Journal of Affective Disorders 138 (2012) 449–457

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research report

Development of the Risk Assessment Suicidality Scale (RASS):

A population-based study
Konstantinos N. Fountoulakis a,⁎, Eleonora Pantoula b, Melina Siamouli a, Katerina Moutou b,
Xenia Gonda c, Zoltan Rihmer c, Apostolos Iacovides a, Hagop Akiskal d
a
3rd department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Greece
b
Psychologist, Thessaloniki, Greece
c
Department of Clinical and Theoretical Mental Health, Semmelweis University, Faculty of Medicine, Budapest, Hungary
d
International Mood Disorders Center, University of California at San Diego, CA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: Suicide and suicide attempts are significant and costly public health problems. In
Received 11 April 2011 order to prevent suicidal and other self-injurious behaviors, research on the multiple factors
Received in revised form 11 December 2011 involved in these behaviors with comprehensive and user-friendly instruments is necessary.
Accepted 29 December 2011 The aim of the current study was to construct a self-report instrument with emphasis on
Available online 31 January 2012
items describing suicide-related behavior itself rather than strongly related clinical features
on the basis of a general population study.
Keywords: Methods: Twelve items comprising a new scale were applied to 734 subjects from the general
Suicide population (40.6% males and 59.4% females) aged 40.8 ± 11.5 along with the STAI and the CES-
Scale
D. Results: The scoring method was developed on the basis of frequency table of responses to
Risk assessment
the individual scale items. The factor analysis returned 3 factors explaining 59.19% of total variance
(Intention, Life, and History). The Cronbach's alpha was 0.85 for the Intention, 0.69 for the Life and
0.52 for the History subscale.
Limitation: The findings need replication in clinical and epidemiologic studies.
Conclusion: The RASS is a reliable and valid instrument which might prove valuable in the assess-
ment of suicidal risk in the general population as well as in mental patients.
© 2012 Elsevier B.V. All rights reserved.

1. Introduction them a top priority in the health agenda. Today, understanding

and preventing suicide are two of the most challenging tasks
Suicide and suicide attempts are significant and costly for psychiatry, and this is especially because during recent de-
public health problems. Recent research suggests that the cades, several psychological autopsy studies of suicide victims
lifetime prevalence of medically treated suicide attempts is have shown that the majority was suffering from a mood disor-
approximately 3% for women and 2% for men (Platt et al., der, usually major depression, with frequent comorbidity of
1992; Schmidtke et al., 1996), while completed suicide varies various other mental disorders especially anxiety and
from 5.5/100,000 in Greece to more than 24/100,000 in Hungary substance-use disorders (Badawi et al., 1999; Barraclough et
and more than 60/100,000 in certain east European countries al., 1974; Beautrais et al., 1996b; Henriksson et al., 1993;
(e.g. Belarus) (WHO, 2011). Their psychological impact on in- Monkman, 1987; Rihmer, 2007; Rihmer et al., 2002). What is
dividuals and their families and the enormous social costs in impressive is the fact that in spite of frequent medical contact
terms of medical treatment and loss of productivity makes before the suicide event, only a small minority of depressive
suicide victims had received appropriate antidepressant phar-
macotherapy, and this observation is particularly strong con-
⁎ Corresponding author. cerning primary care (Henriksson et al., 1993; Isometsa et al.,
E-mail address: kfount@med.auth.gr (K.N. Fountoulakis). 1994b; Luoma et al., 2002; Rihmer et al., 1990, 2002).

0165-0327/$ – see front matter © 2012 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2011.12.045
450 K.N. Fountoulakis et al. / Journal of Affective Disorders 138 (2012) 449–457

