Journal of Affective Disorders 94 (2006) 165 172 www.elsevier.

com/locate/jad

Research report

Factors of suicide ideation and their relation to clinical and other indicators in older adults
Tracy K. Witte a , Thomas E. Joiner Jr. a,, Gregory K. Brown b , Aaron T. Beck b , Anthony Beckman c , Paul Duberstein c , Yeates Conwell c
a b

Florida State University, United States University of Pennsylvania, United States c University of Rochester, United States

Received 7 April 2005; received in revised form 13 February 2006; accepted 10 April 2006 Available online 5 June 2006

Abstract Background: Research on the factor structures of the Scale for Suicidal Ideation (SSI; [Beck, A.T., Kovacs, M., Weissman, M., 1979. Assessment of suicidal intention: the Scale for Suicide Ideation. J. Consult. Clin. Psychol. 47, 343352]) and the Modified Scale for Suicide Ideation (MSSI; [Miller, I.W., Norman. W.H., Bishop, S.B., and Dow, M.G., 1986. The modified scale for suicidal ideation: reliability and validity. J Consult Clin Psychol, 54, 724725]) in younger adults have tended to yield two factor solutions. The purpose of the current study was to examine the factor structure of the SSI in an older population in order to determine whether the factor structure was similar and, if so, whether the factors related to other clinical and demographic correlates. Methods: 199 participants (M age 57, S.D.) were selected from a combined database of psychiatric outpatients and inpatients over the age of 49 currently experiencing suicidal ideation. Principal axis factoring was used in order to determine the factor structure of the SSI. In addition, we ran correlations and regression analyses to determine the relation of each factor with other clinical and demographic correlates. Results: Consistent with prediction, we found a two-factor solution. Also consistent with predictions, clinical and demographic correlates related differentially to each of the factors. Limitations: The relatively small sample size and the fact that our sample was predominantly Caucasian. Conclusion: The current study has provided data on the factor structure of the SSI in an older population, demonstrating that suicidal ideation in this group is similar to younger age groups. 2006 Elsevier B.V. All rights reserved.
Keywords: Suicide; Factor analysis; Older adults

Corresponding author. Department of Psychology, Florida State University, Tallahassee, FL 32306-1270, United States. Tel.: +1 850 644 1454; fax: +1 850 644 7739. E-mail address: joiner@psy.fsu.edu (T.E. Joiner). 0165-0327/$ - see front matter 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2006.04.005

Adults over the age of 65 are at a higher risk for completed suicide than those in any other age group (National Center for Injury Prevention and Control [NCIPC], 2004; Turvey et al., 2002). In a sample of suicides across the lifespan, older age at death was associated with higher levels of suicidal intent (Conwell

166

T.K. Witte et al. / Journal of Affective Disorders 94 (2006) 165172

et al., 1998), suggesting that older individuals are more deliberate and planful when attempting suicide. Almost paradoxically, rates of suicide ideation (Blazer et al., 1985; Bock, 1972; Lynch et al., 1999) and suicide attempts (American Association of Suicidology [AAS], 2004) decrease across the lifespan, while rates of suicide increase (NCIPC, 2004). One explanation for this is the possibility that the mere presence of suicidal ideation among older individuals is an indicator of more severe risk for lethal behavior. Research on the factor structures of the Scale for Suicidal Ideation (SSI; Beck et al., 1979) and the Modified Scale for Suicide Ideation (MSSI; Miller et al., 1986) have tended to yield two-factor solutions. Both Joiner et al. (1997) and Beck et al. (1997) performed factor analyses of the MSSI and found twofactor solutions: Suicidal Desire and Ideation (SDI) and Resolved Plans/Preparation (RPP). These studies had relatively large samples and tested both inpatients and outpatients. Although it is likely that the twofactor solution demonstrated in these studies likely reflects the underlying structure of the scales, threefactor solutions have been reported as well. For example, Steer et al. (1993) found three factors they labeled Active Suicidal Desire, Passive Suicidal Desire and Preparation for Suicide. Active suicidal desire involves an actual desire to complete suicide (including the frequency and intensity of the suicidal thoughts as well as having compelling reasons to complete suicide), and passive suicidal desire involves more vague feelings of having a desire for death and lacking a wish to live. The factor structure of the SSI has not yet been studied in an older population. Despite the fact that there have been previous examinations of the SSI using Exploratory Factor Analysis (EFA), we have chosen to utilize EFA in the current study for two reasons. First, this work is being newly extended to a different population (i.e., older adults), and we are uncertain of the outcome with this sample. Second, we are concerned about a low subject to parameter ratio given our limited number of participants, which could prove problematic with the use of confirmatory factor analysis (CFA). Based on previous research (Joiner et al., 1997; Beck et al., 1997), we expect that the SSI will exhibit two factors in this population (SDI and RPP). Consistent with findings reported in Joiner et al. (1997), we predict that measures of depression and hopelessness will be more related to the SDI factor than to the RPP factor. Because RPP is a more pernicious indicator of suicidality, we would expect previous attempts, which are a strong predictor of future attempts (Joiner et al., 2005) to be

