Disccusion Question

Joyce Chu, Rebecca Floyd, and Hy Diep Palo Alto University

Seth Pardo Alliant International University

Peter Goldblum Palo Alto University

Bruce Bongar Palo Alto University and Stanford University School of Medicine

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Despite important differences in suicide presentation and risk among ethnic and sexual minority groups, cultural variations have typically been left out of systematic risk assessment paradigms. A new self-report instrument for the culturally competent assessment of suicide, the Cultural Assessment of Risk for Suicide (CARS) measure, was administered to a diverse sample of 950 adults from the general population. Exploratory factor analysis yielded a 39-item, 8-factor structure subsumed under and consistent with the Cultural Theory and Model of Suicide (Chu, Goldblum, Floyd, & Bongar, 2010), which characterizes the vast majority of cultural variation in suicide risk among ethnic and sexual minority groups. Psychometric properties showed that the CARS total and subscale scores demonstrated good internal consistency, convergent validity with scores on other suicide-related measures (the Suicide Ideation Scale, the Beck Depression Inventory suicide item, and the Beck Hopelessness Scale), and an ability to discriminate between participants with versus without history of suicide attempts. Regression analyses indicated that the CARS measure can be used with a general population, providing information predictive of suicidal behavior beyond that of minority status alone. Minorities, however, reported experiencing the CARS cultural risk factors to a greater extent than nonminorities, though effect sizes were small. Overall, results show that the CARS items are reliable, and the instrument identifies cultural suicide risk factors not previously attended to in suicide assessment. The CARS is the first to operationalize a systematic model that accounts for cultural competency across multiple cultural identities in suicide risk assessment efforts.

Keywords: culture, diversity, suicide, assessment, measurement

Recently, investigators have illuminated a lack of systematic incorporation of cultural variation into standard suicide risk assessment practice (Chu, Goldblum, Floyd, & Bongar, 2010; Leach, 2006; Leong & Leach, 2008). Even though cultural literature has shown that suicide rates, expression, experience, risk factors, and protective factors vary across gender, ethnic, age, sexual orientation, and other cultural groups (see Chu et al., 2010, for a review), standard risk assessment protocol does not systematically account for these differences. Without particular attention to cultural variation in suicide risk expression, suicide risk may be underdetected and managed improperly (e.g., Joe & Kaplan, 2001;

Langhinrichsen-Rohling, Friend, & Powell, 2009; Morrison & Downey, 2000; Rockett, Samora, & Coben, 2006; Wendler & Matthews, 2006; Willis, Coombs, Drentea, & Cockerham, 2003). Burr (2002), for example, interviewed mental health care professionals and argued that stereotypes and knowledge based on Western culture may result in misdirected assessment and treatment of suicide and depression for South Asian communities. Other research has shown greater misclassification of suicides in African Americans and Latinos compared with European Americans (Phillips & Ruth, 1993; Rockett et al., 2010; Violanti, 2010). The current study provides a critique of existing approaches to culturally competent suicide risk assessment and presents a measure (CARS; the Cultural Assessment of Risk for Suicide measure) designed to facilitate systematic integration of cultural competency into suicide risk assessment.

How Culture Affects Suicide Risk

Cultural literature has shown that suicide rates vary across gender, ethnic, age, sexual orientation, and other cultural groups. When aggregated across age, U.S. suicide rates have been historically highest in White males and lowest in African American women (Centers for Disease Control and Prevention, 2009). A more detailed examination, however, shows that suicide rates are

This article was published Online First January 28, 2013. Joyce Chu, Rebecca Floyd, and Hy Diep, Department of Psychology, Palo Alto University; Seth Pardo, Rockway Institute, Alliant International University; Peter Goldblum, Department of Psychology, Palo Alto University; Bruce Bongar, Department of Psychology, Palo Alto University, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. Correspondence concerning this article should be

