References

Lewinsohn, P., Rohde, P., & Seeley, J. (1994, April) . Psychosocial risk factors for future adolescent
suicide attempts. Journal of Consulting and Clinical Psychology, 62(2), 297-305. Retrieved March 27,
2009, doi:10.1037/0022-006X.62.2.297

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Psychosocial Risk Factors for Future Adolescent Suicide Attempts

By: Peter M. Lewinsohn

Oregon Research Institute, Eugene, Oregon
Paul Rohde
Oregon Research Institute, Eugene, Oregon
John R. Seeley
Oregon Research Institute, Eugene, Oregon

Acknowledgement: Preparation of this article was supported in part by National Institute of Mental
Health Grant MH40501 to Peter M. Lewinsohn.

Correspondence concerning this article should be addressed to: Peter M. Lewinsohn, Oregon Research
Institute, 1715 Franklin Boulevard, Eugene, Oregon 97403-1983

Recent epidemiological studies suggest that the prevalence of adolescent suicide attempts is surprisingly
high, with lifetime rates among high school students ranging from 3.5% to 11% (Andrews & Lewinsohn,
1992; Harkavy-Friedman, Asnis, Boeck, & DiFiore, 1987; Velez & Cohen, 1988). Given the relative
frequency of adolescent suicidal behavior, knowledge regarding its etiology and prevention is of great
importance. This study identifies the psychosocial risk factors of future suicide attempts in community
adolescents and evaluates the relative efficacy of two screeners for future suicide attempts.

The distinguishing characteristics of children and adolescents who have a history of suicide attempt
have been described in a number of studies (e.g., Asarnow, Carlson, & Guthrie, 1987; Brent, Kolko, Allan,
& Brown, 1990; Cohen-Sandler, Berman, & King, 1982; Fowler, Rich, & Young, 1986; Garfinkel, Froese, &
Hood, 1982; Lewinsohn, Rohde, & Seeley, 1993; Pfeffer et al., 1991; Shaffer, 1988). In these studies the
following have emerged as potential risk factors for suicide attempt: being female and not living with
both parents; psychopathology, including a major depressive disorder, particularly when comorbid with
other mental disorders; a previous suicide attempt; hopelessness, suicidal ideation, and depression-
related cognitions; poor problem-solving abilities and coping skills; impulsivity; recent stressful life
events, including suicide attempt by family members or friends and chronic physical illness; family
violence and dysfunction; peer difficulties; and lower academic achievement and school problems.

Although important, the aforementioned studies have a number of limitations. First, most are based on
samples of hospitalized suicide attempters; therefore, the generalizability of findings to community
samples cannot be assumed. Second, few studies have evaluated the contribution of variables when
examined in combination. Third, previous studies have relied on retrospective report. Only prospective
research, such as the present study, provides information about the extent to which characteristics
precede and predict a future suicide attempt.

The general model guiding the present study is that the majority of psychosocial risk factors predictive
of future suicide attempt overlap with variables associated with future depression (Lewinsohn et al., in
press). Consequently, most of the variables included in the present study were selected on the basis of a
know or hypothesized relation with depression. It should be noted that the variables in this study may
also represent risk factors for other forms of psychopathology.

Given the potentially tragic nature of adolescent suicide attempts and the elevated risk of suicide
clustering among adolescents (Gould, Wallenstein, Kleinman, O'Carroll, & Mercy, 1990), the
identification of adolescents at risk for future attempts before their behavior escalates and becomes
more serious would be of obvious value. Whereas the very low base rate of completed suicide makes it
extremely difficult for even a very good screening instrument to accurately predict the degree of risk for
completed suicide, concentrating on a relatively more frequent phenomenon, such as suicide attempt,
may prove more successful.

In our recent review of existing instruments used to screen for suicidal ideaton and attempts in children
and adolescents (Garrison, Lewinsohn, Marsteller, Langhinrichsen, & Lann, 1991), a number of problems
were highlighted (e.g., exclusive assessment of suicidal ideation rather than suicidal behavior;
inadequate normative information; failure to assess intentionality, lethality, and other aspects of the
attempt). Perhaps the most fundamental criticism was that insufficient attention has been paid to issues
of validity, particularly predictive validity. To our knowledge, none of the available suicidal screeners has
been evaluated prospectively.

