Issues in research on aging and suicide

Objective: Late-life suicide is a complex clinical and public health problem.

Method: In this article, some of the key complexities inherent in studying late-life suicide are discussed in the service of promoting high-quality late-life suicide prevention science.

Results: We discuss the following research issues: the relatively greater lethality of suicidal behavior in later life (compared to younger ages); the lack of data on whether thoughts of death in later life are indicators of suicide risk; the fact that older adults do not tend to seek specialty mental health care, necessitating moving research into primary care clinics and the community; the lack of theory-based research in late-life suicide; the unclear role of cognitive impairment; and the promise of taking a ‘patient centered’ and ‘participatory research’ approach to late-life suicide research efforts.

Conclusion: We believe that these perspectives are too often not capitalized upon in research on suicide prevention with older adults and that voice of the older person could contribute much to our understanding of why older adults think about and act on suicidal thoughts, as well as the most acceptable ways to reach and intervene with those at risk.     

A systematic review of the effectiveness of community-based mental health outreach services for older adults

OBJECTIVES: Psychiatric outreach services that provide mental health assessment and treatment to older adults in their homes or communities are widely promoted as improving access and outcomes for older adults. However, a systematic review of the efficacy of these services has not been done. This review evaluates the evidence base for the effectiveness of outreach services for older adults with mental illness in noninstitutional community settings. End points of interest include the ability of the outreach program to increase access to mental health services and improve psychiatric outcomes. METHODS: MEDLINE, CINAHL, PsycINFO, and Web-of-Science databases were searched for articles in English that were indexed through May 2004. Studies were included if they evaluated face-to-face psychiatric services provided to adults aged 65 and older with mental illness and if they were randomized controlled trials, quasi-experimental outcome studies, uncontrolled cohort studies, or comparisons of two or more interventions. Articles were excluded that evaluated interventions that were provided in institutional settings or that focused on persons with dementia or their caregivers. RESULTS: Fourteen studies matched all the inclusion criteria. Two studies (one controlled prospective study and one study that used a comparison group) found support for the use of gatekeepers-nontraditional referral sources-in identifying socially isolated older adults with mental illness. Twelve studies (five randomized controlled trials, one quasi-experimental study, and six uncontrolled cohort studies) found that home and community-based treatment of psychiatric symptoms were associated with improved or maintained psychiatric status. All randomized controlled trials reported improved depressive symptoms, and one reported improved overall psychiatric symptoms. CONCLUSIONS: Limited data supported the effectiveness of outreach services in identifying isolated older adults with mental illness. A more substantial evidence base indicated that home-based mental health treatment is effective in improving psychiatric symptoms. Studies are needed that apply more rigorous methods evaluating the efficacy of case identification models and subsequent treatment for older persons with a variety of psychiatric diagnoses.     

Suicides in Late Life

Suicide in late life is an enormous public health problem that will likely increase in severity as adults of the baby boom generation age. Data from psychological autopsy studies supplemented with recent studies of suicidal ideation and attempts point to a consistent set of risk factors for the spectrum of suicidal behaviors in late life (suicide ideation, attempts, and deaths). Clinicians should be vigilant for psychiatric illness (especially depression), physical illness, pain, functional impairment, and social disconnectedness. Recent advances in late-life suicide prevention have in common collaborative, multifaceted intervention designs. We suggest that one mechanism shared by all preventive interventions shown to reduce the incidence of late-life suicide is the promotion of connectedness. For the clinician working with older adults, our recommendation is to not only consider risk factors, such as depression, and implement appropriate treatments but to enhance social connectedness as well.     

Suicide Risk in Primary Care: Identification and Management in Older Adults

The National Strategy for Suicide Prevention (2012) has set a goal to reduce suicides by 20 % within 5 years. Suicide rates are higher in older adults compared to most other age groups, and the majority of suicide completers have visited their primary care physician in the year before suicide. Primary care is an ideal setting to identify suicide risk and initiate mental health care. We review risk factors for late-life suicide; methods to assess for different levels of suicidality; and recent research developments regarding both effective assessment and management of suicide risk among older primary care patients. We highlight that broader scale screening of suicide risk may be considered in light of findings that suicidality can occur even in the absence of major risk factors like depression. We also highlight collaborative care models targeting suicide risk, and recent innovative interventions that aim to prevent the development of suicidal ideation and suicidal behavior.     

