Journal of Gerontology: PSYCHOLOGICAL SCIENCES Copyright 2000 b\ The Gerontological Swii'lv of America

2000, Vol. 55B, No. I, P18-P26

Personality Traits and Suicidal Behavior and Ideation

in Depressed Inpatients 50 Years of Age and Older
Paul R. Duberstein, Yeates Conwell, Larry Seidlitz, Diane G. Denning, Christopher Cox, and Eric D. Caine

University of Rochester Medical Center, New York.

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Completed suicide may be the most preventable lethal complication of depressive disorders in older adults.
Identification of risk factors for suicidal behavior has therefore become a major public health priority. Using data col-
lected on SI depressed patients 50 years of age and older, we report analyses designed to determine the associations be-
tween the personality traits that constitute the Five Factor Model of personality and measures of suicidal behavior and
ideation. We hypothesized that low Extraversion would be associated with a lifetime history of attempted suicide, and
high Neuroticism would be associated with suicidal ideation. Results were generally consistent with the hypotheses. We
also observed a relationship between Openness to Experience and suicidal ideation. These findings suggest that long-
standing patterns of behaving, thinking, and feeling contribute to suicidal behavior and thoughts in older adults and
highlight the need to consider personality traits in crafting and targeting prevention strategies.

model of personality provides a relatively comprehensive cover-

D EPRESSIVE disorders in older adults are common
(Burvill, 1995; Lebowitz et al., 1997) and are associated
with increased all-cause mortality (Gallo, Rabins, Lyketos,
Tien, & Anthony, 1997; Penninx et al., 1999; Zubenko,
Mulsant, Sweet, Pasternak, & Tu, 1997). Completed suicide
may be the most preventable lethal complication. Although the
greatest number of suicides are committed by young adults, the
rate increases throughout the lifecourse and peaks in 80-84
year olds (Centers for Disease Control [CDC], 1996, 1999).
Recognizing the public health impact of completed suicide on
individuals, families, and society, the United States Congress
passed resolutions in 1997 and 1998 declaring suicide preven-
tion a national priority (Congressional Record, 1997, 1998).
The ultimate success of these resolutions will depend in part on
the identification of suicide risk factors and correlates. Research
aimed at identifying personality traits associated with suicidal
behavior can contribute to prevention efforts by defining groups
at high risk, before the development of a major depressive
episode or an acute suicidal crisis. The identification of high-
risk groups is therefore a critical component of the contempo-
rary prevention research agenda (National Institutes of Health,
1998). Using data collected on a sample of depressed inpatients
50 years of age and older, we report analyses designed to
determine the direction and strength of associations between the
personality traits that constitute the Five Factor Model of per-
sonality (Digman, 1990; John, 1990) and measures of suicidal
behavior.
The Five Factor Model (FFM) as a Hypothesis-Testing
and Hypothesis-Generating Tool
Based on decades of factor-analytic research on personality in
the natural lexicon and questionnaires, there is considerable
(Digman, 1990; John, 1990; McCrae & Costa, 1997), but not
complete (Cloninger, Svrakic, & Przybeck, 1993; Tellegen,
1985), agreement that personality attributes can be grouped
along five major dimensions: Neuroticism, Extraversion,
Openness, Agreeableness, and Conscientiousness. Because this
age of personality traits, it can be used to explore and generate
hypotheses about phenomena that have been relatively underin-
vestigated or about which there is relatively little theorizing.
We are aware of no theory that makes explicit predictions
about the contributions of specific personality traits to specific
dimensions of suicidal behavior in particular demographic and
diagnostic groups. Most personality theories of suicidal behav-
ior lack the specificity warranted by the epidemiological data.
For example, despite long-established age and gender differ-
ences in suicidal behavior (Durkheim, 1897/1951; Monk, 1987),
clinical writings (e.g., Buie & Maltsberger, 1989; Hendin, 1991)
have typically emphasized the role of hostility, independent of
age, gender, or any other demographic or contextual variable.
Use of an omnibus personality questionnaire grounded in the
FFM increases the likelihood that traits central to late-life suici-
dal behavior are not overlooked, even if they are ignored in clin-
ical and theoretical writings. Indeed, the FFM may be construed
as hypothesis-generating. Proponents of the FFM argue that it
provides a fixed reference point from which to assess a variety
of different scales (Costa & McCrae, 1992; Marshall, Wortman,
Vickers, Kusulas, & Hervig, 1994). It therefore overcomes a
perennial problem in personality psychology: Scales with dif-
ferent labels measure the same trait, while those with the same
label measure different traits.
Among others, Kagan (1994), McAdams (1994), and Block
(1995) offer less optimistic opinions of the FFM. Kagan (1994)
critiques its basic premises, including the scientific utility of a
natural language approach to personality, self-report measures,
and factor-analysis itself. He ultimately concedes that, even
though the five factors "omit too much information" and are
"insufficiently differentiated... [they] do tell us something of
interest" (pp. 45-46). McAdams (1994) also takes issue with
the basic premises and criticizes trait assessments in general on
the grounds that they fail to provide causal explanations for
human behavior, disregard the conditional and contextual na-
ture of human experience, and fail to provide enough detailed

