In our observation, the results of final model indicated that an increase in one point of psychological distress increased the risk of suicide ideation and suicide attempts by 1.35- and 1.28-point (p<0.05), respectively. This is consistent with the literature, suggesting the predicting role of psychological distress levels (i.e., suicide ideation, depression, inferiority, anxiety, hostility, and insomnia) for eventual suicide during the one-year follow-up (Wu et al., 2020). On this note, an observation study

of claim data from Japan identified that the hazard ratio for completed suicide was 2.37- and 4.16-fold among participants with moderate and severe psychological distress, respectively (Tanji et al., 2018) Neurobiological factors and psychological factors play a critical role in severe suicide ideation or suicide attempt and completed suicide (Li & Lee, 2022). Thus, mental health providers should consider that a fluctuating trend of psychological distress from T0 to T3 may lead to a particular risk of suicide among TRD patients in the long-term process.

Notably, a similar fluctuation trend could be seen between psychological distress and suicide attempt during hospitalization and post-discharge. These results suggested that suicide is not only an issue of acute crisis but also a prolonged problem of lasting psychological distress and varies over time, so suicide assessment needs to be repeated and applied to at-risk individuals (Maris, 2019; Wu et al., 2020).

Therefore, follow-up and regular assessment of patients with TRD after discharge are critically needed, especially for severely depressed patients with suicidal and refractory treatment features (Rex et al., 2022).

This target should be augmented with a greater focus on the safe transition from the hospital to the community. Hence, mental health providers should consider strategies that may improve transition safety, including a pre-discharge safety plan, stress-coping-based psychoeducation, and regular psychological distress assessment for inpatient to outpatient care. Facing limited mental healthcare resources in the Vietnamese community mental health network, telephone follow-up by the mental health nurses with a concise assessment of psychological distress through a short

rating scale such as BSRS-5 will be a feasible, effective and reliable way to prevent further suicide.

6.3.2. Hopelessness

We found a high prevalence of hopelessness among patients with TRD; this finding is especially pertinent for suicide prevention because hopelessness is a vital independent risk factor for increases in suicidal ideation and suicide attempts (Horwitz et al., 2017; Wolfe et al., 2019). Similarly, our findings highlight that hopelessness is strongly associated with suicidal ideation and suicide attempts in the observation. This finding is in line with other research showing that hopelessness is independently and frequently linked to an increased likelihood of suicidal ideation, suicide attempts, and completed suicide (Samuelsson et al., 2006). Furthermore, in a recent meta-analysis, hopelessness was a stronger predictor of suicide death than the severity of depression (Ribeiro et al., 2018). These prevalence rates and the aforementioned clinical impacts highlight the importance of psychiatric professionals or caregivers understanding the feelings of hopelessness in those with TRD. Thus, adding a simple question to assess recent hopelessness may be a practical means of risk identification in clinical settings where time and patient tolerance for extended interviews are limited (McCullumsmith et al., 2014).

Moreover, psychological intervention should focus on strengthening patients’

hope, which may moderate the association between hopelessness and suicidal ideation, and suicide attempts in those at high risk. As evidence of this, the

International Association for Suicide Prevention has promoted the triennial theme

“Creating hope through action” for World Suicide Prevention Day from 2021 to 2023 (International Suicide Prevention Association, 2021). Community suicide prevention programs targeting hope promotion may help reduce the rate of suicide in high-risk populations.

6.3.3. Resilient coping skill

Research on resilience in patients at high risk of suicide has grown tremendously in the past 15 years, with most studies highlighting resilience as a protective factor against suicide risk (Sher, 2019). Similarly, our univariate results in model 1 from table 20 and 21 confirm the protective effect of resilience against suicidal ideation and suicide attempt among those with TRD. Furthermore, our results suggested the resilience-building possibility in patients with TRD.

Studies have revealed inconsistent findings regarding psychological factors as either risk or protective factors in suicide; by contrast, robust research supports the buffering effect of resilience in suicide (Johnson et al., 2011). In addition, building resilience may promote stable remission from depression (Waugh & Koster, 2015).

Resilience skills are an innate yet adaptive human capacity for dealing with even highly stressful circumstances (PeConga et al., 2020; Waugh & Koster, 2015).

