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Suicide and Suicide Prevention in Later Life

Yeates Conwell, M.D.

Abstract: In 2010, almost 6,000 adults over age 65 died by suicide in the United States, and perhaps 200,000 worldwide. Because older adults are the most rapidly growing segment of the population, the number of suicides in this age group is expected to rise dramatically in coming decades. Development of effective approaches to late-life suicide prevention is a major public health priority. However, older adults pose particular challenges to prevention because self-injurious acts in later life tend to be more immediately lethal and with fewer warning signs than at earlier points in the life course. Research has delineated risk and protective factors in ve domains: psychiatric illness (primarily mood disorders), personality and coping style, physical illnesses, social stressors and supports, and functional impairments. Research ndings also indicate that primary care and other community-based health and human service settings are best suited to intervention implementation. Late-life suicide preventive interventions can be categorized as indicated (targeting high-risk individuals), selective (for individuals or groups with more distal risk factors), or universal (targeting a population) prevention approaches. Relatively few studies of preventive interventions that specically target suicidal ideation, attempts, or completed suicide have been conducted in this age group. Available ndings suggest that rates of suicidal ideation and behavior may be reduced by a variety of approaches. However, older women have been more responsive overall to preventive interventions than elderly men, the group at highest risk. Challenges remain to reducing suicide-related morbidity and mortality in later life.
CLINICAL SYNTHESIS

INTRODUCTION
On March 14, 1932, George Eastman, the fabulously wealthy industrialist and philanthropist who founded the Eastman Kodak Company, took his own life with a gunshot to the left chest (1). He was 77 years old. A suicide note left on his bedside table said simply, Friends. My work is done. Why wait? These last words seemed to reect the autonomy and self-determination that had made Mr. Eastman so successful in life. The reality, however, was far different. For several years Eastman had been racked with pain from a spinal disorder. Becoming progressively more disabled, he was required to cede control of his company. Isolated from friends and struggling to nd meaning in life, Eastman became despondent and ended his own life. Other than for his riches, Eastman is typical in many respects of older adults who take their own lives. With that backdrop, the following sections provide a brief review of the epidemiology of suicide among older adults in the United States, current knowledge regarding risk and protective factors, and evidence for the most promising approaches to reducing suiciderelated morbidity and mortality in later life.

THE

EPIDEMIOLOGY OF SUICIDE

As depicted in Figure 1, suicide rates vary greatly as a function of age, sex, and race (2). Women of all ages and race/ethnicities tend to have lower rates of suicide than men, and whites have higher rates than nonwhites. For both African American and American Indian men, the suicide rate peaks in young adulthood followed by steady declines thereafter. White men show a markedly different pattern in which rates rise to a peak at midlife, diminish somewhat then escalate dramatically to a rate in the oldestold (50.8/100,000) that is over four times higher than that of the general population (12.1/100,000). In 2010, almost 6,000 people over the age of 65 years
Author Information and CME Disclosure Yeates Conwell, M.D., Department of Psychiatry, University of Rochester School of Medicine and Dentistry and Center for the Study and Prevention of Suicide, Rochester, NY The author reports no competing interests. Address correspondence to Yeates Conwell, M.D., Department of Psychiatry, University of Rochester School of Medicine and Dentistry, 300 Crittenden Blvd., Rochester, NY 14642; e-mail: yeates_conwell@urmc.rochester.edu

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Figure 1.
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Suicide Rates in the United States by Age, Sex, and Race, 2010

50

White male Black male Am. Indian male

White female Black female Am. Indian female

Suicide Rate Per 100K

40

30

20

10

0 0 14

15 19

20 24

25 29

30 34

35 39

40 44

45 49

50 54

55 59

60 64

65 69

70 74

75 79

80 84

85+

Age (years)
Source: Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System [WISQARS])

