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Suicide

Epidemiology

Suicide among older adults is a far more common occurrence in the United States than among youth (Centers for Disease Control and Prevention, 2013), and worldwide older people are the group with highest rates of completed suicide (World Health Organization, 2002). Data from the Centers for Disease Control indicate that in 2010, almost 6,000 people over the age of 65 took their own lives in the United States (Centers for Disease Control and Prevention, 2013).

suicide rates Figure 1

Suicide among older adults in the U.S. is most common among white men aged 85 years or older (Heron et al., 2009; see Figure 1). For both black and white women, rates rise through midlife and fall thereafter; black men experience two peaks of risk, one in young adulthood and the second in old age. Most striking is the higher rate at every point in the life course for white men, rising to a peak in the oldest age group of over 45 per 100,000 per year, over 4 times the nation’s overall age adjusted rate of 11.5 per 100,000 per year. Suicide attempts are more often fatal among older adults who tend to use more lethal means (i.e., firearms), are more planful and determined, more frail, and often more isolated and thus less likely to be discovered (Conwell et al., 1990; McIntosh, 1985). While most older adults will die on their first attempt, a previous suicide attempt remains a potent risk factor for suicide death among older adults (Murphy et al., 2012).

A constellation of risk factors converges to place an older adult at elevated risk (see Figure 2): psychiatric illness (primarily depression), functional impairment, physical illness (particularly multiple comorbidities), social disconnectedness (including social isolation, loneliness, family conflict, and feeling like a burden on others), and pain (Conwell, Duberstein, & Caine, 2002; Van Orden, & Conwell, 2011). The greatest risk occurs when multiple domains of risk converge in a given individual.

Suicide Social Domains of Risk

Figure 2: Domains of Risk

However, suicide in late-life is not an expected or “normal” response to aging. Rather, psychological research has demonstrated that later life is often characterized by greater well-being, more positive emotions, and better capacity to manage emotions (cf., Socioemotional Selectivity Theory; Charles & Carstensen, 2010). Geropsychologists have much to bring to bear on the problem of late-life suicide, including beginning to shed light on the puzzle of how later life is both a time characterized by the maintenance, and in some cases, strengthening of well-being, and at the same time, is a period of heightened risk for suicide.

Risk Assessment & Screening

Before we discuss suicide risk assessment and screening, it is helpful to remind ourselves of the purpose of doing so: the goal of a suicide risk assessment is not a prediction about whether or not an older person will die by suicide. The goal is to determine the most appropriate actions to take to keep the older person safe. It is also important to remember to take action for any and all endorsements of suicide ideation, but not the same action for every level of risk. Finally, it is also important to remember that older adults are less likely to spontaneously report suicide ideation: it is up to us to ask. Suicide risk assessments are safe and do not cause or create suicide ideation.

Suicidal thoughts are a symptom of depression, but can occur in older (and younger) adults without depression. These thoughts should always be taken seriously, as both a sign of risk and sign of distress, even if they are not an indication that someone is at imminent risk of suicide. Suicide ideation is categorized as “passive” (i.e., thoughts that one would be better off dead) and “active” (i.e., thoughts of killing oneself). One tool for assessing both passive and active ideation is a depression screening tool, the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 assesses the nine symptoms of depression in the DSM diagnosis of a Major Depressive Episode; the final item asks how often the respondent has had “thoughts that you would be better off dead or of hurting yourself in some way.” If an older adult reports having passive or active suicide ideation (i.e., the PHQ-9 item lumps them together), you must follow-up to determine if the ideation is “passive” or “active” and whether the respondent has current intent to act on his/her thoughts. Recommended follow up questions include, “in the past two weeks have you had thoughts of killing yourself?”

In addition, there are routinized screeners for following up the PHQ-9, including the P4 Suicide Risk Screener (Dube et al., 2010). If a respondent reports active suicide ideation, the P4 can be administered.  The 4 “p’s” in the P4 are: past suicide attempt, suicide plan, probability (perceived risk), and (lack of) preventive factors. The P4 has an algorithm for categorizing risk as minimal (or low), higher (or moderate), and higher (or high) risk. Missing from the P4 are corresponding clinical actions to take for each level of risk. Suggestions for appropriate actions to take for each level of risk are below, with the caveat that there are no empirically supported risk assessment procedures with corresponding actions to take; good clinical judgment must be exercised and any agency procedures followed as well.

