Psychology, Health & Medicine

ISSN: 1354-8506 (Print) 1465-3966 (Online) Journal homepage: https://www.tandfonline.com/loi/cphm20

The factors associated with depression in

schizophrenia patients: the role of self-efficacy,
self-esteem, hope and resilience

Dongwei Liu, Yuqiu Zhou, Guohua Li & Yudi He

To cite this article: Dongwei Liu, Yuqiu Zhou, Guohua Li & Yudi He (2019): The factors associated
with depression in schizophrenia patients: the role of self-efficacy, self-esteem, hope and resilience,
Psychology, Health & Medicine, DOI: 10.1080/13548506.2019.1695862

To link to this article: https://doi.org/10.1080/13548506.2019.1695862

Published online: 25 Nov 2019.

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PSYCHOLOGY, HEALTH & MEDICINE
https://doi.org/10.1080/13548506.2019.1695862

The factors associated with depression in schizophrenia

patients: the role of self-efficacy, self-esteem, hope and
resilience
Dongwei Liua, Yuqiu Zhoua, Guohua Lib and Yudi Hea
a
Department of Nursing, Harbin Medical University Daqing Campus, Daqing, Heilongjiang province, China;
b
Judicial Expertise Center, Chifeng Anding Hospital, Chifeng, China

ABSTRACT ARTICLE HISTORY

Previous studies have shown a significant correlation between Received 4 December 2018
depression, resilience, self-efficacy, self-esteem and hope among Accepted 27 October 2019
schizophrenia patients, but few studies have examined the KEYWORDS
mechanisms among these factors. This study aimed to analyse the Schizophrenia; depression;
relationships among resilience, self-efficacy, self-esteem and hope resilience; hope; self-efficacy
as influencing factors of depression in schizophrenia patients. A
cross-sectional study was conducted, and 361 schizophrenia
patients were recruited. They were interviewed about their self-
efficacy, self-esteem, hope, resilience and depressive symptoms. A
structural equation model was used to examine the direct and
indirect associations between them. The global model showed
good model fit and the structural equation model revealed that
the direct pathway of resilience on depression was significant, and
the indirect pathway of self-efficacy, self-esteem and hope on
depression via resilience was also significant. Notably, self-efficacy,
self-esteem and hope did not directly affect depressive symptoms.
These findings support the mediating model of self-efficacy, self-
esteem and hope relevant to the depressive symptoms of schizo-
phrenia patients in China, in which resilience plays a pivotal role.
These findings elucidate the factors which may be associated with
depressive symptoms and imply that enhancing resilience in peo-
ple with schizophrenia could be beneficial. Moreover, studies with
detailed longitudinal assessments are necessary to confirm these
findings.

Introduction
Depression is estimated to occur in up to 50% of patients with schizophrenia (Addington
et al., 2010). Studies have shown that depression has a higher prevalence in the early or
acute stage, and it is one of the most frequently occurring symptoms in the acute (Tapp,
Kilzieh, Wood, Raskind, & Tandon, 2001), long-term hospitalization and post-hospital
phases of the illness (Kocaturk, Essizoglu, Aksaray, Akarsu, & Musmul, 2015).
Depression worsens the prognosis of the disease and easily leads to recurrence.
Moreover, it might be a risk factor for prolonged hospital stay, social dysfunction, and

CONTACT Yuqiu Zhou hmuzyq@126.com Department of Nursing, Harbin Medical University Daqing Campus,
Gaoxin District, Xinyang Road No.39, Daqing, China
© 2019 Informa UK Limited, trading as Taylor & Francis Group
2 D. LIU ET AL.

