1. SUICIDE IN OLDER ADULTS: What have we learned?
Kelly C. Cukrowicz, Ph.D.
Professor
Department of Psychological Sciences
Texas Tech University

2. MEN
WOMEN
Women
What you can see is that the rate of death by suicide for men over 65 is approximately 30 per 100,000. For women over 65 the rate is closer to 4 per 100,000. I have noted on the left side of the slide where the upper end of the figure for women falls. This suggests a critical need for research aimed at improving our ability to detect suicide risk among older adults, particularly men, as well as to design and evaluate suicide prevention approaches tailored to the needs of older adults and the factors that influence suicide risk in this age group.

3. Prevalence of Suicide Across the Lifespan
44,965 deaths by suicide in 2016 in the United States
10th ranking cause of death in the U.S.
3.4 male deaths by suicide for every female death by suicide
More specific information
White males: 31,032 – rate of 24.8 per 100,000 (10.9 for non-white males)
Firearms accounted for 51% of deaths
As I noted on the previous slide, the rate of death by suicide is high among older adults, particularly among men. This rate increases from age 65 to 85, with the highest rate among those over 85. It is critical to point out the low ratio of attempts to deaths in this age group, which suggests a critical need to focus on suicide ideation so that we can intervene before attempts occur – given that attempts more frequently result in death for this age group.

4. Prevalence of Suicide in Older Adults
8,204 deaths by suicide in 2016 in the United States among those 65+
Rate is for men vs for women 65+ (16.66 overall rate per 100,000)
Rate of death by suicide increases steadily from age 65 to 85, with the highest rate of suicide deaths among older adults ages 85 and older (CDC, 2014).
4.6 male deaths by suicide for every female death by suicide
More specific information
White males more frequently die by suicide (more than 2x other races)
Firearms accounted for 70% of deaths in this age group

5. Risk Factors vs. Warning Signs
Increase vulnerability for suicide ideation and suicidal behavior
Tend to be more stable (e.g., psychiatric disorder, history of suicidal behavior, gender)
Warning signs
Indicate risk is high right now
Tend to be more likely to change in the short term (e.g., agitation, mood changes, anger)

6. Empirically Demonstrated Risk Factors for Suicide
Psychiatric Disorders
Approximately 70-95% of adults had a psychiatric disorder at the time of their suicide death
Affective Disorders
Major depression – 44% to 87%
Other mood disorders – 11% to 36%
Alcohol abuse/dependence – 3% to 43%
Lesser role: psychotic disorder, personality disorders, anxiety disorders, dementia, eating disorders
But, its important to keep in mind that the vast majority of people with psychiatric disorders do not die by suicide.

7. Empirically Demonstrated Risk Factors for Suicide
History of suicidal behavior
Previous suicidal behavior – especially concerning if multiple attempt history
History of self-harm
Expression of severe thoughts of suicide
Plans/preparations for suicide
Access to means for suicide
51% of suicide decedents use guns and more than 50% of the US population own guns; 2/3 of gun deaths are suicide deaths
Presence of a gun in the home has been significantly associated with suicide deaths
Handguns
Risk greater for men

8. Empirically Demonstrated Risk Factors for Suicide
Negative life events
financial problems
physical illness
childhood abuse
combat exposure
Personality traits
impulsivity
rigid and independent style
Affective experiences
hopelessness
agitation
sleep disruption
Social isolation
living alone
low social interaction
family discord

9. Physical Health
Approximately 70% of suicide decedents had significant physical illness
HIV/AIDS, Huntington’s disease, multiple schlerosis, peptic ulcer, renal disease, spinal cord injury (Harris & Barraclough, 1994)
Physical illness burden, serious physical condition, functional impairment

10. Warning Signs Reported suicide or death ideation
IS PATH WARM?
Ideation
Substance abuse
Purposelessness
Anxiety
Trapped
Hopelessness
Withdrawal
Anger
Recklessness
Mood changes
Reported suicide or death ideation
Increased substance use
No reason for living or sense of purpose
Anxiety, agitation, unable to sleep
Feeling trapped, no way out
Hopelessness
Withdrawal from friends, family
Rage, uncontrolled anger
Acting reckless, risky behaviors
Dramatic mood changes

