1. Ideation Among Older Adults 1
Suicidal Ideation Among Older Adults
___________________
Lacy Milonas
Adults over the age of 65 have the highest rate of suicide of all younger age
groups (National Institute of Mental Health, 2009). Suicide among older adults has now
been identified as a serious health concern in all industrialized countries (Neufeld &
O’Rourke (2009). Suicide is a preventable cause of death and therefore arguably more
tragic because of its preventability. Older adults are four times more likely to die from a
suicide attempt than any other age group (Jahn, Cukrowicz, Linton, & Prabhu, F. (2011),
allowing little time or opportunity for an intervention once an attempt has been made.
Identifying suicidal ideation in the older adult is key to implementing therapeutic
interventions.

2. Ideation Among Older Adults 2
Introduction
Adults over the age of 65 have among the highest rate of suicide of all younger
age groups (National Institute of Mental Health, 2009). However, on a global scale, as
adults age, their age cohort has increasingly higher suicide rates, men and women over
the age of 84 having the highest. Suicide among older adults has now been identified as a
serious health concern in all industrialized countries (Neufeld & O’Rourke (2009).
The U.S. Preventative services task force (2014) estimated suicide rates among
older adults to have grown by 40% between 1999 and 2011, 2011 a year in which more
than 9,000 adults died by suicide. As the population of older adults grows, and is
expected to double by 2050, these figures will significantly increase, necessitating a
critical need for public awareness and intervention (Greenlee & Hyde, (2014).
Suicide is a preventable cause of death and therefore arguably more tragic
because of its preventability. The topic of suicide among older adults is
multidimensional and complex, raising questions about the many risk factors to consider,
and how older adults are treated and regarded by younger populations. This topic also
raises existential givens about quality of life, loneliness, worth, and meaning. Despite
knowledge of this cohorts high suicide rates, however, there is little research into suicide
prevention specific to this age cohort.
Risk Factors and Predictors of Suicide
The reasons one has for living is a construct that has been shown to help protect
individuals from suicidal thoughts and actions (Marty, Segal, & Coolidge, 2010). Many
adults report moral obligations, child-related concerns, and social obligations as reasons
for not committing suicide. Others report a fear of the event of the suicide itself. Still, it
is when the older adult’s construct of their reasons for living fall apart that the older adult
begins to contemplate suicide.
Older adults are four times more likely to die from a suicide attempt than any
other age group (Jahn, Cukrowicz, Linton, & Prabhu, F., 2011), allowing little time or
opportunity for an intervention once an attempt has been made. This staggering statistic
is hypothesized to be due to the older adult’s heightened determination to die and
possible failures of previous attempts made earlier in the adult’s lifetime. Furthermore,

3. Ideation Among Older Adults 3
the older adult is more likely to be fragile or otherwise in poor health, more isolated, and
more likely to have a lethal plan.
A 2014 study which researched depressive symptoms and suicide risk in older
adults (Bamonti, Price, & Fiske) found that when individuals who place a high value on
autonomy experience life stressors that block or thwart achievement goals, they are more
likely to become depressed compared to individuals who place less value on autonomy.
As older adults age, they inevitably lose their autonomy. For some adults, this loss can
present as catastrophic. With age, disability may come to prevent the adult from living
alone, the adult may lose an important job due to their aging or age related circumstance
or discrimination, and the adult may become increasingly unable to do things on their
own. Age-related limitations may lead the older adult towards isolation and withdrawal,
as decreased independence due to accelerated functional impairment manifests. For older
adults who place an abundance of value on autonomy, the loss of this autonomy is a
significant risk factor for considering suicide.
Regret is another significant risk factor for suicidal ideation in older adults.
Similar to the later study regarding autonomy, regret of having unmet goals can be a
significant stressor amongst older adults. Research has demonstrated that goal
adjustment in older adulthood is associated with increased psychological well-being,
lower depressive symptoms, and decreased suicidal ideation (Bamonti, Price, & Fiske,
2014; Wrosch, Bauer, & Scheier, 2005). Some older adults may perceive reduced
opportunities to undo the consequences of their regrets, or opportunities to re-attempt
past failures. Severe life regrets can have a significantly adverse effect on older adults
psychologically and lead to a general compromise of subjective well-being.
Impulsivity and hopelessness are risk factor predictors of suicide ideation among
older adults. Neufeld & O’Rourke (2009), found the impulse to self-harm to be even
more pronounced among older adults less likely to present as typically depressed, and
impulsivity to be more broadly associated with suicide-related ideation than
hopelessness. Also found, was that older adults are less likely to utilize mental health
services, and that while many older adults visit their primary care physicians for somatic
symptoms, suicidal ideation or depression was generally not discussed, with it seeming
common for older adults to visit their physicians often within a month of ending their