Outcomes of suicidal behaviors

Research issues associated with outcomes of suicidal behavior include: the appropriate length of time to follow subjects is at least two years, psychiatric controls without a history of suicide attempt are a recommended comparison group, quantitation of traits such as aggression or impulsivity is desirable. Clinical issues include the following: the diathesis for suicide is a trait, the most universal risk factor across groups is the presence of depression, yet under-treatment, such as inadequate dosing of antidepressants and high rates of drop-out from psychotherapy, is a major problem. Other issues include that treatment must take a lifelong perspective, there is an ongoing need for psychoeducation of practitioners and the public, outreach to institutions such as schools, hospitals and jails is needed, when a child or adolescent exhibits suicidal behavior, parents should be screened for psychiatric illness, there is an urgent need to remedy barriers to treatment including insurance coverage obstacles, long wait-lists, and fragmentation of mental healthcare. Improvements should include a focus on step-down treatments and the integration of primary care and mental healthcare. Establishing a national registry of serious suicidal behavior to aid research, and clinical trials of treatments for suicidal behavior is important. Subpopulations for study include children, adolescents, the elderly, institutionalized persons, community samples (as distinct from clinical samples), persons with a family history of suicide (for genetic linkage studies), attempters versus completers, single versus multiple attempters and persons who drop out of treatment.     

Narcissistic personality and vulnerability to late-life suicidality.

OBJECTIVE: Narcissistic personality (NP) has been implicated as a potential vulnerability factor for late-life suicide. The present study investigated whether NP increases vulnerability to suicidal ideation and behavior among geriatric depression day-hospital patients. METHODS: Using a retrospective database analysis, the authors examined demographic data, diagnostic information, and scores on self-report (Geriatric Depression Scale [GDS]) and clinician-rated depression measures (Hamilton Rating Scale for Depression [HAM-D]), for 608 geriatric psychiatry patients 65 years or older. RESULTS: Of the 538 patients meeting study inclusion criteria, 20 had NP, defined as either narcissistic personality disorder (n = 13) or narcissistic personality traits (n = 7). Patients with NP were rated significantly higher on the HAM-D suicide item than those without NP, controlling for age, sex, depression (GDS), and cognitive functioning. CONCLUSION: Findings suggest that NP may be a clinical marker of elevated suicide risk among depressed older adults. Clinicians are advised to assess the presence of self-pathology and its potential impact upon psychological functioning in depressed older patients, and to incorporate discussions of life transitions into therapeutic work with those at-risk for suicide.     

Suicidal ideation and suicide attempts in homeless mentally ill persons

BACKGROUND: Despite reports of high rates of suicidal behavior among mentally ill homeless persons, it remains unknown whether the well-established suicide risks of increased age and comorbid psychiatric and substance abuse disorders ("dual diagnosis") documented in the general population are also markers for increased suicide risk among homeless persons. METHODS: Data from a multi-site outreach program (ACCESS) (N = 7,224) were used to investigate whether rates of serious suicidal ideation and recent suicide attempts varied with the age and substance abuse diagnosis(es) (drug abuse and/or alcohol abuse disorders) among homeless mentally ill clients. RESULTS: The prevalence of 30-day suicidal ideation and suicide attempts (37.5 % and 7.9 %, respectively) was extremely high. Although the risk of serious suicidal ideation and suicide attempts was greater among the younger compared with the older homeless mentally ill clients, risks were not significantly increased by co-morbid alcohol and/or drug abuse. However, a significant interaction between age and co-morbid substance abuse was observed showing that among older clients but not younger clients, those with drug and alcohol abuse were at significantly greater risk of suicidal ideation than those without substance use problems, controlling for confounding factors. CONCLUSION: Efforts to prevent suicide should recognize that among homeless people with mental illness, young-middle-aged (30- to 39-year-old) clients are at greatest risk of suicidal behavior. Among older clients the presence of both drug and alcohol abuse significantly increases suicide risk. These patterns are of special importance because they are quite different from those that are well documented in non-homeless populations.     

Risk factors for suicide in later life.

