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: [email protected] (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.
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