The Role of Demoralization and Hopelessness in Suicide Risk in Schizophrenia: A Review of the Literature
Abstract
:1. Introduction
2. Methods
3. Results
3.1. Demoralization and Suicide Risk in Schizophrenia
3.2. Demoralization, Insight, and Stigma in Schizophrenia
4. Discussion
Limitations
5. Conclusions
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
- Frank, J.D. Psychotherapy: The restoration of morale. Am. J. Psychiatry 1974, 131, 271–274. [Google Scholar] [CrossRef]
- Robinson, S.; Kissane, D.W.; Brooker, J.; Burney, S. A Review of the construct of demoralization: History, definitions, and future direction for palliative care. Am. J. Hos. Pall. Med. 2014, 33, 93–101. [Google Scholar] [CrossRef]
- Frank, J.D. Persuasion and Healing: A Comparative Study of Psychotherapy, 2nd ed.; JHU Press: Baltimore, MD, USA, 1993. [Google Scholar]
- Frank, J.D. The role of hope in psychotherapy. Int. J. Psychiatry 1968, 5, 383–395. [Google Scholar] [PubMed]
- Yalom, I.D. The Yalom Reader: Selections from the Work of a Master Therapist and Storyteller; Basic Books: New York, NY, USA, 1996. [Google Scholar]
- De Figueiredo, J.M.; Frank, J.D. Subjective incompetence, the clinical hallmark of demoralization. Compr. Psychiatry 1982, 23, 353–363. [Google Scholar] [CrossRef]
- Fava, G.A.; Freyberger, H.J.; Bech, P.; Christodoulou, G.; Sensky, T.; Theorell, T.; Wise, T.N. Diagnostic criteria for use in psychosomatic research. Psychother. Psychosom. 1995, 63, 1–8. [Google Scholar] [CrossRef]
- Kissane, D.W.; Clarke, D.M.; Street, A.F. Demoralization syndrome: A relevant psychiatric diagnosis for palliative care. J. Palliat. Care 2001, 17, 12–21. [Google Scholar] [CrossRef]
- Clarke, D.M.; Kissane, D.W. Demoralization: Its phenomenology and importance. Aust. N. Z. J. Psychiatry 2002, 36, 733–742. [Google Scholar] [CrossRef]
- Sansone, R.A.; Sansone, L.A. Demoralization in patients with medical illness. Psychiatry 2010, 7, 42. [Google Scholar] [PubMed]
- Slavney, P.R. Diagnosing demoralization in consultation psychiatry. Psychosomatics 1999, 40, 325–329. [Google Scholar] [CrossRef]
- Angelino, A.F.; Treisman, G.J. Major depression and demoralization in cancer patients: Diagnostic and treatment considerations. Support Care Cancer 2001, 9, 344. [Google Scholar] [CrossRef] [PubMed]
- Kissane, D.W. Distress, demoralization and depression in palliative care. Curr Ther. 2000, 41, 14–19. [Google Scholar]
- Pasquini, M.; Berardelli, I.; Biondi, M. Ethiopathogenesis of depressive disorders. Clinical practice and epidemiology in mental health. Clin. Pract. Epidemiol. Ment. Health 2014, 10, 166–171. [Google Scholar] [CrossRef] [PubMed]
- Tecuta, L.; Tomba, E.; Grandi, S.; Fava, G.A. Demoralization: A systematic review on its clinical characterization. Psychol. Med. 2015, 45, 673–691. [Google Scholar] [CrossRef] [PubMed]
- Fava, G.A.; Cosci, F.; Sonino, N. Current psychosomatic practice. Psychother. Psychosom. 2017, 86, 13–30. [Google Scholar] [CrossRef]
- Grassi, L.; Mangelli, L.; Fava, G.A.; Grandi, S.; Ottolini, F.; Porcelli, P.; Rafanelli, C.; Rigatelli, M.; Sonino, N. Psychosomatic characterization of adjustment disorders in the medical setting: Some suggestions for DSM-V. J. Affect. Disord. 2007, 101, 251–254. [Google Scholar] [CrossRef]
- Nordentoft, M.; Wahlbeck, K.; Hallgren, J.; Westman, J.; Osby, U.; Alinaghizadeh, H.; Gissler, M.; Laursen, T.M. Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden. PLoS ONE 2013, 8, e55176. [Google Scholar] [CrossRef]
- Palmer, B.A.; Pankratz, V.S.; Bostwick, J.M. The lifetime risk of suicide in Schizophrenia: A reexamination. Arch. Gen. Psychiatry 2005, 62, 247–253. [Google Scholar] [CrossRef] [PubMed]
- Bushe, C.J.; Taylor, M.; Haukka, J. Mortality in Schizophrenia: A measurable clinical endpoint. J. Psychopharmacol. 2010, 24, 17–25. [Google Scholar] [CrossRef]
- Pompili, M.; Amador, X.F.; Girardi, P.; Harkavy-Friedman, J.; Harrow, M.; Kaplan, K.; Montross, L.P. Suicide risk in schizophrenia: Learning from the past to change the future. Ann. Gen. Psychiatry 2007, 6, 10. [Google Scholar] [CrossRef] [PubMed]
