Journal of Clinical Neuroscience 68 (2019) 51–54

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Journal of Clinical Neuroscience

journal homepage: www.elsevier.com/locate/jocn

Clinical study

Suicide risk in chronic heart failure patients and its association with
depression, hopelessness and self esteem
Hasan Korkmaz a, Sevda Korkmaz b,⇑, Mustafa Çakar b
a
Department of Cardiology, Fırat University, Faculty of Medicine, Elazıg, Turkey
b
Department of Psychiatry, Fırat University, Faculty of Medicine, Elazıg, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Heart failure is a chronic disease that impairs the quality of life and leads to several psychiatric disorders,
Received 19 March 2019 especially depression and anxiety. The present study intended to investigate suicide risk and its associ-
Accepted 17 July 2019 ation with depression, hopelessness and self-esteem in patients with chronic heart failure. 32 patients
with chronic heart failure and 32 healthy control subjects with similar sociodemographic attributes were
included in the present case control study. Sociodemographic data form, Beck Hopelessness Scale (BHS),
Keywords: Beck Depression Inventory (BDI), Rosenberg Self-Esteem Scale (RSE) and Suicide Probability Scale (SPS)
Heart failure
were applied to all subjects. It was determined that the BHS (11.4 ± 3.74 vs. 4.8 ± 4.02, p < 0.001), BDI
Suicide risk
Self-esteem
(22.2 ± 11.9 vs 9.2 ± 7.6, p < 0.001) and SPS (67.6 ± 15.9 vs 59.2 ± 10.9, p = 0.018) scores were statistically
Hopelessness higher in the patient group when compared to the control group. It was also established that the self-
esteem of subjects in the patient group was lower when compared to the control (p < 0.001). A positive
correlation was determined between the SPS and BHS, and BDI and RSE scores (p < 0.001). Suicide risk
was higher among the patients with heart failure when compared to the control group. This increase
in suicide risk significantly correlated with high levels of hopelessness, depression, and low self-
esteem in the patient group. Heart failure is one of the chronic diseases that increases suicidal ideation.
The identification of suicidal ideation in the present patient group facilitated both the prevention of sui-
cidal behavior and positive contribution to treatment.
Ó 2019 Elsevier Ltd. All rights reserved.

1. Introduction The diagnosis of a physical disease, especially the diagnosis of a

Heart failure, a significant health risk in general population due
to its prevalence, is one of the chronic diseases that disrupts the
quality of life and negatively affects the emotional life of individu-
als. Both clinical symptoms caused by the disease and lifestyle
changes individuals are obliged to implement as a result of the dis-
ease negatively affect the emotional experiences of these
individuals.
Depression and anxiety symptoms are common in patients with
heart failure. This condition increases mortality and morbidity,
since it worsens the prognosis of the disease [1,2]. Based on our
clinical experience, intense suicidal ideas accompany the clinical
appearance of patients with heart failure. However, the relevant
literature includes only a few relevant studies [3,4]. In this patient
group, negative emotions such as hopelessness and pessimism
could be added to the prognosis in addition to depressive symp-
toms to the chronical and progressive nature of the disease [1].
⇑ Corresponding author.
E-mail address: skorkmaz23@hotmail.com (S. Korkmaz).
disease that leads to significant loss in faculties could lead to a
reduction in self-esteem in individuals. Both hopelessness that
accompanies depression and anxiety and the reduction in self-
esteem could negatively affect the coping mechanisms of the indi-
vidual and lead to suicidal ideation. The present study was con-
ducted to investigate suicide risk and its association with
depression, hopelessness and self-esteem in patients with chronic
heart failure.
2. Method
The present case control study was approved by the local ethics
committee and carried out in accordance with the Declaration of
Helsinki. A total of 32 patients with functional class II-IV and ejec-
tion fraction (EF) of 40% or less based on the New York Heart Asso-
ciation classification system (NHYA) were included in the present
study. Diagnosis of heart failure was considered as an essential cri-
terion in patient selection. Certain levels of physical and/or mental
illnesses and illiteracy that could prevent responding the question-
naire and the scales were accepted as exclusion criteria. Patients,

