suicide prevention - yeates conwell

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Yeates Conwell, M.D.

Suicide and SuicidePrevention in Later Life

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 five domains: psychiatric illness (primarily mood disorders), personality and

coping style, physical illnesses, social stressors and supports, and functional impairments. Research findings 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 specifically target suicidal ideation, attempts, or

completed suicide have been conducted in this age group. Available findings 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.

INTRODUCTION

On March 14, 1932, George Eastman, the fab-ulously wealthy industrialist and philanthropist

who founded the Eastman Kodak Company, tookhis own life with a gunshot to the left chest (1). He

was 77 years old. A suicide note left on his bedsidetable said simply, Friends. My work is done. Why

wait? These last words seemed to reflect the au-tonomy and self-determination that had made Mr.Eastman so successful in life. The reality, however,

was far different. For several years Eastman had beenracked with pain from a spinal disorder. Becoming

progressively more disabled, he was required to cedecontrol of his company. Isolated from friends andstruggling to find meaning in life, Eastman becamedespondent and ended his own life.

Other than for hisriches, Eastman is typical in manyrespects of older adults who take their own lives. Withthat backdrop, the following sections provide a briefreview of the epidemiology of suicide among olderadults in the United States, current knowledge re-garding risk and protective factors, and evidence forthe most promising approaches to reducing suicide-related morbidity and mortality in later life.

THE EPIDEMIOLOGY OF SUICIDE

As depicted in Figure 1, suicide rates vary greatlyas a function of age, sex, and race (2). Women of allages and race/ethnicities tend to have lower rates ofsuicide than men, and whites have higher rates thannonwhites. For both African American and Ameri-can Indian men, the suicide rate peaks in youngadulthood followed by steady declines thereafter.

White men show a markedly different pattern inwhich rates rise to a peak at midlife, diminish some-what then escalate dramatically to a rate in the oldest-old (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 andDentistry 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 RochesterSchool of Medicine and Dentistry, 300 Crittenden Blvd., Rochester, NY 14642;e-mail: [email protected]

focus.psychiatryonline.org FOCUS Winter 2013, Vol. XI, No. 1 39

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AXIS I: MAJOR PSYCHIATRIC ILLNESS

Table 1 lists the results of five case-controlledpsychological autopsy studies of suicide in the sec-ond half of life (913). Results were consistent withprevious uncontrolled psychological autopsy stud-ies in demonstrating that a high proportion (80%100%) of suicides die with a diagnosable axis Idisorder (14). Mood disorders consistently showedthe highest associations with suicide case statusacross all studies. Both major depressive disorderand other affective syndromes were associated withincreased risk in this age group. In contrast, only

two offi

ve studies found a signifi

cant associationbetween substance use disorders and completedsuicide in these older adult samples, with similarinconsistent findings for anxiety and schizophrenicspectrum disorders. Only one of four studies thatexamined the role of dementia or delirium founda significant associationan apparent protectiveeffect. This unintuitive finding may represent anartifact of the retrospective psychological autopsymethod. Individuals with dementia may be atgreatest risk for suicide early in the course of theillness when affective symptoms are most common,

but before formal diagnosis is likely to be made andwhen family members and other informants areunaware of its presence. At later stages of dementia

when diagnosis is more easily established, higherlevels of supervision and difficulty planning andcarrying out a suicidal act may explain lower relativerisk. Neuropathology studies of Alzheimers-typechanges in postmortem brains of suicides and con-trols have yielded mixed results (15, 16).

While other axis I psychiatric illnesses likely playa role in late life suicide, affective disorders are themost prominent factor, associated with far higherodds ratios than any other putative risk factor.

AXIS II: PERSONALITY AND COPING

Based on the Five-Factor Model of personality, traitsof high neuroticism (the tendency to experience nega-tive affect) and low openness to experience (preferringthe familiar to the novel, blunted affective and hedonicresponses) were associated in one retrospective case-controlled study of suicide in later life (17). A separatestudy found that anankastic (obsessional) and anxioustraits were also associated with late life suicide (9).

Figure 2. Domains of Risk for Suicide in Older Adults

Area of highest convergent risk

Elderly widower with rigid, constrictedcoping, macular degeneration, anddepression, learns he can no longer drive.

Recently bereaved

older woman, disabledand homebound byarthritis, with no socialnetwork on which tocall for support.