- Pompili, M.; Serafini, G.; Innamorati, M.; Lester, D.; Shrivastava, A.; Girardi, P.; Nordentoft, M. Suicide risk in first episode psychosis: A selective review of the current literature. Schizophr. Res. 2011, 129, 1–11. [Google Scholar] [CrossRef]
- Cassidy, R.M.; Yang, F.; Kapczinski, F.; Passos, I.C. Risk factors for suicidality in patients with schizophrenia: A systematic review, meta-analysis, and meta-regression of 96 studies. Schizophr. Bull. 2018, 44, 787–797. [Google Scholar] [CrossRef]
- Vrbova, K.; Prasko, J.; Ociskova, M.; Latalova, K.; Holubova, M.; Grambal, A.; Slepecky, M. Insight in schizophrenia—A double-edged sword? Neuro. Endocrinol. Lett. 2017, 38, 457–464. [Google Scholar]
- Drake, R.; Whitaker, A.; Gates, C.; Cotton, P. Suicide among schizophrenics: A review. Compr. Psychiatry 1985, 26, 90–100. [Google Scholar] [CrossRef]
- Togay, B.; Noyan, H.; Tasdelen, R.; Ucok, A. Clinical variables associated with suicide attempts in schizophrenia before and after the first episode. Psychiatry Res. 2015, 229, 252–256. [Google Scholar] [CrossRef]
- Bartels, S.J.; Drake, R.E. Depressive symptoms in schizophrenia: Comprehensive differential diagnosis. Compr. Psychiatry 1988, 29, 467–483. [Google Scholar] [CrossRef]
- Hor, K.; Taylor, M. Suicide and schizophrenia: A systematic review of rates and risk factors. J. Psychopharmacol. 2010, 24, 81–90. [Google Scholar] [CrossRef] [PubMed]
- Strauss, J.S. Chronicity: Causes, prevention, and treatment. Psychiatr. Ann. 1980, 10, 23–29. [Google Scholar] [CrossRef]
- Regenold, M.; Sherman, M.F.; Fenzel, M. Getting back to work: Self-efficacy as a predictor of employment outcome. Psychiatr. Rehabil. J. 1999, 22, 361. [Google Scholar] [CrossRef]
- Hoffmann, H.; Kupper, Z.; Kunz, B. Hopelessness and its impact on rehabilitation outcome in schizophrenia–an exploratory study. Schizophr. Res. 2000, 43, 147–158. [Google Scholar] [CrossRef]
- Cohen, L.J.; Test, M.A.; Brown, R.L. Suicide and schizophrenia: Data from a prospective community treatment study. Am. J. Psychiatry 1990, 147, 602–607. [Google Scholar]
- Ventura, J.; Neuchterlein, K.H.; Subotnik, K.L.; Gitlin, M.J.; Sharou, J. How are self-efficacy, neurocognition, and negative symptoms related to coping responses in schizophrenia? Schizophr. Res. 1999, 36, 186–187. [Google Scholar]
- Lysaker, P.H.; Clements, C.A.; Wright, D.E.; Evans, J.; Marks, K.A. Neurocognitive correlates of helplessness, hopelessness, and well-being in schizophrenia. J. Nerv. Ment. Dis. 2001, 189, 457–462. [Google Scholar] [CrossRef]
- Mechanic, D.; McAlpine, D.; Rosenfield, S.; Davis, D. Effects of illness attribution and depression on the quality of life among persons with serious mental illness. Soc. Sci. Med. 1994, 39, 155–164. [Google Scholar] [CrossRef]
- Markowitz, F.E. The effects of stigma on the psychological well-being and life satisfaction of persons with mental illness. J. Health Soc. Behav. 1998, 39, 335–347. [Google Scholar] [CrossRef]
- Wright, E.R.; Gronfein, W.P.; Owens, T.J. Deinstitutionalization, social rejection and the self-esteem of former mental patients. J. Health Soc. Behav. 2000, 41, 68–90. [Google Scholar] [CrossRef]
- Cotton, P.G.; Drake, R.E.; Gates, C. Critical treatment issues in suicide among schizophrenics. Hosp. Community Psychiatry 1985, 36, 534–536. [Google Scholar] [CrossRef]
- Drake, R.E.; Gates, C.; Cotton, P.G.; Whitaker, A. Suicide among schizophrenics. Who is at risk? J. Nerv. Ment. Dis. 1984, 172, 613–617. [Google Scholar] [CrossRef]
- Drake, R.; Cotton, P.G. Depression, hopelessness and suicide in chronic schizophrenia. Brit. J. Psychiat. 1986, 148, 554–559. [Google Scholar] [CrossRef]
- Fenton, W.S.; McGlashan, T.H.; Victor, B.J.; Blyler, C. Symptoms, subtype, and suicidality in patients with schizophrenia spectrum disorders. Am. J. Psychiatry. 1997, 154, 199–204. [Google Scholar] [Green Version]
- Nordentoft, M.; Jeppesen, P.; Abel, M.; Kassow, P.; Petersen, L.; Thorup, A.; Krarup, G.; Hemmingsen, R.; Jørgensen, P. OPUS study: Suicidal behavior, suicidal ideation and hopelessness among patients with first-episode psychosis. Br. J. Psychiatry 2002, 181, 98–106. [Google Scholar] [CrossRef]