This article is the third in a series aimed at contributing to the understanding of suicidal behavior among
adolescents. In the first article of the series (Andrews & Lewinsohn, 1992), data from the Oregon
Adolescent Depression Project (OADP) were presented regarding the lifetime prevalence (7.1%) and 1-
year total incidence (1.7%) of suicide attempts. The lifetime prevalence of attempts was higher for
female adolescents (10.1%) than for male adolescents (3.8%). Past attempts were also associated with
single-parent homes, fathers with less education, and past psychopathology; approximately 80% of
adolescents who had a past attempt met criteria for a previous psychiatric disorder. In the second article
(Lewinsohn, Rohde, & Seeley, 1993), the psychosocial characteristics associated with past suicide
attempts were evaluated. Most of the included psychosocial variables were associated with past
attempt, although controlling for current depression level eliminated the significance of approximately
half of the associations.
The present study takes advantage of the prospective nature of the OADP data set and the extensive
psychosocial assessment battery. Specifically, we focus on 26 adolescents who attempted suicide
between the two assessment points, examining the psychosocial risk factors, singly and in combination,
for future suicide attempt and the predictive efficacy of two screeners for future suicide attempts.
Predictive efficacy is evaluated vis--vis sensitivity (proportion of true cases identified by the screener),
specificity (proportion of true noncases identified by the screener), positive predictive value (PPV;
proportion of true cases among those identified by the screener as cases), and negative predictive value
(NPV; proportion of true noncases among those identified by the screener as noncases).

Method

Subjects and Procedure

The sample consisted of 1,508 adolescents who completed a diagnostic interview and questionnaire at
two time points approximately 1 year apart; of these, 26 participants (1.7%) reported having made at
least one suicide attempt between the two assessments. Participants (ages 1418) were randomly
selected from nine high schools representative of urban and rural districts in western Oregon. A total of
1,710 adolescents completed the initial ( T 1 ) interviews between 1987 and 1989 (additional details
provided in Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993). The representativeness of the T 1
sample was assessed by comparing demographic characteristics of the sample with 1980 census data
and with characteristics of adolescents who declined participation. Only minor differences were noted,
and the participants may be considered to be representative of high schol students in western Oregon.

At the second assessment ( T 2 ) , 1,508 participants (88.2%) returned for a readministration of the
interview and questionnaire (mean interval = 13.8 months, SD = 2.3). Biases that may have emerged
because of attrition in the T 1 T 2 panel sample were examined by comparing the adolescents who did
not participate at T 2 (N = 202) to the 1,508 subjects on demographic characteristics and measures of
psychopathology. Few significant differences were present. The two groups did not differ on any
measures of depression, and the attrition rate for subjects with a history of suicide attempt at T 1 (19 of
121 or 15.7%) did not significantly differ from the attrition rate for subjects without a history of suicide
attempt (183 of 1,589, or 11.5%), 2 (1, N = 1,710) = 1.89, ns .

Approximately half of the T 1 T 2 panel was female (54%), with an average age of 16.5 (SD = 1.2). The
majority (91%) were Caucasian and most (74%) resided in two-parent homes. Written informed consent
was obtained from all adolescents and their legal guardians, and adolescents were paid $25 for their
participation at each assessment procedure.

Diagnostic Interview

Participants were interviewed at T 1 with an adaptation of the Schedule for Affective Disorders and
Schizophrenia for School-Age Children that combined features of the Epidemiologic version (K-SADS-E;
Orvaschel, Puig-Antich, Chambers, Tabrizi, & Johnson, 1982) and the Present Episode version (K-SADS-
P). Additional questions were incorporated to provide information on the presence of most Diagnostic
and Statistical Manual of Mental Disorders (3rd ed., rev.; DSMIIIR;American Psychiatric Association,
1987) disorders. Interviewers completed a 14-item version of the Hamilton Depression Rating Scale
(Hamilton, 1960).

As part of the assessment of affective disorders, information was gathered regarding suicidal ideation
(thoughts of death or dying, wishes to be dead, thoughts of hurting or killing self). These items were
rated for occurrence during the previous 2 weeks and combined into a single measure of K-SADS current
suicidal ideation (Andrews & Lewinsohn, 1992).

Adolescents at T 1 were also asked, Have you ever tried to kill yourself or done anything that could have
killed you? When a positive response was given, interviewers elicited a description of the behavior. The
interviewers asked further questions to rule out purely thrill-seeking behaviors (e.g., skiing very fast on
an extremely steep slope). On the basis of this information, interviewers rated each suicide attempt at T
1 (N = 121) for intentionality (on the 6-point K-SADS scale) and medical lethality (on the 11-point
Lethality of Suicide Attempts Rating Scale; Smith, Conroy, & Ehler, 1984).