https://doi.org/10.1016/j.jocn.2019.07.062
0967-5868/Ó 2019 Elsevier Ltd. All rights reserved.
52 H. Korkmaz et al. / Journal of Clinical Neuroscience 68 (2019) 51–54
who applied to cardiology outpatient clinic for routine controls and
without inpatient history within the previous six months, were
included in the present study. Furthermore, 32 healthy individuals
with similar sociodemographic characteristics, who voluntarily
agreed to participate in the study, were included in the control
group. The control group included healthy individuals who applied
to cardiology outpatient clinic without any cardiological pathology
and had no previous psychological diagnosis. A sociodemographic
data form developed by the authors was completed by both the
patient and control group members. All participants completed
Beck Depression Inventory, Beck Hopelessness Scale, Rosenberg
Self-Esteem Scale and the Suicide Probability Scale.
2.1. Scales used in the present study
2.1.1. Beck depression inventory (BDI)
The scale was developed by Beck et al. [5]. It aims to determine
patient’s depression risk and to measure the level and severity of
depressive symptoms. The scale includes 21 items. Each item is
scored between 0 and 3 points. The total score varies between 0
and 63.
2.1.2. Beck hopelessness scale
The scale that aims to measure an individual’s future expecta-
tions and level of pessimism includes 20 items [6]. The applicable
statements for an individual are marked as true, and the inapplica-
ble ones are marked as false. The outcome of the scale is analyzed
in three sub-dimensions. Items on emotions about the future are
items 1, 6, 13, 15, 19, about the loss of motivation are items 2, 3,
9, 11, 12, 16, 17, 20 and about the future expectations are the items
4, 7, 8, 14, and 18. The scale score reflects the hopelessness score.
2.1.3. Rosenberg Self-Esteem Scale
The scale, developed by Rosenberg, includes 63 items and 12
sub-tests [7]. Only self-esteem sub-test was used in the present
study. In this test, organized based on the Guttman measurement
method, items of positive and negative stimulation were listed
consecutively. Individuals receive scores between 0 and 6 based
on the internal evaluation system of the scale. The comparison of
quantitative measurements provides the level of self-esteem,
which could be high (0–1 points), moderate (2–4 points) or low
(5–6 points). In other words, higher the score, lower the self-
esteem and vice versa.
2.1.4. Suicide probability scale
The scale, developed by Cull and Gill and includes 36 items, is
scored on 4-point Likert-type scale [8]. The scale includes three
sub-dimensions: ‘‘Negative Self and Exhaustion”, ‘‘Detachment
Table 1
Comparison of sociodemographic characteristics for patient and control groups.
Patient group
Age (Year) 59.7 ± 7.02
Gender (female) n 12 (38%)
Elementary education graduate n 24 (75%)
High school graduate n 6 (19%)
University graduate n 2 (6%)
Location (center) n 23 (72%)
Economic conditions (low) n 6 (19%)
Number of smokers n 22 (69%)
Alcohol/substance use – –
Additional medical condition n 3 (9%)
Previous History of psychiatric treatment – –
Psychiatric disorder diagnosis in family n 2 (6%)
t: Student’s t test.
x2: Chi-square test.
from life” and ‘‘Anger”. The lowest possible score is 36 and the
highest possible score is 144 in the scale. Higher scale scores indi-
cate higher suicide risk.
2.2. Statistical analysis
SPSS version 22 software was used in statistical analysis. The
data that exhibited normal distribution were analyzed via the Stu-
dent t-test and for those without normal distribution, Mann-
Whitney-U test was conducted. Pearson correlation analysis was
used to determine whether there was a positive or negative corre-
lation between the tests. Values of p < 0.05 were considered statis-
tically significant.
3. Findings
The statistical analysis indicated that there was no significant
difference between the patient group and the control group based
on sociodemographic characteristics such as age, marital status,
income level and unemployment (Table 1). Furthermore, the total
Beck Hopelessness Scale, Beck Depression Inventory and Suicide
Probability, anger, negative self and exhaustion and detachment
from life sub-scale scores were significantly higher in the patient
group when compared to the control group. On the Rosenberg
self-esteem scale, the patient group score was statistically higher
than the control group. Rosenberg Self-Esteem Scale findings indi-
cated that the patient group scores were statistically higher than
that of the control group. Since higher scores obtained in the
Rosenberg Self-Esteem Scale indicated lower self-esteem, it was
concluded that patient group self-esteem was lower when com-
pared to the control group (Table 2). There was a positive correla-
tion between the suicide probability scores and depression, self-
esteem and hopelessness scores. The Suicide Probability Scale
sub-dimension scores, except the anger sub-scale, correlated with
all other scale scores. Anger subscale was correlated only with sui-
cide probability scores (Table 3).
4. Discussion
A chronic disease diagnosis could destabilize the life balance of
an individual and may demand new adjustments. Such a newly-
developing condition means loss of health for the individual and
leads to reactions and emotions such as mourning, sadness, insur-
rection, denial of the disease, anxiety and anger. Anxiety about the
future, loss of proficiency, concerns about sexuality, productivity
and appearance could occur in the patient. Patients’ adaptation
to diseases depend on factors such as personality characteristics,
physical and psychological resilience, sociocultural characteristics,
Control group p t/x2
58.8 ± 9.9 0.674 .422
14 (44%) 0.799 .259a
19 (60%) 0.397 1.848a
9 (28%)
4 (13%)
28 (88%) 0.213 2.413a
2 (6%)
27 (84%) 0.237 2.177a
– –
3 (9%) 0.664 .000a
– –
2 (6%) 0.694 .000a
 H. Korkmaz et al. / Journal of Clinical Neuroscience 68 (2019) 51–54 53

Table 2
Scale score comparisons for patient and control groups.

