Cognitive Risk Factors and Suicide Attempts Among Formerly Hospitalized Adolescents: A Prospective Naturalistic Study

Cognitive Risk Factors and Suicide Attempts Among Formerly Hospitalized Adolescents: A Prospective Naturalistic Study DAVID B. GOLDSTON, PH.D., STEPHANIE SERGENT DANIEL, PH.D., BETH A. REBOUSSIN, PH.D., DAVID M. REBOUSSIN, PH.D., PATRICIA H. FRAZIER, M.A., AND ASHLEY E. HARRIS, M.A.

ABSTRACT 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. J. Am. Acad. Child Adolesc. Psychiatry, 2001, 40(1): 91–99. Key Words: longitudinal study, hospitalization, cognition, hopelessness, expectations, suicidal behavior.

Cognitive factors have long been recognized as important in the etiology of adult suicidal behavior. As Shneidman (1996) noted, “Every single instance of suicide is an action by the dictator or emperor of your mind. But in every case of suicide, the person is getting bad advice from a part of that mind [that is in a] temporarily . . . panicked state and in no position to serve the person’s best long-range interests” (p. 165). A cognitive analysis of suicidal behavior is advantageous because of its direct implications for treatment. To Accepted August 23, 2000. Drs. Goldston and Daniel, Ms. Frazier, and Ms. Harris are with the Department of Psychiatry and Behavioral Medicine, and Drs. Beth Reboussin and David Reboussin are with the Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC. This project was funded by NIMH grant MH48762 and a Faculty Scholar Award from the William T. Grant Foundation to Dr. Goldston. Correspondence to Dr. Goldston, Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157-1087; e-mail: [email protected]. 0890-8567/01/4001-0091q2001 by the American Academy of Child and Adolescent Psychiatry.

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decrease self-destructive behavior, clinicians need to assist distressed patients in recognizing and reducing maladaptive thinking, while facilitating more positive and adaptive thinking. Studies of adolescents, however, have lagged behind those of adults in systematically examining the cognitive context within which suicidal behavior occurs, and in particular, the degree to which cognitive variables portend risk for later suicidal behavior. Hopelessness is the cognitive variable that has received the most attention as a risk factor for suicidal behavior. Hopelessness is a negative view or negative set of attitudes regarding the future. According to Beck’s (Beck et al., 1979) cognitive theory of depression, this negative view of the future is part of the cognitive triad (along with a negative view of oneself and one’s world) that is characteristic of the thinking of depressed individuals. Among adults, hopelessness repeatedly has been found to be associated with repeated self-harm behaviors (Scott et al., 1997) and eventual suicide (Brown et al., 2000; Fawcett et al., 1990) in clinically referred samples. Nonetheless, although a 91

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number of cross-sectional studies have focused on hopelessness and juvenile suicidal behavior (Rotheram-Borus and Trautman, 1988; Steer et al., 1993), few studies of youths (e.g., Myers et al., 1991) have examined hopelessness as a predictor of later suicidal behavior. Reasons for living, dysfunctional attitudes, problemsolving ability, and expectations about future suicidal behavior are also cognitive variables that may be related to adolescent suicidal behavior. Reasons for living or deterrents to suicide have been found to be negatively associated with both recent and previous suicidal behavior among adults and adolescents (Cole, 1989; Linehan et al., 1983). Dysfunctional attitudes are believed to reflect underlying “depressive schemata” or belief systems that make individuals vulnerable to depression (Beck et al., 1993). Such dysfunctional attitudes promote information-processing errors in which depressed individuals filter or dampen the significance of positive information and exaggerate “the meaning and significance of negative information” (Beck et al., 1993, p. 11). Deficits in problem-solving ability have been described as being associated with suicidality; specifically, suicidal individuals often fail to perceive alternatives for solving difficulties, and they narrowly focus on suicide as their only possible solution to problems (Shneidman, 1996). In addition, personal expectations have long been thought to be associated with later behavioral and health outcomes (e.g., Snyder and Stukas, 1999). Individuals considering suicide may assimilate information that is confirmatory of their negative expectations for the future, therein setting up self-fulfilling prophecies that are predictive of later behavior. Using data from a prospective, naturalistic study of suicidal behavior among adolescents after psychiatric hospitalization, we examined whether hopelessness, reasons for living, dysfunctional attitudes, problem-solving ability, and personal expectations are predictive of posthospitalization suicidal behavior. Because of the relationship between many cognitive variables and past suicidal behavior, as well as possible associations between cognitive variables and psychiatric diagnoses, we also assessed whether cognitive variables predict subsequent suicidal behavior after controlling for prehospitalization history of suicidal behavior, psychiatric diagnoses, and demographic variables. Finally, our prior work (Goldston et al., 1999) indicated that affective disorders and clinically significant depression severity scores were more predictive of later suicidal behavior among individuals with a history of suicide attempts than among individuals with no 92

