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<p class="title-left"><span class="bold">Encouraging a Nuanced Understanding of the Hopelessness-Suicidality Link</span></p>
<p class="byline-regular">Mercedes J. Szpunar, MD, PhD<span class="superscript">a,</span><span class="asterisk">*</span>; Chandra E. Khalifian, PhD<span class="superscript">a</span>; and Ariel J. Lang, PhD, MPH<span class="superscript">a,b,c</span></p>
<p class="drop-cap-with-body-text"><span class="bold-14pt-for-cap"><span class="bold">T</span></span>he “hopelessness theory of depression” was postulated over 40 years ago.<span class="htm-cite"><a href="#ref1">1</a></span> <span class="italic">Hopelessness depression</span> 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.<span class="htm-cite"><a href="#ref2">2</a>,<a href="#ref3">3</a></span> Beck’s<span class="htm-cite"><a href="#ref4">4</a></span> 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,<span class="htm-cite"><a href="#ref5">5</a></span> and some have suggested that hopelessness was a stronger determinant of suicidal intent than depression.<span class="htm-cite"><a href="#ref6">6</a>,<a href="#ref7">7</a></span></p>
<p class="body-text">In our recent pilot investigation,<span class="htm-cite"><a href="#ref8">8</a></span> 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),<span class="htm-cite"><a href="#ref9">9</a></span> the Columbia-Suicide Severity Rating Scale (C-SSRS),<span class="htm-cite"><a href="#ref10">10</a></span> and the Edinburgh Postnatal Depression Scale (EDPS).<span class="htm-cite"><a href="#ref11">11</a></span> 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.</p>
<p class="body-text">Admittedly, our study sample was small and focused on a highly specific population,<span class="htm-cite"><a href="#ref8">8</a></span> but our results paralleled those described in the recent publication by Baryshnikov and colleagues<span class="htm-cite"><a href="#ref12">12</a></span>: 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 al<span class="htm-cite"><a href="#ref12">12</a></span> 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.</p>
<p class="body-text">First, the term <span class="italic">suicidality</span> 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,<span class="htm-cite"><a href="#ref9">9</a>,<a href="#ref13">13</a>,<a href="#ref14">14</a></span> and hopelessness is an important component of multiple current suicide theories.<span class="htm-cite"><a href="#ref15">15–18</a></span> 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 assessments<span class="htm-cite"><a href="#ref19">19–21</a></span> and patient populations.<span class="htm-cite"><a href="#ref22">22–24</a></span></p>
<p class="body-text">Researchers continue to investigate the hopelessness theory of depression<span class="htm-cite"><a href="#ref25">25</a></span> and the significance of hopelessness for SI.<span class="htm-cite"><a href="#ref26">26</a></span> 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.<span class="htm-cite"><a href="#ref12">12</a>,<a href="#ref27">27–33</a></span> Extant literature has robustly established hopelessness as a risk factor for suicide completion.<span class="htm-cite"><a href="#ref4">4–7</a>,<a href="#ref9">9</a>,<a href="#ref13">13</a>,<a href="#ref14">14</a></span> In the future, researchers should differentiate suicidal thoughts or intent from completion to discriminate the impact of hopelessness.<span class="htm-cite"><a href="#ref32">32</a>,<a href="#ref33">33</a></span> In contrast to Baryshnikov et al,<span class="htm-cite"><a href="#ref12">12</a></span> 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.</p>
<p class="end-matter"><span class="bold-italic">Published online:</span> October 8, 2020.</p>
<p class="end-matter"><span class="bold-italic">Potential conflicts of interest:</span> None.</p>
<p class="end-matter"><span class="bold-italic">Funding/support:</span> Support was provided by Majda Foundation, VA Advanced Fellowship in Women’s Health, and VA CESAMH.</p>
<p class="end-matter"><span class="bold-italic">Role of the sponsor:</span> 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.</p>
<p class="end-matter"><span class="bold-italic">Disclaimer</span><span class="italic">: </span>All 3 authors are Federal employees who performed this work as part of their Federal job duties.</p>
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<p class="front-matter-rule"><span class="superscript">a</span>Department of Veterans Affairs (VA) San Diego Healthcare System, San Diego, California</p>
<p class="front-matter"><span class="superscript">b</span>VA San Diego Healthcare System Center of Excellence for Stress and Mental Health (CESAMH), San Diego, California</p>
<p class="front-matter"><span class="superscript">c</span>University of California, San Diego, California</p>
<p class="front-matter"><span class="asterisk">*</span><span class="italic">Corresponding author:</span> Mercedes J. Szpunar, MD, PhD, Veterans Affairs San Diego, 3350 Villa La Jolla Dr, San Diego, CA 92161 <span class="hyperlink">(<a href="
mailto:mszpunar@ucsd.edu">
mszpunar@ucsd.edu</a>)</span>.</p>
<p class="front-matter"><span class="italic">Prim Care Companion CNS Disord 2020;22(5):20br02617</span></p>
<p class="front-matter-rule"><span class="bold-italic">To cite:</span> Szpunar MJ, Khalifian CE, Lang AJ. Encouraging a nuanced understanding of the hopelessness-suicidality link. <span class="italic">Prim Care Companion CNS Disord</span>. 2020;22(5):20br02617.</p>
<p class="doi-line"><span class="bold-italic">To share:</span>
https://doi.org/<span class="doi">10.4088/PCC.20br02617</span></p>
<p class="abstract-copyright"><span class="italic">© Copyright 2020 Physicians Postgraduate Press, Inc.</span></p>
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