Journal of the American Academy of Child and Adolescent Psychiatry, July 1995 v34 n7 p919(10)

Self-esteem deficits and suicidal tendencies among adolescents. James C. Overholser; Dalia M. Adams; Kim L. Lehnert; David C. Brinkman.

Author's Abstract: COPYRIGHT American Academy of Child and Adolescent Psychiatry 1995

Objective: Self-esteem can play an important role in suicidal tendencies among adolescents. The present study was designed to examine the relationship between self-esteem deficits and suicidal tendencies in 254 adolescent psychiatric inpatients and 288 high school students. Method: The direct relationship between self-esteem and suicidal tendencies was examined by assessing suicidal ideation and history of suicide attempts. An indirect relationship between self-esteem and suicidality was examined by assessing depression and hopelessness. Results: Differences were found across gender and hospitalization status, with males reporting higher self-esteem than females and high school students scoring higher in self-esteem than psychiatric inpatients. However, correlations among variables remained similar across gender and hospitalization status. Thus, low self-esteem was related to higher levels of depression, hopelessness, suicidal ideation, and an increased likelihood of having previously attempted suicide. Furthermore, self-esteem added to the understanding of suicidal ideation beyond what could be explained by depression and hopelessness. Conclusions: Low self-esteem was closely related to feelings of depression, hopelessness, and suicidal tendencies. Assessment of adolescents should include an evaluation of self-esteem, and therapy should attempt to address any self-esteem deficits. J. Am. Acad. Child Adolesc. Psychiatry, 1995, 34, 7:919-928. Key Words: self-esteem, depression, suicide, adolescence.

Full Text: COPYRIGHT American Academy of Child and Adolescent Psychiatry 1995

Self-esteem reflects the evaluative component of self-concept. Self-esteem refers to the global appraisal a person makes of his or her own value as a competent and worthwhile person. People with high self-esteem tend to be satisfied with their lives and hold a positive attitude toward themselves. They display a genuine sense of self-acceptance, self-worth, and self-respect (Rosenberg, 1985). In contrast, people with low self-esteem evaluate the self as unworthy and incompetent. Thus, self-esteem can have a profound influence on a person's cognitions, emotions, and responses to stressful life events.

Self-esteem tends to develop during childhood and remains relatively stable throughout adolescence (Dusek and Flaherty, 1981). In longitudinal studies, few changes in self-esteem have been observed from late childhood through the end of the teenage years (Barnes and Farrier, 1985) and into early adulthood (Bachman and O'Malley, 1977). However, the cognitive development that occurs during adolescence leads to an increased ability to conceptualize the self in terms of an abstract, multidimensional framework (Rosenberg, 1986). Also, during adolescence, there is an increased focus on the self and the internal world of thoughts and feelings (Harter, 1990; Rosenberg, 1986). The adolescent becomes increasingly aware of the self and better able to evaluate the self, making self-esteem more salient during adolescence. Therefore, when self-esteem is low, it is likely to be a stable problem and may become a central focus of the adolescent's life. Such a consuming problem may be the cause of much emotional distress.

Self-esteem deficits appear to play an important role in understanding suicidal behavior among adolescents. Both suicidal ideation and suicide attempts may be related to persistent negative views of the self. A negative view of the self may involve seeing the self as worthless and the future as hopeless. The adolescent with low self-esteem may see life as not worth living and may perceive everyday stressors as overwhelming. Low self-esteem has been found to be important in the prediction of suicidal ideation among high school students (Dukes and Lorch, 1989). The presence and severity of suicidal ideation in adolescents with affective disorders has been related to low self-esteem (Brent et al., 1986). Low self-esteem is also implicated in suicide attempts made by adolescents (Kienhorst et al., 1990). Furthermore, negative self-evaluations were associated with increased suicidal tendencies, number of suicidal gestures, seriousness of suicidal intent, and medical lethality of the attempt in a study of 64 adolescent psychiatric inpatients (Robbins and Alessi, 1985). Thus, self-esteem deficits appear to be directly related to suicidal tendencies, including both suicidal ideation and suicide attempts in adolescents.

