ORIGINAL RESEARCH
published: 14 September 2021
doi: 10.3389/fpsyt.2021.737393
Frontiers in Psychiatry | www.frontiersin.org 1 September 2021 | Volume 12 | Article 737393
Edited by:
Daniel Bressington,
Charles Darwin University, Australia
Reviewed by:
Yari Gvion,
Bar-Ilan University, Israel
Adam Horwitz,
University of Michigan, United States
*Correspondence:
M. David Rudd
mdrudd@memphis.edu
Specialty section:
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Psychiatry
Received: 09 July 2021
Accepted: 17 August 2021
Published: 14 September 2021
Citation:
Rudd MD and Bryan CJ (2021) The
Brief Suicide Cognitions Scale:
Development and Clinical Application.
Front. Psychiatry 12:737393.
doi: 10.3389/fpsyt.2021.737393
The Brief Suicide Cognitions Scale:
Development and Clinical Application
M. David Rudd1
* and Craig J. Bryan2
1
Department of Psychology, University of Memphis, Memphis, TN, United States, 2
Department of Psychiatry and Behavioral
Health, The Ohio State University Wexner Medical Center, Columbus, OH, United States
The study explored the development of the Brief Suicide Cognitions Scale (B-SCS),
a simple and brief measure of suicide risk. The B-SCS provides a brief measure that
captures critical aspects of suicide risk embedded in core beliefs about the self as
unlovable, one’s emotional experience as unbearable, and life problems as unsolvable
(i.e., the suicidal belief system), resulting in chronic or enduring suicide risk and
heightened vulnerability for acute episodes secondary to internal and external triggers.
Data were analyzed from three diverse samples, including a student sample (N = 349),
an inpatient psychiatric sample (N = 160), and a sample of emergency department
(ED) patients presenting secondary to a suicidal crisis (N = 94). Those in the student
and inpatient samples completed additional symptom measures (hopelessness, anxiety,
depression) and the ED sample provided 6-month follow-up data for suicide attempts.
Reliability (internal consistency, test-retest), concurrent validity, construct (divergent,
convergent) validity, factorial, incremental, and predictive validity were evaluated,
along with calculation of predictive value of negative and positive tests, sensitivity,
and specificity estimates. The B-SCS demonstrated good reliability and validity, a
unidimensional factor structure across samples, along with good predictive validity and
value in real-world clinical settings. The B-SCS is a brief, reliable and valid measure of
suicide risk, with good ability to identify those with enduring risk for subsequent suicide
attempts. The B-SCS offers a unique contribution to understanding and assessing the
nature of suicide risk over time targeting the suicidal belief system, with easy application
across inpatient and outpatient clinical settings, and good predictive value.
Keywords: suicide risk assessment, acute risk, Chronic risk, long-term risk, Brief Suicide Cognitions Scale
INTRODUCTION
Recent findings have highlighted the limited predictive value of traditional approaches to assessing
suicidal thinking and behaviors in real-world clinical settings, specifically the limitations of
relying on endorsement of suicidal thinking. Both Bjureberg et al. (1) and Simpson et al.
(2), utilizing large samples from psychiatric emergency departments with suicide outcomes at
30 and 365-days post-discharge, found the Columbia Suicide Severity Rating Scale (C-SSRS)
screener to have poor predictive value. Similarly, (3) found that prior suicidal thoughts and
behaviors only provided “marginal improvement in diagnostic accuracy above chance (p. 2).”
In the largest meta-analysis to date, covering a span of 50 years, (4) similarly found: (a) that
predictive value has not improved, (b) predictive values are only slightly better than chance across
Rudd and Bryan Brief Suicide Cognitions Scale
all outcome measures, (c) and ultimately called for fundamental
changes in approach to suicide risk assessment, particularly
across real-world clinical settings.
The application of ecological momentary assessment (EMA)
to suicidal thinking has, arguably, revealed one possible reason
for the poor predictive value of traditional approaches. More
specifically, EMA studies [e.g., (5, 6)] have revealed significant
natural variability in suicidal thinking, negative affect, and
individual history of self-harm, with fluctuations on an hour
to hour, day to day, and week to week basis, characterized by
wide shifts for those at highest risk. EMA also revealed periods
of suicidal thinking that are likely undetected by traditional,
retrospective approaches. Fluid vulnerability theory [FVT; (7)],
a theory addressing the variable nature of suicide risk over
time, offers a fundamental distinction between chronic and
acute suicide risk, and an approach to understanding the rapid
shifts in suicide risk revealed by EMA. Acute episodes of risk
are believed to be time-limited and driven predominantly by
situational and contextual variables (e.g., severity and mix of
current symptoms, life stressors, substance abuse, nature of
suicidal thinking, access to method), while chronic suicide risk
represents enduring individual vulnerability for suicidality that
cuts across multiple domains, including cognitive, physiological,
affective, motivational, and behavioral. Ultimately, chronic or
enduring suicide risk describes an individual’s “baseline” level
of risk, or their underlying vulnerability to experience an acute
episode in the future, an idea that is not markedly dissimilar
from what Maris (8) originally referred to as “suicidal careers.” In
short, FVT argues suicide risk fluctuates over time and when an
acute episode of risk resolves (e.g., following a suicide attempt),
the individual returns to a unique vulnerability “set point,” their
baseline level of risk or what can be referred to as “residual risk,” a
level determined by their life experiences (e.g., previous trauma,
abuse, genetic history), biology/physiology, cognitive, affective,
motivational makeup, and behavioral history.
