Suicide is an important problem among older adults and in particular older men. Risk factors for suicide in older adults include the loss of a loved one, loneliness and physical illness. Suicide in older adults is often attributed to the development of depression due to bereavement or loss of physical health and independence. However, suicide prevention in old age requires avoiding overly simplistic therapeutic approaches. This Perspective discusses the impact of social determinants of health, cultural narratives and the coronavirus disease 2019 (COVID-19) pandemic on suicide among older adults and proposes strategies for a multifaceted approach to suicide prevention.
Older people die by suicide at a disturbing rate. This sad phenomenon occurs more often in older men, particularly those over 80 years of age1, especially when facing conditions such as chronic pain and dependence on others, but also when suffering from loneliness, feelings of abandonment and loss of meaning for life2. All these conditions are risk factors for suicide3; some of these factors can be controlled and their impact limited; some others may simply be too much of a burden on individuals and their families. Ageist attitudes associate old age with physical and cognitive decline (considering older adults to be frail and helpless individuals) and inevitably influence the level of care that these individuals receive4. Thus, opposing ageism (see definitions for key terms in Box 1) can significantly reduce the impact of the risk factors that contribute to suicidal behavior and reduce the number of fatal suicide attempts. Measures to prevent suicide attempts might also reduce suicide risk for others, as there is evidence that exposure to suicide within ones’ social group increases the risk of suicidal behavior5.
This article provides an overview of existing knowledge on suicide in old age and discusses it in the context of the global aging population, the increase in longevity around the world and the potential impact of the pandemic (Boxes 1, 2).
Global aging, longevity and suicide
Suicide rates have declined globally, and quality of life and access to health care have improved. However, suicide rates of older people remain the highest worldwide1 (Fig. 1). In general, there is a progressive increase in suicide rates with age, especially among men6,7, and this trend may continue even among ultra-centenarians8. Globally, in 2017, suicide in old age affected 16.17 individuals per 100,000 inhabitants at the age of 50–69 years and 27.45 individuals per 100,000 inhabitants at the age of 70 or more years1. With epidemiological data predicting an almost doubling of the older population in less than 30 years9 and the increasing proportion of mononuclear families, the concern of increased social isolation, loneliness and addiction, known risk factors for suicide10, does not appear unfounded.
Old age is a social concept rather than a true biological one11. In fact, there is no clearly defined and universally valid threshold that marks old age, as a person’s chronological age is not well linked to their physical and mental capabilities. While chronological age increases at the same rate for everyone everywhere, biological age depends on epigenetic alteration and DNA methylation and related bodily changes occurring in a given person12. The threshold for entering old age is generally considered to be 65 years. However, especially in high-income countries, people aged 65–74 years generally enjoy good health and continue to benefit from satisfactory levels of social inclusion and availability of resources as in younger age. In low- and middle-income countries, rather than chronological age, old age seems to be defined by cessation of active participation in society13.
Literature relating to suicide in old age also generally considers 65 years as the threshold level; however, given the relative numerical rarity of the phenomenon, many investigations have also included younger individuals14. However, especially for a Western country, considering individuals in their fifties or sixties as representative of ‘late-life’ suicides could lead to misleading interpretations. For example, the lifetime prevalence of major depression, an important risk factor for suicide at any age, decreases significantly after the age of 65 years15,16. Therefore, its role may be less relevant in older people than in younger people17. It is true that older people may attribute their depressed mood to physical illness or be ashamed to admit the presence of a mental disorder15. Even early mortality could explain this relatively low prevalence in a population that is certainly more vulnerable than the younger one18. Conversely, the presence of somatic diseases in suicide increases proportionally with aging, becoming very frequent after the age of 85 years19.
The underestimation of death rates from suicide is an important phenomenon everywhere, far from being trivial20. Suicide death rates of older adults are particularly liable to be underestimated21. In a number of cases, it can be challenging to determine whether the death was caused by a deliberate act (for example, not taking or overdosing on life-saving drugs or an accident or a voluntary fall and so on)21.
In particular, in many Western countries, regulations regarding the prescription of opioids (used to reduce somatic pain) are lax and could give older people fairly easy access to an effective suicide method21. It is then known that the death of an older person usually incurs less investigative interest than the death of a young person or a death associated with a medical procedure22.
Furthermore, cases of ‘silent suicide’ such as those due to voluntarily stopping eating and drinking (VSED) are generally not registered as suicide cases, even if, in an obvious sense, VSED is a true suicide case, given that the person’s intention is to die23. Food and water are essential for life; deciding to renounce these elements is done to hasten death. Therefore, VSED is a suicide attempt, not only a desire to reduce food and liquids as a natural consequence of some terminal conditions24. As described by Pope25, VSED has long remained an option to end life in a hidden way; today the debate about VSED is more open, and doctors (especially oncologists) should be well prepared to manage requests of their terminally ill patients. Because VSED represents a possible response to terminal illness, this contributes greatly to its moral acceptability as a form of suicide25.
