{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T13:09:27Z","timestamp":1788959367003,"version":"build-2803163510"},"reference-count":45,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T00:00:00Z","timestamp":1788912000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Behav. Sci.","Behavioral Sciences"],"abstract":"<jats:p>This study examined direct and indirect associations of Machiavellianism, narcissism, psychopathy, and sadism with suicidal ideation through depression, anxiety, and stress in psychiatric patients. A cross-sectional sample of 210 patients completed the Short Dark Tetrad (SD4), Depression Anxiety Stress Scales-21 (DASS-21), and Suicidal Ideation Attributes Scale (SIDAS). Regression paths were estimated using robust maximum likelihood, whereas indirect effects were evaluated using 10,000 bootstrap resamples. Because 92 participants (43.8%) had SIDAS = 0, two-part sensitivity analyses separated the occurrence from the severity of suicidal ideation; additional analyses excluded the two smallest diagnostic groups. Depression, stress, and anxiety correlated with SIDAS (r = 0.560, 0.509, and 0.466, respectively). The sadism\u2013stress\u2013SIDAS indirect effect was significant in the primary model (B = 0.147; 95% bootstrap CI [0.037, 0.291]), after covariate adjustment (B = 0.126; 95% bootstrap CI [0.016, 0.266]), and after excluding psychotic and bipolar groups (B = 0.115; 95% CI [0.006, 0.259]). In two-part analyses, depression was associated with SIDAS occurrence, whereas stress and sadism were associated with severity among participants with SIDAS &gt; 0. The findings support a stress-related indirect association between sadism and suicidal ideation, but causal interpretation is not warranted.<\/jats:p>","DOI":"10.3390\/bs16091606","type":"journal-article","created":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T12:26:11Z","timestamp":1788956771000},"page":"1606","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Dark Tetrad Traits and Suicidal Ideation in Psychiatric Patients: The Role of Depression, Anxiety, and Stress"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0893-7805","authenticated-orcid":false,"given":"Marin","family":"Mami\u0107","sequence":"first","affiliation":[{"name":"General County Hospital Po\u017eega, Osje\u010dka 107, 34000 Po\u017eega, Croatia"},{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"},{"role":"project-administration","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8289-0710","authenticated-orcid":false,"given":"Nikolina","family":"Far\u010di\u0107","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"},{"name":"Department of Neurosurgery, University Hospital Centre Osijek, Josip Huttler Street 4, 31000 Osijek, Croatia"},{"name":"Department of Nursing, Bjelovar University of Applied Sciences, Trg Eugena Kvaternika 4, 43000 Bjelovar, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"methodology","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7539-2019","authenticated-orcid":false,"given":"Ivana","family":"Bara\u0107","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"validation","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5599-0561","authenticated-orcid":false,"given":"\u017deljko","family":"Mudri","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"investigation","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-7488-575X","authenticated-orcid":false,"given":"Marija","family":"Bari\u0161i\u0107","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"},{"name":"Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000 Osijek, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"investigation","vocabulary":"credit"}]},{"given":"Bla\u017eenka","family":"Kljai\u0107 Bukvi\u0107","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"}]},{"given":"Ivana","family":"Mami\u0107","sequence":"additional","affiliation":[{"name":"General County Hospital Po\u017eega, Osje\u010dka 107, 34000 Po\u017eega, Croatia"},{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"data-curation","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2274-8293","authenticated-orcid":false,"given":"Zrinka","family":"Puhari\u0107","sequence":"additional","affiliation":[{"name":"Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2417-1811","authenticated-orcid":false,"given":"Ivan","family":"Vukoja","sequence":"additional","affiliation":[{"name":"General County Hospital Po\u017eega, Osje\u010dka 107, 34000 Po\u017eega, Croatia"},{"name":"Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000 Osijek, Croatia"},{"name":"Faculty of Medicine, University of Rijeka, Bra\u0107e Branchetta 