Depression and Suicide in Older Adults

8/3/2019 Depression and Suicide in Older Adults

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Depression and Suicide in Older Adults

Ratna Roy

Rochester Institute of Technology

The purpose of this paper is to expand upon the finding that depression and suicide are becoming more

and more likely to occur among older adults. The theory behind this finding that older adults are

becoming more and more depressed and committing suicide at a greater rate than ever before is due to

their failing physical and mental health. The purpose of this paper is to expand upon and prove thistheory by gathering statistics about suicide in older adults, examining studies conducted about

depression and suicide, conducting a review of suicide notes from older adults, and by discussing

reasons for depression and suicide among older adults.

Depression and suicide are two causes of death that are increasing in prevalence for all age groups.

They are also on the rise in a specific age group, that of older adults. The theory behind this finding that

older adults are becoming more and more depressed and committing suicide at a greater rate than ever

before is due to their failing physical and mental health. The purpose of this paper is to expand upon

and prove this theory by gathering statistics about suicide in older adults, and by obtaining the

information of scholarly sources by summarizing their views as it relates to the above mentioned theory.

Official suicide statistics identify older adults as a high-risk group (Mireault & Deman, 1996). In 1992, it

was reported that older adults comprised about 13% of the U.S. population, yet accounted for 20% of its

suicides; in contrast, young people, ages 15-24, comprised about 14% of the population and accountedfor 15% of the suicides (Miller, Segal, & Coolidge, 2001). Among older persons, there are between two

to four suicide attempts for every completed attempt (Miller, Segal, & Coolidge, 2001). However, the

suicide completion rate of older adults is 50% higher than the population as a whole. This is because

older adults who attempt suicide die from the attempt more often than any other age group. Not only

do elders kill themselves at a greater rate than any other group in society, but they tend to be more

determined and purposeful (Weaver & Koenig, 2001).


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Studies of Depression and Suicide in Older Adults

Depression in Older Adults

A study was conducted examining the relationships between disease severity, functional impairment,

and depression among a sample of older adults with age-related macular degeneration. It showed that

the relationship between visual acuity and physical function was moderated by depressive symptoms

(Casten, Rovner, & Edmonds, 2002). It appears that when faced with vision loss, depressed persons tend

to generalize their disability to activities that are not necessarily vision dependent. They seem to adopt

the attitude of not being able to see leads to not being able to do. This attitude is in line with the

cognitive theory of depression in which depressed persons engage in faulty information processing

(Casten, Rovner, & Edmonds, 2002).

Suicide in Older Adults

A study about older adult suicide was conducted by Zweig and Hinrichsen (1993). This study included

150 community-dwelling adults, age 60 and over, who were admitted to a psychiatric inpatient service.

Each member met the criteria for major depressive disorder. The patients and family members were

interviewed six and twelve months after the patients were admitted to the hospital. Eleven of the 126

older patients attempted suicide within the year following inpatient admission for major depressive

disorder, however none of the attempts resulted in death (Zweig & Hinrichsen, 1993). Of the patients

who attempted suicide, 73% did so during the six to twelve month period following hospitalization

(Zweig & Hinrichsen, 1993). The study then went on to explore the differences between those who

attempted suicide and those who did not. Individuals who attempted suicide occupied, on average, a

higher social class position (Zweig & Hinrichsen, 1993). They were also less likely to experience

remission, and were more likely to relapse if they did experience remission. The study also found that

interpersonal factors were associated with suicidal behavior in the patients.

Suicide Notes From Older Adults

Suicide notes are traditionally considered markers of the severity of the suicide attempt and often

provide valuable insights into the thinking of suicide victims before the final act (Salib, Cawley, & Healy,

2002). A study was done examining the phenomenon of suicide notes in 125 older people who died

unexpectedly and in whom a suicide verdict was returned by the Coroner over a period of 10 years. The

goal of the study was to see whether there was a difference between suicide note-leavers and non-

note-leavers in older victims of suicide (Salib, Cawley, & Healy, 2002).