P18
 PERSONALITY AND SUICIDE
information to predict specific behaviors in certain circum-
stances. Block (1995) generally accepts the premises upon
which FFM research is based, though he is somewhat critical of
the "arbitrariness" (p. 189) of factor analysis and the over-
reliance on self- and peer-report data. He also raises a number
of technical concerns, such as the high intercorrelations among
the ostensibly uncorrelated five factors. Still, the FFM has with-
stood criticism from those who share, and do not share, its basic
assumptions (Costa & McCrae, 1995; McCrae & Costa, 1997),
and it has proven useful in research on health outcomes in older
adults (Hooker, Frazier, & Monahan, 1994; Hooker, Monahan,
Bowman, Frazier, & Shifren, 1998; Hooker, Monahan, Shifren,
& Hutchinson, 1992). Those achievements may be sufficient
justification for its continued application to questions of public
health significance pertaining to older adults.
Continua versus Categories?
It is generally believed that one must want to die in order to
think about killing oneself, just as one has to have some suici-
dal ideation before making a suicide attempt. And, of course,
one has to attempt in order to complete suicide. It is precisely
this sort of overlap among suicide constructs that has led to the
assumption that suicidal behavior can be conceptualized along
a severity continuum, with absence of death ideation at one end,
completed suicide on the other, and death ideation, suicidal
ideation, and attempted suicide in the middle. Similarly, it has
been assumed that people can be "more or less" suicidal. Thus,
it has been assumed that one's "suicidality" can be captured by
a single, composite, dimensional variable.
The notion of a severity continuum has intuitive appeal.
Completed suicide is undoubtedly a more severe form of suici-
dal behavior than suicidal ideation. However, researchers study-
ing groups of suicide ideators, suicide attempters, and com-
pleted suicides may be examining categorically discrete
populations, each characterized by a discrete set of risk factors,
reflecting distinct underlying personality traits or constituent
cognitive, affective, and motivational processes.
The number and nature of distinct suicidal populations have
been debated for years (Linehan, 1986; Maris, 1992). This dis-
cussion must continue in order to identify and ultimately test
five of the most significant, yet implicit, assumptions in the
severity continuum model. These include the notions that (a) re-
search on attempted suicide may be a proxy for research on
completed suicide; that is, conclusions about completed suicide
can be gleaned from studies of suicide attempters; (b) research
on suicidal ideation may substitute for research on attempted
suicide; (c) suicidal ideation is a clinical risk factor for attempted
suicide and completed suicide; (d) attempted suicide is a clinical
risk factor for completed suicide; and (e) the absence of reported
suicidal ideation indicates decreased risk of attempted or com-
pleted suicide in a given population or study group.
Whereas the severity continuum model implies shared de-
mographic risk factors across the continuum, a categorical
model suggests that each putative category of suicidal behavior
may have specific risk factors. The demographic data are gen-
erally consistent with the categorical model. Rates of attempted
suicide are highest in young women (Kessler, Borges, &
Walters, 1999), but it is older men who are at greatest risk for
completed suicide (CDC, 1999). Similarly, rates of suicidal
ideation decrease throughout the lifecourse (Blazer, Bachar, &
P19
Manton, 1986; Moscicki, 1989), but the risk of completed
suicide increases (CDC, 1999). Following the logic of the cate-
gorical model, we examined the direction and strength of asso-
ciations between each of the personality traits that constitute the
FFM and specific variables related to (a) suicide attempts and
(b) suicidal ideation.
The Present Study: Overview and Hypotheses
The preceding sections point to the need for a study that
measures a range of personality traits and distinguishes among
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putative categories of suicidal behavior. Data were collected on
psychiatric inpatients with major depressive disorder, 50 years of
age and older, about half of whom were men. This is a relatively
homogeneous group both diagnostically and demographically,
which should allay concern that relations between personality
and suicidal behavior may be attributable to major depression,
gender, or age.
We tested two hypotheses: (1) Suicide attempters are char-
acterized by low Extraversion, and (2) Suicidal ideation is
associated with high Neuroticism. Extraversion refers to pref-
erences for social interaction and the tendency to experience
positive emotion (Costa & McCrae, 1992). Low Extraversion
increases risk for suicide attempts in relatively younger sam-
ples (Beautrais, Joyce, & Mulder, 1999; Roy, 1998). Although
there have been some negative findings, low Extraversion has
been empirically associated with poor social support (Krause,
Liang, & Keith, 1990; Von Dras & Siegler, 1997) and the use
of irrational and socially avoidant problem-solving strategies
(Hooker et al., 1994), characteristics also associated with at-
tempted suicide (Linehan, Chiles, Egan, Devine, & Laffaw,
1986). With respect to the second hypothesis, Neuroticism
refers to the disposition to experience negative affect, such as
sadness, anxiety, and self-consciousness. People who are high
in Neuroticism have a tendency to report more severe physical
(Costa & McCrae, 1987) and depressive (Lyness, Duberstein,
King, Cox, & Caine, 1998) symptoms, one of which is suici-
dal ideation. Given the paucity of previous research on person-
ality and suicidal behavior in older adults and our interest in
generating novel hypotheses, it seemed premature to restrict
our analyses to Neuroticism and Extraversion. We therefore
explored the contributions of Openness, Agreeableness, and
Conscientiousness to late-life suicidal behavior. Including
these three variables in the regression analyses also ensured
more precise estimates of the effects of Neuroticism and
Extraversion.
METHODS
Participants
Participants were drawn from a larger, ongoing, case-control
study of attempted suicide in major depressive disorder.
Depressed inpatients 50 years of age and older who were
admitted to the hospital following a suicide attempt were com-
pared with similarly depressed age- (±5 years) and gender-
matched inpatients whose admissions were not precipitated by
a suicide attempt. Although there is significant heterogeneity in
the prevalent diagnoses of young adult suicides, after age 50,
the psychiatric diagnoses associated with completed suicide be-
come increasingly homogeneous, and affective disorders are
present in over 70% of cases (Conwell et al., 1996). Thus, by
P20 DUBERSTE1NETAL.