Elderly man with

chronic back pain andanxious, neuroticpersonality style.

Axis V functioning

Axis III physical health

Axis IV social context

Axis I psychopathology

Axis II personality, coping style


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AXIS III: PHYSICAL HEALTH

A variety of physical illnesses have also been shownin both retrospective psychological autopsy and re-cord linkage studies to be associated with suicide(1820). Specific illnesses most frequently identi-fied as risk factors include malignancies and centralnervous system disorders (e.g., epilepsy, spinal cordinjury, Huntingtons disease), chronic obstructivepulmonary disease, congestive heart failure, andchronic pain. The impact of physical illness may be

cumulative. In a retrospective case-control study oflate-life suicide, Juurlink and colleagues showed thattherelative riskof suicideincreased with thenumberof comorbid physical disorders (19). Compared

with patients with no identified illness, for example,patients with three illnesses had over three timeshigher relative risk of suicide (odds ratio=3.5, 95%CI=2.94.2); patients with five illnesses were at al-most six times greater risk (odds ratio=5.7, 95%CI=4.47.4).

AXIS IV: SOCIAL CONTEXT

Studies comparing older adults who took theirown lives with matched controls show that socialfactors determine suicide risk independent of psy-chiatricillness.Inadditiontolossescommoninolderadulthood (e.g., bereavement, retirement, and dis-ability), stressors that lead to social disconnected-ness are particularly salient. Beautrais reported thatserious relationship problems distinguished olderadults with near fatal suicide attempts from controlsin New Zealand (10), and in both Sweden (21) andthe U.S (22, 23), family discord was significantly

more common in the lives of older adult suicidesthan in matched, living comparison samples. Socialconnectedness appears also to serve as a protectivefactor. Individuals who report a strong family con-nection are less likely to report suicide ideation (24).In other retrospective studies older adult suicides

were significantly less likely to have a confidantethan controls (25), more likely to live alone thantheir peers in the community (26), and less likely toparticipate in community activities (23), be active inorganizations, or have a hobby (21).

AXIS V: FUNCTIONAL IMPAIRMENT

Because physical illness and functional limita-tions are the norm in older people, assessment offunctional capacity and any resulting disablement isa necessary component of comprehensive geriatricassessment. Evidence now shows that functionallimitations and disablement make substantial in-dependent contributions to suicide risk in olderpeople, and therefore represent potential targets forpreventive interventions. In their case-controlled

study of suicide in later life, Waern and colleaguesreported a significant association between suicideand need for help with activities of daily living inthose over age 75 years (27). Tsoh and colleaguesfound that older adults who had attempted orcompleted suicide had greater functional impair-ment than nonsuicidal older adult controls (28),and our group has reported that deficits in in-strumental activities of daily living significantlydifferentiated suicides from controls, even after ac-counting for presence of psychiatric disorders (13).Hospitalization for medical or surgical reasons as

Table 1. Odds Ratios for Suicide by Axis I Diagnosis in Case-ControlledPsychological Autopsy Studies of Older Adults

Study

Number of Cases

Age

Gender (M/F)

Odds Ratios

Suicides Controls Suicides Controls

AnyAxis I

Diagnosis

AnyMood

Disorder

MajorDepressive

Episode

SubstanceUse

DisorderAnxiety

Disorder

Schizo-phrenic

SpectrumDementia/

Delirium

Harwood et al.,2001 (9) 54 54$

60 n/a n/a

4.0

n.s.

n.s. 0.2

Beautrais,2002 (10)

53a

269 $ 55 27/26 n/a 43.9 184.6 4.4

Waern et al.,2002 (11)

85 153 $ 65 46/39 84/69 113.1 63.1 28.6 43.1 3.6 10.7 n.s.

Chiu et al.,2004 (12)

70 100 $ 60 32/38 43/57 50.0 59.2 36.3 n.s. n.s. .1 n.s.

Conwell et al.,2009 (13)

86 86 $ 50 63/23 63/23 44.6 47.7 12.2 n.s. 5.9 n.s. n.s.

a Included both suicides and medically serious suicide attempts.

