By 2040, it is estimated that 82 million Americans will be over the age of 65. Approximately 16 million of them will have mental health issues and/or substance use disorders (SAMHSA, 2017). It is also known that the highest rate of suicide is among those 65 years and older. 90% of those who die by suicide have a mental health issue (American Foundation for Suicide Prevention, 2017). In short, we have a growing problem with suicide among the aging.
In general, the ratio of suicide attempts to completed suicides is 16:1. Among those 65 and older, the ratio is 4:1. The reasons for this are many. The aging population has a greater tendency to use more lethal means such as firearms, hanging, and drowning. Those who are isolated and living on their own are less likely to be discovered in time to thwart the attempt. The physical frailty of the aging also makes it less likely they may survive an attempt.
Likewise, the reasons for attempts and completed suicides are many. Among the factors contributing to this epidemic are the loss of spouses and peers, physical impairments, illness, chronic pain, and isolation. These conditions all tend to be comorbid with depression which is a known risk factor for suicide. As always, stigma plays a role in that it prevents conversation and help seeking.
Depression is frequently undiagnosed, but this is particularly true in older adults who may have a host of other issues. Primary Care Physicians (PCP) frequently either miss the signs of depression or chalk it up to a “normal” part of aging. Depression is not a normal part of the aging process and can be treated. It is vital that PCPs and nursing home attendants make screening for depression as routine as taking a blood pressure reading. The Patient Health Questionnaire-9 (PHQ-9) is an easily administered questionnaire of only nine questions that can quickly assess a patient for signs of depression. The National Committee for Quality Assurance (NCQA) recently added use of the PHQ-9 to its Healthcare Effectiveness Data and Information Set (HEDIS). What’s more, the PHQ-9 has a specific question that screens for the presence of suicidal ideation. This should also become a matter of routine for visiting nurses who may be an important contact for socially isolated older adults.
There is also the Cornell Scale for Depression in Dementia (CSDD) which relies on an interview with a caregiver as well as the patient. This may be an important consideration where cognitive functioning is an issue in accurate screening. As we see a continued integration of physical and behavioral health, the use of these screening tools will hopefully become more widespread.
Another issue with older adults is subsyndromal depression, that is, depression that does not meet the DSM-5 criteria for major depressive disorder or recurrent depression. Lebowitz (Diagnosis and Treatment of Depression in Late Life: Consensus Statement Update, 1997) tells us that the prevalence of subsyndromal depression may be as high as 50% among medically involved older adults and nursing home patients. These symptoms can last for some time and it is urgent that physicians be able to detect and treat this risk factor.
Lebowitz further asserts that “treatment for depression is safe and effective in patients with complex patterns of comorbidity”. Late life depression is readily treatable and can significantly improve both cognitive and physical functioning. In his words, “brief psychotherapy is feasible, acceptable, and effective in short-term depressive symptom reduction in medically ill older persons”. Studies support the effectiveness of Cognitive Behavioral Therapy (CBT) and interpersonal therapy. Problem solving, a form of CBT, has shown to be particularly effective. Psychotherapy combined with medication typically shows the best results but psychotherapy as a standalone treatment would work where there are issues with a patient accepting or tolerating medications.
Selective Serotonin Reuptake Inhibitors (SSRIs) and Selective Norepinephrine Reuptake Inhibitors (SNRIs) may have more adverse effects in older adults but they are generally better tolerated than older tricyclic antidepressants. Additionally, with a growing selection of each type to choose from, physicians are able to select the drug and dosage with the lowest adverse effect profile and drug-to-drug interactions. Some are specifically not recommended for use in older adults. To be fair, there are studies suggesting the use of antidepressants in older adults may not be as safe as assumed. As always, physicians must weigh risks and benefits.
Research in Sweden (Lebowitz, ibid.) has shown that treating depression can have a significant impact on suicide deaths. We must call on both medical and behavioral health providers to be more aware of these issues. Up to three quarters of those who took their life by suicide saw their PCP in the past 30 days (US DHHS, National Statistics of Older Adult Suicide from the National Suicide Prevention Plan). Assessing suicidality can be difficult because passive suicidality (“Soon I want be here anymore” and similar expressions) may be mistaken as the preoccupation with death that is typical at older ages.
In addition to treating depression, physicians must also treat the comorbid conditions, especially chronic pain, which are also risk factors in suicide for older adults. Based on these comorbid conditions as risk factors, suicide prevention includes promoting healthy behavior (Conwell, Suicide Later in Life, 2014).
It should be the role of anyone in contact with older adults to watch for signs and symptoms of depression and suicidality. Likewise, everyone should be prepared to do their bit to increase protective factors and decrease risk factors. Counseling on Access to Lethal Means (CALM) is a crucial part of intervention given that older adults tend to complete suicide more frequently due to their use of lethal means.
In addition to treatment and efforts to reduce risk factors, we must also work to increase protective factors. Improving social connectedness is a key factor in reducing the likelihood of suicidality. Promoting cultural and religious beliefs that discourage suicide and promote self-preservation (US DHHS, National Statistics of Older Adult Suicide from the National Suicide Prevention Plan) is a protective factor. As we have already said, promoting healthy behaviors is a protective factor as is reducing the stigma of suicide and mental health issues. There is much we can do and much we must do to slow this epidemic.