J Clin Psychol - 2016 - Lamis

Depressive Symptoms and Suicidal Ideation in College Students: The
Mediating and Moderating Roles of Hopelessness, Alcohol

Problems, and Social Support
Dorian A. Lamis,1 Elizabeth D. Ballard,2 Alexis M. May,3 and Robert D. Dvorak4
1
Emory University School of Medicine
2
National Institutes of Mental Health
3
University of British Columbia
4
North Dakota State University
Objective: Mixed evidence for the associations among depression, hopelessness, alcohol prob-
lems, and suicidal ideation in college students may be due to the influence of social support.
Method: A moderated–mediation analysis was conducted to examine relationships among sui-
cide risk factors in 2,034 college students. Results: Social support moderated the relation between
depressive symptoms and hopelessness in predicting suicidal thoughts; specifically, the association be-
tween depressive symptoms and hopelessness was diminished among those students with high levels
of social support. This resulted in attenuated indirect associations between depressive symptoms and
suicidal ideation via hopelessness. Alcohol problems were associated with likelihood of experiencing
suicidal ideation, but not severity. Conclusion: Social support may be a key variable for suicide
prevention among college students. C 2016 Wiley Periodicals, Inc. J. Clin. Psychol. 72:919–932, 2016.
Suicide is a leading cause of death among college-aged students (Centers for Disease Control
[CDC], 2015) and an estimated 108,000 full-time college students report a suicide attempt in
the last year (National Action Alliance for Suicide Prevention, 2014). On college campuses,
prevalence estimates of suicidal ideation (SI) range from 6%–12% (Brener, Hassan, & Barrios,
1999; Kisch, Leino & Silverman, 2005; Garlow et al., 2008; Arria et al., 2009, Wilcox et al., 2010).
These prevalence rates are concerning not only because of the relation of SI to later suicidal
behavior (Bebbington et al., 2010), but also because of the association of SI to factors such as
violence and substance abuse in college students (Barrios, Everett, Simon, & Brener, 2010). The
Prioritized Research Agenda for Suicide Prevention (2014), developed by the National Action
Alliance for Suicide Prevention, has called for further research on the development of suicide
risk, specifically the interplay between psychological and social factors, which leads an individual
to consider suicide. Additionally, the recent World Health Organization “Global Imperative”
to prevent suicide has highlighted the importance of individual risk factors to identify those
individuals in need of further assessment and intervention (World Health Organization, 2014).
Research focused on college students has demonstrated the strong association between de-
pression and suicidal thoughts (Arria et al., 2009; Cukrowicz et al., 2011). The development of
suicidal thoughts can be understood within the framework of the much-studied hopelessness
theory of depression. This theory posits that individuals vulnerable to becoming hopeless are
characterized by (a) expectations of negative outcomes for events highly valued to the individual
and (b) helplessness on the part of the individual to change these outcomes (Abramson, Metal-
sky, & Alloy, 1989). These feelings of hopelessness subsequently place the individual at risk for
developing depression, particularly when exposed to negative life events. Hopelessness theory,
while initially developed to explain depression, has been expanded to incorporate suicide. Specif-
ically, hopelessness is thought to mediate the relation of cognitive vulnerability and rumination
Please address correspondence to: Dorian A. Lamis, PhD, Department of Psychiatry and Behavioral
Sciences, Emory School of Medicine, Grady Hospital, 10 Park Place SE, Atlanta, GA, 30303. E-mail:
Dalamis@gmail.com
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 72(9), 919–932 (2016)

C 2016 Wiley Periodicals, Inc.
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22295

