Suicide in older adults

Dying in the age of choice

Due to the unprecedented increase in the United States aging demographics, many more people are living longer and reaching older ages than ever before. However, a longer life is not necessarily a better life, as the vast majority will face a period of prolonged deteriorating health prior to death. Although notable efforts have been underway that are designed to improve the end-of-life experience, increasing numbers of individuals express a desire and/or act upon an intent to end their lives precipitously. Though still limited, the options to actively participate in their own deaths are growing. Requests for a hastened death can occur among people of all ages and includes those with advanced illness as well as others wanting to die due to unbearable suffering. This article provides an overview of the ongoing discourse about the experience of dying faced by many older adults, including aspects frequently associated with "a good death." The limitations of established practices which seek to provide a "better" dying experience are identified followed by discussion of the growing availability of alternative options. Reflective considerations are presented to guide practice vis-à-vis the changing landscape surrounding options in dying.

Associations between anxiety disorders, suicide ideation, and age in nationally representative samples of Canadian and American adults

Suicidal behaviors are of significant concern for the individuals displaying such behavior and for service providers who encounter them. Using nationally representative samples of Canadian and American adults, we aimed to examine: whether age moderates the relationship between having any anxiety disorder and suicide ideation (SI), the prevalence of SI among younger and older adults, and whether age and individual anxiety disorders were differentially associated with SI. Age moderated the relationship between any anxiety disorder and SI among Americans only. Past-year SI was less prevalent among older, compared to younger, adults; though, nearly every anxiety disorder was associated with increased odds of SI among younger and older Canadian and American adults after controlling for covariates. Effect sizes were particularly large for older American adults, but were coupled with large confidence intervals. Findings contribute to a growing literature suggesting that SI in the context of anxiety is a highly prevalent and complex mental health problem across the adult lifespan.

Suicide risk in long-term care facilities: a systematic review

OBJECTIVE

Suicide risk is highest in later life; however, little is known about the risk of suicide among older adults in long-term care facilities (e.g., nursing homes and assisted living facilities). The goal of this paper is to review and synthesize the descriptive and analytic epidemiology of suicide in long-term care settings over the past 25 years.

METHODS

Four databases (PubMed, CINAHL Plus, Web of Knowledge, and EBSCOHost Academic Search Complete) were searched for empirical studies of suicide risk in nursing homes, assisted living, and other residential facilities from 1985 to 2013. Of the 4073 unique research articles identified, 37 were selected for inclusion in this review.

RESULTS

Of the included reports, 21 were cross-sectional, 8 cohort, 3 qualitative, and 5 intervention studies. Most studies indicate that suicidal thoughts (active and passive) are common among residents (prevalence in the past month: 5-33%), although completed suicide is rare. Correlates of suicidal thoughts among long-term care residents include depression, social isolation, loneliness, and functional decline. Most studies examined only individual-level correlates of suicide, although there is suggestive evidence that organizational characteristics (e.g., bed size and staffing) may also be relevant.

CONCLUSIONS

Existing research on suicide risk in long-term care facilities is limited but suggests that this is an important issue for clinicians and medical directors to be aware of and address. Research is needed on suicide risk in assisted living and other non-nursing home residential settings, as well as the potential role of organizational characteristics on emotional well-being for residents.

Suicide in older adults: the role of emotions and cognition

Suicide in older adults is a significant clinical concern. In this review of recent findings, we concentrate on the role of emotions and cognition in suicide risk and behavior in older adults. We discuss the epidemiology of suicide in older adults, integrate recent findings on non-psychotic major depression, schizophrenia and suicidal ideation, explore the relationship of emotion regulation with suicide, present recent advances on suicide in demented patients, and describe the latest developments on cognition and decision processes in suicide.

Shards of sorrow: Older men's accounts of their depression experience

The experience of depression is diverse based on social locations and context. A sociological perspective building on masculinity, illness work, and the self provides a useful theoretical framework to understand how older men negotiate emotional suffering. This article examines older men's accounts of their depression experience from a social constructionist approach. This analysis is based on data from 77 in-depth interviews with depressed older men who participated in a larger mixed-method study, the Men's Health and Aging Study (MeHAS). We show how older men construct depression accounts in which they integrate biological and social factors associated with feeling a loss of control. This is experienced as a shamed masculine self given their inability to perform manhood acts, which leads them to severe social bonds. Men's accounts also shed light on how they resist the shaming of the masculine self by deploying two primary strategies: acting overtly masculine through aggressive behavior and by retracting from social interactions that may lead to feelings of shame. These strategies appear futile and they are only partially able to embrace alternative masculine values in line with roles as grandparents and older, wiser men. Depression in older men is characterized by an ongoing negotiation of limited statuses and roles given dominant conceptions of masculinity.

