“Reasons for living” in patients with schizophrenia.

doi:10.21203/rs.3.rs-2093806/v1

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“Reasons for living” in patients with schizophrenia.

https://doi.org/10.21203/rs.3.rs-2093806/v1

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Reasons for Living (RFL) are a construct allows identifying the reasons for not committing suicide. These reasons are based on significant aspects of life, on the commitment to some ideals which may inhibit the impulse of committing suicide. The present study aims to describe the RFL in a sample of chronic schizophrenia patients. Explore if RFLs are different among male and female patients and the possible relation with clinical the variables: duration of illness, suicide attempts and hospitalizations.

Method: Seventy patients with schizophrenia were assessed. The application of Reasons for Living Inventory (RFLI) and the structured interview for clinical and socio-demographic data was performed by a Psychology master’s degree research assistants and the lead investigator.

Results: The sample mean score was 3.8/ 3.8 cut-off point under which the presence of suicide risk is significant. Patients indicated as most important RFLs those included in the Survival and coping beliefs and Responsibility to family domains. Non-significant differences between groups were observed. No association was found between clinical data and RFLI scores.

Conclusion: Considering that the sample of the present study obtained high scores in Survival and coping beliefs and low scores in Fear of suicide as RFLs, thus reflecting an opposite response pattern to other high suicidal risk populations. We suggest that this construct could represent a protective factor for schizophrenia patients, including chronic patients with previous suicide attempts and high hospitalization rates, which were common variables, observed in clinical sample.

According to global estimates from the World Health Organization, more than 700,000 individuals commit suicide each year. Such estimation positions suicidal behavior up to the fourth place regarding causes of death in young adults (1). It has been reported that being diagnosed with any mental condition, including schizophrenia, constitutes a risk factor for suicidal behavior, regardless of age, gender, or geographical location (2).

Schizophrenia is a psychiatric condition associated with physical and mental progressive decline. Moreover, it significantly impacts the health and economy of the patients’ families (3). It has been reported that 20–40% of the patients have attempted to commit suicide throughout their lifetime, and up to 10% of diagnosed schizophrenia patients have lost their lives due to this cause (4). The suicide rate in schizophrenia patients is 579/1000000 (5). The suicidality risk in schizophrenia may be modified by different factors like age of onset, chronicity, physical disturbances, insight abilities, substance use, previous suicide attempts, hospitalizations, and depression (5, 6).

It is noteworthy that a considerable body of research regarding suicidal behavior in schizophrenia has focused on the description of its risk factors and prevention strategies (7, 8, 9, 10, 11), whilst less research has been conducted to elucidate its potential protective factors (12, 13). Protective factors in this sense, are defined as personal and psychosocial conditions which diminish an individual’s probability of displaying suicidal behaviors (2). Such factors may be related to treatment, support networks, or individual biological and psychological characteristics (14). In schizophrenia patients, protective factors like social support, coping abilities, life satisfaction, and personal recovery have been identified (12, 13).

Another protective factor that has been identified in high-suicidality populations (15, 16) constitutes the Reasons for Living (RFL) domain. This construct allows identifying the reasons for not committing suicide. These reasons are based on significant aspects of life, on the commitment to some ideals which may inhibit the impulse of committing suicide or on resistance attitudes towards this behavior due to fear (2, 14). RFL has been inversely correlated with depression, hopelessness, and suicide ideation in other psychiatric populations (14). Moreso, RFL has been proposed as a variable that may “make the difference” between suicide ideation and attempt (15). At least, two empirical research lines have supported RFL as a significant protective factor: 1) RFL is inversely correlated to suicide ideation in general and clinical populations among teenagers and adults; and 2) RFL is associated with lower levels of depression, hopelessness, and impulsivity (17).

The construct has been mostly explored with an instrument denominated Reasons for Living Inventory (RFLI), which was designed by Marsha Linehan (18). It includes the following domains: Survival and coping beliefs, Responsibility to family, Children-related concerns, Fear of suicide, Fear of social disapproval, and Moral objections.

