SELF-ESTEEM AS A PREDICTOR OF SUICIDE RISK AMONG PSYCHIATRIC PATIENTS

Muhammad Rizwan1 and Riaz Ahmad

Institute of Clinical Psychology University Of Karachi

ABSTRACT

Assessment of the predictive relationship of self-esteem with suicidal tendencies in patients with psychiatric disorders is a core objective of the present study. After detailed literature review, it was hypothesized that (1) Self-esteem would predict suicidal tendencies among patients with psychiatric disorders. The sample of present study was diagnosed psychiatric patients (N=140) according to Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR; American Psychiatric Association, 2000) criterion and were further divided in four sub-groups, including Patients of (a) Schizophrenia

(N=40); (b) Major Depressive Disorder (N=40); (c) Obsessive Compulsive Disorder

(N=40); and (d) Opioid Dependence Disorder (N=20). The age range of participants’ was18-25 years (with the mean age of 22.14 years) and they belonged to middle socioeconomic status. Research measures employed were: standard Intake form of

Institute of Clinical Psychology, University of Karachi, Rosenberg Self-Esteem Scale

(Rosenberg ,1965), and Suicidal Probability Scale (Cull & Gill, 1982). Descriptive

1 Muhammad Rizwan is a Clinical Psychologist at Institute of Clinical Psychology University of Karachi, Pakistan. He is PhD fellow at the same institute. He is involved in teaching along with research and clinical supervision of Interns at Institute of Clinical Psychology. His research work has mainly focused on clinical population’s self-esteem, suicidal risk potentials and social support as well as psychometric and cross- cultural studies. He may be reached at; [email protected] statistics and linear regression analysis were employed to analyze the data in statistical terminology. According to results self-esteem was found to be a statistically significant predictor of suicidal tendencies in psychiatric group (R² = .608, F (1, 138) = 214.467, p

<.05). These findings have implications for clinical interventions.

INTRODUCTION

Suicide behaviors arise as daily life reactions to emotional chaos or disappointment and mostly reflect the misery that exists in a society or cultural system

(Tseng, 2001). Worldwide, there are approximately 900,000 reported suicides each year, including as many as 200,000 adolescents and young adults (Greydanus & Calles, 2007).

In psychiatric text it was reported that among various factors, low self-esteem is found to be one of the stronger predictor of suicide behavior especially in psychiatric patients

(Beautrais, 2002; Crompton & Walmsley, 2002; Sadock & Sadock, 2007; Troister, Links,

& Cutcliffe, 2008).

The association of low self-esteem with suicide behavior in major depressive disorder is widely studied and is well illustrated in literature. During depressive episode the association between low self-esteem and suicidality was found (Daskalopoulou,

Dikeos, & Papadimitriou, et al. 2002; Tarrier, 2008). Likewise, Dori and Overholser

(1999) compared depressed adolescents who had never attempted suicide to depressed adolescents who had attempted suicide to determine the level of hopelessness, self- esteem, and depression across them. Results showed suicidal adolescents experienced significantly lower self-esteem as well as higher levels of depression and hopelessness than did non-suicidal adolescents. Self-esteem was found to be a better indicator of suicide than a person’s level of suicidal ideation. Depressed and hopeless adolescents with adequate level of self-esteem were less likely to demonstrate suicidal behaviors than those with low self-esteem. Similarly, Overholser, Adams, Lehnert, and Brinkman (1995) found that low self-esteem was related to higher levels of depression, hopelessness, suicidal ideation, and an increased likelihood of having previously attempted suicide.

However this link is poorly studied in anxiety disorders and there are little evidences in support and those to our knowledge are added here. Goodwin and Marusic

(2003) determined the association between feelings of inferiority and suicidal ideation and suicide attempt among youth. They have found that feelings of inferiority were associated with a significant increased likelihood of suicidal ideation and suicidal attempt. The results also showed evidence of interaction specifically between anxiety disorders and inferiority in the likelihood of suicidal ideation and between major depression and inferiority in the likelihood of suicide attempt.

The high incidence of suicidal behavior in schizophrenia is also well documented.