Low self-esteem may indirectly heighten the risk of suicidal behavior by increasing a person's vulnerability to depression. The presence of depression is associated with increased risk of suicidal ideation, attempts (Garrison et al., 1991), and completion (Marttunen et al., 1991). The tendency to see oneself as weak, inadequate, and a failure is clearly related to depressed mood. Low self-esteem has been found to be closely related to depression in child psychiatric patients (Asarnow et al., 1987), adult psychiatric patients (Davis and Unruh, 1981), and college student samples (Pietromonaco, 1985; Wilson and Krane, 1980). These findings are consistent with cognitive theories of depression that postulate negative self-perceptions play a central role in the experience of depression (Bebbington, 1985). A negative view of the self is part of the cognitive triad of depression (Beck et al., 1979) and may predispose a person toward depression and suicidal behavior.

Among adolescents, a relationship between low self-esteem and depression has been found in studies with street youths (Smart and Walsh, 1993) and adolescents admitted to an emergency shelter (Maxwell, 1992). Adolescent psychiatric outpatients receiving treatment for depression have been found to report lower self-worth than nondepressed outpatients or high school students (Marton et al., 1993). Also, a strong association has been found between depression severity and low self-esteem in adolescent psychiatric inpatients, with improvement in depression coinciding with increases in global self-esteem (King et al., 1993). In general, depressed adolescents have been described as displaying self-reproach (Strober, 1985), poor self-image (Inamdar et al., 1979), negative self-concept (Marton et al., 1993), and low self-esteem (Fleming and Offord, 1990; Kandel and Davies, 1982; King et al., 1993).

Self-esteem appears to become a more salient feature of depression as a child matures. Self-esteem is especially relevant during adolescence because of the many changes occurring in the adolescent's life, including new interests, greater responsibilities, and frequent stress from peers, school, and family (Larson and Ham, 1993). Adolescence is often a period of considerable self-criticism and turmoil in terms of self-concept (Rosenberg, 1985). In a study examining both depressed children and adolescents, depressive symptoms and self-esteem deficits tended to increase with age (McCauley et al., 1988). Self-esteem deficits are more common among depressed adolescents than are the biological symptoms of depression (e.g., loss of appetite, weight loss, and somatic problems) that are often reported by adults (Inamdar et al., 1979). Thus, cognitive features of depression appear to be particularly relevant during adolescence.

Low self-esteem may indirectly increase the risk of suicidal behavior by increasing the adolescent's hopelessness and pessimism about the future. Hopelessness is a cognitive factor that is closely related to suicidal behavior (Beck et al., 1985) and suicidal ideation (Steer et al., 1993). The relationship between hopelessness and suicide risk is important because feelings of hopelessness appear to be stable over time (Overholser et al., 1987). Hopelessness involves the perception that current problems are likely to continue with little expectation of positive change. As adolescents develop the cognitive maturity required for long-term planning and the ability to anticipate future events, they may become more concerned with expectations and aspirations about their future (Rosenberg, 1986). Adolescents with low self-esteem may feel unable to bring about positive changes in their lives and are likely to have negative expectations for the future.

Research may be able to clarify the relationship between self-esteem, depression, and suicide risk. However, gender differences have been found in self-esteem when studying adolescents. Although the findings are not consistent across all studies (e.g., Marton et al., 1988; Workman and Beer, 1989), gender differences in self-esteem scores have been found in high school students (Hagborg, 1993) and adolescent psychiatric patients (McCauley et al., 1988). Males and females differ in the overall level of their self-esteem (Barnes and Farrier, 1985; Harper and Marshall, 1991) and the stability of their self-esteem scores over time (Barnes and Farrier, 1985). Furthermore, different elements contribute to self-esteem for males versus females (Griffin et al., 1981). In addition to gender differences in self-esteem, research has consistently found gender differences in adolescent depression (Allgood-Merten et al., 1990; Avison and McAlpine, 1992) and suicidal behaviors (Kotila and Lonnqvist, 1988). Thus, research on self-esteem, depression, and suicidal tendencies must take into account the relative impact of gender.

Despite the potentially important role of self-esteem in suicide risk among adolescents, few studies have directly examined the role of self-esteem in depression and suicidal behavior among adolescents. Most research on self-esteem deficits in clinical samples has been limited to larger studies of depression that include self-esteem as a minor part of the study. For example, Kandel and Davies (1982) found that of 24 different predictor variables (e.g., closeness of relationship with parents, quality of relationship with peers, presence of illicit drug use), self-esteem was most strongly correlated with depressed mood for both adolescent males and females. However, their measure of self-esteem consisted of an unspecified item on a personal characteristics questionnaire. Many studies (e.g., Inamdar et al., 1979; Robbins and Alessi, 1985) base their assessment of self-esteem on a single item from a structured interview. Only the most recent studies have begun to examine more thoroughly the role of self-esteem in adolescent depression (King et al., 1993; Marton et al., 1993). Previous studies have compared levels of depression and self-esteem in different groups but have not examined the extent to which self-esteem is related to hopelessness or suicidal tendencies.