At the T 2 interview, subjects were again diagnostically interviewed. The only T 2 information used in the
present study is whether the subject had attempted suicide between T 1 and T 2 . Using probes similar
to those used in the T 1 interview, participants were questioned about any suicide attempts since T 1 .
Twenty-six adolescents reported making one or more attempts since the first interview (a description of
the attempts is available on request). Of the future attempters, 14 (53.8%) had reported a past suicide
attempt at T 1 , whereas 12 (46.2%) reported this attempt to be their first. The mean suicidal intent
score for the attempts was 2.9 (3 = definite but very ambivalent); 26.9% of the attempters had an intent
rating of 5 (very serious) or 6 (extreme; careful planning and every expectation of death). The mean
medical lethality score was 2 (death is improbable); 11.4% had a score of 5 or greater (5 = death is a
fifty-fifty probability). Interview notes for 30 randomly selected nonattempters at T 2 were reviewed for
the presence of reports of dangerous thrill-seeking behaviors; none were reported. It appears that the
K-SADS structure, in which assessment of suicide attempts follows questions regarding suicidal ideation,
elicits appropriate responses.

Diagnostic interviewers were carefully selected and trained. For reliability purposes, all interviews were
audiotaped or videotaped, and 12% were randomly selected and rated by reliability coders. With one
exception (anxiety disorders, kappa = .60), kappas for current disorders were consistently greater than
.80.

Self-Report Questionnaire

Demographics

Adolescents reported gender, age, race (six categories), grade in school, history of repeating a grade, job
history, number of siblings (natural and step), birth order, and composition of the household; parents
reported maximum level of education (seven categories), age, marital status (five categories), and
occupational status (nine categories).

Psychosocial constructs
An extensive questionnaire battery of measures was administered, with the intent of assessing all
psychosocial variables known or hypothesized to be related to depression (materials available on
request). On the basis of extensive pilot studies (Andrews, Lewinsohn, Hops, & Roberts, 1993), most of
the measures were shortened (unless noted, the instrument has been abbreviated).

Because a large number of variables were administered, measures were reduced to a smaller number of
composite scores. Variables were rationally categorized into general clusters, which were submitted to
principal-components factor analysis with varimax rotation. Measures in each factor with factor loadings
>.40 were standardized and summed using unit weighting to create composite scores. Any two
composite scores found to be strongly correlated (i.e., r >.50) were combined into a single construct (see
Lewinsohn et al., in press, for more detail). Using these procedures, most of the psychosocial measures
were categorized into 22 constructs (the remaining 27 variables were retained as miscellaneous
individual measures and are described later). A brief description of each construct is given below,
including the number of items, Cronbach's coefficient alpha (based on scale scores where available
rather than individual items), and testretest ( T 1 T 2 ) reliability. All variables were scored such that
higher values indicated more problematic functioning.

Current depression

This construct (67 items, = .81, r = .40) consisted of the 20-item Center for Epidemiologic Studies-
Depression Scale (CES-D; Radloff, 1977), the 21-item Beck Depression Inventory (BDI; Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961), a single (5-point) item assessing depression level during the past
week, the interviewerrated Hamilton Depression Rating Sclae (Hamilton, 1960), and current depression
(major depressive disorder and dysthymia) diagnosis.

Other psychopathology: Internalizing behavior problems

We used a construct consisting of 43 items ( = .72, r = .55) assessing the tendency to worry (e.g.,
Maudsley Obsessional Compulsive Inventory; Hodgson & Rachman, 1977), hypomanic episodes (General
Behavior Inventory; Depue et al., 1981), state anxiety (State-Trait Anxiety Inventory; Spielberger,
Gorsuch, & Lushene, 1970), quantity and nature of sleep, and hypochondriasis (Pilowsky, 1967).

Other psychopathology: Externalizing behavior problems

This 49-item ( = .68, r = .42) construct consisted of the number of current K-SADS symptoms for
attention deficithyperactivity, conduct, and oppositional disorders; an unpublished scale assessing
conduct problems; and the number of current DSMIIIR externalizing disorders.

