Late-life Suicide Research Articles

Poster Number: NR 29 - Physical Health Problems as a Late-Life Suicide Precipitant: Examination of Coroner/Medical Examiner and Law Enforcement Reports

Poster Number: NR 29 - Physical Health Problems as a Late-Life Suicide Precipitant: Examination of Coroner/Medical Examiner and Law Enforcement Reports

Session 323 - Advances in Understanding Vulnerability to Late-Life Suicide: Clinical Implications

Session 323 - Advances in Understanding Vulnerability to Late-Life Suicide: Clinical Implications

Risk of Suicide Attempts Among Adolescents and Young Adults With Autism Spectrum Disorder: A Nationwide Longitudinal Follow-Up Study.

Previous studies reported a high prevalence of depression among patients with autism spectrum disorder (ASD) and suggested a relationship between ASD and suicidality. However, whether ASD independently increases the risk of attempted suicide regardless of depression has not been determined. Using the Taiwan National Health Insurance Research Database, 5,618 adolescents aged 12-17 years and young adults aged 18-29 years with ASD (ICD-9-CM code: 299) and 22,472 age- and sex-matched controls were enrolled between 2001 and 2009 and followed to the end of 2011. Any suicide attempt was identified during the follow-up period. Patients with ASD had a higher incidence of suicide attempts (3.9% vs 0.7%, P < .001) than did those without ASD. Both adolescents (HR = 5.79; 95% CI, 3.98-8.41) and young adults (HR = 5.38; 95% CI, 3.58-8.06) with ASD were more likely to attempt suicide in later life after adjusting for demographic data and psychiatric comorbidities. Sensitivity analyses after excluding the first year (HR = 4.52; 95% CI, 3.39-6.03) or first 3 years (HR = 3.36; 95% CI, 2.40-4.70) of observation showed consistent findings. Patients with ASD had an increased risk of suicide attempts compared with those without ASD. ASD was an independent risk factor of attempted suicide. Further studies are needed to clarify the underlying pathophysiology between ASD and suicidality and to elucidate whether prompt intervention for ASD may reduce this risk.

Physical Health Problems as a Late-Life Suicide Precipitant: Examination of Coroner/Medical Examiner and Law Enforcement Reports.

In light of high late-life suicide rates, we compared older suicide decedents with and without physical health problems as a suicide precipitant with respect to their clinical characteristics and suicide means. We also examined health-related concerns noted in summary coroner/medical examiner or law enforcement (CME/LE) reports. The National Violent Death Reporting System, 2005-2014, provided data (N = 16,924 aged 65 or older). Quantitative data were analyzed using logistic regression models with physical health problems as a suicide precipitant as the dependent variable and depressive symptoms, other precipitating/risk factors, and suicide means as the independent variables. CME/LE reports were analyzed using content analysis and descriptive statistics. Physical health problems were recorded as a suicide precipitant for 50% of the older decedents. Compared to those without, those with physical health problems as a precipitant were older and more likely to have had depressed mood (adjusted odds ratios [AOR] = 2.39, 95% confidence interval [CI] = 2.21-2.59 for men and AOR = 1.79, 95% CI = 1.50-2.14 for women), disclosed suicide intent, left a suicide note, and used a firearm as suicide means. In CME/LE reports, pain and cancer were mentioned most frequently (29% and 28%, respectively). Dementia-related functional decline, fear of becoming a burden to loved ones, refusal of nursing homes, and loss of independence were also mentioned. Study findings call for more targeted, intensive suicide prevention strategies for older adults suffering from debilitating and painful health conditions. Training health care providers and informal support systems to assess suicide risk and in evidence-based intervention plans/guidelines is needed.

