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Adaptation of the Beck Hopelessness Scale in Hungary

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 Psychological Topics, 19 (2010), 2, 307-321

Scientific paper - UDC - 616.89-008.441.44-07(439)

159.9.072.59(439)

Adaptation of the Beck Hopelessness Scale in Hungary

Dóra Perczel Forintos, Judit Sallai
Semmelweis University, Department of Clinical Psychology, Hungary

Sándor Rózsa
Eötvös University, Department of Personality Psychology, Hungary

Abstract

Hopelessness Scale (BHS) developed by Aaron Beck is an internationally

accepted measure in the prediction of suicide. Our study focusssed on the
adaptation of the scale in Hungary and its psychometric analysis. From the 1950s
Hungary has always been among the top ten countries with the highest suicide
rates in the world therefore a valid and reliable measure as a screening instrument
in suicide prevention has utmost importance. Three different Hungarian samples
(depressed patients with and without suicide attempt as well as control subjects)
participated in the research. Results showed that the Hungarian version of BHS is a
valid and reliable measure.

Keywords: hopelessness, suicide risk, Beck Hopelessness Scale (BHS),

psychometric properties

Research on suicide prevention has a special relevance in Hungary since the

country can be characterized by the fifth highest suicide rate in the world. The
suicide rate has shown a steady decline from the 1980s: while in 1984 it was
45.9‰, the rate decreased to 23.0‰ by 2008 (Central Statistical Office - CSO,
2008; Niméus, Traskman-Bendz, & Alsén, 1997; Rihmer, 1996a; Rihmer,
Appleby, Rihmer, & Belső, 2000). Despite this tendency prevention of attempted
suicide and the use of valid, reliable screening instruments are essential.
Kopp (2008) investigated the psychosocial background factors of attempted
suicide in the Hungarian population. She analysed the interrelationships between
demographic, psychosocial, way of life characteristics and mental health. In their
national representative study, 21.000 persons were interviewed through self-report
questionnaires about suicidal ideation, attempted suicide, need for medical care, the
incidence of suicide in the family and psychosocial background. The results

 Dora Perczel Forintos, Department of Clinical Psychology, Semmelweis University,

1083 Budapest, Tömő utca 25-29, Hungary, E-mail: [email protected]
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 PSYCHOLOGICAL TOPICS 19 (2010), 2, 307-321

showed that 21.6% of the population could be characterised by suicidal ideation,

4% reported suicide attempts, 2.6% received medical care as a direct result of their
attempts and 1.1% people made two or more attempts of suicide. Attempted suicide
is more common among unemployed persons, blue-collar workers, people over 75
and alarmingly increasing among adolescents. The research indicated that the most
important background factors of suicidal behaviour in Hungary are the followings:
inadaptive coping strategies (drug abuse, overeating, alcoholism, and smoking),
increased depressive symptomatology, suicide in the family, hostility, lack of
purposes in life and hopelessness as well as decreased social support. Surprisingly,
hostility was showed as being the most important background factor of suicidal
behaviour.

Hopelessness

The importance of cognitive factors playing significant role in the etiology of

suicide has been recognized for a long time in clinical research and practice.
Several studies were conducted to identify them as vulnerability factors in
attempted suicide (Alloy et al., 1999; Beck, Rush, Shaw, & Emery, 1979; Beck,
Steer, Beck, & Newman, 1993; Beck, Weissman, Lester, & Trexler, 1974; Beevers
& Miller, 2004; Hewitt, Flett, & Weber, 1994; Ivanoff & Jang, 1991; Kovács,
Beck, & Wissman, 1975; Nekada-Trepka, Bishop, & Blackbur, 1983; Salkovskis,
Atha, & Storer, 1990; Williams & Broadbent, 1986). Hopelessness was identified
as one of the most important psychological risk factors. It can be defined as a
negative perspective of the future or a set of negative expectancies toward the
future. According to Beck’s cognitive theory of depression this negative
perspective of the future is part of the "negative cognitive triad" and characteristic
of the depressive thinking style (Beck, 1976; Beck et al., 1979). Beck conducting
research with depressed patients (Beck, Brown, Berchick, & Steer, 1990; Beck,
Steer, Kovacs, & Garrison 1985) observed and described the process of suicidal
ideation leading to suicide attempt. Besides the negative cognitive triad he
identified typical suicidal attitudes and cognitions which make the person
vulnerable for suicide attempt. This cognitions mainly center around the dark
future, the loss of perspective and unsolved difficulties, which lead to hopelessness
and consequently, to suicide ideation or attempt. According to Beck, hopelessness
has a crucial role among suicide risk factors therefore early assessment is the first
and most important step of prevention.
Early studies on hopelessness have already indicated significant correlations
between hopelessness and suicidal behavior (Beck et al., 1990; Minkoff, Bergman,
Beck, & Beck, 1973; Nekada-Trepka, Bishop, & Blackbur, 1983). Consequently,
assessment of hopelessness is extremely important in clinical practice since high
levels of hopelessness can lead to isolation as well as to the inhibition of help-
seeking behaviour. Effective suicide prevention is a complex task and requires
several levels of intervention: prevention programmes, suicide hotlines, easy access

