The Influence of Social Support, Social Stigma, and Medication Compliance on Suicidal
Ideation in Individuals Diagnosed with Schizophrenia
Kseniya Ishina
Written Assignment #3
Social Work 240
Fall 2008
Dr. Lee
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Abstract
This quantitative and qualitative research study will examine the influence of social
support, social stigma, and medication compliance on suicidal ideation in adults diagnosed with
schizophrenia, while controlling for age, gender, socioeconomic status, and ethnicity. It is
hypothesized that adults diagnosed with schizophrenia who have social support, no or little
experience with social stigma, and who comply with their medication will exhibit less suicidal
ideation than individuals with schizophrenia who lack social support, have experienced a lot of
social stigma, and who do not comply with their medication. This study also aims to answer the
question “How do social support, social stigma, and medication compliance influence suicidal
ideation in adults who are diagnosed with schizophrenia, while controlling for age, gender,
socioeconomic status, and ethnicity?” For the quantitative component, 400 outpatients from
twenty mental health clinics in the San Francisco Bay Area will participate in a cross-sectional
survey. For the qualitative component, a subset of 40 participants will participate in a 30-minute
individual semi-structured interview that will further illuminate their experiences with suicidal
ideation and relate them to social support, social stigma, and medication compliance. The
administration of both research methods will take place at the participants' homes. It is
anticipated that the results of this study will support the hypothesis that social support, lack of
social stigma, and compliance with medication will result in less suicidal ideation than lack of
social support, experience with social stigma, and noncompliance with medication in individuals
with schizophrenia. These findings will educate practitioners and policy makers in the field of
social work by illuminating risk factors for suicidal ideation in people with schizophrenia, and,
consequently, providing ideas for treatment for individuals suffering from schizophrenia.
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Introduction
Schizophrenia is one of the most debilitating mental disorders that are affecting many
individuals in the US. About 2.5 million of the people in the U.S. have been diagnosed with this
disorder. Symptoms usually appear between the ages of 13 and 25, and often can be noticed
earlier in males than females. Some of the more severe symptoms include delusions,
hallucinations, social withdrawal, flat affect, and disordered thinking (Mental Health America,
2008). Individuals diagnosed with schizophrenia often have a difficult time coping with the
symptoms of the disorder, which can result in suicidal ideation. This population is at a much
higher risk than the general U.S. population for committing suicide. Research on this subject has
provided varied statistics in terms of completed suicide in this population, but it seems to be that
approximately 10% of people diagnosed with schizophrenia commit suicide, with an attempted
suicide rate of 20-50% (Siris, 2001). Many factors in the lives of people suffering from this
disorder could cause or intensify the desire to want to commit suicide; however, this research
focuses on three specific issues. The purpose of this research is to determine the influence of
social support, social stigma, and medication compliance on suicidal ideation in adults diagnosed
with schizophrenia, while controlling for age, gender, socioeconomic status, and ethnicity.
Relevance to Social Work
Social workers often work with persons who are mentally ill and suicidal. In the Chestnut
Lodge Follow-up Study referenced in Tarrier, Barrowclough, Andrews, and Gregg (2004), 40%
of the 322 patients (187 of which were diagnosed with schizophrenia) had experienced suicidal
ideation, with 23% attempting suicide and 6% actually completing suicide. Other studies
performed on similar individuals yielded comparable results.
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The mentally ill are often overlooked and mistreated in our society, facing discrimination
and often left without social support and treatment. As social workers, we are there to provide
that support and work with these individuals to help them cope with difficulties related to their
mental status; thus, we have to be aware of issues of stigma and prejudice that they may face.
Our other role may lie in helping our clients gain access to any necessary medication that may
help control their symptoms by referring them to a psychiatrist and monitoring their compliance
with the prescribed medication.
In terms of the transcultural perspective, the culture of mental illness needs more
attention from service professionals because individuals with schizophrenia struggling to cope
with their symptoms may end up both homeless and isolated from society if they do not receive
professional care (Harvard College, 2007). For these reasons, it is important for social workers to
acknowledge the high risk of suicide for this extremely vulnerable population and educate
themselves about the factors associated with suicidal ideation, enabling them to effectively
assess the safety of their clients.
