Hopelessness as a Measure of Suicidal Intent in the Depressed Elderly

Abstract

Suicidal ideation in the elderly has been related to depression, changes in health, and anticipation of a limited future. The present study examined the Hopelessness Scale (HS) and its relation to these factors in a depressed geriatric population. A total of 120 elderly outpatients, who had applied to receive psychotherapy for depression, completed the HS, Beck Depression Inventory (BDI), health ratings, and the Schedule for Affective Disorder and Schizophrenia (SADS) at intake. The HS was found to be internally consistent, and a principal components analysis revealed three distinct factors that were related to hope, feelings of giving up, and future planning. The HS, BDI, and health ratings were predictive of suicidal ideation as measured by specific items in the SADS. The relation among suicidal ideation hopelessness, depression, and health perceptions for the depressed aged are discussed.

Full text

Psychology
and
Aging
1988,
VoL3,
No.
£230-232
Copyright
1988
by
the
American
Psychological
Association,
Inc.
0882-7974/88/J00.75
Hopelessness
as a
Measure
of
Suicidal
Intent
in the
Depressed
Elderly
Robert
D.
Hill,
Dolores
Gallagher,
Larry
W.
Thompson,
and Ted
Ishida
Geriatric Research, Education
and
Clinical Center
(GRECC),
Veterans Administration Medical Center, Center
for
Psychotherapy
and
Aging,
Palo Alto, California,
and
Department
of
Psychiatry
and
Behavioral Sciences, Stanford University School
of
Medicine
Suicidal
ideation
in the
elderly
has
been
related
to
depression,
changes
in
health,
and
anticipation
of
a
limited
future.
The
present
study
examined
the
Hopelessness
Scale
(HS)
and its
relation
to
these
factors
in a
depressed
geriatric
population.
A
total
of 120
elderly
outpatients,
who had
applied
to
receive
psychotherapy
for
depression,
completed
the HS,
Beck
Depression
Inventory
(BDI),
health
ratings,
and the
Schedule
for
Affective
Disorder
and
Schizophrenia
(SADS)
at
intake.
The HS was
found
to be
internally
consistent,
and a
principal
components
analysis
revealed
three
distinct
factors
that
were
related
to
hope,
feelings
of
giving
up, and
future
planning.
The
HS,
BDI,
and
health
ratings
were
predictive
of
suicidal
ideation
as
measured
by
specific
items
in the
SADS.
The
relation
among
suicidal
ideation
hopelessness,
depression,
and
health
perceptions
for the
depressed
aged
are
dis-
Suicide
in
depressed geriatric populations
is an
emerging
treatment concern inasmuch
as
little
is
known
about
the
factors
that contribute
to
suicide intent
in the
elderly (Blazer,
Bachar,
&
Manton,
1986).
In
younger populations,
the
construct
of
hopelessness
has
been linked
to
suicidal ideation
in a
wide
vari-
ety
of
psychiatric populations (Dyer
&
Kreitman,
1984)
and has
been
described
as a
significant
factor,
within
depression,
under-
lying
suicidal wish.
Although
denning
hopelessness
has
been
elusive,
there
is
general consensus that
it
represents
a
subset
of
depressive symptomatology
and
reflects
an
individual's assess-
ment
of the
probability
of
attaining important goals
and
expec-
tations.
Melges
and
Bowlby
(1969)
postulated that
"although
a
depressed
patient's
goals remain relatively unchanged,
his
esti-
mate
of the
likelihood
of his
achieving them
and his
confidence
in
the
efficacy
of his own
skilled action
are
diminished"
(p.
694). Thus, hopelessness
may
interact with control
and ex-
pectations activating
the
depressed individual
to
consider sui-
cide
as an
alternative.
The
Hopelessness Scale (HS; Beck,
Weissman,
Lester,
&
Trexler,
1974)
was
designed
to
quantify
hopelessness
and has
been shown
to be an
internally consistent, reliable,
and
valid
instrument
for
measuring
perceptions
of
hopelessness
in
both
young
and
middle-aged
groups. Factor analytic studies
of the
scale
in
these
age
groups
(Kazdin,
Rodgers,
&
Colbus,
1986;
Nekanda-Trepka,
Bishop,
&
Blackburn,
1983)
reveal
factors
representing
the
following
constructs:
(a)
ideation about
future
events,
(b)
present motivation
due to
expectations about
future
events,
and (c)
affective
determinants about
future
conse-
quences. Hopelessness
has
also been
found
to be
more
predic-
This
study
was
supported
in
part
by
Grants
MH37196
and
MH17621
from
the
National
Institute
of
Mental
Health
to
Larry
W.
