Download
Download
Download
Abstract: University students are particularly susceptible to suicidal ideation and behavior due to issues inherent to this vital lives’
moment. The Rorschach test can help to understand these students’ suffering. The objective was to evaluate perception, thinking, stress,
and distress in the Rorschach test domains in university students attended at a public university mental health service, comparing students
with suicidal ideation with those without it. A total of 36 students aged 18 or over were assessed. The instruments were: Rorschach
Performance Assessment System (R-PAS), Columbia Suicide Severity Rating Scale (C-SSRS) and Self Report Questionnaire (SRQ-20).
Two analyses were performed using Wilcoxon Mann-Whitney test, according to the presence of suicidal ideation in the last 30 days
(SRQ-20) and in the last six months (C-SSRS). Statistically significant differences were found in the two analyses, indicative of greater
perceptual distortion in students without suicidal ideation and of stress and distress in students with ideation.
Palabras clave: test de Rorschach, suicidio, distorción perceptiva, estrés, salud mental
Available in www.scielo.br/paideia 1
Paidéia, 33, e3330
unfathomable. This is a problem that should be considered as card turning, transparency responses, responses with color
a priority in public health (WHO, 2021a, 2021b). The most shading blend responses, and morbid content. In the use of the
recent calculation of the suicide death rate in Brazil is 6.9 per Rorschach test for suicidal ideation, it may be useful to evaluate
100,000 inhabitants, with 3.0 women per 100,000 inhabitants two of the different domains that can be investigated through
and 10.9 men per 100,000 inhabitants (WHO, 2021a). Between this method. First, the Perception and Thinking Domain, since
2011 and 2016, more than 176,000 cases of self-injury were ideas of suicide are related to cognitive and ideational aspects
recorded in Brazil, and suicide attempts were identified in of the individual; and the Stress and Distress Domain, for
more than 48,000 cases, with just over two-thirds carried out evaluation of stress and distress experienced by them and that
by women (Ministério da Saúde, 2017). However, it is known could predispose to suicidal thoughts. The association between
that these numbers are always underestimated, as they are stress and distress and suicidal ideation or behavior seems
based on official data on cause of death in death certificates well established according to the literature. The study of Liu
and on the Violence and Accident Surveillance of the Notifiable et al. (2019) confirms that stress has a strong association with
Diseases Information System (VIVA/SINAN), which are often suicide attempts and mental health diagnoses. Holdaway et al.
inaccurate, since several deaths due to hit-and-run, poisoning (2018) associated rumination, referring to a repetitive focus on
and automobile accidents may have a suicidal intention, without symptoms of distress, with suicide risk, ideations, and suicide
such intention being identified (Cassorla, 2017), or also self- attempts. Wang et al. (2017), in a systematic review, found
injury may not be identified by the professional as a suicide a moderate association between depressive symptoms and
attempt. Moreover, stigmatized causes of death, such as HIV suicidal ideation in Chinese university students. The same can
and suicide, are recognizedly underreported (WHO, 2020). be observed with Brazilian students in the work of Sousa et
Thus, it is very likely that suicide attempts and deaths by suicide al. (2021). The authors also cite studies that relate depressive
have a higher occurrence than that shown by the statistics. symptoms to suicidal ideation, and one of them (Wu & Zao,
Suicidal ideation is related to self-destructive thoughts and 2009) concluded that depressive symptoms can accurately
the idea that life is not worth living, and may involve desires, predict suicidal ideation in more than 94% of cases. In the
attitudes and/or plans to end one’s life (Ramírez et al., 2020). study of Ramírez et al. (2020), suicidal ideation and suicidal
This is a fact frequently observed among people undergoing behaviors were related to gender issues in Brazilian university
treatment for psychiatric disorders, especially depressive students and associated with discomfort, malaise, anguish,
ones. However, suicidal ideation also occurs in the general distress, social exclusion, and psychological and physical
population, outside psychiatric contexts (Sojer et al., 2021). violence suffered by the population of lesbian, gay, bisexual and
Most university students are at an age of frequent incidence transgender (LGBT) persons.
of mental disorders, that is, late adolescence and early adulthood Taking this evidence into consideration, the objective
(Akram et al., 2020; Costa et al., 2019; Ramírez et al., 2020), was to evaluate the perception, thinking, stress and distress
being considered particularly susceptible to ideation and suicide domains in the Rorschach test of university students treated
because of challenges inherent to this period of life. Such in a mental health service of a public university, comparing
challenges may include, for example, adapting to a new study students with suicidal ideation with those without ideation.
routine, academic pressures, living away from family, suffering The hypothesis is that suicidal ideation could be associated
from loneliness or helplessness, having new responsibilities, with perceptual and thought difficulties of the individual
and making new friends. Considering the global university and/or with a high level of stress and affective discomforts.