The present study was designed to examine self-esteem deficits as related to suicidality among adolescents. Because depression and hopelessness are known risk factors for adolescent suicidal behavior, the relationship between these factors and self-esteem was also examined. We used several standardized questionnaires to assess both male and female adolescent psychiatric inpatients and high school students. The goal was to evaluate the importance of self-esteem as related to depression, hopelessness, and suicidal tendencies in psychiatrically hospitalized and nonhospitalized adolescents. Although differences across gender and hospitalization status were expected in the observed levels of depression and self-esteem, it was hypothesized that the relationships between variables would remain consistent across groups. Thus, both mean comparison and correlational analyses were used. It was expected that low self-esteem would be related to increased depression, hopelessness, and suicide risk, and these relationships were expected to remain consistent across gender and hospitalization status. Whenever self-esteem is low, it should reflect a general risk for depression, hopelessness, and suicidal tendencies, regardless of the setting or gender of the subject.

METHOD

Subjects

A total of 542 adolescents participated in the present study. The psychiatric inpatient group was composed of 254 adolescents, including 108 males and 146 females with an average age of 15.19 years (SD = 1.39). Some of these patients were included in a study of objective and projective assessment (Brinkman et al., 1994). To minimize the influence of hospital treatment on the assessment of mood states, all inpatients were assessed during the first week of their stay at a private psychiatric hospital. Most of the inpatients were Caucasian (89.8%) and had been hospitalized for a variety of presenting problems. Psychiatric diagnoses were gathered through a review of patients' medical records after their discharge from the hospital. Diagnoses were made by the attending psychiatrists on the basis of DSM-III-R criteria (American Psychiatric Association, 1987). Final diagnoses were made at the time of discharge, after numerous unstructured clinical interviews had been conducted with the patients and their parents. The diagnoses most often given to the adolescent inpatients included depression (diagnosed in 61% of patients), substance abuse (33%), anxiety disorders (14%), adjustment disorders (23%), disorders of childhood (e.g., conduct disorder) (10%), and bipolar disorder (5%). Several patients were given more than one diagnosis and, as a result, the diagnostic percentage totals are greater than 100%. Seven patients with psychotic disorders were excluded from the present analyses.

To control for the impact of hospitalization status on self-esteem and suicide risk, a high school comparison group was used. The comparison group included 288 high school students from two local public high schools and one private high school. The students were recruited by asking teachers and guidance counselors to distribute consent forms and written descriptions of the study to the students. Participation was voluntary and contingent upon both parent and student consent. Students were asked to return the signed consent forms the following school day in order to participate in the study. Because the study materials were distributed in study halls, assemblies, and a wide variety of regular classes in which teachers were willing to help with the research, the percentage of students participating was not always available. In one school in which the information was distributed only by teachers in their regular classes, the participation rate was 66%. Although a few students actively chose not to participate, the majority of students who did not participate had forgotten to return the signed consent forms. The assessment was conducted during normal school hours and was supervised by two clinical psychology graduate students. The high school comparison group included 113 males and 175 females, with an average age of 15.15 years (SD = 1.52). Their racial background was predominantly Caucasian (94.4%). There were no significant differences between the psychiatric inpatients and high school students in terms of age, t(541) = 0.52, not significant (NS); race, [[Chi].sup.2](3) = 5.80, NS; or gender, [[Chi].sup.2](1) = 0.47, NS. Schools were selected from communities that were similar to the patient population in geographic location and socioeconomic status.

Measures

The Rosenberg Self-Esteem Scale (RSE) (Rosenberg, 1965) includes 10 general statements assessing the degree to which respondents are satisfied with their lives and feel good about themselves. The RSE provides an established measure of global self-worth. Statements are rated on a 4-point scale ranging from strongly agree to strongly disagree. The RSE has obtained adequate evidence of internal consistency and temporal stability among young males (Bachman and O'Malley, 1977). Also, the RSE has shown evidence of construct validity as a measure of global self-esteem in adolescents (Hagborg, 1993) and young adults (Fleming and Courtney, 1984). The RSE has been recommended as a psychometrically sound measure for use with school-age children (Chiu, 1988; Gurney, 1986).

