Elders*

Yeates Conwell, M.D.
Professor of Psychiatry & Associate Chair for Academic Affairs
University of Rochester School of Medicine &
Co-Director, Center for the Study and Prevention of Suicide

Suicide among older people is a major public health problem here in New York and across the United States. In 2002, the suicide rate for elders (age 55 and up) was 24 % higher than the rate for New Yorkers under the age of 55.* * In coming decades it is likely to take an even greater toll on senior citizens and their families. The determined and aggressive nature of self-destructive behaviors in late life makes suicide an especially challenging problem to address. The challenge must be taken up on a variety of fronts simultaneously.

Key Trends

The Office of Mental Health's (OMH) analysis of population projections prepared from 2000 U.S. Census data identifies five major trends that will have a major impact on the mental health needs of New York elders in the next ten years. (NYSOMH: 2002)

1. Increased Racial and Ethnic Diversity. While New Yorks projected population  growth of 4.2% between 2000 and 2015, is expected to be among the lowest in the nation, significant changes will occur in the composition: the group of older New Yorkers will increase faster, up 19%, and be more diverse than any preceding old age group in terms of ethnicity, income level, education, family configurations, living arrangements and health. Minority elderly populations will increase the fastest: black, non-Hispanic (up 27%); Hispanic (up 76%); and Asian/Pacific (up over 110%).
2. Weakened Family Support Structures. The large cohort of baby boomers moving into the older population will be more likely than the preceding cohort to enter old age without spouses, and more will be childless or parents of only children. Still, more grandparents will be involved in the raising of their grandchildren, and the most significant mental health problem for this group is depression, with one in four grandparent care givers nationally experiencing a significant level of depression.
3. Major Growth in Two Important Groups. Rapid population growth of younger and older minority populations, as well as major growth in the older worker and pre-retirement populations as the baby boomers age out is expected. Cultural factors, immigration, socioeconomic status, language and literacy will need to be considered in designing responses to the mental health needs of the elderly in the future.
4. Dramatic Increases in Dementia. One of the fastest rising age groups will be those 85 and older. By 2010, the number of cases of Alzheimer's disease and other dementias will have increased by at least 25 percent. Alzheimer's disease poses an enormous burden to health service and public health resources. Also, improvements in general health and health care techniques will lengthen the survival of patients with dementia, increasing the number of severely affected patients and raising the level of morbidity among patients with dementia.
5. More Demand for Care, Less supply of Care Givers. New York's dependency ratio is changing: there are fewer care givers available for more older persons needing care. Therefore, the family, which currently provides 80% of the long-term care services, will be providing less and the "systems of care" must provide more. At the same time, we should recognize that many senior citizens are reluctant to utilize traditional mental health services which will require OMH to work with county mental health departments to increase the accessibility of mental health services in locations where the elderly reside and spend their time, especially home and congregate living situations. Accomplishing this goal will require review of regulations and reimbursement methodologies, as well as focused training of providers in such issues as the risk/treatment of suicide.(Project 2015:: OMH: 2000)

1. Conclusions

   A great deal of pre-intervention research remains to be done before we have an adequate understanding of suicide's pathogenesis in older people. Biological, psychological, and social factors all warrant rigorous study. Even as pre-intervention research continues, however, the ongoing loss of senior citizens to suicide demands that preventive interventions be designed and implemented. Indeed, major advances in the identification of modifiable risk factors are being made, and major initiatives to test the effectiveness of specific preventive interventions are underway. The recognition and optimal treatment of clinical depressive illnesses in older people, particularly in primary care settings, must remain an area of special emphasis.

   Outreach to those elders at risk in the community who avoid, or lack access to, medical care is a second important element in any comprehensive plan for late life suicide prevention. The cost-effectiveness and reproducibility of these and other strategies informed by pre-intervention research must be tested in rigorously designed randomized, controlled trials. The relatively small scale of many programs precludes their use of attempted or completed suicide as outcome measures.

   Empirically established risk factors for late life suicide should be used in those circumstances as the benchmarks against which to measure success. Opportunities should be encouraged for programs to collaborate, sharing methodology and procedures, to increase the likelihood of observing a significant impact on suicide outcomes. To facilitate that effort, a national database for suicide prevention strategies should be established to serve as a clearinghouse for information regarding program design and evaluation.

   Finally, biased attitudes towards aging, deficits in knowledge about depression and suicide on the parts of health care providers and their older patients, and systemic barriers to mental health care access make suicide prevention more difficult in this population than in younger age groups. A comprehensive approach to suicide prevention in late life, therefore, must include the creative input of health policy makers with regard to the financial, medicolegal, and organizational barriers to effective suicide prevention. It also should include education programs aimed both at health care providers as well as elderly consumers and their families. The objectives of the education programs should be to foster an appreciation of healthy aging, improve understanding of signs and symptoms of clinical depression, and to teach older people and their support systems about the risks, warning signs, and treatment responsiveness of suicidal ideation and behavior in late life.

