Journal of Consulting and Clinical Psychology Copyright 1994 by the American Psychological Association, Inc.

0022-006X/94/S3.00
1994, Vol. 62, No. 2,297-305

Psychosocial Risk Factors for Future Adolescent Suicide Attempts

Peter M. Lewinsohn, Paul Rohde, and John R. Seeley

An array of psychosocial risk factors for making a suicide attempt were examined in a representative
sample of 1,508 older (14- to 18-year-old) high school students, 26 of whom made a suicide attempt
during the year following entry into the study. Strongest predictors of future suicide attempt were
history of part attempt, current suicidal ideation and depression, recent attempt by a friend, low
self-esteem, and having been born to a teenage mother. The results suggest that adolescents who are
depressed and those who attempt suicide share many psychosocial risk factors. The efficacy of two
screeners (one consisting of 4 items and the other of 6 variables) is reported. Potential usefulness for
research and communitywide prevention is discussed.

Recent epidemiological studies suggest that the prevalence of retrospective report. Only prospective research, such as the
adolescent suicide attempts is surprisingly high, with lifetime present study, provides information about the extent to which
rates among high school students ranging from 3.5% to 11% characteristics precede and predict a future suicide attempt.
(Andrews & Lewinsohn, 1992; Harkavy-Friedman, Asnis, The general model guiding the present study is that the ma-
Boeck, & DiFiore, 1987; Velez & Cohen, 1988). Given the rela- jority of psychosocial risk factors predictive of future suicide
tive frequency of adolescent suicidal behavior, knowledge re- attempt overlap with variables associated with future depres-
garding its etiology and prevention is of great importance. This sion (Lewinsohn et al., in press). Consequently, most of the vari-
study identifies the psychosocial risk factors of future suicide ables included in the present study were selected on the basis of
attempts in community adolescents and evaluates the relative a known or hypothesized relation with depression. It should be
efficacy of two screeners for future suicide attempts. noted that the variables in this study may also represent risk
The distinguishing characteristics of children and adolescents factors for other forms of psychopathology.
who have a history of suicide attempt have been described in a Given the potentially tragic nature of adolescent suicide at-
number of studies (e.g., Asarnow, Carlson, & Guthrie, 1987; tempts and the elevated risk of suicide clustering among adoles-
Brent, Kolko, Allan, & Brown, 1990; Cohen-Sandier, Berman, cents (Gould, Wallenstein, Kleinman, O'Carroll, & Mercy,
& King, 1982; Fowler, Rich, & Young, 1986; Garfinkel, Froese, 1990), the identification of adolescents at risk for future at-
& Hood, 1982; Lewinsohn, Rohde, & Seeley, 1993; Pfeffer et tempts before their behavior escalates and becomes more seri-
al., 1991; Shaffer, 1988). In these studies the following have ous would be of obvious value. Whereas the very low base rate
emerged as potential risk factors for suicide attempt: being fe- of completed suicide makes it extremely difficult for even a very
male and not living with both parents; psychopathology, includ- good screening instrument to accurately predict the degree of
ing a major depressive disorder, particularly when comorbid risk for completed suicide, concentrating on a relatively more
with other mental disorders; a previous suicide attempt; hope- frequent phenomenon, such as suicide attempt, may prove
lessness, suicidal ideation, and depression-related cognitions; more successful.
poor problem-solving abilities and coping skills; impulsivity; re-
In our recent review of existing instruments used to screen
cent stressful life events, including suicide attempt by family
members or friends and chronic physical illness; family violence for suicidal ideation and attempts in children and adolescents
and dysfunction; peer difficulties; and lower academic achieve- (Garrison, Lewinsohn, Marsteller, Langhinrichsen, & Lann,
ment and school problems. 1991), a number of problems were highlighted (e.g., exclusive
Although important, the aforementioned studies have a num- assessment of suicidal ideation rather than suicidal behavior;
ber of limitations. First, most are based on samples of hospital- inadequate normative information; failure to assess intention-
ized suicide attempters; therefore, the generalizability of find- ality, lethality, and other aspects of the attempt). Perhaps the
ings to community samples cannot be assumed. Second, few most fundamental criticism was that insufficient attention has
studies have evaluated the contribution of variables when ex- been paid to issues of validity, particularly predictive validity.
amined in combination. Third, previous studies have relied on 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
Peter M. Lewinsohn, Paul Rohde, and John R. Seeley, Oregon Re-
search Institute, Eugene, Oregon.
the first article of the series (Andrews & Lewinsohn, 1992), data
Preparation of this article was supported in part by National Institute from the Oregon Adolescent Depression Project (OADP) were
of Mental Health Grant MH40501 to Peter M. Lewinsohn. presented regarding the lifetime prevalence (7.1%) and 1-year
Correspondence concerning this article should be addressed to Peter total incidence (1.7%) of suicide attempts. The lifetime preva-
M. Lewinsohn, Oregon Research Institute, 1715 Franklin Boulevard, lence of attempts was higher for female adolescents (10.1%)
Eugene, Oregon 97403-1983. than for male adolescents (3.8%). Past attempts were also asso-
297
298 P. LEWINSOHN, P. ROHDE, AND J. SEELEY

