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Aging & Mental Health

ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: http://www.tandfonline.com/loi/camh20

Issues in research on aging and suicide

Kimberly A. Van Orden & Yeates Conwell

To cite this article: Kimberly A. Van Orden & Yeates Conwell (2016) Issues in research on aging and suicide, Aging & Mental Health, 20:2, 240-251, DOI: 10.1080/13607863.2015.1065791

To link to this article: http://dx.doi.org/10.1080/13607863.2015.1065791

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Issues in research on aging and suicide

Kimberly A. Van Orden* and Yeates Conwell

Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY 14642, USA

(Received 23 February 2015; accepted 16 June 2015)

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.

Keywords: suicide; depression; quality of life/well-being

Introduction

The more one learns about late-life suicide, the clearer the

complexities become. On the whole, older adults maintain

(and even increase) emotional well-being compared to

those at younger ages (Carstensen et al., 2011). Yet, at the

same time, adults aged 70 and older have the highest rates

of suicide deaths in most regions in the world (World

Health Organization, 2014). Thus, later life is both a time

of enhanced well-being and a time of markedly increased

risk for suicide. As another example, there appear to be

not just age effects on suicide risk, but cohort effects as

well, with the Baby Boomer and later cohorts likely bring-

ing with them an elevated suicide rate as they enter a time

of heightened risk (Phillips, 2014).

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

and generating ideas and directions for future research.

We discuss the relative lethality of suicidal behavior in

later life and how that has implications for the design of

preventive intervention studies for older adults. Next, we

discuss an emerging body of literature on the nature of

thoughts of death and wishes for death in later life and

whether ‘death ideation’ is an indicator of risk for suicide

in later life; we encourage researchers to consider this

basic question in their studies on suicide risk in later life

as it could inform risk assessment and selection of inter-

vention targets. We then discuss key settings for research-

ers to address in studies of late-life suicide, including

primary care and the aging services network (ASN),

including our suggestions on what type of interventions

may be best suited for these settings. Next, we discuss the

relative lack of theory-driven research in late-life suicide

prevention studies and make a call for grounding future

research in psychological, sociological, and/or biological

theories to promote hypothesis driven studies of etiology

as well as investigation of mechanisms of effectiveness

for intervention studies. The next research issue we

address is the role of cognitive impairment, including

dementia, as well as cognitive deficits, as diatheses for

suicidal behavior in later life, and suggest future direc-

tions for clarifying the role of cognition in late-life suicide

risk. Finally, we conclude with an integration of our direc-

tions for future research with a discussion of the unifying

themes of the roles of aging research, the perspective of

patient centeredness, and the use of community participa-

tory research methods.

Lethality of late-life suicidal behavior

Suicidal behavior in older adults is more likely to result in

death than at younger ages. In the US in particular, older

men are more likely to use firearms to attempt suicide

than at younger ages (Kaplan & Geling, 1999) and are

likely to die from their attempts (Conwell, 2014). The

ratio of suicide attempts to suicide deaths is estimated to

be 10-20:1 in the general population and as high as 200:1

in adolescents (Nock et al., 2008). Among older adults,

however, there are estimated to be only 1 to 4 suicide

attempts for each death by suicide (Crosby, Cheltenham,

*Corresponding author. Email: [email protected] Present address: Kim Van Orden, PhD, Department of Psychiatry, University of Rochester Medical Center, 300 Crittenden Blvd, Box PSYCH, Rochester, NY 14642, USA

� 2015 Taylor & Francis

Aging & Mental Health, 2016

Vol. 20, No. 2, 240�251, http://dx.doi.org/10.1080/13607863.2015.1065791

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& Sacks, 1999; McIntosh, Santos, Hubbard, & Over-

holser, 1994). This disparity may be explained by the

medical illness burden of older adults making any injury

more likely to result in death; their relatively greater

social isolation, making life-saving rescue less likely; and

the suicidal person’s greater lethality of planning and

implementation (Conwell et al., 1998).

Combine this lethality with the fact that older adults

are less likely to report suicidal thoughts than individuals

at younger ages (e.g., Duberstein, et al., 1999), and the

significance of this problem looms large. To address this

issue, we, along with our colleagues and others, have

emphasized taking a public health approach to late-life

suicide prevention (Conwell, Van Orden, & Caine, 2011;

Knox, 2014). This approach emphasizes prevention across

the spectrum of interventions, not just those interventions

that target high-risk individuals, which is most often con-

sidered in the literature. The Institute of Medicine has sug-

gested the use of terminology describing preventive

interventions at three levels: indicated, selective, and uni-

versal (Institute of Medicine, 1994). Indicated interven-

tions are those that target high-risk individuals; in the case

of suicide prevention, this might include individuals with

suicidal thoughts, previous suicide attempts, or psychiat-

ric disorders. These types of interventions most often are

provided in mental health and primary care clinics. Exam-

ples include, antidepressant medications, cognitive ther-

apy for suicide attempters (Brown et al., 2005), problem

solving therapy for late-life depression (Arean et al.,

2010), and collaborative care models for late-life depres-

sion (Unutzer et al., 2002).

Selective preventive interventions are those that target

individuals or groups with more distal risk factors; in the

case of late-life suicide, this might be socially discon-

nected older adults, or those with multiple comorbid dis-

orders and significant functional impairment. These types

of interventions could be provided in many settings out-

side the mental health or primary care clinic, such as

through aging services agencies � a potential benefit given that older adults do not tend to seek specialty mental

health services. A selective preventive intervention that

provided supportive phone calls to older adults (mostly

women), called the Tele Help � Tele Check program, was found (in a quasi-experimental design) to signifi-

cantly reduce the number of suicide deaths (De Leo, Dello

Buono, & Dwyer, 2002).

