Family and Individual Factors of Suicidal Ideation in Adolescents

The aim of this study was to better understand the phenomenon of suicidal behavior of adolescents by establishing relations between characteristics of a family system and suicidal ideation, as well as determining the influence of family and individual factors on suicidal ideation in adolescents. The systemic family therapy was used as the theoretical framework for this investigation. The study sample included 96 adolescents, aged 14–21 years, who assessed the functionality of their own families that were in the adolescent phase of a family life cycle at the time of the study. Participants were assigned to one of the three groups: the first consisted of adolescents who had previously attempted suicide, the second of adolescents who had another psychiatric problem at the time of the study, and the third was made up of adolescents who had never had psychiatric or psychological problems. The following instruments were used: Self-report Family Inventory (SFI), Beck’s Depression Inventory (BDI), Rosenberg’s Self-Esteem Scale, and Beck’s Suicidal Ideation Scale (SIS). The results suggest that family has a significant, but indirect influence on suicidal ideation in adolescents. Suicidal ideation is primarily related to adolescents’ individual characteristics, which are indeed strongly influenced by family functionality.

are not even reported, and that studies on this topic have not been consistent in conceptualizing suicide attempts (Wilde, 2000).Suicide attempts can be considered as part of a continuum of suicidal behavior that can be conceptualized as the one ranging from suicidal ideation, on one end, to suicide attempt, on the other, where attempts may possibly result in completed suicide (Palmer, 2004;Wetzler, Asnis, Hyman, & Virtue, 1996;Wilde, 2000).In this particular research, suicide attempt is understood as a potentially harmful behavior with a non-fatal outcome, and in which the person has a genuine intention of killing him/herself (Ostamo, 2001).
Families of adolescents who have attempted suicide differ in functioning and reacting to stressful events from those without adolescent psychiatric symptoms.However, it appears that suicidal families are not any different from those with another adolescent psychiatric problem.They are not only similar in terms of strategies used when facing stressful events, but also in the way of functioning (Srdanović Maraš, Marković, Šobot, & Dukić, 2011).This finding is hardly surprising when put in the context of systemic family therapy.It has to do with general differences between functional and dysfunctional families (Minuchin, 1974).Family therapy regards family as a system in which a change in one segment affects the rest, and each segment of the system contributes to the family as a whole (Rivet & Street, 2009).In dysfunctional families, a symptom in one of the members of the system becomes a way of preserving the family, while the symptom itself functions as the means of maintaining family homeostasis (Marković, 2008;Milojković, Srna, & Mićović, 1997;Minuchin, 1974).The systemic way of thinking understands and explains psychopathological manifestations in an adolescent by placing them into the context of family functioning (Čalovska-Hercog, Draganić-Gajić, & Nagulić, 2006;Goldenberg & Goldenberg, 1990).

INDIVIDUAL CHARACTERISTICS AND ATTEMPTED SUICIDES IN ADOLESCENTS
One of the most important risk factors of suicidality in adolescents is suicidal ideation (D'Eramo et al., 2004).Suicidal ideation is in the core of both committed (Brent et al.,1993) and attempted suicides (Andrews & Lewinsohn, 1992;Brent et al., 1993).Typically, it involves contemplating suicide (Ostamo, 2001), ie.having thoughts about committing suicide or about engaging in behavior leading to it (Gutierrez, Osman, & Kopper, 2000).As much as 60% of secondary school students report the presence of suicidal ideation, while some 9% attempt suicide (Harkavy, Friedman, Boeck, & DiFiore, 1987;Wetzler et al., 1996).A large majority of adolescents who contemplate suicide never act upon it.Nevertheless, those who attempt it describe more frequent thoughts of death and suicide compared to the non-suicidal population of the same age (Spirito & Overholser, 2003).The possibility for a suicide attempt is higher in adolescents with more serious suicidal ideation (Dubow, 1989).
The presence of depression symptoms is thought to be one of the key factors for explaining suicide attempts and committed suicides in adolescents (Apter, 2010;Hawton, 1999).Research shows that 60% of boys and 44% of girls who have attempted suicide, have symptoms of moderate or severe depression (Von Knorring & Kristiansson, 1995).Some studies have found lower self-esteem in adolescents who have attempted suicide (Wilde, 2000), and also a significant positive relationship with the level of depression.Based on a large body of research, it is believed that adolescents account for 10-20% of the general population reporting feelings of depression.Nevertheless, most such adolescents never become suicidal later in life (Nock & Kazdin, 2002).The one common thing for depressed youth who attempt suicide is the presence of a multi-system context involving a broken home, family history of attempted or committed suicide, physical and mental abuse, problems in school, impulsive and antisocial behavior (Hawton, 1999).
To our knowledge, there has not been a study on the provincial population (the northern Serbian province of Vojvodina) that has taken into account all the discussed factors of suicide risks for attempted suicides in adolescents, and only a few have looked at the clinical population of the adolescents attempting suicide.It is important to add that the Province of Vojvodina has one of the highest rates of suicide in the region (Stanković & Penev, 2009).
The purpose of this study was to better understand the phenomenon of adolescent suicide attempt by means of the systemic family therapy.The more specific points of interest were the individual characteristics of adolescents who attempt suicide, the relationship between family characteristics and suicidal ideation, and the extent of the influence of individual or family characteristics on an adolescent's suicidal ideation.Accordingly, we tested the following hypotheses: 1) adolescents who had attempted suicide would have a higher level of depression and suicidal ideation and lower self-esteem than adolescents with another psychiatric problem, or those without a history of psychiatric problems; 2) there is a relationship between the level of family functionality and that of suicidal ideation in adolescents; 3) individual and family characteristics have significant and direct influence on suicidal ideation in adolescents