dated with single-parent homes, fathers with less education, vaschel, Puig-Antich, Chambers, Tabrizi, & Johnson, 1982) and the
and past psychopathology; approximately 80% of adolescents Present Episode version (K-SADS-P). Additional questions were incor-
who had a past attempt met criteria for a previous psychiatric porated to provide information on the presence of most Diagnostic and
disorder. In the second article (Lewinsohn, Rohde, & Seeley, Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-IH-R;
1993), the psychosocial characteristics associated with past sui- American Psychiatric Association, 1987) disorders. Interviewers com-
pleted a 14-item version of the Hamilton Depression Rating Scale
cide attempts were evaluated. Most of the included psychosocial
(Hamilton, 1960).
variables were associated with past attempt, although control- As part of the assessment of affective disorders, information was gath-
ling for current depression level eliminated the significance of ered regarding suicidal ideation (thoughts of death or dying, wishes to
approximately half of the associations. be dead, thoughts of hurting or killing self). These items were rated for
The present study takes advantage of the prospective nature occurrence during the previous 2 weeks and combined into a single
of the OADP data set and the extensive psychosocial assessment measure of K-SADS current suicidal ideation (Andrews & Lewinsohn,
battery. Specifically, we focus on 26 adolescents who attempted 1992).
suicide between the two assessment points, examining the psy- Adolescents at TI were also asked, Have you ever tried to kill yourself
chosocial risk factors, singly and in combination, for future sui- or done anything that could have killed you? When a positive response
cide attempt and the predictive efficacy of two screeners for fu- was given, interviewers elicited a description of the behavior. The in-
terviewers asked further questions to rule out purely thrill-seeking be-
ture suicide attempts. Predictive efficacy is evaluated vis-a-vis haviors (e.g., skiing very fast on an extremely steep slope). On the basis
sensitivity (proportion of true cases identified by the screener), of this information, interviewers rated each suicide attempt at TI (N
specificity (proportion of true noncases identified by the = 121) for intentionality (on the 6-point K-SADS scale) and medical
screener), positive predictive value (PPV; proportion of true lethality (on the 11-point Lethality of Suicide Attempts Rating Scale;
cases among those identified by the screener as cases), and neg- Smith, Conroy, & Ehler, 1984).
ative predictive value (NPV; proportion of true noncases among At the T2 interview, subjects were again diagnostically interviewed.
those identified by the screener as noncases). The only T2 information used in the present study is whether the subject
had attempted suicide between T1 and T2. Using probes similar to those
used in the Tj interview, participants were questioned about any suicide
Method attempts since TI . Twenty-six adolescents reported making one or more
attempts since the first interview (a description of the attempts is avail-
Subjects and Procedure able on request). Of the future attempters, 14 (53.8%) had reported a
past suicide attempt at TI , whereas 12 (46.2%) reported this attempt to
The sample consisted of 1,508 adolescents who completed a diagnos-
be their first. The mean suicidal intent score for the attempts was 2.9 (3
tic interview and questionnaire at two time points approximately 1 year
= definite but very ambivalent); 26.9% of the attempters had an intent
apart; of these, 26 participants (1.7%) reported having made at least one
rating of 5 (very serious) or 6 (extreme; careful planning and every ex-
suicide attempt between the two assessments. Participants (ages 14-18)
pectation of death). The mean medical lethality score was 2 (death is
were randomly selected from nine high schools representative of urban
improbable); 11.4% had a score of 5 or greater (5 = death is a fifty-fifty
and rural districts in western Oregon. A total of 1,710 adolescents com-
probability). Interview notes for 30 randomly selected nonattempters at
pleted the initial (T,) interviews between 1987 and 1989 (additional
T2 were reviewed for the presence of reports of dangerous thrill-seeking
details provided in Lewinsohn, Hops, Roberts, Seeley, & Andrews,
behaviors; none were reported. It appears that the K-SADS structure,
1993). The representativeness of the T, sample was assessed by compar-
in which assessment of suicide attempts follows questions regarding sui-
ing demographic characteristics of the sample with 1980 census data
cidal ideation, elicits appropriate responses.
and with characteristics of adolescents who declined participation.
Diagnostic interviewers were carefully selected and trained. For reli-
Only minor differences were noted, and the participants may be consid-
ability purposes, all interviews were audiotaped or videotaped, and 12%
ered to be representative of high school students in western Oregon.
were randomly selected and rated by reliability coders. With one excep-
At the second assessment (T2), 1,508 participants (88.2%) returned tion (anxiety disorders, kappa = .60), kappas for current disorders were
for a readministration of the interview and questionnaire (mean in- consistently greater than .80.
terval = 13.8 months, SD = 2.3). Biases that may have emerged because
of attrition in the T|-T2 panel sample were examined by comparing the
adolescents who did not participate at T2 (N = 202) to the 1,508 subjects Self-Report Questionnaire
on demographic characteristics and measures of psychopathology. Few Demographics. Adolescents reported gender, age, race (six catego-
significant differences were present. The two groups did not differ on ries), grade in school, history of repeating a grade, job history, number
any measures of depression, and the attrition rate for subjects with a of siblings (natural and step), birth order, and composition of the house-
history of suicide attempt at TI (19 of 121 or 15.7%) did not significantly hold; parents reported maximum level of education (seven categories),
differ from the attrition rate for subjects without a history of suicide age, marital status (five categories), and occupational status (nine cate-
attempt (183 of 1,589, or 11.5%), X 2 (1,JV = 1,710)= 1.89,ns. gories).
Approximately half of the Ti-T2 panel was female (54%), with an Psychosocial constructs. An extensive questionnaire battery of mea-
average age of 16.5 (SD = 1.2). The majority (91 %) were Caucasian and sures was administered, with the intent of assessing all psychosocial
most (74%) resided in two-parent homes. Written informed consent was variables known or hypothesized to be related to depression (materials
obtained from all adolescents and their legal guardians, and adolescents available on request). On the basis of extensive pilot studies (Andrews,
were paid $25 for their participation at each assessment procedure. Lewinsohn, Hops, & Roberts, 1993), most of the measures were short-
ened (unless noted, the instrument has been abbreviated).
Diagnostic Interview Because a large number of variables were administered, measures
were reduced to a smaller number of composite scores. Variables were
Participants were interviewed at Tj with an adaptation of the Sched- rationally categorized into general clusters, which were submitted to
ule for Affective Disorders and Schizophrenia for School-Age Children principal-components factor analysis with varimax rotation. Measures
that combined features of the Epidemiologic version (K-SADS-E; Or- in each factor with factor loadings >.40 were standardized and summed
 ADOLESCENT SUICIDE ATTEMPT 299