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to counselling services, psychiatric care, etc. However, measures constructed

especially for the assessment of suicide risk are also very important. Though no
questionnaire can accurately predict suicide, it should be sensitive across a full
range of intensity from mild concern to serious suicidality. Also, it should be a
"user-friendly" tool for easy application in general practice.

The Beck Hopelessness Scale

Based on his cognitive theory of depression and his research on attempted

suicide, Aaron Beck had developed the Hopelessness Scale. The scale became an
internationally accepted and widely used measure in suicide prevention and since
its first publication in 1974 (Beck, et al., 1974) several studies analysed its
psychometric properties (Aish & Wasserman, 2001; Beck & Weishaar, 1991;
Ivanoff & Jang, 1991; Salkovskis, Atha & Storer, 1990). Other instruments were
also developed to assess hopelessness in special patient groups such as children
(Hopelessness Scale for Children (HSC) - Kazdin, Rodgers, & Colbus, 1983) or the
elderly (Geriatric Hopelessness Scale (GHS) - Fry, 1984). Dowd (1992) and Owen
(1992) both positively reviewed the effectiveness of the instrument, with Dowd
concluding that the BHS was a well-constructed and validated instrument, with
adequate reliability.

Studies on Hopelessness

Several studies were conducted on hopelessness. Some of them (Barrera et al.,

1991; Beck et al., 1993; Milnes, Owens, & Blenkiron, 2002; Steer, Kumar, &
Beck, 1993) focussed on the relationship among hopelessness, suicide ideation,
suicide behavior and depression. These studies showed a strong, statistically
significant correlation between hopelessness and suicidal behavior, and this
correlation was stronger than that of depression and suicide behavior. Beck and his
collegues found that hopelessness is a stronger predictor of suicidal behavior than
depression. (Beck et al., 1990; Beck et al., 1985). Results of these studies should be
interpreted very carefully because they have been retrospective.
Other studies (Brown, Beck, Steer, & Grisham, 2000; Goldston et al., 2001;
Hughes & Neimeyer, 1993; Keller & Wolfersdrof, 1993; Niméus, Traskman-
Bendz, & Alsén, 1997) had been prospective in which subjects were followed up
for some years. Brown et al. (2000) used a large sample size of 6 891 psychiatric
outpatients in a 20-year long follow-up study. Standardized measures were used to
examine risk factors for attempted suicide. Their results indicated that high levels
of suicide ideation, depression and hopelessness were predictors of suicide. These
results are consistent with previous prospective studies (Glanz, Haas, & Sweeney,
1995) that have also identified hopelessness as an important risk factor for suicide.
Brown et al. (2000) found that patients who scored nine or above on the BHS were

