Abstract
Abstract
Background
Suicide is the leading cause of premature death among those with schizophrenia (Palmer, Pankratz, & Bostwick, 2005). However, it is unclear what places someone at high risk of suicide. Given the difficulties of living with schizophrenia, many individuals rely on family for assistance with housing, food, and other critical needs (National Alliance on Mental Illness, 2018). Moreover, family members are often individuals’ sole source of emotional support (Awad & Voruganti, 2008). Thus, family members are vital to the lives and functioning of those with schizophrenia. Indeed, greater family cohesion has been associated with lower psychiatric symptom severity in patients with schizophrenia (Weisman, Rosales, Kymalainen, & Armesto, 2005). Similarly, perceived family cohesion was found to be protective against suicidal attempts in non-clinical samples (Borowsky, Ireland, & Resnick, 2001). However, no research has assessed the relationship between suicidal ideation and family cohesion in schizophrenia. Additionally, given how disabling schizophrenia can be, becoming aware of one’s limitations may be dismaying and lead to suicidal ideation. Crumlish and colleagues (2005) found that greater insight at 6 months predicted suicide attempts in individuals with schizophrenia 4 years later. Therefore, the present study assesses whether patient’s perceptions of family cohesion and cognitive insight are associated with suicidal ideation. It is hypothesized that lower levels of family cohesion and greater insight will predict greater endorsement of suicidal ideation, and these effects will be mediated by depression, anxiety, and stress.
Methods
Individuals with schizophrenia (N = 120) were assessed using the family cohesion index (FC) of the Family Environment Scale (Moos & Moos, 1994), the suicidal ideation (SI) item (1–7 Likert rating) from the Brief Psychiatric Rating Scale (Ventura, Lukoff, Nuechterlein, Liberman, Green, & Shaner, 1993), Beck’s Cognitive Insight Scale (CI; Beck, et al., 2004), and the Depression, Anxiety and Stress Scale (DASS; Lovibond & Lovibond, 1995). Participants were, on average, 40.3 years old (SD = 15.75), male (62.5%), and Hispanic (48.3%, Caucasian=17.5%, Black=27.5%, Other=2.5%, missing=4.2%).
Results
As expected, significant relationships were found between SI and FC (r = -.22, p = .02), SI and CI (r = .26, p = .02), SI and DASS (r = .43, p < .001), and FC and DASS (r = -.41, p < .001). CI was not significantly correlated with DASS (r = .17, p = .15) nor FC (r = .12, p = .33). A mediation model was assessed in which SI was regressed on FC and DASS and DASS was regressed on FC. Additionally, SI was regressed on CI.
Increases in observed DASS (depression: b = .02, SE = .004, p < .001), cognitive insight (b = .06, SE = .02, p = .02), and decreases in family cohesion (b = -.14, SE = .06, p = .02) were all significantly associated with a greater likelihood of suicidal ideation. Moreover, a Sobel test of mediation revealed a significant indirect effect from FC to SI, through DASS (Sobel = 3.24, SE = .03, p = .001).
Discussion
Family cohesion may be protective for individuals with schizophrenia, or, stated differently, weaker family cohesion may be a stressor, exacerbating suicidal ideation through increased depression, anxiety, and stress. Insight also played an important role, with more insightful individuals endorsing greater suicidal ideation. Individuals who are more aware of their disorder and limitations are at greater risk for suicidal ideation. It is important to note that both insight and family cohesion independently predicted suicidal ideation. Study findings suggest that interventions aimed at increasing family cohesion and revamping detrimental attributions resulting from greater insight may be warranted.
