Journal of Gerontology: PSYCHOLOGICAL SCIENCES2000, Vol. 55B, No. I, P18-P26

Copyright 2000 b\ The Gerontological Swii'lv of America

Personality Traits and Suicidal Behavior and Ideationin 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.

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 andideation. We hypothesized that low Extraversion would be associated with a lifetime history of attempted suicide, andhigh Neuroticism would be associated with suicidal ideation. Results were generally consistent with the hypotheses. Wealso 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 andhighlight the need to consider personality traits in crafting and targeting prevention strategies.

DEPRESSIVE disorders in older adults are common(Burvill, 1995; Lebowitz et al., 1997) and are associatedwith increased all-cause mortality (Gallo, Rabins, Lyketos,Tien, & Anthony, 1997; Penninx et al., 1999; Zubenko,Mulsant, Sweet, Pasternak, & Tu, 1997). Completed suicidemay be the most preventable lethal complication. Although thegreatest number of suicides are committed by young adults, therate increases throughout the lifecourse and peaks in 80-84year olds (Centers for Disease Control [CDC], 1996, 1999).Recognizing the public health impact of completed suicide onindividuals, families, and society, the United States Congresspassed 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 onthe identification of suicide risk factors and correlates. Researchaimed at identifying personality traits associated with suicidalbehavior can contribute to prevention efforts by defining groupsat high risk, before the development of a major depressiveepisode 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 inpatients50 years of age and older, we report analyses designed todetermine the direction and strength of associations between thepersonality traits that constitute the Five Factor Model of per-sonality (Digman, 1990; John, 1990) and measures of suicidalbehavior.

The Five Factor Model (FFM) as a Hypothesis-Testingand Hypothesis-Generating Tool

Based on decades of factor-analytic research on personality inthe natural lexicon and questionnaires, there is considerable(Digman, 1990; John, 1990; McCrae & Costa, 1997), but notcomplete (Cloninger, Svrakic, & Przybeck, 1993; Tellegen,1985), agreement that personality attributes can be groupedalong five major dimensions: Neuroticism, Extraversion,Openness, Agreeableness, and Conscientiousness. Because this

model of personality provides a relatively comprehensive cover-age of personality traits, it can be used to explore and generatehypotheses 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 predictionsabout the contributions of specific personality traits to specificdimensions of suicidal behavior in particular demographic anddiagnostic 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 ofage, gender, or any other demographic or contextual variable.

Use of an omnibus personality questionnaire grounded in theFFM 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 construedas hypothesis-generating. Proponents of the FFM argue that itprovides a fixed reference point from which to assess a varietyof different scales (Costa & McCrae, 1992; Marshall, Wortman,Vickers, Kusulas, & Hervig, 1994). It therefore overcomes aperennial problem in personality psychology: Scales with dif-ferent labels measure the same trait, while those with the samelabel 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 anatural language approach to personality, self-report measures,and factor-analysis itself. He ultimately concedes that, eventhough the five factors "omit too much information" and are"insufficiently differentiated... [they] do tell us something ofinterest" (pp. 45-46). McAdams (1994) also takes issue withthe basic premises and criticizes trait assessments in general onthe grounds that they fail to provide causal explanations forhuman behavior, disregard the conditional and contextual na-ture of human experience, and fail to provide enough detailed