Suicide rates are higher in later life than in any other age group. The design of effective suicide prevention strategies hinges on the identification of specific, quantifiable risk factors. Methodological challenges include the lack of systematically applied terminology in suicide and risk factor research, the low base rate of suicide, and its complex, multidetermined nature.Although variables in mental, physical, and social domains have been correlated with completed suicide in older adults, controlled studies are necessary to test hypothesized risk factors. Prospective cohort and retrospective case control studies indicate that affective disorder is a powerful independent risk factor for suicide in elders. Other mental illnesses play less of a role. Physical illness and functional impairment increase risk, but their influence appears to be mediated by depression. Social ties and their disruption are significantly and independently associated with risk for suicide in later life, relationships between which may be moderated by a rigid, anxious, and obsessional personality style.Affective illness is a highly potent risk factor for suicide in later life with clear implications for the design of prevention strategies. Additional research is needed to define more precisely the interactions between emotional, physical, and social factors that determine risk for suicide in the older adult.     

When the Pain Becomes Unbearable: Case-Control Study of Mental Pain Characteristics Among Medically Serious Suicide Attempters

The unbearable mental pain experience is recognized as a key antecedent of suicidal behavior. We aimed to examine the precise nature of the mental pain among medically serious suicide attempters (MSSAs), a population closely resembling those who died by suicide. We evaluated various factors of mental pain from the Orbach and Mikulincer Mental Pain Scale, as well as medical lethality and suicide intent. MSSAs were higher than non-MSSAs and psychiatric controls for Irreversibility of pain. Moreover, Emptiness predicted medical lethality, while Cognitive Confusion negatively predicted suicide intent level, controlling for hopelessness and depression. high sense of Irreversibility of pain as well as high Emptiness and low Cognitive Confusion are important risk factors for more severe suicidal behavior. Implications for identification of at-risk groups for suicide as well as for suicide prevention and treatment of suicidal individuals are discussed.     

Risk factors for late-life suicide: a prospective, community-based study.

Despite the fact that people age 65 and older have the highest rates of suicide of any age-group, late-life suicide has a low prevalence, making it difficult to conduct prospective studies. The authors examined risk factors for late-life suicide on the basis of general information collected directly from older subjects participating in a community-based prospective study of aging, the Established Populations for Epidemiologic Studies of the Elderly. Demographic variables, presence of a relative or friend to confide in, alcohol use, and sleep quality were assessed at baseline interview. Baseline and follow-up data were used to determine physical, cognitive, and affective functioning, as well as medical status. Of 14,456 people, 21 committed suicide over the 10-year observation period. Depressive symptoms, perceived health status, sleep quality, and absence of a relative or friend to confide in predicted late-life suicide. Suicide victims did not have greater alcohol use and did not report more medical illness or physical impairment. This study provided additional information about the context of late-life depression that also contributes to suicidal behavior: poor perceived health, poor sleep quality, and limited presence of a relative or friend to confide in.     

Psychogenic nonepileptic seizures and suicidal behavior on a video/EEG telemetry unit: The need for psychiatric assessment and screening for suicide risk

Patients with epilepsy and psychogenic nonepileptic seizures (PNES) have an increased prevalence of psychiatric illness and risk for suicidal ideation/suicidal behavior/suicide compared with the general population. Recent literature suggests that antiepileptic drugs (AEDs) used to treat epilepsy, pain, and psychiatric disorders increase the risk of suicide and that this increased risk may be AED selective. This case analyzes a suicide attempt on a video/EEG telemetry unit. Specific risk factors associated with increased risk of suicidal behaviors pertinent to this case are reviewed: epilepsy, multiple psychiatric diagnoses including affective disorder, AEDs, PNES, prior medically serious suicide attempt, and suicide attempt within the past month. Specific psychometric rating scales to screen for both psychiatric illness and suicide risk and psychiatric assessment should be integral components of the evaluation and treatment of patients on video/EEG telemetry units.     

Psychogenic nonepileptic seizures and suicidal behavior on a video/EEG telemetry unit: the need for psychiatric assessment and screening for suicide risk

Patients with epilepsy and psychogenic nonepileptic seizures (PNES) have an increased prevalence of psychiatric illness and risk for suicidal ideation/suicidal behavior/suicide compared with the general population. Recent literature suggests that antiepileptic drugs (AEDs) used to treat epilepsy, pain, and psychiatric disorders increase the risk of suicide and that this increased risk may be AED selective. This case analyzes a suicide attempt on a video/EEG telemetry unit. Specific risk factors associated with increased risk of suicidal behaviors pertinent to this case are reviewed: epilepsy, multiple psychiatric diagnoses including affective disorder, AEDs, PNES, prior medically serious suicide attempt, and suicide attempt within the past month. Specific psychometric rating scales to screen for both psychiatric illness and suicide risk and psychiatric assessment should be integral components of the evaluation and treatment of patients on video/EEG telemetry units.     

