Hopelessness in suicide attempters after acute treatment of major depression in late life

The Social Hopelessness Questionnaire (SHQ): Psychometric properties, distress, and suicide ideation in a heterogeneous sample of older adults

BACKGROUND

Older adults have high rates of suicide, necessitating attention to psychological factors that confer risk for suicide. Hopelessness is significantly associated with psychological despair and suicide risk factors; however, research has been limited by unidimensional treatment of the construct. The purpose of the present study was thus to investigate the psychometric properties of the Social Hopelessness Questionnaire (SHQ; Flett et al., 2021), a 20-item measure of hopelessness in the interpersonal domain, in a heterogeneous sample of older adults.

METHODS

Ninety adults 65 years of age or older were recruited from community, residential, or healthcare facilities in the context of a validation study of the Geriatric Suicide Ideation Scale (GSIS; Heisel & Flett, 2006). Participants voluntarily completed the SHQ, a demographics form, and concurrent measures of global hopelessness, depressive symptom severity, suicide ideation, and subjective well-being.

RESULTS

The SHQ demonstrated strong internal consistency, construct validity by way of significant positive associations with negative psychological factors and negative associations with positive factors, and differentiated older adults recruited from community and mental health settings. It also explained significant variability in depression, suicide ideation, and subjective well-being beyond that accounted for by an age-specific measure of global hopelessness.

LIMITATIONS

Findings were limited by a small clinical sub-sample, relatively few male participants, cross-sectional analysis, and focus on suicide ideation rather than suicide behavior.

CONCLUSION

These findings suggest that the SHQ is a reliable and valid measure of an interpersonal form of hopelessness for use with older adults across diverse settings.

Development and pilot study of a suicide prevention intervention delivered by peer support specialists

Suicide rates in the United States have been increasing in recent years, and the period after an inpatient psychiatric hospitalization is one of especially high risk for death by suicide. Peer support specialists may play an important role in addressing recommendations that suicide prevention activities focus on protective factors by improving hope and connectedness. The present study developed a peer specialist intervention titled Peers for Valued Living (PREVAIL) to reduce suicide risk, incorporating components of motivational interviewing and psychotherapies targeting suicide risk into recovery-based peer support. A randomized controlled pilot study was conducted to assess the acceptability, feasibility, and fidelity of the intervention. A total of 70 adult psychiatric inpatients at high risk for suicide were enrolled into the study. Participants were randomized to usual care (n = 36) or to the 12-week PREVAIL peer support intervention (n = 34). Those in the PREVAIL arm completed an average of 6.1 (SD = 5.0) peer sessions over the course of 12 weeks. Fidelity was rated for 20 peer support sessions, and 85% of the peer specialist sessions demonstrated adequate fidelity to administering a conversation tool regarding hope, belongingness, or safety, and 72.5% of general support skills (e.g., validation) were performed with adequate fidelity. Participants' qualitative responses (n = 23) were highly positive regarding peer specialists' ability to relate, listen, and advise and to provide support specifically during discussions about suicide. Findings demonstrate that a peer support specialist suicide prevention intervention is feasible and acceptable for patients at high risk for suicide. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Determinants of mental and physical health-related quality of life among patients hospitalized for suicidal behavior

The current study was interested in exploring the clinical factors related to mental and physical health-related quality of life among patients hospitalized for suicidal behavior. A multicenter cross-sectional study was designed to compare data obtained form 246 patients hospitalized for suicide behavior. Results suggest that mental health-related quality of life was negatively associated with hopelessness while physical health-related quality of life was negatively associated with age, medical disease and the number of previous suicide attempts and positively associated with employment. Findings are discussed in the context of theoretical evidence and clinical implications.

Negative Emotions and Suicidal Ideation during Psychosocial Treatments in Older Adults with Major Depression and Cognitive Impairment

OBJECTIVE

To examine the relationship of negative emotions with suicidal ideation during 12 weeks of Problem Adaptation Therapy (PATH) versus Supportive Therapy of Cognitively Impaired Older Adults (ST-CI), hypothesizing that improved negative emotions are associated with reduced suicidal ideation, PATH improves negative emotions more than ST-CI, and improved negative emotions, rather than other depression symptoms, predict reduction in suicidal ideation.

METHODS

In a randomized controlled trial of two home-delivered psychosocial interventions, 74 older participants (65-95 years old) with major depressive disorder and cognitive impairment were recruited in collaboration with community agencies. The sample reported less intense feelings than suicidal intention. Interventions and assessments were conducted in participants' homes. PATH focuses on improving emotion regulation, whereas ST-CI focuses on nonspecific therapeutic factors, such as understanding and empathy. Improved negative emotions were measured as improvement in Montgomery Asberg's Depression Rating Scales' (MADRS) observer ratings of sadness, anxiety, guilt, hopelessness, and anhedonia. Suicidal ideation was assessed with the MADRS Suicide Item.

RESULTS

MADRS Negative Emotions scores were significantly associated with suicidal ideation during the course of treatment (F_[1,165] = 12.73, p = 0.0005). PATH participants had significantly greater improvement in MADRS emotions than ST-CI participants (treatment group by time: F_[1,63.2] = 7.02, p = 0.0102). Finally, improved negative emotions, between lagged and follow-up interview, significantly predicted reduction in suicidal ideation at follow-up interview (F_{[1, 96]} = 9.95, p = 0.0022).

CONCLUSION

Findings thatimprovement in negative emotions mediates reduction in suicidal ideation may guide the development of psychosocial interventions for reduction of suicidal ideation (clinicaltrials.gov; NCT00368940).

Depression, Hopelessness, and Suicidal Ideation among the Elderly: A Comparison between Veterans and New Immigrants

The study attempts to compare between levels of depression, hopelessness, and suicidal ideation among two groups of independent and relatively independent elderly in Israel: a) old immigrants from the former Soviet Union (FSU); and b) veteran persons who live in Israel since 1948 or earlier. The research assumption was that depression, hopelessness, and suicidal ideation will be found in higher levels among old immigrants compared to those veterans in Israel. Three hundred and seventy-six elderly immigrants and 392 veterans participated in the study. Findings show negatively significant differences regarding hopelessness, helplessness and depression among immigrants compared to those veterans. The conclusions of the study indicate the need for paying interdisciplinary attention to the mental health of elderly immigrants.

