Egyptian Journal of Psychiatry

: 2014  |  Volume : 35  |  Issue : 3  |  Page : 151--160

Demographic and personality assessment in relation to suicidal ideation in depressive disorders

Amany E Mohamed, Nelly R Abdel Fattah, Nagda M El Masry 
 Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Correspondence Address:
Nelly R Abdel Fattah
Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig


Background Suicidal ideation is common in depressive disorders, but only moderately related to depression severity. To prevent suicidal behavior, it is important to better understand the personality traits associated with suicidal ideation because prediction and assessment of suicidal ideation in depressed patients is an essential factor for proper management. Objective We aimed to assess some demographic profile and personality traits in relation to suicidal ideation in depressive disorders. Patients and methods A cross-sectional study was conducted in the Inpatient Ward and the Outpatient Clinic of the Psychiatry Department, Zagazig University Hospitals, Sharkia, Egypt, during the period from January 2013 to June 2014. Seventy patients (46 female and 24 male), age from 18 to 60 years, with depressive disorders diagnosed according to the Diagnostic and statistical manual of mental disorders, 4th ed. (DSM-IV) were subjected to a screening using the Modified Scale for Suicidal Ideation and the Eysenck�SQ�s Personality Questionnaire (Arabic version). Results 65.7% of the patients included in the study had suicidal ideation during the course of their illness. Female patients, patients who were divorced, widowed, or married, and those with more than 6 years of education had high rates of suicidal ideation. Also, there was a statistically significant relation between suicidal ideation and Psychoticism and Neuroticism personality domains. Conclusion Suicide ideations are common among patients with depressive disorders and are associated with neurotic and psychotic personality traits.

How to cite this article:
Mohamed AE, Abdel Fattah NR, El Masry NM. Demographic and personality assessment in relation to suicidal ideation in depressive disorders.Egypt J Psychiatr 2014;35:151-160

How to cite this URL:
Mohamed AE, Abdel Fattah NR, El Masry NM. Demographic and personality assessment in relation to suicidal ideation in depressive disorders. Egypt J Psychiatr [serial online] 2014 [cited 2023 Dec 10 ];35:151-160
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Full Text


Suicidal behavior is a major public health problem and presents significant challenges to individuals, families, and public health systems throughout the world (Bertolote and Fleishman, 2002; Schlebusch L., 2005; Suicidal behaviour in South Africa, Pietermaritzburg, University of KwaZulu-Natal Press; Brezo et al., 2006).

Suicidal behavior, ranging from suicide ideation to suicidal acts such as parasuicide, attempted suicide, and completed suicide, is widely pervasive and has reached critically wide-ranging proportions in South Africa (Schlebusch, 2005) as well as internationally (Fergusson et al., 2000; Fanous et al., 2004).

Figures from the WHO show that about one million people worldwide commit suicide every year, accounting for more deaths than homicide and war combined (Schlebusch, 2005).

In the year 2000, a suicide was completed every 40 s and attempted every 3 s worldwide (Moosa et al., 2005).

Furthermore, according to the WHO estimates based on current worldwide trends, for the year 2020, ~1.53 million people will die from suicide and 10-20 times more people will attempt suicide, representing on average of one death every 20 s and one attempt every 1-2 s (Bertolote and Fleishman, 2002).

Depression is the fourth leading cause of disease burden, and it causes the largest amount of nonfatal burden, accounting for almost 12% of all total years lived with disability worldwide. It represents a major public health problem that affects patients and the society (Usten et al., 2004).

Fountoulakis et al. (2004) mentioned that depression is the most common mental disorder related to suicidal behavior. They further suggested the possible presence of neurobiological mechanisms to support the presence of a higher arousal level or disinhibition of self-directed aggressive thoughts in order for a patient to become suicidal.

Research on depression and suicide is important for three reasons.

(1) They represent a large health burden: depression is the leading cause of disability-adjusted life years attributable to mental, neurological, and substance-use disorders in both high-income, low-income, and middle-income countries (Collins et al., 2011), and suicide accounts for one million deaths per year worldwide (World Health Organization, 2011).

(2) To support the increasing efforts of the WHO and other organizations to implement task shifting in mental healthcare in low-income settings, there is a need to identify optimal referral strategies and key risk factors for screening (Belkin et al., 2011).