Also, there is substantial amount of research which demonstrates the association of self- esteem with suicidal behavior in schizophrenia. For example, Fialko, Freeman,

Bebbington, et al. (2006) studied the clinically significant trend of suicidal ideation in psychosis and found that suicidal ideation was related with depressed mood, anxiety, low self-esteem, negative illness perception, negative evaluative beliefs about the self and others, and daily alcohol consumption. Likewise, Tarrier, Barrowclough, Andrews, and

Gregg (2004) found in their study that negative self-esteem was significantly correlated with measures of depression, hopelessness and suicidal ideation, whereas positive self- esteem was negatively correlated only with hopelessness in schizophrenia patients. They concluded that isolation and poor self-worth/negative self-evaluation work through a common factor of hopelessness to increase suicide risk in schizophrenia patients.

Researches have also indicated low self-esteem to be one of the factors associated with suicidal behavior in drug dependence disorders. A study conducted by Wilke (2004) designated a significant link in the predicted direction, between self-esteem and abstinence and no effect for gender. Conversely, it was also assessed that those who had lower levels of self-esteem, regardless of abstinence or continued use, had practically indistinguishable likelihood of suicidal ideation. Likewise, Demibas, Celik, Ilhan, and

Dogan (2003) evaluated correlations of self-esteem, depression, and state-trait anxiety with suicide probability in alcohol dependence. It was found that self-esteem, depression, and trait anxiety predict suicide probability. Other researchers have found that alcohol dependence disorder carry itself a loss of self-esteem and negative self-image and suicidal process found speed up by presence of hopelessness that is usually seen in both depression and alcoholism (Arikan, Cepik-Kuruoglu, Eltutan, & Isık, 1999; Cornelius,

Salloum, Mezzich, et al., 1995; Dukes & Lorch, 1989; Malone, Haas, Sweeney, & Mann,

1994).

On the basis of above mentioned analysis of literature it was hypothesized that:

1. Self-Esteem would predict Suicidal Tendencies among Patients with

Psychiatric Disorders METHOD

Sample

140 psychiatric patients are participated in this study as volunteer subjects. These samples recruited from population of those who had been taking treatment for their mental health problems from outpatient clinics of different Psychiatric and Psychological settings with in urban areas of Karachi and were diagnosed according to diagnostic criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR;

American Psychiatric Association, 2000), including patients of (a) Schizophrenia (N=40);

(b) Major Depressive Disorder (N=40); (c) Obsessive Compulsive Disorder (N=40); and

(d) Opioid Dependence Disorder (N=20). Participants of Opioid Dependence Disorder group comprised of males only, because of the unavailability of the females with Opioid dependence disorder in out patient clinical setups of Karachi city.

Measures

Semi Structured Interview Form

This qualitative measure is designed by the Institute of Clinical Psychology,

University of Karachi, based on the criteria of Diagnostic and Statistical Manual for Mental Disorders as well as other details necessary to screen out the diagnosis. It consisted of items focusing on an individual’s demographic information, presenting problems, history of problem, medical history, family history, educational history, social and occupational history, recreational activities, sexual history, mental state examination, extrasensory perceptions, belief system, affective state, anxieties, gender identity problems, psychosomatic complaints, addiction problems, family psychopathology, personality traits, motivation, and behavior during interview. It is a qualitative measure which usually takes 20- 30 minutes to be administered.

Rosenberg Self-Esteem Scale

The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) is a 10-items scale that was originally designed to measure the global self-esteem. It has a 4-point Likert- type response format and each of the ten items has four possible responses: Strongly

Agree, Agree, Disagree, and Strongly Disagree. The scores can range from 0 to 30, with the higher scores indicating high level of self-esteem and lower score indicating low level of self-esteem. In the presented study translated version (Urdu Translation) of the RSE

(Sardar, 1998) was used. For the present study Cronbach’s alpha obtained was .87 that shows appropriate internal consistency.