Finally, universal prevention strategies target the

entire population of older adults. Examples include legis-

lation (e.g., restricting access to potentially lethal means),

or public health messaging campaigns, for instance on the

importance of social engagement for all older people.

Given the lethality of suicidal behavior in later life, we

propose that indicated preventive interventions may be

less likely to be effective at reducing suicide deaths at a

population level than at younger ages. Given that most

older adults who die by suicide will do so on their first

attempt, targeting older adults who have attempted sui-

cide, for example, will fail to prevent the deaths of the

majority of older adults at risk. We do not mean to suggest

that indicated interventions should not be provided when

an older adult presents with a suicidal crisis � in that case interventions must be highly aggressive and intensive.

Rather, we suggest that more research is needed that

examines the effectiveness of selective interventions that

target groups at risk but well before the development of

the acutely suicidal state, as intervening at this point

in the trajectory toward suicide may be ‘too late’ for

some older adults. Some studies exist, including the Tele

Help � Tele Check study described above, as well as a study we are conducting with our colleagues of the effec-

tiveness of peer companionship for socially disconnected

older adults (Van Orden et al., 2013), but more work is

needed. Finally, all forms of intervention � universal, selective, and indicated � play an important role in sui- cide prevention in later life. Indeed, the most useful pre-

vention models are likely ones that are multi-layered,

including universal, selective, and indicated components.

Thoughts of death in later life

Are thoughts of death in later life a normative response to

the nearing of the end of life, and/or the stressors and chal-

lenges of aging? Or are thoughts of death an indicator of

risk for suicide? What about wishing for death in later

life � is this an indicator of suicide risk or weariness with life that does not increase risk for suicide? These are

empirical questions that have not been fully answered. In

this section, we provide a brief overview of the scientific

literature that has begun to address the issue of thoughts

of death in later life.

Estimates of the prevalence of death ideation (i.e.,

thoughts of one’s own death or wishes for death), also

called passive suicide ideation, in later life are quite vari-

able depending on the setting, characteristics of the sam-

ple, timeframe assessed, and the measure used (for a

review, see O’Riley, Van Orden, & Conwell, 2014).

Importantly, there are definitional issues that vary across

samples: thoughts of one’s own death and wishing for

one’s death may have different relationships with suicide

risk, yet they are often included together under the

umbrella of death ideation. For community samples of

older adults, lifetime prevalence rates of passive suicide

ideation range from 18.7% (Rurup, Deeg, Poppelaars,

Kerkhof, & Onwuteaka-Philipsen, 2011) to 40.9%

(Cohen, Colemon, Yaffee, & Casimir, 2008), while preva-

lence in the past month has been estimated at 6.5%

(Ayalon & Litwin, 2009). For primary care samples, the

past year prevalence has been estimated at 27.5% (Bartels

et al., 2002) and for the past two weeks the prevalence has

been estimated as 15% (Raue et al., 2010). For depressed

older adults, estimates of past week prevalence of passive

suicide ideation range from 25% (Bruce et al., 2004) up to

58% (Britton et al., 2008).

These prevalence estimates should be interpreted in

light of several findings regarding reporting of death idea-

tion in later life. Gallo and colleagues (Gallo, Anthony, &

Muthen, 1994) examined age differences in the endorse-

ment of symptoms of depression, including thinking about

and wishing for death, using latent trait analysis, which

allowed the authors to compare younger and older adults

Aging & Mental Health 241

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on how often they endorsed the various symptoms of

depression given comparable levels of depression sever-

ity. They found that, after adjusting for gender, minority

status, cognitive functioning, employment status, marital

status, and severity of depression, older adults (those aged

65 or older) were more likely to endorse thinking about

death and wishing for their death compared to younger

adults, but were less likely to endorse depressed mood.

These findings suggest that thinking about and wishing

for death may be more frequently endorsed by older

adults, if the characteristics of the older adults are appro-

priately considered, especially adjustments for level of

depressive symptoms; this is essential given that the raw

prevalence of death ideation in this sample indicated that

death ideation was less likely to be reported by older

adults. It was only after adjusting for level of depression

severity that it was clear that older adults were more likely

to endorse passive suicide ideation. Another study found

that older age is associated with decreased likelihood of

reporting depressed mood and both passive and active sui-

cide ideation among depressed suicide attempters and

non-attempters (Duberstein et al., 1999). The authors of

this latter paper suggest that older adults may be more

likely to escape detection in terms of their suicide risk

because of this lower rate of reporting thoughts of suicide.

However, depression severity was not accounted for in

their analyses, and doing so could possibly have changed

their findings. Together, these papers indicate that the

‘true’ prevalence of passive suicide ideation among older

adults is difficult to estimate. Older adults with compara-

ble levels of depression are less likely to endorse feelings

of depressed mood but more likely to endorse passive sui-

cide ideation than younger adults � a finding that only emerges when estimating the ‘true’ level of depression

severity using a latent trait model. Passive suicide ideation

may be more common in later life; does this mean, how-

ever, that it is normative for older adults to wish for death?

Several studies suggest that this may not be the case.

Szanto and colleagues (1996) found that among older

adults with recurrent major depression, those who

endorsed passive suicide ideation were very similar in

their clinical presentations to older adults who endorsed

active suicide ideation, and that over time, older adults

very often switched from passive to active suicide idea-

tion and vice versa during depressive episodes. These data

suggest that among depressed older adults passive and

active suicide ideation in later life may represent similar

levels of suicide risk. In line with this hypothesis, the

Geriatric Suicide Ideation Scale includes a ‘death idea-

tion’ subscale which measures a passive wish to die

(Heisel & Flett, 2006); this subscale is significantly corre-

lated with the ‘suicide ideation’ subscale which measures

an active wish to end one’s own life. Thus, passive and

active suicide ideation may be closely linked in later life

in the context of depressive illness.