For those categorized as low or moderate risk, the following is recommended: 1) expressing concern about suicide ideation, 2) obtaining consent to contact the primary care physician, 3) urge they remove means, 3) create a safety plan (see a template from Barbara Stanley and Greg Brown); 4) provide emergency numbers including 1-800-273-TALK; 4) consult a colleague or supervisor. For those at high risk, emergency services must be considered right away (ED, mobile crisis, 9-1-1)—do not leave the patient alone until appropriate actions are taken.

Other relevant assessment measures include the Geriatric Suicide Ideation Scale (GSIS), which can be used to monitor changes in suicide risk across the course of treatment (Heisel et al., 2006). Also, the Columbia Suicide Severity Rating Scale is becoming the “gold standard” for standardized suicide risk assessment; more information can be found at: www.cssrs.columbia.edu/‎

Intervention

Several interventions have been shown (in quasi-experimental studies) to be associated with reductions in suicide rates among older adults, and all were multi-component, multi-level interventions that involved: 1) telephone-based outreach, evaluation and support services (DeLeo and colleagues’ Telehelp/Telecheck intervention; De Leo et al., 1995; De Leo et al., 2002); 2) screening and referral for care, and engagement in health education, volunteer, and peer support activities (Oyama and colleagues, 2006; 2008); and, 3) case management, supportive phone calls, psychoeducation, and psychiatric care (Chan et al., 2011). Collaborative care models (CCM) that include Interpersonal Psychotherapy (the PROSPECT study; Alexopoulos et al., 2009) and Problem Solving Therapy (the IMPACT study; Unutzer et al., 2002) are associated with reductions in suicidal ideation for some depressed older adults.

Treating depression to remission, as well as addressing other risk factors such as functional impairment, pain, and social disconnectedness, are key components of suicide prevention in later life (Conwell et al., 2011). Other key components include removing access to lethal means, particularly firearms (Conwell et al., 2011), and coordination of care with primary care physicians, given that many older adults who die by suicide are seen by their PCP’s in the months and weeks leading up to their deaths (Luoma et al., 2002). Finally, older adults may be less likely to disclose depression and suicidal ideation, perhaps in part due to cohort differences as well as personality traits present in some older adults, including low openness to experience (Duberstein, 1995). Thus, directly and routinely inquiring about suicide risk is imperative, especially for older adults who present with depression. Just as a physician regularly checks blood pressure, geropsychologists working with depressed older adults must regularly assess suicide risk. Coordinating safety plans with family members or other key people in the older person’s life is also recommended, especially given that cognitive impairment may accompany depression in later life.

Written by Kimberly Van Orden, PhD, University of Rochester Medical Center

General

World Health Organization. (2002). Distribution of suicides rates (per 100,000), by gender and age, 2000, 2002. Retrieved from: http://www.who.int/mental_health/prevention/suicide/suicide_rates_chart/en/index.html

World Health Organization. (2002). Distribution of suicides rates (per 100,000), by gender and age, 2000, 2002.  Retrieved from:  http://www.who.int/mental_health/prevention/suicide/suicide_rates_chart/en/index.html

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Van Orden, K., & Conwell, Y. (2011). Suicides in late life. Current psychiatry reports, 13(3), 234-41.

Van Orden, K., & Conwell, Y. (2011). Suicides in late life. Current psychiatry reports, 13(3), 234-41.

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Murphy, E., Kapur, N., Webb, R., Purandare, N., Hawton, K., Bergen, H., . . . Cooper, J. (2012). Risk factors for repetition and suicide following self-harm in older adults: Multicentre cohort study. British Journal of Psychiatry, 200, 399-404.

Murphy, E., Kapur, N., Webb, R., Purandare, N., Hawton, K., Bergen, H., . . . Cooper, J. (2012). Risk factors for repetition and suicide following self-harm in older adults: Multicentre cohort study. British Journal of Psychiatry, 200, 399-404.

Posted in reference | Tagged , | Comments Off on Murphy, E., Kapur, N., Webb, R., Purandare, N., Hawton, K., Bergen, H., . . . Cooper, J. (2012). Risk factors for repetition and suicide following self-harm in older adults: Multicentre cohort study. British Journal of Psychiatry, 200, 399-404.

McIntosh, J.L., & Santos JF. (1985). Methods of suicide by age: Sex and race differences among the young and old. International Journal of Aging & Human Development, 22(2), 123-39.

McIntosh, J.L., & Santos JF. (1985). Methods of suicide by age: Sex and race differences among the young and old. International Journal of Aging & Human Development, 22(2), 123-39.

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Luoma, J. B., Martin, C. E., & Pearson, J. L. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159(6), 909-916.

Luoma, J. B., Martin, C. E., & Pearson, J. L. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159(6), 909-916.