choosing 50 as the lower age limit for study entry, we are able
to control for affective disorder without excluding a large por-
tion of people at risk for completed suicide.
The study was conducted at four teaching hospitals in the
northeastern United States (Rochester, NY), including two
community hospitals, one tertiary care facility, and one aca-
demic medical center. Acknowledging that there are problems
inherent in any definition of "suicide attempt" (Beck &
Greenberg, 1971; O'Carroll et al., 1996), attempted suicide was
defined as an intentional self-destructive act; an expressed wish
to die was not necessary.
Recruitment procedures were as follows. Project coordina-
tors screened the records of all patients 50 years of age and
older admitted to the four hospitals or seen in psychiatric con-
sultation on the medical and surgical services following a sui-
cide attempt. Because the amount and type of comorbidity were
important variables that may have distinguished groups, comor-
bid medical or psychiatric conditions were not exclusionary
criteria if the diagnosis of major depressive disorder was sus-
pected. Following approval from the patient's attending physi-
cian, a member of the research team approached patients to
obtain their informed consent to be interviewed by one of the
project coordinators (all of whom have masters degrees), and to
complete self-report questionnaires. Psychiatric diagnoses were
made on the basis of an integration of all data sources accord-
ing to DSM-TII-R criteria (American Psychiatric Association,
1987) in a consensus conference attended by members of the
research team. Potential participants were excluded if the labo-
ratory work-up, physical examination findings, and the tempo-
ral relation of depressive symptoms to the course of associated
physical illness or substance exposure suggested that the pa-
tient's mood syndrome was etiologically related to a specific
medical condition or substance exposure. Of the 87 participants
who completed the NEO Personality Inventory-Revised (NEO-
PI-R), only 2 suicide attempters and 4 nonattempters were sub-
sequently excluded because they met criteria for organic mood
disorder; 4 other suicide attempters and 1 nonattempter who
met criteria for that disorder did not complete the NEO-PI-R.
All participants (n = 81; 34 [42%1 men, 47 [58%] women)
who completed the NEO-PI-R and met inclusion criteria were
included in the analyses; 14 others completed the NEO-FFI (60
item short form; Costa & McCrae, 1992), and 50 (34.5%) re-
fused or were unable to complete any personality inventory de-
spite their participation in other phases of the research and our
assiduous efforts to increase the return rate. Participants in the
larger study from which these analyses were conducted were,
on average, about 6 years older, and scored nearly 2 points
lower on the Mini Mental State Exam (Folstein, Folstein, &
McHugh, 1975; M = 25.7, SD = 4.1; M = 27.5, SD = 2.5). The
sample was predominantly Caucasian (« = 78; 96.3%), with a
mean (SD) age of 61.3 (9.6) years. The age range was 50 to 87
years. Thirty-three (40.7%) participants were married, 21 (25.9
%) were separated/divorced, and 34 (42%) lived alone at the
time of admission. One-third of the sample (n = 27, 33.3%) was
employed, and slightly less than one-third (30.8%) was either
on disability (n = 14) or unemployed (n = 1 1 ) . Thirty-seven
(45.6%) were in the midst of their first episode of major depres-
sion. Slightly less than half (n - 40,49.4%) was diagnosed with
severe major depression (American Psychiatric Association,
1987); 27 cases were judged to be moderate, and 3 were mild.
Eleven patients (14.2%) had psychotic features. Slightly more
than half (n = 44; 54.4%) had at least one additional Axis I diag-
nosis. The most common comorbid Axis I diagnosis was alco-
hol or substance abuse or dependence in full remission (n = 21,
25.9%). Dysthymia was present in about 12% of the sample (n
= \ 0). Somatoform disorders (n = 8), active alcohol/substance
disorders (n — 8), panic disorder (« = 7), and phobias (n = 7)
were each present in slightly less than 10% of the sample. Scores
on the Beck Hopelessness Scale (Beck, Weissman, Lester, &
Trexler, 1974) were elevated (M = 12.4, SD = 5.7), consistent
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with scores obtained on an older, depressed outpatient sample
(Hill, Gallagher, Thompson, & Ishida, 1988). Thirty-four of the
81 (41.9%) participants were admitted to the study following a
suicide attempt; 20 of these participants had made previous at-
tempts. Eleven of the 47 patients (13.6%) whose admissions
were not precipitated by a suicide attempt had previously at-
tempted suicide. Excluding the suicide attempts that immedi-
ately preceded and precipitated hospitalization, dates of the most
recent previous suicide attempt ranged from less than 1 week to
more than 5 years prior to admission, with the majority occur-
ring more than 2 years prior to admission.
Materials
NEO-Pl-R.—T\ie NEO-PI-R (Costa & McCrae, 1992) is a
240-item measure of the five personality dimensions consis-
tently identified in factor-analytic studies: Neuroticism,
Extraversion, Openness to Experience, Agreeableness, and
Conscientiousness. An extensive literature supports its reliabil-
ity and validity. Coefficient alphas for the five scales range from
.86 to .92 (Costa & McCrae, 1992). Longitudinal studies con-
ducted over periods of up to 7 years have frequently reported
test-retest correlation coefficients greater than .6, attesting to
the stability of these five domains (Costa & McCrae, 1992).
Although the 60-item NEO-FFI has been used in gerontology
research (e.g., Hooker et al., 1994) and in research on depressed
outpatients (Bagby et al., 1998), we are unaware of any study
that has used the 240-item NEO-PI-R with older, depressed
inpatients.
History and number of suicide attempts.—For decades, the
standard approach to research on personality and attempted
suicide involved a static group comparison of individuals seek-
ing health care following a suicide attempt with individuals
seeking care for another reason ("nonattempters"). This ap-
proach is limited primarily because a portion of those de-
scribed as nonattempters have attempted suicide in the past. As
a general principle, when personality traits increase risk for
certain adverse health outcomes, such as attempted suicide,
risk refers to the entire lifecourse and is not confined to the pe-
riod of time during which subjects are enrolled in a study.
Thus, in the present study we examined the relationship be-
tween personality and (a) lifetime suicide attempter status, and
(b) number of suicide attempts.
Our data on the number of suicide attempts were based, in
part, on participants' responses to the questions: "How many
times all together in your life have you actually done something
with the intention of taking your life?" and "How many suicide