Studies conducted by our group addressed this issue of

whether wishing for one’s death in later life is normative.

In one paper, we examined this question in a sample of 85

year olds from Sweden (Van Orden, Simning, Conwell,

Skoog, & Waern, 2013). We found that the majority of

older adults who endorsed passive suicide ideation within

the last month also endorsed either active thoughts of kill-

ing themselves in their lifetimes or significant depressive

or anxious symptomatology in the past month, indicating

that passive suicide ideation was closely linked with indi-

cators of suicide risk. However, there was a small propor-

tion of older adults who reported thoughts that life was

not worth living (10%) and desire for death (5%) in the

absence of these risk factors for suicide (i.e., active sui-

cide ideation, depression, anxiety). Thus, we sought to

further understand this group of older adults in a subse-

quent study. Using a sample of older adults with elevated

levels of social and functional impairment, we sought to

examine if there might be a group of older adults who

responded to the stresses of aging, including functional

impairment, with passive suicide ideation, who were not

necessarily at risk for suicide (as evidenced by a lack of

active suicide ideation and a lack of depression and anxi-

ety). Our results were largely inconsistent with the

assumption that passive suicide ideation reflects norma-

tive developmental processes (i.e., coming to term with

aging) because the vast majority of those who endorsed

thinking life was not worth living and wishing for their

death also endorsed active suicide ideation (either recently

or in the past year) and/or significant depression/anxiety

(Van Orden et al., 2014). However, there was a small

minority of our sample (3%) who endorsed thoughts that

life was not worth living in the absence of desire for death

and suicide. Thus, it is possible that thinking that life is

not worth living and desiring death are not equivalent in

terms of their association with suicide risk and that some

older adults may believe life is not worth living without

being at elevated risk for suicide.

The most compelling data for determining whether

thoughts of death or wishes for death are associated with

suicide in later life would be a longitudinal analysis com-

paring survival rates among older adults with and without

death ideation at baseline. This analysis has not been con-

ducted. However, a retrospective (uncontrolled) analysis

of older adults who died by suicide found that ‘life-wear-

iness’ and wishes for death were frequently the most

intense level of suicide ideation expressed to a close infor-

mant during the year preceding the suicide death. The

authors conclude that passive suicide ideation may signal

risk for suicide in some older adults, particularly those

with residual symptoms of depression, or other risk fac-

tors, such as interpersonal problems, functional

impairment, or physical pain (Waern, Beskow, Runeson,

& Skoog, 1999). An analysis of responses to the Patient

Health Questionnaire-9 (PHQ-9), a depression self-report

measure that includes an item assessing ‘thoughts that

you would be better off dead or of hurting yourself in

some way,’ found that among outpatients aged 13 and

older, those endorsing thoughts of death or self-harm

were significantly more likely to attempt or die by suicide

in the months following their completion of the question-

naire than those who denied those thoughts (Simon et al.,

2013). This association remained after controlling for age,

sex, treatment history, and severity of depression symp-

toms. Limitations of this study with regards to our

242 K.A. Van Orden and Y. Conwell

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question regarding the prognostic significance of death

ideation in later life include that thoughts of death and

self-harm were grouped together and not analyzed sepa-

rately, and the sample was not limited to older adults, but

included patients aged 13 and older. Future research spe-

cifically examining thoughts of death and wishes for death

among older adults over time is needed. Furthermore,

qualitative research on the meaning of thoughts of death

that older adults themselves ascribe to these thoughts

could shed light on what types of death ideation may be

pernicious with regards to suicide risk, and which

thoughts, if any, may reflect distress not necessarily reflec-

tive of suicide risk.

The ultimate challenge, however, for suicide preven-

tion, is not necessarily showing that death and suicide ide-

ation are functionally the same, but showing for whom

they function similarly and for whom they function differ-

ently, and in both cases how these thoughts translate to

behavior. For depressed older adults, passive and active

suicide ideation may both indicate increased risk for sui-

cide. However, there may be a group of older adults who,

in the midst of aging-related stressors such as increased

disability and declining physical health, believe that their

quality of life has diminished to a point where life is no

longer worth living, but they would never consider sui-

cide. Identifying subgroups for whom death ideation is an

indicator of suicide risk versus an indicator of distress and

diminished quality of life is a key area for research in

late-life suicide. However, regardless of the context of the

belief that life is not worth living, in all cases it represents

dissatisfaction with quality of life. For some, this belief

may resolve on its own, while for others, intervention

may be needed. Identifying for whom and under what

contexts intervention is needed to resolve death ideation

should be a priority for research.

Important settings for late-life suicide research

The settings where it may be possible to reach and inter-

vene with older adults at risk for suicide differ from those

for younger adults. In particular, older adults are not likely

to present for care in mental health clinics (Conwell &

Thompson, 2008; Young, Klap, Sherbourne, & Wells,

2001). Rather, primary care is a key site for prevention:

two-thirds or more of older adults who die by suicide are

seen by primary care physicians within a month of their

deaths, and up to half within a week (Conwell et al., 2000;

Luoma, Martin, & Pearson, 2002). However, what does

this mean should be done? A common reaction many pro-

fessionals have to learning about the number of older

adults seen in primary care in the months and weeks

before their deaths by suicide is to promote mandated

screening for suicide ideation in primary care. In line with

this view, research suggests that brief depression screens

can accurately identify older adults with suicidal thoughts

(Heisel, Duberstein, Lyness, & Feldman, 2010). However,

we suggest that mandated, universal screening is a prema-

ture, impractical, and incomplete solution.