The Children's Depression Inventory (CDI) (Kovacs, 1985) includes 27 items describing common symptoms of depression. The CDI has demonstrated adequate levels of reliability and validity in previous research (Nelson et al., 1987; Smucker et al., 1986). The CDI is an established measure of depression severity in children and adolescents (Kendall et al., 1989).

The Hopelessness Scale for Children (HSC) (Kazdin et al., 1983) includes 17 true/false items designed to measure pessimism and negative expectations for the future. The HSC has demonstrated evidence of reliability and validity with adolescent samples (Spirito et al., 1988). Because of poor psychometric properties associated with item 4 (Kazdin et al., 1986), this item was omitted from the total score.

During assessment, all subjects were asked about current and previous suicidal feelings. Suicidal ideation was rated as absent, passive (thoughts of suicide without concrete plans or method and a stated unwillingness to attempt suicide), or active (current thoughts of and desire for death by suicide) based on item I of the CDI which addresses suicidality. Previous suicidal behavior was assessed by several questions added to the CDI. Subjects were asked whether they had ever attempted suicide. If they had previously made a suicide attempt, they were asked to report the number, method, and dates of any previous attempts.

RESULTS

Because the present study focuses on the assessment of self-esteem, preliminary analyses examined the internal consistency of the RSE to ensure that it provides a reasonable estimate of self-esteem as a unidimensional construct. Item-to-total score correlations were consistently high for both the adolescent psychiatric inpatients and the high school comparison group (Table 1). Also, Cronbach's (1951) coefficient [Alpha] was high, reflecting adequate internal consistency of the scale. Despite its brevity, the RSE appears to be a reliable measure of self-esteem.

To examine differences in the levels of self-esteem of the male and female psychiatric inpatients and high school students, we used a 2 x 2 analysis of variance, which revealed significant differences across hospitalization status, F(1,541) = 5.74, p [less than] .02, and gender, F(1,541) = 12.47, p [less than] .001, with high school students scoring slightly higher than the psychiatric inpatients on the RSE and males reporting significantly higher self-esteem scores than females.

TABLE 1
 
Internal Consistency of the Rosenberg Self-Esteem Scale
 
                                             Item-to-Total Score r
 
                                           Psychiatric   High School
                                           Inpatients     Students
 
Rosenberg Self-Esteem Scale items
 
On the whole, I am satisfied with
myself.                                        .74          .70
 
At times I think I am no good
at all.                                        .81          .69
 
I feel I have a number of good
qualities.                                     .80          .72
 
I am able to do things as well as
most people.                                   .71          .70
 
I feel that I do not have much
to be proud of.                                .80          .70
 
I take a positive attitude toward
myself.                                        .83          .79
 
I feel that I'm a person worthy
of at least being on an equal
plane with others.                             .68          .51
 
I certainly feel useless at times.             .82          .70
 
I wish I could have more respect
for myself.                                    .57          .63
 
All in all, I am inclined to feel that
I am a failure.                                .83          .70
 
Coefficient [Alpha]                            .92          .87
 
Total score
 
Mean                                         29.43        30.64
SD                                            6.81         5.44

Because of the preliminary differences across gender and hospitalization status, in subsequent analyses we divided subjects into groups based on gender and hospitalization status. However, to examine the relative importance of self-esteem on depression, hopelessness, and suicidal tendencies, main analyses were done using a 2 x 2 x 2 analysis of variance design to examine the differential impact of hospitalization status, gender, and self-esteem (Table 2). This allowed us to examine the relative importance of group differences on the various measures. Low versus high self-esteem was dichotomized using the standard cutoff score of 30 for the RSE. Subjects scoring exactly at the cutoff score were excluded from these analyses. A significant hospitalization status by self-esteem interaction was observed on the CDI, F(1,491) = 21.65, p [less than] .0001. The preliminary gender differences disappear when using a 2 x 2 x 2 design. Hence, the figures show differences in level of self-esteem across hospitalization status but not across gender. When self-esteem was high, there were no differences in depression severity between psychiatric inpatients and high school students [ILLUSTRATION FOR FIGURE 1 OMITTED]. However, psychiatric inpatients with low self-esteem reported higher levels of depression than did high school students with low self-esteem. A significant group by self-esteem interaction was observed on the HSC, F(1,390) = 14.85, p [less than] .0001, indicating that when self-esteem was low, psychiatric inpatients showed significantly higher levels of hopelessness. When self-esteem was high, hospitalization status had no effect on hopelessness scores [ILLUSTRATION FOR FIGURE 2 OMITTED!.