died by their own hand. In contrast to the U.S., most countries for which World Health Organization statistics are available report that rates for suicide rise steadily throughout the life course for both men and women (3) Unlike completed suicide, period prevalence rates of both suicidal ideation (4) and attempted suicide (2) decrease in frequency with greater age. As a consequence, the ratio of completed to attempted suicides is far higher among older adults than in younger and middle-aged populations. Studies estimate one suicide death of an older adult for every two to four who are hospitalized with a nonfatal selfinicted injury (5). Among the general population, that ratio is estimated to be 1:30, and among female adolescents as much as 1:200 (6). Possible explanations for this pattern include the greater physical frailty and lesser resilience of older people, making death more likely as a result of any injury; that older adults are more likely than younger and middleaged people to live alone, and thus are less likely to be rescued in the event of self-injury; and because older people in suicidal crises are more planful and determined to die (7). Whereas just over half of all suicides in the United States are with a rearm, almost three quarters of older adults who take their own lives do so with a gun (2). Because older adults

are less likely to endorse suicidal ideation or have prior histories of suicide attempts than younger people, the detection of those at imminent risk is that much more difcult. The fact that older people at elevated risk for suicide are both more likely to escape notice and more likely to die as a result of any initiated selfdestructive act has two important implications. First, concern that an older person might be suicidal requires aggressive clinical intervention to maintain their safety, assess their risk status, and intervene as indicated. Second, special emphasis should be placed on approaches that prevent development of suicidal states in later life, because once an older adult enters a suicidal crisis, death is a far more likely outcome than for a younger person in that condition.

RISK

AND PROTECTIVE FACTORS

The design of preventive interventions hinges on adequate understanding of those factors that predispose or protect from suicide. Figure 2 depicts one useful way to organize current knowledge about risk and protective factors their categorization into ve domains analogous to the ve axes of psychiatrys Diagnostic and Statistical Manual of Mental Disorders (8).

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Figure 2.

Domains of Risk for Suicide in Older Adults


Axis III physical health

Axis II personality, coping style

Elderly man with chronic back pain and anxious, neurotic personality style.

Axis V functioning

CLINICAL SYNTHESIS

Axis I psychopathology

Recently bereaved older woman, disabled and homebound by arthritis, with no social network on which to call for support.

Area of highest convergent risk Elderly widower with rigid, constricted coping, macular degeneration, and depression, learns he can no longer drive.

Axis IV social context

AXIS I:

MAJOR PSYCHIATRIC ILLNESS

Table 1 lists the results of ve case-controlled psychological autopsy studies of suicide in the second half of life (913). Results were consistent with previous uncontrolled psychological autopsy studies in demonstrating that a high proportion (80% 100%) of suicides die with a diagnosable axis I disorder (14). Mood disorders consistently showed the highest associations with suicide case status across all studies. Both major depressive disorder and other affective syndromes were associated with increased risk in this age group. In contrast, only two of ve studies found a signicant association between substance use disorders and completed suicide in these older adult samples, with similar inconsistent ndings for anxiety and schizophrenic spectrum disorders. Only one of four studies that examined the role of dementia or delirium found a signicant associationan apparent protective effect. This unintuitive nding may represent an artifact of the retrospective psychological autopsy method. Individuals with dementia may be at greatest risk for suicide early in the course of the illness when affective symptoms are most common,

but before formal diagnosis is likely to be made and when family members and other informants are unaware of its presence. At later stages of dementia when diagnosis is more easily established, higher levels of supervision and difculty planning and carrying out a suicidal act may explain lower relative risk. Neuropathology studies of Alzheimers-type changes in postmortem brains of suicides and controls have yielded mixed results (15, 16). While other axis I psychiatric illnesses likely play a role in late life suicide, affective disorders are the most prominent factor, associated with far higher odds ratios than any other putative risk factor.

AXIS II:

PERSONALITY AND COPING

Based on the Five-Factor Model of personality, traits of high neuroticism (the tendency to experience negative affect) and low openness to experience (preferring the familiar to the novel, blunted affective and hedonic responses) were associated in one retrospective casecontrolled study of suicide in later life (17). A separate study found that anankastic (obsessional) and anxious traits were also associated with late life suicide (9).