Approaches to assess and understand suicidality have
disproportionately focused on measuring acute risk episodes, and
frequently take the form of assessing suicidal ideation, plans,
intent, and urges, with predictive shortcomings summarized
above. By comparison, efforts to assess and understand
underlying and enduring individual vulnerability to suicidality,
or chronic risk, have been more limited. The construct of
hopelessness has played a central role in understanding suicide
risk over time [e.g., (9, 10)], cutting across both acute and chronic
risk dimensions. As originally conceptualized by Abramson et
al. (11) hopelessness had both enduring features (i.e., trait)
and contextual ones (i.e., state), noting that trait hopelessness
involved negative future expectancies that cut across most
domains of daily functioning, driven in large part by core beliefs
about self, with core beliefs that are self-punitive, negative,
and derogatory in nature being especially key. As a result,
hopelessness has often been a key variable in understanding and
assessing enduring risk [e.g., (9)]. Similarly, the constructs of
perceived burdensomeness [e.g., (12)] and acquired capability
(13) have both been demonstrated to be critical to understanding
and capturing enduring suicide risk, as discussed in Joiner’s
(14) Interpersonal-Psychological Theory of Suicide. In FVT, core
beliefs about self are referred to as the “suicidal belief system”
and are characterized by pervasive identity-based hopelessness
and captured, to some degree, by core beliefs about the self as
unlovable, one’s emotional experience as unbearable, and one’s
life problems as unsolvable.
Similarly, Wenzel et al. (15) emphasized the importance
of “schemas” in understanding suicide risk and related states
over time. In particular, they emphasized the importance of
trait hopelessness and “unbearability,” with both representing
enduring vulnerability to suicidal episodes, consistent with the
notion of chronic risk in FVT. The idea of enduring vulnerability
and subsequent emergence of an acute suicidal episode was also
captured by the suicidal mode (16), an elaboration of traditional
linear cognitive theory and models (17), including cognitive,
behavioral, affective and motivational dimensions. Enduring
vulnerability to new episodes of suicidality following resolution
of an acute episode of suicidality represent “residual risk,” with
the suicidal belief system and trait hopelessness being a critical
component, and capturing much of its explanatory power (7).
The original Suicide Cognitions Scale [SCS; Rudd et al.1]
was developed to measure suicide-specific and identity-based
hopelessness consistent with FVT and the suicidal mode (7). SCS
items are believed to tap the source of suicidal hopelessness along
two primary themes, that is, two dimensions of the cognitive
triad: self and others (18). Within the self-theme, items address
sources of hopelessness well-documented in the suicide literature
including unlovability (18, 19), helplessness [e.g., (20, 21)], and
poor distress tolerance (22), the latter of which has been referred
to as unbearability by Wenzel et al. (15). Within the other-theme
items assess the construct of perceived burdensomeness (23, 24).
Subsequent work on the SCS has been promising,
with findings across settings and populations suggesting
three potential factors that have been termed unlovability,
unbearability, and unsolvability (25–28), consistent with the
original conceptualization of the suicide belief system and FVT
(16). Ellis and Ruffino (28) also found evidence to support the
idea that the SCS measured enduring suicide risk consistent
with identity-based hopelessness and core beliefs that the self
was unlovable, one’s emotional experience was unbearable,
and one’s life problems were unsolvable. Subsequent research
using bifactor modeling indicates that although the SCS has
some multidimensionality, as theorized and demonstrated, item
responses are also strongly influenced by a general latent factor
(29). These findings suggest that that unlovability, unbearability,
and unsolvability are influenced by a common, underlying
suicidal belief system captured by the items in the Brief Suicide
Cognitions Scale.
Accumulating research also supports the SCS’s validity as an
indicator of emerging and residual suicide risk. For instance,
SCS scores significantly differentiate those who have attempted
suicide from those with a history of suicide ideation only, and
prospectively predict suicide attempts even when accounting for
suicidal ideation (25, 29). In light of these findings, researchers
1Rudd MD, Schmitz B, McClenen R, Joiner TE, Elkins G, Claassen C.
The Suicide Cognitions Scale: Measuring Suicide-Specific Cognitions (2008).
unpublished manuscript.
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Rudd and Bryan Brief Suicide Cognitions Scale
have tested and validated shortened versions of the scale that
may be more practical for use in clinical settings as a screening
and/or assessment tool (26, 29). Taken together, these studies
suggest the SCS assesses aspects of suicidality that are distinct
from suicidal ideation, plans, intent and urges, consistent with
recent calls for new approaches (30), and arguably the most
important contribution of the B-SCS.