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Data was collected from the files of a Coroner's office in a particular town. All of the data was from

deceased people aged 60 and above whose deaths were ruled as suicides. Deceased older adults who

left suicide notes were compared to those who did not over a period of ten years. During the 10-year

review period, 125 older people died as a result of suicide. In 54 cases (43%), a suicide note was found in

the coroner's records for 31 (57%) males and 23 (47%) females (Salib, Cawley, & Healy, 2002). For note-

leavers, the average age was 71, and for those who did not leave notes, the average age was 74.

Older suicide note-leavers were less likely to be known to psychiatric services, did not have recent

psychiatric treatment, and were less l ikely to have used violent methods, and did not previously attempt

suicide. Suicide notes accompanied most of the cases of suicide that resulted from an overdose, using

plastic bags, electrocution, or using car exhausts. Most cases of drowning did not leave suicide notes,

none of the men who kil led themselves by drowning or falling from a height left suicide notes, nor did

the deceased who fatally wounded themselves or jumped in front of a train. More women than men

who chose to die by hanging left notes (Salib, Cawley, & Healy, 2002). Those who died by hanging,

jumping from heights, immolation, or wounding appeared equally likely to leave or not leave a note

(Salib, Cawley, & Healy, 2002). Also, older people who killed themselves at weekends were less likely to

leave a suicide note. older people who were in their 70s referred primarily to financial problems, social

isolation, fear, sadness, loneliness, and physical illness (Salib, Cawley, & Healy, 2002).

This study found that many older people may be isolated and have no one to communicate with, while

others may no longer have the ability to express themselves. Failure to identify consistent parameters

that could differentiate between note-leavers and non-note-leavers should not be taken to mean that

absence of a suicide note must not be considered an indicator of a less serious attempt (Salib, Cawley, &Healy, 2002).

Reasons for Depression and Suicide in Older Adults

Depression in Older Adults

Depression is the most common diagnosis in older adults who have attempted suicide (Zweig &

Hinrichsen, 1993). Depression frequently accompanies a chronic disease, particularly when the disease

impairs function (Casten, Rovner, & Edmonds, 2002). Physical health status is the most consistentlyreported risk factor for the onset and persistence of depression in late life (Gatz & Fiske, 2003). Several

other common correlates have been associated with older adult depression, such as cognitive

dysfunction, genetic factors, interpersonal relations, and stressful life events.


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Depression can also be brought on by anxiety in older adults. In fact, the relationship between anxiety

and depressive symptoms in later life are relatively common among older adults (Wetherell, Gatz, &

Pederson, 2001). However, little is known about the particular features that may distinguish elders with

anxious depression from elders with depression alone (Lynch, Compton, Mendelson, Robins, & Krishnan,

2000).

Suicide in Older Adults

Physical illness is a common antecedent to suicide in older people, though prevalence figures vary

widely from 34% to 94%; however the risk of suicide associated with physical illness is unclear because

there are few controlled studies (Waern et al., 2002). Other factors that have been associated with late-

life behavior are chronic severe pain, debilitating disease, and diagnosis of a terminal illness (Mireault &

Deman, 1996). Also, of older adult suicides who have been studied through a psychological autopsy

method, it is most often the case that a psychiatric illness, in particular depression, was present prior to

death (Pearson, Conwell, Lindesay, Takahashi, & Caine, 1997).

Another reason that older people commit suicide is due to unbearable psychological pain, which

produces a heightened state of perturbation. The person wants primarily to flee from pain, such as

feeling boxed in, rejected, and especially hopeless and helpless (Leenaars, 2003). The suicide is

functional because it provides relief from the intolerable suffering. Also, a history of suicide attempts

and the level of intent associated with suicidal acts have been demonstrated to be correlates of

subsequent completed suicide (Connor, Conwell, & Duberstein, 2001).

Inability to adjust is yet another reason for older adult suicide. This includes several disorders such as

depressive disorders, anxiety disorders, schizophrenic disorders, brain-dysfunction disorders, and

substance-related disorders.

Another reasoning of older adult suicide, rejection-aggression, was first documented by Stekel in the

famous 1910 meeting of the Psychoanalytic Society in Freud's home in Vienna (Leenaars, 2003). The

idea behind this reason is that often times a rejection leads to pain and self-directed aggression.

