Association between attachment style and suicide risk in patients receiving online psychotherapy: a cross-sectional study of five psychotherapy services

Restrictions imposed during the COVID-19 pandemic have raised concern among suicidology and mental health researchers regarding a possible increase in suicide risk, particularly among people already in psychological distress. Attachment style is one relational characteristic that may act as either a vulnerability or a protective factor. To analyze the association between attachment style and suicide risk among patients undergoing online psychotherapy. Additionally, it sought to explore the influence of depression on this relationship and to estimate the prevalence of suicide risk. Cross-sectional analysis of a multi-center sample of patients in online psychotherapy during the COVID-19 pandemic ( n  = 94) with complete data on all instruments analyzed. Measures included sociodemographic data, attachment style (Adult Attachment Scale-R, AAS-R), depression (PHQ-9), and suicide risk (PHQ-9-item9). Group comparisons used the Mann-Whitney U test; associations used the chi-square test, and relationships between scores used Spearman correlations. The prevalence of higher suicide risk was 43.6% ( n  = 41; 95% CI 34.0–53.7). Patients at higher suicide risk scored higher on anxiety/fear of abandonment (3.53 ± 0.99 vs. 3.03 ± 1.04; p = .018; r = .28) and lower on comfort with intimacy (2.88 ± 0.82 vs. 3.44 ± 0.73; p = .003; r  = − .36) and trust in others (2.54 ± 0.76 vs. 2.87 ± 0.68; p = .044; r  = − .24). Depression severity fully mediated the effects of comfort with intimacy and trust in others on suicide risk, but not that of anxiety/fear of abandonment. Attachment style was associated with suicide risk in patients receiving online psychotherapy. Much, though not all, of this association operated through depression severity. The findings support the early identification of insecure attachment as a clinically useful component of suicide risk assessment and underline that suicidal ideation is not confined to patients who screen positive for depression.