population, suicide is the second leading cause of death and
the estimated annual suicide rate is 7.5 per 100,000 university
students. About 8% of undergraduate students and 5% of Method
graduate students report that they have attempted suicide and
up to 32% of students have had suicidal thoughts at some point Participants
in their lives (Costa et al., 2019). Therefore, it is very important
to study and understand the mental suffering of these students. We evaluated 36 undergraduate and graduate university
The Rorschach test is a psychological test that evaluates students, regardless of sex and aged at least 18 years. The
“personality characteristics that are based on what people do,” inclusion criterion was having spontaneously sought a mental
that is, behaviors, and can also “assess implicit characteristics health service of the university; without exclusion criteria.
that may not be recognized by the respondent him or herself”
(Meyer et al., 2011, p. 1); thus, it can be useful to broaden the Instruments
understanding of the suffering of those people who think of
suicide as a solution to difficulties. Although it has been used The instruments used were: the Rorschach Performance
for more than 50 years to evaluate suicidal behavior (Blasczyk- Assessment System (R-PAS) (Meyer et al., 2011) to assess
Schiep et al., 2011), few recent studies on suicide have used aspects of the participants’ personality; the Columbia-Suicide
the Rorschach test as an evaluation method. Zare et al. (2022) Severity Rating Scale (C-SSRS) (Posner et al., 2008), which
conducted a narrative review to identify characteristics in provides the possibility of evaluating suicidal ideation and/or
the Rorschach test that indicate suicide risk. They found behavior throughout life and also more recently; and the Self-
four individual signs of the presence of suicidal ideation: Report Questionnaire (SRQ-20), which is a self-administered
2
Marques-Reis, T. C., Antúnez, A. E. A., & Yazigi, L. (2023). Suicidal Ideation, University Students, Rorschach.
instrument developed by the WHO for screening psycho- trends that can be verified with future sample expansion. The
emotional disorders in primary health care contexts, through the effect size (Pearson’s r) was calculated and we considered 0.10
evaluation of twenty symptoms that occurred in the previous 30 as small effect size, equal to or above 0.30 as average effect size,
days; it was validated in Brazil by Mari and Williams (1986). and equal to or above 0.50 as large effect size.
Procedure
Ethical Considerations
Data collection. Students who sought an open-door
mental health service of a public university within a one-year The research was approved by the Human Research
period were invited to participate in this research. For those Ethics Committee of the School of Arts, Sciences and
who accepted the invitation, a time was scheduled at which Humanities at the University of São Paulo, Opinion No.
the participant read and signed an informed consent form and 3,242,990, CAAE No. 08455219.3.0000.5390. As this is a
answered the SRQ-20, R-PAS and C-SSRS instruments. At delicate time and a possible crisis of the students, the first
the end, a space for conversation was opened and after that contacts were made in the form of welcoming care with one
the contact with the participant was closed. of the psychologists collaborating with the service. Only
Data analysis. IBM SPSS Statistics and Microsoft Excel afterward was the possibility of participating in the research
software were used. Descriptive statistics were performed offered. And, after participation, they continued with the
for age and sex and the frequency of each student’s current previously established care in the university service
program was counted, whether they were undergraduate or
graduate students.
For the SRQ-20 instrument, the frequency of each total Results
score was counted, and students with a score equal to or
greater than seven, which would be indicative of psycho- Of the 36 students evaluated, 24 are female and 12 male, the
emotional disorder, were also considered. We also calculated age ranged from 18 to 44 years (M = 25.81; SD = 6.52). Twenty-
how many students presented suicidal ideation in the SRQ-20 six students attended undergraduate programs, five attended
in the previous 30 days by answering “YES” to question 17: doctoral programs, three attended master’s programs, one
“Has the thought of ending your life been on your mind?”. attended postdoctoral program, and one student was a special
In the C-SSRS instrument, we counted the frequency student, graduated but not enrolled in a graduate program.
of (1) students who have never had suicidal ideation, (2) Regarding the SRQ-20, 31 students had a score equal
students with active suicidal thoughts, (3) students with to or greater than seven, indicative of psycho-emotional
suicidal plans, and (4) students with suicidal intent, referring disorder. The average total score was 11.86 (SD = 4.415),
to the previous six months. Students with a history of at least with a minimum value of 1 point and a maximum value of
one suicide attempt during their lives and students who had 20 points. Eleven students answered “YES” to question 17 of
non-suicidal self-injury (NSSI) behavior were also counted. SRQ-20 referring to the previous 30 days, which represents
Regarding the R-PAS instrument, a reliability study almost a third of the sample (30.56%).