differentially related to this factor. We also predict that age will be more correlated with the RPP factor, as Conwell et al. (1998) found that an older age at death by suicide was related to elevated suicidal intent scores, which they hypothesized could indicate greater planfulness. No a priori hypotheses are offered about sex differences or employment status. 1. Methods 1.1. Participants Participants were selected from a combined database of psychiatric outpatients and inpatients if they met the following criteria: (a) they were over the age of 49 and (b) they scored above 0 on either item 4 or 5 of the SSI, because if a participant scores a 0 for both items 4 and 5, he or she does not complete the remainder of the measure. This resulted in 89 of the participants being selected from a larger sample of 6891 psychiatric outpatients consecutively evaluated at the Center for Cognitive Therapy (CCT) of the University of Pennsylvania between January 1, 1975 and December 31, 1995. This sample was previously studied by Brown et al. (2000). Additionally, 110 participants from a group of depressed inpatients from four teaching hospitals in the northeastern United States (Rochester, New York) who had been drawn from a study of suicidal ideation met our selection criteria. Eighty-one of our participants were male and 118 were female. Mean age for the sample was 57 (S.D. = 7.0 years). The median age was 55 with a range from 50 to 84. Seventy-three percent of our participants were in their fifties, 20% were in their sixties, 5% were in their seventies and 2% were in their eighties. The racial/ethnic breakdown of our sample was the following: n = 170 (85.4%) Caucasians, n = 9 (4.5%) African Americans and n = 3 (1.5%) members of other racial/ethnic groups. The ethnicity of 17 participants (8.5%) is unknown due to missing data. Forty-four percent of our sample had attempted suicide at least one time (including multiple attempters), and 18% had attempted multiple times. 1.2. Measures Scale for Suicide Ideation (SSI; Beck et al., 1979). This 19-item interviewer-rated measure was used to evaluate the current intensity of patients' specific attitudes, behaviors and plans to complete suicide. The items are rated on a three-point scale from 0 to 2. The total score can range from 0 to 38, with higher scores indicating more intense levels of suicidal ideation. All

