5-class models were speci ed via Mplus version 8, including Bayesian Information Criterion (BIC), Adjusted Bayesian Information Criterion (ABIC), signi cant levels of bootstrapped likelihood ratio test (BLRT), and the percentages of the total sample across class membership.The model was selected based the signi cant BLRT, the most robust indicator of class membership, and no classes with <5% of the total sample 57 .Subsequent analyses were conducted with IBM SPSS Statistics (Version 26).To compare the bit-tting classes on sociodemographic, mental and physical health conditions, and emotion regulation related factors variables, independent sample t-tests were conducted for continuous variables, and chi-square tests were conducted for dichotomous variables.The predictors of PD class membership were assessed rstly using base models including each individual predictor.Signi cant predictors were then included in a multivariate logistic regression model to assess the impact while adjusting for potentially confounding effects.Signi cance levels were set at p < 0.05.All analyses were performed using SPSS Version 26 (SPSS Inc, Chicago, IL, USA).The PD cases reported lower levels of di culties in emotion regulation (46.8 vs 57.6, t = -6.14, df = 555, p < .001),higher coping exibility (24.9 vs 22.6, t = 3.56, df = 555, p < .001)and higher cognitive exibility (54.4 vs 46.8, t = 7.26, df = 555, p < .001)than the non-PD cases.The PD cases also had higher levels of self-e cacy in expressing positive emotions (14.6 vs 11.2, t = 6.00, df = 555, p < .001), in managing despondency and distress (9.4 vs 7.8, t = 3.51, df = 555, p < .001),and in managing anger and irritation (10.3 vs 8.8, t = 3.08, df = 555, p = .002)than the non-PD cases.The PD cases were less likely to use digital technology (2.9 vs 3.1, t = -2.38,df = 555, p = .018)and less likely to use maladaptive coping behaviour including self-harm and substance use (1.9 vs 2.5, t =-6.31, df = 555, p < .001) as a response to emotional distress.They were more likely to engage in physical exercise (2.1 vs 1.8, t = 3.36, df = 555, p =.001) and self-transcendence (2.2 vs 2.0, t = 2.83, df = 555, p = .005)than the non-PD cases.There was no signi cant difference between the PD and the non-PD cases on age, sex, sexual orientation, geographical location, living situation, relationship status, current medication status and likelihood of engaging in creative arts or self-care activities under emotional distress.

Predictors of the PD class
Predictors of the PD latent class are presented in Table 3.Having lower levels of emotion dysregulation (p < .001),higher coping (p = .001)or cognitive exibility (p < .001),great self-e cacy in expressing positive affect (p < .001),reduced use of digital technology (p = .019),less self-harm or substance use (p < .001) as a response to emotional distress, more use of exercise (p = .001)and self-transcendence (p = .005)were associated with membership in the PD class.After adjustment for confounders (i.e., signi cant sociodemographic and mental health factors differentiating the PD and the non-PD classes), having higher cognitive exibility (p < .001),higher self-e cacy in expressing positive affect (p = .013),reduced use of digital technology (p = .005),and less self-harm and substance use (p = .026)were signi cantly associated with PD class membership.