A meta-analytic review on social relationships and suicidal ideation among older adults

Social relationships play an important role in mental health as well as suicidal ideation in later life. In contrast with the other well-established risk factors, despite an increasing number of related studies, no meta-analyses focusing on social relationships and late-life suicidal ideation have been published. Synthesis of data across the studies using different measurements of social relationships would allow for comparison of the effects on late-life suicidal ideation that have not been studied before. Therefore, we conducted a meta-analysis on the studies published between January 1, 2000 and November 31, 2016 extracted from 7 medical and social science databases. 31 studies with 83 estimates of Odds Ratios (“ORs”) on the associations between social relationships and late-life suicidal ideation were identified to compute effect sizes using a random-effect model. Sensitivity analyses were also performed to evaluate their heterogeneity and bias. Moderator analyses were further conducted to determine moderating factors of the associations. Eventually, across the 31 studies (203,152 participants), the overall random effect size was OR = 1.57(95% CI [1.40, 1.76]), indicating a 57% likelihood increase of suicidal ideation for elderly participants with discordant social relationships. The functional measures (OR = 1.77; 95%CI [1.48, 2.10]) of social relationships, however, were more predictive than structural measures (OR = 1.37; 95%CI [1.25, 1.51]). Among all the measures of social relationships, elderly mistreatment (OR = 2.31; 95%CI [1.81, 2.94]) had the strongest effect size, followed by perceived loneliness (OR = 2.24; 95%CI [1.73, 2.90]) and poorly perceived social support (OR = 1.59; 95% CI [1.37, 1.83]). The associations between social relationships and late-life suicidal ideation were moderated by country income levels, social-cultural context, study types, and various measurements of social relationships. More importantly, our study is the first meta-analysis to provide significant evidence for improving social relationships, especially in perceived bonds, is a promising strategy in reducing late-life suicide risks.

Late-Life Suicide in Terminal Cancer: A Rational Act or Underdiagnosed Depression?

ContextPrevious studies have reported significantly elevated standardized mortality rates in older people with cancer. Terminally ill people represent a unique group where suicide may be considered as rational. ObjectivesThe aims of this study are to compare the sociodemographic and clinical characteristics of older people with and without terminal cancer who died by suicide and analyze the suicide motives of those with terminal cancer to determine whether they represent rational suicide. MethodsThe New Zealand Coronial Services provided records of all older people (aged 65 years and older) who died by suicide between July 2007 and December 2012. Sociodemographic and clinical data were extracted from the records. Using the characteristics for defining rational suicide, we determined whether the motives in terminal cancer cases represented rational suicide. ResultsOf the 214 suicide cases, 23 (10.7%) older people were diagnosed with a terminal cancer. Univariate analysis found that older people with terminal cancer who died by suicide were less likely to have a diagnosis of depression (8.7% vs. 46.6%; P = 0.001) or previous contact with mental health services (4.5% vs. 35.0%; P = 0.004) than those without terminal cancer. About 82.6% of the terminal cancer cases had a motivational basis that would be understandable to uninvolved observers. ConclusionA high proportion of those with terminal cancer had motives suggestive of rational suicide. Future studies are needed to clarify whether the low rate of depression is secondary to underdiagnosis of depression or people with terminal cancer choosing to end their life as a rational act to alleviate suffering.

Intoxication with alcohol at the time of self-harm and pre-existing involvement with mental health services are associated with a pre-disposition to repetition of self-harming behavior in a large cohort of older New Zealanders presenting with an index episode of self-harm.

The paper on predictors of repeat self-harm and suicide by Cheung et al. (2017), which has been chosen by the editorial team as paper of the month for this issue of International Psychogeriatrics, makes a very useful contribution to the study of self-harm and suicide in late life. Of 339 individuals presenting with an index episode of self-harm to one of seven Emergency Departments (EDs) in New Zealand, close to 15% harmed themselves again within one year and for nearly one in six of these 50 people, the repeat episode was fatal. Having alcohol in the blood and already being engaged with mental health services at the time of the index episode both had some utility in predicting the occurrence of a further self-harm episode. While it is encouraging that mental health services look to have been focusing on those who turned out to be at highest risk, clinicians may need to be particularly vigilant when following up individuals who had been drinking alcohol at the time of an initial self-harm presentation. This study also emphasizes the high risk of recurrent self-harm and completed suicide in those older adults who harm themselves and survive the initial episode. It deserves to be widely cited and gives some direction for future research on interventions designed to diminish the recurrence of self-harm in those of our patients who have presented to an ED with an initial self-harm episode.

The Indirect Costs of Late-Life Depression in the United States: A Literature Review and Perspective.

