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.
Achtâ K (1988), Suicidal tendencies in the elderly. Suicide Life Threat Behav 18(1):55-65.
Are'n PA, Cook BL (2002), Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression. Biol Psychiatry 52(3):293-303.
Baumeister RF (1990), Suicide as escape from self. Psychol Rev 97(1):90-113.
Beautrais AL (2002), A case control study of suicide and attempted suicide in older adults. Suicide Life Threat Behav 32(1):1-9.
Beck AT, Brown G, Berchick RJ et al. (1990), Relationship between hopelessness and ultimate suicide: a replication with psychiatric outpatients. Am J Psychiatry 147(2):190-195 [see comment].
Beck AT, Brown G, Steer RA (1989), Prediction of eventual suicide in psychiatric inpatients by clinical ratings of hopelessness. J Consul Clin Psychol 57(2):309-310.
Beck AT, Steer RA, Kovacs M, Garrison B (1985), Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry 142(5):559-563.
Blazer DG (2003), Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci 58(3):249-265.
Brown GK, Beck AT, Steer RA, Grisham JR (2000), Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol 68(3):371-377.
Clark DC (1993), Narcissistic crises of aging and suicidal despair. Suicide Life Threat Behav 23(1): 21-26 [see comment].
Conaghan S, Davidson KM (2002), Hopelessness and the anticipation of positive and negative future experiences in older parasuicidal adults. Br J Clin Psychol 41(pt 3):233-242.
Conwell Y, Duberstein PR, Caine ED (2002), Risk factors for suicide in later life. Biol Psychiatry 52(3):193-204.
Dean PJ, Range LM (1999), Testing the escape theory of suicide in an outpatient clinical population. Cognitive Therapy and Research 23(6):561-572.
Draper B (1996), Editorial review: attempted suicide in old age. Int J Geriatr Psychiatry 11(7):577-587.
Draper B, MacCuspie-Moore C, Brodaty H (1998), Suicidal ideation and the 'wish to die' in dementia patients: the role of depression. Age Ageing 27(4):503-507.
Duberstein PR, Conwell Y, Conner KR et al. (in press), Do social and family variables confer suicide risk in middle and older age? Psychol Med.
Erikson EH (1963), Childhood and Society, 2nd ed. New York: Norton.
Fawcett J, Scheftner WA, Fogg L et al. (1990), Time-related predictors of suicide in major affective disorder. Am J Psychiatry 147(9):1189-1194 [see comment].
Flett GL, Hewitt PL (1994), The Social Hopelessness Questionnaire: psychometric characteristics and association with adjustment in adolescents. Presented at the annual conference of the Association for Advancement of Behavior Therapy. San Diego.
Flett GL, Hewitt PL, Heisel MJ et al. (2003), The Social Hopelessness Questionnaire: development of a domain-specific measure. Manuscript submitted for publication.
Frankl VE (1971), The Doctor and the Soul: From Psychotherapy to Logotherapy, Winston C, Winston R, trans. New York: Bantam.
Frankl VE (1984), Man's Search for Meaning. New York: Simon and Schuster.
Fry PS (2000), Religious involvement, spirituality and personal meaning for life: existential predictors of psychological wellbeing in community-residing and institutional care elders. Aging Ment Health 4(4):375-387.
Fry PS (2001), The unique contribution of key existential factors to the prediction of psychological well-being of older adults following spousal loss. The Gerontologist 41(1):69-81.
Garcia Pintos CC (1988), Depression and the will to meaning: a comparison of the GDS and PIL in an Argentine population. Clin Gerontol7(3/4):3-9.
Goldstein RB, Black DW, Nasrallah A, Winokur G (1991), The prediction of suicide: sensitivity, specificity, and predictive value of a multivariate model applied to suicide among 1906 patients with affective disorders. Arch Gen Psychiatry 48(5):418-422.
Heisel MJ (2002), The prediction and prevention of suicide in the elderly. Dissertation Abstracts International-B 63/04, p2057.
Heisel MJ, Duberstein PR (2003), Reasons for living and suicide ideation in older adults. Presented at the 111th annual convention of the American Psychological Association. Toronto; August.
Heisel MJ, Flett GL (in press), Meaning in life and the prevention of elderly suicidality. In: Advances in the Positive Psychology of Meaning and Spirituality, Wong PTP, McDonald M, Klaassen D, eds. Abbotsford, B.C., Canada: INPM Press.
Heisel MJ, Flett GL, Besser A (2002a), Cognitive functioning and geriatric suicide ideation: testing a mediational model. Am J Geriatr Psychiatry 10(4):428-436.
Heisel MJ, Flett GL, Hewitt PL (2003), Social hopelessness and college student suicide ideation. Archives of Suicide Research 7(3):221-235.
Heisel MJ, Links PS, Flett GL (2002b), Reasons for living, attitudes toward hastened death, and suicide ideation among seniors: an exploration of end-of-life issues toward the end of life. Presented at Attending to Psychosocial Issues Near the End of Life. Cleveland; February.
Hewitt PL, Flett GL, Turnbull-Donovan W (1992), Perfectionism and suicide potential. Br J Clin Psychol 31(pt 2):181-190.
Hewitt PL, Flett GL, Weber C (1994), Dimensions of perfectionism and suicide ideation. Cognit Ther Res 18(5):439-460.