Until today, although prediction and prevention of suicide age, BMI, STAI-S, STAI-T and CES-D. Exploratory t-test was
and suicide-related behavior are problematic, a number of risk also performed between subjects with high CES-D vs. those
factors have been identified (poor self-esteem, inadequate with low CES-D (cut-off 23/24) and between subjects with
problem solving abilities, and hopelessness) (Beautrais et al., different history of self-injury or suicidal acts.
1996a; Brent et al., 1993; De Man and Leduc, 1995). In most
empirical investigations, hopelessness (negative attitudes or 3. Results
expectations about future life events) has been identified as
the most reliable risk factor (Beck, 1986; Beck et al., 1985, In the current study sample, from a total of 734 subjects,
1989; Cochrane-Brink et al., 2000; MacLeod et al., 2005; 436 (59.40%) were females and 298 (40.60%) were males.
McMillan et al., 2007). However, hopelessness is composed The composition of the study sample in terms of gender
by multiple aspects of positive and negative thinking (MacLeod and age in comparison to the general population according
et al., 2005; Osman et al., 1998, 2002, 2010) and also hope to the Greek National Statistics Service for 2009 (available
seems to be multidimensional (positive expectancies for oneself at http://www.statistics.gr) is shown in Table 1. The study
and for the future) (Herth, 1992; Hinds and Gattuso, 1991; sample population does not include retired from work people
Nowotny, 1989; Snyder et al., 1997). Suicide rumination, suicide or patients, and in that sense it is representative of the active
ideation, and the wish to die are also important areas to assess part of the general population in Greece.
(Evans et al., 2005; Haynes and Lench, 2003; Spirito et al., 2003). The mean age was 40.80 ± 11.48 years (range 25–67) and
In order to prevent suicidal and other self-injurious be- the scores in the STAI-S, STAI-T, CES-D and the body mass
haviors, research on the multiple factors involved in these index (BMI) were within the normal range both for males
behaviors is necessary. To assess these factors, researchers and for females (Table 2). However, 84 subjects (11.44%)
and clinicians require a comprehensive and user-friendly in- had CES-D scores above the threshold for depression (>23).
strument that allows for reliable data collection across a wide Of them, 62 were females (14.22%) and 22 were males
range of settings. (7.38%). Occupation data were available for 533 subjects
The aim of the current study was to construct a self-report (72.61%) and of them 63.41% were clerks (civil or private),
instrument which would include multiple replicable dimen- 11.63% were free professionals and 14.07% were doctors, law-
sions with emphasis on those items describing suicide- yers, priests, teachers etc. It seems the study sample resem-
related behavior itself rather than strongly related clinical bles urban Greek population with an overrepresentation of
features (e.g. hopelessness). Such an instrument will provide higher education levels. The detailed composition of the sam-
useful data for developing a clinical risk management plan for ple in terms of occupation is shown in Table 3.
a particular patient and it will also allow a comparison of the The frequency table of responses to the individual scale
diverse research studies on suicidal behavior. A central axis in items, is shown in Table 4. These frequencies led to the calcu-
this effort was to develop the instrument on the basis of a general lation of percentiles and the development of the scoring
population study and the use of normative data and scores. method which is shown in Table 5.
The factor analysis with the use of raw scores returned 4
2. Material and methods factors which altogether explain 64.95% of total variance,
while the use of standardized scores returned 3 factors
The first step was to review the literature and indentify explaining 59.19% of total variance (Table 6). These three fac-
depressive scales and scales assessing suicidality. MEDLINE tors correspond to three sub-scales (Intention, Life, and His-
search ‘suicide’ plus ‘scale’ plus ‘development’ originally tory) and their scores are shown in Table 7. If raw scores
returned 147 articles. Twenty one of them were considered are used to construct the subscales, then a fourth subscale ap-
relevant for the current study. The review led to the develop- pears and includes only item #1 (Fear subscale).
ment of 12 items assessing different aspects of suicide-related When using the raw scores, the Cronbach's alpha was
behavior and inner experience. These items were applied to equal to 0.75 (standardized value 0.80) with all items being
734 subjects from the general population (40.6% males and equivalent (alpha if item deleted ranged from 0.72 to 0.78).
59.4% females) aged 40.8 ± 11.5. The study sample was repre- When using the standardized score, Cronbach's alpha was
sentative of the active working Greek population aged
25–67 years. Although there was some effort to avoid including Table 1
overtly mental patients (especially psychotic) there was no Composition of the study sample in terms of gender and age in comparison
structured method to avoid this. Thus patients with overt men- to the general population according to the Greek National Statistics Service
for 2009.
tal disorders were not included. The STAI and the CES-D were
also administered. It is also important to note that the collec- Age group Greek population Study sample
tion of the data has been completed by 2008, that is before (approximation for 2009)
the current economic crisis began. Total population 11,282,751 734
The analysis included the development of descriptive sta- Females vs. males 48% vs. 52% 40.6% vs 59.4%
tistic tables for the study sample, and specifically frequency 25–29 years old 11.02% 25.81%
29–34 years old 11.31% 12.90%
tables for each reply in each item of the new scale. On the
34–39 years old 10.00% 15.44%
basis of these frequencies, a scoring method was developed. 40–44 years old 10.00% 13.13%
The statistical analysis included item analysis and the calcula- 44–49 years old 9.21% 10.60%
tion of Cronbach's alpha, factor analysis with varimax nor- 50–54 years old 8.92% 10.14%
malized rotation and the calculation of Pearson Product 55–59 years old 6.83% 8.29%
60–64 years old 7.09% 3.69%
moment correlation coefficient between the new scale and
 K.N. Fountoulakis et al. / Journal of Affective Disorders 138 (2012) 449–457 451

Table 2
Scores in the STAI-S, STAI-T, CES-D and the body mass index (BMI) in the study sample.

