JOURNAL OF PERSONALITY ASSESSMENT, 79(3), 512530 Copyright 2002, Lawrence Erlbaum Associates, Inc.

The Positive and Negative Suicide Ideation (PANSI) Inventory: Psychometric Evaluation With Adolescent Psychiatric Inpatient Samples

Augustine Osman and Francisco X. Barrios

Department of Psychology University of Northern Iowa

Peter M. Gutierrez and Jennifer J. Wrangham

Department of Psychology Northern Illinois University

Beverly A. Kopper, Ronald S. Truelove, and Sena C. Linden

Department of Psychology University of Northern Iowa

In this study, we evaluated the factor structure of the Positive and Negative Suicide Ideation (PANSI) Inventory (Osman, Gutierrez, Kopper, Barrios, & Chiros, 1998) using confirmatory factor analysis (CFA). The PANSI assesses the frequency of negative risk and protective factors that are related to suicidal behavior. Participants (n = 195) were adolescent psychiatric inpatients, ages 14 to 17 years, in the CFA. Results of the CFA supported the fit for the 2-factor oblique model as the best fitting model. The internal consistency reliability estimates of the 2 subscales, the PANSINegative ( = .96) and the PANSIPositive ( = .89) were high. Scores on the PANSI scales differentiated between suicide attempters and controls and those at severe risk for suicide and controls. Correlational analyses provide strong support for the concurrent validity of the scales. The results of the logistic regression analyses provide support for the use of this new inventory as a risk measure of suicide-related behaviors. Scores

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on the PANSI scales (n = 54) also showed satisfactory evidence for testretest reliability over a 2-week period.

In 1998, Osman and his colleagues (Osman, Gutierrez, Kopper, Barrios, & Chiros, 1998) developed the Positive and Negative Suicide Ideation (PANSI) Inventory, a 14-item self-report instrument, for assessing the frequency of negative risk and protective factors associated with suicide-related behaviors. The development of this instrument was based on contemporary theoretical rationale that both negative risk and protective (buffering) factors are important in the analyses of suicide-related behaviors (e.g., see Prinstein, Boergers, Spirito, Little, & Grapentine, 2000; Thompson, Eggert, & Herting, 2000). Negative risk factors in suicidal behavior may include symptoms such as depression, hopelessness, and negative thoughts or perceptions about stress-related events. These factors may increase the risk for suicidal ideation and behaviors. Protective factors modulate or serve as buffers against taking ones own life. Examples of protective factors may include the use of adequate problem-solving strategies as well as having adequate family connectedness and positive friendship relationships (King, 2000; Rubenstein, Heeren, Housman, Rubin, & Stechler, 1989; Whatley & Clopton, 1992). In their review of current suicide assessment measures, Osman, Gutierrez, et al. noted that most existing self-report instruments of suicidal behavior (ideation or attempts) tap either negative risk (e.g., the Adult Suicidal Ideation Questionnaire; Reynolds, 1991) or positive (e.g., the Reasons for Living Inventory for Adolescents [RFLA]; Osman, Downs, et al., 1998) factors rather than both dimensions of the suicide behavior construct simultaneously. The PANSI has a unique advantage; as a screening instrument, it can be used to assess both positive and negative risk factors that are related to suicidal behaviors. The development and initial psychometric properties of the PANSI have been described in detail elsewhere (see Osman, Gutierrez, et al., 1998). Briefly, the inventory consists of 14 items; each item is rated on a 5-point Likert-type scale format ranging from 1 (none of the time) to 5 (most of the time). The time reference for rating the PANSI items is the past 2 weeks, including today. The initial items in this inventory were generated, in part, with input from adolescents and college-age students. Following a series of item evaluation procedures, the remaining 14 items were submitted to an exploratory principal-axis factor analysis with varimax rotation in a sample of 150 men and 300 women at a mid-sized Midwestern state university. Osman, Gutierrez, et al. extracted two factor scales, Negative Suicide Ideation (PANSINegative; 8 items) and Positive Suicide Ideation (PANSIPositive; 6 items). Both scales were internally consistent (i.e., alpha estimates were .80 and .91 for the Positive and Negative Ideation scales, respectively). Additional validation data including construct validity per confirmatory factor analyses (CFAs), concurrent, and predictive validity were also reported by Osman,