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growing quickly among African American adolescent boys (Heron, 2007; Joe & Kaplan, 2001) and among older adults are highest in Asian Americans (Bartels et al., 2002; Centers for Disease Control and Prevention, 2009; Shiang et al., 1997). Additionally, research shows that suicidal behavior is elevated among Latino adolescents (Centers for Disease Control and Prevention, 2004; Choi, Meininger, & Roberts, 2006) and LGBTQ1 adolescents (young gay men in particular; King et al., 2008; McDaniel, Purcell, & D’Augelli, 2001; Meyer, 2003). Minority group variations in suicide rates may reflect underlying differences in other important aspects of suicide: expression, experience, risk factors, or protective factors (see Chu et al., 2010, for a detailed review). These cultural differences in suicide among ethnic and sexual orientation minorities affect the types of questions one must ask to accurately capture and predict self-harm risk. For example, within a clinical setting, ethnic minorities are referred to as hidden ideators—clients who are less likely than Whites to self-disclose feelings of suicide unless directly assessed by clinicians (Morrison & Downey, 2000). Methods of query that decrease the potential of stigma or embarrassment may elicit a more accurate picture of risk for someone prone to hidden suicidal ideation. Assessing for family conflict may be a particularly important indicator of suicide risk for individuals from interdependent cultures such as Asian Americans or Latinos (Cheng et al., 2010; Fortuna, Perez, Canino, Sribney, & Alegria, 2007; Garcia, Skay, Sieving, Naughton, & Bearinger, 2008; Lau, Jernewall, Zane, & Myers, 2002). Additionally, research shows that LGBTQ individuals often turn to community supports in the face of rejection from family members, making high levels of family rejection and alienation from one’s social community particularly important suicide risk factors (D’Augelli, 2002; McBee-Strayer & Rogers, 2002; Ryan, Huebner, Diaz, & Sanchez, 2009; Van Heeringen & Vincke, 2000). Assessing social isolation from a supportive LGBTQ community may be a better indicator of suicide risk than social isolation from friends for an LGBTQ client struggling with the coming-out process. To understand how clinicians typically account for such cultural variations in their risk assessment efforts, we turn to an examination of current suicide risk assessment tools and procedures.

How Is Cultural Variation Currently Incorporated Into Suicide Risk Assessment?

Several researchers have provided guidelines for the incorporation of cultural influence into current suicide risk assessment practices. Westefeld, Range, Greenfeld, and Kettmann (2008), for example, recommended that four aspects of cultural sensitivity be included in the science and process of risk assessment: (a) inclusion of ethnic minorities in the standardization of suicide instruments, (b) awareness of differences in likelihood to disclose suicide information, (c) recognition and acknowledgment of various minority groups, and (d) careful attention to cultural issues when assessing for suicidal thoughts and behaviors. Worchel and Gearing (2010) advised that culturally competent suicide assessment should include careful and active consideration of culture-specific risk and protective factors and attitudes regarding suicide acceptability. In its seminal document providing practice guidelines on the assessment of suicidal behaviors, the American Psychiatric

Association Work Group on Suicidal Behaviors (2003) provided general recommendations to explore common contributors to suicide in different cultural groups and cultural differences in beliefs about death and view of suicide as part of the suicide assessment process. These assessment guidelines also advised remembering that cultural beliefs influence one’s willingness to talk about suicide. Other researchers have recommended the inclusion of specific cultural factors into risk assessment for certain minority groups. Kaslow et al. (2004), for example, recommended assessing for aggression in flagging suicide risk for African Americans, whereas Cheng et al. (2010) advised that family conflict and perceived discrimination are instrumental in identifying Asian Americans at risk for suicide. An abundance of individual empirical studies delineate a multitude of cultural risk and protective factors that should be integrated into the risk assessment practices for specific cultural groups.

Weaknesses of Existing Cultural Risk Assessment

Taken together, existing efforts to integrate cultural factors into risk assessment practices have been sparse and unsystematic and carry several weaknesses. First, most recommendations are general without specific or concrete guidelines to direct the incorporation of cultural factors into suicide assessment, leaving clinicians and researchers without a course of action for an arguably complex task. Second, individual recommendations to include specific cultural factors into assessment efforts do not aid clinicians in synthesizing the volume of findings identifying differences in suicide-related factors for multiple ethnic and sexual minority groups. The range of research on cultural suicide risk factors is difficult for any one clinician or researcher to comprehensively grasp or access quickly within the limited time often allowed in crisis situations. Additionally, people typically identify not with one cultural group but instead with multiple identities (e.g., an African American woman who is bisexual carries multiple identity categories), making prioritization or synthesis of research findings for suicide in these multiple cultural groups an involved effort. Third, specific to existing suicide assessment tools, most suicide questionnaires are presumed to have reliable and valid interpretations of suicide risk for cultural minorities without empirical research to support such assumptions (Molock & Douglas, 1999; Molock, Matlin, & Prempeh, 2008). Furthering the problem, few suicide questionnaires were specifically developed with minority populations in mind (e.g., Brown, 2002; Dana, 2000; Wendler & Matthews, 2006; Westefeld et al., 2008). Although some validation samples may have included (usually limited numbers of) minority group members, measure items do not assess for the range of risk factors unique to cultural minority groups and do not incorporate the variation in language or content of query needed to account for important cultural minority differences in how suicide develops, is expressed, or is experienced (Brown, 2002; Colucci, 2006; Leach & Leong, 2008; Westefeld et al., 2008).