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four times more likely to attempt suicide than patients who scored eight or below
within a given year of follow-up.
Several studies were conducted into the analysis of psychometric properties of
BHS (Bouvard, Charles, Guerin, & Aimard 1992; Durak, 1994; Durham, 1982;
Hughes & Neimeyer, 1993; Shek, 1993). The psychometric analysis indicated high
internal consistency, high reliability and good concurrent validity of the scale (Beck
et al., 1974). The internal reliability coefficients were shown to be reasonably high
(Pearson r = .82 to .93 in seven norm groups), but the BHS test-retest reliability
coefficients are modest (.69 after one week and .66 after six weeks; Aiken, 2002).
The reliability and validity of BHS was also examined by a Turkish research
team in 1994 (Durak, 1994). Durak assessed 373 psychiatric patients and controlls
between age of 15 and 65. The BHS proved to be a reliable and valid measure in
the Turkish sample according to their results.
Predictive validity of the BHS was also examined using a longitudinal study
design (13-year follow-up) with a communitiy sample of more than 3000
participants (Tanaka, Sakamoto, Ono, Fujihara, & Kitamura, 1998). According to
their results hopelessness was an independent risk factor for completed and
attempted suicide and suicide ideation. Another follow-up study has also found a
high predictive power of BHS (Beevers & Miller, 2004). A recent follow-up
research focussed on predictors of attempted suicide such as dysfunctional
attitudes, hopelessness, rumination and negative cognitive styles (Smith, Alloy, &
Abramson, 2006). It was found that the presence and duration of suicidal ideation
was predicted prospectively by hopelessness and rumination. Aanalyzing the
relationship between hopelessness and suicide attempts, individuals with suicide
attempt within one year scored the highest versus those with an earlier attempt.
Thus, hopelessness, depression and suicide risk are closely related and assessing
hopelessness is an important and essential part of suicide prevention. According to
extensive literature data (Kuyken, 2004; Williams, Crane, Barnhofer, & Duggan
2005) hopelessness is a modifiable risk factor that can be diminished by proper
psychotherapeutic interventions.
In summary, BHS is the most well-known scale on hopelessness; several
studies support its validity and reliability. It has also been validated in previous
studies as a measure of suicidality. In addition, BHS can be filled in and evaluated
in a very short time making rapid assessment of suicide risk possible which is very
important in Hungary due to the high suicide rates.

Aims of the Study

The aim of our study was to accomplish the Hungarian adaptation of the Beck
Hopelessness Scale in order to introduce a quick and reliable measure in Hungary
which could be used as an efficient screening questionnaire in for example
psychiatric as well as general practice. It has special importance because people

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with suicidal ideation tend to consult their GP’s two to four weeks before
attempting suicide (Ajtay, Petruska, Hegyi, & Perczel Forintos, 2008; Rihmer,
1996b; Rihmer et al., 2000). An easy-to-fill scale in Hungary for the early
assesment as well as for the prevention of suicide is very much needed. Our other
goal was to perform the psychometric analysis of BHS including reliability,
convergent and concurrent validity.

METHOD

Subjects

Two clinical and a control group participated in the research, alltogether 300
subjects. The first group (N = 101) consisted of depressed patients with suicide
attempt; they were recruited from the emergency ward of a crisis intervention unit
of a general hospital. Patients with suicide attempt (SD group) were seen by the
duty psychiatrist following a reported suicide attempt. Their mean age was 36.06
years (SD = 13.11), 80% women and 20% men, 39% single, 36% married, 20%
divorced and 5% widow.
The second group (N = 100) included depressed patients without suicide
attempt; their mean age was 41.70 years (SD = 14.60), 72% women and 28% men,
31% single, 43% married, 20% divorced, 2% lived with partner and 4% widow.
Depressed patients were recruited from patients referred for treatment to
departments of psychiatry in Budapest. Inclusion criteria were: major depression
diagnosis Axis I according to the DSM-IV-TR (APA, 2000) and 18-60 years.
Personality disorder diagnosis was excluded.
The control group (N = 100) consisted of volunteers (university students,
students’ family) who previously didn’t have depression or suicide attempt. Mean
age of the control group was 30.93 years, (SD = 8.87), 65% women and 35% men,
63% single, 30% married and 7% divorced. Control group subjects (C-group)
voluntarily participated in the study. A two-way ANOVA found a significant main
effect of group on age. Differences in age are significant between all three groups
(Table 1).