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PERSONALITY AND SUICIDE P19

information to predict specific behaviors in certain circum-stances. Block (1995) generally accepts the premises uponwhich FFM research is based, though he is somewhat critical ofthe "arbitrariness" (p. 189) of factor analysis and the over-reliance on self- and peer-report data. He also raises a numberof technical concerns, such as the high intercorrelations amongthe ostensibly uncorrelated five factors. Still, the FFM has with-stood criticism from those who share, and do not share, its basicassumptions (Costa & McCrae, 1995; McCrae & Costa, 1997),and it has proven useful in research on health outcomes in olderadults (Hooker, Frazier, & Monahan, 1994; Hooker, Monahan,Bowman, Frazier, & Shifren, 1998; Hooker, Monahan, Shifren,& Hutchinson, 1992). Those achievements may be sufficientjustification for its continued application to questions of publichealth 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 preciselythis sort of overlap among suicide constructs that has led to theassumption that suicidal behavior can be conceptualized alonga severity continuum, with absence of death ideation at one end,completed suicide on the other, and death ideation, suicidalideation, and attempted suicide in the middle. Similarly, it hasbeen assumed that people can be "more or less" suicidal. Thus,it has been assumed that one's "suicidality" can be captured bya 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 discretepopulations, each characterized by a discrete set of risk factors,reflecting distinct underlying personality traits or constituentcognitive, affective, and motivational processes.

The number and nature of distinct suicidal populations havebeen debated for years (Linehan, 1986; Maris, 1992). This dis-cussion must continue in order to identify and ultimately testfive of the most significant, yet implicit, assumptions in theseverity continuum model. These include the notions that (a) re-search on attempted suicide may be a proxy for research oncompleted suicide; that is, conclusions about completed suicidecan be gleaned from studies of suicide attempters; (b) researchon suicidal ideation may substitute for research on attemptedsuicide; (c) suicidal ideation is a clinical risk factor for attemptedsuicide and completed suicide; (d) attempted suicide is a clinicalrisk factor for completed suicide; and (e) the absence of reportedsuicidal 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 categoricalmodel suggests that each putative category of suicidal behaviormay have specific risk factors. The demographic data are gen-erally consistent with the categorical model. Rates of attemptedsuicide are highest in young women (Kessler, Borges, &Walters, 1999), but it is older men who are at greatest risk forcompleted suicide (CDC, 1999). Similarly, rates of suicidalideation decrease throughout the lifecourse (Blazer, Bachar, &

Manton, 1986; Moscicki, 1989), but the risk of completedsuicide 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 theFFM and specific variables related to (a) suicide attempts and(b) suicidal ideation.

The Present Study: Overview and HypothesesThe preceding sections point to the need for a study that

measures a range of personality traits and distinguishes amongputative categories of suicidal behavior. Data were collected onpsychiatric inpatients with major depressive disorder, 50 years ofage and older, about half of whom were men. This is a relativelyhomogeneous group both diagnostically and demographically,which should allay concern that relations between personalityand 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 isassociated with high Neuroticism. Extraversion refers to pref-erences for social interaction and the tendency to experiencepositive emotion (Costa & McCrae, 1992). Low Extraversionincreases risk for suicide attempts in relatively younger sam-ples (Beautrais, Joyce, & Mulder, 1999; Roy, 1998). Althoughthere have been some negative findings, low Extraversion hasbeen empirically associated with poor social support (Krause,Liang, & Keith, 1990; Von Dras & Siegler, 1997) and the useof 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, Neuroticismrefers to the disposition to experience negative affect, such assadness, anxiety, and self-consciousness. People who are highin 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 ingenerating novel hypotheses, it seemed premature to restrictour analyses to Neuroticism and Extraversion. We thereforeexplored the contributions of Openness, Agreeableness, andConscientiousness to late-life suicidal behavior. Includingthese three variables in the regression analyses also ensuredmore precise estimates of the effects of Neuroticism andExtraversion.

METHODS

ParticipantsParticipants 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 wereadmitted 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 bya suicide attempt. Although there is significant heterogeneity inthe prevalent diagnoses of young adult suicides, after age 50,the psychiatric diagnoses associated with completed suicide be-come increasingly homogeneous, and affective disorders arepresent in over 70% of cases (Conwell et al., 1996). Thus, by

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P20 DUBERSTE1NETAL.

choosing 50 as the lower age limit for study entry, we are ableto 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 thenortheastern United States (Rochester, NY), including twocommunity hospitals, one tertiary care facility, and one aca-demic medical center. Acknowledging that there are problemsinherent in any definition of "suicide attempt" (Beck &Greenberg, 1971; O'Carroll et al., 1996), attempted suicide wasdefined as an intentional self-destructive act; an expressed wishto die was not necessary.

