The Role of Demoralization and Hopelessness in Suicide Risk in Schizophrenia: A Review of the Literature

Abstract

Background and Objectives: Demoralization has been defined by hopelessness and helplessness attributable to a loss of purpose and meaning in life. Demoralization is a meaningful mental health concern, frequently associated with suicide risk in medical and psychiatric patients. The aim of this systematic review was to synthesize the recent empirical evidence on demoralization in patients with schizophrenia and to better understand the relationship between demoralization and suicide risk in patients with schizophrenia. Methods: A comprehensive literature search using key words and subject headings was performed following PRISMA guidelines with several bibliographic databases, resulting in the identification of 27 studies. Results: The findings suggested that demoralization is prevalent in patients with schizophrenia and supported the hypothesis that the association between depression and suicide is moderated by hopelessness. In clinical practice, it is important to recognize symptoms of demoralization using appropriate psychological tools to better understand the suffering of patients with schizophrenia and to implement suicide prevention programs.

Demoralization and Its Relationship with Depression and Hopelessness in Suicidal Patients Attending an Emergency Department

“…Yet, due to the non-nested nature of these two models, both constructs could not be compared directly and, therefore, the significance of this difference could not be assessed. In their recent systematic review on the role of demoralization and hopelessness in suicide risk in schizophrenia, Berardelli et al [32] supported the hypothesis that the association between depression and suicide is moderated by hopelessness.…”

“…However, in this study, psychological factors, not eventual psychiatric diagnoses, were considered. In patients with schizophrenia, Drake and colleagues [31] first elaborated on a demoralization syndrome, postulating that repeated exacerbation of psychotic symptoms and functional deterioration can lead to suicide, especially in individuals with good premorbid adjustment and insight (for a review of the role of demoralization role in suicide risk in schizophrenia, see [32]). In a cohort of patients attending the ED for SB, the mean demoralization score was almost twice as high as that of patients with cancer [34].…”

“…Kissane emphasizes the predictable progress of a desire to die or to commit suicide in patients under palliative care, who can be demoralized, but not necessarily depressed [19,20,26]. A progressive instillation of SB in demoralized patients was confirmed in the setting of somatic care, with or without a concomitant psychiatric disorder [18,[27][28][29], in socially disadvantaged individuals [30] and schizophrenia [31,32]. Demoralization has also been observed in women with a history of SB [33] and in patients visiting EDs for SB [34].…”

Attributional Styles and Social Functioning in Schizophrenia. Is the Learned Helplessness Model Suitable?

“…However, recent studies notice that several attributional biases as hostility, guilt, or aggressiveness are not associated with SF, unlike other social cognition domains, such as the Theory of Mind or emotion perception (Saffarian et al, 2018). Currently, the prevalence of depressive disorders in schizophrenia is estimated at around 40% and is correlated with poorer outcomes (Berardelli et al, 2019). Beyond this, "hopelessness", regardless of depressive symptoms, predicts a worse global functioning and is an important risk factor for suicidal behaviour (Cassidy et al, 2018).…”

“…Beyond this, "hopelessness", regardless of depressive symptoms, predicts a worse global functioning and is an important risk factor for suicidal behaviour (Cassidy et al, 2018). Given the importance of depressive symptoms (Berardelli et al, 2019;Davidson et al, 2018) and the increased "helplessness" (a bias to externalise both positive and negative events) found in persons with psychosis (Lincoln et al, 2010), the present study aimed to verify whether the reformulated Learned Helplessness Model and the more fully articulated form, Hopelessness Theory of Depression, may be specifically suitable to predict depressive symptoms in persons with schizophrenia-spectrum disorders. Moreover, our principal focus is not to demonstrate the relationship between attribution styles and psychotic symptoms that influent models satisfactorily explain (Bentall et al, 2001;Garety & Freeman, 2013;Moritz et al, 2018;Murphy et al, 2018) but to test their utility to explain increased depressive patterns and predict SF in persons with schizophrenia-spectrum disorders.…”