Late-life depression is a leading cause of disability in older adults and is associated with significant economic burden. This article draws from the existing literature and publicly available databases to describe the relative importance of the indirect costs associated with late-life depression. The authors found that unpaid caregiver costs represent the largest component of the indirect costs of late-life depression, with the highest level of economic burden attributed to the majority of care recipients who have fewer depressive symptoms. Other indirect costs, such as productivity losses related to early retirement, reduced ability to fulfill work and family functions and diminished financial success were mostly under-appreciated in the literature. Also, mortality cost estimates provided little clarity, employing variable methodologies and revealing mixed results. With respect to late-life suicide studies, studies approximated both economic costs and savings. More rigorous efforts to evaluate the indirect costs of late-life depression would afford a better understanding of the social and economic toll of this disorder and could influence the allocation of resources for research and treatment.

Suicide in older men: The health in men cohort study (HIMS)

Suicide rates are high in later life, particularly among older men. Mood disorders are known risk factors, but the risk of suicide associated with poor physical health remains unclear. We completed a cohort study of a community representative sample of 38,170 men aged 65–85 in 1996 who were followed for up to 16years. Data on suicide attempts and completion were obtained from the Western Australia Data Linkage System, as was information about medical and mental health diagnoses. 240 (0.6%) participants had a recorded history of past suicide attempt, most commonly by poisoning (85%). Sixty-nine men died by suicide during follow up (0.3% of all deaths), most often by hanging (50.7%). Age-adjusted competing risk regression showed that past suicide attempt was not a robust predictor of future suicide completion (sub-hazard ratio, SHR=1.58, 95% CI=0.39, 6.42), but bipolar (SHR=7.82, 95% CI=3.08, 19.90), depressive disorders (SHR=2.26, 95% CI=1.14, 4.51) and the number of health systems affected by disease (SHR for 3–4 health systems=6.02, 95% CI=2.69, 13.47; SHR for ≥5 health systems=11.18, 95% CI=4.89, 25.53) were. The population fraction of suicides attributable to having 5 or more health systems affected by disease was 79% (95% CI=57%, 90%), and for any mood disorder (bipolar or depression) it was 17% (95% CI=3%, 28%). Older Australian men with multiple health morbidities have the highest risk of death by suicide, even after taking into account the presence of mood disorders. Improving the overall health of the population may be the most effective way of decreasing the rates of suicide in later life.

Understanding the Progression from Physical Illness to Suicidal Behavior: A Case Study Based on a Newly Developed Conceptual Model

ABSTRACTSuicide in older people is a significant public health issue given the aging population and increasing suicide rates with age in many parts of the world. Depression and physical illness are two factors consistently associated with suicidal behavior in older people; however, their inter-relationships are not well understood. We present here a case study based on a newly developed conceptual model illustrating the various medical, psychological, social and resilience factors involved in the progression of physical illness to suicidal behavior. This model provides a framework for clinicians to understand protective factors and address late-life suicide risk.

Deploying an Ecological Model to Stem the Rising Tide of Firearm Suicide in Older Age

ABSTRACTA central objective of the Surgeon General’s National Strategy for Suicide Prevention is to focus on older adults. We review individual risk-factors for suicide in late life and then introduce an ecological model to expand conceptualization of elder suicide. We first look at the role of firearms, providing evidence that firearm availability increases the means of elder suicide and gun access policies can contribute to reducing risk. Next, we focus on primary care providers, documenting how older adults often come into contact with these professionals before ending their lives and how these providers could take a more active role in mediating individual-level risk factors. We then turn our attention to the intersection between gun access and primary care and consider how advancing standards of care concerning gun access and suicide risk might be an effective policy alternative for blocking the pathway to suicide among older adults.

