Editorials
Suicide among the Elderly: Issues Facing Public Health Suicide (from the Latin sui 'self and caedere 'to kill'), self-destruction, selfmurder, self-killing, and self-slaughter are the various terms that have been used to describe the intentional taking of one's own life. Many views of suicide have been offered, from the early Christian introduction of the idea that suicide was a crime and a sin, to St. Thomas Aquinas' belief that it was a mortal sin because it usurped God's power over man's life and death, to Rousseau who perpetuated the idea of sin but transferred the sin from man to society (which introduced the ongoing controversy regarding the locus of blameindividual vs society). In the nineteenth century, Emile Durkheim's sociologic model introduced the concept of different origins or reasons for suicide (e.g., altrustic suicide). Although not a totally new idea, the recent introduction (by Derek Humphreys of the Hemlock Society, and others) of the idea of suicide as a choice, a rational act, gives rise to the ongoing debate about euthanasia, assisted suicides, and the "right to die." The past several decades have seen a dramatic increase in the rate of suicide among the young. From 1950 to 1980 suicide rates among 15- to 19-year-olds more than doubled.' The acknowledgment of this trend led to increased funding for services and research in the area of adolescent suicide. Less commonly known is the fact that suicide rates are highest among the elderly. As Meehan and colleagues note in this issue of the journal,2 in 1986, there were 22.2 suicides per 100 000 persons over the age of 65 years. Furthermore, the authors note that, after a 30-year decrease, suicide rates among the elderly have increased from 1980 to 1986. This trend appears to be most pronounced among men over 70 years of age.
What is unique about the elderly? Explanations offered for the higher rates of suicide among the elderly include access to more lethal methods for committing suicide; living alone, which may delay discovery; declining health, which gives rise to chronic medical problems; organic mental dysfunction, which impairs judgment or the ability to generate alternative options; and greater premeditation about the action.-5 Social and economic factors may differentially impact the elderly and be associated with increased risk of suicide. Additionally, the relatively small size of the population may spuriously inflate suicide rates among the elderly. Since more people live longer and the number of elderly persons at risk increases, it will be possible to reexamine these speculations in future years. Although occurring in other age groups, three types of suicide are particularly frequent among the elderly: suicide associated with depression, suicide associated with extreme stress, and suicide as a deliberate act. Depression is a long-acknowledged risk factor for suicide attempt and completion. The recognition and treatment of depression in the elderly often are complicated by coexisting health problems. Although antidepressant medication is a standard antidote to protracted clinical depressions, "aggressive treatment of depression in the elderly" is not necessarily commensurate with "antidepressant medications."2 Many clinicians today prefer supportive services (such as senior citizen centers and day care), which increase social support and decrease isolation. Also, the medical community is beginning to
Editor's Note: See related article on page 1198 of this issue. American Journal of Public Health 1109
Editoials
more fully appreciate the role of prescription medication in the elderly; dose levels may vary with age and, without accurate doses, side-effects common to a number of medications (e.g., depression) may be more frequent. Moreover, visiting a physician on a regular basis may be more common among this cohort of elderly than it was, perhaps, 20 years ago. Therefore, elders may be more likely to take prescnbed medications than theywere in the past. The role of the physician may have grown among the elderly. Some data indicate that 75% of the elderly persons who committed suicide visited a physician within 1 month of their death; more than one third did so within 1 week of their suicide.6 Most attempts and completions among the young appear to be impulsive actions following a significant external stressor. The elderly often have inadequate financial assets, insufficient social support, and limited personal resources-all of which can restrict the ability to cope successfully. In addition to identifying and treating psychiatric disorders (which typically are chronic or, at least, recurrent and which place one at increased risk for suicide behavior), public health should place priority on dealing with the impulsive nature of most suicidal acts. If we adopt this perspective, efforts would be made to expand crisis intervention services and improve skills to deal with interpersonal losses, economic stressors, ill health, etc., in addition to addressing overall mental health concerns. Thus, the problem is not solely with the mental illness itself but with the management of stressors. Lethality of the method is paramount in impulsive responses to extreme stress. We can learn something from the framework applied to violence and firearms. Knowing that it will take many years to address the basic roots of violence, we, as public health professionals, believe that the lethality of such violence could be reduced through decreasing easy access to firearms. Likewise, we might not have sufficient resources (knowledge, funding) to address basic issues of mental health/illness and the function filled by elders in our society. Going beyond individual-level variables and the perpetuation of the concept of "dangerous persons," we can focus on dangerous situations and access to lethal means. In addition to identifying those at high risk (the traditional focus of mental health and social service agendas), public health must concentrate equally on the hazards themselves and the circumstances that are associated with self-directed injury. While firearms use increased by 10% from 1980