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Gutierrez, et al. (1998) for nonclinical samples. For example, results of their CFAs showed that the two-factor oblique model provided an excellent fit to the study sample (n = 286 undergraduates) data: SatorraBentler 2(75, N = 286) = 91.71, p = .09, ns. Scores on the Positive Suicide Ideation (referred to here as PANSIPositive) scale were correlated moderately and negatively with scores on traditional measures of suicidal behavior such as the Suicide Probability Scale (SPS; Cull & Gill, 1982). As expected, the Negative Suicide Ideation (referred to in this study as PANSINegative) scale scores correlated moderately and positively with scores on the SPS (r = .59, p < .001) and slightly to moderately with scores on the four Suicidal Behaviors Questionnaire (SBQ; Linehan & Nielsen, 1981) items (range rs = .39 to .61). In addition, scores on both scales were useful in predicting scores on the Brief Symptom Inventory (Derogatis, 1992), and the Beck Hopelessness Scale (BHS; Beck, Weissman, Lester, & Trexler, 1974). Given that the PANSI was developed to assess suicide-related behaviors in clinical and nonclinical samples, additional studies are needed to validate this instrument in other nonclinical and clinical samples. Since the Osman, Gutierrez, et al.s (1998) instrument development study, only Lester (1998) has examined the psychometric properties of the PANSI. Briefly, using a sample of 69 undergraduates, Lester noted that scores on the PANSI were as useful as scores on the BHS (Beck et al.,1974) in predicting current and lifetime suicidal ideation. No study to date has been conducted with clinical inpatient samples to replicate factor structure or examine other psychometric properties of the PANSI. Indeed, establishing the factor structure and psychometric properties of reliability and validity such as concurrent and convergent validity of the PANSI in clinic samples with high prevalence rates of suicide-related behaviors will provide stronger validational support for this new instrument. Our study was designed to confirm the factor structure of the PANSI, examine reliability and testretest estimates for the two scales, and evaluate evidence for known-groups discriminant and concurrent validity of the scales in samples of psychiatric inpatient adolescents recruited from two adolescent units of a state psychiatric hospital.

METHOD Participants Potential participants were recruited from consecutive admissions to two separate adolescent inpatient units of a state psychiatric hospital. The hospital serves patients in need of long-term psychiatric (and related medical) care from several counties in the eastern part of a Midwestern state. Adolescents are generally admitted to these units because of a range of psychiatric and psychosocial problems in-

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cluding conduct disorder and suicide-related behaviors. One of these units specifically serves youth with psychiatric and medical-related problems. Of 203 participants, 195 (96.1%) who completed three or more of the study measures were included in these analyses. Chi-square analyses showed that participants from the separate units (97 vs. 98) did not differ significantly in demographic variables of gender (p = .47) and ethnicity (p = .11). Likewise, result of the independent samples t-test analysis showed no significant difference between the groups from the different units in terms of age, t(193) = 0.77, p = .44. Thus, the samples were combined for the analytic procedures. The combined sample was composed of 107 boys (M age = 15.50 years, SD = 1.06) and 88 girls (M age = 15.38 years, SD = 1.12); boys and girls did not differ significantly in age, t(193) = 1.43, p = .16. The majority of the participants (n = 163) were White (83.6%), 8 were African American (4.1%), 8 were Hispanic American (4.1%), 7 were Native American (3.6%), and 9 were of other ethnic or racial groups (4.6%). Regarding diagnoses, our review of the medical chart diagnoses (Diagnostic and Statistical Manual of Mental Disorders, 4th edition; American Psychiatric Association, 1994), as established by the attending psychiatrists and interdisciplinary treatment teams, identified the following primary diagnoses: 37.9% conduct disorder, 23.1% oppositional disorder, 21.5% major depressive disorder (single or recurrent), 5.6% adjustment disorder, 4.1% attention deficit hyperactivity disorder, and 7.7% other psychiatric conditions.

Suicide group status. To evaluate the ability of scores on the PANSI scales to differentiate between psychiatric inpatient adolescents with differing degrees of suicide-related behaviors, we formed three subgroups (known groups) similar to the groups reported in Pinto, Whisman, and McCoy (1997). The suicide attempter (SA) group (n = 55; 20 boys and 35 girls) was composed of adolescents who (a) were admitted because of suicide attempts and (b) had documented histories of prior attempts (range = 1 to 6) in their medical records. The specific methods documented included deliberate attempts to use firearm (n = 2), overdose of medications (n = 34), hanging (n = 2), jumping from a height (n = 5), and self-injury/cutting (n = 12) with the intent to die. The severe at-risk (SAR) suicidal group (n = 49; 26 boys and 23 girls) was made up of those adolescents who were admitted because they had verbalized or threatened to kill themselves (with no current or history of prior attempts). Clinically, individuals who have attempted suicide can be differentiated from serious ideators in terms of symptoms such as severity of suicidal thoughts and hopelessness. The nonsuicidal (NS) control group (n = 91; 61 boys and 30 girls) was composed of adolescents who were admitted for reasons other than severe suicide-related behaviors (threats or attempts). In addition to our reviewing of the medical records, two independent agency clinical staff members (raters) who were unaware of the study objectives and the initial subgroup classifications of the participants together randomly selected approximately 25% of the participants from

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each subgroup and administered suicide-related items from the Reynoldss Suicidal Behavior History Form (SBHF; Reynolds, 1992). The SBHF, a semistructured interview, is composed of 29 items (most of the items are openended questions) designed to obtain additional information related to prior and most recent suicide attempts, number of previous attempts, method, and lethality of the suicide attempts. Only Section II (history of suicide attempts; Items 1, 2a to 2c) and Section IV (prior attempt history; Items 14, 14a to 14b) of the SBHF were administered. No participant was reassigned (total rated n = 49) after the ratings, suggesting high agreement between the multidisciplinary assessments and the brief ratings of suicidal status.1