The Suicidal Probability Scale The Suicidal Probability Scale (SPS; Cull & Gill, 1982) is 36-items; self- report screening measure designed to aid in the assessment of suicide risk in adolescents and adults. The major function of the SPS is to provide a global index of suicide risk on the basis of sum of scores on four clinical subscales: Hopelessness, Suicide Ideation,

Negative Self-Evaluation, and Hostility. Individuals are asked to rate the frequency of their subjective experience and past behaviors using a 4-point Likert scale format ranging from “None or a little of the time” to “Most or all of the time.” The responses are then hand scored to evaluate both general and specific suicide risk along several key dimensions. The SPS is a self report measure of suicide risk that can be used as a research instrument to provide quantitative scores. For the present study Udru translation of SPS was used and Cronbach’s alpha (a measure of internal consistency) obtained was .93 that shows good internal consistency.

Research Procedure

The sample was recruited from different psychiatric departments and mental health clinics with in urban areas of Karachi. A letter of consent describing the research project was provided to authorities of selected organization. After getting permission from authorities, the psychiatric patients were approached individually with the help of respective Psychiatrists and Psychologist who have already made a diagnosis of these psychiatric patients. The first few minutes were spent putting the patients at ease and then the purpose of the study was briefed and discussed in very general terms. The researcher assured the confidentiality of the participant’s personal information and responses. The formal consent was taken from patients through Consent Form and only those patients who gave consent to participate were included in the sample. First, the researcher conducted a detailed diagnostic interview and recorded all necessary information about participant’s illness on Semi Structured Interview Form which further confirmed the diagnosis made by the respective psychiatrist/psychologists according to the diagnostic criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA,

2000). The participants’ final diagnosis was determined by a consensus meeting between the researcher, respective psychiatrist/psychologist and an expert clinician’s opinion.

Finally, Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) and The Suicidal

Probability Scale (SPS; Cull & Gill, 1982) were administered to assess the psychiatric patients’ level of self-esteem and suicidal risk potential. Participants were allowed to ask questions if they had any difficulty in following instructions and understanding the statements. At the end of the administration of research measures psychiatric patients and concerned authorities were thanked for their cooperation and time. During the process of study, researcher adhered to four key ethical principles: respect for the person’s rights and dignity, responsibility, and integrity.

Statistical Analysis

After scoring, the research data was analyzed to interpret it in statistical terminology. Data was initially compiled into a Microsoft Excel spreadsheet and then analyzed on Statistical Package for Social Sciences (SPSS, V-13.0) software. Descriptive statistics and linear regression analysis were employed to analyze the data in statistical terminology. RESULTS

Table 1 Summary of Linear Regression with Self-Esteem as predictor of Suicidal tendencies (Hopelessness, Suicidal Ideation, Negative Self-Evaluation and Hostility) in Psychiatric Patients

Dependant Variable R R² Adj R²

Suicidal Probability Scale (total) .780 .608 .606

Hopelessness (Subscale) .727 .528 .525 Suicidal Ideation (Subscale) .702 .492 .489 Negative Self-Evaluation (Subscale) .572 .330 .325 Hostility (Subscale) .699 .489 .485 df= 1, 138

Table 2 Analysis of Variance for Linear Regression with Self-Esteem as predictor of Suicidal tendencies (Hopelessness, Suicidal Ideation, Negative Self-Evaluation and Hostility) in Psychiatric Patients

Model SS Df MS F Sig.

Regression 58424.300 1 58424.300 214.467 .000 Suicidal Residual 37593.493 138 272.417 Probability Total 96017.793 139 Scale

Subscales of Suicidal Probability Scale Regression 6660.192 1 6660.192 154.447 .000 Residual 5950.951 138 43.123 Hopelessness Total 12611.143 139

Regression 5898.736 1 5898.736 133.890 .000 Suicidal Residual 6079.799 138 44.057 Ideation Total 11978.536 139

Regression 936.317 1 936.317 68.025 .000 Negative Residual 1899.476 138 13.764 Self- Total 2835.793 139 Evaluation

Regression 2777.150 1 2777.150 131.805 .000 Hostility Residual 2907.672 138 21.070 Total 5684.821 139 DISCUSSION

Suicidal risk potential is a product of psychiatric disorders but there are other potential factors discussed by various researchers that elevate suicide risk in clinical population and self-esteem is one of them (e.g., Wilke, 2004; Laukkanen, Korhonen,

Peiponen, Nuutinen, & Viinamaki, 2001; McGee & Williams, 2000). Our findings add on these previous studies based on the following evidences. Statistical analysis indicates that self-esteem explains 60% variation in the scores of suicidal tendencies for psychiatric patients (R² = .608, F = 214.467, p <.05; Table 1 & 2). Additional regression analyses have also been done for subscales of Suicidal Probability Scale (i.e., Hopelessness,

Suicidal ideation, Negative Self-Evaluation, and Hostility). Some interesting findings have been found: Self-esteem explains 52% variation in the scores of hopelessness (R² = .