Hewitt PL, Norton GR, Flett GL et al. (1998), Dimensions of perfectionism, hopelessness, and attempted suicide in a sample of alcoholics. Suicide Life Threat Behav 28(4):395-406.
Hill RD, Gallagher D, Thompson LW, Ishida T (1988), Hopelessness as a measure of suicidal intent in the depressed elderly. Psychol Aging 3(3):230-232.
Hughes SL, Neimeyer RA (1993), Cognitive predictors of suicide risk among hospitalized psychiatric patients: a prospective study. Death Studies 17(2):103-124.
Karel MJ, Hinrichsen G (2000), Treatment of depression in late life: psychotherapeutic interventions. Clin Psychol Rev 20(6):707-729.
Kish GB, Moody DR (1989), Psychopathology and life purpose. The International Forum for Logotherapy 12(1):40-45.
Linehan MM, Goodstein JL, Nielsen SL et al. (1983), Reasons for staying alive when you are thinking of killing yourself: the reasons for living inventory. J Consult Clin Psychol 51(2):276-286.
Maltsberger JT (1991), Psychotherapy with older suicidal patients. J Geriatr Psychiatry 24(2):217-234.
Margo GM, Finkel J (1990), Early dementia as a risk factor for suicide. Hospital and Community Psychiatry 41(6):676-678.
McIntosh JL, Santos JF, Hubbard RW et al. (1994), Elder Suicide: Research, Theory and Treatment. Washington, D.C.: American Psychological Association.
McIntosh JL (2000), USA suicide: 1998 official final data. Available at: www.iusb.edu/~jmcintos/USA98Summary.htm. Accessed Aug. 20, 2003.
Minio AM, Arias E, Kochanek KD et al. (2002), Deaths: final data for 2000. National Vital Statistics Reports, 50(15). Publication No. (PHS) 2002-1120. Hyattsville, Md.: National Center for Health Statistics.
Minkoff K, Bergman E, Beck AT et al. (1973), Hopelessness, depression, and attempted suicide. Am J Psychiatry 130(4):455-459.
Missinne LE, Willeke-Kay J (1985), Reflections on the meaning of life in older age. J Relig Aging 1(4):43-58.
Pearson JL, Brown GK (2000), Suicide prevention in late life: directions for science and practice. Clin Psychol Rev 20(6):685-705.
Priester MJ, Clum GA (1992), Attributional style as a diathesis in predicting depression, hopelessness, and suicide ideation in college students. Journal of Psychopathology and Behavioral Assessment 14(2):111-122.
Rifai AH, George CJ, Stack JA et al. (1994), Hopelessness in suicide attempters after acute treatment of major depression in late life. Am J Psychiatry 151(11):1687-1690.
Rubenowitz E, Waern M, Wilhelmsson K, Allebeck P (2001), Life events and psychosocial factors in elderly suicides-a case control study. Psychol Med 31(7):1193-1202.
Rubio A, Vestner AL, Stewart JM et al. (2001), Suicide and Alzheimer's pathology in the elderly: a case-control study. Biol Psychiatry 49(2):137-145.
Sadavoy J (1988), Character disorders in the elderly: an overview. In: Treating the Elderly With Psychotherapy: The Scope for Change in Later Life, Leszcz M, Sadavoy J, eds. Madison, Conn.: International Universities Press.
Schotte DE, Clum GA (1987), Problem-solving skills in suicidal psychiatric patients. J Consult Clin Psychol 55(1):49-54.
Schotte DE, Cools J, Payvar S (1990), Problem-solving deficits in suicidal patients: trait vulnerability or state phenomenon? J Consult Clin Psychol 58(5):562-564.
Shneidman ES (1991), Key psychological factors in understanding and managing suicidal risk. J Geriatr Psychiatry 24(2):153-174.
Shneidman ES (1997), The suicidal mind. Presented at the 105th annual conference of the American Psychological Association. Chicago.
Stillion JM, McDowell EE (1996), Suicide Across the Life Span, 2nd ed. Washington, D.C.: Taylor and Francis.
Szanto K, Mulsant BH, Houck P et al. (2003), Occurrence and course of suicidality during short-term treatment of late-life depression. Arch Gen Psychiatry 60(6):610-617.
Szanto K, Mulsant BH, Houck PR et al. (2001), Treatment outcome in suicidal vs. non-suicidal elderly patients. Am J Geriatr Psychiatry 9(3):261-268.
Ulmer A, Range LM, Smith PC (1991), Purpose in life: a moderator of recovery from bereavement. Omega 23(4):279-289.
Uncapher H (2000-2001), Cognitive biases and suicidal ideation in elderly psychiatric inpatients. Omega 42(1):21-36.
Uncapher H, Gallagher-Thompson D, Osgood NJ (1998), Hopelessness and suicidal ideation in older adults. The Gerontologist 38(1):62-70.
Weishaar ME, Beck AT (1992), Hopelessness and suicide. Int Rev Psychiatry 4(2):177-184.
Weisman AD (1991), Vulnerability and suicidality in the aged. J Geriatr Psychiatry 24(2):191-201.
Zika S, Chamberlain K (1992), On the relation between meaning in life and psychological well-being. Br J Psychology 83(pt 1):133-145.