Abstract
The National Strategy for Suicide Prevention (2012) has set a goal to reduce suicides by 20 % within 5 years. Suicide rates are higher in older adults compared to most other age groups, and the majority of suicide completers have visited their primary care physician in the year before suicide. Primary care is an ideal setting to identify suicide risk and initiate mental health care. We review risk factors for late-life suicide; methods to assess for different levels of suicidality; and recent research developments regarding both effective assessment and management of suicide risk among older primary care patients. We highlight that broader scale screening of suicide risk may be considered in light of findings that suicidality can occur even in the absence of major risk factors like depression. We also highlight collaborative care models targeting suicide risk, and recent innovative interventions that aim to prevent the development of suicidal ideation and suicidal behavior.
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References
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Centers for Disease Control and Prevention: FASTSTATS: suicide and self-inflicted injury. Available at http://www.cdc.gov/nchs/fastats/suicide.htm. Accessed May 2014.
De Leo D, Spathonis K. Suicide and suicidal behavior in late life. In: De Leo DB-B U, Kerkhof A, Schmidtke A, Ashland OH, editors. Suicidal behavior: theories and research findings. Hogrefe & Huber; 2004. p. 253–86.
Shah A. The relationship between suicide rates and age: an analysis of multinational data from the World Health Organization. Int Psychogeriatr. 2007;19:1141–52.
American Foundation for Suicide Prevention. Facts and figures: suicide deaths, Available at http://www.afsp.org/understanding-suicide/facts-and-figures. Accessed May 2014.
World Health Organization. Distribution of suicide rates (per 100,000) by gender and age, Geneva. Available at http://www.who.int/mental_health/prevention/suicide/suicide_rates_charte/en/index.html. Accessed May 2014.
U.S. Surgeon General and the National Action Alliance for Suicide Prevention: 2012 National Strategy for Suicide Prevention: Goals and objectives for action. Available at http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf. Accessed May 2014. This report from the U.S. Surgeon General and the Action Alliance outlines goals and objectives for reducing suicides over the nexet al.t 10 years.
Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168:1266–77.
Scocco P, Meneghel G, Caon F, et al. Death ideation and its correlates: survey of an over-65-year-old population. J Nerv Ment Dis. 2001;189:210–8.
Skultety KM, Rodriguez RL. Treating geriatric depression in primary care. Curr Psychiatry Rep. 2008;10:44–50.
Schulberg HC, Bruce ML, Lee PW, et al. Preventing suicide in primary care patients: the primary care physician's role. Gen Hosp Psychiatry. 2004;26:337–45.
Goldney RD, Fisher LJ, Wilson DH, et al. Suicidal ideation and health-related quality of life in the community. Med J Aust. 2001;175:546–9.
Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry. 2002;159:909–16.
Ahmedani BK, Simon GE, Stewart C, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014;29:870–7. Large representative sample of individuals who died by suicide that investigates health care contacts in the year prior to suicide, and whether a mental health condition was documented.
O'Connor E, Gaynes BN, Burda BU, Soh C, Whitlock EP. Screening for and treatment of suicide risk relevant to primary care: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013;158:741–54.
McNamee JE, Offord DR. Prevention of suicide. In: Canadian Task Force on the Periodic Health Examination, Canadian guide to clinical preventive health care. Ottawa: CCG; 1994. p. 456–67.
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.
Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin N Am. 2008;31:333–56.
O'Connell H, Chin AV, Cunningham C, et al. Recent developments: suicide in older people. BMJ. 2004;329:895–9.
Waern M, Rubenowitz E, Runeson B, et al. Burden of illness and suicide in elderly people: case-control study. BMJ. 2002;324:1355.
Van Orden KA, Simning A, Conwell Y, et al. Characteristics and comorbid symptoms of older adults reporting death ideation. Am J Geriatr Psychiatr. 2013;21:803–10. Population-based study in Sweden that investigates whether death ideation among older adults is associated with markers of increased risk for suicide, or reflects normal developmental processes.
Erlangsen A, Jeune B, Bille-Brahe U, et al. Loss of partner and suicide risks among oldest old: a population-based register study. Age Ageing. 2004;33:378–83.
Murphy GE. Suicide and substance abuse. Arch Gen Psychiatry. 1988;45:593–4.
Robinson D, Renshaw C, Okello C, et al. Suicide in cancer patients in South East England from 1996 to 2005: a population-based study. Br J Cancer. 2009;101:198–201.
Raue PJ, Morales KH, Post EP, et al. The wish to die and 5-year mortality in elderly primary care patients. Am J Geriatr Psychiatr. 2010;18:341–50.
Bomyea J, Lang AJ, Craske MG, et al. Suicidal ideation and risk factors in primary care patients with anxiety disorders. Psychiatry Res. 2013;209:60–5.
Wiborg JF, Gieseler D, Fabisch AB, et al. Suicidality in primary care patients with somatoform disorders. Psychosom Med. 2013;75:800–6.
Magruder KM, Yeager D, Brawman-Mintzer O. The role of pain, functioning, and mental health in suicidality among Veterans Affairs primary care patients. Am J Public Health. 2012;102 Suppl 1:S118–24.
Almeida OP, Draper B, Snowdon J, et al. Factors associated with suicidal thoughts in a large community study of older adults. Br J Psychiatry. 2012;201:466–72.