Thompson.
Special
thanks
go to
Robin
Braneth
for her
assistance
in the
data
analysis.
Correspondence
concerning
this
article
should
be
addressed
to
Rob-
ert D.
Hill,
who is now at the
Department
of
Educational
Psychology,
327
Milton
Bennion
Hall,
The
University
of
Utah,
Salt
Lake
City,
Utah
84112.
live
of
suicidal ideation than
level
of
depression within these
groups,
and
high
scores
are
suggested
as a
danger sign
of
suicide
gestures
(Nekanda-Trepka
etal.,
1983).
For
aging
populations,
the HS as a
clinical outcome measure
has
received
very
little empirical
attention.
Greene
(1981)
ad-
ministered
the HS to 400
adults
to
derive norms. Mean ratings
of
the HS
were
5.87
in
subjects
65
years
and
older (compared
with
M =
3.36
in
subjects under
24
years).
It was
concluded that
as
age
increases there
is an
increase
in HS
scores.
Templer
and
Cappalletty
(1986)
have
postulated that
level
of
depression
and
changes
in
health
and
life
situation, compounded
by
advancing
age,
play
an
important role
in
suicidal
ideation
in the
depressed
elderly.
The
purpose
of the
present investigation
was (a) to
as-
sess
the
psychometric properties
of the HS in a
clinically
de-
pressed, geriatric population,
(b) to
examine
its
association
with
suicidal
ideation,
and (c) to
assess
its
relation
to
other
sa-
lient factors, namely, depression, age,
and
health
perception.
Method
Community
volunteers,
55
years
old or
older,
were
solicited
through
radio
and
newspaper
advertisements
to
participate
in a
psychotherapy
treatment
program
for
depression.
All of the
participants
were
screened
for
inclusion
on the
basis
of the
Schedule
for
Affective
Disorders
and
Schizophrenia
interview
(SADS;
Endicott
&
Spitzes
1978)
and
Re-
search
Diagnostic
Criteria
(Spitzer,
Endicott
&
Robins,
1978):
(a)
diag-
nosis
of
major
depressive
disorder,
(b) the
absence
of
psychosis,
(c) no
significant
organicity
as
measured
by the
Mini-Mental
State
Exam
(a
score
of at
least
25;
Folstein, Folstein,
&
McHugh,
1975),
(d) no
sub-
stance
abuse
and not
currently
taking
medication
for
depression,
or
sta-
bilized
on
medications
at
least
4
months
with
no
improvement,
and (e)
not in
concurrent
psychological
treatment.
The
120
treatment
subjects
who
met
this
criteria
had
an
average
age
of
66.9
years(SI>
=
5.7,
range
=
58-82)
and a
mean
education
level
above
high
school
graduation.
Women
comprised
72% of the
subjects.
At
intake,
the
120
participants
were
given
a
battery
of
self-report
measures
including
the
Beck
Depres-
sion
Inventory
(BDI;
Beck,
Ward,
Mendelson,
Mock,
&
Erbaugh,
1961;
M
=
25.5,
SD =
7.23)
and the HS (M =
11.9;
SD =
4.47)
and
rated
their
present
health
on a
4-point
scale—excellent
(1),
good
(2),
fair
(3),
poor
(4)—(M
=
2.91,
SD =
.45).
The
SADS
interview,
which
includes
230
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

HOPELESSNESS
231
Table
1
Item
Loadings
From
the
Factor
Analysis
of
the
Hopelessness
Scale
Item
Factor*
1.
I
look
forward
to the
future
with
hope
and
enthusiasm
.70 .12 .09
15.
I
nave
great
faith
in the
future
.62 .20
.11
3.
When things
are
going
badly,
I
am
helped
by
knowing
that
they
can't
stay
that
way
forever
.60
-.01 -.01
19.
I
can
look
forward
to
more
good times
than
bad
times
.58 .22 .20
6. In the
future
I
expect
to
succeed
in
what concerns
me
most
.58
.31
.35
13.
When
I
look ahead
to
the
future
I
expect
I
will
be
happier
than
I
am
now
Al
.22 .26
5.
I
have
enough
time
to
accomplish
the
things
I
most
want
to
do .43
-.37
.10
9. I
just
don't
get the
breaks,
and
there's
no
reason
to
believe
I
will
in the
future
—.14
.72 .02
16.
