Yeates Conwell, M.D., came to his studies of suicide among the elderly from an opposite direction, an interest in the resilience
of older people. "They face, manage, and successfully negotiate a tremendous number of challenges in their lives and, for
the most part, succeed," said Conwell, a professor of psychiatry at the University of Rochester School of Medicine and Dentistry.
The people who have trouble managing those challenges are the exception rather than the rule.
"So how can we take the lessons of people who have aged successfully and learn to prevent bad outcomes among those who might
not be so well equipped?" he asked in an extended interview in his office at the university's medical center (see Multidisciplinary Approach Used).
Throughout the worldânot just in the United Statesâolder people, especially older men, are at greater risk for suicide than
other segments of society.
Why men are more likely to commit suicide and why they are less amenable to preventive interventions remains a mystery, even
for an expert in the field such as Conwell.
"The question takes us to the leading edge of our knowledge of suicide in later life," he said.
Perhaps there are biological differences between men and women that come into play, he said. Men also tend to use more lethal
means of suicide, like guns. However, the reasons are more likely social.
"In my clinical experience, men are more difficult to engage in mental health treatment or even in discussions of emotional
states that would reveal distress and might give a signal for interventions," he said.
Also, women are more likely to have a history of engagement and social connectedness. "Engaging in social relationships and
finding meaning in life offer protection against suicide, at least empirically."
No one would suggest that suicide is a simple phenomenon. Conwell tries to isolate and then tie together the many sets of
factors that lead to that tragic endpoint by elaborating on the multiaxial system familiar to psychiatrists.
A review of the literature reveals that most elderly people who committed suicide had an Axis I disorder, most often an affective
disorder, he said. Schizophrenia or anxiety rarely come into play as risk factors among older populations. Studies of dementia
have produced mixed results although, as a precaution, Conwell said that dementia and delirium in elderly patients should
still be considered risk factors for suicide.
Among Axis II diagnoses, personality disorder among suicide decedents is not a useful predictor, but symptoms of high neuroticism
and a low degree of openness to experience do appear as suicide risk factors.
Medical illness and pain listed on Axis III are both independent and interdependent variables, he noted. Studies have found
that subjects with multiple comorbid physical illnesses have an increased risk for suicide.
Two other dimensions play significant roles in suicide among older people.
Psychological autopsy studies have shown that social factors such as loss, bereavement, social isolation, financial troubles,
or disruptions in family life indicated in Axis IV raise the risk of suicide.
Axis V indicators of functional status become significant when joined by other factors. "Most older people normally ride through
functional decline, so it's not those factors alone."
No single factor predicts suicide, he said.
"If you think of the axes as Venn diagrams, no single one can predict suicide," he said. "But where those five circles overlap,
you get increased cumulative risk, and we need to understand the interactions among those domains."
Finding vulnerable individuals and intervening with them is unlikely to fall to mental health providers alone, because the
elderly use them too rarely, he said.
Since two-thirds of older people who kill themselves have visited their primary care physician in the month before death,
primary care is a logical place to situate screening and intervention tactics.
Looking at suicide among the elderly is not an academic exercise, now that the "baby boom" generation has begun turning 65.
"As a cohort, they already have increased rates of suicide, and now they are entering a period of life that is always associated
with higher rates," he said.
But that statistical confluence may be partially offset by some mitigating factors.
"They have strength in numbers," said Conwell. "They have political clout, they're active, and they demand services."
The older population bulge may also shift the country's youth-oriented culture at least part of the way toward an appreciation
of the values conferred by age.
"Older people have experience and skills and knowledge," said Conwell. "If that could be appreciated and valued, it might
change the social context for suicide happening."