The International Journal of the Addictions, 14(4), 451-464, 1979

Drug Abuse, Hopelessness,

and Suicidal Behavior
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Arlene N. Weissman, Ph.D.

Aaron T. Beck, M.O."
Maria Kovacs, Ph.D.
University of Pennsylvania
Philadelphia, Pennsylvania 19104
For personal use only.

Abstract
This study focused on assessing variables which may differentiate
suicidal drug abusers from nonabusers. Data from a sample of
drug abusing (n = 86) and nonabusing ( n = 298) suicide at-
tempters were subjected to a stepwise multiple regression analysis
to identify factors related to suicidal intent. The analysis revealed
that in our sample of suicide attempters, drug abuse status was
not a significant contributor to the severity of suicidal intent.
However, it was found that hopelessness accounted for a
significant proportion of the variance of intent. The findings
suggest that hopelessness among drug abusers, an important
determinant of suicidal behavior, presents an important target for
therapeutic intervention.
*To whom requests for reprints should be addressed at 133 South 36th Street, Room 602,
Philadelphia, Pennsylvania 19104.

45 1

Copyright @ 1979 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any
part may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, microfilming, and recording, or by any information
storage and retrieval system, without permission in writing from the publisher.
 452 WEISSMAN, BECK, A N D KOVACS

The psychological and social correlates of drug dependence have

attracted considerable research and clinical interest, often with dubious
results. One issue which still requires exploration is the relationship
between drug abuse and suicidal behavior. Are there specific behavior
patterns of psychological features associated with being a drug abuser
which are potential predictors of suicide?
There is no question that there is a relationship between suicide and
drug abuse. There is accumulating evidence that numerous suicide victims
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are drug abusers and that a high proportion of drug abusers exhibit
suicidal behaviors. Morris et al. (1974) reported that 10%of the completed
suicides in Phildadelphia in 1972 had histories of drug abuse. In Finland, a
10-year investigation of a random sample of brain injured war veterans
who committed suicide revealed that 42% of the cases were drug de-
pendent (Achte et al., 1970).
Among addicts the rate of death by suicide has been reported as nearly
five times the rate found in the population at large (O’Donnell, 1964). A
study by James revealed that the suicide rate in a male heroin addict
population in London, England was 50 times the aged-adjusted average
For personal use only.

for the general population. Similarly, Frederick et al. (1973) found a

greater incidence of suicide attempts among heroin addicts in methadone
or abstinence programs than in groups of nonaddicted controls. Clearly,
then, the relationship between addiction and suicidal behavior is sub-
stantial enough to warrant further attention.
Over the years, various models have been offered to explain the
process and dynamics of narcotic addiction. In fact, some explanatory
models have suggested an intimate relationship between suicidal and
addictive behaviors. The psychoanalysts were among the first to relate
drug abuse to suicide. For example, in a number of papers, Rado (1926,
1933) noted not only that drugs function to help regain a state of infantile
euphoria but also that both stupor and suicide may be sequelae. Rado also
suggested that a history of depression predisposes a person to experience
narcotic elation.
Menninger (1938) asserted that addiction is not only a symptom of
depression, but that it is also a form of chronic suicidal behavior. Thus he
interpreted drug addiction as a manifestation of primary aggressive
tendencies directed against the self. Other schools of thought have viewed
drug addiction as a form of seductive‘behavior (Blachly, 1970) or as a
misguided form of “self-treatment” (Wurmser, 1972).
The problem of suicidal behavior among addicts was a topic of clinical
investigation as early as 1940 (Prescor and Surgeon, 1940). More recently,
 DRUG ABUSE, HOPELESSNESS, AND SUICIDAL BEHAVIOR 453

the relationship between depression, drug usage, and suicidal behaviors

has been attracting increased clinical interest (cf. Farberow, 1969). For
example, Litman et al. (1972) noted that drug addicts often exhibit
depressive and suicidal behaviors. Thus the Litman et al. (1972) study
offers some support for the hypothesis that narcotics are used both as self-
medication and as an alternative to suicide. Litman et al. (1972) also
found that with decreased methadone dosage, previously attenuated
suicidal patterns tend to reemerge with elevated depression, There have
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been numerous other clinical studies on the psychopathological aspects of

