The relationship between metacognition and adverse childhood experiences in patients with bipolar disorder and a history of suicide attempts

Objective: Bipolar disorder is a severe psychiatric condition associated with a high lifetime risk of suicide. Adverse childhood experiences (ACEs) are among the key factors that heighten this risk, and such early-life adversities may influence the development of cognitive processes, thereby increasing vulnerability to suicidal behavior later in life. Metacognition refers to the capacity to recognize and regulate one's own patterns of thinking; maladaptive metacognitive beliefs, in particular, are considered to be among the cognitive mechanisms linked to suicide risk.This study aimed to investigate the relationship between adverse childhood experiences (ACEs) and dysfunctional metacognitive beliefs in individuals diagnosed with bipolar disorder, and to explore the role of these beliefs in suicidal behavior. Methods: The study sample included individuals diagnosed with bipolar disorder with (n=52) and without (n=54) a history of suicide attempt, as well as a healthy control group (n=53), all recruited from the outpatient psychiatry clinic of Van Yüzüncü Yıl University Medical Faculty. Participants completed the Adverse Childhood Experiences Questionnaire (ACE), the Metacognitions Questionnaire-30 (MCQ-30), and the Suicide Behaviors Questionnaire (SBQ). All statistical analyses were performed using SPSS software. Results: Participants with a history of suicide attempt scored significantly higher on the ACE, MCQ-30, and SBQ scales. Notably, the "Need to Control Thoughts" subscale of the MCQ-30 showed positive correlations with both ACE and SBQ scores. Mediation analysis revealed that part of the effect of ACE on suicidal behavior was mediated by metacognitive beliefs. Specifically, neglect scores within the ACE were found to exert an indirect effect on suicidal behavior through the need to control thoughts. Furthermore, each one-point increase in MCQ-30 total score and ACE abuse score significantly increased the likelihood of a suicide attempt. In regression analyses, ACE-abuse and MCQ-30 total scores emerged as significant predictors of suicide attempts. Conclusion: Our findings suggest that adverse childhood experiences contribute to suicidal behavior in individuals with bipolar disorder not only directly, but also indirectly through maladaptive metacognitive beliefs. Among these, the need to control thoughts and reduced cognitive confidence appear particularly salient. These findings underscore the potential utility of metacognition-focused interventions in reducing suicide risk among individuals with bipolar disorder.