Suicide Prevention

Suicide is a public health problem affecting people across the lifespan. It is currently the 10th leading cause of death, with rates having remained relatively flat for the past century. This article summarizes the problem of suicide and suicidal behavior along with suicide prevention efforts in the United States. Part 1 provides an overview of the epidemiology of suicide, including groups most at risk of suicide and suicidal behavior. Part 2 provides a review of common risk factors, organized by developmental life stage. A brief discussion of the lesser well-researched area of protective factors follows. Part 3 provides an overview of suicide prevention today, including the major types of prevention strategies, their successes, including means restriction, quality improvement in behavioral services, and comprehensive programs; and limitations to date, such as a lack of evidence for impact on actual deaths or behavior, small sample sizes, and low base rates. Finally, part 4 discusses challenges and future directions with an eye toward the great many opportunities that exist for prevention.

Suicide later in life: challenges and priorities for prevention

Suicide in later life is a major public health concern in the U.S., where more than 6,000 older adults take their own lives every year. Suicide prevention in this age group is made challenging by the high lethality of older adults' suicidal behavior; few survive their first attempt to harm themselves. Research has revealed that factors in each of five domains place older adults at increased risk for suicide-psychiatric illness, personality traits and coping styles, medical illness, life stressors and social disconnectedness, and functional impairment. Little research has examined the effectiveness of interventions to reduce the toll of suicide in older adulthood. The study of strategies to decrease suicide deaths in later life should emphasize four areas. First is approaches to early detection of older people at risk through improved understanding of multi-dimensional determinants and their interactions. Second is research on the impact of general health promotion that optimizes well-being and independent functioning for older adults on suicide outcomes. Third concerns the study of approaches to the provision of mental health care that is evidence-based, accessible, affordable, acceptable, and integrated with other aspects of care. The fourth area of high priority for research is approaches to improvement of social connectedness and its impact on suicide in older adults.

Few older people in New Zealand who commit suicide receive specialist psychogeriatric services

OBJECTIVE

Suicide in older people is a growing public health concern in many parts of the world. The literature on this issue is lacking in New Zealand. The aim of this study is to ascertain whether this group is accessing specialist psychogeriatric services. A retrospective case series study of completed suicides in older people (≥65 years) during a three-year period from January 2010 to December 2012 was performed.

METHOD

An online survey detailing demographic and clinical information was completed by psychiatrists in 15 of the 20 District Health Boards in New Zealand.

RESULTS

Only about 15% of older people who committed suicide were accessing specialist psychogeriatric services and the group with the highest suicide rate (men≥85 years) did not feature in specialist services. Depression (61%) was the most common diagnosis and nearly half (35%) had had contact with specialist services within three days prior to the suicide. Over half (52%) had a history of past suicide attempt(s).

CONCLUSIONS

Older people who complete suicide are infrequently accessing specialist services. In those that do, there are questions to be answered regarding suicide prediction and prevention for this high-risk group of vulnerable individuals. More research is required targeting those not accessing specialist services, in particular the high risk group of older men. The role of general practitioner, community care, the assessment and management of depression and whether there is any access issue to specialist psychogeriatric services require elucidation.

Impaired Executive Function in Contemplated and Attempted Suicide in Late Life

OBJECTIVE: Executive deficits may play an important role in late-life suicide. Yet, current evidence in this area is inconclusive and does not indicate whether these deficits are broadly associated with suicidal ideation or are specific to suicidal behavior. This study examined global cognition and specifically executive function impairments as correlates of suicidal ideation and suicidal behavior in depressed older adults, with the goal of extending an earlier preliminary study. DESIGN: Case-control study. SETTING: University-affiliated psychiatric hospital. PARTICIPANTS: All participants were age 60+: 83 depressed suicide attempters, 43 depressed individuals having suicidal ideation with a specific plan, 54 nonsuicidal depressed participants, and 48 older adults with no history of psychiatric disorders. MEASUREMENTS: Global cognitive function was assessed with Dementia Rating Scale (DRS) and executive function with Executive Interview (EXIT). RESULTS: Both suicide attempters and suicide ideators performed worse than the two comparison groups on the EXIT, with no difference between suicide attempters and suicide ideators. On the DRS total score, as well as on Memory and Attention subscales, suicide attempters and ideators and nonsuicidal depressed subjects performed similarly and were impaired relative to nonpsychiatric control subjects. Controlling for education, substance use disorders, and medication exposure did not affect group differences in performance on either the EXIT or the DRS. CONCLUSIONS: Executive deficits, captured with a brief instrument, are associated broadly with suicidal ideation in older depressed adults but do not appear to directly facilitate suicidal behavior. Our data are consistent with the idea that different vulnerabilities may operate at different stages in the suicidal process.