Other psychopathology: Suicidal ideation

This construct ( = .52, r = .39) consisted of a four-item screener and the three K-SADS items assessing
current suicidal ideation. Items in the screener (I thought about killing myself, I had thoughts about
death, I felt that my family and friends would be better off if I was dead, I felt that I would kill myself if I
knew a way) assessed suicidal ideation, on a 4-point scale, for the past week.
Stress: Daily hassles

This construct ( = .79, r = .55) consisted of 20 items from the Unpleasant Events Schedule (Lewinsohn,
Mermelstein, Alexander, & MacPhillamy, 1985).

Stress: Major life events

This construct ( = .78, r = .52) consisted of 14 events from the Schedule of Recent Experience (Holmes
& Rahe, 1967) and the Life Events Schedule (Sandler & Block, 1979), rated for occurrence to self,
significant others, or both in the past year.

Negative cognitions

For this construct, we used 27 items ( = .61, r = .61) from the Frequency of Self-Reinforcement Attitude
Questionnaire (Heiby, 1982), the Subjective Probability Questionnaire (Muoz & Lewinsohn, 1976), the
Dysfunctional Attitude Scale (Weissman & Beck, 1978), and items assessing perceived control over one's
life (Pearlin & Schooler, 1978).

Attributional style

We used the 48-item ( = .63, r = .55) Kastan Attributional Style Questionnaire for Children (Kaslow,
Tannenbaum, & Seligman, 1978). Two scores were derived, standardized, and summed: positive events
attributed to unstable, external, and specific causes; and negative events attributed to stable, internal,
and global causes.

Self-consciousness

This construct consisted of nine items ( = .74, r = .54) from the Self-Consciousness Scale (Fenigstein,
Scheier, & Buss, 1975).

Self-esteem

This construct consisted of nine items ( = .59, r = .62) from the Body Parts Satisfaction Scale (Berscheid,
Walster, & Bohrnstedt, 1973), the Physical Appearance Evaluation Subscale (Winstead & Cash, 1984),
and the Rosenberg Self-Esteem Scale (Rosenberg, 1965).

Social self-competence

This construct consisted of 12 items ( = .81, r = .64) from the Social subscale of the Perceived
Competence Scale for Children (Harter, 1982) and adjectives assessing perceived social competence
(Lewinsohn, Mischel, Chaplin, & Barton, 1980).

Emotional reliance

We used 10 items ( = .83, r = .54) from the Emotional Reliance Scale (Hirschfeld, Klerman, Chodoff,
Korchin, & Barrett, 1976) assessing the extent to which individuals desire more support and approval
from others and are interpersonally sensitive.
Academic aspirations

This nine-item construct ( = .77, r = .74) contained measures of estimated future education, grade
average last term, self-perceived adequacy of school performance, perceived ability to complete college,
and items adapted from the Importance Placed on Life Goals Scale (Bachman, Johnston, & O'Malley,
1985) assessing the importance of future academic goals.

Family aspirations

This five-item construct ( = .61, r = .58) assessed the importance of future goals related to marriage and
family (adapted from Bachman et al., 1985).

Occupational aspirations

This 3-item construct ( = .63, r = .48) assessed the importance of future income level and steady
employment (adapted from Bachman et al., 1985).

Coping skills

This construct ( = .76, r = .55) consisted of 17 items from the Self-Control Scale (Rosenbaum, 1980), the
Antidepressive Activity Questionnaire (Rippere, 1977), and the Ways of Coping Questionnaire (Folkman
& Lazarus, 1980).

Family social support

This 24-item construct ( = .77, r = .64) consisted of items from the Appraisal of Parents subscale of the
Conflict Behavior Questionnaire (Prinz, Foster, Kent, & O'Leary, 1979), the Parent Attitude Research
Instrument (Schaefer, 1965), the Cohesion subscale of the Family Environment Scale (Moos, 1974), the
Competence scale of the Youth Self-Report (Achenbach & Edelbrock, 1987), and a paper-and-pencil
adaptation of the Arizona Social Support Interview Schedule (ASSIS; Barrera, 1986).

Friends' social support

This 15-item construct ( = .72, r = .60) consisted of items from the Social Competence Scale (Harter,
1982), the UCLA Loneliness Scale (Russell, Peplau, & Cutrona, 1980), and the Competence scales of the
Youth Self-Report and the ASSIS.

Interpersonal: Conflict with parents

This construct ( = .81, r = .51) consisted of the 45-item Issues Checklist (Robin & Weiss, 1980). The
occurrence of events during the previous 2 weeks and average intensity were standardized and
summed.