1 “LGBTQ” populations are also referred to as sexual minorities. LGBTQ is an abbreviation for lesbian, gay, bisexual, and transgender or transsexual individuals, and people questioning their sexual orientation.

ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers. Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.

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CULTURAL ASSESSMENT OF RISK FOR SUICIDE (CARS)

A New Approach for Culturally Competent Risk Assessment: The Cultural Assessment of Risk for Suicide (CARS) Measure

The numerous challenges of recommendations that are too general, limited measures validated on diverse samples, a complex range of research findings, and multiple cultural identities have presented barriers to the systematic incorporation of cultural variations into risk assessment practices. To address the need for parsimony in culturally competent risk assessment, Chu et al. (2010) developed the Cultural Theory and Model of Suicide that inductively categorized cultural differences in suicide into major risk or protective factors common across four major ethnic and sexual minority groups (African American, Asian American, Latino/a American, and LGBTQ). Chu et al. (2010) performed a comprehensive literature review of studies in North America from 1991 to 2011 that examined cultural factors related to beliefs, norms, practices, or customs that have been shown to influence suicidal behaviors. As such, findings on the effects of simple minority status or on prevalence rates were excluded. Results found that over 95% of empirical data showing unique cultural factors in suicide risk for the four referenced ethnic and sexual minority groups were encompassed within four major categories: Cultural Sanctions, Idioms of Distress, Minority Stress, and Social Discord. The first factor, Cultural Sanctions, is defined by Chu et al. (2010) as cultural values or practices conveying messages about the acceptability of suicide as an option or the acceptability or shame associated with certain life events that may precipitate suicide risk. The association of moral objections and lower acceptance of suicide to decreased suicidal behavior in African American communities is an example of a Cultural Sanction risk factor (Neeleman, Wessley, & Lewis, 1998). Idioms of Distress are defined as cultural variations in one’s likelihood to express suicidality, the way suicide symptoms are expressed, and chosen methods or means of attempting suicide. The tendency to express suicidality as risky behavior among Latinos exemplifies the Idioms of Distress factor (Olshen, 2007). The third cultural factor, Minority Stress, includes stresses cultural minorities experience because of social identity or position (e.g., acculturation, discrimination related strain, or social disadvantages). Mistreatment, harassment, and discrimination as strong suicide risk factors for sexual minority groups illustrates the Minority Stress factor (Clements-Nolle, Marx, & Katz, 2006; Huebner, Rebchook, & Kegeles, 2004). The final factor of Social Discord includes the suicide risk factors of alienation, conflict, or lack of integration with one’s family, community, or friends. The association of family conflict with increased suicide risk among Asian Americans is an example of Social Discord as a cultural risk factor (Cheng et al., 2010; Lau et al., 2002). The categories of the Cultural Model of Suicide integrate and streamline the body of knowledge regarding cultural suicide factors and identify a set of risk factors that have not been incorporated into existing suicide assessment tools. Chu et al. (2010) highlighted the need for development of an assessment tool based on the Cultural Model of Suicide to operationalize its framework in clinical, screening, and research application.

The Present Study

The purpose of the present study was to develop and examine psychometric properties of scores on a measure of cultural suicide risk based on the Cultural Model of Suicide (Chu et al., 2010). The Cultural Assessment of Risk for Suicide (CARS) measure assesses cultural factors not typically examined in general suicide assessment research. We sought to administer the CARS with a diverse community sample overly inclusive of the racial/ethnic and sexual minority individuals often overlooked in previous suicide assessment study samples. An exploratory factor analysis (EFA) followed by internal consistency calculation was performed to examine the consistency of scores on the CARS with the major cultural categories of risk from the Cultural Model of Suicide: Cultural Sanctions, Idioms of Distress, Minority Stress, and Social Discord. We expected the CARS to demonstrate good convergent validity with other established measures of suicidal ideation and risk and to show further evidence of construct validity in terms of its ability to discriminate between participants with high versus low suicide attempt history. Wealso tested the CARS measure’s application in assessing risk for cultural minority versus nonminority groups. Because the cultural factors of the CARS encompass cultural context, beliefs, values, norms, and practices separate from differences in suicide risk due to simple minority status alone (Chu et al., 2010), we hypothesized that the CARS would apply to a general population, providing information predictive of suicidal behavior beyond that of cultural minority versus nonminority status. Yet, we expected that cultural minorities would report experiencing the cultural constructs assessed by the CARS to a greater extent than nonminorities.