No description of the RFL factor focused exclusively on patients with a chronic and highly disabling condition like schizophrenia has been reported. A preceding study on this matter is titled: A study of quality of life and reasons for living in patients suffering from chronic mental illnesses (19). The authors described that the most important RFL in male patients diagnosed with schizophrenia, bipolar disorder, depression, or alcohol use disorder, were Survival and coping beliefs and Responsibility to family, whilst females’ main RFL was Fear of suicide.

Studying RFL in schizophrenia is essential, since this factor does not focus exclusively on positive attitudes or coping strategies, but may provide an orientation for the future, even in circumstances of loss, social helplessness, or other life challenges. Therefore, this construct is highly correlated with resilience (14). The present study aims to describe the RFL factor in a sample of chronic schizophrenia patients and to explore if RFLs are different among male and female patients.

The present is a cross-sectional descriptive study. The assessment was approved by the Research Ethics Committee from the Instituto Nacional de Psiquiatría “Ramón de la Fuente Muñiz” (INPRFM) with registry number CEI/C/004/2019, as part of a broader research project denominated “Non-pharmacological treatments for schizophrenia patients”.

Participants

Seventy patients with schizophrenia, who were diagnosed according to DSM-5 criteria, were recruited at the INPRFM, in Mexico City. All participants were at least 18 years old, had a minimum of 6 years of formal education, were undergoing pharmacological treatment, and were clinically stable at the time of the assessment, according to their psychiatrist. Exclusion criteria included any comorbid neurological condition, substance use disorder (except for nicotine), clinical diagnosis of intellectual disability, or presence of any perceptual or motor disability which could prevent the assessment.

Materials

An structured interview was used for clinical and socio-demographic data.

Reasons for Living Inventory (RFLI; Linehan et al., 1983). It is a self-report instrument comprised of 48 items which are presented in a Likert punctuation scale from 1 (Not at all important) to 6 points (Extremely important). Each item explores the relevance of distinct reasons for not committing suicide as scored by the patient. The cut-off point (gold-standard) of the instrument’s original version is 3.8/6 points, meaning scores under 3.8 are indicative of the presence of suicide risk (Linehan et al., 1983). The RFLI includes six domains: Survival and coping beliefs (items 2,3,4,8,10,12,13,14,17,19,20,22,24,25,29,32,35,36,37,39,40,42,44,45); Responsibility to family (items 1,7,9,30,47,48); Children-related concerns (items 11,21,23); Fear of suicide (items 6,15,18,26, 33,38,46); Fear of social disapproval (items 31,41,43); and Moral objections (items 5,23,27,34). Cut-off points and means per domain analyses have been reported in Latin-American versions (20, 21). The RFLI Mexican validation can be found in Villela, Molina y Senties (2015).

Procedure

Participants were invited to enroll in the study. Those who voluntarily agreed to participate signed an informed consent letter, which was approved by the institution’s Research Ethics Committee. Psychology master’s degree research assistants and the lead investigator obtained the sociodemographic information and supervised the RFLI application.

Statistical analyses

Frequencies and descriptive statistics were calculated, including the mean score for each domain and RFLI’s total score. Normality distribution was explored with the Kolmogorov-Smirnov test and comparisons of RFLI’s domains and total score among men and women were performed with Mann-Whitney’s U test; Spearman correlation analysis was used to explore the association between RFLI six domains and the Chronicity (years), Number of hospitalizations and Suicide attempts. SPSS v. 22 was used for all statistical analyses.

A total of 70 participants were included, 30% (n = 21) were women and 70% (n = 49) were men. Table 1 includes demographic and clinical information.