Patient Group Control Group p t

mean ± std.d mean ± std.d
BHS 11.4 ± 3.74 4.8 ± 4.02 p < 0.001* 6.825
BDI 22.2 ± 11.9 9.2 ± 7.6 p < 0.001* 5.206
RSE 2.07 ± 1.2 0.72 ± 0.67 p < 0.001* 5.566
SPS-A 12.7 ± 3.94 16.3 ± 5.9 0.006* 2.889
SPS-NS 34.6 ± 10.6 28.6 ± 6.45 0.009* 2.727
SPS-D 19.6 ± 6.0 14.3 ± 3.95 p < 0.001* 4.135
SPS 67.6 ± 15.9 59.2 ± 10.9 0.018* 2.442

BHS: Beck Hopelessness Scale, BDI: Beck Depression Inventory, RSE: Rosenberg self-esteem scale, SPS-A: Suicide Probability Scale- Anger, SPS-NS: Suicide Probability Scale-
Negative Self and Exhaustion, SPS-D: Suicide Probability Scale- Detachment from life, SPS: Suicide Probability Scale *p < 0.05: statistically significant.

Table 3
Scale score comparisons via pearson correlation analysis.

BHS BDI RSE SPS SPS-NS SPS-D SPS-A

BHS r 1 .741 .744 .770 .720 .729 .014
p .000 .000 .000 .000 .000 .914
BDI r .741 1 .716 .649 .500 .732 .004
p .000 .000 .000 .000 .000 .975
RSE r .744 .716* 1 .629 .601 .608 –.059
p .000 .000 .000 .000 .000 .645
SPS r .770 .649 .629 1 .843 .788 .334
p .000 .000 .000 .000 .000 .007
SPS-NS r .720 .500 .601 .843 1 .570 –.077
p .000 .000 .000 .000 .000 .545
SPS-D r .729 .732 .608 .788 .570 1 .066
p .000 .000 .000 .000 .000 .602
SPS-A r .014 .004 -.059 .334 -.077 .066 1
p .914 .975 .645 .007 .545 .602

BHS: Beck Hopelessness Scale, BDI: Beck Depression Inventory, RSE: Rosenberg self-esteem scale, SPS: Suicide Probability Scale, SPS-NS: Suicide Probability Scale-Negative
Self and Exhaustion, SPS-D: Suicide Probability Scale- Detachment from life, SPS-A: Suicide Probability Scale- Anger, r: Pearson correlation coefficient.