Literature Review
Background of Suicide in Individuals with Schizophrenia
Individuals diagnosed with schizophrenia are eight times more likely to commit suicide
than the general population (Aguilar, Siris, & Leal, 2008). The more often these thoughts occur,
the more likely a client is to have a plan and the means to carry out such plan, resulting in a
much higher fatality risk. Suicidal ideation in individuals with schizophrenia are not dependent
on any one risk factor. Previous suicide attempts often suggest that an individual may try to end
his or her own life again. Suicide in the individual’s family may also be a predictor for suicidal
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behavior, as evidence shows the behavior is often hereditary (Harkavy-Friedman & Nelson,
1997).
Multiple factors are involved in suicide risk in individuals with schizophrenia. In the
study performed by Evren and Evren (2004) of 60 schizophrenic patients, 27 had a history of
attempted suicide. Depression, paranoia, and family history of psychiatric disorders were all
correlated with suicidal behavior. Other risk factors for suicide include hospitalization, distress
caused by psychotic symptoms, reduced social functioning, loss of social support, traumatic
events, childhood and/or current abuse, and substance abuse. Additionally, life changes or events
similar to those that could occur in the general population, such as a death in the family, may
cause a period of higher risk for the individual suffering from schizophrenia (Harkavy-Friedman,
2007).
Social Constructionist Perspective and Suicide in Schizophrenic Populations
The issue of suicide among individuals diagnosed with schizophrenia can be viewed from
a social constructionist perspective. This perspective is commonly studied in both psychology
and sociology and posits that people learn how to understand the world around them as well as
their sense of self through interactions with other people. These interactions are based on shared
meanings and understandings derived from interactions with the surrounding world (Hutchinson
& Charlesworth, 2008). People who have been diagnosed with schizophrenia are stigmatized
with a label which tells others that their mental ability and behavior does not fit the normal
standards of society.
The diagnosis of schizophrenia is based on criteria listed in the Diagnostic and Statistical
Manual of Mental Disorders (DSM), which pointedly distinguishes between normal behavior and
functioning versus abnormal. The social constructionist perspective can be used to both examine
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and critique what "normal" means in American society. "Normal" is a socially-constructed
category that people use as a basis for comparison and judgment. If normalcy is socially
constructed, then "abnormal" is as well, therefore schizophrenia is a social construction.
However, people often don't critically examine schizophrenia as something socially constructed,
and don't question the standards of "normal" and "abnormal." By being classified as a disorder,
schizophrenia is automatically seen as something negative. Through social interactions related to
schizophrenia, shared meanings develop about the illness, which in turn lead to negative beliefs,
ultimately causing a stigma to develop around the diagnosis. This causes a diagnosed individual
to be stigmatized due to the label of the disorder, to be seen as possibly dangerous and
psychopathic, and suicidal ideation may result from difficulty coping with stigma. The individual
may also lose social support once others find out about the disorder.
Additionally, since schizophrenia is now seen as such a stigmatized disorder due to the
socially constructed beliefs about its nature, it becomes something that needs to be controlled.
The popular idea is that the people suffering from schizophrenia need to be medicated in order to
be kept from acting out and becoming dangerous. Medication is then viewed as a necessity, and
clients may be resistant to it, seeing it as something that is being forced on to them to alter them
and dull their personalities. This could affect the issue of medication compliance. In other words,
the social constructionist perspective may be utilized to view suicidal ideation in people with
schizophrenia as a result of the stigma surrounding the disorder, which may cause a loss of social
support and incompliance with medication.
Social Support and Suicidal Ideation in Individuals with Schizophrenia
Although limited information is available regarding the specific relationship between
suicide in the schizophrenic population and social support, there is a vast amount of information
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about suicide and social support as well as mental illness and social stigma. And, although more
information is needed, it is possible to make an assumption about a possible relationship between
social support and suicidal ideation among those diagnosed with schizophrenia.