Cohen A, Chapman BP, Gilman SE, et al. Social inequalities in the occurrence of suicidal ideation among older primary care patients. Am J Geriatr Psychiatr. 2010;18:1146–54.
Gilman SE, Bruce ML, Ten Have T, et al. Social inequalities in depression and suicidal ideation among older primary care patients. Soc Psychiatry Psychiatr Epidemiol. 2013;48:59–69.
Gensichen J, Teising A, Konig J, et al. Predictors of suicidal ideation in depressive primary care patients. J Affect Disord. 2010;125:124–7.
Chang EC, Yu EA, Lee JY, et al. An examination of optimism/pessimism and suicide risk in primary care patients: does belief in a changeable future make a difference? Cogn Ther Res. 2013;37:796–804.
Bostwick JM, Rackley S. Addressing suicidality in primary care settings. Curr Psychiatry Rep. 2012;14:353–9.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13.
Chen S, Chiu H, Xu B, et al. Reliability and validity of the PHQ-9 for screening late-life depression in Chinese primary care. Int J Geriatr Psychiatr. 2010;25:1127–33.
Inagaki M, Ohtsuki T, Yonemoto N, et al. Validity of the Patient Health Questionnaire (PHQ)-9 and PHQ-2 in general internal medicine primary care at a Japanese rural hospital: a cross-sectional study. Gen Hosp Psychiatry. 2013;35:592–7. Examined ability of the PHQ-2 to identify suicidal ideation, and validity of the suicidal ideation item in detecting suicidal ideation in Japanese patients.
Sung SC, Low CC, Fung DS, et al. Screening for major and minor depression in a multiethnic sample of Asian primary care patients: a comparison of the nine-item Patient Health Questionnaire (PHQ-9) and the 16-item Quick Inventory of Depressive Symptomatology - Self-Report (QIDS-SR16. Asia Pac Psychiatry. 2013;5:249–58.
Gelaye B, Williams MA, Lemma S, et al. Validity of the Patient Health Questionnaire-9 for depression screening and diagnosis in East Africa. Psychiatry Res. 2013;210:653–61.
Pratt LA, Brody DJ. Implications of two-stage depression screening for identifying persons with thoughts of self-harm. Gen Hosp Psychiatry. 2014;36:119–23. Investigated the optimal cutoff on the PHQ-2 for identifying individuals with suicidal ideation.
Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41:1284–92.
Lawrence ST, Willig JH, Crane HM, et al. Routine, self-administered, touch-screen, computer-based suicidal ideation assessment linked to automated response team notification in an HIV primary care setting. Clin Infect Dis. 2010;50:1165–73.
Dube P, Kurt K, Bair MJ, et al. The p4 screener: evaluation of a brief measure for assessing potential suicide risk in 2 randomized effectiveness trials of primary care and oncology patients. Prim Care Companion J Clin Psychiatry. 2010; 12:e1–e8. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3067996/?tool=pubmed. Accessed May 2014.
Heisel MJ, Duberstein PR, Lyness JM, et al. Screening for suicide ideation among older primary care patients. J Am Board Fam Med. 2010;23:260–9.
Szanto K, Lenze EJ, Waern M, et al. Research to reduce the suicide rate among older adults: methodology roadblocks and promising paradigms. Psychiatr Serv. 2013;64:586–9.
Raue PJ, Brown EL, Meyers BS, et al. Does every allusion to possible suicide require the same response? J Fam Pract. 2006;55:605–12.
Lapierre S, Erlangsen A, Waern M, et al. A systematic review of elderly suicide prevention programs. Crisis. 2011;32:88–98. Reviews the results of a number of interventions to prevent suicide among older adults, predominantly focused on reduction of risk factors and calls attention to the need for study of innovative interventions that aim to improve protective factors.
Alexopoulos GS, Reynolds 3rd CF, Bruce ML, et al. Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study. Am J Psychiatry. 2009;166:882–90.
Unutzer J, Tang L, Oishi S, et al. Reducing suicidal ideation in depressed older primary care patients. J Am Geriatr Soc. 2006;54:1550–6.
Van Orden KA, Stone DM, Rowe J, et al. The Senior Connection: design and rationale of a randomized trial of peer companionship to reduce suicide risk in later life. Contemp Clin Trials. 2013;35:117–26. Presents a peer companionship intervention that aims to prevent the development of suicidal ideation among at-risk older adults by bolstering social connectedness.
Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19:256–64.
National Action Alliance for Suicide Prevention RPTF. A prioritized research agenda for suicide prevention: an action plan to save lives. Available at http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/Agenda.pdf. Accessed May 2014. The Research Prioritization Task Force (RPTF) of the Action Alliance details key questions for suicide research to target and proposes a prioritized research agenda to prevent suicide.
Acknowledgments
This work was supported by Grant Nos. R01 MH084872; R01 MH082425; R01 MH096441; P30 MH085943; T32 MH073553 from the National Institute of Mental Health.
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Patrick J. Raue, Angela R. Ghesquiere, and Martha L. Bruce declare that they have no conflict of interest.
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This article does not contain any studies with human or animal subjects performed by any of the authors.
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Raue, P.J., Ghesquiere, A.R. & Bruce, M.L. Suicide Risk in Primary Care: Identification and Management in Older Adults. Curr Psychiatry Rep 16, 466 (2014). https://doi.org/10.1007/s11920-014-0466-8
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DOI: https://doi.org/10.1007/s11920-014-0466-8