Alcohol use also appears to be a major precipitating factor in geriatric suicide. Older adults who abuse

alcohol are more likely to attempt suicide compared to those who consume little or no alcohol (Mireault

& Deman, 1996).


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Identification-aggression, an idea hypothesized by Freud, is another factor in older adult suicide. With

this idea, Freud believed that intense identification (attachment) with a lost or rejecting person is crucial

in understanding the suicidal person. If this emotional attachment is not met, the suicidal person

experiences a deep pain (discomfort) and wants to egress or escape (Leenaars, 2003).

Interpersonal relations are often a factor in older adult suicide. If older adults have trouble establishing

or maintaining relationships, they develop a disturbed, unbearable interpersonal calamity.

Cognitive constriction is also a factor in older adult suicide. The common cognitive state in suicide is

mental constriction, such as rigidity in thinking, narrowing of focus, tunnel vision, and concreteness

(Leenaars, 2003). The person experiences combinations of a trauma such as poor health or rejection

from a family member, moments before his or her death.

It has also been found, in one population based case-control study, that visual impairment, neurological

disorders, and malignant disease were associated with suicide in older people, along with cardiovascular

disease, and musculoskeletal disorders (Waern et al., 2002).

Indirect expressions are a reason for suicide among older adults. The suicidal person is ambivalent; they

experience complications, contradictory feelings, attitudes and/or thrusts, often toward a person and

even toward life (Leenaars 2003). However, the conscience of a person is only a fragment of the suicidal

mind (Leenaars 2003).

Summary and Conclusions

The theory to be corroborated in this paper was that older adults are becoming more and more

depressed and committing suicide at a greater rate than ever before, due to failing physical and mental

health. The paper discussed several aspects of this theory including statistics of suicide in older adults,

reasons for depression in older adults, reasons for suicide in older adults, and included studies on

depression and suicide in older adults. A review of suicide notes from older adults was also conducted. Itwas found that the theory to be corroborated was successful. It is true, based on the findings from the

above mentioned sources, that depression and suicide are increasing in prevalence among older adults

due to their failing physical and mental health. There are several aspects to physical and mental health,

however they appear to be the main causes for the increase in depression and suicide among older

adults.


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Reasons for depression among older adults briefly include anxiety, cognitive dysfunction, genetic

factors, interpersonal relations, and stressful life events. Reasons for suicide among older adults can be

briefly summarized by physical and psychiatric illnesses, unbearable psychological pain, cognitive

construction, indirect expressions, inability to adjust, interpersonal relations, rejection-aggression,

alcohol abuse, identification-egression, visual impairment, neurological disorders, malignant disease

cardiovascular disease, and musculoskeletal disorders.

Peer Commentary

A Closer Look at Relationships, Genetics, and Choice

David E. Chinander


Roy did a fabulous job of discussing what persons were at risk for attempting suicide and the role that

both depression and physical illness play in the process. One of areas that troubled me after reading

Roy's paper was that I did not feel adequate evidence was provided for the assertion that older persons

are committing suicide at a faster rate now than they did before. I do not dispute this idea, but rather I

would like to be able to walk away from the paper feeling that it has been clearly established that this is

so. To assist in making this point clearer, I visited the home page for Suicide Awareness Voices for

Education. Their "Facts About Suicide" page said that in the decade between 1980-1990, the number of

suicides among older adults increased by 0.5% rather than the steady decrease that researchers had

seen since 1940. I think it would also be helpful to note that suicide rates increase with age.

Roy did an excellent job of describing some of the causes of older adult suicide. First and foremost is

physical illness. This is in keeping with what one might intuitively think about as a cause for older adult

suicide. Roy went on to discuss psychological factors, including interpersonal relationships. I believe that

it would be appropriate to unpack the effect of interpersonal relationships a bit further. As persons age,it is likely that they will lose their significant other as well as the close friends in their lives. Like younger

people, aging persons' peers help to make up the social support system that they rely on to help them

through difficult times. As these persons pass from the aging persons' lives, their social network is

weakened, and they become more psychologically vulnerable to life events. Community support is an

important protective factor against attempted suicide, and lack of this support is an important risk

factor.