The United States Preventive Services Task Force

(USPSTF) states that there is not enough known about the

benefits and risks of routine screening in primary care for

suicidal thoughts to recommend such screening for all

patients; they note, however, that physicians should ‘be

aware of psychiatric problems in their patients and should

consider asking these patients whether they have consid-

ered suicide and refer them for mental health care’ (pp.

I-22, U.S. Preventive Services Task Force, 2014). In short,

the research literature simply is not strong enough yet

regarding the effectiveness of screening for suicide risk to

mandate suicide risk screening in primary care settings

for all patients. However, the USPSTF does recommend

screening for depression in adults (U.S. Preventive Serv-

ices Task Force, 2009), but only ‘when staff-assisted

depression care supports are in place to assure accurate

diagnosis, effective treatment, and follow-up.’ Thus, until

consistently effective and widely accessible interventions

to prevent suicide are implemented, one appropriate

response to the rates of older adults who die by suicide

who are seen in primary care is to ensure that best practi-

ces regarding depression treatment are provided in that

setting. The IMPACT model for integrated depression

care management for older adults (Unutzer, et al., 2002)

is one example. IMPACT stands for Improving Mood-

Promoting Access to Collaborative Treatment and was

tested in a large randomized trial. The ingredients of

IMPACT’s collaborative care model include a depression

care manager (e.g., social worker) who is located in the

primary care clinic and provides psychoeducation, care

management, support of antidepressant usage (including

monitoring of treatment response), and evidence based

psychotherapy (in this case, Problem Solving Therapy);

supervision of the care manager by a psychiatrist and pri-

mary care expert; and education of primary care physi-

cians in stepped care protocols for antidepressant

prescription. The IMPACT model has been shown to

improve patient outcomes for depression and to reduce

suicide ideation among older adults receiving the inter-

vention (Unutzer et al., 2002; Unutzer et al., 2006), and is

being widely disseminated internationally (http://impact-

uw.org/).

A similar model was tested in the PROSPECT trial

(Bruce et al., 2004). PROSPECT stands for The Preven-

tion of Suicide in Primary Care Elderly: Collaborative

Trial. This study tested a care management intervention in

primary care, and a primary outcome variable was suicide

ideation. The rationale of PROSPECT is that effective

treatment of depression should reduce suicide risk in older

adults. The intervention consisted of care managers intro-

duced into primary care practices with psychiatric super-

vision; care managers were responsible for working with

primary care physicians to deliver algorithm-based antide-

pressant treatment, monitor treatment response, encourage

adherence, and offer evidence-based psychotherapy (in

this case Interpersonal Psychotherapy). PROSPECT was

effective in the treatment of depression and was also asso-

ciated with a faster resolution of suicide ideation (com-

pared to care-as-usual) over two years (Alexopoulos et al.,

2009). The PROSPECT intervention is also the first

depression care management study in older adults to have

a documented effect on mortality, with those patients with

Aging & Mental Health 243

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major depressive disorder at baseline who received the

intervention being 24% less likely to die during follow-up

compared to patients in care-as-usual (Gallo et al., 2013).

Deaths from cancer were more common in usual care

patients compared to those who received the intervention.

No deaths by suicide were reported.

Finally, although not tested in a randomized trial, and

not specifically focused on older adults, a collaborative

care model for depression treatment and suicide preven-

tion implemented in a large health maintenance organiza-

tion (HMO) of about 200,000 members was found to

reduce the suicide rate from to 89 per 100,000 members

to zero suicides for nine consecutive reporting quarters

(Hampton, 2010). These data suggest that the ‘Zero

Suicide’ concept of the 2012 National Strategy for Suicide

Prevention (U. S. Department of Health and Human Serv-

ices (HHS) Office of the Surgeon General and National

Action Alliance for Suicide Prevention, 2012; zerosui-

cide.sprc.org) is not only aspirational, but also attainable.

Taken together, these studies on collaborative care indi-

cate that treating depression and addressing suicide risk in

older adult primary care patients can save lives, thereby

emphasizing the importance of primary care as a site for

intervention with older adults at risk for suicide.

Another response to data that indicate the importance

of primary care is to improve the linkage of primary care

to the ASN of agencies. The ASN was initially developed

as part of the Older Americans Act to help ensure that

adults aged 60 and older are connected to supportive serv-

ices necessary to maintain independent living. Specifi-

cally, ASN organizations provide older adults access to

services for nutrition, long-term care and supports, disease

prevention, health promotion, and vulnerable elder rights

protection. As we have discussed previously (O’Riley

et al., 2014), the ASN is a key resource for late-life suicide

prevention. Older adults accessing ASN services report

high levels of psychological distress (Richardson, He,

Podgorski, Tu, & Conwell, 2010), functional impairment

and medical comorbidity (Richardson, Simning, He, &

Conwell, 2011), as well as both active and passive suicide

ideation (O’Riley et al., 2014). Furthermore, the ASN is

designed and well-equipped to manage several risk factors

for late-life suicide, including functional impairment and

social isolation. Routine screening for depression is possi-

ble in ASN agencies; the largest ASN provider agency in

our region now screens all older adults seeking care man-

agement services for depression, suicide risk, anxiety,

cognitive impairment, and alcohol misuse. They also pro-

vide evidence based depression care through the PEARLS

program, a collaborative care depression treatment for

late-life depression (Ciechanowski et al., 2004). A key

part of PEARLS when patients do not show improvement

after four to five weeks, is coordination of care by the

team psychiatrist with primary care physicians, who pre-

scribe antidepressant medications when indicated. Thus,

an important component of late-life suicide prevention is

the coordination of care between primary care and other

venues for service provision, including aging services.