Testretest subgroup. A subset (n = 54; 28 boys and 26 girls) of the 195 participants (27.7 %) also completed the PANSI after 2 weeks of initial questionnaire administration to assess testretest reliability estimates. Approximately equal proportions were recruited from the SA (21.8%), the SAR (30.6%), and the NS (29.7%) groups, 2(2, N = 54) = 1.33, p = .51. In addition, the majority included youths with diagnoses of conduct (29.6%), oppositional (20.4%), and depressive (18.5%) disorders; also, 85.2% were White. We recruited participants who were admitted for 2 weeks or longer since the initial questionnaire administration.2

Measures and Procedure All participants completed the 14-item PANSI and a brief demographic questionnaire used to obtain background information including age, gender, and ethnicity. A subset of the participants, described previously (n = 195), completed the following self-report instruments.

SBQR. The SBQRevised (SBQR; Osman et al., 2001) is a brief 4-item self-report instrument designed to assess the frequency of lifetime suicide ideation, suicide attempts, threats of suicide, and self-reported suicide likelihood. Osman et al. (2001) reported an alpha estimate of .88 for psychiatric adolescent inpatients. In addition, Osman et al. provided evidence for the clinical utility of the SBQR in that scores on the instrument differentiated between subgroups of suicidal and
1We thank the clinical staff and teachers at the Mental Health Institute, Independence, Iowa, for their support and assistance with data collection. Special thanks go to the program directors and the medical directors of each unit. 2We did not collect data on the length of hospitalization in this investigation. We note, however, that in previous studies with this long-term population, the average length of hospitalizations noted have ranged from 1 to 12 months.

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nonsuicidal youth and adults. In this study, the alpha estimate for the total SBQR was .86. The total SBQR score was used as a measure of suicide-related behavior (negative risk factor) to evaluate evidence for concurrent validity.

BHS. The BHS (Beck et al., 1974) is a 20-item truefalse self-report instrument designed to tap symptoms of hopelessness about future events. Scores on this instrument range from 0 to 20; high scores indicate higher levels of negative expectations about future events. The BHS scores have established internal consistency and validity in the psychometric literature (Gutierrez, Osman, Kopper, & Barrios, 2000; Lyndall, 2001; Novy, Nelson, Goodwin, & Robert, 1993). The KuderRichardson 20 estimate for the BHS in this study was high at .91. The total BHS score was used as a measure of feelings of hopelessness (negative risk factor) to tap evidence for concurrent validity. RFLA. The RFLA (Osman, Downs, et al., 1998) is a 30-item, self-report instrument designed to assess reasons adolescents give for not killing themselves. The RFLA items are rated on a 6-point scale with anchors of 1 (not at all important) to 6 (extremely important). Recently, Gutierrez, Osman, Kopper, and Barrios (2000) reported satisfactory psychometric properties of concurrent and predictive validity of the RFLA in samples of psychiatric adolescent inpatients. The total RFLA scale ( for our study sample = .91) was used in this study as a measure of reasons for living (protective factor) to evaluate evidence of concurrent validity. PANAS. The Positive and Negative Affect Scale (PANAS; Watson, Clark, & Tellegen, 1988) is a 20-item self-report measure of symptoms related to positive affect (PANASPA; 10 items) and negative affect (PANASNA; 10 items). Each item is rated on a 5-point scale ranging from 1 (very slightly) to 5 (extremely). In this study, the time reference for rating the items was the past 2 weeks. The PANAS has been shown to have excellent internal consistency, testretest reliability, and concurrent and convergent validity in clinical and nonclinical samples (see Burger & Caldwell, 2000; Kvaal & Patodia, 2000; Thomas, 2000; Watson & Clark, 1992). The PANASPA was used as a measure of positive affect (protective factor) and the PANASNA was used as a measure of negative affect (risk factor). In this study, the reliability estimates for the PANASPA and PANASNA were .86 and .90, respectively. The PANAS scores were used to evaluate evidence for concurrent validity. The Institutional Review Board of the hospital and the university approved the procedures for conducting this study. Because the questionnaire packets were included in the intake evaluations on each unit, parental (or guardian) consent was obtained at the time of admission of the potential youth participant. Youth assent, however, was obtained at the time of the individual questionnaire administrations.

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All the initial questionnaires were administered by members of the multidisciplinary treatment team after receiving group and individual training by Augustine Osman. Participants individually completed the questionnaire packet within 1 week of admission to the unit.

RESULTS Reliability Analysis of the PANSI Scales We assessed the internal consistency of the positive and negative scales in the total sample (n = 195). The Cronbach alpha estimate for the PANSIPositive scale was .89 (corrected item-total correlations ranged from .65 to .78). The alpha estimate for the PANSINegative scale was .96 (corrected item-total correlations ranged from .75 to .90). These findings show acceptable alpha estimates of the PANSI scales for our psychiatric inpatient sample data.