Insomnia brings soldiers into mental health treatment,predicts treatment engagement,and outperforms other suicide-related symptoms as a predictor of major depressive episodes

Given the high rates of suicide among military personnel and the need to characterize suicide risk factors associated with mental health service use, this study aimed to identify suicide-relevant factors that predict: (1) treatment engagement and treatment adherence, and (2) suicide attempts, suicidal ideation, and major depressive episodes in a military sample. Army recruiters (N = 2596) completed a battery of self-report measures upon study enrollment. Eighteen months later, information regarding suicide attempts, suicidal ideation, major depressive episodes, and mental health visits were obtained from participants’ military medical records. Suicide attempts and suicidal ideation were very rare in this sample; negative binomial regression analyses with robust estimation were used to assess correlates and predictors of mental health treatment visits and major depressive episodes. More severe insomnia and agitation were significantly associated with mental health visits at baseline and over the 18-month study period. In contrast, suicide-specific hopelessness was significantly associated with fewer mental health visits. Insomnia severity was the only significant predictor of major depressive episodes. Findings suggest that assessment of sleep problems might be useful in identifying at-risk military service members who may engage in mental health treatment. Additional research is warranted to examine the predictive validity of these suicide-related symptom measures in a more representative, higher suicide risk military sample.     

Terminal mental illness: resident experience of patient suicide

Suicide prevention efforts are a major focus of psychiatry residency training. Residents are taught to identify suicide risk factors, monitor for suicidal ideation, and develop crisis stabilization plans for patients at risk for self harm. In contrast, training and support for dealing with suicide completion is often lacking. Although suicide remains a predictable outcome for many patients with severe mental illness, this topic may be avoided or reviewed only with residents who are directly affected by patient suicide. The purpose of this paper is to present a psychiatry resident's experience of dealing with a patient suicide and identify obstacles to developing this aspect of training. Options for "preventative" training in helping trainees deal with this unfortunate outcome of mental illness will be reviewed.     

Suicidal ideation and risk factors in primary care patients with anxiety disorders

The presence of an anxiety disorder is associated with greater frequency of suicidal thoughts and behaviors. Given the high personal and societal costs of suicidal behaviors, suicide prevention is a priority. Understanding factors present within individuals with anxiety disorders that increase suicide risk may inform prevention efforts. The aims of the present study were to examine the prevalence of suicidal ideation and behaviors, as well as factors associated with suicide risk in patients with anxiety disorders in primary care. Data from a large scale randomized controlled study were analyzed to assess prevalence of suicidal thoughts and behaviors, as well as factors associated with suicide risk. Results revealed that suicidal ideation and behaviors were relatively common in this group. When examining mental and physical health factors jointly, presence of depression, mental health-related impairment, and social support each uniquely accounted for variance in suicide risk score. Methodological limitations include cross-sectional data collection and lack of information on comorbid personality disorders. Moreover, patients included were from a clinical trial with exclusion criteria that may limit generalizability. Results highlight the complex determinants of suicidal behavior and the need for more nuanced suicide assessment in this population, including evaluation of comorbidity and general functioning.     

Does the geriatric depression scale (GDS) distinguish between older adults with high versus low levels of suicidal ideation?

OBJECTIVE: The Geriatric Depression Scale (GDS) is a common screening measure for late-life depression, but it does not directly assess thoughts of death or suicide. The present study asked whether 30-item (GDS) and 15-item (GDS-SF) GDS scales differentiate older adults with high versus low levels of suicidal ideation. METHODS: This cross-sectional study included a sample of 105 adults age 65 or older recruited from medical and psychiatric inpatient and outpatient practices, nursing and retirement residences, and community-based seniors' programs. RESULTS: GDS scores were associated positively with self-report and clinician-administered measures of suicidal ideation. Fifteen of 30 GDS items and 7 of 15 GDS-SF items distinguished groups high or low in self-reported suicidal ideation. Receiver Operating Characteristic curve analyses indicated criterion validity for the GDS measures with respect to suicidal ideation at cut-off scores of 12 for the GDS and 6 for the GDS-SF. Five internally consistent GDS items were identified that were highly associated with suicidal ideation, assessing hopelessness, worthlessness, emptiness, an absence of happiness, and absence of the perception that it is "wonderful to be alive." CONCLUSION: Long and short forms of the GDS may be used to screen older patients at risk for suicide. Clinicians using the GDS for this purpose are advised to further assess suicide risk with measures designed specifically to assess presence and severity of suicidal ideation.     

