www.elsevier.com/locate/jad

Journal of Affective Disor

Research report

Symptom components of standard depression scales and past

suicidal behaviorB

Michael F. Grunebaum*, John Keilp, Shuhua Li, Steven P. Ellis, Ainsley K. Burke,

Maria A. Oquendo, J. John Mann

Department of Neuroscience, New York State Psychiatric Institute and Columbia University, United States

Received 15 November 2004; accepted 11 March 2005

Available online 31 May 2005

Abstract

Background: Global severity on depression scales may obscure associations between specific symptoms and suicidal behavior.

Methods: We studied 298 persons with major depressive disorder. Factor analysis of the 24-item Hamilton Depression Rating

Scale (HDRS) and the Beck Depression Inventory (BDI) was used to compare symptom clusters between past suicide

attempters and non-attempters.

Results: Factor analyses extracted five HDRS and three BDI factors. Suicide attempters had significantly lower scores on an

HDRS anxiety factor and higher scores on a BDI self-blame factor. The factor scores correlated with total number of suicide

attempts and with known risk factors for suicidal behavior.

Limitations: The differences in factor scores between suicide attempters and non-attempters were significant but modest and

may be most relevant in suggesting areas for further clinical studies. Structured diagnostic interviews in this study may have

limited the detection of Bipolar II or milder bipolar spectrum disorders.

Conclusions: Depressed suicide attempters exhibit comparably severe mood and neuro-vegetative symptoms, but less anxiety

and more intense self-blame than non-attempters. This clinical profile may help guide studies of biological correlates and of

treatments to reduce suicide risk.

D 2005 Elsevier B.V. All rights reserved.

Keywords: Suicide attempt correlates; Depression scales; Factor analysis

0165-0327/$ - see front matter D 2005 Elsevier B.V. All rights reserved.

doi:10.1016/j.jad.2005.03.002

B Supported by PHS grants MH62185 (Conte Center for the

Neuroscience of Mental Disorders: The Neurobiology of Suicidal

Behavior) and MH48514 (Psychobiological Predictors of Suicidal

Behavior in MDE).

* Corresponding author. Department of Neuroscience, New York

State Psychiatric Institute, 1051 Riverside Drive, Box 42, New

York, NY 10032, United States. Tel.: +1 212 543 5842; fax: +1

212 543 6017.

E-mail address: mfg14@columbia.edu (M.F. Grunebaum).

1. Introduction

About 90% of suicides are psychiatrically ill at the

time of death, with about 60% suffering from depres-

sion; most of these were not treated with antidepres-

sant medication at the time of death (Robins et al.,

1959; Dorpat and Ripley, 1960; Barraclough et al.,

ders 87 (2005) 73–82

M.F. Grunebaum et al. / Journal of Affective Disorders 87 (2005) 73–8274

1974; Hagnell and Rorsman, 1979; Carlson et al.,

1991; Henriksson et al., 1993). Global severity of

depression, measured using the observer-rated HDRS

(Hamilton, 1960) or the self-report BDI (Beck et al.,

1961), has a weak relationship to suicidal behavior

(Mann et al., 1999; Mann and Malone, 1997; Lester

and Beck, 1977) (Van Gastel et al., 1997). However,

specific depressive features that are hidden in these

scales’ total scores may occur with greater or lesser

frequency in those at risk. These specific depressive

features may provide a more direct link to the under-

lying biology of suicidal behavior. A number of factor

analyses have been performed to define depressive

symptom clusters within the HDRS (Steer et al.,

1987; Sayer et al., 1993; Gibbons et al., 1993; Rhoades

and Overall, 1983) and BDI (Lester and Beck, 1977;

Steer et al., 1987; Brown et al., 1995; Sayer et al.,

1993; Gibbons et al., 1993). We performed a factor

analysis on a well-characterized sample of patients

with major depressive disorder and compared scores

on the extracted factors between subjects with and

without a lifetime history of a suicide attempt. We

examined associations of the factors we identified

with recognized risk factors for suicidal behavior.

Table 1

Demographic and clinical characteristics of suicide attempters and non-at

Past attempters

N 145

Age 34.5F11.2

Education (years) 14.2F3.1

Prior episodes of depression (Ln) 1.3F0.8 [Median=2]

Prior hospitalizations (Ln) 1.1F0.9 [Median=2]

Length current depressive episode (Ln) 2.9F1.1 [Median=16

HDRS (24-item) 27.7F7.8

BDI 30.1F11.2

Beck hopelessness 13.1F5.7

Scale for suicidal ideation, prior to admission 18.0F11.0

Scale for suicidal ideation, current 9.4F9.1

Barratt impulsiveness scale 54.0F15.6

Buss–Durkee hostility inventory 38.9F12.6

Brown–Goodwin aggression history 20.0F6.1

Past attempters

N

Sex (female) 98

Race (Caucasian) 104

Language (Nat. English) 106

Inpatient 126

Axis II borderline personality disorder 70

2. Methods

2.1. Subjects

The sample comprised 298 subjects with DSM IV

defined major depressive disorder consecutively

enrolled in depression protocols with similar recruit-

ment methods at two university hospitals. Persons

diagnosed with a bipolar disorder were excluded. The

sample was largely inpatient (N =239, 80%). Patients

had a clinical history, physical and laboratory examina-

tions to rule out neurological illness or acute medical

conditions and illicit substance use (including a drug

screen). Demographic and clinical data for suicide

attempters and non-attempters are presented in Table 1.

