Suicidal Ideation and Attitudes Toward Suicide

Transcription

1 12 Suicide and Life-Threatening Behavior 36(1) February The American Association of Suicidology Suicidal Ideation and Attitudes Toward Suicide Brandon E. Gibb, PhD, Margaret S. Andover, MA, and Steven R. H. Beach, PhD Although hopelessness and depression are known risk factors for suicide, most individuals who are hopeless or depressed never make a suicide attempt. In this study, we tested the hypothesis that college students (n = 230) attitudes toward suicide (the degree to which they see it as an acceptable option under some circumstances) would moderate the link between both hopelessness and depressive symptoms and their levels of suicidal ideation. This moderation hypothesis was supported, but only among men. Specifically, among men, levels of hopelessness and depressive symptoms were significantly related to suicidal ideation among only those with relatively positive attitudes toward suicide. Numerous studies have supported the link likelihood that depression or hopelessness between risk for suicide and both hopelessness will contribute to a suicide attempt. and depression (for reviews, see Conner, One such potential moderating factor Duberstein, Conwell, Seidlitz, & Caine, 2001; is individuals attitudes toward suicide. Spe- Gould, Greenberg, Velting, & Shaffer, 2003). cifically, there is evidence that individuals However, most individuals who are hopeless vary widely in the degree to which they conor depressed never make a suicide attempt. sider suicide as an acceptable option (for a Thus, although measures of depression and review, see Ingram & Ellis, 1992). Thus, hopelessness exhibit good sensitivity in pre- some individuals view suicide as an acceptable dicting future suicide (low rate of false negatives), option under some circumstances whereas othrate they exhibit fairly poor specificity (high ers do not view it as acceptable under any of false positives) (Beck, Brown, & Steer, circumstances. There is also evidence that in- 1989; Beck, Steer, Kovacs, & Garrison, 1985; dividuals who are more accepting of suicide Brown, Beck, Steer, & Grisham, 2000; see exhibit higher levels of suicidal ideation and also Stolberg, Clark, & Bonger, 2002). Given are more likely to have attempted suicide in this, studies are needed to identify factors the past (e.g., Limbacher & Domino, 1985 that may moderate (increase or decrease) the 86; McAuliffe, Corcoran, Keeley, & Perry, 2003; Stein, Witztum, Brom, DeNour, & Elizur, 1992; Wellman & Wellman, 1988). Therefore, it may be that those most at risk for suicide in the presence of hopelessness or Brandon Gibb and Margaret Andover depression are those who believe that suicide are with Binghamton University in New York. Steven Beach is with the University of Georgia. is an acceptable option. This would be con- An earlier version of this paper was presented sistent with an emerging perspective on risky at the annual meeting of the Association behavior suggesting that willingness or for the Advancement of Behavior Therapy, New positive attitudes toward a behavior may in- Orleans, LA, teract with situational cues to produce prob- Address correspondence to Brandon E. Gibb, Department of Psychology, Binghamton Univerrard, 1997, for a review in the context of lematic consequences (see Gibbons & Gersity (SUNY), Binghamton, NY ; E- mail: bgibb@binghamton.edu health-linked behavior). Specifically, favor-