T.K. Witte et al. / Journal of Affective Disorders 94 (2006) 165172

167

patients complete the first five items; patients who report a desire to make an active (item #4) or passive (item #5) suicide attempt complete the remaining 14 items. The SSI has demonstrated good psychometric properties for psychiatric outpatients (Beck et al., 1997) and is one of the few suicide assessment instruments to have documented predictive validity for completed suicide (Brown et al., 2000). In the current sample, SSI M = 7.88, S.D. = 8.34, = .93. Beck Hopelessness Scale (BHS; Beck et al., 1974a, b). This 20-item, true-false self-report scale was designed to measure the degree to which one's cognitions are dominated by negative future expectancies. Psychometric assessment of this scale shows high internal consistency as well as high levels of concurrent and construct validity (Beck et al., 1974a,b). In the current sample, BHS M = 13.40, S.D. = 5.16. Beck Depression Inventory (BDI; Beck et al., 1961). The BDI is a 21-item self-report measure of symptoms of depression that has been used consistently as a measure of depressive symptoms in research settings. In the current sample, BDI M = 27.65, S.D. = 11.28. Revised Hamilton Rating Scale for Depression (HRSD-R; Hamilton, 1960). This scale was administered by trained interviewers to assess the severity of depression. The revised scale has demonstrated adequate reliability and validity in psychiatric outpatients (Riskind et al., 1987). In the current sample, HRSD-R M = 28.27, S.D. = 8.36. Employment status. We created a dichotomized variable for employment status. Participants received a score of 0 if they were employed either full time or part time or were a student and a score of 1 if they were unemployed, retired, or on disability. Structured Clinical Interview for DSM-III-R (SCID). The SCID-III was utilized in order to determine primary Axis I psychiatric diagnosis (Spitzer et al., 1987). In the current sample, 76 participants (38%) met criteria for major depressive disorder (38%), 8 participants (4%) met criteria for bipolar disorder (including bipolar II disorder) and 2 participants (1%) met criteria for depressive disorder NOS. One hundred and thirteen participants (57%) did not meet criteria for any Axis I psychiatric diagnosis. 1.3. Factor analytic strategy Analyses were conducted using principal axis factoring. We chose an oblique rotation procedure (Oblimin) consistent with our expectation that the factors would be correlated. Standard criteria for the retention of factors were used as follows: (a) Kaiser's

criterion to retain factors with eigenvalues of the unrotated solution greater than one, (b) a scree test and (c) the examination of solutions with different extraction criteria to determine the point at which trivial or redundant factors emerge (Gorsuch, 1983). 2. Results The oblique principal axis factoring produced five factors with unrotated eigenvalues greater than one (5.74, 1.73, 1.36, 1.15, 1.01). A relatively clear scree occurred after the second factor. We opted for a twofactor solution because the other factors were either difficult to interpret or were redundant. Furthermore, the two-factor solution was consistent with previous factor analyses (Beck et al., 1997; Joiner et al., 1997). Together, the two factors accounted for 39% of the SSI items' variance. In the current sample, seven items failed to load clearly on either factor (i.e., ability/ motivation, future attempt, desire to attempt, reasons for suicide, passive suicidal feelings, suicide note and shared ideas), four of which (i.e., ability/motivation, future attempt, reasons for suicide and passive suicidal feelings) did not clearly load on any of the five factors with eigenvalues over 1. Three items (i.e., suicide note, desire to attempt and shared ideas) loaded on factors three, four and five, respectively, but these factors did not contain more than one item each. The results of the principal axis factoring are displayed in Table 1. We chose to use the same labels as Joiner et al. (1997, i.e., Suicidal Desire and Ideation [SDI] and Resolved Plans and Preparation [RPP]). The SDI factor reflects desire for death, frequency of suicidal thoughts and attitudes toward suicide. This factor does not contain items that indicate readiness to complete suicide or intense levels of ideation. The RPP factor reflects more concrete suicidal behaviors such as making preparations and tying up loose ends in order to complete suicide. This factor seems to indicate more intense and potentially lethal aspects of suicidal ideation. We computed internal consistency coefficients for two subscales based on the two factors. These subscales were formed by summing respective items for each factor. For the SDI composite, SSI items 13, 68 and 910 were summed ( = .81); for the RPP composite, SSI items 1213, 16 and 18 were summed ( = .75). Items 4, 5, 11, 1415, 17 and 19 were not assigned because they did not load clearly on either factor. The correlation between these subscales (r = .40, p< .01) was similar to the factor intercorrelation (r = .45, p< .01). Next, we determined whether these factors display

168

T.K. Witte et al. / Journal of Affective Disorders 94 (2006) 165172

Table 1 Factor loadings, communalities and eigenvalues from principal axis analysis of Scale for Suicidal Ideation, with oblique rotation extracting two factors Item Factor 1: Factor 2: Communality suicidal desire resolved plans and ideation and preparation .34 .21 .24 .50 .40 .28 .27 .48 .40 .20 .15 .18 .10 .79 .74 .68 .46 .36 .28 1.82 9.6 .53 .49 .49 .52 .44 .39 .32 .43 .48 .22 .23 .12 .22 .58 .46 .45 .35 .29 .21

