A few weeks ago, I wrote about the suicide of a 19-year old University of Pennsylvania student
. Most suicides reported in the media involve young people. In our youth-oriented society, this is understandable. Yet, suicide at any age is tragic—not just for the person who dies, but for the entire family.
Sadly, I know this from personal experience as described in my forthcoming book, Surrounded By Madness: A Memoir of Mental Illness and Family Secrets. When my mother was 51 and I was finishing my senior year of college, she killed herself. My father, brothers, and I were devastated. Suicide immediately crushes those it leaves behind and has profound effects on them for the rest of their lives.
Although most suicides reported in our daily newspapers center on young people, recent rates of suicide among people aged 15-24 (10.5 per 100,000 people) were significantly lower than those for people aged 45-64 (18.6 per 100,000) or those aged 85 and older (17.6 per 100,000).1
Evidence suggests suicide rates among middle-aged adults in the United States have grown. An investigation by the Centers For Disease Control and Prevention revealed that the annual age-adjusted suicide rate among persons aged 35-64 years increased 28.4% between 1999 and 2010. Though suicide rates historically are higher among men, the suicide rate for women in this age group increased more (31.5%) than did the suicide rate for men (27.3%)2 Among men, the greatest increases were evident for those aged 50-60; among women, the largest increase was observed for those aged 60-64. Since increases occurred during a period of time in which suicide rates for young people increased only slightly and those for people over age 65 declined, these findings warrant attention.
Why has there been such an increase in suicide rates among middle-aged adults? What does this mean for our future?
One explanation is the recent economic downturn. Historically, suicide rates correlate with business cycles. During times of economic hardship, rates of suicide increase.3 If the economic recession is the explanation for the increase in suicide rates, we should expect to see suicide rates drop among people in this group as the economy recovers.
An alternative explanation centers on the unique characteristics of people aged 35-64, the majority of whom are part of the baby boom generation. This generation had unusually high suicide rates during their adolescent years.4 They are the generation who vowed not to trust anyone older than 30; those who crooned to the Beatles’ question “Will you still need me when I’m 64?” and rocked to the Who’s “I hope I die before I get old.” If this is a generation effect, we should expect to see suicide rates increase among this cohort over time as more and more people follow Dylan Thomas’ plea, “Do not go gentle into that good night. Rage, rage against the dying of the light.”
Of course, only time and more research will tell whether the increased suicide rate among this middle-aged cohort is a function of the economy, something peculiar to this generation, or something else. However, prevention efforts are particularly important for this generation because of its size, history of elevated suicide rates, and movement toward old age—the period of life that has traditionally been associated with the highest suicide rates.5
Effectively reducing the suicide rate requires understanding the causes of suicide. This has proven to be a daunting task because suicide is a relatively rare event and retrospective reports are suspect. Nonetheless, research has identified several risk factors:
- Psychiatric illness. Like my mother who suffered from manic depression, most who commit suicide have a mental illness. Affective disorders such as major depression are most common. Psychotic disorders, including schizophrenia, schizoaffective illness, and delusion disorder as well as anxiety disorders are present in lower proportions.5
- Acute and chronic physical illnesses.
- Impaired ability to cook, shop, or manage finances.
- Cognitive deficits (e.g. dementia).
- Stressful events, including bereavement, ruptured relationships with family or friends, or financial problems.
However, addressing these factors alone is insufficient for effectively preventing suicide. False-positives would lead to unnecessary, intrusive, and expensive interventions for those who did not need them, while many false-negative results would leave at-risk older people undetected and unprotected.
Conwell and his colleagues recommend that high suicide rates in older people are most effectively reduced through a public health preventive intervention framework with three levels: (1) indicated, (2) selective, and (3) universal.
- Indicated interventions target individuals with detectable symptoms and other risk factors for suicide. The objective is to diagnose and treat psychiatric disorder in order to prevent suicide. Among those who commit suicide, 77% see a primary care provider within their last year of life and 58% do so within their final month.6 Implementing routine standard screening for depression and suicidal ideation is critical for primary healthcare physicians and their team of nurses and social workers.
- Selective interventions target individuals with chronic, painful, functionally limiting conditions or those who have become socially isolated. Visiting nurses, those delivering meals to homebound older people, and community agencies providing services to older people provide intervention.
- Universal interventions target an entire population. Broad dissemination of public health messages or legislative policy effects change across a population. Instituting longer waiting periods for handgun purchases is exemplary.
Suicide at any age is a tragedy. While the media are captivated by suicides of young people, suicides of middle-aged and older people—people like my mother—are also devastating and deserve greater attention.
This blog was written in collaboration with Karen Whiteman, MSW, PhDc, Robert Stempel College of Public Health and Social Work. I invite others to collaborate on future blogs.
- Reeves, A. Stuckler, D., McKee, M., Gunnell, D., Chang, S., & Basu, S. (2010) Increase in state suicide rates in the USA during economic recession. Lancet, 380, 1813-14.
- Phillips, J.A., Robin, A.V., Nugent, C.N., & Idler, E.L. (2010). Understanding recent changes in suicide rates among the middle-aged: Period or cohort effects? Public Health Rep 125, 680-688.
- Conwell, Y., Van Orden K., & Caine, E.D. (2011). Suicide in older adults. Psychiatric Clin N Am 34, 451-468.
- Luoma, J.B., Martin, C.E., & Pearson, J.L. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159 (6), 909-916.