Posted in reference | Tagged , | Comments Off on Luoma, J. B., Martin, C. E., & Pearson, J. L. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159(6), 909-916.

Heron, M.P., Hoyert, D.L., Murphy, S.L., Jiaquan, X., Kochanek, K.D., & Tejada-Vera, B. (2009) Deaths: Final Data for 2006. National Vital Statistics Reports, 57(14), 1-135.

Heron, M.P., Hoyert, D.L., Murphy, S.L., Jiaquan, X., Kochanek, K.D., & Tejada-Vera, B. (2009) Deaths: Final Data for 2006. National Vital Statistics Reports, 57(14), 1-135.

Posted in reference | Tagged , | Comments Off on Heron, M.P., Hoyert, D.L., Murphy, S.L., Jiaquan, X., Kochanek, K.D., & Tejada-Vera, B. (2009) Deaths: Final Data for 2006. National Vital Statistics Reports, 57(14), 1-135.

Duberstein, P.R. (1995) Openness to experience and completed suicide across the second half of life. International Psychogeriatrics, 7(2), 183-198.

Duberstein, P.R. (1995) Openness to experience and completed suicide across the second half of life. International Psychogeriatrics, 7(2), 183-198.

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Conwell, Y., Van Orden, K., & Caine, E.D. (2011). Suicide in older adults. The Psychiatric clinics of North America, 34(2), 451-68.

Conwell, Y., Van Orden, K., & Caine, E.D. (2011). Suicide in older adults. The Psychiatric clinics of North America, 34(2), 451-68.

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Conwell, Y., Rotenberg, M., & Caine, E.D. (1990). Completed suicide at age 50 and over. Journal of the American Geriatric Society, 38(6), 640-4.

Conwell, Y., Rotenberg, M., & Caine, E.D. (1990). Completed suicide at age 50 and over. Journal of the American Geriatric Society, 38(6), 640-4.

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Conwell, Y., Dubertstein, P.R., & Caine, E.D. (2002). Risk factors for suicide in later life. Biological Psychiatry, 52(3), 193-204.

Conwell, Y., Dubertstein, P.R., & Caine, E.D. (2002). Risk factors for suicide in later life. Biological Psychiatry, 52(3), 193-204.

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Charles, S.T., & Carstensen, L.L. (2010). Social and emotional aging. Annual Review of Psychology, 61, 383-409

Charles, S.T., & Carstensen, L.L. (2010). Social and emotional aging. Annual Review of Psychology, 61, 383-409

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Centers for Disease Control and Prevention. (2013). Web-based injury statistics query and reporting system (WISQARS). Leading causes of death reports. Atlanta, GA: National Center for Injury Prevention and Control. http://www.cdc.gov/injury/wisqars/index.html

Centers for Disease Control and Prevention. (2013). Web-based injury statistics query and reporting system (WISQARS). Leading causes of death reports. Atlanta, GA: National Center for Injury Prevention and Control. http://www.cdc.gov/injury/wisqars/index.html

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Bernick, L., & Reid, J. (2005). Suicide Prevention Among Older Adults. Symposium presented at the SPRC Regions III and V Conference, Pittsburgh, Pennsylvania. Powerpoint slides available here.

Bernick, L., & Reid, J. (2005). Suicide Prevention Among Older Adults. Symposium presented at the SPRC Regions III and V Conference, Pittsburgh, Pennsylvania.  Powerpoint slides available here.

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Assessment

Look at the extensive assessment database of geriatric measures from the University of Alabama’s Alabama Research Institute on Aging! Register for access to the database HERE.

Heisel, M. J., & Flett, G. L. (2006). The development and initial validation of the Geriatric Suicide Ideation Scale. The American Journal of Geriatric Psychiatry, 14, 742-751.

Heisel, M. J., & Flett, G. L. (2006). The development and initial validation of the Geriatric Suicide Ideation Scale. The American Journal of Geriatric Psychiatry, 14, 742-751.