was initially carried out: 12 protocols were independently Regarding the C-SSRS, of the 36 students evaluated,
recoded by people proficient in administration and coding six never had active suicidal thoughts, which means that at
by the R-PAS. The Intraclass Correlation Coefficient (ICC) some point in life they may have even thought about dying or
was calculated for the protocol-level variables, according to sleeping and never waking up again, but never thought about
the guidelines of recent researchers (Pianowski et al., 2021, killing themselves; in the previous six months, 22 students
Schneider et al., 2022). The variables for study were selected, had a desire to be dead or suicidal thoughts; of these, 16 had
all belonging to the Perception and Thinking Domain and active suicidal thoughts, of which eight had the intention to
the Stress and Distress Domain, variables referring to task kill themselves, and, of these, four prepared a specific plan
behavior and specific concerns, as well as the SC-Comp, TP- and intended to put it into practice. When these questions
Comp and V-Comp composites and the Complexity variable. are extended to the entire life period, eight students reported
To examine the groups of students with and without having prepared plans but having had no intention of putting
suicidal ideation, the non-parametric Wilcoxon Mann-Whitney them into practice, while other eight students reported having
test was used to compare means, considering that the variables had intention of executing a plan. Eight students have had at
do not follow normal distribution. We performed two analyses: least one suicide attempt at some point in their lives. Fifteen
(1) the sample was divided according to the presence or absence students have had non-suicidal self-injury behavior, that
of suicidal thoughts in the previous 30 days based on the YES is, they practiced some type of self-mutilation without the
or NO answers given to question 17 of the SRQ-20; and (2) intention of killing themselves.
the group was divided according to active suicidal thoughts in Regarding the R-PAS, the results of the reliability
the previous six months, according to what was observed in study showed that of the 61 protocol-level variables, 47
C-SSRS. The 95% confidence interval (CI) and also the 90% presented excellent ICC (above 0.75), and, of these, 18
CI were considered, since the sample size was considered presented ICC above 0.95. Six variables presented good
statistically reduced; variables in a 90% CI can mark significant ICC (between 0.60 and 0.75) and three variables presented
3
Paidéia, 33, e3330
poor ICC (less than 0.40), namely: FQu% (percentage of In the first analysis, the group of 36 students was
unusual form quality), Vg% (percentage of vague answers), separated according to the answer to question 17 of the SRQ-
and IntCont (intellectualized content). Four variables did 20, referring to the previous 30 days, as already described.
not present valid results because they are proportion values Thus, 25 students answered “NO” and eleven students
whose denominator can be zero and, therefore, cannot be answered “YES”. Table 1 shows the means and standard
calculated ([CF+C]/SumC; MAP/MAHP; Mp/[Ma+Mp]; deviation of each group, the Wilcoxon Mann-Whitney test
NPH/SumH). and the level of significance for the selected variables.
Table 1
Wilcoxon Mann-Whitney and r effect size tests for selected variables, with the group divided according to the answer to question 17 of the SRQ-20
Answer NO Answer YES
Mann- Wilcoxon Exact sig. Exact sig.
Parameter M SD M SD Z r
Whitney U W (bilat) (unilat)
Perception and Thinking Domain Variables
EII-3 0.652 0.21316 1.3455 0.401 95.0 420.0 −1.462 0.148 0.074** 0.24
TP-Comp 1.40 0.2329 1.509 0.3786 126.5 451.5 −0.378 0.716 0.358 0.06
WSumCog 9.56 2.124 22.36 7.176 72.0 397.0 −2.256 0.023 0.012* 0.38
SevCog 0.84 0.309 1.73 0.945 129.0 454.0 −0.326 0.764 0.365 0.05
FQo% 47.28 1.806 47,0 3.018 133.5 458.5 −0.138 0.899 0.449 0.02
FQu% 32.48 1.671 35.73 3.292 123.0 448.0 −0.499 0.629 0.314 0.08
FQ-% 18.12 1.912 15.27 3.125 116.5 182.5 −0.722 0.481 0.241 0.12
WD-% 15.44 1.836 9.27 2.457 76.0 142.0 −2.115 0.034 0.017* 0.35
Popular 4.32 0.345 4.64 0.509 126.0 451.0 −0.405 0.703 0.353 0.07
Stress and Distress Domain Variables
m 1.56 0.342 2.27 0.821 111.0 436.0 −0.942 0.358 0.179 0.16
Y 2.28 0.41 3.36 0.742 99.5 424.5 −1.342 0.186 0.094** 0.22
YTVC’ 5.28 0.537 6.27 1.184 120.0 445.0 −0.605 0.557 0.279 0.10
mY 3.84 0.506 5.64 1.377 112.0 437.0 −0.883 0.387 0.194 0.15
MOR 1.80 0.316 2.36 0.823 127.0 452.0 −0.373 0.72 0.361 0.06
CBlend 0.56 0.142 0.73 0.195 115.5 440.5 −0.837 0.443 0.24 0.14
C’ 1.72 0.262 2,00 0.33 116.0 441.0 −0.764 0.458 0.232 0.13
V 0.84 0.229 0.55 0.247 122.0 188.0 −0.599 0.59 0.311 0.10
PPD 10.12 0.961 11.73 2.054 120.0 445.0 −0.603 0.558 0.279 0.10
CritCont% 28.16 2.474 35.45 6.759 115.5 440.5 −0.756 0.461 0.23 0.13
SC-Comp 5.064 0.1863 4.927 0.3524 127.0 193.0 −0.361 0.729 0.364 0.06
Variables of other Domains
R 25.00 0.819 24.82 1.334 134.0 459.0 −0.121 0.912 0.456 0.02
Pr 0.60 0.163 1.36 0.491 90.0 415.0 −1.766 0.081 0.046* 0.29
Pu 0.52 0.252 0.36 0.279 125.5 191.5 −0.544 0.623 0.359 0.09
CT 9.68 1.31 5.55 1.791 87.5 153.5 −1.732 0.085 0.042* 0.29
SR 0.56 0.154 1.09 0.368 105.5 430.5 −1.218 0.249 0.117 0.20
An 3.20 0.321 3.27 0.574 119.0 444.0 −0.657 0.527 0.265 0.11
SumH 7.08 0.568 8.82 1.967 131.0 456.0 −0.224 0.832 0.416 0.04
M- 0.80 0.20 1.27 0.384 109.0 434.0 −1.043 0.302 0.150 0.17
M 3.80 0.462 5.64 1.397 113.5 438.5 −0.835 0.415 0.207 0.14
FM 3.28 0.498 3.18 0.444 127.5 452.5 −0.350 0.738 0.37 0.06
F 10.56 1.026 8.82 1.500 114.5 180.5 −0.793 0.439 0.219 0.13
WSumC 3.30 0.40 3.773 0.581 118.0 443.0 −0.673 0.512 0.256 0.11
MC 7.10 0.6856 9.41 1.768 111.5 436.5 −0.895 0.381 0.191 0.15
(continued...)