1110 American Journal of Public Health
to 1986, the rate of suicide among elders increased by 23% for white men, 42% for black men, 17% for white women, and 71 % for black women.2 Without disputing the importance of firearms, the method of choice for both male and female elders, it would be helpful to know more about the use of other methods. As is true with certain homicides, some suicides are well-planned (and perhaps rational) acts. This appears to be especially true among the elderly. Among younger groups, those who complete suicide and those who attempt suicide may represent two distinct populations: (a) suicide attempters who are likely to be female and to have taken an overdose and (b) suicide completers who are likely to be male and to have used a more lethal means such as a firearm. Distinctions between suicide attempters and completers appear to blur among the elderly.5 Unlike some suicide gestures and attempts among younger persons in which the objective is to change one's life, not end it, suicide attempts among the elderly appear to be very similar to suicide completions. If suicides among the elderly are more clearly planned or premeditated than those among younger persons, we must consider whether we, as public health professionals, consider suicide a rational choice. As a society, we appear to consider suicide a viable option for the elderly. In public places, members of the pre-elderly generation can be heard discussing suicide. The circumstances most often associated with suicide when it is considered an option are incapacitating illness, inevitably diminishing health, dwindling resources, and issues related to "being a burden" to others. Media treatment of recent cases of suicide among the elderly indicates an increased willingness to acknowledge suicide as a rational choice (e.g., "He Paid His Dues: He Understood Life and Exercised His Privilege to Leave It" headlined a March 18, 1990, Los Angeles Times article by syndicated columnist Ellen Goodman on the suicide of child psychiatrist Bruno Bettelheim). Several recent celebrated cases of assisted suicide have provoked spirited controversy over the idea of whether older persons, in the face of declining health and specific biologicalvulnerabilities (e.g., arthritic hands which make pill containers difficult to open, mobility limitations which reduce the likelihood of jumping from a height), may have help in carrying out their wishes. Thus, it appears that controversy surrounds the concept of assisted suicide among elders but not suicide itself.
Suicide and the significance assigned to the problem is closely tied to social values. Groups of people who traditionally are not valued in society tend to be the perpetrators and victims of intentional injury. Young minority males tend to be both the perpetrators and the victims of homicide. The elderly, the emotionally stressed, and personswho lack stable connections with others appear to be the most frequent victims of suicide. As a not insignificant number of elders (6275 in 1986 according to Meehan and colleagues2) take their own lives, we in public health need to face some rather difficult issues. Although they may overlap, suicide phenomena for the young and the elderly appear to differ fundamentally. The taking ofone's own life and the meaning attributed to the act may differ based on life course stage. Thus, the circumstances under which suicide may be perceived as an optionvary for individuals, as does society's reaction and, by extension, public health's willingness to label it a health "problem" (especially if years of potential life lost is the barometer of issue importance). Suicide is an issue where public health views and individual rights sharply intersect. An imperfect but perhaps useful comparison can be drawn between abortion and suicide among the elderly. These two complex issues, at opposite ends of the developmental spectrum, raise a similar question: Whose choice is it? l Susan B. Sorenson, PhD Susan B. Sorenson is with the Southern California Injury Prevention Research Center and the School of Public Health, University of California, Los Angeles. Requests for reprints should be sent to Susan B. Sorenson, PhD, UCLA School of Public Health, 10833 Le Conte Avenue, Los Angeles, CA 90024-1772.
References 1. Rosenberg ML, Smith JC, Davidson LE, Conn JM. The emergence of youth suicide: an epidemiologic analysis and public health perspective. Annu Rev Public Health.
1987;8:417-440. 2. Meehan PJ, Saltzman LE, Sattin RW. Suicides among older United States residents: epidemiologic characteristics and trends. Am JPublic Health. 1991;81:1198-1200. 3. Richardson R, Lowenstein S, Weissberg M. Coping with the suicidal elderly: a physician's guide. Genatrics. 1989;9:43-51. 4. Koenig HG, Breitner JC. Use of antidepressants in medically ill older patients. Psychosomatics. 1990;31:22-31. 5. Frierson RL. Suicide attempts by the old and the very old. Arch Intern Med.
1991;151:141-144. 6. Miller M. Geriatric suicide: the Arizona study. Gerontoloy. 1978;18:488-495.