As evidence has emerged to support the SCS and its ability
to assess unlovability, unbearability, and unsolvability and its
unique role in understanding and targeting suicide risk over
time, questions persist about the construct of identity-based
hopelessness and how best to capture: (a) chronic or enduring
suicide risk consistent with FVT, (b) the suicidal belief system
embedded within the suicidal mode, and (c) the idea of residual
risk following an acute episode (7). Over the course of the
last several years, FVT has been modified to include a more
refined and precise understanding of identity-based hopelessness
specific to the issue of suicidality, noting that identity-based
hopelessness is captured by the constructs of unlovability,
unbearability, and unsolvability. The B-SCS captures suicide risk
embedded in beliefs about the self as unlovable, one’s emotional
experience as unbearable, and life problems as unsolvable (i.e.,
the suicidal belief system), resulting in chronic suicide risk or
heightened vulnerability for the emergence of acute suicidal
crises over time and elevated residual risk after an acute episode
has resolved. Consistent with FVT, unlovability, unbearability,
and unsolvability are what creates enduring vulnerability (i.e.,
chronic risk) and greater likelihood that an acute episode of
suicidality will be triggered in some individuals, along with the
idea of “residual risk” following an attempt or acute episode
of suicidality. A review of the SCS item content and previous
findings convinced us it was possible to capture risk across
the suicide belief system in a simple, brief, and potentially
unidimensional scale (i.e., the general latent factor noted above),
representing a natural evolution of the suicidal belief system
and, hopefully one that is: (a) easier to use in clinical settings,
(b) effective in predicting suicide risk and behavior over time,
and (c) helpful in the treatment of specific aspects of underlying
identity beliefs that generate enduring individual vulnerability.
Consistent with these objectives, the current study included the
following aims:
1 Development of the B-SCS that would be easy to use in
real-world clinical settings.
2 Development of a brief measure that predicts
suicidal behavior.
3 Exploration of the reliability and validity, including construct,
factorial, incremental, and predictive validity, of the B-SCS.
4 Initial exploration of scale properties across both clinical and
non-clinical samples.
5 Review of possible clinical applications of the scale, including
the assessment and treatment of suicide risk.
METHODS
Participants
Participants included three diverse samples, a non-clinical
sample of undergraduate students (N = 349) participating
in research as a requirement for an introductory psychology
course, a clinical sample of consecutive inpatient admissions
to a psychiatric unit in a major tertiary care medical center
(over an 18-month period; N = 160), and a clinical sample
of 94 suicide attempters (N = 53) and ideators (N = 41)
presenting to an emergency department in a tertiary care medical
center. The three studies did not occur simultaneously, rather
were conducted over approximately a 24-month time frame.
There were no exclusion criteria for the undergraduate sample,
aside from evidence of an acute crisis warranting emergency
evaluation and intervention (i.e., individual distress or upset
during the study). No students were excluded for this reason,
however. Exclusion criteria for the two clinical samples included:
(a) active psychosis, (b) cognitive impairment that prevented
participation (e.g., dementia, delirium, diminished intellectual
functioning), and (c) impairment in reading and comprehension
that resulted in an inability to read, understand, and complete
study instruments, as well as the informed consent documents
(e.g., severe learning disorders). As the study was reviewed
and approved by the institutional review board, all participants
reviewed and signed appropriate informed consent documents.
Each sample is described in more detail below.
Sample 1: Undergraduate Students
The student sample included 291 females (83%) and 58
males (17%) participating in research for extra credit for an
introductory psychology course, for a total N of 349. Ages ranged
from 18 to 33, with a mean of 19. There was reasonable selfidentified
diversity in the sample, with 34 African-American
(10%) participants, 29 Hispanic/Latino (8%), 31 Asian (9%), 1
Native American (0.3%), 1 East Indian (0.3%), 247 White/NonHispanic
(71%), and 6 participants designated as “other” (1.4%).
With respect to marital status, the overwhelming majority were
single and had never been married (N = 345, 99%), with
only 4 (1%) reporting being married. In terms of academic
status, the majority were freshman (N = 165, 47%), with 87
(25%) sophomores, 61 (18%) juniors, and 36 (10%) seniors.
Although clinical diagnostic assessments were not completed on
the student sample, participants did complete a few additional
demographic and personal history questions, including one on
previous mental health care. Additionally, the full Beck Scale for
Suicidal Ideation (31) was administered, and item 20 on the scale
allowed us to identify those with a previous history of suicide
attempts. As would be expected with a non-clinical student
sample, a relatively small number, 40 (11%), reported a previous
history of mental health care (either inpatient or outpatient) and
a similar number (31, 9%) reported a previous history of at least
one suicide attempt, providing limited variability in the sample
and the opportunity for clinical comparisons.
Sample 2: Psychiatric Inpatients
The first clinical sample included 160 consecutive admissions to
an inpatient psychiatric unit, including 113 females (71%) and
47 males (29%). The mean age was 40, with a range of 18–81
years old. As with the student sample, self-identified diversity
was reasonable with 16 (10%) African-American participants,
3 (2%) Native American, 17 (11%) Hispanic/Latino, 122 (76%)
White/Non-Hispanic participants and two indicating ethnicity as
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Rudd and Bryan Brief Suicide Cognitions Scale
“other” (1%). In terms of marital status, 38 (24%) were single and
never married, 60 (38%) married, 18 (11%) separated, 34 (21%)
divorced, and 10 (6%) widowed. With respect to educational
history, 22 (14%) reported that they did not have a high school
degree, 81 (51%) graduated from high school, 26 (16%) attended
some college, 21 (13%) completed a college degree, and 10 (6%)
had advanced degrees.
Participants in this clinical sample were administered a
brief demographic interview with a trained nurse to obtain
background information (ethnicity, educ1ation level, marital
status, number of previous psychiatric hospitalizations if any,
and number of previous suicide attempts if any). Suicide
attempt status and Axis-I clinical diagnosis(es) were determined
by reviewing the admission note in the medical record. Not
all subjects received an Axis I diagnosis in the chart, with
some receiving a deferred diagnosis and others receiving a
primary diagnosis on Axis II. Fifty-eight (36%) participants
did not receive an Axis I diagnosis, with indications that the
diagnosis was pending or the primary diagnosis was on Axis II.
