Abstract and Introduction
Abstract
Purpose: The purposes of these studies were to develop and initially evaluate the psychometric properties of the Reasons for Living Scale—Older Adult version (RFL-OA), an older adults version of a measure designed to assess reasons for living among individuals at risk for suicide.
Design and methods: Two studies are reported. Study 1 involved instrument development with 106 community-dwelling older adults, and initial psychometric evaluation with a second sample of 119 community-dwelling older adults. Study 2 evaluated the psychometric properties of the RFL-OA in a clinical sample. One hundred eighty-one mental health patients 50 years or older completed the RFL-OA and measures of depression, suicide ideation at the current time and at the worst point in one's life, and current mental status and physical functioning.
Results: Strong psychometric properties were demonstrated for the RFL-OA, with high internal consistency (Cronbach's alpha coefficient). Convergent validity was evidenced by negative associations among RFL-OA scores and measures of depression and suicide ideation. RFL-OA scores predicted current and worst-episode suicide ideation above and beyond current depression. Discriminant validity was evidenced with measures of current mental status and physical functioning. Criterion-related validity was also demonstrated with respect to lifetime history of suicidal behavior.
Implications: These findings provide preliminary support for the validity and reliability of the RFL-OA. The findings also support the potential value of attending to reasons for living during clinical treatment with depressed older adults and others at risk for suicide.
Introduction
Older adults, 65 years of age and older, are at greater risk for suicide than any other age group in the United States, with White men, aged 85 years and older, having the highest rate of suicide (National Center for Injury Prevention and Control [NCIPC], 2007). Older adults less frequently engage in self-harm behavior than do younger individuals but are considerably more likely to die as a result of self-harm (Draper, 1996). Older adults account for 20% of deaths by suicide but represent only 13% of the U.S. population (NCIPC).
Although these suicide rates are astonishingly high, little research has addressed suicidal ideation and behavior among older adults (Pearson & Brown, 2000). Equally astonishing is the fact that 70% of older adults who died by suicide had seen their primary care provider within 30 days of their deaths (Conwell, Olsen, Caine, & Falnnery, 1991; Diekstra & van Egmond, 1989; Luoma, Martin, & Pearson, 2002). These data suggest that many individuals who are at risk for suicide are, in principle, identifiable, and their suicides are potentially preventable. Although some predictors of older adult suicide are known (e.g., psychiatric illness, physical illness, functional impairment; Heisel & Duberstein, 2005), the lack of research focus on older adults to date has hindered the advancement of our knowledge regarding the assessment of suicide risk and prevention of suicide in this population. Age-related changes in the phenomenology and presentation of mental disorders (e.g., Edelstein, Kalish, Drozdick, & McKee, 1999; Kogan, & Edelstein, 2004; Edelstein et al., 2008) suggest the need for assessment instruments tailored to older adults. Unfortunately, to date there is only one published self-report suicide risk assessment instrument created explicitly for older adults (Heisel & Flett, 2006). Much of the research on suicide risk among younger adults, and most of the risk assessment instruments, have focused on demographic risk factors (e.g., marital status, age, sex), clinical variables (e.g., depression), and behaviors that place individuals at risk for suicide (see Brown, 1999, for instrument reviews). Another approach to suicide risk assessment focuses on assessing resiliency factors potentially preventive of suicide risk (Heisel & Flett, 2008). One example is an instrument initially developed by Linehan, Goodstein, Nielsen, and Chiles (1983) that measures reasons for not taking one's life despite suicidal thoughts or considerations. A major assumption of these reasons for living instruments is that suicidal individuals are lacking in adaptive beliefs present among nonsuicidal individuals that deter suicidal behavior. The reasons for living examined through these instruments can be considered buffers or personal and environmental contingencies operating against suicide. Reasons for living instruments have been developed for a variety of different age groups.
In their original research, Linehan and colleagues (1983) found that individuals with prior suicidal behavior reported fewer reasons for living than individuals with no suicidal history. Moreover, those with suicidal histories valued reasons for living to a smaller degree. That is, they rated reasons for living as less important than individuals with no suicidal history. More recent research (Cole, 1989; Gutierrez et al., 2002; Osman et al., 1993, 1998) has offered further support for the assessment of reasons for living in diverse populations (e.g., psychiatric inpatients, college students, delinquent adolescents). As one might expect, reasons for living are different for different age groups (Koven, Edelstein, & Charlton, 2001). In a preliminary study, Koven and colleagues combined reasons for living from scales developed for adolescents (Osman et al., 1998), adults (Linehan et al.) and older adults (Edelstein, McKee, & Martin, 2000) and found age-related differences in reasons for living for participants ranging in age from 19 to 88 years. Miller, Segal, and Coolidge (2001) compared older and younger adults' reasons for living using the reasons for living inventory (Linehan et al.) and found both overlap and differences in reasons for living between these two age groups. These foregoing studies suggest that scales intended to measure reasons for living must be appropriate to the age group being assessed (i.e., content valid), consistent with geropsychology practice guidelines (American Psychological Association, 2004). Although reasons for living inventories have been developed for adolescents, college students, young adults, and adults, no such inventory had been created for older adults. The purpose of the present article was to describe the development and psychometric evaluation of an older adult reasons for living inventory, termed the Reasons for Living Scale—Older Adult version (RFL-OA; Edelstein et al., 2000). The first study involved the initial development of the RFL-OA and was divided into three parts. In the first part, the items of the RFL-OA were developed. In the second part, the items were administered to a group of older adults to examine the preliminary psychometric properties of the instrument. Study 2 examined the psychometric properties of the RFL-OA with a group of depressed older mental health patients. Specific aims included examination of the internal consistency of the RFL-OA. Construct validity was assessed by correlations among the RFL-OA and established clinical research measures of depression and suicide ideation (convergent validity), and exploration of potential incremental validity of RFL-OA scores in explaining additional variability in suicide ideation scores above and beyond that contributed by depression severity. Correlations between the RFL-OA and current mental and functional status explored the measure's discriminant validity. Criterion-related validity was assessed by comparing RFL-OA scores for participants with or without a lifetime history of suicidal behavior.