using unit weighting to create composite scores. Any two composite Social self-competence. This construct consisted of 12 items (a =
scores found to be strongly correlated (i.e., r >.50) were combined into .81, r = .64) from the Social subscale of the Perceived Competence Scale
a single construct (see Lewinsohn et al., in press, for more detail). Using for Children (Barter, 1982) and adjectives assessing perceived social
these procedures, most of the psychosocial measures were categorized competence (Lewinsohn, Mischel, Chaplin, & Barton, 1980).
into 22 constructs (the remaining 27 variables were retained as miscel- Emotional reliance. We used 10 items (a = .83, r = .54) from the
laneous individual measures and are described later). A brief descrip- Emotional Reliance Scale (Hirschfeld, Klerman, Chodoff, Korchin, &
tion of each construct is given below, including the number of items, Barrett, 1976) assessing the extent to which individuals desire more sup-
Cronbach's coefficient alpha (based on scale scores where available port and approval from others and are interpersonally sensitive.
rather than individual items), and test-retest (T!-T2) reliability. All Academic aspirations. This nine-item construct (a = .77, r = .74)
variables were scored such that higher values indicated more problem- contained measures of estimated future education, grade average last
atic functioning. term, self-perceived adequacy of school performance, perceived ability
Current depression. This construct (67 items, a = .81, r = .40) con- to complete college, and items adapted from the Importance Placed on
sisted of the 20-item Center for Epidemiologic Studies-Depression Scale Life Goals Scale (Bachman, Johnston, & O'Malley, 1985) assessing the
(CES-D; Radloff, 1977), the 21-item Beck Depression Inventory (BDI; importance of future academic goals.
Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), a single (5-point) Family aspirations. This five-item construct (a = .61, r = .58) as-
item assessing depression level during the past week, the interviewer- sessed the importance of future goals related to marriage and family
rated Hamilton Depression Rating Scale (Hamilton, 1960), and current (adapted from Bachman et al., 1985).
depression (major depressive disorder and dysthymia) diagnosis. Occupational aspirations. This 3-item construct (a = .63, r = .48)
Other psychopathology: Internalizing behavior problems. We used a assessed the importance of future income level and steady employment
construct consisting of 43 items (a = .72, r = .55) assessing the tendency (adapted from Bachman et al., 1985).
to worry (e.g., Maudsley Obsessional Compulsive Inventory; Hodgson Coping skills. This construct (a = .76, r= .55) consisted of 17 items
& Rachman, 1977), hypomanic episodes (General Behavior Inventory; from the Self-Control Scale (Rosenbaum, 1980), the Antidepressive Ac-
Depue et al., 1981), state anxiety (State-Trait Anxiety Inventory; tivity Questionnaire (Rippere, 1977), and the Ways of Coping Question-
Spielberger, Gorsuch, & Lushene, 1970), quantity and nature of sleep, naire (Folkman & Lazarus, 1980).
and hypochondriasis (Pilowsky, 1967). Family social support. This 24-item construct (a = .77, r = .64)
Other psychopalhology: Externalizing behavior problems. This 49- consisted of items from the Appraisal of Parents subscale of the Conflict
item (a - .68, r = .42) construct consisted of the number of current K- Behavior Questionnaire (Prinz, Foster, Kent, & O'Leary, 1979), the Par-
SADS symptoms for attention deficit-hyperactivity, conduct, and op- ent Attitude Research Instrument (Schaefer, 1965), the Cohesion sub-
positional disorders; an unpublished scale assessing conduct problems; scale of the Family Environment Scale (Moos, 1974), the Competence
and the number of current DSM-IH-R externalizing disorders. scale of the Youth Self-Report (Achenbach & Edelbrock, 1987), and a
Other psychopathology: Suicidal ideation. This construct (a = .52, paper-and-pencil adaptation of the Arizona Social Support Interview
r = .39) consisted of a four-item screener and the three K-SADS items Schedule (ASSIS; Barrera, 1986).
assessing current suicidal ideation. Items in the screener (I thought Friends' social support. This 15-item construct (a = .72, r = .60)
about killing myself, I had thoughts about death, I felt that my family consisted of items from the Social Competence Scale (Harter, 1982), the
and friends would be better off if I was dead, I felt that I would kill myself UCLA Loneliness Scale (Russell, Peplau, & Cutrona, 1980), and the
if I knew a way) assessed suicidal ideation, on a 4-point scale, for the Competence scales of the Youth Self-Report and the ASSIS.
past week. Interpersonal: Conflict with parents. This construct (a = .81, r =
Stress: Daily hassles. This construct (a = .79, r = .55) consisted of .51) consisted of the 45-item Issues Checklist (Robin & Weiss, 1980).
20 items from the Unpleasant Events Schedule (Lewinsohn, Mer- The occurrence of events during the previous 2 weeks and average in-
melstein, Alexander, & MacPhillamy, 1985). tensity were standardized and summed.
Interpersonal: Attractiveness. For this construct, we used the 17-
Stress: Major life events. This construct (a = .78, r = .52) consisted
item (a = .94, r = .22) interviewer-rated Interpersonal Attraction Mea-
of 14 events from the Schedule of Recent Experience (Holmes & Rahe,
sure (McCroskey & McCain, 1974).
1967) and the Life Events Schedule (Sandier & Block, 1979), rated for
Physical health and illness in the past year. This construct (a = . 51,
occurrence to self, significant others, or both in the past year.
r = .46) consisted of number of visits to a physician, days spent in bed
Negative cognitions. For this construct, we used 27 items (a = .61, r
as a result of illness, and the occurrence of 88 physical symptoms during
= .61) from the Frequency of Self-Reinforcement Attitude Question-
the previous 12 months.
naire (Heiby, 1982), the Subjective Probability Questionnaire (Mufioz
Maturational level. This construct (eight items, a = .64, r = .56 for
& Lewinsohn, 1976), the Dysfunctional Attitude Scale (Weissman &
female adolescents; 11 items, a = .74, r = .74 for male adolescents)
Beck, 1978), and items assessing perceived control over one's life (Pear-
contained items adapted from Petersen, Crockett, Richards, and'Boxer
lin & Schooler, 1978).
(1988) assessing current pubertal status. Items assessed the amount of
Attributional style. We used the 48-item (a = .63, r = .55) Kastan hair on various body parts and changes in body shape (female adoles-
Attributional Style Questionnaire for Children (Kaslow, Tannenbaum, cents only) and changes in voice (male adolescents only).
& 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 Miscellaneous Measures
causes.
Self-consciousness. This construct consisted of nine items (a = .74, Additional measures were not included in the constructs because ei-
r = .54) from the Self-Consciousness Scale (Fenigstein, Scheier, & Buss, ther they did not fit rationally into a general cluster or they did not load
1975). sufficiently on a factor (i.e., ^ .40). Two items from the BDI were se-
Self-esteem. This construct consisted of nine items (a = .59, r = lected to assess hopelessness (r = .23) and suicidal ideation (r = .27).
.62) from the Body Parts Satisfaction Scale (Berscheid, Walster, & Adolescents reported whether a family member (r = . 16) or close friend
Bohrnstedt, 1973), the Physical Appearance Evaluation Subscale (r = . 18) had tried to commit suicide within the past year, whether either
(Winstead & Cash, 1984), and the Rosenberg Self-Esteem Scale (Rosen- of their parents had died before the adolescent was 12 years of age, the
berg, 1965). number of times during their lifetime they had moved to a new place to
300 P. LEWINSOHN, P. ROHDE, AND J. SEELEY