such history (Goldston et al., 1999). Therefore, we considered whether the predictive utility of cognitive variables differs as a function of previous suicidal behavior. METHOD Subjects The 180 adolescents participating in this study were hospitalized between September 4, 1991, and April 10, 1995. The youths were recruited from among consecutive discharges from the Adolescent Inpatient Psychiatry Unit of Wake Forest University Baptist Medical Center. Sampling was not based on history of suicidal behavior. To be eligible for the study, adolescents needed to meet the following inclusionary criteria: (1) aged 12 to 19 years, (2) no evidence of mental retardation, (3) hospitalization on the unit for at least 10 days, (4) no evidence of serious systemic physical disease such as insulindependent diabetes mellitus or seizure disorder, (5) still residing in North Carolina or Virginia at the time of the first follow-up assessment, (6) not a sibling of a subject already participating in the study, and (7) able to cooperate with and complete the inpatient assessment. To recruit the planned sample of 180, we attempted to locate 225 youths one-half year after their hospitalization. One subject died before he could be asked to participate. We found 96.0% of the remaining pool of eligible subjects; of these, 83.7% agreed to participate in the longitudinal study. The resulting sample consisted of 91 girls and 89 boys whose ages ranged from 12 to 18 years (mean = 14.8 years, median = 14.8 years) at the time of hospitalization. The majority of the subjects (80%) were white, 16.7% were African American, and the remainder were Hispanic, Native American, or of Asian American heritage. Additional demographic and clinical characteristics for the sample have been described by Goldston et al. (1999). All youths were assessed during their hospitalization with a standardized battery including semistructured interview instruments. Thereafter, youths were asked to participate in semiannual follow-up assessments. The interviews were typically scheduled every 6 to 8 months but varied within and among subjects because of scheduling conflicts, staff shortages, and subject requests. To maximize the resources of the study, youths who entered the study at the beginning of subject recruitment were followed for a longer period than were youths who entered the study at the end of the recruitment period. At the cutoff date for these analyses (October 7, 1998), subjects in the study had been monitored for up to 6.9 years (mean = 4.0 year, median = 4.3 year), and 7.2% of the sample (n = 13) had dropped out of the study. This study is ongoing, and the youths are still being monitored. Instruments and Procedures Suicide Attempts. Suicide attempts were assessed with the Interview Schedule for Children and Adolescents (ISCA) (Kovacs, 1985). At the hospitalization assessment, the ISCA was administered to adolescents. Auxiliary information was obtained from interviews with parents, other mental health professionals, behavioral observations, data recorded in medical charts, and prior records. For the follow-up assessments, the ISCA was administered to both the adolescents and adult informants (until subjects were aged 18 or living independently). Auxiliary information was obtained from school, treatment, and legal records. Interviewers using the ISCA were mental health professionals extensively trained in the administration of semistructured interview instruments. Suicidal behaviors were assessed with standardized ISCA questions (e.g., “Have you ever thought about killing yourself?”) and cor-

