Psychological factors in deliberate self-harm as seen in a urban African population in Uganda: a case-control study

Psychological factors associated with deliberate self-harm (DSH) as seen in an African population in Uganda are described. A case-control study design was employed in which a Luganda version (predominant language in the study area) of the modified European Parasuicide Interview Schedule I (EPSIS I) was used to collect data. The controls were patients admitted to the participating hospitals for non-recurrent medical conditions. Hopelessness, global psychological distress, and state anger, but not depression, were significantly associated with DSH after controlling for other factors. Both depression and hopelessness were significantly associated with suicidal intent independent of each other. Differences were observed on the psychological factors associated with suicidal intent in the different age/sex groups and in the depressed/nondepressed group. Interventions for DSH in this population should include treatments for both depression and hopelessness. This study further raises questions about the universality of the structural relationship among depression, hopelessness, and suicidality.     

Is There a Relationship between Suicidal Intent and Lethality in Deliberate Self‐Poisoning?

The relationship between suicidal intent and lethality of deliberate self‐poisoning (DSP) episodes and their associations with suicide have yielded contradictory findings. The aims of this study were to investigate the association between patients’ suicidal intent and independently rated lethality of DSP episodes, and whether the association changes over time. Eighty‐nine DSP patients were investigated longitudinally. Self‐reported suicidal intent, including perceived likelihood of dying, wish to die, and whether or not the DSP was considered a suicide attempt, was measured at the time of the index episode (t1), 3 months (t2), and 12 months (t3) later. Lethality was assessed independently by three clinical toxicologists. Lethality was significantly associated with patients’ reported wish to die (p = .01) and perceived likelihood of dying (p = .04) at t1, but not at t2 and t3. No association was found between whether the episode was considered a suicide attempt or not and lethality at t1, t2, or t3. Lethality and suicidal intent should be considered as largely separate dimensions of self‐harm. Clinicians should bear this in mind during clinical assessment, especially regarding historical information.     

Subtyping borderline personality disorder by suicidal behavior

Course and outcome of Borderline Personality Disorder (BPD) are favorable for the vast majority of patients; however, up to 10% die by suicide. This discrepancy begs the question of whether there is a high lethality subtype in BPD, defined by recurrent suicidal behavior and increasing attempt lethality over time. In a prospective, longitudinal study, we sought predictors of high lethality among repeat attempters, and defined clinical subtypes by applying trajectory analysis to consecutive lethality scores. Criteria-defined subjects with BPD were assessed using standardized instruments and followed longitudinally. Suicidal behavior was assessed on the Columbia Suicide History, Lethality Rating Scale, and Suicide Intent Scale. Variables discriminating single and repeat attempters were entered into logistic regression models to define predictors of high and low lethality attempts. Trajectory analysis using three attempt and five attempt models identified discrete patterns of Lethality Rating Scale scores. A high lethality trajectory was associated with inpatient recruitment, and poor psychosocial function, a low lethality trajectory with greater Negativism, Substance Use Disorders, Histrionic and/or Narcissistic PD co-morbidity. Illness severity, older age, and poor psychosocial function are characteristics of a poor prognosis subtype related to suicidal behavior.     

Dependency and self-criticism as predictors of suicidal behavior

Individuals have been theorized to develop anaclitic and introjective depression to the extent that they may be characterized as dependent and self-critical, respectively (e.g., Blatt, 1990). Blatt's theory was applied to suicidal behavior to determine if suicidal behavior could also be reliably broken down into two distinctive types, with respect to a number of parameters. Sixty-four undergraduate students who had attempted suicide were interviewed, and the lethality of their attempts was assessed with the Risk-Rescue Rating scale (Weisman & Worden, 1972). Participants were also administered an Intent and Precipitating Events scale, a modified version of the BDI-II, and the Depressive Experiences Questionnaire (DEQ). Self-critical individuals showed greater intent to die and greater lethality in their suicide attempts than did dependents. Self-critics were also more likely to attempt in response to an intrapsychic stressor, with the explicit motivation to escape. In contrast, dependents were more likely to attempt in response to an interpersonal stressor, with the motivation to communicate some form of unhappiness. Implications for suicide prediction and treatment are discussed, with special reference to the importance of identifying different suicidal subtypes.     