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Table 1. Descriptive statistics: Age and gender status of the three groups

Group
ANOVA
With suicide Without suicide
Control Fa
attempt attempt
Gender x
Age Male Female Male Female Male Female Gender Group
Group
M 37.23 35.87 45.33 39.25 31.14 32.29 1.35 11.17** 1.31
SD 12.41 13.71 11.22 14.04 8.04 10.24
a
Degrees of freedom: Gender and Group: 2, 291; Gender x Group: 2, 291
**p < .01

Since the aim of the study was the early assessment of suicidal risk as well as
the reliability and validity analysis of the BHS, a large and heterogeneous sample
was needed. Marital status of the three groups can be seen in Table 2, indicating
strong significant differences between them. Subjects in the group with suicide
attempt are more often single, while subjects without suicide attempt are more
often married or have a life partner. This suggests that suicidal people might be
more isolated and feel less social support, that is in line with the well known
psychosocial background factors of attempted suicide in the Hungarian population
(Kopp, 2008).

Table 2. Marital status of participants in the three groups

Marital status
Married /
Group Divorced / Total
Single life
widowed
partner
With suicide attempt N 39 37 25 101
Without suicide attempt N 31 45 24 100
Control N 63 30 7 100
N 133 112 56 301
Total
% 44.19 37.21 18.60 100
Chi-square 26.50**
**p < .01

Procedure

Participants were informed about the aim of the study and filled in a consent
form. Then they were given a set of questionnaires to complete. Depressed patients
with suicide attempt (SD group) were asked to fill in the measures one or two days
after their intake when they were physically able to do it. Depressed patients (D

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group) filled in the measures following their intake to the ward. Members of the
control group filled in the questionnaires in their homes or at their working places.
The pack of self-report rating scales included the Beck Hopelessness Scale,
Beck Depression Inventory and the Dysfunctional Attitude Scale.
The study protocol was approved by the Ethical committee of the National
institute of psychiatry and neurology.

Measures

Beck Hopelessness Scale (BHS, Beck et al., 1974) was designed to measure
three major aspects of hopelessness: feelings about the future, loss of motivation,
and expectations. The test is designed for adults, age 17-80, and consists of a list of
20 statements. The person is asked to decide about each sentence whether it
describes his/her attitude for the last week including that day. If the statement is
false for him, he should write false next to it. If the statement is true for him, he
should write true next to it. There are seven reversed items: 1, 5, 6, 8, 13, 15 and
19. Scores 4-8 indicate mild hopelessness, 9-14 moderate and 15-20 severe
hopelessness. The translation of the BHS was accomplished according to the
internationally accepted way of scientific measures
Beck Depression Inventory (BDI, Beck, Ward, Mendelson, Mock, & Erbaugh
1961) was created by Aaron T. Beck is a 21-question multiple-choice self-report
inventory, one of the most widely used instruments for measuring the severity of
depression. In its current version the questionnaire is composed of items relating to
symptoms of depression such as hopelessness and irritability, cognitions such as
guilt or feelings of being punished, as well as physical symptoms such as fatigue,
weight loss, and lack of interest in sex. Participants asked to make ratings on a four-
point scale (1 = not true at all, 4 = very much true). Scoring: 11-16 mild depression,
17-20 borderline clinical depression, 21-30 moderate depression, 31-40 severe
depression, over 40 extreme depression.
Dysfunctional Attitude Scale (DAS, Weissmann, 1979) is a self-report
inventory of beliefs derived from Beck's (1976) cognitive theory of depression to
measure depressionogenic 'schemas' constituting predisposition to depression. It
consists of seven subscales (attitudes) with five items in each subscale, altogether
35 items. The seven subscales are the followings: need approval, need for love,
need for achievement, perfectionism, entitlement, omnipotence, autonomy. The
DAS was jointly administered with the Beck depression inventory (BDI) to 275
hospital employees and their spouses, 105 males and 170 females, and its
psychometric properties were examined. Six-week test-retest reliability of the DAS
was .73 (p < .01). This conclusion is lent support by the DAS's alpha coefficient of
.90. Reliability and validity data for the DAS thus support its use as a measure of
depressionogenic beliefs in the unselected adult population (Oliver & Baumgart,
2004).