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responding predefined rating scales. Self-destructive behavior was classified as a suicide attempt if it was associated with any desire to die, regardless of multiple motives or ambivalence associated with the act. Self-harm behaviors not associated with intent to kill oneself were not considered to be suicide attempts. Suicidal acts that were stopped before they were executed were considered to be suicidal ideation rather than suicide attempts. This classification scheme is similar to that proposed by O’Carroll et al. (1996) and has been used previously (Goldston et al., 1998, 1999). Results obtained from a previous interrater trial of 46 cases indicated that interrater agreement for the ISCA item regarding suicide attempts (computed as Cohen κ) was 1.00 (M. Kovacs, unpublished manuscript, University of Pittsburgh, 1981). A separate interrater trial was conducted as part of the current study. Two raters examined transcribed interviewer notes regarding suicidal behaviors for 40 subjects initially rated as having either suicidal ideation or suicide attempts. The raters (who did not conduct the original interviews and were blind to subjects’ identities) independently determined whether subjects had experienced suicidal ideation or attempted suicide. Interrater agreement in classifications of suicidal ideation and attempts was 95% (Cohen κ = 0.90). Suicide Completions. A search of the Social Security Death Index was used to help determine whether subjects with whom we had lost contact had died. We have no evidence that anyone in this study completed suicide by the cutoff date for these analyses. Hopelessness, Reasons for Living, and Dysfunctional Attitudes. The Beck Hopelessness Scale (BHS) (Beck and Steer, 1988) is a 20-item scale that assesses pessimism and negative expectancies for the future. Typical items are “My future seems dark to me” and “I might as well give up because there is nothing I can do about making things better for myself.” The BHS has concurrent validity with both adults and adolescents (Steer and Beck, 1988) and is predictive of suicidal behavior in adult clinically referred samples (Beck and Steer, 1988). Among adolescent psychiatric inpatients, the BHS is internally consistent and has a similar factor structure to that described for adults (Steer et al., 1993). The Reasons for Living Scale (RFL-48) (Linehan et al., 1983) is a 48-item scale that assesses deterrents against suicidal behavior, or reasons that people have for living. The RFL-48 has six factor-derived and internally consistent scales: Survival and Coping Beliefs, Responsibility to Family, Child-Related Concerns, Fear of Suicide, Fear of Social Disapproval, and Moral Objections. Because most adolescents in our study did not have children of their own, we did not score the ChildRelated Concerns Scale. The Survival and Coping Beliefs scale (RFLSC) has the most items, the highest level of internal consistency, and the most demonstrated convergent validity of the RFL scales. Typical items on the RFL-SC are “I believe I can find a purpose in life, a reason to live” and “I believe I can find other solutions to my problems.” RFL scales have been found to differentiate adults and adolescents with and without suicidal behavior (Cole, 1989; Linehan et al., 1983). The version of the Dysfunctional Attitudes Scale (DAS) (Weissman, 1980) used in this study has 40 items reflecting the maladaptive attitudes and beliefs associated with depression. The maladaptive beliefs assessed in the DAS represent domains such as need for approval, dependence, self-criticism, and perfectionism. Among adults, the DAS has been found to be reliable and internally consistent (Weissman, 1980). Expectations for Posthospitalization Suicide Attempts. Prior to their hospital discharge, adolescents were asked: “How likely is it that you will attempt suicide in the future (after your discharge)?” They were asked to circle their response on a Likert-type scale, ranging from 1 (“not at all likely”) to 7 (“extremely likely”). The responses to this question were skewed: 67% of subjects had ratings of 1, 13% had rat-

