Preventing Suicide Among Older Adults

September is National Suicide Prevention Month.  This month is dedicated to promoting awareness about suicide and its prevention.  Preventing suicide among older adults is a major, complex issue.  Statistics, risk factors, warning signs, and protective factors are addressed well in the literature (e.g., CDC, Suicide Prevention Resource Center, National Council on Aging).  What is key to remember, based on 2022 data:  Of those who died by suicide nationwide, 22% were older adults.  The highest overall rate was for males aged 75+.  One in four suicide attempts resulted in death.

Throughout September and the entire year, our objective should be to SAVE LIVES, while aiming to help older adults THRIVE not just SURVIVE.

In an ideal world, the goal would be to have interconnected, trauma-informed, “helping” communities.  Several organizations/professionals may be involved in “intervening” with older adults who are at risk of suicide, who threaten suicide or express suicidal ideation, or attempt suicide.  These include mental health care professionals, primary care physicians, emergency rooms, psychiatric wards/hospitals, law enforcement.  But there are “cons” to reaching out to any of them when thinking about suicide or feeling that life is no longer worth living.  There are valid reasons for why an older adult will deny thinking about suicide, death, hopelessness, and burdensomeness.

After reflecting on what research reveals and well-grounded positions made by mental health advocates regarding what does not really work or is not “safe,” and what I have personally experienced:

The most critical mechanism for preventing suicide among older adults is

• Healthy connectedness with and support from those in your informal network, and
• Finding “non-biological family” members who you can count on if you have no family members or do not want them to be involved in your life.

Your informal support network may include biological family members, close friends, peers (e.g., individuals who are facing similar issues that you are), colleagues, co-workers if you are employed, emotional support animals, pet companions, and neighbors.

Involvement with the aging network and with the faith community may both be beneficial, dependent on the older adult’s wishes and preferences.  Both provide already-existing organized mechanisms for older people to connect with others, preventing isolation, minimizing loneliness, and promoting overall wellbeing.  Older adults can keep socially active (e.g., participate in group activities and socialize; attend religious services; volunteer) and intellectually engaged, developing and strengthening supportive relationships.

Inevitably, older adults turn to primary care physicians with both physical and mental health concerns; discuss problems being treated by specialists; and are prescribed medications (including psychotropic medications).  Older adults may reach out to mental health professionals, especially if they have a psychiatric diagnostic label and have sought mental health care for a very long time.  Notably, however, there is a shortage of psychiatrists, especially geriatric psychiatrists, nationwide.  For all types of mental health providers, it can be incredibly difficult to find ones with expertise in geriatric mental health.

Psychotropic medications aren’t the answer to suicide prevention.  They can do serious, life-threatening harm, especially among older adults, who are more likely to take multiple medications (polypharmacy), even if medication optimization principles are followed by prescribers.  Being told what you need to do by medical and mental health providers isn’t the answer.  Calling 988 or 911 if you are thinking about suicide is risky, way too risky, because the possibility of law enforcement arriving on your doorstep is real.  Ultimately, you can be “forced” or coerced into being assessed in an emergency room, and admitted to a psychiatric ward/hospital.  Both of those experiences can be traumatizing and devastating.

People who are older, isolated, thinking about death or being a burden, feeling hopeless may remain quiet, stop caring for themselves, take risks, and engage in what can only be defined as “undercover” suicide.

Part of the solution to preventing suicide among older adults is to strengthen the informal network, the aging network, and the faith community by promoting awareness of suicide risks and red flags, and the prevention of suicide.  Significantly, however, older adults must be empowered to indicate their wishes and preferences in dealing with mental health crises, especially when they are not able to speak for themselves.  It is imperative for older adults to have psychiatric advance directives, especially if they have serious psychiatric diagnostic labels, or are beginning to demonstrate dementia-like symptoms.  Psychiatric advance directives should be developed before there is any chance that the older adult will be viewed as incompetent.

Psychiatric advance directives are legal documents in which the older adult would identify a proxy, who would be empowered to make decisions on his/her behalf.  The older adult could (1) identify where he/she would or would not want to be admitted if psychiatric inpatient care is warranted; (2) what treatments he/she would or would not agree to; (3) what medications he/she would or would not agree to be administered; (4) who he/she does or does not want involved in any decision-making about mental health care.  Psychiatric advance directives empower older adults, and if they wish, family members can be empowered.  However, the legal document will allow the older adult to set boundaries about the extent to which he/she wants family members or other individuals to be involved in any decision-making.