10974679, 2016, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jclp.22295 by Kinnaird College for Women, Wiley Online Library on [22/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
920 Journal of Clinical Psychology, September 2016
with suicidal thoughts and behaviors (Abramson et al., 1998; Smith, Alloy, & Abramson, 2006).
Thus, the association between depressogenic features and suicide ideation appear to operate via
increased hopelessness.
Social support is one possible moderator of the relation between depression, hopelessness, and
suicidal thoughts. Social support has been studied as a protective factor for suicide (Kleiman,
Riskind, & Schaefer, 2014), with the CDC promoting “healthy connectedness” as a strategic
direction for suicide prevention (CDC, 2011). Social support has also been incorporated into
several theories of suicide risk. The three-step theory of suicide emphasizes the role of connect-
edness, identifying it as a protective factor that guards against the escalation of suicide ideation
(Klonsky & May, 2015). An absence of social support is incorporated into Joiner’s interpersonal
psychological theory of suicide as thwarted belongingness (Joiner, 2005). In an integration of
hopelessness theory and Joiner’s interpersonal psychological theory of suicide, thwarted belong-
ingness partially mediated the relation between negative cognitive style and suicidal thoughts
(Kleiman, Law, & Anestis, 2014). In fact, Abramson and colleagues’ (1989) original theory, as
well as the expanded framework (Panzarella, Alloy, & Whitehouse, 2006), included social sup-
port as another potential causal contributory pathway between hopelessness and depression.
Therefore, social support may play a protective role within the hopelessness theory of depression
in the development of suicidal thoughts.
Social support may have particular relevance for college students because students often
live and work together in a community environment. As students make the transition from
high school to college, their social networks change and they may be expected to forge new
relationships outside the context of parental monitoring (Arnett, 2000). For students who are able
to form new relationships, this healthy connectedness may buffer them from feelings of sadness
or loneliness. Concurrently, social supports may observe negative changes in these students and
intervene quickly to connect them with appropriate resources. In contrast, students without
social supports may experience worsening depression, hopelessness, and perhaps even suicidal
thoughts, without the influence of or intervention from their social network. Furthermore,
interventions aimed at promoting healthy connectedness may be particularly suited for college
campuses because targeted messaging and social activities can be used to develop and strengthen
social networks. Therefore, investigations of the interaction of social support with other suicide
risk factors may inform the development of suicide prevention activities for colleges.
Another suicide risk factor with particular relevance for college students is alcohol. An
analysis of the National Violent Death Reporting System found approximately one quarter of
18- to 20-year-olds who died by suicide had consumed alcohol shortly before their death (Kaplan
et al., 2014). While, similar to other analysesof alcohol and suicide death, this percentage does
not represent the majority of suicide deaths (Anestis, Joiner, Hanson, & Gutierrez, 2014), the
18-to 20-year-olds had the highest odds of consuming alcohol before suicide when compared
to any other age group. Alcohol use disorders have also been associated with suicidal thoughts
in college students, although this relation may be most robust in the absence of high levels of
depressive symptoms (Arria et al., 2009).
According to a model of suicide risk in college students put forth by Lamis, Malone and
Jahn (2014), alcohol use, alcohol-related problems, and negative life events are all related to
suicide “proneness,” which is defined as the engagement in risk-taking thoughts and behaviors
that reflect an individual’s propensity at a given time to partake in suicidality (Lewinsohn
et al., 1995). As stated in Pompili et al.’s (2011) extensive review of suicide and alcohol abuse,
alcohol has a complex relationship to suicide risk; specifically, alcohol use has a transactional
relationship with depression, such that depressive symptoms lead to increased alcohol use, and
alcohol use leads to increased depression.
Therefore, in light of the relationship between SI and alcohol use problems, as well as the
transactional relationship between alcohol use and depression, it is possible that problematic
alcohol use plays an important role in understanding the relationship between depression and
suicidal thoughts. Specifically, depression or hopelessness may increase the propensity for prob-
lematic alcohol use patterns, which then increase risk for suicidal thoughts. Such findings would
point to the importance of interventions to reduce problematic alcohol use on college campuses,
especially for students identified as depressed or hopeless.
College Student Suicidal Ideation 921
Current Study
The current study investigated the associations among depressive symptoms, hopelessness, social
support, alcohol problems, and SI within a sample of college students. Consistent with the
hopelessness theory of depression in which a depressogenic style combines with low social
support to result in hopelessness1 , we hypothesized (H1) that depressive symptoms would be
positively associated with feelings of hopelessness and (H2) this association would be moderated
by social support. Specifically, we expected that (H2a) at high social support this association
would be attenuated, while (H2b) at low social support this association would be potentiated.
It was expected that this moderation would result in a decreased association between depressive
symptoms and SI when social support is high but an increase in this association when social
support low. Finally, we hypothesized (H3) that both depressive symptoms and hopelessness
would be associated with higher levels of maladaptive behaviors. Specifically, it was expected
that associations between suicide ideation and both depressive symptoms and hopelessness
would be partially mediated via problematic alcohol use patterns.
Methods
Participants
Data were collected from 2,034 undergraduate psychology students at a large southeastern
university. Participants were between the ages of 18 and 26 years (mean [M] age = 19.35,
standard deviation [SD] = 1.35) and 73.0% (n = 1,485) were female. The majority described
their race/ethnicity as Caucasian (n = 1,588, 78.1%), followed by African American (n = 253,
12.4%), Asian American (n = 73, 3.6%), and Hispanic/Latino (n = 41, 2.0%), and an additional
3.9% (n = 79) of the sample indicated “other” for race/ethnicity. The sample comprised freshmen
(n = 968, 47.6%), sophomores (n = 491, 24.1%), juniors (n = 334, 16.4%), and seniors (n = 241,
11.8%). Of the students who participated in the study, 1,167 (57.4%) reported they were not
currently in a relationship; 60.6% (n = 1,233) reported living on campus; and 52.5% (n = 1068)
indicated they were a member of a social fraternity or sorority.
Measures
Rutgers Alcohol Problem Index (RAPI; White & Labouvie, 1989). The RAPI was used to assess
alcohol-related consequences common among college students (e.g., missing class, getting into
fights or arguments, driving after drinking). The RAPI assesses the occurrence of 23 alcohol
problems within the last year using a 4-point scale ranging from 0 (never) to 3 (more than
5 times). A total score on the RAPI can range from 0 to 69, with a higher score indicating a
