Self-Esteem and Suicide Ideation in Psychiatric Outpatients

Transcription

1 Suicide and Life-Threatening Behavior 38(5) October The American Association of Suicidology 511 Self-Esteem and Suicide Ideation in Psychiatric Outpatients Sunil Bhar, PhD, Marjan Ghahramanlou-Holloway, PhD, Gregory Brown, PhD, and Aaron T. Beck, MD Depression, hopelessness, and low self-esteem are implicated as vulnerability factors for suicide ideation. The association of self-esteem with suicide ideation after controlling for depressed mood and hopelessness was examined. Adult psychiatric outpatients (N = 338) completed measures of self-esteem, suicide ideation, hopelessness, and depression. Self-esteem was operationalized as beliefs about oneself (self-based self-esteem) and beliefs about how other people regard oneself (other-based self-esteem). Each dimension of self-esteem was negatively associated with suicide ideation after controlling for depression and hopelessness. Of the two dimensions of self-esteem, other-based self-esteem was the more robust predictor of suicide ideation. These findings suggest that even in the context of depression and hopelessness, low self-esteem may add to the risk for suicide ideation. Suicide ideation involves a wide range of ex- Steer, Epstein, & Brown, 1990; McGee et al., pressions, from the wish to die to thinking 2001), although the extent to which this rela- about detailed plans to commit suicide tionship is mediated by depression and hopelessness ( Joiner, Steer, Brown, Beck, Pettit, & Rudd, is less well established. 2003). Research has shown that robust pre- A number of researchers have suggested dictors of suicide ideation include depression that low self-esteem contributes to vulnera- (Beck, Steer, Beck, & Newman, 1993; Jin & bility for developing suicidal behaviors (Baumeister, Zhang, 1998) and hopelessness (Beck, 1986; 1990; Harter & Marold, 1994). For Beck, Steer, & Brown, 1993; McGee, Wil- example, Baumeister proposed that suicide liams, & Nada-Raja, 2001). Studies have also ideation arises from a strong desire to escape shown a negative relationship between self- aversive self-awareness. According to his theory, esteem and suicide ideation (Beck, Brown, people are at risk when they set unattainesteem Steer, Kuyken, & Grisham, 2001; Beck, able goals and then blame themselves for their failure to achieve these goals. These negative self-attributions provide a context Sunil Bhar, Gregory Brown, and Aaron for the emergence of suicidal intent and de- Beck are with the University of Pennsylvania; and sire. One study found that low self-esteem Marjan Ghahramanlou-Holloway is with the predicted the emergence of suicide ideation Uniformed Services University of the Health Sciover a period of 3 years (McGee et al., 2001), ences. This research was supported by a grant thus demonstrating the potential importance from the National Institute of Mental Health of self-esteem difficulties in creating a long- (P30 MH45178). standing vulnerability for suicide ideation. Address correspondence to Sunil S. Bhar, One criticism of research examining PhD, Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Room 2034, the relationship between self-esteem and sui- Philadelphia PA 19104; sbhar@mail. cide ideation is that confounding mediating med.upenn.edu or moderating variables are not often speci-