Method
Sample and procedures: Ninety-six adolescents participated in the study.They were assigned to one of the following groups: Suicidal group (adolescents who attempted suicide); Second clinical group (non-suicidal adolescents with other psychiatric problems); Non-clinical group, adolescents without any psychiatric symptoms or diagnosis.All the adolescents came from families that were in the adolescent phase of a family life cycle (Carter & McGoldrick, 1989).The participants' age ranged from 14-21 years, which is commonly thought of as the adolescent stage of development (Mitrović, 2008).The clinical portion of the sample was recruited from the Center for Child and Adolescent Psychiatry in the city of Novi Sad, Serbia, during a one-year period.This population included adolescents who were hospitalized in the Center.The non-clinical population was recruited in Novi Sad's primary and secondary schools.Groups were matched for age (age mean, 17 years), number and sex, as well as the number of family members and children in the family (Table 1).Prior to their participation, all volunteers and their parents were informed in writing about the purpose and means of research, and that they were able to withdraw from the study at any time.They were also guaranteed confidentiality of data.Finally, before the beginning of procedures, a signed informed consent was obtained.Participants filled questionnaires on the functionality of their families, as well as the instruments for the assessment of depression, self-esteem, and suicidal ideation.Instruments: A Questionnaire of Demographic Characteristics of Adolescents was designed for the purpose of this research, and had two versions.One was intended for the clinical population, and was administered by an experienced clinician, psychologist or psychiatrist, during an interview with the patient.The other version was designed for the non-clinical population, and was filled out by the adolescent him/herself.There were the same questions on the self-report version as were asked by clinicians.Interwier collected data by reading measures aloud to adolescents.Both versions included the information on the sex, age, birth order, number of siblings, family structure (had to choose among the following options: intact, divorced, widowed, re-married, extended two parent, extended single parent).The subjects were also asked to answer basic questions about his or her own history of mental illness, suicide, attempted suicide, substance abuse, and psychiatric treatment.A suicide attempt was defined as a self-destructive act with at least some intent to end one's life.We assessed previous suicide attempts (Have you ever attempted suicide?).Subjects were asked about the number.It was scored as zero if there had been no attempt, one if there was one attempt, and two if there were more than one attempt.Also they were asked about the method used (eg, self-poisoning, cutting, hanging, gas, firearms, jumping and all other methods) for each attempt.For the actual attempt we assessed impulsivity of the attempt.Interrater reliability for impulsivity of the attempt was estimated in a subgroup of subjects, kappa coefficient was 0.87.Previous diagnosis and data about comorbity in the clinical portion of the sample were obtained from medical records.
Beck's Suicidal Inventory or BSI (Beck & Steer, 1991) is a questionnaire filled out by the participant, and is designed to measure the intensity of the subject's opinions, attitudes and plans for committing suicide during the week immediately before the testing.BSI has been developed based on the Scale of Suicidal Ideation (SSI) that appeared in the form of a semi-structured interview administered by a clinician.BSI is highly correlated with clinical assessments on SSI, with the correlation coefficient ranging from .90 for psychiatric patients to .94 for non-patients (Brown, 2001).A modified, culturally sensitive version of BSI was used in the present study.The procedure involved a translation of the BSI into Serbian language by a professional translator, after which an independent back-translation into the original language is done to verify that the translation captures the meaning of the original.It consisted of 21 items, 15 of which were ranked on a three-point scale (from 0-2), and 6 on a four-point scale (0-3).The final score represented the sum of all scores (0-48).The scale was validated on a mixed sample of patients and non-patients (91 subjects).The scale has a high internal reliability, with Cronbach alpha of .94,and is highly correlated with Beck's Depression Inventory (BDI) .75(Novović, in preparation).A similar internal reliability, with Cronbach alpha of .91,was achieved on our sample.
Beck's Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) includes 21 items with a four-point scale (0-3).BDI has been shown to be a very good instrument in identifying depression in adolescents (Barrera & Garrison-Jones, 1988, as cited in Wilde, 2004).The inventory is commonly applied in both research and clinical practice.
Rosenberg's Self-Esteem Scale (Rosenberg, 1965) was developed in order to measure orientation toward oneself -self-esteem.It consists of ten statements, five positive and five negative.Likert's five-point scale (1-5) is given with each statement, and total score is calculated by simple addition of the scores on individual scales.High scores indicate high self-esteem, and vice versa.Rosenberg's Self-Esteem Scale was translated and adapted to Serbian, reliability of the Serbian version were satisfactory, with Cronbach alpha coefficient of .74(Bezinović, 1988, as cited in Grubor, 2008).In this study, Rosenberg's Self-Esteem Scale showed a very high reliability, with Cronbach alpha coefficient of .89.
Self-Report Family Inventory (SFI) (Beavers, Hampson, & Hulgus, 1990) (Hampson & Beavers, 1996).A lower score on each of the subscales suggests greater competence (Beavers & Hampson, 2000).The SFI has high reliability (Cronbach alphas between .84 and .93(Hampson & Beavers, 1996).Test-retest reliability ranges from .84 to .87 for Health/Competence, .50 to .59 for Conflicts, .50 to .70 for Cohesion, .79 to .89 for Expressiveness, and .41 to .49for Leadership (Beavers, 1990).Related research has further confirmed that the scale has the capacity of discriminating groups of psychiatric patients with different diagnoses (Beavers & Hampson, 1996).Some of these subscales correspond well with other scales measuring similar concepts, such as Cohesion, that has been shown to be highly correlated with the cohesiveness scale in FACES III (Beavers & Hampson, 2000).The SFI was translated and adapted to Serbian by a professional translator, followed by back translation into English to ensure that the translation adequately captured the original meaning.The research team then inspected each translated item to ensure that it captured the meaning of the original item well and would be understood by adolescents.To our knowledge, SFI had never before been applied in studies on a local/Serbian population.In our study, coefficient of reliability (Cronbach-Kaiser for internal consistency) for the entire scale was α = .91.Individual coefficients were as follows: Health α = .87;Conflicts α = .83;Cohesion α = .58;Expresiveness α = .77;Leadership α = .19.Reliability is at a satisfactory level for the total score and the Health, Conflicts, and Expresiveness scales.The Cohesion scale, in spite of its relatively low reliability, was kept and used in the analyses due to its relevance, whereas the Leadership scale was not used for individual analyses due to the unsatisfactory level of reliability.