Recruitment procedures were as follows. Project coordina-tors screened the records of all patients 50 years of age andolder 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 wereimportant variables that may have distinguished groups, comor-bid medical or psychiatric conditions were not exclusionarycriteria 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 toobtain their informed consent to be interviewed by one of theproject coordinators (all of whom have masters degrees), and tocomplete self-report questionnaires. Psychiatric diagnoses weremade 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 theresearch 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 associatedphysical illness or substance exposure suggested that the pa-tient's mood syndrome was etiologically related to a specificmedical condition or substance exposure. Of the 87 participantswho 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 mooddisorder; 4 other suicide attempters and 1 nonattempter whomet 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 wereincluded in the analyses; 14 others completed the NEO-FFI (60item 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 ourassiduous efforts to increase the return rate. Participants in thelarger study from which these analyses were conducted were,on average, about 6 years older, and scored nearly 2 pointslower on the Mini Mental State Exam (Folstein, Folstein, &McHugh, 1975; M = 25.7, SD = 4.1; M = 27.5, SD = 2.5). Thesample was predominantly Caucasian ( = 78; 96.3%), with amean (SD) age of 61.3 (9.6) years. The age range was 50 to 87years. Thirty-three (40.7%) participants were married, 21 (25.9%) were separated/divorced, and 34 (42%) lived alone at thetime of admission. One-third of the sample (n = 27, 33.3%) wasemployed, and slightly less than one-third (30.8%) was eitheron 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 withsevere 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 morethan 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/substancedisorders (n 8), panic disorder ( = 7), and phobias (n = 7)were each present in slightly less than 10% of the sample. Scoreson the Beck Hopelessness Scale (Beck, Weissman, Lester, &Trexler, 1974) were elevated (M = 12.4, SD = 5.7), consistentwith scores obtained on an older, depressed outpatient sample(Hill, Gallagher, Thompson, & Ishida, 1988). Thirty-four of the81 (41.9%) participants were admitted to the study following asuicide attempt; 20 of these participants had made previous at-tempts. Eleven of the 47 patients (13.6%) whose admissionswere 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 mostrecent previous suicide attempt ranged from less than 1 week tomore 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 a240-item measure of the five personality dimensions consis-tently identified in factor-analytic studies: Neuroticism,Extraversion, Openness to Experience, Agreeableness, andConscientiousness. 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 reportedtest-retest correlation coefficients greater than .6, attesting tothe stability of these five domains (Costa & McCrae, 1992).Although the 60-item NEO-FFI has been used in gerontologyresearch (e.g., Hooker et al., 1994) and in research on depressedoutpatients (Bagby et al., 1998), we are unaware of any studythat has used the 240-item NEO-PI-R with older, depressedinpatients.

History and number of suicide attempts.For decades, thestandard approach to research on personality and attemptedsuicide involved a static group comparison of individuals seek-ing health care following a suicide attempt with individualsseeking 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. Asa general principle, when personality traits increase risk forcertain 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, inpart, on participants' responses to the questions: "How manytimes all together in your life have you actually done somethingwith the intention of taking your life?" and "How many suicideattempts have you made in your life?" With respect to the latterquestion, past self-destructive behaviors were coded as suicide

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PERSONALITY AND SUICIDE P21

attempts if participants labeled the behavior as a suicide attempteven if they disavowed an expressed intention to die. Previouspsychiatric and medical charts were reviewed in an effort togather additional data on the number of suicide attempts.Discrepancies between the number of self-reported suicide at-tempts and chart-documented suicide attempts were resolvedby recording the higher number documented or reported.