In a study by Erickson, Beiser, and Iacono (1998) 175 participants who had just
experienced their first episode of psychosis were assessed after 18 months and 5 years to
determine how social support affected their social and occupational functioning. The results
show that for patients with schizophrenia, functioning rose after five years of social support.
Although this study did not deal directly with suicide risk, we can assume that higher social and
occupational functioning translate into successful coping strategies and mental stability in the
population of individuals with schizophrenia. From this, we can conclude that an individual may
be less likely to commit suicide if she or he has good coping skills; however, more empirical
evidence is needed to establish this link.
Research shows that individuals often seek support from others when experiencing
suicidal ideation. A study of callers on a crisis hotline showed that callers with suicidal ideation
most often called for social support to relieve stress and improve coping, not emergency
intervention (Watson, McDonald, & Pearce, 2006). Many callers will establish relationships with
the hotline and then call back when they need support; in this study, over 29% of all calls were
from repeat callers. The mentally ill callers that utilize the service are often socially isolated from
other people in their environment and see the hotline as their social support. Many callers report
feeling less suicidal at the end of the call. “Dealing with caller stress and social isolation before it
reaches critical levels may avert potentially more acute crisis situations such as suicide attempts
from occurring” (Watson et al., 2006, p. 479). This research shows that social support may help
an individual suffering from schizophrenia to reconsider ending his or her life.
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Social Stigma and Suicidal Ideation in Individuals with Schizophrenia
Social stigma in regards to mental illness is vastly present in the U.S. society. Noe (1997)
discusses the stigmatization of mental illness on a macro level, using examples of insurance
companies failing to pay for mental health treatment, and service professionals avoiding
providing services to patrons with mental illness. Environmental stressors such as these may
precipitate psychotic relapses in people with schizophrenia, and may possibly be a link to
suicidal ideation, although more information is needed.
Negative stereotypes about those diagnosed with a mental illness may possibly be used as
justification for mistreatment of this population. A study by Link, B.G., Phelan, J.C., Bresnahan,
M., Stueve, A., & Pescosolido, B.A. (1999) of a sample size of 1,444 shows strong support for
the stereotype of dangerousness in mentally ill individuals. The study included a presentation of
several vignettes where the main character had to be judged on the basis of his or her disorder.
“When the symptoms of mental illnesses are presented in vignettes, people's fears are
dramatically heightened. This occurs even though there is no mention of violent behavior in the
vignettes” (Link et. al., 1999, p. 1332). The idea that people with schizophrenia are dangerous
and potentially violent contributes to the stigma surrounding this disorder.
Social stigma is commonly experienced by individuals diagnosed with schizophrenia. In
a study of 74 outpatients with schizophrenia, all but one respondent indicated that they had at
least one experience of stigma, their number one worry being that others view them unfavorably
due to their illness. Other concerns included avoidance of telling others about their disorder,
having heard others talking negatively about people with mental illness, and hearing or seeing
negative accounts of mental illness in the media (Dickerson, F.B., Sommerville, J., Origoni,
A.E., Ringel, N., & Parente, F., 2002).
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Research shows that stigma can be seen and felt by the individual with schizophrenia in
more than just interpersonal interactions, in which stigma is the most prevalent (Schultze &
Angermeyer, 2003). Negative depictions of schizophrenia seem to have the second greatest
impact on individuals diagnosed with schizophrenia.
The derogatory treatment of this population by the media has a negative impact on both
these individuals and their families. These socially constructed caricatures can cause individuals
to isolate themselves from the social and economic life (Schultze & Angermeyer, 2003).
Although more support is needed, and what this research will provide, from this data, it is not
unreasonable to assume that social stigma can result in isolation, with the possible consequence
of suicidal ideation.