Self-esteem deficits were associated with an increased likelihood of suicidal ideation among high school students, [TABULAR DATA FOR TABLE 2 OMITTED] [[Chi].sup.2](1) = 57.11, p [less than] .0001, and psychiatric inpatients, [[Chi].sup.2](1) = 68.11, p [less than] .0001 [ILLUSTRATION FOR FIGURE 3 OMITTED!. In the present sample, 43% of high school students and 45% of psychiatric inpatients expressed some degree of suicidal ideation. Self-esteem had a significant relationship with suicidal ideation regardless of gender or hospitalization status of the subject. When self-esteem was low, 69% of high school students and 75% of psychiatric inpatients expressed some degree of suicidal ideation. Of all subjects with low self-esteem (combining inpatients and high school students), 72% reported current suicidal ideation (versus 21% of subjects with high self-esteem).

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To examine self-esteem score as a continuous variable, we performed correlational analyses. Because of the initial group differences, Pearson correlations between self-esteem and the other variables were computed separately by gender and hospitalization status (Table 3). For correlations between depression and suicidal ideation, the suicide item (item I) was omitted from the CDI total score. Results indicated that self-esteem was strongly correlated with depression, hopelessness, and suicidal tendencies. Correlations between self-esteem and depression were consistently high across all groups of subjects. Correlations between self-esteem and hopelessness were strong for all groups except for male high school students, yet this correlation remained significant (p [less than] .01). Self-esteem was correlated with current suicidal ideation and, to a lesser extent, with previous suicide attempts.

To evaluate the overall strength of the relationship between self-esteem and depression and hopelessness, we partialled out the effects of gender and hospitalization status by using a hierarchical multiple regression analysis. Results indicated that self-esteem accounted for almost 60% of the variance in depression scores, increase in [R.sup.2] = .592, F(3,415) = 627.39, p [less than! .0001, and 44% of the variance in hopelessness scores, increase in [R.sup.2] = .442, F(3,415) = 330.63, p [less than] .0001. A hierarchical regression analysis was used to examine the unique contribution made by self-esteem in understanding suicide risk. When predicting the presence of suicidal ideation, gender accounted for 2% of the variance, [R.sup.2] = .023, F(1,413) = 9.67, p [less than] .01. Hospitalization status accounted for no significant increase in variance explained. Depression and hopelessness explained an additional 20% of the variance in suicidal ideation, increase in [R.sup.2] = .203, F(4,410) = 53.83, p [less than] .0001. Finally, self-esteem explained an additional 9% of the variance, increase in [R.sup.2] = .085, F(5,409) = 50.62, p [less than] .0001. When examining the presence or absence of previous suicide attempts, gender accounted for 2% of the variance, [R.sup.2] = .016, F(1,38) = 6.29, p [less than] .01, and hospitalization status accounted for an additional 14% of the variance, increase in [R.sup.2] = .138, F(2,384) = 62.46, p [less than] .0001. Depression and hopelessness explained an additional 11% of the variance in suicide attempts, increase in [R.sup.2] = .107, F(4,382) = 27.71, p [less than] .0001. Self-esteem added less than 1% additional variance increase in [R.sup.2] = .007, F(5,381) = 3.42, p [less than] .07.

DISCUSSION

In the present study, adolescents with low self-esteem were more likely to have previously attempted suicide and were more likely to be experiencing suicidal ideation at the time of the assessment. Furthermore, adolescents with low self-esteem reported elevated levels of depression and hopelessness. Thus, self-esteem may be a key variable for understanding depression and suicidal behavior among adolescents. The present findings extend previous studies that found low self-esteem was related to depression in child (Asarnow et al., 1987), adolescent (King et al., 1993), and adult psychiatric inpatients (Davis and Unruh, 1981). Furthermore, self-esteem adds to the understanding of [TABULAR DATA FOR TABLE 3 OMITTED! suicidal thoughts beyond that provided by an assessment of depression and hopelessness.