higher instance of problematic drinking behaviors. The RAPI has regularly demonstrated good
internal consistency in college student samples (Martens, Neighbors, Dams-O’Connor, Lee, &
Larimer, 2007). In the present study, the internal consistency reliability estimates for the RAPI
was .93.
1 We also examined an alternative model in which hopelessness, social support, and the interaction of
hopelessness × social support predicted depression. This model also fit the data well, 95% CI of the
difference between observed and the replicated χ2: −19.206 to 375.616, p = .299. In this model, there
was no change in the variance accounted for in the outcome. However, the hopelessness × social support
interaction did not predict depression (β = −0.008, 95% BCI = −0.050 to 0.033). This is consistent with
the hopelessness theory of depression in which depression and hopelessness have a reciprocal relationship
whereby a depressogenic style interacts with social support to predict hopelessness, which in turn leads to
more depression. We tried to model this reciprocal association using a nonrecursive model, but this led to
convergence issues (i.e., K-S statistics with p-values < .001) and what appeared to be suppression due to
high collinearity between depression and hopelessness assessed at the same time. Extending this model using
temporal ordering of depression and hopelessness across time is an important area of future study.
Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, &
Farley, 1988). The MSPSS is a 12-item self-report measure assessing perceived social support
from family, friends, and significant others. Sample items included “I can talk about my prob-
lems with my family” and “I can count on my friends when things go wrong.” Response options
ranged from 1 (very strongly disagree) to 7 (very strongly agree), with higher scores indicating
higher levels of global satisfaction with perceived support. Recently, Osman, Lamis, Freeden-
thal, Gutierrez, and McNaughton-Cassill (2014) found support for the use of the MSPSS as a
unidimensional instrument, and the MSPSS has demonstrated solid psychometric properties in
university student samples (Clara, Cox, Enns, Murray, & Torgrudc, 2003; Zhou, Zhu, Zhang,
& Cai, 2013). In the current study, the Cronbach alpha for the MSPSS was .96.
Beck Hopelessness Scale (BHS; Beck, Weissman, Lester, & Trexler, 1974). The BHS is a
20-item self-report measure of hopelessness or negative attitudes about future events. Each
dichotomous (true/false) item reflects how the respondent currently feels. Sample items on the
BHS included “All I can see ahead of me is unpleasantness rather than pleasantness” and “My
future seems dark to me.” Individual items were summed to derive a total scale score, with
higher scores being indicative of stronger negative attitudes about the future. Studies with the
BHS have reported satisfactory estimates of internal consistency and concurrent validity for the
total BHS score (Hanna et al., 2011). Moreover, convergent validity has been demonstrated by
high correlations between the BHS and similar constructs in university students (Steed, 2001).
In the current study, the estimate of internal consistency reliability for the BHS was .79.
Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996). The BDI-II is a 21-item
self-report measure of current severity of depressive symptoms. The items (groups of specific
statements) are scored from 0 to 3 to assess an individual’s level of symptom severity, yielding a
summed minimum score of 0 and a maximum score (indicative of high depressive symptomology)
of 63. In accordance with previous suicide research (Bagge, Lamis, Nadorff, & Osman, 2014;
Kleiman, Miller & Riskind, 2012), the BDI item assessing suicide (item 9) was removed to avoid
contamination with the outcome variable (i.e., suicide ideation), so the range of possible total
scores on the BDI in the current study was 0 to 60. An example of an item on the BDI-II is
“Worthlessness”; response options were 0 (I do not feel like I am worthless), 1 (I don’t consider
myself as worthwhile and useful as I used to be), 2 (I feel more worthless as compared to other
people), and 3 (I feel utterly worthless). Good estimates of internal consistency and concurrent
validity have been demonstrated in samples of college students (Naragon-Gainey, Watson, &
Markon, 2009; Osman, Kopper, Barrios, Gutierrez, & Bagge, 2004). In the current study, the
estimate of internal consistency reliability for the BDI-II was .92.
Modified Scale for Suicide Ideation (MSSI; Miller, Norman, Bishop, & Dow, 1986). The MSSI
is an 18-item self-report continuous measure that assesses the presence and severity of SI during
the past 2 weeks. Participants rated each item on a 4-point scale, which were summed to obtain
a total scale score ranging from 0 to 54, with higher scores indicative of higher levels of SI. A
sample item on the MSSI is “Over the past two weeks, have you wanted to die? If so, how much
did you want to die?”; response options were 0 (none - I had no wish to die), 1 (weak - I was
not sure whether I wanted to die), 2 (moderate - I had many thoughts about dying), 3 (strong - I
really wanted to die). The MSSI has been used in samples of college students (Lamis, Leenaars,
Jahn, & Lester, 2013), and higher scores on the MSSI have demonstrated good internal consis-
tency, convergent validity, and discriminant validity (Pettit et al., 2009; Wingate, Van Orden,
Joiner, Williams, & Rudd, 2005). The Cronbach alpha was .91.
Procedure
Before data collection, the university’s institutional review board approved the study and elec-
tronic informed consent was obtained from all participants. College students were informed of
the study in regularly scheduled classes and through a posting on the participant pool website.
Participants were told that the main objective of the study was to assess risk and protective
factors for suicide and specific instructions on how to complete the measures were provided.
Data collection was conducted through an online survey over the course of four semesters, with
approximately equal numbers of participants completing the study during each of the semesters.
Table 1
Correlations, Mean, SD, Skew, and Range Among Primary Study Variables
1. 2. 3. 4. 5. 6. 7. 8. 9.
1. Gender —
2. Age .05* —
3. BDI −.07** .04 —
***
4. BHS .07** −.02 .56 —
*** *** ***
5. RAPI .11 −.03 .29 .26 —
*** *** ***
6. MSPSS −.12 −.04 −.24 −.33 −.07** —
a *** *** *** ***
7. MSSI .04 −.02 .50 .51 .21 −.25 —
b *** *** *** ***
8. MSSI .02 .01 .38 .32 .22 −.16 n/a —
c *** *** *** ***
9. MSSI .06 −.05 .49 .51 .16 −.31 n/a n/a —
Mean 0.27 19.35 8.52 2.99 10.07 70.48 1.71 0.41 4.17
SD 0.44 1.35 8.27 2.95 11.17 14.92 4.21 0.49 5.75
Skew 1.04 1.16 1.54 2.12 1.63 −1.92 4.54 0.37 3.04
Range: Low 0.00 18.00 0.00 0.00 0.00 12.00 0.00 0.00 1.00
Range: High 1.00 26.00 50.00 19.00 66.00 84.00 40.00 1.00 40.00
Note. SD = standard deviation; BDI = Beck Depression Inventory-II; BHS = Beck Hopelessness Scale;
MSPSS = Multidimensional Scale of Perceived Social Support; RAPI = Rutgers Alcohol Problem Index;
MSSI = Modified Scale for Suicide Ideation; n/a = not applicable.
a Total score for suicidal ideation across the full sample (n = 2,034)
b Likelihood of experiencing any suicidal ideation (scored 0 = none; 1 = some) across the full sample
(n = 2,034)
c Severity of reported suicidal ideation among those endorsing any suicidal ideation (n = 834)
*** p ࣘ .001. ** p ࣘ .01. * p ࣘ .05.
Participants voluntarily completed the online survey outside of class time in return for extra
credit in their psychology course. The students completed a demographic survey and the ran-
domly ordered study measures assessing the variables of interest, which did not significantly
differ by semester of data collection.
Data Preparation and Analysis Approach