live (r = .83), and whether they had moved within the past year (r = . 18). Results
Six items from the Marlowe-Crowne Social Desirability Scale (Crowne
& Marlowe, 1960) assessed the tendency to present oneself in a socially Demographic Characteristics Associated With Future
desirable manner (a = .53, r = .54). Fifteen items from the Hypomanic Suicide Attempt
Personality Scale (Eckblad & Chapman, 1986) identified persons with
hypomanic personality style (a = .68, r = .55). Ten items from the Vo- Two of the demographic variables significantly predicted fu-
cabulary subtest of the Shipley Institute of Living Scale (Shipley, 1940) ture attempt: Compared with the control group, the future at-
measured verbal ability (a = .72, r = .71). tempters had younger mothers (39.0 years of age vs. 41.2),
Adolescents reported satisfaction with grade average (r = .24), per- t( 1,427) = 2.08, and had parents with less education, t( 1,374)
ceived parental satisfaction with grade average (r = .30), frequency of
= 2.06. To clarify the magnitude of the effect of mother's age,
school absence (r = .34) and tardiness (r = .39) in the past 6 weeks, and
mother's age was dichotomized into teenage mother (i.e.,
frequency of failure to complete homework (r = .46).
Additional health measures included self-rated health (r = .49); the mother was less than 20 years of age at the time of the subject's
Quetelet Obesity Index (weight/height2) as a measure of adiposity (body birth) versus nonteenage mother. Twenty-seven percent of the
fat percentage; r = .75); frequency of exercise (r = .47); adequacy of attempters had a teenage mother compared with 9% of the non-
appetite (r = .43); energy level relative to others in age group (r = .51); attempters, x20, N = 1,300) = 7.90, p < .01. When teenage
use of medications (r = .29); overnight stays in a hospital (r = .05); mothers were not included in the analysis, mother's age no
whether an injury or illness in the past year had caused difficulties with longer significantly predicted suicide attempts.
feeding, dressing (r = .24), climbing stairs, or getting outdoors (r = .27), There was a trend for female adolescents to be overrepre-
an inability to work or participate in school (r = .23), or a reduction or sented in the future attempters group (69% vs. 53%); x 2 (l, N
change in activity level (r = .21); and the lifetime occurrence of 88 phys- = 1,508) = 2.56, p = .11. We examined whether the expected
ical symptoms.
preponderance of female future attempters would be accentu-
ated among those with a history of suicide attempt. Female ad-
Statistical Analyses olescents with a past attempt were no more likely than male
Demographic characteristics were examined using chi-square analy- adolescents with a past attempt to make an additional attempt
sis and analysis of variance, with alpha set at p < .05 (two-tailed). Psy- during the course of the study; rates for these female adolescents
chosocial risk factors for future suicide attempt were examined using were actually slightly lower than rates for the male adolescents
logistic regression, which follows the same general principles used in (13% and 17%, respectively), x 2 (l, # = 102) = .23, ns. Differ-
linear regression. The logistic model is considered more appropriate ences on the remaining variables (age, race, grade in school,
than the linear model when the outcome variable is dichotomous repeating a grade, adolescent's job history, father's age, number
(Hosmer & Lemeshow, 1990). The associations between risk factors and of siblings, number in household, birth order, and either par-
future suicide attempt are presented by means of the odds ratio, which
ent's occupational status) did not attain the .05 level of signifi-
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. cance.
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 Psychosocial Variables Associated With Future Suicide
indicates that suicide attempts occur twice as often among those who Attempt
have the risk factor than those who do not. For continuous variables,
the odds ratio indicates the increased likelihood of suicide attempt given Separate logistic regression analyses were conducted for each
an increase of one unit in the independent variable. of the psychosocial variables examining the main effect of the
The predictive significance of each of the psychosocial variables and variable and then the interaction of the variable with gender in
the interaction of variables with gender were examined first. Given the association with future suicide attempt. None of the interac-
number of psychosocial variables, the alpha level of each comparison tions with gender were significant. The odds ratios and 99.5%
was set at p < .005. Because specific hypotheses stipulated a predicted confidence intervals for significant variables appear in the first
direction of results, one-tailed significance tests were computed. Given
column of Table 1 (the second and third columns of Table 1
that many of the individual variables were correlated with current de-
contain data from this sample that have been presented else-
pression level (that was the reason for their inclusion into the study) and
were intercorrelated with each other, two additional steps were taken. where; these two columns will be addressed in the discussion
First, the ability of significant individual risk factors to predict future section). Measures of past psychopathology were also examined
suicide attempt controlling for current depression level was examined. but were nonsignificant.
Second, predictors that remained significant after controlling for de- Future suicide attempts were significantly associated with ap-
pression were considered for inclusion in multivariate analyses. proximately half (22 of 50) of the psychosocial variables. Ex-
The significant individual risk factors (controlling for current depres- amination of the magnitude of the odds ratios indicates that the
sion) were examined in multiple logistic regression analyses to deter- strongest predictor of future attempt was the occurrence of a
mine which variables made a unique (i.e., independent of the other vari- past attempt. Adolescents with a history of suicide attempt were
ables) contribution to the prediction of future suicide attempt. The
almost 18 times more likely than adolescents with no past at-
model goodness-of-fit statistics had acceptable values for all of the logis-
tempt to make a suicide attempt during the Ti-T2 period.
tic 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 regression-de- Associations With Future Suicide Attempt Controlling
rived risk factors were then examined. Overall classification ability and for Depression
comparison of the two screeners were examined by the \buden Index
(Youden, 1950), a measure (ranging from 0 to 1, with standard error) of Because the independent variables were initially selected on
the proportions correctly classified in case and control groups. the bases of a known or hypothesized association with depres-
 ADOLESCENT SUICIDE ATTEMPT 301