11. This is a lot of information…
How do we organize it and use it?
A good theory can be really helpful.

12. Interpersonal Theory of Suicide (Joiner, 2005)
Acquired Capability
Perceived Burden + Thwarted Belonging
I fear I’m a burden.
No one cares about me.
I have attempted suicide.
I have experienced a lot of pain in my life.
Death by Suicide or
Near-Lethal Suicide Attempt

13. What is perceived burdensomeness?
The sense that one does not contribute to others in their life
Others would be better off without him or her
These perceptions lead to emotionally painful thoughts of self-hatred
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C.
et al. (2010). The interpersonal theory of
suicide. Psychological Review, 117,

14. What is thwarted belongingness?
A sense of feeling disconnected from others
Feeling alone, even in the presence of others
Feeling that he/she doesn’t care about people and they don’t care about/support him/her
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C.
et al. (2010). The interpersonal theory of
suicide. Psychological Review, 117,

15. What is acquired capability?
The loss of the fear of suicidal behaviors
Acquired over time through exposure to physically painful and/or fear inducing experiences
Over time, these experiences result in lowered fear of death and greater pain tolerance
Evidence:
Lethality of method and seriousness of intent increase with aeempts.
◻¨ People who have experienced or witnessed violence or injury have higher rates of suicide – pros^tutes, self-injec^ng drug abusers, people living in high-crime areas, physicians.
◻¨ Those with a history of suicide attempt have higher pain tolerance than others.
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C.
et al. (2010). The interpersonal theory of
suicide. Psychological Review, 117,

16. The Interpersonal Theory of Suicide
Death Ideation
Loneliness
Nonreciprocal Care
Self Resentment
Liability
Thwarted Belongingness
Perceived Burdensomeness
Hopelessness
Desire for Suicide
Suicidal Intent
Lethal or Near Lethal Suicide Attempt
Lowered Fear of Death
Increased Pain Tolerance
Acquired Capability
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C.
et al. (2010). The interpersonal theory of
suicide. Psychological Review, 117,

17. Importance of Suicide Ideation
We can think of suicide ideation as a critical flag for those who might die by suicide
BUT – we must keep in mind some important things:
Many people at risk for suicide do not disclose thoughts of suicide.
Lots of people who think about suicide do not ever harm themselves.
Suicide ideation can be chronic.
For contradiction 1 – could indicate that SI is not critical to suicide deaths in older adults, BUT more likely suggests that they may not be reporting SI.
For contradiction 2 – may specifically indicate that older adult males are the ones most likely to underreport SI.

18. Example: Reporting Concerns with Suicide Risk in Older Adults
Research suggests that older adults may not report suicide ideation even when they experience suicide ideation
Contradiction 1
Rate of deaths by suicide increases in late life
Rate of self-reported suicide ideation decreases with increasing age
Contradiction 2
Older males more likely to die by suicide
Suicide ideation has not been shown to be greater in older males than in females
For contradiction 1 – could indicate that SI is not critical to suicide deaths in older adults, BUT more likely suggests that they may not be reporting SI.
For contradiction 2 – may specifically indicate that older adult males are the ones most likely to underreport SI.

19. So What Do We Do When Things Don’t Add Up?
Person who denies thoughts of suicide, but their actions suggest otherwise
They have some of the risk factors or warning signs mentioned above

20. Example Distribution for Illustration
This distribution is one quite similar to what we often see when we examine the distribution of suicide ideation in primary care and community samples of older adults. A lot of people indicating that they are not thinking about suicide (1 = zero) and some endorsement along the continuum of scores for suicide ideation. BUT…what if some of the people who are indicating that they are not thinking about suicide are really under reporting?

21. Study of Suicide Ideation in Older Adults
We wanted to know whether the variables that are part of the interpersonal theory (thwarted belonging, perceived burden, hopelessless) are more painful when experienced together
Do people who feel thwarted belonging and perceived burdensomeness report the greatest suicide ideation if they also feel hopeless?
Would elevated scores on these three variables allow us to identify those who deny thoughts of suicide, but report other experiences that are highly associated with suicide ideation (i.e., depressive symptoms, isolation).