Results
Our data show that more than half of the hospitalized adolescents (59.4%) attempted suicide for the first time.Table 2 further breaks down the impulsiveness (as assessed by the interviewer), number of previous attempts, presence of a comorbid disorder, and previous diagnoses, if any.Adolescents from Second clinical group belong to various diagnostic categories, where 18.8% of them had previously attempted suicide, but at the time of the study were admitted to hospital for a different reason (Table 3).Adolescents from Suicidal group had comorbid disorders (eating and conduct disorders are most commonly reported) more frequently compared to Second clinical group (χ² = 11.68,df = 1, p <.01).

Differences between groups in suicidal ideation, depression and self-esteem
In order to determine the differences between groups in suicidal ideation, depression and self-esteem, the analysis of variance (ANOVA) was used.From the descriptive data, it could be noticed that in Second clinical group the rate of suicide attempts in the adolescents was almost 19% (Table 3).We decided to exclude these individuals from further analyses to avoid any misinterpretation of results.
ANOVA showed that the level of suicidal ideation was significantly higher for Suicidal group when compared to the other two groups (F/2,87/ =30.37; p <.01).The lowest level of suicidal ideation was found in Non-clinical group, followed by Second clinical group.
Differences between groups were found in depression, however were significant only for the Non-clinical compared to either clinical group (F/2,85/ = 10.14;p <.01).The clinical groups were not significantly different from each other in the level of depression.
ANOVA also indicated that there were statistically significant differences in the level of self-esteem between groups (F/2,87/ = 10.62;p <.01).Subsequent post hoc LSD analysis showed that Non-clinical group had significantly higher self-esteem compared to the other two groups.
Results demonstrated that our first hypothesis that adolescents who had previously attempted suicide would have higher level of depression and suicidal ideation and lower self-esteem than adolescents with another psychiatric problem, or those without a history of psychiatric problems, was partially supported.It was shown that with the exception of higher suicidal ideation, suicidal adolescents do not differ from those with other psychiatric problems in the level of self-esteem and depression.

Family characteristics and suicidal ideation
As shown in Table 1, families of adolescents from Suicidal group were mostly intact.The typical family had four members, and the suicidal adolescent was usually first-born.Indeed, there were no statistically significant differences between groups regarding family structure.
Statistically significant correlations were found between the level of suicidal ideation and the following dimensions of family functionality on SFI: Health (r = .448;p<.05), Expressiveness (r = .470;p<.01), and the total SFI score (r = .421;p<.05).
Results showed that our second hypothesis that there would be a relationship between family functionality and the level of suicidal ideation was supported as certain dimensions (eg, Health, Expressiveness and total SFI score) were correlated with the level of suicidal ideation in adolescents.

Relationship between individual and family characteristics and suicidal ideation of adolescents
In order to test the relationship between the variables of family functioning and individual characteristics on one hand, and suicidal ideation of the adolescent on the other, the PATH analysis was applied.Both direct and indirect influences of family functioning (measured by SFI test), adolescent depression (BDI questionnaire), and self-esteem (Rosenberg's test) on the level of suicidal ideation (BIS test) were analyzed.
In the first step, the independent variables were self-esteem, depression and level of family functioning, while the level of adolescent suicidal ideation was identified as the dependent variable.The results of this analysis showed that only depression was directly related to suicidal ideation (beta = .68;p <.01), explaining about 46% of its variance (F/1,92/ = 79.56;p <.01).
The second step explored the relationship between the level of family functionality and self-esteem of the adolescent and depression.It was determined that the former two variables explained about 51% of the depression variance (F/2,91/ = 49.95;p <.01).Expectedly, both variables were found to be correlated with depression, with self-esteem having much higher correlation as compared to depression.These data are presented in Table 4.The third and final step was to look at the relationship between self-esteem and the level of family functioning.This analysis demonstrated that family functioning explained only about 16% of the self-esteem variance (F/1,94/ = 21.76;p <.01), even though beta coefficient was relatively high (-0.43;p <.01).The results of Path analysis are summarized in Figure 1.Path analysis was also done with individual SFI subscales.These results singled out Expressiveness as the only one in relation with adolescent depression (beta = .33;p<.01), whereas Health was in relation with adolescent self-esteem (beta= -.73; p<.01).Like in previous analyses, these two dimensions of family functioning (as measured by SFI questionnaire) were isolated as the most significant in explaining the dynamics of adolescent suicidal ideation and behavior.
The third hypothesis that both individual and family characteristics would have a significant and direct influence on suicidal ideation in adolescents was not supported.Our findings suggested that family, unlike depression, only had an indirect influence on adolescents' suicidal ideation.