Medication Compliance and Suicide in Individuals with Schizophrenia
Non-compliance with neuroleptic (anti-psychotic) medication is an important topic in the
literature on mental illness. The noncompliance rate among those diagnosed with schizophrenia
is 50-70% (Kane, 1985 as referenced in Rogers, et. al., 1998). Side-effects are the most
significant reason for non-compliance, although newer medication has been developed with
fewer of these problems. Atypical antipsychotics have been shown to improve symptoms that
could lead to suicide such as agitation, hostility, and depression (Aguilar, Siris, & Leal, 2008).
In a study by Rogers et. al. (1998), the interview data of 22 men and 12 women, aged
between 18 and 56 years relates the participants’ view that the most important benefit of their
medication was its “calming effect” on their minds. The medications decreased the agitated
feelings of the individuals. The same study showed that another benefit of the medication was
the prevention of symptoms such as voices and auditory hallucinations which the individual
perceives as being coercive in trying to induce self-harm. Diminished insight is linked with
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medication non-compliance, with research showing that medication improves insight, causing
some individuals to recognize the full extent of their illness (Novak-Gubric & Tavcar, 2002).
Research also shows that medication non-compliance is linked with diminished cognitive
capacity, such as found in patients who stopped taking anti-psychotics within the first year and
had “poorer estimated pre-morbid cognitive capacity” than those who continued taking the
medication (Narasimhan, Pae, Masand, & Masand, 2007, p. 3). These studies suggest that since
neuroleptic medication seems to improve the overall functioning of the individual, medication
compliance may prevent suicidal ideation.
An alternative theory presented by some researchers that believe that the side effects of
the medication may be difficult enough for the person to cope with that it may instead be a
precipitant for suicide. However, the research that has supported this view is dated and refers to
older medications that had much harsher side effects (Harkavy-Friedman, 1997).
Hypothesis and Research Question
While evidence suggests a link between social support, social stigma, medication
compliance, and suicidal tendencies in individuals diagnosed with schizophrenia, minimal
research has been done on these interactions. This is something that needs to be explored further.
In this study, while controlling for age, gender, socioeconomic status, and ethnicity, it is
hypothesized that adults who have social support, who have no or little experience with social
stigma with schizophrenia, and who comply with their medication will exhibit less suicidal
ideation than individuals with schizophrenia who lack social support, have experienced a lot of
social stigma, and who do not comply with their medication. This study also aims to answer the
question “How do social support, social stigma, and medication compliance influence suicidal
The Influence of Social Support 10
ideation in adults who are diagnosed with schizophrenia, while controlling for age, gender,
socioeconomic status, and ethnicity?”
Methods
Design
This study has quantitative and qualitative components. Cross-sectional survey research
will be used for the quantitative part via self-administered, paper and pencil instruments. The
qualitative component will be performed through the method of phenomenology focusing on the
experience of being diagnosed with schizophrenia. The information for this component will be
gathered through 30-minute face-to-face semi-structured interviews.
Sample
For the quantitative portion, through convenience sampling, participants will be recruited
from twenty community mental health outpatient clinics in the San Francisco Bay Area. The first
twenty people ages 20 to 45 from each clinic that respond to the posted flier about the study will
be accepted into the study, for a total of 400 participants for the quantitative portion. These 400
participants will be given the survey to complete.
For the qualitative component, the phenomenology performed through semi-structured
interviews, a subset of forty participants will be selected using purposive sampling based on their
responses about suicidal ideation. Forty of the individuals who report having suicidal ideation
will be interviewed.
Study Site
The quantitative component of the study will be conducted at the participants’ homes
The Influence of Social Support 11
since the surveys will be mailed to them. The qualitative component, the interview, will also take
place in the participants’ homes; the researcher will visit the participant if the participant agrees
to take part in the qualitative portion.
Variables, Measurement, and Themes
For the quantitative component, social support, social stigma, and medication compliance
are examined as predictors of suicidal ideation in people with schizophrenia while controlling for
age, gender, socioeconomic status, and ethnicity. One paper-and-pencil instrument, divided into
five parts, measuring demographics, social support, social stigma, medication compliance, and
suicidal ideation, will be used to collect the information on these variables.