Discussion
This study investigated suicide resilience using a positive deviance (PD) informed analytic approach.
Using latent class analysis, a single PD class, who had high levels of wellbeing and an absence of suicide attempt, was identi ed.The PD class constitutes 10% of the total sample.The PD class was found to have less severe suicidal thoughts, greater positive affect, and less negative affect than the non-PD class as There were few sociodemographic factors that the PD group from the non-PD group, other than signi cantly greater rates of educational attainment and higher socioeconomic status.
Greater cognitive exibility, higher self-e cacy in expressing positive affect, and adaptive emotion regulation strategies, including reduced use of digital technology and reduced self-harm and substance use were signi cantly associated with membership of the PD class after adjusting for sociodemographic and mental health factors.Associations between PD class and emotion dysregulation, coping exibility, more use of exercise and self-transcendence were signi cant in bivariate analysis but not signi cant in adjusted models.These ndings indicate a number of potentially important foci for interventions to support individuals with current suicidal experience.
Cognitive exibility but not coping exibility appears to be strongly associated with positive deviance.
Approximately one standard deviation increase in cognitive exibility was associated with double odds of positive deviance.This nding is in large consistent with the literature indicating that psychotherapies (e.g., cognitive behavioural therapy) that appear to increase cognitive exibility 58 are effective for reducing suicidal thoughts and behaviour 59,60 .While cognitive reframing is a key focus of CBT, the current ndings suggest that providing an explicit focus on cognitive exibility for people with suicidal thoughts may increase their resilience to suicidal behaviour.Cognitive exibility may be a potential mechanism as to how cognitive restructuring impacts suicidal thoughts and behaviour but this explanation warrants further experimental investigation.We found no signi cant relationship between coping exibility and positive deviance after adjusting for current mental health status and sociodemographic characteristics.This nding is consistent with previous ndings 38 indicating the moderating effects of coping exibility on the relationship between depressive symptoms and suicide risks.Future studies may investigate the interaction between coping exibility and mental health symptoms in individuals with suicidal thoughts or behaviour in a larger sample size.
Our study indicates a signi cant relationship between regulatory emotional self-e cacy and the PD membership, speci cally through greater expression of positive affect.This nding echoes the increasing literature suggesting the important role of regulatory emotional self-e cacy in suicide prevention 61,62 .A recent study indicates signi cant mediating effects of regulatory emotional self-e cacy, but not acquired capability for suicide, on the relationships between nonsuicidal self-injury frequency and lifetime suicide attempts in both community-based and clinic samples 40 .Our ndings extend this knowledge and suggest that regulatory emotional self-e cacy in expressing positive affect, but not managing despondency distress or anger irritation may play a critical role in the transition to suicidal attempts.
Further study to unveil the factors that differentiate the impacts of domains of regulatory emotional self-e cacy, for example, social support, self-esteem, or personality, may help in understanding the mechanisms underlying this association.
The ndings around the use of speci c coping behaviour also points to the focus areas where health promotion and clinical interventions may bene t people at risk of suicide.Young adults in the PD class were less likely to use digital technology to cope with emotional distress.While recent reviews indicate that minimum impact of digital technology use on mental health symptoms 63,64 , our ndings suggest that using digital technology (e.g., TV, online videos, social media) as a distraction to emotional distress can be a maladaptive coping strategy amongst young adults at risk of suicide.This is consistent with previous research reporting that use of digital technology is not effective for coping with distress 65 and associated with lower levels of psychological wellbeing 66 .
Those in the PD class were also less likely to use substances or self-harm to cope with emotional distress, echoing previous ndings on the roles of self-harm 67 and substance use 68 in suicidal behaviour and a recent cohort study focusing on the transition from suicidal thoughts to behaviour amongst adolescents 69 .Although physical activity and practice of self-transcendence (e.g., prayer, mindfulness or meditation) were signi cantly associated with the PD class in the bivariate associations, they became non-signi cant in the adjusted models.This nding is in large consistent with the qualitative research in suicide prevention 70 , suggesting the di culties in practicing mindfulness and exercise during a crisis, particularly when fatigue is present.Nevertheless, physical activity has also been shown to improve cognitive exibility in adults 58 , suggesting that behavioural activation and other health behaviour change approaches to increase physical activity may also aid in individuals' coping with suicidal experience, outside of a crisis.Interestingly, emotion dysregulation was not signi cant in the adjusted model.Previous reviews have suggested that dialectical behaviour therapy (DBT), which focuses on emotion regulation, is associated with only modest reductions in suicidal thoughts 60 , although effects tend to be larger among people with personality disorders 71 .Our ndings are consistent with previous ndings indicating: (1) that the relationship between emotion regulation and wellbeing is complex and largely explained by mental health status 72 , (2) that emotion regulation may only impact wellbeing for certain subgroups of the population 73 , and (3) that observed effects are only related to speci c emotion regulation strategies 73 .In combination, the ndings suggest that a sole focus on emotion regulation is unlikely to be an optimal universal approach for suicide prevention interventions.
This study was the rst to apply a positive deviance framework to identifying resilience to suicidal behaviour, using a large non-clinical sample of young adults with recent suicidal thought.We found 10% of the surveyed population met the criteria of PD.This number aligns with the previous estimate that PDs typically account for 0% to 10% of a population 74 .There were a few meaningful differences between the PD and the non-PD classes, which provides a potential practical approach to revisit the evidence in suicide prevention research.Some limitations to this study need to be acknowledged.The direction and causation of signi cant associations could not be established due to the cross-sectional nature of the study.Nevertheless, the ndings of this research suggest potential novel targets further clinical, experimental and health promotion research.Examining longitudinal outcomes for people identi ed as positive deviants, including suicidal thoughts, suicide attempts and wellbeing, would also be an important extension of this research.
Due to the epidemiological approach and distal assessment methodology adopted in this research, all of the outcomes were based on self-report, without clinician veri cation of mental health outcomes.
Although established, validated measures were used, examination of positive deviance in a clinical context may reveal other factors that support resilience to suicidal behaviour.There may have been factors associated with positive deviance that we did not measure, which may be worthy of future investigation.Such factors may include personality, social connectedness and hopelessness.Finally, the recruitment strategy is unlikely to result in a sample that was representative of the population of interest.
We chose online recruitment because young adults have high use of social media and low rates of service use.Nevertheless, variability in social media use and trust in advertising may have in uenced the composition of the sample.

Conclusions
This study demonstrated a methodology to understand suicidal resilience by identifying positive deviants, who comprised approximately 10% of a non-clinical sample with suicidal thoughts.We found that greater cognitive exibility, greater self-e cacy in expression of positive affect, reduced use of digital technology, and less self-harm and substance use for coping were associated with greater resilience to suicidal behaviour.These ndings suggest that speci c emphasis on cognitive exibility, regulatory emotional self-e cacy, and avoidance of maladaptive coping in therapeutic and health promotion interventions may be important for increasing wellbeing and reducing suicidal behaviour among young adults.A greater focus on strengths-based approaches to suicide prevention may bene t young adults at risk of suicide.