2 512 Self-Esteem and Suicide Ideation fied or controlled (Swann, Chang-Schneider, significantly associated despite controlling & McClarty, 2007). A number of studies that for depression (Vella, Persic, & Lester, 1996) have examined the relationship between self- and hopelessness (Overholser, Adams, Lehnert, esteem and suicide ideation have not controlled & Brinkman, 1995; Reynolds, 1991). for depression or hopelessness (e.g., Given these disparate findings, the question Beck, Steer, et al., 1993; Vilhjalmsson, Krisjansdottir, of whether or not depression and hopelessdition & Sveinbjarnardottir, 1998). In ad- ness explain the relationship between self- to being a symptom of clinical depression esteem and suicidal ideation remains to be (American Psychiatric Association, 2000), empirically examined. low self-esteem has been related to vulnerability Furthermore, despite the proliferation for depressive states (Beck, 1967; Brown, of theories describing self-esteem as a multi- Bifulco, Harris, & Bridge, 1986) and is dimensional concept (Harter, 1999; James, strongly associated with hopelessness (Beck 1890), many studies examining the association et al., 1990; Dori & Overholser, 1999; Tarrier, between self-esteem and suicide ideation Barrrowclough, Andrews, & Gregg, 2004). have not used a multidimensional definition Therefore, it is possible that the association of self-esteem, which includes both personal between self-esteem and suicide ideation is and projected beliefs about self-worth. Many mediated by depression or hopelessness. researchers have conceptualized self-esteem Conversely, it is also possible that self-esteem as personal evaluations of self-worth (i.e., may directly relate to suicide ideation. self-based self-esteem), and have ignored the The literature is equivocal about role of one s beliefs about how other people whether the relationship between self-esteem value oneself (i.e., other-based self-esteem) in and suicide ideation is mediated by depres- predicting suicide ideation (McGee et al., sion and hopelessness. Some researchers suggest 2001; Overholser et al., 1995). Beck and colthink that individuals with low self-esteem leagues (2001) found that both these dimen- about suicide only if they also have sions of self-esteem were associated with sui- high levels of depression or hopelessness. For cide ideation in an adult psychiatric outpatient example, Harter (1999) proposed that negative sample; however, they did not control for the beliefs about self cannot be separated effects of depression and hopelessness, and from the broader context of depressed mood therefore were unable to examine the inde- and hopelessness when predicting suicide pendence of each dimension of self-esteem ideation. For Harter, it is the constellation from such factors in predicting suicide ide- of low self-worth, depressed affect and hope- ation. There is some research that suggests lessness (p. 203) that explains the emergence that factors such as depression may explain of suicide ideation. Consistent with this the relationship between suicide ideation and model, studies have shown that self-esteem self-based but not other-based self-esteem. does not predict suicide ideation once con- For example, Wild, Flisher, and Lombard trolling for depression (De Man, 1999; Pinto (2004) found that after controlling for de- & Whisman, 1996; Wagner, Rouleau, & pression, suicidal ideation was predicted by Joiner, 2000) or hopelessness (Tarrier et al., other-based self-esteem; that is, one s percep- 2004). However, other researchers suggest tions of being valued by family members but that self-esteem constitutes a risk factor for not by one s own estimations of self-worth. suicide ideation independent of mitigating More research is needed to clarify if factors such as low mood and hopelessness. the relationships between self-based and McGee and colleagues (2001) found that low other-based dimensions of self-esteem and self-esteem at ages 11 to 13 predicted suicide suicide ideation are independent from the ef- ideation in early adulthood even after con- fects of both depression and hopelessness. trolling for the effects of hopelessness. Similarly, The purpose of the current study was to ex- other researchers found that measures tend Beck et al. s (2001) research to examine of self-esteem and suicide ideation remained the extent to which self-based self-esteem

3 Bhar, Brown, and Beck 513 and other-based self-esteem were associated.01, one tailed) and Other Scale (r =.65, p < with suicide ideation after controlling for depressed.05, one tailed). Demonstrating concurrent mood and hopelessness. validity, the BSE Self and Other scales corre- lated significantly ( p <.001) with other measures METHOD of self-esteem, including the Beck De- pression Inventory (BDI) self-dislike item Participants (r =.49 and.36, respectively), the Revised Hamilton Psychiatric Rating Scale for Depression The sample consisted of 338 psychiatworthlessness (Hamilton, 1960; Williams, 1988) ric outpatients (54% women; mean age = item (r =.47 and 0.39, reric 36.3, SD = 10.6). These patients were se- spectively), and the Beck Self Concept Test lected from a pool of 360 patients who were (Beck et al., 1990: r =.67 and.55, respec- assessed at an outpatient psychotherapy clinic tively). Further, the BSE Self and Other (Center for Cognitive Therapy at the Unimeasures Scales significantly correlated ( p <.001) with versity of Pennsylvania) between October of psychopathology such as the 1992 and April 1994 and included in a psy- BDI (r =.55 and.41, respectively), Beck chometric study of the Beck self-esteem Hopelessness Scale (r =.60 and.50, re- scales (Beck et al., 2001). Patients were se- spectively), and Scale for Suicide Ideation lected for the current study if they were as- (r =.40 and.38, respectively). sessed for self-esteem. The patients psychi- Beck Depression Inventory. The BDI atric diagnoses were determined by the (Beck & Steer, 1987) is a 21-item self-report Structured Clinical Interview for DSM-III-R instrument used to measure the severity of (SCID; Spitzer, Williams, Gibbon, & First, depression. The BDI has demonstrated ade- 1990). The broad diagnostic categories in- quate psychometric properties (Beck & Steer, cluded mood disorders (74%), anxiety disor- 1987; Beck, Steer, & Garbin, 1988). ders (46%), substance use disorders (28%), Beck Hopelessness Scale. The BHS (Beck and personality disorders (51%). & Steer, 1993) consists of 20 true-false state- ments designed to assess the extent of positive Measures and negative beliefs about the future. Beck Self-Esteem Scales. The BSE (Beck Adequate internal reliability has been reported for the BHS across diverse clinical et al., 2001) consists of two scales which mea- and nonclinical populations, with KR-20s sure beliefs about oneself (BSE Self Scale) typically in the.80s (Beck & Steer, 1993). and beliefs about how people perceive one- Scale for Suicide Ideation. The SSI self (BSE Other Scale). Each scale lists 18 (Beck, Kovacs, & Weissman, 1979) is a 21- pairs of semantic-differential adjectives (e.g., item interviewer administered measure that smart dumb; lovable unlovable). Respondents evaluates the current intensity of the patient s are asked to make an X at a point specific attitudes, behaviors, and plans to between each pair of adjectives to indicate commit suicide. The predictive validity of the their evaluation of themselves (for the BSE SSI for completed suicide is supported. Patients Self Scale) or their evaluation of how others who score a 3 or higher on the SSI would rate them (for the BSE Other Scale). were found to be approximately seven times Total scores for each scale range from 18 to more likely to die by suicide than those scor- 180 (see Beck et al., 2001). Adequate validity ing less than 3 (Brown, Beck, Steer, & Grisham, and reliability have been demonstrated with 2000). each scale (Beck et al., 2001). Internal consistency alphas for the Self and Other Scales Procedure At the time of their initial presentation to the outpatient clinic, patients were as- were 0.94 and 0.95, respectively. Test-retest reliability was moderately high over a 2-week interval for the BSE-Self Scale (r = 0.84, p <

