Older adults have higher rates of suicide than younger adults in many industrialized nations.
Older adults have higher rates of suicide than younger adults in many industrialized nations.1,2 Any discussion of this increasingly important issue must be qualified by 2 caveats. First, the age at which a person is considered to be "older" varies across cultures and from one era to the next. Age 65 is the traditional but arbitrary retirement age in many industrialized nations. This group is heterogeneous, but few studies have determined whether the clinical risk markers for persons aged 65 to 70 years are identical to those aged 80 to 85 years.
Second, in many nations, rates of at tempted suicide are highest in younger women,3 but rates of completed suicide are highest in older men.1,2 Just as the demographics of nonlethal and lethal suicide attempts are different, their clinical risk markers probably differ.4,5 The extent to which research on at tempted suicide might inform efforts to prevent completed suicide is arguable.6 When researchers conflate suicidal behavior and completed suicide, they are likely to reach inaccurate con clusions that could misdirect treatment and prevention efforts.6 In this article we focus primarily on completed suicide.
Demographics of suicide Age, sex, race, and national differences in suicide rates
As shown in the Figure 1, suicide rates for men in the United States increase with age, but women's rates peak in midlife and remain stable or decline slightly thereafter. Suicide rates in white men aged 85 years and older are almost 6 times the nation's age-adjusted rate. In the United States, whites have higher rates than blacks across the life span.
In the United States, the mid-Atlantic states and New England have lower suicide rates than do the mountain states. Acknowledging minor annual variations, the crude rates in the mountain states are nearly twice those of the mid-Atlantic region. These differences could be attributed in part to the density of available mental health services.7 Other possible explanations include differences in religious practice and de nomination, ethnicity, community cohesiveness or social capital, and availability of firearms.
It should not be assumed that all risk factors for suicide are similar in strength across sociodemographic groups or geographic locales. For example, alcohol dependence is a more potent risk factor in Sweden than it is in France,8 and it might well be a more potent driver of risk in one region of the United States than in another. Despite the need for demographically and geographically sensitive risk assessments, available data are of little guidance to the clinician.
Durkheim9 reported that suicide rates for people who are single, divorced, or widowed are higher than for married people. Widowhood is a more potent risk factor for suicide in younger people than in older adults,10 perhaps because the death of a spouse is often an un expected event in young adulthood.11 Nonetheless, widowhood confers risk in older adults as well. The clinical as sessment of marital status should in clude inquiries about current marital status, relationship satisfaction, presence of conflict, and past marital history. Married individuals with previous histories of divorce or widowhood might be at heightened risk, although there are no firm data on this issue.
Residential choice is determined by local cultural and subcultural norms, housing prices, and population density. Therefore, it is not surprising that some studies indicate that living alone does not confer suicide risk12,13 and others suggest that it does.14 Living alone might confer risk in some contexts be cause it increases loneliness and com promises adherence to mental health treatments. Living with others may amplify risk if these arrangements engender family discord.
After determining whether a patient lives alone, the clinical interviewer should follow up with questions about recent changes in living arrangements, reasons for any changes, and satisfaction with living arrangements.
Our data suggest that older adults who have less education15 and lower income16 may be at increased risk. Reasons for this disparity include less access to good-quality and affordable health care; subtle bias on the part of service providers; lower levels of mental health literacy; more stigmatized attitudes toward the receipt of mental health care; and chronic exposure to life event stress ors and chronic strains, such as the daily consequences of poverty.17,18 By itself, poor access to good-quality services probably could not explain the socioeconomic disparity as observed in a study of older patients receiving anti depressant treatment from a university-affiliated tertiary care facility because access to care in this study was controlled by design.19
The assessment of socioeconomic status should include questions about educational attainment, annual household income, changes in income, reasons for any changes in income, and sat isfaction or dissatisfaction with in come. Socioeconomic status is often tied to neighborhood influences, which could, in turn, independently increase risk of poor mental health outcomes.20 Clinicians may wish to inquire about perceived neighborhood poverty or affluence, safety, and the patient's comfort with the surrounding neighborhood.
One study showed that religious practice mitigates suicide risk among older adults.14 The relationship between religious practice and suicide was attenuated in analyses that controlled for the presence of alcohol use disorders, suggesting that the attitudes of many religious groups toward drinking might help decrease suicide risk. Other possible explanations include religious proscriptions against suicide, the tendency of people from the same religious denomination to live in proximity to eachother, the ability of faith communities to provide opportunities for socialization and the exchange of health-relevant information, and the availability of pastoral counseling.