attempts have you made in your life?" With respect to the latter
question, past self-destructive behaviors were coded as suicide
 PERSONALITY AND SUICIDE
attempts if participants labeled the behavior as a suicide attempt
even if they disavowed an expressed intention to die. Previous
psychiatric and medical charts were reviewed in an effort to
gather additional data on the number of suicide attempts.
Discrepancies between the number of self-reported suicide at-
tempts and chart-documented suicide attempts were resolved
by recording the higher number documented or reported.
Scale of Suicidal Ideation (SSI).—Two outcome measures
were extracted from this 19-item, observer-rated measure: (a)
presence of suicidal ideation and (b) presence of death ideation
(Beck, Kovacs, & Weissman, 1979). Questions pertained to the
week prior to the interview or the interval between the suicide
attempt and interview, whichever was shorter. Thus, for those
hospitalized following a suicide attempt, the SSI provides data
on the presence of suicidal and death ideation following a sui-
cide attempt. The first three items concern the wish to live, the
wish to die, and the extent to which one wish outweighs the
other. The presence of death ideation was operationally denned
as a score of 1 or greater in response to these three items, mean-
ing that the wish to die outweighed the wish to live. Items 4 and
5 concern thoughts of self-destruction, either by active (e.g.,
shoot yourself) or passive (e.g., not taking medicine that is
needed to survive, refusing to nourish oneself) means. The pres-
ence of suicidal ideation was operationally defined as an affir-
mative response to either Question 4 or Question 5. The final
14 questions, which concern the frequency, duration, and the
participant's attitude toward suicidal thoughts, were adminis-
tered only to those who reported suicidal ideation in response
to Items 4 or 5. Participants obtain relatively high SSI scores if
they report that they "accept" the suicidal thoughts, have little
control over them, have little concern about family, religion, or
other potential deterrents to suicide, have thought extensively
about how to kill themselves, written suicide notes, or changed
wills or life insurance policies. Severity of suicidal ideation was
operationally defined as the total score on the SSI. The SSI has
established reliability and concurrent validity (Beck et al.,
1979). Coefficient alpha for the current study (ideators only)
was .91.
Spectrum of Suicidal Behavior Scale (SSB).—Project coordi-
nators used this 5-point ordinal scale (Pfeffer, Stokes, &
Shindledecker, 1991) to rate the participants' most serious sui-
cidal behavior over the past month. Thus, the SSB and SSI
cover different time frames (month prior to hospitalization vs.
week prior to interview). Participants were rated a 1 (nonsuici-
dal) if there was "no evidence of any self-destructive or suicidal
thoughts or actions," a 2 if there is evidence of suicidal ideation,
a 3 if they made a suicidal threat, a 4 if they made a mild sui-
cide attempt, or a 5 if they made a serious suicide attempt. In
the present study, the SSB served primarily as a measure of sui-
cidal ideation in the month prior to admission. For analytic pur-
poses, we therefore dichotomized SSB scores (1 vs. other) and
estimated its reliability by means of the kappa-coefficient (K =
.54) using chart documentation of preadmission suicidal behav-
ior as the criterion.
Structured Clinical Interview for DSM-III-R.—This instru-
ment was used to establish Axis I psychiatric diagnoses
(Spitzer, Williams, & Gibbons, 1987). In order to examine its
P21
validity in this group of older inpatients with major depression,
some members of the research team assessed psychiatric inpa-
tients while others independently interviewed family infor-
mants (n = 26 pairs). Kappa coefficients for the diagnoses of
any substance use disorder, affective disorder, and their comor-
bidity ranged from 0.61 to 0.75.
Mini Mental State Exam (MMSE).—The MMSE measures
cognitive function (Folstein et al., 1975). Scores can range from
0 to 30. The MMSE score is not used as an inclusion criterion;
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rather, it serves solely as a means of characterizing cognitive
function.
Analytic Plan and Overview of Presentation of Results
First, descriptive statistics and intercorrelations among study
variables are reported. Kendall's tau and t statistics are pre-
sented because many of the endpoints were binary or counts
with skewed distributions. Next, the results of a series of regres-
sion analyses are reported. Binary endpoints were analyzed by
multiple logistic regression. Goodness of fit was examined by
using the Hosmer-Lemeshow (1989) test. Continuous end-
points were analyzed by multiple linear regression analysis,
which included an examination of residuals as a check on the
required assumptions of normally distributed errors with con-
stant variance. If the residual analysis indicated a violation of
assumptions, then the data were logarithmically transformed
and standardized to behave like normal deviates (Chatterjee &
Hadi, 1988). Cases with standardized residuals greater than 3 in
absolute value were excluded as outliers from the regression
analysis. Counts and endpoints with skewed distributions were
analyzed by Poisson regression (McCullagh & Nelder, 1989),
which also included an outlier analysis. Standardized residuals
are based on components of the Pearson chi-square statistic for
goodness of fit of the model. All analyses were adjusted for age
and gender. Predictors included age, gender, and each of the
five traits that constitute the FFM: Neuroticism, Extraversion,
Openness to Experience, Agreeableness, and Conscientious-
ness. All reported p values are two-tailed.
RESULTS
Descriptive statistics and zero-order correlations (Kendall's
tau) between the NEO factors and continuous outcomes (SSI
and number of suicide attempts) are presented in Table 1. There
were slight, downward trends with age in Neuroticism and
Openness. The SSI score was positively correlated with
Neuroticism. t tests were conducted to examine the unadjusted
relationships between the personality variables and dichoto-
mous endpoints. Table 2 shows that women, suicide ideators,
and death ideators obtained higher Neuroticism scores, and
those who had attempted suicide obtained lower scores on
Extraversion. Of the 10 intercorrelations among the 5 NEO
variables, five had absolute values less than .07; the highest
value was .46. Therefore, multicollinearity did not appear to
pose any problems for the regression analyses.
Presence and Number of Suicide Attempts
The first logistic regression sought to determine whether the
personality variables were associated with having made a sui-
cide attempt. As shown in Table 3, those who obtained lower
Extraversion scores were more likely to have made a lifetime
P22 DUBERSTEIN ET AL.