Total sample N = 734 Females N = 436 Males N = 298

Mean Min Max SD Mean Min Max SD Mean Min Max SD

Age 40.80 25 67 11.48 39.43 25 65 10.87 42.82 25 67 12.06

STAI-S 38.83 20 80 11.96 39.75 20 77 11.69 37.48 20 80 12.25
STAI-T 42.71 3 78 10.07 44.30 20 71 9.70 40.39 3 78 10.17
CES-D 11.89 0 53 9.13 13.04 0 46 9.40 10.21 0 53 8.47
BMI 25.25 16 73 4.57 24.21 16 73 4.96 26.75 18 42 3.46

equal to 0.79 (standardized value 0.82) again with all items had a history of suicide attempts and 9 subjects (1.22%) had
being equivalent (alpha if item deleted ranged from 0.76 to past history of both self-injury and suicidal attempts. Al-
0.80). Alpha was 0.85 for the Intention subscale, 0.69 for the though these groups were small, exploratory ANOVA sug-
Life subscale and 0.52 for the History subscale. gested that subjects with self-injury alone differed from
The correlations between raw and standardized scores of those with past suicide attempt and both past suicide and
the individual items, subscales and total score to age, BMI, self-harm in terms of total RASS and Intention subscale
STAI-S, STAI-T and the CES-D are shown in Table 8. (p b 0.001), and that subjects with self-injury in the past dif-
The comparison between subjects with CES-D scores fered from subjects with both self-injury and suicidal attempt
above vs. those with CES-D scores below the cut-off for de- in History subscale (p b 0.001). No differences between these
pression (23/24) suggested that the two groups differed in groups in terms of the Life subscale, total CES-D and hope-
the scores of all individual items and subscales with the ex- lessness item were detected.
ception of females for item #1 (Table 9). Item #8 of the
CES-D reflects hope/hopelessness and its relationship to the 4. Discussion
elements of the RASS is shown in Table 10. The results of
the comparison of subjects with history of self-injury and sui- Greece is one of the countries with the lowest completed
cide attempts concerning the RASS items, CES-D and hope- suicide rate in the world (5.5/100,000) (WHO, 2011). The
lessness are shown in Table 11. It is to be noted that 36 current study reports on the development of the Risk Assess-
subjects (4.9%) had a past history of self-injury, 4 (0.54%) ment of Suicidality Scale (RASS) which is the first instrument
to utilize a percentile derived method of scoring on the basis
of a general population study. The results suggest that the
Table 3 scale has satisfactory internal consistency and is composed
Occupation characteristics of the study sample. by three subscales (Intention, Life and History). The RASS
correlates significantly with STAI-S, STAI-T and the CES-D
Count % and hopelessness but not with age and BMI.
He/she used to work but is currently unemployed 0 0.00 Since the current study is cross-sectional there is no ‘gold-
He/she never worked and neither does now 0 0.00 en standard’ against which to validate the RASS. Only infor-
Clerk (civil or private) 338 63.41
mation on the distribution of suicidal ideation and related
Free professional (tradesman, craftsman) 62 11.63
Doctor, lawyer, engineer, priest, teacher etc. 75 14.07 thoughts can be gathered as well as information on past his-
Student (college or university) 12 2.25 tory of self-injury and suicide attempts. However the utility
Blue collar worker (construction worker, farmer) 26 4.88 of such information is unclear. Although they constitute
Housewife 20 3.75
widely accepted risk factors, it is also true that their predic-
Total 533 100.00
tive validity is limited. Several risk factors for suicidal behavior

Table 4
Frequency table of responses to the individual scale items.

Item description Not at all A little bit Much Very much

0 % 1 % 2 % 3 %

Are you afraid that you are going to die? 428 58.31 230 31.34 56 7.63 20 2.72
Do you ever think that it would be better if you were dead? 630 85.83 72 9.81 22 3.00 10 1.36
Do you think that it is a wonderful thing that you are alive? 41 5.59 30 4.09 119 16.21 544 74.11
Have you felt that it's not worth living? 556 75.75 116 15.80 40 5.45 22 3.00
Do you think of harming yourself physically? 688 93.73 32 4.36 12 1.63 2 0.27
Do you often think of committing suicide if you have the chance? 707 96.32 18 2.45 8 1.09 1 0.14
Do you make plans concerning the method to use in order to finish your life? 690 94.01 35 4.77 8 1.09 1 0.14
I am thinking of suicide but I won't do it 697 94.96 22 3.00 9 1.23 6 0.82
Do you enjoy life? 18 2.45 79 10.76 347 47.28 290 39.50
Are you feeling tired from your life? 322 43.87 286 38.96 96 13.08 30 4.09
Never Once 2–3 times Many times
Have you ever hurt yourself in any way deliberately during your whole life so far? 689 93.87 30 4.09 9 1.23 6 0.82
Have you ever attempted suicide during your whole life so far? 721 98.23 10 1.36 1 0.14 2 0.27
452 K.N. Fountoulakis et al. / Journal of Affective Disorders 138 (2012) 449–457

Table 5
Scoring of the individual scale items derived from the frequency tables of responses.

Not at all A little bit Much Very much

1. Are you afraid that you are going to die? 0 60 90 100

2. Do you ever think that it would be better if you were dead? 0 85 95 100
3. Do you think that it is a wonderful thing that you are alive? 95 90 75 0
4. Have you felt that it's not worth living? 0 75 90 100
5. Do you think of harming yourself physically? 0 95 100 100
6. Do you often think of committing suicide if you have the chance? 0 95 100 100
7 Do you make plans concerning the method to use in order to finish your life? 0 95 100 100
8. I am thinking of suicide but I won't do it 0 95 100 100
9. Do you enjoy life? 100 85 40 0
10. Are you feeling tired from your life? 0 45 80 95
Never Once 2–3 times Many times
11 Have you ever hurt yourself in any way deliberately during your whole life so far? 0 95 100 100
12 Have you ever attempted suicide during your whole life so far? 0 100 100 100

Table 6
Factor analysis with varimax normalized rotation.