6. Duration of .72 ideation 1. Wish to live .69 3. Reasons for .66 living or dying 14. Capability .64 7. Frequency of .63 ideation 2. Wish to die .60 8. Attitudes toward .57 ideation 15. Expectancy and .56 anticipation 4. Active suicidal .55 desire 10. Deterrents to .46 attempt 9. Control over .43 action 11. Reason for .30 attempt 5. Passive suicidal .27 desire 12. Specificity of .49 planning 16. Actual .41 preparation 13. Availability and .33 opportunity 18. Final acts .08 17. Suicide note .20 19. Deception or .21 concealment Eigenvalue 5.74 % of variance 30.2 accounted for

Cohen and Cohen's (1983, pp. 56 57) test for significance of the difference between independent r's (t = 1.62, ns and t = 0.93, ns, respectively). The BHS was differentially more correlated with the SDI factor (t = 2.36, p < .05). Contrary to expectations, age was not significantly correlated with either factor, and Cohen and Cohen's test showed no significant difference between the correlations (t = 0.38, ns). Also contrary to our predictions, previous attempt history was significantly correlated with the SDI factor, but not with the RPP factor. These correlations were significantly different according to Cohen and Cohen's test (t = 4.57, p < .01). Employment status was positively and significantly correlated with the SDI factor, but sex was not correlated with either factor. Thus, only the BDI was significantly associated with the RPP factor, but this relationship was not unique, as the BDI was also correlated with the SDI factor. It is important to note that the range of scores for the RPP factor (M = 2.84, S.D. = 2.24) was more restricted than that of the SDI factor (M = 6.94, S.D. = 4.11), and its internal consistency coefficient was somewhat lower, thereby possibly decreasing power for this factor to correlate with other variables. 2.2. Regression analyses of the factors of the SSI predicting clinical correlates In order to determine if the correlations between SDI and the other variables would remain when controlling for the RPP factor, we conducted hierarchical regression analyses. In these analyses, we entered both factors as predictors and used them to predict each of the other variables. The results were all similar to the correlation

Table 2 Scale for Suicidal Ideation factors in relation to clinical variables

differential patterns of relations to various clinical and other indices. 2.1. Clinical and other correlates of the two factors Table 2 displays the correlations of the two SSI factors with the variables mentioned above. Consistent with predictions, the HRSD-R and BHS were significantly correlated with the SDI factor and were not significantly correlated with the RPP factor. However, the BDI was significantly correlated with both factors. Neither the HRSD-R nor the BDI were significantly more correlated with SDI than with RPP according to

Measure Correlations Sex Age Attempt status Employment HRSD-Ra BDIb BHS

Suicidal desire and ideation .07 .07 .43 .22 .25 .36 .24

Resolved plans and preparation .05 .04 .10 .06 .12 .26 .04

199 199 190 191 179 119 160

HRSD-R = Hamilton Scale for Depression, BDI = Beck Depression Inventory, BHS = Beck Hopelessness Scale. The different number of participants for each correlation was due to missing data. p < .05. p < .01.

T.K. Witte et al. / Journal of Affective Disorders 94 (2006) 165172

169

analyses with the exception that, in the regression analyses, the BDI was only predicted by the SDI factor and not by the RPP factor. All relationships between SDI and the other variables remained even when controlling for RPP. Results from these analyses can be found in Table 3. 3. Discussion Our analyses demonstrated a two-factor structure of the SSI. The first (SDI) consists of items that indicate general suicidal thoughts and desires, whereas the second factor, (RPP) consists of items that typically indicate more pernicious aspects of suicide ideation. Our results were thus consistent with the two-factor solutions of Joiner et al. (1997) and Beck et al. (1997), whereas they were inconsistent with the three-factor solution found by Steer et al. (1993). According to Gorsuch (1983), an important criterion in the determi-