Poster Number: NR 14 - Socially ENGAGE: Pilot Trial to Demonstrate Feasibility of an Intervention for Social Engagement

Introduction: Older adults who are socially isolated—defined as those with restricted social networks and/or loneliness—are at risk for numerous suicide risk factors, including reduced quality of life, physical illness, functional impairment, cognitive impairment, and depression, as well as suicide ideation, attempts, and suicide deaths. The premise of this work is that among depressed older adults, social disconnectedness is both a risk factor for late-life suicide and a potential intervention target. Despite the negative consequences for late-life mental health, little is known about how to reduce social isolation and increase social engagement. Here, we present the rationale and feasibility results of a project testing the use of the ENGAGE intervention (Alexopoulos & Areán, 2014; Alexopoulos, Raue, Kiosses, Seirup, Banerjee, & Areán, 2014) as a means of increasing social engagement, and thereby reducing risk factors for suicide. ENGAGE is designed to work primarily through “reward exposure,” which, in line with RDoC principles (e.g., Insel, 2014), targets the behavioral expression of positive valence systems' dysfunction by having patients re-engage with pleasant, physical, or social activities they may have stopped doing because of depression. For this trial, subjects were focused solely on social activities because the hypothesis of the study is, in line with the Interpersonal Theory of Suicide (Van Orden et al., 2010), that targeting social engagement will increase positive connections and contributions to others, thus reducing two proximal risk factors for suicide—thwarted belongingness and perceived burdensomeness, thereby reducing suicide risk. We report here the experience and outcomes of the first three subjects enrolled, with the objectives of demonstrating that these older adults would complete 10 sessions, develop action plans based exclusively on social engagement, and demonstrate reductions in thwarted belongingness, depression, and suicide risk. We hypothesized that the changes in thwarted belongingness would temporally precede changes in depression and suicide risk.

More to Look in the Diabetic Patients: Depression

Suicide risk varies by age, sex, and race/ethnicity. Risk factors for suicide attempt include presence of a mental health disorder; serious adverse childhood events; family history of suicide; prejudice or discrimination associated with being lesbian, gay, bisexual, or transgender; access to lethal means; and possibly a history of being bullied, sleep disturbances, and chronic medical conditions. In men, socioeconomic factors, such as low income, occupation, and unemployment are also related to suicide risk. In older adults, additional risk factors, such as social isolation, spousal bereavement, neurosis, affective disorders, physical illness, and functional impairment, increase the risk for suicide. Risk factors of special importance to military veterans include traumatic brain injury, separation from service within the past 12 months, posttraumatic stress disorder, and other mental health conditions. Individual risk factors have only limited ability to predict suicide in an individual at any particular time. A large proportion of Americans have a risk factor for suicide; however, only a small proportion will attempt suicide, and even fewer will die from it. U.S. Prevention Services Task Force Organization. (file:///Users/vivian/Downloads/suicidesumm.pdf. 9, October 2015). Suicide in later life is a global public health problem, with those aged 65 and above constituting the demographic group with the highest suicide rate in most countries that report suicide statistics to the World Health Organization [1]. Age-group specific suicide rates have traditionally been highest

Does Recognition of Meaning in Life Confer Resiliency to Suicide Ideation Among Community-Residing Older Adults? A Longitudinal Investigation

To test a theoretical model of the onset and/or exacerbation of late-life suicide ideation, incorporating consideration of risk, resiliency, and precipitating factors. A longitudinal study investigating whether recognition of meaning in life (MIL) at baseline confers resiliency to the onset and/or exacerbation of suicide ideation over a 6- to 22-month period of follow-up, controlling for baseline depression, self-rated health, and physical functioning, and for frequency and intensity of intervening daily hassles. Mental health research offices in an urban academic health sciences center. 173 community-residing older adults (mean: 73.9 years, SD: 6.1 years, range: 65-93 years) recruited from health, wellness, and interest programs, and from newspaper ads and flyers posted in London, Ontario, a mid-sized Canadian city. A total of 126 (73%) completed follow-up assessments. Participants completed a demographics form, a cognitive screen, and measures of suicide ideation and of risk (depressive symptom severity, self-rated health problems, and physical functioning) and potential resiliency (recognition of MIL) factors at baseline and follow-up assessment points, and a measure of intervening daily hassles. MIL at baseline was negatively associated with the onset and/or exacerbation of suicide ideation over time, controlling for risk factors and intervening precipitating factors. The extent and relative significance of this finding differed with the manner in which MIL and suicide ideation were operationalized. Study findings add to a growing body of knowledge suggesting that MIL may play an important role in promoting mental health and well-being and potentially conferring resiliency to contemplations of suicide in later life.