A total of 145 (49%) subjects reported a lifetime

history of a suicide attempt and 147 (49%) had no

attempt history. Six subjects with an unclear suicide

attempt history were included in the depression scale

factor analysis, but excluded from the attempter

versus non-attempter comparisons. We defined a

suicide attempt as a self-destructive act with intent

to die. After a complete description of the study

protocol, participants gave written informed consent

tempters

Non-attempters p

147

40.8F15.2 b 0.001

14.5F3.2 0.35

1.0F0.7 [Median=2] 0.03

0.4F0.6 [Median=0] b 0.001

] 3.2F1.3 [Median=21] 0.04

29.1F8.3 0.12

26.6F11.1 0.02

11.2F5.9 0.01

9.7F8.9 b 0.001

4.4F6.0 b 0.001

49.6F17.3 0.06

33.7F11.5 0.002

16.3F4.9 b 0.001

Non-attempters p

% N %

67.6 79 53.7 0.02

71.7 120 81.6 0.05

87.6 118 86.1 0.73

86.9 109 74.7 0.01

48.3 18 12.2 b 0.001

M.F. Grunebaum et al. / Journal of Affective Disorders 87 (2005) 73–82 75

as approved by the hospitals’ Institutional Review

Boards.

2.2. Measures

Consensus Axis I and II diagnoses were made

based on the Structured Clinical Interview for DSM-

IIIR/DSM-IV patient edition (SCID I and II) (Spitzer

et al., 1990; First et al., 1996). Current depression was

assessed with the 24-item HDRS (Hamilton, 1960)

and the BDI (Beck et al., 1961). All subjects received

the HDRS and 243 (82%) of the subjects (122 past

attempters, 121 non-attempters) received the BDI as

well. Suicide attempt history was gathered with the

Columbia Suicide History Form (Oquendo et al.,

2003). Lifetime aggression and impulsivity were

rated with the Brown–Goodwin Aggression Inventory

(BGAI) (Brown et al., 1979), the Buss–Durkee Hos-

tility Inventory (BDHI) (Buss and Durkee, 1957), and

the Barratt Impulsivity Scale (BIS) (Barratt, 1965).

Current suicidal ideation was assessed using the Scale

for Suicidal Ideation (SSI) (Beck et al., 1979) and

hopelessness with the Beck Hopelessness Scale

(BHS) (Beck et al., 1974). Suicidal intent was mea-

sured with the Suicide Intent Scale (SIS) (Beck et al.,

1975). The medical severity of suicide attempts was

rated with the Medical Lethality Scale (MLS) (Beck et

al., 1975)(scored 0–8; 0=no medical harm; 8=death;

intraclass coefficient=0.94). Interrater agreement and

intraclass coefficients for other diagnostic and rating

scales were good to excellent (Mann et al., 1999).

2.3. Statistical methods

Factor analyses were conducted separately on the

HDRS and BDI. The factor analysis was based on

polychoric correlations, using a method for polycho-

tomous data, which corrects for the attenuation in

range inherent in limited-choice rating scale responses

(Mieczkowski et al., 1993). With each factor analysis,

an initial principal components analysis was con-

ducted and factors were retained that met criteria

based on the expected eigenvalues of the sample

correlation matrix of a random dataset, X, of the

same size as the real data but with statistically inde-

pendent–and hence uncorrelated–variables. The

eigenvalues of the theoretical correlation matrix of

such a dataset are equal, but the eigenvalues of the

sample correlation matrix are random and unequal. A

factor computed from the real data was retained if the

corresponding eigenvalue exceeded the expected

value of the corresponding eigenvalue of the sample

correlation matrix of X. The expected values were

estimated by simulating 1000 independent copies of

X. This method is similar to the bparallel analysisQmethod described in Zwick and Velicer (1986).

Retained factors were then rotated using a non-

orthogonal Promax procedure, based on the assump-

tion that there would be some overlap in the compo-

nents of depression in a sample of depressed subjects.

Scale items that loaded on each factor were summed

in an un-weighted fashion to produce a set of factor

scores for each subject. These factor scores were then

compared between past attempters and non-attemp-

ters, using t-tests at an alpha level of 0.05. Relation-

ships to demographic and clinical variables were

examined, and controlled for in a set of secondary

analyses using analysis of covariance. A stepwise

descriptive discriminant function was run to evaluate

the degree of overlap among factors in relation to their

ability to distinguish attempters and non-attempters.