Cognitive Biases and Suicidal Ideation in Elderly Psychiatric Inpatients

Cognitive factors such as perceptions of poor health and negative expectancies toward the future may mediate relationships between health variables, depressive symptoms, and suicidal ideation. In this study of risk factors associated with late life suicidal ideation, thirty older psychiatric inpatients were interviewed using standardized instruments. Self-reported symptoms of hopelessness, perceived health, and depression, as well as number of impaired medical illness systems were examined in relation to presence of suicidal thoughts. Several aspects of a cognitive model of suicide were supported using partial correlation and regression analyses. First, patients who were more depressed and suicidal had more negative cognitions than those who were less depressed and not suicidal. Second, depressive symptoms were strongly related to suicidal thoughts even after controlling for the patients' number of impaired illness systems. Third, cognitive factors versus health factors were shown to influence the relationship between depression and suicidal ideation. These findings emphasize the importance of cognitive biases in geriatric suicidal ideation.

Self-Rated Depression Severity Relative to Clinician-Rated Depression Severity: Trait Stability and Potential Role in Familial Transmission of Suicidal Behavior

Self-rated depression and hopelessness severity are predictors of suicide attempt in major depression. This study evaluated whether: (1) greater self-rated distress relative to severity of clinician-rated depression is a trait; (2) that trait is familial; and (3) that trait is linked to familial transmission of suicidal behavior. A total of 285 mood disorder probands and 457 offspring were assessed twice, at least 1 year apart. Family and subject intra-class correlations for self-report depression and hopelessness, controlling for clinician-rated depression severity, were computed. Mixed general linear models determined offspring-proband correlations. Within-individual intra-class correlation (ICC) for depression-hopelessness was 37.8% (bootstrap 95% CI: 31.0-46.3%). Parent-offspring ICC was 10.7% (bootstrap 95% CI: 3.5-17.8%). Suicide attempt concordant parent-offspring correlation for subjective depression was positive, but negative for attempter parent and nonattempter offspring (p = .0213 for slope interaction). Pessimism was greater in proband or offspring attempters than proband or offspring nonattempters (p < .05). Self-reported hopelessness is partly trait-dependent, and there is modest familial transmission of self-reported depression linked to suicidal behavior that may partly explain familial transmission of suicidal behavior.

Core belief content examined in a large sample of patients using online cognitive behaviour therapy

BACKGROUND

Computerised cognitive behavioural therapy provides a unique opportunity to collect and analyse data regarding the idiosyncratic content of people's core beliefs about the self, others and the world.

METHODS

'Beating the Blues' users recorded a core belief derived through the downward arrow technique. Core beliefs from 1813 mental health patients were coded into 10 categories.

RESULTS

The most common were global self-evaluation, attachment, and competence. Women were more likely, and men were less likely (than chance), to provide an attachment-related core belief; and men were more likely, and women less likely, to provide a self-competence-related core belief. This may be linked to gender differences in sources of self-esteem. Those who were suffering from anxiety were more likely to provide power- and control-themed core beliefs and less likely to provide attachment core beliefs than chance. Finally, those who had thoughts of suicide in the preceding week reported less competence themed core beliefs and more global self-evaluation (e.g., 'I am useless') core beliefs than chance.

LIMITATIONS

Concurrent symptom level was not available. The sample was not nationally representative, and featured programme completers only.

CONCLUSIONS

Men and women may focus on different core beliefs in the context of CBT. Those suffering anxiety may need a therapeutic focus on power and control. A complete rejection of the self (not just within one domain, such as competence) may be linked to thoughts of suicide. Future research should examine how individual differences and symptom severity influence core beliefs.

Beliefs about antidepressants among persons aged 70 years and older in treatment after a suicide attempt

BACKGROUND

The use of antidepressants is associated with decreased suicide risk in late life, and these drugs are often prescribed after a suicide attempt. Yet little is known about attitudes to antidepressants in older persons with suicidal behavior. The aim of this study was to assess beliefs about antidepressant medicines in older persons in treatment one year after a suicide attempt.

METHODS

Forty-four individuals aged 70 years and older, who were treated in emergency wards at five hospitals in western Sweden in connection with a suicide attempt, were interviewed at index attempt and one year later. Beliefs about medicines questionnaire (BMQ) specific for antidepressants were analyzed one year after index attempt, in relation to sociodemographic variables, medication use, psychiatric evaluation, and personality traits.

RESULTS

The majority of participants perceived the necessity of their antidepressant medicine to outweigh their concerns. Lower perceived necessity of antidepressants was observed in those who were not on antidepressants at the time of the attempt as well as those with no prior history of suicide attempt before the index attempt. Individuals reporting hopelessness at follow-up had a higher perceived concern about using medication.

CONCLUSIONS

Beliefs about antidepressants tended to be more positive than negative in older persons taking these drugs in the aftermath of a suicide attempt. Further studies are called for, and should include objective measures of medication adherence.

Hopelessness and suicidal feelings among the community dwelling elderly in Dublin

Objective: The aim of this study was to determine the one-month frequency of hopelessness and suicidal feelings in a community dwelling elderly sample in Dublin.

Method: A total of 891 individuals of 65 years and over, without a dementia, were interviewed using the Geriatric Mental State (GMS)-AGECAT system. Items from the GMS relating to reports of hopelessness and suicidal feelings over the previous month were identified and the relationship of these items to gender and age was studied.

Result: Serious suicidal feelings were rare with 0.2% of the sample expressing a pervasive wish to die, but less intense feelings were more common with 15.5% reporting that life was not worth living. Hopelessness and suicidal feelings were present with similar gender frequencies unlike other studies which have demonstrated a higher frequency among females. Any feeling of hopelessness or suicidality was present in 18.4% of those aged 65-74 years (‘young elderly’) compared with 14.8% of those over 75 years (‘old elderly’). Depressed elderly who reported hopelessness or suicidal feelings were not more likely to be taking antidepressants than the depressives without such feelings.