   Reduction of late life suicides is a realistic goal. Creative partnerships of primary care providers, the mental health care sector, aging services, and other agencies and insurers will be needed to achieve it.

2. Action Steps
   1. State policy should reflect the fact that the suicide rate for elderly (>65)males is the highest for any sub-population in New York.
   2. Depression is more prevalent among elders than the general population. However, it is not a normal part of the aging process and should be treated appropriately. Validated, self-administered voluntary screening tools for depression should be routinely used with elderly patients in primary care health offices. Diagnosis and treatment of depression in elders should be aggressively pursued in the primary care practitioners office.
   3. Gatekeeper programs and telephone support (warm lines) systems should be implemented and evaluated as "indicated" preventive interventions for isolated, high-risk elders. These services should be part of a comprehensive network of offerings, including case-finding, acute response, multi-disciplinary assessments, and other support services.
   4. Elders tend to employ more lethal means of self-harm in the act of suicide. Restricting access to such means of self-harm as firearms and household poisons could save lives.
   5. Since the vast majority of elders who die by suicide have seen their health care provider within 30 days of their death, it is essential that such visits include an assessment of suicidal thoughts, intent and plans they may have.
   6. Chronic pain and debilitating physical illnesses are frequent precursors to suicide among elders. Death of a spouse, loss of companions and socialisolation are also contributing risk factors.
   7. Greater emphasis should be placed in medical, nursing and social service training on recognizing and treating depressive disorders and suicidal states in elders.
   8. Research should seek to determine whether treatments designed to mitigate hopelessness and related effects in older people are effective in lowering suicide risk.
   9. Include high-risk suicidal elders in controlled clinical trials of preventive interventions, while guaranteeing the ethical conduct of the research and the rights of the subjects themselves.
3. Prevalence

   Older people in the United States have a higher suicide rate than any other segment of the population. While the elderly constitute 12.7% of the population in 1998, they accounted for 19.0% of completed suicides (Murphy, 2000). The suicide rate for the general population was 11.3/100,000. Combined rates for men and women of all races rose through young adulthood to a high of 15.5/100,000 in the 40-44 year age group, plateaued through mid-life, and rose to a peak of 22.9/100,000 in 80-84 year olds. The increased suicide risk with aging is accounted for in large part by the strikingly high rates for white males in later life. In 1998, the group at highest risk was white males aged 85 and older, whose rate of 62.7/100,000 was almost six times the nations age-adjusted average (National Center for Health Statistics, 2001).

   In contrast, rates for women peak in mid-life and remain stable, or decline slightly, thereafter. This pattern is unlike patterns in most other countries of the world where, according to statistics reported by the World Health Organization, later life is the highest risk for both men and women (Pearson and Conwell, 1995). Suicide rates for the general population have remained relatively stable throughout the second half of the 20th century. However, rates among older people declined by up to 50% between 1930 and 1980 (McIntosh et al; 1994). Optimistic explanations offered for this decline include increased economic security for older people resulting from the implementation of Social Security and Medicare legislation (Busse, 1994) and the more widespread and effective use of antidepressant medications (Conwell, 1994). Others ascribe such variation to generational or cohort effects, a propensity to suicide that is characteristic of a group born within a specific time frame (Blazer et al., 1986; Manton et al., 1987). For example, people who entered old age before 1930 had higher rates of suicide at all points in the life course than did birth cohorts that entered late life from 1930 to 1980. If cohort effects do influence suicide rates, then the trend for lower suicide risk among older people would be expected to reverse.

   At all ages, the large postwar "baby boom" cohort has had substantially higher suicide rates than preceding generations (McIntosh, 1992). As more of these people enter later life, their suicide rates are likely to rise above those of the current elderly cohort. Perhaps presaging this trend, a recent report by the Centers for Disease Control and Prevention (CDC) found that the suicide rate for the population aged 65 and over rose 9% between 1980 and 1992 (MMWR, 1996). Rates among men and women aged 80-84 showed rises of 35% and 36% respectively. Some authors have argued that the size of the baby boom generation may work to the benefit of that cohort in later life through greater political influence and accumulated resources (McIntosh, 1992). Nonetheless, older people are the fastest growing segment of the population. Haas and Hendin (1983) projected that the number of suicides committed in later life would double by the year 2030 as a function of this demographic shift alone. There is, therefore, an urgent need for efficient and effective measures to prevent suicide in older people.

   Havens (1965) characterized suicide as "the final common pathway of diverse circumstances, of an independent network rather than an isolated cause, a knot of circumstances tightening around a single time and place." General understanding of suicide among older people is often oversimplified, ascribed to a single factor such as severe physical illness or depression. The reality is far more complex. There is no single cause for any suicide, and no two can be understood to result from exactly the same constellation of factors. As no single factor is universally causal, no single intervention will prevent all suicide deaths. The multi-determination of suicide present great challenges but also has important implications for prevention (O'Carroll, 1993).