Table 1. Unadjusted Relationship Between NEO-PI and Continuous Variables: Kendall's Tau
Continuous Variable N M SD Ne Ex Op Ag Co
Age 81 61.30 9.6 -.29*** .04 -.17* -.06 .07
Number of lifetime SA 81 0.85 1.6 .19* -.19* .04 -.04 -.15
Total SSI score 81 7.52 10.3 2g*** -.15 .11 -.04 -.14

Ne = Neuroticism; Ex = Extraversion; Op = Openness to Experience; Ag = Agreeableness; Co = Conscientiousness; SA= Suicide Attempts; SSI = Scale for
Suicidal Ideation.
*/><•05. ***p< .001.

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Table 2. Unadjusted Relationships Between NEO-PI and Dichotomous Variables: /-Statistics
Categorical Variable Ne Ex Op Ag Co
Gender (« = 47 women, 34 men) 1 .97'* -0.15 0.85 1.91 -1.77
Lifetime SA (n = 45 yes, 36 no) 1 .69" -2.03* -0.44 0.14 1.31
Suicidal ideation - SSB (n = 61 yes, 20 no) 2.66** -1.50 1.48 -1.23 -1.60
Suicidal ideation - SSI (n = 32 yes, 49 no) 3.11*** -1.06 1.80 -1.21 -1.64
Death ideation - SSI (n = 53 yes, 28 no) 3.01*** -1.24 1.76 -0.86 -0.69

Lifetime SA = participants with a lifetime history of at least one suicide attempt were contrasted with all others. Suicidal ideation - SSB = participants who scored
a 1 (absence of suicidal ideation or suicide attempt in the month prior to hospitalization) were contrasted with all others; Suicidal ideation - SSI = participants who
reported suicidal ideation in the week prior to interview (scored a 1 or higher on the Scale for Suicidal Ideation) were contrasted with all others; Death ideation - SSI
= participants who acknowledged that their wish to die outweighed their wish to live in the week prior to interview (scored a 1 or higher on the death ideation items
of the Scale for Suicidal Ideation) were contrasted with all others; Ne = Neuroticism; Ex = Extraversion; Op = Openness to Experience; Ag = Agreeableness: Co =
Conscientiousness. *p < .05; **p < .01 ;***/}< .001. All rf/s = 79, except where otherwise noted.
"Women scored higher than men.
h
Unequal variance (p < .05), there was greater heterogeneity among those with a lifetime SA; d/'tbr t-test = 78.

