Boosting the Mental/Behavioral Health Infrastructure to Prevent Elder Suicide

Suicide is a serious public health problem. In 2020 (the most recent data available), nearly 46,000 Americans died by suicide—equating to approximately 130 deaths by suicide each day—and another 1.20 million suicide attempts occurred. What may be surprising to some is that more than a third of people who die by suicide are ages 55 or older. Too often, despair and suffering in late life is perceived as an expected reaction to the challenges associated with aging. This portrayal of older adults—as isolated and facing impending disability or death—may mask preventable deaths and foster the idea that older adults have nothing to live for.

Suicide in Older Adults

Older adults are less likely to be assessed for suicidal risk when in fact, older men are one of the highest risk groups. Ageism plays a part if healthcare providers, caregivers or other close contacts assume suicidal thoughts are an expected reaction to aging; this assumption contributes to suicide risk with older adults and blocks access to care. For older individuals, suicide attempts are more likely to result in death compared to younger people, in part because older adults tend to plan suicide more carefully and use more immediately lethal means. They are less likely to be discovered and rescued, and physical frailty makes it less likely for them to recover from self-injury.

Two strong predictors of suicidal thinking are perceived burdensomeness and thwarted belonginess. The first, perceived burdensomeness, refers to a painful sense that one’s mere existence burdens family, close friends or others, and a belief by the suicidal person that it would be “easier on everyone” if they were no longer alive.

Thwarted belonginess is the experience that one is alienated from others and not an integral part of a family or other social network. Disability and loss of functioning; chronic, life-limiting or terminal illnesses; and other phase-of-life changes can lead to a sense of being a burden to others. Older adults also may be prone to social isolation and a lack of belonging through life changes such as retirement, being widowed, death of friends, and an otherwise narrowing of one’s social network. Taken together, these become strong predictors of suicidal ideation.

The Mental and Behavioral Health Infrastructure

Obstructive provider attitudes, ageism and lack of mental health providers formally trained to work with older adults have contributed to challenges, setbacks and barriers in managing suicidality. Reducing ageist beliefs alongside increasing knowledge of aging and experience with older adults could prove beneficial in boosting detection and intervention for elder suicide.

• The best way to reduce death by suicide is early detection of risk. This includes systematic screening of suicide risk in primary care settings and other routine care settings serving older adults. Although depression is closely associated with suicidality, not all older adults who are depressed will be suicidal. Furthermore, not everyone who attempts or dies by suicide is depressed. Therefore, risk assessment must extend beyond mental health conditions and incorporate multiple areas of well-being, including physical health, coping style and personality factors, functioning, and social support and social context.
• Mental/behavioral healthcare must be accessible and acceptable to older adults. For example, integrating behavioral healthcare into settings that older adults frequent, such as primary care and social service agencies. Older adults often seek out primary care for routine evaluation (e.g., annual exams) and for care of chronic disease or other ailments. Such settings hold less stigma than seeking traditional mental health treatment.

• Strengthen community supports and reduce social isolation among older adults. This holds true across the care continuum. For example, easy and affordable access to rehabilitation services, long-term care services, and palliative and end-of-life care are essential to empower patients, promote well-being, and optimize functioning.
• The mental/behavioral healthcare workforce must be trained in issues related to aging and older adulthood. There is a dire shortage of professionals equipped to care for older adults with mental health and substance use conditions. To reduce suicide deaths, we need an adequate and well-trained mental healthcare workforce equipped to handle the unique and complex needs of diverse older adults. Public funding—such as through funding from federal agencies under the U.S. Department of Health and Human Services—is necessary to invest in the human capital of the geriatric workforce. Training programs also must integrate work with older adults and deem such work essential to a well-prepared, generalist clinician. Finally, training must extend across diverse older adult populations (e.g., LGBTQIA older adults, racial and ethnically diverse communities) and care settings (e.g., primary care, social service agencies).

The Way Forward

By understanding the factors associated with suicide in later life, we can identify crucial next steps and implement programs to improve suicide detection and management in older adults.

• The 988 Suicide & Crisis Lifeline (988) connects people in crisis (or their loved ones) directly to the National Suicide and Crisis Lifeline, where counselors provide free, unbiased and confidential support 24/7. Older adults who call or send a text message to 988 are connected with a trained counselor from the existing Suicide Prevention Lifeline network.
• Community-based social service agencies may partner with researchers and clinicians to better equip their own staff in screening for suicide and delivering evidence-based psychosocial interventions to improve well-being. Although not specific to suicide, demonstrations such as these have trained non-specialists, including senior center volunteers and employees of an aging service agency that provides home-delivered meals, to successfully deliver brief interventions to reduce depression.
• Mental health providers can assess strengths and bolster protective factors in their work with older adults. Such focus should leverage social connectedness and a sense of personal worth and autonomy.
• To integrate mental healthcare most effectively, insurance payers and healthcare companies need to find ways to consistently and meaningful reimburse integrated models such as Collaborative Care and the primary care behavioral health model. For example, the PROSPECT intervention effectively reduced suicidal ideation among older adults with depression in primary care by improving physician knowledge about geriatric depression and embedding depression care managers, who offered support and follow-up. The dissemination and sustainment of such integrated models remains challenging in the absence of payment models to meaningfully support them.

More information about community supports to prevent older adult suicide is available from the National Association of State Mental Health Program Directors.

Rakshitha Mohankumar, MA, is a doctoral student in clinical psychology with research interests in identifying stressors and improving mental and emotional functioning via coping. Brenna Renn, PhD, is an assistant professor and licensed psychologist who specializes in geropsychology. Dr. Renn directs the UNLV TREATment Lab, of which Mohankumar is a member. Both are in the department of Psychology at the University of Nevada, Las Vegas.