Despite differences between psychiatric inpatients and high school students on scores of depression severity and global level of self-esteem, correlations between variables remained quite similar across groups. This suggests that self-esteem plays an important role in depression and suicidal tendencies irrespective of hospitalization status. In the present study, both hospitalized and nonhospitalized adolescents with low self-esteem were more likely to report current suicidal thoughts and a history of suicidal behavior. The high rates of suicidal tendencies observed in the present study are consistent with epidemiological surveys that have found 60% of high school students had thought about killing themselves and 9% had previously attempted suicide (Friedman et al., 1987). Another study (Rubenstein et al., 1989) found 20% of high school students had tried to hurt or kill themselves within the previous year. In the present sample, the rates of suicidal ideation and history of suicide attempts rose substantially when self-esteem was low. Among adolescents with low self-esteem, 33% of high school students and 64% of psychiatric inpatients had previously attempted suicide at least once. Thus, suicidal feelings and behaviors were prevalent among hospitalized and nonhospitalized adolescents, especially when self-esteem was low. However, a moderate proportion of patients with high self-esteem reported a history of suicide attempts. It is possible that the adolescents' suicidal behavior elicited support and assistance from their family and friends, resulting in an increased sense of self-worth in the adolescents. A more comprehensive assessment of adolescent psychopathology could examine issues such as stressful life events, coping style, social support, and family functioning related to suicidal behavior.

Because self-esteem deficits are related to depression, hopelessness, and suicidal behavior among adolescents, efforts are needed to improve the identification and treatment of adolescents who have low self-esteem. The multiple regression analysis showed that even after controlling for gender and hospitalization status, self-esteem was strongly related to depression and hopelessness. Moreover, results from the hierarchical regression analysis showed that even after controlling for levels of depression and hopelessness, self-esteem added to our understanding of suicidal ideation. Thus, self-esteem has a direct impact on suicidal ideation beyond what could be accounted for by depression and hopelessness. The present study used a brief standardized measure of self-esteem. The RSE is well established, has demonstrated adequate psychometric properties, and provides an efficient unidimensional estimate of self-esteem. However, some authors (e.g., Bingham, 1983) have found the RSE to suffer from ceiling effects, with many adult subjects scoring at the top end of the scale. Future research on self-esteem deficits could explore different dimensions of self-esteem using other scales (e.g., Piers-Harris Self-Concept Scale, Harter Self-Perception Profile, Coopersmith Self-Esteem Inventory) that are more comprehensive in scope and include subscales that measure social, academic, and physical dimensions of self-esteem. The social basis of self-esteem may play an important role in depression and suicide among adolescents. Self-esteem deficits are likely to have generalized and lasting effects on an adolescent's social and emotional adjustment, potentially increasing tendencies for depression and hopelessness. Furthermore, low self-esteem can inhibit participation in activities that could otherwise help to enhance a person's self-esteem. This may become self-perpetuating whereby social withdrawal further reduces the person's self-esteem. Improving the person's ability and willingness to engage in different social activities may serve an important role in the treatment of low self-esteem (Brennan, 1985). Programs designed to identify self-esteem deficits early could make positive changes that would reduce the risk of adolescents' becoming depressed or suicidal. Previous research has shown that high self-esteem protects youths from the adverse effects of life stress (Rutter, 1987). In the present study, adolescent psychiatric inpatients and high school students with high self-esteem both reported low levels of depression and were unlikely to report suicidal behavior. Thus, the present findings suggest that a protective influence of high self-esteem occurs in both inpatient and community settings. Many adolescents may benefit from school or community programs designed to promote positive self-esteem. Treatment of depressed and suicidal adolescents should address the self-esteem deficits that may underlie these emotional problems. For many patients, their definition of the self is fragile and limited to a few general areas of their life. For example, social functioning may play an important role in the self-esteem of some adolescents, whereas athletic or academic skills may be important for others. The self-esteem in males is often based on the accomplishment of specific goals whereas females emphasize social relationships and personal qualities (Overholser, 1993). Improvement in one or more areas related to self-esteem can have a profound impact on the person's emotional well-being. As research begins to identify specific areas of self-esteem deficits commonly observed in adolescents, professionals may be able to begin structuring treatments designed to enhance self-esteem by strengthening the particular strengths and interests of each individual. Because most of the subjects from both the psychiatric hospital and control sample were Caucasian and middle class, the findings may not generalize to samples with different ethnic backgrounds or socioeconomic levels. In addition, the present findings are limited by their reliance on self-report data collected during one assessment session. Although cross-sectional data cannot demonstrate a causal relationship between self-esteem deficits and depression or suicide, the present findings do show a strong relationship between these variables. It seems plausible to assume that the development of self-esteem predates the onset of depression and suicidal feelings. Therefore, low self-esteem and feelings of personal inadequacy may serve as vulnerability factors predisposing the individual to depression (Becker, 1979) and suicidal tendencies. However, depression also has a negative impact on self-esteem (Rosenberg et al., 1989). 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