even suicide in schizophrenia patients. Knowledge of the factors which associated with
depression may assist clinicians in choosing the most appropriate and effective psy-
chotherapy. However, the influencing factors of depression remain poorly understood in
this population. Recent works have argued for a better understanding of the variables that
contribute to depression.
Resilience is a construct that encompasses several aspects of personal resources
and defined as a dynamic process of adapting to challenging living conditions that
can prevent mental disorders. Liddle and Barnes believed that depression may be
due to psychological defects in schizophrenia (Liddle & Barnes, 1988). The sub-
jective experience of defects may indicate susceptibility to depression due to psy-
chological or neurological mechanisms. From this perspective, the main aspect of
resilience may play a role in shaping depression and some studies have tested the
buffer effect in patients with cardiovascular diseases and cancer (Carvalho et al.,
2016; Sharpley, Bitsika, Wootten, & Christie, 2014). Studies have investigated the
value of resilience as a predictor of depression in patients with schizophrenia
(Bozikas et al., 2016; Rossi et al., 2017).
Previous study has proposed a framework of resilience which is made up of
environmental context and internal resiliency factors. It pointed out that self-esteem,
self-belief and hope might compose a major part of the internal resilience (Kumpfer,
2002). People with schizophrenia are likely to internalize the external negative evalua-
tions they suffer, weakening self-protection mechanisms. Furthermore, patients are
prone to concealing the disease and avoiding obstacles. In the long run, the negative
consequences of self-evaluation and a decline in self-esteem occur. A recent study
showed that self-esteem was strongly correlated with resilience (Hofer et al., 2016).
Meanwhile, lower self-esteem has repeatedly been shown to be associated with
depressive symptoms in patients with schizophrenia (Fannon, Green, & Wykes,
2003; Haug et al., 2016).
Self-efficacy, defined as ‘beliefs in one’s capabilities to mobilize the motivation,
cognitive resources, and courses of action needed to meet given situational demands’
(Wood & Bandura, 1989), has been studied extensively in mental illness research (Chiu &
Tsang, 2004). Kelleher and Rinaudo believed that self-efficacy played an important role in
fostering resilience (Kelleher & Rinaudo, 2011). Many surveys have also reported the
direct relationship between self-efficacy and depression (Vauth, Kleim, Wirtz, &
Corrigan, 2007).
Many researchers believe that hope is an intrinsic source for patients to overcome
disease and rebuild confidence (Kylmä & Katri, 1997). The rehabilitation of schizophre-
nia patients is the result of the mutual penetration and transformation of biological-
psychosocial factors. Patients often require multiple hospitalizations or long-term med-
ications, which not only seriously affect social function but also dampen their confidence
for recovery. Studies have shown that hope is significantly related to psychological
development and health status (Song, Hyun, & Lee, 2011). Compared to healthy subjects,
schizophrenia patients indicated significantly lower degrees of resilience and hope. The
correlation between them was significant (Fannon et al., 2003) and hope is also associated
to depression (Schrank, Amering, Grant, Weber, & Sibitz, 2014).
These studies have advanced our knowledge of the influencing factors of depression in
schizophrenia. The relationship between self-esteem, self-efficacy, hope, resilience and
 PSYCHOLOGY, HEALTH & MEDICINE 3

depression had been revealed in the past studies, however few studies have focused on
resilience as the mediating role, nor did they uncover the impact factors in one study or
investigate the direct or indirect pathways between them. Structural equation modeling is
a useful statistical procedure to test theories involving straightforward and non-straight-
forward relationships and it has been widely used in exploring the mediation
mechanisms.

Hypothesis
Based on previous studies, we hypothesized that self-efficacy, self-esteem, hope and
resilience would have a direct effect on depression, and self-efficacy, self-esteem, hope
would have an indirect effect on depression via resilience. We also hypothesized that
resilience would be the most important influencing factor of depression (see Figure 1).

Methods
Study design and sample
Analysis was based on a cross-sectional study, which was conducted from May to July
2018 in two cities in China. All patients involved were asked to voluntarily complete
questionnaires on paper during a 30-minute period. They were informed of their rights
and the protection of their personal information by an informed consent form, empha-
sizing the fact that the data would only be used for research purposes. In all, 385

Figure 1. Hypothetical sequential process with the effects of self-efficacy, self-esteem, hope, resilience
and depression.
4 D. LIU ET AL.

questionnaires were sent out and 361 valid questionnaires were returned; the valid
response rate was 93.77%.
In this study, participants were recruited among 2 hospitals based on inclusion criteria
and exclusion criteria. Inclusion criteria were a diagnosis of schizophrenia according to
DSM-IV or ICD-10 and an age between 18 and 60 years. Exclusion criteria were: a history
of head trauma with loss of consciousness; a history of moderate to severe mental
retardation or neurological diseases; a history of alcohol and/or substance abuse in the
last six months; treatment modifications due to symptom exacerbation in the last three
months. All the above exclusion criteria were based on the recommendation of the
clinicians and the patients who inability to provide informed consent would also be
excluded. All patients signed a written informed consent form to participate after
receiving a comprehensive explanation of the study procedures and goals. The study
was approved by the Ethics Committee of the Department of Nursing of Harbin Medical
University.