I
never
get
what
I
want
so
it's
foolish
to
want anything
.13 £5 .12
20.
There's
no
use
in
really trying
to
get
something
I
want because
I
probably won't
get
it .22
.61
.34
2.
I
might
as
well
give
up
because
there's
nothing
I
can
do
about making things
better
for
myself
.26 .57
-.06
17.
It
is
very
unlikely
that
I
will
get
any
real satisfaction
in
the
future"
.42 .56
.28
11.
All
I
can
see
ahead
of
me
is
unpleasantness rather than pleasantness
.06 55 .37
8. I
happen
to
be
particularly
lucky
and
I
expect
to
get
more
of
the
good things
in
life
than
the
average
person
.33
AS
.03
4. I
can't
imagine what
my
life
would
be
like
in
10
years
—.26
—.02
A3
12.
I
don't
expect
to get
what
I
really want
.05 .25
.63
14.
Things
just
won't
work
out
the
way
I
want
them
to .19 .19 .62
18.
The
future
seems
vague
and
uncertain
to me .27 .04 .53
7.
My
future
seems dark
to me .31 .16 .49
10. My
past experiences
have
prepared
me
well
for my
future
.28 .12 .42
%
of
total variance
26.5
9.1 7.3
Note.
Items with loadings greater than
.40
were
used
to
identify
the
meaning
of
each
factor.
"
Factor
1:
hopefulness
about
future;
Factor
2:
giving
up;
Factor
3:
future
anticipation.
"
Shared loadings
on
Factors
1 and 2 and was
assigned
to
Factor
2
with highest loading.
two
items rated
on
7-point
scales
to
assess suicidal
intent—no
thoughts
of
suicide
(1)
to
suicide
attempt
with
intent
to die
(7)—-was
used
as the
outcome measure
for
suicidal
ideation.
On the
basis
of
standard scoring
criteria
(Endicott
&
Spitzer,
1978),
57% of the
participants reported
clinically
significant suicidal ideation
(a
score
of 3 or
more) either dur-
ing
the
past
week
(SADS Item
246:
M
=
2.8,
SO =
1.4,
range
= 1 to 7)
or at its
worst during
the
present illness (SADS Item
247:
M =
2.1,
SD
=
1.1,
range
=
1 to 5).
The
criterion
for
suicidal
ideation
was
based
on the
sum
of
the
two
scores
(M
=
4.8,
SD =
2.2, range
- 2 to
10).
Results
The
HS
total score
did not
correlate
with
age
(r = -.
11,
ns)
or
level
of
education
(r =
.04,
p >
.30).
It
correlated with
severity
of
depression
as
measured
by the
BDI
(r
=
.41,
p <
.001)
and
health ratings
(r =
.25,
p <
.01).
It is
noteworthy that this
de-
pressed group reported
HS
scores nearly triple those reported
by
Greene
(1981)
in a
nondepressed elderly sample. Unlike
Greene,
the HS did not
appear
to
increase
with
age;
however,
the
restricted
age
range
of
this group
may be
limiting.
An
examination
of
the
internal consistency
of
the HS
yielded
a
coefficient
alpha
of
.84,
and
Spearman-Brown split-half reli-
ability
of
.82.
A
principal components analysis
usinga
varimax-
rotation
procedure yielded three factors
that
accounted
for
42%
of
the
variance.
As
shown
in
Table
1,
seven items related
to
optimism about
the
future,
or
hope,
had
high
loadings
on
Factor
1
(Items
1,3,5,6,13,15,
and
19);
seven
items related
to
expec-
tations
of
giving
up
loaded
highly
on
Factor
2
(Items
2,8,9,
11,
16,
17,
and
20);
and six
items suggesting
a
future
anticipation,
or
plans about
the
future,
loaded
on
Factor
3
(Items
4, 7, 10,
12,14,
and
18).
The
unique contribution
of
specific
factors
within
the HS for
predicting suicidal intent
(as
measured
by the
combined
two
suicidal
ideation items
from the
SADS)
was
also assessed.
All
three factors
were
related
to
suicidal ideation: Factor
1 (r =
.21,
p
<
.01),
Factor
2 (r =
.34,
p <
.001),
and
Factor
3 (r =
.24,
p <
.001).
From stepwise regression procedures
(a
entry
=
.05,
a
exit
=
.1),
upon entering
the
three factors, only Factor
2 was
significant
(R2
=
.11),
P(l,
118)
=
15.0,p
<
.001.
The
remain-
ing
two
factors
exceeded entry criteria.