Univariate plots and distributional statistics were examined before analysis. This suggested
substantial skew in the outcome variable and modest skew in several of the predictor variables
(see Table 1). Multivariate normality using Cooks’ D and plotting the loglikelihood against
the MSSI outcome indicated four potentially extreme multivariate outliers. Subsequent removal
of these outliers produced no substantial change to model estimates and did not affect the
interpretation of results. Thus, these four observations were retained in the model for the final
analysis.
The outcome variable in this data was heavily skewed (skew = 4.54) with a large floor
effect (59% of the sample endorsed no SI). Further, many of the predictor variables were not
normally distributed (see Table 1). Thus, the outcome variable comprised two different types
of participants: (a) those who endorsed SI and (b) those who did not. Further, the majority of
individuals who endorsed SI did so at very low base rates. Thus, the analytic approach needed to
separate differences between those with and without SI, as well as examining differences in the
model predictors for varying rates of SI (among those who endorsed some ideation). Further,
traditional methods of estimation that rely on least squares and/or maximum likelihood are
untenable due to the highly skewed distribution of the outcome.
To address these, we used a Bayesian approach in Mplus 7.3 (Muthén & Muthén, 2012;
Muthén, 2010; Muthén & Asparouhov, 2012). This approach allows for the calculation of model
parameters based on a posterior distribution, formed from previously identified parameters when
available (informative priors) and the model log-likelihoods (noninformative priors). Thus, the
posterior provides empirically derived distributional information used to test model parameters,
avoiding the need to meet distributional assumptions for statistical tests (Gelman, Carlin, Stern,
& Rubin, 2004). The current analysis used noninformative priors for all parameter estimate
calculations. Tests of “statistical significance” use 95% Bayesian credibility intervals (BCIs). In
addition, for complex models such as this, a frequentist (e.g., maximum likelihood) approach
precludes testing model fit because numerical integration is required. However, a Bayesian
approach allows for an estimate of model fit using posterior predictive checking, which compares
the predictive distribution to the observed data (Muthén & Asparouhov, 2012).
As noted above, the outcome variable was heavily skewed. In addition, there were a number of
zero observations. This presents complications for the analysis, given that previous research has
identified important differences between those that experience SI and those who do not (Kessler,
Borges, & Walters, 1999; May & Klonsky, in press), as well differences in the magnitude of SI
among those who endorse some SI (Czyz & King, 2015; Prinstein et al., 2008). To address this,
the data were analyzed using a two-part Bayesian hurdle model with a continuous outcome after
the hurdle. This allows for the examination of the likelihood of experiencing any SI, as well as
the effects of each predictor on the intensity of SI among those who endorse experiencing some
SI.
Gender and age were added as covariates in the model because both have been found to
be related to mood disorder symptoms, alcohol use, and SI in past research (Caetano et al.,
2013; Lamis & Lester, 2013). Indirect effects were calculated using the “model constraints”
function of Mplus and thus were also derived from posterior distributions of indirect effects
(Muthén & Asparouhov, 2012; van de Schoot et al., 2014). Significant moderation effects by
social support were probed at +/−1 SD social support (Aiken & West, 1991). Model coefficients
are standardized for ease of interpretation.
Results
Descriptive Statistics
Table 1 lists pairwise correlations, means, standard deviations, skew, and ranges among study
variables. There were more women (73.01%) in the sample than men (26.99%). Relative to women,
men were older, had lower BDI scores, higher BHS scores, less social support, and higher levels
of alcohol problems. Men and women did not differ in the likelihood of experiencing SI, χ2 (1) =
0.643, p = .423, or in the severity of SI among those who endorsed experiencing SI. There were
positive correlations among depression, hopelessness, alcohol problems, and SI (both likelihood
and severity). Social support was inversely correlated with these variables.
Bayesian Two-Part Hurdle Model