- Kim, C.H.; Jayathilake, K.; Meltzer, H.Y. Hopelessness, neurocognitive function, and insight in schizophrenia: Relationship to suicidal behavior. Schizophr. Res. 2002, 60, 71–80. [Google Scholar] [CrossRef]
- Montross, L.P.; Kasckow, J.; Golshan, S.; Solorzano, E.; Lehman, D.; Zisook, S. Suicidal ideation and suicide attempts among middle-aged and older patients with schizophrenia spectrum disorders and concurrent subsyndromal depression. J. Nerv. Ment. Dis. 2008, 196, 884–890. [Google Scholar] [CrossRef]
- Restifo, K.; Harkavy-Friedman, J.M.; Shrout, P.E. Suicidal behavior in schizophrenia. A test of the demoralization hypothesis. J. Nerv. Ment. Dis. 2009, 197, 147–153. [Google Scholar] [CrossRef] [PubMed]
- Pompili, M.; Lester, D.; Grispini, A.; Innamorati, M.; Calandro, F.; Iliceto, P.; De Pisa, E.; Tatarelli, R.; Girardi, P. Completed suicide in schizophrenia: Evidence from a case-control study. Psychiatry Res. 2009, 167, 251–257. [Google Scholar] [CrossRef] [PubMed]
- David Klonsky, E.; Kotov, R.; Bakst, S.; Rabinowitz, J.; Bromet, E.J. Hopelessness as a predictor of attempted suicide among first admission patients with psychosis: A 10-year cohort study. Suicide Life-Threat. Behav. 2012, 42, 1–10. [Google Scholar] [CrossRef] [PubMed]
- Fulginiti, A.; Brekke, J.S. Escape from discrepancy: Self-esteem and quality of life as predictors of current suicidal ideation among individuals with schizophrenia. Community Ment. Health J. 2015, 51, 654–662. [Google Scholar] [CrossRef] [PubMed]
- Tarrier, N.; Barrowclough, C.; Andrews, B.; Gregg, L. Risk of non-fatal suicide ideation and behavior in recent onset schizophrenia—The influence of clinical, social, self-esteem and demographic factors. Soc. Psych. Psych. Epid. 2004, 39, 927–937. [Google Scholar] [CrossRef]
- Acosta, F.J.; Aguilar, E.J.; Cejas, M.R.; Gracia, R. Beliefs about illness and their relationship with hopelessness, depression, insight and suicide attempts in schizophrenia. Psychiatr. Danub. 2013, 25, 0–54. [Google Scholar]
- Yoo, T.; Kim, S.W.; Kim, S.Y.; Lee, J.Y.; Kang, H.J.; Bae, K.Y.; Yoon, J.S. Relationship between suicidality and low self-esteem in patients with schizophrenia. Clin. Psychopharm. Neu. 2015, 13, 296. [Google Scholar] [CrossRef] [PubMed]
- Ran, M.S.; Xiang, M.Z.; Mao, W.J.; Hou, Z.J.; Tang, M.N.; Chen, E.Y.A.; Chan, C.L.W.; Yip, P.S.F.; Conwell, Y. Characteristics of suicide attempters and nonattempters with Schizophrenia in a rural community. Suicide Life Threat Behav. 2005, 35, 694–701. [Google Scholar] [CrossRef]
- Drake, R.J.; Pickles, A.; Bentall, R.P.; Kinderman, P.; Haddock, G.; Tarrier, N.; Lewis, S.W. The evolution of insight, paranoia and depression during early schizophrenia. Psychol. Med. 2004, 34, 285–292. [Google Scholar] [CrossRef]
- Hasson-Ohayon, I.; Kravetz, S.; Meir, T.; Rozencwaig, S. Insight into severe mental illness, hope, and quality of life of persons with schizophrenia and schizoaffective disorders. Psychiatry Res. 2009, 167, 231–238. [Google Scholar] [CrossRef]
- Mansouri, L.; Dowell, D.A. Perceptions of stigma among the long-term mentally ill. Psychosoc. Rehabil. J. 1989, 13, 79. [Google Scholar] [CrossRef]
- Schulze, B.; Angermeyer, M.C. Subjective experiences of stigma. A focus group study of schizophrenic patients, their relatives and mental health professionals. Soc. Sci. Med. 2003, 56, 299–312. [Google Scholar] [CrossRef]
- Vass, V.; Morrison, A.P.; Law, H.; Dudley, J.; Taylor, P.; Bennett, K.M.; Bentall, R.P. How stigma impacts on people with psychosis: The mediating effect of self-esteem and hopelessness on subjective recovery and psychotic experiences. Psychiatry Res. 2015, 230, 487–495. [Google Scholar] [CrossRef] [Green Version]
- Birchwood, M.; Mason, R.; MacMillan, F.; Healy, J. Depression, demoralization and control over psychotic illness: A comparison of depressed and non-depressed patients with a chronic psychosis. Psychol. Med. 1993, 23, 387–395. [Google Scholar] [CrossRef] [PubMed]