Metabolic syndrome and suicidal ideation in korean based on the 2010 korean national health and nutrition examination survey

The aim of this study was to investigate the relationship between metabolic syndrome and suicidal ideation in Korean. This study was based on the 2010 Korean National Health and Nutrition Examination Survey. A questionnaire was used to measure suicidal ideation and physical examination was performed to measure waist circumference, blood pressure, fasting glucose, cholesterol and triglyceride levels. Complex samples logistic regression was performed to estimate the relationship between metabolic syndrome and suicidal ideation among adults and adolescents. Subjects with metabolic syndrome were more likely to have suicidal ideation in adult. There would be essential needs to evaluate suicidal ideation in adult with metabolic syndrome and to follow up suicidal ideation in adolescents with metabolic syndrome.

Social support mediates loneliness and depression in elderly people

This study investigated the effect of loneliness on depression and further tested the mediating effect of social support. A total of 320 elderly persons completed the Emotional and Social Loneliness Scale, Multidimensional Scale of Perceived Social Support, and Self-Rating Depression Scale. Results revealed that loneliness and social support significantly correlated with depression. Structural Equation Modeling indicated that social support partially mediates loneliness and depression. The final model illustrated a significant path from loneliness to depression through social support. This study sheds light on the concurrent effects of loneliness and social support on depression, providing evidence on how to reduce depression among the elderly.

Suicide rates in China from 2002 to 2011: an update

PURPOSES

The aims of this study were: (1) to present the time trend of suicide rate among people aged 15 or above in China over the period 2002-2011 and (2) to examine the current profile of completed suicides during 2009-2011.

METHODS

Data on suicide rate in 2002-2011 were provided by the Chinese Ministry of Health (MOH). The trends of region-, gender-, and age-specific suicide rates were examined using Poisson regression models. The mean number of completed suicides for each cohort during 2009-2011 was calculated and a mean national suicide rate was estimated.

FINDINGS

The overall suicide rate decreased significantly over the past decade, but rates in young males and rural older adults did not reduce and in fact increased among older adults in both urban and rural areas towards the end of the study period. For 2009-2011, 44 % of all suicides occurred among those aged 65 or above and 79 % among rural residents. The estimated mean national suicide rate was 9.8 per 100,000 and was slightly higher for males than females.

CONCLUSION

The benefits of economic growth, such as higher employment and more educational opportunities for the rural population in particular, may have contributed to the reduced suicide rate in China. However, the recent rapid changes in socioeconomic conditions could have increased stress levels and resulted in more suicides, especially among the elderly. Despite the significant reduction reported here, the latest figures suggest the declining trend is reversing. It will be important to continue monitoring the situation and to examine how urbanization and economic changes affect the well-being of 1.3 billion Chinese.

Interactions between a serotonin transporter gene, life events and social support on suicidal ideation in Korean elders

INTRODUCTION

The functional polymorphism in the serotonin transporter gene linked promoter region (5-HTTLPR) may modify associations between environmental stressors and suicidality in adolescents and working-age adults. We investigated whether the 5-HTTLPR s/l polymorphism interacts with stressful life events (SLEs) and social support deficits (SSDs) on late-life suicidal ideation.

METHODS

732 Korean community residents aged 65+ were evaluated and, of 639 without suicidal ideation, 579 (90.6%) were followed two years later. Prevalence and incidence of suicidal ideation was ascertained. Information on SLEs and SSDs were gathered, and covariates included socio-demographic characteristics, depressive symptoms, cognitive function, and disability.

RESULTS

Significant interactions were observed between 5-HTTLPR genotype, SLEs and SSDs on both prevalence and incidence of suicidal ideation after adjustment for covariates. The associations of SLEs and SSDs with suicidal ideation were strengthened in combination with higher numbers of s alleles, and were only significant predictors in those with s/s genotype. A significant three-way interaction between 5-HTTLPR genotype, SLEs and SSDs was also found.

LIMITATIONS

The generalizability of suicidal ideation as a marker of suicidality should be considered.

CONCLUSIONS

Gene-environment interactions on suicidal behavior are therefore identifiable even in old age.

Protective factors against suicide among young-old Chinese outpatients

BACKGROUND

Suicide is common among the elderly worldwide. However, no literature could be found on the beliefs/expectations that protect young-old people from attempting suicide. The purpose of this study was to explore young-old outpatients' reasons for not killing themselves in Taiwan.