Instruments
Depression
Calgary Depression Scale for Schizophrenia (CDSS) was used to assess the severity of
depression in people with schizophrenia in the past two weeks (Addington, Addington, &
Matickatyndale, 1994). The CDSS includes nine items (e.g. ‘Have you felt that life wasn’t
worth living?’). Responses were recorded on a four-point scale ranging from 0 (absent) to
3 (severe). Higher scores represent higher levels of depression. Ratings > 6 on the total
score indicate clinically significant depression (Rybakowski et al., 2012). Cronbach’s α in
this study was 0.81.

Resilience
Resilience was assessed using the Connor-Davidson Resilience Scale (CD-RISC). It
examines intra- and interpersonal protective factors thought to facilitate adaptation
when facing psychosocial adversity. It has been applied to children and breast cancer
patients (Poole, Dobson, & Pusch, 2017; Ulrika et al., 2018). Items are organized into
five factors (Connor & Davidson, 2003). It contains 25 items, each rated from 0 (not
true at all) to 4 (true nearly all of the time) (e.g. ‘Pride in your achievements’). The scale
is rated based on how the subject has felt over the past month. The total score ranges
from 0 to 100, with higher scores reflecting greater resilience. Cronbach’s α in this study
was 0.87.

Hope
Hope was assessed using the Herth Hope Index (HHI) (Herth, 2010). It is a reliable and
theory-driven instrument developed to evaluate three components of hope. It is suitable
for all adults, including cancer patients and alcohol co-dependent people (Rustøen,
Lerdal, Gay, & Kottorp, 2018; Wnuk & Marcin, 2015). The scale contains 12 items (e.g.
‘I feel all alone’), each rated from 1 (strongly disagree) to 4 (strongly agree), and the total
score ranges from 12 to 48, with higher scores indicates higher level of hope. Cronbach’s
α in this study was 0.61.
 PSYCHOLOGY, HEALTH & MEDICINE 5

Self-efficacy
The General Self-Efficacy Scale (GSES) is a 10-item instrument. It was developed to
evaluate how confident respondents were regarding their abilities to deal with novel or
demanding situations. This scale has been conducted in many kinds of people, such as
university students (Ersoz, 2017). It contains 10 items (e.g. ‘I can usually handle whatever
comes my way.’). It was a single latent factor structure scale based on a factor analysis
(Wu, 2009). The index score ranges from 10 to 40; a higher score indicates better self-
efficacy. Cronbach’s α in this study was 0.87.

Self-esteem
Self-esteem was assessed using the Rosenberg Self-Esteem Scale (RSES). The scale was
originally designed to assess adolescents’ overall feelings about self-worth and self-
acceptance (Rosenberg, 1965). And now it has been used in patients with mental illness
(Shimotsu & Horikawa, 2016). It consists of 10 items (e.g. ‘I certainly feel useless at
times’), and the subjects report directly whether the descriptions are in line with them.
Each item is rated from 1 to 4. The total score ranges from 10 to 40, with a higher score
indicating greater self-esteem. In this study, Cronbach’s α was 0.68.

Statistical analysis
Descriptive characteristics and bivariate associations were computed using SPSS (SPSS
Statistics for Windows. Version 23.0). Mplus 7.4 was used for the structural equation
model analysis. The goodness of fit of the final model was assessed using χ2/df,
RMSEA, CFI and TLI statistics, with χ2/df <3, RMSEA <0.080 (Browne & Cudeck,
1992), CFI > 0.900 and TLI > 0.900 (Hu & Bentler, 1999) denoting a good or
acceptable fit.
Five resilience clusters of CD-RISC (Competence, strengthening effect of stress,
Positive acceptance of change, Perceptions of control, Spirituality) were each modeled
as manifest indicators of a latent factor for resilience. For hope, all three subscales of the
HHS (Temporality and future, Positive readiness and expectancy, Interconnectedness)
were used as latent variables. For self-esteem, two subscales of the RSES (Self-affirmation,
Self-denial) were used as latent variables. For self-efficacy, all ten items from the GSES
were first tested in a measurement model and found to adequately demonstrate a one-
factor solution. Therefore, it was subsequently parceled into two observed variables.
Meanwhile, all nine items of the CDSS were also parceled into two observed variables
(Item parceling can be used when existing factors are not available and it is a theoretical
technique in which a measure is broken up into a smaller number of groups, or parcels,
by combining two or more individual items) (Bandalos, 2008).