- Aguilar, E.J.; Haas, G.; Manzanera, F.J.M.; Hernández, J.; Gracia, R.; Rodado, M.J.; Keshavan, M.S. Hopelessness and first-episode psychosis: A longitudinal study. Acta Psychiatr. Scand. 1997, 96, 25–30. [Google Scholar] [CrossRef]
- Carroll, A.; Pantelis, C.; Harvey, C. Insight and hopelessness in forensic patients with schizophrenia. Aust. N. Z. J. Psychiatry 2004, 38, 169–173. [Google Scholar] [CrossRef] [PubMed]
- Lysaker, P.H.; Davis, L.W.; Hunter, N.L. Neurocognitive, social and clinical correlates of two domains of hopelessness in schizophrenia. Schizophr. Res. 2004, 70, 277–285. [Google Scholar] [CrossRef] [PubMed]
- White, R.G.; McCleery, M.; Gumley, A.I.; Mulholland, C. Hopelessness in schizophrenia: The impact of symptoms and beliefs about illness. J. Nerv. Ment. Dis. 2007, 195, 968–975. [Google Scholar] [CrossRef]
- Cavelti, M.; Kvrgic, S.; Beck, E.M.; Kossowsky, J.; Vauth, R. The role of subjective illness beliefs and attitude toward recovery within the relationship of insight and demoralization among people with schizophrenia spectrum disorders. J. Clin. Psychol. 2012, 68, 462–476. [Google Scholar] [CrossRef]
- Cavelti, M.; Kvrgic, S.; Beck, E.M.; Rüsch, N.; Vauth, R. Self-stigma and its relationship with insight, demoralization, and clinical outcome among people with schizophrenia spectrum disorders. Compr. Psychiatry 2012, 53, 468–479. [Google Scholar] [CrossRef]
- Boursier, S.; Jover, F.; Pringuey, D. Relevance of the concept of demoralization in schizophrenic patients. Eur. Psychiatry 2013, 28, 1. [Google Scholar] [CrossRef]
- Wartelsteiner, F.; Mizuno, Y.; Frajo-Apor, B.; Kemmler, G.; Pardeller, S.; Sondermann, C.; Hofer, A. Quality of life in stabilized patients with schizophrenia is mainly associated with resilience and self-esteem. Acta Psychiatr. Scand. 2016, 134, 360–367. [Google Scholar] [CrossRef]
- Touriño, R.; Acosta, F.J.; Giráldez, A.; Álvarez, J.; González, J.M.; Abelleira, C.; Benítez, N.; Baena, E.; Fernández, J.A.; Rodriguez, C.J. Suicidal risk, hopelessness and depression in patients with schizophrenia and internalized stigma. Actas Esp. Psiquiatr. 2018, 46, 33–34. [Google Scholar]
- Upthegrove, R.; Marwaha, S.; Birchwood, M. Depression and schizophrenia: Cause, consequence, or Trans-diagnostic issue? Schizophr. Bull. 2017, 43, 240–244. [Google Scholar] [CrossRef]
- Conley, R.R.; Ascher-Svanum, H.; Zhu, B.; Faries, D.E.; Kinon, B.J. The burden of depressive symptoms in the long-term treatment of patients with schizophrenia. Schizophr. Res. 2007, 90, 186–197. [Google Scholar] [CrossRef] [Green Version]
- Gardsjord, E.S.; Romm, K.L.; Friis, S.; Barder, H.E.; Evensen, J.; Haahr, U.; Ten Velden Hegelstad, W.; Joa, I.; Johannessen, J.O.; Langeveld, J.; et al. Subjective quality of life in first-episode psychosis. A ten year follow-up study. Schizophr. Res. 2016, 172, 23–28. [Google Scholar] [CrossRef]
- Pompili, M.; Lester, D.; Innamorati, M.; Tatarelli, R.; Girardi, P. Assessment and treatment of suicide risk in schizophrenia. Expert Rev. Neurother. 2008, 8, 51–74. [Google Scholar] [CrossRef]
- Wetzel, R.D.; Margulies, T.; Davis, R.; Karam, E. Hopelessness, depression, and suicide intent. J. Clin. Psychiatry 1980, 41, 159–160. [Google Scholar] [CrossRef]
Authors | Purpose | Measures | Results/Discussion |
---|---|---|---|
Drake et al. (1984) | Risk factors for suicide in patients with schizophrenia N = 104 (15 clinical vs. 89 controls; all met DSM-III diagnostic criteria for Schizophrenia) | 3d edition of the Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association (DSM-III) | Depressed mental status is more frequently observed in suicide group vs. non-suicide group (80% vs. 48%; p < 0.01). |
Cotton et al. (1985) | Psychotherapy of suicidal schizophrenic patients. N = 20 (schizophrenia) | Semi-structured interviews | Patients with schizophrenia reported hopelessness and a strong desire to escape through death at the time of suicide. It is important to assess self-esteem, the presence of psychosis, and distinguish inability to function from unwillingness to function |