To test the hypotheses, we estimated a Bayesian two-part hurdle path model. Depression (BDI
score), social support, and the interaction of depression × social support were exogenous vari-
ables predicting the hopelessness (BHS score) mediator. In addition, alcohol problems were
hypothesized to have an indirect effect on the associations between hopelessness and SI and
between depression and SI (both likelihood and severity).
The two-part model divides the outcome into a logistic portion predicting the likelihood of
experiencing any SI among the full sample (n = 2,034) and a continuous portion among those
who endorsed experiencing some SI (n = 834). The initial model converged in the first 100
iterations. Examination of the Kolmogorov-Smirnov (K-S) correlations comparing associations
between posterior distributions of parameters across chains 1 and 2 indicated no significant cor-
relations across chains. The Potential Scale Reduction (PSR) in the final iteration was 1.061. All
of which is consistent with model convergence (see Muthén & Asparouhov, 2012). Nonetheless,
we conducted a second model run using 5,000 first-burn iterations to ensure convergence. The
second run produced a final PSR of 1.003 (and did not increase in the final iteration) and a
maximum K-S of r = .13, p = .344, again indicating model convergence.
Figure 1. Bayesian continuous hurdle model of likelihood and severity of suicidal ideation.
Note. Likelihood of experiencing any suicidal ideation above vinculum; severity of suicidal ideation among
those who endorse experiencing suicidal ideation below the vinculum. Path coefficients are standardized.
* 95% Bayesian credibility intervals do not include 0.
The 95% confidence interval (CI) of the difference between observed and the replicated χ2
indicated the model was a reasonable fit to the data (95% CI [−14.810, 37.449], p = .205). The
final model, depicted in Figure 1, accounted for 39% of the variance in hopelessness, 12% of the
variance in alcohol problems, 30% of the variance SI likelihood, and 28% of the variance in SI
severity. For clarity, the results for the two portions of the model are presented separately below.
Conditional indirect and total effects for both model portions are presented in Table 2.
Likelihood of SI. In the likelihood portion of the final model, the association between so-
cial support and the likelihood of SI was negative but did not reach conventional levels of
statistical significance. However, there was a negative specific indirect association for the social
support → hopelessness→ SI likelihood path, indicating a protective effect of social support via
reduced hopelessness. The specific indirect path from social support→ hopelessness→ alcohol
problems → SI likelihood was also significant. Finally, the total effect (combined total indirect
and direct effects) was statistically significant. Thus, the protective effects of social support ap-
pear to reduce the likelihood of experiencing SI indirectly via inverse associations with other
risk factors.
Depressive symptoms, hopelessness, and alcohol problems had direct positive associations
with the likelihood of experiencing any SI. Further, there was a positive total indirect association
for the hopelessness →alcohol problems →SI likelihood path. Finally, the three specific indirect
effects from depressive symptoms to SI likelihood were all significant, as was the total indirect
effect from depressive symptoms to SI likelihood via these three paths; however, these indi-
rect associations were qualified by the moderation of the depressive symptoms →hopelessness
path by social support. This interaction was probed at high (i.e., +1SD) and low (i.e., −1SD)
levels of social support.
Figure 2 depicts the association between depressive symptoms and hopelessness at +/− 1 SD
social support. At high levels of social support, the relationship between depressive symptoms
and hopelessness was diminished (β = 0.297, 95% BCI = 0.234, 0.350); however, at low levels of
social support this association was potentiated (β = 0.611, 95% BCI = 0.573, 0.651). This resulted
in diminished specific indirect, total indirect, and total effects between depressive symptoms and
the likelihood of SI at high levels of social support and potentiated specific indirect, total indirect,
and total effects between depressive symptoms and the likelihood of SI at low levels of social
support (see Table 2).
Severity of SI. In the continuous portion of the final model, the association between social
support and SI severity was negative and, in contrast to the logistic portion, reached conventional
Table 2
Indirect and Total Effects of Predictor Variables On the Likelihood and Severity of Suicidal
Ideation
Predictor variables
Depression Depression Depression Social