Table 1
Relation ofPsychosocial Variables and Future Suicide Attempt,
Future Depressive Episode, and Past Suicide Attempt
Future
Future attempt depression8 Past attemptb

Variable OR 99.5% CI OR 99% CI OR 99% CI

Current Depression" 3.0 2.0-4.3 1.8 1.4-2.4 2.4 1.9-3.0

Externalizing Problem Behaviors" 2.3 .4-3.6* 1.6 1.2-2.2 2.3 1.7-3.0
Internalizing Problem Behaviors" 4.0 .8-8.8 2.8 1.9-4.1 3.6 2.4-5.3
Suicidal Ideation" 2.1 .6-2.7* 1.5 1.2-1.9 1.8 1.5-2.2
Daily Hassles" 1.6 .6-1.7 1.0 1.0-1.1 1.0 1.0-1.1
Major Life Events" 1.1 .0-1.2 1.1 1.0-1.1 1.1 1.0-1.1
Negative Cognitions" 4.8 2.4-9.5* 1.6 1.2-2.3 3.2 2.2-4.5
Attributional Style" 3.1 1.6-5.7* 1.4 1.1-1.9 2.1 1.5-2.8
Self-Consciousness" 1.1 1.0-1.3 1.1 1.0-1.1 1.1 1.0-1.1
Self-Esteem" 4.0 2.0-8.1* 1.5 1.1-2.1 2.5 1.8-3.5
Social Self-Competence" 2.8 1.5-5.4 — — 1.8 1.3-2.5
Emotional Reliance" 1.1 1.0-1.2 1.1 1.0-1.1 1.1 1.0-1.2
Academic Aspirations" — — — 2.0 1.5-2.8
—
Family Aspirations" — — — — — —
Occupational Aspirations" — — — — — —
Coping Skills" 1.2 1.1-1.3* 1.1 1.0-1.1 1.1 1.1-1.2
Family Support" 4.3 2.0-9.2* 1.6 1.1-2.2 2.6 1.8-3.8
Friends Support" 2.7 1.3-5.4 — — 2.1 1.5-3.1
Conflict with Parents" — — 1.4 1.1-1.7 1.4 1.1-1.7
Interpersonal Attractiveness" — — 1.6 1.2-2.1
— —
Health/Illness" — — 1.5 1.2-1.9 1.9 1.4-2.5
Maturation Level" — — — — — —
Past suicide attempt 17.6 6.0-52.0* 6.1 3.4-11.2 NA NA
BDI hopelessness" 2.8 .6-5.1 — — 2.0 1.4-2.8
BDI suicidal ideation" 6.9 3.6-13.2* 2.1 1.5-3.0 3.9 2.7-5.6
Attempt by family — — — — — —
Attempt by friend 3.5 .2-10.2* — — 2.0 1.1-3.6
Early death of parent — — — — — —
Moved in lifetime" — — — — 1.4 1.1-1.7
Moved in last year — — — — — —
Social desirability" — — — — 1.2 1.0-1.4
Hypomanic measure" — — — — 1.1 1.0-1.2
Vocabulary" — — — — — —
Satisfaction with grades — — 1.7 1.1-2.7 2.6 1.6-4.4
Parental satisfaction with grades — — — — 2.6 1.6-4.4
Missed school days" — — — — 1.5 1.2-1.8
Late for school" — — —
Failure to do homework" — — 1.3 1.0-1.5 1.4 1.2-1.7
Self-fated health" — — 1.8 1.1-3.1 1.9 1.3-2.7
Obesity" — — — — — —
Frequency of exercise" — — — — 1.5 1.1-2.0
Problems with appetite" 2.7 1.5-4.8* 1.8 1.2-2.7 1.6 1.1-2.2
Energy level" — — 2.2 1.5-3.2 1.9 1.3-2.8
Use of medications — — — — 2.0 1.1-3.7
Hospital stays" — — — — 3.8 1.7-8.5
Difficulties with:
Feeding/dressing — — — —
Climbing stairs 8.2 1.6-44.0 5.2 1.4-19.2 — —
Work or school — — — — 2.2 1.3-3.6
Activities 3.2 1.1-9.5 2.5 1.2-5.4 2.0 1.1-3.5
Lifetime physical symptoms" — — 1.1 1.0-1.1 1.0 1.0-1.1
Note. Dashes indicate that odds ratios are nonsignificant. OR = odds ratio, adjusted for gender. CI =
confidence interval; NA = not applicable.
* Results presented in Lewinsohn, Roberts, Seeley, Rohde, Gotlib, and Hops (in press). b Results presented
in Lewinsohn, Rohde, and Seeley (1993). " Continuous variable.
* Significant at p < .05 after controlling for concurrent depression.
302 P. LEWINSOHN, P. ROHDE, AND J. SEELEY