Lastly, Pearson correlations were computed between

clinical variables and factor scores, to evaluate their

association to other typical risk factors for suicidal

behavior.

3. Results

3.1. Factor analyses

Five factors meeting initial retention criteria were

extracted and rotated from the HDRS. Based on their

item content, these factors were labeled: psychic

depression, loss of motivation, disturbed thinking,

anxiety, and disturbed sleep. Three factors were

extracted and rotated from the BDI. These factors

were labeled: subjective depression, self-blame, and

somatic complaints. The factors, their component

HDRS and BDI items, and their loadings are pre-

sented in Tables 2 and 3.

3.2. Attempter/non-attempter comparison

Past suicide attempters did not differ significantly

from non-attempters on the total score of the HDRS

Table 3

Items and factor loadings for Beck Depression Inventory

Beck Depression Inventory Item #, content (factor loading)

Factor 1: Subjective depression

(eigenvalue=6.28)

1. Sadness (0.553)

2. Pessimism (0.531)

4. Lack of satisfaction (0.719)

12. Loss of interest (0.637)

13. Indecisiveness (0.728)

14. Appearance (0.487)

15. Work inhibition (0.912)

17. Tiredness (0.738)

21. Loss of Libido (0.593)

Factor 2: Self-blame

(eigenvalue=5.28)

3. Sense of failure (0.636)

5. Guilt (0.782)

6. Feeling of punishment

(0.801)

7. Sense of disappointment

(0.746)

8. Self-criticism (0.806)

Factor 3: Somatic complaint

(eigenvalue=2.50)

16. Disturbed sleep (0.608)

18. Appetite loss (0.681)

19. Weight Loss (0.828)

(Unassigned) 9. Suicidal thinking

10. Frequent crying

11. Irritability

20. Somatic concern

Table 2

Items and factor loadings for Hamilton Depression Rating Scale

(24-item)

Hamilton rating scale for

depression

Item #, content (factor loading)

Factor 1: Psychic depression

(eigenvalue=3.13)

1. Depressed Mood (0.592)

2. Guilt (0.462)

3. Suicidal thoughts (0.672)

8. Retardation (0.441)

22. Helplessness (0.410)

23. Hopelessness (0.650)

24. Worthlessness (0.789)

Factor 2: loss of motivated

behavior (eigenvalue=2.64)

7. Work and activities (0.416)

12. Somatic symptoms: gastric

(0.836)

14. Genital symptoms (0.504)

16. Weight loss (0.741)

Factor 3: Disturbed thinking

(eigenvalue=2.35)

17. Lack of insight (0.735)

19. Depersonalization (0.412)

20. Paranoia (0.683)

21. Obsessions/Compulsions

(0.682)

Factor 4: Anxiety

(eigenvalue=2.68)

9. Agitation (0.741)

10. Psychic anxiety (0.624)

11. Somatic anxiety (0.524)

15. Hypochondriasis (0.675)

Factor 5: Sleep disturbance

(eigenvalue=2.25)

4. Insomnia, early (0.747)

5. Insomnia, middle (0.832)

6. Insomnia, late (0.587)

(Unassigned) 13. Somatic symptoms: general

18. Diurnal variation

M.F. Grunebaum et al. / Journal of Affective Disorders 87 (2005) 73–8276

(Table 1). However, on factor scores of the HDRS

(Fig. 1), past attempters had significantly lower scores

on the anxiety factor (4.1F2.3 vs. 5.3F2.8 in non-

attempters, t[289]=4.15, p b0.001). Their scores did

not differ on psychic depression (12.3F4.4 vs. 11.7F4.0, t[290]=1.17, p =0.24), loss of motivated beha-

vior (4.8F2.5 vs. 5.2F2.4, t[290]=1.58, p =0.12),

disturbed thinking (1.4F1.5 vs. 1.5F1.9, t[290]=

0.28, p =0.78), or disturbed sleep (3.0F1.9 vs. 3.0F2.0, t[290]=0.15, p =0.88).

At baseline assessment, past attempters were more

subjectively depressed than non-attempters on the

self-report BDI (Table 1). On the three factors

extracted from the BDI (Fig. 2), however, past attemp-

ters had significantly higher scores on self-blame

(7.6F3.7 vs. 6.0F3.9, t[240]=3.40, p =0.001), but

not on subjective depression (14.0F5.5 vs. 13.1F5.1, t[235]=1.34, p=0.18) or somatic complaints

(3.3F2.3 vs. 3.0F2.1, t[238]=1.29, p =0.20).

A higher percentage of the past attempters had a co-

morbid Axis II diagnosis of Borderline Personality

Disorder (BPD). Since co-morbid BPD is an important

confounding factor in the relationship of depression to

suicidal behavior we re-ran our attempter/non-attemp-

ter comparisons using a two-way analysis of variance,

with BPD status as an additional factor in the analysis.