Scale of Suicidal Ideation (SSI).Two outcome measureswere 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 theweek prior to the interview or the interval between the suicideattempt and interview, whichever was shorter. Thus, for thosehospitalized following a suicide attempt, the SSI provides dataon the presence of suicidal and death ideation following a sui-cide attempt. The first three items concern the wish to live, thewish to die, and the extent to which one wish outweighs theother. The presence of death ideation was operationally dennedas 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 and5 concern thoughts of self-destruction, either by active (e.g.,shoot yourself) or passive (e.g., not taking medicine that isneeded 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 final14 questions, which concern the frequency, duration, and theparticipant's attitude toward suicidal thoughts, were adminis-tered only to those who reported suicidal ideation in responseto Items 4 or 5. Participants obtain relatively high SSI scores ifthey report that they "accept" the suicidal thoughts, have littlecontrol over them, have little concern about family, religion, orother potential deterrents to suicide, have thought extensivelyabout how to kill themselves, written suicide notes, or changedwills or life insurance policies. Severity of suicidal ideation wasoperationally defined as the total score on the SSI. The SSI hasestablished 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 SSIcover 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 suicidalthoughts 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. Inthe 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) andestimated 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

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 ofany substance use disorder, affective disorder, and their comor-bidity ranged from 0.61 to 0.75.

Mini Mental State Exam (MMSE).The MMSE measurescognitive function (Folstein et al., 1975). Scores can range from0 to 30. The MMSE score is not used as an inclusion criterion;rather, it serves solely as a means of characterizing cognitivefunction.

Analytic Plan and Overview of Presentation of ResultsFirst, 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 countswith skewed distributions. Next, the results of a series of regres-sion analyses are reported. Binary endpoints were analyzed bymultiple logistic regression. Goodness of fit was examined byusing 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 therequired assumptions of normally distributed errors with con-stant variance. If the residual analysis indicated a violation ofassumptions, then the data were logarithmically transformedand standardized to behave like normal deviates (Chatterjee &Hadi, 1988). Cases with standardized residuals greater than 3 inabsolute value were excluded as outliers from the regressionanalysis. Counts and endpoints with skewed distributions wereanalyzed by Poisson regression (McCullagh & Nelder, 1989),which also included an outlier analysis. Standardized residualsare based on components of the Pearson chi-square statistic forgoodness of fit of the model. All analyses were adjusted for ageand gender. Predictors included age, gender, and each of thefive traits that constitute the FFM: Neuroticism, Extraversion,Openness to Experience, Agreeableness, and Conscientious-ness. All reported p values are two-tailed.

RESULTSDescriptive statistics and zero-order correlations (Kendall's

tau) between the NEO factors and continuous outcomes (SSIand number of suicide attempts) are presented in Table 1. Therewere slight, downward trends with age in Neuroticism andOpenness. The SSI score was positively correlated withNeuroticism. t tests were conducted to examine the unadjustedrelationships between the personality variables and dichoto-mous endpoints. Table 2 shows that women, suicide ideators,and death ideators obtained higher Neuroticism scores, andthose who had attempted suicide obtained lower scores onExtraversion. Of the 10 intercorrelations among the 5 NEOvariables, five had absolute values less than .07; the highestvalue was .46. Therefore, multicollinearity did not appear topose any problems for the regression analyses.

Presence and Number of Suicide AttemptsThe 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 lowerExtraversion scores were more likely to have made a lifetime

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Table 1. Unadjusted Relationship Between NEO-PI and Continuous Variables: Kendall's Tau

Continuous Variable

AgeNumber of lifetime SATotal SSI score

N

818181

M

61.300.857.52

SD

9.61.6

10.3

Ne

-.29***.19*2g***

Ex

.04-.19*-.15

Op-.17*

.04

.11

Ag

-.06-.04-.04

Co

.07-.15-.14

Ne = Neuroticism; Ex = Extraversion; Op = Openness to Experience; Ag = Agreeableness; Co = Conscientiousness; SA= Suicide Attempts; SSI = Scale forSuicidal Ideation.