Analysis with raw scores Analysis with

standardized scores

Factor 1 Factor 2 Factor 3 Factor 4 Factor 1 Factor 2 Factor 3

Are you afraid that you are going to die? 0.07 0.08 0.05 0.95 − 0.04 0.36 0.54
Do you ever think that it would be better if you were dead? 0.36 0.64 − 0.03 0.01 0.68 0.39 − 0.03
Do you think that it is a wonderful thing that you are alive? 0.20 0.64 − 0.05 − 0.23 0.22 0.64 − 0.03
Have you felt that it's not worth living? 0.21 0.69 0.15 − 0.04 0.39 0.55 − 0.06
Do you think of harming yourself physically? 0.72 0.23 0.19 − 0.08 0.82 0.03 0.13
Do you often think of committing suicide if you have the chance? 0.86 0.19 0.10 − 0.03 0.83 0.08 0.21
Do you make plans concerning the method to use in order to finish your life? 0.81 0.16 0.04 0.06 0.68 0.26 0.10
I am thinking of suicide but I won't do it 0.79 0.18 0.03 0.14 0.80 0.14 0.24
Do you enjoy life? 0.05 0.69 0.02 0.22 − 0.04 0.73 0.20
Are you feeling tired from your life? 0.12 0.71 0.14 0.14 0.20 0.72 0.06
Have you ever hurt yourself in any way deliberately during your whole life so far? 0.00 0.08 0.85 0.07 0.19 − 0.03 0.78
Have you ever attempted suicide during your whole life so far? 0.22 0.05 0.81 − 0.01 0.26 − 0.03 0.77
Explained variable 2.83 2.44 1.48 1.05 3.29 2.15 1.67
Proportion of total 23.56% 20.31% 12.31% 8.77% 27.38% 17.88% 13.94%
Total proportion of variance explained 64.95% 59.19%

have been identified and have been classified as primary (such lack of positive future thinking is more important than presence
as the presence of psychiatric and medical conditions, severe of negative future thinking (MacLeod et al., 2005). After con-
somatic illness, previous suicide attempts), secondary (adverse trolling for depressive symptoms, the association between
life situations and psychosocial risk factors) and tertiary (de- family functioning and continued suicidal behavior was no lon-
mographic factors such as male gender and old age) ger significant (Spirito et al., 2003).
(Henriksson et al., 1993; Rihmer et al., 2002). A number of However, predictive value is far from satisfactory. Suicide
risk factors have been proposed and studied, included hope- risk is highest when primary risk factors are present; the
lessness, body type (Bjerkeset et al., 2008), thought content, presence of secondary and tertiary suicide risk factors indi-
depression severity, coping qualities (Dinya et al., 2009), etc. cates high suicide risk almost exclusively only in the presence
Attitudes toward life and death might relate to suicidal tenden- of primary risk factors (Rihmer, 2007; Rihmer et al., 2002).
cies in a different way. In adolescents suicidality was negatively Unfortunately, the association of risk factors and suicide is
related to attraction to death and positively related to repulsion mainly statistical, as they predict individual cases of suicide
by life (Cotton and Range, 1996). Hopelessness about the fu- only to a limited extent. Awareness of risk factors, however,
ture in suicidal individuals is a multi-faceted construct but is a valuable tool for clinicians in estimating the suicide risk.
Clinically the strongest predictors for a suicide attempt
are considered to be hopelessness, guilt and related previous
Table 7 suicidal behavior, however these are state-related, severity-
Mean scores and standard deviations of the subscales. The percentage repre-
dependent phenomena, while the recurrence of suicidal idea-
sents the ratio of mean score to max score.
tion across depressive episodes shows a high consistency
Mean Min Max Std. Dev. Max score % (Rihmer, 2007; Rihmer et al., 2002; Sokero et al., 2006;
Intention scale 32.79 0.00 500 89.73 500 6.55 Valtonen et al., 2005; Williams et al., 2006). Also the presence
Life scale 103.29 0.00 390 94.93 390 26.48 of mixed symptoms (pseudo-unipolar depression) or agitation
History scale 36.08 0.00 300 48.74 300 12.02 substantially increases the risk of both attempted and commit-
Total suicide 172.17 0.00 1015.00 180.26 1190 14.46 ted suicide (Akiskal et al., 2005; Balazs et al., 2006; Isometsa
score
et al., 1994c; Rihmer, 2007; Rihmer and Akiskal, 2006).
 K.N. Fountoulakis et al. / Journal of Affective Disorders 138 (2012) 449–457 453

Table 8
Correlations between raw and standardized scores of the individual items, subscales and total score to age, BMI, STAI-S, STAI-T and the CES-D. Significant are
values >0.09 at p level 0.01 (in bold italics underlined).