METHOD

Data for this qualitative descriptive study were extracted from a large research series. From the 83 elderly outpatients in the original sample, 31 were chosen for this study because they were young-old (65-74 years old) and from two randomly selected medical centers in northern Taiwan. Data on participants' reasons for not killing themselves in unhappy situations were collected in individual interviews using a semi-structured guide and analyzed by content analysis.

RESULTS

Analysis of interview data identified six major themes: satisfied with one's life, suicide cannot resolve problems, fear of humiliating one's children, religious beliefs, never thought about suicide, and living in harmony with nature.

CONCLUSION

These identified protective factors (reasons for living) could be added to suicide-prevention programs for the elderly. Our findings may also serve as a reference for geriatric researchers in western countries with increasing numbers of elderly ethnic minority immigrants.

A controlled study of suicide in middle-aged and older people: personality traits, age, and psychiatric disorders

Personality traits were examined using the NEO Five-Factor Inventory-Revised in an Australian psychological autopsy study involving 259 suicide deaths and 181 sudden death controls aged 35 years and over. Interviews included the Structured Clinical Interview for DSM-IV to determine the presence of psychiatric disorder. Personality traits of suicide deaths differed significantly from those of controls, scoring higher in the Neuroticism and Openness to Experience domains and lower on the Agreeableness and Extraversion domains. These findings varied with the presence of psychiatric disorder and by age. High Neuroticism scores were the most consistent finding in people who died by suicide, although these scores decreased in older suicides.

Psychotherapies for Late-Life Depression

Late-life depression often occurs in the context of cognitive impairment, medical burden, and disability. For this reason, the assessment of depressed older adults consists of detailed psychiatric history and mental status examination and focuses on their broader clinical context and their ecosystem. This article outlines assessment procedures and the principles of therapies developed to utilize their assets and address limitations imposed by their clinical problems and their behavioral consequences.

Path analysis of suicide ideation in older people

BACKGROUND

Suicide among older people is one of the most rapidly emerging healthcare issues. The objective of this study was to identify the factors associated with suicide ideation in the aged population in South Korea.

METHODS

The study recruited 684 subjects older than 65 years old (males = 147, females = 537, mean age = 78.20±7.02 years), and trained interviewers performed the interviews. The study was performed as part of a community mental health suicide prevention program. The subjects' socio-demographic data, physical health, alcohol problems, social relationships, psychological well-being, and depression severity were all considered. The Korean version of the Beck Scale for Suicide Ideation (K-BSI) was used to evaluate the intensity of suicide ideation. Correlation and hierarchical multiple regression analyses were performed to identify the factors associated with the K-BSI. The study results were tested using a path analysis.

RESULTS

Depression severity was positively correlated with suicide ideation, and economic status, psychological well-being, and social relationships were negatively correlated with suicide ideation. Depression severity had the largest direct impact, and economic status and social relationships had indirect impacts on suicide ideation. Psychological well-being exerted both direct and indirect influences.

CONCLUSION

Depression severity was the most important predictor of suicide ideation among older people. Other direct and indirect factors played secondary roles. Effective suicide prevention strategies should focus on early detection and active intervention for depression. Socio-economic programs may also indirectly reduce suicide ideation among the aged population.

Normal Aging or Depression? A Qualitative Study on the Differences Between Subsyndromal Depression and Depression in Very Old People

PURPOSE OF THE STUDY

The aim of this study was to make a qualitative comparison of experiences of being in very old people with subsyndromal depression (SSD), in relation to the experiences of very old people with syndromal depression or nondepression. Through investigation and deeper understanding of the interface between depressive disease and normal aging, clinicians might give more accurate prevention or treatment to those very old persons who need such help.

DESIGN AND METHODS

Semistructured qualitative interviews were conducted for 27 individuals of 87-88 years of age, who were categorized in the 3 strata of nondepressive, SSD, and syndromal depression. Transcripts were analyzed using qualitative content analysis within each stratum and later with a comparison between the strata.

RESULTS

The content analysis resulted in 4 themes in people with SSD, as defined by a self-report depression screening instrument, giving a comprehensive picture of SSD in very old people, and also showed qualitative differences between the SSD, syndromal depression, and nondepressive groups. A main finding was that SSD differs qualitatively from syndromal depression but not clearly from nondepression.

IMPLICATIONS

The results might indicate that SSD in very old people is not related to pathology but to normal aging, even though the condition correlates with negative health parameters. Overlooking certain psychosocial aspects of living in the very old may pose a risk of both underdiagnosis and overdiagnosis in the spectrum of depressive disorders.