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Dube, P., Kurt, K., Bair, M. J., Theobald, D., & Williams, L. S. (2010). The P4 screener: Evaluation of a brief measure of assessing potential suicide risk in randomized effectiveness trials of primary care and oncology patients. Primary care companion to the Journal of Clinical Psychiatry, 12, doi: 10.4088/PCC.10m00978blu

Dube, P., Kurt, K., Bair, M. J., Theobald, D., & Williams, L. S. (2010). The P4 screener: Evaluation of a brief measure of assessing potential suicide risk in randomized effectiveness trials of primary care and oncology patients. Primary care companion to the Journal of Clinical Psychiatry, 12, doi: 10.4088/PCC.10m00978blu

Posted in reference | Tagged , | Comments Off on Dube, P., Kurt, K., Bair, M. J., Theobald, D., & Williams, L. S. (2010). The P4 screener: Evaluation of a brief measure of assessing potential suicide risk in randomized effectiveness trials of primary care and oncology patients. Primary care companion to the Journal of Clinical Psychiatry, 12, doi: 10.4088/PCC.10m00978blu

Oyama. H., Fujita, M., Goto, M., Shibuya, H., & Sakashita, T. (2006). Outcomes of community-based screening for depression and suicide prevention among Japanese elders. Gerontologist, 46(6), 821-26.

Oyama. H., Fujita, M., Goto, M., Shibuya, H., & Sakashita, T. (2006). Outcomes of community-based screening for depression and suicide prevention among Japanese elders. Gerontologist, 46(6), 821-26.

Posted in reference | Tagged , | Comments Off on Oyama. H., Fujita, M., Goto, M., Shibuya, H., & Sakashita, T. (2006). Outcomes of community-based screening for depression and suicide prevention among Japanese elders. Gerontologist, 46(6), 821-26.

Fremouw, W., McCoy, K., Tyner, E., & Musick, R. (2009). Suicide Older Adult Protocol – SOAP. Unpublished manuscript, West Virginia University. ACCESS MANUAL HERE.

Fremouw, W., McCoy, K., Tyner, E., & Musick, R. (2009).  Suicide Older Adult Protocol – SOAP.  Unpublished manuscript, West Virginia University.  ACCESS MANUAL HERE.

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Reiss, N.S. & Tishler, C.L. (2008). Suicidality in nursing home residents: Part I. Prevalence, risk factors, methods, assessment, and management. Professional Psychology: Research and Practice, 39(3), 264-270. doi: 10.1037/0735-7028.39.3.264

Reiss, N.S. & Tishler, C.L. (2008). Suicidality in nursing home residents: Part I. Prevalence, risk factors, methods, assessment, and management.  Professional Psychology: Research and Practice, 39(3), 264-270. doi: 10.1037/0735-7028.39.3.264

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Treatment

Bruce, M. L., Ten Have, T. R., Reynolds, C. F., III, Katz, I. I., Schulberg, H. C., Mulsant, B. H., . . . Alexopoulos, G. S. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: A randomized controlled trial. JAMA: Journal of the American Medical Association, 291, 1081–1091. doi:10.1001/jama.291.9.1081

Bruce, M. L., Ten Have, T. R., Reynolds, C. F., III, Katz, I. I., Schulberg, H. C., Mulsant, B. H., . . . Alexopoulos, G. S. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: A randomized controlled trial. JAMA: Journal of the American Medical Association, 291, 1081–1091. doi:10.1001/jama.291.9.1081

Posted in reference | Tagged , , , | Comments Off on Bruce, M. L., Ten Have, T. R., Reynolds, C. F., III, Katz, I. I., Schulberg, H. C., Mulsant, B. H., . . . Alexopoulos, G. S. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: A randomized controlled trial. JAMA: Journal of the American Medical Association, 291, 1081–1091. doi:10.1001/jama.291.9.1081

Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr., Hunkeler, E., Harpole, L., . . . Treatment, I. I. I. M.-P. A. t. C. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA, 288(22), 2836-2845.

Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr., Hunkeler, E., Harpole, L., . . . Treatment, I. I. I. M.-P. A. t. C. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA, 288(22), 2836-2845.

Posted in reference | Tagged , | Comments Off on Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr., Hunkeler, E., Harpole, L., . . . Treatment, I. I. I. M.-P. A. t. C. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA, 288(22), 2836-2845.

Oyama, H., Sakashita, T., Ono, Y., Goto, M., Fujita, M., & Koida J. (2008). Effect of community-based intervention using depression screening on elderly suicide risk: A meta-analysis of the evidence from Japan. Community Mental Health Journal, 44(5), 311-20.

Oyama, H., Sakashita, T., Ono, Y., Goto, M., Fujita, M., & Koida J. (2008). Effect of community-based intervention using depression screening on elderly suicide risk: A meta-analysis of the evidence from Japan. Community Mental Health Journal, 44(5), 311-20.

Posted in reference | Tagged , | Comments Off on Oyama, H., Sakashita, T., Ono, Y., Goto, M., Fujita, M., & Koida J. (2008). Effect of community-based intervention using depression screening on elderly suicide risk: A meta-analysis of the evidence from Japan. Community Mental Health Journal, 44(5), 311-20.