After completion of the history and chart review, participants
completed all self-report measures in random order. As part of
the participant’s discharge paperwork, they were also given the BSCS
items. The length of stay for the clinical sample ranged from
1 to 21 days, with a mean of 4.8 days.
The most common primary Axis I diagnosis was a depressive
disorder (including major depressive disorder both single and
recurrent episodes, along with depressive disorder not otherwise
specified), with 60 (38%) subjects diagnosed as depressed,
followed by substance abuse (N = 18, 11%) (including alcohol,
cannabis, opioids, and polysubstance abuse), bipolar disorder
(N = 9, 6%) and adjustment disorder (N = 5, 3%). The most
frequent Axis II was borderline personality disorder, with 19
(12%) participants receiving this diagnosis. A total of 100 (63%)
participants were admitted for a suicidal crisis and 68 (43%)
reported multiple admissions over their lifetime, with a range of
1–25 and a mean of two. Ninety (56%) reported that it was their
first admission for suicidality. A total of 87 (54%) participants
reported a prior history of suicide attempts regardless of the
status of the current admission, with a range of 1–20, and a
mean of 2.5 previous suicide attempts, providing an opportunity
to compare ideators, single attempters, and multiple attempters.
As mentioned above, suicide attempt status at the time of
admission was accomplished by clinical chart review, with the
admitting psychiatrist indicating suicide intent and categorizing
the behavior as a suicide attempt. Participants completed the
Beck Depression Inventory [BDI; (32)], the Beck Hopelessness
Scale [BHS; (33)], the Beck Anxiety Inventory (34), the Beck Scale
for Suicide Ideation (35), and the Trait Suicidality Scale items.
Sample 3: Emergency Department Patients
The second clinical sample included a total of 94 participants
(51 making suicide attempts, 43 experiencing suicidal thoughts)
presenting to an emergency department at a tertiary care medical
center during an acute episode of suicidality. A significant
majority of the sample (N = 77, 81.9%) reported previous
episodes of suicidality. The mean age was 38 years (SD =
10.5), and a range of 18–58 years, with 51 females and 43
males. Self-identified diversity was reasonable with 58 (61.7%)
reporting as White, 22 (23.4%) Black, 12 (12.8%) Hispanic, and
2 (2.1%) Native American. With respect to marital status, 32
(34%) reported being single/never married, 23 (24.5%) married,
19 (20.2%) divorced, 7 (7.4%) separated, 9 (9.6%) cohabitating,
and 4 (4.3%) widowed. Although additional measures were not
collected, participants agreed to a 6-month phone follow-up call
to assess the presence of any subsequent suicide attempts (i.e.,
suicide attempt Time 2), allowing an opportunity to address the
predictive value of the B-SCS items. A total of 16 suicide attempts
were reported at T2 (17% of the original sample).
Measures
All participants in Samples 1 and 2 completed the same
measurement battery, with the order of presentation
randomized, those in Sample 3 did not, they completed the
B-SCS items and a 6-month follow-up call to assess the presence
of any subsequent suicide attempts (i.e., suicide attempt Time
2). Total completion time varied across subjects, with a range
of ∼20–60 min. As mentioned above, Sample 2 participants
completed the B-SCS items at both admission and discharge
and Sample 3 had a 6-month follow-up interview regarding
subsequent suicide attempts.
Beck Hopelessness Scale
Beck Hopelessness Scale [BHS; (33)]. The Beck Hopelessness
Scale (BHS) is a 20-item, true-false scale that was designed to
measure the degree to which a person’s cognitions are dominated
by negative future expectancies (36). Scores are obtained by
summing the keyed responses which yields a score between 0 and
20. The BHS has been found to have high internal consistency
reliability (K-R 20s typically in the 0.90’s) in previous research (9)
and good validity. Correlations for the BHS with clinical ratings
of hopelessness are in the 0.70’s (33). In the present study KR-20
was 0.94 for the clinical sample and 0.96 for the student sample.
Beck Depression Inventory-II
Beck Depression Inventory-II [BDI; (32)]. The Beck Depression
Inventory-II (BDI-II) is a 21-item, self-report scale that has been
used widely in research. Scores are obtained by summing the
21 ratings yielding a score that ranges from 0 to 63. The BDI
has accrued a sound research base (37) with sound psychometric
properties. High levels of convergent and divergent validity, as
well as reliability have been established in prior research (37, 38).
In the present study, internal consistency reliability was good
with a Cronbach’s alpha of 0.93 for the clinical sample and 0.87
for the student sample.
Beck Anxiety Inventory
Beck Anxiety Inventory [BAI; (33)]. The Beck Anxiety Inventory
(BAI) is a 21-item self-report scale that was designed to measure
the breadth and intensity of anxiety symptoms. BAI scores are
calculated by summing the item scores and yields a score between
0 and 63. The BAI has shown high internal consistency and
convergent validity (34). In the present study, Cronbach’s alpha
was 0.93 for the clinical sample and 0.97 for the student sample.
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Rudd and Bryan Brief Suicide Cognitions Scale
Beck Scale for Suicide Ideation
Beck Scale for Suicide Ideation [BSS; (31)]. The Beck Scale for
Suicide Ideation is a 21-item self-report scale that was designed to
measure suicidal ideation. BSS scores are calculated by summing
item scores and yields a score between 0 and 63. The BSS has
been shown to possess high internal consistency and convergent
validity, with a previous alpha of 0.90 (35). In the present study
Cronbach’s alpha was 0.95 for the clinical sample and 0.81 for the
student sample.