drug abuse which report evidences of notable depression among the
subject populations (e.g., Blake and Distasio, 1973; DeLeon et al., 1973;
Vaillant, 1966; Wurmser, 1972).
As evident from the brief survey presented above (see summary in
Table l), the theoretical, clinical, and empirical literature all attest to a
relationship between drug abuse, depression, and suicidal behaviors.
Nevertheless, the potential use of the variables of depression and drug
abuse as predictors of suicidal behavior have not been clearly established.
The role of hopelessness in the suicidal behaviors of drug-dependent
For personal use only.

populations has received even less systematic attention. Historically,

laymen as well as clinicians have proposed that despairing hopelessness is
a precursor of suicidal behaviors (Farber, 1968; Rosen, 1971; Shneidman,
1973). More recently, Beck and his colleagues (Beck, Kovacs, and
Weissman, 1975; Kovacs et al., 1975; Lester and Beck, 1975; Minkoff et
a]., 1973) have demonstrated that hopelessness is an important covariate
of both depression and suicidal behavior. With this empirical basis, part of
the present study focused on the assessment of hopelessness as a contri-
butor to suicidal behavior in drug-dependent individuals.
Specifically, the present study had two major goals. The first goal was
to determine the extent to which suicidal intent, a component of suicidal
risk, is a function of three classes of variables: drug abuse, depression, and
hopelessness. The second goal was to attempt an explanation of the
apparently high suicidal risk among drug abusers by examining two
potential predictor variables: depression and hopelessness.
To guide data analyses and interpretation of results, the following
questions were posed:

1. In what sequence do the three variables studied (i.e., drug abuse,

depression, and hopelessness) yield the maximum amount of information
about suicidal intent?
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For personal use only.
Table 1
Resource Table
Author(s) Year Subjects
DeLeon et al. 1973 147 male and 61 female par-
ticipants in the Phoenix
Program’s facilities at all
stages of treatment and
rehabilitation. 83.7 % were
heroin addicts; 16.3 % were
not.
Frederick et al. 1973 Total N was 268 subjects aged
15-26 years from District of
Columbia and suburban
Maryland. The 268 were
broken down into the
following groups:
Methadone, N = 78 Hard-core
Abstinence, N = 20 )addicts
Delinquent, N = 50
Nonchurch, N = 30
Protestant, N = 30
Jewish, N = 30
1
Controls
Black, N =. 30
ul
P
P
Findings
Six psychometric scales were administered with
the following results:
(1) Addicts who come to the program con-
sistently score in the psychiatric range on
all scales.
(2) The magnitude of the pathology scores is
significantly lower for residents in the later
stage of the program.
(3) Scores also dropped significantly for a
group of residents retested after 7 1/2 months.
(4) Residents who left the program without
clinical advice revealed significantly higher
pathology scores than those who remained.
A Morbidity Attitude Survey Scale and a
Depression Scale (Zung) were employed.
There was distinct evidence of depression
among the addicted groups compared with
controls.
A greater incidence of suicide attempts among W
addicts than control groups, except Blacks. R
Findings suggest that suicide attempts among “R
young people are greater than is commonly P
believed, particularly among addicts, and a z
U
total treatment program is necessary in R
addition to the use of methadone.
9
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For personal use only.
James 1967 321 male and 115 female heroin
addicts in Britain known
to the Home Office Index
during years 1955-1964
and whose addiction origi-
nally derived from illicit
supplies of heroin.
Morris et al. 1974 236 cases ruled as suicide
by the Medical Examiner in
Philadelphia in 1972.
O’Donnell 1964 266 White residents of Ken-
tucky treated for narcotic
addiction at the U.S. Public
Health Service Hospital be-
tween May 1935 and
December 1959.
Prescor and Surgeon 1940 28 subjects admitted to the
U.S. Public Health Service
Hospital for treatment of
drug addiction and who at
one time or another either
overtly displayed or sub-
jectively professed self-
destructive tendencies.
Fifteen were sincerely
suicidal: 13 insincerely
suicidal: 1036 patients were
controls.
(1) Suicide rate among male heroin addicts
was over 50 times the expected suicide rate for
a normal population, corrected for age.
(2) Mortality rate among heroin addicts in the
United Kingdom approximates to 22 per 1,OOO
per year-20 times that expected in a popula-
tion of comparable age distribution.
This was an epidemiological study. Of the 236
cases, 10% were known to have abused
drugs; 9 % were alcoholics or excessive drinkers.
( I ) I13 died of natural causes.
(2) 37 died of nonnatural causes.
(3) Approximately equal percentages of men
and women were addicted to narcotics but 2/3
of the women, compared to less than 1/3 of
the men, were completely abstinent.
(4) 73 % of the men and 62 % of the women
would be classified as relapsed (all who had any
period of addiction subsequent to discharge).
Hypothetical individual most likely to be
genuinely suicidal : 40 years old, White,
married prisoner serving a sentence of 3 years
or longer; addicted through physical illness
some I 1 years prior to admission; 8th grade
education.
Admits to marital problems due to his drug
addiction: denies any suicide attempts.
Usually has some affective disorder before
attempt; tries attempt on mental ward;
usually cuts throat or wrists with piece of
broken razor blade.
(roonrinued)
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For personal use only.
Table 1 (continued)
Aut ho r(s) Year Subjects
Vaillant 1966 50 Black and 50 White New
York narcotic addicts first
admitted to the U S . Public
Health Service Hospital.
Willis 1969 42 male and 16 female hos-
pitalized inpatients admitted
to psychiatric hospital in
United Kingdom for treat-
ment of diamorphine
addiction.
35 male and 15 female dia-
morphine addicts in New
York Hospital.
100 controls.
Findings
R
OI
Followed patients for 12 years. Findings
suggest :
( I ) Such individuals have been deprived not
only in a sociological sense by virtue of
minority group membership and slum
residence, but also by physical loss of parents
and having been born into a culture different
from the one in which their parents were
reared.
(2) Delinquency later preceded drug use.
(3) Use of drugs did not conceal a latent
psychotic condition.
(4) Ethnic differences did not lead to different
patterns of drug usage.
(5) Less difference between the urban heroin
and the chronically delinquent nonaddict.
(1) Both the U.S. and U.K. patients showed
similar degrees of intrafamilial disturbance in E
terms of parental disharmony. Also a similar B
degree of overt familial psychiatric dis-
turbance including alcoholism in parents.
Z
(2) Extent of delinquent behavior under
W
achievement at school and poor work m
records were similar. "R
(3) In U.K.,they chose drugs as a form of
relief of turbulent feelings against a setting
of intrafamilial disturbance with negligible
socioeconomic deprivation.
(4) In U.S., personal pathology was set
clearly against a background of real material
deprivation and environmental influence
where delinquency and hopelessness seemed
omni present.
 DRUG ABUSE, HOPELESSNESS, AND SUICIDAL BEHAVIOR 457

2. Are hopelessness and suicidal behavior similarly related in drug

abusers and in nonabusers?
3. Does knowledge of whether an individual is a drug abuser or
nonabuser significantly add to the prediction of suicidal intent?

METHOD

Subjects
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As part of a large-scale, longitudinal study of suicidal behaviors, data

were collected from 384 suicide attempters admitted to two large metro-
politan hospitals. The sample was composed of 160 men and 224 women
who ranged in age from 17 to 63 years with a mean age of 30.2 years.
Mean years of education was 10.9. Of the 250 patients who attempted
suicide by ingestion of some dangerous substance, 222 used coma-
producing drugs. Cutting or piercing instruments were employed by 66
persons. The rest used a variety of other methods such as jumping, gas
inhalation, and drowning; 28 persons had used more than one method.
For personal use only.