September 1991, Vol. 81, No. 9
Suicide among the Elderly: Issues Facing Public Health Suicide (from the Latin sui 'self and caedere 'to kill'), self-destruction, selfmurder, self-killing, and self-slaughter are the various terms that have been used to describe the intentional taking of one's own life. Many views of suicide have been offered, from the early Christian introduction of the idea that suicide was a crime and a sin, to St. Thomas Aquinas' belief that it was a mortal sin because it usurped God's power over man's life and death, to Rousseau who perpetuated the idea of sin but transferred the sin from man to society (which introduced the ongoing controversy regarding the locus of blameindividual vs society). In the nineteenth century, Emile Durkheim's sociologic model introduced the concept of different origins or reasons for suicide (e.g., altrustic suicide). Although not a totally new idea, the recent introduction (by Derek Humphreys of the Hemlock Society, and others) of the idea of suicide as a choice, a rational act, gives rise to the ongoing debate about euthanasia, assisted suicides, and the "right to die." The past several decades have seen a dramatic increase in the rate of suicide among the young. From 1950 to 1980 suicide rates among 15- to 19-year-olds more than doubled.' The acknowledgment of this trend led to increased funding for services and research in the area of adolescent suicide. Less commonly known is the fact that suicide rates are highest among the elderly. As Meehan and colleagues note in this issue of the journal,2 in 1986, there were 22.2 suicides per 100 000 persons over the age of 65 years. Furthermore, the authors note that, after a 30-year decrease, suicide rates among the elderly have increased from 1980 to 1986. This trend appears to be most pronounced among men over 70 years of age.
What is unique about the elderly? Explanations offered for the higher rates of suicide among the elderly include access to more lethal methods for committing suicide; living alone, which may delay discovery; declining health, which gives rise to chronic medical problems; organic mental dysfunction, which impairs judgment or the ability to generate alternative options; and greater premeditation about the action.-5 Social and economic factors may differentially impact the elderly and be associated with increased risk of suicide. Additionally, the relatively small size of the population may spuriously inflate suicide rates among the elderly. Since more people live longer and the number of elderly persons at risk increases, it will be possible to reexamine these speculations in future years. Although occurring in other age groups, three types of suicide are particularly frequent among the elderly: suicide associated with depression, suicide associated with extreme stress, and suicide as a deliberate act. Depression is a long-acknowledged risk factor for suicide attempt and completion. The recognition and treatment of depression in the elderly often are complicated by coexisting health problems. Although antidepressant medication is a standard antidote to protracted clinical depressions, "aggressive treatment of depression in the elderly" is not necessarily commensurate with "antidepressant medications."2 Many clinicians today prefer supportive services (such as senior citizen centers and day care), which increase social support and decrease isolation. Also, the medical community is beginning to
Editor's Note: See related article on page 1198 of this issue. American Journal of Public Health 1109
Editoials
more fully appreciate the role of prescription medication in the elderly; dose levels may vary with age and, without accurate doses, side-effects common to a number of medications (e.g., depression) may be more frequent. Moreover, visiting a physician on a regular basis may be more common among this cohort of elderly than it was, perhaps, 20 years ago. Therefore, elders may be more likely to take prescnbed medications than theywere in the past. The role of the physician may have grown among the elderly. Some data indicate that 75% of the elderly persons who committed suicide visited a physician within 1 month of their death; more than one third did so within 1 week of their suicide.6 Most attempts and completions among the young appear to be impulsive actions following a significant external stressor. The elderly often have inadequate financial assets, insufficient social support, and limited personal resources-all of which can restrict the ability to cope successfully. In addition to identifying and treating psychiatric disorders (which typically are chronic or, at least, recurrent and which place one at increased risk for suicide behavior), public health should place priority on dealing with the impulsive nature of most suicidal acts. If we adopt this perspective, efforts would be made to expand crisis intervention services and improve skills to deal with interpersonal losses, economic stressors, ill health, etc., in addition to addressing overall mental health concerns. Thus, the problem is not solely with the mental illness itself but with the management of stressors. Lethality of the method is paramount in impulsive responses to extreme stress. We can learn something from the framework applied to violence and firearms. Knowing that it will take many years to address the basic roots of violence, we, as public health professionals, believe that the lethality of such violence could be reduced through decreasing easy access to firearms. Likewise, we might not have sufficient resources (knowledge, funding) to address basic issues of mental health/illness and the function filled by elders in our society. Going beyond individual-level variables and the perpetuation of the concept of "dangerous persons," we can focus on dangerous situations and access to lethal means. In addition to identifying those at high risk (the traditional focus of mental health and social service agendas), public health must concentrate equally on the hazards themselves and the circumstances that are associated with self-directed injury. While firearms use increased by 10% from 1980