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Biological causes are missing from Roy's discussion of older adult suicide. Although people are definitely

a product of their environment, they are also a product of their genes. The most common way to

identify genetic causes is by studying monozygotic (identical) twins. Researchers have found some

evidence that suicide can run in families, and studies of monozygotic twins show that they are five timesmore likely than dizygotic (fraternal) twins to attempt suicide. The majority of these data focus on

reduced serotonin levels in suicide attempters.

Roy did an excellent job of discussing the impact of depression on older adult suicide. It is important to

add that it is not normal for older persons to experience bouts of deep depression as they age. In

dealing with depression, aging persons are confronted by the specter of hopelessness that drives people

to think that there is no other solution to their problems than ending their life. Fortunately, if depressed

persons seek treatment, then it is 90% likely that they will recover. This treatment can include

antidepressants, talk therapy, or a combination of the two.

Finally, Roy avoided the controversial topic of a person's right to die. Dr. Jack Kevorkian helped insert

this issue into kitchen table discussions around the country. Critics of assisted suicide assert that people

who are terminally ill or incapacitated may feel pressure to end their lives rather than be a burden on

their family or on society. In the Netherlands, where assisted suicide is legal, very few such cases are

seen to happen. Certainly, any assisted suicide program should probably include screening for

depression, but as we all age, we may wish to have more of a choice in how we spend our final days and

ultimately how we end our lives.

Peer Commentary

A Cause-Effect Relation and Preventive Measures?

Juliana C. Lehr


Ratna Roy's paper discussed the causes and statistics of suicide among older adults in the American

population. She did a wonderful job of establishing the reasons for older adult depression, including

visual acuity, physical and cognitive function, chronic disease, and interpersonal relationships. She also


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clearly stated the current figures and statistics for suicide rates among this specific age group. Roy

suggested a cause-effect relation between the two factors, demonstrating how depression severely

affects older individuals and drives them toward suicide. Several important aspects of her review,

however, are lacking in necessary information, such as correlations and preventive measures.

Roy touched on the topic of older adult depression, explaining the reasons for such a high prevalence,

but did not discuss features such as onset and severity relating to suicidal tendencies. Are people with a

history of depression more likely to suffer from it in old age, causing an increased rate of suicide? This is

an important correlation to note. Furthermore, though Roy did explain the specific causes of depression,

she failed to elaborate on the effects of depression on older people. The state of mind going into suicide

is an important aspect of older adult suicide. Depression is not a topic to be taken lightly, it must be

thoroughly analyzed and studied, so readers have a clear idea of what mental state many older people

are in when they choose to commit suicide. It should also be noted that though depression is a major

cause of suicide, there are other factors involved--for example, believing one has led a full life and not

wanting to continue living in psychological and physical pain.

The statistics cited were helpful in understanding the occurrence of older adult suicide, making it clear

to readers what percentage left notes, previously attempted suicide, and suffered from a specific form

of depression. Roy used up-to-date statistics to demonstrate her point of correlation, but made no

effort to explain past correlation. It is necessary to be able to compare past and current statistics before

claiming that suicide rates for older adults are on the rise, as Roy claimed in her opening sentence. What

factors have caused an increase in suicide rates and depression--is it culture or simply personal choice?

It should be noted that the life span for people has increased over time, due to improvements in medicaltechnology, medicine, and assisted living or nursing homes. It is important to understand whether the

relation between life span and suicide rates is a cause-effect relation or not. By explaining both past a

current statistics, Roy could corroborate her opening statement.

In a paper with a topic of such magnitude, Roy should also have discussed preventive measures, if any.

It is hard to fathom that, if an older person suffers from depression, the only answer is suicide.

Medications and therapy are available for individuals suffering, regardless of age group. Roy should

touch on what forms of intervention reduce the risks. Often, living in an assisted-living community

decreases feelings of being alone, rejected, or isolated, reducing the severity of depression. Can family

and friends step in and prevent a possible suicide, or is it truly the only hope left for the older individual?

Depression can be often be overcome without a life being unnecessarily ended. This important aspect of

depression and suicide should most definitely be included in Roy's paper.


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Depression and suicide in older adults is a topic not commonly discussed, so reading a paper about such

a topic was quite educational. Many do not realize the increased rates of such happenings. Though the

topic was excellent, more detailed information, comparisons of statistics, and possible preventive

measures are necessary to demonstrate a true relation between depression and suicide.