Drake & Cotton (1986) | DSM-III depressive symptoms vs. hopelessness in schizophrenic suicides and non-suicides patients N = 104 (15 = s; 89 = n-s) | 3d edition of the Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association (DSM-III); Beck Hopelessness Scale (BHS) | Suicide ideas, depressive mood, and hopelessness rather than depression increases risk of suicide (respectively 87%, 80%, and 67% vs. 33% of depression in suicide sample); p < 0.01 |
Cohen et al. (1990) | Suicide in long-term treatment schizophrenia. N = 122 (67.2% male) with Schizophrenia, schizoaffective disorder (research diagnostic criteria), or schizotypal personality disorder (DSM-III) | Symptom Checklist 90-R (SCL-90-R); Brief Psychiatric Rating Scale (BPRS); Self-report measure of satisfaction | Baseline SCL-90-R scores for: hopelessness (6.30 vs. 2.96), hostility (3.53 vs. 1.63), depression (5.89 vs. 3.52), paranoid ideation (4.51 vs. 2.71), and obsessive-compulsive (3.73 vs. 2.23) were very discriminative between suicides (N = 8) and non-suicides (N = 74) |
Fenton et al. (1997) | Suicidality in schizophrenia and its relationship with subtypes N = 322 (schizophrenia n =187; schizoaffective disorder n = 87; schizophreniform disorder N = 15; schizotypal personality disorder n = 33) | 3d edition of the Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association (DSM-III); Positive and Negative Symptoms Scale (PANSS); self-report interviews | Negative symptoms: blunted affect (p = 0.03), poverty of speech (p = 0.02), stereotyped thinking (p = 0.005), and only one of positive symptoms (grandiosity (p < 0.05)) were correlated with suicide behavior. |
Nordentoft et al. (2002) | Suicidal behavior and treatment in first-episode schizophrenia (FEP) N = 341 (FEP disorder); attempts reported at baseline (N = 321); attempts during first year of treatment (N = 275) Diagnosis: schizophrenia, schizotypal disorder, delusional disorder, acute or transient psychosis, schizoaffective psychosis, induced psychosis, or unspecific non-organic psychosis according to ICD–10 | Schedules for Clinical Assessment in Neuropsychiatry (SCAN 2.0), Scale for the Assessment of Negative Symptoms (SANS), Scale for the Assessment of Positive Symptoms (SAPS) | Baseline period: being male (p = 0.001) and suicidal plans the week prior (p = 0.001) were significant predictors of suicide; Follow up period: being male (p = 0.002), suicidal plans the week prior (p < 0.001), and previous suicide attempts (p = 0.001) were significantly associated with suicide. There was a weak association between hopelessness and suicide in the integrated treatment’s group one year after treatment compared to the standard treatment’s group (p < 0.01) |
Kim et al. (2002) | Hopelessness, insight, cognitive dysfunction, and suicidality in schizophrenia N = 333 (schizophrenia) | Schedule for Affective Disorders and Schizophrenia (SADS), Hamilton Depression Rating Scale (HDRS), Brief Psychiatric Rating Scale (BPRS) | Regression analysis predicted Hopelessness as the most important predictor of current and lifetime suicidality (β = 0.41, p = 0.0001; β = 0.35, p = 0.01, respectively). Further, insight and substance abuse were predictors for lifetime and current suicidality (p = 0.001 and p = 0.004; p = 0.001 and p = 0.033, respectively). |
Tarrier et al. (2004) | Factors (self-esteem, relatives’ expressed emotions, demographic, social, clinical) associated with suicidal ideation and/or previous suicide attempts as proxy measures of suicide risk N = 59 (DSM-IV diagnosis of recent onset schizophrenia) | 4d edition of the Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association (DSM-IV); Modified Self-Evaluation and Social Support for Schizophrenia (SESS-sv); Positive and Negative Symptoms Scale (PANSS); Beck Depression Inventory (BDI); Beck Hopelessness Scale (BHS); Insight Scale (IS) | Greater hopelessness (OR 1.22) and longer duration of illness (OR 1.13) increase suicide risk. Hopelessness was also associated with higher negative self-evaluation and social isolation. |