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ings of 2, and 20% had ratings of 3 to 7. The treatment team was not kept blind to these ratings. Indeed, hospitalizations of several youths were prolonged because of concerns raised when subjects indicated their expectation of attempting suicide after discharge. Problem-Solving Ability. The Means-Ends Problem-Solving Task (MEPS) is designed to assess interpersonal problem-solving ability, specifically “the ability to plan step-by-step means to reach a stated goal in a given situation” (Platt et al., 1975). During the MEPS administration, subjects are provided with vignettes in which there is a statement of need and a description of the desired outcome and are asked to describe how the main character in each story might achieve the desired outcome. Different outcome indices can be derived from the MEPS responses; however, we focused on the total number of “relevant means” generated by subjects for the vignettes during hospitalization. The MEPS indices have been noted to have adequate reliability (e.g., Kingsbury et al., 1999) and to have concurrent and predictive validity in adolescent and adult samples (Platt et al., 1975). Psychiatric Diagnoses. Psychiatric disorders were assessed with the ISCA (Kovacs, 1985). The ISCA is a semistructured symptomoriented psychiatric interview. For each symptom assessed with the ISCA, operational criteria specify the severity levels with which symptoms are considered “clinically significant.” Only symptoms that are “clinically significant” in duration, severity, and functional impairment contribute to the operational diagnostic criteria for psychiatric diagnoses. More details regarding the ISCA and our diagnostic procedures are described by Goldston et al. (1999). Sociodemographic Variables at Hospitalization. Sociodemographic variables including gender, race, and age at hospitalization were recorded from medical records. Occupation and education of parents (for determining socioeconomic status) were assessed with the Followup Information Sheet, a data entry form modeled after the Intake Information Sheet developed by Kovacs (unpublished manuscript, University of Pittsburgh, 1982). Overview of Procedure Adolescents (and informants when appropriate) were interviewed with the ISCA both at the time of their index hospitalization and at each follow-up assessment. The cognitive variables (other than the question about future expectations) were assessed both at hospitalization and at each follow-up assessment. The question regarding expectations of future attempts was administered only at hospitalization. Statistical Methods In initial cross-sectional analyses, we examined correlations among the cognitive variables at hospitalization and the ability of these variables to discriminate between hospitalized adolescents with and without histories of suicide attempts after adjusting for age, gender, and race, using logistic regression analysis. The survival distribution curve for the risk over time for a first suicide attempt after hospitalization was described by Goldston et al. (1999). Cox proportional hazards models were used to model the effect of cognitive variables assessed at hospitalization on time until posthospitalization suicide attempts (Cox and Oakes, 1984). These methods use all available data, regardless of varying numbers and timing of subject interviews. Subjects not attempting suicide were censored at their most recent interview. All covariates in models reflected measurements taken at the baseline hospitalization. For the Cox models, assumptions of proportionality and constancy of effects over time were tested with the correlation of the Schoenfeld residuals and event times (Schoenfeld, 1980; Therneau et al., 1990). The effects of covariates were examined both as univariate predictors and in models with multiple predictors. Except as noted

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in the “Results” section, age, gender, and race were included in all models. All models involving interactions also controlled for corresponding main effects. RESULTS Cognitive Variables at Hospitalization: Cross-Sectional Analyses

The intercorrelations among cognitive variables are presented in Table 1. Most of the cognitive variables (with the exception of the MEPS relevant means) were moderately intercorrelated. As seen in Table 1, several (7/9) of the cognitive variables were significantly correlated with severity of depression (p , .05). Depression scores were most highly correlated with BHS, RFL-SC, and DAS scores (sharing 51%, 30%, and 20% of the variance, respectively). At hospitalization, higher BHS and DAS scores and higher ratings on the question assessing expectations for future suicide attempts were associated with an increased likelihood of being a prior suicide attempter (b = 0.090, exp(b) = 1.09, se(b) = 0.028, p = .001; b = 0.013, exp(b) = 1.01, se(b) = 0.005, p = .005; and b = 0.482, exp(b) = 1.62, se(b) = 0.141, p , .001, respectively). No other variables discriminated between the two groups at baseline. Posthospitalization Suicide Attempts as a Function of Cognitive and Demographic Variables

Both severity of hopelessness at hospitalization and greater expectations of later suicide attempts were associated with increased risk for posthospitalization suicide attempts (b = 0.073, exp(b) = 1.076, se(b) = 0.027, p =