Table 3 Summary of hierarchical regression analyses of each subscale predicting the clinical correlates Measure Sex Desire and ideation Plans and Preparation Age b Desire and ideation Plans and preparation Attempt status c Desire and ideation Plans and preparation Employment status d Desire and ideation Plans and preparation HRSD-R e Desire and ideation Plans and preparation BDI f Desire and ideation Plans and preparation BHS g Desire and ideation Plans and preparation
a

B 0.01 0.01 0.11 0.04 0.10 0.03 0.03 0.01 0.50 0.08 0.83 0.48 0.29 0.12

SE B 0.01 0.02 0.13 0.24 0.02 0.03 0.01 0.02 0.16 0.30 0.26 0.47 0.09 0.17

.05 .03 .07 .01 .46 .08 .23 .04 .24 .02 .31 .10 .26 .06

HRSD-R = Hamilton Scale for Depression, BDI = Beck Depression Inventory, BHS = Beck Hopelessness Scale. a R2 = .01. b R2 = .01. c R2 = .19. d R2 = .05. e R2 = .06. f R2 = .14. g R2 = .06. p < .01.

nation of a factor structure is that the factors are not trivial or redundant and are theoretically meaningful. It may be that the distinction between active and passive suicidal desire does not add additional utility to the interpretation of the measure, even though this is an issue on which clinicians place some importance. Seven items did not clearly load on either factor and, as mentioned above, did not load clearly on a third factor. Interestingly, of these seven items, only two had consistently loaded onto the same factors in previous large-scale factor analyses of the SSI and MSSI (Beck et al., 1997; Joiner et al., 1997), but the other five items have not performed consistently across studies. In addition to not being correlated with either of the factors, the lack of intercorrelation among these five items indicates that they are a heterogeneous mixture of items. We also demonstrated that these factors displayed a differential relationship to some variables, but not to others. Consistent with our predictions, our measures of depression and hopelessness generally were associated with SDI factor, but not with RPP. This result was similar to results found in Joiner et al.'s (1997) study. This differential relationship is interesting in that it demonstrates the possibility that many people who are depressed and hopeless consider, but do not prepare for, suicide. None of our variables were significantly correlated with RPP, with the exception of the BDI in the correlational analyses, which was not differentially associated with either factor. Surprisingly, previous attempt status was significantly correlated with SDI, but not with RPP. This result was inconsistent with previous work (Joiner et al., 1997), which demonstrated a significant relationship between suicide planning and history of attempt. Because the items on the RPP factor seem to indicate more acute and dangerous levels of suicidal ideation, it seems logical that it would be related to an important risk factor for future suicide, such as previous attempt status. There are a number of possible explanations for our result. One is that this factor performs differently in an older sample, but this seems unlikely. Much research (Clark and Fawcett, 1992; Joiner et al., 1999; Rudd et al., 1996) indicates that multiple attempt status is a very important risk factor for completed suicide. Further research shows that this relationship holds in an older population (e.g., Chiu et al., 2004; Salib and Tadros, 2000). It is also possible that the factor structure we see in this sample of ideators may not be applicable to an understanding of elders who attempt or complete suicide. Duberstein et al. (1999) found that increasing