*/>

PERSONALITY AND SUICIDE P23

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 theunadjusted analyses, which implicated Neuroticism in suicidalideation (Table 2). We also conducted a linear regression withthe total score on the SSI as the dependent variable. Again, onlyage was associated with that outcome, F(l,73) - 4.56,p = .04,but there was a trend for those higher in Openness to obtainhigher SSI scores, F( 1,73) = 3.25, p = .07. Next, we createdtwo groups, those who reported death ideation in response toItems 1-3 of the SSI and those who did not. Table 3 (Analysis5) shows that higher Neuroticism and higher Opennessemerged as significant predictors of death ideation. TheHosmer-Lemoshow for the overall model was nonsignificant,X2 (8) = 8.33, p = .40, indicating a satisfactory fit.

DISCUSSIONThese findings reinforce the notion that personality traits

ought to be seriously considered as potential risk factors forlate-life suicidal behavior and ideation. Even in this demo-graphically and diagnostically homogenous group of psychi-atric inpatients, personality traits were important predictors ofsuicide attempts and suicidal ideation. Although there weresome negative findings, regression analyses supported hypothe-sized associations between Extraversion and attempted suicideand between Neuroticism and suicidal ideation. These analysesalso generated a novel hypothesis linking Openness to suicidalideation.

Substantive FindingsThree 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) andincreased social support (e.g., Von Dras & Siegler, 1997), andnegatively correlated with trait, but not state, hopelessness(Young et ah, 1996). Extraverted individuals may be less likelyto engage in suicidal behavior even in the midst of a depressiveepisode because they are more likely to recruit and affectivelybenefit 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 mayreflect a tendency to take matters into one's own hands, ratherthan attempt to recruit help from others. Strategies for treatingyoung 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) withsuicidal 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 tointerventions designed to decrease the risk of nonfatal suicidalbehavior. This is important in part because suicide attemptsmay 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-lifedepressive disorders.

Although our findings are consistent with the notion thatExtraversion 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 relationshipsbetween Neuroticism and measures of suicidal ideation wereobtained in all three univariate analyses (SSB, SSI-SuicidalIdeation, SSI-Death Ideation), the regression analyses told amore complex story. Neuroticism was a strong predictor of SSI-Death Ideation in these analyses, but was not associated withthe other two suicide ideation variables. Thus, the associationsbetween 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 toreport suicidal ideation. Perhaps patients low in Openness areprotected from suicidal ideation, and consistent with the severitycontinuum 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 findingscan be ascribed to methodological differences. Self-reportedOpenness and informant-reported Openness may not be compa-rable constructs in older, depressed persons. This is unlikely,given the extensive literature supporting the relationship betweenself- and informant-reported data (Costa & McCrae, 1992), evenin depressed outpatients (Bagby et ah, 1998). In our own sampleof 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. Acknowledgingthat other methodological explanations may account for the ap-parently discrepant findings, substantive hypotheses must also beentertained. People with major depression who are low inOpenness may be at increased risk for completed suicide preciselybecause they are less likely to feel, or report feeling, suicidal. Thishypothesis represents a genuine challenge to the severity contin-uum model. Affective muting may be adaptive at earlier points inthe lifecourse, but could also increase risk for late-life completedsuicide (Clark, 1993; Duberstein, 1995). Further research onOpenness and suicidal behavior is warranted, given the obviousimplications for risk detection and prevention.

Limitations and StrengthsIt cannot be assumed that the present findings generalize to

other diagnostic and demographic subgroups. Participants whocompleted the NEO-PI-R were about 6 years younger and mayhave had slightly better cognitive function than those who didnot complete the 240-item inventory. Nor can it be assumedthat these findings generalize to the small fraction of depressedpatients with organic mood disorder. The sample size is alsorelatively small for personality research, so caution must be ex-ercised, especially in interpreting negative findings. Finally, itmust be acknowledged that the results may have differed hadother age cutoffs been used as the lower limit of study entry(e.g., 60 or 65).

