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

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

Passive Suicide Ideation: An Indicator of Risk Among Older Adults Seeking Aging Services?

OBJECTIVES: This study examines patterns of endorsements of active suicide ideation (SI), passive SI (synonymous with death ideation), and psychological distress (i.e., depressive and anxious symptomatology) in a sample of vulnerable older adults. METHODS: Data were collected via in-home interviews with aging services care management clients aged 60 years and older (n = 377). The Paykel scale for suicide measured the most severe level of suicidality over the past year, and the ninth item of the Patient Health Questionnaire (PHQ-9) measured current passive/active SI. The remaining items from the PHQ (i.e., PHQ-8) and the Goldberg Anxiety scale measured distress. RESULTS: Latent class analysis revealed a four-class model: a group with mild distress and no active SI, a group with high distress and no ideation, a group with mild distress and both passive and active SI, and a group with high distress and both passive and active SI. DISCUSSION: Results indicate that passive SI rarely presents in vulnerable older adults in the absence of significant risk factors for suicide (i.e., psychological distress or active SI). Thus, the desire for death and the belief that life is not worth living do not appear to be normative in late life.

Course of late-life depression in China is chronic and unremitting.

OBJECTIVE: The world's largest aging population resides in China. Depressive disorders represent a public health problem among older adults in China; however, little is known about the course and natural outcomes with routine treatment in primary care. METHODS: We examined the one-year naturalistic course of depressive symptoms in older adult Chinese primary care patients (Hangzhou, China). FINDINGS: We found slight improvement among most of the older adults who initially presented with mild or subsyndromal depressive symptoms, but marked increase in severity in one group of initially mildly depressed older adults; a lack of improvement among all older adults with severe initial presentations. Greater physical illness burden, lower functional capacity, and lower family support were associated with greater initial depressive symptom severity and lack of improvement over time. CONCLUSION: The naturalistic course of depressive illness in older adult primary care patients in urban China is typically chronic and unremitting for those with severe symptoms and slowly improving for those with milder symptoms. Because access to specialty mental health care is limited, treatments for late-life depression need to be developed that can be effectively and feasibly implemented in Chinese primary care practices.

Age-related concerns of male veteran callers to a suicide crisis line.

In July 2007, the United States Department of Veterans Affairs (VA) partnered with the Department of Health and Human Services' Substance Abuse and Mental Health Service Administration (SAMHSA) to create the Veterans Crisis Line (VCL) in order to meet the unique needs of Veterans in distress. The current study utilized a mixed methods design to examine characteristics of male callers to the VCL. Results from qualitative analyses demonstrated that the majority of callers between April 1 and August 31, 2008 contacted the VCL with concerns related to mental health issues, suicide ideation, and substance abuse issues. Quantitative analyses demonstrated age differences associated with concerns presented by callers such that middle-aged and older callers were more likely to present with loneliness and younger callers were more likely to present with mental health concerns. The results of this study will help to inform future research designed to optimize the effectiveness of the VCL for suicide prevention in Veterans.

Suicide and death ideation in older adults obtaining aging services.

OBJECTIVES: To assess the frequency and correlates of death and suicide ideation in older adults accessing aging services. DESIGN: Cross-sectional. SETTING: Data for this study were collected via in-home interviews. PARTICIPANTS: Aging Services Network (ASN) care management clients aged 60 years and older (N = 377) were recruited for this study. MEASUREMENT: The PHQ-9 and the Paykel Suicide Scale were used to assess death and suicide ideation. Correlates of death and suicide ideation were also examined. RESULTS: Fourteen percent of subjects endorsed current death or suicide ideation, 27.9% of subjects endorsed death ideation in the past year, and 9.3% of subjects endorsed suicide ideation in the last year. Current death and suicide ideation were associated with greater depressive symptoms. As compared with individuals without ideation, individuals with death ideation demonstrated higher levels of depressive symptoms, more medical conditions, and lower social support. Individuals with suicide ideation demonstrated higher depressive and anxiety symptoms and less perceived social support. Finally, as compared with individuals with death ideation, individuals with suicide ideation demonstrated higher depressive and anxiety symptoms and more alcohol misuse. CONCLUSIONS: Death and suicide ideation are common among ASN clients. There were both differences and similarities between correlates of death and suicide ideation. ASN providers are uniquely situated to address many of the correlates of suicide ideation identified in this study; in order to effectively manage suicide ideation in an ASN setting, however, links to primary and mental health care providers are necessary.

Online support for individuals with spinal cord injuries: an ethnographic investigation.

BACKGROUND: Although social support is an important protective factor for individuals with spinal cord injuries (SCIs), individuals often encounter significant barriers to obtaining support after experiencing a SCI. It has been suggested that the Internet may serve to help individuals with disabilities overcome common barriers in obtaining support, yet research examining the efficacy of Internet-based support for individuals with SCI has been mixed. OBJECTIVE: To develop a more nuanced understanding of how individuals with SCI can or might use the Internet for support. DESIGN: Using an ethnographic approach, we conducted semi-structured interviews with nine individuals with SCI to explore perceived needs and barriers to information-seeking and online support. SETTING: Participants were recruited from Veterans Administration medical center outpatient and inpatient units providing specialty care to individuals with SCIs and from a community SCI Center of Excellence. RESULTS: Individuals with SCI gain emotional, problem-focused, and reciprocal support from online sources. CONCLUSIONS: Online resources can provide important opportunities for social support for individuals with SCI.