.007; and b = 0.361, exp(b) = 1.435, se(b) = 0.086, p , .001, respectively). In contrast, fear of social disapproval was related to a decreased risk for posthospitalization attempts (b = 20.248, exp(b) = 0.780, se(b) = 0.105, p = .018). No other cognitive variables predicted later suicidal behavior. The cognitive variables did not interact with gender in predicting suicidal behavior. Posthospitalization Suicide Attempts as a Function of Cognitive and Demographic Variables, Prior Suicide Attempts, and Index Psychiatric Diagnoses

After we controlled for past suicide attempts and psychiatric diagnosis at hospitalization, severity of hopelessness and greater expectations of later suicide attempts were still predictive of future attempts (b = 0.065, exp(b) = 1.067, se(b) = 0.032, p = .044; and b = 0.303, exp(b) = 1.354, se(b) = 0.108, p ,.001, respectively). The risk of posthospitalization attempts as a function of expectations about future suicidal behavior is depicted in Figure 1. Fear of social disapproval remained marginally related to subsequent suicidal behavior (b = 20.192, exp(b) = 0.825, se(b) = 0.113, p = .087). No other cognitive variables predicted suicidal behavior. Differential Predictive Utility of Cognitive Variables Depending on History of Suicide Attempts

As shown in Figure 2, hopelessness scores were more strongly predictive of suicide attempts among individuals with histories of prior attempts than they were for individuals who had never made a suicide attempt (b = 0.165, exp(b) = 1.179, se(b) = 0.063, p = .009). More specifically, hopelessness failed to predict suicidal behav-

TABLE 1 Cross-Sectional Correlations Between Cognitive Variables and the Beck Depression Inventory at Hospitalization DAS RFL-SC RFL-RF RFL-FS RFL-FD RFL-MO EFSA MEPS BDI

BHS

DAS

RFL-SC

RFL-RF

RFL-FS

RFL-FD

RFL-MO

EFSA

MEPS

0.51** –0.58** –0.28** –0.11 –0.22* –0.31** 0.35** –0.03 0.71**

— –0.52** –0.05 0.10 0.08 –0.09 0.25* –0.11 0.45**

— 0.45** 0.28** 0.39** 0.53** –0.37** 0.02 –0.55**

— 0.41** 0.55** 0.48** –0.13 –0.06 –0.19*

— 0.57** 0.52** 0.01 –0.06 –0.03

— 0.43** –0.09 –0.05 –0.24*

— –0.19* 0.07 –0.20*

— 0.08 0.35**

— –0.02

Note: BHS = Beck Hopelessness Scale; DAS = Dysfunctional Attitudes Scale; RFL-SC = Reasons for Living Scale-Survival and Coping Beliefs; RFL-RF = Reasons for Living Scale-Responsibility to Family; RFL-FS = Reasons for Living Scale-Fear of Suicide; RFL-FD = Reasons for Living Scale-Fear of Social Disapproval; RFL-MO = Reasons for Living Scale-Moral Objections; EFSA = expectations for future suicide attempts; MEPS = Means-Ends Problem-Solving Task Relevant Means; BDI = Beck Depression Inventory. * p < .05; ** p < .001 (two-sided).

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Fig. 1 Risk for suicide attempts after hospital discharge as a function of expectations about future suicidal behavior (rated on a 1 to 7 scale).

Fig. 2 Risk for suicide attempts after hospital discharge as a function of Beck Hopelessness Scale (BHS) scores and previous attempts.

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ior among adolescents without a history of suicide attempts (p = .790). Hopelessness was strongly predictive of suicide attempts after hospitalization for teenagers with previous suicidal behavior (p , .001). As depicted in Figure 3, scores from the RFL-48 Survival and Coping Beliefs Scale were associated with decreased risk for posthospitalization suicide attempts; this effect was more pronounced among individuals with prior suicide attempts than among individuals without such histories (b = 20.683, exp(b) = 0.505, se(b) = 0.303, p = .024). Specifically, survival and coping beliefs were not predictive of suicide attempts among adolescents without a history of attempts (p = .420). In contrast, survival and coping beliefs were associated with a decreased risk for repeated suicide attempts among previously suicidal adolescents (p = .005). The other cognitive variables did not interact with history of suicidal behavior in predicting posthospitalization attempts. Effectiveness as Screeners