42 Winter 2013, Vol. XI, No. 1 F O C U S T H E J O U R N A L O F L I F E L O N G L E A R N I N G I N P S Y C H I A T R Y

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well as use of visiting nurse or home health aide ser-vices increased risk as well. Findings of Dombrovskiand colleagues highlight more specifically the roleof neurocognitive deficits in late life suicidal be-havior as well (29). They have reported impairedreward/punishment learning in older adult suicideattempters, but not ideators, positing that olderadults who attempt suicide over-emphasize presentreward/punishment contingencies to the exclusionof past experiences. More research is clearly neededthat links studies of brain structure and function-ing, using refined measures of discrete cognitive pro-cesses and carefully characterized samples of olderadults with and without suicidal behavior.

OTHER

Given that such a high proportion of older adultswho die by suicide used afirearm, it is important toknowwhether access togunsis itself a riskfactor. We

compared gun ownership and storage amongmatched samples of older adults who killed them-selves and living controls (30). Suicides were sig-nificantly more likely to have a handgun in thehome; easy access to long guns did not distinguishthe groups.

Access to and familiarity with firearms has beenpostulated to explain the increased risk for suicideobserved among veterans of the armed forces at allages (31). The elevated risk associated with veteranstatus is particularly pertinent to suicide preventionin later life because two thirds of men over age 65

have served in the military (32).One final point warrants emphasis for clinical

practice. Research that specifically examines the im-pact on suicide risk of interaction between factorsis scarce. Nonetheless, clinicians should be increas-ingly concerned about their older patients, not onlyas the number and severity of risk factors for sui-cide within any domain rises, but as the number ofdomains represented in the individuals risk assess-ment increases as well. Figure 2 illustrates commonscenarios among older adults at the areas of interfacebetween domains of risk. Where a larger number of

domains overlap, risk is increased. Where allfi

vedomains are represented, referred to here as the areaof highest convergent risk, the likelihood of suicideis greatest.

POINTS OF ACCESS

In order to design effective preventive inter-ventions, one must know not only characteristicsthat place older adults at risk for suicide that areamenable to change, butalso where older adultswiththese risk characteristics can be most efficiently

identified and engaged in prevention activities. Olderpeople at risk for suicide seek help from mentalhealthcare providers far less often than younger andmiddleagedcohorts.Ontheotherhand,one-quarterto a third of older adults who took their own lives

were seen in a primary care practitioners office withinthe 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 whichto detect at-risk elders and intervene. Another ishome health and community-based long-term caresupports and services, clients of which have beenshown also to have a high prevalence of mood dis-orders and suicidal ideation as well as physical illnessburden, functional impairment, and other socialstressors (3538). Given the large number of olderadult men who are veterans, a group at even greaterrisk for suicide, Veterans Service Organizations andVeterans Health Administration facilities are likelyto be important venues for prevention program-

ming as well.

PREVENTIVE INTERVENTIONS

The Institute of Medicine classifies preventiveinterventions into three types (39). The first, andmost familiar to clinicians, is indicated pre-vention, which targets individuals at high risk withdetectable symptoms of major psychiatric illnessand/or other proximal risk factors for suicide. Thesecond is selective preventive interventions, whichtarget asymptomatic or presymptomatic individuals

or groups with distal risk factors for suicide, or whohave a higher than average risk of developing mentaldisorders due to presence of more distal factors. Fi-nally, there are universal preventive interventionsthat address risk in an entire population irrespectiveof the risk of any individual or subgroup. Multilevelpreventive interventions refer to those approaches thatcombine components from more than one level (forexample, a combination of indicated and selectiveinterventions.)

Table 2 lists published studies in which suicidalideation or behavior in older adults was the targeted

outcome. Of eight studies listed,fi

ve are best char-acterized as indicated interventions (4044), one asa selective approach (45), one universal (46), andone multilevel (47). Because suicidal ideation andbehavior are uncommonly expressed in later life,their study is challenging and, as a result, the evi-dence base for preventive interventions is limited.Further complicating interpretation of the availableevidence is that relationships between suicidal ide-ation and behavior in later life have yet to be fullydefined. For example, do wishes for an early deathand thoughts of taking ones own life carry the same


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Table 2. Interventions Associated With Suicide Risk Reduction in Later Life

StudyStudy

DesignPreventionApproach

aIntervention Participants Age

OutcomeAssessed Effect

b

Untzeret al.,2006(U.S.A.)

