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 statistics and linear
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 crosscultural studies. He may be reached at; muhammad29psy@yahoo.com
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, selfesteem, 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 selfesteem 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 selfesteem 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 Likerttype 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
R
R²
Adj R²
Suicidal Probability Scale (total)
.780
.608
.606
Hopelessness (Subscale)
Suicidal Ideation (Subscale)
Negative Self-Evaluation (Subscale)
Hostility (Subscale)
.727
.702
.572
.699
.528
.492
.330
.489
.525
.489
.325
.485
Dependant Variable
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
Suicidal
Probability
Scale
SS
Df
MS
F
Sig.
1
138
139
58424.300
272.417
214.467
.000
1
138
139
6660.192
43.123
154.447
.000
Regression 5898.736
Residual
6079.799
Total
11978.536
1
138
139
5898.736
44.057
133.890
.000
Regression
Residual
Total
936.317
1899.476
2835.793
1
138
139
936.317
13.764
68.025
.000
Regression
Residual
Total
2777.150
2907.672
5684.821
1
138
139
2777.150
21.070
131.805
.000
Regression 58424.300
Residual
37593.493
Total
96017.793
Subscales of Suicidal Probability Scale
Regression 6660.192
Residual
5950.951
12611.143
Hopelessness Total
Suicidal
Ideation
Negative
SelfEvaluation
Hostility
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 selfesteem and suicidal risk.
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