Toward an understanding of late life suicidal behavior: the role of lifespan developmental theory

Objectives: Suicidal behavior in late life differs in important ways from suicidal behavior that occurs earlier in the lifespan, suggesting the possibility of developmental differences in the etiology of suicidal behavior. This paper examines late life suicidal behavior within the context of lifespan developmental theory.Methods: This paper presents a conceptual framework for using lifespan developmental theory to better understand late life suicidal behavior.Results: We argue that the motivational theory of lifespan development, which focuses on control, is particularly relevant to late life suicide. This theory posits that opportunities to exert control over important aspects of one's life diminish in late life as a result of declines in physical functioning and other factors, and that successful aging is associated with adaptive regulation of this developmental change. Although continued striving to meet goals is normative throughout the lifespan, most individuals also increase the use of compensatory strategies in old age or when faced with a decline in functioning. We propose that individuals who do not adapt to developmental changes by altering their strategies for exerting control will be at risk for suicidal behavior in late life. This paper reviews evidence that supports the importance of control with respect to suicidal outcomes in older adults, as well as findings regarding specific types of control strategies that may be related to suicide risk in older adults with health-related limitations.Conclusion: Although suicidal behavior is not a normal part of aging, the application of lifespan developmental theory may be useful in understanding and potentially preventing suicide among older adults.

Reasons for living, meaning in life, and suicide ideation: investigating the roles of key positive psychological factors in reducing suicide risk in community-residing older adults

Objectives: To investigate the roles of reasons for living (RFL) and meaning in life (MIL) in potentially promoting mental health and well-being and protecting against suicide ideation among community-residing older adults and to investigate the psychometric properties of the Reasons for Living Scale-Older Adult version (RFL-OA).Method: Of 173 older adults initially recruited into a longitudinal study on late-life suicide ideation, 109 completed the RFL-OA and measures of cognitive and physical functioning and positive and negative psychological factors at a two-year follow-up assessment. We tested a model in which RFL and MIL protect against suicide ideation, controlling for demographic and clinical factors. We also assessed the psychometric properties of the RFL-OA in community-residing older adults, investigating its internal consistency and its convergent (MIL, perceived social support, and life satisfaction), divergent (loneliness, depressive symptom severity, and suicide ideation), and discriminant validity (cognitive and physical functioning).Results: RFL-OA scores explained significant variance in suicide ideation, controlling for age, sex, depressive symptom severity, and loneliness. MIL explained significant unique variance in suicide ideation, controlling for these factors and RFL, and MIL significantly mediated the association between RFL and suicide ideation. Psychometric analyses indicated strong internal consistency (α = .94), convergent, divergent, and discriminant validity for the RFL-OA relative to positive and negative psychological factors and cognitive and physical functioning.Conclusion: These findings add to a growing body of literature suggesting merit in investigating positive psychological factors together with negative factors when assessing suicide risk and planning psychological services for older adults.

Investigating the psychometric properties of the Geriatric Suicide Ideation Scale (GSIS) among community-residing older adults

Objectives: To investigate the psychometric properties of the Geriatric Suicide Ideation Scale (GSIS) among community-residing older adults.Method: We recruited 173 voluntary participants, 65 years and older, into a 2+ year longitudinal study of the onset or exacerbation of depressive symptoms and suicide ideation. We assessed the internal consistency of the GSIS and its four component subscales, and its shorter and longer duration test–retest reliability, convergent (depression, social hopelessness, and loneliness), divergent (psychological well-being, life satisfaction, perceived social support, and self-rated health), discriminant (basic and instrumental activities of daily living and social desirability), criterion (history of suicide behavior), and predictive validity (future suicide ideation).Results: The GSIS demonstrated strong test–retest reliability and internal consistency. Baseline GSIS scores were significantly positively associated with suicide risk factors, negatively associated with potential resiliency factors, and not associated with functional impairment or social desirability. GSIS scores significantly differentiated between participants with as compared to those without a history of suicide behavior. Baseline GSIS scores significantly predicted suicide ideation at a 2+ year follow-up assessment.Conclusion: Findings suggest strong measurement characteristics for the GSIS with community-residing older adults, including impressive consistency over time. These results are consistent with research attesting to the empirical and pragmatic strengths of this measure. These findings have implications for the monitoring of suicide risk when aiming to enhance mental health and well-being and prevent suicide in later life.