22. Novel Statistical Approach: Zero-Inflated Modeling
Allows for estimation of both the zero and positive responses to questionnaires assessing suicide ideation.
Some zeros arise from participants who deny suicide ideation and have little or no psychological distress (non-ideators)
Additional zeros may arises from participants who deny suicide ideation while reporting other empirically-based risk factors (e.g., depression, hopelessness) for suicide ideation (potential ideators)
Person in front of you – what do they look like? Non-ideator – responses across all questions suggest truly not thinking about suicide. Potential ideator – currently reporting no ideation, but other responses are more like a person who is thinking about suicide.
Our goal is to predict which people are potential ideators and which are non-ideators – what questions do we ask?

23. What Our Distributions Look Like
Death ideation = 66 occurrences of zero
Suicide ideation = 104 occurrences of zero

24. At lower levels of perceived burdensomeness and mean scores on thwarted belonging, those with hopelessness scores one standard deviation above the mean have a lower probability of being a non-ideator. Further, for those with thwarted belonging and hopelessness one standard deviation above the mean, the probability of being a non-ideator is lower.
When individuals report elevated perceptions of being a burden on others and also feel hopelessness that these states will change, they are much more likely to be a potential ideator.

25. Figure 2. Probability of Non-ideator Status (Excess Zero) as a Function of Perceived Burdensomeness and Hopelessness Along the Continuum of Scores for Thwarted Belonging. TB = Thwarted Belonging, BHS = Beck Hopelessness Scale.
At lower levels of thwarted belonging, individuals with scores at the mean or one standard deviation above the mean on perceived burdensomeness and hopelessness may have a lower probability of being a non-ideator.
As reported experiences of perceived burdensomeness, hopelessness, and thwarted belonging increase, the probability of the individual being a non-ideator (i.e., excess zero) reduces substantially, suggesting that an individual is very likely to be experiencing suicide ideation, even if it is not reported.
Elevated scores on perceived burdensomeness, thwarted belonging, and hopelessness are associated with a much greater probability that the individual is experiencing suicide ideation, even if it is not reported.

26. What The Data Tells Us
Increasing scores on thwarted belonging, perceived burdensomeness, and hopelessness are associated with:
Greater probability that an individual may be experiencing thoughts of suicide, whether or not they are reported.
The presence or absence of suicide ideation, but less important to determining the severity of thoughts of suicide.
Additionally, the pattern of results (though non-significant) is consistent with Van Orden et al. (2010)’s prediction that individuals with elevated perceived burdensomeness and thwarted belonging would develop suicide ideation when they feel hopeless that these states will change. These findings provide further support for the interpersonal theory of suicide.

27. Implications
Perceived burden, thwarted belonging, and hopelessness should be key targets in the determination of whether someone might be experiencing thoughts of suicide
Regardless of whether the person is reporting such thoughts
Questions assessing perceived burden and thwarted belonging may be less threatening to endorse than thoughts of suicide
Mental health practitioners should target perceptions of being a burden, a sense of thwarted belonging, and hopelessness to reduce the risk of developing suicide ideation