Functional disability and death wishes in older Europeans: results from the EURODEP concerted action

PURPOSE

Physical illness has been shown to be a risk factor for suicidal behaviour in older adults. The association between functional disability and suicidal behaviour in older adults is less clear. The aim of this study was to examine the relationship between functional disability and death wishes in late life.

METHODS

Data from 11 population studies on depression in persons aged 65 and above were pooled, yielding a total of 15,890 respondents. Level of functional disability was trichotomised (no, intermediate, high). A person was considered to have death wishes if the death wish/suicidal ideation item of the EURO-D scale was endorsed. Odds ratios for death wishes associated with functional disability were calculated in a multilevel logistic regression model.

RESULTS

In total, 5 % of the men and 7 % of the women reported death wishes. Both intermediate (OR 1.89, 95 % CI 1.42; 2.52) and high functional disability (OR 3.22, 95 % CI 2.34; 4.42) were associated with death wishes. No sex differences could be shown. Results remained after adding depressive symptoms to the model.

CONCLUSIONS

Functional disability was independently associated with death wishes in older adults. Results can help inform clinicians who care for older persons with functional impairment.

Age-related concerns of male veteran callers to a suicide crisis line

In July 2007, the United States Department of Veterans Affairs (VA) partnered with the Department of Health and Human Services' Substance Abuse and Mental Health Service Administration (SAMHSA) to create the Veterans Crisis Line (VCL) in order to meet the unique needs of Veterans in distress. The current study utilized a mixed methods design to examine characteristics of male callers to the VCL. Results from qualitative analyses demonstrated that the majority of callers between April 1 and August 31, 2008 contacted the VCL with concerns related to mental health issues, suicide ideation, and substance abuse issues. Quantitative analyses demonstrated age differences associated with concerns presented by callers such that middle-aged and older callers were more likely to present with loneliness and younger callers were more likely to present with mental health concerns. The results of this study will help to inform future research designed to optimize the effectiveness of the VCL for suicide prevention in Veterans.

Characterizing suicide in Toronto: an observational study and cluster analysis

OBJECTIVE

To determine whether people who have died from suicide in a large epidemiologic sample form clusters based on demographic, clinical, and psychosocial factors.

METHOD

We conducted a coroner's chart review for 2886 people who died in Toronto, Ontario, from 1998 to 2010, and whose death was ruled as suicide by the Office of the Chief Coroner of Ontario. A cluster analysis using known suicide risk factors was performed to determine whether suicide deaths separate into distinct groups. Clusters were compared according to person- and suicide-specific factors.

RESULTS

Five clusters emerged. Cluster 1 had the highest proportion of females and nonviolent methods, and all had depression and a past suicide attempt. Cluster 2 had the highest proportion of people with a recent stressor and violent suicide methods, and all were married. Cluster 3 had mostly males between the ages of 20 and 64, and all had either experienced recent stressors, suffered from mental illness, or had a history of substance abuse. Cluster 4 had the youngest people and the highest proportion of deaths by jumping from height, few were married, and nearly one-half had bipolar disorder or schizophrenia. Cluster 5 had all unmarried people with no prior suicide attempts, and were the least likely to have an identified mental illness and most likely to leave a suicide note.

CONCLUSIONS

People who die from suicide assort into different patterns of demographic, clinical, and death-specific characteristics. Identifying and studying subgroups of suicides may advance our understanding of the heterogeneous nature of suicide and help to inform development of more targeted suicide prevention strategies.

Sociodemographic, psychiatric and somatic risk factors for suicide: a Swedish national cohort study

BACKGROUND

More effective prevention of suicide requires a comprehensive understanding of sociodemographic, psychiatric and somatic risk factors. Previous studies have been limited by incomplete ascertainment of these factors. We conducted the first study of this issue using sociodemographic and out-patient and in-patient health data for a national population.

METHOD

We used data from a national cohort study of 7,140,589 Swedish adults followed for 8 years for suicide mortality (2001-2008). Sociodemographic factors were identified from national census data, and psychiatric and somatic disorders were identified from all out-patient and in-patient diagnoses nationwide.

RESULTS

There were 8721 (0.12%) deaths from suicide during 2001-2008. All psychiatric disorders were strong risk factors for suicide among both women and men. Depression was the strongest risk factor, with a greater than 15-fold risk among women or men and even higher risks (up to 32-fold) within the first 3 months of diagnosis. Chronic obstructive pulmonary disease (COPD), cancer, spine disorders, asthma and stroke were significant risk factors among both women and men (1.4-2.1-fold risks) whereas diabetes and ischemic heart disease were modest risk factors only among men (1.2-1.4-fold risks). Sociodemographic risk factors included male sex, unmarried status or non-employment; and low education or income among men.