In my end is my beginning: developmental trajectories of adverse childhood experiences to late-life suicide

Objectives: Converging evidence suggests that the sequelae of adverse childhood experiences (ACEs) including childhood abuse (e.g., sexual, physical, emotional/verbal abuse, neglect) and other ACE (e.g., family dysfunction, parental loss, parental psychopathology, substance abuse, incarceration, and domestic violence) have pronounced effects on suicidal behaviors (suicidal ideation, attempts, and death by suicide) in older age. There are fundamental changes in the developmental trajectory of biological, psychological and behavioral processes that result from ACE and that exert influence throughout the life span. Different moderators and mediators may affect the extent and nature of the relationship. However, the literature on the specific mechanisms whereby ACE affects suicidality in later life has not been well identified.Method: We review and draw from extant multidisciplinary evidence to develop a heuristic framework through which to understand how ACE may lead to suicide in later life.Results: Proposed mechanisms span biological factors (neurological, gene-environment), psychiatric and health functioning, and psychosocial development (cognitive biases, coping resources, interpersonal deficits). Evidence suggests that ACEs affect each of these constructs, and it is likely in the interaction of these constructs with late-life stressors that suicidality in older adulthood emerges.Conclusion: ACEs have persistent and multifaceted effects on suicidality in late life. This association is due to multi-varied pathways. It is believed that the explanatory framework developed herein – in which biological, psychological and behavioral factors are organized, and the role of late-life stressors is highlighted – will spark further scientific inquiry into this important area.

Issues in research on aging and suicide

Objective: Late-life suicide is a complex clinical and public health problem. Method: In this article, some of the key complexities inherent in studying late-life suicide are discussed in the service of promoting high-quality late-life suicide prevention science. Results: We discuss the following research issues: the relatively greater lethality of suicidal behavior in later life (compared to younger ages); the lack of data on whether thoughts of death in later life are indicators of suicide risk; the fact that older adults do not tend to seek specialty mental health care, necessitating moving research into primary care clinics and the community; the lack of theory-based research in late-life suicide; the unclear role of cognitive impairment; and the promise of taking a ‘patient centered’ and ‘participatory research’ approach to late-life suicide research efforts. Conclusion: We believe that these perspectives are too often not capitalized upon in research on suicide prevention with older adults and that voice of the older person could contribute much to our understanding of why older adults think about and act on suicidal thoughts, as well as the most acceptable ways to reach and intervene with those at risk.

Late-life suicide: Insight on motives and contributors derived from suicide notes

ObjectivesThe aims of this study were: (i) to investigate the proportion of older people writing suicide notes in New Zealand; (ii) to compare the socio-demographic and clinical variables of older suicide note writers and non-note writers; and (iii) to perform a thematic analysis of the content of suicide notes. MethodsThe Coronial Services provided records of all suicide cases aged 65 years and over (n=225) between July 2007 and December 2012. We were able to determine whether there was a suicide note written in 212 cases. The content of 39 coroners/medical examiners’ excerpts and 5 suicide notes was available for thematic analysis using a general inductive approach. Findings88 (41.5%) older people left a suicide note. Logistic regression showed that female gender (OR=2.8, 95% CI=1.4−5.7, p=0.005) and Caucasian ethnicity (OR=13.7, 95% CI=1.7−111.0, p=0.014) are significantly associated with older people writing suicide notes. 33.3% of those who left a suicide note gave health-related reasons for their suicide and a significant proportion (73.3%) of them had underlying medical conditions. Another common theme is around people leaving specific instructions and wishes. ConclusionsApart from gender and ethnicity, suicide note writers are similar to non-writers on broad socio-demographic and clinical factors. Suicide notes indicated free will in and reasons for their suicide and emotional/farewell messages to their loved ones. Many documented poor quality of life or physical illness but the progression of these factors to suicide in older people should be further researched.