CFAs of the PANSI Items We estimated the fit of two models to our sample data using the EQS for Windows 6.0 (Bentler & Wu, 2001) software program. Model 1 specified a one-factor model in which all 14 items were forced to load on a single factor of general suicide risk. Model 2 specified a two-factor oblique model as reported in the exploratory procedure by Osman, Gutierrez, et al. (1998). Specifically, the eight PANSINegative items (Items 1, 3, 4, 5, 7, 9, 10, and 11) were allowed to load on the PANSINSI factor, and the six PANSIPositive items (Items 2, 6, 8, 12, 13, and 14) were allowed to load on the PANSIPSI factor. The factors were allowed to correlate. The oblique model was used because we expected some degree of correlation between the factors. For both Model 1 and Model 2, the variance of each factor was set to 1.0. Mardias (1970) normalized estimate was 51.23 and the univariate kurtosis values ranged from .52 (Item 13, Felt that life was worth living?) to 2.33 (Item 5, Thought about killing yourself because you could not accomplish something important in your life?). Thus, we used the maximum likelihood robust procedure because it is less sensitive to normality of distribution of the data (Bentler & Bonett, 1980). Although a model with a nonsignificant chi-square estimate is generally considered the best fitting model, we also considered additional fit estimates in evaluating the adequacy of each model: the SatorraBentler scaled chi-square (SB2) divided by degrees of freedom (SB2/df, value 2) ratio, the robust comparative fit index (value .90), the Bentler and Bonett (1980) nonnormed fit index (value .90), and the root mean square error of approximation (value < .08) index. We also examined the fit of the null model as a baseline model (e.g., for dis-

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cussions of these estimates, see Bentler & Bonett, 1980; Browne & Cudeck, 1993; Hu & Bentler, 1999; Steiger, 1990). Results of the fit estimates for the null-, one-, and two-factor models are given in Table 1. The two-factor oblique model met all the preestablished criteria, providing the best fit to this sample data: SB2/df = 1.36; robust comparative fit index = .980; nonnormed fit index = .976; and the root mean square error of approximation = .043 (90% confidence interval [CI] = .017, .062). Both the nulland one-factor models did not meet any of the prior specified fit criteria. As in Osman, Gutierrez, et al. (1998), allowing correlations between a set of error terms (E3 and E10) within the PANSINegative factor resulted in an excellent fit of the model to the sample data, SB2 = 94.82, df = 75, p = .06. The correlation between E3 and E10 (.33) was significant, p < .01. The factor loadings (all values > .40) for the two-factor (unmodified) oblique model are given in Table 2. The R2 values for the PANSINegative items ranged from .583 to .839; the values for the PANSIPositive items ranged from .439 to .755. Thus, each item had adequate loading on its respective factor. The correlation between the PANSINegative and PANSIPositive oblique factors was .65, p < .05.

Group Differences on the PANSI Scales Comparisons of the three groups on demographic variables showed significant differences in gender composition, 2(2, N = 196) = 13.11, p < .001. The proportion of boys in the NS group was higher than in the SA (p < .01) or the SAR (p < .01) group. There were no significant differences among the groups in terms of ethnic composition or age (all ps > .05). A 2 (gender) 3 (groups) multivariate analysis of variance (MANOVA) was conducted to evaluate the effects for gender and groups on the two PANSI scales. The result of the MANOVA showed a significant effect for group, Wilkss = .67, F(4, 376) = 20.82, p < .001. However, the effect for gender, Wilkss = .99, Exact
TABLE 1 Goodness-of-Fit Indexes Model M0 M1 M2 SB2 1469.12 326.51 103.05 df 91 77 76 p< .05 .05 .02 SB2/df 16.14 4.24 1.36 RCFI .819 .980 NNFI .804 .976 RMSEA .164 .043

Note. SB2 = SatorraBentler chi-square; df = degrees of freedom; RCFI = robust comparative fit index; NNFI = nonnormed fit index; RMSEA = root mean square error of approximation; M0 = null model; M1 = one-factor model; M2 = two-factor oblique model.

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OSMAN ET AL. TABLE 2 Confirmatory Factor Analyses of the Two-Factor Oblique Model

PANSI Abbreviated Items PANSINSI 1. Considered killing yourself 3. Felt hopeless and wondered 4. Felt unhappy about 5. Thought you could not accomplish 7. Thought you could not find solution 9. You felt like a failure 10. Thought problems were overwhelming 11. Felt lonely PANSIPSI 2. Felt you were in control 6. Felt hopeful 8. Felt excited 12. Felt confident about ability 13. Felt life worth living 14. Felt confident with plans

Robust SE

R2

.880 .914 .763 .911 .874 .882 .884 .916 .000 .000 .000 .000 .000 .000

.000 .000 .000 .000 .000 .000 .000 .000 .679 .663 .765 .707 .822 .869

.082 .072 .079 .083 .077 .077 .087 .077 .075 .074 .064 .081 .067 .067

.774 .836 .583 .830 .764 .779 .781 .839 .461 .439 .586 .500 .675 .754

Note. PANSI = Positive and Negative Suicide Ideation Inventory; SE = standard error; PANSINSI = PANSINegative Suicide Ideation; PANSIPSI = Positive Ideation.