Results
General characteristics of the study sample
Table 1 shows the demographic and medical characteristics of the samples. This study
consisted of 361 schizophrenia patients, 225 male (62.3%) and 136 female (36.7%). Their
ages ranged from 18 to 60 (M = 42, SD = 9.75). In terms of marital status, 152 were single
6 D. LIU ET AL.

Table 1. Sociodemographic characteristics of the samples

(N = 361).
Variable N (%)
Gender
Male 225(62.3)
Female 136(36.7)
Age
18 ~ 30 49(13.6)
31 ~ 40 103(28.5)
41 ~ 50 132(36.6)
51 ~ 60 77(21.3)
Marital Status
Single 152(42.1)
Married 94(26.0)
Divorced 102(28.3)
Widowed 13(3.6)
Employment Status
Employed 220(60.9)
Unemployed, housewives or retired 141(39.1)
Living Situation
Live alone 103(28.5)
Live with one or more persons 258(71.5)
Duration of Illness
<10 Years 194(53.7)
≥10 Years 167(46.3)
Duration of Untreated Psychosis
<1year 205(56.8)
≥1year 105(43.2)
Frequency of Relapse
≤3 times 81(42.7)
>3 times 280(57.3)
Depressive Symptoms
Yes 143(39.6)
No 218(60.4)

(42.1%), 94 were married (26.0%), 102 were divorced (28.3%), and 13 were widowed
(3.6%). In terms of employment status, 220 were employed (60.9%) and 141 were
unemployed (39.1%). Nearly half of the patients had a duration of illness of more than
10 years (46.3%), and 43.2% of the participants reported that their untreated period was
more than one year. More than half of patients relapsed more than 3 times. Moreover,
more than one-third (39.6%) of the patients with schizophrenia had depressive
symptoms.

Correlation analysis
The Pearson correlation analysis is shown in Table 2. Specifically, a positive correlation was
found between self-efficacy, self-esteem and hope. Depression was negatively correlated with
self-efficacy, self-esteem and resilience. However, depression was not significantly associated
with hope. Table 2 shows the correlations of the variables within the study sample.
 PSYCHOLOGY, HEALTH & MEDICINE 7

Table 2. Pearson correlations of self-efficacy, self-esteem, hope, resilience and depression.

Study variable Mean SD Self-efficacy Self-esteem Hope Resilience Depression
1 Self-efficacy 20.27 5.19 1
2 Self-esteem 26.18 3.33 0.29** 1
3 Hope 30.92 4.06 0.29** 0.13** 1
4 Resilience 39.09 14.30 0.71** 0.37** 0.39** 1
5 Depression 6.41 4.45 −0.16** −0.27** −0.06 −0.17** 1
**Correlation is significant at the 0.01 level (two-tailed). * Correlation is significant at the 0.05 level (two-tailed).

Figure 2. Graphical representations of the Structural Equation Model (SEM). Numbers by single-
headed arrows reflect the standardized regression weight.

Structural equation model

The structural equation model is illustrated in Figure 2. (The final model with factor
loadings is illustrated in Appendix: Diagram 1 and the hypothesis model with insignif-
icant coefficients is illustrated in Appendix: Diagram 2) The model results showed a good
fit with χ2 = 188.155, df = 70, χ2/df = 2.69, CFI = 0.936, TLI = 0.916, RMSEA = 0.068. The
direct path from resilience to depression was significant (standardized pathway coeffi-
cient = −0.459, P < 0.001). For the hypothesized mediating role of resilience tested in this
procedure, the results showed that resilience mediates the link between self-efficacy
(standardized pathway coefficient = −0.272, P < 0.001), self-esteem (standardized path-
way coefficient = −0.115, P = 0.02), hope (standardized pathway coefficient = −0.112,
P < 0.001) and depression. However, we did not find a direct path from self-efficacy, self-
esteem or hope to depression. Estimates for the saturated model are shown in Table 3.

