--- - |2+ Abstract Objectives Using a 4‐year follow‐up design, this research investigated Shneidman's model of psychache (i.e., intense mental pain/anguish) as the cause of suicide. Operationalizing suicidal manifestations using suicide ideation, we evaluated Shneidman's assertion that psychache is the prominent predictor of suicide ideation and that other suicide‐related psychological variables associate with suicide ideation only through psychache. Method Eighty‐two undergraduates at elevated suicide risk were assessed at baseline and follow‐up with measures of suicide ideation and three psychological predictors: depression, hopelessness, and psychache. Results At baseline, only psychache and neither depression nor hopelessness contributed significant, unique information to statistically predicting suicide ideation. For 4‐year change in suicide ideation, only psychache and neither depression nor hopelessness provided significant, unique information. Conclusions Results provided partial support for Shneidman's contention of the importance of psychache for suicidal behavior and that other psychological factors are only important to suicide insofar as they relate through psychache. - Journal of Clinical Psychology, EarlyView.