F(2, 188) = .84, p = .43, and the Gender Group interaction effect, Wilkss = .99, F(4, 376) = .33, p = .86, were not statistically significant. Table 3 shows the means and standard deviations on the PANSI scales for the groups. Subsequent one-way ANOVA (with Tukey HSD comparisons) showed that the SA group scored significantly higher on the PANSINegative scale score than did the NS control and the SAR groups (all ps < .05). As expected, the SA group had a significantly lower PANSIPositive scale score than did the NS control and the SAR groups (all ps < .05). These findings provide strong evidence for use of scores on the PANSI scales to evaluate the responses of the suicidal and nonsuicidal inpatient adolescents in our sample. Similar one-way ANOVAs with Tukey HSD comparisons were conducted to examine mean differences among the groups on the study measures SBQR, BHS, PANAS, and RFLA (see Table 3). The SA group, compared with the SAR and NS control groups, scored significantly higher on the SBQR and BHS scale scores (all ps < .01). The SA group, as expected, obtained significantly lower scores on the PANASPA and RFLA scales scores than did the NS control and SAR groups. Both the SA and SAR groups obtained significantly higher scores on the PANASNA scale scores than did the nonclinical control groups. These additional analyses further highlight differences among these groups on the negative and protective factors.

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Correlational Analyses The PANSINegative and the PANSIPositive scale scores were moderately and negatively correlated (r = .59, p < .001). Scores on the PANSI scales were correlated with scores on the study measures to assess concurrent validity. Examination of Table 4 shows that the PANSINegative scale scores correlated highest with the PANASNA and the SBQR scale scores. Dependent correlational analyses showed that the correlation between the PANSINegative and the PANASNA scale scores was comparable to the correlation between the PANSINegative and the SBQR scale scores, t(192) = 0.39, ns. However, the correlation between the PANSINegative and the SBQR scale score was significantly higher than the correlation between the PANSINegative and (a) the PANASPA scale, t(192) = 14.02, p < .05; (b) the BHS scale score, t(192) = 3.77, p < .001; and (c) the RFLA scale score, t(192) = 16.78, p < .001. Similar results were obtained in the comparisons involving the correlations between the PANSINegative and the PANASNA with scores on the PANASPA, BHS, and RFLA scales (all ps < .05). The PANSIPositive scale score correlated highest with the RFLA total and the PANASPA scale scores. The correlation of the PANSIPositive scale score with the RFLA total score was similar to the correlation of the PANSIPositive scale score with the PANASPA scale score, t(192) = 1.73, ns. The correlation between the PANSIPositive and the PANASPA scale score was significantly higher than the correlation between the PANSIPositive and (a) the PANASNA

TABLE 3 Means and Standard Deviations of the Study Measures by Suicide Status SAa Measures PANSINegative PANSIPositive SBQR BHS PANASPA PANASNA RFLA M 2.58 2.91 14.36 8.78 28.05 25.04 3.66 SD 1.19 0.95 2.43 6.59 7.51 9.24 1.15 M 1.54 3.78 9.98 5.63 31.51 22.61 4.34 SARb SD 0.79 0.89 1.35 4.77 8.20 8.61 0.85 M 1.23 3.79 4.98 3.59 33.15 18.95 5.17 NSc SD 0.38 0.88 2.36 3.72 7.83 7.53 0.75 Group Comparisons SA > NS, SAR SA < NS, SAR SA > NS, SAR; SAR > NS SA > NS, SAR; SAR > NS SA < NS, SAR SA, SAR > NS SA < NS, SAR; SAR < NS

Note. N = 195. SA = suicide attempters; SAR = severe at-risk; NS = nonsuicidal; PANSI = Positive and Negative Suicide Ideation Inventory; SBQR = Suicidal Behaviors QuestionnaireRevised; BHS = Beck Hopelessness Scale; PANAS = Positive and Negative Affect Scale; PANASNA = PANASNegative Affect; PANASPA = PANASPositive Affect; RFLA = Reasons for Living Inventory for Adolescents. an = 55. bn = 49. cn = 91.