Peer Commentary

A Problem Overlooked

Udochi I. Okeke


This paper on depression and suicide in older adults brings attention to a very serious topic in society.

The question of why older adults commit suicide is one that needs attention. This paper began with a

concise explanation of the topic, citing studies on the topic and listing statistics on suicide in older adults

and in general. It then went into specifics of the problem, explaining differences in suicides committed

by people who left versus did not leave suicide notes. Then it discussed the reasons why older adults

may be committing suicide, followed by a summary of the paper as a whole.

Certain points, however, may need more extensive analysis. It was stated in the paper that physical

health status, interpersonal relationships, and other factors were correlated with depression in older

adults, but I feel that more detail could have been given on this. It would be beneficial to know to what

degree a correlation exists.

Physical illness and social problems are factors that almost all older adults have to go through, and it

would be useful to know why others going through this do not get depressed or commit suicide. What is

it about their lifestyle that keeps them going? This would be a good question to consider.

Seeing how serious the issue of depression and suicide is, perhaps older individuals should be

psychologically evaluated. This information may make it increasingly possible to identify depression in

older adults and make it easier to examine the differences among older suicide victims.


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Perhaps we as a society are not paying enough attention to our older citizens. Considering the way

many of them are put into poorly equipped nursing homes, it is no wonder that some of them get

depressed. We as a society need to work more actively toward making our older citizens more

comfortable. After all, none of us is impervious to the power of old age.

Peer Commentary

A Cultural Responsibility?

Kathryn O. Tacy


The focus of Roy's paper is depression and suicide among older adults. The statistics of suicide among

older adults point to a serious dilemma. We all would like to think that when we get older, things get

easier. For most this is true, but for some this is devastatingly not the case. For some, with age come

bigger complications than expected, like physical and mental illness. Debilitating diseases cause much

more harm than what is seen in the physical realm. A sense of worthlessness sets in without proper

support that would otherwise help relieve some of the burden laid down by these circumstances.

People spend much of their teen years fighting with their parents for individual freedom and in turn

spend much of their adulthood relishing this freedom. Childhood is the time when people gather the

skills that will provide them with the strength to go the distance. Once we are "adults," we take on the

responsibilities that go along with being adults. Sometimes it can be overwhelming, but it is an inborn

right that in some aspect every person needs. It gives people pride, it gives them a sense of worthiness

and belongingness.

Investigators cannot be sure of the circumstances surrounding every suicide, and the results reveal too

little, too late. I think that we as a society underestimate our role in the survival of older adults through

a phase that can be invigorating and inspiring. Cultural "norms" play a big part in the healthiness of

people's lifestyles. Some societies consider this phase a noble gift, to be taken seriously and respected. I

would not go so far as to assume such for this culture. In western culture, people have a tendency to

stereotype older adults as bad drivers and nuisances in the grocery store line. Though there may be


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some truth to this, it is still a gross generalization that yields harmful effects. Our society is losing more

and more respect for older adults. I feel that advnced age is as fragile as the teen years. Society needs to

have support groups for older adults that include activities. No, I am not talking about senior centers

either (not that they are all bad). Mobile or not, young people have a responsibility to nourish the

wisdom that has preceded them and to respect it. The naturalness of it all needs to be recognized.

I feel that the important topic of society's role was overlooked in this paper, and I would inquire about

this and any other related cultural diversities. As how important do people view their roles in society?

Author Response

Expanding Upon Depression and Suicide Among Older Adults

Ratna Roy


I feel that, for the most part, the peer commentators found my paper to be educational; they felt,

however, that it was lacking information in several areas, and those areas should have been expanded

upon. First, Chinander stated that I did a good job of describing causes of suicide among older adults but

that I did not expand upon the topic of Dr. Jack Kevorkian and his role in physician-assisted suicide. I feel

that the topic of Dr. Kevorkian relates to all age groups and not just older adults. Thus, it would not be

entirely appropriate to include it, because he was not really a factor in suicide in older adults, he was

merely someone who helped people that were already suicidal, he did not help them become that way.

