On March 14, 1932, George Eastman, founder of the Eastman Kodak Company in Rochester, NY, and one of the leading philanthropists of his time, killed himself at the age of 77 with a bullet to the chest. His suicide note read simply, "My work is done. Why wait?"
Eastman's death was a great shock to his friends and community, who had known him as a man of power, generosity, and self-determination. News reports from the time suggest that many took comfort in the interpretation that his suicide was as straightforward as Mr Eastman's note implied. As expressed by close associates, "George Eastman played the game to the last. By his own hand he lived his life, and by his own hand he ended it."1 The reality is more complex and involves physical health and emotional factors, personality vulnerabilities and social stressors, depression and demoralization. Far from being the "exceptional" case of suicide in an older man, George Eastman's death is emblematic in many respects of suicide in later life, providing illustrative examples of risk factors in each key domain and indicators of opportunities for prevention.
Prevalence rates of suicidal ideation and suicide attempts decrease with increasing age.2 In contrast, incidence rates of completed suicide increase with age for men and women worldwide.3 The United States is somewhat atypical in that suicide rates for women peak at midlife and remain stable thereafter, while the suicide rates for men rise dramatically through old age. The risk is particularly great for white men. Rates of suicide among African Americans peak
in young adulthood, drop somewhat through midlife, remain stable to about age 70, and then rise again; at each point, however, the rate remains lower than that of whites. Asian Americans show a pattern similar to that of whites while rates for Hispanic persons are in the mid-range.
Just as for younger persons, older adults who are married are at lower
risk for suicide than those who are single, separated, divorced, or widowed.2 George Eastman never married and,
except for his attendants, lived alone. Despite being one of the richest men in America, he shared the demographic features of the highest risk group.
CHARACTERISTICS OF SUICIDE
Beyond demographic characteristics, risk and protective factors for suicide in older adults have been much more clearly defined in recent years by a series of methodologically rigorous, case-controlled psychological autopsy (PA) studies.4-12 These studies indicate the
importance of factors in 5 domains that correspond loosely to Axes I through V of psychiatry's multiaxial diagnostic system (Figure).
Axis I: major psychiatric illness
Older adults who take their own lives typically do so in the midst of active psychiatric illness. Studies show that 77% to 95% of elderly persons who completed suicide had an Axis I diagnosis.2 Affective disorders are by far the most common (present in 63% to 86% of cases). Alcohol use disorders, other drug disorders, anxiety, and nonaffective psychosis play a far smaller role. Interestingly, no carefully conducted PA study has found dementia to be a risk factor for suicide, perhaps because of the low sensitivity of the PA method to detect early dementia when affective symptoms are most common and cognitive and behavioral changes are easily missed.
Axis II: personality traits
Too few data are available from studies on which to base conclusions about the role of personality disorders in late-life suicide. Instead, emphasis has been placed on personality traits that may make older adults vulnerable to suicide in the face of other risk factors. High neuroticism and low openness to experience (preference for the routine and familiar, a constricted range of intellectual interests, and blunted affective and hedonic responses) have been associated with completed suicides in older adults.13 An introverted style that prevents the development of support networks to mobilize in times of need may also be a factor.14
Axis III: medical illness
Physical illness may increase the risk
of suicide in older people, even when the effects of depression are accounted for.9 Illnesses that have been most closely associated with increased risk are cancer, chronic obstructive pulmonary disease, and neurologic illness (in particular, seizure disorders). Data are suggestive for visual impairment, bone fractures, and GI disease.15-17 Many suicides in the face of medical illness are no doubt mediated by depression. The emergence of suicidal ideation, even
in the context of terminal illness, should signal the need for screening and assessment for a comorbid affective
Axis IV: stressful life events
Life events tend to cluster in the days and weeks before suicide in older adults just as for younger persons. The events tend to be those associated with aging, such as bereavement, other interpersonal losses, and social isolation.18 Controlled PA studies have consistently shown that social isolation, family discord, and financial strains are associated with suicide in later life.5,6,10
Axis V: functional status
Whereas Axis V is typically reserved for emotional functioning, we broaden the construct here to acknowledge the importance of physical functioning in late-life suicide. Case-controlled PA studies show significantly greater impairment in the conduct of instrumental and basic activities of daily living for suicide decedents than for controls.8
As previously noted, cognitive impairments have not been directly linked to suicide in later life,4,12 but most clinicians would argue for careful monitoring for the emergence of suicidal ideation whenever mental status changes are evident.
Having a rich social support network, and, in particular, friends or relatives in whom one can confide is associated with lower suicide risk.17 Similarly, religious practice and higher ratings on spiritual values are associated with lower suicide rates.17,19
George Eastman experienced a slow course of deteriorating physical function and increasing pain over the last 2 years of his life.20 Suffering with a degenerative spinal disease, he experienced increasing pain and difficulty in ambulation and self-care. For a man whose favorite activities were hunting, camping, and work, the results of his infirmities, including passivity, increased restriction to his home, and dependency, were intolerable. As he became more ill, he withdrew from friends and colleagues into a more socially isolated state.
Unmarried and with few surviving extended family members, several weeks before his own death his despondency was exacerbated by the death of a lifelong friend and business associate whose illness had confined him to bed for the last several years. In the months before his death, Eastman confided to his associates that he felt there was nothing left to live for and on occasion talked of suicide. He withdrew from his business and social ties, and was observed to "shuffle along in great pain, inexplicably weepy and depressed, dragging one foot behind him."1,20 We lack sufficient data with which to construct a confident retrospective diagnosis of depression, but Eastman may well have been typical of the modal elder suicide in this respect as well.
