Encouraging a Nuanced Understanding of the Hopelessness-Suicidality Link

Encouraging a Nuanced Understanding of the Hopelessness-Suicidality Link

Mercedes J. Szpunar, MD, PhDa,*; Chandra E. Khalifian, PhDa; and Ariel J. Lang, PhD, MPHa,b,c

The "hopelessness theory of depression" was postulated over 40 years ago.1 Hopelessness depression was described as a subtype of depression with negative expectations at its core: those with negative expectations become hopeless and may subsequently develop suicidality because of cognitive vulnerability.2,3 Beck’s 4 cognitive theory of depression includes hopelessness as a central characteristic and an important link between depression and suicide. Hopelessness has been strongly associated with suicidal intent,5 and some have suggested that hopelessness was a stronger determinant of suicidal intent than depression.6,7

In our recent pilot investigation,8 women veterans were evaluated for suicidal ideation (SI), depression, and hopelessness, specifically during pregnancy and postpartum. We utilized a psychological assessment battery including the Beck Hopelessness Scale (BHS),9 the Columbia-Suicide Severity Rating Scale (C-SSRS),10 and the Edinburgh Postnatal Depression Scale (EDPS).11 Although we hypothesized that more severe hopelessness and depression would be related to SI, we found no correlation between hopelessness—as measured by the BHS—and SI. As expected, we did determine a positive correlation between hopelessness and depression.

Admittedly, our study sample was small and focused on a highly specific population,8 but our results paralleled those described in the recent publication by Baryshnikov and colleagues12: the severity of depression was a stronger predictor of SI than hopelessness. This finding is not surprising given that depression is a broad construct assessing cognitive, emotional, and behavioral aspects of functioning, whereas hopelessness is a narrow cognitive measure. Baryshnikov et al12 concluded that the role of hopelessness as a factor for SI in depressed individuals may have been overestimated, but several important considerations are worthy of discussion.

First, the term suicidality can be used to encompass SI, suicide intent, and suicide completion, but this aggregation can be misleading when describing research outcomes. Ideation can be passive, whereas intent and completion are active. As contemplation and enactment are inherently different, this distinction may be a critical differentiation when describing future research populations. Second, the BHS has been shown to be predictive of suicide completion,9,13,14 and hopelessness is an important component of multiple current suicide theories.15-18 However, it is possible that hopelessness as calculated by the BHS may differ from severity of depression or SI. Hence, the method of assessment for SI and hopelessness requires attention given variability observed with different assessments19-21 and patient populations.22-24

Researchers continue to investigate the hopelessness theory of depression25 and the significance of hopelessness for SI.26 Some investigators have asserted that other factors—such as anxiety or the severity of depression—may act as moderating factors of hopelessness and hence be driving factors for suicidal thoughts.12,27-33 Extant literature has robustly established hopelessness as a risk factor for suicide completion.4-7,9,13,14 In the future, researchers should differentiate suicidal thoughts or intent from completion to discriminate the impact of hopelessness.32,33 In contrast to Baryshnikov et al,12 we assert that hopelessness may yet prove to be a critical risk factor for SI, especially for depressed individuals, and we caution against disregarding its importance.

Published online: October 8, 2020.

Potential conflicts of interest: None.

Funding/support: Support was provided by Majda Foundation, VA Advanced Fellowship in Women’s Health, and VA CESAMH.

Role of the sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of data; or preparation, review or approval of the manuscript.

Disclaimer: All 3 authors are Federal employees who performed this work as part of their Federal job duties.

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aDepartment of Veterans Affairs (VA) San Diego Healthcare System, San Diego, California

bVA San Diego Healthcare System Center of Excellence for Stress and Mental Health (CESAMH), San Diego, California

cUniversity of California, San Diego, California

*Corresponding author: Mercedes J. Szpunar, MD, PhD, Veterans Affairs San Diego, 3350 Villa La Jolla Dr, San Diego, CA 92161 (mszpunar@ucsd.edu).

Prim Care Companion CNS Disord 2020;22(5):20br02617

To cite: Szpunar MJ, Khalifian CE, Lang AJ. Encouraging a nuanced understanding of the hopelessness-suicidality link. Prim Care Companion CNS Disord. 2020;22(5):20br02617.

To share: https://doi.org/10.4088/PCC.20br02617

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