The present findings and related research on resilience highlight the importance of strengthening the resilience of those with TRD. Psychiatric

people with TRD achieve remission from residual symptoms and reduce their suicidal ideation; this approach may help lower the suicide attempt rate.

6.3.4. Quality of life

Related suicide ideation and attempt, Model 1 analysis reported that worse quality of life was associated with suicidal ideation and attempt in TRD patients.

Further, consistent with the previous study, the EQ-5D-5L questionnaire revealed that patients with TRD were more likely to have experienced pain or discomfort and anxiety or depression (Corral et al., 2022). Notable, physical pain is a significant risk factor for suicide, implying a possible link between treatment resistance and suicide behavior (Elman et al., 2013). The low quality of life was observed during our critical follow-up period lower compared to the general Vietnamese adult population (Mai et al., 2020), but compatible among patients with chronic depressive depression (Buszewicz et al., 2016) and TRD (Corral et al., 2022). According to previous research (Heerlein et al., 2021), a lower quality of life score may reflect an unmet treatment need in TRD patients who have a high disease burden, reduced function, and productivity significant proportion are long-term sick leave or unemployment.

Moreover, a recent review demonstrated that hospitalization cost and depression severity among TRD patients might contribute to reducing the patient quality of life (Johnston et al., 2019). In our observation, this TRD group had a relatively high rate of re-examination and hospitalization within one year before participating in this study, and even within three months post-discharge, nearly one-fifth (18.87%) of

patients were re-hospitalized. Thus, it is essential in the Vietnamese healthcare system, where the mental healthcare provider's team only sees a patient once after admission and then only once a month to see the psychiatrist for medication. Follow-up is currently the most challenging aspect of treating TRD patients. As a result, improving patient access to follow-up care can positively impact treatment quality, costs, and quality of life among TRD patients, who have a high risk of suicide and impairments in daily activities ranging from essential self-care to the ability to work maintain interpersonal relationships.

6.3.5. Self-rated recovery and self-efficacy

In the model 1 analysis of both table 20 and 21, low self-rated recovery significantly associated with suicide ideation and attempt among patients with TRD during our observation. In addition, model 1 also revealed that low self-efficacy significantly associated with suicidal ideation in the long term among patients with TRD. During the follow-up, TRD patients reported their self-rated recovery status and self-efficacy as relatively low, with a mean score of 4.06 to 6.26 and 4.26 to 5.94 on a scale of 0 to 10, respectively. Noteable, in a national survey, people with more significant chronic illness and depression had lower confidence in taking care of their health (Finney Rutten et al., 2016). In addition, the low self-rating of recovery can be attributed to the fact that TRD patients exhibited unsatisfactory responses and refractory depression. Thus, more than a third of people with TRD tend to achieve remission, while the remaining patients continue to suffer from the residual symptoms

(Al-Harbi, 2012). Notable, our participants reported high medication adherence throughout the study; hence, additional research is required to identify the most effective therapeutic modalities for TRD patients. Antidepressants and other drugs based on biomarkers and non-drug strategies are on the horizon to further address the multiple, complex issues associated with TRD (Ah-Harbi, 2012, Han et al., 2020).

The association between self-efficacy and suicide was demonstrated in a previous study in Taiwan (Isaac et al., 2018). In addition, individuals with a history of suicide attempts might experience a reduced sense of mastery in safely managing suicidal ideation; this notion is consistent with self-efficacy theory, which suggests that an influential critical source of self-efficacy is previous successful performance (Bandura, 1990). Our findings suggest that psychiatric and mental health providers should briefly assess TRD patients with self-rated recovery and self-efficacy for early detection of suicidal ideation because the self-rated assessment is simple and is not associated with stigmatization in clinical settings. Furthermore, mental health professionals should promote the health self-efficacy of those with TRD by increasing patients’ mental health literacy and promoting their willingness to seek help from mental health professionals; this would help enhance patients’ self-management skills, thus mitigating long-term suicidal ideation.

6.4. Socio demographic and suicide risk

In document 越南難治性憂鬱症患者的自殺傾向、心理因素和社區融入:一項短期追蹤研究 (Page 116-122)