Raw score Standardized score

Age BMI STAI-S STAI-T CES-D Age BMI STAI-S STAI-T CES-D

Are you afraid that you are going to die? 0.06 − 0.03 0.21 0.25 0.21 0.06 − 0.03 0.19 0.24 0.19
Do you ever think that it would be better if you were dead? 0.08 0.00 0.20 0.24 0.41 0.08 0.07 0.23 0.28 0.43
Do you think that it is a wonderful thing that you are alive? 0.09 0.02 0.20 0.18 0.29 0.08 − 0.05 0.23 0.21 0.32
Have you felt that it's not worth living? 0.08 0.07 0.26 0.29 0.41 0.08 − 0.02 0.28 0.32 0.41
Do you think of harming yourself physically? − 0.02 − 0.01 0.12 0.15 0.34 − 0.05 − 0.01 0.14 0.17 0.35
Do you often think of committing suicide if you have the chance? 0.00 − 0.01 0.11 0.14 0.31 − 0.02 − 0.01 0.12 0.16 0.32
Do you make plans concerning the method to use in order to finish − 0.03 − 0.02 0.10 0.15 0.32 − 0.06 − 0.02 0.12 0.15 0.29
your life?
I am thinking of suicide but I won't do it 0.00 0.00 0.12 0.13 0.30 − 0.01 0.00 0.16 0.16 0.35
Do you enjoy life? 0.07 0.01 0.35 0.40 0.50 0.07 0.00 0.36 0.42 0.51
Are you feeling tired from your life? 0.09 0.01 0.33 0.40 0.45 0.09 0.07 0.33 0.39 0.44
Have you ever hurt yourself in any way deliberately during your − 0.01 − 0.01 0.15 0.12 0.21 − 0.05 − 0.01 0.17 0.12 0.24
whole life so far?
Have you ever attempted suicide during your whole life so far? 0.02 0.01 0.08 0.09 0.12 − 0.03 0.02 0.11 0.13 0.17
Intention scale − 0.02 − 0.01 0.14 0.17 0.39 − 0.01 0.02 0.21 0.25 0.46
Life scale 0.12 0.03 0.39 0.43 0.58 0.11 0.00 0.41 0.45 0.57
History scale 0.00 − 0.01 0.14 0.13 0.21 0.01 − 0.02 0.24 0.26 0.30
Fear scale 0.06 − 0.03 0.21 0.25 0.21
Total suicide score 0.09 0.01 0.38 0.43 0.61 0.06 0.00 0.38 0.43 0.61

Unfortunately, since the majority of suicide victims die by their indicating that other both specific (suicide related) and
first attempt (Isometsa et al., 1994a; Rihmer et al., 2002) the non-specific factors besides major depression must also
history of prior suicide attempt(s) has a relatively limited play a crucial role. Psychotic patients are consistently more
value in suicide prevention. likely to apply violent suicide methods, such as guns, hanging
On the other hand, data indicate that a significantly higher or jumping from height (Isometsa et al., 1994a) and thus they
rate of suicidal patients communicate their intention to com- also have a higher risk of completed suicide compared to
mit suicide in a psychiatric care than in a general medical nonpsychotic depressives (Angst et al., 2005).
care (59% vs. 19%) setting. The same ratio is reflected in treat- In the current study, 36 subjects (4.9%) had a past history
ment; in psychiatric care 60% of victims are given antidepres- of self-injury, 4 (0.54%) had a history of suicide attempts and
sants in contrast to only 16% in general medical care 9 subjects (1.22%) had past history of both self-injury and
(Isometsa et al., 1994b). suicidal attempts. The absolute numbers are small, and the
Thus, prediction of suicide is not impossible although it percentages are similar to those reported in the literature
still constitutes a difficult task. The statistical fact is that al- concerning other countries (Platt et al., 1992; Schmidtke et
though depression is very closely related to suicide, more al., 1996), although a systematic review of the international
than two thirds of depressed patients never attempt suicide literature on the prevalence of suicidal phenomena in adoles-
and the vast majority of depressives never complete suicide, cents (128 studies and 513,188 adolescents) reported that

Table 9
Comparison of subjects with CES-D scores above or below the cut-off for depression (23/24) in terms of individual items standardized scores, subscales scores and
total score.