4
Marques-Reis, T. C., Antúnez, A. E. A., & Yazigi, L. (2023). Suicidal Ideation, University Students, Rorschach.
Table 1
Continuation
Answer NO Answer YES
Mann- Wilcoxon Exact sig. Exact sig.
Parameter M SD M SD Z r
Whitney U W (bilat) (unilat)
F% 41.72 3.324 34.73 5.399 112.0 437.0 −0.883 0.288 0.144 0.15
MC-PPD −3.02 0.924 −2.31 1.310 134.5 459.5 −0.103 0.926 0.463 0.02
AGM 0.68 0.160 1.27 0.407 104.5 429.5 −1.217 0.246 0.122 0.20
AGC 3.48 0.347 4.82 0.872 92.5 417.5 −1.583 0.114 0.058** 0.26
ODL 2.60 0.374 3.36 0.866 123.0 448.0 −0.505 0.625 0.312 0.08
ODL% 10.72 1.563 13.09 2.968 120.5 445.5 −0.586 0.569 0.285 0.10
V-Comp 3.824 0.220 4.27 0.416 112.0 437.0 −0.877 0.391 0.195 0.15
Complexity 76.60 3.827 87.09 10.029 116.5 441.5 −0.722 0.481 0.241 0.12
Note. M = Mean; SD = Standart deviation; Answer “NO” to question 17, n = 25; Answer “YES” to question 17, n = 11; * Indicates significant
variables with 95% CI (p ≤ 0.05); ** Indicates significant variables with 90% CI (p < 0.10).
It can be observed that the variables WSumCog (weighted In the second analysis, the C-SSRS was used,
sum of the six cognitive codes), WD-% (percentage of form considering as active suicidal ideation the participant
quality minus responses in W and D areas), both with a having really thought about killing themself in the previous
medium effect size; Pr (asking the subject to provide another six months. Presence of suicide plans and intent are also
answer for the card) and CT (card turning) showed significant included in present active ideation. Thus, 20 students
differences, with a small effect size, for a 95% CI; and, for did not present active suicidal ideation in the previous 6
90% CI, also the variables EII-3 (Ego Impairment Index-3), Y months and 16 students presented suicidal ideation. The
(diffuse shading determinant), and AGC (aggressive content) results of the analysis of the variables using the Wilcoxon
also showed a trend towards statistical significance. Mann-Whitney test are shown in Table 2.
Table 2
Statistics for Wilcoxon Mann-Whitney and r effect size with the group divided according to the presence or absence of active suicidal idea-
tion based on the C-SSRS
Ideation absent Ideation present
Mann- Exact sig. Exact sig.
Parameter M SD M SD Wilcoxon W Z r
Whitney U (bilat) (unilat)
Perception and Thinking Domain Variables
EII-3 0.835 0.29085 0.90 0.26188 153.0 363.0 −0.223 0.832 0.416 0.04
TP-Comp 1.555 0.2855 1.281 0.2643 145.5 281.5 −0.462 0.654 0.327 0.08
WSumCog 12.2 3.907 15.06 3.952 108.5 318.5 −1.644 0.102 0.051* 0.27
SevCog 1.10 0.518 1.13 0.499 132.5 342.5 −0.979 0.338 0.174 0.16
FQo% 47.75 1.936 46.50 2.518 154.5 290.5 −0.175 0.869 0.434 0.03
FQu% 30.40 1.666 37.31 2.474 100.0 310.0 −1.915 0.056** 0.028 0.32
FQ-% 19.15 2.281 14.88 2.226 120.0 256.0 −1.275 0.208 0.104 0.21
WD-% 15.90 2.202 10.63 1.923 105.5 241.5 −1.738 0.084 0.042* 0.29
Popular 4.20 0.374 4.69 0.435 142.5 352.5 −0.571 0.577 0.288 0.10
Stress and Distress Domain Variables
m 1.25 0.323 2.44 0.632 103.5 313.5 −1.861 0.064 0.033* 0.31
Y 2.40 0.467 2.88 0.598 147.5 357.5 −0.409 0.694 0.346 0.07
YTVC’ 4.95 0.667 6.38 0.785 113.0 323.0 −1.507 0.135 0.067** 0.25
mY 3.65 0.617 5.31 0.952 116.5 326.5 −1.397 0.167 0.083** 0.23
MOR 1.55 0.294 2.50 0.632 125.5 335.5 −1.135 0.261 0.132 0.19
CBlend 0.50 0.154 0.75 0.171 126.0 336.0 −1.199 0.255 0.143 0.20
C’ 1.65 0.319 2.00 0.242 127.0 337.0 −1.088 0.285 0.144 0.18
(continued...)
