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What role might cognitive functioning play in suicidal ideation in elderly patients? How can psychiatrists determine the cognitive functioning skills of older patients who express suicidal thoughts?
Seniors have among the highest rates of suicide across all age groups in the United States and worldwide. Recent U.S. mortality data indicate that adults 65 years and older complete suicide at a rate nearly 50% higher than that of the national average (approximately 15.3 versus 10.7 per 100,000) and that suicide rates increase with advancing age (Minio et al., 2002). Data from the National Center for Health Statistics (NCHS) reveal that this rate almost doubles their population representation in the United States (McIntosh et al., 1994), averaging one suicidal death by a senior every 90 minutes (McIntosh, 2000). The National Institute on Aging estimates that older adults may represent nearly 20% (70 million) of the U.S. population by 2030, due, in part, to the aging of the baby boomer cohort, representing 75 million Americans born between 1946 and 1964. There is a pressing need to identify vulnerability and protective factors associated with late-life suicidal ideation and behavior in order to inform assessment and treatment considerations with seniors at risk of suicide. Suicide ideation logically precedes suicidal behavior and amplifies risk for death by suicide (Brown et al., 2000; Fawcett et al., 1990; Goldstein et al., 1991). This paper focuses on potential cognitive vulnerability factors for suicide ideation among older adults, given theory and research, linking thoughts of suicide in late life with decreased cognitive functioning, global and social forms of hopelessness, and an impaired recognition of meaning or purpose in life.
It is commonly believed that "anyone who would think of ending their life must not be thinking clearly." Associations among suicide ideation, poor problem-solving skills, negative self-appraisals and a negativistic attributional style support such a contention (Hughes and Neimeyer, 1993; Priester and Clum, 1992; Schotte and Clum, 1987; Schotte et al., 1990). However, it has been my experience that many believe suicide in late life to be a rational response to painful old age. Such a notion appears to reflect an incorrect belief that aging inevitably brings with it a host of physical, psychological and social insults and may reflect a deep-seated dread of growing old and of dying more than reasoned thinking. Empirical evidence suggests an association between decreased cognitive functioning and late-life suicidal thoughts and behavior, with limited evidence for a possible link between dementia and late-life suicidality (Draper et al., 1998; Margo and Finkel, 1990; Rubio et al., 2001).
Theoretical supports link cognitive functioning with suicidal thoughts and behavior across the life span (Stillion and McDowell, 1996). Cognitive factors play a role in Shneidman's (1991) theories on the commonalities of suicide, as intolerable psychological pain or "psychache," is considered the common stimulus for suicide, which, when coupled with extreme lethality, is believed to lead to suicide. Shneidman (1997) listed additional cognitive variables among his "ten commonalities of suicide": seeking a solution, ceasing consciousness, helplessness-hopelessness, ambivalence, constricted perception and frustration of psychological needs. Associations among suicidal thoughts and behavior in older adults and depression (Conwell et al., 2002), hopelessness (Conaghan and Davidson, 2002), personality disorders (Clark, 1993; Maltsberger, 1991; Sadavoy, 1988), and feared or experienced losses (Acht,, 1988; Draper, 1996) support Shneidman's theory.
Beck's cognitive theory of suicide identifies hopelessness, a cognitive distortion involving negative future expectancies, as a key psychological variable driving suicidal processes (Weishaar and Beck, 1992). Suicide is theorized to result from intractable hopelessness as "a pessimistic or hopeless individual expects or believes that nothing will turn out right for him, nothing he does will succeed, his important goals are unattainable, and his worst problems will never be solved" (Minkoff et al., 1973). Put differently, people who are depressed cannot conceive of a possible end to their emotional pain, which might lead them to contemplate suicide; whereas one who is hopeful of reprieve from such pain may not. Hopelessness is strongly associated with suicidal thoughts and behavior among psychiatric patients (Beck et al., 1990, 1989, 1985; Brown et al., 2000) and older adults (Conaghan and Davidson, 2002; Heisel et al., 2002a; Hill et al., 1988; Pearson and Brown, 2000; Uncapher, 2000-2001). Suicidal thoughts and behavior are more strongly associated with hopelessness than with depression among adults (Weishaar and Beck, 1992), although findings with older adults do not yet support this finding (Uncapher et al., 1998). Hopelessness discriminates depressed from non-depressed community-dwelling seniors (Conaghan and Davidson, 2002), suicide ideators from non-ideators (Szanto et al., 2001) and suicide attempters from non-attempters (Rifai et al., 1994).
Hopelessness has traditionally been treated as a monolithic entity; however, researchers have begun exploring domain-specific dimensions of hopelessness in order to clarify the association between hopelessness and psychopathology (Flett and Hewitt, 1994; Flett et al., 2003; Heisel et al., 2003; Hewitt et al., 1998). It is conceivable that an older adult might anticipate successes in financial ventures, creative pursuits or in other spheres of life, yet be at elevated risk of suicide given negative expectancies regarding the prospect of ever experiencing satisfying interpersonal relationships. Hewitt and colleagues (1998) found such an association between social hopelessness and suicidal behavior among a young to middle-aged clinical sample of substance abusers. They specifically indicated that suicidal and non-suicidal groups could be differentiated based on measures of global hopelessness and domain-specific measures of achievement hopelessness and social hopelessness, with social hopelessness emerging as the strongest hopelessness variable differentiating these groups. Social hopelessness is associated with stress, depression and suicide ideation among college students (Heisel et al., 2003), and global hopelessness with depression and suicide ideation among seniors (Heisel et al., 2002a). My colleagues and I further found empirical support for a theoretical model in which depression and both global and social forms of hopelessness mediate the association between decreased cognitive functioning and elevated suicide ideation among a heterogeneous sample of seniors (Heisel et al., 2002a). These findings, and others revealing an interpersonal component to late-life suicide (Beautrais, 2002; Duberstein et al., in press; Rubenowitz et al., 2001), are consistent with the idea that distressed social relations could drive suicide risk.