Eastman thus shared many of the characteristics of older people at risk for suicide. He was an older white male, was single, and had a constricting social network. He was physically ill, functionally impaired, in pain, and depressed, with suicidal thoughts and
access to a handgun.21 What options would his primary care or mental health provider have to manage this high-risk situation?
1. George Eastman is mourned. Democrat & Chronicle. March 15, 1932:1.
2. Conwell Y. Suicide. In: Roose SP, Sackeim HA, eds. Late-Life Depression. New York: Oxford University Press; 2006:95-106.
3. World Health Organization. Distribution of suicides rates (per 100 000) by gender and age, 2000. Geneva: World Health Organization; 2002.
4. Waern M, Runeson B, Allebeck P, et al. Mental disorder in elderly suicides: a case-control study. Am J Psychiatry. 2002;159:450-455.
5. Rubenowitz E, Waern M, Wilhelmsson K, Allebeck P. Life events and psychosocial factors in elderly suicides: a case control study. Psychol Med. 2001;31:1193-1202.
6. Beautrais AL. A case control study of suicide and attempted suicide in older adults. Suicide Life Threat Behav. 2002;32:1-9.
7. Harwood D, Hawton K, Hope T, Jacoby R. Psychiatric disorder and personality factors associated with suicide in older people: a descriptive and case-control study. Int J Geriatr Psychiatry. 2001;16:155-165.
8. Conwell Y, Lyness JM, Duberstein P, et al. Completed suicide among older patients in primary care practices: a controlled study. J Am Geriatr Soc. 2000;48:23-29.
9. Duberstein PR, Conwell Y, Conner KR, et al. Suicide at 50 years of age and older: perceived physical illness, family discord and financial strain. Psychol Med. 2004;
10. Duberstein PR, Conwell Y, Conner KR, et al. Poor social integration and suicide: fact or artifact? A case-control study. Psychol Med. 2004;34:1331-1337.
11. Waern M, Rubenowitz E, Runeson B, et al. Burden of illness suicide in elderly people: case-control study. BMJ. 2002;324:1355.
12. Chiu HF, Yip PS, Chi I, et al. Elderly suicide in Hong Kong: a case-controlled psychological autopsy study.
Acta Psychiatr Scand. 2004;109:299-305.
13. Duberstein PR. Are closed-minded people more open to the idea of killing themselves? Suicide Life Threat Behav. 2001;31:9-14.
14. Duberstein PR, Conwell Y, Seidlitz L, et al. Personality traits and suicidal behavior and ideation in depressed inpatients 50 years of age and older. J Gerontol B Psychol Sci Soc Sci. 2000;55:P18-P26.
15. Juurlink DN, Herrmann N, Szalai JP, et al. Medical illness and the risk of suicide in the elderly. Arch Intern Med. 2004;164:1179-1184.
16. Quan H, Arboleda-Florez J, Fick GH, et al. Association between physical illness and suicide among the elderly. Soc Psychiatry Psychiatr Epidemiol. 2002;37:190-197.
17. Turvey CL, Conwell Y, Jones MP, et al. Risk factors for late-life suicide: a prospective, community-based study. Am J Geriatr Psychiatry. 2002;10:398-406.
18. Conwell Y, Rotenberg M, Caine ED. Completed suicide at age 50 and over. J Am Geriatr Soc. 1990;38:640-644.
19. Tsoh J, Chiu HF, Duberstein PR, et al. Attempted suicide in elderly Chinese persons: a multi-group, controlled study. Am J Geriatr Psychiatry. 2005;13:562-571.
20. Brayer E. George Eastman: A Biography. Baltimore, Md: Johns Hopkins University Press; 1996.
21. Conwell Y, Duberstein PR, Connor K, et al. Access to firearms and risk for suicide in middle-aged and older adults. Am J Geriatr Psychiatry. 2002;10:407-416.
22. US Preventive Services Task Force. Screening for suicide risk: recommendation and rationale. Ann Intern Med. 2004;140:820-821.
23. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-613.
24. Almeida OP, Almeida SA. Short versions of the geriatric depression scale: a study of their validity for the
diagnosis of a major depressive episode according to ICD-10 and DSM-IV. Int J Geriatr Psychiatry. 1999;14: 858-865.
25. Schulberg HC, Bruce ML, Lee PW, et al. Preventing suicide in primary care patients: the primary care physician's role. Gen Hosp Psychiatry. 2004;26:337-345.
26. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(suppl 11):1-60.
27. Conwell Y, Duberstein PR, Cox C, et al. Age differences in behaviors leading to completed suicide. Am J Geriatr Psychiatry. 1998;6:122-126.
28. Institute of Medicine. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: National Academy Press; 1994.
29. Bruce ML, Ten Have T, Reynolds CF 3rd, et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA. 2004;291:1081-1091.
30. De Leo D, Dello Buono M, Dwyer J. Suicide among the elderly: the long-term impact of a telephone support and assessment intervention in northern Italy. Br J Psychiatry. 2002;181:226-229.
31. Ludwig J, Cook PJ. Homicide and suicide rates associated with implementation of the Brady Handgun Violence Prevention Act. JAMA. 2000;284:585-591.