Interpersonal: Attractiveness

For this construct, we used the 17-item ( = .94, r = .22) interviewer-rated Interpersonal Attraction
Measure (McCroskey & McCain, 1974).
Physical health and illness in the past year

This construct ( = .51, r = .46) consisted of number of visits to a physician, days spent in bed as a result
of illness, and the occurrence of 88 physical symptoms during the previous 12 months.

Maturational level

This construct (eight items, = .64, r = .56 for female adolescents; 11 items, = .74, r = .74 for male
adolescents) contained items adapted from Petersen, Crockett, Richards, and Boxer (1988) assessing
current pubertal status. Items assessed the amount of hair on various body parts and changes in body
shape (female adolescents only) and changes in voice (male adolescents only).

Miscellaneous Measures

Additional measures were not included in the constructs because either they did not fit rationally into a
general cluster or they did not load sufficiently on a factor (i.e., .40). Two items from the BDI were
selected to assess hopelessness (r = .23) and suicidal ideation (r = .27). Adolescents reported whether a
family member (r = .16) or close friend (r = .18) had tried to commit suicide within the past year,
whether either of their parents had died before the adolescent was 12 years of age, the number of
times during their lifetime they had moved to a new place to live (r = .83), and whether they had moved
within the past year (r = .18). Six items from the Marlowe-Crowne Social Desirability Scale (Crowne &
Marlowe, 1960) assessed the tendency to present oneself in a socially desirable manner ( = .53, r =
.54). Fifteen items from the Hypomanic Personality Scale (Eckblad & Chapman, 1986) identified persons
with hypomanic personality style ( = .68, r = .55). Ten items from the Vocabulary subtest of the Shipley
Institute of Living Scale (Shipley, 1940) measured verbal ability ( = .72, r = .71).

Adolescents reported satisfaction with grade average (r = .24), perceived parental satisfaction with
grade average (r = .30), frequency of school absence (r = .34) and tardiness (r = .39) in the past 6 weeks,
and frequency of failure to complete homework (r = .46).

Additional health measures included self-rated health (r = .49); the Quetelet Obesity Index (
weight/height 2 ) as a measure of adiposity (body fat percentage; r = .75); frequency of exercise (r = .47);
adequacy of appetite (r = .43); energy level relative to others in age group (r = .51); use of medications (r
= .29); overnight stays in a hospital (r = .05); whether an injury or illness in the past year had caused
difficulties with feeding, dressing (r = .24), climbing stairs, or getting outdoors (r = .27), an inability to
work or participate in school (r = .23), or a reduction or change in activity level (r = .21); and the lifetime
occurrence of 88 physical symptoms.

Statistical Analyses

Demographic characteristics were examined using chi-square analysis and analysis of variance, with
alpha set at p < .05 (two-tailed). Psychosocial risk factors for future suicide attempt were examined
using logistic regression, which follows the same general principles used in linear regression. The logistic
model is considered more appropriate than the linear model when the outcome variable is dichotomous
(Hosmer & Lemeshow, 1990). The associations between risk factors and future suicide attempt are
presented by means of the odds ratio, which compares the odds of making a suicide attempt for those
with the risk factor to the odds of making an attempt for those without the risk factor. An odds ratio of
1.0 indicates no association between the risk factor and future suicide attempt. An odds ratio of 2.0 for
a dichotomous variable indicates that suicide attempts occur twice as often among those who have the
risk factor than those who do not. For continuous variables, the odds ratio indicates the increased
likelihood of suicide attempt given an increase of one unit in the independent variable.

The predictive significance of each of the psychosocial variables and the interaction of variables with
gender were examined first. Given the number of psychosocial variables, the alpha level of each
comparison was set at p < .005. Because specific hypotheses stipulated a predicted direction of results,
one-tailed significance tests were computed. Given that many of the individual variables were correlated
with current depression level (that was the reason for their inclusion into the study) and were
intercorrelated with each other, two additional steps were taken. First, the ability of significant
individual risk factors to predict future suicide attempt controlling for current depression level was
examined. Second, predictors that remained significant after controlling for depression were considered
for inclusion in multivariate analyses.