Baumeister's (1990) escape theory of suicide posited that suicidal behavior is the end stage of a chain of events and decisions beginning with perceptions of failure to meet rigid self-strivings. Although this theory is not specific to older adults, one can conceive of an older adult with extreme self-expectations struggling to cope with age-related functional change. These negative self-perceptions can lead to painful self-awareness and might foment a state of "cognitive deconstruction (constricted temporal focus, concrete thinking, immediate or proximal goals, cognitive rigidity, and rejection of meaning)" initiated in an attempt to escape from painful cognitions (Baumeister, 1990). This state of cognitive deconstruction might then engender irrational thinking, leading to a disinhibition of self-destructive tendencies. Although tested in younger adults (Dean and Range, 1999), the escape theory of suicide does not appear to have been tested among seniors. However, Clark's (1993) model of late-life suicide and associated findings similarly indicated that suicide may result from an inability to accommodate one's self-image to fit with changes associated with aging, reflective, perhaps, of a latent narcissistic tendency lying dormant until late life. Findings of significant associations among perfectionististic cognitions and suicidal thoughts and behavior, albeit among clinical samples of younger adults, further underscore a potential link between unrealistic self-strivings and suicidal crises (Hewitt et al., 1998, 1994, 1992). Associations between suicidal behavior, perfectionistic expectations of others (other-oriented perfectionism) and perceptions of external expectations of perfection (socially prescribed perfectionism; e.g., Hewitt et al., 1998) further point to the potential role of social-cognitive variables in late-life suicidality. Research is needed in examining the role of these interpersonal constructs in geriatric suicide ideation, but individual cognitive factors are important as well. In particular, clinicians ought to listen for expressions of psychological pain among older adults (whether termed "psychache," hopelessness, painful self-awareness, despair or meaninglessness).
Frankl's (1984, 1971) meaning-centered approach to the study and prevention of suicide has implications for the conceptualization, study and treatment of older adults at risk for suicide. He posited that meaning exists objectively in unique life events, that the perception of meaning can promote psychological well-being and prevent despair, and that an absence of meaning recognition can promote suicide. Heindicated that meaning is generally discovered in creative pursuits, in life's experiences and relationships, and in attitudes taken toward both positive life experiences and the "tragic triad" of pain/suffering, guilt and death. It is this latter concept, of finding meaning in suffering, that appears most promising in the prevention of suicide, as in the Nietzschean dictum "he who has a why to live for can bear with almost any how" (Frankl, 1984). In this same work, Frankl detailed the role of meaning in life in enhancing survival and preventing suicide among prisoners of Nazi concentration camps; and underscored the importance of orientation toward others in this respect. Linehan and colleagues (1983) later adopted Frankl's thinking in conceptualizing the Reasons For Living construct as a set of adaptive beliefs associated with an orientation toward life and away from suicide. Reasons For Living is negatively associated with suicide ideation among older adults (Heisel and Duberstein, 2003; Heisel et al., 2002b).
Meaning or purpose in life is positively associated with adaptive psychological factors among older adults, including life satisfaction, psychological well-being, perceived social support and reasons for living (Fry, 2001, 2000; Ulmer et al., 1991; Zika and Chamberlain, 1992), and is negatively associated with indices of psychopathology (Garcia Pintos, 1988; Kish and Moody, 1989) and suicide ideation (Heisel and Flett, in press; Ulmer et al., 1991). My colleagues and I have found that the perception of purpose in life is positively associated with life satisfaction and psychological well-being among seniors and negatively associated with depression, global and social hopelessness, and suicide ideation (Heisel and Flett, in press). I have also found meaning recognition associated positively with cognitive functioning among seniors (Heisel, 2002).
Weisman (1991) outlined the three main tasks in life as "(1) searching for meaning; (2) maintaining morale; and (3) negotiating with mortality"; and Erikson (1963) described "ego integrity," the final stage of psychosocial development, as an overall sense of meaning in life and acceptance of the sum total of one's life experiences and achievements. Many seniors have difficulty fulfilling these life tasks and achieving ego integrity. The ability of older adults to search for and recognize meaning in life can help improve their acceptance of, and adaptation toward, negative experiences that can accompany aging, including the grief inherent in terminal illness, the loss of loved ones, retirement, personal tragedy and profound suffering (Missinne and Willeke-Kay, 1985).
Findings from the treatment literature on late-life depression show individual and interpersonal cognitive interventions (including life review,problem-solving therapy, cognitive behavioral therapy and interpersonal psychotherapy) to be efficacious in reducing depression (Are'n and Cook, 2002; Blazer, 2003; Karel and Hinrichsen, 2000), with some evidence for their efficacy in potentially ameliorating late-life suicide ideation (Szanto et al., 2003).
By better assessing and addressing cognitive and social-cognitive vulnerability factors for suicidal features in older adults, and by focusing on sources of meaning in the lives of older adults, we may not only prevent suicide but also promote more meaningful living in later life.
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