Abstract
Introduction: Several features contribute to determining suicide risk. This study was designed with the aim of evaluating whether insight into illness and demoralization are involved in suicide risk (active suicidal ideation or behavior). Methods: For this purpose, in a sample of 100 adult psychiatric inpatients, we used the Columbia Suicide Severity Rating Scale to assess suicide risk, the Demoralization Scale for demoralization symptoms, and the Insight Scale to assess illness insight. We also investigated several demographic and clinical features, including gender, age, duration of untreated illness, previous suicide attempts, and nonsuicidal self-injurious behavior. Results: The results demonstrated that patients with higher scores on the insight-high dimension had 1.35 greater odds of having a higher suicide risk, and those with lifetime suicide attempts had 7.45 greater odds of having a higher suicide risk. Among the various clinical factors, the study indicated that only nonsuicidal self-harm behaviors in the last 3 months was a risk factor for suicide risk. Conclusions: The results indicated that greater illness insight is involved in suicide risk regardless of demoralization.
References
1.
Baldessarini
RJ
. Epidemiology of suicide: recent developments
. Epidemiol Psychiatr Sci
. 2019
;29
:71
. .2.
Ferrari
AJ
, Charlson
FJ
, Norman
RE
, Patten
SB
, Freedman
G
, Murray
CJ
, et al. Burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010
. PLoS Med
. 2013
;10
(11
):e1001547
. .3.
Lopez-Morinigo
JD
, Di Forti
M
, Ajnakina
O
, Wiffen
BD
, Morgan
K
, Doody
GA
, et al. Insight and risk of suicidal behaviour in two first-episode psychosis cohorts: effects of previous suicide attempts and depression
. Schizophr Res
. 2019
;204
:80
–9
. .4.
Frank
JD
. Psychotherapy: the restoration of morale
. Am J Psychiatry
. 1974
;131
(3
):271
–4
. .5.
Kissane
DW
, Clarke
DM
, Street
AF
. Demoralization syndrome–a relevant psychiatric diagnosis for palliative care
. J Palliat Care
. 2001
;17
(1
):12
–21
. .6.
De Figueiredo
JM
, Frank
JD
. Subjective incompetence, the clinical hallmark of demoralization
. Compr Psychiatry
. 1982
;23
(4
):353
–63
. .7.
Fava
GA
, Freyberger
HJ
, Bech
P
, Christodoulou
G
, Sensky
T
, Theorell
T
, et al. Diagnostic criteria for use in psychosomatic research
. Psychother Psychosom
. 1995
;63
(1
):1
–8
. .8.
Kissane
DW
, Kelly
BJ
. Demoralisation, depression and desire for death: problems with the Dutch guidelines for euthanasia of the mentally ill
. Aust NZ J Psychiatry
. 2000
;34
(2
):325
–33
. .9.
Clarke
DM
, Kissane
DW
. Demoralization: its phenomenology and importance
. Aust N Z J Psychiatry
. 2002
;36
(6
):733
–42
. .10.
Vehling
S
, Kissane
DW
. Existential distress in cancer: alleviating suffering from fundamental loss and change
. Psychooncology
. 2018
;27
(11
):2525
–30
. .11.
Drake
RE
, Gates
C
, Whitaker
A
, Cotton
PG
. Suicide among schizophrenics: a review
. Compr Psychiatry
. 1985
;26
(1
):90
–100
. .12.
Grassi
L
, Pasquini
M
, Kissane
D
, Zerbinati
L
, Caruso
R
, Sabato
S
, et al. Exploring and assessing demoralization in patients with non-psychotic affective disorders
. J Affect Disord
. 2020 Sep 1
;274
:568
–75
. .13.
Mintz
AR
, Dobson
KS
, Romney
DM
. Insight in schizophrenia: a meta-analysis
. Schizophr Res
. 2003
;61
(1
):75
–88
. .14.
McEvoy
JP
. The relationship between Insight into psychosis and compliance with medications
. In: Amador
XF
, David
AS
, editors. Insight and psychosis: awareness of illness in schizophrenia and related disorders
. Oxford
: University Press
; 2004
. p. 311
–33
.15.
Lincoln
TM
, Wilhelm
K
, Nestoriuc
Y
. Effectiveness of psychoeducation for relapse, symptoms, knowledge, adherence and functioning in psychotic disorders: a meta-analysis
. Schizophr Res
. 2007
;96
(1–3
):232
–45
. .16.
Lysaker
PH
, Roe
D
, Yanos
PT
. Toward understanding the insight paradox: internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders
. Schizophr Bull
. 2007
;33
(1
):192
–9
. .17.