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RESULTS
Reliability of BHS
The Alpha coefficient for the Hungarian version of the BHS was good: .91 for
all participants together indicating strong reliability. Item 6 (In the future, I expect
to succeed in what concerns me the most) and 7 (My future seems dark to me) have
the best item-rest reliability (r = .72; r = .75). Only one item (My past experiences
have prepared me well for my future) showed very low (r = .10) corrected item-
total correlation, but the scale as a whole proved to have good internal consistency
(Table 3).
Table 3. Descriptive item-statistics of BHS

Corrected
Items item-total Mean SD
r
1. I look forward to the future with hope and enthusiasm. .66 0.48 0.50
2. I might as well give up because there’s nothing I can do .61 0.26 0.44
about making things better for myself.
3. When things are going badly, I am helped by knowing .44 0.25 0.43
they cannot stay that way forever.
4. I can’t imagine what my life would be like in ten years. .47 0.63 0.48
5. I have enough time to accomplish the things I want to do. .46 0.37 0.48
6. In the future, I expect to succeed in what concerns me the .72 0.32 0.47
most.
7. My future seems dark to me. .75 0.36 0.48
8. I happen to be particularly lucky, and I expect to get more .45 0.67 0.47
of the good things in life than the average person.
9. I just can’t get the breaks, and there’s no reason I will in .55 0.40 0.49
the future.
10. My past experiences have prepared me well for the .10 0.39 0.49
future.
11. All I can see ahead of me is unpleasantness rather than .70 0.38 0.49
pleasantness.
12. I don’t expect to get what I really want. .63 0.43 0.50
13. When I look ahead to the future, I expect that I will be .28 0.28 0.45
happier than I am now.
14. Things just don’t work out the way I want them to. .69 0.35 0.48
15. I have great faith in the future. .62 0.43 0.50
16. I never get what I want, so it’s foolish to want anything. .53 0.22 0.42
17. It’s very unlikely that I will get any real satisfaction in .46 0.43 0.50
the future.
18. The future seems vague and uncertain to me. .62 0.54 0.50
19. I can look forward to more good times than bad times. .59 0.43 0.50
20. There’s no use in really trying to get anything I want .70 0.30 0.46
because I probably won’t get it.

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The most frequently chosen items of each group were also analyzed. Negative
perspective and negative expectations (items 4, 18, 17) were selected by 72% of the
group of depressed patients with suicide attempt ; uncertain perspective of the
future (item 18) was chosen most frequently (49%) by the group of depressed
patients without suicide attempt. Feelings and expectations about positive future
(items 1, 15 and 8) were represented by the highest frequency (74%) in the control
group.

Convergent Validity

Convergent validity of BHS was analyzed by using Beck Depression Inventory

(BDI) and Dysfunctional Attitude Scale (DAS). The Beck Hopelessness Scale
showed strong significant positive correlations with the total BDI (r = .76, p < .01).
In addition, moderate positive correlations were found between BHS and all the
seven subscales of DAS indicating moderate convergent validity between
hopelessness and dysfunctional attitudes (Table 4). In accordance with other
studies, the BHS showed strong significant correlation with the Beck Depression
Inventory; although other research indicated that, the BDI was better suited for
predicting suicidal ideation behavior (Aiken, 2002).

Table 4. Correlations of BHS with DAS subscales and BDI

Scales r
DAS Need for approval .40**
Need for to be loved .40**
Need for achievement .38**
Perfectionism .34**
Rightful expectations .20*
Omnipotency .34**
External control-autonomy .50**
BDI BDI total .76**

*p < .05; **p < .01

Concurrent Validity

In concurrent validity analysis, we compared BHS both with BDI and with
previous suicidal attempts.
First, we predicted the BHS total score with the two items (item 2 and item 9)
of BDI, which refer to hopelessness and suicidal thoughts. High concurrent validity
(Table 5) was found for the whole sample between BHS and negative thoughts
about the future (BDI item 2), as well as between BHS and thoughts about killing

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oneself (BDI item 9). Linear regression analysis was carried out separately also in
the three groups. The Hopelessness Scale and BDI 2nd and 9th items showed
moderate concurrent validity in both clinical groups (in the SD and in the D
groups). Moderate concurrent validity was found between BHS and negative
thoughts about the future, as well as with thoughts about killing oneself in the SD
group. The BHS showed similarly strong concurrent validity in the D (depressed)
group in both items of the BDI (item 2 and 9). However, predictive value of the
BHS was still significant in the C (control) group, but to a lower degree than in the
two clinical groups.

