Risk factors for suicide in later life
Introduction
In May 2001 the Office of the Surgeon General of the United States released the National Strategy for Suicide Prevention: Goals and Objectives for Action (U.S. Public Health Service 2001). The prevention of suicide in later life is a central objective of that strategy. Older adults are at higher risk for suicide than any other age group. They are also the fastest growing segment of the population. Individuals born in the post-World War II “baby boom” have carried with them substantially higher suicide rates than preceding or subsequent birth cohorts (Blazer et al 1986). As large numbers of this high-risk cohort enter later life in coming decades, therefore, the absolute number of seniors who take their own lives may rise dramatically (Haas and Hendin 1983). We must be prepared to intervene.
The design of effective suicide prevention strategies hinges on the definition and quantification of risk and protective factors for suicide in the target population of older adults. Our objective with this paper is to evaluate the strength of the evidence for whether correlates of suicide in each of three broad domains-mental health, physical health, and social factors-constitute risk factors for suicide in later life. We begin with consideration of methodological issues that pose challenges for the definition of suicide risk and protective factors in older adults. We then provide a brief overview of the prevalence of suicidal behaviors-suicidal ideation (SI), attempted suicide (AS), and completed suicide (CS)- in U.S. seniors. In the remainder of the paper we focus primarily on observed correlates of CS in later life, emphasizing the evidence derived from a recent series of retrospective, case control, psychological autopsy studies. The conclusion to which they lead is that affective illness (its prevention, early recognition, effective diagnosis, and aggressive treatment) should be the leading target of later life suicide prevention efforts.
Section snippets
Methodologic issues
A number of methodologic issues complicate the study of suicide in later life. First, the terms used in the literature and clinical settings to describe suicidal behavior are often ill defined and loosely applied, making the interpretation and generalization of findings difficult. As well, SI, AS, CS are often conflated in discussions of suicidal behavior, leading to an inaccurate understanding of risk. Consensus on a precise typology of aggressive and self-destructive behaviors has been
Suicidal ideation
Older adults are less likely to endorse suicidal ideation than are younger subjects Gallo et al 1994, Blazer et al 1986, Duberstein et al 1999. Estimates of the prevalence of suicidal ideation in older adults vary widely. Lish and colleagues found that 7.3% of an older sample in VA primary care practices had suicidal ideation, with rates seven times higher in patients with a history of mental health treatment (Lish et al 1996). Using a more stringent criterion set for suicidal ideation (within
Risk factors for suicide in older adults
In the following sections we review evidence for later life suicide risk factors in three broad domains - mental health, physical health, and social function. Each section provides a brief overview of descriptive studies that were important in the characterization of elders at risk for suicide. Our emphasis, however, is on the small number of PA studies that meet (with varying degrees of success) rigorous methodological standards for evaluating risk (Kraemer et al 1997).
Access to means
Older adults tend to use more immediately lethal methods for suicide than do younger age groups. In 1998, for example, 57% of suicides in the United States were committed with a firearm (62% of men and 39% of women) (Murphy 2000). Seventy-one percent of elderly suicide victims, however, used guns. Brent and colleagues demonstrated that the presence of a firearm in the home was a significant risk factor for suicide among adolescents regardless of whether the weapon was stored in a secure place,
Summary and implications
Demographic characteristics associated with elevated risk for suicide are better termed “fixed markers” because they are immutable (Kraemer et al 1997). These include older age, male gender, and white race. Epidemiologic studies provide strong evidence that unmarried conjugal status confers risk for suicide as well.
Table 4 lists risk factors for suicide in older adults in mental health, physical health, and social domains that are derived from statistical testing of multivariate models in
Acknowledgements
This work was supported in part by NIMH K24 MH01759 (Dr. Conwell).
Aspects of this work were presented at the conference, “Unmet Needs in Diagnosis and Treatment of Mood Disorders in Late Life,” October 9–10, 2001 in Washington, DC. The conference was sponsored by the National Depressive and Manic-Depressive Association (National DMDA) through unrestricted educational grants provided by Abbott Laboratories, AstraZeneca, Forest Laboratories, GlaxoSmithKline, Janssen Pharmaceutica, Eli Lilly and
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