(3) Known risk factors can be used to design prevention activities to minimize the incidence, the morbidity, and the mortality associated with depression and suicide (Collins et al., 2011).

Prediction of suicidal risk in major depressive disorders is very important for preventing suicide (Lee and Kim, 2011).

It is well established that suicidal ideation is closely linked to suicidal behavior such as attempted or completed suicide (Sokero et al., 2003; Heisel, 2006; Reinherz et al., 2006; Oquendo et al., 2007).

To understand and prevent suicidality, it is important to get a deeper insight into those personality traits and demographic data that may be linked to suicidal ideation. In this context, the temperament and the character model of personality is of special importance, because it attempts to describe the neurobiological structure underlying the pervasive attitudes of the individual towards the environment (Cloninger et al., 1993, 1994).

Pervin and John (1997) suggest that trait theories facilitate the exploration of the relationship between personality and various behaviors. Specifically, personality traits have been implicated as playing an important role in understanding suicidal behavior and have a number of properties that make them targets in the area of suicidal behavior research.

Brezo et al. (2006) explain that personality traits affect variables that may contribute to diathesis for suicide, namely our perception of and adaptation to the environment and self. In addition, personality trait predictors of suicidal behavior could be useful in identifying subgroups of suicidal individuals before these individuals' attempt, repeatedly attempt, or complete suicide.


(1) To determine a demographic profile in relation to suicidal ideation in depressive disorders.

(2) To assess personality traits in relation to suicidal ideation in depressive disorders.

 Patients and methods


This work included 70 patients (46 female and 24 male) with depressive disorders diagnosed according to the Diagnostic and statistical manual of mental disorders, 4th ed. (DSM-IV) diagnostic criteria (the sample size was estimated by a professional statistician according to a population size of 600, the power of study at 80%, and confidence interval 95%). Patients were selected from both the Inpatient Ward and the Outpatient Clinic of the Psychiatry Department, Zagazig University Hospitals, Sharkia, Egypt, by the systematic random sampling technique.

Patients were divided into two groups:

(1) The suicidal ideator group: 46 patients with depressive disorders with suicidal ideation.

(2) The nonsuicidal ideator group (controls): 24 patients with depressive disorders without suicidal ideation.

Inclusion criteria

Criteria for inclusion were as follows:

(1) All patients should meet DSM-IV criteria for a depressive episode.

(2) Both sexes will be included.

(3) Age range from 18 to 60 years.

Exclusion criteria

(1) Age below 18 and above 60 years.

(2) A history of substance abuse.

(3) Presence of severe physical disorders, organic brain disease, mental retardation, and low comprehension skills.

Patients who met the inclusion criteria were selected by the systematic random sampling technique and asked to participate in the study after their agreement.


All patients were subjected to the following assessment procedures under the supervision of supervisors:

(1) Full psychiatric examination through a semi-structured interview (including specific data regarding demographic data) using the sheet of the Department of Psychiatry, Zagazig University.

The semi-structured interview contained a full psychiatric sheet, which allowed each patient to receive psychiatric diagnosis by its end, during which the DSM-IV diagnosis of a depressive episode was confirmed according to the DSM-IV criteria (American Psychiatric Association, 2000).

(2) General medical examination of patients was performed to exclude the presence of severe physical disorders and organic brain disease.

(3) The following psychometric scales were administered for psychometric assessment:


The Modified Scale for Suicidal Ideation (MSSI) for the assessment of suicidal ideation (Miller, 1991).


The Eysenck's Personality Questionnaire (EPQ) (Arabic version) (Eysenck and Eysenck, 1985).

The Modified Scale for Suicidal Ideation

Description : The scale consists of 18 questions that are scored from 0 to 3. Total scores range from 0 to 54. A total score based on the sum of all items is calculated to estimate the severity of suicidal ideation. For efficiency purposes, the first four items of the scale are designated as screening items (e.g. patients reporting a moderate or strong wish to die) to warrant the administration of the entire scale.

Reliability: The MSSI has high internal consistency, with Cronbach's α coefficients ranging from 0.87 (Clum and Yang, 1995) to 0.94 (Miller et al., 1986), and good item-total correlations (0.41 to 0.83) (Miller et al., 1986). The MSSI also has adequate test-retest reliability (r = 0.65) over a 2-week period (Clum and Yang, 1995).