Table 3. Regression Results

Significant
Predicted Variable Analysis Model Predictor(s) Coeff SE X:(D p value
Lifetime SA 1 Logistic Extraversion -.032 .016 4.43 .035
Number of lifetime S A (outliers removed) 2 Poisson Extraversion -.026 .007 14.06 .0002
No suicidal ideas-SSB 3 Logistic Openness -.054 .025 5.65 .02
Agreeableness +.038 .021 3.73 .05
Suicidal ideation-SSI 4 Logistic Age -.087 .038 6.38 .01
Death ideation-SSI 5 Logistic Openness +.038 .021 3.87 .05
Neuroticism +.037 .018 4.49 .02
Lifetime SA = participants with a lifetime history of at least one suicide attempt were contrasted with all others; Suicidal ideation - SSB = participants who scored
a 1 (absence of suicidal ideation or suicide attempt in the month prior to hospitalization) were contrasted with all others; Suicidal ideation - SSI = participants who
reported suicidal ideation in the week prior to interview (scored a 1 or higher on the Scale for Suicidal Ideation) were contrasted with all others; Death ideation - SSI
= participants who acknowledged that their wish to die outweighed their wish to live in the week prior to interview (scored a 1 or higher on the death ideation items
of the Scale for Suicidal Ideation) were contrasted with all others; CoetT = coefficient.