28. Suicide in Rural Communities
Suicide is also prevalent among rural-dwelling adults in the U.S. and in countries around the world (Hirsch, 2006)
Rural communities have had significantly higher rates of death by suicide than those in urban areas throughout the past two decades (Hirsch, 2006)
Rural older adults are 30% – 50% more likely to die by suicide when compared to older adults residing in urban locations (Baume & Clinton, 1997)
For Erin: little research has examined risk or protective factors for suicide among rural adults in the U.S. In a recent review, Hirsch (2006) found that stigma regarding mental health disorders, accessibility of lethal means (e.g., firearms, pesticides), lack of reliance on others for assistance, poor community infrastructure, and geographic or social isolation were most prominently associated with rural suicide. Although these factors were associated with increased risk, this literature is quite preliminary, with few studies rigorously examining these risk factors.
Much of the literature regarding suicide in rural areas of the U.S. and elsewhere (e.g., China, Sri Lanka, Australia) has focused on the description of frequently used lethal methods, change in suicide rate over time, and demographic variables (e.g., gender, location, age; Abeyasinghe & Gunnell, 2008; Johnson, Gruenewald, & Remer, 2009; Kapusta et al., 2008; Kong & Zhang, 2010; Zhang, Li, Tu, Xiao, & Jia, 2011). Taken together, the current literature on rural suicide consists primarily of anecdotal reports and urban-rural comparisons with few attempts to quantify specific facets of rural life and psychological experience that may lead to higher suicide risk. Further, little research thus far has examined the prevalence of suicide ideation, suicide attempts, or deaths by suicide in rural middle-aged and older adults in the United States; neither has research investigated risk factors for suicide in these adults. This gap in knowledge makes it impossible to develop empirically based intervention approaches to modify risk factors in this population. This study aims to address this gap by examining a variety of theoretically based psychological risk factors.

29. Extending this Research to Middle-Aged and Older Adults in Rural Communities
Primary goals:
To determine a preliminary estimate of the prevalence of suicide ideation, self-injury, and history of suicide attempts in rural communities.
To examine risk factors that may be unique to rural locations.

30. What We’ve Learned…

31. Thwarted Belonging
Anxiety
Rural Identity
Suicide Ideation
History of Suicide Attempts
Economic Distress
Depressive Symptoms
Moderators:
Life Satisfaction
Hope
Lower Conformity to Masc. Norms
Reasons for Living
Perceived Burden

32. Assessment of Suicide Risk

33. Eliciting Information on Suicide Risk
Include questions about perceived burdensomeness, thwarted belonging, and hopeless!
Normalize thoughts of suicide
“It sounds like you’ve been experiencing a lot of emotional pain recently, others in your situation might think about suicide. Have you had any thoughts about suicide recently?”
Begin assessment with the past and work forward
Ensure a complete picture of current experiences
Frequency – “How often do you think about suicide?”
Intensity – “When you think about suicide, are intense are your thoughts (scale 1 to 10)?” “How does this compare to how intense they usually are?”
Duration – “How long have you had these thoughts?”

34. COLUMBIA-SUICIDE SEVERITY RATING SCALE Screen Version - Recent
cssrs.columbia.edu
Screening versions and extended versions
Pediatric & adult
Lifetime and recent
Versions for ED, law enforcement, family/friends, corrections, outpatient
For inquiries and training information contact: Kelly Posner, Ph.D.
New York State Psychiatric Institute, 1051 Riverside Drive, New York, New York, 10032;
© 2008 The Research Foundation for Mental Hygiene, Inc.

35. Interpersonal Needs Questionnaire
How Do I Assess Perceived Burden and Thwarted Belonging?
Interpersonal Needs Questionnaire
The following questions ask you to think about yourself and other people. Please respond to each question by using your own current beliefs and experiences, NOT what you think is true in general, or what might be true for other people. Please base your responses on how you’ve been feeling recently. Use the rating scale to find the number that best matches how you feel and circle that number. There are no right or wrong answers: we are interested in what you think and feel. 1 2 3 4 5 7
Not at all true for me
Somewhat true for me
Very true for me
These days the people in my life would be better off if I were gone
These days the people in my life would be happier without me
These days I think I am a burden on society
These days I think my death would be a relief to the people in my life
These days I think the people in my life wish they could be rid of me
These days I think I make things worse for the people in my life
These days, other people care about me
These days, I feel like I belong
These days, I rarely interact with people who care about me
These days, I am fortunate to have many caring and supportive friends
These days, I feel disconnected from other people
These days, I often feel like an outsider in social gatherings
These days, I feel that there are people I can turn to in times of need
These days, I am close to other people
These days, I have at least one satisfying interaction every day
Note. Items 7, 8, 10, 13, 14, and 15 are reverse coded.