This coordination of care is a key component of the

movement toward patient centered care. ‘Patient

centeredness’ refers to an approach to medical care that

places patients’ needs and wants front and center during

encounters between patients and providers (Duberstein &

Jerant, 2014). Patient centered care involves attention to

the whole person, including social needs, thus would

emphasize inclusion of aging services providers as key

players in an older person’s health. Another response,

therefore, to the data indicating that older adults at risk for

suicide present in primary care, is to promote such health

care reform initiatives as the patient centered medical

home (PCMH), but with emphasis on incorporation of

social services into the integrated care team. The Agency

for Healthcare Research and Quality (AHRQ) proposes

that PCMH’s should have five key characteristics (Agency

for Healthcare Research and Quality, 2014): (1) provision

of comprehensive care that addresses prevention, chronic

care, and acute care through the coordination of health

care teams; (2) provision of patient-centered care that

addresses patient and family priorities, emphasizes the

patient-physician relationship, and attends to the whole

person (i.e., social needs as well as medical diagnoses);

(3) provision of care coordination across the entire health-

care system � specialty care, hospitals, home health care, and community services and supports � especially during care transitions; (4) provision of accessible services,

including shorter wait times for acute problems, access to

a member of the healthcare team during off-hours, com-

munication with the healthcare team via alternate modes

of communication, like email, and increased hours for

patients to meet with providers; (5) provision of high

quality and safe healthcare, through such activities as evi-

denced-based medicine and use of clinical decision-sup-

port tools with patients and families, as well as collecting

performance measurement and improvement data on serv-

ices provided. The PCMH has the potential to improve

health care delivery for older and younger adults alike,

and may thereby serve to reduce suicide risk through a

range of selective preventive interventions; for example,

collaborative care of depression, diabetes, and other

health conditions; an enduring relationship with a PCP

that may promote disclosure of suicidal thoughts;

enhanced care coordination during care transitions (e.g.,

from hospital to home, or to a long-term care facility);

and increased access to providers for acute problems.

Future research should investigate opportunities afforded

by the adoption of the PCMH model for reduction of sui-

cide risk in later life. For example, does adoption of the

PCMH model lead to greater continuity and trust in the

patient-provider relationship leading to increased detec-

tion and disclosure of suicide ideation? Does the PCMH

improve care transitions such as those from psychiatric

hospitals to home and long-term care facilities to home,

such that suicide risk is reduced during those high-risk

periods? Does the presence of care managers cause

increased implementation of collaborative care models

for depression treatment and suicide risk? Might ‘caring

letters’ interventions be possible to implement with the

population approach to healthcare taken by PCMH?

Our discussion of health services in relation to suicide

prevention has thus far been focused on systems and

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practices of developed countries. Services differ, and

resources are often more scant, in developing countries.

Although not focused on late-life suicide, a promising

stepped-care intervention using lay persons as care man-

agers in primary care clinics in India demonstrated a 36%

reduction in suicide plans/attempts during a 12 month fol-

low-up period (Patel et al., 2010). Thus, a key future

direction for suicide prevention in later life involves test-

ing interventions that are feasible, acceptable, and effec-

tive across diverse settings. Furthermore, understanding

how these interventions work (i.e., mechanisms), as well

as how they are implemented (i.e., fidelity) will be key to

ensuring the success of interventions outside the realm of

clinical trial settings. Regarding mechanisms of interven-

tions, identifying mechanisms common to suicide inter-

ventions could have significant public health impact:

implementation would be more effective because the key

psychological processes that must be impacted by the

intervention are known and could be tailored to be deliv-

ered in a culturally sensitive and acceptable manner.

Finally, a common characteristic of older adults at risk

for suicide is social isolation. Social support has long

been recognized as a buffer against stressful events

(Cohen & Wills, 1985), and those older adults without

social supports are at greater risk for suicide, and other

negative health outcomes. Other proposed protective buf-

fers against suicide risk, include meaning in life (Krause,

2007), and feelings of agency and autonomy (Johnson,

Wood, Gooding, Taylor, & Tarrier, 2011). Gatekeeper

programs may detect older adults at risk for suicide who

are isolated in their own homes, with potentially low feel-

ings of agency, who would not otherwise seek care. Gate-

keeper programs involve teaching individuals who

regularly come into contact with older adults warning

signs that an older adult is at risk for negative outcomes

(e.g., suicide, unsafe living conditions, etc.) and how to

share that information with a gatekeeper agency, which

takes responsibility for engaging the older adult in serv-

ices, as well as short-term case management and referral

to longer term programs/services. Gatekeepers could

include postal workers, meals on wheels drivers, meter

readers, grocery store clerks, pharmacists, and others. The

Institute of Medicine report on suicide prevention (Gold-

smith, Pellmar, Kleinman, & Bunney, 2002) calls for the

implementation of gatekeeper programs for older adults.

The studies by Oyama and colleagues (Oyama et al.,

2008) support this recommendation. The studies examine

the effectiveness of a multi-component intervention for

late-life suicide that included gatekeeper training in the

form of universal screening for depression in older adults

and psycho-education on mental health in older adults for

the older adult community (i.e., gatekeeper training). In

some instances, the intervention also included volunteer,

and peer support activities. This intervention was shown

(in a meta-analysis of five quasi experimental studies) to

be associated with a reduction in suicide deaths: the sui-

cide reduction was observed for women whose follow-up

was conducted by a psychiatrist or general practitioner

and for men whose follow-up was conducted by a psychi-

atrist (but not a general practitioner). Psychiatrists and

general practitioners took different actions in response to

positive depression screens. These results suggest that

gatekeeper programs may reduce suicide deaths in older

adults, but there may be gender differences in response

rates and, further, that the necessary components of the

program follow-up for positive depression screens should

be empirically delineated (e.g., which actions taken are

associated with positive outcomes), thereby indicating

future directions for research on gatekeeper programs.