4. Ideation Among Older Adults 4
lives. Clinical implications of these findings suggest that impulsivity and hopelessness
are as crucial to suicide assessment as depression, and that somatic symptoms should also
be considered when assessing an older adult.
While little research exists in direct regards to suicidal impulsivity and older
adults, impulsivity is a significant character risk factor in association with suicide.
Wyder (2007) found that 51% of patients between the ages of 17-65 attempted suicide
after deliberating for 10 minutes or less, an additional 16% contemplated for less that half
an hour. It is reasonable to speculate that given the correlation between impulsivity and
suicide, adults within the age cohort with the highest suicide rates are more likely to be at
risk than those older adults that lack impulsivity.
Perceived burdensomeness arises when an older adult believes he or she is so
flawed that they are a liability to others. “This perception leads to affectively-laden
cognitions of self-hatred” (Jahn, Cukrowicz, Linton, & Prabhu, 2011, p. 215). Indicators
of perceived burdensomeness include a sense of expendability, distress from
homelessness, incarceration, unemployment, physical illness, low self-esteem, self-
blame, shame, and physical agitation created by unbearable self-loathing (Van Oren et
al., 2010). Because of high reports of perceived burdensomeness among adults
experiencing suicidal ideation, perceived burdensomeness is a risk factor that ought to be
assessed and further researched.
Additional risk factors not previously highlighted, but embedded in many of the
previous risk factors are being socially isolated, in poor physical health, experiencing
cognitive decline, loss of self-esteem, and loss of purpose or meaning in life. Economic
insecurities can also feed into the older adults loss of self-esteem and loss of autonomy.
Due to the amount of risk factors evidenced to contribute to the high levels of suicide
among older adults, it is important that more research be done regarding prevention for
this vulnerable population.
Treatment Interventions
Firstly and primarily, identifying suicidal ideation in an older adult is key to
implementing therapeutic interventions. While suicidal ideation and depression are
linked, there are many mediating factors that ought to be assessed for. Asking the older
adult about their suicidal ideation may not be effective, as during the assessment, the