The effectiveness of different instruments as screeners for suicide attempts during the first year after hospitalization (the highest risk period for attempts) was exam-

ined. In examining effectiveness of screeners, we focused on the instruments found to predict suicidal behavior in earlier analyses. The effectiveness of the question regarding expectations was examined among all youths. The effectiveness of BHS scores and RFL-48 Survival and Coping Beliefs scores (alone and in combination) was examined among adolescents with prehospitalization attempts only (because previous analyses indicated they were predictive primarily among these youths). For the expectation question, adolescents responding with 2 or greater on the 1 to 7 scale were considered to be “at risk.” Scores of 9 or greater on the BHS and scores of less than 4.9 on the RFL-SC also were considered to indicate “risk.” To examine the combined efficiency of the BHS and RFL-SC, we first considered adolescents to be “at risk” if they scored above the cutoff either on the BHS or below the cutoff on the RFL-SC. In a second set of analyses, we considered youths to be “at risk” if they scored beyond the cutoffs on both of the scales. For each of these screeners, the positive predictive value, negative predictive value, sensitivity, and specificity are presented in Table 2. As can be seen, the expectations question had

Fig. 3 Risk for suicide attempts after hospital discharge as a function of the Reasons for Living Scale-Survival and Coping Beliefs (RFL-SC) and previous attempts.

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TABLE 2 Efficacy of Screeners of Posthospitalization Attempts Within One Year of Hospital Discharge Predictors Future expectations BHS RFL-SC BHS and RFL-SCa BHS and RFL-SCb

DISCUSSION

Sensitivity (%)

Specificity (%)

PPV (%)

NPV (%)

71 85 83 92 75

73 49 48 31 66

28 27 26 24 32

95 93 93 94 92

Note: PPV = positive predictive value; NPV = negative predictive value; BHS = Beck Hopelessness Scale; RFL-SC = Reasons for Living Scale-Survival and Coping Beliefs. The expectations question was examined among all youths. The BHS and RFL-SC were examined among previous attempters only. a Either scale beyond cutoff. b Both scales beyond cutoff.

moderate to good sensitivity and specificity for the entire sample. The BHS and RFL-SC were more sensitive but less specific (i.e., produced more false positives) for adolescents with previous attempts. Association Between Hopelessness and Depression

Because of the association between depression and hopelessness and the similar manner in which both variables interacted with prior attempts (Goldston et al., 1999), we examined the interrelationship between these two variables as predictors. When the main effects of depression and hopelessness scores were simultaneously examined as predictors of suicidal behavior, neither BDI nor BHS scores were significantly related to later suicide attempts. That is, because of collinearity, the effects of the two variables effectively “canceled each other out.” In a predictive model in which demographic variables, prehospitalization suicide attempts, and the interactions between prior attempts and both BDI scores and BHS scores were examined simultaneously, the interaction between depression scores and prior attempts remained related to later suicidal behavior (b = 0.078, exp(b) = 1.081, se(b) = 0.038, p = .038). However, in the presence of the interaction with depression scores, the interaction between hopelessness and prior attempts no longer independently predicted posthospitalization attempts. Results were not substantially different when analyses were repeated using BDI scores adjusted by removing the pessimism/hopelessness and suicidal ideation items from the total scores. Results also were not different when we simultaneously examined the interaction with hopelessness and interaction with baseline diagnoses of affective disorders (instead of severity of depression scores). J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 1 , J A N U A RY 2 0 0 1