The significant individual risk factors (controlling for current depression) were examined in multiple
logistic regression analyses to determine which variables made a unique (i.e., independent of the other
variables) contribution to the prediction of future suicide attempt. The model goodness-of-fit statistics
had acceptable values for all of the logistic regression analyses reported herein (i.e., the 2 log likelihood
chi-square p values exceeded .10). The screening properties of both a brief suicide screening instrument
and the multiple logistic regressionderived risk factors were then examined. Overall classification
ability and comparison of the two screeners were examined by the Youden Index (Youden, 1950), a
measure (ranging from 0 to 1, with standard error) of the proportions correctly classified in case and
control groups.

Results

Demographic Characteristics Associated With Future Suicide Attempt

Two of the demographic variables significantly predicted future attempt: Compared with the control
group, the future attempters had younger mothers (39.0 years of age vs. 41.2), t(1,427) = 2.08, and had
parents with less education, t(1,374) = 2.06. To clarify the magnitude of the effect of mother's age,
mother's age was dichotomized into teenage mother (i.e., mother was less than 20 years of age at the
time of the subject's birth) versus nonteenage mother. Twenty-seven percent of the attempters had a
teenage mother compared with 9% of the nonattempters, 2 (1, N = 1,300) = 7.90, p < .01. When
teenage mothers were not included in the analysis, mother's age no longer significantly predicted
suicide attempts.

There was a trend for female adolescents to be overrepresented in the future attempters group (69% vs.
53%); 2 (1, N = 1,508) = 2.56, p = .11. We examined whether the expected preponderance of female
future attempters would be accentuated among those with a history of suicide attempt. Female
adolescents with a past attempt were no more likely than male adolescents with a past attempt to make
an additional attempt during the course of the study; rates for these female adolescents were actually
slightly lower than rates for the male adolescents (13% and 17%, respectively), 2 (1, N = 102) = .23, ns .
Differences on the remaining variables (age, race, grade in school, repeating a grade, adolescent's job
history, father's age, number of siblings, number in household, birth order, and either parent's
occupational status) did not attain the .05 level of significance.

Psychosocial Variables Associated With Future Suicide Attempt

Separate logistic regression analyses were conducted for each of the psychosocial variables examining
the main effect of the variable and then the interaction of the variable with gender in association with
future suicide attempt. None of the interactions with gender were significant. The odds ratios and 99.5%
confidence intervals for significant variables appear in the first column of Table 1 (the second and third
columns of Table 1 contain data from this sample that have been presented else where; these two
columns will be addressed in the discussion section). Measures of past psychopathology were also
examined but were nonsignificant.

Future suicide attempts were significantly associated with approximately half (22 of 50) of the
psychosocial variables. Examination of the magnitude of the odds ratios indicates that the strongest
predictor of future attempt was the occurrence of a past attempt. Adolescents with a history of suicide
attempt were almost 18 times more likely than adolescents with no past attempt to make a suicide
attempt during the T 1 T 2 period.

Associations With Future Suicide Attempt Controlling for Depression

Because the independent variables were initially selected on the bases of a known or hypothesized
association with depression, the extent to which significant psychosocial variables continued to predict
future attempt was examined in logistic regressions controlling for the effects of current depression
level. Controlling for current level of depression eliminated half of the previously significant variables.
Future suicide attempts continued to be significantly (p < .05) associated with externalizing problem
behaviors (odds ratio = 1.6), suicidal behavior (1.5), pessimism (2.3), attributions (1.7), self-esteem (2.3),
coping skills (1.1), social support from family (2.6), past suicide attempt (8.1), BDI suicidal ideation (4.4),
suicide attempt by a friend (2.4), and problems with appetite (1.5).

Multivariate Associations With Future Suicide Attempt

To examine the extent to which significant individual variables made a unique contribution to the
prediction of future suicide attempt in this sample, we entered two blocks of measures in a multiple
logistic regression analysis. The first block consisted of current depression level and the significant
demographic differences, including gender, which had approached significance. The second block, which
was examined with backward stepwise variable deselection, consisted of the psychosocial variables that
had a significant association with future suicide attempt after controlling for current depression.
Criterion for removal from the solution was set at p > .05 (likelihood-ratio test).
In addition to current depression (odds ratio = 1.8; 95% confidence interval = 1.22.6) and younger
mother's age (1.1; 1.01.2), four psychosocial variables were retained in the final solution: past suicide
attempt (5.8; 2.513.6), recent suicide attempt by a friend (3.2; 1.47.3), suicidal ideation as per the BDI
item (2.6; 1.54.5), and self-esteem (1.8; 1.03.1). Similar to multiple linear regression, multiple logistic
regression combines the predictor variables (within the logistic function) by multiplying each variable by
its beta weight and summing these terms plus a constant. Using an approximation of R2 proposed for
use with logistic regression (Hosmer & Lemeshow, 1990; p. 148), the six-factor solution accounted for
39.8% of the variance of future suicide attempts.