Table 1

Sociodemographic and clinical data
	Minimum	Maximum	Mean (S.D.)
Age Years of education Duration of illness (years) Number of hospitalizations Suicide attempts	18 6 1 0 0	60 18 37 4 3	37.9 (10.74) 12.9 (2.63) 12.12 (7.77) .60 (.89) .30 (.70)
Antipsychotic treatment Amisulpride Paliperidone Haloperidol Sulpiride Clozapine Olanzapine Risperidone Aripiprazole			% 1.4 2.9 4.3 7.1 11.4 17.1 27.1 28.6

Table 2 includes RFLI’s domains and total mean scores. Considering the cut-off point of 3.8, under which the presence of suicide risk is significant, the sample mean score can be considered within borderline parameters. Patients indicated as most important RFLs those included in the Survival and coping beliefs and Responsibility to family domains. Fear of suicide and Fear of social disapproval were the least relevant RFLs in the studied sample. No association was found between the duration of illness, Number of hospitalizations and Suicide attempts and the RFLI scores

Table 2

Mean RFLI’s scores in schizophrenia patients and Spearman correlation with the clinical data.
Reasons for Living Inventory	Minimum	Maximum	Mean	S.D.
Total Survival and coping beliefs Responsibility to family Children-related concerns Fear of suicide Moral objections Fear of social disapproval	1.98 2.75 1.57 1 1 1 1	5.04 5.88 6 6 5.29 6 6	3.8 4.4 4.2 3.2 2.6 3 2.8	.74 .82 1.1 1.6 1.1 1. 1.4
Total Survival and coping beliefs Responsibility to family Children-related concerns Fear of suicide Fear of social disapproval Moral objections	Duration of illness .187 .170 .166 .077 .042 .208 .008	Number of hospitalizations .-066 -066 − .029 − .047 .055 − .181 − .075	Suicide attempts .-.097 − .089 − .062 − .119 .217 − .022 − .127

RFLI’s domains did not fulfill normality criteria according to the Kolmogorov-Smirnov Total ( .072, p = 0.20); Survival and coping beliefs (.079, p = .20); Responsibility to family (.103, p = .06); Children-related concerns (.156, p = .00); Fear of suicide (.150, p = .00), Moral objections (.087, p = .20); Fear of social disapproval (.154, p = .00). Thus, a non-parametric Mann-Whitney U test was performed for comparisons between men and women. Non-significant differences between groups were observed (Fig. 2). The frequency analysis for the answer options in both groups is shown in Fig. 3.

The present study aimed to describe the protective factor of RFL in a sample of chronic schizophrenia patients. The results point out that although the total mean score of RFLI in the sample reached borderline suicide risk scores, clinically stable patients can identify a significant number of reasons for not committing suicide as observed in RFLI’s mean total scores. The most important identified reasons corresponded to the Survival and coping beliefs domain, which represents the patients’ confidence in conducting themselves effectively through difficult circumstances. This domain includes items like: “I believe I can learn to adjust or cope with my problems”; “I believe I have control over my life and destiny”; and “I have a desire to live”. The Responsibility to family domain explores the following assumptions: “My family might believe I did not love them”; “I have a responsibility and commitment to my family”. This domain showed to be relevant for the schizophrenia sample. The least important reasons corresponded to the Fear of suicide and Fear of social disapproval. These results are consistent with the report of Siva Anoop Yella, Gireesh Kumar & Umashankar (19) in a clinical sample of patients with different psychiatric conditions. Unlike these authors, we did not observe statistical differences between males and females. We believe that this difference may be due to the fact that our sample is composed only of patients with schizophrenia, in contrast to the authors who include several psychiatric conditions.

The relevance of the present study relays on the evidence of an inverse association between RFLI scores and suicidal ideation and attempt in both, clinical populations with affective disorders and schizophrenia, and healthy samples, including adolescents, adults, and the elderly (21). Considering that the sample of the present study obtained high scores in Survival and coping beliefs, and low scores in Fear of suicide as RFLs, thus reflecting an opposite response pattern to high suicidal risk populations (18), we suggest that this construct could represent a protective factor for schizophrenia patients, including chronic patients with previous suicide attempts, and high hospitalization rates, which were common variables observed in our clinical sample.

Targeted interventions focused on reinforcing RFLs can enable individuals to consider their motivations for continuing living, thus resulting in a significant difference regarding the internal debate of the reasons to live versus the reasons to die, even in those patients with previous suicide attempts (22).

The Authors have declared that there are no conflicts of interest in relation to the subject of this study.

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No competing interests reported.

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“Reasons for living” in patients with schizophrenia.

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