Males N = 298 Females N = 436

CES-D b 24 CES-D > 23 CES-D b 24 CES-D > 23

Mean SD Mean SD t-value df p Mean SD Mean SD t-value df p

Item #1 22.68 32.18 51.82 39.11 − 4.02 296 0.000 30.29 35.28 34.03 37.17 − 0.77 434 0.444
Item #2 7.70 25.06 36.82 45.45 − 4.86 296 0.000 9.59 27.40 43.39 45.34 − 8.07 434 0.000
Item #3 17.86 34.22 53.86 42.26 − 4.66 296 0.000 18.01 33.73 43.06 42.50 − 5.21 434 0.000
Item #4 13.59 30.27 45.91 43.52 − 4.65 296 0.000 17.43 33.44 51.94 42.33 − 7.22 434 0.000
Item #5 3.48 17.98 22.05 41.62 − 4.07 296 0.000 3.60 18.27 26.61 43.67 − 7.13 434 0.000
Item #6 1.03 9.87 26.36 44.08 − 7.57 296 0.000 2.06 13.95 15.73 36.17 − 5.32 434 0.000
Item #7 3.10 16.90 31.14 46.67 − 6.18 296 0.000 3.32 17.50 23.31 41.61 − 6.48 434 0.000
Item #8 2.83 16.39 34.77 47.09 − 7.15 296 0.000 2.35 15.01 18.79 38.68 − 5.96 434 0.000
Item #9 23.68 26.56 53.64 31.25 − 5.02 296 0.000 28.80 26.67 63.06 28.99 − 9.25 434 0.000
Item #10 24.31 28.97 55.23 34.14 − 4.75 296 0.000 30.74 29.61 64.19 26.49 − 8.36 434 0.000
Item #11 4.22 19.84 17.50 38.01 − 2.77 296 0.006 4.13 19.57 20.24 39.63 − 5.01 434 0.000
Item #12 1.09 10.39 13.64 35.13 − 4.13 296 0.000 0.27 5.17 9.68 29.81 − 5.64 434 0.000
Intention subscale 18.13 62.71 151.14 196.89 − 7.50 296 0.000 20.91 65.92 127.82 151.81 − 9.34 434 0.000
Life subscale 79.44 80.66 208.64 113.39 − 6.99 296 0.000 94.97 83.34 222.26 103.33 − 10.74 434 0.000
History subscale 27.99 45.25 82.95 84.06 − 5.06 296 0.000 34.69 42.35 63.95 63.55 − 4.65 434 0.000
Total score 125.56 139.10 442.73 290.52 − 9.25 296 0.000 150.57 136.69 414.03 247.84 − 12.23 434 0.000
454 K.N. Fountoulakis et al. / Journal of Affective Disorders 138 (2012) 449–457

Table 10 problems of predictive accuracy mainly because suicidal

Relationship of CES-D Item # 8 (hope/hopelessness) with the elements of thoughts and tendencies rarely lead to suicidal behavior,
the RASS scale and the total CES-D score. Significant are values >0.09 at p
level 0.01 (in bold italics underlined).
and completed suicide is a rare phenomenon (Burk et al.,
1985). Clinical rating scales cannot predict suicide in the indi-
Hopelessness vidual and strict cut-off scores should not be used to dictate
(CES-D Item # 8) the type of intervention (Cochrane-Brink et al., 2000).
CES-D 0.53 While the Beck's Hopelessness Scale measures a single risk
Are you afraid that you are going to die? 0.11 factor (Aish et al., 2001), other scales assess a variety of risk
Do you ever think that it would be better if 0.24
factors and behaviors.
you were dead?
Do you think that it is a wonderful thing that 0.24 Most demonstrate satisfactory reliability like the Deliberate
you are alive? Self-Harm Inventory and the Self-Harm Behavior Question-
Have you felt that it's not worth living? 0.29 naire (Gutierrez et al., 2001) (Cronbach's alpha = 0.81–0.96)
Do you think of harming yourself physically? 0.11 (Fliege et al., 2006), the Depression and Suicide Screen (DSS)
Do you often think of committing suicide if 0.17
with Cronbach's alpha= 0.62 (Fujisawa et al., 2005), the
you have the chance?
Do you make plans concerning the method to 0.14 Herth Hope Index (HHI), with Cronbach's alpha= 0.97
use in order to finish your life? (Herth, 1992), the Depression and Suicide Screen (DSS) with
I am thinking of suicide but I won't do it 0.15 Cronbach's alpha= 0.62 (Fujisawa et al., 2005), the Nowotny
Do you enjoy life? 0.35
Hope Scale for cancer patients with Cronbach's alpha= 0.90
Are you feeling tired from your life? 0.28
Have you ever hurt yourself in any way 0.09
(Nowotny, 1989), the Positive and Negative Suicide Ideation
deliberately during your whole life so far? (PANSI) Inventory, which includes 2 factors (Positive and Nega-
Have you ever attempted suicide during your 0.07 tive Ideation) (Osman et al., 1998) with PANSI-Negative
whole life so far? alpha =0.96 and PANSI-Positive alpha =0.89 (Osman et al.,
Intention scale 0.22
2002). The Suicide Resilience Inventory-25, has alpha =0.90–
Life scale 0.40
History scale 0.14 0.95 (Osman et al., 2004) and the Suicidal Trigger Scale (STS)-
Total suicide score 0.35 2, has Cronbach's alpha= 0.95(Yaseen et al., 2010).
The Beck Hopelessness Scale (Lennings, 1992) assesses
hopelessness which is considered to be the most significant
risk factor for suicide, however the performance was lower
the mean proportion of adolescents reporting they had than anticipated (McMillan et al., 2007). The Chinese version
attempted suicide at some point in their lives was 9.7% of the Suicide Intent Scale (SIS) is composed of 3 factors (Pre-
while 29.9% of adolescents said they had thought about sui- cautions, Planning, and Seriousness) explaining 92.9% of the
cide at some point. The current study is also the first report total variance (Gau et al., 2009). The Geriatric Suicide Idea-
of such epidemiological-like results from Greece. It is interest- tion Scale (GSIS), is composed of four-factors with subscales
ing that subjects with a past history of self-injury alone differed assessing Suicide Ideation, Death Ideation, Loss of Personal
from those with suicide attempt in the past in terms of the sub- and Social Worth, and Perceived Meaning in Life (Heisel
scale alone but not concerning the Life subscale. and Flett, 2006). The Herth Hope Index (HHI), includes two
A significant number of instruments have been developed factors: positive readiness and expectancy and interconnec-
so far and they all assess different aspects and risk factors of tedness accounting for 41% of the total variance (Herth,
suicidality and related behaviors. Almost all have serious 1992). The Life Attitudes Schedule (LAS) measures four dif-