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Table 1. Odds Ratios for Suicide by Axis I Diagnosis in Case-Controlled Psychological Autopsy Studies of Older Adults Odds Ratios Any Any Major Substance SchizoAxis I Mood Depressive Use Anxiety phrenic Dementia/ Suicides Controls Age Suicides Controls Diagnosis Disorder Episode Disorder Disorder Spectrum Delirium Number of Cases Gender (M/F)
54 53a 85 70 86 54 269 153 100 86 $ 60 $ 55 $ 65 $ 60 $ 50 n/a 27/26 46/39 32/38 63/23 n/a n/a 84/69 43/57 63/23 43.9 113.1 50.0 44.6 4.0 184.6 63.1 59.2 47.7 28.6 36.3 12.2 n.s. 4.4 43.1 n.s. n.s. 3.6 n.s. 5.9 n.s. 10.7 .1 n.s. 0.2 n.s. n.s. n.s.

Study
Harwood et al., 2001 (9) Beautrais, 2002 (10) Waern et al., 2002 (11) Chiu et al., 2004 (12) Conwell et al., 2009 (13)
a

Included both suicides and medically serious suicide attempts.

AXIS III:

PHYSICAL HEALTH

A variety of physical illnesses have also been shown in both retrospective psychological autopsy and record linkage studies to be associated with suicide (1820). Specic illnesses most frequently identied as risk factors include malignancies and central nervous system disorders (e.g., epilepsy, spinal cord injury, Huntingtons disease), chronic obstructive pulmonary disease, congestive heart failure, and chronic pain. The impact of physical illness may be cumulative. In a retrospective case-control study of late-life suicide, Juurlink and colleagues showed that the relative risk of suicide increased with the number of comorbid physical disorders (19). Compared with patients with no identied illness, for example, patients with three illnesses had over three times higher relative risk of suicide (odds ratio=3.5, 95% CI=2.94.2); patients with ve illnesses were at almost six times greater risk (odds ratio=5.7, 95% CI=4.47.4).

more common in the lives of older adult suicides than in matched, living comparison samples. Social connectedness appears also to serve as a protective factor. Individuals who report a strong family connection are less likely to report suicide ideation (24). In other retrospective studies older adult suicides were signicantly less likely to have a condante than controls (25), more likely to live alone than their peers in the community (26), and less likely to participate in community activities (23), be active in organizations, or have a hobby (21).

AXIS V:

FUNCTIONAL IMPAIRMENT

AXIS IV:

SOCIAL CONTEXT

Studies comparing older adults who took their own lives with matched controls show that social factors determine suicide risk independent of psychiatric illness. In addition to losses common in older adulthood (e.g., bereavement, retirement, and disability), stressors that lead to social disconnectedness are particularly salient. Beautrais reported that serious relationship problems distinguished older adults with near fatal suicide attempts from controls in New Zealand (10), and in both Sweden (21) and the U.S (22, 23), family discord was signicantly

Because physical illness and functional limitations are the norm in older people, assessment of functional capacity and any resulting disablement is a necessary component of comprehensive geriatric assessment. Evidence now shows that functional limitations and disablement make substantial independent contributions to suicide risk in older people, and therefore represent potential targets for preventive interventions. In their case-controlled study of suicide in later life, Waern and colleagues reported a signicant association between suicide and need for help with activities of daily living in those over age 75 years (27). Tsoh and colleagues found that older adults who had attempted or completed suicide had greater functional impairment than nonsuicidal older adult controls (28), and our group has reported that decits in instrumental activities of daily living signicantly differentiated suicides from controls, even after accounting for presence of psychiatric disorders (13). Hospitalization for medical or surgical reasons as

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well as use of visiting nurse or home health aide services increased risk as well. Findings of Dombrovski and colleagues highlight more specically the role of neurocognitive decits in late life suicidal behavior as well (29). They have reported impaired reward/punishment learning in older adult suicide attempters, but not ideators, positing that older adults who attempt suicide over-emphasize present reward/punishment contingencies to the exclusion of past experiences. More research is clearly needed that links studies of brain structure and functioning, using rened measures of discrete cognitive processes and carefully characterized samples of older adults with and without suicidal behavior.

