Concurrent Validity and Normative Data of the Depression Hopelessness and Suicide Screening Form with Women Offenders

This report was written under a contract managed by the Correctional Service of Canada, Research Branch, Correctional Research Division.

The views expressed in this report are those of the authors and do not necessarily reflect those of the Correctional Service of Canada

Acknowledgements

We are grateful to Michelle Green and Iliana Lilova for their assistance with data gathering and to Dr. Andrew Harris for his administrative assistance with this project. Special thanks to Dr. Lynn Stewart for her helpful comments on an earlier version of this manuscript.

ExecutiveSummary

The purpose of this study was to examine the concurrent validity and establish a normative range for scores on the Depression Hopelessness and Suicide Screening Form (DHS; Mills & Kroner, 2003) among federally incarcerated women offenders.

The DHS was originally developed on successive samples of federal male offenders to screen for the presence of depression (Depression Scale) and hopelessness (Hopelessness Scale) as well as to gather information on suicide related risk factors (Critical Items). The DHS has been well validated among male offenders but less so among women offenders. Thus far a single study on women offenders using the DHS has been conducted on women admissions to a county jail in the United States (Stewart, 2007).

The study examined data collected from two samples of federally incarcerated women offenders. The first sample of 100 offenders was comprised of volunteers from Grand Valley Institution in the Ontario Region and from Joliette Institution in the Quebec Region who took part in a broader study of suicide and mental health/emotional functioning. The second sample of 122 offenders was drawn from admissions to three federal institutions (Edmonton Institution for Women, Grand Valley Institution, and Nova Institution) and collected as part of the Computerized Mental Health Intake Screening System (CoMHISS).

The findings confirmed the concurrent validity of the DHS. The measure produced strong correlations with well validated measures of depression, hopelessness and affective functioning. Further, the study found that the mean scores on the DHS for new recent admissions were greater than for women offenders who had been incarcerated for some time. This was not unexpected given the deterioration in emotional functioning associated with periods of significant adjustment, but it did confirm that these differences should be accommodated through different normative ranges. Finally, the study confirmed previous findings that women offenders report higher rates of endorsing suicide risk factors than do male offenders.

Introduction

Suicide is a leading cause of death among those incarcerated in prisons and jails (Hayes, 1995). Risk factors associated with suicidal ideation include depression (Emery, Steer & Beck, 1981; Lester & Beck, 1977), hopelessness (Beck, Brown, & Steer, 1989; Holden & Kroner, 2003), prior suicide attempts (Cole, 1988; Dexter & Towl, 1995) and suicidal ideation (Fawcett et al., 1990). The rate of suicide in correctional facilities is generally higher than in the general population (Bland, Newman, Dyck, & Orn, 1990; Green, Andre, Kendall, Looman, & Polvi, 1992). This is true for both U.S. detention facilities (Hayes, 1995; Hayes & Rowan, 1988) Canadian prisons (Bland et al., 1990, Burtch & Ericson, 1979) and other countries (Smith, 1984). This makes it imperative to establish the early identification of suicide related risk factors among this group of individuals.

Incarcerated offenders experience a high prevalence of depression and depressive disorders (Bland et al., 1990; Reitzel & Harju, 2000). Using the Beck Depression Inventory (Beck & Steer, 1987) Boothby and Durham (1999) reported elevated scores in a large sample of offenders. In other research, a higher prevalence of major depressive episodes and anxiety/somatoform disorders differentiated offenders who attempted suicide from those who did not (Bland et al., 1990). Hopelessness is also an important factor in the assessment of risk for suicide (Beck et al., 1989; Beck, Steer, Kovacs & Garrison, 1985).

Screening for risk factors for suicide is a different task from diagnosing depression or measuring degree of severity of suicidal ideation or intent. Many studies of suicide risk are conducted on patients referred for psychiatric evaluation who are by definition in distress (Brown, Beck, Steer, & Grisham, 2000; Joiner et al., 2003). Screening for suicide risk factors among offenders who have higher rates of suicide but may not be clinically acute with respect to their symptomatology is clearly not the same task as determining the level of risk for suicide among clinically depressed patients, but the exercise is important and necessary.