Declarations
and the Cognitive Flexibility Scale CFS; 51 respectively.The Coping Flexibility Scale has 10 items, and items 2 and 7 are reverse coded.The total score ranges from 0 to 30 with higher scores indicating higher ability of coping exibility.The Cognitive Flexibility Scale comprises 12 items measuring aspects of cognitive exibility relevant to effective interactions and communication.Items 2, 3, 5, and 10 items are reverse scored and the total scores of the scale range between 12 and 72.Higher scores indicate stronger cognitive exibility.Both scales demonstrated good internal consistency (Coping Flexibility Scale: Cronbach's α = 0.77, Cognitive Flexibility Scale: Cronbach's α = 0.75) in the current study.

Table 1
displays the t statistics for the latent class analysis (Table1a) and the description of latent classes (Table1b).This study tested models with 2-5 classes, all of which were supported by BLRT .5 vs 22.4, t = -13.18,df = 555, p < .001)and physical (46.3 vs 79.1, t = -18.96,df = 100.6,p < .001)wellbeing than Class 2 (n=55, 9.9% of the total sample).Participants in Class 2 hereafter are referred as positive deviant (PD) cases who demonstrated resilience to suicidal behaviour and high mental and physical wellbeing.
except the 5-class model.Whilst ABIC and BIC supported a 5-class model, membership of the fth class in the model was low, comprising 3.1% of the total sample.The 3-class and the 4-class models also included a class of less than 5% of the total sample.Consequently, the 2-class model was retained in this study.Membership for the 2-class model was as follows: Class 1 had 502 individuals (90.1% of the total sample) with 53.4% who reported lifetime suicidal attempts and signi cantly lower subjective mental (17Note.PD: Positive Deviant; BIC: Bayesian Information Criterion; ABIC: Adjusted Bayesian Information Criterion; BLRT: Bootstrapped Likelihood Ratio Test for k versus k-1 classes; class membership is sorted from largest to smallest.Note.SD: Standardised Deviance; PD: Positive Deviant; SWEMSWS: short Warwick-Edinburgh Mental Well-being Scale; EQ-VAS: EuroQol visual analogue scale (0-100).

Table 2
presents the differences between PD cases and non-PD cases on sociodemographic, mental and physical status, and emotion regulation and related factors.The PD cases had signi cantly higher Note.M: Mean; SD: standardized deviance; PD: positive deviant; LGBTI: lesbian, gay, bisexual, trans, and/or intersex; SIDAS: Suicidal Ideation Attributes Scale; PHQ-9: The Patient Health Questionnaire-9; GAD-7: General Anxiety Disorder-7; PANAS-SF: Positive and Negative Affect Schedule-Short Form; DERS-16: The Di culties in Emotion Regulation Scale-16; CFS: Coping Flexibility Scale; CFS: Cognitive Flexibility Scale; RESE: Regulatory Emotional Self-e cacy Scale; Bold values indicate p < 0.05 based on independent groups t-tests for continuous variables and 2 tests for categorical variables, comparing PD and non-PD group.M: Mean; SD: standardized deviance; PD: positive deviant; LGBTI: lesbian, gay, bisexual, trans, and/or intersex; SIDAS: Suicidal Ideation Attributes Scale; PHQ-9: The Patient Health Questionnaire-9; GAD-7: General Anxiety Disorder-7; PANAS-SF: Positive and Negative Affect Schedule-Short Form; DERS-16: The Di culties in Emotion Regulation Scale-16; CFS: Coping Flexibility Scale; CFS: Cognitive Flexibility Scale; RESE: Regulatory Emotional Self-e cacy Scale; Bold values indicate p < 0.05 based on independent groups t-tests for continuous variables and 2 tests for categorical variables, comparing PD and non-PD group.M: Mean; SD: standardized deviance; PD: positive deviant; LGBTI: lesbian, gay, bisexual, trans, and/or intersex; SIDAS: Suicidal Ideation Attributes Scale; PHQ-9: The Patient Health Questionnaire-9; GAD-7: General Anxiety Disorder-7; PANAS-SF: Positive and Negative Affect Schedule-Short Form; DERS-16: The Di culties in Emotion Regulation Scale-16; CFS: Coping Flexibility Scale; CFS: Cognitive Flexibility Scale; RESE: Regulatory Emotional Self-e cacy Scale; Bold values indicate p < 0.05 based on independent groups t-tests for continuous variables and 2 tests for categorical variables, comparing PD and non-PD group.

Table 3
Logistic regression models of cognitive emotion regulation factors in predicting the PD latent class (n=557) Emotional Self-e cacy Scale; the results were adjusted for age, sex, education, social economic status, severity of suicidal thoughts, depression, and anxiety, and positive and negative affect.