Estimate (−1SD SS) (Mean SS) (+1SD SS) support Hopelessness
* * * *
Specific IND: 0.142 (0.025) 0.105 (0.019) 0.069 (0.014) −0.046 (0.009) n/a
a
Likelihood
* * * *
Specific IND: 0.177 (0.019) 0.132 (0.015) 0.086 (0.012) −0.038 (0.006) n/a
a
Severity
*
Specific IND: n/a 0.033 (0.008) n/a n/a n/a
b
Likelihood
Specific IND: n/a 0.005 (0.006) n/a n/a n/a
b
Severity
* * * *
Specific IND: 0.010 (0.003) 0.008 (0.002) 0.005 (0.002) −0.003 (0.001) n/a
c
Likelihood
Specific IND: 0.002 (0.002) 0.001 (0.001) 0.001 (0.001) 0.000 (0.001) n/a
c
Severity
* * * * *
Total IND: 0.186 (0.027) 0.147 (0.021) 0.107 (0.016) −0.050 (0.009) 0.017 (0.005)
Likelihood
* * * *
Total IND: 0.184 (0.019) 0.138 (0.015) 0.092 (0.013) −0.038 (0.006) 0.002 (0.003)
Severity
* * * * *
Total: 0.592 (0.037) 0.553 (0.036) 0.514 (0.036) −0.111 (0.032) 0.250 (0.040)
Likelihood
* * * * *
Total: Severity 0.474 (0.048) 0.428 (0.043) 0.382 (0.039) −0.107 (0.028) 0.192 (0.027)
Note. SD = standard deviation; IND = indirect effect; SS = social support; BDI = Beck Depression
Inventory-II; BHS = Beck Hopelessness Scale; MSPSS = Multidimensional Scale of Perceived Social
Support; RAPI = Rutgers Alcohol Problem Index; MSSI = Modified Scale for Suicide Ideation; SI =
suicidal ideation; n/a = not applicable.
a Predictor Variable → Hopelessness → Suicidal Ideation.
b Predictor Variable → Alcohol Problems → Suicidal Ideation.
c Predictor Variable → Hopelessness → Alcohol Problems →Suicidal Ideation.
* 95% Bayesian credibility intervals do not include 0.
Figure 2. Simple slopes of hopelessness on depression at +/−1SD social support.