5
Paidéia, 33, e3330
Table 2
Continuation
Ideation absent Ideation present
Mann- Exact sig. Exact sig.
Parameter M SD M SD Wilcoxon W Z r
Whitney U (bilat) (unilat)
V 0.60 0.21 0.94 0.295 134.5 344.5 −0.913 0.381 0.186 0.15
PPD 9.40 1.125 12.13 1.431 106.0 316.0 −1.726 0.086 0.043* 0.29
CritCont% 26.35 3.026 35.44 4.514 111.0 321.0 −1.561 0.121 0.061** 0.26
SC-Comp 4.78 0.2069 5.325 0.2558 104.0 314.0 −1.785 0.075 0.038* 0.30
Variables of other Domains
R 24.55 0.977 25.44 0.975 139.0 349.0 −0.671 0.512 0.256 0.11
Pr 0.80 0.321 0.88 0.18 125.5 335.5 −1.189 0.231 0.117 0.20
Pu 0.55 0.312 0.38 0.202 158.5 294.5 −0.063 0.952 0.483 0.01
CT 8.40 1.663 8.44 1.387 159.5 295.5 −0.016 0.994 0.497 0.00
SR 0.60 0.169 0.88 0.287 147.0 357.0 −0.459 0.646 0.332 0.08
An 2.80 0.451 3.75 0.233 92.0 302.0 −2.238 0.024 0.012* 0.37
SumH 7.75 0.757 7.44 1.329 131.5 267.5 −0.912 0.37 0.185 0.15
M- 1.15 0.264 0.69 0.237 122.5 258.5 −1.272 0.207 0.108 0.21
M 4.40 0.723 4.31 0.84 157.0 293.0 −0.097 0.93 0.465 0.02
FM 3.20 0.588 3.31 0.405 136.5 346.5 −0.762 0.456 0.228 0.13
F 10.40 1.313 9.56 1.004 152.0 288.0 −0.256 0.807 0.403 0.04
WSumC 3.20 0.4845 3.75 0.4233 128.0 338.0 −1.024 0.314 0.157 0.17
MC 7.60 0.9945 8.063 1.0972 152.5 362.5 −0.239 0.819 0.41 0.04
F% 41.30 4.37 37.44 3.428 136.5 272.5 −0.749 0.464 0.232 0.12
MC-PPD −1.80 1.086 −4.062 0.9375 116.0 252.0 −1.403 0.165 0.083** 0.23
AGM 0.90 0.25 0.81 0.228 159.0 295.0 −0.034 0.987 0.502 0.01
AGC 2.95 0.32 5.06 0.616 68.0 278.0 −3.000 0.002 0.001+ 0.50
ODL 2.60 0.40 3.13 0.67 154.5 364.5 −0.178 0.866 0.433 0.03
ODL% 11.15 1.792 11.81 2.284 159.0 369.0 −0.032 0.981 0.491 0.01
V-Comp 3.985 0.2402 3.931 0.3395 153.0 289.0 −0.223 0.832 0.416 0.04
Complexity 73.80 4.064 87.31 7.30 120.5 330.5 −1.259 0.214 0.107 0.21
Note. Ideation absent in the previous 6 months, n = 20; ideation present in the previous 6 months, n = 16; + Indicates significant variable
with 99% CI (p ≤ 0.001); * Indicates significant variables with 95% CI (p ≤ 0.05); ** Indicates significant variables with 90% CI (p < 0.10).
These variables were significant within a 95% CI: [AGM], and anatomy, blood, explosion, fire and sex contents),
WSumCog (weighted sum of the six cognitive codes), and MC-PPD (human movements plus the weighted sum of
WD-% (percentage of form quality minus responses in W color determinants, minus PPD described above), all with
and D areas), PPD (potentially problematic determinants, small size effect, except for the variable FQu%, with medium
which includes FM [animal movement], m [inanimate effect size.