Theory-based research

Much of the research on the prevention of late-life suicide

(and suicide across the lifespan) has been atheoretical,

emphasizing reduction of empirically derived risk factors � those variables shown to be associated with increased

probability of suicidal behaviors occurring. Specifically

among older adults, psychological autopsy studies have

identified depression and other psychiatric illnesses (e.g.,

Waern et al., 2002b), physical illness (e.g., Waern et al.,

2002a), functional impairment (e.g., Conwell et al.,

2010), pain (e.g., Harwood, Hawton, Hope, Harriss, &

Jacoby, 2006), personality factors such as neuroticism and

low openness to experience (e.g., Duberstein, Conwell, &

Caine, 1994), a previous suicide attempt (e.g., Chiu et al.,

2004), social isolation (e.g., Turvey et al., 2002), and fam-

ily conflict (e.g., Rubenowitz, Waern, Wilhelmson, &

Allebeck, 2001) as key factors differentiating older adults

who died from suicide from community controls (for a

review, see Van Orden & Conwell, 2011). However, the

body of research on risk factors does not clearly delineate

how preventive interventions should be designed: Given

an array of risk factors, what should be the target of inter-

vention? One response is to treat depression aggressively,

including treatment to remission. However, not all older

adults at risk for suicide have symptoms for which depres-

sion treatment is indicated. In such situations, scientific

theory regarding etiological mechanisms underlying asso-

ciations between empirically-demonstrated risk factors

and suicidal behavior can help determine priorities for

interventions research. Understanding mechanisms that

determine suicide risk is needed to ensure that the key

aspects of the intervention are implemented when trans-

ported to another site or used with diverse populations on

which the intervention was not tested.

There are suicide specific theories that can be applied

to the development or testing of suicide preventive inter-

ventions, each of which helps in part to suicidal behavior.

Beck and colleagues’ (Beck, Brown, Berchick, Stewart, &

Steer, 1990; Beck, Steer, Kovacs, & Garrison, 1985)

hopelessness theory is able to explain the robust associa-

tion between hopelessness and later death by suicide. Bio-

logically-based theories are able to explain associations

such as those between serotonergic abnormalities and sui-

cide (Mann, 2003; Plutchik, Van Praag, & Conte, 1989;

van Praag, 2001). Family systems theories (Richman,

1986; Sabbath, 1969) can explain associations between

family conflict and suicide. Emotion-based theories, such

as Shneidman’s psychache theory (Shneidman, 1998) and

Linehan’s (Linehan, 1993) emotion dysregulation theory,

Aging & Mental Health 245

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are able to account for the association between social iso-

lation � an emotionally painful experience � and suicide. Two contemporary theories of suicide, the interpersonal

theory of suicide (Van Orden et al., 2010) and the motiva-

tional-volitional theory of suicide (O’Connor, 2011), pro-

pose to account for many empirically demonstrated risk

factors, including the associations between previous sui-

cidal behavior and later death. The interpersonal theory

emphasizes the role of low (or thwarted) belongingness

and perceiving oneself to be a burden on others as causes

of the desire to die by suicide, and an acquired capability

for tolerating the fear and pain involved in suicidal behav-

ior as a necessary element for ideation to transition to

behavior. The motivational-volitional model emphasizes

the role of defeat/humiliation, entrapment, and threat to

self as key constructs in suicide risk. All of these theories

have relative merits and weaknesses, and all could be fur-

ther leveraged in designing and testing interventions.

In this issue, articles by Joiner and Stanley, and Fiske

and O’Riley provide perspectives on theory and late-life

suicide. Specifically, Joiner and Stanley provide an over-

view of theoretical perspectives on suicide (with an

emphasis on psychological theories) and apply these theo-

ries to late-life suicide. Fiske and O’Riley discuss the role

of lifespan developmental theories of aging and how these

perspectives can inform late-life suicide prevention. Both

of these articles provide rich generative research material

to foster ideas and future research.

Left unaddressed thus far, however, is the open ques-

tion as to whether a theory specific to late-life suicide

would be useful for the field. Such a theory would rest

on the assumption that late-life suicide differs in impor-

tant ways with regards to etiology and epidemiology so

as to warrant an age-specific theoretical account. Alterna-

tively, theories not designed to be age specific could be

adapted to address the specific challenges (and opportuni-

ties) older adults face during the aging process, including

psychosocial, environmental, and biological challenges

and changes. For example, given that bereavement is a

common stressor in later life, and that complicated grief

reactions are associated with increased risk for the pres-

ence and persistence of passive and active suicide, as

well as the presence of indirect suicidal behaviors (e.g.,

not taking medications, not eating) in older adults

(Szanto et al., 2006), bereavement might play a promi-

nent role in a theory of late-life suicide. Regardless of

which route � theory generation or theory adaptation � we urge researchers to consider the role and value of the-

ory in their work both for the generation of ideas and

hypotheses and for the investigation of mechanisms of

intervention effectiveness.

Cognition and cognitive impairment

The role of cognitive impairment, dementia in particular,

as a potential risk factor for suicide is under-studied and

not well understood (Haw, Harwood, & Hawton, 2009).

However, cognitive changes play an important role in

health and well-being in later life, and represent one

domain in which risk factors for suicide in later life may

differ from those of middle aged and younger adults, thus

warranting attention. A prospective study using nation-

wide register data from Denmark found that a diagnosis

of dementia made during hospitalization significantly

increased risk for dying by suicide, even when controlling

for mood disorders (Erlangsen, Zarit, & Conwell, 2008).