The Depression Hopelessness and Suicide Screening Form (Mills & Kroner, 2003) was developed to screen for depression and hopelessness as well as gather information on suicide risk factors such as history of suicide attempts, previous diagnosis for depression, family members who have committed suicide, as well as suicidal ideation. The DHS has been shown to have good internal consistency, factor structure, and validity (Mills & Kroner, 2004). The DHS scales were significantly related to institutional file information such as history of depression and history of psychiatric intervention as well as information from an intake interview such as recent psychiatric/ psychological intervention and number of prior suicide attempts. Mills, Reddon, and Kroner (2006) found strong correlations between the DHS Depression scale and the BDI-II (r = .77) and the DHS Hopelessness scale and the Beck Hopelessness Scale (r = .70) in a sample of male offenders. Other research has shown the DHS to generalize to a university student sample (Mills, Morgan, Reddon, Kroner and Steffan, 2010). In this sample, the DHS Depression scale was strongly related to the BDI, and the DHS Hopelessness scale was strongly related to the Beck Hopelessness Scale (BHSS; Beck & Steer, 1988).

Perhaps the research most salient to the current study was conducted by Lisa Stewart (2007) who examined the results of the DHS among women admitted to a US County Jail. A significant majority of the 100 volunteer participants were Caucasian and single. Fifty-two percent had used drugs within the past 90 days. Seventy percent of the women reported receiving prior mental health treatment with 28% reporting a diagnosis of depression and 24% a diagnosis of bipolar disorder. A majority of women reported experiencing some form of childhood abuse (60%) and incidents of domestic violence (68%). The mean number of times the women had been placed in jail was 8.3 times suggesting the majority had ongoing conflict with the law.

Results from the administration of the DHS produced a mean score on the Depression Scale of 9.5 and a mean score on the Hopelessness Scale of 4.0. These means are significantly higher than those found among male offenders in the Mills and Kroner (2004) study. In addition to the administration of the DHS, the number of depressive symptoms as outlined in the DSM-IV-TR was identified through an interview and recorded and the Beck Scale for Suicide Ideation (SSI; Beck, 1991) was completed. The DHS Depression Scale was strongly correlated with the number of depressive symptoms (r = .71) while the Hopelessness Scale was only moderately related to the same symptoms (r = .42). The DHS Depression Scale was moderately and significantly related to the SSI (r = .31) and somewhat more strongly related than were the number of depression symptoms and the SSI (r = .25). A history of mental illness was correlated with both the DHS Depression scale (r = .47) and the number of reported depressive symptoms (r = .36). The DHS Depression scale was significantly correlated with a history of abuse (r = .30) and recent drug use (r = .30). The Depression scale score on the DHS was more strongly associated with depressive symptoms than were the number of depressive symptoms as obtained through an interview (r = .14 and r = .18 respectively). The general finding was that the DHS was as strongly related to a history of mental illness as were the results of an interview-based assessment of depressive symptoms.

The purpose of this study is to examine the concurrent validity of the DHS among federally incarcerated women offenders through its association with well known and validated instruments such as the Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996) and the Beck Hopelessness Scale (BHSS; Beck & Steer, 1988). The report will also provide guidelines for normative ranges for the scales that are components of the DHS to assist in interpretation of the results when it is used with women offenders.

Method

Participants

Sample 1

The data for the first sample were provided by 100 federally sentenced women incarcerated at Grand Valley Institution in the Ontario Region (n = 66) and Joliette Institution in the Quebec Region (n = 34). Racial composition of the sample was predominantly Caucasian (70%); 11% were Aboriginal. The average age of the participants was 37.7 years (SD = 10.9) with a range of 20 to 67 years. Twenty-seven women (27 %) reported a past psychiatric diagnosis with the most common being depression (n = 13). Twenty-seven women (27%) reported they were taking a psychotropic medication at the time of the study.