Ran et al. (2005) | Suicide attempters’ (N = 38) vs. non-attempters’ (N = 472) clinical features. N = 510 (schizophrenia) | Screening schedule for Psychosis, Present State Examination, Chinese version (PSE-9), Social Disability Screening Schedule (SDSS), General Psychiatric Interview Schedule and Summary Form | Hopelessness and depressed mood were present in 60.5% of the patients with a history of lifetime suicide attempt (p < 0.001). |
Montross et al. (2008) | Prevalence and correlates of suicide in 40-year-old and older schizophrenic patients N = 132 (schizophrenia spectrum disorder and concurrent depressive symptoms) | SCID, Beck Scale for Suicidal Ideation (BSSI), Hamilton Depression Rating Scale (HAM-D), Calgary Depression Rating Scale (CDRS), Positive and Negative Symptoms Scale (PANSS), Clinical Global Impression Scale (CGI), Cumulative Illness Rating Scale-Geriatrics version C(IRS-G), Beck Hopelessness Scale (BHS) | Hopelessness rated by BHS (5.8; p = 0.001), and level of depression rated by HAM-D (13; p = 0.000) and CDR (6.4; p = 0.001) significantly differentiated the suicidal ideation and non-suicidal ideation groups. |
Restifo et al. (2009) | Demoralization model (premorbid adjustment x insight) N = 164 (schizophrenia, N = 115; schizoaffective, N = 49) | Diagnostic Interview of Genetic Studies (DIGS), Premorbid Adjustment Scale (PAS) | Interaction between premorbid adjustment and insight did not significantly predict suicide attempt (p = 0.88, p =0.91) |
Pompili et al. (2009) | Understanding suicide risk in 20 patients with schizophrenia who died by suicide vs. C 20 controls | Beck Hopelessness Scale (BHS) | Hopelessness (OR = 51.00; 95%CI = 7.56–343.72) was a risk factor for suicide |
Klonsky et al. (2012) | Longitudinal relationship of hopelessness and attempted suicide in DSM-III-R psychotic disorders N = 414 | 3d edition of the Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association DSM-III-R; Beck Hopelessness Scale (BHS); Hamilton Depression Rating Scale (HAM-D) | Hopelessness in psychotic disorders provides information about suicide risk. In comparison to non-psychotic population, even relatively modest levels of hopelessness increase risk for suicide in psychotic patients. |
Acosta et al. (2012) | Relationship between schizophrenic patients’ cognitions about their illness and past suicidal behaviors Relationship between patients’ beliefs about the illness with potential mediators of suicidal behaviors such as depressive symptoms, hopelessness, and insight N = 60 (ICD-10 diagnosis of schizophrenia) | International Classification of Diseases 10th Revision); (ICD-10); Calgary Depression Scale (CDS); Beck Hopelessness Scale (BHS); | Negative appraisals were associated with hopelessness and depressive symptoms (negative expectations and stigma showed the strongest associations). No differences between patients with and without past suicidal behaviors |
Fulginiti & Brekke (2015) | Association between discrepancy factors (self-esteem and quality of life) and suicidal ideation in DSM-IV schizophrenia spectrum disorders N = 162 | 4d edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); Extended Version of the Brief Psychiatric Rating Scale (BPRS-E); Subjective Well-being under Neuroleptic Treatment scale (SWL); Index for Self-Esteem (ISE); Medical Outcomes Study Social Support Survey (MOS-SSS); Survey); RFS (Role Functioning Scale) | QoL and self-esteem added value to predicting suicidal ideation beyond clinical and demographic factors. Self-esteem mediates the relationship between QoL and suicidal ideation. |
Yoo et al. (2015) | Associations between suicidality and self-esteem in patients with schizophrenia according to DSM-IV N = 87 (20 attempted suicide) | 4d edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); Positive and Negative Symptoms Scale (PANSS); Beck Depression Inventory (BDI); Beck Hopelessness Scale (BHS); Rosenberg Self-Esteem Scale (SES); Korean version of the Internalized Stigma of Mental Illness Scale (K-ISMI) | Patients with a history of suicide attempt had significantly higher scores on BDI (p = 0.036) and K-ISMI (p = 0.009) and significantly lower scores on SES (p = 0.001) |