The first part of the questionnaire is the demographics portion that will assess the age,
gender, socioeconomic status, and ethnicity of the participant. Age is operationally defined as a
self-reported number in the fill in the blank response to the question “what is your age?” Gender
is operationally defined as a self-reported category either male or female, indicated with a check
mark. Socioeconomic status is operationally defined as a self-reported category indicated with a
check mark out of four possible categories: $0-10,000 per year, $10,000-30,000 per year,
$30,000-70,000 per year, or $70,000 and above per year in answer to the question “What is your
estimated annual income?” Ethnicity is operationally defined as a self-reported fill-in-the-blank
answer to the question “What is your ethnicity?”
The second part of the questionnaire is the short form of the Social Support Questionnaire
developed by Sarason, I.G., Sarason, B.I., Shearin, E.N., & Pierce, G.R. (1987) (please see
Appendix A for an example of the questions). The reliability of the SSQ has been tested by
administering the survey several times and getting the same responses each time; therefore, the
SSQ has good test-retest reliability (Sarason, I.G. et. al. 1987). The SSQ also has face validity:
The Influence of Social Support 12
the questionnaire seems to measure exactly what it intends to measure. Internal reliability of the
short form of the SSQ was acceptable for a measure with so few questions (Sarason, I.G. et. al,
1987).
The third part of the questionnaire consists of nine questions regarding stigma from the
Consumer Experiences of Stigma Questionnaire (CESQ) developed by Wahl (1999) (please see
Appendix B for sample questions). Stigma is measured with a 5-point scale from “never” to
“very often” for each of the nine questions. Validity and reliability of the measure was
established by pilot testing the measure and getting feedback from the National Alliance for the
Mentally Ill (NAMI).
The fourth part of the questionnaire will assess medication compliance with eight newlyconstructed questions measured with a 5-point Likert scale from with levels from “strongly
agree” to “strongly disagree” for each question. These questions will ask about the compliance of
the participant with his or her prescribed neuroleptic medication. This part of the questionnaire
will ask questions such as “Do you often find yourself missing doses of your prescribed
medication?” and ask the participant to agree or disagree based on the scale with statements such
as “I always remember to take all of my medication for my mental health symptoms.”
The fifth part of the questionnaire will contain ten questions from the Beck Scale of
Suicidal Ideation (BSI; Beck & Steer, 1991) to assess for the presence and history of suicidal
ideation. Questions include "I have a moderate to strong desire to kill myself" and other
questions assessing suicidal intent and willingness to live. The BSI has internal reliability, and
concurrent and predictive validity. Concurrent validity was established by comparing this
measure to other measures testing similar variables.
The Influence of Social Support 13
The measurement used for the quantitative portion of this study will consist of these five
portions. Validity and reliability of the full instrument will be established by pilot-testing the
instrument with the first twenty people who respond to the flier advertising the study. Face
validity will be established by looking at the wording of each of the items in this instrument and
seeing whether and how well it asks what it is supposed to ask. Reliability of the instrument will
be established by looking at the internal consistency in terms of each item's correlation with the
full scale. Alternate-form reliability will be established by giving the participants of the pilot test
a second form of the measurement where sections of the questionnaire will be swapped with
others, and where the order of questions will be changed.
For the qualitative component, a semi-structured interview will be conducted with a
subset of 40 participants. This interview will take approximately thirty minutes during which
questions regarding demographic information, suicidal ideation, social support, social stigma,
and medication compliance will be asked. For example, a question regarding suicidal ideation
may ask “Have you ever in your life felt like committing suicide, and if so, what was your
experience like?” Participants will have the option of elaborating on their answers and giving
background information that will present a clear picture of their experiences. A question
assessing social support may ask “Is there someone in your life that you would turn to when you
are struggling?” or “Are there people in your life that you spend a lot of time with?” Social
stigma may be assessed by asking the participant to “Please tell me if you have ever felt that
other people were looking down on you for being diagnosed with a mental health disorder and
explain your experience.” Medication compliance could be assessed by asking the participant if
she or he has ever had difficulties with taking all of their prescribed medication and seeing if
missing doses of the medication affected their symptoms in any way. The nature of the semi-
The Influence of Social Support 14
structured interview will allow for follow-up questions to be asked for more clarification, and
will make it possible for the researcher to go back to topics already discussed, asking the
participant about any connections that might exist between the variables.