20, 51000 Rijeka, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,9]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1016\/j.cpr.2015.11.008","article-title":"Anxiety and its disorders as risk factors for suicidal thoughts and behaviors: A meta-analytic review","volume":"43","author":"Bentley","year":"2016","journal-title":"Clinical Psychology Review"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"100758","DOI":"10.1016\/j.newideapsych.2019.100758","article-title":"Nonlinear change processes and the emergence of suicidal behavior: A conceptual model based on the fluid vulnerability theory of suicide","volume":"57","author":"Bryan","year":"2020","journal-title":"New Ideas in Psychology"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2201","DOI":"10.1177\/0956797613490749","article-title":"Behavioral confirmation of everyday sadism","volume":"24","author":"Buckels","year":"2013","journal-title":"Psychological Science"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/j.paid.2015.03.051","article-title":"The Dark Tetrad: Identifying personality profiles in high-school students","volume":"83","author":"Chabrol","year":"2015","journal-title":"Personality and Individual Differences"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e70189","DOI":"10.1002\/ijop.70189","article-title":"Dark Tetrad traits and mental and physical health: Mediating role of coping strategies","volume":"61","year":"2026","journal-title":"International Journal of Psychology"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"399","DOI":"10.1111\/bjop.12046","article-title":"From alpha to omega: A practical solution to the pervasive problem of internal consistency estimation","volume":"105","author":"Dunn","year":"2014","journal-title":"British Journal of Psychology"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1037\/bul0000084","article-title":"Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research","volume":"143","author":"Franklin","year":"2017","journal-title":"Psychological Bulletin"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1111\/spc3.12018","article-title":"The Dark Triad of personality: A 10 year review","volume":"7","author":"Furnham","year":"2013","journal-title":"Social and Personality Psychology Compass"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Gal\u00e1n, M., Garc\u00eda del Castillo-L\u00f3pez, \u00c1., Ruiz-Fuster, F., and Pineda, D. (2026). The mediating role of emotional regulation strategies in the relationship between the Dark Tetrad of personality and anxious-depressive symptomatology. BMC Psychology, 14.","DOI":"10.1186\/s40359-026-04872-0"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"928","DOI":"10.1037\/abn0000300","article-title":"Dark traits and suicide: Associations between psychopathy, narcissism, and components of the interpersonal-psychological theory of suicide","volume":"126","author":"Harrop","year":"2017","journal-title":"Journal of Abnormal Psychology"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1016\/j.jad.2013.01.004","article-title":"Risk factors for suicide in individuals with depression: A systematic review","volume":"147","author":"Hawton","year":"2013","journal-title":"Journal of Affective Disorders"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.brat.2016.11.001","article-title":"Regression-based statistical mediation and moderation analysis in clinical research: Observations, recommendations, and implementation","volume":"98","author":"Hayes","year":"2017","journal-title":"Behaviour Research and Therapy"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1348\/014466505X29657","article-title":"The short-form version of the Depression Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large non-clinical sample","volume":"44","author":"Henry","year":"2005","journal-title":"British Journal of Clinical Psychology"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"936","DOI":"10.1080\/13811118.2025.2599416","article-title":"Gender-specific pathways from Dark Triad traits to suicidal ideation: A prospective test of the interpersonal theory of suicide","volume":"30","author":"Huang","year":"2026","journal-title":"Archives of Suicide Research"},{"key":"ref_15","unstructured":"Ivezi\u0107, E., Jak\u0161i\u0107, N., Joki\u0107-Begi\u0107, N., and Sur\u00e1nyi, Z. (, January May). Validacija hrvatske adaptacije Skale depresivnosti, anksioznosti i stresa (DASS-21) na klini\u010dkom uzorku [Validation of the Croatian adaptation of the Depression, Anxiety, Stress Scales\u201321 (DASS-21) in a clinical sample] [Poster presentation]. 18th Psychology Days in Zadar, Zadar, Croatia."