Conclusion: Cultural factors may explain the pattern of suicidal feelings reported in our sample, with the more intense feelings being rare, and may influence the gender distribution. Hopelessness and suicidality is not more common in the ‘old elderly’ than in the ‘young elderly’ and should not be regarded as an integral part of ageing. The small number of elderly depressives with feelings of hopelessness or suicidality wh o are being treated with antidepressants is a cause for concern.

Emergency room validation of the revised Suicide Trigger Scale (STS-3): a measure of a hypothesized suicide trigger state

BACKGROUND

The Suicide Trigger Scale (STS) was designed to measure the construct of an affective 'suicide trigger state.' This study aims to extend the inpatient setting validation study of the original Suicide Trigger Scale version 2 to the revised Suicide Trigger Scale version 3 (STS-3) in an acute psychiatric emergency room setting.

METHODS

The 42-item STS-3 and a brief psychological test battery were administered to 183 adult psychiatric patients with suicidal ideation or attempt in the psychiatric emergency room, and re-administered to subjects at 1 year follow up. Factor analysis, linear and logistic regressions were used to examine construct structure, divergent and convergent validity, and construct validity, respectively.

RESULTS

The STS-3 demonstrated strong internal consistency (Cronbach's alpha 0.94). Factor analysis yielded a three-factor solution, which explained 43.4% of the variance. Principal axis factor analysis was used to identify three reliable subscales: Frantic Hopelessness, Ruminative Flooding, and Near-Psychotic Somatization (Cronbach's alphas 0.90, 0.80, and 0.76, respectively). Significant positive associations were observed between Frantic Hopelessness and BSI depression and anxiety subscales, between Ruminative Flooding and BSI anxiety and paranoia subscales, and Near Psychotic Somatization and BSI somatization subscales. Suicidal subjects with suicide attempt history had mean scores 7 points higher than those without history of suicide attempts. Frantic hopelessness was a significant predictor of current suicide attempt when only attempts requiring at least some medical attention were considered.

CONCLUSION

The STS-3 measures a distinct clinical entity, provisionally termed the 'suicide trigger state.' Scores on the STS-3 or select subscales appear to relate to degree of suicidality in terms of severity of ideation, history of attempt, and presence of substantive current attempts. Further study is required to confirm the factor structure and better understand the nature of these relations.

Drinking to cope as a statistical mediator in the relationship between suicidal ideation and alcohol outcomes among underage college drinkers

Etiological models of alcohol use that highlight the role of negative affect and depression have not been applied to the association of suicidality and alcohol use. The authors examined whether a motivational model of alcohol use could be applied to understand the relationship between suicidal ideation and alcohol outcomes in a sample of underage college drinkers who had a history of passive suicidal ideation (n = 91). In this cross-sectional study, regression analyses were conducted to examine whether drinking to cope with negative affect statistically mediated or was an intervening variable in the association between suicidal ideation and alcohol outcomes. Results revealed that drinking to cope was a significant intervening variable in the relationships between suicidal ideation and alcohol consumption, heavy episodic drinking, and alcohol problems, even while controlling for depression. These results suggest that the relationship between suicidal ideation and alcohol outcomes may be due to individuals using alcohol to regulate or escape the distress associated with suicidal ideation. Consideration of alcohol-related models can improve the conceptualization of research on suicidality and alcohol use.

What cognitive functions are associated with passive suicidal ideation? Findings from a national sample of community dwelling Israelis

PURPOSE

To identify the specific cognitive domains associated with passive suicidal ideation (e.g. thoughts of being better off dead).

METHODS

A cross sectional, national based study of 1,712 individuals over the age of 50. Outcome measure, passive suicidal ideation, was evaluated by the question, 'in the past month, have you felt that you would rather be dead?', taken from the Euro-D. Cognitive domains assessed were time orientation, verbal learning, verbal recall, word fluency, and arithmetic.

RESULTS

After adjusting for demographic and clinical information, those reporting passive suicidal ideation were significantly more likely to have impaired performance on the time orientation task. None of the other cognitive domains were associated with passive suicidal ideation.

CONCLUSIONS

Clinicians working with older adults need to be aware not only of demographic and clinical information, but also of cognitive functioning and more specifically, time orientation, as a potential determinant of passive suicidal ideation. Possibly, cognitive domains that are less affected by education and prior learning (e.g. time orientation) have a unique association with passive suicidal ideation.

The role of moral objections to suicide in the assessment of suicidal patients

BACKGROUND

Moral and religious objections to suicide (MOS) are reported to be associated with less suicidal behavior in depressed patients, and are proposed to act as a protective factor against suicidal behavior. It is unclear whether MOS are a protective factor against suicide attempt per se, or if this effect is mediated through other variables.

METHOD

Depressed inpatients (n=265) reporting low or high MOS were compared on history of suicidal behaviour, demographic and clinical characteristics.

RESULTS

Patients with low MOS had significantly more lifetime suicide attempts, were more often without religious affiliation, had greater depression severity, hopelessness and trait impulsivity, less anxiety and fewer reasons for living. Logistic regression revealed that lower MOS was independently associated with suicide attempt.

CONCLUSIONS

Moral and religious objections to suicide may serve as a protective factor against suicidal acts given their unique association with less suicidal behavior in depressed inpatients.

Neurobiology of suicidal behavior. An integration of biological and clinical findings

Suicide is among the top ten leading causes of death in individuals of all ages. An explanatory model for suicidal behavior that links clinical and psychological risk factors or endophenotypes, to the underlying neurobiological abnormalities associated with suicidal behavior may enhance prediction, help identify treatment options and have heuristic value. Our explanatory model proposes that developmental factors that are biological (genetics) and psychological or clinical (early childhood adversity) may have causal relevance to the disturbances found in subjects with suicidal behavior. In this way, our model integrates findings from several perspectives in suicidology and attempts to explain the relationship between various neurobiological, genetic, and clinical observations in suicide research, offering a comprehensive hypothesis to facilitate understanding of this complex outcome.