sion, the extent to which significant psychosocial variables con- the point that maximized the \buden Index (.63). By raising or
tinued to predict future attempt was examined in logistic re- lowering the cutpoint, one could maximize the screening prop-
gressions controlling for the effects of current depression level. erty of most interest (e.g., a cutpoint of 7 would increase the
Controlling for current level of depression eliminated half of specificity [88%] and PPV [9%] at the expense of sensitivity
the previously significant variables. Future suicide attempts [65%]). For all calculations, NPV was greater than or equal to
continued to be significantly (p < .05) associated with external- 98%, which is attributable to the fact that the vast majority of
izing problem behaviors (odds ratio = 1.6), suicidal behavior adolescents identified as noncases by the screener did not make
(1.5), pessimism (2.3), attributions (1.7), self-esteem (2.3), cop- a suicide attempt during the 1-year follow-up period.
ing skills (1.1), social support from family (2.6), past suicide Using the predicted probability retained from the multiple
attempt (8.1), BDI suicidal ideation (4.4), suicide attempt by a logistic regression solution, the screening ability of the six TI
friend (2.4), and problems with appetite (1.5). risk factors was calculated for various predicted probabilities of
future attempt; results appear in the middle portion of Table 2.
Multivariate Associations With Future Suicide Attempt Sensitivity (81%), specificity (92%), and PPV (17%) were maxi-
mized at the .04 predicted probability cutpoint (Youden Index
To examine the extent to which significant individual vari- = .75).
ables made a unique contribution to the prediction of future The potential value of the six risk factors as a screener for
suicide attempt in this sample, we entered two blocks of mea- future suicide attempt can also be illustrated by treating each
sures in a multiple logistic regression analysis. The first block risk factor as a dichotomous variable (continuous variables
consisted of current depression level and the significant demo- were considered to be present if the subject scored one or more
graphic differences, including gender, which had approached standard deviations above the mean). The distribution of risk
significance. The second block, which was examined with back- factors was highly skewed: 49% of the sample had zero risk fac-
ward stepwise variable deselection, consisted of the psychoso- tors, 91% had no more than two risk factors, and only 8 subjects
cial variables that had a significant association with future sui- (0.6%) had five or six of the factors. Screening properties based
cide attempt after controlling for current depression. Criterion on the number of factors are shown in the lower portion of Table
for removal from the solution was set at p > .05 (likelihood- 2. As can be seen, the screening ability of a cutpoint of three
ratio test). risk factors approaches the level of classification obtained in the
In addition to current depression (odds ratio = 1.8; 95% con- multiple logistic regression solution, and for those with four or
fidence interval = 1.2-2.6) and younger mother's age (1.1; 1.0- more risk factors, the PPV is 20%.
1.2), four psychosocial variables were retained in the final solu- The mean number of risk factors for female and male at-
tion: past suicide attempt (5.8; 2.5-13.6), recent suicide at- tempters did not significantly differ (3.1 and 3.4, respectively),
tempt by a friend (3.2; 1.4-7.3), suicidal ideation as per the BDI t(24) - —.64, ns, although female nonattempters (1.0) had more
item (2.6; 1.5-4.5), and self-esteem (1.8; 1.0-3.1). Similar to risk factors than male nonattempters (0.6), t( 1,395) = 6.44, p <
multiple linear regression, multiple logistic regression combines .001. Rates of increase in the probability of future suicide at-
the predictor variables (within the logistic function) by tempt as a function of the number of risk factors were compa-
multiplying each variable by its beta weight and summing these rable for female and male adolescents.
terms plus a constant. Using an approximation ofR2 proposed
for use with logistic regression (Hosmer & Lemeshow, 1990; p. Discussion
148), the six-factor solution accounted for 39.8% of the variance
of future suicide attempts. Two demographic variables predicted future adolescent sui-
To examine the possibility that the results were in part attrib- cide attempts: having been born to a teenage mother and less
utable to a general tendency of adolescent suicide attempters to parental education. Although there was a trend for more female
answer questionnaire items in a less socially desirable direction, adolescents to make a future suicide attempt than male adoles-
we recomputed the multiple logistic regression analysis, forcing cents (2.2% vs. 1.1 %, respectively), gender differences in the pre-
in the social desirability measure as the first block, followed by dictive ability of the psychosocial variables were nonsignificant.
current depression level and the demographic variables as the At the univariate level, many of the psychosocial variables were
second block and the psychosocial variables as the third block. significantly associated with future suicide attempt. Adoles-
Social desirability did not make a significant contribution and cents who made a future suicide attempt were more likely to
did not change the contribution of the other variables. have a history of attempt, psychopathology (depression, exter-
nalizing problems, internalizing problems), depression-related
cognitions, current suicidal ideation, low self-esteem, low per-
Screening for Future Suicide Attempt
ceived social support from family members and friends,
The screening efficacy of the brief (four-item) suicide exposure to suicidal behavior by peers, poor self-rated health,
screener, at five cutpoints, is shown in Table 2. As can be seen, and greater perceived functional impairment as a result of ill-
sensitivity and specificity were both greater than 80% at a cut- ness or injury. In multivariate analyses, six variables were found
point greater than or equal to 6, although PPV was only 7%. to make significant unique contributions to the prediction of
Applied to the study sample, this translates into 21 true posi- future suicide attempt: past suicide attempts, recent suicide at-
tives (i.e., identified future attempters), 269 false positives, 5 tempt by a friend, suicidal ideation as per one item of the BDI,
false negatives (i.e., future attempters not identified by the current depression, lowered self-esteem, and having a younger
screener), and 1,211 true negatives. A cutpoint of 6 was also mother.
 ADOLESCENT SUICIDE ATTEMPT 303