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TABLE 4 Descriptive Statistics and Correlations Between the PANSI Scales and Study Measures Controlling for Companion Scale PANSINI .39* .04 .11 .39* .15 PANSIPI .03 .43* .19* .07 .25*

Total Sample Measure PANASNA PANASPA BHS SBQR RFLA M 21.58 31.30 5.57 8.88 4.54 SD 8.68 8.08 5.38 4.54 1.11

Zero-Order PANSINI .47* .34* .26* .50* .34* PANSIPI .30* .52* .30* .34* .39*

Note. N = 195. PANSI = Positive and Negative Suicide Ideation Inventory; PANSINI = PANSINegative Scale; PANSIPI = PANSIPositive Scale; PANAS = Positive and Negative Affect Scale; PANASNA = PANASNegative Affect; PANASPA = PANASPositive Affect; BHS = Beck Hopelessness Scale; SBQR = Suicidal Behaviors QuestionnaireRevised; RFLA = Reasons for Living Inventory for Adolescents. *p < .01, Bonferroni adjusted (.05/5).

scale score, t(192) = 13.49, p < .001; (b) the BHS scale score, t(192) = 13.30, p < .001; and (c) the SBQR scale score, t(192) = 14.34, p < .001. Overall, the patterns of these relationships were maintained when we also used partial correlational analyses to control for the effect of scores on the companion scale. For example, when we controlled statistically for the effect of the PANSIPositive scale scores, the PANSINegative correlated significantly with only scores on the PANASNA and the SBQR. These findings provide strong support for the concurrent validity of the PANSI scales.

Logistic Regression Analyses Logistic regression analyses were conducted to evaluate the unique contribution of the PANSI scales and three of the study measures (the PANAS, BHS, and RFLA) as risk measures in differentiating between (a) patients with suicide attempts (coded 1) from patients who were admitted for reasons other than suicidal behavior (NS controls, coded 0) and (b) patients with SAR behaviors (coded 1) from NS controls (coded 0). We selected the PANAS, BHS, and RFLA because scores on these instruments have received extensive support in the suicide literature as risk factors for suicide-related behaviors. In the first analysis, scores on the negative risk instruments, the PANSINegative, PANASNA, and BHS, were entered simultaneously in the equation as predictors; suicide status (e.g., SAs vs. NS controls) served as the criterion variable. In the second analysis, scores on the positive protective instruments, the PANSIPositive, PANASPA, and RFLA, were entered simulta-

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neously in the equation and suicide status also served as the criterion measure. We initially examined the traditional estimates including the standardized coefficients, odd ratios (OR) with 95% CIs, and effect sizes from each equation in evaluating the statistical significant contribution of the measures.3 However, only estimates that contained 95% lower bounds of 1 were identified further as useful measures of risk factors (see Kleinbaum, Kupper, & Chambliss, 1982) for suicide-related behaviors in our sample. In the comparison involving the SA and control groups, scores on both the BHS (estimate = 0.21, t ratio = 3.95, p < .001; OR = 1.24, 95% CI = 1.11, 1.38), and the PANSINegative (estimate = 2.18, t ratio = 5.06, p < .001; OR = 8.81, 95% CI = 3.79, 20.47) instruments were identified as significant and useful risk measures for differentiating between the SA and NS controls. Together, both instruments had an overall classification accuracy estimate of 83.6%, d = 1.92 (a large effect). In the second equation that included scores from the positive protective instruments only scores on the RFLA (estimate = 1.38, t ratio = 5.39, p < .001; OR = 0.25, 95% CI = 0.15, 0.42) and the PANSIPositive (estimate = 0.54, t ratio = 1.93, p < .05; OR = 0.58, 95% CI = 0.34, 1.01) were statistically significant in differentiating between the groups. Used together, the RFLA and the PANSIPositive scale scores had an overall classification accuracy estimate of 79.5%, d = 1.57 (a large effect). However, scores from both instruments were not identified as useful measures for differentiating the SAs and NS controls (see confidence bounds for related OR). For the analyses involving the SAR and control groups, both the BHS (estimate = 1.00, t ratio = 2.22, p < .03; OR = 1.11, 95% CI = 1.01, 1.21) and the PANSINegative (estimate = 0.73, t ratio = 2.10, p < .04; OR = 2.08, 95% CI = 1.05, 4.11) scale scores were identified as significant and useful measures for differentiating between the groups. Together, the BHS and the PANSINegative had an overall classification accuracy estimate of 67.9%, d = .66 (a medium effect). In the equation that included scores on the positive protective instruments, we found that only scores on the PANSIPositive (estimate = 0.60, t ratio = 2.05, p < .04; OR = 1.82, 95% CI = 1.03, 3.22) and the RFLA (estimate = 1.44, t ratio = 4.96, p < .001; OR = 0.24, 95% CI = 0.42, 0.13) scale scores were identified as statistically significant measures for distinguishing between the SAR and control groups. Used together, both the RFLA and PANSIPositive scales had an overall classification accuracy estimate of 72.1%, d = .99 (a large effect). However, only the PANSIPositive was identified as a more useful scale in differentiating between the SAR and control groups (see confidence bounds for related OR).

3Computing Cohens effect size estimates directly from the regression models is not available in SPSS 10.0 for Windows. Thus, we used the related classification tables to derive the effect size estimates.

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TestRetest Reliability As noted in the Participants section, testretest reliability analysis of the PANSI scale scores were conducted in a subsample of 54 adolescents with duration of stay for 2 or more weeks. The testretest reliability estimates for the PANSINegative and the PANSIPositive were .79 and .69, respectively. As a state measure of suicide-related behavior, these estimates are considered satisfactory.