Deliberate self-harm in older adults: a review of the literature from 1995 to 2004

BACKGROUND

The prevention of suicide is a national and international policy priority. Old age is an important predictor of completed suicide. Suicide rates in old age differ markedly from country to country but there is a general trend towards increasing rates with increasing age. In 1996 Draper reviewed critically the evidence on attempted suicide in old age in the 10 years between 1985 and 1994. The review highlighted a need for prospective controlled studies in older people with more representative samples as well as studies examining the interaction of risk factors, precipitants, motivations, psychopathology and response to treatment. The aim of this paper is to update this review and to summarise the advances in our understanding of DSH in later life.

METHOD

We have critically reviewed relevant studies published between 1995 and 2004 to summarise the advances in our understanding of factors associated with deliberate self-harm in later life.

RESULTS

The main advances in understanding have been to clarify the effect of personality and cultural factors, service utilisation pre and post attempt, and the (lesser) impact of socio-economic status and physical illness. Methodological weaknesses continue to include inadequate sample sizes performed on highly selected populations, inconsistent age criteria and lack of informant data on studies relating to role of personality.

CONCLUSIONS

Future studies should include prospective, cross-cultural research with adequate sample sizes and which are population-based. Such approaches might confirm or refute the results generated to date and improve knowledge on factors such as the biological correlates of deliberate self-harm, service utilisation, costs and barriers to health care, and the interaction of these factors. Intervention studies to elucidate the impact of modifying these factors and of specific treatment packages are also needed.

Enhancing spiritual well-being among suicidal African American female survivors of intimate partner violence

Spirituality has been identified as one component of a culturally competent therapeutic intervention for African American women. The present study was designed to investigate the ability of factors, such as level of hopelessness and the use of positive religious coping strategies, to predict spiritual well-being over time. Seventy-four low-income African American women were administered self-report questionnaires measuring hopelessness, use of religious coping strategies, and two domains of spiritual well-being. Path analysis indicated that hopelessness, existential well-being, religious well-being, and positive religious coping are correlated with one another. Further, lower levels of hopelessness predict increases in existential well-being over time; higher levels of positive religious coping predict increases in religious well-being over time. Results were consistent with the study hypotheses and highlight the need to attend to predictors of spiritual well-being when implementing culturally relevant interventions with abused, suicidal African American women. Therapeutic strategies for reducing hopelessness and enhancing positive religious coping to improve spiritual and existential well-being are presented; such strategies will ensure the interventions are more culturally competent.

Future orientation and suicide ideation and attempts in depressed adults ages 50 and over

OBJECTIVE

The objective of this study was to test the hypothesis that future orientation is associated with lower levels of suicide ideation and lower likelihood of suicide attempt in a sample of patients in treatment for major depression.

METHODS

Two hundred two participants (116 female, 57%) ages 50-88 years were recruited from inpatient and outpatient settings. All were diagnosed with major depression using a structured diagnostic interview. Suicide ideation was assessed with the Scale for Suicide Ideation (both current and worst point ratings), and a measure of future orientation was created to assess future expectancies. The authors predicted that greater future orientation would be associated with less current and worst point suicide ideation, and would distinguish current and lifetime suicide attempters from nonattempters. Hypotheses were tested using multivariate logistic regression and linear regression analyses that accounted for age, gender, hopelessness, and depression.

RESULTS

As hypothesized, higher future orientation scores were associated with lower current suicidal ideation, less intense suicidal ideation at its worst point, and lower probability of a history of attempted suicide after accounting for covariates. Future orientation was not associated with current attempt status.

CONCLUSIONS

Future orientation holds promise as a cognitive variable associated with decreased suicide risk; a better understanding of its putative protective role is needed. Treatments designed to enhance future orientation might decrease suicide risk.

Concomitant use of vagus nerve stimulation and electroconvulsive therapy for treatment-resistant depression

OBJECTIVE

This study explored the use of electroconvulsive therapy (ECT) in the pivotal study of vagus nerve stimulation (VNS) for treatment-resistant depression.

METHODS

The clinical characteristics and outcomes of study participants who received ECT during the first 12 months of VNS were compared with those who did not receive ECT. Physicians were instructed to turn off VNS during administration of ECT.

RESULTS

Of 205 (evaluable sample) patients who received VNS, 14 also received ECT. Participants who received ECT had a statistically significant greater number of hospital admissions (P = 0.037, Wilcoxon) and number of suicide attempts during their lifetimes (P= 0.022, Fisher exact test). Of 55 responders (> or =50% reduction in Hamilton Rating Scale for Depression-24 questions [HRSD-24] scores) after 12 months of VNS, 3 had received ECT. Of 32 remitters (HRSD-24 score, < or =9), 2 had received ECT. Administration of ECT did not affect the implanted VNS device, and the presence of the implanted VNS device did not affect the administration of ECT.

CONCLUSIONS

Electroconvulsive therapy and VNS are not mutually exclusive. They can be used safely and effectively either sequentially or concurrently. Each can be prescribed as the depressive condition warrants-ECT for emergently worsening depressive symptoms and maintenance therapy and VNS for chronic, long-term therapy.

Personality and reports of suicide ideation among depressed adults 50 years of age or older

BACKGROUND

Accuracy in patient reports of suicide ideation is a concern in clinical assessment, given that some patients deny suicide ideation even when suicidal. Despite this concern, there is little research on the psychological processes driving reported suicide ideation in at-risk patients.

METHODS

A cross-sectional design was used to examine the association of personality and suicide ideation in a clinical sample of 134 depressed adults 50 years and older. Patients completed a structured diagnostic interview, an interviewer-rated measure of current suicide ideation and self-report measures of personality (NEO-Personality Inventory Revised; NEO-PI-R) and hopelessness. The main outcome variable in logistic regression analyses was suicide ideator status; covariates included comorbid psychopathology, hopelessness and physical illness burden. Predictors were Neuroticism and Openness to Experience (OTE) scores on the NEO-PI-R.