Brief Suicide Cognitions Scale
Brief Suicide Cognitions Scale (B-SCS). The B-SCS is a 6-item
self-report scale that was designed to measure the suicidal belief
system using items originally developed for the SCS, capturing
enduring or identity-based hopelessness embedded in core
beliefs about the self as unlovable, one’s emotional experience
as unbearable, and one’s life problems as unsolvable (i.e., the
elements of the suicidal belief system), resulting in persistent
vulnerability for the emergence of acute suicidal crises over time
secondary to both internal and external triggers. The six items
selected for the B-SCS include two items each for unlovability,
unbearability, and unsolvability, and were those that evidenced
the strongest factor loadings across previous research, coupled
with content validity. B-SCS employs Likert-scaling (1–5) and
scores are calculated by summing the keyed responses and yields
a score between 6 and 30. Only on item mentions the word
“suicide.” Reliability and validity data are presented below.
RESULTS
Internal Consistency and Test-Retest
Reliability
Internal consistency reliability for the B-SCS was excellent,
particularly for a six-item scale, with Cronbach’s alpha of 0.90 for
Sample 1 (students), 0.91 for Sample 2 (psychiatric inpatients),
and 0.84 for Sample 3 (ED patients). A small group from
Sample 1 (N = 33) was randomly selected to test the general
stability of scores over a very brief period of time, i.e., 5
days. The test-retest reliability coefficient (Pearson productmoment
correlation) for the initial B-SCS and that taken 5
days later was 0.84 (p < 0.0001), consistent with expectations
that scores would remain reasonably stable in non-clinical
samples. As mentioned above, Sample 2 was tested at both
intake and discharge (i.e., a second B-SCS was administered
at discharge). Unlike Sample 1, however, it was anticipated
that there would be some change in B-SCS scores from
admission to discharge, consistent with symptom recovery and
stabilization during the course of the hospital stay for an acute
episode of suicidality. However, we did anticipate continued
clinical elevation in scores and greater temporal stability given
the enduring nature of core beliefs and the suicidal belief
system. This was evident in the test-retest reliability coefficient
(Pearson product-moment correlation) of 0.46 (p < 0.0001),
with a moderate value, again consistent with the nature of
the construct.
TABLE 1 | Item descriptive statistics for B-SCS.
Item M SD Item-total correlation* % Endorsing each response option
1 2 3 4 5
Inpatient sample (N = 160)
I am completely unworthy of love. 2.75 1.45 0.72 26.8 23.5 14.4 19.0 16.3
Nothing can help me solve my problems. 2.59 1.32 0.77 25.2 29.0 17.4 18.1 10.3
I can’t cope with my problems any longer. 3.43 1.33 0.79 12.3 12.9 20.6 27.7 26.5
I can’t imagine anyone being able to withstand this kind of pain. 3.45 1.41 0.71 14.8 11.0 18.7 25.2 30.3
There is nothing redeeming about me. 2.77 1.33 0.78 22.8 20.8 25.5 18.1 12.8
Suicide is the only way to end this pain. 2.45 1.35 0.75 34.2 20.0 22.6 12.9 10.3
ED patient sample (N = 94)
I am completely unworthy of love. 2.44 1.31 0.65 27.7 36.2 10.6 16.0 9.6
Nothing can help me solve my problems. 2.33 1.22 0.52 26.6 42.6 9.6 13.8 7.4
I can’t cope with my problems any longer. 3.12 1.44 0.71 17.0 25.5 7.4 28.7 21.3
I can’t imagine anyone being able to withstand this kind of pain. 3.45 1.33 0.52 8.5 24.5 6.4 35.1 25.5
There is nothing redeeming about me. 2.51 1.28 0.65 24.5 36.2 10.6 21.3 7.4
Suicide is the only way to end this pain. 2.51 1.47 0.68 33.0 27.7 10.6 12.8 16.0
Student sample (N = 349)
I am completely unworthy of love. 1.25 0.72 0.70 86.2 7.1 3.0 3.0 0.7
Nothing can help me solve my problems. 1.25 0.61 0.77 81.7 13.1 3.7 1.1 0.4
I can’t cope with my problems any longer. 1.23 0.63 0.76 85.1 9.0 4.1 1.5 0.4
I can’t imagine anyone being able to withstand this kind of pain. 1.27 0.75 0.68 85.1 7.5 3.7 2.6 1.1
There is nothing redeeming about me. 1.21 0.57 0.82 84.8 10.8 3.3 0.7 0.4
Suicide is the only way to end this pain. 1.07 0.35 0.60 95.1 3.7 0.7 0.0 0.4
*All item-total correlations significant a p < 0.0001.
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Rudd and Bryan Brief Suicide Cognitions Scale
TABLE 2 | Correlations of B-SCS with other clinical variables across inpatient and
student samples.
BDI BHS BSS BAI B-SCS-A
Inpatient sample (N = 160)
B-SCS-admission 0.71** 0.75** 0.72** 0.35**
B-SCS-discharge 0.33** 0.47** 0.39** 0.14 NS 0.46**
B-SCS-revised
(B-SCS-discharge scores)
0.31** 0.45** 0.32** 0.12 NS
Student sample (N = 349)
B-SCS 0.34** 0.13* 0.32** 0.08 NS
**Correlation is significant at the 0.01 level.
*Correlation is significant at the 0.05 level.