A significant main effect was found for BPD status on

HDRS anxiety (F[1,287]=4.2, p =0.04), with BPD

subjects scoring lower (3.9F2.2 vs. 5.0F3.9). How-

ever, the main effect for attempt status remained sig-

nificant for HDRS anxiety (F[1,287]=5.05, p =0.03),

with no interaction (F[1,287]=0.40, p =0.53). The

main effect for BPD status was not significant

for BDI self-blame (F[1,238]=1.81, p =0.18), and

the main effect for attempt status remained significant

(F[1,238]=6.09, p =0.01) with no interaction

(F[1,238]=0.09, p =0.77). No other effects of BPD

status were found, and attempt status differences

remained the same as in our original comparisons.

Among suicide attempters, none of the HDRS or

BDI factor scores were correlated with medical

severity of past suicide attempts (either most lethal

*p<0.001a Factor scores converted to z-scores against the sample mean for illustration.

-0.30

-0.20

-0.10

0.00

0.10

0.20

0.30

PsychDep

LossMotiv

DistThink

Anxiety DistSleep

Attempters

Non-Attempters

*

Z-S

core

Fig. 1. Past suicide attempters versus non-attempters compared with respect to HDRS factors (factor scores converted to z-scores against the

sample mean for illustration). *p b0.001.

M.F. Grunebaum et al. / Journal of Affective Disorders 87 (2005) 73–82 77

or most recent) or with suicide intent. Both HDRS

anxiety and BDI self-blame, on the other hand, were

correlated with number of past suicide attempts

(HDRS anxiety rho=� 0.22, pb0.001; BDI self-

blame rho=0.20, p =0.001). Low anxiety and high

self-blame, then, were associated with more frequent

suicidal behavior.

We also subdivided the sample into groups based

on the presence of suicide ideation and recency/remo-

teness of suicide attempt: Recent and remote attemp-

ters (those who had made attempts in their current

depressive episode versus those who had made

attempts in a prior episode) did not differ on the

HDRS, the BDI, or any of the factor scores. Non-

*p=0.001a Factor scores converted to z-scores a

-0.30

-0.20

-0.10

0.00

0.10

0.20

0.30

Subj Dep Self-Blame

*

Z-S

core

Fig. 2. Past suicide attempters and non-attempters compared with respect to

mean for illustration). *p =0.001.

ideator non-attempters, on the other hand, did differ

from both non-attempter ideators and all past attemp-

ters in having less HDRS psychic depression (factor 1:

F[2,272]=12.85, pb0.001) and less BDI subjective

depression (factor 1: F[2,232]=4.17, p =0.02), as

well as lower total HDRS (F[2,272]=6.38, p =

0.002) and BDI (F[2,235]=4.80, p =0.01) scores.

Thus, non-attempters without suicidal ideation appear

to be less depressed, particularly on the bdepressedmoodQ factors of both scales. Past attempters continue

to differ from both non-attempter groups (regardless

of ideation) in having less HDRS anxiety (factor 4:

F[2,271]=7.38, p =0.001) and greater BDI self-blame

(factor 2: F[2,234]=6.70, p =0.001).

gainst the sample mean for illustration.

Somat Compl

Attempters

Non-Attempters

BDI factors (factor scores converted to z-scores against the sample

M.F. Grunebaum et al. / Journal of Affective Disorders 87 (2005) 73–8278

3.3. Associations with demographic variables

Age differed between attempters and non-attemp-

ters, and was correlated positively with HDRS anxiety

(r=0.31, p b0.001) and negatively with BDI self-

blame (r=� 0.21, p =0.001). Using analysis of covar-

iance, with age as a covariate, differences between

attempters and non-attempters on HDRS anxiety

(F[1,288]=9.84, p b0.001) and BDI self-blame

(F[1,239]=7.68, p =0.006) were maintained. Non-

Caucasian subjects were found to have lower HDRS

anxiety than Caucasians (4.0F2.2 vs. 4.9F2.7,

t[292]=2.42, p =0.016), but attempter/non-attempter

differences were maintained with both age and race in

the model (F[1,286]=7.32, p =0.007). Females had

higher BDI self-blame than males (7.3F4.1 vs.

6.0F3.5, t[241]=2.72, p =0.007) and comprised a

higher proportion of attempters (Table 1), but attemp-

ter/non-attempter differences remained significant

with both age and sex in the model (F[1,237]=5.26,

p =0.023).

3.4. Discriminant analysis

Stepwise discriminant analysis produced a function

containing only the HDRS anxiety factor and BDI

self-blame factor (for function, F[2,232]=9.77,

p b0.001). Both factors were approximately equally

weighted in the final equation (standardized function

coefficients, � 0.71 and 0.78 respectively). The final

equation correctly identified 66% of past attempters

and 58% of non-attempters (62% correct classification

overall).