Belvederi Murri
M
, Respino
M
, Innamorati
M
, Cervetti
A
, Calcagno
P
, Pompili
M
, et al. Is good insight associated with depression among patients with schizophrenia? Systematic review and meta-analysis
. Schizophr Res
. 2015
;162
(1–3
):234
–47
. .18.
Drake
RE
, Cotton
PG
. Depression, hopelessness and suicide in chronic schizophrenia
. Br J Psychiatry
. 1986
;148
(5
):554
–9
. .19.
Melle
I
, Barrett
EA
. Insight and suicidal behavior in first-episode schizophrenia
. Expert Rev Neurother
. 2012 Mar
;12
(3
):353
–9
. .20.
Lysaker
PH
, Pattison
ML
, Leonhardt
BL
, Phelps
S
, Vohs
JL
. Insight in schizophrenia spectrum disorders: relationship with behavior, mood and perceived quality of life, underlying causes and emerging treatments
. World Psychiatry
. 2018 Feb
;17
(1
):12
–23
. .21.
Pompili
M
, Amador
XF
, Girardi
P
, Harkavy-Friedman
J
, Harrow
M
, Kaplan
K
, et al. Suicide risk in schizophrenia: learning from the past to change the future
. Ann Gen Psychiatry
. 2007 Mar 16
;6
:10
. .22.
Eneman
M
, Vanhee
L
, Tang
E
, Sabbe
B
, Corveleyn
J
, Luyten
P
. The role of demoralization in the relationship between insight and suicidality in schizophrenia
. Neurol Psychiatry Brain Res
. 2020
;38
:12
–5
. .23.
Berardelli
I
, Sarubbi
S
, Rogante
E
, Hawkins
M
, Cocco
G
, Erbuto
D
, et al. The role of demoralization and hopelessness in suicide risk in schizophrenia: a review of the literature
. Medicina
. 2019
;55
(5
):200
. .24.
Costanza
A
, Baertschi
M
, Richard-Lepouriel
H
, Weber
K
, Berardelli
I
, Pompili
M
, et al. Demoralization and its relationship with depression and hopelessness in suicidal patients attending an emergency department
. Int J Environ Res Public Health
. 2020
;17
(7
):2232
. .25.
Berardelli
I
, Forte
A
, Innamorati
M
, Imbastaro
B
, Montalbani
B
, Sarubbi
S
, et al. Clinical differences between single and multiple suicide attempters, suicide ideators, and non-suicidal inpatients
. Front Psychiatry
. 15 Dec 2020
;11
:605140
.26.
American Psychiatric Association
. Diagnostic and statistical manual of mental disorders
. 5th ed. Arlington, VA
: American Psychiatric Association
; 2013
.27.
Lecrubier
Y
, Sheehan
D
, Weiller
E
, Amorim
P
, Bonora
I
, Sheehan
KH
, et al. The mini international neuropsychiatric interview (MINI). A short diagnostic structured interview: reliability and validity according to the CIDI
. Eur Psychiatry
. 1997
;12
(5
):224
–31
. .28.
Posner
K
, Brown
GK
, Stanley
B
, Brent
DA
, Yershova
KV
, Oquendo
MA
, et al. The Columbia–suicide severity rating scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults
. Am J Psychiatry
. 2011
;168
(12
):1266
–77
.29.
Kissane
DW
, Wein
S
, Love
A
, Lee
XQ
, Kee
PL
, Clarke
DM
. The demoralization scale: a report of its development and preliminary validation
. J Palliat Care
. 2004
;20
(4
):269
–76
. .30.
Mehnert
A
, Vehling
S
, Höcker
A
, Lehmann
C
, Koch
U
. Demoralization and depression in patients with advanced cancer: validation of the German version of the demoralization scale
. J Pain Symptom Manage
. 2011
;42
(5
):768
–76
. .31.
Costantini
A
, Picardi
A
, Brunetti
S
, Trabucchi
G
, Bersani
FS
, Minichino
A
, et al. Italian version of demoralization scale: a validation study
. Riv Psichiatr
. 2013
;48
(3
):234
–9
.32.
Markova
IS
, Berrios
GE
. The assessment of insight in clinical psychiatry: a new scale
. Acta Psychiatr Scand
. 1992
;86
(2
):159
–64
.33.
Butterworth
P
, Fairweather
AK
, Anstey
KJ
, Windsor
TD
. Hopelessness, demoralization and suicidal behaviour: the backdrop to welfare reform in Australia
. Aust NZ J Psychiatry
. 2006
;40
(8
):648
–56
. .34.
