Suicide Prevention

My mom and her good friend, Marion, just returned from their annual weeklong winter cruise in the Caribbean. Their adventure ended with some uncertainty as to whether the ship would make it back to their destination as scheduled. Due to mechanical problems with the winch, the cruise line was forced to drag the anchor through the sea on the final leg of the trip. Much to their chagrin, their respite in the tropical wonderland aboard an otherwise fabulous ship finally ended.

Unfortunately, the story often does not play out this way for many older adults who go about their daily routines intentionally or unthinkingly pursuing a lifestyle that brings meaning and purposefulness into their lives. The anchor drifts under the radar, so to speak. Many times, it is overlooked or discounted by those we rely on for detecting and diagnosing our ailments. It seems as though a built-in filter naturally protects us from confronting the complex, troubling issues in our lives that, for any number of reasons, we are not prepared to address. To complicate matters, the anchor of clinically significant depression symptoms is often labeled as being part and parcel to aging. How many times have we heard it ourselves, “Of course I’m depressed!”

Healthy doses

For those of us who have committed our professional lives to aging services, we understand and embrace the notion that living well requires positive engagement in a balanced life that includes a healthy dose of each dimension of wellness: physical, nutritional, social, spiritual, emotional, intellectual, vocational, and environmental. The antithesis of wellness could be labeled as depression. In many cases, depression and other mental health conditions have paralyzing implications that can lead to suicidal ideations or the act of suicide itself, silently or in unmistaken ways.

Research finds that suicide is complex, with a variety of causes and contributors. These factors may be conceptualized according to a social ecological model, which recognizes that causes occur at multiple levels:

  • Individual factors (e.g., biology, individual beliefs)

  • Group/family factors (e.g., family and/or peer influences)

  • Institutional factors (In this context, the policies and structures of the senior living community, and the programs or services it offers)

  • Community factors (attributes of the community in which the facility is located; for example, community-based resources or services)

  • Public policy and societal factors (factors outside the immediate community, including state or federal policy and larger cultural forces)

Myths and Misconceptions Pose Barriers to Help-Seeking

  • Depression is inevitable with aging.

  • Depression is really laziness, weakness, or a character fault.

  • Treatment for depression does not work because it does not change or eliminate the depressing circumstances.

Studies show that 15 to 20% of elders who reside in the general community and 25-35% of residents in long-term care facilities have depression.

Sources: Koenig HG, Blazer DG. Epidemiology of geriatric affective disorders. Clinics in Geriatric Medicine 1992;8(2):235-51; Fabacher DA, Raccio-Robak N, McErlean MA, et al. Validation of a brief screening tool to detect depression in elderly ED patients. American Journal of Emergency Medicine 2002;20(2):99-102; Koenig HG, George LK, Peterson BL, Pieper CF. Depression in medically ill hospitalized older adults: Prevalence, characteristics, and course of symptoms according to six diagnostic schemes. Journal of Gerontology 1997;44(1):1376-83; Parmelee PA, Katz IR, Lawton MP. Depression among institutionalized aged: Assessment and prevalence estimation. Journal of Gerontology 1989;44(1):M-22-9.

The nonpassive cases of suicide I have witnessed, the most recent one in particular, led to my crusade of sorts to do something broad-reaching and call upon aging services professionals to join the campaign. It was in the aftermath of a shocking suicide between Christmas and New Year’s Day 2005 that I came to grips with how ill-prepared I was to deal with the full spectrum of issues surrounding suicide and mental health concerns.

No good answers

In the midst of crisis, I was flooded with questions that had no good answers. “How could this have happened? Why didn’t I see it coming…I was just talking with him six hours ago? Where is his wife? How will we console her? What will the family tell his grandchildren? How will I explain this to my residents and associates? Will the media be looking for a story? How will we prevent this from happening again?”

So many tough questions and there was no playbook to guide me out of this dark tunnel. Most providers, when faced with such devastating circumstances, have probably asked similar questions to those I grappled with on the eve of yet another suicide on my watch.

Fortunately, I was in a place where the resources, talent, and one remarkable resident in particular, Dr. James T. Clemons, DD, PhD, inspired the decision to pursue this mammoth challenge and ultimately help liberate seniors from the burdens of mental illness. Dr. Clemons, founded and served as executive director of OASSIS, Organization for Attempters and Survivors of Suicide in Interfaith Services, is an ordained minister for the United Methodist Church and was named professor emeritus by Wesley Theological Seminary.

Major Risk Factors for Suicide Among Elders

  • Depression, both major depression and other categories

  • Prior suicide attempt

  • Co-occurring general medical condition

  • Often experience pain and decline of role function

  • Social dependency or isolation

  • Family discord

  • Losses

  • Personal inflexibility, rigid coping

  • Substance use

  • Access to firearms

Suicide rates are higher with the co-existence of medical illness. For example, people with seizure disorders are more than twice as likely, and people with severe pain are more than four times as likely, to attempt suicide.

Source: Juurlink DN, Herrmann N, Szalai JP, et al. Medical illness and the risk of suicide in the elderly. Archives of Internal Medicine 2004;164:1179-84.

Protective Factors Against Suicide Include:

  • Restricted access to highly lethal methods.

  • Family and community support. Elders’ family members may move away or die or just not “be there,” and organized activities may not always be available.

  • Effective and appropriate clinical care.

  • Easy access to a variety of clinical interventions and support for help-seeking behaviors.

  • Support from ongoing medical and mental healthcare relations.

Source: American Psychological Association (APA Online). Facts about suicide in older adults, 2007.