170

T.K. Witte et al. / Journal of Affective Disorders 94 (2006) 165172

age is associated with the endorsement of lower levels of depression and suicidal ideation even in depressed inpatients whose hospitalization was precipitated by a suicide attempt. However, psychological autopsies of completed suicides have shown that older suicide completers can be distinguished from ideators using personality traits such as neuroticism and openness to experience (OTE; Duberstein et al., 2000). These characteristics increase risk for completed suicide because they inhibit the suicidal individual from both feeling and expressing suicidal ideation that could lead to intervention by family members or treatment providers (Duberstein, 2001). It is a limitation of our study that we cannot say whether we would find this same factor structure when applying the scale to a sample of older adults who then went on to actually take their own lives. Given that the majority of our sample (56%) was expressing suicidal ideation without history of attempt, the generalizability of these findings toward older individuals who have attempted or go on to complete suicide may be limited. Research also shows that RPP is a grave indicator of suicidal behavior. Joiner et al. (2003) found worst-point (the participant's self-report of his or her most severe suicidal symptoms) RPP to be most related to eventual suicide. However, it is important to note that, although Joiner et al.'s (2003) study found worst-point RPP to be the strongest predictor of previous suicide attempts, current SDI was also a significant predictor. Our results are consistent with this latter finding, as we found a significant relationship between current SDI and attempt status. Age was not significantly correlated with either factor, which was inconsistent with our prediction that it would be positively correlated with RPP. Conwell et al. (1998) demonstrated that higher age at death by suicide was associated with a measure of suicidal intent, which they hypothesized might indicate greater planfulness in older individuals. Not only were neither of the factors in the current study correlated with age, but also the SSI total score was not correlated with age. One possible explanation is the restricted age range of our sample (age 50 and up), as the Conwell et al. (1998) study contained people ranging in age from 21 to 92. Additionally, if being extremely elderly is in fact a risk factor, we may not have been able to detect the difference with our current sample, which did not contain a large number of individuals who were extremely aged. Further explanation for the lack of a significant correlation with age may be that our participants were suicide ideators, whereas Conwell et al.'s (1998) sample consisted of suicide completers.

Sex was not related to either factor. This is interesting for two reasons. First, women are more likely to experience suicidal ideation than are men, so one might expect the SDI factor to be positively related to female sex. Second, men are more likely than women to complete suicide, as they are at a higher risk for suicide than any other demographic group (Caine and Conwell, 2001), so one might expect male sex to be related to the RPP factor. Nevertheless, it is possible that there may be no sex difference in ideation for patients who are evaluated in a mental health setting as in the present study. Indeed, several studies (e.g., Beautrais et al., 1996) have shown that among individuals who are currently experiencing a mood disorder, gender differences in terms of suicidal behavior tend to disappear. Given that 42% of our sample was experiencing a mood disorder, this may have impacted our ability to find a relationship between RPP and sex. Employment status was significantly related to SDI, such that full-time, part-time or student status was associated with less SDI. This lends some support to Turvey et al.'s (2002) findings that connections with the outside world can be protective against suicide. Our findings should be regarded with caution, however, because there are a number of possible confounds that could be driving this relationship (e.g., those who are employed may be in better health or in a better financial situation). Future research should use a more valid social support variable to test this idea more directly. The current study has several notable strengths. It is the first factor analysis of the SSI performed on a sample of adults over age 50. Hence, it has not only described and illuminated the structure of the SSI in this group, but also aspects of suicide ideation. This is important, as older individuals are an at-risk population that demands attention in the realm of suicidal behavior and ideation. Another strength of this study is that it further validates the factor structure found in two previous studies of the SSI and MSSI (Beck et al., 1997; Joiner et al., 1997). These studies were diverse in terms of participant age (M = 22 years, S.D. = 2.3 for Joiner et al.; M = 35.9 years, S.D. = 11.9 for Beck et al.; M = 57 years, S.D. = 7.0 for the current study), gender distribution (82% male for Joiner et al., 44% male for Beck et al., 69% male for the current study), suicide attempt status (59% had previous suicide attempts in Joiner et al., 13% for Beck et al., 44% for the current study) and patient status (combined inpatients and outpatients for Joiner et al., outpatients for Beck et al., and combined inpatients and outpatients for the current study). The similarity in structure among these three diverse samples demonstrates that this view of suicidal