To examine the possibility that the results were in part attributable to a general tendency of adolescent
suicide attempters to answer questionnaire items in a less socially desirable direction, we recomputed
the multiple logistic regression analysis, forcing in the social desirability measure as the first block,
followed by current depression level and the demographic variables as the second block and the
psychosocial variables as the third block. Social desirability did not make a significant contribution and
did not change the contribution of the other variables.

Screening for Future Suicide Attempt

The screening efficacy of the brief (four-item) suicide screener, at five cutpoints, is shown in Table 2. As
can be seen, sensitivity and specificity were both greater than 80% at a cutpoint greater than or equal to
6, although PPV was only 7%. Applied to the study sample, this translates into 21 true positives (i.e.,
identified future attempters), 269 false positives, 5 false negatives (i.e., future attempters not identified
by the screener), and 1,211 true negatives. A cutpoint of 6 was also the point that maximized the
Youden Index (.63). By raising or lowering the cutpoint, one could maximize the screening property of
most interest (e.g., a cutpoint of 7 would increase the specificity [88%] and PPV [9%] at the expense of
sensitivity [65%]). For all calculations, NPV was greater than or equal to 98%, which is attributable to the
fact that the vast majority of adolescents identified as noncases by the screener did not make a suicide
attempt during the 1-year follow-up period.

Using the predicted probability retained from the multiple logistic regression solution, the screening
ability of the six T 1 risk factors was calculated for various predicted probabilities of future attempt;
results appear in the middle portion of Table 2. Sensitivity (81%), specificity (92%), and PPV (17%) were
maximized at the .04 predicted probability cutpoint (Youden Index = .75).

The potential value of the six risk factors as a screener for future suicide attempt can also be illustrated
by treating each risk factor as a dichotomous variable (continuous variables were considered to be
present if the subject scored one or more standard deviations above the mean). The distribution of risk
factors was highly skewed: 49% of the sample had zero risk factors, 91% had no more than two risk
factors, and only 8 subjects (0.6%) had five or six of the factors. Screening properties based on the
number of factors are shown in the lower portion of Table 2. As can be seen, the screening ability of a
cutpoint of three risk factors approaches the level of classification obtained in the multiple logistic
regression solution, and for those with four or more risk factors, the PPV is 20%.

The mean number of risk factors for female and male attempters did not significantly differ (3.1 and 3.4,
respectively), t(24) = .64, ns, although female nonattempters (1.0) had more risk factors than male
nonattempters (0.6), t(1,395) = 6.44, p < .001. Rates of increase in the probability of future suicide
attempt as a function of the number of risk factors were comparable for female and male adolescents.

Discussion

Two demographic variables predicted future adolescent suicide attempts: having been born to a
teenage mother and less parental education. Although there was a trend for more female adolescents
to make a future suicide attempt than male adolescents (2.2% vs. 1.1%, respectively), gender differences
in the predictive ability of the psychosocial variables were nonsignificant. At the univariate level, many
of the psychosocial variables were significantly associated with future suicide attempt. Adolescents who
made a future suicide attempt were more likely to have a history of attempt, psychopathology
(depression, externalizing problems, internalizing problems), depression-related cognitions, current
suicidal ideation, low self-esteem, low perceived social support from family members and friends,
exposure to suicidal behavior by peers, poor self-rated health, and greater perceived functional
impairment as a result of illness or injury. In multivariate analyses, six variables were found to make
significant unique contributions to the prediction of future suicide attempt: past suicide attempts,
recent suicide attempt by a friend, suicidal ideation as per one item of the BDI, current depression,
lowered self-esteem, and having a younger mother.

Examination of the two screening instruments suggests that reasonably high levels of sensitivity and
specificity for future adolescent suicidal behavior can be obtained, although the ratio of false positives
to true positives will be high (i.e., low PPV). It is possible that some of the false-positive adolescents
would have attempted suicide if they had been assessed over a longer follow-up period.