3.5. Associations with risk factors for suicidal behavior

The HDRS anxiety factor correlated negatively with

suicidal ideation prior to admission (r=� 0.16,

p =0.01) and lifetime aggression severity measured

by the Brown–Goodwin Aggression History (r=�0.15, p =0.02). Less anxiety was associated with

more severe suicidal ideation and greater lifetime

aggression.

The BDI self-blame factor correlated with higher

lifetime impulsiveness (r=0.31, pb0.001), hostility

(r=0.31, p b0.001), and aggression (r=0.19, p =

0.01). It also correlated with greater hopelessness

(r=0.51, p b0.001) and suicidal ideation prior to

admission (r=0.26, p b0.001). The BDI subjective

depression factor correlated with current suicidal idea-

tion (r=0.30, p b0.001) and hopelessness (r=0.61,

p b0.001).

4. Discussion

In this study, factor analysis was used to identify

symptom clusters in major depressive disorder, and to

examine associations of these with suicidal behavior.

Compared with non-attempters, past suicide attemp-

ters had less intense anxiety and a higher degree of

self-blame. Among past attempters, lower anxiety and

higher self-blame were correlated with total number of

lifetime suicide attempts. Factor scores assessing other

core depressive symptoms such as depressed mood

(HDRS psychic depression and BDI subjective

depression) and vegetative and somatic symptoms

(HDRS loss of motivated behavior, HDRS insomnia,

BDI somatic complaints), did not distinguish between

suicide attempters and non-attempters. Discriminant

analysis indicates that these factors were relatively

independent in their relationship to past attempter

status.

Published factor analyses of the HDRS have

extracted from 5 to 8 factors (Gibbons et al., 1993;

Rhoades and Overall, 1983; Steer et al., 1987; Sayer

et al., 1993). The factor structure that our analysis

identified is relatively similar to that reported by Steer

et al. in a factor-analytic study of the 24-item HDRS

in 300 consecutive outpatients diagnosed with major

depressive disorder (Steer et al., 1987).

Published factor analyses of the BDI have

extracted from two to five factors (Lester and Beck,

1977; Steer et al., 1987; Brown et al., 1995; Sayer et

al., 1993). Our factor analysis of the BDI is consistent

with published reports (Steer et al., 1987; Brown et

al., 1995) in extracting one factor that captures sub-

jective depression and functional impairment, a sec-

ond factor composed of negative self-perception items

and a third somatic/neuro-vegetative factor. This sug-

gests that the factor structure of the BDI is relatively

stable, despite some variability depending on the

sample studied and analytic methods used.

The magnitude of the differences we found in

factor scores between attempters and non-attempters

was modest (~ 0.4 S.D.). Thus, they may not be useful

M.F. Grunebaum et al. / Journal of Affective Disorders 87 (2005) 73–82 79

as clinical indicators of suicide risk. The factors

appeared to be associated with the occurrence, but

not with the recency, lethality, or degree of intent of

past suicide attempts. Non-ideators appeared mainly

to be less depressed. Nonetheless, the factor score

associations suggest that there are subtle differences

in the depressive symptom profile of those with ten-

dencies toward suicidal behavior. These differences

may be useful guideposts for research on biological

correlates and as target symptoms for treatment inter-

vention studies. We have found, for example, that the

depression factors reported in this analysis correlate

with glucose metabolism in relatively distinct brain

regions (Milak, et al., in press).

4.1. HDRS anxiety factor

The role of anxiety in suicidal behavior appears to

be complex. In a prospective follow-up of 954 persons

with mood disorders, psychic anxiety was associated

with suicide within 1 year, but not within 2–10 years

(Fawcett et al., 1990). In the same study, panic

attacks, but not panic disorder, were associated with

suicide within 1 year of assessment (Fawcett et al.,

1990). Two retrospective studies found high rates of

reported anxiety symptoms preceding 76 inpatient

suicides (Busch et al., 2003) and 100 suicide attempts

that led to inpatient hospitalization (Hall et al., 1999).

Thus, it is possible that certain types of anxiety or

agitation may be a risk factor for more lethal attempts

or for suicide completion.

However, other studies, including from our group

(Placidi et al., 2000), have found no association or an

inverse association of anxiety symptoms with suicidal

behavior (Roy-Byrne et al., 2000; Apter et al., 2003;

Grucza et al., 2003). The role of anxiety in suicidal

behavior may be influenced by characteristics of the

sample studied as well as by the specific subtype of

anxiety under examination.

The Hamilton items included in our anxiety factor,

in descending order of loading strength, were agita-

tion, hypochondriasis, psychic anxiety and somatic

anxiety. A higher score on this factor appeared to be

protective against a lifetime suicide attempt history in

our sample. Panic attacks may increase the risk for

suicidal behavior in some patients, but not in others.

Our result is consistent with the hypothesis that some

milder forms of anxiety, such as hypochondriacal

symptoms, may be protective against suicidal beha-

vior. This may be related to the common clinical

observation that many patients with suicidal ideation

state that they would not act on these thoughts due to

fear of bodily damage. Further studies of the relation-

ship of anxiety and agitation to suicidal behavior are

warranted.