Note. Coefficients are standardized. 95% Bayesian credibility intervals for all slopes were greater than 0.
levels of statistical significance. Furthermore, there was a negative total indirect association for
the social support →hopelessness →SI severity path. The specific indirect path of social sup-
port →hopelessness →alcohol problems →SI severity was not statistically significant. However,
the total indirect effect from social support to SI severity was significant, as was the total (direct
and indirect) effect. Thus, social support not only buffered against experiencing SI but also
reduced SI severity among those that endorsed some SI via reduced hopelessness.
Depressive symptoms and hopelessness had direct positive associations with SI sever-
ity. Further, there was a positive specific indirect association for the depressive symp-
toms →hopelessness →SI severity path. However, alcohol problems were not associated with SI
severity. Consequently, the specific indirect paths from depressive symptoms and hopelessness
through alcohol problems were not statistically significant. However, the total effects (combined
total indirect and direct effects) indicated that both depressive symptoms and hopelessness were
positively associated with SI severity. As with the logistic portion of the model, we examined
the indirect and total effects conditional on social support. Similar to the logistic portion of the
model, there were attenuated specific indirect, total indirect, and total effects from depressive
symptoms to SI severity at high levels of social support. However, the specific indirect, total
indirect, and total effects between depressive symptoms and SI severity were potentiated at low
levels of social support (see Table 2).
Discussion
Suicide ideation is a pernicious problem among college students (Wilcox et al., 2010). Although
many correlates of suicide ideation have been identified, the structure of the relationship among
them remains unclear. In the present study, we investigated the associations among depressive
symptoms, hopelessness, alcohol problems, social support, and suicide ideation among college
students. Past research has consistently found that hopelessness and depression are associated
with increased suicide ideation in general. However, these results are more nuanced when the role
of alcohol use and social support are accounted for. Thus, the primary aims of the study were
to (a) clarify how social support influences the relation between depression and hopelessness,
(b) examine the indirect effect of alcohol problems on the relationship between depression and
hopelessness and the subsequent impact on SI, and (c) explore the degree to which these patterns
relate to the existence of suicide ideation versus its severity. Overall, our results were consistent
with the study hypotheses.
As expected and in line with a large body of previous work, depressive symptoms, hopelessness,
alcohol problems, low social support, and suicide ideation were all associated with each other
in the expected direction and generally to a small to moderate degree. Specifically, depressive
symptoms and hopelessness displayed the strongest bivariate relationship, consistent with the
hopelessness theory of depression as well as substantial empirical literature.
We hypothesized, and found, that this relationship was influenced by the degree to which
students felt socially supported. The association between depressive symptoms and hopelessness
was stronger among poorly supported students compared to students perceiving higher levels
of social support. One might imagine a college student who feels depressed but has a strong
supportive social network. This individual may be protected against developing hopelessness
about his or her situation and, in turn, be less likely to experience suicidal thoughts. As causality
cannot be assumed from this model due to the cross-sectional nature of the measurement,
it may also be possible that hopeless students are buffered from depression by the presence
of social support. In either case, social support plays a role in explaining the link between
depressive symptoms and hopelessness, exerting influence on downstream suicidal thinking. This
is consistent with existing literature that demonstrates the importance of feeling connected and
supported in buffering against depression (George, Blazer, Hughes, & Fowler, 1989), hopelessness
(Zaleski, Levey-Thors, & Schiaffino, 1998), and suicide ideation (Kleiman et al., 2014; Wilcox
et al., 2010).
This finding also aligns with a new theory of suicide ideation, the three-step theory (Klonsky
& May, 2015), that suggests that the combination of pain (in this case operationalized by
depression) and hopelessness are the key ingredients to the development of suicide ideation, but
it is the role of connectedness, one example of which being social support, that protects against
the progression in severity of suicidal thinking. In the results presented here, socially supported
students evidence less of a relationship between depressive symptoms, hopelessness, and suicide
ideation (presence or severity) than poorly supported students.
Finally, we hypothesized that both depressive symptoms and hopelessness would be associated
with higher levels of alcohol use problems, which was the case to a small degree. Additionally
we hypothesized that these problems would partially explain the associations among depressive
symptoms, hopelessness, and suicidal thinking. Results suggested that alcohol use problems
explained a small part of the relationship among these variables in the presence of suicide
ideation but did not relate to the severity of ideation. This may be due in part to the limited
variability in ideation severity but also suggests that risk factors may differ in whether they
influence the initiation of suicidal thinking or are more important in increasing the severity of
such thoughts.
These findings have some important implications for theory development, suicide assessment,
suicide prevention efforts, and methodological approaches to examining suicide data. Regarding
theory development, there are many risk factors for suicide ideation that overlap quite often,
for example, psychiatric disorders, pathological personality traits, and trauma history. A better
understanding of how these risk factors explain and influence each other will help us improve
our models of suicidality and confirm that our theories apply across populations. Our findings
suggest that the role of hopelessness in explaining the link between depressive symptoms and