(40)

Randomizedcontrolledtrial

Indicated IMPACT: Primary care-based depressioncare management; txalgorithms; patient,

family, providereducation

1801 with majordepression/dysthymia: 996intervention, 895

controls

$ 60 Suicidalideation

Resolution of suicidalideation: OR=0.7(95% CI=0.40.8)

Alexopouloset al.,2009;Bruceet al., 2004(U.S.A.)(41)

Randomizedcontrolledtrial

Indicated PROSPECT: Primarycare-baseddepression caremanagement;treatment algorithms;patient, family,provider education

599 with mooddisorders: 320intervention, 279controls


For patients with majordepression,resolution of suicidalideation at 24months: OR=3.2(95% CI=1.19.5)

Heisel et al.,2009(Canada)(42)

Case series Indicated IPT to improve socialfunctioning + existingtreatment

11 referrals fromclinicians/medicalstaff


Pre/post reduction insuicidal ideationscore: p=0.01

Stone et al.,2009(U.S.A.)(43)

Meta-analysis

Indicated Antidepressantmedications

372 randomized,placebo-controlledtrials, with 99,231randomized subjectswith affectivedisorders (50%) orother psychiatricconditions (50%)

$ 18 Suicidalideation(or behavior[14%])

Decreasing risk ofnewly emergingsuicidal ideation withage:,25 yrs:OR=1.62 (95%CI=0.972.71); 2564: OR=0.79 (95%CI=0.640.98);$65: OR=0.37 (95%CI=0.180.76)

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

Meta-analysis

Multilevel Depression screening,psychoeducationworkshops, referral,follow-up, treatmentby psychiatry or

primary care

Five quasi-experimentalstudies comparingregions with andwithout intervention.Men: 20,598 person

years; women:28,437 person years

$ 65 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]

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

Ecologicalstudy

Selective 24 hr. access tosupports as needed;weekly phone contact

Men: 2,983 women:15,658

$ 65 S uicide For women,standardizedmortalityratio=16.7% (2.0%59.9%); for men: n.s.

Chan et al.,2011(HongKong) (44)

Cohort study Indicated Primary care-basedgatekeeper training,referral togeropsychiatry, caremanagement, activeaftercare for suicide

attempters.

351 suicide attemptersreceived intervention(66 preintervention),all diagnoses

$ 65 Suicide andsuicideattempt

2-year suicide rate:p=0.028; reattemptrates: p=n.s.

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

Ecologicalstudy

Universal Relative change inhandgun suicides instates thatimplemented guncontrol legislationversus those with nonew policyimplementation.

All 50 U.S. states, vitalstatistics data reportsof suicides from 1985through 1997

All ages Handgunsuicides

Rate reduction per100,000 population:20.92 (95%CI=21.43 to20.42)for those$ 55 years.No difference forhomicide rates oroverall suicide rates.

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


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risk of future suicide or suicide attempts? Whoamong those older persons with histories of priorsuicidal behavior is most likely to take his own life?It is premature, therefore, to assume that inter-ventions effective in addressing suicidal ideation willhave the same effect on attempted or completedsuicide in later life.

STUDIES OF INTERVENTIONS THAT TARGET SUICIDAL

IDEATION

The PROSPECT and IMPACT studies wererigorously conducted randomized controlled trialsdesigned to test whether primary care-based col-laborative depression care management for olderadultswasmoreeffectivethanenhancedcareasusualin reducing suicidal ideation among older adults

with major depression and dysthymia (48, 49). Bothstudies found significantly greater improvement indepressive symptoms and suicidal ideation in those

who received the care management intervention(40, 41). In neither study were there sufficient sui-cide attempts to examine the effectiveness of de-pression care management on suicidal behavior.Given the importance of primary care as a venuefor suicide risk management in later life, and be-cause integrated approaches to the managementof comorbid mental illness and chronic physicaldisorders have been shown so effective (50, 51), the

wider dissemination of primary care-based collab-orative depression care management is a promisingapproach to addressing late-life suicide. Whether

suicide deaths can actually be reduced remains to bedetermined.