Dr. Clemons’ cadre of colleagues and friends were called upon to collaborate with my facility, Asbury Methodist Village, on what became a national initiative to identify opportunities across a range of policy and practice areas for promoting mental health and reducing suicide risk in senior living communities. Our first major milestone was a national summit focusing on mental health promotion and suicide prevention in senior living communities in October 2008.

Linda Langford, ScD, evaluation scientist, Suicide Prevention Resource Center, Newton, Massachusetts, was instrumental in the conceptual framework that guided the summit agenda. The framework included three categories of approaches by which to address suicide prevention:

  1. Whole population approaches that build health-promoting environments and address risk and protective factors across the whole population, regardless of risk status or behavior.

  2. At-risk approaches that provide assistance with symptomatic illness or higher risk, or greater risk factors in the environment.

  3. Response to crises and suicidal behaviors, which includes responding to acute crises (including suicidal behavior), providing support to the community after a suicide death, and addressing the media.

The summit set the wheels in motion at the Center for Mental Health Services/Substance Abuse and Mental Health Services Administration (SAMHSA). With the assistance of Education Development Center, Inc., and the National Association of State Mental Health Directors, SAMHSA recently completed a toolkit for senior living communities. The soon to be released publication, Promoting Mental Health and Preventing Suicide: A Toolkit for Senior Living Communities, will guide administrators and clinicians in developing and implementing practical policies, protocols, programs, and activities that include a trifocal strategy vital to a well-rounded mental health promotion and suicide prevention plan.

David M. W. Denton

Customized approach

James T. Clemons, DD, PhD

Because every senior living community is different, the approaches to promoting mental health and preventing suicide must be tailored to the local context, population, and resources. Successful implementation of prevention programs entail several key processes, including:

  • Leadership to place emotional health and wellness on the agenda and champion and provide support to the efforts.

  • Collaboration within an organization and with the greater community.

  • Review of data and research to define and understand problems both nationally and locally, and to identify evidence-based programs and best practices.

  • Strategic planning to tailor plans based on local data and thoughtfully choose multiple, reinforcing initiatives that respond to local circumstances.

  • Evaluation to determine whether efforts are achieving their desired results.

  • Sustainability planning to ensure that efforts are ongoing.

Healthy People 2010, the nation’s target for the health of its population, set a goal to reduce the suicide rate to 5.0 suicides per 100,000 persons; baseline 11.3 per 100,00 in 1998 (https://www.healthy, National Vital Statistics System, CDC, NCHS). Females have been reaching that target, but the risk for males remains extremely high. As Baby Boomers begin to age into “elder” status, the impact of this astronomical public health problem is anticipated to intensify. The good news is the abundant evidence that shows depression is treatable even among elders with chronic medical conditions that cause pain or physical disability, including those in nursing homes without real prospects of ever being discharged home.

Nevertheless, a concerted effort is needed to reel in the sizeable mental health anchor holding too many of our elders back from living their best life. I am encouraged by all the work that has gone into developing the toolkit, Promoting Mental Health and Preventing Suicide: A Toolkit for Senior Living Communities. Once released, we will need all hands on deck to help us leave the surging sea of mental health issues we face in our wake.

Subscribe to SAMHSA’s e-mail updates to be notified when free copies of Promoting Mental Health and Preventing Suicide: A Toolkit for Senior Living Communities are available. Sign up now at: and select the “Suicide Prevention” topic area. For more information about other SAMHSA resources, visit or call 1-877-SAMHSA-7 (1-877-726-4727).

Burden of Suicide in the United States

  • Every 100 minutes an older adult dies by suicide.

  • Suicide was the 11th leading cause of death in the United States in 2006 (the most recent year for which statistics are available).

  • Older adults have the highest suicide rate of any age group, particularly among men 65 and older.

  • While older adults constituted 12.4% of the U.S. population, they accounted for 16.6% of the suicides.

  • Eleven persons per 100,000 in the U.S. population took their own lives, and among persons older than 65, the suicide rate was 14.7 per 100,000.

  • Adults over age 65 have a vastly higher suicide completion rate than other age groups: one estimated suicide for every four attempts (Kung, Hoyert, Xu, & Murphy, 2008).

  • From 1999 through 2005, the suicide rate in the United States increased for the first time in a decade, mostly among whites ages 40 to 64. Middle-aged women and middle-aged men experienced the largest annual increases at 3.9% and 2.7%, respectively.

Sources: Kung HC, Hoyert DL, Xu J, Murphy SL. National Vital Statistics Reports April 24, 2008;56(10); Hu G, Wilcox HC, Wissow L, Baker SP. Mid-life suicide: An increasing problem in U.S. whites, 1999-2005. American Journal of Preventive Medicine 2008;5(6):589-93. Available at:

Workshops planned to introduce Promoting Mental Health and Preventing Suicide: A Toolkit for Senior Living Communities:

  • American Association of Suicidology Annual Conference

    Orlando, Florida

    Wednesday, April 21, 2010

    Workshop #9B, 1:00 to 4:30 p.m.

    Older Adults Suicide, Part II:

    Promoting Mental Health and

    Preventing Suicide Among Older Adults in Senior Living Communities (SLCs)

    Register at:

  • American Association of Homes & Services for the Aging Annual Meeting

    Los Angeles, California

    Sunday, October 31, 2010 8:00 a.m. – 12:00 p.m.

    Pre-conference details TBD

David Denton has worked as an executive in the senior living and healthcare industry for more than 20 years. Mr. Denton graduated from Ithaca College’s Administration of Health Services program in 1986 and one year later became a licensed Nursing Home Administrator in New York and California. Since then, he has had the opportunity to lead diverse healthcare and senior living operations in eight organizations in California and Maryland. He can be reached at

To send your comments to the editor, please e-mail

Long-Term Living 2010 April;59(4):16-22

Topics: Articles , Clinical