T.K. Witte et al. / Journal of Affective Disorders 94 (2006) 165172

171

ideation seems generalizable. Our study is further strengthened by its approximately equal sex distribution (41% male, 59% female) and its inclusion of inpatients and outpatients. There are some notable limitations of the current study as well. First, our sample size was not extremely large (n = 199), although it is adequate for a factor analysis of a 19-item measure (Gorsuch, 1983). It should also be acknowledged that the relationship of suicidal ideation to attempted and completed suicide is unclear in any age group, including older adults, although data suggest it is a risk factor for subsequent suicidal behavior, including completed suicide (e.g., Scocco and De Leo, 2002). Nevertheless, many characteristics differsex distribution and method, for example. Further prospective study will be needed to determine whether the factor structure observed here applies to those who go on to harm or kill themselves. Another limitation that we have noted is the restricted range of the RPP, which might have contributed to its lack of significant correlations. In addition, our predominantly Caucasian sample limits the generalizability of our results to members of other ethnic groups. Aside from these limitations, we believe that the current study has provided fertile ground for future research on suicidal ideation across the lifespan, as we have not only validated previous factor analyses, but we have provided new information on the structure of suicide ideation in adults 50 and older. Acknowledgements This research was supported, in part, by grants from the National Institute of Mental Health to Drs. Beck (P20 MH071905), Conwell (MH51201) and Duberstein (MH60285), and to Dr. Joiner from the John Simon Guggenheim Memorial Foundation. References
American Association of Suicidology, 2004. Elderly suicide fact sheet. Retrieved November 18, 2004, from http://www.suicidology.org/ associations/1045/files/ElderlySuicide.pdf. Beautrais, A.L., Joyce, P.R., Mulder, R.T., Fergusson, D.M., Deavoll, B.J., Nightingale, S.K., 1996. Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a case-control study. Am. J. Psychiatry 153, 10091014. Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J., 1961. An inventory for measuring depression. Arch. Gen. Psychiatry 4, 561571. Beck, A.T., Schuyler, D., Herman, I., 1974a. Development of suicidal intent scales. In: Beck, A.T., Resnick, H.C.P, Lettieri, D., Bowie, M.D. (Eds.), The Prediction of Suicide. Charles Press Publishers, Oxford, England, pp. 4556.

Beck, A.T., Weissman, A., Lester, D., Trexler, L., 1974b. The measurement of pessimism: the hopelessness scale. J. Consult. Clin. Psychol. 42, 861865. Beck, A.T., Kovacs, M., Weissman, M., 1979. Assessment of suicidal intention: the Scale for Suicide Ideation. J. Consult. Clin. Psychol. 47, 343352. Beck, A.T., Brown, G.K., Steer, R.A., 1997. Psychometric characteristics of the Scale for Suicide Ideation with psychiatric outpatients. Behav. Res. Ther. 35, 10391046. Blazer, D., George, L.K., Landerman, R., Pennybacker, M., Melville, M.L., Woodbury, M., Manton, K.G., Jordan, K., Locke, B., 1985. Psychiatric disorders: a rural/urban comparison. Arch. Gen. Psychiatry 42, 651656. Bock, E., 1972. Aging and suicide: the significant of marital, kinship, and alternative relations. Fam. Coord. 21, 7179. Brown, G.K., Beck, A.T., Steer, R.A., Grisham, J.R., 2000. Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J. Consult. Clin. Psychol. 68, 371377. Caine, E.D., Conwell, Y., 2001. Suicide in the elderly. Int. Clin. Psychopharmacol. 16s, S25S30. Chiu, H.F.K., Yip, P.S.F., Chi, J., Chan, S., Tsoh, J., Kwan, C.W., Li, S. F., Conwell, Y., Caine, E., 2004. Elderly suicide in Hong Konga case-controlled psychological autopsy study. Act. Psychiatr. Scand. 109, 299305. Clark, D.C., Fawcett, J., 1992. Review of empirical risk factors for evaluation of the suicidal patient. In: Bongar, B.M. (Ed.), Suicide: Guidelines for Assessment, Management, and Treatment. Oxford University Press, New York, pp. 1648. Cohen, J., Cohen, P., 1983. Applied Multiple Regression/Correlation Analysis for the Behavioral and Life Sciences, 2nd ed. Erlbaum, Hillsdale, NG. Conwell, Y., Duberstein, P.R., Cox, C., Herrmann, J., Forbes, N., Caine, E.D., 1998. Age differences in behaviors leading to completed suicide. Am. J. Geriatr. Psychiatry 6, 122126. Duberstein, P.R., 2001. Are closed minded people more open to the idea of killing themselves? Suicide Life-Threat. Behav. 31, 914. Duberstein, P.R., Conwell, Y., Seidlitz, L., Lyness, J.M., Cox, C., Caine, E.D., 1999. Age and suicidal ideation in older depressed inpatients. Am. J. Geriatr. Psychiatry 7, 289296. Duberstein, P.R., Conwell, Y., Seidlitz, L., Denning, D.G., Cox, C., Caine, E.D., 2000. Personality traits and suicidal behavior and ideation in depressed inpatients 50 years of age and older. J. Geront., B Psychol. Sci. Soc. Sci. 55, P18P26. Gorsuch, R., 1983. Factor Analysis. Erlbaum, Hillsdale, NJ. Hamilton, M., 1960. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 23, 5661. Joiner Jr., T.E., Rudd, M.D., Rajab, M.H., 1997. The Modified Scale for Suicidal Ideation: factors of suicidality and their relation to clinical and diagnostic variables. J. Abnorm. Psychol. 106, 260265. Joiner, T.E., Walker, R.L., Rudd, M.D., Jobes, D.A., 1999. Scientizing and routinizing the assessment of suicidality in outpatient practice. Prof. Psychol. Res. Pract. 30, 447453. Joiner Jr., T.E., Steer, R.A., Brown, G., Beck, A.T., Pettit, J.W., Rudd, M.D., 2003. Worst-point suicidal plans: a dimension of suicidality predictive of past suicide attempts and eventual death by suicide. Behav. Res. Ther. 41, 14691480. Joiner Jr., T.E., Conwell, Y., Fitzpatrick, K.K., Witte, T.K., Schmidt, N. B., Berlim, M.T., Fleck, M.P.A., Rudd, M.D., 2005. Four studies on how past and current suicidality relate even when Everything but the kitchen sink is covaried. J. Abnorm. Psychology 114, 291303.

