Research report
Hopelessness and suicidal behavior

https://doi.org/10.1016/S0165-0327(96)01404-8Get rights and content

Abstract

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.

Introduction

In the search for factors predicting suicide, several rating scales related to suicidal behavior have been constructed. While some scales are based on empirical statistical risk-factors, others are rather related to psychopathology (Burk et al., 1985, Beck et al., 1990a). So far, such scales could be regarded as useful complements to the clinical evaluation. The problem when studying unique events such as suicide is however that there are always many patients who are evaluated as being at risk, even though they never repeat their suicidal behavior, i.e. "false positives". This has been discussed by e.g. Pokorny (1983), Beck et al. (1990a).

Hopelessness is a key psychological factor in suicidal behavior, and could be regarded as part of the cognitive distortion of depressed and suicidal patients (Beck et al., 1989aMinkoff et al., 1973Beck and Weishaar, 1990bBeck et al., 1985Salter and Platt, 1990).

Fawcett et al. (1987)reported that high clinician-ratings of hopelessness in patients with major depressive disorder (MDD) shortly after admission to hospital were characteristic of those who later committed suicide. Similarly, Hamdi et al. (1991)estimated from clinical interviews and Salter and Platt (1990)from the Beck Hopelessness Scale (BHS), an association between hopelessness and high suicidal intent according to the Suicidal Intent Scale (SIS), (Beck et al., 1974b), in patients who were evaluated after a suicide attempt. In another study, Minkoff et al. (1973)found that the degree of suicidal intent was rather associated with hopelessness rated in the Generalized Expectancies Scale than with depressed mood.

Hopelessness, as measured by the BHS (Beck et al., 1974a), has emerged as the modulating variable linking depression and suicidal intent. In a multiple regression analysis, hopelessness was 1.3 times more important than depression in explaining suicidal ideation (Beck et al., 1993a), and in another study hopelessness combined with a history of a past suicide attempt were suggested to be the two most important variables identifying suicide ideators (Beck et al., 1993b).

Beck et al. constructed the BHS from two different sources. Nine items were gathered from a test on future attitudes, and eleven from empirically well known pessimistic statements from psychiatric patients. The reliability and validity of the scale was evaluated in 294 hospitalized suicide attempters (Beck et al., 1974a), and the reliability coefficient (Cronbach's alpha) was 0.93. In a factor analysis obtained from these 294 suicide attempters, Beck et al. (1974a)found three factors which made sense clinically; The most important factor reflected affective aspects, followed by motivational and cognitive aspects, respectively.

A study of psychiatric out-patients with either mood or anxiety disorders showed that patients with a score of 9 (out of 20) or above ran 11 times higher risk of future suicide than did those below (Beck et al., 1990a). The sensitivity was 94.1% while the specificity was 41.0%. Consequently, the percentage of false positives was high (59.0%).

In another study by Beck et al. (1985), the BHS was the only scale that significantly differentiated between suicide ideators who did and did not eventually die by suicide. They again found a cutoff score of 9 in the BHS to clearly separate the two groups. The sensitivity was 90.9%. Keller and Wolfersdorf (1993)in a one year follow up of depressed in-patients found a high sensitivity with a score of 8 or more, but similarly to findings by Beck and others a high proportion of false-positives.

Finally, Rifai et al. (1994)found that patients who had made a suicide attempt in the past had significantly higher BHS scores than nonattempters when measured both at the index assessment and when followed up. On the contrary, Beck et al. (1989a)found the BHS not to be a useful instrument in predicting suicide in a sample of attempters.

In the present study, which is part of a large comprehensive study, we will discuss the BHS in patients, who were hospitalized after a suicide attempt. The aims of the study were to describe the BHS and its possible value of predicting suicide in subgroups of suicide attempters.