4.2. BDI self-blame factor

The present study suggests that among persons

with major depressive disorder, self-blame may be a

marker of greater risk for suicidal behavior. The BDI

self-blame factor can be viewed as a form of moti-

vation for self-harm or aggression directed at the

self. This factor appears linked to a second crucial

deficit in restraint or behavioral inhibition, which

when combined with a greater drive towards self-

harm becomes a more serious risk factor for suicidal

behavior. In support of this view is the fact that the

self blame factor correlated positively with ratings of

impulsivity (BIS), as an index of behavioral non-

restraint or disinhibition, hostility (BDHI), as a mea-

sure of externally directed feelings, and aggression

(BGAI), as a measure of the effect of more hostility

and less restraint. It is noteworthy that the self-blame

factor contains no item explicitly identified with

these traits.

This model may generalize to conditions other than

mood disorders, based on our prior finding in a mixed

diagnostic sample of 347 patients (51% depressed,

36% schizophrenia spectrum, 13% other) that more

pronounced subjective depression, suicidal ideation

and aggression traits (measured with the BGAI) are

associated with lifetime suicide attempt history, irre-

spective of psychiatric diagnosis (Mann et al., 1999).

The BDI items included in the self-blame factor, in

descending order of loading strength, were self-criti-

cism, feeling of punishment, guilt, sense of disap-

pointment, and sense of failure. This factor overlaps

with the clinical construct of melancholia for which

excessive guilt is a DSM IV criterion. The present

finding that the self-blame factor correlates with a

history of suicide attempt is consistent with our report

that the melancholic subtype of depression was asso-

ciated with a higher probability and lethality of sui-

cide attempts, compared with non-melancholic

depression (Grunebaum et al., 2004).

M.F. Grunebaum et al. / Journal of Affective Disorders 87 (2005) 73–8280

The main limitation of this study is its retrospective

design. A history of suicide attempts was obtained at a

baseline interview by self-report. It is possible, though

unlikely, that subjects with lower HDRS anxiety and

higher BDI self-blame are more likely to remember

past suicide attempts. Prospective studies currently

underway may answer this question. Hypochondria-

sis, which loaded on what we labeled the banxietyQfactor, is technically a somatoform disorder (Spitzer et

al., 1990). However, the DSM-IV criterion A for

hypochondriasis involves bpreoccupation with

fears. . .,Q which overlaps with anxiety (American Psy-

chiatric Association, 1994).

Factor analyses are influenced by the characteris-

tics of the sample studied and our research clinic

population tends to over-sample persons with lifetime

suicide attempt histories. Also, the sample was largely

inpatient, and therefore more ill, which may have

limited our ability to detect between-group differences

and limits the degree to which the results can be

generalized. It is also possible that our SCID interview

and consensus diagnosis process, while rigorous, may

fail to adequately exclude persons with Bipolar II

disorder, given the difficulty of identifying hypomania

retrospectively (Dunner, 2003). Strict adherence to

SCID interview methods may under-diagnose Bipolar

II conditions, some authors have reported (Benazzi

and Akiskal, 2003). This could have affected our

results in that some (Rihmer and Pestality, 1999;

Balazs et al., 2003), though not all (Slama et al.,

2004), reports find a higher frequency of suicidal

behavior in association with Bipolar II disorder or

with mixed or cycling mood states (Maser et al.,

2002). However, the fact that our factor analyses

were similar to those in published reports (Lester

and Beck, 1977; Steer et al., 1987; Brown et al.,

1995; Sayer et al., 1993; Gibbons et al., 1993;

Rhoades and Overall, 1983) suggests that the factor

structure we found may be applicable to other samples

of depressed patients.

We have reported the lack of consistency in the

severity of individual depressive symptoms across

successive episodes and this extends to factors of

the HDRS (Oquendo et al., 2004). However, the

only correlations that were significant and strongest

were for anxiety and suicidality, suggesting that they

were more consistently recurrent from episode to

episode and therefore more likely to correlate with

traits (Oquendo et al., 2004). In the present study, the

only HDRS factor that differentiated attempters and

non-attempters was the anxiety factor. Unlike the

observer-rated HDRS, the BDI is a self-report instru-

ment, and may show more consistency across epi-

sodes with regard to the self-blame factor, which

correlates with behavioral traits such as hostility.

The stability of self-blame across episodes of depres-

sion remains to be demonstrated and is an area for

future study.

In summary, we identified subtle differences in

the depressive symptom profile of past suicide

attempters that were related to other risk factors for

suicidal behavior. Isolating these symptom features

may help guide future research into their biological

correlates. They may also be potential symptom

targets for treatment trials designed to reduce suicide

risk.

Acknowledgments

Clinical ratings were completed by members of the

Clinical Evaluation Core of the Conte Center for the

Neuroscience of Mental Disorders. Dr. Grunebaum

would like to acknowledge the support of a Young

Investigator Grant from NARSAD.