Sample 2

CSC has recently implemented a national assessment procedure to screen for mental health disorders among incoming federally sentenced offenders. The components of the assessment are two psychological tests: the BSI (Brief Symptom Inventory) and the DHS as well as the Paulhus Deception Scales. Data collected from the pen and paper administration of the CoMHISS comprised the second sample. These data came from three women’s institutions: Edmonton Institution for Women in the Prairie Region (n = 46), Grand Valley Institution in the Ontario Region (n = 59), and Nova Institution in the Atlantic Region (n = 17). The average age of the women was 34.9 years (SD = 11.2) with a range from 19 to 63 years.

Procedure/Analytic Approach

Sample 1

Two research assistants were trained on the administration of a structured interview and the self-report inventories. Offenders were recruited through general awareness of the study in the institution (posters and inmate committee notification) as well as direct appeal by the researchers. All volunteers provided informed consent both in writing and verbally.

Sample 2

Descriptive statistics for the study measures are presented along with correlational analyses for comparative validity purposes. T-tests were used to compare the scale scores of the two samples. Standardized scores (T-scores) were calculated using the formula 10[Xi – M]/s] + 50. Where Xi is the observed score, M is the scale mean and s is the standard deviation of the scale scores. This calculation results in a standardized score with a mean of 50 and a standard deviation of 10.

Measures/Material

Sample 1

Depression Hopelessness and Suicide Screening Form (DHS; Mills & Kroner, 2003). The DHS is a 39-item instrument developed to screen for depression, hopelessness, and suicide risk factors. The DHS is comprised of a Depression scale (17 items), a Hopelessness scale (10 items), and a Critical Item Checklist (12 items). All items are answered in a two-category agree/disagree format. The DHS has been shown to be as effective as interview or file review in identifying offenders with a history of suicide related behaviour in addition to accurately identifying offenders in distress (Mills & Kroner, 2005).

Brief Symptom Inventory (BSI; Derogatis, 1993). The BSI is a 53 item self-report, multidimensional measure of psychological distress. The scale was designed to assess for symptoms of psychological problems. The test is based on nine primary symptom dimensions; somatization, obsessive-compulsive, interpersonal-sensitivity, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The items are scored on a 5 point scale from 0 (not at all distressed) to 4 (extremely distressed) (Aroian, Gianan, Levin, and Patsdaughter, 1995). The BSI provides separate norms for adult male and female psychiatric outpatients and inpatients as well as for non patients. The measure has demonstrated good internal consistency (α=.76 to .89) and reliability (Boulet & Boss, 1991).

Profile of Mood States (POMS; Lorr, McNair, Heuchert, & Droppleman, 2003). The Profile of Mood States (POMS) is a 65 item self-report measure of the participant’s mood. Participants are asked to report their mood for three different time periods: in the past week, right now, or a specified period indicated by filling in a blank space. Six mood factors can be identified and measured through the POMS: Tension-anxiety, Depression-Dejection, Anger-Hostility, Vigor-Activity, Fatigue-Inertia, and Confusion-Bewilderment. Research has shown the POMS to be internally consistent and have a stable factor structure (Norcross, Guadagnoli, & Prochaska, 2006).

Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996). The BDI-II is a 21-item, self-report questionnaire that assesses the severity of the symptoms of depression. Depressive symptoms on the BDI are rated from 0 to 3 in terms of severity. The BDI-II is a revision of the earlier BDI undertaken to be more consistent with DSM-IV criteria for major depression. Studies have confirmed the validity and reliability of the BDI (e.g., Beck, Steer, & Garbin, 1988; Gallagher, Nies, & Thompson, 1982; Lightfoot & Oliver, 1985; Oates-Johnson & DeCourville, 1999) and more recently the BDI-II (Whisman, Perez, & Ramel, 2000).

Beck Hopelessness Scale (BHSS; Beck & Steer, 1988). The BHSS is a self-report questionnaire that contains 20 true/false items assessing thoughts or feelings about the future. Stability of the BHSS has been demonstrated through satisfactory test-retest reliability of the scale (Holden & Fekken, 1988). The BHSS has been shown to be a valid measure within both prison (Power & Beveridge, 1990; cited in Biggam & Power, 1999) and general populations (Greene, 1981).

Sample 2

The data obtained from the CoMHISS for the second sample came from the DHS and the BSI instruments which are described above.