Religious practice is probably pro tective only if it matches local cultural norms, however. Suicide may be more prevalent in the United States among members of relatively peripheral religious groups or cults than among members of denominations with deeper ties and established traditions. People who participate in a religious activity in a supportive cultural context might still be at risk, particularly if their involve ment in the faith community is minimal or peripheral.14
Physicians, including psychiatrists, tend to have lower participation in religious practices than the general population.21 Although they may not be less spiritual,22 mental health practitioners might underestimate the importance of conducting a careful assessment of religious practice in their patients.23 Such assessments should include questions about the nature and frequency of attendance at religious services and functions, social involvement with a faith community, the extent to which he or she derives meaning and fulfillment from his religious practice and feels comfortable practicing his faith in the local context, and recent changes in religious practice or in feelings of support from the local faith community. In addition, clinicians should inquire whether a patient's religious commitment or beliefs would deter suicidal behavior, and under which specific circumstances.
Clinical risk markers
Few studies have been conducted with sufficient rigor to conclude that any single clinical risk indicator is a truly independent risk factor.24,25 Nonetheless, the emerging literature points to risk markers that can be assessed reliably and rapidly (Table). Personality traits may also serve as risk markers,24 but these findings have not been translated into clinically useful assessment tools.
|TABLE Domains of suicide risk in older adults|
|Domain||Clinicians should inquire about|
|Mental illness||Unipolar major depression, minor depression, dysthymic disorders, bipolar disorder, early dementia, active or remitted substance misuse, psychotic disorders, comorbidities|
Suicidal behavior (include suicide ideation expression/communication of a wish to die)36
|Prior suicide attempts, the extent to which earlier attempts were planned or impulsive; lethality of earlier suicide attempts|
|Physical illness and functional limitations||Cancer, neurologic disease, chronic lung disease, visual impairment, functional decline, perceived illness|
|Social isolation||Number of contacts with others, social network size, small family size, living in relative distance from others, presence of a confidant|
|Life stressors||Family discord, financial problems, caregiving stress, residence change, relationship endings|
|Access to lethal means||Firearms, stockpiled medications|
Advice for the Practicing Clinician Assessment
Recommendations for risk assessment are based on the fundamental premise that suicide is multidetermined. No single risk marker is paramount, and no single intervention will decrease risk in all at-risk individuals. Risk assessment is best accomplished through clinical interview of the patient in the context of a meaningful therapeutic relationship. Clinicians should never make a judgment about suicide risk based solely on a patient's response to a self-report instrument.
It is important to inquire about suicide ideation but research on the best phrasing and timing of these questions has not been conducted. Most measures of suicide ideation are neither developed nor standardized with older adult samples.26,27 A recent exception is the Geriatric Suicide Ideation Scale (GSIS),28 a 31-item self-report assessment measure developed and validated specifically for older adults.
To facilitate the identification of at-risk patients, clinicians might consider using cut-scores on widely used measures of depression.29 Acknow ledging the limitations of relying exclusively on self-report data, we showed that 5 items on the Geriatric Depression Scale (GDS)30 distinguish older adults reporting higher versus lower levels of suicide ideation.29 Tapping hopelessness, worth lessness, emptiness, and un hap piness, these items mainly pertain to the "absence of positives" (eg, hope, self-worth, happiness). Similarly, others have suggested that it is important for clinicians to ask patients to identify positive events and positive attributes, such as the presence of a supportive social network and people in whom they can confide.28,30
Concerns with assessing suicide risk include false positives: incorrectly judging a patient to be at risk for completed suicide; and false negatives: incorrectly judging a suicidal older adult to be at no or low risk for suicide. False positives could lead to unnecessary treatment, adverse effects, and financial costs. Patients who have been said to elicit hatred and other strong reactions from clinicians31 are probably more likely to be falsely identified as at-risk for death.
False negatives can lead to serious physical injury and/or death. These errors are more likely to occur with "difficult-to-reach" patients: persons who have little or no history with the mental health care system, attribute their symptoms to medical issues or life events,32 have difficulty in verbalizing their feelings, and believe that suicide is a noble, private, and ethical act.