OTHER
Given that such a high proportion of older adults who die by suicide used a rearm, it is important to know whether access to guns is itself a risk factor. We compared gun ownership and storage among matched samples of older adults who killed themselves and living controls (30). Suicides were signicantly more likely to have a handgun in the home; easy access to long guns did not distinguish the groups. Access to and familiarity with rearms has been postulated to explain the increased risk for suicide observed among veterans of the armed forces at all ages (31). The elevated risk associated with veteran status is particularly pertinent to suicide prevention in later life because two thirds of men over age 65 have served in the military (32). One nal point warrants emphasis for clinical practice. Research that specically examines the impact on suicide risk of interaction between factors is scarce. Nonetheless, clinicians should be increasingly concerned about their older patients, not only as the number and severity of risk factors for suicide within any domain rises, but as the number of domains represented in the individuals risk assessment increases as well. Figure 2 illustrates common scenarios among older adults at the areas of interface between domains of risk. Where a larger number of domains overlap, risk is increased. Where all ve domains are represented, referred to here as the area of highest convergent risk, the likelihood of suicide is greatest.

identied and engaged in prevention activities. Older people at risk for suicide seek help from mental healthcare providers far less often than younger and middle aged cohorts. On the other hand, one-quarter to a third of older adults who took their own lives were seen in a primary care practitioners ofce within the last week of life, and a half to three-quarters within the last month (12, 33, 34). Primary care, therefore, represents one important setting in which to detect at-risk elders and intervene. Another is home health and community-based long-term care supports and services, clients of which have been shown also to have a high prevalence of mood disorders and suicidal ideation as well as physical illness burden, functional impairment, and other social stressors (3538). Given the large number of older adult men who are veterans, a group at even greater risk for suicide, Veterans Service Organizations and Veterans Health Administration facilities are likely to be important venues for prevention programming as well.

CLINICAL SYNTHESIS

PREVENTIVE

INTERVENTIONS

POINTS

OF ACCESS

In order to design effective preventive interventions, one must know not only characteristics that place older adults at risk for suicide that are amenable to change, but also where older adults with these risk characteristics can be most efciently

The Institute of Medicine classies preventive interventions into three types (39). The rst, and most familiar to clinicians, is indicated prevention, which targets individuals at high risk with detectable symptoms of major psychiatric illness and/or other proximal risk factors for suicide. The second is selective preventive interventions, which target asymptomatic or presymptomatic individuals or groups with distal risk factors for suicide, or who have a higher than average risk of developing mental disorders due to presence of more distal factors. Finally, there are universal preventive interventions that address risk in an entire population irrespective of the risk of any individual or subgroup. Multilevel preventive interventions refer to those approaches that combine components from more than one level (for example, a combination of indicated and selective interventions.) Table 2 lists published studies in which suicidal ideation or behavior in older adults was the targeted outcome. Of eight studies listed, ve are best characterized as indicated interventions (4044), one as a selective approach (45), one universal (46), and one multilevel (47). Because suicidal ideation and behavior are uncommonly expressed in later life, their study is challenging and, as a result, the evidence base for preventive interventions is limited. Further complicating interpretation of the available evidence is that relationships between suicidal ideation and behavior in later life have yet to be fully dened. For example, do wishes for an early death and thoughts of taking ones own life carry the same

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Table 2. Study
Untzer et al., 2006 (U.S.A.) (40)

Interventions Associated With Suicide Risk Reduction in Later Life


Study Design
Randomized controlled trial

Prevention Approacha
Indicated

Intervention

Participants

Age
$ 60

Outcome Assessed
Suicidal ideation

Effectb
Resolution of suicidal ideation: OR=0.7 (95% CI=0.40.8)

IMPACT: Primary care- 1801 with major based depression depression/ care management; tx dysthymia: 996 algorithms; patient, intervention, 895 family, provider controls education PROSPECT: Primary 599 with mood care-based disorders: 320 depression care intervention, 279 management; controls treatment algorithms; patient, family, provider education IPT to improve social 11 referrals from functioning + existing clinicians/medical treatment staff Antidepressant medications 372 randomized, placebo-controlled trials, with 99,231 randomized subjects with affective disorders (50%) or other psychiatric conditions (50%)

