Despite a modest reduction in the prevalence of suicide in older Americans, the increasing size of the aged population insures an increase in the number of suicidal deaths. And because suicide in one generation conveys a 6-fold increase in risk to the next, the need to reduce the number of late life suicides is a public health imperative. Both the WHO and the US Institute of Medicine have called for broad based efforts to reduce the prevalence of suicide. However, data that might be applied to a population-based strategy of prevention derive from post-mortem or case-cohort series.
Objective: At 15 suicidal deaths per 100,000, older Americans' direct detection of risk and protective factors through epidemiologic investigation is unrealistic. We sought to review the literature on suicidal ideation, which is far more prevalent, and a key element in the clinical determination of risk.
Materials and Methods: We examined 9 population-based English language reports since 1976 to compare measures of suicidal ideation, examine associated characteristics and assess subsequent mortality.
Results: All measures of suicidal ideation distinguished “passive” thoughts of death from “active” intent or plans. However, the period in which the measures were applied varied considerably from “in the last week” to “have you ever”. Several studies employed terms such as “do away with yourself” rather than “suicide”. Among the Epidemiologic Catchment Area (ECA) sample of 18,000 adults, 4% not meeting criteria for any DSM-III diagnosis had “contemplated suicide”. Neither age nor depression was associated with suicidal ideation. Similarly, 3% of 19,000 Canadians had “seriously considered” suicide, but “loneliness” rather than depression related to suicidal thought. Among ECA respondents aged 65 and over, the number who “wished they were dead” ranged from 0.9–1.7%. The number who found “life not worth living” ranged from 7–8.3%. In Padua (Scocco et al 2001) 2.5% of older adults felt “life not worth living” and 4.2% had “wished for death”. In Goteburg (Skoog et al 1996) 4% felt “life not worth living” and 4% had “wished for death”. Women who felt “life not worth living” exhibited a three-fold increase (43.2% vs.14.2%) in mortality compared to those feeling otherwise. Suicidal ideation predicted a 6-fold increase in mortality in Kuo et al’s 2001 ECA follow-up study but the number of older adults in the sample was negligible.
Conclusion: Active and passive suicidal ideas are from 200 to 500 times more prevalent than suicidal deaths among older community residents and may predict subsequent mortality. Problems with terminology, methodology, and diagnostic measures limit the utility of the existing data. There are no epidemiologic data predicting the emergence, persistence or remission of suicidal ideas. However, the frequency of suicidal ideation in old age suggests that epidemiologic study can realistically advance suicide prevention from clinic-based to population-based approaches.
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