Lau
R
, Morse
CA
, Macfarlane
S
. Psychological factors among elderly women with suicidal intentions or attempts to suicide: a controlled comparison
. J Women Aging
. 2010
;22
(1
):3
–14
. .35.
Vehling
S
, Kissane
DW
, Lo
C
, Glaesmer
H
, Hartung
TJ
, Rodin
G
, et al. The association of demoralization with mental disorders and suicidal ideation in patients with cancer
. Cancer
. 2017
;123
(17
):3394
–401
. .36.
Fang
CK
, Chang
MC
, Chen
PJ
, Lin
CC
, Chen
GS
, Lin
J
, et al. A correlational study of suicidal ideation with psychological distress, depression, and demoralization in patients with cancer
. Support Care Cancer
. 2014
;22
(12
):3165
–74
. .37.
Uliaszek
AA
, Al-Dajani
N
, Sellbom
M
, Bagby
RM
. Cross-validation of the demoralization construct in the revised NEO personality inventory
. Psychol Assess
. 2019
;31
(2
):159
–66
. .38.
Touriño
R
, Acosta
FJ
, Giráldez
A
, et al. Suicidal risk, hopelessness and depression in patients with schizophrenia and internalized stigma
. Actas Esp Psiquiatr
. 2018
;46
(2
):33
–41
.39.
McGirr
A
, Séguin
M
, Renaud
J
, Benkelfat
C
, Alda
M
, Turecki
G
. Gender and risk factors for suicide: evidence for heterogeneity in predisposing mechanisms in a psychological autopsy study
. J Clin Psychiatry
. 2006
;67
(10
):1612
–7
. .40.
Logan
J
, Hall
J
, Karch
D
. Suicide categories by patterns of known risk factors: a latent class analysis
. Arch Gen Psychiatry
. 2011
;68
(9
):935
–41
. .41.
Nierenberg
AA
, Gray
SM
, Grandin
LD
. Mood disorders and suicide
. J Clin Psychiatry
. 2001
;62
(Suppl 25
):27
–30
.42.
Rihmer
Z
, Rihmer
A
. Depression and suicide–the role of underlying bipolarity
. Psychiatr Hung
. 2019
;34
(4
):359
–68
.43.
Bertolote
JM
, Fleischmann
A
. Suicide and psychiatric diagnosis: a worldwide perspective
. World Psychiatry
. 2002
;1
(3
):181
–5
.44.
Altamura
AC
, Dell'Osso
B
, Berlin
HA
, Buoli
M
, Bassetti
R
, Mundo
E
. Duration of untreated illness and suicide in bipolar disorder: a naturalistic study
. Eur Arch Psychiatry Clin Neurosci
. 2010
;260
(5
):385
–91
. .45.
Azorin
JM
, Kaladjian
A
, Adida
M
, Hantouche
E
, Hameg
A
, Lancrenon
S
, et al. Risk factors associated with lifetime suicide attempts in bipolar I patients: findings from a French National Cohort
. Compr Psychiatry
. 2009
;50
(2
):115
–20
. .46.
Verrocchio
MC
, Carrozzino
D
, Marchetti
D
, Andreasson
K
, Fulcheri
M
, Bech
P
. Mental pain and suicide: a systematic review of the literature
. Front Psychiatry
. 2016
;7
:108
. .47.
Klonsky
ED
, Glenn
CR
, Styer
DM
, Olino
TM
, Washburn
JJ
. The functions of nonsuicidal self-injury: converging evidence for a two-factor structure
. Child Adolesc Psychiatry Ment Health
. 2015
;9
:44
. .48.
Muehlenkamp
JJ
, Gutierrez
PM
. Risk for suicide attempts among adolescents who engage in non-suicidal self-injury
. Arch Suicide Res
. 2007
;11
(1
):69
–82
. .49.
Finkelstein
Y
, Macdonald
EM
, Hollands
S
, Sivilotti
ML
, Hutson
JR
, Mamdani
MM
, et al. Risk of suicide following deliberate self-poisoning
. JAMA Psychiatry
. 2015
;72
(6
):570
–5
. .50.
Leon
AC
, Friedman
RA
, Sweeney
JA
, Brown
RP
, Mann
JJ
. Statistical issues in the identification of risk factors for suicidal behavior: the application of survival analysis
. Psychiatry Res
. 1990
;31
(1
):99
–108
. .© 2021 S. Karger AG, Basel
2021
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.