DISCUSSION
The purpose of this study was to gain a better understanding of the phenomenon of suicidal behavior in adolescents.Results suggest that adolescents, currently hospitalized because of an attempted suicide, in most cases did so impulsively, and for the first time ever.Even though the initial attempt is rarely lethal, caution should be exercised since a failed suicide attempt may increase the risk for subsequent suicide attempts, usually with more severe, even lethal consequences compared to the first one (Spirito & Overholser, 2003).
In our sample, adolescents who had attempted suicide were more depressed than those without a psychiatric diagnosis, but not compared to those with a different psychiatric diagnosis.It may be interesting to note that the two clinical groups were not different in the severity of depression.We believe this is due to the fact that Suicidal group is dominated by impulsive suicide attempts, where poor control of affects (Pataki, 2000) rather than the depressiveness affect, can explain the behavior dynamics.These data are very relevant for the planning of therapeutic interventions, which need to target the control of impulsive behavior in adolescents.
In literature, there is much data supporting the notion that there exists a relationship between low self-esteem and suicidal ideation or suicide attempts in adolescents (Barber, 2003;Hull-Blank, Kerr, & Robinson Kurpius, 2004;Wilde, 2000).Suicidal ideation increases as self-esteem decreases, even when depression and helplessness are statistically controlled for (Bhar, Ghahramanlou-Holloway, Brown, & Beck, 2008).In this study, it was found that self-esteem was the greatest for Non-clinical group and significantly higher than for Suicidal group.Interestingly, suicidal adolescents were not significantly different in the level of self-esteem from those with another psychiatric diagnosis.Similar results were found for depression and the ensuing differences among groups.It is important to emphasize that lower self-esteem can be understood as one of the symptoms of depression (Spirito & Overholser, 2003).Similar to depression, level of self-esteem can differentiate Suicidal group from Non-clinical group, but not from Second clinical group.
Our first hypothesis concerning the differences between suicidal and non-suicidal adolescents was only partially supported.With the exception of higher suicidal ideation, suicidal adolescents do not differ from those with other psychiatric problems in the level of self-esteem and depression.Clinicians have long been challenged to identify and prove the existence of models explaining a certain behavior or to identify a personality structure that is especially vulnerable for developing a certain disorder.Our research, however, does not allow us to draw conclusions concerning the structure of differences between the two clinical groups, due to a small sample size, and also the fact that Second clinical group consists of a heterogeneous group of adolescents.It is also likely that we could expect more conclusive results if a future study design included a control group which would include depressed adolescents who do not have a history of suicide attempts.
The next hypothesis put the family in focus.Our findings confirm the hipothesis associating suicidal ideation with the perceived family disfunctionality.Results of this study suggest that most families of suicidal adolescents are intact.The majority of them have four members, and the suicidal adolescent is usually the first-born child.This particular piece of information is quite interesting when placed in the context of systemic family therapy, in which the order of birth is considered to be very relevant.A first-born child often carries a burden of previous generations and family anxiety passed on from past generations within the family system.He/she is at a high risk of developing symptoms (McGoldrick & Gerson, 1985), and in adolescence has more internalized problems in behavior in comparison with his/her siblings (Downey & Dennis, 2004).
Health and Expressiveness have been singled out in our study as the most important dimensions of family functioning (measured by SFI test) for the understanding of adolescent suicidal ideation.Study findings sugges that adolescents had more intense suicidal ideations in situations when perceiving their family as less functional: poor negotiating and problem-solving skills within the family, a weak parental subsystem, disregarding the autonomy of each member within the family system, emotionally flat exchanges.Many research studies link, level of suicidal ideation in adolescents and family functioning (Marušić et al., 2004;Melhem et al., 2007;Spirito & Overholser, 2003).Families with frequent conflicts, as well as those lacking closeness and intimacy, are generally considered to have higher risks (Barber, 2003;Hernandez, 2006;Kerr et al., 2006;Levy, Jurkovic, & Spirito,1995;Medvedova, 2000;Spirito & Overholser, 2003).It is apparent that a disfunctional family environment early in life, but also during adolescence, has a tremendous influence on personality development, problem-solving skills, and also on the onset of mental disorders (Marušić et al., 2004).Health and Expressiveness have earlier been identified as the most important dimensions of family functionality.We believe they should be mostly focused on in the process of family assessments.