Method

Participants The total sample included 950 participants who were 18 years and older (M 25.26 years, SD 10.39) and diverse in ethnicity and sexual orientation. The sample was composed of mostly women (63.8%) but also included 31.1% men, 1.3% transgender (four male-to-female and eight female-to-male), and 3.9% unspecified. The sample was diverse and overly inclusive of ethnic and sexual minorities typically underrepresented in suicide assessment study samples. For example, 22.4% of participants identified as having a nonheterosexual orientation (10.5% homosexual, 8.2% bisexual, 3.5% questioning, and 1% unlabeled). More than half of the respondents identified as ethnic minorities, including 34.1% Asian Americans, 19.1% Latino/a American, and 5.8% African Americans. Suicide risk was also adequately represented, with roughly16.4%oftherespondentsreportedahistoryofoneormore suicide attempts.

Procedures Participants were recruited from universities, colleges, community fliers, social networking sites, and online advertisements targeted at recruiting a sample diverse in ethnicity and sexual orientation. Participants completed a set of questionnaires either online via Survey Monkey (75.3%) or via paper form completed in

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person (24.7%). The study was advertised to potential participants as a study of culture and self-harm risk assessment. Recruitment from colleges and universities was accomplished through announcements made during class with the permission of the instructor or through listings on university human subject pools. Student respondents were offered extra credit or course credit in exchange for their participation. University and college recruitment involved both paper and online administration, depending on the preference of the course instructor or subject pool administrator. Recruitment through social networking sites and online advertisements was accomplished via postings on www .craigslist.org. In addition, investigators shared Survey Monkey links accompanied by a brief description of the study as a study of culture and self-harm risk assessment to their network of online contacts. Snowball sampling continued as contacts were free to forward the link to their own contacts. Finally, fliers with the Survey Monkey link were posted in coffee shops and grocery stores. After providing informed consent, participants were prompted to fill out a demographic questionnaire, the Cultural Assessment of Risk for Suicide (CARS), one item assessing suicidal behaviors from the Beck Depression Inventory (BDI; Beck & Steer, 1987), a question about past suicide attempts, the Suicide Ideation Scale (SIS; Rudd, 1989), and the Beck Hopelessness Scale (BHS; Beck & Steer, 1988). The BDI suicide item, SIS, and BHS were used to assess the convergent validity of the CARS. Participants were provided debriefing information that included suicide crisis telephone numbers and Web resources. Contact information for the principle investigator (a licensed psychologist), and the institutional review board chair were also provided to allow participants opportunities to ask further questions or express concerns. This study was approved by and operated in accordance with a human subject’s review committee.

Measures

Demographic questionnaire. Participants were asked to complete demographic questions regarding age, gender, race or ethnicity, and sexual orientation identity.

The Cultural Assessment of Risk for Suicide (CARS).

The CARS included an initial set of 52 items developed to assess for the four cultural risk categories of the Cultural Model of Suicide (Cultural Sanctions, Idioms of Distress, Minority Stress, and Social Discord) with the purpose of guiding the researcher or clinician in incorporating cultural factors into risk assessment efforts. The CARS was designed to be used in adjunct to usual suicide assessment procedures. All initial CARS items were based on the psychological literature on cultural variations in suicidal behaviors and refined by a research team of three licensed clinical psychologists and 11 clinical psychology doctoral students. Items are rated on a 6-point Likert scale (1 =strongly disagree,2 = moderately disagree,3= slightly disagree,4= slightly agree,5= moderately agree, and 6 = strongly agree), and participants are instructed to “Choose the response that best applies to you.” Higher scores on the CARS indicate greater suicide risk.

Suicide item from the Beck Depression Inventory (BDI; Beck & Steer, 1987). The BDI is a 21-item self-report questionnaire assessing depression symptoms. Item 9 was administered to participants to assess suicidal ideation on a 4-point scale (from 0 =

I don’t have any thoughts of harming myself and 1 = I have thoughts of harming myself, but I would not carry them out to 3 = I would kill myself if I could). This BDI suicide item demonstrates good stand-alone convergent validity with the Beck Scale for Suicide Ideation in inpatient and outpatient samples in terms of desire to attempt suicide (r = .56–.58; Beck & Steer, 1991).

Past suicide attempts. Respondents reported lifetime history of suicide attempts using Item 20 from the Beck Scale for Suicide Ideation (BSI; Beck & Steer, 1991): 0 = I have never attempted suicide;1= I have attempted suicide once; or 2= I have attempted suicide two or more times. The latter two response options were combined to create two participant groups: those who never attempted suicide versus those who have attempted suicide one or more times.

