Brenna N. Renn, PhD, Licensed Clinical Psychologist and Acting Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Washington
September was National Suicide Prevention month, lending a well-timed platform to shed light on society’s marginalization of older adults and the issue of suicide in late-life. There is a widespread and dangerous popular misconception that permeates our society that aging and despair—and even depression—go hand in hand. One of the most drastic consequences of such marginalization is the resultant isolation and feelings of burdensomeness that, when exacerbated with key risk factors, may drive suicide in older adults.
Death by suicide is a tragedy for all involved, whatever the age of the decedent. At schools and universities, philanthropies like the Jed Foundation and nonprofit organizations like the Trevor Project raise awareness of, and promote research on, the important issue of suicide among teens and young adults. For example, the Jed Foundation offers resources and consultation to assess efforts toward mental health promotion and suicide prevention on campus and identify strengths and targets for improvement. Similarly, MindWise Innovations offers Signs of Suicide, a school-based suicide prevention program that raises awareness and conducts screening in a single program and popular media such as 13 Reasons Why (a 2017 novel by Jay Asher and now a Netflix series) have sparked discussion. However, when it comes to late-life suicide, public discourse is missing the same level of conversation and attention.
Although most older adults report higher levels of well-being and greater meaning in life than their younger counterparts, late-life suicide remains a pressing public health concern. There are sobering data to support this paradox. In 2017, when the average suicide rate in the U.S. was 14.0 deaths per 100,000 individuals, the second highest rate (20.1) occurred in those 85 years or older (CDC 2019). Research estimates suggest that there are as many as 200 attempts for each completed suicide in adolescent and young adult samples, but this is drastically cut to 2-to-4 attempts for each suicide death among older adults (Conwell 2013). Suicide attempts are more likely to result in death among older adults than younger individuals, in part because older adults tend to plan more carefully, use more lethal means, and are less likely to be discovered and rescued. Their physical frailty also means they are less` likely to recover from an attempt.
Suicide in later life is a complex phenomenon that is likely driven by multiple determinants. As such, it will take a commitment across health care and social service systems to systematically improve detection and intervention to prevent suicide deaths. The following are considerations to improve suicide care and reduce the number of individuals falling through the cracks of our systems.
- Consider the role of ageism. There exists a dangerous and outdated norm that decline, deficits, or disorders are common, normal, and expected among older adults. You may have heard something to this effect when people joke about being “put out to pasture” or celebrating an “over the hill” birthday. Ageism can have an insidious role in our society and shape not just an individual’s experience but also expectations of normative aging. It can permeate health care practices and policies. At worst, it can marginalize older adults and lead patients and providers to think that thoughts of death or suicidal behavior are expected reactions to the aging process.
Grantmakers should work with their grantees and provider partners to promote a version of the aging experience that challenges simplistic notions that later life is a period of inevitable loss, decline, and pathology.
- Consider the stakeholders. Aging can be a complicated process. An individual is typically referred to as an “older adult” at the age of 65. U.S. life expectancy at the time of this writing is nearly 79 years; importantly, if one makes it to the age of 65, they are expected to live an additional 14 years or more (Kochanek et al. 2017). Longer life expectancy means that people are living with chronic conditions for a longer period, sometimes with a lifetime diagnosis of one or more psychiatric disorders. This means that many older adults receive care from primary care providers for their chronic physical conditions (e.g., diabetes, cardiovascular disease) if not also their mental health conditions (e.g. depression, anxiety).
Thus, primary care providers and staff have a key role in reducing suicide deaths through early detection. This is often done through screening for depression or routinely asking patients about thoughts of death or self-harm. However, although primary care providers are increasingly asked to screen for a variety of conditions, both physical and psychological, they often lack the capacity to offer treatment or make appropriate referrals. The Suicide Prevention Resource Center offers a suicide prevention toolkit for primary care practices, which includes both provider and patient tools and educational materials. The Zero Suicide Institute also offers expert consultation for health and behavioral health organizations that are implementing a “zero suicide” approach, which includes trainings, evidence-based practices for suicide prevention, and quality improvement efforts.
One way to lessen the strain on primary care practices is to consider other services that support older adults. This includes Area Agencies on Aging, residential care settings, adult protective services, and anyone working with homebound older adults (e.g., home meal delivery service, aka “Meals on Wheels”). In California, the Institute on Aging offers a “Friendship Line,” which is a 24-hour toll-free accredited crisis line for people aged 60 and older. They also make outreach calls to lonely adults.
- Consider the evidence base for effective treatment. The primary driver of reduced suicide deaths is early detection of risk. However, matching a suicide prevention intervention to an individual in need can be difficult because individuals at risk may be missed, and not all individuals who appear to be at risk (e.g., have depression) need a suicide prevention treatment. Moreover, aligning an individual with support appropriate to their level of risk is a nuanced clinical decision.
At this time, only a few interventions are supported by research, including structured psychotherapies, collaborative assessment and treatment planning (Jobes 2012), and “caring contacts” for military personnel (Comtois et al. 2019). Much of this research has not been extended to older adults but may provide successful templates for treatment. Because only a small proportion of older adults in need of mental health care receive adequate treatment, it is particularly important to target nontraditional linkages to care, such as integrated mental health care in other medical or aging (social) services.
For more information, the National Association of State Mental Health Program Directors wrote a technical brief in 2018 entitled, Weaving a Community Safety Net to Prevent Older Adult Suicide.
Asher, J. 13 Reasons Why. New York City, NY: Penguin Random House, 2017.
Centers for Disease Control and Prevention (CDC). “Fatal Injury Data.” 2019.
Comtois, K. A., Kerbrat, A., H., DeCou, C. R., Atkins, D. C., Majeres, J. J., Baker, J. C., & Ries, R. K. “Effect of Augmenting Standard Care for Militiary Peronnel with Brief Caring Text Messages for Suicide Prevention: A Ranodmized Clincal Trial.” JAMA Psychiatry. 76, 5 (2019): 474-483.
Conwell, Y. “Suicide and Suicide Prevention in Later Life.” Focus. 11, 1 (2013): 39-47.
Jobes, D. A. “The Collaborative Assessment and Management of Suicidality (CAMS): An Evolving Evidence-Based Clinical Approach to Suicidal Risk.” Suicide and Life-Threatening Behavior. 42, 6 (2012): 640-653.
Kochanek, K. D., Murphy, S. L., Xu, J., & Arias, E. Mortality in the United States, 2016. NCHS Data Brief No. 293, 2017.