RESULTS

Elevated OTE and neuroticism were associated with suicide ideation in unadjusted analyses; OTE was also associated with suicide ideation in adjusted regression analyses.

LIMITATIONS

This study used a cross-sectional methodology with depressed patients 50 years or older; it is possible that patients' depression severity may have influenced their responses to personality measures. Prospective studies of personality vulnerability to future suicide ideation are warranted.

CONCLUSIONS

Elevated neuroticism increases the likelihood of reporting suicide ideation, just as it may enhance risk for suicidal behavior and death by suicide. The pattern for openness is markedly different. Although elevated openness increases the likelihood of reporting suicide ideation, previous research has shown that it may decrease risk of death by suicide, suggesting that the personality-mediated expression of suicide ideation may be adaptive in certain contexts. In contrast, low levels of openness may mute reports of suicide ideation in at-risk patients and confer risk for poor outcomes by potentially undermining clinician vigilance.

A psychometric analysis of the Geriatric Hopelessness Scale (GHS): towards improving assessment of the construct

BACKGROUND

Hopelessness increases vulnerability to late-life depression and risk for suicide. The present study examined the psychometric properties of the Geriatric Hopelessness Scale (GHS; Fry, 1984) among a heterogeneous sample of older adults and its association with depression and suicide ideation.

METHODS

Seventy-eight adults 65 years or older recruited from psychiatric, medical, residential, and community were administered the study measures. We examined the item-response characteristics, factor structure, and reliability of the GHS, its construct validity by way of associations with depression, hopelessness, and suicide ideation, and criterion validity in terms of differentiating psychiatric patients from non-psychiatric participants.

RESULTS

The GHS had poor item-response characteristics but acceptable internal consistency and construct validity. A factor analysis yielded three internally consistent factors assessing Fatalistic, Interpersonal, and Spiritual Hopelessness. An 11-item GHS-Suicide Risk subscale was identified with acceptable internal consistency, significant association with measures of hopelessness, depression, and suicide ideation, and that differentiated psychiatric patients from non-psychiatric participants.

LIMITATIONS

This study had a relatively small sample size, included a high proportion of female respondents (79%), and a relatively low proportion of patients in mental health care (17%).

CONCLUSIONS

The GHS had acceptable reliability and construct validity, but poor item-response characteristics and criterion validity with respect to differentiating psychiatric patients from non-psychiatric participants. Use of shortened GHS measures may improve upon the limitations of the full scale, and may be preferable when seeking to identify older adults at risk for suicide.

Personality traits as intermediary phenotypes in suicidal behavior: genetic issues

A genetic contribution to the risk of suicidal behavior is now supported by many studies. It probably involves specific factors acting on their own, independently of the genetic transmission of associated psychiatric disorders. A history of childhood maltreatment, adverse events, psychosocial stress, psychological traits and major psychiatric disorders all appear to contribute to the global risk of suicide attempt or completion. The interplay between previously identified risk factors, different as they are in nature and degree of complexity, still remains to be clarified. A stress-diathesis model has been proposed, where trait-like genetic and developmental risk factors (the diathesis) interact through still unknown mechanisms with actual (stress-related) factors to create the conditions for a suicidal gesture. Disentangling the effects of these risk factors, and specifically the effects of the genetic factors influencing these different pathological conditions, appears to be a difficult task. Indeed the results of candidate gene association studies suggest that genetic vulnerability factors for various related psychiatric phenotypes (major psychiatric disorders and personality traits) partly overlap with more specific factors predisposing to suicidal behavior. Personality traits are partly under genetic control and may be closer to the genetic effects than psychiatric syndromes. We review here the available data on the genetics of personality traits presumably involved in suicidal behavior, focusing on the association studies carried out with serotonin-related genes. We suggest that future studies on the genetic vulnerability to suicidal behavior should include the investigation of endophenotypes, with the aim of deciphering the mechanisms underlying the genetic susceptibility to these closely associated phenotypes.

Pharmacotherapy of suicidal behavior in bipolar disorder

Patients with Bipolar Disorder (BD) are at particularly high risk for both attempted and completed suicides. The period of highest risk for completed suicide is during the 2 years following discharge from a hospitalization. To date, pharmacological studies of suicidal behavior in BD have been quite limited. While strong evidence has been found regarding the anti-suicidal effects of lithium, evidence for such properties in other commonly prescribed medications for BD, including anticonvulsants, SSRIs and anti-psychotics, has been largely unexplored. Considering the high risk of suicidal acts in patients with BD, further research on the pharmacotherapy of suicidal behavior is crucial.

A model predicting suicidal ideation and hopelessness in depressed older adults: the impact of emotion inhibition and affect intensity

The purpose of this study was to begin a preliminary examination of constructs theorized to be related to suicidal behavior by testing a model of the influence of both temperament and emotion regulation on suicidal ideation and hopelessness in a sample of depressed older adults. The model was evaluated using structural equation modeling procedures in a sample of depressed, older adults. Findings supported a temporally predictive model in which negative affect intensity and reactivity lead to emotion inhibition, operationalized as ambivalence over emotional expression and thought suppression, which in turn lead to increased presence of suicidal predictors, operationalized as hopelessness and suicidal ideation. These results suggest that suicide prevention efforts in older adults may be improved by targeting emotion inhibition in treatment, especially among affectively intense and reactive older adults.

Hopelessness and suicidal ideation in outpatients with treatment-resistant depression: prevalence and impact on treatment outcome

Depression and hopelessness are risk factors for suicide. The purpose of this study was to examine the extent of suicidal ideation and hopelessness in outpatients with treatment-resistant depression (TRD) and to study the impact of suicidal ideation and hopelessness on treatment with nortriptyline (NT). The degree of suicidal ideation and hopelessness was assessed during the screen visit with the use of items #3 and #30 of the Hamilton Depression Rating Scale (HAM-D) in 89 patients with TRD who entered a 6-week open trial of NT. Forty of these patients also completed the Beck Hopelessness Index (BHI) during the screen visit. In separate logistic regressions, the scores from the BHI and the two HAM-D items were then tested as predictors of clinical response to the 6-week trial with NT, controlling for the severity of depression. More than half of patients reported thoughts or wishes of death to self and significant hopelessness. A greater degree of hopelessness before treatment in completers, reflected by the score on the HAM-D item #30, predicted response to NT. More than half of patients with prominent hopelessness who completed the trial responded. Patients with TRD are more likely than not to report prominent suicidal ideation and hopelessness. Furthermore, a full 6-week trial of NT, a relatively noradrenergic tricyclic antidepressant, may be particularly useful in patients who have failed to respond to several antidepressants and also report significant hopelessness.