Alexopoulos Randomized et al., controlled 2009; trial Bruce et al., 2004 (U.S.A.) (41) Heisel et al., 2009 (Canada) (42) Stone et al., 2009 (U.S.A.) (43) Case series

Indicated

$ 60

Suicidal ideation

For patients with major depression, resolution of suicidal ideation at 24 months: OR=3.2 (95% CI=1.19.5) Pre/post reduction in suicidal ideation score: p=0.01

Indicated

$ 60

Suicidal ideation

Metaanalysis

Indicated

$ 18

Suicidal Decreasing risk of ideation newly emerging (or behavior suicidal ideation with [14%]) age: ,25 yrs: OR=1.62 (95% CI=0.972.71); 25 64: OR=0.79 (95% CI=0.640.98); $65: OR=0.37 (95% CI=0.180.76) Suicide Psychiatrist follow-up: men: IRR=0.3 (95% CI=0.10.7), women: IRR=0.3 (95% CI=0.20.6); GP follow-up: men: n.s., women: IRR=0.4 [0.20.6] For women, standardized mortality ratio=16.7% (2.0% 59.9%); for men: n.s. 2-year suicide rate: p=0.028; reattempt rates: p=n.s.

Oyama et al., Metaanalysis 2008 (Japan) (47)

Multilevel

Depression screening, psychoeducation workshops, referral, follow-up, treatment by psychiatry or primary care

Five quasi-experimental studies comparing regions with and without intervention. Men: 20,598 person years; women: 28,437 person years

$ 65

De Leo et al., Ecological 2002 study (Italy) (45)

Selective

24 hr. access to Men: 2,983 women: supports as needed; 15,658 weekly phone contact

$ 65

Suicide

Chan et al., Cohort study 2011 (Hong Kong) (44)

Indicated

Primary care-based gatekeeper training, referral to geropsychiatry, care management, active aftercare for suicide attempters.

351 suicide attempters received intervention (66 preintervention), all diagnoses

$ 65

Suicide and suicide attempt

Ludwig & Cook, 2000 (U.S.A.) (46)

Ecological study

Universal

Relative change in All 50 U.S. states, vital All ages Handgun handgun suicides in statistics data reports suicides states that of suicides from 1985 implemented gun through 1997 control legislation versus those with no new policy implementation.

Rate reduction per 100,000 population: 20.92 (95% CI=21.43 to 20.42) for those $ 55 years. No difference for homicide rates or overall suicide rates.

a b

Indicated: targeting high-risk individuals; selective: for individuals or groups with more distal risk factors; universal: targeting a population. OR=odds ratio; IRR=incidence rate ratio.

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risk of future suicide or suicide attempts? Who among those older persons with histories of prior suicidal behavior is most likely to take his own life? It is premature, therefore, to assume that interventions effective in addressing suicidal ideation will have the same effect on attempted or completed suicide in later life.

suicidal ideation in older adults as well. Heisel and colleagues, for example, demonstrated in a case series of suicidal older adults that thoughts of killing themselves signicantly diminished over the course of treatment with adapted interpersonal psychotherapy (IPT) (42). More denitive trials of IPT as well as cognitive behavioral therapy for high risk elders are ongoing.