movement], Y [diffuse shading], T [texture], V [vista], C’
[achromatic color]), these three with small effect size; m
(inanimate movement determinant), SC-Comp (suicide Discussion
concern composite) and An (anatomy content) with medium
effect size; and AGC (aggressive content) with p ≤ 0.001 Regarding the first statistical analysis performed, it is
and large effect size; and there was a trend toward statistical interesting to note that there were variables of the Perception
significance, with a 90% CI, in the variables FQu% and Thinking Domain that had higher means in the groups
(percentage of form quality unusual), YTVC’ (sum of the with and in the group without suicidal ideation, indicating
shadings and achromatic color determinants), mY (sum of specific difficulties in these aspects in each group. The
the inanimate movement and diffuse shading determinants), variable WD-% had higher means in the group of students
CritCont% (percentage of critical content, which comprises who reported not having had suicidal ideation in the previous
the codes for morbid content [MOR], aggressive movement 30 days, and the increase is significant when compared with
6
Marques-Reis, T. C., Antúnez, A. E. A., & Yazigi, L. (2023). Suicidal Ideation, University Students, Rorschach.
data for the normative sample (M = 8.2, SD = 6.7). The mean is also significant when we examine the normative sample
of the variable FQ-% (percentage of form quality minus) is data (M = 4.1; SD = 4.5). This finding is consistent with
also higher in the group of students without ideation, but it is the narrative review of Zare et al. (2022), in which card
not a statistically significant difference. Thus, the distortions turning was associated with suicidal ideation. The variable
in the perception of reality in the group without ideation AGC, aggressive content, reflects annoyances, concerns
occurred in W and D areas mostly, which indicates significant and aggressive identifications and high values can reflect
impairment in the reality test. On the other hand, WSumCog both identification with power and aggressiveness and
(weighted sum of the six cognitive codes) was significantly fear of aggressive dangers in the environment, or even an
higher in the group of students with suicidal ideation and EII- oscillation between both. The group with ideation has
3 (ego impairment index-3) showed a trend toward statistical higher AGC values, which could represent an increase in
significance (p = 0.074). WSumCog suggests greater disorder aggressive identifications in this group. As for variable Y,
and disorganization of thought or immature and inefficient it can be thought that people with suicidal ideation have a
thought; EII-3 is considered a general measure of disorder greater tendency to present feelings of helplessness in the
of thought and severity of psychopathology. It involves face of stressors, which could be a factor that contributes to
calculation with the variables FQ-% (percentage of form predispose them to suicidal thought.
quality minus, or distorted), M- (human movement with Regarding the second analysis, with the group divided
form quality minus), WSumCog, CritCont%, PHR, (poor according to the presence or absence of suicidal ideation in
human representation), GHR (good human representation), the previous six months, the same trend shown in the first
and R (total number of responses). EII-3 indicates greater analysis can be observed in relation to the variables WD-%
disorder of thought in the group of students with ideation, and WSumCog: the variable WD-% presented higher means
having shown a higher average than the normative sample in the group of students without ideation, and WSumCog
(M = -0.1; SD = 0.8; percentile 95 = 1.2). Here are some presented higher means in the group with ideation. Within
examples of answers from the group of students with ideation the variables of the Perception and Thinking Domain, FQu%
that involve cognitive codes: “two close people with wings” showed trend toward statistical significance; however, it
(card I, W, INC1), “several small animals partying together” was not taken into account for the analysis given the low
(card X, W, FAB1), “a frog with an ear” (card IV, D7, INC2), reliability of this variable in this study, possibly because
“a rabbit crying something green” (card X, D10, FAB2). The part of this type of response belonged to objects that are not
cognitive codes are related to ideational aspects, concept included in the form quality lists of the R-PAS.
formation, and thought process. In turn, the form quality Students who had thought about killing themselves in
minus responses, increased in the group of students without the previous six months showed greater concerns about the
ideation, are considered distorted and are more significant body or even vulnerability in body image or psychic aspects
when they occur in W and D areas, because they are more (anatomy responses, An). It can be observed that both groups
global (W) and more obvious (D) environmental situations. are above the range expected in the normative sample (An
They are closely related to the judgment of reality, that is, to percentile 75 = 2.0), which leads us to think that the entire
a way of capturing the world differently from other people, group of students presents concerns with the body or psychic
of perceiving the outside in their own and not shared way. vulnerability, and more markedly in those students with
This seems to be a significant difference between students active suicidal ideation. The AGC code is significantly
who have and students who do not have recent suicidal higher in the group of students with ideation, which is also
ideation — students who had no ideation had problems with increased when compared with the normative sample (M =
the judgment of reality, while students who had suicidal 3.1; SD = 1.9; percentile 75 = 4.0). With regard to AGC, it can
ideation had problems with the thought process. Perhaps be assumed, then, that suicidal ideation is related to aspects
suicidal ideation itself can be considered as a specificity in of aggressiveness, and this increase in AGC can either refer
the thought processes in this group. to the desire for suicide, which is a self-aggressive act, or to
The variable Pr is coded when the respondent gives only the fear of performing such act. This idea is reinforced by
one response to a blot and the examiner encourages them to the fact that it is an increased variable both in the protocols
give more responses. This can be related to different aspects, of students with more immediate suicidal ideation in the
such as cognitive deficit, “rigidity, inflexible perception, previous 30 days and in those with ideation in the previous six
depression, lack of trust and engagement, evasiveness, months. In addition, for this second analysis, it is the variable
defensiveness, resistance” (Meyer et al., 2011, p. 347). It that presented the most significant statistical difference (p ≤
can be noted that the group of students with ideation more 0.001 and large effect size) and may be a more representative
often needed to be motivated to see other things in the blots. marker of this difference between the groups.