Ecological studies of medication prescribing ratesand their association with suicide mortality havesuggested that antidepressant administration is aneffective indicated preventive intervention (5254).Interpretation of the findings remains a subject ofdebate, including in older adults, however (55, 56).Stone and colleagues reported results of a large meta-analysis of Food and Drug Administration (FDA)data from 372 randomized, placebo-controlled trialsof antidepressant medications (43). The data revealed

a statistically greater risk that suicidal ideation wouldemerge in adolescents and young adults during thecourse of treatment with active medication thanplacebo. Thesefindings contributed to theinstitutionby the FDA of ablack box warning for the use ofantidepressant medications in this age group. Less

widely appreciated was the finding that among thoseresearch subjects over the age of 40, risk of suicidalideation or behavior emerging during the drug trials

was significantly reduced.Early findings indicate the likelihood that psy-

chosocial interventions may be effective in reducing

suicidal ideation in older adults as well. Heisel andcolleagues, forexample,demonstratedin a case seriesof suicidal older adults that thoughts of killingthemselves significantly diminished over the courseof treatment with adapted interpersonal psycho-therapy (IPT) (42). More definitive trials of IPT as

well as cognitive behavioral therapy for high riskelders are ongoing.

STUDIES OF INTERVENTIONS THAT TARGET SUICIDEAND SUICIDE ATTEMPTS

Because of complex ethical and logistical con-straints, no randomized controlled trials have yetbeen reported in which the outcome was attemptedor completed suicide. Four trials listed in Table 2,however, provide some indication of potential effectof selective, universal, and multilevel approachestested by less rigorous methods. De Leo and col-leagues, for example, reported results of the Tele-

help/Tele-check intervention in which older adultsat risk for adverse physical and mental health out-comes were provided telephone-based access tosupportive services (45). Both on-demand andservice-initiated contact by social workers with at-risk elders was associated over 11 years of inter-vention delivery with significantly fewer suicidesthan would have been expected in a comparablepopulation (standardized mortality ratio of 0.167).The intervention is best characterized as a selectiveapproach because it targeted a group with risk char-acteristics of functional impairment and social iso-

lation rather than individuals at high risk.In five separate studies Oyama and colleagues

tested multilevel approaches to suicide preventionthat combined varying elements of indicated, se-lective, and universal preventive interventions forolder adults in rural Japanese villages. Componentsincluded depression screening for older adult resi-dents, referral to either a general practitioner ormental health specialist for those who screenedpositive, engagement of older adults in group ac-tivities, and community-based psychoeducationalsessions. Suicide rates in the intervention villages

were then compared with demographically similarregions. Merging thefive studies using meta-analyticmethods (47), the investigators found that whenfollow up was conducted by a psychiatrist, the sui-cide incidence rate ratios in intervention areas weresignificantly reduced for both men and women.

When general practitioners provided the de-pression care, however, the significant effect wasfound only for older female participants. Inter-estingly, more detailed analysis of the Tele-help/Tele-check intervention also revealed an effect onlyfor women (45).


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Chan and colleagues reported results of an in-dicated preventive intervention in Hong Kong in

which older adults who survived a suicide attemptwere referred to a multicomponent preventionprogram that included psychiatric evaluation andcare and ongoing care management (44). Theyfound significantly fewer suicides occurred duringtwo years of program implementation than in acomparable group in the periodbefore the program

was begun. However, there was no apparent pre/postintervention difference in reattempts.

Finally, almost no data are available about theeffectiveness of a purely universal preventive ap-proachonreducingsuicidalbehaviorinolderpeople.

A signal that universal prevention may be helpfulwas provided, however, by Ludwig and Cook in ananalysis of ecological data associated with implement-ation of the Brady Handgun Violence Prevention Actof 1994 (46). They observed that in the years fol-lowing implementation of the legislation there was

a significantly greater reduction in firearm suicidesby people over the age of 55 years in those states thatnewly implemented background checks and waitingperiods for gun purchase than in states in which noadditional gun control regulations were required.

CONCLUSIONS

In coming decades, the size of the older adultpopulation in the U.S. will increase dramatically.Similar changes will be observed in countriesthroughout the world due to increasing life expec-tancy and falling fertility rates. Far more work mustbe done in a number of areas to limit suicide-relatedmorbidity and mortality in this vulnerable and rap-idly growing population of older people. We mustbetter understand factors that place older adults atrisk for suicide, in particular through multivariateresearch designs that define not only which factorsand domains of factors are most potent in deter-mining risk, but how they interact to determine riskstatus. We must define with greater precision theimplications for risk assessment of thoughts of deathand suicide in later life. Andfinally, we must apply

that knowledge to the design and rigorous testing ofpreventive interventions that incorporate the mostpromising approaches to late life suicide preventionat all levelsindicated, selective, and universal.

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