Predictors and correlates of interest in assisted suicide in the final month of life among ALS patients in Oregon and Washington

To understand the factors associated with interest in assisted suicide among terminally ill patients, we surveyed 50 caregivers of decedent amyotrophic lateral sclerosis (ALS) patients from Oregon and Washington regarding perceptions of patients' interest in assisted suicide and their physical and emotional state in the last month of life. For 38 caregivers, we had baseline information from the patients themselves, gathered a median of 11 months before death, regarding depression, hopelessness, sense of burden, social support, quality of life, pain, and suffering. According to our respondents, one-third of ALS patients discussed wanting assisted suicide in the last month of life. Hopelessness and interest in assisted suicide at baseline predicted desire for assisted suicide later on. ALS patients who were interested in assisted suicide, compared to those who were not, had greater distress at being a burden to others and more insomnia, pain, and discomfort other than pain.

Identification of suicidal ideation and prevention of suicidal behaviour in the elderly

In almost all industrialised countries, men aged 75 years and older have the highest suicide rate among all age groups. Although in younger age groups suicide attempts are often impulsive and communicative acts, suicide attempts in older people (defined as aged 65 years and older) are often long planned and involve high-lethality methods. These characteristics, in addition to the fact that elderly are more fragile and frequently live alone, more often lead to fatal outcome. In later life, in both sexes, the most common diagnosis in those who attempt or complete suicide is major depression. In contrast to other age groups, comorbidity with substance abuse and personality disorders is less frequent. Physical illness plays an important role in the suicidal behaviour of the elderly: most frequently, depression and illness co-occur; less often, the physical illness or the treating medications are causally related to the depressive symptoms. However, only 2 to 4% of terminally ill elderly commit suicide. In addition to physical illness, complicated or traumatic grief, anxiety, unremitting hopelessness after recovery from a depressive episode and history of previous suicide attempts are risk factors for suicide attempts and completed suicide. During a depressive episode, elderly patients with suicidal ideation have higher levels of anxiety and, during treatment, anxiety decreases the probability of remission and recovery. As well as overt suicide attempts, indirect self-destructive behaviours, which often lead to premature death, are common, especially in residents of nursing homes, where more immediate means to commit suicide are restricted. Although we do not have randomised trials of treatment, studies suggest that antidepressant treatment may decrease suicide risk. Prevention and treatment trials are underway to detect the effectiveness of improved treatment of depression by primary care physicians as a means of reducing the prevalence of depressive symptoms, hopelessness and suicidal ideation.

Recent research on suicide in the elderly

Older adults, and older men in particular, are the segment of the US population that has the highest suicide rate. Although research on risk factors continues to grow, there remains limited knowledge of the biologic changes that increase risk for suicide, as well as limited information about contributing psychosocial processes that extend beyond demographic factors. No proven interventions are known at this time, although efforts are underway to test approaches that reach older adults who use primary care services. Continued efforts are needed to change attitudes about mental illness and treatment in order to reach older adults who do not use health care services.

Stress, coping styles, and hopelessness in self-poisoners

This study examined the association between level of hopelessness with stress and coping style for a sample of 80 people who had recently attempted suicide. Higher levels of hopelessness were found to be associated with higher levels of stress. Level of hopelessness was also associated with the use of problem-focused but not with emotion-focused coping. Analyses of the interaction between stress and coping style suggested that these variables influence the level of hopelessness in an independent and linear fashion. The implications for clinical intervention are discussed.

The systematic assessment of depressed elderly primary care patients

Studies of the primary care treatment of depressed elderly patients are constrained by limited time and space and by subject burden. Research assessments must balance these constraints with the need for obtaining clinically meaningful information. Due to the wide-ranging impact of depression, assessments should also focus on suicidality, hopelessness, substance abuse, anxiety, cognitive functioning, medical comorbidity, functional disability, social support, personality, service use and satisfaction with services. This paper describes considerations concerning the assessment selection process for primary care studies, using the PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) study as an example. Strategies are discussed for ensuring that data are complete, valid and reliable.

Cognitive risk factors and suicide attempts among formerly hospitalized adolescents: a prospective naturalistic study

OBJECTIVE

To examine the relationship between cognitive variables and time until suicide attempts among 180 adolescents who were monitored for as much as 6.9 years after discharge from an inpatient psychiatry unit.

METHOD

In a prospective naturalistic study, adolescents were assessed at the time of their psychiatric hospitalization and semiannually thereafter. Suicidal behavior at index hospitalization and over the follow-up period was assessed with semistructured psychiatric diagnostic interviews. At hospitalization, cognitive risk factors were assessed with a problem-solving task and with questionnaires assessing hopelessness, expectations for posthospitalization suicidal behavior, reasons for living, and dysfunctional attitudes.

RESULTS

Expectations about future suicidal behavior were related to posthospitalization suicide attempts. Among youths with previous suicide attempts, higher levels of hopelessness were associated with increased risk, and greater survival and coping beliefs were associated with decreased risk for posthospitalization suicide attempts. Hopelessness and survival and coping beliefs were not related to posthospitalization attempts among adolescents without prior suicidal behavior, and hopelessness was not predictive after controlling for overall severity of depression.

CONCLUSIONS

Expectations for suicidal behavior, hopelessness, and survival and coping beliefs provide important prognostic information about later suicidal behavior and should be targeted in interventions with suicidal youths.