However, for both groups, the mean value of this variable The variables m (inanimate movement), PPD (potentially
is between percentiles 25 and 75 of the normative sample problematic determinants), YTVC’ (diffuse shading, texture,
(percentile 25 = 0; percentile 75 = 1.5). It was also possible vista, and achromatic color determinants) and mY (inanimate
to learn that students who had not had suicidal ideation in the movement and diffuse shading determinants) are all related to
previous 30 days turned the card more (CT), demonstrating determinants indicative of distress, both chronic and related
greater flexibility, interest, curiosity or anxiety. This increase to situational stressors (m, mY). All have higher averages in
7
Paidéia, 33, e3330
the group of students with ideation, which can be an important ideation in the previous 30 days, and the C-SSRS, in the last
factor for them to have this type of thought. Accordingly, the six months; thus, we can assume that those who scored by the
Suicide Concern Composite is calculated with the variables C-SSRS had thoughts of suicide for a longer period and then
V (vista determinant), FD (form dimension determinant), more stable, which led to greater differences in functioning
CBlend (color shading blends), reflection determinant that could be captured by the Rorschach method.
and pair, MOR (morbid content), complexity, PPD, color The increased distorted responses (WD-%) in the group
responses, FQo% (percentage of form quality ordinary), of students without ideation, which goes against the initially
space responses, popular and whole human content. It is a raised hypotheses of greater distortion in the group of students
measure of the risk of suicide and self-destructive behavior with ideation, could be the result of greater defense of the group
and may be, from a psychic point of view, related to feelings of students with ideation. This hypothesis can be reinforced by
of despair. The group of students with suicidal ideation had the increased Pr in the group of students with ideation: this
significantly higher SC-Comp compared with the group group needed to be more stimulated to give more answers,
without ideation, which also denotes more distressing perhaps because they tried to suppress the distorted answers
feelings in that group. However, for SC-Comp, both groups they could have given. In addition, they also had fewer card
have values within the range expected for the normative turning (CT) behaviors, which could be a result of greater
sample (M = 4.7; SD = 1.4; percentile 75 = 5.6). In any case, behavioral rigidity and, therefore, less flexibility. However,
it is possible to think that SC-Comp seems to be a measure for these students, the difficulties related to the cognitive
sensitive to aspects related to suicide, since we are studying aspects ended up being shown in the conceptualization of the
students with and without suicidal ideation, who did not act responses that were not suppressed, through the increased
on the ideation by making an attempt; although it is a subtle WSumCog. Thus, they appear to have managed to defend
difference between the two groups, of suicide restricted to themselves by suppressing distorted responses, but have failed
thoughts and without behaviors, the composite was able to to defend themselves from revealing ideational problems
capture the difference between the groups. through the responses of severe cognitive codes.
The variable MC-PPD is an equation calculated with It can be observed in the group of students with suicidal
the sum of the human movement and chromatic color ideation in the previous six months the predominance of
determinants (MC), subtracting the potentially problematic variables related to the Stress and Distress Domain and,
determinants (PPD). It represents a measure of the ideational even variables that are outside this domain, can be referred
and affective resources (MC) in relation to the distress to the presence of distress. The variable anatomy contents,
experienced by the person. The lower the value of the although related to the Representation of Self and Others
equation, the more distressing feelings invade the person, Domain, contains characteristics of concerns about one’s
which decreases the ability to cope with everyday events. In own body, illnesses or psychic vulnerability that are possibly
the samples analyzed, the group of students with ideation has burdened by distress. The permanence of distressing living
a lower MC-PPD than the students with suicidal ideation, experiences in conjunction with the presence of disorganized
which could also indicate a lower coping and handling thoughts could be associated with thoughts of suicide as an
capacity of the group of students with ideation, generating unusual reasoning to deal with the distress they feel. This
a predisposition to suicidal thought. And, finally, critical hypothesis is consistent with the studies of Holdaway et al.
content (CritCont%) also increased in the group of students (2018), Liu et al. (2019), and Sousa et al. (2021), in which
with ideas of suicide also in relation to the normative sample there was an association of stress symptoms with suicide
(M = 20.4; SD = 13.5; percentile 75 = 28.0), which indicates ideation and attempts. Three of the four signs cited by Zare
the possible presence of traumatic experiences and/or et al. (2022) were not confirmed in this study, which in the
primitive thoughts in this group. This refers to the possibility R-PAS can be seen by the variables CT, CBlend, and MOR.
of trauma and dissociation and to the presence of little Transparency responses were not individually analyzed,
precise or primary cognitions that can generate censorship being part of the FAB2 cognitive code, which is included in
failures such as occurs in psychotic and borderline states. A the calculation of the variables EII-3, TP-Comp, WSumCog,
third hypothesis that could be interpreted from the increase and SevCog.