Results

Sample 1

The descriptive statistics of the study measures are reported in Table 1. Internal consistency of the scales, as represented by alpha reliabilities, is considered good to excellent across the measures employed. The internal reliabilities of the DHS Depression and Hopelessness scales were excellent and consistent with those of the Beck scales. The mean scores of the DHS Depression scale (M = 5.3) and the DHS Hopelessness scale (M = 1.9) were greater than the means from the male offender sample from which the scales were originally validated (M = 2.8 and M = 0.6) respectively.

The data collected in the first sample included the Beck inventories for depression (BDI-II; Beck, Steer, & Brown, 1996) and hopelessness (BHSS; Beck & Steer, 1988). These two inventories have been used widely in both clinical and research settings and are considered valid indices of their respective constructs. The concurrent administration of these measures afforded the opportunity to examine how the DHS scales related to the Beck scales directly and how the DHS and Beck scales related comparatively to other measures of affect and mental health (i.e. Brief Symptom Inventory (BSI), Profile of Mood States (POMS)). Table 2 reports these correlations. The DHS Depression scale was more strongly associated with the BDI than the BHSS and the DHS Hopelessness scale was more strongly associated with the BHSS than the BDI. Generally, there were moderate to strong correlations between both the DHS and Beck scales and the measures of negative affect from the BSI and POMS with the strongest correlations found between these measures and similar depression related measures from the BSI (Depression) and POMS (Depression-Dejection). Table 2 shows that there were very similar relationships between the DHS and Beck scales and the BSI and POMS. For example, the DHS Depression scale and BDI correlated more strongly with the Somatization scale of the BSI than did either of the DHS Hopelessness and BHSS scales. Similarly, smaller negative correlations between the Beck scales and the Vigor-Activity and Friendliness scales of the POMS were consistent with the same relationships the DHS scales had to these POMS measures.

Discussion

The results of this study support the construct validity of the DHS with women offenders as has been done for men and further clarify the normative interpretative ranges for the scales. Construct validity of the DHS is supported by the relationship of the scales with well known and widely used instruments which measure the same constructs of depression and hopelessness. In addition, the comparative relationship of the DHS scales and the Beck scales with other measures of negative affect followed a very similar pattern indicating that the representation of depression and hopelessness as measured by the DHS scales was similar to those of the Beck scales.

Our studies’ findings would also indicate that depressive symptomatology changes over time as the women adjust to incarceration. We attempted to identify the possible source of these differences in women offender norms by comparing them with male offenders as well as comparing the results for women offenders assessed at intake and those assessed after a period of incarceration. It would appear that women offenders endorse more depressive symptoms and cognitions of hopelessness than male offenders (Sample 1 of the women offenders as compared to a sample of incoming male offenders) and that women offenders at intake, who are undergoing the situational adjustment of acclimating to incarceration, are experiencing more depressive symptoms than women who have been incarcerated for a period of time. There appears therefore to be both a temporal as well as gender difference in the rates of endorsement of items on the DHS depression and hopelessness scales. These temporal differences on the depression scale are not found for other symptoms related to mental health functioning. However, even the elevated endorsement rates for federal women at the time of intake (Sample 2) were not as high as those for women who were admitted to a county jail in the United States. This difference may also be due to the situational stress associated with arrest and confinement which was closer to the time the DHS was administered in the county jail than it was when women responded to the DHS on the CoMHISS.

Interpretation of the DHS scales with women offenders should be undertaken in the context of knowing their previous suicide related behavior. Studies with male offenders show that offenders who have a history of suicide related behavior and are presently experiencing symptoms of depression and/or cognitions of hopelessness are also more likely to be experiencing suicide related thoughts (Mills & Kroner, 2008). It is important to highlight that suicide related thoughts do not equate to suicidal intent, and that the findings were based upon offenders who were willing to admit to suicide related thoughts. Nonetheless, intervening with individuals who are likely to be experiencing suicide related thoughts is good clinical practice.