suicide attempt (Table 3, Analysis 1). The Hosmer-Lemeshow
goodness of fit was not significant, x2 (8) = 9.90, p = .27, indi-
cating a satisfactory fit. Next, we examined predictors of the
number of previous suicide attempts using Poisson regression.
Higher Neuroticism and lower Extraversion emerged as signifi-
cant predictors; however, 4 participants were outliers. In each
case, the predicted number of suicide attempts was lower than
the actual number. All 4 had at least two Axis I diagnoses; 3 of
the 4 had psychotic features. Concerned that the nature and in-
terpretation of our findings may have been unduly influenced
by this relatively small group reporting numerous suicide at-
tempts, we removed the outliers and conducted another Poisson
regression. The results (Table 3, Analysis 2) partially duplicated
the previous analysis. Again, Extraversion was a strong predic-
tor, but Neuroticism was not, despite its significance in the pre-
vious analysis and its association with the number of lifetime
suicide attempts in the unadjusted analyses (Table 2). Next, we
conducted a Poisson regression to predict the number of suicide
attempts among those with a lifetime history of attempted sui-
cide (n = 45; analyses not shown). No significant predictors
emerged, but there was a trend for those higher in Neuroticism
to make more attempts, x2 (1) = 3.17, p = .07.
Suicidal and Death Ideation
Two groups were constructed from the SSB data, those who
reported no suicidal ideation or behavior in the past month and
those who reported suicidal ideas or made a suicide attempt.
Table 3 (Analysis 3) shows that, in a logistic regression predict-
ing absence of suicidal ideation, low Openness and high
Agreeableness emerged as significant predictors. This contrasts
 PERSONALITY AND SUICIDE
with the unadjusted analyses, which showed a relationship be-
tween Neuroticism and the SSB score (Table 2). The Hosmer-
Lemeshow for the multiple regression was nonsignificant, \2
(8) = 10.75, p = .22, indicating a reasonable fit. When we di-
chotomized the SSI score (0 vs. > 0) and created two groups,
suicide ideators and nonideators, the logistic regression (Analy-
sis 4) yielded one significant predictor (age), in contrast to the
unadjusted analyses, which implicated Neuroticism in suicidal
ideation (Table 2). We also conducted a linear regression with
the total score on the SSI as the dependent variable. Again, only
age was associated with that outcome, F(l,73) - 4.56,p = .04,
but there was a trend for those higher in Openness to obtain
higher SSI scores, F( 1,73) = 3.25, p = .07. Next, we created
two groups, those who reported death ideation in response to
Items 1-3 of the SSI and those who did not. Table 3 (Analysis
5) shows that higher Neuroticism and higher Openness
emerged as significant predictors of death ideation. The
Hosmer-Lemoshow for the overall model was nonsignificant,
X2 (8) = 8.33, p = .40, indicating a satisfactory fit.
DISCUSSION
These findings reinforce the notion that personality traits
ought to be seriously considered as potential risk factors for
late-life suicidal behavior and ideation. Even in this demo-
graphically and diagnostically homogenous group of psychi-
atric inpatients, personality traits were important predictors of
suicide attempts and suicidal ideation. Although there were
some negative findings, regression analyses supported hypothe-
sized associations between Extraversion and attempted suicide
and between Neuroticism and suicidal ideation. These analyses
also generated a novel hypothesis linking Openness to suicidal
ideation.
Substantive Findings
Three findings are especially noteworthy. First, higher
Extraversion distinguishes people who have never made an at-
tempt from those who have. Extraversion is positively associ-
ated with positive affect (Clark, Watson, & Mineka, 1994) and
increased social support (e.g., Von Dras & Siegler, 1997), and
negatively correlated with trait, but not state, hopelessness
(Young et ah, 1996). Extraverted individuals may be less likely
to engage in suicidal behavior even in the midst of a depressive
episode because they are more likely to recruit and affectively
benefit from friendships and family relations, perhaps as a re-
sult of better social skills (cf. Zweig & Hinrichsen, 1993).
Suicide attempts among those who are low in Extraversion may
reflect a tendency to take matters into one's own hands, rather
than attempt to recruit help from others. Strategies for treating
young adult suicide attempters (Linehan, 1993) have been in-
formed by data linking personal concerns (Linehan et ah, 1986)
or personality dimensions (Rudd, Joiner, & Rajab, 1996) with
suicidal behavior, but similar data on older adults are rare.
Future research aimed at identifying the mediators of the rela-
tionship between Extraversion and attempter status may lead to
interventions designed to decrease the risk of nonfatal suicidal
behavior. This is important in part because suicide attempts
may exacerbate the physical morbidity (Gallo et ah, 1997; Katz,
1996 ) and mortality risks (Gallo et ah, 1997; Penninx et ah,
1999; Zubenko et ah, 1997) frequently associated with late-life
depressive disorders.
P23
Although our findings are consistent with the notion that
Extraversion is associated with lifetime suicide attempter status,
it is possible that other personality traits (e.g., low Openness,
high Neuroticism) are associated with the lethality of attempts.
This idea could be examined in a study that includes a suffi-
cient sample of individuals whose suicide attempts lead to se-
vere medical complications.
Second, as hypothesized, Neuroticism is associated with sui-
cidal ideation. However, whereas significant relationships
between Neuroticism and measures of suicidal ideation were
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obtained in all three univariate analyses (SSB, SSI-Suicidal
Ideation, SSI-Death Ideation), the regression analyses told a
more complex story. Neuroticism was a strong predictor of SSI-
Death Ideation in these analyses, but was not associated with
the other two suicide ideation variables. Thus, the associations
between Neuroticism and suicidal ideation in univariate analy-
ses may be due in part to its associations with other traits, par-
ticularly Agreeableness and Openness.
Third, patients low in self-reported Openness are less likely to
report suicidal ideation. Perhaps patients low in Openness are
protected from suicidal ideation, and consistent with the severity
continuum model, they are less vulnerable to completed suicide.
However, we have previously reported that low informant-
reported Openness may be a risk factor for completed suicide
(Duberstein, Conwell, & Caine, 1994). How can this discrep-
ancy be reconciled? Perhaps the apparently discrepant findings
can be ascribed to methodological differences. Self-reported
Openness and informant-reported Openness may not be compa-
rable constructs in older, depressed persons. This is unlikely,
given the extensive literature supporting the relationship between
self- and informant-reported data (Costa & McCrae, 1992), even
in depressed outpatients (Bagby et ah, 1998). In our own sample
of 57 depressed inpatients 50 years of age and older, the relation-
ship between self- and informant Openness (intraclass correla-
tion coefficient = .49) was moderately strong. Acknowledging
that other methodological explanations may account for the ap-
parently discrepant findings, substantive hypotheses must also be
entertained. People with major depression who are low in