DISCUSSION The primary purposes of this study were to confirm the oblique two-factor structure of the PANSI (Osman, Gutierrez, et al., 1998) and to assess the reliability and validity of this measure. The results indicate that the data provided a good fit to this model. The null and one-factor models did not reach the preestablished criteria for any of the fit indexes, providing additional support for the robustness of the twofactor model. As is the case with other measures designed to look at different components of suicidality such as the Multi-Attitude Suicide Tendency Scale (Orbach et al., 1991; see also Hagstrom, & Gutierrez, 1998), SPS (Tatman, Green, & Karr, 1993), and RFLA (Gutierrez, Osman, Kopper, & Barrios, 2000; Osman, Downs, et al., 1998), the two factors are correlated. Conceptually, one would expect a relationship to exist between risk and protective factors in most individuals. Due to the complex nature of thoughts about suicide, ambivalence is common and seems to be reflected in the factor correlations found in studies with related measures. In other words, as positive, life-affirming thoughts increase for an individual, negative lifethreatening thoughts should decrease. Also in keeping with the original PANSI study (Osman, Gutierrez, et al., 1998), the internal consistency estimates for the positive and negative scales were quite acceptable, with the negative scale achieving a slightly higher alpha level. Although both scales are valid, it appears that the assessment of risk factors is somewhat more internally consistent. That finding may be due to the relative specificity of items on the negative scale and the more diffuse nature of elements that are protective against suicide. The values are within the reported range of other scales measuring similar concepts within normal populations. Osman, Jones, and Osman (1991) found the internal consistency of the RFL (Linehan, Goodstein, Nielsen, & Chiles, 1983) to be .70 for a sample of undergraduates and Osman, Downs, et al. (1998) reported internal consistency levels ranging from .82 to .95 for the RFLA. Along a similar vein, Cotton, Peters, and Range (1995) reported the internal consistency of the SBQ (Linehan & Nielsen, 1981) to be .75 for a clinical sample and .80 for a nonclinical sample. Overall, we note that these reliability and subsequent validity estimates should be considered conservative because of the restricted range of responses from these clinical youths.

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In addition, the testretest results were acceptable as one would expect some stability in adolescent inpatients thoughts about suicide during a relatively brief stay in the hospital. For example, Reynolds and Mazza (1999) reported a 5-week testretest reliability for the Suicidal Ideation QuestionnaireJunior (Reynolds, 1988) of .89, Osman et al. (1991) found the testretest of the RFL subscales to range from .78 to .87, and Cotton et al. (1995) found the testretest reliability of the SBQ to be .95. Although these reliabilities are slightly higher than the corresponding values for the PANSI scales, one should not judge the PANSI too quickly because few studies of suicide ideation scales report testretest reliabilities and those that do are often conducted with a nonclinical sample. It is possible that the reliabilities from nonclinical samples are inflated as a result of the low baseline for suicide-related behaviors, which would contribute to more stability over time. In addition, the moderate reliability estimates found for the PANSI scales may have, in part, resulted from a treatment confound. The sample used for the testretest estimates were involved in a number of inpatient treatment programs. We did not assess the impact of any of the programs but this could be done so in future investigations with the PANSI. Also, including nonclinical participants might help address the adequacy of testretest reliability for the PANSI. To assess concurrent validity of the PANSI, correlations were calculated between the two scales and established measures of related suicide risk factors. These results were in the expected directions indicating that negative ideation relates to negative affect, hopelessness, and history of suicide-related behaviors. Positive ideation relates to positive affect and reasons for living. The correlations were stronger with more closely related measures, without being so high as to indicate redundancy between scales. Some degree of overlap between newly developed scales and existing measures is required for validation to demonstrate that similar constructs are being assessed. Overly low correlations indicate that the new scale may not be measuring what it claims, whereas overly high correlations would suggest the two scales are too similar to justify use of the new one. The correlations between the PANSI scales and related measures were strong enough and in the appropriate direction to indicate concurrent validity without risking redundancy. Additional evidence for concurrent validity of the PANSI was also established. Participants with a history of suicide attempts scored significantly higher on the PANSINegative scale and significantly lower on the PANSIPositive scale than either the SAR or control groups. In addition, the SAR group scored higher than controls on the PANSINegative scale and on other comparable measures of suicide-related behaviors, indicating that the PANSI is able to reflect, and is sensitive to, differences in the severity of suicide-related behaviors within this sample. Discriminative validity of the PANSI was assessed through logistic regression analyses. Although the BHS and the PANSINegative scales were useful in differentiating between the SAs, high-risk, and control individuals, the PANSINegative scale proved to be a better predictor in both analyses. Hope-