With regard to the last hypothesis, claiming that individual and family characteristics would have a significant direct influence on suicidal ideation in adolescents, the overall analysis indicates a greater significance of individual compared to family characteristics.Generally, this hypothesis was only partially supported.Depression seems to be the key factor (Spirito & Overholser, 2003;Wilde, 2000), and is the best predictor of adolescent suicidal ideation.Family variables also appear as predictors of adolescent suicidal ideation, however not independently.Path analysis has revealed that depression is the only predictor with a direct effect on suicidal ideation in adolescents.Family variables, as well as the level of self-esteem, are associated with suicidal ideation indirectly through adolescent depression.Many research demonstrate that adolescents have lower self-esteem and higher depression in situations when perceiving their family as less functional (Marušić et al., 2004;Melhem et al., 2007).Our research suggests that adolescents will be more depressed when they perceive their families to be without real and authentic intimacy or exchange of positive emotions.Their level of self-esteem will be lower if there is a weak parental alliance, pessimistic views, poor problem-solving abilities, and if they perceive that the autonomy of each member within the family system is disregarded.This kind of a family system creates tension and insecurity in all of its members.Due to his/her vulnerability, the adolescent often becomes the "scapegoat" and the "carrier" of symptoms (Milojković et al., 1997;Whitacker & Keith, 1981).One may speculate that suicide attempts can even become a "way out" from such a threatening family system (Jurich, 2008).In concluson, our findings confirm that if family is perceived as less functional, and the level of self-esteem is lower, the level of depression is greater, as is suicidal risk.Therefore, family has an apparent, although indirect influence on suicidal ideation in adolescents.
Suicidal ideation has been recognized as a risk factor for adolescent suicide attempts (Brent et al., 1993;D'Eramo et al., 2004), and, in the present study, depression was found to be the strongest predictor of suicidal ideation.However, it would be inappropriate to explain adolescentne suicidal behavior with a single factor.Rather, it is a combination of a number of factors and influences, and can be viewed as a time-dependent process (Harter, 1992, as in Wenar, 2003).Suicide cannot be classified into a single nosological category, nor can it be defined as a consequence of the exact same combination of symptoms (Biro, 1981).Hence, suicidal behavior in adolescents is not necessarily a guaranteed outcome of the adolescent psychopathology, but only one of its possible manifestations.
The results of this study remind us that prevention strategies should be directed toward all young people with a problem, addressing a whole range of possible difficulties.As demonstrated in this research, suicidal adolescents are not at all different in their individual characteristics from those with other psychologicalpsychiatric problems.When planning for therapeutic interventions, it is critical to deal with two therapeutic fronts: individual treatment of the suicidal adolescent, and family intervention, since family functioning is indeed related to suicidal ideation in adolescents.Furthermore, recognizing that individual characteristics play a critical role in adolescent suicidal ideation, it is necessary to emphasize their enforcement, increase the level of self-esteem, and reduce impulsiveness and depression through individual psychotherapeutic treatment.
In conclusion, we believe that we are a little closer to understanding psychopathology of suicide attempts in adolescents.On the other hand, it is important to keep in mind the limitations of this study, primarily those concerning the sample size and heterogeneous diagnostic categories in Second clinical group.Also, a truly systemic approach would include several members of each family in the family assesment.This would illuminate the multiple perspectives of different family members.These issues could further be addressed in a future research study.