36. How to assess acquired capability?
Questions about fearlessness about suicide
Duration of thoughts of suicide and details of imagery
Plans for suicide; preparations made to carry out that plan
Previous experiences with self-harm, suicidal behavior
Exposure to violence

37. CAMS SUICIDE STATUS FORM–4 (SSF-4) INITIAL SESSION
Patient: Clinician: Date: Time:
Section A (Patient):
Rank
Rate and fill out each item according to how you feel right now. Then rank in order of importance 1 to 5 (1 = most important to 5 = least important)
1) RATE PSYCHOLOGICAL PAIN (hurt, anguish, or misery in your mind, not stress, not physical pain):
Low pain: :High pain
What I find most painful is:
2) RATE STRESS (your general feeling of being pressured or overwhelmed):
Low stress: :High stress
What I find most stressful is:
3) RATE AGITATION (emotional urgency; feeling that you need to take action; not irritation; not annoyance):
Low agitation: :High agitation
I most need to take action when:
4) RATE HOPELESSNESS (your expectation that things will not get better no matter what you do):
Low hopelessness: :High hopelessness
I am most hopeless about:
5) RATE SELF-HATE (your general feeling of disliking yourself; having no self-esteem; having no self-respect):
Low self-hate: :High self-hate
What I hate most about myself is:
N/A
6) RATE OVERALL RISK Extremely low risk: :Extremely high risk
OF SUICIDE: (will not kill self) (will kill self)
How much is being suicidal related to thoughts and feelings about yourself? Not at all: 1
How much is being suicidal related to thoughts and feeling about others? Not at all: 1
: completely
Please list your reasons for wanting to live and your reasons for wanting to die. Then rank in order of importance 1 to 5.
Rank
REASONS FOR LIVING
REASONS FOR DYING

38. Section B (Clinician):
Y N Suicide ideation
Frequency
Duration
Y N Suicide plan
Describe:
per day
seconds
per week
minutes
per month
hours
When: Where: How: Access to means Y N How: Access to means Y N
Describe: Describe:
Y N Suicide preparation Y N Suicide rehearsal Y N
History of suicidal behaviors
Single attempt
Multiple attempts
Y N Impulsivity
Y N Substance abuse Y N Significant loss
Y N Relationship problems Y N Burden to others
Y N Health/pain problems Y N Sleep problems
Y N Legal/financial issues Y N Shame
Describe: Describe:
Describe: Describe: Describe: Describe: Describe: Describe: Describe: Describe: Describe:
Section C (Clinician):
TREATMENT PLAN
Problem #
Problem Description
Goals and Objectives
Interventions
Duration 1
Self-Harm Potential
Safety and Stability
Stabilization Plan Completed D 2 3

39. Management of Suicide Risk

40. Treatment recommendations
Treatment for suicide or another problem (e.g., depression)?
For chronic suicide risk or longer duration ideation – suicide specific treatment
Collaborative Assessment and Management of Suicide Risk (Jobes, 2017)
Suicide-specific assessment and treatment-planning
Tracking of on-going risk
Clinical outcomes and dispositions
Flexible in approach to addressing drivers of suicide risk
Only suicidal in context of depressive episode – treatment targeting the specific area of concern

41. Between Session Care
Individuals thinking about suicide may need help with:
Reminders of signals of crisis
Assistance with managing strong emotions tied to suicide risk
Ideas for distraction (people, activities)
People to call for help
Where to go for help
How to make the environment safe
Crisis Response Plans address these concerns

42. Crisis Response Plan

43. Acknowledgements American Foundation for Suicide Prevention
Thank you for your attention!
Acknowledgements American Foundation for Suicide Prevention
Former graduate students:
Erin F. Schlegel, Ph.D.
Danielle R. Jahn, Ph.D.
Erin Poindexter, Ph.D.
Ryan Graham, Ph.D.
Project FRONTER staff:
Billy Philips, Ph.D.
Theresa Huckabee
Cathy Hudson
Collaborators:
Jennifer S. Cheavens, Ph.D.
Kimberly A. Van Orden, Ph.D.
Ryan B. Williams, Ph.D.
Friona Prabhu, M.D.
Michael Ragain, M.D.
Ron Cook, D.O.
Kitten Litton, M. D.