stress causes, negative beliefs about the disease, coping strategies,
past experiences, lifestyle, hereditary characteristics, social sup-
port, type of disease and the approach of the treatment team to
the patient [9,10].
Given that a patient accepts, adapts, and uses appropriate cop-
ing mechanisms, a part of the psychosocial problems due to the
disease could be prevented. When the individual coping mecha-
nisms, employed to strive the challenges of a chronic disease, do
not work, individuals could face various psychiatric symptoms,
especially anxiety and depression.
In the present study, we found that suicide risk for individuals
with chronic heart failure was significantly higher and their self-
esteem levels were lower when compared to the individuals in
the control group. It was also found that their hopelessness and
depression scores were higher than the healthy controls.
In patients with heart failure, quality of life is impaired due to
effort limitations in daily activities, dietary restrictions, drug side
effects, changes in sexual life, problems encountered at work and
interpersonal environment and frequent hospitalizations [11].
Anxiety and depression triggered by stress are common conditions
in such patient groups, due to the complexity of the disease, high
mortality rates and disease burden perceived by the patients [1].
Koenig et al. [2] reported that the prevalence of depression was
37% in patients, 60 years of age or older, who were hospitalized
due to heart failure. Zahid et al. [12] indicated that the rate of
depression incidence in patients with heart failure was 60%. There
exists a two-way relationship between heart failure and depres-
sion. Depression itself is capable of increasing the symptoms of
heart failure and physical and social restrictions related to the dis-
ease could cause depression due to the development of heart fail-
ure [13]. In patients with cardiovascular diseases, depression is
considered a significant risk factor, since it increases cardiac
mortality [14].
The self-esteem an individual has could affect his/her reaction
to the disease or prevent him/her getting used to newly-
developing conditions [15]. Commonly, self-esteem is defined as
the feeling of self-worth, strength and success and either could
be defined as the difference between the self-perception of an indi-
vidual and the individual he/she wants to be. Individuals with high
self-esteem are better in adapting a negative situation and control-
ling their emotions through coping mechanisms once they encoun-
ter a negative situation in daily life. Furthermore, individuals with
high self-esteem have high levels of satisfaction with their social
environment and life [16]. However, those with low self-esteem
could face difficulties in adapting to changes since they are more
anxious, pessimistic, and have negative thoughts about the future
[17]. In certain cases, high self-esteem of an individual could
decrease due the occurrence of a physical or psychological disorder
[18]. In the present study, we determined that self-esteem was
very low in patients with heart failure and there was a negative
relationship between self-esteem and suicide risk.
In literature, it was established that suicide risk in individuals
with heart failure was higher than the general population [3].
Increased suicide risk in heart failure patients was indicated as clo-
sely related to depression in these patients [19]. Suicide attempts
resulting with death were studied for a time period of 13 years
and the existence of chronic diseases were evaluated. It was deter-
mined that 4.4% of these cases were diagnosed with heart failure
[4].
In a 15-year retrospective study conducted by Wu et al., in
2018, the mortality rates related to suicide were investigated in
patients with cardiovascular diseases. The study concluded that
death by suicide rates were higher in the patient group than the
control group. The same study established that progressive mortal-
ity rates increased in patients with heart failure and in patients
with pacemakers [20]. Another study conducted in 2009, it was
54 H. Korkmaz et al. / Journal of Clinical Neuroscience 68 (2019) 51–54
examined whether the quality of life and depression levels were
related to suicidal thoughts and self-injurious behaviors in patients
with congestive heart failure. The study pointed out that suicidal
thoughts and self-harm behavior were determined in 17.1% of
the patient group [21].
Given that an individual considers suicidal behavior as a solu-
tion to his/her problems, the health status of that individual
becomes an important factor. Individuals with impaired health
were found to have more suicidal thoughts or attempt suicide than
individuals with good health conditions [22]. Such finding could
stem from the fact that a patient who maintained his/her life as
an independent individual, had to put several changes into practice
regarding his/her lifestyle due to the disabilities occurred after the
disease. Furthermore, the dependence on other individuals, feel-
ings of self-helplessness, powerlessness and not being productive
as before could play an important role in such cases. Suicidal
behavior occurs as a result of the self-directed anger, furor and
frustration rather than directing these feelings to the real object/-
condition [23]. In the present study, anger scores were found to be
lower in the patient group. Such outcome could be interpreted as
not reflecting anger outwards and instead directing it towards self
as a form of suicidal ideation.
A recent review indicated that the most important variable
associated with suicidal ideation was hopelessness [11]. Feelings
of hope and confidence towards future was considered one of the
most significant factors that help the patient to cope with many
adverse situations due to disease progression. An individual expe-
riencing hopelessness and suffering wants to get rid of the adverse
situation he/she is in. The individual, who fails to figure out a solu-
tion other than death could choose to end his/her life. Hopeless-
ness is more effective than depression in predicting suicidal
ideation [24]. The present study established that hopelessness
scores were higher in the patient group compared to the control
group and were significantly correlated with suicide probability
scores. The risk of suicidal behavior in individuals, who are
attached to life and have reasons to survive, would as well be quite
low. Individuals, who have no reason to survive and who do not
have positive thoughts about future, have a higher risk of suicidal
behavior due to any encountered stressor [22].
5. Conclusion
Suicide risk was higher in patients with heart failure incompar-
ison to the control group. Such increase in suicide risk significantly
correlated with high levels of hopelessness, depression, low self-
esteem in the patient group. The identification of suicidal ideation
in the present patient group facilitates both the prevention of sui-
cidal behavior and the positive contribution to treatment.
6. Limitations of the study
Only patients who accepted to respond the scales were included
in the present study. It is possible that several patients with heart
failure did not participate in the study due to their existing condi-
tions (avolüsyon) and depressive moods. Although the mean scores
of the patient group were significantly higher than the control
group, these rates could tend to increase due to the participation
of these patients. It is also evident that there is certain need for
studies that target larger sample populations. Furthermore,
although the scales used in the study were self-report measures,
it was concluded that the information reported by the patients
were genuine. Although clinical examinations were conducted to
evaluate the patients, the use of the scales implemented directly
by the physician could lead to more objective findings. The sample
size was limited in the present study. Expanding the sample size in
similar studies would contribute to the production of more
detailed findings in the future.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jocn.2019.07.062.
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