De Leo, D., Carollo, G., Dello Buono, M. (1995). Lower suicide rates associated with a Tele-Help/Tele-Check service for the elderly at home. American Journal of Psychiatry, 152(4), 632-4.

De Leo, D., Carollo, G., Dello Buono, M. (1995). Lower suicide rates associated with a Tele-Help/Tele-Check service for the elderly at home. American Journal of Psychiatry, 152(4), 632-4.

Posted in reference | Tagged , | Comments Off on De Leo, D., Carollo, G., Dello Buono, M. (1995). Lower suicide rates associated with a Tele-Help/Tele-Check service for the elderly at home. American Journal of Psychiatry, 152(4), 632-4.

De Leo, D., Dello Buono, M., & Dwyer, J. (2002). Suicide among the elderly: the long-term impact of a telephone support and assessment intervention in northern Italy. British Journal of Psychiatry, 181, 226-9.

De Leo, D., Dello Buono, M., & Dwyer, J. (2002). Suicide among the elderly: the long-term impact of a telephone support and assessment intervention in northern Italy. British Journal of Psychiatry, 181, 226-9.

Posted in reference | Tagged , | Comments Off on De Leo, D., Dello Buono, M., & Dwyer, J. (2002). Suicide among the elderly: the long-term impact of a telephone support and assessment intervention in northern Italy. British Journal of Psychiatry, 181, 226-9.

Chan, S.S., Leung, V.P., Tsoh, J., Li, S.W., Yu, C.S., Yu, G.K., et al. (2011). Outcomes of a two-tiered multifaceted elderly suicide prevention program in a Hong Kong Chinese community. American Journal of Geriatric Psychiatry, 19(2):185-96.

Chan, S.S., Leung, V.P., Tsoh, J., Li, S.W., Yu, C.S., Yu, G.K., et al. (2011). Outcomes of a two-tiered multifaceted elderly suicide prevention program in a Hong Kong Chinese community. American Journal of Geriatric Psychiatry, 19(2):185-96.

Posted in reference | Tagged , | Comments Off on Chan, S.S., Leung, V.P., Tsoh, J., Li, S.W., Yu, C.S., Yu, G.K., et al. (2011). Outcomes of a two-tiered multifaceted elderly suicide prevention program in a Hong Kong Chinese community. American Journal of Geriatric Psychiatry, 19(2):185-96.

Alexopoulos, G. S., Reynolds, C. F., 3rd, Bruce, M. L., Katz, I. R., Raue, P. J., Mulsant, B. H., . . . Group, P. (2009). Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study. American Journal of Psychiatry, 166(8), 882-890.

Alexopoulos, G. S., Reynolds, C. F., 3rd, Bruce, M. L., Katz, I. R., Raue, P. J., Mulsant, B. H., . . . Group, P. (2009). Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study. American Journal of Psychiatry, 166(8), 882-890.

Posted in reference | Tagged , | Comments Off on Alexopoulos, G. S., Reynolds, C. F., 3rd, Bruce, M. L., Katz, I. R., Raue, P. J., Mulsant, B. H., . . . Group, P. (2009). Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study. American Journal of Psychiatry, 166(8), 882-890.

Reiss, N.S. & Tishler, C.L. (2008). Suicidality in nursing home residents: Part I. Prevalence, risk factors, methods, assessment, and management. Professional Psychology: Research and Practice, 39(3), 264-270. doi: 10.1037/0735-7028.39.3.264

Reiss, N.S. & Tishler, C.L. (2008). Suicidality in nursing home residents: Part I. Prevalence, risk factors, methods, assessment, and management.  Professional Psychology: Research and Practice, 39(3), 264-270. doi: 10.1037/0735-7028.39.3.264

Posted in Uncategorized | Tagged , , , | Comments Off on Reiss, N.S. & Tishler, C.L. (2008). Suicidality in nursing home residents: Part I. Prevalence, risk factors, methods, assessment, and management. Professional Psychology: Research and Practice, 39(3), 264-270. doi: 10.1037/0735-7028.39.3.264

Webinars available for viewing/downloading on Late Life Suicide Prevention:

National Council on Aging: http://www.ncoa.org/calendar-of-events/webinars/suicide-prevention-webinar.html

Suicide Prevention Resource Center: http://www.sprc.org/training-institute/r2p-webinars/all-listings/243

For geropsychologists working with older adults in senior living communities, there is a free toolkit available online through the SAMHSA website: 

http://store.samhsa.gov/product/Promoting-Emotional-Health-and-Preventing-Suicide/SMA10-4515