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1177\/1073191113514105","article-title":"Introducing the Short Dark Triad (SD3): A brief measure of dark personality traits","volume":"21","author":"Jones","year":"2014","journal-title":"Assessment"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"5","DOI":"10.24141\/2\/9\/1\/1","article-title":"The presence of suicidal thoughts and their connection with loneliness in nurses in social, family and romantic context","volume":"9","author":"Zirdum","year":"2025","journal-title":"Croatian Nursing Journal"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1521\/ijct.2015.8.2.114","article-title":"The Three-Step Theory (3ST): A new theory of suicide rooted in the ideation-to-action framework","volume":"8","author":"Klonsky","year":"2015","journal-title":"International Journal of Cognitive Therapy"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1016\/j.copsyc.2017.07.020","article-title":"Ideation-to-action theories of suicide: A conceptual and empirical update","volume":"22","author":"Klonsky","year":"2018","journal-title":"Current Opinion in Psychology"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1016\/j.cpr.2014.01.006","article-title":"Life events and suicidal ideation and behavior: A systematic review","volume":"34","author":"Liu","year":"2014","journal-title":"Clinical Psychology Review"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1016\/0005-7967(94)00075-U","article-title":"The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories","volume":"33","author":"Lovibond","year":"1995","journal-title":"Behaviour Research and Therapy"},{"key":"ref_22","first-page":"3","article-title":"The influence of an interdisciplinary treatment approach in a psychiatric day hospital on defense mechanisms in non-psychotic patients with anxiety and\/or depressive disorders","volume":"11","year":"2026","journal-title":"Bulgarian Journal of Psychiatry"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Mami\u0107, M., Jovanovi\u0107, T., Lovri\u0107, B., Pomper, G. K., Mami\u0107, I., Bara\u0107, I., Lovri\u0107, R., Rafaj, G., Kumpovi\u0107, D., and Vukoja, I. (2026a). The mediating role of burnout and secondary traumatic stress in the relationship between perceived stress and quality of life among nurses. International Journal of Environmental Research and Public Health, 23, (4).","DOI":"10.3390\/ijerph23040540"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Mami\u0107, M., Radmilovi\u0107, G., Ivkovi\u0107, J., Dokozi\u0107, B., Mikuli\u0107, D., Mami\u0107, I., Matijevi\u0107, V., and Vukoja, I. (2026b). Personality traits, affective distress, and addictive behaviors in patients with neurotic disorders: A mediation analysis. European Journal of Investigation in Health, Psychology and Education, 16, (3).","DOI":"10.3390\/ejihpe16030035"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1176\/ajp.156.2.181","article-title":"Toward a clinical model of suicidal behavior in psychiatric patients","volume":"156","author":"Mann","year":"1999","journal-title":"American Journal of Psychiatry"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1037\/1082-989X.12.1.23","article-title":"Bias in cross-sectional analyses of longitudinal mediation","volume":"12","author":"Maxwell","year":"2007","journal-title":"Psychological Methods"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"816","DOI":"10.1080\/00273171.2011.606716","article-title":"Bias in cross-sectional analyses of longitudinal mediation: Partial and complete mediation under an autoregressive model","volume":"46","author":"Maxwell","year":"2011","journal-title":"Multivariate Behavioral Research"},{"key":"ref_28","unstructured":"McDonald, R. P. (1999). Test theory: A unified treatment, Lawrence Erlbaum Associates."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1177\/1745691616666070","article-title":"The malevolent side of human nature: A meta-analysis and critical review of the literature on the Dark Triad","volume":"12","author":"Muris","year":"2017","journal-title":"Perspectives on Psychological Science"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"20170268","DOI":"10.1098\/rstb.2017.0268","article-title":"The integrated motivational-volitional model of suicidal behaviour","volume":"373","author":"Kirtley","year":"2018","journal-title":"Philosophical Transactions of the Royal Society B: Biological Sciences"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"523","DOI":"10.1037\/a0022400","article-title":"The psychometric properties and utility of the Short Sadistic Impulse Scale (SSIS)","volume":"23","author":"Davies","year":"2011","journal-title":"Psychological