STUDIES

OF INTERVENTIONS THAT TARGET SUICIDAL IDEATION

STUDIES

The PROSPECT and IMPACT studies were rigorously conducted randomized controlled trials designed to test whether primary care-based collaborative depression care management for older adults was more effective than enhanced care as usual in reducing suicidal ideation among older adults with major depression and dysthymia (48, 49). Both studies found signicantly greater improvement in depressive symptoms and suicidal ideation in those who received the care management intervention (40, 41). In neither study were there sufcient suicide attempts to examine the effectiveness of depression care management on suicidal behavior. Given the importance of primary care as a venue for suicide risk management in later life, and because integrated approaches to the management of comorbid mental illness and chronic physical disorders have been shown so effective (50, 51), the wider dissemination of primary care-based collaborative depression care management is a promising approach to addressing late-life suicide. Whether suicide deaths can actually be reduced remains to be determined. Ecological studies of medication prescribing rates and their association with suicide mortality have suggested that antidepressant administration is an effective indicated preventive intervention (5254). Interpretation of the ndings remains a subject of debate, including in older adults, however (55, 56). Stone and colleagues reported results of a large metaanalysis of Food and Drug Administration (FDA) data from 372 randomized, placebo-controlled trials of antidepressant medications (43). The data revealed a statistically greater risk that suicidal ideation would emerge in adolescents and young adults during the course of treatment with active medication than placebo. These ndings contributed to the institution by the FDA of a black box warning for the use of antidepressant medications in this age group. Less widely appreciated was the nding that among those research subjects over the age of 40, risk of suicidal ideation or behavior emerging during the drug trials was signicantly reduced. Early ndings indicate the likelihood that psychosocial interventions may be effective in reducing

OF INTERVENTIONS THAT TARGET SUICIDE AND SUICIDE ATTEMPTS

CLINICAL SYNTHESIS

Because of complex ethical and logistical constraints, no randomized controlled trials have yet been reported in which the outcome was attempted or completed suicide. Four trials listed in Table 2, however, provide some indication of potential effect of selective, universal, and multilevel approaches tested by less rigorous methods. De Leo and colleagues, for example, reported results of the Telehelp/Tele-check intervention in which older adults at risk for adverse physical and mental health outcomes were provided telephone-based access to supportive services (45). Both on-demand and service-initiated contact by social workers with atrisk elders was associated over 11 years of intervention delivery with signicantly fewer suicides than would have been expected in a comparable population (standardized mortality ratio of 0.167). The intervention is best characterized as a selective approach because it targeted a group with risk characteristics of functional impairment and social isolation rather than individuals at high risk. In ve separate studies Oyama and colleagues tested multilevel approaches to suicide prevention that combined varying elements of indicated, selective, and universal preventive interventions for older adults in rural Japanese villages. Components included depression screening for older adult residents, referral to either a general practitioner or mental health specialist for those who screened positive, engagement of older adults in group activities, and community-based psychoeducational sessions. Suicide rates in the intervention villages were then compared with demographically similar regions. Merging the ve studies using meta-analytic methods (47), the investigators found that when follow up was conducted by a psychiatrist, the suicide incidence rate ratios in intervention areas were signicantly reduced for both men and women. When general practitioners provided the depression care, however, the signicant effect was found only for older female participants. Interestingly, more detailed analysis of the Tele-help/ Tele-check intervention also revealed an effect only for women (45).

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Chan and colleagues reported results of an indicated preventive intervention in Hong Kong in which older adults who survived a suicide attempt were referred to a multicomponent prevention program that included psychiatric evaluation and care and ongoing care management (44). They found signicantly fewer suicides occurred during two years of program implementation than in a comparable group in the period before the program was begun. However, there was no apparent pre/ postintervention difference in reattempts. Finally, almost no data are available about the effectiveness of a purely universal preventive approach on reducing suicidal behavior in older people. A signal that universal prevention may be helpful was provided, however, by Ludwig and Cook in an analysis of ecological data associated with implementation of the Brady Handgun Violence Prevention Act of 1994 (46). They observed that in the years following implementation of the legislation there was a signicantly greater reduction in rearm suicides by people over the age of 55 years in those states that newly implemented background checks and waiting periods for gun purchase than in states in which no additional gun control regulations were required.

CONCLUSIONS
In coming decades, the size of the older adult population in the U.S. will increase dramatically. Similar changes will be observed in countries throughout the world due to increasing life expectancy and falling fertility rates. Far more work must be done in a number of areas to limit suicide-related morbidity and mortality in this vulnerable and rapidly growing population of older people. We must better understand factors that place older adults at risk for suicide, in particular through multivariate research designs that dene not only which factors and domains of factors are most potent in determining risk, but how they interact to determine risk status. We must dene with greater precision the implications for risk assessment of thoughts of death and suicide in later life. And nally, we must apply that knowledge to the design and rigorous testing of preventive interventions that incorporate the most promising approaches to late life suicide prevention at all levelsindicated, selective, and universal.

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