Point of View – Elder Suicide: A Public Health Challenge of the Elder Boom

By the age of 88, Mr. W.* had lost most of his closest friends to death or dementia. His children had moved to other parts of the country. He saw them and his grandchildren rarely. He had retired from his long career as a teacher without finding new interests. But he and his wife were happy. They both read a great deal, and every day they took a walk together, talked about books and the state of the world, stopped for happy hour at a local restaurant where “everyone knew their name.” When his wife developed lung cancer, he took her for treatment and nursed her at home. But her cancer was more virulent than most. She died quickly. The children came for the funeral and stayed a couple of weeks, but then they went back to their homes. He was alone, and he felt lost. He began to have bouts of dizziness and severe heart burn. He went to the doctor, who prescribed medications that helped a bit. One day after a doctor’s visit he went home and took his own life.¹

Nearly 15 older adults take their own lives every day in the U.S.—about 5400 per year.² The frequency of suicide among older adults is not well-known, probably because older adults die from many other causes. Suicide is among the top three causes of death for teenagers and young adults; it is not among the top 20 causes of death for women over 65 and is only the 17^th leading cause of death for older men. But the fact of the matter is that older adults complete suicide at a rate nearly 50 percent greater than people 15-24 years old. Older white men are particularly vulnerable, completing suicide at a rate three times that of the general population. White men over 85 are the population at highest risk; they take their own lives at about four times the rate of the general population.³

There are a number of striking facts about suicide among older adults.

• Older men are far more likely to take their own lives than older women, despite the fact that women are far more likely to have a major depressive disorder.⁴
• Most older adults who complete suicide have seen their primary care physician within 30 days of taking their own lives but have not been identified as a suicide risk.⁵
• Older adults may not attempt suicide more frequently than younger people, but their attempts are generally more lethal.⁶
• Men usually use guns to take their lives. Women usually take pills.⁷

Reducing suicide among older adults is an important public health imperative that will become even more important over the next two decades as the population of older adults booms.⁸ But it will not be easy to achieve.

Frequently the onus is placed on primary care physicians because a majority of older adults who take their own lives have made a doctor’s visit shortly before they choose to end their lives. And it is likely that if doctors screened for depression as a matter of course, asked more questions and explored what was going on in their patients’ lives, they would identify more of their patients who are depressed and might be able to provide treatment that would avert suicide.⁹

But suicide risk is not easy to identify. Most people who are depressed are not going to kill themselves, some people who kill themselves are not depressed, and a great many people who do kill themselves hide their intention very effectively. Let me rush to say that some do not hide their intentions, and people who say they are considering suicide must be taken seriously.

There are other warning signs of suicide in addition to talking about suicide, including depression, substance abuse, history of suicide attempts, and more. For older adults, recent loss, severe physical illness, social disconnection or increased dependency and loss of dignity sometimes contribute to the decision to attempt suicide. For more warning signs visit NSPL at www.suicidepreventionlifeline.org/GetHelp/SuicideWarningSigns.aspx.

But most people who exhibit warning signs do not attempt suicide, and people like Mr. W., who are stoic by nature, keep their feelings to themselves and who have guns at home, are very hard to identify as suicide risks.

Yeates Conwell, perhaps the nation’s leading expert on suicide among older adults, uses the interpersonal theory of suicide¹⁰ to explain the complex factors that contribute to older adults’ decisions to take their own lives. According to this theory the decision arises in large part from a mix of “thwarted belongingness” and “perceived burdensomeness.”

The implication of this theory is that prevention of suicide cannot be accomplished solely through improved identification of risk, timely intervention and access to help. These are important; but, in addition, older people need a place of belonging and a sense that becoming dependent does not mean becoming an intolerable burden.

That will be a tremendous challenge in our ageist society, which tends disparage age. Even in families who choose to be caregivers, older adults with disabilities are often not treated with enough dignity and respect.

In other contexts, the kind of societal change that is needed has been called building “age-friendly communities.”^11,12 It may well be that in the long run the public health challenge of elder suicide is more about building such communities than about traditional preventive interventions.

Michael Friedman teaches at Columbia University. He is the co-founder and Honorary Chair of the Geriatric Mental Health Alliance of New York. He can be reached at mf395@columbia.edu. Mr. Friedman’s article was originally published on The Huffington Post.

References

1. Mr. W. is a composite of characteristics of men over 85 who take their own lives.
2. According to data at the Centers for Disease Control, 27,000 people 65 or older took their own lives in the five year period from 2004-2008, the most recent years for which data are available. http://www.cdc.gov/injury/wisqars/index.html
3. All data in this paragraph are from “Injury Prevention and Control: Data and Statistics (WISQARS)” on the website of the Centers for Disease Control. http://www.cdc.gov/injury/wisqars/index.html
4. National Institute of Mental Health. Suicide in the U.S.: Statistics and Prevention. 2011. http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml
5. Louoma, J. et al. “Contact with Mental Health and Primary Care Providers Before Suicide: A Review of the Literature” in American Journal of Psychiatry, June 2002. http://ajp.psychiatryonline.org/article.aspx?Volume=159&page=909&journalID=13
6. Centers for Disease Control. Suicide Facts At A Glance. 2009. http://www.cdc.gov/ViolencePrevention/pdf/Suicide-DataSheet-a.pdf
7. Centers for Disease Control. “Injury Prevention and Control: Data and Statistics (WISQARS)” on the website of the Centers for Disease Control. http://www.cdc.gov/injury/wisqars/index.html
8. U.S. Census Bureau. “U.S. Population Projections.” 2008. www.census.gov/population/www/projections/2008projections.html
9. Friedman, M., Sederer, L. et al. Treating The Individual—Advice for Physicians Treating Older Adults“ in Aging Well, Fall 2011. http://www.agingwellmag.com/archive/fall2011_p18.shtml
10. Joiner T. et al. Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients. American Psychiatric Association, 2009. http://www.apa.org/pubs/books/4317175.aspx
11. World Health Organization. Global Age Friendly Cities: A Guide. 2007 http://whqlibdoc.who.int/publications/2007/9789241547307_eng.pdf
12. Williams, K and Friedman, M. Addressing The Mental Health Needs of Older Adults in Age Friendly Communities, 2010. http://www.michaelbfriedman.com/mbf/images/stories/geriatric_MH_policy/Age-Friendly_Communities/Age-Friendly_Communities–Guide_for_Planners.pdf

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