Suicide Ideation Scale (SIS; Rudd, 1989). The SIS is a 10-item self-report measure of a continuum of suicidal thoughts from covert ideation to overt ideation and attempts among nonclinical and clinical samples. Items are scored on a 5-point Likert scale (from 1 = never to 5 = always). The SIS items have shown high internal consistency (coefficient a=.86). The measure’s ability to determine suicide risk has moderate convergent validity via correlations with the Beck Hopelessness Scale (r = .49) and the Center for Epidemiologic Studies–Depression Scale (r = .55; Rudd, 1989). The SIS also discriminates between individuals who have attempted versus those who have not attempted suicide (Rudd, 1989). In the present study, items of the SIS had a Cronbach’s alpha value of .94.

Beck Hopelessness Scale (BHS; Beck & Steer, 1988). The BHSisa20-itemtrue–false self-report measure of hopelessness, or positive and negative beliefs about the future. The BHS has shown highly consistent scores among clinical and nonclinical populations with Kuder–Richardson reliabilities from .87 to .93 (Beck & Steer, 1988) and scores that correlate moderately well with scores on the Suicide Intent Scale (e.g., Beck, Steer, & McElroy, 1982; Dyer & Kreitman, 1984) and suicide ideation items on the Scale for Suicidal Ideation (r = .46; Beck, Steer, Beck, & Newman, 1993). The BHS has also shown excellent predictive validity as a risk factor for suicide attempts and completed suicide in numerous studies(e.g.,Beck,Brown,Berchick,Stewart,&Steer,1990;Beck & Steer, 1989; Brown, Beck, Steer, & Grisham, 2000). In the present study, items of the BHS had a Cronbach’s alpha value of .90.

Results

Factor Analysis

We conducted an EFA on the data to discern the underlying factor structure of the CARS scale. The solution was produced using an oblique rotation because some correlations between factors were expected. Three criteria guided the exploratory factor analysis to ensure a coherent solution: (a) a minimum of three variables per factor, (b) factor loading size greater than .40, and (c) inclusion of items in factors with the strongest factor cross-loading (Costello & Osbourne, 2005; Guadagnoli & Velicer, 1988; Kahn, 2006; Velicer & Fava, 1998). We combined several approaches to determine the number of factors to retain in the final solution, including parallel analysis (Hayton, Allen, & Scarpello, 2004), examination of the scree plot

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of eigenvalues, and interpretability of factors. The scree plot of eigenvalues indicated the acceptability of either a seven- and eight-factor solution, and the parallel analysis revealed that seven factors achieved statistical significance. Results showed that the primary difference between the seven- and eight-factor solutions was the retention of a minority stress factor nonspecific to sexual orientation or ethnic minorities in the eight-factor solution. These nonspecific minority stress items are important for inclusion because they broaden the range and generalizability of minority stress in the CARS scale. In particular, they capture minority stress applicable across different minority individuals, whereas other factor items (forming the sexual minority stress and the acculturative stress factors) are more specifically tied to sexual minority or ethnic minority issues. Further, examination of the internal consistency and concurrent validity with other measures of suicidal behavior showed that the nonspecific minority stress items stand alone as a coherent factor. As such, preference was given to the eight-factor solution, shown in Table 1. Bartlett’s test of sphericity was significant for the full sample factor solution, X2(741) = 14,450.30, p < .001, indicating that the sample is adequate and appropriate for factor analysis.

The final eight-factor solution included 39 items that accounted for 57.39% of the total variance. CARS items are listed in the factor solution shown in Table 1, and Cronbach’s alpha coefficients for items of the total CARS scale and its eight subscales are shown in Table 2. Individual factors were interpreted and labeled based on the items that grouped together and the strongest defining items of each factor; an overall examination of all eight factors revealed that they distinguished a structure similar to that expected by the four theoretical constructs of the Cultural Model of Suicide. Two factors—Family Discord and Social Support—accounted for 28.25% of the total variance and are related to the Social Discord construct of the Cultural Model of Suicide. The six items of the Family Discord factor had a Cronbach’s alpha value of .82 and identify the extent to which one experiences discord with family members. The Social Support factor includes five items that assess one’s access to a variety of social resources as protective factors in situations of psychological distress. Items of the Social Support factor had a Cronbach’s alpha value of .76. Three factors—Sexual Minority Stress, Acculturative Stress, and Nonspecific Minority Stress—accounted for 12.87% of the total variance and measure the Minority Stress construct of the Cultural Model of Suicide. The Sexual Minority Stress factor includes five items that assess stresses related to sexual or gender orientation and showed a Cronbach’s alpha value of .74. The three items of the Acculturative Stress factor had a Cronbach’s alpha value of .76 and encompass a subtype of minority stress that cultural minorities experience in dealing with the challenges of balancing one’s culture of origin with American culture. Acculturative stress is most commonly experienced by ethnic minority individuals. The Nonspecific Minority Stress factor assesses issues related to many minority groups and is composed off our items that assess the stresses that cultural minorities experience because of their minority status. Items of the Nonspecific Minority Stress factor had a Cronbach’s alpha value of .73. Two factors—Idioms of Distress (Emotional/Somatic) and Idioms of Distress (Suicidal Actions)—accounted for 8.73% of the total variance and are related to the Cultural Model of Suicide’s Idioms of Distress construct. The seven items of the Idioms of