CONCLUSIONS

All psychiatric disorders, COPD, cancer, spine disorders, asthma, stroke, diabetes, ischemic heart disease and specific sociodemographic factors were independent risk factors for suicide during 8 years of follow-up. Effective prevention of suicide requires a multifaceted approach in both psychiatric and primary care settings, targeting mental disorders (especially depression), specific somatic disorders and indicators of social support.

Assessment of the person with late-life depression

This article discusses characteristic factors in the presentation of depressive disorders in persons older than age 65 years. Clinical presentation is discussed along with risk and protective factors. Detailed descriptions of tests useful for screening and diagnosis of depression in the elderly are presented. Each test is reviewed according to time to administer, sensitivity and specificity, outcomes, advantages, and disadvantages. The importance of clinical history and the diagnostic interview, as well as the role of laboratory studies and neuroimaging in the clinical evaluation are discussed.

What are the causes of late-life depression?

Although depression in old age is less common than depression in younger populations, it still affects more than 1 million community-living older adults. Depression in late life has been associated with reduced quality of life and increased mortality from both suicide and illness. Its causes are multifactorial but are prominently related to both biologic and social factors. Psychological factors, although less studied in elders, are also important in understanding its cause. In this article, multiple facets of late-life depression are reviewed, including its clinical presentation, epidemiology, and biopsychosocial causes.

Suicidal ideation in family carers of people with dementia: a pilot study

OBJECTIVE

The objective of this pilot study was to gather preliminary evidence on suicidal ideation in family carers of people with dementia.

METHODS

An online, cross-sectional survey was conducted with 120 family carers, the majority of whom were located in Australia and USA. The survey included measures of suicidality, self-efficacy, physical health, depression, hopelessness, anxiety, optimism, caregiver burden, coping strategies and social support.

RESULTS

Twenty-six percent of carers had contemplated suicide more than once in the previous year. Only half of these had ever told someone they might commit suicide and almost 30% said they were likely to attempt suicide in the future. Carers who had contemplated suicide had poorer mental health, lower self-efficacy for community support service use and greater use of dysfunctional coping strategies than those who had not. In a logistic regression, only depression predicted the presence of suicidal thoughts.

CONCLUSIONS

A significant number of people might contemplate suicide while caring for a family member with dementia. Although more research is required to confirm this finding, there are clear implications for policy and clinical practice in terms of identifying and supporting carers who are already contemplating suicide.

Suicidality among older male veterans in the United States: results from the National Health and Resilience in Veterans Study

Older men have a higher rate of suicide than the general population, but little is known about the prevalence and correlates of suicidality among older male veterans. In this study, we evaluated the prevalence, and risk and protective factors associated with current suicidal ideation (SI) and past suicide attempt (SA) in a contemporary, nationally representative sample of older male veterans. We analyzed data from 1962 male veterans aged 60 or older who participated in the National Health and Resilience Veterans Survey (NHRVS) between October and December 2011. Bivariate analyses and multivariate logistic regression were used to evaluate risk and protective factors associated with current SI and past SA in the full sample, and separately among combat and non-combat veterans. Six percent of the sample reported past 2-week SI, and combat veterans were more likely to contemplate suicide (9.2%) than non-combat (4.0%) veterans. Lifetime SA was reported by 2.6% of respondents. Major depression and physical health difficulties were the strongest risk factors for SI in combat veterans, while generalized anxiety disorder (GAD) was the strongest risk factor for SI in non-combat veterans. Posttraumatic stress disorder (PTSD) was independently associated with SI in both groups of veterans, and social connectedness was negatively related to SI in both groups. These results suggest that a significant proportion of older male veterans in the United States contemplates suicide, with higher rates of SI among combat than non-combat veterans. Interventions designed to mitigate psychological distress and physical difficulties, and to promote social connectedness may help mitigate suicidality risk in this population.

Evaluating current patterns of assessment for self-harm in emergency departments: a multicenter study

OBJECTIVES

The objective was to describe self-harm assessment practices in U.S. emergency departments (EDs) and to identify predictors of being assessed.

METHODS

This was a prospective observational cohort study of adults presenting to eight U.S. EDs. A convenience sample of adults presenting to the EDs during covered research shifts was entered into a study log. Self-harm assessment was defined as ED documentation of suicide attempt; suicidal ideation; or nonsuicidal self-injury thoughts, behaviors, or both. Institution characteristics were compared relative to percentage assessed. To identify predictive patient characteristics, multivariable generalized linear models were created controlling for weekend presentation, time of presentation, age, sex, and race and ethnicity.