Concurrent validity: Concurrent validity of the MSSI has been established. The MSSI has a moderately high correlation with the SSI (r = 0.74) (Clum and Yang, 1995) and a moderate correlation with the suicide item from beck depression invenitory (BDI) (r = 0.60) (Miller et al., 1986). Also, the MSSI is significantly correlated with the total BDI (r = 0.34) (Miller et al., 1986), the Zung Depression Scale (r = 0.45) (Clum and Yang, 1995), and the Beck Hopelessness Scale (r = 0.46) (Clum and Yang, 1995). In addition, patients who made multiple suicide attempts scored higher on the MSSI than patients who had attempted suicide only once or suicidal patients who had not attempted suicide (Rudd et al., 1996).

Evaluation: The MSSI is a modification of the SSI that includes the addition of several items that assess aspects of suicide thinking. Ratings of individual MSSI items use a four-point scale instead of the three-point scale. The reliability and concurrent validity of the MSSI has been established. MSSI items measure suicide ideation as defined by O'Carroll et al. (1996).

Eysenck's Personality Questionnaire for the assessment of personality

Arabic version : It was translated to Arabic by Ahmed Mohamed Abdel Khalek in 1991. It is used to assess Neuroticism, Psychoticism, Extraversion, and Lie scale. Extraversion is characterized by being outgoing, talkative, high on positive affect (feeling good), and in need of external stimulation. Neuroticism or Emotionality is characterized by high levels of negative effects such as depression and anxiety. Psychoticism is associated not only with the liability to have a psychotic episode (or break with reality), but also with aggression. Psychotic behavior is rooted in the characteristics of tough mindedness, nonconformity, inconsideration, recklessness, hostility, anger, and impulsiveness. The lie scales were originally introduced into personality measures to detect the tendency of some respondents to fake good. The questionnaire is formed of 91 questions divided into 23 questions to measure the Neuroticism domain, 20 questions to measure the Extroversion domain, 23 questions to measure the Psychoticism domain, and 23 questions to measure the Lie domain, answered by yes or no, and each question takes a score; then, the total score for each domain is calculated.

Administrative design

Written informed consents were obtained from participants. The study design was approved by Ethical Committee of Zagazig University Hospital.

The following statistical techniques were used:

Data were collected, revised, entered, and then analyzed on a PC. Data collected were analyzed using the statistical program for the social sciences (SPSS, version 20; SPSS Inc., Chicago, Illinois, USA) software by a professional statistician. Data were expressed as mean±SD for quantitative variables, and the number and percentage for categorical variables.

The following tests were conducted:

Mean, SD, χ2 -test, and analysis of variance. The correlation coefficient was used when the appropriate logistic regression model was used to find the predictors of suicidal ideation. P value was used to indicate the level of significance. The results were considered significant when P value was less than 5% (P < 0.05), nonsignificant when P value was more than 5% (P > 0.05), and highly significant when the P value was less than 0.1% (P < 0.001) (Armitage, 1998).


Demographic data of the studied individuals are shown in [Table 1], major depressive disorder is the most common among depressive disorders in the studied group, and the majority of the sample was never hospitalized to a psychiatric hospital [Table 2], but there was a high prevalence (65.7%) of suicidal ideation [Table 3], with the highest score of the serious patients for the MSSI [Table 4]. There was no statistically significant difference regarding the diagnosis of depressive disorders between the suicidal ideator and the nonsuicidal ideator patient groups [Table 5]. In relation to demographic data, female patients, divorced, or widowed, and those with more than 6 years of education had a high rate of suicidal ideation. Also, there was a statistically significant relation between suicidal ideation and Psychoticism and Neuroticism personality domains ([Table 6], [Table 7], [Table 8], [Table 9]).{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}{Table 7}{Table 8}{Table 9}


This study was conducted with the aim of studying some demographic profiles in addition to the personality assessment of suicidal ideation in depressive patients.