NS, non-significant; BDI, Beck Depression Inventory-II; BHS, Beck Hopelessness Scale;
BSS, Beck Scale for Suicide Ideation; BAI, Beck Anxiety Inventory.
TABLE 3 | B-SCS predictive value.
Follow-up
suicide attempt
No follow-up
suicide attempt
Totals
B-SCS above cutoff 13 16 51 67
B-SCS below cutoff 13 0 27 27
Totals 16 78 94
Negative predictive value 1.00
Positive predictive value 0.239
Sensitivity 1.00
Specificity 0.346
Bold values indicate number of participants reporting either suicide attempts or no suicide
attempts at follow-up.
Item Analysis and Content Validity
The means, standard deviations, item-total correlations,
and item-level responses are provided in Table 1. Item-level
responses mirror what would be anticipated across all three
samples, including marked elevations in item-level scores at
higher levels (i.e., 4-agree or 5-strongly agree) for the two clinical
samples in contrast to the non-clinical student sample. Across
all three samples, the item-total correlations also suggested
appropriate item inclusion, with all correlations significant
beyond the 0.001 level.
Concurrent Validity
Table 2 provides the correlation matrix for all study variables
for Sample 1 and Sample 2. As noted, participants in Sample 3
did not complete the assessment battery. The table includes the
admission and discharge administrations for the B-SCS (B-SCSA
for admission and B-SCS-D for discharge); as indicated, these
only apply to Sample 2. In order to address any concern about
construct overlap, a revised B-SCS score was calculated, deleting
the one B-SCS item (#6) that used the word “suicide” in item
content, thereby allowing comparisons uncompromised by any
conceptual overlap due to item content.
As expected, correlations between the B-SCS and measures
of hopelessness, suicidal ideation, depression, and anxiety (see
Table 2) were significant. Correlations were significant across
all samples and, appropriately, the strongest relationships were
evidenced in the clinical samples. Also as expected, the strongest
relationships were with measures of depression, suicidal ideation,
and hopelessness, all of which are critical in the assessment,
management, and treatment of suicidality (24). B-SCS-revised
correlations were also significant, evidencing the same pattern
as the B-SCS across both samples and no apparent distortion
secondary to item overlap.
Construct Validity: Convergent and
Divergent Aspects
Given the stated purpose of the B-SCS to assess trait suicidality,
the scale should effectively differentiate high-risk groups from
others in the general population, suicidal and non-suicidal
clinical patients, and those with a range of suicide risk in
clinical populations. In Sample 1, B-SCS scores were significantly
higher for those with a past history of self-reported suicide
attempts (M = 9.8, SD = 4.1) in comparison to those with no
suicidal history (M = 7.1, SD = 2.9) (F = 7.57, p = 0.006;
Cohen’s d = 0.76). Similarly, B-SCS scores were significantly
lower for those in Sample 1 with no previous history of mental
health treatment (M = 7.1, SD = 2.9) when compared to
those with a treatment history (M = 8.5, SD = 4.0) (F =
4.16, p = 0.043, Cohen’s d = −0.40). In Sample 2, the BSCS
at admission effectively discriminated between those with
a past history of suicide attempts (M = 19.0, SD = 6.7) vs.
those without (M = 15.7, SD = 6.5) (F = 8.23, p = 0.005,
Cohen’s d = 0.50). This finding was similar at discharge, with
significantly higher B-SCS scores among those with a history of
suicide attempts (M = 14.1, SD = 6.28) when compared to those
with no history of attempts (M = 11.1, SD = 4.52) (F = 9.33,
p = 0.003, Cohen’s d = 0.55). Also consistent with the extant
literature and hypotheses, there were significant differences in BSCS
scores across diagnostic groups, with the those diagnosed
with a bipolar disorder or major depression (M = 13.87, SD
= 5.67) evidencing significantly higher scores in contrast to
those with a primary diagnosis of an anxiety disorder (M =
11.2, SD = 4.88) (F = 5.77, p = 0.018; Cohen’s d = 0.51).
Among the measures used, the BAI is that with the weakest
relationship to suicidality (31). Finally, as hypothesized, the BSCS
differentiated between multiple attempters (N = 50) and
ideators (N = 66) (F = 14.32, p = 0.0001, Cohen’s d = 0.77),
and multiple attempters (N = 50) and single attempters (N = 30)
(F = 6.08, p = 0.016, Cohen’s d = 0.60) in Sample 2, consistent
with previous findings regarding significantly higher chronic risk
among multiple attempters (39). Findings regarding past history
of suicide attempt, previous history of mental health treatment,
and diagnosis were comparable when B-SCS item #6, that used
the word “suicide,” was deleted.
Given that the B-SCS is capturing enduring suicide risk in a
manner different from traditional approaches like hopelessness,
potential unique explanatory power beyond the traditional BHS
was explored. In short, if the B-SCS offers unique explanatory
power, it should evidence incremental validity when compared
with the BHS. In the student sample, the partial correlation
between the BSS and B-SCS, controlling for the BHS was 0.33
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Rudd and Bryan Brief Suicide Cognitions Scale
(p = 0.0001) clearly consistent with good incremental validity.
