Innovations In Clinical Neuroscience

SEP-OCT 2014

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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48 harm, and feeling about general levels of impulsivity. Measurements: The InterSePT Scale for Suicidal Thinking–Plus, the Sheehan-Suicidality Tracking Scale, the Columbia–Suicide Severity Rating Scale, and six additional questions to assess hopelessness and impulsivity. Results: Recent and trait hopelessness correlated positively with suicidal ideation. Patients who reported any suicide attempt endorsed higher levels of general impulsivity than those who did not report a history of at least one suicide attempt. Those enrolled in the study secondary to a very recent suicide attempt reported more difficulties with recent suicidal impulses. Conclusion: Simple measures of hopelessness and impulsivity are associated with suicidal ideation and attempts and may add to determination of suicide risk. INTRODUCTION While death by suicide is now the 10 th leading cause of death in the United States overall, 1A prediction of those most at risk for death by suicide or suicide attempts remains difficult. Existing scales to assess suicidal ideation or risk of suicide largely focus on quantifying and describing suicidal thoughts and intentions. 2–4 While suicidal ideation is very common in those with a history of suicide attempts, most patients with suicidal ideation never make a suicide attempt or die by suicide. 5–7 Prediction of future suicidal behavior among those individuals with suicidal ideation or among those who never report suicidal ideation may require t he consideration of other risk factors, ideally ones that could be altered with therapy or medication. Two independent factors significantly associated with suicidal behavior are hopelessness and impulsivity. 8–29 Hopelessness has been independently and repeatedly associated with increased risk for suicidal ideation, suicide attempts, and death by suicide, both prospectively and retrospectively. 8–19 Impulsivity has been strongly associated with risk of suicide attempts and death by suicide, with few papers linking impulsivity to increased suicidal ideation. 20–29 From a review of this extensive literature, we have developed a simple model of progression from suicidal ideation to suicide attempt where hopelessness increases suicidal ideation, and impulsivity increases risk for suicide attempt (Figure 1). However, some studies have not found association of hopelessness and/or impulsivity with suicide attempts or behavior. 4,18,30 A potential source of variability in these findings is the manner in which the constructs of hopelessness and impulsivity are measured. Different scales used to assess hopelessness and impulsivity may well be measuring entirely different dimensions or constructs. Longer scales like the Beck Hopelessness Scale 10 or Barratt Impulsivity Scale 31 may be more comprehensive, while shorter scales may address only a few or even one aspect of hopelessness or impulsivity. An additional important point of variance between existing scales is time frame: that is, does the scale attempt to measure recent and/or transient mood states (that may reflect attacks of impulsive suicidality) or more stable personality traits? Some preliminary studies suggest that the stability of hopelessness and impulsivity could be critical. 17,32–37 For instance, patients who are hopeless only while depressed are not as likely to harm themselves in the future as those who are hopeless when not depressed. 17 Similarly, while i ndividuals who are prone to acting out impulsively in general are more likely to exhibit suicidal behavior generally, the addition of factors that transiently increase impulsivity (such as cocaine or alcohol) may add significant immediate risk. 32–37 Combining our simple model of A) the relationship of hopelessness and impulsivity to suicidal behavior and B) our consideration of the differential effects of stable and recent (e.g., within the past 7 days) effects of hopelessness and impulsivity, we made a number of specific hypotheses with regard to the relationships of hopelessness and impulsivity to suicidal ideation and behavior (SIB), as follows: 1. Trait hopelessness will be positively associated with current suicidal ideation. 2. Recent hopelessness will be positively associated with current suicidal ideation. 3. Patients reporting a history of suicide attempts will have higher trait impulsivity than those who do not report suicide attempts. 4. Patients with recent suicidal behavior will report higher levels of recent impulsivity reflecting attacks of impulsive suicidality than those without recent suicidal behavior. We examined these hypotheses within the context of an experimental sample assembled to assess correspondence between three previously validated scales of SIB. As part of this study, we included a smaller pilot questionnaire designed to assess the extent to which recent and trait hopelessness and impulsivity might influence the results of these scales. This paper focuses on how the hopelessness- and impulsivity-related questions from this pilot questionnaire were associated with patient history of SIB and current SIB. Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 1 , N U M B E R 9 – 1 0 , S E P T E M B E R – O C T O B E R 2 0 1 4 ] FIGURE 1. Model for relationship of hope- lessness and impulsivity to suicidal ideation and suicide attempts

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