A Paucity of Data on Veterans 65 and Older and Risk of Suicide: A Systematic Review

Older veterans are vastly underrepresented in studies that shape national suicide prevention strategies. This is of great concern because factors that impact younger veterans may not be as robust in later life. Although younger veterans have higher rate of suicide, the highest counts of death by suicide are in older veterans. However, it remains unclear from the extant literature what factors may influence increased or decreased risk of late-life suicide in veterans. The objective of this systematic review was to identify risk and protective factors related to suicide outcomes (i.e., ideation, attempt, death, or suicide-related behavior [SRB]) among older veterans. Furthermore, it offers data regarding future study directions and hypothesis generation for late-life suicide research and for informing potential intervention and prevention efforts in this area. We searched 4 databases from inception up to May 5, 2022. We screened 2,388 abstracts for inclusion and 508 articles required full text review. The final sample included 19 studies published between 2006 and 2022. We found five domains of factors studied (i.e., neuropsychiatric, social determinants of health, aging stereotypes, residential and supportive housing settings, and multifactorial–neuropsychiatric/mental health and physical health) with more risk factors than protective factors reported. Across the three suicide outcomes only neuropsychiatric factors were consistently identified as risk factors. Neuropsychiatric factors also comprised the largest group of risk factors studied. More innovative targets to consider for intervention and more innovative methods to predict suicide in late-life are needed. There is also continued necessity to design suicide prevention interventions for older veterans given lethality trends.     

Post-acute crisis text messaging outreach for suicide prevention: A pilot study

Several post-suicide prevention strategies such as sending postcards or making phone calls have been used to keep in contact with suicide attempters. The continuity of care has been beneficial to the prevention of post-acute suicidal behaviors. The aim of the study was to evaluate the technical feasibility and acceptability of text messaging outreach in post-acute suicide attempters. Eighteen post-suicidal patients were included in a prospective, monocentric, open-label, 2 months pilot study. The text messages were sent from the intranet program that we specially developed for the study. Technical feasibility of this text message intervention was evaluated by the analysis of text message reports. Acceptability of such intervention was evaluated by a standardized phone interview. Our study showed that receiving text messages sent from an intranet program after a suicide attempt is technically possible. This post-crisis outreach program was accepted by the patients who found it to have a positive preventive impact. Text messaging outreach offers several advantages such as lower cost, and easier utilization compared to current post-acute care strategies. We suggest further randomized controlled trials in a large sample of suicidal patients to assess the efficacy of this novel outreach tool for prevention of post-acute suicide.     

Management of the depressed, suicidal child or adolescent

Two prominent risk factors for completed suicide and suicidal behavior in adolescents are previous suicide attempts and a diagnosis of a depressive episode. Adolescents with different degrees of suicidal risk and severity are referred or admitted to various clinical settings. Research has yet to identify clearly the treatment of choice for suicidal patients. Regardless, clinical interventions should be based on a thorough suicide risk assessment. Treatment strategies should be multidimensional, targeting suicidal behavior and the underlying psychiatric illness or other personality and environmental risk factors. Because adolescents are referred from one clinical setting to another, continuity of care must be one of mental health practitioners' major concerns. Lack of continuity of care places patients at an elevated risk for additional suicide attempts.     

Recent research on suicide in the elderly

Older adults, and older men in particular, are the segment of the US population that has the highest suicide rate. Although research on risk factors continues to grow, there remains limited knowledge of the biologic changes that increase risk for suicide, as well as limited information about contributing psychosocial processes that extend beyond demographic factors. No proven interventions are known at this time, although efforts are underway to test approaches that reach older adults who use primary care services. Continued efforts are needed to change attitudes about mental illness and treatment in order to reach older adults who do not use health care services.