Table 11
Comparison of subjects with history of self-injury and suicide attempts concerning the RASS items, CES-D and hopelessness.

Self injury in the past Suicide attempt in the past

No (N = 689) Yes (N = 45) No (N = 721) Yes (N = 13)

Mean SD Mean SD p Mean SD Mean SD p

Are you afraid that you are going to die? 27.47 34.38 42.44 39.03 0.005 28.06 34.77 46.92 34.97 0.053
Do you ever think that it would be better if you were dead? 11.45 29.82 29.33 42.06 0.000 11.92 30.32 47.31 45.72 0.000
Do you think that it is a wonderful thing that you are alive? 20.63 35.79 29.00 39.82 0.132 20.58 35.71 52.69 43.90 0.001
Have you felt that it's not worth living? 18.78 34.44 34.67 43.52 0.003 19.11 34.71 55.38 46.25 0.000
Do you think of harming yourself physically? 5.18 21.77 19.33 39.12 0.000 5.22 21.86 51.92 50.06 0.000
Do you often think of committing suicide if you have the chance? 2.95 16.68 12.78 32.95 0.000 2.68 15.90 51.92 50.06 0.000
Do you make plans concerning the method to use in order to finish 5.15 21.65 15.00 35.36 0.005 5.06 21.48 44.23 49.74 0.000
your life?
I am thinking of suicide but I won't do it 3.94 19.17 19.44 39.34 0.000 4.44 20.29 30.00 46.86 0.000
Do you enjoy life? 29.72 28.69 42.67 33.53 0.004 30.13 29.13 51.54 22.21 0.009
Are you feeling tired from your life? 30.62 30.97 51.11 30.34 0.000 31.26 31.02 66.54 28.31 0.000
Intention subscale 28.68 82.37 95.89 154.02 0.000 29.33 81.90 225.38 220.24 0.000
Life subscale 99.75 93.39 157.44 102.74 0.000 101.07 93.48 226.15 97.51 0.000
Total RASS 156.49 162.88 412.44 252.25 0.000 163.28 165.26 665.77 278.74 0.000
CES-D 11.34 8.69 20.47 11.40 0.000 11.69 9.01 23.62 8.94 0.000
Hopelessness CES-D Item #8 1.11 0.98 1.47 1.06 0.018 1.12 0.98 1.62 1.19 0.074
 K.N. Fountoulakis et al. / Journal of Affective Disorders 138 (2012) 449–457 455