528, F(1, 138) = 154.447, p <.05; Table 1 & 2); 49% variation in the scores of suicidal ideation (R² = .492, F = 133.890, p <.05; Table 1 & 2); 33% variation in the scores of negative self-evaluation (R² = .330, F = 68.025, p <.05; Table 1 & 2); and 48% variation in the scores of hostility (R² = .489, F = 131.805, p <.05; Table 1 & 2).

Self-esteem is a powerful resource for combating the effects of stress and suicidal behavior among psychiatric patients. As Wolfe (2005) described that self-esteem implies a tolerance for painful feelings that develops over time, as well as a willingness to confront fears, take responsibility for feelings, decisions, and actions, and push on despite obstacles and adversity. Whereas, Tarrier (2008) implied that feelings of low self-worth can both inhibit the effective us of coping strategies and increase the risk of self-harm.

Thus, low self-esteem can increase psychiatric patients’ level of stress by reducing their coping and effective problem solving. Consequently, they find life’s difficulties too hard to cope with and develop feelings of hopelessness which in turn increases the likelihood of suicidal behavior in psychiatric patients. Thus, one’s perception and the value assigned to oneself play a very important role in suicidal behavior. High self-esteem can alleviate one’s stress, enhance one’s stress tolerance and strengthens effective coping mechanisms which in turn reduce suicidal tendencies in psychiatric patients.

Self-esteem has profound consequences for our existence (Branden, 1994).

Baumeister, Campbell, Krueger, and Vohs (2003) explained that it is difficult, if not impossible, for people to remain indifferent to information that bears on their self-esteem, such as being told that they are incompetent, attractive, untrustworthy, or lovable. Groves and Muskin (2005) illustrated that for many people, feelings of accomplishment, productivity, and usefulness are important for their self-image. Thus, self-esteem is damaged when they lose this important source of gratification. They start personalizing negative information about the self and perceive them as worthless and unproductive.

Consequently, increases and decreases in self-esteem generally bring strong emotional reactions as Hayes, Strosahl, and Wilson (1999) described that as persons who commit suicide evaluate them-selves quite negatively, believing themselves to be worthless, inadequate, rejected, or blameworthy; the dominant motivation for suicide appears to be an attempt to flee from aversive states of mind such as guilt, anxiety, worthlessness, inadequacy, or blame. On the basis of our findings it can be concluded that among psychiatric disorders the self-esteem is strong predictor. The findings suggest potential pathways for developing effective prevention and intervention strategies for psychiatric patients to improve level of self-esteem and reduce likelihood of suicide. The findings of this study offer important suggestions to mental health professionals, health agencies, community caretakers, and NGOs, etc.

This research focused only on the self-esteem as a predictor of suicidal behavior.

Future research considering the other variables, like, stigmatization, nature of stressors, styles of coping, hopelessness, loneliness, personal, situational, and demographic characteristics will also be fruitful in knowing the vulnerability to suicidal behavior among psychiatric patients. Future researches should utilize samples of varied age groups and of patients from different diagnostic categories. Also, future research should focus on gender and socioeconomic status effects while working on the same variables.

There are several limitations of this study. One of the limitations of the study is the limited power of generalizeabilty of the findings due the reasons, such as: Sample with restricted age range i.e., young adults—also referred to as youth population— with an age range of 18-25 years is selected. The sample comprised patients of only four psychiatric disorders (e.g. Major depression, schizophrenia, obsessive compulsive disorder and opioid dependence disorder). The prediction of suicide by self-esteem was only a statistical estimation of the causal relationships, and it is not one that can be obtained in a robust study design. Therefore, one should be careful while interpreting the results. Last limitation of this study was the use of self-report measures to assess self- esteem and suicidal risk. REFERENCES

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