Psychopathology of adolescent suicide: hopelessness, coping beliefs, and depression

Two studies of adolescents examined the relation of several cognitive variables and depression to suicide-related behaviors. Study 1 compared hopelessness and depression in 281 high school students. Unlike research with adults, depression was significantly related to suicidal behaviors, even after hopelessness was statistically controlled. When depression was controlled, hopelessness was unrelated to suicidal behaviors for boys and only modestly related for girls. Study 2 examined depression, hopelessness, survival-coping beliefs, fear of social disapproval, and social desirability in relation to suicidal behaviors in 53 male juvenile delinquents. Again, hopelessness did not account for a significant proportion of the variance in suicide. Depression was uniquely related to past suicide attempts. Survival-coping beliefs were associated with self-predicted future suicide and other suicidal behaviors. Survival-coping beliefs are discussed as a cognitive buffer to suicidal ideation in adolescence.     

Specificity of Depressive Symptoms and Suicidality in a Juvenile Delinquent Population

Research which has related scores on the Children's Depression Inventory (CDI) to suicidality have generally neglected to examine the possibility that specific depressive factors within the CDI may be more predictive of suicidality than the full scale score. Knowledge of such factors would help to explain the relationship between depression and suicidality and improve the prediction of suicidal behavior. The current study examined the relationship of depressive factors to suicidality in a sample of 200 incarcerated juvenile delinquents. The published factor structure for the CDI and one derived from the delinquent population were compared. Results revealed two factors from the derived solution, hopelessness and low self-esteem, to be more powerful predictors of suicidal ideation than the full-scale CDI score. These results suggest that symptoms such as low self-esteem and hopelessness may be responsible for the well-documented relationship between depression and suicidality. Furthermore, it appears that the prediction of suicidality may be improved by examining specific depressive factors in suicide research as opposed to full-scale scores from depression inventories such as the CDI.     

Are Reports of Life Event Stress among Suicidal Youth Subject to Cognitive Bias?

Severity of depressive symptoms, hopelessness, and suicidal ideation were examined to determine whether they were significantly associated with the accuracy of suicidal adolescents' ratings of stressful life events. The sample included 130 inpatient adolescents who endorsed suicide‐related behaviors. Stress interviews were administered, and the severity of stressful events was rated separately by adolescents and an independent team. A residualized cognitive bias score was created by regressing adolescents' severity ratings to the independent team's severity ratings of the same events. Depressive symptoms, but not hopelessness or suicidal ideation, were significantly associated with cognitive bias scores. A negative cognitive bias in adolescents' reports of life stress may be present at higher levels of depression relative to minimal levels of depression. Further research on the relations between stress and suicide‐related behaviors is encouraged to include independent ratings of stress severity.     

Quality of Social Support Predicts Hopelessness and Depression Post Spinal Cord Injury

Research has documented elevated levels of depression and suicide in the spinal cord injured (SCI) population, with the majority of suicide attempts occurring within 12 months of injury onset. Social support has been linked with depression and suicidal intent, and this study aimed to determine the impact of the quality and quantity of social support on levels of depression and hopelessness, an indirect indicator of suicide risk in the SCI population. Fifty-three individuals with traumatic SCI at Week 6 of their rehabilitation, and 42 at Week 18, with an approximate male to female ratio of 4:1, completed the Beck Depression Inventory (BDI), Beck Hopelessness Scale (BHS), and Social Support Questionnaire. Stepwise multiple regression analyses revealed that high quality of social support was associated with low hopelessness and depression scores, being more pronounced at Week 18 postinjury. The impact of social support on psychological well-being demonstrates the importance of fostering and integrating social support in rehabilitation following spinal cord injury.     

Positive and Negative Expectations of Hopelessness as Longitudinal Predictors of Depression,Suicidal Ideation,and Suicidal Behavior in High‐Risk Adolescents

The relationship between hopelessness and depression in predicting suicide‐related outcomes varies based on the anticipation of positive versus negative events. In this prospective study of adolescents at elevated risk for suicide, we used two Beck Hopelessness Scale subscales to assess the impact of positive and negative expectations in predicting depression, suicidal ideation, and suicidal behavior over a 2‐ to 4‐year period. In multivariate regressions controlling for depression, suicidal ideation, and negative‐expectation hopelessness, positive‐expectation hopelessness was the only significant predictor of depressive symptoms and suicidal behavior. Clinical interventions may benefit from bolstering positive expectations and building optimism.     