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lessness has consistently been found to relate to depression and suicide-related behaviors in adolescents (e.g., Woods, Silverman, Gentilini, Cunningham, & Grieger, 1991). Our findings suggest that assessing hopelessness alone may not be adequate to correctly identify at-risk adolescents. Although the PANSIPositive made only a small contribution to explaining differences between groups, examination of Table 3 indicates that for both the SAR and NS groups, nearly identical PANSIPositive scores (3.78 and 3.79, respectively) were obtained. As correctly noted by a reviewer, youths at severe risk for suicide-related thoughts may show greater benefits than SAs from effective intervention strategies. Following this line of reasoning, screening adolescents for suicide risk should include an assessment of both positive and negative factors. Indeed, adolescents who have not made a prior suicide attempt might be prevented from acting on their negative thoughts if their positive, protective beliefs can be identified and strengthened (Gutierrez, Osman, Kopper, & Barrios, 2000; Gutierrez, Osman, Kopper, Barrios, & Bagge, 2000). Subgroup differences on the PANSI were further examined to make suggestions regarding preliminary norms for this scale. The clinical control group had a slightly higher percentage of boys than the attempter group. This difference suggests our sample was similar in terms of gender composition with what one finds in the general population. Specifically, more female adolescents attempt suicide than male adolescents (Kann et al., 1998). In addition, other studies of adolescent inpatients have found similar differences in the gender composition of their attempter and clinical control groups (e.g., Spirito, Overholser, & Hart, 1991). It therefore seemed reasonable to examine gender differences on the PANSI within the three subgroups of adolescents. Information regarding gender differences for various aspects of adolescent suicide-related behavior is mixed. In a study (Langhinrichsen-Rohling et al., 1998) of high school students, male students were found to have engaged in more suiciderelated behaviors, but no gender differences were found for hopelessness or depressive symptoms. Another study (Spirito et al., 1991) found female attempters to be more hopeless than female controls but male controls to be more hopeless than male attempters, suggesting an interaction between gender and group. In addition, Lewinsohn, Rohde, Seeley, and Baldwin (2001) found that between the ages of 12 and 18, gender differences existed for frequency of suicide attempts, depression, and level of ideation, with female participants scoring significantly higher in all three areas. However, by age 19, gender differences in suicide-related behaviors were no longer significant. Other studies have also found that although females had higher levels of ideation and depression than males, the same variables acted as predictors for suicide attempts in both genders (Rich, Kirkpatrick-Smith, Bonner, & Jans, 1992; Vannatta, 1997). A study (Spirito et al., 1993) of adolescent inpatient SAs failed to find any significant gender differences for a wide variety of sociodemographic variables. In addition, Spirito et al. (1993) reported no differ-

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ences between male inpatients and female inpatients mean scores on the SIQ or several other widely used measures of depression and hopelessness. Based on these studies it seems safe to conclude that the lack of gender differences on the PANSI scales are reflecting the complex nature of suicide-related behaviors. Tentatively, we conclude that it will not be necessary to establish separate male and female norms for the PANSI. Before conclusively recommending adoption of the PANSI for research and clinical purposes, several limitations of this study must be noted. Although a large sample of psychiatric inpatient adolescents were studied, they all came from the same hospital in the Midwest. As a result, ethnic diversity was limited and these results may not generalize to adolescents of different ethnic backgrounds or geographic locale. However, the sample did include adolescents with a broad range of psychiatric diagnoses, at least suggesting careful generalization to other clinical samples. Except for diagnostic status, which was not used in any of the analyses, all data on these adolescents were generated by self-report. Although there are reasons to question self-report data, especially from adolescents, there are few viable alternatives when studying their attitudes, beliefs, and cognitive state. Youth are certainly capable of providing valid self-report data, but they tend to endorse fewer symptoms than do either parents or clinicians (Kendall, Cantwell, & Kazdin, 1989). Benefits of self-report measures include standardized administration, wording, and ordering of questions. In addition, participants may be more comfortable divulging information about topics such as depression and suicide through the relative anonymity of a self-report scale than by speaking face-to-face with an interviewer (Erdman, Greist, Gustafson, Taves, & Klein, 1987; Greist et al., 1973). In most cases, self-report questionnaires are preferable to interviews in that they are faster to administer and are more efficient because they can be completed in groups (Eyman & Eyman, 1990). Besides the practical considerations of self-report methodologies, it has been argued that the quality of data produced may be comparable to that obtained through clinical interviews (Shain, Naylor, & Alessi,1990). Research such as this study is important in establishing the clinical and research utility of self-report measures. The PANSI appears to be a promising general measure of risk and protective factors related to adolescent suicidality. Preliminarily, the psychometric properties of this scale are comparable to other widely used self-report measures of related constructs. Further research with ethnically diverse samples and adolescents from diverse cultural and socioeconomic backgrounds is needed before any firm recommendations for adoption can be made. The incremental predictive validity of the PANSI scales should be assessed in future investigations using hierarchical logistic regression models. Overall, although it is too early to draw conclusions about the clinical utility of the scale, the evidence does exist to recommend use of this tool for research purposes and potentially to screen adolescents for risk.

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Augustine Osman Department of Psychology University of Northern Iowa 334 Baker Hall Cedar Falls, IA 506140505 E-mail: augustine.osman@uni.edu Received August 23, 2001 Revised March 11, 2002