The setting of a study, whether inpatient based or outpatient based, is one of the most important factors that determines the rate of suicidal behavior because hospitalized patients reflect the more severe forms of depressive disorders with high rates of suicidal ideation and attempts. However, some studies conducted in an outpatient setting reported figures close to those reported in other studies conducted in inpatient settings. To overcome this variable, our study was conducted on both outpatients and inpatients.

The rate of suicidal ideation in patients with depressive disorders in the current study was 65.7%. This high rate conforms to rates reported in other studies conducted within inpatient and outpatients settings (Duggan et al., 1991; Nordström et al., 1995; Keilp et al., 2012).

Regarding the association between suicidal ideation and age, several follow-up studies have found that the risk of suicidal ideation was greater in older than in younger respondents (Hjelmeland et al., 1998; Beautrais, 2001; Gibb et al., 2005). Furthermore, an increase in age was found to be associated with a higher suicidal ideation (Harriss et al., 2005). This result was in contrast to other studies, which found that suicidal ideation was more likely in younger than in older respondents (Shaheen, 1983; Kessler et al., 2005; Nock et al., 2008; Johnston et al., 2009; Tomlin et al., 2012). However, some studies have not found an association between age and suicidal ideation (Hjelmeland et al., 1998; Druss and Pincus, 2000) or age as a significant predictor of suicidal ideation (Ostamo and Lönnqvist, 2001).

In our study, the proportion of patients having suicidal ideation tended to increase as the participants aged (56.0% in the age group of 18-30 years, 65.0% in the age group of 30-40 years, and 76.0% in the age group of 40-60 years), but it was not statistically significant. This result more or less confirms previous findings in this concern.

The preponderance of suicidal ideation in the younger age group could be explained by the ambitious tendencies of the youth and immaturity, but suicidal ideations among patients between the ages of 40 and 60 years can be attributed to a frustrating environment and frequent crises that characterize this age.

The female-to-male ratio among suicidal ideators was variable. Most of the studies in this field indicate that suicidal ideation is more common in women than in men (Applepy et al. (1999); Isomet et al., (2005); Keilp et al., 2012).

In a study by Allison et al. (2001) that examined depression and suicidal ideation among adolescent Australian women, the results demonstrated that women (27.3%) reported suicidal ideation with greater frequency in comparison with men (18.9%).

A sex difference was also found in the prevalence of suicide ideation. A significantly higher lifetime prevalence of suicide ideation was found in women compared with men (De Leo et al., 2005; Nock et al., 2008).

In our study, sex was found to have a strong relation with suicidal ideation according to logistic regression analysis, which shows that women have more suicidal ideation than men, and so, female sex may be considered as a predictive factor and a significant determinant of suicidal ideation. This can be attributed to the following.

Although being male is an important risk factor to commit suicide, the presentation of suicidal ideation is generally more common among women. Women are also more likely to seek help from general practitioners for their mental health problems (Osvath et al., 2003). These differences may be viewed as artifacts of men's lower likelihood to seek help or because the symptoms of male depression are different from that of women's. If the symptoms of a mental disorder are perceived as inconsistent with masculinity, men try to hide such symptoms (as signs of weakness) and do not ask for treatment (Payne et al., 2008). Men rarely ask for professional help, and they are also more reluctant to ask for support from family and friends (Biddle et al., 2004). This reluctance and the special features of male depression may contribute to the fact that depression is more often undetected and untreated among men (Rihmer et al., 2002). This may - at least partially - explain the striking paradox: major depression (which has the strongest association with suicide among mental disorders) is about twice as common among women than men, but men are four times more likely to commit suicide than women (Rihmer et al., 2002).

In the current study, suicidal ideation was higher (85.7%) among patients with more than 6 years of education (statistical significance, P = 0.02). Nonsuicidal ideation was higher (53.8%) among illiterate patients (statistical significance, P = 0.01). This result was in contrast to a previous study that associated higher education with a lower prevalence of suicidal ideation (Andrews et al., 2001). However, this agrees with the most recent study by Wang et al. (2013) and Ang and Huan (2006), who found that higher education was significantly associated with suicidal ideation.

This contradiction can be attributed to the different methodologies and sample sizes in some studies.

The higher suicidal ideation among patients with higher education in our study can be explained by the fact that patients with a higher education encounter a variety of biopsychosocial, environmental, and/or sociocultural factors, which could increase their risk for developing depression, anxiety disorders, substance abuse, and suicidal behaviors.