Authors | Purpose | Measures | Results/Discussion |
---|---|---|---|
Birchwood et al. (1993) | Relationship between depression and acceptance or rejection of mental illness and perceived controllability of illness in chronic psychosis N = 84 (49 schizophrenia, 35 manic-depressive disorder) | Beck Depression Inventory (BDI); Personal Beliefs about Illness Questionnaire (PBIQ); Crown Self-Esteem Scale; degree of acceptance of two statements regarding acceptance or rejection of mental illness label | Patients’ perception of controllability of their illness powerfully discriminated depressed from non-depressed psychotic patients. Label acceptance was not associated with depression, low self-esteem, or unemployment. |
Aguilar et al. (1997) | Hopelessness in first-episode psychotic patients in 96 neuroleptic-naive psychotic patients (49 schizophrenic patients and 47 other non-affective psychotic patients) | Hopelessness Scale (HS) | High HS scores at baseline predicted poor short-term outcome in patients with schizophrenia, as evidenced by worse global functioning at the 12-month follow-up. |
Carrol et al. (2004) | Explores the level of insight in patients with schizophrenia and its relationship to symptoms and history of violence. Relationship between the insight’s dimensions of “compliance” and “awareness of illness” and hopelessness N = 28 (DSM-IV diagnosis of schizophrenia) | 4d edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); Beck Hopelessness Scale (BHS); Positive and Negative Symptoms Scale (PANSS); | Awareness of illness (p = 0.028), but not compliance with treatment, was positively correlated with level of hopelessness. |
Lysaker et al. (2004) | Explores two aspects of hope (expectations of the future and motivation to persist), neurocognition, personality, symptoms, and social functioning in post-acute phase of schizophrenia N = 52 (39 DSM-IV diagnosis of schizophrenia; 13 DSM-IV diagnosis of schizoaffective disorder) | 4d edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); Positive and Negative Symptoms Scale (PANSS); Hopkins Verbal Learning Test (HVLT); Wisconsin Card Sorting Test (WCST); (NEO Five-Factor Inventory (NEO); Vocabulary; Beck Hopelessness Scale (BHS); Quality of Life Scale (QOL) | Neuroticism, verbal memory, and income were each related to expectations of the future. Neuroticism and social isolation were related to motivational hope. Positive and negative symptoms were unrelated to either form of hopelessness. |
White et al. (2007) | Relationship between psychiatric symptoms levels, beliefs about illness and hopelessness N = 100 (DSM-IV diagnosis of schizophrenia) | 4d edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); Personal Beliefs about Illness Questionnaire (PBIQ); Extended Version of the Brief Psychiatric Rating Scale (BPRS); Scale for the Assessment of Negative Symptoms (SANS); Beck Hopelessness Scale (BHS); | There were significant differences between the hopeless and non-hopeless participants on PBIQ, SANS, and BPRS. CDSS score, “humiliating need to be marginalized” PBIQ subscale and BPRS score contributed significantly (60% of the variance) to hopelessness scores. |
Cavelti et al. (2012) | Mechanisms underlying the association of insight, depressive symptoms, and protective factors in patients with DSM-IV diagnosis of schizophrenic spectrum disorders N = 142 | 4d edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); Scale to Assess Unawareness of Mental Disorder (SUMD); Beck Depression Inventory (BDI-II); Subjective Well-being under Neuroleptic Treatment scale (SWN); Illness Perception Questionnaire for Schizophrenia (IPQS); | Higher levels of insight and psychotic symptoms were associated with more depressive symptoms. Participants’ perception of their illness as chronic and disabling mediates the relationship between insight and depressive symptoms. The association of insight and depressive symptoms was less pronounced in patients with positive recovery attitude |