5. Ideation Among Older Adults 5
adult might not feel particularly depressed, nor be willing to express depression or
suicidal ideation. Also, not all older adults with depression commit suicide, and not all
suicides result from depression. Therefore, broadening assessment questions by assessing
not only for suicide and death ideation, history of self-harm, and mental or personality
disorders, but for the adults levels of perceived burdensomeness, regret, and impulsivity,
all mediating factors between depression and suicidal ideation, is critical in uncovering
suicidal ideation in older adults.
A full assessment for suicidality should also include coping styles and reasons for
living, as although these are not part of assessment for depression or suicidality, they are
strongly interrelated to the older adult’s perceived level of burdensomeness, which is a
mediating factor between depression and suicide. Risk factors ought to also be assessed,
as not all risk is high risk, and different levels of risk need to be treated differently.
Preventive factors are also important during assessment, as internal strengths and
internal/external resources available to the older adult will affect possible treatment
interventions.
As adults age they may develop physical disabilities or chronic medical
conditions that limit physical or cognitive function and/or life expectancy. Arthritis,
cardiovascular disease, and cancer are some conditions for which the older adult might be
required medications. Depression is associated with the disease course of each of these
chronic conditions, but is also a side effect of medicines commonly taken by older adults,
such as statins, beta-blockers, and corticosteroids (Greenlee & Hyde, (2014). Including
medication considerations in assessment when working with an older adult is therefore a
key factor in treatment planning and designing the older adults level of care.
Once suicidal ideation is identified, psychotherapy ought to be the central
component of the older adult’s treatment plan. Findings from randomized controlled
trials have indicated that dialectical behavioral therapy (DBT), problem solving therapy
(PST), cognitive behavioral therapy (CBT), and psychodynamic-interpersonal
psychotherapy (IPT) may all decrease suicidal ideation amongst older adults (Heisel,
Duberstein, Talbot, King, & Tu, 2009). However, because suicide risk among older
adults is so highly associated with interpersonal problems, social support deficits, and
difficulty adjusting to life transitions, it is suggested that interpersonally oriented

6. Ideation Among Older Adults 6
interventions with at risk older adults may have higher levels of efficacy (Heisel,
Duberstein, Talbot, King, & Tu, 2009).
IPT theory hypothesizes “a bidirectional association between interpersonal
functioning and depression wherein the inability to satisfy one’s interpersonal needs
contributes to mood disturbance, which, in turn interferes with interpersonal functioning”
(Stuart & Robertson, 2003). IPT, therefore, is more suitable than other theoretical
frameworks at addressing the older adults systemic issues around grief, role transitions,
and interpersonal deficits. IPT techniques can also aid at risk older adults in clarifying
and improving the expression of their interpersonal needs, in turn decreasing depressive
symptoms. Because older adults with suicidal ideation are more likely to lack secure
attachment, have poor coping skills, and lack a sense of security, the therapeutic
relationship within an IPT framework can be reparative. Having the opportunity to
connect to a therapist, have a stable interpersonal relationship within which it is safe to
express the feelings behind one’s suicidal ideation, and a reliable format to do so is an
effective intervention for adults experiencing suicidal ideation.
Coping strategies are essential interventions for older adults experiencing suicidal
ideation. Lazarus and Folkman (1984) describe coping as efforts to manage individual
and environmental demands that are believed to challenge or surpass an individual’s
resources. Marty et al (2010) found that coping strategies oriented towards engagement
and action in the direction of finding a resolution to a problem were associated with
reasons for living, with dysfunction coping to be positively associated with suicidal
ideation. This finding suggests that how an older adult copes with life’s problems may be
a major preventive factor for considering suicide.
Suls & Flectcher (1985) note that while avoidance can be effective in reducing
pain, stress, and anxiety in the short run, with time non-avoidant strategies are associated
with more positive outcomes. Therefore, in using non-avoidant coping strategies and
attending to one’s emotion, venting or expressing that emotion may provide the
emotional and physical release and may engender support from others, in turn decreasing
suicidal symptoms. If coping activities oriented towards disengagement or maladaptive
avoidance of the older adult’s problems heighten suicidal ideation, than healthy coping