An increased likelihood of suicidal ideation among unemployed people has been reported in numerous studies (Thomas et al., 2002; Gunnell et al., 2004; Beautrais et al., 2006).

In addition, there is a well-established link between unemployment and suicide and self-harm (Platt and Hawton, 2000; Janet Kuramoto et al., 2013).

Andrés and Halicioglu (2010) found that a higher income was associated with higher suicide rates. The employment status was found to be associated with suicide ideation (Crosby et al., 1999), suicide-related behavior (Crosby et al., 1999; Taylor et al., 2004; Carter et al., 2007), and suicide (Andrés and Halicioglu, 2010).

Even though our result shows that there is no statistically significant association between occupation and suicidal ideation, yet 66.7% of suicide ideator patients were employed and 66% of suicide ideator patients were unemployed, and this in agreement with the above-mentioned studies. This can be attributed to stressful life events and frustrations in both unemployed and employed patients.

Our results show that the highest rate of suicidal ideation was reported by divorced patients (100.0%), followed by widowed patients (71.4%), and then married patients (65.2%), and finally single patients (60.0%).

These results are consistent with previous studies, as Lee et al. (2010) reported that divorce was a significant risk factor for suicidal ideation among 2054 Taiwanese adults. Whereas being divorced is associated with higher suicide rates (Andrés and Halicioglu, 2010), being not married or in a difficult relationship is associated with suicide ideation in the past year (Pirkis et al., 2000) and suicide-related behavior (Hawton et al., 2003).

The relation between being married and suicidal ideation is surprising as similar effects have not been observed previously, as marriage is a protective factor against suicide, and generally, marriage is an institution of protection against pressures of everyday life. However, some studies have confirmed our findings, as they reported that marriage might not be protective in all cultures, especially for young women as marriage itself may become an instrument of distress, because married individuals are affected by various problems in life such as a lack of intimacy, marital strife, and financial concerns (Al Ansari and Ali, 2009; Watzka, 2012).


While analyzing the place of residence and its relation with suicidal ideation, we found that 67.2% urbanites and 58.3% ruralites had suicidal ideation. This shows a high percentage of suicidal ideation in the urban population. This may indicate the hazards of overcrowding of urban areas with subsequent social deprivation and weak family ties.

In our results, 66.7% of the patients in the suicide ideator group were not admitted in psychiatric hospitals before. One explanation for this is that in our community, people prefer to treat most of the psychiatric disorders in private outpatients clinics where more confidential conditions are available.

After determining the relation between demographic data and suicide ideation, we sought to establish whether there was an association between personality and suicide ideation.

There is accumulating empirical evidence on personality traits as correlates of suicide ideation and that certain personality traits may increase individual vulnerability to suicidality.

In our study, we found that the rate of suicidal ideation among depressed patients according to the Neuroticism domain of EPQ was 65% high, 6.5% low, and 28.5% normal on Neuroticism.

This illuminates the relation between suicidal ideation and high Neuroticism, which is statistically significant (P = 0.001).

This finding is consistent with the findings of previous studies that showed that individuals high in Neuroticism were more likely to present with suicidal ideation (Lester and Francis, 1993; Fergusson et al., 2000; Kerby, 2003; Useda et al., 2004; Brezo et al., 2006).

The finding of the present study reaffirms that Neuroticism is related to suicide ideation and underscores the importance of understanding the role that personality plays in suicidal behavior.

Specifically, elevated Neuroticism scale scores characterize individuals who are susceptible to psychological distress, which in turn interferes with an individual's adaptation and results in coping more poorly than others with stress (Costa and McCrae, 1992).

Accordingly, empirical evidence indicates that high scores on Neuroticism are consistently associated with ineffective and passive coping mechanisms, such as avoidant and emotion-focused coping, which represent the least effective coping mechanisms (Watson and Hubbard, 1996).

In other words, the problem-solving style of individuals who score high on Neuroticism tend to be characterized by avoidance and being emotion focused, which tend to be ineffective. This is particularly significant as coping styles have been implicated as being a mediator between stressful situations and negative outcomes (Lazarus and Folkman, 1984) such as engaging in suicidal behavior (Josepho and Plutchik, 1994).