Risk was highest during the first several months after the

diagnosis of dementia was made, though for some, risk

continued to be elevated years after the diagnosis. How-

ever, psychological autopsy studies have not identified

dementia as a distinguishing feature of late-life suicide

deaths (Haw et al., 2009) and overall the literature

remains mixed as to whether dementia confers risk for

suicide (Haw et al., 2009).

What is clearer in the literature is that cognitive abnor-

malities, especially executive functioning and decision-

making deficits, appear to characterize suicidal individu-

als among both younger/middle-aged (Bartfai, Winborg,

Nordstrom, & Asberg, 1990; Cha, Najmi, Park, Finn, &

Nock, 2010; Gujral et al., 2013; Keilp, Gorlyn, Oquendo,

Burke, & Mann, 2008; Keilp et al., 2013; Keilp et al.,

2001; Marzuk, Hartwell, Leon, & Portera, 2005; West-

heide et al., 2008) and older adults (Clark et al., 2011;

Dombrovski et al., 2008; Dombrovski et al., 2010;

Dombrovski et al., 2011; Gibbs et al., 2009; Gujral et al.,

2013; King et al., 2000; McGirr, Dombrovski, Butters,

Clark, & Szanto, 2012; Richard-Devantoy et al., 2012;

Szanto et al., 2012; Vanyukov et al., 2014; Wiktorsson,

Runeson, Skoog, Ostling, & Waern, 2010). A more fine-

grained interpretation of the studies described as measur-

ing executive functioning above reveals older adults at

risk for suicide are characterized by deficits in cognitive

control (associated with high-lethality suicide attempts),

deficits in decision-making (associated with lower lethal-

ity impulsive suicide attempts), and deficits in social cog-

nition and social decision making (for a review, see

Kiosses, Szanto, & Alexopoulos, 2014). One recent study

using fMRI (Vanyukov, et al., 2014) found that greater

impulsivity in social problem solving, as well as the pres-

ence of past unplanned suicide attempts, were associated

with increased activation in the prefrontal cortex when

viewing angry faces, suggesting that socioemotional stim-

uli are processed differently among older adults with

impulsive suicide attempts. In sum, deficits in cognitive

control, and potentially social decision making, may be

especially troublesome with regards to suicide risk in later

life, but the cognitive patterns of deficits/differences likely

differ for unplanned and planned attempts.

Future research on the role of cognitive factors and

cognitive impairment should seek to examine how cogni-

tion and cognitive impairment might interact with life

stress to increase risk for suicidal behavior, perhaps by

limiting help seeking, impairing emotion regulation or

distress tolerance skills, or by increasing hopeless cogni-

tions (Kiosses, et al., 2014).

The voice of the older person

Research is needed that utilizes qualitative methods to

capitalize on the wisdom attained by listening to the voice

246 K.A. Van Orden and Y. Conwell

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of the older person. What do the older adults themselves

believe will help them maintain their quality of life and

enhance their reasons for living? Quantitative studies

addressing protective factors have shown that strong rea-

sons for living are associated with adaptive coping skills

(i.e., problem-focused and emotion-focused coping)

(Marty, Segal, & Coolidge, 2010) and a sense of belong-

ing (McLaren, Gomez, Bailey, & Van Der Horst, 2007).

Furthermore, higher meaning in life (Heisel & Flett,

2006) and higher social support (Parkhurst, Conwell, &

Van Orden, 2015) demonstrate negative associations with

suicide ideation in older adults, indicating they may serve

as protective factors. Spirituality has also been shown to

buffer the association between loss of meaning in life and

depression among older adults (Bamonti, Lombardi,

Duberstein, King, & Van Orden, 2015). Thus, research is

beginning to emerge on potential protective factors for

suicide in older adults. Qualitative studies could add to

this literature. For example, by examining differences

between men and women � what protects against suicide for men and for women � given that cultural scripts for suicidal behavior have been found to play a role in the

association between physical illness and suicide (Waern,

et al., 2002a), and may play a role in the association

between social factors and suicide (Fassberg et al., 2012).

Qualitative studies have examined reasons for suicidal

behavior in older adults. A qualitative examination of rea-

sons older adults gave for their suicide attempts found

that older adults attributed their attempts to multiple rea-

sons � there did not appear to be a single most common cause (Van Orden et al., 2015). Those attributions, how-

ever, did cluster into several themes: a desire to escape,

reduced functioning and autonomy, psychological prob-

lems, including depression, somatic problems and physi-

cal pain, perceived burdensomeness, social problems that

reflected either low belongingness or family conflict, and

lack of meaning in life (Van Orden et al., 2015). Another

qualitative investigation of the development of a ‘wish to

die’ in older adults found similar themes: being widowed,

loneliness, being a victim, dependency, and wanting to be

useful (Rurup et al., 2011). A commonality in both studies

was that most older adults did not view depression as the

source of their wish to die or suicide attempt. While

depression is one of the strongest risk factors for suicide

deaths in older adults, a patient-centered perspective

would emphasize asking the older adult what lead to his/

her feelings that life is not worth living or of suicide, and

potentially including those reasons as targets in preventive

interventions. A qualitative investigation of the experien-

ces of older adults before their deaths by suicide using a

psychological autopsy method with informant interviews

found several common themes around reasons for desiring

death, including � ‘this life has been lived’ and ‘life as a burden.’ Another theme concerned ‘losing themselves’ in

the face of mounting physical disability and dependence

on others. Finally, the belief that ‘death is better than life’

emerged as a theme, and many of the older adults had

expressed a wish to die to others in their lives (Kjolseth,

Ekeberg, & Steihaug, 2010). Thus, there is a growing lit-

erature addressing the older adult’s views on reasons for

suicide ideation, but less examining protective factors

(such as reasons for living) or ways to prevent suicide.