ferent content categories: death related, health related, inju- Since it is simple and short, it can easily be used in the prima-
ry related, and self-related and includes positive (life-en- ry care, since up to 66% of suicide victims and suicide attemp-
hancing) and negative (life-threatening) behaviors ters contact their GPs or psychiatrists 4 weeks before the
(Lewinsohn et al., 1995). The Suicide Attempt Self-Injury In- suicidal act (Luoma et al., 2002; Pirkis and Burgess, 1998). A
terview (SASII) assesses variables related to method, lethality limitation is that the findings need replication in clinical
and impulsivity of the act, likelihood of rescue, suicide intent and epidemiologic studies.
or ambivalence and other motivations, consequences, and
habitual self-injury (Linehan et al., 2006). The Nowotny
Role of the funding source
Hope Scale for cancer patients has 6 dimensions of hope Nothing declared.
(subscales): confidence in the outcome, possibility of a fu-
ture, relates to others, spiritual beliefs, comes from within,
Conflict of interest
and active involvement (Nowotny, 1989). The Positive and Dr Fountoulakis is/was member of the International Consultation Board
Negative Suicide Ideation (PANSI) Inventory, includes 2 fac- of Wyeth for desvenlafaxine, BMS for aripiprazole in bipolar disorder and
tors, Positive Ideation and Negative Ideation (Osman et al., Servier for agomelatine and has received honoraria for lectures from Astra-
Zeneca, Janssen-Cilag, Eli-Lilly and research grants from AstraZeneca and Pfizer
1998). The University of Texas at San Antonio Future Disposi-
Foundation.
tion Inventory (UTSA FDI) is designed to evaluate future re- Eleonora Pantoula has no conflict of interest relevant to the current
lated thoughts and feelings that are associated with suicide- study.
Dr Siamouli has no conflict of interest relevant to the current study.
related risk behaviors: positive focus, suicide orientation,
Katerina Moutou has no conflict of interest relevant to the current
and negative focus (Osman et al., 2010). The Suicide Resil- study.
ience Inventory-25, includes 3 correlated factors, Internal Dr Gonda has received travel support from GlaxoSmithKline, Krka, Lilly,
Protective, Emotional Stability, and External Protective Montrose, Organon, Richter, Sanofi, and Schering-Plough.
Dr Rihmer has received speaker's honoraria from AstraZeneca, GlaxoS-
(Osman et al., 2004). The factor analysis of 6 scales related mithKline, Lilly, Lundbeck, Organon, Pfizer, Richter, Sanofi-Aventis, Servier-
to suicidality (Hopelessness Scale, Zung Self-Rating Depres- EGIS, and Wyeth Pharmaceuticals. He also received honoraria as a member
sion Scale, Scale for Suicide Ideation, Reasons for Living In- of scientific advisory boards of AstraZeneca, Lilly, Organon, Pfizer, Richer,
Sanofi-Aventis and Servier-EGIS.
ventory, Suicide Probability Scale, and the Suicide Ideation Dr Akiskal has no conflict of interest relevant to the current study.
Questionnaire) returned four factors (Suicidal/Negative Dr Iacovides has received speaker's honoraria from AstraZeneca, Lilly,
Ideas, Reasons for Living, Self-Doubt, and Suicide Desire) Wyeth Pharmaceuticals.
The authors have no other relevant affiliations or financial involvement
(Range and Antonelli, 1990). The Trinity Inventory of Precur- with any organization or entity with a financial interest in or financial con-
sors to Suicide (TIPS) has a single factor solution (Smyth and flict with the subject matter or materials discussed in the manuscript apart
MacLachlan, 2005). The Suicidal Trigger Scale (STS)-2, has 2 fac- from those disclosed.
tors (near-psychotic somatization and ruminative flooding, and
hopelessness) (Yaseen et al., 2010).
Appendix A. The Risk Assessment Suicidality Scale (RASS)
Other approaches to assess suicidality include the use of
the six most direct MMPI-2 suicide items (Items 150, 303,
Please respond to the following questions by ticking the
506, 520, 524, and 530; constituting the Suicidal Potential
square to the right that corresponds best to what is charac-
Scale (SPS) and suicidal behavior (Glassmire et al., 2001)).
teristic of you during the last week.
Other instruments are the Iowa Model of Evidence-Based
Practice to Promote Quality Care (Hermes et al., 2009) and
the Children's Hope Scale (Snyder et al., 1997). The results Not A little Much Very
of the EPIDEP National Multisite French Study on 493 consec- at all bit much
utive DSM-IV major depressive patients evaluated in at least 1 Are you afraid that you are going ❒ ❒ ❒ ❒
two semi-structured interviews 1 month apart, reported that to die?
2 Do you ever think that it would be ❒ ❒ ❒ ❒
155 (33.7%) were classified as suicide attempters, and 295 better if you were dead?
(66.3%) as nonattempters, after exclusion of bipolar I pa- 3 Do you think that it is a wonderful ❒ ❒ ❒ ❒
tients. According to that study, attempters had a longer dura- thing that you are alive?
tion of illness, longer delays before seeking help and correct 4 Have you felt that it's not ❒ ❒ ❒ ❒
worth living?
diagnosis and a higher number of previous episodes. Also
5 Do you think of harming ❒ ❒ ❒ ❒
they were more frequently bipolar II spectrum disorders, yourself physically?
rapid cyclers, with depressive, cyclothymic and irritable tem- 6 Do you often think of committing ❒ ❒ ❒ ❒
peraments and with fewer free intervals between episodes. suicide if you have the chance?
Lifetime suicide attempts were associated with higher num- 7 Do you make plans concerning the ❒ ❒ ❒ ❒
method to use in order to finish
ber of previous depressive episodes, multiple hospitaliza-
your life?
tions, cyclothymic temperament, rapid cycling, earlier age at 8 I am thinking of suicide but I won't ❒ ❒ ❒ ❒
onset and more comorbid bulimia and substance abuse do it
(Azorin et al., 2009). 9 Do you enjoy life? ❒ ❒ ❒ ❒
10 Are you feeling tired from ❒ ❒ ❒ ❒
your life?
5. Conclusion 11 Have you ever hurt yourself in any Never Once 2–3 Many
way deliberately during your times times
Conclusively, the RASS is a reliable and valid instrument whole life so far?
which might prove valuable in the assessment of suicidal 12 Have you ever attempted suicide Never Once 2–3 Many
during your whole life so far? times times
risk in the general population as well as in mental patients.
456 K.N. Fountoulakis et al. / Journal of Affective Disorders 138 (2012) 449–457

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