Cortisol in violent suicidal behaviour: association with personality and monoaminergic activity

BACKGROUND

According to recent theories, suicidal behaviour is associated with depressive disorders that are commonly induced by social stressors in persons with a trait-dependent vulnerability. Stressor-induced increased cortisol secretion may interfere with this vulnerability that can be defined in terms of (possibly inter-related) biological and psychological or personality-related characteristics. Delineation of such trait-like characteristics may increase the specificity in the prediction of suicidal behaviour and thus lead to new approaches to the treatment and prevention of suicidal behaviour.

METHODS

Psychiatric symptomatology, personality dimensions (Cloninger's Temperament and Character), peripheral markers of serotonergic (whole blood serotonin, platelet MAO activity) and noradrenergic (plasma MHPG) activity, and urinary cortisol were measured in a random sample of patients with a history of violent suicidal behaviour and compared to those of patients without such a history.

RESULTS

When compared to patients without a history of violent suicidal behaviour (n=23), patients with such a history (n=17) were characterised by higher urinary cortisol levels, a significantly lower mean score on Reward Dependence, a borderline significantly increased score on Novelty Seeking and a significantly lower mean plasma MHPG level. Urinary cortisol level correlated significantly with Reward Dependence and Novelty Seeking scores. There were no differences between patient groups regarding severity of anxiety or depressive symptomatology. No differences with regard to the biological parameters were found between patients who recently attempted suicide and those with a history of suicidal behaviour.

LIMITATIONS

Limitations of this study included a relatively small number of study subjects and the use of peripheral markers to assess central neurotransmission functions.

CONCLUSIONS

Violent suicidal behaviour is associated with increased cortisol secretion, a personality profile defined by low Reward Dependence (reflecting the degree of sensitivity to social stressors) and a tendency of increased Novelty Seeking (related to impulsivity and the regulation of anger), and reduced noradrenergic functioning (possibly reflecting an inability to adapt to stressors).

Suicide prevention in late life: directions for science and practice

Suicide among the elderly is a critical public health problem, yet there remains limited information on risk factors to target due to the few number of controlled studies that could help isolate and focus on the most potent risk factors. We suggest that because there are no proven, effective interventions showing reduced suicidal behaviors in older adults, the best current approach is to improve detection and treatment of later-life depression. This effort may be especially effective in primary care settings, where the majority of our nation's elderly seek and receive their mental health care. We review approaches to assessment and treatment of later life depression that seem most relevant for later life suicide prevention. Testing and determining whether these treatment approaches are effective is an immediate goal on the path to advancing the science and practice of late-life suicide prevention.

The ultimate resignation: suicide and search activity

This paper presents an integrative approach to suicidal behavior in terms of search activity concept. Search activity concept displays a broad and holistic approach to behavior, adaptation to environment, body resistance, brain amine metabolism, and REM-sleep functions. Search activity is defined as activity that is oriented to change the situation (or at least the subject's attitude to it) in the absence of a precise prediction of the outcome of such activity, but taking into consideration outcomes at all previous stages of activity. According to the proposed hypothesis, renunciation of search (a state opposed to search activity) leads to a feeling of helplessness, problem-solution deficits, inefficient coping, dreams that represent renunciation of search, and a drop in the activity of amines. All these factors further exacerbate the state of renunciation of search and elevate suicidal risk. In addition, the remnants of search activity are misdirected to self-defeating behaviors that increase mental pain and contribute to renunciation of search. This hypothesis integrates findings from a number of fields of study of suicidal behavior, resolves some paradoxes, suggests new lines of research, and raises suggestions for assessment and treatment of suicidal behavior.

Analysis of catechol-O-methyltransferase and 5-hydroxytryptamine transporter polymorphisms in patients at risk for suicide

Genotype frequencies of functional polymorphisms in the genes encoding the serotonin transporter (5-HTT) and the enzyme catechol-O-methyltransferase (COMT) were not different in 51 suicidal inpatients compared to 51 control subjects. Within the patient group, increased hopelessness and suicide ideation were associated with homozygosity of the 5-HTT high promotor activity allele.

Correlates of suicidal ideation among an elderly depressed sample

BACKGROUND

Suicidal ideation has been shown to be strongly associated with suicide completion and elders take their own lives more than any other age group.

METHODS

The present study examined clinical and phenomenological correlates of suicidal ideation among an elderly sample (n = 167) derived from subjects enrolled in the Duke Clinical Research Center for the Study of Depression in Late Life.

RESULTS

Bivariate results indicated that clinical variables associated with psychomotor retardation, a history of dysthymia, a previous psychiatric in-patient stay, and being a 'younger' elder were related to greater suicidal ideation. Multivariate analyses indicated that feeling guilty, sinful, or worthless was associated with over six times greater odds of having suicidal thoughts.

LIMITATIONS

Findings are based on correlational analyses, and thus, the direction of causality cannot be inferred.

CONCLUSIONS

This study provides evidence for clinicians of some of the 'red flags' associated with the presence of suicidal ideation among depressed older adults.

Suicidal feelings in the last year of life in elderly people who commit suicide

We examined suicidal feelings noted by doctors and by relatives of 85 elderly (> or = 65 years) people who died by suicide. When depression is suspected in an elderly patient, suicidal feelings should be assessed even during follow-up treatment.

Studies of suicide in later life: methodologic considerations and research directions

Later-life suicide is a tragedy that occurs worldwide. Often it is preventable. Here, the authors summarize an international workshop where they review four research approaches to studying putative risk factors: epidemiologic studies of suicidal behaviors, clinic-based follow-up studies, studies of suicide attempters, and psychological autopsy studies. They provide brief descriptions of the approaches, examples of questions best addressed by each approach, and their weaknesses and limitations; they also recommend promising areas for future research and propose opportunities for research that could be conducted cross-nationally.

Toward a clinical model of suicidal behavior in psychiatric patients

OBJECTIVE

Risk factors for suicide attempts have rarely been studied comprehensively in more than one psychiatric disorder, preventing estimation of the relative importance and the generalizability of different putative risk factors across psychiatric diagnoses. The authors conducted a study of suicide attempts in patients with mood disorders, psychoses, and other diagnoses. Their goal was to determine the generalizability and relative importance of risk factors for suicidal acts across diagnostic boundaries and to develop a hypothetical, explanatory, and predictive model of suicidal behavior that can subsequently be tested in a prospective study.