In this prospective, naturalistic study of adolescents after psychiatric hospitalization, we examined both the cognitive predictors of posthospitalization suicide attempts and the differential predictive utility of these variables in adolescents with and without past suicidal behavior. Among the cognitive variables, hopelessness was one of the strongest predictors of later suicide attempts but was predictive primarily for adolescents who already had a history of suicidal behavior. The finding regarding the predictive utility of hopelessness contrasts with findings from two other prospective studies of youths; one of these studies (Myers et al., 1991) examined hopelessness with a scale other than the BHS, and the second (Hawton et al., 1999) was limited in power because of the small number of youths reattempting suicide during a 1-year follow-up. In prospective studies of clinically referred adults, hopelessness has predicted both repeated suicide attempts and completed suicide (Brown et al., 2000; Scott et al., 1997). Nonetheless, the differential predictive utility of hopelessness among adults with different histories of suicidal behavior apparently has not been examined. The fact that hopelessness predicted posthospitalization suicide attempts primarily for previous suicide attempters dovetails with our earlier findings regarding the differential predictive utility of affective disorders and severity of depression (Goldston et al., 1999). It is possible that youths who present at hospitalization with suicide attempts have a greater genetic, biochemical, or dispositional vulnerability or liability than other youths and therein are more likely to attempt suicide than other youths when hopelessness and other risk factors are prominent. Alternatively, the act of making a suicide attempt itself may engender increased vulnerability, particularly when circumstances or cognitions (e.g., hopelessness) are similar to those that precipitated earlier suicidal behavior (Goldston et al., 1999). The predictive effects of hopelessness in part may have been due to the relationship between hopelessness and overall depression. Indeed, both in the current study and in a recent study of adult outpatients (Brown et al., 2000), hopelessness did not predict later suicidal behavior after controlling for depression. According to Beck’s cognitive theory of depression (Beck et al., 1979), a negative view of the future is a central part of the experience of depression, and hence it should be no surprise that these constructs are related. Nonetheless, among adults, hopelessness has 97

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been found to be as potent a predictor of suicidal behavior as severity of depression (Brown et al., 2000), to predict suicide even among clinically depressed individuals (Fawcett et al., 1990), to have trait-like properties (Young et al., 1996), and to persist, even when other depressive symptoms have improved with treatment (Rifai et al., 1994). Future analyses of data from this sample will help us to understand the interrelationship and relative stability of depression and hopelessness over time, as well as the relationship of each of these variables over time to risk for suicidal behavior. In addition to hopelessness, expectations for later suicidal behavior also were a very potent predictor of posthospitalization suicide attempts. Self-rated expectations were predictive, regardless of adolescents’ histories of suicidal behavior and despite the fact that the inpatient treatment team was not kept blind to the results of the ratings at discharge. Behavioral intentions or expectancies (see Ajzen and Fishbein, 1980) have been found to be predictive of subsequent behavior in a number of different areas including sexual behavior and substance use (Marcoux and Shope, 1997; Stanton et al., 1996). However, we are unaware of studies examining the predictive utility of such expectations regarding suicidal behavior. Adolescents’ estimation of whether they will try to kill themselves seems to be as good a predictor of later suicidal behavior as more indirect indicants of risk. The fact that some adolescents were unwilling to completely rule out the possibility of later suicide attempts may reflect their continuing ambivalence about current life situations despite inpatient treatment and their lingering doubts about coping satisfactorily in the future. In contrast to hopelessness and expectations about later suicidal behavior, reasons for living were negatively related to posthospitalization suicidal behavior. Fear of social disapproval was a protective factor against later suicidal behavior, but its protective effect was no longer significant after former patients’ histories of suicidal behavior were considered. This suggests that there is a partial confounding between adolescents’ fear of social disapproval and their history of suicidal behavior, with individuals who have already made attempts having less fear of the social ramifications of self-injurious behavior. In contrast, greater survival and coping beliefs protected against later suicidal behavior for adolescents with a history of suicide attempts, but did not serve as a protective factor for those youths without histories of suicide 98