172

T.K. Witte et al. / Journal of Affective Disorders 94 (2006) 165172 act as they did in previous attempt. Int. J. Geriatr. Psychiatry 15, 10731074. Scocco, P., De Leo, D., 2002. One-year prevalence of death thoughts, suicide ideation, and behaviours in an elderly population. Int. J. Geriatr. Psychiatry 17, 842846. Spitzer, R.L., Williams, J.B.W., Gibbon, M., 1987. Structured Clinical Interview for DSM-III-R-Patient Version. Biometrics Research Department, NY State Psychiatric Institute, New York. Steer, R.A., Rissmiller, D.J., Ranieri, W.F., Beck, A.T., 1993. Dimensions of suicidal ideation in psychiatric inpatients. Behav. Res. Ther. 31, 229236. Turvey, C.L., Conwell, Y., Jones, M.P., Phillips, C., Simonsick, E., Pearson, J.L., Wallace, R., 2002. Risk factors for late-life suicide: a prospective, community-based study. Am. J. Geriatr. Psychiatry 10, 398406.

Lynch, T.R., Johnson, C.S., Mendelson, T., Robins, C.J., Ranga, K., Krishnan, R.R., Blazer, D.G., 1999. Correlates of suicidal ideation among an elderly depressed sample. J. Affect. Disord. 56, 915. Miller, I.W., Norman, W.H., Bishop, S.B., Dow, M.G., 1986. The Modified Scale for Suicidal Ideation: reliability and validity. J. Consult. Clin. Psychol. 54, 724725. National Center for Injury Prevention and Control (2004). Suicide: fact sheet. Retrieved November 18, 2004, from http://www.cdc.gov/ ncipc/factsheets/suifacts.htm. Riskind, J.H., Beck, A.T., Brown, G., Steer, R.A., 1987. Taking the measure of anxiety and depression: validity of the reconstructed Hamilton scales. J. Nerv. Ment. Dis. 175, 474479. Rudd, M.D., Joiner, T.E., Rajab, M.H., 1996. Help negation after acute suicidal crisis. J. Consult. Clin. Psychol. 63, 499503. Salib, E., Tadros, G., 2000. Do elderly victims of fatal self-harm with history of deliberate self-harm use the same methods in their final