Figure 1 .
Figure 1.The results of PATH analysis.

Table 1 .
Descriptive statistics regarding participants' sex and family structure.
Conflict includes 12 content items involving overt vs. covert conflict, including arguing, blaming, fighting openly, acceptance of personal responsibility, unresolved conflict, and negative feeling tone.The Conflict subscale is related to family competence with respect to problem-solving without arguing, blaming, and fighting.Cohesion includes 5 content items dealing with family togetherness, satisfaction received from inside the family vs. outside and spending time together.Cohesion refers to the family's satisfaction derived through togetherness vs. distance.Leadership includes three content items involving parental leadership, directiveness, and degree of rigidity of control.Leadership measures patterns of directedness of leadership in the system and is related to overall competence.Emotional Expressiveness includes 6 content items dealing with verbal and nonverbal expression of warmth, caring, and closeness.It assesses family closeness and expression of feelings and caring is aimed at the assessment of individual perception of family members on family functionality.It consists of 36 items, with a five-point scale from 1-5, which can be divided into 5 subscales: Family Health/Competence, Conflicts, Cohesion, Expressiveness, and Leadership.Health/ Competence includes 19 content items involving family affect, parental coalitions, problemsolving abilities, autonomy and individuality, optimistic vs. pessimistic views, and acceptance of family members.The Health subscale represents a global rating of family functioning.

Table 2 .
Characteristics of suicide attempt, previous diagnoses, and comorbid disorders in Suicidal group.

Table 3 .
Present diagnoses, previous diagnoses, comorbid disorders, and previous suicide attempts in Second clinical group.

Table 4 .
Path analysis -step two.On this scale lower scores are interpreted as better family functioning. *