considering suicide may vary depending on level of social support. Highlighting the unique
role of social support and connection is consistent with multiple existing theories of suicide
that also place a special emphasis on connection (or its absence), by suggesting it reduces the
link between hopelessness and depression (Abramson et al., 1989), explains the development
of suicidal thoughts (Joiner, 2005), or buffers the intensity of suicide ideation (Klonsky &
May, 2015).
Finally, our data suggest some rather important differences between those that endorse SI
and those that do not, which extends beyond a simple linear association. For example, at
the bivariate level, hopelessness accounts for 25% of the variance in total SI as well as the
likelihood of experiencing any SI. However, this estimate is inflated due to the high number of
individuals reporting no SI. Indeed, among those that report SI, hopelessness accounts only for
9% of the bivariate variance in SI. A similar pattern was found across a number of bivariate
associations. Thus, differentiating these two important constructs has important implications
for understanding the role of hopelessness in predicting if someone will experience SI versus the
severity of SI among those who endorse it to some degree.
When trying to prevent SI among college students, this study suggests that building healthy
connections and social support may be a way of protecting college students from suicidal
thinking. This could also involve educating college students about the mental health value of
social support, providing mechanisms to build new social networks at college (e.g., study groups,
sports teams, clubs), and giving advice on how to maintain social supports from afar (e.g., family,
high school friends). This leads to questions about the role of perceived versus received social
support, constructs that are known to relate moderately and be differentially related to health
outcomes (Haber, Cohen, Lucas, & Baltes, 2007). Further study is warranted to determine the
importance of perceived versus actual or received support to better understand whether fostering
social groups or targeting the individuals’ beliefs about using social networks for support is a
more effective intervention to increase connection and reduce negative psychological outcomes
among college students.
Limitations
Our study is not without limitations. First, the data were cross-sectional, so though the analyses
assume causal relationships among the variables, a causal interpretation of the results is not
possible. Experimental and longitudinal designs are best suited to meditational models; however,
they are difficult to implement when studying suicidality because of the low-base rate nature
of suicidal thoughts and behavior and concerns about intervening with high-risk participants.
However, further study using these methods is suggested to enhance our understanding. Second,
the study relied on self-report measures of all constructs. Participants may have been motivated
by social desirability to present themselves in a more favorable light, which can skew results by
increasing the likelihood that associations are found due to shared methods of variance rather
than true relationships.
Additionally, social support was measured subjectively. More objective measures of social
support, such as social network analysis (Borgatti, Mehra, Brass, & Labianca, 2009) or novel
methodologies, such as electronically activated recordings of the environment (Mehl, 2014), may
help to further elucidate the degree to which an actual supportive network or the perception of a
supportive network is important. Our use of “depressive symptoms” as a proxy for depressogenic
features within the hopelessness theory of depression is also a limitation. The theory posits a
reciprocal relationship between depressogenic features, hopelessness, and depression, which we
were unable to model with the current data. However, we did examine the moderating effects
of social support on two paths independently (i.e., from depressive symptoms to hopelessness
and from hopelessness to depressive symptoms). Though both models fit well, only the former
was moderated by social support. Thus, a model that tests these variables across time may
seek to parse out “depression” from “depressogenic features,” with the expectation that social
support would only moderate the link from depressogenic features to hopelessness, and not the
subsequent association between hopelessness and depression.
Additionally, other moderators may also be important in explaining the relation between
depression and hopelessness. For example, the presence of other types of psychache such as
anxiety or grief, physical pain, or agitation may also help explain the relation between depression
and hopelessness. Finally, it should be noted that the effects (both direct and indirect) were quite
modest, despite being statistically significant. This is due in large part to a fairly large sample
size.
Strengths
This project also has a number of strengths. The use of a sophisticated analytical approach
allowed us to examine the presence or absence of suicide ideation, as well as the severity of
ideation among ideators. The study also used well-validated measures of the constructs of
interests and took care to use measures that assessed all variables in the same time frame (i.e.,
within the past 2 weeks). Finally, the analyses were able to control for potential confounds (e.g.,
gender, age), so the associations among depressive symptoms, hopelessness, and suicide ideation
could be observed more clearly.
Conclusion
Overall, the study supports findings in the existing literature demonstrating robust relationships
among suicide risk factors such as depressive symptoms, hopelessness, alcohol problems, and
suicide ideation. The investigation pushes our knowledge one step further by demonstrating the
effect of social support on both the development and severity of suicide ideation.
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Depressive Symptoms and Suicidal Ideation in College Students: The

Mediating and Moderating Roles of Hopelessness, Alcohol

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 72(9), 919–932 (2016)

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22295

Data Preparation and Analysis Approach

Bayesian Two-Part Hurdle Model

Depression Depression Depression Social

Figure 2. Simple slopes of hopelessness on depression at +/−1SD social support.

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