Challenges Associated With Managing Suicide Risk in Long-Term Care Facilities.

Little information about suicidal ideation and behavior in long-term care (LTC) facilities is available. Nonetheless, the implementation of the Minimum Data Set 3.0 requires that LTC facilities screen their residents for suicide risk and have protocols in place to effectively manage residents' responses. In this article, the authors briefly discuss the risk factors of suicide in the elderly and the problems that suicidal ideation and behavior pose in the LTC environment. The authors explain issues that arise when trying to manage suicide risk in the elderly LTC population with general, traditional approaches. These inherent issues make it difficult to develop an effective protocol for managing suicide risk in LTC facilities, leading the authors to propose their own framework for assessing and managing suicide risk in the LTC setting.

Emphasis on autonomy and propensity for suicidal behavior in younger and older adults.

A cognitive style marked by emphasis on autonomy has been linked to negative outcomes throughout the life span. Two preliminary studies are presented that examined factors on a measure of autonomy (Personal Style Inventory-Revised) in relation to propensity for suicidal behavior (Suicidal Behaviors Questionnaire-14; SBQ-14). Perfectionism, B=.15, SE=0.03, p<.01, and Defensive Separation, B=.04, SE=0.01, p ≤ .01, predicted SBQ-14 in younger adults. Need for Control, B=.234, SE=0.10, p<.05, predicted SBQ-14 in older adults. Findings suggest that aspects of autonomy may be relevant to understanding suicidal behavior; however, more research is needed examining the association between autonomy and suicidal behavior in the context of depression. Nonetheless, these studies suggest a promising avenue for future research.

Effects of a late-life suicide risk--assessment training on multidisciplinary healthcare providers.

Older adults are among the highest at risk for completing suicide, and they are more likely to seek mental health services from providers outside of traditional mental health care, but providers across the spectrum of care have limited training in suicide risk assessment and management and particularly lack training in suicide prevention for older adults. An educational program was developed to increase awareness and improve suicide risk assessment and management training for a range of healthcare providers who may see older adults in their care settings. One hundred thirty-two participants from two Veterans Affairs Medical Centers participated in a 6.5-hour-long workshop in the assessment and management of suicide risk in older adults. Participants were asked to complete pre- and postworkshop case notes and report on subjective changes in knowledge, attitudes, and confidence in assessment and managing suicide risk in older adults. Participants included social workers, nurses, physicians, psychologists, and occupational therapists from a variety of care settings, including outpatient and inpatient medical, outpatient and inpatient mental health, specialty clinics, home, and community. After the workshop, participants demonstrated improvement in the overall quality of case notes (P = .001), greater ability to recognize important conceptual suicide risk categories (P = .003), and reported heightened awareness of the importance of late-life suicide. The results suggest that educational training may have beneficial effect on the ability of multidisciplinary care providers to identify and manage suicide risk in elderly adults.

Psychometric properties of the Beck Depression Inventory II (BDI-II) among community-dwelling older adults.

The psychometric properties of the Beck Depression Inventory-II (BDI-II) as a self-administered screening tool for depressive symptoms were examined in a sample of community-dwelling older and younger adults. Participants completed the BDI-II, the Center for Epidemiologic Studies Depression Scale, the Coolidge Axis II Inventory, the Perceived Stress Scale, and the Short Psychological Well-Being Scale. Internal reliability of the BDI-II was found to be good among older and younger adults. The average BDI-II depression score did not differ between younger and older adults. Solid evidence for convergent and discriminant validity was demonstrated by correlations between the BDI-II with the other measures. The BDI-II appears to have strong psychometric support as a screening measure for depression among older adults in the general population. Implications for using the BDI-II as an assessment instrument in behaviorally based psychotherapy are discussed.

Attitudes toward suicide and suicidal risk among younger and older persons.

Despite a burgeoning literature on some aspects of elder suicide, little is known about the specific attitudes that older people hold about suicide. The present study examined attitudes toward suicide and suicidal risk among 96 younger and 79 older adults. Participants completed the Suicide Opinion Questionnaire and the Suicide Risk Scale. Regarding suicidal risk, younger adults scored significantly higher than older adults. Regarding attitudes, older adults scored significantly higher than younger adults on 7 of 15 subscales, indicating that for older adults, suicide was more acceptable, more strongly related to a lack of religious conviction, more lethal, more normal, more irreversible or permanent, more strongly related to demographics, and more strongly related to individual aspects. An implication is that older adults hold both adaptive and maladaptive attitudes about suicide that may be useful in providing a social and cultural context to the study, prevention, and treatment of elder suicide.