Distress (Emotional/Somatic) factor had a Cronbach’s alpha value of .80 and encompass alternative expressions of distress such as anger, somatization, risky behavior, or feelings of shame. The five items of the Idioms of Distress (Suicidal Actions) factor had a Cronbach’s alpha value of .83 and assess cultural variations in one’s expression of suicidal intentions, actions, and choice of self-harm method. One final factor—Cultural Sanctions—accounted for 7.53% of the total variance and includes four items that reflect familial or cultural messages about the acceptability of suicide that can precipitate or protect against suicidal behaviors. Items of the Cultural Sanctions subscale had a Cronbach’s alpha value of .65. None of the items seemed to improve the internal consistency of this subscale score if dropped; thus, all four items were retained. With 39 total items, the total summed overall CARS score also demonstrated excellent internal consistency, .90. When the sample was split by minority (racial/ethnic or sexual minorities) versus nonminority status, the internal consistencies of CARS subscale and total scores were similar, suggesting that they are similarly reliable across both minority and nonminority samples (see Table 3).

External Validation of the CARS

Convergent validity of scores on the CARS scale with established measures of suicidal behavior or hopelessness (a construct highly predictive of suicide) was estimated by correlating each of the total and subscale CARS scores with the following measures: the SIS, the suicide item from the BDI, and the BHS (see Table 4). We computed CARS subscale scores by calculating the total sum of item scores within each subscale. An examination of the distribution of the CARS scale scores indicated skewed data with the amount of skew exceeding the range of plus-or-minus twice the value of standard error. Given the low base rate of suicide risk, skew is inevitable and reflects reality (i.e., the population) rather than a problem with our sample. Convergent validity was assessed with Spearman’s rho nonparametric correlation coefficients to account for the skewed data. As expected, all of the psychometric validation measures were significantly correlated at the p .001 level in the expected directions. Although the correlations were moderate to low in magnitude, the CARS total and subscale scores were each significantly and positively correlated with the SIS, suicide item from the BDI, and BHS. The nonparametric Kruskal–Wallis test was utilized to test the CARS measure’s ability to discriminate between those with versus those without suicide attempt history. Results provided additional evidence of construct validity. Respondents who reported a history of suicide attempts reported significantly higher scores on the CARS total scale and subscales compared with those without a history of suicide attempts (see Table 2). Effect sizes of group differences ranged from small to large.

CARS as Applied to Cultural Minority Versus Nonminority Groups

A hierarchical logistic regression analysis was performed to test how well the total CARS scale predicted suicidal behavior over and above the variance predicted by minority status. For parsimony, regressions were performed with only the CARS total scale

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Table 1

and history of past suicide attempts. Minority status (racial/ethnic or sexual minority versus nonminority status) was entered in Step 1. Alone, minority status predicted two thirds greater risk of having at least one suicide attempt in the past (odds ratio [OR = 1.67], df = 1, p = .02) with an explanatory power of R2 = .01. After minority status was controlled, the addition of the CARS

total scale score in Step 2 indicated greater explanation of suicide attempt history, ^R2 = .27, X2(1) = 156.75, p <.001. Minority status was no longer a significant predictor (OR = 1.13, df = 1, p > .05); instead, the CARS total scale was the only significant predictor of past suicide attempts in the full model (OR = 1.04, df = 1, p < .001), indicating that higher

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Table 2

CARS scores were related with a greater likelihood of having a past suicide attempt. For each unit of increase on the total CARS scale, there was a corresponding 4% rate of increase in the odds of having a history of one or more suicide attempts. The full logistic regression model was significant with a correct-classification rate of 85.2% in predicting suicide attempt history. A final series of nonparametric Kruskal–Wallis tests was performed to test the CARS as a measure of cultural factors more common among minorities than nonminorities. Results showed that participants with any minority status demonstrated significantly higher CARS total score and most CARS subscale scores than nonminority participants, though effect sizes were mostly small (see Table 3). The minority and nonminority groups demonstrated significant differences in the same direction across all subscales except the Social Support and Idioms of Distress (Suicidal Action) subscales, where both minority and nonminority subsamples reported equal scores.