Conclusions

Our findings support the construct validity of the DHS scales with women offenders. The findings confirm that women offenders report more suicide related behaviours than do men offenders and they endorse more symptoms of depression and cognitions of hopelessness. Further, our findings indicate that more depressive symptoms are evident during the women’s period of adjustment to incarceration which would suggest different normative ranges may be necessary to determine relative levels of depressive symptoms. Hopelessness cognitions do not appear to be similarly influenced by adjustment issues in the two samples that we examined. In keeping with previous research among male offenders, interpretation of the DHS depression and hopelessness scales should be undertaken within an ecological context, specifically with knowledge of the individual’s history of suicide related behaviours.

References

Aroian, K. J., Patsdaughter, C. A., Levin, A., & Gianan, M. E. (1995). Use of the Brief Symptom Inventory to assess psychological distress in three immigrant groups. International Journal of Social Psychiatry, 41, 31-46.

Beck, A. T., (1991). Beck Scale for Suicide Ideation. St. Antonio, TX: Pearson.

Beck, A. T., Brown, G. & Steer, R. A. (1989). Prediction of eventual suicide in psychiatric inpatients by clinical ratings of hopelessness. Journal of Consulting and Clinical Psychology, 57, 309-310.

Beck, A. T., & Steer, R. A. (1987). Beck Depression Inventory Manual. Orlando, FL: The Psychological Corporation Harcourt Brace Jovanovich, Inc.

Beck, A. T., & Steer, R. A. (1988). Beck Hopelessness Scale Manual. Orlando, FL: The Psychological Corporation Harcourt Brace Jovanovich, Inc.

Beck, A. T., Steer, R. A., Brown, G. K. (1996). Beck Depression Inventory-Second Edition manual. San Antonio, TX: The Psychological Corporation.

Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8, 77-100.

Beck, A. T., Steer, R. A., Kovacs, M., & Garrison, B. (1985). Hopelessness and eventual suicide: A 10-year prospective study of patients hospitalized with suicidal ideation. American Journal of Psychiatry, 142, 559-563.

Biggam, F. H., & Power, K. G. (1999). A comparison of the problem-solving abilities and psychological distress of suicidal, bullies, and protected prisoners. Criminal Justice and Behavior, 26, 196-216.

Bland, R. C., Newman, S. C., Dyck, R. J., & Orn, H. (1990). Prevalence of psychiatric disorders and suicide attempts in a prison population. Canadian Journal of Psychiatry, 35, 407-413.

Boothby, J. L., & Durham, T. W. (1999). Screening for depression in prisoners using the Beck Depression Inventory. Criminal Justice and Behavior, 26, 107-124.

Boulet, J., & Boss, M. W. (1991). Reliability and validity of the Brief Symptom Inventory. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3, 433-437.

Brown, G. K., Beck, A. T., Steer, R. A., & Grisham, J. R. (2000). Risk factors for suicide in psychiatric outpatients: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 68, 371-377.

Burtch, B., & Ericson, R. (1979). The silent system: An inquiry into prisoners who suicide. Toronto: Centre of Criminology, University of Toronto.

Cole, D. A. (1988). Hopelessness, social desirability, depression, and parasuicide in two college student samples. Journal of Consulting and Clinical Psychology, 56, 131-136.

Derogatis, L. R. (1993). Brief Symptom Inventory. Minneapolis, MN: Pearson, Inc.

Dexter, P., & Towl, G. (1995). An investigation into suicidal behaviours in prison. In N. K. Clark and G. M. Stephenson (Eds.). Criminal Behaviour: Perceptions, Attributions and Rationality. London: British Psychological Society.

Emery, G. D., Steer, R. A., & Beck, A. T. (1981). Depression, hopelessness, and suicidal intent among heroin addicts. International Journal of Addictions, 16, 425-429.

Fawcett, J., Scheftner, W. A., Fogg, L., Clark, D. C., Young, M. A., Hedeker, D., & Gibbons, R. (1990). Time-related predictors of suicide in major affective disorder. American Journal of Psychiatry, 147, 1189-1194.

Gallagher, D., Nies, G., & Thompson, L. W. (1982). Reliability of the Beck Depression Inventory with older adults. Journal of Consulting and Clinical Psychology, 50, 152-153.