RESULTS

Among 94,354 charts, self-harm assessment ranged from 3.5% to 31%, except for one outlying site at 95%. Overall, 26% were assessed (11% excluding the outlying site). Current self-harm was present in 2.7% of charts. Sites with specific self-harm assessment policies had higher assessment rates. In the complete model, adjusted risk ratios (aRR) for assessment included age ≥ 65 years (0.56, 95% confidence interval [CI] = 0.35 to 0.92) and male sex (1.17, 95% CI = 1.10 to 1.26). There was an interaction between these variables in the smaller model (excluding outlying site), with males < 65 years of age being more likely to be assessed (aRR = 1.14, 95% CI = 1.02 to 1.37).

CONCLUSIONS

Emergency department assessment of self-harm was highly variable among institutions. Presence of specific assessment policies was associated with higher assessment rates. Assessment varied based upon patient characteristics. The identification of self-harm in 2.7% of ED patients indicates that a substantial proportion of current risk of self-harm may go unidentified, particularly in certain patient groups.

[Suicide in the elderly: age-related specificities?]

Suicide in the elderly raises the question of our relationship with aging and death. Suicide rate is relatively high in this group and is significantly related to depression widely under-diagnosed in the elderly. Suicidal behaviour in the elderly has clinical specificities including high intentionality and lethality, usually little personal history of suicidal behaviour and low levels of impulsivity-aggression. Suicidal vulnerability could rely on etiopathogenic mechanisms both common and different according to age; for example, a preponderance of early developmental factors and impulsivity-aggression in adolescents and young adults vs. pathological aging in older adults, but partly similar neurocognitive deficits leading individuals not to respond adequately to their environment (itself different with age). Direct comparisons between elderly and younger subjects would be required. The article concludes with a summary of the principles of recognition and management of suicide risk.

Challenges Associated With Managing Suicide Risk in Long-Term Care Facilities

Little information about suicidal ideation and behavior in long-term care (LTC) facilities is available. Nonetheless, the implementation of the Minimum Data Set 3.0 requires that LTC facilities screen their residents for suicide risk and have protocols in place to effectively manage residents' responses. In this article, the authors briefly discuss the risk factors of suicide in the elderly and the problems that suicidal ideation and behavior pose in the LTC environment. The authors explain issues that arise when trying to manage suicide risk in the elderly LTC population with general, traditional approaches. These inherent issues make it difficult to develop an effective protocol for managing suicide risk in LTC facilities, leading the authors to propose their own framework for assessing and managing suicide risk in the LTC setting.

The Senior Connection: design and rationale of a randomized trial of peer companionship to reduce suicide risk in later life

There is a pressing public health need to find interventions that reduce suicide risk in later life. Psychiatric and physical illness, functional decline, and social factors place seniors at risk for suicide. Reflecting this body of evidence, the Centers for Disease Control and Prevention (CDC) has identified the promotion and strengthening of social connectedness, between and within the individual, family, community, and broader societal levels, as a key strategy for suicide prevention. The Senior Connection, a randomized trial of peer companionship for older adults, is described here, with an emphasis on the most novel features of the study design-grounding in a psychological theory of suicide and intervening at an early stage in the suicide risk trajectory by linking primary care patients with the Aging Services Provider Network.

Control strategies and suicidal ideation in older primary care patients with functional limitations

OBJECTIVES

Failure to adapt to limitations in control may place older adults at risk for suicidal behavior. The present study examined the relation between control strategies, depressive symptoms, and suicidal ideation in older adults with health-related limitations.

METHODS

Cross-sectional study of 50 older adult (aged 65-94) primary care patients with health-related limitations.

RESULTS

Compensatory primary control strategies characterized by seeking help from others were associated with lower levels of suicidal ideation, independent of depressive symptoms. Selective primary control strategies (e.g., persistence) were also associated with reduced suicidal ideation independent of depressive symptoms, but only when a low level of compensatory primary control strategies was endorsed. Selective secondary control strategies were associated with higher suicidal ideation, whereas compensatory secondary control strategies (e.g., goal disengagement) were unrelated in this sample after controlling for covariates.

CONCLUSIONS

Findings demonstrate that primary care patients with functional limitations who are not striving to meet their goals, either through persistence or by seeking help from others, are at elevated risk of suicidal thinking.

Factors associated with suicidal thoughts in a large community study of older adults

BACKGROUND

Thoughts about death and self-harm in old age have been commonly associated with the presence of depression, but other risk factors may also be important.

AIMS

To determine the independent association between suicidal ideation in later life and demographic, lifestyle, socioeconomic, psychiatric and medical factors.