Discussion

The current effort addresses the substantial gap in availability of assessment methods that account for cultural variation in suicide risk. The main goal was to establish the psychometric properties of the Cultural Assessment of Risk for Suicide (CARS) measure, a self-report instrument for detecting cultural suicide risk factors. CARS items were developed to reflect categories of the Cultural Theory and Model of Suicide that characterize the vast majority of cultural variation in suicide risk: Cultural Sanctions, Idioms of Distress, Minority Stress, and Social Discord (Chu et al., 2010). Overall, results showed that scores on the 39-item CARS are reliable, and the instrument is a valid measure of cultural suicide risk factors not previously attended to in suicide assessment efforts. EFA yielded eight theoretically meaningful and coherent factors for the CARS, each with good internal consistencies. CARS scale scores were similarly reliable for both cultural minority and non

Table 3

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Table 4

minority subsamples. This eight-factor structure was subsumed under and consistent with the four theoretical constructs of the Cultural Model of Suicide, thus adding weight to the idea that cultural risk for suicide is differentiated along the main categories of Cultural Sanctions, Idioms of Distress, Minority Stress, and Social Discord. Specifically, two of the eight CARS factors (Idioms of Distress–Emotional/Somatic and Idioms of Distress– Suicide Actions) are consistent with the larger Cultural Model of Suicide component of Idioms of Distress. One CARS factor is consistent with the Cultural Model component of Cultural Sanctions. The Cultural Model’s component of Minority Stress is represented within three CARS factors representing separate subtypes of minority stress: (a) Nonspecific Minority Stress encompassing stressors of minority status, (b) Sexual Minority Stress specific to LGBTQ individuals, and (c) Acculturative Stress. Finally, the social discord component of the Cultural Model is parsed into general Social Support and Family Conflict factors. The CARS also showed good psychometric properties as an overall measure of risk, with the entire 39-item total score showing good internal consistency. We assessed convergent validity of the CARS factors and overall scale by analyzing their relationships with other established measures of suicidal ideation and behavior. Correlation coefficients showed that each of the eight CARS factors and the total CARS score demonstrated convergent associations with measures of suicidal behaviors and hopelessness as measured by the suicide item from the BDI, the SIS, and the BHS. Analyses also showed that CARS subscale and total scores adequately discriminated between individuals with and without reported history of suicide attempts. Finally, analyses testing the CARS measure’s application in measuring risk for cultural minority versus nonminority groups indicated that regardless of whether an individual identified as a cultural minority or not, the CARS provided additional information predictive of suicide risk. These results suggest that the CARS may assess suicide risk factors related to cultural contexts that are applicable for the general population. Analyses did show, however, that the CARS constructs were reported more commonly among racial/ethnic and sexual orientation minority than nonminority individuals, though effect sizes were small.

Though the CARS factors provided risk information for all individuals regardless of minority identity, minority individuals experience the CARS risk factors to a significantly greater, though small, extent. Several limitations must be considered in interpreting the current study. Although the sample was large and representative of a diverse population, young adults were over presented and African Americans underrepresented relative to the other groups in the sample. Second, this study’s recruitment of a nonclinical sample precludes its generalization to clinical samples. It is notable, however, that suicide risk in the current sample (e.g., 16.4% of the sample reporting a history of suicide attempts) is comparable to that of past suicide-related studies involving clinical samples (e.g., Brown et al., 2000; Yen et al., 2003), indicating the presence of adequate levels of risk to validate the CARS. Still, individuals who self-report the occurrence of suicide attempts in nonclinical samples may conflate self-harm or self-mutilating acts with actual suicide attempts, making it difficult to know the current sample’s true risk level free of the inaccuracies of self-report. Studies involving clinical samples often have the added benefit of confirming the validity of suicide attempts via clinical interview or medical record verification. Despite these limitations, a nonclinical sample offers several important benefits. A general population was chosen in order to oversample cultural minority individuals that have been typically underrepresented in both previous suicide-related research and in clinical settings due to long-standing problems with low service utilization among ethnic minorities (e.g., U.S. Department of Health and Human Services, 2001). A general population was also chosen to obtain participants reflective of the general population where CARS can be used as an assessment and screening instrument. It will be useful for future research to test the CARS with outpatient and inpatient samples, as it is important to validate measures related to suicide risk in both clinical and nonclinical samples. In addition, a clinical sample will offer the benefit of testing the CARS in a setting where self-reported risk level can be confirmed with other clinician ratings.