Green, C., Andre, G., Kendall, K., Looman, T., & Polvi, N. (1992). A study of 133 suicides among Canadian federal prisoners. Forum on Corrections Research, 4. Correctional Service of Canada: Ottawa, Canada.

Greene, S. M. (1981). Levels of hopelessness in the general population. British Journal of Clinical Psychology, 20, 11-14.

Hayes, L. M. (1995). Prison suicide: An overview and guide to prevention. The Prison Journal, 75, 431-456.

Hayes, L. M., & Rowan, J. R. (1988). National study of jail suicides: Seven years later. Alexandria, VA: National Center on Institutions and Alternatives.
Holden, R. R., & Kroner, D. G. (2003). Differentiating suicidal motivations and manifestation in a forensic sample. Canadian Journal of Behavioural Science, 35, 35-44.

Holden, R. R., & Fekken, G. C. (1988). Test-retest reliability of the Hopelessness Scale and its items in a university population. Journal of Clinical Psychology, 44, 40-43.

Joiner, T. E., Steer, R. A., Brown, G., Beck, A. T., Pettit, J. W., & Rudd, M. D. (2003). Worst-point suicidal plans: A dimension of suicidality predictive of past suicide attempts and eventual death by suicide. Behavior Research and Therapy, 41, 1469-1480.

Lester, D., & Beck, A. T. (1977). Suicidal wishes and depression in suicidal ideators: A comparison with attempted suicides. Journal of Clinical Psychology, 33, 92-94.

Lightfoot, S. L., & Oliver, J. M. (1985). The Beck Inventory: Psychometric properties in university students. Journal of Personality Assessment, 49, 434-436.

Lorr, M., McNair, D. M., Heuchert, J. W. P., & Droppleman, L. F. (2003). Profile of Mood States. Toronto, Canada: Multi-Health Systems.

Mills, J. F., & Kroner, D. G. (2003). Depression, Hopelessness and Suicide Screening Form (DHS): User Guide.

Mills, J. F., & Kroner, D. G. (2004). A New Instrument to Screen for Depression, Hopelessness and Suicide in Offenders. Psychological Services, 1, 83-91.

Mills, J. F., & Kroner, D. G. (2005). Screening for Suicide Risk Factors in Prison Inmates: Evaluating the Efficiency of the Depression, Hopelessness and Suicide Screening Form (DHS). Legal and Criminological Psychology, 10, 1-12.

Mills, J. F., & Kroner, D. G. (2008). Predicting Suicidal Ideation with the Depression Hopelessness and Suicide Screening Form (DHS). Journal of Offender Rehabilitation, 47, 74-100.

Mills, J. F., Reddon, J. R., & Kroner, D. G. (2006). Construct validity and factor structure of the Depression Hopelessness and Suicide Screening Form (DHS). Manuscript under review.

Mills, J. F., Morgan, R. D., Reddon, J. R., Kroner, D. G., & Steffan, J. (2010). The Validity and Factor Structure of the Depression, Hopelessness, Suicide Screening Form to a Non-offender Population. Manuscript under review.

Norcross, J. C., Guadagnoli, E., Prochaska, J. O. (2006). Factor structure of the Profile of Mood States (POMS): Two partial replications. Journal of Clinical Psychology, 40, 1270-1277.

Oates-Johnson, T., & DeCourville, N. (1999). Weight preoccupation, personality, and depression in university students: An interactionist perspective. Journal of Clinical psychology, 55, 157-1166.

Reitzel, L. R. & Harju, B. L. (2000). Influence of locus of control and custody level on intake and prison-adjustment depression. Criminal Justice and Behavior, 27 (5), 625-644.

Stewart, L. M. (2007). Perceived stress, self-efficacy, and depression, hopelessness, and suicidal ideation in a group of incarcerated women. Unpublished doctoral dissertation, Fielding Graduate University, Santa Barbara.

Whisman, M. A., Perez, J. E., & Ramel, W. (2000). Factor structure of the Beck Depression Inventory- Second Edition (BDI-II) in a student sample. Journal of Clinical Psychology, 56, 545-551.