Assessment"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1027\/1015-5759\/a000602","article-title":"Screening for dark personalities: The Short Dark Tetrad (SD4)","volume":"37","author":"Paulhus","year":"2021","journal-title":"European Journal of Psychological Assessment"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"556","DOI":"10.1016\/S0092-6566(02)00505-6","article-title":"The Dark Triad of personality: Narcissism, Machiavellianism, and psychopathy","volume":"36","author":"Paulhus","year":"2002","journal-title":"Journal of Research in Personality"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"879","DOI":"10.3758\/BRM.40.3.879","article-title":"Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models","volume":"40","author":"Preacher","year":"2008","journal-title":"Behavior Research Methods"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1192\/bjp.2018.27","article-title":"Depression and hopelessness as risk factors for suicide ideation, attempts and death: Meta-analysis of longitudinal studies","volume":"212","author":"Ribeiro","year":"2018","journal-title":"British Journal of Psychiatry"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"102850","DOI":"10.1016\/j.msard.2021.102850","article-title":"Psychometric properties of the Croatian version of the depression, anxiety, and stress scale-21 and multiple sclerosis impact scale-29 in multiple sclerosis patients","volume":"50","year":"2021","journal-title":"Multiple Sclerosis and Related Disorders"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1080\/13607863.2014.1003280","article-title":"Relationships among depressive, passive-aggressive, sadistic and self-defeating personality disorder features with suicidal ideation and reasons for living among older adults","volume":"19","author":"Segal","year":"2015","journal-title":"Aging & Mental Health"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1097\/00005053-199303000-00001","article-title":"Suicide as psychache","volume":"181","author":"Shneidman","year":"1993","journal-title":"Journal of Nervous and Mental Disease"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1038\/s41572-019-0121-0","article-title":"Suicide and suicide risk","volume":"5","author":"Turecki","year":"2019","journal-title":"Nature Reviews Disease Primers"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"575","DOI":"10.1037\/a0018697","article-title":"The interpersonal theory of suicide","volume":"117","author":"Witte","year":"2010","journal-title":"Psychological Review"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"408","DOI":"10.1111\/sltb.12084","article-title":"The Suicidal Ideation Attributes Scale (SIDAS): Community-based validation study of a new scale for the measurement of suicidal ideation","volume":"44","author":"Batterham","year":"2014","journal-title":"Suicide and Life-Threatening Behavior"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1037\/per0000222","article-title":"Differences among Dark Triad components: A meta-analytic investigation","volume":"9","author":"Vize","year":"2018","journal-title":"Personality Disorders: Theory, Research, and Treatment"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"104332","DOI":"10.1016\/j.jrp.2022.104332","article-title":"The Dark Triad traits and suicidal ideation in Chinese adolescents: Mediation by social alienation","volume":"102","author":"Wang","year":"2023","journal-title":"Journal of Research in Personality"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"83","DOI":"10.19090\/pp.v16i1.2426","article-title":"Theoretical models of Short Dark Tetrad (SD4) and its relationship with socially desirable responding: Findings on the Croatian version","volume":"16","author":"Wertag","year":"2023","journal-title":"Primenjena Psihologija"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1086\/651257","article-title":"Reconsidering Baron and Kenny: Myths and truths about mediation analysis","volume":"37","author":"Zhao","year":"2010","journal-title":"Journal of Consumer Research"}],"container-title":["Behavioral Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-328X\/16\/9\/1606\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T12:57:42Z","timestamp":1788958662000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-328X\/16\/9\/1606"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,9]]},"references-count":45,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["bs16091606"],"URL":"https:\/\/doi.org\/10.3390\/bs16091606","relation":{},"ISSN":["2076-328X"],"issn-type":[{"value":"2076-328X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,9]]}}}