Assessment and treatment of suicidal patients is one of the most difficult and anxiety-provoking tasks for mental health care professionals. In the case of elderly patients who may often talk about death and dying, assessing suicide risk is even more challenging.
Epidemiological data may help to understand risk and protective factors but they cannot guide the evaluation of individual patients. Suicide rates vary greatly with age, gender and ethnicity. The elderly population has the highest suicide rates in almost all countries in the world where data are available. Some countries follow the Hungarian pattern (i.e., suicide rate increases with age in both genders), while others show the U.S. pattern (i.e., suicide rate increases with age only in men). The elderly (65 and over) made up 12.4% of the U.S. population in 2001 while they represented 17.6% of suicides (McIntosh, 2003). Men accounted for about four out of five completed suicides in the 65 and older age group over the past two decades. This is partly explained by the fact that men are more likely to use more lethal methods of suicide. Seventy-six percent of men and 33% of women who completed suicide used firearms, while 3% of men and 33% of women who completed suicide overdosed on medications (McIntosh, 2003).
The suicide rate of white, Chinese-American, Japanese-American and Filipino-American men increases with age. In comparison, the middle-aged group of African-American, Hispanic, Native American and Alaskan Native men have the highest suicide rate. As a consequence of the gender and ethnic differences in the United States, the suicide rate by age 80 ranges from 3/100,000 among African-American women to 60/100,000 among white men (McIntosh, 2003).
Investigating risk factors and protective factors across ethnic groups may help to understand the unexplained striking differences in suicide rates.Risk Factors
So far, identified risk factors for suicide attempts and completed suicides in late-life include past history of suicidal behavior, depression, substance abuse, hopelessness and certain personality characteristics (e.g., rigidity and lack of openness to new experience) (Duberstein et al., 1994).
The role of medical comorbidity is controversial, as medical illness in general is frequent among the elderly; previous non-controlled studies may have overestimated its role. One case-controlled study from New Zealand failed to find differences in physical illness (Beautrais, 2002), while a Swedish study found that visual impairment and neurological and malignant disease were associated with suicide risk (Waern et al., 2002a). Interestingly, this association was only true for men. This finding needs to be replicated prior to further interpretation due to the small sample size of women.
A preliminary unpublished data from a Hungarian psychological autopsy study conducted by my colleagues and me indicated that fear of serious physical illness plays an important role in late-life suicide. In addition to anticipatory anxiety, change in functional status and pain may be better correlates of suicidality than physical illness itself.