In contrast, the partial correlation between the BSS and BHS,
controlling for the B-SCS was 0.09 (p = 0.251), with the BHS
adding no significant explanatory power beyond that accounted
for by the B-SCS. Results were similar in Sample 2, with the
partial correlation between the BSS and B-SCS, controlling for
hopelessness, of 0.45 (p = 0.0001), with the B-SCS adding
incremental explanatory power. Again, results were comparable
when B-SCS item #6, that used the word “suicide” was deleted
partial correlation between the BSS and B-SCS, controlling for
hopelessness was 0.39 (p = 0.0001).
Predictive Validity and Residual Risk
In Sample 3 participants agreed to a 6-month follow-up call
to assess the occurrence of any subsequent suicide attempts,
allowing an opportunity to address the predictive value of the BSCS,
including the idea that trait suicidality results in heightened
“residual risk” following resolution of and acute episode of
suicidality. A total of 16 suicide attempts were reported during
follow-up (17% of the original sample). Mean B-SCS scores were
significantly higher for those making a follow-up suicide attempt
(M = 19.7, SD = 4.2), in comparison to those without (M = 15.2,
SD = 6.4) (F = 7.21, p = 0.008; Cohen’s d = 0.83).
The positive predictive value, negative predictive value,
sensitivity and specificity of the B-SCS were calculated next. As
previously illustrated in Table 1, the item-level responses for
the B-SCS demonstrate the remarkably low frequency nature
of endorsement outside of the 1–2 range (i.e., 2-disagree or 1strongly
disagree), particularly in a non-clinical sample. Given
the nature of item content, endorsement distributions, and the
purpose of the B-SCS (to identify enduring risk), the cutoff
score was set at a score of ≥13 (approximately one SD below
the mean for those admitted to an inpatient unit). Subsequent
analysis revealed that the B-SCS was able to uniformly identify
those at risk for a follow-up suicide attempt (χ2 = 7.77, p =
0.005), with negative predictive value of a test of 1.00, positive
predictive value of 0.230, sensitivity of 1.00, and specificity of
0.346. The lower specificity is not particularly surprising given the
nature of the sample, that is, those presenting at the emergency
department in suicidal crisis (See Table 3). The receiver operating
characteristics curve is presented in Figure 1, with the area under
the curve (AUC) of 0.724, falling in the adequate range, not
surprising given both the small sample size and limited number
of subsequent attempts (N = 16, 17% of original sample).
Factorial Validity
As mentioned previously, the B-SCS is conceptualized as a
brief measure of enduring suicide risk, defined as identity-based
hopelessness embedded in core beliefs about the self as unlovable,
one’s emotional experience as unbearable (unbearability), and
one’s life problems as unsolvable (unsolvability), resulting in
persistent vulnerability for the emergence of acute suicidal crises
and residual risk after resolution of an acute episode. Given the
exploratory nature of this initial study, principal components
analysis was used, along with Cattell’s (40) scree test to determine
factor extraction based on the magnitude of the eigenvalues
(cutoff set at >1) derived with the two clinical samples and
FIGURE 1 | B-SCS ROC Curve.
the non-clinical student sample. Table 4 provides factor loadings
for all items, with the scale proving unidimensional across all
three samples. In Sample 1, a single factor accounted for 66%
of the variance (eigenvalue of 3.96). In Sample 2, a single factor
accounted for 69.3% of the variance (eigenvalue of 4.157) and
in Sample 3, a single factor accounted for 56% of the variance
(eigenvalue of 3.36). Current results support the construct of a
general unidimensional measure of the suicidal belief system,
with a comparable factor structure across both clinical and nonclinical
samples.
To further confirm the unidimensionality of the B-SCS, a
confirmatory factor analysis (CFA) was conducted in Sample 2
using the MPlus 7.4 software (41). To account for skewed item
responses, we used a robust maximum likelihood estimator with
all 6 items loading onto a single factor. Results indicated marginal
fit [root mean square error of approximation (RMSEA) = 0.22,
95% confidence interval (CI) = 0.17–0.26; comparative fit index
(CFI) = 0.84; standardized root mean square residual (SRMR)
= 0.06]. Review of the modification indices suggested model fit
could be improved if the following residuals were allowed to
correlate, however: items 1 and 4, items 3 and 4, and items 2
and 6. When repeated with these additional parameters, model fit
improved dramatically: RMSEA = 0.08, 95% CI = 0.00–0.15; CFI
= 0.99; SRMR = 0.02. Item-factor loadings for this final model
exceeded 0.70 (see Table 4).
DISCUSSION
The B-SCS performed well overall, across both non-clinical
and clinical samples, particularly for a brief measure developed
for the unique demands of clinical settings. Current results
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Rudd and Bryan Brief Suicide Cognitions Scale
TABLE 4 | Item-factor loadings across samples.
Inpatient sample (N = 160) Item-factor
loading
I am completely unworthy of love. 0.81
Nothing can help me solve my problems. 0.84
I can’t cope with my problems any longer. 0.86
I can’t imagine anyone being able to withstand this kind
of pain.
0.80
There is nothing redeeming about me. 0.85
Suicide is the only way to end this pain. 0.83
ED patient sample (N = 94)
I am completely unworthy of love. 0.79
Nothing can help me solve my problems. 0.74
I can’t cope with my problems any longer. 0.84
I can’t imagine anyone being able to withstand this kind
of pain.
0.69
There is nothing redeeming about me. 0.79
Suicide is the only way to end this pain. 0.82
Student sample (N = 349)
I am completely unworthy of love. 0.80
Nothing can help me solve my problems. 0.85
I can’t cope with my problems any longer. 0.84
I can’t imagine anyone being able to withstand this kind
of pain.