A
stepwise multiple
re-
gression
was
again conducted
to
assess
the
unique predictive
variance
of the
BDI,
HS, and
health ratings
for
suicidal ide-
ation.
All
three measures were significant:
In
order
of
entry,
the
cumulative
percentages
of
predictive variance
for
the BDI
were
R2
=
.21,
F(l,
118)
=
31.1,
p <
.001;
the HS,
R2
=
.24,
F(2,
117)=
18.0,
p <
.001;
and
health
perception,
R2
=
.27,
F{3,
116)=
14.0,
p<.001.
Discussion
These results indicate that
the HS has an
acceptable
level
of
internal consistency
for use
with
a
geriatric outpatient popula-
tion.
The
principal components analysis revealed three
distinct
factors:
Factor
1
included
only
items that reflected
on
positive
outcomes
in the
future;
thus,
it is
paradoxically labeled,
hope-
fulness.
Factor
2
involved issues
of
control
and
feelings
of
giving
up, and
thus
is
labeled
giving
up.
Factor
3 is
labeled
future
ex-
pectations
because
of its
focus
on the
outcome
of
future
events.
The
factor
structure
of the HS
from
this study
was
very
similar
to the
original
Beck
et
al.
(1974)
findings in
which three factors
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

232
HILL,
GALLAGHER,
THOMPSON,
AND
ISHIDA
were
isolated:
affective,
motivational,
and
cognitive items that
accounted
for
42.7,6.2,
and
5.6%
of the
variance, respectively.
There
were
noteworthy
differences
between
the
Beck
et
al.
younger
sample
and the
present older sample among items
within
the
factors,
and
they
are
noted
as
follows:
Factor
1 in-
cluded
two
additional items
(3 and 5),
both
positively
keyed,
that
appeared
to tap a
more global notion
of
hope, involving
resources necessary
to
accomplish goals (e.g., Item
3:
"When
things
are
going badly
. . .
they won't
stay
that
way
forever,"
and
Item
5: "I
have
time to
expend"). Item
8 ("I
happen
to be
particularly
lucky") loaded
on
Factor
2 in the
current study
and
suggests
that receipt
of
good
fortune
is
based
on
external cri-
teria
(luck)
and is out of the
individual's control.
The
feeling
of
giving
up
might result
in a
negative response
to
this
item
for an
older subject, particularly
when
one
perceives
a
long pattern
of
being
unlucky.
Item
10
("My past experience
has
prepared
me
for
the
future")
and
Item
12
("I
don't
expect
to get
what
I
really
want") loaded
on
Factor
3.
Both items relate
to
future
expecta-
tions
in
terms
of
reviewing
the
past
as a way to
expect
future
outcomes. These items
may be
more relevant
to the
elderly,
in-
asmuch
as the
past
may
have
a
greater impact
on
influencing
future
expectations than
in
younger
groups.
Hopelessness, depression,
and
health perception
were
found
to be
interrelated,
and all
were
predictive
of
suicidal ideation
as
measured
by the
SADS. Depression accounted
for the
greatest
percentage
of the
predictive variance,
followed
by
hopelessness
and
perceived health status.
It is of
interest that
the
three com-
bined
measures accounted
for
only
27% of the
predictive vari-
ance
for
suicidal ideation, much less than
has
been reported
in
previous research with younger
subjects
(Dyer
&
Kreitman,
1984).
This
may
suggest
that suicidal ideation
is
perhaps
influ-
enced
by
other
factors
(e.g., retirement
or
death
of a
spouse)
unique
to
elderly populations
and not
reflected
in
current
as-
sessment devices originally designed
for
younger
age
groups.
Al-
though
the findings
from
this
study
did not
support research
suggesting
that
the HS
correlates with suicide intent better than
measures
of
depression
(Nekanda-Trepka
et
al.,
1983)
in
youn-
ger
populations,
it is
plausible that
the
SADS
measure
of
suicide
ideation
may not
have
been
sufficiently
sensitive
to
distinguish
the
unique variance
of
hopelessness
and
depression
in
older
adults. Future research might examine
the
role
of
hopelessness
in
suicide
attempts,
as the HS has
been
found
to
predict suicide
more
accurately than reported depression
in
younger popula-
tions (Beck,
Kovacs,
&
Weissman,
1975).
Thus,
beyond
know-
ing
that
an
older depressed person
has
suicidal ideation,
an
awareness
of
interacting
factors,
namely,
hopelessness
and
health
perceptions,
may
suggest
distinctive
avenues
for
inter-
vention.
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•
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