Section snippets

Sample

Adult suicide attempters (more than 18 years old) were evaluated both in the Medical Intensive Care Unit and during psychiatric hospitalization. A suicide attempt was defined as "a situation in which a person has performed an actually or seemingly life-threatening behavior with the intent of jeopardizing his life, or to give the appearance of such an intent, but which has not resulted in death" (Beck et al., 1972). Our patients were subdivided into violent and non-violent attempters. Violent

Patient characteristics

Two hundred and twelve patients who had consented to research, filled out the BHS, 92 men (43.4%) and 120 women (56.6%). Their mean age was 37.66±13.55 years, and their median age was 36. The mean age of men was 38.61±12.41, range 18–70 years. Women were 36.93±14.37 years old, range 18–80 years. Twenty-six men and 14 women made violent suicide attempts, while 66 men and 106 women made non-violent attempts. Eighty-four patients (39.6%) had made previous suicide attempts (repeaters), 28 (33.3%)

Discussion

Our patient-group is a subsample of adult suicide attempters, which is estimated to be in need of hospitalization due to suicide risk or severe psychopathology, and in this sense not comparable to all examined adult suicide attempters in the catchment area. However, concerning sex and age distribution they are comparable (Öjehagen et al., 1991).

When Beck et al. (1974a)first presented the BHS, their homogeneity analyses showed the same alpha coefficient as ours. They also included a factor

Acknowledgements

Our studies are supported by the Swedish Medical Research Council nos 8319-9 and 714/85, The Bank of Sweden Tercentenary Foundation 87/257 and Funds from the University of Lund. Dr Göran Regnell and our nursing staff are greatly acknowledged.

References (25)

  • Beck, A.T., Davis, J.H., Frederick, C.J., Perlin, S., Pokorny, A., Schulman, R., Seiden, R. and Wittlin, B. (1972)...
  • Beck, A.T., Weissman, A., Lester, D. and Trexler, L. (1974a) The measurement of pessimism: The Hopelessness Scale. J....
  • Beck, A.T., Herman, I. and Schuyler, D. (1974b) Development of Suicidal Intent Scales. In: A.T. Beck, H.L.P. Resnik, D....
  • Beck, A.T., Steer, R.A., Kovacs, M. and Garrison, B.S. (1985) Hopelessness and Eventual Suicide: A 10-Year Prospective...
  • Beck, A.T., Brown, G. and Steer, R.A. (1989a) Prediction of eventual suicide in psychiatric inpatients by clinical...
  • Beck, A.T. and Steer, R.A. (1989b) Clinical predictors of eventual suicide: a 5- to 10-year prospective study of...
  • Beck, A.T., Brown, G., Berchick, R.J., Stewart, B.M. and Steer, R.A. (1990a) Relationship between hopelessness and...
  • Beck, A.T. and Weishaar, M.E. (1990b) Suicide Risk Assessment and Prediction. Crisis 11/2,...
  • Beck, A.T., Steer, R.A., Beck, J.S. and Newman, C.F. (1993a) Hopelessness, depression, suicidal ideation and clinical...
  • Beck, A.T., Steer, R.A. and Brown, G. (1993b) Dysfunctional attitudes and suicidal ideation in psychiatric outpatients....
  • Burk, F., Kurz, A. and Möller, H.-J. (1985) Suicide risk scales: do they help to predict suicidal behaviour? Eur. Arch....
  • Conover, W.J. and Iman, R.L. (1981) Rank transformations as a bridge between parametric and nonparametric statistics....
  • Cited by (65)

    • Suicide in males and females with cardiovascular disease and comorbid depression

      2016, Journal of Affective Disorders
      Citation Excerpt :

      Furthermore, many studies have shown that patients with cancer, diabetes mellitus, stroke and neurological conditions among other chronic illnesses have an increased risk of suicide (Christensen et al., 2007; Harris and Barraclough, 1994; Hawton and van Heeringen, 2009; Hietanen and Lonnqvist, 1991; Kyvik et al., 1994). Other recognized factors that could contribute to suicide risk include substance use (Schneider, 2009; Wilcox et al., 2004) and hopelessness (Beck et al., 1990; Beevers and Miller, 2004; Minkoff et al., 1973; Nimeus et al., 1997). Furthermore, the CVD literature suggests that individuals with heart disease have a higher prevalence of psychological distress compared to those without heart disease (Ferketich and Binkley, 2005).

    View all citing articles on Scopus
    View full text