Hence, it is proposed that elevated Neuroticism represents an individual risk for suicidal behaviors as these individuals may resort to engaging in suicidal behaviors as a result of coping ineffectively with stress. Furthermore, a prediction model of suicide risk proposes that problem-solving deficits could increase the severity of hopelessness and depression, which then in turn increases suicidal risk (D'Zurilla et al., 1998).

High Neuroticism denotes an enduring diathesis for negative emotionality and a variety of distress disorders, in particular depression (Costa and McCrae, 1992; Cox et al., 2004), which has been consistently associated with suicidality (Vuorliehto et al., 2006). It could be conceptualized that the interaction of all of these variables may increase an individual's susceptibility to suicide ideation and possibly eventually engaging in more serious suicidal acts.

Low Neuroticism characterizes individuals who are emotionally stable (Digman, 1990; Costa and McCrae, 1992; Watson and Hubbard, 1996; Larsen and Buss, 2005; Ryder et al., 2005) and tend to be calm, secure, relaxed, even-tempered, and deal with stressful experiences effectively (Costa and McCrae, 1992; Ryder et al., 2005).

Hence, participants in this study who were emotionally stable and tend to be calm, secure, relaxed, even-tempered, and deal with stressful experiences effectively reported being more optimistic and hopeful about the future, scoring low on Neuroticism, which acts as a protective factor against suicide ideation. Costa and McCrae (1992) report that individuals who tend to be confident and optimistic are low in the Neuroticism domain, which may serve as a protective factor against suicide ideation, which in turn could protect against eventually engaging in more serious suicidal acts. This finding has the potential to inform prevention and intervention strategies aimed at addressing suicide ideation. Factors that contribute to emotional instability and insecurity could be targeted. Furthermore, these strategies could address techniques that assist in being calmer, more relaxed, even-tempered, and with coping more effectively with stressful experiences.

This finding may be attributed to the fact that those who score high on Neuroticism are prone to experience negative emotions (such as sadness, fear, and guilt), have irrational ideas, have difficulty controlling impulses, and be less able to cope with stress. Relative to high scorers, those who score low on Neuroticism are more likely to be calm and even-tempered.

In our study, we found that the rate of suicidal ideation among depressed patients according to the Extraversion domain of EPQ was 10% high, 19.6% low, and 69.6% normal on Extraversion, and there was no statistically significant correlation between the presence of suicidal ideation and the Extraversion domain.

This is consistent with previous studies (Farmer et al., 2002; Useda et al., 2004, 2007; Tsoh et al., 2005; Heisel et al., 2006; Cha and Nock, 2009) that showed that suicidal ideation is negatively correlated with suicidal ideation.

Extraverted individuals, even in the midst of a depressive episode, were found to be less likely to engage in suicidal behavior as a result of being more likely to recruit and effectively benefit from interpersonal relations, possibly because of better social skills (Duberstein et al., 2000).

Studies have also reported that psychoticism is significantly related to suicide (Velting, 1999; Kerby, 2003; Brezo et al., 2006; Pienaar et al., 2007).

Hills and Frncis (2005) demonstrated that previous studies have generally linked high levels of suicidal ideation with higher Psychoticism scores.

In our study, we found that the rate of suicidal ideation among depressed patients according to the Psychoticism domain of EPQ was 69.5% high, 6.5% low, and 24% normal on Extraversion, and there was a statistically significant correlation between the presence of suicidal ideation and the Psychoticism domain. This is consistent with above-mentioned studies. This may be attributed to the following features that characterize this domain: being cold, impersonal, hostile, lacking in sympathy, unfriendly, untrustful, odd, unemotional, unhelpful, lacking in insight, strange, with paranoid ideas that people were against them.

Also, a nonparametric correlation between the personality scale and suicidal ideation was found, and it showed that there was a significant relation between suicidal ideation and Psychoticism and Neuroticism, but a nonsignificant correlation between suicidal ideation with Extraversion, and this confirms our results.[88]

In addition, a logistic regression analysis on all our patients' data showed that the highly significant factors that predict suicidal ideation and add significance to the model were sex, education, and psychoticism, which also reaffirm our results.



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