Table 5. Predictive power of BDI item 2 and 9 to BHS score

BDI item 2 BDI item9

2
Beta R Beta R2
Total sample .75** .56 .59** .35
With suicide attempt .59** .34 .42** .17
Group
Without suicide attempt .64** .40 .40** .15
Control .29** .08 .28** .07

**p < .01

Second, we analyzed how BHS scores of the SD group predict the fact that
they had had suicidal attempts previously. Discriminant analysis indicated reliable
concurrent validity between BHS and suicide attempts (Table 6). Even if
discriminant analysis has been carried out on retrospective data, Wilkinson’s
lambda allows us making predictions concerning the probability of future suicide
attempts. According to our results, the BHS has predictive value for suicide
attempts.

Table 6. Discriminant analysis between BHS and suicide attempt

Wilks’ Lambda Adjusted R2

Suicide attempt .87** .13

**p < .01

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DISCUSSION

Several studies were conducted in suicide research about the reliability and
validity of the Beck Hopelessness Scale. Response to this questionnaire has been
identified as a significant predictor of suicide-related ideation and self-harm, of
note, to a greater degree than severity of depressive symptoms. The BHS is the
most widely used instrument to assess this construct.
The Hungarian version of the BHS proved to be a reliable and valid measure
also. The scale has strong internal consistency (Cronbach alpha .91). Convergent
validity of the scale proved to be good also in all the three groups, showing strong
correlations between BHS and BDI (r = .76, p < .01). Moderate convergent validity
was found between BHS and DAS. Hopelessness and dysfunctional attitudes also
turned out to move into the same direction, highly hopeless subjects can be
characterized by several dysfunctional attitudes: Investigating the concurrent
validity of BHS we found that the total score of BHS in the SD and D groups
showed strong positive correlation with the second and ninth items of BDI, which
assess expectancies about the future and the prevalence of suicidal thoughts.
Interestingly, this relationship was not significant in the C group, which might
indicate that negative expectancies about the future do not necessarily lead to
pessimism. Our results support the findings by Dowd (1992) and Owen (1992) who
both positively reviewed the effectiveness of the instrument, with Dowd concluding
that the BHS was a well-constructed and validated instrument, with adequate
reliability. Aiken (2002) reported that the internal reliability coefficients were
shown to be reasonably high (Pearson r from .82 to .93 in seven norm groups) and
we found that the Hungarian version of BHS could be characterized by similarly
strong internal consistency (Cronbach alpha: .91). As recently Neufeld, O'Rourke,
& Donnelly (2010) reported enhanced measurement sensitivity of hopeless ideation
among suicidal older adults. It seems that BHS has predictive value also for suicide
attempts meaning that statistical analysis allowed us to make predictions
concerning the probability of future suicide attempts (Table 6).

Conclusion

Beck and his followers studying depression identified several risk factors such
as negative view of the future, loss of perspective and hopelessness playing central
role in attempted suicide. Recognition of these factors has always been essential in
effective suicide prevention. The Beck Hopelessness Scale was developed in 1974
and became one of the most accepted predictive measures in suicide risk
assessment. Numerous prospective as well as retrospective studies found that
suicide risk could be predicted more reliably based on hopelessness than by the
seriousness of depression only (Beck et al., 1993; Kuyken, 2004; Minkoff et al.,
1973; Nekada-Trepka, Bishop, & Blackbur, 1983; Williams et al., 2005).

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Considering the high suicide rate in Hungary the aim of our study was to
investigate and introduce BHS in Hungary. Three hundred subjects (100 suicide
depressed, 100 depressed without suicide attempt, 100 controls) participated in the
project. Levels of hopelessness, dysfunctional attitudes and depression were
assessed by standardized measures, and psychometric analysis of BHS was
performed. The Hungarian version of the scale proved to be a valid, reliable and
consistent measure. Our study has special relevance in Hungary because of the high
suicide rates of the country, but the analysis should be carried out on a larger
representative sample. We do hope that BHS will be widely used as a proper
measure in suicide prevention in Hungary.

Acknowledgements

We are very grateful to the patients because this research could not have been
completed without their contribution. In addition, we would like to express our
gratefulness to Veronika Mészáros for her help in the statistics as well as to the
"Andorka Rudolf" Association of social sciences for their financial support.

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Received: October 2, 2010

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