attempts. In cross-sectional studies of adults and adolescents (Cole, 1989; Linehan et al., 1983), reasons for living have been found to be correlated with suicidality. To our knowledge, however, this is the first prospective study of a clinically ascertained sample to demonstrate that reasons for living serve as a protective factor against later suicide attempts. Among adolescents at high risk, there have been few other protective factors identified that buffer against subsequent suicidal behavior. When considering the protective effects of RFL survival and coping beliefs, it is worth noting that the latter are not simply the obverse of hopelessness, despite the moderate negative correlation between the two variables. Survival beliefs are beliefs about one’s purpose in life and ability to persevere. Hopelessness is a generalized feeling of pessimism about the future and is not necessarily related to a personal inability to cope or lack of purpose in life. Dysfunctional attitudes differentiated between adolescents with and without suicide attempts at study entry, but neither dysfunctional attitudes nor problem-solving ability predicted posthospitalization attempts. Modification of dysfunctional attitudes is often useful in reducing depression, just as helping suicidal individuals focus on alternative solutions (and the steps involved in those solutions) is a useful therapeutic strategy for reducing the constricted focus on suicidal behaviors. Nonetheless, the fact that these variables are useful as targets of interventions does not necessarily imply that such attitudes or deficits are useful predictors of later suicidal behavior. Dysfunctional attitudes and problem-solving deficits may be “state phenomena” rather than enduring attributes that might portend later risk (Schotte et al., 1990), or they simply may not be specific to individuals at risk for suicidality in clinically referred samples (Beck et al., 1993). Limitations

This sample is 80% white and was recruited from a single inpatient psychiatric facility. Results may therefore not be generalizable to primarily minority samples, to nonclinically ascertained samples, or to youths in other clinical settings. Findings regarding predictors of suicide attempts in this study are based on the baseline values of these variables at index hospitalization (i.e., the same data that would be available to an attending physician in a hospital setting trying to ascertain future risk). Data pertaining to the relationship of these variables after hospitalization and risk for suicidal behavior will be examined in a future article. J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 1 , J A N UA RY 2 0 0 1

ADOLESCENT SUICIDE ATTEMPTS

Clinical Implications

If replicated, the results of this study have straightforward clinical implications for the assessment and treatment of suicidal behavior. Among hospitalized youths, the question assessing expectations appears to have utility as a screener for later risk. Admittedly, some youths who later attempt suicide report that they do not expect to try to kill themselves again; however, those youths who claim to “rule out” the possibility of later suicidal behavior are at significantly reduced risk for suicidal behavior than other adolescents. Likewise, among hospitalized adolescents with a history of suicide attempts, BHS scores of 9 or greater or RFL-SC scores of less than 4.9 have utility as screens for later risk. These cutoffs yield a significant number of false-positive results, but they also identify the majority of youths in this group who make later attempts. The cognitive risk and protective factors described in this study serve functions for the suicidal patient which need to be considered in treatment. The cognitive state of hopelessness amplifies the degree to which steps to resolve life difficulties are perceived as futile. Lingering expectations about future suicidal behavior and beliefs about suicide as a viable option paradoxically make it more difficult for suicidal patients to focus on more adaptive or constructive ways of dealing with stressors. In this context, clinicians should help patients to recognize and combat the self-defeating and constricted cognitions that perpetuate and heighten distress and distract from efforts to generate multiple solutions to problems. Moreover, clinicians should help patients to cultivate reasons for living and help facilitate patients’ expectancies that they will be able to cope adaptively. REFERENCES Ajzen I, Fishbein M (1980), Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice-Hall Beck A, Rush A, Shaw B, Emery G (1979), Cognitive Therapy of Depression. New York: Guilford Beck A, Steer R (1988), Beck Hopelessness Scale Manual. New York: Psychological Corporation Beck A, Steer R, Brown G (1993), Dysfunctional attitudes and suicidal ideation in psychiatric outpatients. Suicide Life Threat Behav 23:11–20 Brown G, Beck A, Steer R, Grisham J (2000), Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol 68:371–377 Cole D (1989), Validation of the Reasons for Living Inventory in general and delinquent adolescent samples. J Abnorm Child Psychol 17:13–27 Cox D, Oakes D (1984), Analysis of Survival Data. New York: Chapman and Hall Fawcett J, Scheftner W, Fogg L et al. (1990), Time-related predictors of suicide in major affective disorder. Am J Psychiatry 147:1189–1194

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