4 514 Self-Esteem and Suicide Ideation sessed by doctoral-level diagnosticians. As- size ( f 2 ) =.02. Likewise, after controlling for sessments were conducted after the patients depression and hopelessness, the BSE Other signed informed consent forms. The assess- Scale was significantly associated with the ment included a psychological assessment of SSI, R 2 change =.02, F change (1, 334) = 9.27, presenting problems, the SCID, and a bat- p =.003, f 2 =.03. In summary, both dimensions tery of measures of mood, self-esteem, negative of self-esteem significantly predicted automatic thoughts, and suicide ideation. the level of suicide ideation after controlling A subset of these measures was relevant for for both depression and hopelessness. this study. These measures were completed Given that the BSE scales were highly in no specific order. Overall, the assessment intercorrelated (r =.82, p <.001), two addi- lasted approximately 3 hours. tional hierarchical regressions were conducted to examine the association between each BSE scale and SSI while controlling for the other RESULTS BSE scale along with depression and hopelessness. Once controlling for these variables, The means and standard deviations for suicidal ideation was not predicted by the the measures were as follows: BDI (M = 14.8, BSE Self Scale, R 2 change =.00, F change (1, SD = 9.2), BHS (M = 8.2, SD = 5.5), SSI (M = 334) =.02, p =.90, f 2 =.00. After controlling 1.3, SD = 4.0), BSE Self Scale (M = 125.6, for the BSE Self Scale, hopelessness, and depression, SD = 28.5), and BSE Other Scale (M = 133.3, however, the relationship between SD = 29.0). The means for the BSE scales in SSI and BSE Other Scale approached significance, this sample are nearly identical to means reported R 2 change =.01, F change (1, 333) = 3.75, for the pool of 360 patients in Beck et p =.054, f 2 =.01. al. (2001): BSE Self Scale: M = , SD = 28.56; BSE Other Scale M = , SD = 28.94). DISCUSSION The goal of the analyses was to examine whether each dimension of self-esteem In this study we examined whether predicted suicide ideation after controlling self-esteem predicted suicide ideation while for the effects of depression and hopeless- controlling for depression and hopelessness. ness. Hierarchical regression analyses were Self-esteem was conceptualized as the indi- conducted with depression and hopelessness viduals beliefs about themselves and their entered at the first step as covariates, and beliefs about how other people perceive each self-esteem scale entered at the second them. Both dimensions of self-esteem predicted step. Separate regression analyses were conducted suicide ideation beyond the effects of for each of the two self-esteem scales. depression and hopelessness. Suicide ideation, as measured by the SSI, was This finding is consistent with empirithe dependent variable in each regression cal studies (McGee et al., 2001; Overholser model. Scores on the SSI were transformed et al., 1995; Reynolds, 1991; Vella et al., 1996) to their square roots to improve normality in that found poor self-esteem was an important the distribution of scores. Tolerance values risk factor for suicide ideation even after con- for each model were within acceptable limits, trolling for mitigating factors such as depression indicating that multicollinearity was not a and hopelessness. Conversely, the curindicating problem. rent finding contradicts studies that failed to Depression and hopelessness constituted find an independent relationship between a significant composite predictor of sui- self-esteem and suicide ideation (De Man, cide ideation, R 2 =.26, F (2, 335) =.57.64, p = 1999; Pinto & Whisman, 1996; Wagner et.000. Once controlling for both depression al., 2000). One difference between the current and hopelessness, the BSE Self Scale was significantly study and those latter studies is the age associated with the SSI, R 2 change = of participants sampled. Past research that.01, F change (1, 334) = 5.47, p =.02, effect failed to find an independent relationship be-