Discussion
This study explored this issue for the first time using a structural equation model approach
that highlighted the non-straightforward relationships between self-efficacy, hope, self-esteem
8 D. LIU ET AL.

Table 3. The structural equation model (SEM) predicts depression, with resilience as the mediating
variable.
Variables in the model Estimate S.E. Std. Estimate 95% CI P
Resilience–Depression −0.220 0.068 −0.459 −0.591, 0.001
−0.327
Hope–Resilience 0.969 0.058 0.245 0.131, 0.001
0.359
Self-efficacy–Resilience 1.023 0.073 0.592 0.448, 0.001
0.736
Self-esteem–Resilience 0.731 0.090 0.250 0.073, 0.006
0.427
Hope–Resilience–Depression −0.214 0.032 −0.112 −0.176, 0.001
−0.049
Self-efficacy–resilience–depression −0.226 0.045 −0.272 −0.359, 0.001
−0.184
Self-esteem–resilience–depression −0.161 0.049 −0.115 −0.211, 0.020
−0.018
Direct effect 1.087
Indirect effect 0.499
Total effect 1.586

and resilience and depression. The model showed good fit with the data, and our findings
partly confirmed the hypotheses. Resilience was the feature most related to depression,
whereas self-efficacy, self-esteem and hope were moderately and indirectly associated with
depression via resilience. These findings provide several referable results that could have
implications in decreasing the depressive symptoms of schizophrenia patients.
First, resilience was the most important factor that directly affected depression,
supporting the findings of previous research (Rossi et al., 2017). The mean score of
CD-RISC was much lower than healthy individuals in a previous study (Rossi et al.,
2017). Resilience plays a key role in the recovery of patients with schizophrenia and
higher resilience indicates protection towards depression. A subject’s lack of tenacity and
strength easily produces frustration, which can lead to its loss of ability to organize his/
her autonomy when facing external pressure and adverse life events (Alessandrini et al.,
2016). Resilient patients complain less and have the capacity of a dynamic system to
adapt successfully to disturbances. Considering the patient’s perspective on resilience
may enhance their commitment to caring and relieving depression symptoms. So it can
be seen as a major influencing factor of depressive symptoms. Attempts to improve
depressive symptoms should therefore target improvements to resilience through psy-
chological interventions, such as CBT or positive psychology therapy (Bozikas et al.,
2016; Padesky & Mooney, 2012).
For the second objective, this study examined the mediating effect of resilience. As
expected, self-efficacy, self-esteem and hope had a moderate, indirect and negative effect on
depression via resilience. A strong sense of self-belief influences the way a patient thinks,
feels, and behaves and provides assurance in their ability to face and overcome adversity
(Bandura, 1986). Patients with high self-efficacy are more aware of individual values in the
face of negative events, are more able to gain control of the external environment, and
convert difficulties into empirical resources, which may enhance the individual’s resistance
to stress and resilience (Tugade & Fredrickson, 2004), then avoiding depressive symptoms.
Moreover, resilience also played a mediating role between self-esteem and depression. In
other words, good self-esteem was related to better resilience. High self-esteem provides
 PSYCHOLOGY, HEALTH & MEDICINE 9