As expected, the strongest predictor of future suicide attempt was past attempt. However, it is
important to note that five additional measures in the multiple logistic regression analyses were
predictive even after controlling for the influence of past attempt. Consistent with previous research
with adolescents and adults, psychopathology appeared to represent an important potentiator or
precondition for suicidal behavior, and depression was the most influential form of pathology. The
significance of reduced self-esteem in suicidal behavior has been addressed in an extensive literature
regarding the association of self-derogation, self-hatred, and suicidal behavior (e.g., Ryan et al., 1987),
although it has never been evaluated prospectively in adolescents. We are not aware of any other study
reporting an association between adolescent suicide attempt and having been born to a teenage
mother. If replicated, this variable represents an important new risk factor and adds to the growing
literature pointing to the vulnerability of children born to teenage mothers (e.g., Hechtman, 1989).

Some measures were not associated with future suicide attempt, even at the univariate level (e.g., early
death of a parent). Contrary to expectation, the influence of suicide attempts by family members (which
included parents, stepparents, siblings, or other relatives) was nonsignificant; 3.8% of the adolescent
attempters had a family member attempt suicide, compared with 4.1% of the adolescent
nonattempters.

Our general model of suicidal behavior stipulated that variables predictive of depression in adolescents
would also predict future suicide attempts. The second column of Table 1 presents the T 1 variables that
significantly (p < .01) predicted a future (i.e., T 1 T 2 ) depressive episode in this sample, as originally
reported in Lewinsohn et al. (in press). As can be seen, future depression and future suicidal behavior
are indeed associated with many of the same psychosocial risk factors. Specifically, of the 22 primary
psychosocial constructs in the study, 13 were associated with the future occurrence of both depression
and suicide attempt. Of the miscellaneous variables, past suicide attempt, BDI suicidal ideation, and
three health problems predicted both events.

Also shown in Table 1 (third column) are the variables found to be significantly (p < .01) associated with
a past suicide attempt in the study sample (Lewinsohn et al., 1993). Almost all of the variables predictive
of suicide attempt and depression were also significantly associated with past suicide attempt. One
perspective that may be useful is to think of variables only associated with future attempts as triggers
for suicidal behavior. Only one variable in the present study (i.e., illness- or injury-related difficulties
climbing stairs and getting outdoors) fit that pattern. Conversely, variables only associated with past
attempts can be conceptualized as consequences. According to this perspective, the fact that indices of
problematic school performance (e.g., academic aspirations, self-satisfaction and perceived parental
satisfaction with grades, school absenteeism) were only associated with past attempts suggests that
impaired academic functioning follows and may be a consequence of suicidal behavior. A similar pattern
is suggested for several self-report measures of physical illness (i.e., following an attempt, adolescents
are more likely to rate themselves as being in poor health and as taking medications).

Several limitations of the study should be noted. First, many statistical comparisons were conducted,
which increase the risk of Type I error; interpretation of positive results should be considered tentative
pending cross-validation. A second limitation of the study is the exclusive reliance on adolescent self-
report. Consequently, our measure of suicide attempts is potentially vulnerable to over- and
underreporting biases. The use of multiple informants and, in cases of disagreement, best estimate
diagnoses would have been more rigorous in providing independent corroboration of the actual
occurrence of the attempt. In the strictest sense, this study only deals with reports of psychosocial
functioning predicting future reports of suicide attempts.

An additional limitation is that the number of adolescents who made an attempt between the two
assessment points was relatively small, which made it difficult to examine gender differences. We were
also unable to determine whether the predictors for repeat attempters were different from predictors
for first-time attempters. Because a few of the psychosocial measures had only fair to moderate levels
of internal consistency (i.e., = .50 .70), alternative labels for some constructs are possible. Last, it is
important to keep in mind that this article focuses on suicide attempts; the risk factors for suicide
completions may be different.
Despite such limitations, the study did have some positive points. First, the prospective design provided
an opportunity to determine the ability of psychosocial risk factors to predict future suicide attempts. To
our knowledge, no other prospective study of adolescent suicide attempts has been published to date.
Second, our data set provided a unique opportunity to compare the predictors of suicide attempt with
those of future depression. Third, the study made use of a representative community sample, which
should enhance the generalizability of the findings. Finally, more so than in previous research, a wide
array of putative risk factors was examined both singly and in combination.

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Submitted: June 8, 1992 Revised: May 13, 1993 Accepted: May 26, 1993

Copyright 1994 American Psychological Association

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Source: Journal of Consulting and Clinical Psychology. Vol.62 (2) pp. 297-305.
Accession Number: ccp-62-2-297 Digital Object Identifier: 10.1037/0022-006X.62.2.297