Chinander also stated that I was missing biological factors as a cause for depression and suicide among

older adults. It was not my intention to include this information, although it may have been an effective

addition; rather, I was focused solely on why adults become depressed later in life and not on debating

whether they were depressed from an earlier age. Chinander made a good point, however, in stating

that I did not show clear support for older adults committing suicide at a faster rate. I provided astatistic at the beginning of the paper, but perhaps further expansion could have made the point clearer.

A point made by Lehr was my omission of preventative measures and my failure to mention the effects

of depression in older people. Although preventative measures relate to the topic, this paper was not

intended to provide solutions to the problem but simply to make people aware of the problem and that


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it is continuing to grow. The paper did not hint at any solutions; therefore, readers should not have

expected any. Lehr stated that I did not mention the effects of depression in older adults; I feel,

however, that I did so throughout the paper. One line directly from my paper is this: "The person wants

primarily to flee from pain, such as feeling boxed in, rejected, and especially hopeless and helpless

(Leenaars, 2003)." I feel that this clearly represents what the person is thinking at the time of suicide

contemplation.

A peer commentary by Okeke had some good points that would have enhanced my paper. Okeke stated

that I should have considered addressing the issue of why some older adults become depressed and

suicidal while others go about their normal lives. I actually did not think about this aspect, and it would

have enhanced my paper.

The peer commentary by Tacy did an excellent job of adding insight to my paper. Tacy's main criticismwas that I did not describe the role of society as a factor in depression and suicide in older adults.

Although I considered this issue when writing the paper, I did not include this issue because I wanted to

focus mainly on the physical and psychological attributes of suicide and depression in older adults.

Overall, I feel that everyone came away from my paper with a better understanding of the causes of

suicide and depression in older adults, although some points could have been clearer. I appreciate the

positive feedback and constructive criticism.

References

Casten, R., Rovner, B., & Edmonds, S. (2002). The impact of depression in older adults with age-related

macular degeneration. Journal of Visual Impairment and Blindness, 11, 399-405.

Connor, K., Conwell, Y., & Duberstein, P. (2001). The validity of proxy-based data in suicide research: A

study of patients 50 years of age and older who attempted suicide. II. Life events, social support and

suicidal behavior. Acta Psychiatrica Scandinavia, 104, 452-457.


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Gatz, M., & Fiske, A. (2003). Aging women and depression. Professional Psychology: Research and

Practice, 34, 3-9.

Leenaars, A. (2003). Can a theory of suicide predict all "suicides" in older adults? Crisis, 24, 7-16.

Lynch, T., Compton, J., Mendelson, T., Robins, C., & Krishnan, K. (2000). Anxious depression among

older adults: Clinical and phenomenological correlates. Aging and Mental Health, 4, 268-274.

Miller, J., Segal, D., & Coolidge, F. (2001). A comparison of suicidal thinking and reasons for living among

younger and older adults. Death Studies, 25, 357-365.

Mireault, M., & DeMan, A. (1996). Suicidal ideation among older adults: Personal variables, stress and

social support. Social Behavior and Personality, 24, 385-392.

Pearson, J., Conwell, Y., Lindesay, J., Takahashi, Y., & Caine, E. (1997). Elderly suicide: A multi-national

view. Aging and Mental Health, 1, 107-111.

Salib, E., Cawley, S., Healy, R. (2002). The significance of suicide notes in older adults. Aging and Mental

Health, 6, 186-190.

Waern, M., Rubenowitz, E., Runeson, B., Skoog, I., Wilhelmson, K., & Allebeck, P. (2002). Burden of

illness and suicide in older adults: Case-control study. British Medical Journal, 324, 1355-1357.

Weaver, A., & Koenig, H. (2001). Elderly suicide, mental health professionals, and the clergy: A need for

clinical collaboration, training, and research. Death Studies, 20, 495-508.

Wetherell, J., Gatz, M., & Pedersen, N. (2001). A longitudinal analysis of anxiety and depressive

symptoms. Psychology and Aging, 16, 187-195.


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Zweig, R., & Hinrichsen, G. (1993). Factors associated with suicide attempts by depressed older adults: A

prospective study. American Journal of Psychiatry. 150, 1687-1692.

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