The difficult patient
Suicide risk (see Table) should be addressed directly, calmly, and empathically.33 When indicated, a critical care protocol should be developed33 and day treatment, partial hospitalization, and inpatient care considered.The need for continuity of care is ab solutely critical. Suicide risk among recently hospitalized adults,7,34,35 including older adults,13,36,37 is high shortly after discharge and remains high for many years.38 Discharge stress, incomplete treatment, and the tendency of some patients to conceal their suicide plans from care providers in order to facilitate prompt discharge may in crease risk. Poor communication39 and poor continuity of care have been shown to elevate risk in relatively young (mean age less than 50 years) patients.7,40 No study has attempted to identify predictors of suicide after discharge in an older adult sample, but alarmingly low levels of treatment engagement following discharge from gero psychiatric units have been documented.41 If hospitalization decreases risk, then discharge may be viewed as the withdrawal of a protective factor35 and should be handled with caution.41 It can be argued that the siloed health care delivery system undermines this effort.41
The difficult-to-reach patient
A qualitative study of people who completed suicide without seeking medical advice in their final month of life revealed that many were older men who were characterized as "habitual nonconfiders."42 In one study, nearly 10% of the older adults who went on to complete suicide denied having thoughts of suicide when asked directly beforehand.43 Clearly, the expression of suicide ideation is neither a necessary nor sufficient condition for completed suicide in older adults; the same is true for a history of suicidal behavior-an undeniably important risk marker. How ever, it is important to keep in mind that people who have never previously engaged in suicidal behavior account for 58%12 to 75%44 of completed suicides in older age.Persons who deny previous suicidal behavior may be at heightened risk by virtue of the presence of other risk factors. Seasoned clinicians might have difficulty in eliciting good clinical in formation from some at-risk older patients, given the tendency of some, particularly men,45,46 to minimize depressive symptoms.32,47-49 As a consequence, mood disorders and related symptoms are less likely to be diagnosed and treated.
Clinicians must gather collateral in formation from relatives, friends and acquaintances, clergy, and other care providers, including primary care physicians. These persons are more likely to report the presence of some mood disorder symptoms than at-risk patients; however, they are less able to report suicide ideation.
The phenomenology of mood disorders in older adults can mask suicide risk. Neurovegetative symptoms are non specific indicators of an array of phy sical diseases and treatment side effects. They are not specific indicators of mood disorders, let alone suicide risk. Clinicians should be particularly attentive to symptoms of depression among those presenting for treatment of memory, physical, and functional problems. Subsyndromal conditions should be monitored, especially in patients who may be at risk by virtue of family history or other risk markers (see Table).
No discussion of the difficult-to-reach patient would be complete without some mention of sociodemograph ic issues. Primary care physicians may be less likely to recognize and diagnose mood disorders in men than in women.50,51 Whether the same is true of psychiatrists is unknown. It is also not known whether ethnic factors affect the interactions between patients and psychiatrists, although patient-physician communication18,52 and the diagnosis of mood disorders53 are more difficult when primary care physicians and patients are of different races or ethnic backgrounds. Either way, sensitivity and empathy are instrumental in developing good clinical rapport that can help facilitate effective treatment.
Using solid data on clinical risk markers, interventions can be developed that specifically target the symptom or symptoms that appear to confer risk. This clinical research strategy, successfully used in 2 prior studies,54,55 is not foolproof. Many at-risk patients will not avail themselves of treatment, and few treatments are tailored to patients' needs and preferences, leading to poor adherence levels.56
Clinical initiatives are most effective with patients who are conflictually engaged with the health care system but fail to reach disengaged patients outside the system. Prevention programs can indirectly lead to lower suicide rates by modifying attitudes about aging, shifting cultural norms concerning the acceptability of suicide, restricting access to lethal means, and increasing rates of mental health literacy and health-promoting behaviors.57-59
However, many ostensibly "universal" interventions will not reach all at-risk people,60 some universal initiatives (screening, firearms control) are vul nerable to political gridlock, and these interventions are unlikely to exert much of an influence on those at greatest risk. Of course, the long-term goal is not to bring the suicide rate down to zero, an unrealistic goal in a free society, but rather to do whatever must be done to decrease the number of people who believe that suicide is their only option. This will require better treatments and better prevention programs, targeting individuals, families, and communities.Dr Duberstein is professor of psychiatry, University of Rochester Medical Center in New York. He reports no conflicts of interest concerning the subject matter of this article.
Dr Heisel is assistant professor of psychiatry and epidemiology and biostatistics, University of West ern Ontario. He discloses that he is the author of one of the measures of the Geriatric Suicide Ideation Scale and that he has contrib uted to research on suicide ideation screening items for the Geriatric Depression Scale; both are mentioned in this article.
Preparation of this article was partially supported by Grant K24MH072712 from the United States Public Health Service (P.D.), and a Young Investigator Award from the American Founda tion for Suicide Prevention (M.J.H.).
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