References

American Psychiatric Association, 1994. Diagnostic and Statistical

Manual for Mental Disorders, DSM-IV. American Psychiatric

Association, Washington, DC.

Apter, A., Horesh, N., Gothelf, D., Zalsman, G., Erlich, Z., Soreni,

N., Weizman, A., 2003. Depression and suicidal behavior in

adolescent inpatients with obsessive compulsive disorder. J.

Affect. Disord. 75, 181–189.

Balazs, J., Lecrubier, Y., Csiszer, N., Kosztak, J., Bitter, I., 2003.

Prevalence and comorbidity of affective disorders in persons

making suicide attempts in Hungary: importance of the first

depressive episodes and of bipolar II diagnoses. J. Affect.

Disord. 76, 113–119.

Barraclough, B., Bunch, J., Nelson, B., Sainsbury, P., 1974. One

hundred cases of suicide. Clinical aspects. Br. J. Psychiatry 125,

355–373.

Barratt, E.S., 1965. Factor analysis of some psychometric measures

of impulsiveness and anxiety. Psychol. Rep. 16, 547–554.

Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J.,

1961. An inventory of measuring depression. Arch. Gen. Psy-

chiatry 4, 53–63.

M.F. Grunebaum et al. / Journal of Affective Disorders 87 (2005) 73–82 81

Beck, A.T., Weissman, A., Lester, D., Trexler, L., 1974. The mea-

surement of pessimism: The hopelessness scale. J. Consult.

Clin. Psychol. 42 (6), 861–865.

Beck, A.T., Beck, R., Kovacs, M., 1975. Classification of suicidal

behaviors: I. Quantifying intent and medical lethality. Am. J.

Psychiatr. 132 (3), 285–287.

Beck, A.T., Kovacs, M., Weissman, A., 1979. Assessment of sui-

cidal intention: the scale for suicide ideation. J. Consult. Clin.

Psychol. 47, 343–352.

Benazzi, F., Akiskal, H.S., 2003. Refining the evaluation of bipolar

II: beyond the strict SCID-CV guidelines for hypomania. J.

Affect. Disord. 73, 33–38.

Brown, G.L., Goodwin, F.K., Ballenger, J.C., Goyer, P.F., Major,

L.F., 1979. Aggression in human correlates with cerebrospinal

fluid amine metabolites. Psychiatry Res. 1, 131–139.

Brown, C., Schulberg, H.C., Madonia, M.J., 1995. Assessing

depression in primary care practice with the Beck Depression

Inventory and the Hamilton Rating Scale for Depression. Psy-

chol. Assess. 7, 59–65.

Busch, K.A., Fawcett, J., Jacobs, D.G., 2003. Clinical corre-

lates of inpatient suicide. J. Clin. Psychiatry 64, 14–19.

Buss, A.H., Durkee, A., 1957. An inventory for assessing different

kinds of hostility. J. Consult. Psychol. 21 (4), 343–349.

Carlson, G.A., Rich, C.L., Grayson, P., Fowler, R.C., 1991. Secular

trends in psychiatric diagnoses of suicide victims. J. Affect.

Disord. 21, 127–132.

Dorpat, T.L., Ripley, H.S., 1960. A study of suicide in the Seattle

area. Compr. Psychiatry 1, 349–359.

Dunner, D.L., 2003. Clinical consequences of under-recognized

bipolar spectrum disorder. Bipolar Disord. 5, 456–463.

Fawcett, J., Scheftner, W.A., Fogg, L., Clark, D.C., Young, M.A.,

Hedeker, D., Gibbons, R., 1990. Time-related predictors of

suicide in major affective disorder. Am. J. Psychiatr. 147,

1189–1194.

First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.M.G., Benjamin,

L., 1996. Structured Clinical Interview for DSM-IV Axis II

Personality Disorders (SCID-II), (Version 2.0). Biometrics

Research Department, New York State Psychiatric Institute,

New York.

Gibbons, R.D., Clark, D.C., Kupfer, D.J., 1993. Exaclty what does

the Hamilton Depression Rating Scale measure? J. Psychiatr.

Res. 27, 259–273.

Grucza, R.A., Przybeck, T.R., Spitznagel, E.L., Cloninger, C.R.,

2003. Personality and depressive symptoms: a multi-dimen-

sional analysis. J. Affect. Disord. 74, 123–130.

Grunebaum, M.F., Galfalvy, H.C., Oquendo, M.A., Burke,

A.K., Mann, J.J., 2004. Melancholia and the probability

and lethality of suicide attempts. Br. J. Psychiatry 184,

534–535.

Hagnell, O., Rorsman, B., 1979. Suicide in the Lundby study: a

comparative investigation of clinical aspects. Neuropsychology

5, 61–73.

Hall, R.C.W., Platt, D.E., Hall, R.C.W., 1999. Suicide risk assess-

ment: a review risk factors for suicide in 100 patients who made

severe suicide attempts. Psychosomatics 40, 18–27.