Cavelti et al. (2012) | Investigates self-stigma both as a moderator and as a mediator variable in the relationship between insight and demoralization in patients with DSM-IV diagnosis of schizophrenic spectrum disorder N = 145 | 4d edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); Scale to Assess Unawareness of Mental Disorder (SUMD); Beck Depression Inventory (BDI); Subjective Well-being under Neuroleptic Treatment scale (SWN); Self-Stigma of Mental Illness Scale (SSMIS); | The association of insight and demoralization was stronger as self-stigma increased, confirming self-stigma as a moderator. Self-stigma also partially mediates the positive relationship between insight and demoralization. Demoralization fully mediates the adverse associations of self-stigma with psychotic symptoms and global functioning |
Boursier et al. (2013) | Demoralization in psychotic patients N = 55 (schizophrenic disorder) | Positive and Negative Symptoms Scale (PANSS), Beck Hopelessness Scale (BHS), Poor quality of life (SqOL) | 94% of the sample was found to be demoralized. Demoralization correlates with positive symptoms (p = 0.016), depression (p < 0.001), despair (p = 0.015), suicidality (p < 0.01), and poor quality of life (p = 0.007). |
Vass et al. (2015) | Impact of stigma on symptomatic and subjective recovery from psychosis (currently and longitudinally). Investigates whether self-esteem and hopelessness mediate the association between stigma and outcomes N = 80 | International Classification of Diseases 10th Revision (ICD-10); Beck Hopelessness Scale (BHS); Questionnaire about the Process of Recovery (QPR); Positive and Negative Symptoms Scale (PANSS) | Stigma predicted both symptomatic and subjective recovery. Hopelessness and self-esteem mediated the effect of stigma on symptomatic and subjective recovery. At the follow-up, stigma predicted recovery and symptoms. |
Wartelsteiner et al. (2016) | Examines the correlation of resilience, self-esteem, hopelessness, and psychopathology with quality of life N = 129 (52 DSM-IV diagnosis of schizophrenia; 77 healthy controls) | 4d edition of the Diagnostic and Statistical Manual of Mental Disorders | Patients with schizophrenia had lower levels of QoL, resilience, self-esteem, and hope than healthy control subjects. In these patients, QoL correlated moderately with resilience, self-esteem, and hopelessness and weakly with symptoms (negative correlation with depression and positive symptoms) |
Touriño et al. (2018) | Assesses prevalence of internalized stigma in patients with ICD-10 diagnosis of schizophrenia who attend psychosocial rehabilitation programs. Investigate the relationship between internalized stigma and sociodemographic, general clinical, psychopathologic, psychological, and suicidal behaviour variables in schizophrenic patients N = 71 | ICD-10; ISMI; RSES; SUMD; BHS; CGI-SCH; CDS; SCS | Stigma was associated with higher prevalence of suicidal ideation, a higher number of suicide attempts, higher current suicidal risk, worse self-compassion, higher self-esteem, higher scores on depression, higher prevalence of depression, and higher hopelessness. Hopelessness and the existence of depression were independently associated with internalized stigma |
© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
Berardelli, I.; Sarubbi, S.; Rogante, E.; Hawkins, M.; Cocco, G.; Erbuto, D.; Lester, D.; Pompili, M. The Role of Demoralization and Hopelessness in Suicide Risk in Schizophrenia: A Review of the Literature. Medicina 2019, 55, 200. https://doi.org/10.3390/medicina55050200
Berardelli I, Sarubbi S, Rogante E, Hawkins M, Cocco G, Erbuto D, Lester D, Pompili M. The Role of Demoralization and Hopelessness in Suicide Risk in Schizophrenia: A Review of the Literature. Medicina. 2019; 55(5):200. https://doi.org/10.3390/medicina55050200
Chicago/Turabian StyleBerardelli, Isabella, Salvatore Sarubbi, Elena Rogante, Michael Hawkins, Gabriele Cocco, Denise Erbuto, David Lester, and Maurizio Pompili. 2019. "The Role of Demoralization and Hopelessness in Suicide Risk in Schizophrenia: A Review of the Literature" Medicina 55, no. 5: 200. https://doi.org/10.3390/medicina55050200