Table 2
Performance of Two Screenersfor Future Suicide Attempts
Sensitivity Specificity PPV NPV
Screener
Four-item screener
Cutpoint
5 gg 66 4 100
6 81 82 7 100
7 65 88 9 99
8 58 92 11 99
9 50 94 12 99
Six-factor screener
Multiple logistic regression
solution predicted probability
.01 92 78 g 100
.02 g5 gg 12 100
.03 85 91 15 100
.04 81 92 17 100
.05 77 93 19 100
.10 58 97 26 99
.20 42 99 39 99
.50 27 100 70 9g
Presence of dichotomous variables
1 100 50 4 100
2 92 80 8 100
3 73 92 14 100
4 35 9g 20 99
5 15 100 50 98
Note. Sensitivity = proportion of attempters identified by screener; Specificity = proportion of nonat-
tempters identified by screener; PPV = proportion of attempters among those identified by screener as
attempters; NPV = proportion of nonattempters among those identified by screener as nonattempters.

Examination of the two screening instruments suggests that or other relatives) was nonsignificant; 3.8% of the adolescent
reasonably high levels of sensitivity and specificity for future attempters had a family member attempt suicide, compared
adolescent suicidal behavior can be obtained, although the ratio with 4.1% of the adolescent nonattempters.
of false positives to true positives will be high (i.e., low PPV). It Our general model of suicidal behavior stipulated that vari-
is possible that some of the false-positive adolescents would have ables predictive of depression in adolescents would also predict
attempted suicide if they had been assessed over a longer follow- future suicide attempts. The second column of Table 1 presents
up period. the T! variables that significantly (p < .01) predicted a future
As expected, the strongest predictor of future suicide attempt (i.e., T!-TZ) depressive episode in this sample, as originally re-
was past attempt. However, it is important to note that five ad- ported in Lewinsohn et al. (in press). As can be seen, future
ditional measures in the multiple logistic regression analyses depression and future suicidal behavior are indeed associated
were predictive even after controlling for the influence of past with many of the same psychosocial risk factors. Specifically, of
attempt. Consistent with previous research with adolescents the 22 primary psychosocial constructs in the study, 13 were
and adults, psychopathology appeared to represent an impor- associated with the future occurrence of both depression and
tant potentiator or precondition for suicidal behavior, and de- suicide attempt. Of the miscellaneous variables, past suicide at-
pression was the most influential form of pathology. The sig- tempt, BDI suicidal ideation, and three health problems pre-
nificance of reduced self-esteem in suicidal behavior has been dicted both events.
addressed in an extensive literature regarding the association of Also shown in Table 1 (third column) are the variables found
self-derogation, self-hatred, and suicidal behavior (e.g., Ryan et to be significantly (p < .01) associated with a past suicide at-
al., 1987), although it has never been evaluated prospectively in tempt in the study sample (Lewinsohn et al., 1993). Almost all
adolescents. We are not aware of any other study reporting an of the variables predictive of suicide attempt and depression
association between adolescent suicide attempt and having been were also significantly associated with past suicide attempt. One
born to a teenage mother. If replicated, this variable represents perspective that may be useful is to think of variables only asso-
an important new risk factor and adds to the growing literature ciated with future attempts as triggers for suicidal behavior.
pointing to the vulnerability of children born to teenage moth- Only one variable in the present study (i.e., illness- or injury-
ers (e.g., Hechtman, 1989). related difficulties climbing stairs and getting outdoors) fit that
Some measures were not associated with future suicide at- pattern. Conversely, variables only associated with past at-
tempt, even at the univariate level (e.g., early death of a parent). tempts can be conceptualized as consequences. According to
Contrary to expectation, the influence of suicide attempts by this perspective, the fact that indices of problematic school per-
family members (which included parents, stepparents, siblings, formance (e.g., academic aspirations, self-satisfaction and per-
304 P. LEWINSOHN, P. ROHDE, AND J. SEELEY