METHOD

A cross-sectional study was conducted of a community-derived sample of 21 290 adults aged 60-101 years enrolled from Australian primary care practices. We considered that participants endorsing any of the four items of the Depressive Symptom Inventory -Suicidality Subscale were experiencing suicidal thoughts. We used standard procedures to collect demographic, lifestyle, psychosocial and clinical data. Anxiety and depressive symptoms were assessed with the Hospital Anxiety and Depression Scale.

RESULTS

The 2-week prevalence of suicidal ideation was 4.8%. Male gender, higher education, current smoking, living alone, poor social support, no religious practice, financial strain, childhood physical abuse, history of suicide in the family, past depression, current anxiety, depression or comorbid anxiety and depression, past suicide attempt, pain, poor self-perceived health and current use of antidepressants were independently associated with suicidal ideation. Poor social support was associated with a population attributable fraction of 38.0%, followed by history of depression (23.6%), concurrent anxiety and depression (19.7%), prevalent anxiety (15.1%), pain (13.7%) and no religious practice (11.4%).

CONCLUSIONS

Prevalent and past mood disorders seem to be valid targets for indicated interventions designed to reduce suicidal thoughts and behaviour. However, our data indicate that social disconnectedness and stress account for a larger proportion of cases than mood disorders. Should these associations prove to be causal, then interventions that succeeded in addressing these issues would contribute the most to reducing suicidal ideation and, possibly, suicidal behaviour in later life.

Observar, ouvir, compartilhar: trabalho de campo para autópsias psicossociais

O artigo descreve as etapas de realização do trabalho de campo da pesquisa. É possível prevenir a antecipação do fim? Suicídio de Idosos no Brasil e possibilidades de Atuação do Setor de Saúde, realizada em 10 municípios das cinco regiões do país. A amostra composta por 51 autópsias psicossociais abrangeu cinco idosos que faleceram por suicídio em nove municípios e seis em um deles. Oitenta e quatro familiares foram entrevistados. Trabalhou-se com um roteiro denominado autópsia psicossocial e com observação do contexto. Cada entrevista durou 60 minutos em média, e na maioria dos casos, houve mais de um encontro com os familiares. O estudo foi construído por meio de um processo coletivo que abrangeu compartilhamento da revisão bibliográfica, discussão do universo, das amostras, das estratégias de abordagem, dos resultados de campo e das análises empíricas. Este artigo destaca a preparação teórica, conceitual e prática dos pesquisadores; o processo de elaboração dos instrumentos para o trabalho de campo; informações sobre as fontes de dados existentes e sobre as efetivamente acessadas; apresentação de credencial institucional; entrada no contexto das famílias, dificuldades e estratégias para realização do estudo empírico; entrada e saída do campo; e impacto da pesquisa sobre os investigadores.

Analysis of the psychometric properties of the Interpersonal Needs Questionnaire (INQ) among community-dwelling older adults

OBJECTIVES

This study evaluated the structure and validity of the use of the 18-item Interpersonal Needs Questionnaire (INQ-18), a measure of thwarted belongingness (TB) and perceived burdensomeness (PB), among older adults.

METHOD

Community-dwelling older adults (N = 284; mean age = 73 years; age range = 64-96 years; 56% women) anonymously completed a questionnaire packet.

RESULTS

Principal axis factor analysis indicated that two factors should be retained. Items in the first factor reflected the concept of TB, whereas items in the second factor were consistent with the concept of PB. Both factors had medium-to-large positive correlations with hopelessness, depression, suicide ideation, and low meaning in life, providing evidence for convergent validity.

CONCLUSIONS

Findings from this study support the use of the INQ-18 among community-dwelling older adults.

A systematic review of social factors and suicidal behavior in older adulthood

Suicide in later life is a global public health problem. The aim of this review was to conduct a systematic analysis of studies with comparison groups that examined the associations between social factors and suicidal behavior (including ideation, non-fatal suicidal behavior, or deaths) among individuals aged 65 and older. Our search identified only 16 articles (across 14 independent samples) that met inclusion criteria. The limited number of studies points to the need for further research. Included studies were conducted in Canada (n = 2), Germany (n = 1), Hong Kong (n = 1), Japan (n = 1), Singapore (n = 1), Sweden (n = 2), Taiwan (n = 1), the U.K. (n = 2), and the U.S. (n = 3). The majority of the social factors examined in this review can be conceptualized as indices of positive social connectedness-the degree of positive involvement with family, friends, and social groups. Findings indicated that at least in industrialized countries, limited social connectedness is associated with suicidal ideation, non-fatal suicidal behavior, and suicide in later life. Primary prevention programs designed to enhance social connections as well as a sense of community could potentially decrease suicide risk, especially among men.

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.