Prediction of Suicide Intent in Aboriginal and Non-Aboriginal Adolescent Inpatients: A Research Note

The relationship among depressive symptoms, anxiety, hopelessness, and suicidal intent was explored in a group of 77 adolescents who had been hospitalized after attempting suicide. Regression analyses indicated that hopelessness was the only significant predictor of suicide intent in Caucasian patients, and depressed mood was the only significant predictor in the Aboriginal group. Clinicians should be aware that measures of hopelessness may be of limited value in assessing suicidal risk in Aboriginal adolescents.     

A Longitudinal Investigation of Depression,Hopelessness, Social Support,and Major and Minor Life Events and Their Relation to Suicidal Ideation in Adolescents

The longitudinal relationship of psychological and social-environmental factors with adolescent suicidal ideation over a 1-year-period was examined in a sample of 374 high school students. Students were assessed twice over a 1-year period with measures of depression, hopelessness, major negative life events, daily hassles, social support, and suicidal ideation. At the initial assessment, daily hassles and negative life events for males and social support and depression for females were significant factors related to suicidal ideation levels 1 year later. Changes in depression and hopelessness were significantly related to changes in suicidal ideation over the 1 year interval for males and females. Differences found between males and females in the relationship of psychological and social-environmental variables with suicidal ideation supports the need to examine gender specific relationships when conducting research on suicidal behavior in adolescents.     

The Measurement of Positive Attitudes: The Glass is Half Full

Positive thoughts play a significant role in the experience and recovery from depression. The Coping Attitudes Scale (CAS) is a rationally derived measure of positive cognitions. The CAS contains statements reflective of coping attitudes along five domains: life perspective, personal accomplishment, positive future, self-worth, and coping with problems. The current study examined the CAS in psychiatric outpatients and college students. Measures of depression, hopelessness, suicidal ideation and positive attitudes were administered to 82 adult psychiatric outpatients and 156 college students. Depression and hopelessness were strongly, negatively, partially correlated with each of the CAS factors, after controlling for age. Relationships among individual CAS factors and suicidal ideation demonstrated weak to moderate partial associations, after controlling for age. Depression was significantly associated with the coping with problems subscale (R ² = .530). Hopelessness was significantly related to the positive future subscale (R ² = .696). Further, the CAS demonstrated a significant relationship with depression and hopelessness, even after accounting for the Automatic Thoughts Questionnaire-Revised, Positive subscale. The CAS may be an improved measure of positive attitudes that could be useful in establishing a patient’s baseline of positive thinking, determining targets for therapy, and in monitoring progress in treatment.     

Cognitive aspects of suicidal behavior.

Recent efforts to quantify various aspects of suicide ideation are described. The Suicide Intent Scale, Hopelessness Scale, and the Scale for Suicide Ideation all assess components of the individual's suicidal ruminations. Hopelessness seems to account for the bulk of the relationship between depression and suicidal intent. The Scale for Suicide Ideation seems to show promise as a predictive instrument, as a dependent variable in research on treatment efficacy, and as a tool for clinical assessment of suicide potential. Implications for further research and clinical practice are discussed.     

Interpersonal precipitants and suicide attempts in borderline personality disorder

Borderline personality disorder (BPD) is often characterized by multiple low lethality suicide attempts triggered by seemingly minor incidents, and less commonly by high lethality attempts that are attributed to impulsiveness or comorbid major depression. The relationships among life events, impulsiveness, and type of suicidal behavior has hardly been studied in BPD and mood disorders. This study compared depressed attempters with and without BPD to identify specific suicide precipitants and risk factors in BPD and their relationship to severity of suicidal behavior. Attempters with comorbid BPD and major depressive disorder (MDD) had a higher number of lifetime suicide attempts; made their first attempt at a younger age; reported more interpersonal triggers; and had higher levels of lifetime aggression, hostility, and impulsivity, compared with attempters with major depression only. Environmental triggers of attempts in BPD are more likely to be interpersonal stressors. Lethality of attempts in BPD plus MDD is equal to that in MDD only, indicating that the seriousness of precipitants is unrelated to the lethality of the suicidal behavior. The differences between groups suggest that risk assessment and treatment should target both depression and personality disorder in those with combined illness.     

Hopelessness

ABSTRACT: In a sample of 87 hospitalized suicide attempters, a hopelessness scale was found to be significantly better than a depression inventory as an indicator of suicidal risk. Hopelessness also correlated better than depression with self-ratings of the attenuation of the desire to go on living.     