4. Preventive Interventions

   Two general approaches to suicide prevention in late life have been identified: public health or population based strategies, and high-risk models (Lewis et al., 1997). The public health model advocates universal prevention through interventions that have a potential impact on large segments of a society. Examples include gun control legislation (Kellerman et al., 1992), detoxification of a domestic gas (Charlton et al., 1992), or restrictions on access to drugs with a low therapeutic index (Gunnell & Frankel, 1994). The high-risk model targets more highly selected populations. Among the elderly, two approaches to selective interventions in high-risk samples have been proposed: interventions in primary care settings designed to improve recognition and treatment of depressed and suicidal older patients, and community outreach to isolated elders at risk.

   Interventions in Primary Care

   The majority of older people at greatest risk for suicide already have access to health care services in which preventative intervention should be feasible. At least six studies conducted in Great Britain and the United States have demonstrated that from 43% to 76% of older people who committed suicide saw a primary care provider (PCP) within 30 days of death (Barraclough, 1971; Clark, 1991; Carney et al., 1994; Cattell & Jolley, 1995; Conwell, 1994; Miller, 1976). From 19% to 49% saw a physician within one week of their suicide. This observation is critical for prevention as it suggests a means for providing access for elders in, or immediately preceding, the development of the suicidal state.

   Depression is the most common psychopathology associated with suicide in late life, and the most prevalent mental disorder seen among older patients in primary care settings. Yet many studies in the medical and psychiatric literature have demonstrated that PCP's have difficulty recognizing treatable depression in their patients. Screening tools for depression have been validated for use in elderly primary care patients. Such measures should be used routinely in primary care offices. In addition, greater emphasis should be placed in undergraduate, graduate, and continuing medical education on recognition and effective treatment of depressive disorders and suicidal states in older people. Since older people rarely utilize mental health services, active collaborations between psychiatry and primary care in medical settings may yield optimal outcomes.

   Suicidal people are frequently excluded from treatment research because of liability concerns (Linehan, 1997). Without their participation, we lack the evidence with which to judge the interventions' efficacy and effectiveness at reducing suicidal outcomes. The ethical and medicolegal implications are profound. Nonetheless, it is important that regulatory mechanisms be devised that shield investigators from unjustified liability claims, enabling the inclusion of individuals at high risk, while at the same time guaranteeing the ethical conduct of the research and the rights of the subjects themselves.

   Community Outreach

   Although initiatives in primary care settings promise to provide access for prevention to the majority of older people at risk for suicide, a substantial minority would slip through the cracks: those without resources to pay for care, those who are homebound and physically unable to access care, and those who, out of fear and misunderstanding, choose not to seek help. For these elders, who may indeed be the most vulnerable segment of the population, outreach is required.

   Although older adults are reluctant to use crisis or "hot" lines, telephone support systems should be tested further as indicated preventive interventions for the most isolated segments of the elderly population. However, they must be embedded in a more comprehensive network that includes means for case finding, acute response, multi-disciplinary in-home assessment, and other support services. Although telephone services offer a promising means of support to isolated elders, their effectiveness as a suicide prevention measure hinges on the availability of other services.

   Coupled with education of health care providers, a public campaign should be mounted to educate older Americans and their families about the signs and symptoms of clinical depression and the risks and warning signs of suicide in late life. They should be informed of the benefits of available treatments, and dispelled of the myths that depression and suicidal ideation are a "normal" aspect of aging. This campaign should be coupled with the development of gatekeeper programs. These networks of lay people trained to recognize and refer elders who may be at risk for suicide cannot operate effectively in isolation. They must be linked to systems capable of providing a full range of social, medical, and psychiatric services.

   Benefits of Prevention

   Prevention of late-life suicide can be expected to have benefits of reduced morbidity and mortality among the surviving spouse and other loved ones. There is a great deal of evidence to suggest that prevention of suicide in older people by improved recognition and treatment of its most potent risk factor, depression, will result in a host of other "ancillary" benefits. In addition to being at greater risk of suicide, older people with depression have higher mortality from all causes. Their functioning is significantly more impaired, their quality of life is diminished, and utilization of health care resources is greatly increased.

   A range of studies have confirmed an association between depression and increased morbidity due to stroke, acute myocardial infarction, chronic obstructive pulmonary, hip fracture, Parkinson's disease, and arthritis (see review by Katz, 1996). Moreover, depression has been shown to significantly predict mortality at six month and 18 month follow-up of patients with acute myocardial infarction (Frasure-Smith et al., 1993, 1995), and to be associated with increased all-cause mortality in both the general population (Bruce et al., 1994) as well as among older people in nursing homes (Rovner et al., 1991).

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