METHOD

Following admission to a university psychiatric hospital, 347 consecutive patients who were 14-72 years old (51% were male and 68% were Caucasian) were recruited for study. Structured clinical interviews generated axis I and axis II diagnoses. Lifetime suicidal acts, traits of aggression and impulsivity, objective and subjective severity of acute psychopathology, developmental and family history, and past substance abuse or alcoholism were assessed.

RESULTS

Objective severity of current depression or psychosis did not distinguish the 184 patients who had attempted suicide from those who had never attempted suicide. However, higher scores on subjective depression, higher scores on suicidal ideation, and fewer reasons for living were reported by suicide attempters. Rates of lifetime aggression and impulsivity were also greater in attempters. Comorbid borderline personality disorder, smoking, past substance use disorder or alcoholism, family history of suicidal acts, head injury, and childhood abuse history were more frequent in suicide attempters.

CONCLUSIONS

The authors propose a stress-diathesis model in which the risk for suicidal acts is determined not merely by a psychiatric illness (the stressor) but also by a diathesis. This diathesis may be reflected in tendencies to experience more suicidal ideation and to be more impulsive and, therefore, more likely to act on suicidal feelings. Prospective studies are proposed to test this model.

High levels of hopelessness persist in geriatric patients with remitted depression and a history of attempted suicide

OBJECTIVE

To determine whether a high level of hopelessness after treatment of a depressive episode is an indicator of a history of lifetime suicide attempts in older people.

DESIGN

Groups of suicide attempters, suicidal ideators, and nonsuicidal patients were compared via analysis of variance with respect to levels of hopelessness, depression, anxiety, and global functioning before and after treatment of depression.

SETTING

An outpatient research clinic providing two treatment protocols of late-life mood disorders.

PARTICIPANTS

A total of 107 consecutive outpatients (mean age 67) with major depression who responded to treatment.

MEASUREMENTS

Levels of hopelessness, severity of depression, anxiety, and global functioning were compared across the three groups at the beginning of treatment and at remission.

RESULTS

After remission there were no differences between the three groups in depression severity, anxiety, and global functioning. Hopelessness remained significantly higher in the attempter group than among ideators or nonsuicidal patients.

CONCLUSIONS

Suicide attempts, the most important risk factor for subsequent suicide, are associated with persistent, high levels of hopelessness following remission of depression in late-life patients. These findings suggest that treatments designed specifically to lower hopelessness (such as cognitive, behavioral or interpersonal therapy) may be effective in reducing suicide risk.

Hopelessness and suicidal behavior

The main purpose of this study was to investigate the relationship of the Beck Hopelessness Scale (BHS) with suicidal behavior and other clinical variables in 212 hospitalized suicide attempters. Another purpose was to analyze the usefulness of BHS in this particular context. Those who later committed suicide (N = 13) had significantly higher median scores than those who did not. Even though the median BHS score for the total population was above the cut-off score for future suicide risk, suggested by Beck et al., the relative ratio of correctly positive/false positive was low. Therefore the BHS does not seem to be a satisfactory instrument for predicting future suicide in hospitalized suicide attempters. Our findings rather suggest that the BHS is related to depression ratings, mood disorders and/or personality disorders.

Treatment of major depression in later life: a life cycle perspective

The goal of this article is to provide a life-cycle perspective on the treatment of major depressive episodes in later life. Our studies have suggested that older patients appear to benefit as much, though perhaps more slowly, than mid-life patients from acute combined treatment (nortriptyline+interpersonal psychotherapy) of major depression. Given also the apparently higher relapse rate among the elderly, however, continuation treatment needs to be vigorous and closely monitored. The occurrence of severe life events prior to the index episode and the co-existence of an anxiety disorder both appear to prolong treatment response times, while chronic medical burden per se neither compromises response rates nor prolongs time to response. Self-rated perception of health improves with remission of depression in the elderly. As in mid-life patients, both antidepressant medication (nortriptyline) and interpersonal psychotherapy appear to possess chronic efficacy with respect to the prevention of recurrent episodes and prolongation of wellness. Finally, treatment of depression in the elderly results in improved quality of life, especially in domains of well being and coping. Particular challenges in the treatment of elderly patients are noncompliance and the prevention of suicide. The latter is closely linked to feelings of hopelessness, and these may be persistent in some patients.

Elderly suicide, mental health professionals, and the clergy: a need for clinical collaboration, training, and research

This article addresses the need for improved clergy-mental health professional collaboration in the assessment and treatment of elderly suicide. Millions of older adults with personal problems seek the counsel of clergy. A recent Gallup survey found that elders are more willing to turn to their clergy than their medical doctor or a mental health specialist for help when a friend is contemplating suicide (Gallup Organization, 1992). Elder suicide prevention presents the mental health and religious communities with unique opportunities to work together in the best interests of those they serve.

Treatment of depression in late life

Depression is a common, but treatable, source of suffering, excess disability, and caregiver strain in late life. It is important to take a long-term view of the treatment of late-life depression because of the high risk for relapse, recurrence, and chronic illness. Elderly patients with medical and neurological illness or bereavement-related depressions also merit greater attention. Recent data highlight several important caveats: (a) the role of medical and psychosocial factors in the course of major depression; (b) variability in etiology, clinical presentation, and treatment response; (c) need for additional studies of syndromal and subsyndromal depression in primary and long-term care facilities, particularly in patients > 75 years of age; and (d) importance of continuation and maintenance treatment to maintain quality of life and to lower the risk for chronic illness. Nortriptyline, desipramine, and the newer selective serotonin reuptake inhibitors (SSRIs), paroxetine and sertraline, are preferred pharmacotherapy for short-term and long-term treatment. The newer SSRIs should be further studied in controlled trials of elderly depressed patients, including those > 75 years and those with medical or neurological illness. Psychotherapy also appears to be of major importance in successful outcome but, as does pharmacotherapy, merits further controlled investigation in both short- and long-term clinical trials.