Human Subjects
For both the quantitative and qualitative components, informed consent will be obtained
by having the participant sign a consent form describing the nature of the research study and the
rights of the participant in the context of this study. This document will also inform the
participant about the protection of confidentiality of his or her personal information. To protect
the confidentiality of the individual, each participant will be assigned a participant number that
will be used in each correspondence, and will be put on the individual’s questionnaire instead of
their name. No identifying information will be released to anyone else outside of the research
study. We will make sure that no one in this study is harmed by obtaining consent and protecting
the people’s information. This proposed project will also be submitted to the Institutional Review
Board at the San Jose State University for review and approval.
Procedure
For the quantitative portion, fliers will be posted advertising the purpose of the study and
recruiting participants in each of the twenty mental health clinics in the San Francisco Bay Area.
The first twenty participants from who respond to the flier will be interviewed over the phone in
order to be accepted to pilot test the instrument. After that, the first twenty participants from each
clinic that respond to the flier will be accepted into the study after a short phone interview to
ensure that the participant fits the criteria of an adult diagnosed with schizophrenia, and has the
mental capacity to participate in the study and give his or her consent. The questionnaire will
then be sent out to the participants using the participant number assigned to the individual during
The Influence of Social Support 15
the phone interview instead of the person’s name in order to protect the participant’s identity.
Included with the questionnaire will be a return envelope for the participants to use to send back
the questionnaires with their responses.
For the qualitative portion, a subset of 40 participants who had expressed interest in the
qualitative portion of the study after completing the first portion will be interviewed during a
thirty-minute semi-structured interview. This interview will take place in the participants' homes
in a private setting. As in the quantitative part of the study, the participants' names will not be
included on any of the notes taken by the researcher, and the participant will instead be referred
to by the assigned participant number to protect confidentiality.
Study Design Limitations
Some limitations exist in this research study. Cross sectional survey research does not
establish a causal relationship; therefore, the results may show a correlation, but will not prove
causation. Convenience sample may not be large enough or representative enough of the whole
population of adults with schizophrenia. Because this study looks only at adults, the information
will not be generalizable to children and youth populations. Also, because of the length and
complexity of the quantitative instrument, responses may not be complete or fully accurate.
Despite these limitations, this research study will provide valuable information about the
possible risk factors for suicidal ideation in adults with schizophrenia.
Anticipated Findings and Implications for Social Work
The expected findings from this research study are that, after controlling for age, gender,
socioeconomic status, and ethnicity, results will show that individuals with schizophrenia who
have social support, have experienced little to no social stigma, and are compliant with their
prescribed medication will have less suicidal ideation than those individuals with schizophrenia
The Influence of Social Support 16
who do not have social support, have experienced a lot of social stigma, and are not compliant
with their prescribed medication. These results will be particularly important to the field of social
work because they will inform practitioners about what areas of clients' lives should be put in
focus in order to prevent suicidal ideation. They will also inform policy by illuminating the fact
that social attitudes and media representation of mental illness can have alarming effects on the
population that struggles with disorders like schizophrenia.
The Influence of Social Support 17
References
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Appendix A
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The Influence of Social Support 22
Appendix B
Sample Questions from the Consumer Experiences of Stigma Questionnaire (CESQ)
Have you avoided telling others outside of your immediate family that you have received
psychiatric treatment?
Have you been treated as less competent by others when they learned you had received
psychiatric treatment?
Have you been in situations where you heard others say unfavorable or offensive things about
persons and their psychiatric disorders?
Have you seen or read things in the mass media about persons receiving psychiatric treatment
and their psychiatric disorders which you found hurtful or offensive?