0.78
There is nothing redeeming about me. 0.88
Suicide is the only way to end this pain. 0.72
Sample for CFA (N = 160)
I am completely unworthy of love. 0.82
Nothing can help me solve my problems. 0.78
I can’t cope with my problems any longer. 0.75
I can’t imagine anyone being able to withstand this kind
of pain.
0.73
There is nothing redeeming about me. 0.84
Suicide is the only way to end this pain. 0.72
support the strong psychometric properties for this brief measure
capturing enduring suicide risk embedded in beliefs about the
self as unlovable, one’s emotional experience as unbearable, and
life problems as unsolvable (i.e., the suicidal belief system),
resulting in chronic suicide risk or heightened vulnerability
for the emergence of acute suicidal crises over time and
elevated residual risk after an acute episode has resolved.
Findings demonstrate strong reliability estimates, particularly for
a six-item measure, good evidence of concurrent, convergent,
incremental and divergent validity, along with good evidence of
predictive validity, consistent with FVT and the idea of chronic
and residual suicide risk. In terms of factorial validity, findings
suggest the B-SCS is unidimensional (across both clinical and
non-clinical samples) and represents the suicidal belief system
as described in FVT, the suicidal mode (7, 16) and the cognitive
model of suicide (15). Findings confirmed that the B-SCS offers
good incremental validity, with unique predictive value when
compared to frequently used measures of hopelessness, like
the Beck Hopelessness Scale. In particular, the importance of
recognizing, understanding, and assessing enduring or chronic
suicide risk (i.e., the suicidal belief system including unlovability,
unbearability, and unsolvability) as part of a comprehensive
suicide risk assessment is supported.
As results revealed, the B-SCS faces the same clinical screening
and predictive validity challenges as other measures in clinical
settings, with an AUC of 0.724 and limited specificity, despite
good sensitivity at a low cutoff score. Although additional study
is certainly needed, particularly with larger samples and longer
follow-up periods, results across both non-clinical and clinical
samples suggest the B-SCS has potential as a brief screening
measure targeting enduring individual vulnerability. The mere
presence of unlovability, unbearability, and unsolvability can
elevate risk and the B-SCS could potentially offer a response to
the screening problems revealed by recent EMA findings and
significant, natural variations in suicidal thinking over time.
Current findings have a number of significant implications
for clinical practice, particularly suicide risk assessment, and
treatment. As described in FVT (7) accurate assessment of
suicide risk cuts across both acute and chronic domains. The
assessment of acute risk and related contextual variables such
as symptom severity, life stressors, suicidal thinking and intent
is well chronicled [e.g., (42)], but the issue of recognizing,
understanding and assessing chronic risk in a reliable and valid
manner has received less attention. The B-SCS is a simple and
brief instrument that can be completed in a matter of minutes,
one that will provide meaningful clinical information about
enduring suicide risk. Additionally, only a single B-SCS item
mentions the word “suicide,” offering a unique approach to
recognizing vulnerability to suicide risk not reliant on current
suicidal thinking. The B-SCS helps the clinician recognize, track,
and target the suicidal belief system in treatment and related
identity-based hopelessness (43). Of specific importance, an
elevated B-SCS score indicates heightened vulnerability for future
episodes, alerting clinicians to more closely monitor individuals,
recognizing that residual risk does not resolve in parallel to an
acute episode and related symptoms, and does not always parallel
active suicidal thinking.
The current study is not without significant limitations,
however. It should be noted that although the two clinical
samples good representation of those experiencing suicidal
thoughts and those making suicide attempts, subsequent studies
should include individuals from both outpatient and inpatient
settings, larger numbers, and greater heterogeneity in past
suicidal thoughts and behaviors. Additionally, longer followup
periods are needed to further address predictive value and
validity, which is particularly important for a measure of chronic
risk. In particular, the number of follow-up suicide attempt
is relatively small, limiting statistical power and conclusions
based on the current findings. Furthermore, Sample 3 did not
include comprehensive assessment of other clinical symptoms
or psychiatric diagnoses. In light of our findings that B-SCS
scores significantly differed across participants with and without
mood disorders in Sample 2, additional research investigating
how B-SCS responses and performance across different clinical
subgroups is warranted. Despite these limitations, the B-SCS is
a promising measure of chronic or residual suicide risk, with
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Rudd and Bryan Brief Suicide Cognitions Scale
considerable potential in clinical settings, particularly given it can
be administered in a few minutes.
DATA AVAILABILITY STATEMENT
The raw data supporting the conclusions of this article will be
made available by the authors, without undue reservation.
ETHICS STATEMENT
The studies involving human participants were reviewed
and approved by Texas Tech University Institutional Review
Board. The patients/participants provided their written informed
consent to participate in this study.
AUTHOR CONTRIBUTIONS
MR conceptualized the original study, collected the data,
conducted data analysis, along with writing, and editing the final
manuscript. CB contributed to data analysis and interpretation,
along with manuscript writing, and editing. All authors
contributed to the article and approved the submitted version.
ACKNOWLEDGMENTS
Several individuals, including Bill Schmitz, Thomas Joiner, Ray
McClenen, and Cindy Claassen contributed to data collection for
the original manuscript on the original Suicide Cognitions Scale
in 2008, work that ultimately went unused and unpublished.
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
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