Of the total sample, 86 subjects were judged to be dependent on drugs

in accordance with the diagnostic criteria stated in the Diagnostic and
Statistical Manual of Mental Disorders I1 (American Psychiatric Associ-
ation, 1968). Among the drug-dependent individuals, 14 were dependent
on sedatives, 9 on stimulants, 14 on hallucinogens, 30 on narcotics, and 19
on more than one drug.

Procedure

Each patient in the study was seen by members of our research staff
within 48 hours of admission to the hospital. In a psychiatric interview, an
experienced clinician elicited information pertaining to the patient’s drug
use and also completed the Suicidal Intent Scale (SIS). The SIS is a 15-
item scale that evaluates the seriousness of the patient’s psychological
intent to kill himself. It assesses the circumstances surrounding the suicide
attempt and the patient’s postattempt description of his intentions and
expectations during the attempt. The SIS has an interrater reliability of .95
and has been consistently validated as a measure of the severity of intent
connected with a suicide attempt (Beck, Beck, and Kovacs, 1975; Beck,
Herman, and Schuyler, 1974; R. Beck, Morris and Beck, 1974). Each item
is coded on a three-point continuum from 0 to 2; thus the possible range of
scores is 0 to 30.
 458 WEISSMAN, BECK, AND KOVACS

A psychological technician independently administered and scored the

Beck Depression Inventory (BDI) and the Hopelessness Scale (HS), the
psychometric instruments used to measure the intensity of depression and
hopelessness, respectively. The 21-item BDI covers cognitive, affective,
motivational, and vegetative symptoms of depression, while the 20-item
HS assesses the extent of negative or hopeless outlook. The reliability and
validity of both the BDI (Beck, 1967; Beck and Beamesderfer, 1974) and
the HS (Beck, Weissman, Lester, and Trexler, 1974) have been previously
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reported.
For the purposes of this study, patients who were judged to be
dependent on drugs were grouped together (n = 86) and compared with

Table 2
Demographic Characteristics of Drug Abusers and Nonabusers
Who Attempted Suicide (in percent)

Drug abusers Nonabusers

Variable (n = 86) (n = 298)
For personal use only.

Sex :
Male 39.5 40.9
Female 60.5 59.1
Race :
White 54.1 50.2
Nonwhite 45.3 49.8
Age l a
30 80.2 53.1
30-59 19.8 43.9
60+ 0.0 3 .O
Marital status:
Single 50.6 39.7
Married 8.2 19.9
Separated, divorced, widowed 30.6 35.4
Cohabitating 10.6 5.0
Last grade completed:
Grade school or less 12.8 15.2
High school 69.8 71.6
College or more 17.4 13.2
Employment status:
Unemployed, retired, housewife 16.5 71.9
Employed 16.4 21.8
Student 7.1 6.3
"Drug abusers were significantly younger than nonabusers, p < .001.
 DRUG ABUSE, HOPELESSNESS, A N D SUICIDAL BEHAVIOR 459

Table 3
Mean Suicidal Intent Scores by Levels of Depression and Hopelessness

Sample
Drug abusers Nonabusers
Depression level :
Low 9.7 (n = 30) 11.6(n = 105)
Moderate 12.6 (n = 23) 14.0(n = 87)
High 15.5 (n = 33) 14.9 (n = 106)
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Hopelessness level :
Low 8.9 (n = 28) 11.6(n = 97)
Moderate 13.6 (n = 22) 13.1 (n = 109)
High 15.2 (n = 36) 15.9 (n = 92)

patients considered to be nonabusers of drugs (n = 289). Table 2 presents

the demographic characteristics of both groups.
For personal use only.