Dispositional and explanatory style optimism as potential moderators of the relationship between hopelessness and suicidal ideation

To test the hypothesis that higher levels of optimism reduce the association between hopelessness and suicidal ideation, 284 college students completed self-report measures of optimism and Beck scales for hopelessness, suicidal ideation, and depression. A statistically significant interaction between hopelessness and one measure of optimism was obtained, consistent with the hypothesis that optimism moderates the relationship between hopelessness and suicidal ideation. Hopelessness is not inevitably associated with suicidal ideation. Optimism may be an important moderator of the association. The development of treatments to enhance optimism may complement standard treatments to reduce suicidality that target depression and hopelessness.     

Attributional style as a diathesis in predicting depression,hopelessness, and suicide ideation in college students

Attributional style was examined as a diathesis for depression, hopelessness, and suicidal ideation. A naturalistic stressor—obtaining a D or F on an Introductory Psychology exam—was used in a longitudinal design to test for the effects of stress in predicting these criteria. Controlling for preexam levels of depression, hopelessness, and suicide ideation, prestress attributional style was consistently related to poststress levels of each of these criteria. Both positive and negative attributional styles measured at Time 1 were predictive of these criteria at Time 2. Regression analyses revealed that exam grade, attributional style alone, and attributional style in interaction with stress predicted each of the three criteria. The results are seen as supportive of a prestress attributional style diathesis to depression, hopelessness, and suicidal ideation.     

AIDS-related factors predictive of suicidal ideation of low and high intent among gay and bisexual men.

AIDS-related stressors were studied in relationship to suicidal ideation and suicide intent among 778 gay and bisexual men (none with AIDS). Over the previous six months, 27% (n = 212) reported suicidal ideation. Subjects who reported suicidal ideation (compared to those who did not) were more likely to report recent (last 6 months) bereavement of partner, recent ARC diagnosis, and multiple close friends with ARC. Suicide ideators were divided by a median split on a self-report scale of suicide intent into low (n = 105) and high (n = 107) intent suicide ideators. News of HIV seropositivity was specifically related to low intent suicidal ideation. High intent suicidal ideation was associated with having a partner with AIDS or ARC, or multiple close friends with AIDS, or having ARC. Generally speaking, while temporally discrete AIDS-related events were associated the report of suicidal ideation, ongoing stressors which may more greatly challenge adaptational capacities were more associated with high intent suicidal ideation.     

Suicidal Ideation in Elderly Bereaved: The Role of Complicated Grief

This study examined whether symptoms of complicated grief at baseline predicted suicidal ideation during a depressive episode in elderly bereaved individuals. Over a 17-month period, serial ratings of suicidal ideation, hopelessness, and symptoms of depression, anxiety, and complicated grief were obtained from 130 elderly participants who had lost their spouses within the past 2 years. Groups of active and passive suicidal ideators, as well as nonideator controls, were compared via analysis of variance (ANOVA) with respect to levels of complicated grief, depression, and anxiety. Elderly bereaved with both active and passive suicidal ideation were found to have higher symptomatic levels of depression, hopelessness, complicated grief, and anxiety, as well as lower levels of perceived social support, than nonideators at study entry. Fifty-seven percent of the patients with high complicated grief scores were found to be ideators during the follow-up versus 24% of the patients with low complicated grief scores. Patients with any suicidal ideation had higher symptom levels of depression, anxiety, and complicated grief when they were ideators as compared with periods when they denied ideation. Fifteen out of the 39 ideators had recurrent depressive episodes versus 5 of the 91 nonideators. Patients with a history of suicide attempts were more likely to be ideators after loss than other bereaved. Thus, the condition of having high levels of complicated grief symptoms and depressive symptoms appears to make bereaved individuals vulnerable to suicidal ideation. Detection of high levels of complicated grief could help clinicians identify patients who may be at heightened risk for suicide.     

Relationship Between Religious Coping and Suicidal Behaviors Among African American Adolescents

This study investigated whether hopelessness and depression were risk factors for suicidal thoughts and behaviors in African American adolescents and looked at whether religious participation and religious coping protected these students from suicidality. Participants were 212 African American high school students (133 females, 79 males). The results of multiple and logistic regression analyses found that hopelessness and depression were risk factors for suicidal ideation and attempts. Religious coping style was significantly related to suicidal behaviors: Self-directed coping was related to increased hopelessness, depression, and suicide attempts, and collaborative coping was related to increased reasons for living. Gender differences were found in symptoms of depression, religious coping style and religious participation. Results provide additional support for suicide interventions to target hopelessness and depressive symptoms and highlight the importance of examining the role of culturally salient variables, such as religious participation and religious coping style, when developing intervention programs for suicide.