7. Ideation Among Older Adults 7
interventions, perhaps problem-focused or emotion-focused, could potentially save the
life of the suicidal older adult.
Conclusion
Counselors, aging service providers, behavioral healthcare providers, and primary
health care providers can all assist in preventing suicide by identifying at-risk older
adults. Providing and mandating suicide prevention webinars specific to this population
could potentially save the lives of thousands of older adults in the U.S. alone every year.
This could require essentially overhauling the way suicide assessments are conducted, but
by training mental health providers around this populations specific needs and how to
identify risk factors, implementing age specific assessment for this cohort could be
achieved effectively.
Knowing what signs to look for will be critical in identifying older adults at risk
of suicide. Mental health problems are not a normal part of aging (Greenlee & Hyde,
(2014). The ability to know and identify risk factors associated with suicide will be
critical in identifying older adults at risk of suicide and the first step towards providing
appropriate interventions.
A full assessment for suicidality should include coping styles and reasons for
living, as although these are not part of assessment for depression or suicidality, they are
strongly interrelated to the older adult’s perceived level of burdensomeness which is a
mediating factor between depression and suicide. Mental health clinicians working with
older adults should be vigilant for cognitive styles marked by higher value placed on
autonomy, especially if the older adult is experiencing depressive symptoms (Bamonti,
Price, & Fiske, 2014).
Finally, it is necessary to raise suicide awareness with older adults and their
families. Along with clinicians, older adults and their families also need to be informed
that that may be at risk, and that there is a critical concern around risk factors amongst
their cohort. Counseling can be an effective and lifesaving intervention for an at-risk
older adult and their family. Identifying the risk and raising awareness are the crucial
first steps.

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References
Bamonti, P. M., Price, E. C., & Fiske, A. (2014). Depressive symptoms and suicide risk
in older adults: Value placed on autonomy as a moderator for men but not
women. Suicide And Life-Threatening Behavior, 44(2), 188-199.
doi:10.1111/sltb.12062
Greenlee, K., Hyde, P. (2014). Suicide and Depression in Older Adults: Greater
Awareness Can Prevent Tragedy. Generations, 38(3), 23-26.
Heisel, M. J., Duberstein, P. R., Talbot, N. L., King, D. A., & Tu, X. M. (2009). Adapting
interpersonal psychotherapy for older adults at risk for suicide: Preliminary
findings. Professional Psychology: Research And Practice, 40(2), 156-164.
doi:10.1037/a0014731
Jahn, D., Cukrowicz, K., Linton, K., & Prabhu, F. (2011). The mediating effect of
perceived burdensomeness on the relation between depressive symptoms and
suicide ideation in a community sample of older adults. Aging & Mental Health,
15(2), 214-220.
Lazarus, R., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.
Marty, M. L., Segal, D., Coolidge, F. (2010). Relationships among dispositional coping
strategies, suicidal ideation, and protective factors against suicide in older adults.
Aging & Mental Health, 14(8), 1015-1023.
Neufeld, E. & O’Rourke, N. (2009). Impulsivity and Hopelessness as Predictors of
Suicide-Related Ideation Among Older Adults. Canadian Journal Of Psychiatry,
54(10), 684-692.
National Institute of Mental Health. 2009. Older Adults: Depression and suicide facts.
Retrieved from http:/nimh.noh.gov/health/piblications/older-adults-depression-
and-suicide-fact-sheet/index.shtml.
Stuart, S., & Robertson, M. 2003. Intersonal psychotherapy: a clinician’s guide.
London: Arnold.
Suls, J., & Fletcher, B. (1985). The relative efficacy of avoidant and non-avoidant
coping strategies: A meta-analysis. Health Psychology, 4, 249-288.

9. Ideation Among Older Adults 9
U.S. Preventative Task Force. 2014. Suicide Risks is Adolescents, Adults, and Older
Adults in Primary Care; Recommendations Statement”. Retrieved from:
www.uspreventionservicetaskforce.org/uspstf13/suicide/suicidefinalrs.htm#ref2.
Van Orden, K.A., Witte, T.K., Cukrowicz, K.C., Braithe, S.R., Selby, E.A., & Joiner,
T.E. (2010). The interpersonal theory of suicide. Psychological Review, 117,
575-600.
Wrosch, C., Bauer, I., & Scheier, M. F. (2005). Regret and quality of life across the adult
life span: The influence of disengagement and available future goals. Psychology
And Aging, 20(4), 657-670. doi:10.1037/0882-7974.20.4.657
Wyder, M., De, L. 2007. Behind impulsive suicide attempts: Indications from a
community study. Journal of Affective Disorders , Volume 104 , Issue 1 , 167 -
173