5 Bhar, Brown, and Beck 515 tween self-esteem and suicide ideation has Some researchers have found that self-esteem tended to examine participants aged between is prospectively predictive of suicide ideation 7 and 18. In contrast, we used a sample of (McGee et al., 2001), but further longitudinal adults with a mean age of 36.9 years. Thus, research is required to examine the extent to while low self-esteem and suicidal ideation which self-esteem difficulties pre-date the appear to be associated across age groups, emergence of suicidal ideation. Second, we this association may be more independent did not examine the extent to which other from depression and hopelessness in adulthood facets of self-esteem such as certainty and than in younger age groups. stability of views about self impinge on Further, unlike studies that have conceptualized thoughts of suicide. There is some research self-esteem as a single dimension suggesting that uncertainty about self-worth (McGee et al., 2001; Overholser et al., 1995), predisposes certain individuals toward negawe considered two dimensions of self-esteem tive mood states (Swann et al., 2007). Therefore, self-based and other-based. After controlling more research is required also to invesself-based for depression and hopelessness, differences tigate the importance of various aspects of were observed in the relationship between self-esteem for predicting suicide ideation. each dimension of self-esteem and suicide The findings of the current study have ideation. Other-based self-esteem accounted potential implications for the clinical assess- for more variance in suicidal ideation than ment and treatment of suicide ideation. Low self-based self-esteem. Moreover, it remained self-esteem, particularly inferences about a somewhat significant predictor of suicidal how other people value oneself, may relate to ideation ( p =.054), even after controlling for the development or maintenance of suicide self-based self-esteem. Conversely, the rela- ideation, beyond the effects of depressed tionship between self-based self-esteem and mood or hopelessness. Therefore, low self- suicide ideation was nonsignificant after con- esteem may be an important construct to assess trolling for other-based self-esteem, depression, and address when managing patients and hopelessness. Such findings are with suicidal ideation. Perhaps improvements consistent with research by Wild, Flisher, in beliefs about self serve as an important and Lombard (2004), who suggest that other- mechanism underlying improvement in suicidal based self-esteem may constitute a more potent phenomena. Such a question can be exbased and independent predictor of suicide amined in further research. Experimental and ideation than personal evaluations of selfworth. treatment outcome research would be very useful for examining the extent to which ma- Two limitations are salient in the current nipulations of self-esteem affect levels of suibetween study. First, we did not test for causation cide ideation. self-esteem and suicide ideation. REFERENCES American Psychiatric Association. (2000). properties of the Beck Self-Esteem Scales. Behav- Diagnostic and statistical manual Text revision iour Research and Therapy, 39, (DSM-IV-TR) (4 ed.). Washington, DC: Author. Beck, A. T., Kovacs, M., & Weissman, A. Baumeister, R. F. (1990). Suicide as escape (1979). Assessment of suicidal intention: The from self. Psychological Review, 97, Scale for Suicide Ideation. Journal of Consulting Beck, A. T. (1967). Depression: Clinical, ex- and Clinical Psychology, 47, periential and theoretical aspects. New York: Harper Beck, A. T., & Steer, R. A. (1987). Manual & Row. for the Beck Depression Inventory. San Antonio, TX: Beck, A. T. (1986). Hopelessness as a predictor Psychological Corporation. of eventual suicide. Annals of the New York Beck, A. T., & Steer, R. A. (1993). Manual Academy of Sciences, 487, for the Beck Hopelessness Scale. San Antonio, TX: Beck, A. T., Brown, G. K., Steer, R. A., Psychological Corporation. Kuyken, W., & Grisham, J. (2001). Psychometric Beck, A. T., Steer, R. A., Beck, J. S., &

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