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These limitations must be weighed against the study'sstrengths, chief of which are its public health significance andits foray into new territory. No previous study has applied acomprehensive personality taxonomy to the study of late-lifesuicidal behavior. Suicide is a major public health problem. Byattempting to identify putative risk factors for suicidal behavior,social scientists can contribute to prevention efforts by defininggroups at high risk, before the development of an acute crisis.This study represents a step in that direction. Other strengths ofthe study include a well characterized and carefully diagnosedsample at future risk for self-harm.

ConclusionOur 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 andbehavior are not an inevitable consequence of aging, disease,disability, or even depression. The current findings thuschallenge an ageist stereotype that has probably contributedto a lack of interest in preventing late-life suicide (AARPFoundation/Center for Mental Health Services, 1997). On theother hand, findings must be regarded as preliminary. Severallines of preintervention research ought to be pursued.

The "state-trait problem" potentially confounds research onpsychiatric inpatients, many of whom may be in acute distresswhile 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 nolonger 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 psychologicalinformation.

By collecting data on a relatively homogeneous group ofolder persons with major depression, we sought to decrease theprobability that potentially confounding effects of age or majorpsychiatric diagnosis would obscure relationships between per-sonality and suicide variables. Still, heterogeneity was apparentin the analyses on previous suicide attempts. These analysessuggested that Neuroticism may contribute to multiple suicideattempts in those with comorbidity. Further research on largersamples may be necessary to determine whether the personalitytraits associated with suicidal behavior in depressed patientswith 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, attemptedsuicide, and completed suicide are categorically distinct (cf.Flett, Vredenburg, & Krames, 1997; Meehl, 1992), tragediesmay 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 bemisguided. Variables associated with the absence of reportedsuicidal ideation, such as low Openness, may not confer de-creased risk for completed suicide. Paradoxically, in somepatients 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 suicidalideation, with Extraversion associated with the former andOpenness more closely tied to the latter. We are not arguing foreliminating the severity continuum model of suicide; rather, weare suggesting that the categorical model has much to offer. It islikely that suicide ideators, suicide attempters, and completedsuicides are categorically discrete groups, each characterized bya discrete set of risk factors, reflecting distinct underlying per-sonality and constituent cognitive, affective, and motivationalprocesses. Recognition of these differences may result in moreefficient prediction of attempted and completed suicide (Ruddet al., 1996).

A promising approach to preventing suicide in older adultsinvolves screening for depression in primary care practices(Unutzer, Katon, Sullivan, & Miranda, 1999). However, somebelieve that the need for legalization of assisted suicide in cer-tain contexts is as pressing a need as suicide prevention. Thisdilemma is complicated by the absence of consensus regardingthe conceptualization, measurement, or treatment of psycholog-ical distress or psychiatric disorders in individuals with life-threatening illnesses. Still, screening instruments have beenshown to have adequate sensitivity and specificity in predictingmajor 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 aswell. All screening and surveillance mechanisms should belinked to systems capable of providing a range of interventionsand services.

ACKNOWLEDGMENTSThis project was financially supported in part by Public Heakh Service

Grants K07-MH01135, R03-MH55149, and RO1-MH51201. Nancy Talbot, JillEichele, and anonymous reviewers provided helpful comments on previousdrafts of the manuscript. We also wish to extend our appreciation to AndreaDiGiorgio, Wendy Wyland, Jack Herrmann, Barbara Hughson, MeganCavanagh, and Tamson Kelly Noel for their assistance in data collection; toCarrie Irvine for data management; and to Josephine Lauri and Marge Robertsfor manuscript preparation. An earlier version of this article was presented atthe 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, NY14642. E-mail: Paul_Duberstein@unnc.rochester.edu

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Received August 12. 1998Accepted August 18, 1999Decision Editor: Toni C. Antonucci, PhD

CALL FOR PAPERS!The 53rd Annual Scientific Meeting ofThe Gerontological Society of America

November 17-21, 2000, Washington, D.C

Abstracts due April 3, 2000. See www.geron.org for details.

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