Evidence-Based Reviews

Preventing late-life suicide: 6 steps to detect the warning signs

Current Psychiatry. 2003 August;2(8):15-26

When a life is at stake, vigilance for deadly plans and weapons and a specific strategy for screening and decision-making are vital.

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References

1. Centers for Disease Control and Prevention. Surveillance for Injuries and Violence Among Older Adults (CDC Surveillance Summary, December 17, 1999, Chap. 3:27-50). www.cdc.gov/mmwr/PDF/SS/SS4808.pdf

2. Kaplan HI, Sadock BJ. Synopsis of psychiatry (6th ed). Baltimore: Williams & Wilkins, 1991.

3. Lyon DE, Chase LS, Farrell SP. Using an interview guide to assess suicidal ideation. Nurse Practitioner 2002;27:26-31.

4. Conwell Y, Lyness JM, Duberstein P, et al. Completed suicide among older patients in primary care practices: A controlled study. J Am Geriatr Soc 2000;48:23-9.

5. Conwell Y, Duberstein PR, Cox C, et al. Relationships of age and Axis I diagnoses in victims of completed suicide: A psychological autopsy study. Am J Psychiatry 1996;153:1001-8.

6. Harwood D, Hawton K, Hope T, Jacoby R. Psychiatric disorder and personality factors associated with suicide in older people: A descriptive and case-control study. Int J Geriatr Psychiatry 2001;16:155-65.

7. Henriksson MM, Marttunen MJ, Isometsa ET, et al. Mental disorders in elderly suicide. Int Psychogeriatr 1995;7:275-86.

8. Conwell Y, Duberstein PR, Caine ED. Risk factors for suicide in later life. Biol Psychiatry 2002;52:193-204.

9. Beck AT, Brown GK, Steer RA. Psychometric characteristics of the Scale for Suicide Ideation with psychiatric outpatients. Behav Res Ther 1997;35:1039-46.

10. Beck AT, Steer RA. Manual for the Beck Depression Inventory. San Antonio, TX: The Psychological Corporation, 1987.

11. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: Twenty-five years later. Clin Psychol Rev 1988;8:77-100.

12. Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: The hopelessness scale. J Consult Clin Psychol 1974;42:861-5.

13. Drake RE, Cotton PG. Depression, hopelessness and suicide in chronic schizophrenia. Br J Psychiatry 1986;148:554-9.

14. Beck AT, Steer RA, Kovacs M, Garrison B. Hopelessness and eventual suicide: A 10-year perspective study of patients hospitalized with suicidal ideation. Am J Psychiatry 1985;142:559-63.

15. Riskind JH, Beck AT, Brown G, Steer RA. Taking the measure of anxiety and depression: Validity of the reconstructed Hamilton Scales. J Nerv Ment Dis 1987;175:474-9.

16. Lamberg L. Psychiatric emergencies call for comprehensive assessment and treatment. JAMA 2002;288:686-7.

17. Sadavoy J, Lazarus LW, Jarvik LF. Grossberg GT (eds). Comprehensive review of geriatric psychiatry (2nd ed). Washington, DC: American Psychiatric Press, 1996.

CASE REPORT: I have a gun

Mr. V, age 77, appears depressed and anxious during his appointment at a mental hygiene clinic. He reports insomnia, concentration trouble, and anhedonia. He tells the psychiatrist he keeps a loaded gun at home and is not sure he can control his suicidal impulses.

The patient is Caucasian and has a history of heart failure, pulmonary disease, and type 2 diabetes. His wife died 18 months ago. He lives alone, but his sister lives nearby. He recently received a right hip replacement, which required 3 months of rehabilitation in a nursing home to recover from surgical complications. He still has trouble walking.

As in Mr. V’s case, treating older patients referred for psychiatric care often involves evaluating suicide risk. His age, race, gender, depressed mood, recent bereavement, and medical ailments place him in the population at highest risk of suicide (Box, Table 1).^1-8

Box

Studies: Suicide risk increases in later life

Approximately 20% of all suicides in the United States are committed by persons age 65 or older,¹ who account for 13% of the total population. The suicide rate among persons older than 75 is three times higher than it is for the young.² Older Caucasian men have the highest per-capita rate of completed suicide, compared with any other group of Americans.³

Psychiatric disorders. The rates of Axis I disorders among older persons who commit suicide fall within the average range for all age groups (70 to 90%). However, the types of disorders seen in the older population differ from those of younger suicides (Table 1).^4-8

Affective illness has been termed “the predominant psychopathology associated with suicide in later life.”⁴ Among older persons who commit suicide, three-fourths (76%) have diagnosable mood disorders⁴ and nearly two-thirds (63%) have depression.⁶ Contributing risk factors include alcoholism and substance abuse,^4,6,7 Axis II disorders, and dementia.⁶

Losses and medical illness. In later life, bereavement, loss of independence, or financial reversals may lead to depression. Older persons who take their own lives also tend to have greater physical health burdens and more functional disabilities than those who do not commit suicide.^6,8

This article describes an age-based psychiatric workup of the suicidal older patient, including factors to consider when screening for depressive symptoms, prescribing drug therapy, and determining the need for hospitalization.

AGE-BASED CLINICAL WORKUP

For older patients who report suicidal ideation, an age-appropriate workup—using clinical interviews and screening instruments—is essential. The clinical interview can build rapport and gather information about the patient’s suicidal plan or intent. Based on our experience, we recommend the following 6-step screening interview, summarized in Table 2.

Ask about a specific plan. Does the patient have the means readily available to carry out this plan? What is the timeline (imminent versus vaguely futuristic)? Does the patient report having control over this plan?
Gather a suicide history. Has the patient attempted suicide before? By what means? Is there a family history of suicide? If yes, by what means did this family member commit suicide, and how was the patient affected?
Assess social status. How isolated is the patient? Have there been recent changes in his or her social circle, such as loss of a spouse? Can the patient identify at least one person who would be negatively affected by the suicide?
Assess medical health. Does the patient suffer from chronic pain? Does the patient have a recently diagnosed medical condition? Has a longstanding medical condition become more debilitating? Does the patient report feeling hopeless about impending medical difficulties? Has he or she been keeping regularly scheduled medical appointments with outpatient clinicians?
Assess mental health. Does the patient meet DSM-IV criteria for depression or schizophrenia, which are associated with high suicide risk? Does he or she report being hopeless or helpless? Is the suicidal ideation ego dystonic?
Ascertain clinical signs of suicidal intent. Has the patient:

Table 1

Suicide risk with mental and physical illness, by patient age

Risk factors	Young (21 to 34 yrs)	Middle-aged (35 to 54 yrs)	Young-old (55 to 74 yrs)	Elderly (77+ yrs)
Psychiatric disorders	•	•	•	•
Mood disorders		○	•	•
Alcohol abuse	○	•	○
Primary psychoses	•	○
Personality disorders	○
Physical ailments			•	•
• Significant risk factor ○ Potential risk factor
Source: Compiled from information in references 4-8.

CASE REPORT continued: Some telling signs

Mr. V’s laboratory screening reveals slightly elevated serum glucose and mild anemia. An ECG reveals a type I heart block, but all other lab results are unremarkable. His sister reports he recently gave away his dog, which he and his wife had owned for many years. He has also mentioned a desire to revise his will when speaking to other family members. Hospital records indicate he has missed numerous medical appointments over the past 4 months.