ceived parental satisfaction with grades, school absenteeism) self-perceptions, hopelessness, and perceived family environments in
were only associated with past attempts suggests that impaired depressed and suicidal children. Journal of Consulting and Clinical
academic functioning follows and may be a consequence of sui- Psychology, 55, 361-366.
cidal behavior. A similar pattern is suggested for several self- Bachman, J. G., Johnston, J., & O'Malley, P. M. (1985, May). Some
report measures of physical illness (i.e., following an attempt, recent trends in the aspirations, concerns, and behaviors of American
adolescents are more likely to rate themselves as being in poor young people. Paper presented at the Annual Conference of the Amer-
health and as taking medications). ican Association for Public Opinion Research, McAfee, NJ.
Barrera, M., Jr. (1986). Distinctions between social support concepts,
Several limitations of the study should be noted. First, many
measures, and models. American Journal of Community Psychology,
statistical comparisons were conducted, which increase the risk 14, 413-445.
of Type I error; interpretation of positive results should be con- Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J.
sidered tentative pending cross-validation. A second limitation (1961). An inventory for measuring depression. Archives of General
of the study is the exclusive reliance on adolescent self-report. Psychiatry, 4, 561-57'1.
Consequently, our measure of suicide attempts is potentially Berscheid, E., Walster, E., & Bohrnstedt, G. (1973). The happy Ameri-
vulnerable to over- and underreporting biases. The use of can body: A survey report. Psychology Today, 7, 119-131.
multiple informants and, in cases of disagreement, best esti- Brent, D. A., Kolko, D. J., Allan, M. J., & Brown, R. V. (1990). Sui-
mate diagnoses would have been more rigorous in providing cidality in affectively disordered adolescent inpatients. Journal of the
independent corroboration of the actual occurrence of the at- American Academy of Child and Adolescent Psychiatry, 29, 586-593.
tempt. In the strictest sense, this study only deals with reports Cohen-Sandier, R., Berman, A. L., & King, R. A. (1982). Life stress
of psychosocial functioning predicting future reports of suicide and symptomatology: Determinants of suicidal behavior in children.
Journal of the American Academy of Child Psychiatry, 21, 178-186.
attempts.
Crowne, D. P., & Marlowe, D. (1960). A new scale of social desirability
An additional limitation is that the number of adolescents
independent of psychopathology. Journal of Consulting Psychology,
who made an attempt between the two assessment points was 24, 349-354.
relatively small, which made it difficult to examine gender Depue, R. A., Slater, J. F., Wolfsetter-Kausch, H., Klein, D., Goplerud,
differences. We were also unable to determine whether the pre- E., & Farr, D. (1981). A behavioral paradigm for identifying persons
dictors for repeat attempters were different from predictors for at risk for bipolar depressive disorder: A conceptual framework and
first-time attempters. Because a few of the psychosocial mea- five validation studies. Journal of Abnormal Psychology, 90, 381-437.
sures had only fair to moderate levels of internal consistency Eckblad, M., & Chapman, L. J. (1986). Development of a scale for hy-
(i.e., a = .50-.70), alternative labels for some constructs are pos- pomanic personality and validation. Journal of Abnormal Psychology,
sible. Last, it is important to keep in mind that this article fo- 95,214-222.
cuses on suicide attempts; the risk factors for suicide comple- Fenigstein, A., Scheier, M. F., & Buss, A. H. (1975). Public and private
tions may be different. self-consciousness: Assessment and theory. Journal of Consulting and
Despite such limitations, the study did have some positive Clinical Psychology, 43, 522-527.
points. First, the prospective design provided an opportunity to Folkman, S., & Lazarus, R. S. (1980). An analysis of coping in a middle-
aged community sample. Journal of Health and Social Behavior, 21,
determine the ability of psychosocial risk factors to predict fu- 219-239.
ture suicide attempts. To our knowledge, no other prospective Fowler, R. C., Rich, C. L., & Young, D. (1986). San Diego suicide study.
study of adolescent suicide attempts has been published to date. II. Substance abuse in young cases. Archives of General Psychiatry,
Second, our data set provided a unique opportunity to compare 43, 962-965.
the predictors of suicide attempt with those of future depres- Garfinkel, B. D., Froese, A., & Hood, J. (1982). Suicide attempts in
sion. Third, the study made use of a representative community children and adolescents. American Journal of Psychiatry, 139,
sample, which should enhance the generalizability of the find- 1257-1261.
ings. Finally, more so than in previous research, a wide array of Garrison, C. Z., Lewinsohn, P. M., Marsteller, F., Langhinrichsen, J., &
putative risk factors was examined both singly and in combina- Lann, I. (1991). The assessment of suicidal behavior in adolescents.
tion. Suicide and Life Threatening Behavior, 21, 217-230.
Gould, M. S., Wallenstein, S., Kleinman, M. H., O'Carroll, P., & Mercy,
J. (1990). Suicide clusters: An examination of age-specific effects.
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