in the CritCont% variable would be that of malingering, In summary, the variables WSumCog and AGC were the
which occurs when people want to exaggerate symptoms in most significant to delimit the differences between students
Rorschach. However, as the students evaluated were in the with suicidal ideation and students without suicidal ideation.
context of research within a service in which they sought It is concluded that, for this sample, suicidal ideation seems to
help due to mental health issues, they would be unlikely to be result from the combination of rational and emotional aspects,
interested in faking symptoms or psychopathologies. that is, the way they think about dealing with this overflow
It is notable that there were more variables with statistically of negative and distressing feelings. Thus, it is understood
significant differences in the comparison of the groups in the that these are students who experience a great burden of
second analysis. This could be explained according to the these negative feelings, to the extent of thinking that there is
nature of the Rorschach method, which captures not only no other way out of suffering but death. Having a service to
situational characteristics of a person’s psychic state, but of care for students and so they are listened to can be essential in
a stable functioning. The SRQ-20 evaluates the presence of reducing distress and, consequently, preventing suicides. The
8
Marques-Reis, T. C., Antúnez, A. E. A., & Yazigi, L. (2023). Suicidal Ideation, University Students, Rorschach.
Holdaway, A. S., Luebbe, A. M., & Becker, S. P. (2018). Sojer, P., Kainbacher, S., Hüfner, K., Freudenthaler, H.,
Rumination in relation to suicide risk, ideation, and Kemmler, G., & Deisenhammer, E. A. (2021). The
association of intrapersonal trait emotional intelligence
attempts: Exacerbation by poor sleep quality? Journal of
and resilience with suicidal ideation in university
Affective Disorders, 236, 6-13. https://doi.org/10.1016/j.
students. Psychiatria Danubina, 33(3), 298-305. https://
jad.2018.04.087
doi.org/10.24869/psyd.2021.298
Liu, C. H., Stevens, C., Wong, S. H. M., Yasui, M., &
Sousa, G. S., Ramos, B. M. D., Tonaco, L. A. B., Reinaldo,
Chen, J. A. (2019). The prevalence and predictors of A. M. D. S., Pereira, M. O., & Botti, N. C. L. (2021).
mental health diagnoses and suicide among U.S. college Factors associated with suicide ideation of healthcare
students: Implications for addressing disparities in university students. Revista Brasileira de Enfermagem,
service use. Depression and Anxiety, 36(1), 8-17. https:// 75(Suppl. 3), e20200982. https://doi.org/10.1590/0034-
doi.org/10.1002/da.22830 7167-2020-0982
Mari, J. J., & Williams, P. (1986). A validity study of a Wang, Y. H., Shi, Z. T., & Luo, Q. Y. (2017). Association
psychiatric Screening Questionnaire (SRQ-20) in of depressive symptoms and suicidal ideation among
primary care in the city of Sao Paulo. British Journal university students in China: A systematic review and
of Psychiatry, 148, 23-26. https://doi.org/10.1192/ meta-analysis. Medicine (Baltimore), 96(13), e6476.
bjp.148.1.23 https://doi.org/10.1097/MD.0000000000006476
9
Paidéia, 33, e3330
World Health Organization. (2020). WHO methods and data Thaís Cristina Marques dos Reis is an Adjunct Professor
sources for country-level causes of death 2000-2019. of the Pontifícia Universidade Católica de São Paulo, São
World Health Organization. https://www.who.int/docs/ Paulo-SP, Brazil.
default-source/gho-documents/global-health-estimates/
ghe2019_cod_methods.pdf Andrés Eduardo Aguirre Antúnez is an Associate Professor
of the Universidade de São Paulo, São Paulo-SP, Brazil.
World Health Organization. (2021a). Suicide worldwide
in 2019: Global Health Estimates. World Health Latife Yazigi is a Full Professor of the Escola Paulista de
Organization. https://iris.who.int/bitstream/hand
Medicina, Universidade Federal de São Paulo, São Paulo-
le/10665/341728/9789240026643-eng.pdf?sequence=1
SP, Brazil.
World Health Organization. (2021b). Live life: An
implementation guide for suicide prevention in countries.
World Health Organization. https://iris.who.int/
bitstream/handle/10665/341726/9789240026629-eng.
Authors’ Contribution:
pdf?sequence=1
All authors made substantial contributions to the conception
Wu, S. Y., & Zhao, H. J. (2009). The relationship between life and design of this study, to data analysis and interpretation,
stress, depression and suicide ideation among undergraduates. and to the manuscript revision and approval of the final
Modern Preventive Medicine, 36(15), 2918-2919.
version. All the authors assume public responsibility for
Zare, F., Bakhshani, N., & Fardin, M. (2022). Rorschach content of the manuscript.
suicide indicators and constellation: A narrative review.
International Journal of High Risk Behaviors and Addiction,
11(3), e124044. https://doi.org/10.5812/ijhrba-124044
Associate editor:
Wanderlei Abadio de Oliveira
10