R ESU LTS
Scores on the SIS constituted the dependent variable under exam-
ination. Two separate analyses were performed to test the relative contri-
butions of level of depression (BDI) and hopelessness (HS) in conjunction
with the drug abuse status of the patient to changes in suicidal intent
scores, Table 3 presents the mean SIS scores for abusers and nonabusers
by levels of depression and hopelessness.
Groupings into levels of depression and hopelessness (low, moderate,
and high) were accomplished by dividing the sample into three approx-
imately equal size groups, first according to the BDI and then according to
the HS score. The first 3 x 2 (Depression Level x Drug Abuse Status)
analysis of variance for unequal n’s revealed a highly significant effect due
to the level of depression (F = 19.30,p < .001). In this analysis the drug
abuse component accounted for practically none of the variance. In
addition, there was no significant interaction.
A similar 3 x 2 analysis was carried out with level of hopelessness as
the independent variable. The data analysis yielded a highly significant
hopelessness effect ( F = 20.05, p < .001),and again virtually no effect due
to either drug abuse or an interaction.
These results indicate that the severity of suicidal intent is not
dependent upon whether the patient is a drug abuser or nonabuser. From
 460 WEISSMAN, BECK, AND KOVACS

these data, one may infer that among individuals who attempted suicide
only two of the examined variables, namely depression and hopelessness,
are significant determinants of degree of suicidal intent.
To obtain a further understanding of the power of the BDI and HS to
predict suicidal intent, the data were separately analyzed for the drug
abusers and nonabusers. The raw, multiple, and partial correlations of the
BDI and HS scores with SIS are shown in Table 4. Previous findings that
the BDI, HS, and SIS are significantly correlated were corroborated in
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these two subsamples.

While the BDI and HS scores were significantly correlated for drug
abusers and nonabusers ( r = .SO, p < .001; r = .66, p < .001, respec-
tively), when BDI scores were partialed out, the HS scores were still
significantly correlated with SIS ( r = .27, p < .01; r = .20, p < .001). On
the other hand, when HS scores were removed statistically, the correlation
of BDI and SIS fell to a nonsignificant level in both subsamples ( r = .04;
r = .09). Moreover, as the significant R2 for drug abusers indicates, the
depression and hopelessness measures taken together account for over
22% of the variance in SIS, compared to 22% for the HS taken alone and
For personal use only.

15% for the BDI taken alone. Thus, while from a statistical viewpoint the
HS was not a significantly better predictor of SIS than the BDI, the two
measures taken together produced no better predictions than the HS
alone.
The multiple correlation patterns for the nonabusers were similar to
those for the abusers. The HS scores were consistently better predictors of
the measure of suicidal intent than the BDI scores. In general, the data for
both drug abusers and nonabusers support the expectation that both
instruments (i.e., BDI and HS) account for complementary portions of the

Table 4
Correlations of Depression ( B D i ) and Hopelessness ( H S ) with Suicidal intent

r R (R2) Partial r

Population BDI HS BDI and HS BDI HS

Drug abusers .39** .47** .47** (.22) .04 .27*
( N = 86)
Nonabusers .28** .33** .34** (.12) .09 .20*
( N = 298)

*p < .01.
**p < .001.
 DRUG ABUSE, HOPELESSNESS, A N D SUICIDAL BEHAVIOR 46 1

variance in SIS. However, in both subsamples, the HS scores seem to be

more successful as a predictor of SIS.

DISCUSSION
The results of the present study provide some clarification of the
complex relationship between drug abuse and suicidal behavior. The data
obtained from a group of drug abusers and nonabusers who had at-
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tempted suicide reveal that for both groups hopelessness rather than
depression accounts for a greater portion of variance of suicidal intent.
Moreover, the data indicate that among individuals hospitalized for
suicide attempts, drug abuse status does not appear to be a relevant
clinical variable vis-u-uis suicidal intent.
Hopelessness, defined in terms of negative expectancies, appears to be
the key determinant of suicidal intent for both drug abusers and non-
abusers. As indicated above, hopelessness has been demonstrated to be a
link between depression and suicidal behavior in previous clinical and
empirical studies of suicidal individuals. It is evident from the present
For personal use only.

