Testimony for Senate Hearing on Elderly Suicide

Jane L. Pearson

Chief, Clinical and Developmental Psychopathology Program

Mental Disorders of the Aging Research Branch

National Institute of Mental Health

Suicide is an important public health problem. In 1993, the most recent available statistics indicate that the total number of suicides in the U.S. was 31, 102. Although persons age 65 and older accounted for 13 percent of the population, they accounted for 20 percent, or over 6,000 of the 1993 suicides. the most accurate index for looking at the total number of suicides in the U.S., and those by age group are age adjusted rates. Using these rates, the Centers for Disease Control and Prevention's National Center for Health Statistics reports that there were 12 suicides for every 100,000 persons in 1993. For people 65 and older, the rate of suicide climbs with age: It ranges from 15 100,000 among persons aged 65 to 69, and to 24 per 100,000 for persons aged 80 to 85 - double the U.S. rate.

In the U.S. and other industrialized nations, older age and male gender are consistent demographic factors related to suicide patterns. With few exceptions, the most recent World Health Organization Statistics from over 30 industrialized nations (1994-94) indicate that men who are 75 years and older have the highest rates of suicide. In the U.S., older white males have the highest rates of any age, gender, or racial group. Suicide rates for white males among the "oldest-old", age 80 and older, have been consistently in the range of 60 to 70 per 100,000 since 1985. This is 6 times the current overall national rate, 3 times the rate of same-aged African-American males, twice the rate of Indian and Alaskan Natives, and Hispanic, Asian and Pacific Islander elderly males.

This high risk group has not been ignored by public health officials. Healthy People 2000, a document establishing a National health promotion and disease prevention agenda in 1990, targeted older white men among the groups most at risk for suicide. Although objectives to reduce suicides by 15 percent in this group by the year 2000 were set, they are, unfortunately, far from being met.

The NIMH, as part of its mission to understand, treat, and prevent mental disorders, regards suicide as an important public health issue. Research aimed at improving our understanding of ways to prevent suicide is a significant priority for the National Institute on Mental Health. In fiscal year 1995, NIMH spent approximately $9 million for support of studies focused primarily on suicide and suicidal behavior. This represents a nearly eight-fold increase over the last decade.

Along with several other NIH components and Federal agencies NIMH is a co-sponsor of the Centers for Disease Control and Prevention's National Mortality Followback Survey. NIMH is supporting the inclusion of an over sampling of elderly suicide cases, and questions regarding depressive symptoms to be asked of informants about all suicides. This will be the first study of a national sample of elderly suicides that documents their possible depression and their health service use.

In addition to serving as the NIMH contact for this survey, I serve as Chair of the NIMH Suicide Consortium. The purposes of this consortium are to monitor and encourage research program development in suicide across the life span, keep abreast of scientific developments in suicide research, convene workshops to help the field determine new directions to go, and to disseminate scientific knowledge to the public, media, and policy makers. Two NIMH Fact Sheets, one describing current statistics and risk factors for all age groups, and a second focused on elderly suicide are examples of the type of public information documents and Internet web--site pages that have bee prepared for public dissemination. These documents are in the public domain, and are freely reproduced for use by clinicians, social service providers, professional and lay organizations, and the general public.

I would now like to highlight some of what we have learned about suicide. Research has clearly demonstrated that almost all people who kill themselves have at least one diagnosable mental or substance abuse disorder. We know this from data gathered through the use of the psychological autopsy method. Analogous to the physical autopsy, where organ systems are examined for the purpose of establishing diagnoses of major physical illness the psychological autopsy uses interview data from family, friends, co-workers, classmates, and others to develop a psychological profile and to establish diagnoses of mental disorders. Studies using the psychological autopsy method have consistently documented that nearly 90 percent of those who commit suicide have at least on diagnosable psychiatric condition.

From physical autopsy studies, altered levels of neurotransmitter serotonin have been found in suicide completers. Similarly, depressed persons, those with extreme impulsivity, and persons who have made violent suicide attempts also have altered serotonin. Psychological autopsy results have also indicated that adverse life events can contribute to suicide risk. Other risk factors that have been identified include family history of violent behavior, mental disorder, or suicide, and exposure to the suicidal behaviors of others. Therefore, our current scientific picture of suicide risk suggests that acute stress, in combination with mental disorder, family history, exposure to suicide, and biological risk factors, can result in significant risk profile.