Community participatory research (CBPR) is a meth-

odology for, and an attitude toward, conducting research

using academic/community partnerships. In CBPR proj-

ects, academic researchers are true partners with commu-

nity members in the conceptualization of research

problems, study design, collection of data, interpretation

of results, and dissemination of findings. The goal is the

promotion of health and well-being among community

members, often with a focus on the reduction in health

disparities. Researchers learn from community members

and vice versa. The end product is community-relevant

research to promote positive change and health improve-

ment in the community. This approach to research is not

often used in late-life suicide prevention efforts (or sui-

cide prevention projects in general).

One example of the field of suicidology moving in the

direction of CBPR has come in the recent (2014) effort to

make suicide attempt survivors (and those who have expe-

rienced suicidal thoughts) partners with a leadership voice

in American Association of Suicidology through the crea-

tion of the Attempt Survivors/Lived Experience Division

(http://www.suicidology.org/members/divisions/attempt-

survivor), with the promise that this move will lead to a

more meaningful input of survivors and consumers’ voi-

ces in the questions, priorities, and design of suicide pre-

vention research studies. The goal of the Division of

Lived Experience is to ensure that people who have been

suicidal (i.e., thoughts of suicide or suicide attempts) are

involved in, and central to, research, policy-making, pub-

lic messaging, treatment and support. It is our hope that

more of these CBPR efforts will emerge as a result of des-

tigmatization of suicide and therefore promote those with

lived experience in suicidal behavior as full partners in

the research effort for suicide prevention.

Conclusions

Aging confers both vulnerabilities and strengths for emo-

tional well-being (Charles, 2010). A greater integration of

the basic research on the psychology, biology, and sociol-

ogy of aging with applied work on clinical and public

health approaches to late-life suicide has the greatest

potential to move the field forward towards reducing the

suicide rate among older adults. In short, our call is for an

approach to late-life suicide prevention that draws on the

strengths of multiple disciplines to bring differing and

complementary ideas of how aging may both protect

against and increase risk for suicide in later life.

Associations have long been observed between socio-

political and macroeconomic factors and suicide rates

(e.g., Durkheim, 1897; Yip & Caine, 2011). As changes in

the context and make-up of older adulthood continue to

occur, they will likely influence rates among older adults

over time. For example, healthcare delivery and financing

reforms may help reduce suicides in later life by their

emphasis on outcomes and quality of care, patient and

family centered approaches, and integrated service deliv-

ery models that bring mental health care into primary care

Aging & Mental Health 247

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offices. The latter approach, as we described above, has

been shown in two well-designed clinical trials of collabo-

rative, primary care-based late-life depression care man-

agement to result in greater reduction in suicidal ideation

than care as usual (Alexopoulos, et al., 2009; Unutzer,

et al., 2006).

As well, characteristics of birth cohorts must also be

considered. Phillips’ work indicates that while the current

older adult cohort has had higher suicide rates at each

point in the lifecourse than its preceding generation, sub-

sequent birth cohorts demonstrate even higher risk, sug-

gesting that as they age into older adulthood � a time of heightened risk � rates may rise even higher (Phillips, 2014).

Throughout, we have encouraged taking a ‘patient

centered’ and ‘participatory research’ approach to late-

life suicide research efforts. ‘Patient centeredness’ places

the older adult and his/her viewpoints and needs front and

center. Ways to incorporate patient centeredness into late-

life suicide research could be to use mixed methods

approaches that include qualitative aspects to incorporate

the voice of the older person into studies. Participatory

research approaches, in a similar spirit, seek to incorpo-

rate the voice of the subject into research questions and

designs. By partnering with older adults and those who

serve them in the communities, the more relevant our

research will be to the lives of the older people we are try-

ing to save and improve. We believe that these perspec-

tives of community participatory research and patient

centeredness are too often not capitalized upon in research

on suicide prevention with older adults. By utilizing these

perspectives, the voice of the older person could contrib-

ute 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.

Finally, we have suggested throughout that taking a

public health approach to late-life suicide prevention. In

line with such an approach is consideration of policy

issues surrounding late-life suicide. For example, the liter-

ature suggests that collaborative care models addressing

depression and suicide risk are likely to be helpful in pre-

venting suicide among older adults. Policies promoting

the integration of behavioral health into primary care,

including appropriate reimbursement for mental health

services in primary care, especially for integrated models,

could potentially have an impact on reducing suicides in

later life. Relatedly, policies and legislation addressing

firearm accessibility could have an impact on late-life sui-

cide rates, as the presence of a firearm in the home is asso-

ciated with increased risk for suicide among older adults,

even when accounting for psychiatric illness (Conwell

et al., 2002). Addressing these issues in the Veterans

Health Administration may be especially potent with

regards to reducing late-life suicide given the number of

older men who are Veterans and keep firearms at home.

Other target groups could include retired police officers,

firefighters, and physicians; the latter group � physicians � has an empirically demonstrated elevated rate of sui- cide (Center et al., 2003). Finally, universal prevention

regarding the reduction of ageism in societies could lead

to policies that address the challenges of later life, while

not neglecting the opportunities that also come with age.

These policies should also be examined empirically to

determine whether their effects, when implemented, lead

to beneficial effects for the lives of older adults.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

This work was supported by the National Institute of Mental Health [grant number K23MH096936]; the Centers for Disease Control [grant number R49CE002093].

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