Hamilton, M., 1960. A rating scale for depression. J. Neurol.

Neurosurg. Psychiatry 23, 56–62.

Henriksson, M.M., Aro, H.M., Marttunen, M.J., Heikkinen, M.E.,

Isometsa, E.T., Kuoppasalmi, K.I., Lonnqvist, J.K., 1993. Men-

tal disorders and comorbidity in suicide. Am. J. Psychiatr. 150,

935–940.

Lester, D., Beck, A.T., 1977. Suicidal wishes and depression in

suicidal ideators: a comparison with attempted suicides. J. Clin.

Psychol. 33, 92–94.

Mann, J.J., Malone, K.M., 1997. Cerebrospinal fluid amines and

higher lethality suicide attempts in depressed inpatients. Biol.

Psychiatry 41, 162–171.

Mann, J.J., Waternaux, C., Haas, G.L., Malone, K.M., 1999.

Towards a clinical model of suicidal behavior in psychiatric

patients. Am. J. Psychiatr. 156, 181–189.

Maser, J.D., Akiskal, H.S., Schettler, P., Scheftner, W., Mueller, T.,

Endicott, J., Solomon, D., Clayton, P., 2002. Can temperament

identify affectively ill patients who engage in lethal or near-

lethal suicidal behavior? A 14-year prospective study. Suicide

Life-Threat. Behav. 32, 10–32.

Mieczkowski, T.A., Sweeney, J.A., Haas, G.L., Mann, J.J., Brown,

R.P., Junker, B., 1993. Factor composition of the suicide intent

scale. Suicide Life-Threat. Behav. 23, 37–45.

Oquendo, M.A., Halberstam, B., Mann, J.J., 2003. Risk

factors for suicidal behavior: utility and limitations of

research instruments. In: First, M.B. (Ed.), Standardized Eva-

luation in Clinical Practice. APPI Press, Washington, DC,

pp. 103–130.

Oquendo, M.A., Barrera, A., Ellis, S.P., Li, S., Burke, A.K., Gru-

nebaum, M.F., Endicott, J., Mann, J.J., 2004. Instability of

symptoms in recurrent major depression: a prospective study.

Am. J. Psychiatr.

Placidi, G.P.A., Oquendo, M.A., Malone, K.M., Brodsky, B., Ellis,

S.P., Mann, J.J., 2000. Anxiety in major depression: relationship

to suicide attempts. Am. J. Psychiatr. 157, 1614–1618.

Rhoades, H.M., Overall, J.E., 1983. The Hamilton depression scale:

factor scoring and profile classification. Psychopharmacol. Bull.

19, 91–96.

Rihmer, Z., Pestality, P., 1999. Bipolar II disorder and sui-

cidal behavior. Psychiatric Clin. North Am. 22, 667–673.

Robins, E., Murphy, G.E., Wilkinson Jr., R.H., Gassner, S., Kayes,

J., 1959. Some clinical considerations in the prevention of

suicide based on a study of 134 successful suicides. Am. J.

Public Health 49, 888–899.

Roy-Byrne, P.P., Stang, P., Wittchen, H.U., Ustun, B., Walters, E.E.,

Kessler, R.C., 2000. Lifetime panic–depression comorbidity in

the National Comorbidity Survey. Association with symptoms,

impairment, course and help-seeking. Br. J. Psychiatry 176,

229–235.

Sayer, N.A., Sackeim, H.A., Moeller, J.R., Prudic, J., Devanand,

D.P., Coleman, E.A., Kiersky, J.E., 1993. The relations between

observer-rating and self-report of depressive symptomatology.

Psychol. Assess. 5, 350–360.

Slama, F., Bellivier, F., Henry, C., Rousseva, A., Etain, B., Rouillon,

F., Leboyer, M., 2004. Bipolar patients with suicidal behavior:

toward the identification of a clinical subgroup. J. Clin. Psy-

chiatry 65, 1035–1039.

Spitzer, R.L., Williams, J.B.W., Gibbon, M., First, M.B.,

1990. Structured Clinical Interview for DSM-III-R. Patient

M.F. Grunebaum et al. / Journal of Affective Disorders 87 (2005) 73–8282

Edition (SCID-P). American Psychiatric Press, Washington,

DC.

Steer, R.A., Beck, A.T., Riskind, J.H., Brown, G., 1987. Relation-

ships between the Beck Depression Inventory and the Hamilton

Psychiatric Rating Scale for Depression in depressed outpati-

ents. J. Psychopathol. Behav. Assess. 9, 327–339.

Van Gastel, A., Schotte, C., Maes, M., 1997. The prediction of

suicidal intent in depressed patients. Acta Psychiatr. Scand. 96,

254–259.

Zwick, W.R., Velicer, W.F., 1986. Comparison of five rules for

determining the number of components to retain. Psychol.

Bull. 99, 432–442.