2 Gibb et al. 13 able attitudes toward suicide may increase other SOQ subscales (Domino, Su, & Shen, the attractiveness of suicide should situational 2000; McAuliffe et al., 2003; Rogers & Decreased cues arise, placing an individual at in- Shon, 1992), and (c) it has been linked in pre- risk of suicidal ideation. vious studies to suicidal ideation (e.g., Mc- The primary goal of this study, there- Auliffe et al., 2000). The SOQ-RTD includes fore, was to test the hypothesis that participants items such as: Suicide is an acceptable means attitudes toward suicide would moder- to end an incurable illness, If someone ate the link between both hopelessness and wants to commit suicide, it is their business depressive symptoms and participants levels and we should not interfere, and People do of suicidal ideation. We expected the relations not have the right to take their own lives between both hopelessness and depres- (reverse scored). Participants are asked to sion and participants suicidal ideation to be rate the degree to which they agree/disagree strongest among participants reporting posi- with each statement on a 5-point Likert-type tive attitudes toward suicide. Given evidence scale ranging from strongly disagree to strongly of gender differences in the variables exam- agree. Scores on the 8-item SOQ-RTD can ined in this study (Limbacher & Domino, range from 8 to 40, with higher scores re ; Nolen-Hoeksema, 2002; Stolberg flecting more positive attitudes toward suicide. et al., 2002), we also examined whether participants The SOQ-RTD has demonstrated good gender moderated any of the rela- reliability and validity (Domino, 1996; Domino, tions examined. MacGregor, & Hannah, ; Mctions Auliffe et al., 2003). In this study, the SOQ- RTD scale exhibited good internal consistency METHOD (α =.85). Hopelessness. The Beck Hopelessness Participants Scale (HS; Beck, Weissman, Lester, & Trexler, 1974), a 20-item true-false self-report Participants in this study included 230 questionnaire, was used to assess participants undergraduate students (163 women, 67 negative expectations regarding the future. men) enrolled in introductory-level psychology Scores on the HS can range from 0 to 20, courses. Of these, 204 (88.7%) were with higher scores reflecting more hopeless- Caucasian, 17 (7.4%) were African American, ness. The HS has demonstrated good interand the remaining 9 (3.9%) participants ei- nal consistency and concurrent validity with ther were from other ethnic groups or did clinician s ratings of hopelessness (Beck et al., not report their ethnicity. The mean age of 1974), as well as good retest reliability (Holden the participants was years (SD = 2.06). & Fecken, 1988). The hopelessness scale exhibited good internal consistency in the Measures current study (α =.89). Depressive Symptoms. The Center for Attitudes Toward Suicide. Participants Epidemiologic Studies-Depression Scale (CESattitudes toward suicide were assessed using D; Radloff, 1977), a 20-item self-report inventory, the Right to Die subscale of the Suicide was used to assess participants levels Opinion Questionnaire (SOQ-RTD; Dom- of depressive symptoms. Total scores on the ino, Moore, Westlake, & Gibson, 1982). Although CES-D range from 0 to 60, with higher the SOQ contains a number of sub- scores indicating more severe levels of de- scales, we chose to focus on the Right to Die pressive symptoms. Numerous studies have subscale because (a) it taps the construct we supported the reliability and validity of the are most interested in (i.e., acceptance of suicide CES-D (e.g., Radloff, 1977; Santor, Zuroff, as an option under some circumstances), Ramsay, Cervantes, & Palacios, 1995). In the (b) there is some evidence that it exhibits current study, the CES-D exhibited good instronger psychometric properties than the ternal consistency (α =.91).