Openness may be at increased risk for completed suicide precisely
because they are less likely to feel, or report feeling, suicidal. This
hypothesis represents a genuine challenge to the severity contin-
uum model. Affective muting may be adaptive at earlier points in
the lifecourse, but could also increase risk for late-life completed
suicide (Clark, 1993; Duberstein, 1995). Further research on
Openness and suicidal behavior is warranted, given the obvious
implications for risk detection and prevention.
Limitations and Strengths
It cannot be assumed that the present findings generalize to
other diagnostic and demographic subgroups. Participants who
completed the NEO-PI-R were about 6 years younger and may
have had slightly better cognitive function than those who did
not complete the 240-item inventory. Nor can it be assumed
that these findings generalize to the small fraction of depressed
patients with organic mood disorder. The sample size is also
relatively small for personality research, so caution must be ex-
ercised, especially in interpreting negative findings. Finally, it
must be acknowledged that the results may have differed had
other age cutoffs been used as the lower limit of study entry
(e.g., 60 or 65).
P24 DUBERSTE1NETAL.
These limitations must be weighed against the study's
strengths, chief of which are its public health significance and
its foray into new territory. No previous study has applied a
comprehensive personality taxonomy to the study of late-life
suicidal behavior. Suicide is a major public health problem. By
attempting to identify putative risk factors for suicidal behavior,
social scientists can contribute to prevention efforts by defining
groups at high risk, before the development of an acute crisis.
This study represents a step in that direction. Other strengths of
the study include a well characterized and carefully diagnosed
sample at future risk for self-harm.
Conclusion
Our findings suggest that suicidal thoughts and behavior are
rooted in longstanding patterns of behaving, thinking, and feel-
ing, and highlight the need to consider personality traits in craft-
ing and targeting prevention strategies. Suicidal ideas and
behavior are not an inevitable consequence of aging, disease,
disability, or even depression. The current findings thus
challenge an ageist stereotype that has probably contributed
to a lack of interest in preventing late-life suicide (AARP
Foundation/Center for Mental Health Services, 1997). On the
other hand, findings must be regarded as preliminary. Several
lines of preintervention research ought to be pursued.
The "state-trait problem" potentially confounds research on
psychiatric inpatients, many of whom may be in acute distress
while completing questionnaires or participating in interviews.
Although it is unlikely that our observation that suicidal behav-
ior and ideas are associated with Extraversion, Neuroticism,
and Openness, follow-up data, collected when patients no
longer meet diagnostic criteria for major depressive disorder,
would be useful (e.g., Santor, Bagby, & Joffe, 1997). Future re-
search may also benefit from informant reports and projective,
physiological, or other nonverbal sources of psychological
information.
By collecting data on a relatively homogeneous group of
older persons with major depression, we sought to decrease the
probability that potentially confounding effects of age or major
psychiatric diagnosis would obscure relationships between per-
sonality and suicide variables. Still, heterogeneity was apparent
in the analyses on previous suicide attempts. These analyses
suggested that Neuroticism may contribute to multiple suicide
attempts in those with comorbidity. Further research on larger
samples may be necessary to determine whether the personality
traits associated with suicidal behavior in depressed patients
with psychiatric comorbidity differ from those without comor-
bidity.
Even in the absence of consensus concerning the ideal de-
sign, sampling strategy, and statistical analysis required to de-
termine whether the constructs of suicidal ideation, attempted
suicide, and completed suicide are categorically distinct (cf.
Flett, Vredenburg, & Krames, 1997; Meehl, 1992), tragedies
may be prevented for now simply by acknowledging that devel-
oping risk-identification and prevention strategies based on as-
sumptions implicit in the severity continuum model could be
misguided. Variables associated with the absence of reported
suicidal ideation, such as low Openness, may not confer de-
creased risk for completed suicide. Paradoxically, in some
patients who are low in Openness, the absence of reported suici-
dal ideation may confer increased suicide risk.
This study uncovered the possibility that different personal-
ity variables are associated with attempted suicide and suicidal
ideation, with Extraversion associated with the former and
Openness more closely tied to the latter. We are not arguing for
eliminating the severity continuum model of suicide; rather, we
are suggesting that the categorical model has much to offer. It is
likely that suicide ideators, suicide attempters, and completed
suicides are categorically discrete groups, each characterized by
a discrete set of risk factors, reflecting distinct underlying per-
sonality and constituent cognitive, affective, and motivational
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processes. Recognition of these differences may result in more
efficient prediction of attempted and completed suicide (Rudd
et al., 1996).
A promising approach to preventing suicide in older adults
involves screening for depression in primary care practices
(Unutzer, Katon, Sullivan, & Miranda, 1999). However, some
believe that the need for legalization of assisted suicide in cer-
tain contexts is as pressing a need as suicide prevention. This
dilemma is complicated by the absence of consensus regarding
the conceptualization, measurement, or treatment of psycholog-
ical distress or psychiatric disorders in individuals with life-
threatening illnesses. Still, screening instruments have been
shown to have adequate sensitivity and specificity in predicting
major depression in older primary care patients (Lyness et al.,
1997). If carefully conducted preintervention research contin-
ues to implicate certain personality traits in late-life suicidal be-
havior, it may be desirable to screen for personality traits as
well. All screening and surveillance mechanisms should be
linked to systems capable of providing a range of interventions
and services.
ACKNOWLEDGMENTS
This project was financially supported in part by Public Heakh Service
Grants K07-MH01135, R03-MH55149, and RO1-MH51201. Nancy Talbot, Jill
Eichele, and anonymous reviewers provided helpful comments on previous
drafts of the manuscript. We also wish to extend our appreciation to Andrea
DiGiorgio, Wendy Wyland, Jack Herrmann, Barbara Hughson, Megan
Cavanagh, and Tamson Kelly Noel for their assistance in data collection; to
Carrie Irvine for data management; and to Josephine Lauri and Marge Roberts
for manuscript preparation. An earlier version of this article was presented at
the annual meeting of the American Psychological Association, Chicago,
August 1997.
Address correspondence to Paul R. Duberstein, Department of Psychiatry,
University of Rochester Medical Center, 300 Crittenden Blvd., Rochester, NY
14642. E-mail: Paul_Duberstein@unnc.rochester.edu
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233-241. Decision Editor: Toni C. Antonucci, PhD

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