It is important to note that these are statistical associations only. Suicidal behavior is not the typical response to stress. Many people experience a number of these risk factors, and do not kill themselves.

In a 1992 NIMH workshop on suicide across the life course, researchers further focused on what may be unique among older suicides relative to middle-aged and younger suicides. A key finding was that the most common psychiatric disorder among elderly suicides is major depression, most often a first episode. This is a in striking contrast to younger suicides, where substance abuse an other psychiatric disorders are more common. Moreover, this first episode of depression is typically characterized by the absence of complicating factors such as psychosis or mania, and it tends to be of moderate severity. This type of depression is, classically, the most amenable to treatment.

Tragically, however, recognition of depression and initiation of treatment among elderly suicide victims has been rare. This is not due to social isolation or withdrawal. Research has shown that most elderly suicide victims either live with family members or are in contact with family members and friends. We also know that access to health care is not a problem among elderly suicides: At least 70 percent of these older suicide victims have visited primary care providers within a month of the suicide. Virtually none have seen mental health professional, and very few have ever received mental health treatment, including treatment for depression from their primary care physicians.

The clear implication from these findings is that a great opportunity to prevent suicide lies at the primary care office doorstep. Unfortunately, we know that primary care physicians tend to allot less time with older patients on average, and that they frequently do not recognize nor adequately treat depression in their older patients. But physicians should not get all of the blame: Older patients are less likely than their younger counterparts to tell their doctor that they feel depressed. There may be many reasons for this pattern: stigma over mental illness or a tendency to verbalize physical pain more easily than emotional pain. In addition, older persons, as well as their family members, may hold "ageist" attitudes that consider depression a normal reaction to growing old.

Fortunately the ground work establishing the fact that depression in late life in not normal, and that it is treatable, is in place. The 1991 NIH Consensus Development Conference on Late Life Depression identified effective treatments, which have been incorporated into the Clinical Practice Guidelines for Depression for Primary Care Physicians. One of the next policy and practice challenges is similar t that of all mental health treatments: How to integrate effective treatment in health care settings where primary care physicians are increasingly asked to take on more responsibilities. This task is particularly critical for the recognition and treatment of depression in the elderly, as most elderly seek help from primary care physicians and not mental health professionals.

In addition to examining the mental disorders and service use patterns among older persons who suicide, the HIMH is also supporting research t help build a basic and clinical research base about the neurobiology of aging, depression, and suicide. NIMH is not alone in these efforts: We work in a coordinated manner with other HIM components in a concerted effort to apply the basic and behavioral neurosciences to disorders of brain and behavior. New technologies are helping us understand the possible biological and neurobehavioral vulnerabilities that increase risk for depression and suicide. New approaches to brain imaging are allowing us to characterize the structure and function of specific neurotransmitter systems. New approaches in molecular biology and behavioral pharmacology are allowing us to develop experimental models of these self-destructive behaviors and to pilot test potential treatments. Associations between alterations in the serotonin system and completed suicide, violent suicide attempts, impulsive disorders, and depression continue to be important avenues of investigation. Alterations in the serotonin system have also been proposed to occur with normal aging, raising the question as to whether a neurobiological vulnerability occurs with aging, which may interact with other vulnerabilities and stressors.

Suicide research must continue on many fronts. More studies utilizing the psychological autopsy method can help clarify what factors converge to create suicide risk. More research from the laboratory should help us better understand the contribution of serotonin. Studies based in hospitals and outpatient clinics, where the psychiatric diagnoses can be best characterized and where older suicide attempters can be studied are needed. In the community setting, more research on the role of life events, service use, and patterns of depressive symptoms that appear in the elderly should be done. Finally, given our current state of knowledge about the role of major depression in late life suicide, we need to urgently find effective ways to educate older persons and their families, and health care providers who are most likely to interface with older persons (ie., primary care physicians), about how to detect and treat late life depression.

In closing I would like to emphasize that suicide is a multi-dimensional event. We are still unable to adequately predict who will and who won't commit suicide. We do not know enough about what protects people from acting on suicidal thoughts. We do know, however, that most elderly suicide attempts and completions are expressions of extreme distress, and that they rarely occur in the absence of depression. Suicide is a public health issue of concern for the individual, the family, and the community. It deserves our full and active attention as researchers clinicians, educators, and public policy makers. The NIH is committed to continue to pursue an aggressive program of research in this area.

To direct comments about the information contained in these pages, please write to marsiske@ufl.edu