Informal Network

Individuals comprising an older adult’s social support network are well-positioned to ask him/her how she is doing, to listen.  They will be able to probe more if the older adult revealed that he/she is feeling sad, hopeless, that things aren’t going to get better, that he/she feels like a burden.  The older adult will feel more comfortable with being asked questions and so forth by someone he/she knows well and cares about him/her personally.  The proxy identified in the psychiatric advance directives could be notified in crisis situation faced by older adult, or when red flags for suicidal risk are apparent or pronounced.

The informal network plays a major role in providing support, helping someone to hold on to hope, and—in the process—preventing suicide.

Biological family members may serve as primary supporters to individuals who are struggling.  However, older adults may have sustained losses of spouses, children, and close friends, or may age alone as Solo Agers (AARP).  Some older adults may not have had children, may not have living children, or may have had problematic biological family relationships, including having endured mistreatment and exploitation.  They may rely on non-biological family members.

Support from friends and peers promotes overall wellbeing, social connectedness, and resilience.  Peers can help reduce isolation and increase a sense of connectedness through in-person contacts, texts, phone calls, email messages, cards, and letters.  Quick check-in contacts even just to say “hello, how are you doing?” can help an isolated older adult, who is struggling, feel cared about and not alone.

Pet companions and emotional support animals can help:

• Minimize the adverse effects of being isolated or lonely;
• Offer companionship and unconditional love;
• Provide emotional support and cuddles; and
• Maintain or improve overall wellbeing and mental health.

Aging Network

Organizations serving older adults provide opportunities to forge social connections, to minimize social isolation and loneliness.  In the process, healthy social networks may be developed or strengthened, serving as a protective factor against attempting suicide, giving up.  Some agencies offer “friendly call’ or support group programs.  Regarding the former, the older adult may request periodic check-in contacts, just to talk, or family members may request that their loved one be placed on the call list.  Staff from these agencies, if well trained and monitored, are positioned well to do “check ins” on older adults e.g., when delivering meals at their homes or when providing transportation.

Faith Community

Significantly, attending church and engaging in church-related social gatherings provide positive opportunities for forging healthy social connections and making friends.  Older adults can take advantage of pastoral counseling to help deal with grief due to loss of loved ones, to address existential issues, to discuss how to resolve family conflicts, and work through ways of strengthening their relationship with God.  Older adults may find a sense of peace through church attendance, prayer, singing religious hymns, and reading/discussing the Bible.

IDEAS FOR WHAT IS NEEDED, in addition to empowering older adults as well as strengthening the informal support network, aging network, and faith community:

• Have WARMLINES—which are distinctly different than crisis lines, 911, or 988—made more available.  Those individuals responding to WARMLINE phone calls—ideally—should be certified peer recovery supporters or those who have received sufficient training to deal with potential crisis situations, to listen and hear, and to keep conversations stress-free and “safe.”
• Telehealth for physical health care and mental health services—psychiatric care, therapy, case management, medication management—should be widely available.  Telehealth can be lifesaving in efforts to reach those who are struggling, isolated or homebound.  For some older adults, their physical health status and related disabilities set limits on being able to attend in-person sessions on a routine basis.
• It can feel insensitive even ludicrous—when you are suicidal and isolated—to be told “You are not alone.”  I believe it would make more sense to send the following message:  “You may feel alone, and I empathize, but consider opening the door to someone else to listen to you, to discover that you do not have to be alone.”
• I read a “banner” type platitude saying “Take a minute, save a life.”  It takes more than a few minutes to listen, to ask questions, to make suggestions, and to help someone receive needed help.  BUT it only takes a minute or two to reach out to someone, anyone, who you may not even know to hold on to hope, to feel cared about.  Simply say “Hello,” engage in a random act of kindness.
• While a larger support network can be ideal, the reality is that it only takes ONE person who knows you well, who you can trust, who you can count on to help you hold on.  Open your heart, be willing to be the “one” for someone you care about and who needs you.