3 14 Attitudes Toward Suicide Suicidal Ideation. Participants levels each variable and SI scores, statistically controlling of suicidal ideation were assessed using four for the influence of the other variof supplemental questions contained within the ables. The two-way interactions were entered SOQ (Domino et al., 1982). These items assess in Step 2, and the three-way interaction was the frequency, strength, and duration of entered in Step 3. As can be seen in Table 2, past suicidal ideation, as well as participants each of the main effects was significant. Of perceived probability of a future suicide at- the two-way interactions, only the sex tempt. Specifically, participants were asked if SOQ-RTD was significant. This two-way in- they have ever considered suicide in their life teraction was further modified by a significant and if so, how strong was your wish to die sex SOQ-RTD HS interaction. Explor- (weak, moderate, strong), how long did the ing the SOQ-RTD HS interaction separately episode last (that is, what was its duration)?, for men and women, we found that it (brief, longer, continuous or almost continuous), was significant for men, t(63) = 2.56, p =.01, and how often do you think about it? β=.37, but not women, t(159) = 0.05, p = (rarely, occasionally, intermittently, persistently or.96, β=.004. The forms of these interactions continuously). They were then asked, What is were explored following the recommenda- the probability that at some point in your life tions of Aiken and West (1991) and are depicted you might attempt suicide? (zero, less than in Figure 1. Among men, levels of 10%, 50 50, somewhat probable, highly proba- hopelessness were significantly related to suicidal ble). Reponses to these items were standardized ideation for those scoring high on the (transformed to a 5-point scale with val- SOQ-RTD (+1 SD), t(63) = 3.55, p <.001, ues ranging from 0 to 4) and then summed β=.39, but not among those scoring low on to create our suicidal ideation composite (SI). the SOQ-RTD ( 1 SD), t(63) =.49, p =.63, Scores on this composite could range from 0 β=.09. In contrast, among women, hopeto 16, with higher scores indicating more sui- lessness was significantly related to suicidal cidal ideation. In the current study, the SI scale ideation among those with both high, t(159) = exhibited good internal consistency (α =.90). 5.40, p <.001, β =.43, and low, t(159) = 3.81, p <.001, β=.42, SOQ-RTD scores. Procedure Next, we tested the moderation hypothesis for depressive symptoms. Paralleling Participants completed the questionnaires what was found for hopelessness, the sex in groups and received course credit SOQ-RTD CES-D interaction was signifi- for their participation. cant (see Table 3). Exploring the SOQ-RTD CES-D interaction separately for men and women, we found that it was highly significant RESULTS for men, t(63) = 2.83, p =.006, β =.37, but only marginally significant for women, Correlations among the study variables, t(159) = 1.97, p =.05, β=.15. The forms as well as descriptive statistics for each of these interactions are depicted in Figure 2. variable, are presented in Table 1. The means Among men, depressive symptoms were sig- are consistent with those obtained in other nificantly related to suicidal ideation for nonclinical samples (e.g., Domino et al., those scoring high on the SOQ-RTD ( ; Gibb, Alloy, Abramson, & Marx, SD), t(63) = 5.49, p <.001, β =.57, but not 2003; McAuliffe et al., 2003; Santor et al., among those scoring low on the SOQ-RTD 1995). In testing our moderation hypotheses, ( 1 SD), t(63) = 1.06, p =.29, β =.15. In contrast, we first focused on hopelessness. Using SI as among women, depressive symptoms the criterion variable, participants sex as well were significantly related to suicidal ideation as SOQ-RTD and HS scores were entered among those with both high, t(159) = 3.00, in the first step of a hierarchical regression p =.003, β =.30, and low, t(159) = 5.87, p < equation. In so doing, this first step allowed.001, β=.59, SOQ-RTD scores. Finally, al- us to examine the unique relation between though we also examined the four-way inter-

4 Gibb et al. 15 TABLE 1 Correlations and Descriptive Statistics Mean SD 1. Sex 2. SOQ-RTD.25*** HS.10.26*** CES-D.13*.13.56*** SI.08.26***.44***.48*** Note. SOQ-RTD = Suicide Opinion Questionnaire-Right to Die subscale; HS = Hopelessness Scale; CES-D = Center for Epidemiologic Studies-Depression Scale; SI = Suicidal Ideation. *p <.05; ***p <.001. action of sex SOQ-RTD HS CES-D, it both hopelessness and depressive symptoms was not significantly related to participants and levels of suicidal ideation. We found sup- suicidal ideation, t(215) = 0.27, p =.79, β = port for the moderating role of attitudes toward.05. suicide, but only among men. Specifi- cally, among men, levels of hopelessness and DISCUSSION depressive symptoms were only related to suicidal ideation among those with relatively The primary goal of this study was to positive attitudes toward suicide. In contrast, determine whether individuals attitudes to- among women, hopelessness and attitudes ward suicide (the degree to which they see it toward suicide appeared to be independent as an acceptable option under some circum- predictors of suicidal ideation. Finally, among stances) moderated the relationships between women, it appeared that attitudes toward sui- cide had a stronger effect upon suicidal ideation at lower, compared to higher, levels of TABLE 2 depressive symptoms. Summary of Hierarchical Regression Analysis That the hypothesized moderation effor Sex, SOQ-RTD, and Hopelessness Predicting fects were observed among men, but not Suicidal Ideation women, was surprising. Given that this was Variable B SE B B not hypothesized at the outset, we will await replication before drawing any firm conclusions. Step 1 However, for both men and women at- Sex ** titudes toward suicide accounted for variance SOQ-RTD ** in suicidal ideation that was not explained by HS *** level of depressive symptoms or hopelessness, Step 2 suggesting that attitudes toward suicide are Sex SOQ-RTD * important in understanding suicidal ideation. Sex HS In addition, the pattern of results appears SOQ-RTD HS consistent with the tendency of men relative Step 3 to women to look for active ways to escape Sex SOQ-RTD HS * negative mood states (Nolen-Hoeksema, 1998). Note. R 2 =.24 for Step 1 (p <.001); R 2 = This tendency may accentuate the effect of at-.02 for Step 2 (p =.11); R 2 =.02 for Step 3 (p < titudes toward suicide on suicidal ideation among.05). men because those who are more accepting SOQ-RTD = Suicide Opinion Questionof suicide would view it as a potentially effecnaire-right to Die subscale; HS = Hopelessness Scale. tive option whereas those who are not ac- *p <.05; **p <.01; ***p <.001. cepting would be more likely to dismiss it.