study that this link is also a powerful one in a sample of drug-dependent

individuals.
In light of the select nature of our sample, it is not surprising that drug
abuse status per se does not seem to affect significantly the degree of
suicidal intent. It is important to realize that this finding does not negate
the observation that in other samples drug abuse may be a factor that
predisposes to suicidal behavior. In fact, it is probable that factors that
predispose to suicidal behaviors and the psychological correlates of a
currently suicidal individual represent separate although overlapping
areas. In other words, the complex psychological, sociological, and legal
concommitants of drug addiction may in fact define a group at a higher
risk for suicide than other groups. However, once the actual suicidal
behavior has taken place, its clinical phenomenology and psychological
dimensions may override presuicidal personality and life-style characteris-
tics typical of drug-addicted individuals.
The present study is suggestive of a number of areas which need
additional verification. Future studies should test the discriminant validity
of the finding that in suicidal individuals hopelessness is a predictor of
suicidal intent while drug abuse status does not appear to have much
relevance. Epidemiological investigations could provide more in formation
on the incidence of hopelessness and suicidal tendencies in drug-
dependent populations. Corroboration of a high correlation between
 462 WEISSMAN, BECK, AND KOVACS

hopelessness and suicidal intent in drug-dependent individuals may under-

line the importance of hopelessness as a determinant of their suicidal
behavior. Furthermore, a prospective study of drug abusers focused on
the relationship between hopelessness and eventual death by suicide could
ascertain whether the high suicidal risk of drug abusers may be related to a
high prevalence of hopelessness. To date, at least one investigator has
noted that hopelessness was an aspect of drug dependence among addicts
in the United States (Willis, 1969). Thus, for the researcher and clinician it
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may prove to be important to monitor hopelessness in this population.

Of considerable interest is the present finding that once hopelessness is
assessed, knowing the extent of depression does not measurably add to
knowledge of the severity of suicidal intent. This result is consistent with
previous findings that hopelessness accounts for the positive relationship
between depression and suicide (Beck, Kovacs, and Weissman, 1975;
Beck, Weissman, and Kovacs, 1976; Minkoff et al., 1973; Wetzel, 1976).
Although the present study was a preliminary attempt to evaluate the
predictive usefulness of hopelessness and drug abuse status, the results
suggest various avenues for further investigation. Hopelessness appears to
For personal use only.

be worthy of continued study in drug-dependent populations to determine

whether it is a major correlate of drug abuse or simply an important
psychological factor in suicidal behaviors.
These findings also have important clinical implications. First, in
terms of identifying drug abusers who are high suicide risks, it is
important to look at two psychopathological factors, depression and
hopelessness. It is conceivable that early detection of drug abusers at high
risk of suicide would be implemented fairly rapidly through routine
administration of the standardized instruments available for measuring
depression and hopelessness. The results obtained on these instruments
could be used in conjunction with drug history as a screening device to
select patients in need of intensive observation and treatment.
Another implication of this study is that professionals and parapro-
fessionals dealing with drug abusers may be able to identify crucial
“targets” to treat. Attention should be directed to hopelessness which
appears to be a more sensitive danger signal of suicidal intent than is
depression. If we focus on reducing the patient’s hopelessness, we may be
able to alleviate suicidal crises more effectively than in the past.
How such changes can best be accomplished is still a subject for future
research. Recently, therapists have emphasized the evocation of hope as
being fundamental to all forms of therapy (Frank, 1968). Beck and
Greenberg (1974) have formulated an active cognitive-behavioral ap-
 DRUG ABUSE, HOPELESSNESS, AND SUICIDAL BEHAVIOR 463

proach directed at correcting the pervasive misconceptions inherent in a

hopeless attitude. By concentrating on the patient’s hopelessness, the
therapist is more likely to “get a hold” of the self-destructive tendencies.
One of the ways of breaking the patient’s negative cast of thinking is to
show him that there are alternatives to his present way of looking at things
and also to his present way of behaving. By examining his assumptions,
the patient may be guided to shift the balance between life-preservative
wishes versus self-destructive wishes. Once the hopelessness has been
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substantially reduced, the therapist can deal with the problem of the
patient’s drug abuse.

ACKNOWLEDGMENT

This research was supported by National Institute of Mental Health

Grant Number MH19989-06.

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