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 this theory 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 accounted for 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).
Studies of Depression and Suicide in Older Adults
Depression in Older AdultsA 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 AdultsA 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 AdultsSuicide 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).
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 likely 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 killed 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 AdultsDepression 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 consistently reported 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.
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 AdultsPhysical 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).
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).
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. It was 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.
Summary and Conclusions
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.
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.
A Closer Look at Relationships, Genetics, and Choice
David E. Chinander
Rochester Institute of Technology
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.
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 times more 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.
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 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.
A Cause-Effect Relation and Preventive Measures?
Juliana C. Lehr
Rochester Institute of Technology
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 medical technology, 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.
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.
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.
A Problem Overlooked
Udochi I. Okeke
Rochester Institute of Technology
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.
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.
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.
A Cultural Responsibility?
Kathryn O. Tacy
Rochester Institute of Technology
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 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?
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 a statistic at the beginning of the paper, but perhaps further expansion could have made the point clearer.
Expanding Upon Depression and Suicide Among Older Adults
Rochester Institute of Technology
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 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 criticism was 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.
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.
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.
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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