1110 American Journal of Public Health
to 1986, the rate of suicide among elders increased by 23% for white men, 42% for black men, 17% for white women, and 71 % for black women.2 Without disputing the importance of firearms, the method of choice for both male and female elders, it would be helpful to know more about the use of other methods. As is true with certain homicides, some suicides are well-planned (and perhaps rational) acts. This appears to be especially true among the elderly. Among younger groups, those who complete suicide and those who attempt suicide may represent two distinct populations: (a) suicide attempters who are likely to be female and to have taken an overdose and (b) suicide completers who are likely to be male and to have used a more lethal means such as a firearm. Distinctions between suicide attempters and completers appear to blur among the elderly.5 Unlike some suicide gestures and attempts among younger persons in which the objective is to change one's life, not end it, suicide attempts among the elderly appear to be very similar to suicide completions. If suicides among the elderly are more clearly planned or premeditated than those among younger persons, we must consider whether we, as public health professionals, consider suicide a rational choice. As a society, we appear to consider suicide a viable option for the elderly. In public places, members of the pre-elderly generation can be heard discussing suicide. The circumstances most often associated with suicide when it is considered an option are incapacitating illness, inevitably diminishing health, dwindling resources, and issues related to "being a burden" to others. Media treatment of recent cases of suicide among the elderly indicates an increased willingness to acknowledge suicide as a rational choice (e.g., "He Paid His Dues: He Understood Life and Exercised His Privilege to Leave It" headlined a March 18, 1990, Los Angeles Times article by syndicated columnist Ellen Goodman on the suicide of child psychiatrist Bruno Bettelheim). Several recent celebrated cases of assisted suicide have provoked spirited controversy over the idea of whether older persons, in the face of declining health and specific biologicalvulnerabilities (e.g., arthritic hands which make pill containers difficult to open, mobility limitations which reduce the likelihood of jumping from a height), may have help in carrying out their wishes. Thus, it appears that controversy surrounds the concept of assisted suicide among elders but not suicide itself.
Suicide and the significance assigned to the problem is closely tied to social values. Groups of people who traditionally are not valued in society tend to be the perpetrators and victims of intentional injury. Young minority males tend to be both the perpetrators and the victims of homicide. The elderly, the emotionally stressed, and personswho lack stable connections with others appear to be the most frequent victims of suicide. As a not insignificant number of elders (6275 in 1986 according to Meehan and colleagues2) take their own lives, we in public health need to face some rather difficult issues. Although they may overlap, suicide phenomena for the young and the elderly appear to differ fundamentally. The taking ofone's own life and the meaning attributed to the act may differ based on life course stage. Thus, the circumstances under which suicide may be perceived as an optionvary for individuals, as does society's reaction and, by extension, public health's willingness to label it a health "problem" (especially if years of potential life lost is the barometer of issue importance). Suicide is an issue where public health views and individual rights sharply intersect. An imperfect but perhaps useful comparison can be drawn between abortion and suicide among the elderly. These two complex issues, at opposite ends of the developmental spectrum, raise a similar question: Whose choice is it? l Susan B. Sorenson, PhD Susan B. Sorenson is with the Southern California Injury Prevention Research Center and the School of Public Health, University of California, Los Angeles. Requests for reprints should be sent to Susan B. Sorenson, PhD, UCLA School of Public Health, 10833 Le Conte Avenue, Los Angeles, CA 90024-1772.
References 1. Rosenberg ML, Smith JC, Davidson LE, Conn JM. The emergence of youth suicide: an epidemiologic analysis and public health perspective. Annu Rev Public Health.
1987;8:417-440. 2. Meehan PJ, Saltzman LE, Sattin RW. Suicides among older United States residents: epidemiologic characteristics and trends. Am JPublic Health. 1991;81:1198-1200. 3. Richardson R, Lowenstein S, Weissberg M. Coping with the suicidal elderly: a physician's guide. Genatrics. 1989;9:43-51. 4. Koenig HG, Breitner JC. Use of antidepressants in medically ill older patients. Psychosomatics. 1990;31:22-31. 5. Frierson RL. Suicide attempts by the old and the very old. Arch Intern Med.
1991;151:141-144. 6. Miller M. Geriatric suicide: the Arizona study. Gerontoloy. 1978;18:488-495.
September 1991, Vol. 81, No. 9