patients emotional support and the ability to confidently cope with various difficulties in
life, cushioning the impact of stressful events on individuals (Liu, Zhou, Sun, Li, & Chai,
2019; Rutter, 2010), which would ultimately alleviate the depression symptoms.
Wartelsteiner’s study indicated that patients with schizophrenia presented with signifi-
cantly less resilience and hope, which were considered subjective elements of recovery.
Several studies demonstrated that hope is a positive predictor of resilience, while resilience
was a negative predictor of depression. As Hofer stated (Hofer et al., 2016), hope is needed
for resilience, so those who maintain hope construct a ‘defensible space’ and establish a self-
protection mechanism to enhance their internalized resistance and resilience. Considering
a patient’s perspective on resilience may enhance their mental health, including depressive
symptoms, as mentioned previously. And it could also mediate the relationship between
self-efficacy, self-esteem, hope and depression. So it can be seen as a core influencing factor
of depressive symptoms. These results suggested that self-efficacy, self-esteem and hope
must not be overlooked in understanding the relationships between depression and its
influencing factors. Patients need an entire intervention course to prevent depression.
Psychiatrists and nurses should not only to be responsible for treating the psychological
symptoms of schizophrenia patients but also to correct the patients’ psychological–func-
tional defects, improving self-efficacy, self-esteem and hope, enhancing resilience to reduce
the risk of depressive symptoms.
The absence of a direct path between self-efficacy, self-esteem, hope and depression should
be discussed. One factor could be the differences in the instruments and differences in the
patient selection criteria. For example, many studies evaluated depression using the Centre for
Epidemiological Studies Depression Scale (Kelleher & Rinaudo, 2011; Song et al., 2011), and
some only incorporated inpatients (Song et al., 2011). Another factor could be the peculiarity
of SEM compared with the Pearson correlation. Previous research mainly used correlation
analysis to investigate the association between depression and its influencing factors, so these
confounding factors might be overlooked. To be specific, our findings do not signify that those
factors were not the critical influencing factors of depression. Instead, these factors have long
been considered to be essential for engagement in treatment and psychotherapeutic progress
and have therefore been identified as the essential factors influencing depressive symptoms
(Bozikas et al., 2016; Kelleher & Rinaudo, 2011; Vrbova, Prasko, Holubova, Slepecky, &
Ociskova, 2018). However, it was unexpected that resilience fully mediated the relationship
between depression and self-efficacy, self-esteem and hope. This may suggest that resilience
might be the most essential aspect of depression in schizophrenia. A resilience framework for
promoting stable remission from depression said that resilience could be a buffer or a
protector for those vulnerability factors, like stress, negative emotions and coping flexibility
(Waugh & Koster, 2015). Previous findings suggest that mental health problems result from
the combination of low self-evaluation, lack of confidence and hopelessness (Bozikas et al.,
2016; Wartelsteiner et al., 2016). Thus, by settling psychosocial issues, they are able to improve
resilience and release stress (Heiden, Regina, Maurer, Ropeter, & Häfner, 2005). The final
consequence of these actions is the remission of depressive symptoms in patients with
schizophrenia. As with all observations regarding unanticipated results, these should be
regarded as speculations and a basis for future study.
10 D. LIU ET AL.

Strengths and limitations

The main strength of our study is the development of a multidimensional model that
integrates the contribution of multiple factors that influence the depression of schizophre-
nia patients. Furthermore, studies rarely target schizophrenia patients with regard to this
subject. Since the number of schizophrenia patients suffering from depressive symptoms is
increasing, a study of the influencing factors of depression is necessary to offer meaningful
suggestions and ways to relieve depressive symptoms. However, some limitations of this
study must be carefully considered. Considering that the study sample size was not large
enough, and all the participants were only recruited from two psychiatric hospitals in
China. Which may cause sample selection bias and it also partly explains why some direct
pathways could not be found in this study. Multicenter studies with large sample sizes
should be carried out in the future. Moreover, environmental effects will be discussed in
future study, such as community and family. Specifically, the study is limited by its cross-
sectional design, which allows for the inference causal pathways between the factors on a
statistical basis only. Future research could overcome the limitations of this study by using
a longitudinal design to better understand the associations between these variables.

Conclusion
This study contributes to a better understanding of the influencing factors of depression
in schizophrenia. Resilience appeared to be the most important direct effect on depres-
sion, whereas self-efficacy, self-esteem and hope had an indirect effect that was mediated
by resilience. Mental health staff should pay attention to the patients’ internal feelings
and coping situation during the clinical intervention process. Interventions that focus on
improving self-efficacy, self-esteem, hope and resilience simultaneously may be effective
in reducing depressive symptoms among patients with schizophrenia.

Acknowledgments
The authors wish to thank all participants in this study for their support and assistance.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
The research was supported by the National Natural Science Foundation of China.

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Appendix

Diagram 1. The Final Structural Equation Model with Factor loadings.

Diagram 2. The Hypothesis Median Model with Insignificant Coefficients.