5 16 Attitudes Toward Suicide Figure 1. Summary of SOQ-RTD HS interaction for men and women. toward suicide. Second, all the assessments were based on participants self-report. Thus, it is unclear the extent to which the relations among variables were inflated due to shared method variance. Future studies, therefore, should seek to replicate the current findings while including multi-method assessments of each construct (e.g., questionnaire and inter- view assessments). Third, participants in the current study were university undergraduates. There are several limitations to the current study which should be noted. First, the study was cross-sectional, which precludes causal conclusions. Future longitudinal studies are needed to determine whether the cognitive vulnerability-affective stress interaction actually predicts the onset of suicidal ideation and behavior. In addition, prospective studies should seek to determine factors that may contribute to changes in individuals attitudes Figure 2. Summary of SOQ-RTD CES-D interaction for men and women.

6 Gibb et al. 17 TABLE 3 attitudes toward suicide serve as a vulnerability Summary of Hierarchical Regression Analysis that, when activated by negative affective for Sex, SOQ-RTD, and CES-D Predicting states, contributes to an increased risk for suicide. Suicidal Ideation Given the cross-sectional design of this study, however, this conclusion remains ten- Variable B SE B B tative. Specifically, although the results are Step 1 consistent with a model in which attitudes Sex toward suicide contribute to suicide risk in SOQ-RTD *** the presence of hopelessness or depression, CES-D *** the cross-sectional design did not allow us to Step 2 examine the temporal precedence of attitudes Sex SOQ-RTD toward suicide. Thus, although studies have Sex CES-D provided some evidence that attitudes toward SOQ-RTD CES-D suicide may be relatively trait-like (e.g., Dom- Step 3 ino, 1996), we did not investigate whether atti- Sex SOQ-RTD CES-D *** tudes toward suicide actually preceded the Note. R 2 =.28 for Step 1 (p <.001); R 2 = onset of suicidal ideation. Therefore, prospec-.02 for Step 2 (p =.18); R 2 =.03 for Step 3 (p = tive longitudinal studies, in which attitudes to-.001). ward suicide and suicidal ideation as well as SOQ-RTD = Suicide Opinion Questionhopelessness and depressive symptoms are naire-right to Die subscale; HS = Hopelessness Scale. repeatedly assessed, are needed to more de- ***p.001. finitively test the vulnerability model. If the vulnerability-stress model is supported in longitudinal research, there may be important clinical implications. At a minimum, As such, they represent a fairly high functioning it would suggest that clinicians should sample, which may limit the gener- assess patients attitudes toward suicide. Research alizability of the current findings to other has suggested that individuals differ in populations. Future studies should seek to the conditions under which suicide is seen as replicate the current findings in samples with acceptable (e.g., elderly person with terminal more severe levels of depression and hope- disease versus a college students with depression; lessness. Future studies should also seek to Droogas, Siiter, & O Connell, 1982 determine whether the results obtained in 83; Ingram & Ellis, 1995). Knowing where this study generalize to actual suicide attempts along this continuum a patient falls could or whether they are limited to the provide important information regarding risk prediction of suicidal ideation. for suicide. Further, if the patient views his The current results have a number of or her depression as a justifiable reason for potentially important implications. First, the suicide rather than simply seeing the suicidal results may represent a kind of vulnerability- ideation as a symptom of depression, these stress model of suicide risk in which positive attitudes may become a focus of intervention. REFERENCES Aiken, L. S., & West, S. G. (1991). Multi- Beck, A. T., Steer, R. A., Kovacs, M., & ple regression: Testing and interpreting interactions. Garrison, B. (1985). Hopelessness and eventual Newbury Park, CA: Sage. suicide: A 10-year prospective study of patients Beck, A. T., Brown, G., & Steer, R. A. (1989). Prediction of eventual suicide in psychiatnal of Psychiatry, 142, hospitalized with suicidal ideation. American Jourric inpatients by clinical ratings of hopelessness. Journal of Consulting and Clinical Psychology, 57, Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessi-

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