Third, it is worth noting that statistical significance does not necessarily yield clinical significance. For example, in the current sample, cultural minorities scored an average of 10 points higher than nonminorities on the CARS total score, and individuals with past suicide attempts scored 30 points higher than individuals without an attempt history. Though the clinical significance or meaning of these statistical mean differences cannot be fully deduced from the present analyses, results indicated that a 1-point increase on the CARS yielded a 4% increase in the odds of having a past suicide attempt. Thus, it is likely that a 10- or 30-point difference is clinically meaningful with regards to increased suicide risk. Fourth, it was necessary to base the CARS on four major cultural minority populations that had sufficient literature and data to inform the Cultural Theory and Model of Suicide (Chu et al., 2010). As such, it is unknown whether the CARS applies to cultural groups other than African American, Asian American, Latino, or LGBTQ individuals. Future research is needed to examine the application and need for modification or expansion of the CARS with other cultural identity groups (e.g., religious, disability, age, or American Indian groups). Despite its basis on four cultural groups, the CARS forges significant progress along a

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multiple-identities perspective with its application across both sexual minority and major ethnic minority groups.

Implications

The current study yielded a CARS measure composed of subscales that identify eight distinct and meaningful areas of cultural suicide risk. Clinical interpretation of the CARS may involve examination of the profile of CARS scores to flag particularly elevated subscales of interest. Elevated subscales indicate cultural risk areas that will be important to incorporate into suicide risk assessment and management efforts. Meaning of the total CARS score will vary depending on individual profiles of elevated subscales, as an individual with relative elevations on Family Conflict and Cultural Sanctions may report the same total CARS score as another individual with elevations on Idioms of Distress–Suicidal Actions and Nonspecific Minority Stress. Data from the current study do indicate, however, that the CARS total score has the potential to be a relatively powerful indicator of suicide risk, with each unit of increase on the total CARS score (out of a total possible score from 39 to 234) yielding a 4% increase in the odds of having attempted suicide in the present sample. Future research will be needed to establish clinical cutoff criteria that can be used to further inform specific clinical recommendations. The CARS tool carries several advantages over existing approaches to cultural competent suicide risk assessment. In contrast to the numerous existing suicide risk assessment tools that have not systematically accounted for culture in their construction, CARS was developed specifically with culture and diversity factors in mind. Additionally, the CARS instrument recognizes that a serviceable measure could not include items that represent every possible cultural variation in suicide risk. Instead, the CARS synthesizes the wide range of cultural variations in suicide risk into four streamlined concepts (via eight factors) that account for the vast majority of the empirical culture and suicide risk literature (Chu et al., 2010). This synthesis allows clinicians to access streamlined assessment of cultural risk factors in the short amount of time often allowed for crisis assessment and management. Interand intragroup expression of the CARS themes is not lost as clinicians can examine specific items and apply individualized risk management techniques based on CARS item responses.

Finally, CARS gives a common language to understand and classify cultural variation in suicide. The CARS has potential to be utilized in the service of several capacities: screening, prevention, and management of suicide. Of particular importance is the finding that CARS identifies cultural risk factors for suicide that have not previously been attended to by existing assessment measures and that CARS provides additional risk information beyond that of minority status alone. With this additional risk information, CARS may identify suicide risk that is not captured by traditional or existing assessment protocols. Systematic and accurate assessment of suicide risk is an essential first step in providing culturally competent suicide prevention and management. The CARS flags important categories of suicide risk that can be utilized in developing culturally competent safety and risk management plans. For example, a Latina individual who scores high on the family conflict factor on the CARS may benefit from a suicide prevention plan that incorporates coping with

family-triggered stress or integrates friends instead of family as key sources of support in situations of crisis. Individuals may report different profiles on the eight CARS subscales, yielding important clinical information that can inform individually tailored treatments. Additional efforts may focus on further examination of the CARS with individual minority populations or in clinical settings to refine procedures for its utility in clinical risk management. The CARS provides substantial advancement in the field of culture and suicide and provides a viable method of assessing for the variegatedwaysinwhichculturalvariationismanifestedinsuiciderisk.

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Received January 15, 2012

Revision received October 29, 2012

Accepted November 13, 2012