Other than VSED, patients with terminal illness may ask their doctors to accelerate their death in another way and be assisted to do this. Medical aid for dying is not yet an accepted practice in most countries of the world. Australia has proven to be one of the most active countries in debating these issues, with the Queensland Parliament recently approving the law on voluntary assisted dying (VAD), following a decision similar to that of the parliaments of Victoria, Western Australia, Tasmania and South Australia. To be eligible to access VAD in Queensland, a person must be an adult, have a progressive condition that is expected to cause death within 12 months and causing intolerable suffering, have decision-making capacity and be acting voluntarily and without coercion26.
The spread of euthanasia practices is even more limited. Spain has recently become the sixth country worldwide to acknowledge the right to euthanasia, after the Netherlands, Belgium, Luxembourg, Canada and New Zealand. Several US states allow assisted dying, while Switzerland permits assisted suicide for ‘unselfish reasons’27. Swiss law tolerates assisted suicide when patients effect the act themselves and helpers have no vested interest in their death. The law prohibits doctors, spouses, children or other such related parties from directly participating in one’s death. In Switzerland, two main groups operate in this area: Exit and Dignitas. While Dignitas also assists people from abroad, Exit only supports citizens or permanent residents of Switzerland in taking their own life. In 2020, Exit helped 1,282 people, mostly affected by terminal illnesses, to die28. While the number of assisted suicides appears to be growing, to some extent this might reflect the aging population in Switzerland. Total figures of assisted suicide cases are not included in the official count of suicide cases for Switzerland28.
What impact has the pandemic had, if any?
Studies that specifically clarify the impact of the COVID-19 pandemic on rates of death from suicide among older adults are not available yet; however, it is conceivable that the pandemic has a negative impact on suicide in old age29. The 2003 severe acute respiratory syndrome (SARS) outbreak in Hong Kong was associated with an increase in the number of suicides in old age, especially in women. Compared to previous years, the increase was 30% of the expected numbers30.
In Japan, after an initial decline in suicide rates during the first wave of the pandemic, a 16% increase was noted during the second wave (July to October 2020), with women experiencing the largest increase31. Japan has appointed a minister of loneliness (Tetsushi Sakamoto) after seeing suicide rates in the country rise for the first time in 11 years. Factors such as social distancing, quarantine, personal protective equipment, loneliness and the inability to contact loved ones (even for the last goodbye) have the potential to aggravate anxiety, depression and post-traumatic stress symptoms, potential triggers of self-harm and suicide episodes32,33. The limited availability of institutions able to provide real-time suicide data (R. Benson et al., unpublished) thus far has provided a non-alarming picture in terms of suicide outcomes. Studies carried out in Australia34 and the UK35 have not shown any particular increase in the number of suicides among older adults. However, in particular for older adults living in nursing homes, the current global health crisis has had traumatizing effects in terms of psychological suffering as well as mortality due to the pandemic36. Apparently, this did not translate into an increase in suicide mortality, despite some subgroups of the population—for example, those who are jail inmates or are socially ‘fragile’ (such as bullied persons)—being more exposed to suicide risk factors37,38.
During the pandemic, many media representations of aging were particularly disturbing and inadequate. They made older adults feel a charge to society and to their families; they made them aware that they might be denied care or considered less deserving of it39,40. These factors can cause feelings of loss of value and meaning and compromise the feeling of independence41,42. Furthermore, people who ask for help might feel exposed, in particular, if the request is due to suicidal behavior, mental illness and substance abuse.
A further element of concern is the difficulty in accessing health care, especially in low- and middle-income countries43. For older people specifically, inadequate access to help is likely to have negative consequences44. This problem tends to worsen in emergency situations, such as in the current pandemic. The reduction of usual care for somatic and psychiatric diseases45, the lack of adequate staff, the limitation of provisions for people living in long-term care facilities46, the abolishment of outpatient visits, home services and public transport as well as long waiting times47,48 are all elements capable of increasing mental distress and thus can cause a rise in suicide risk49.
Actually, as shown in a survey by Carstensen et al.50 on a sample of 945 American individuals between the ages of 18 and 76 years, during the spreading of the pandemic, older adults showed relatively greater emotional well-being than younger adults and this persisted even in the face of prolonged stress. Similar results were obtained by another survey performed during March and April 2020 on a sample of 776 individuals aged 18–91 years from Canada and the USA51. Furthermore, another study suggested that older age leads to a greater focus on positive aspects of the initial phases of the pandemic52.
These findings appear to be in line with Carstensen et al.’s theory of socio-emotional selectivity53. According to this theory, with aging, people realize that the time at their disposal is limited and become more inclined to focus on the present than the future. They place more value on meaningful social ties and less on embarking on new adventures. This motivational change leads to greater investment in the quality of social relations and a general appreciation of life53. Relying on emotion-centered strategies can contribute to a greater sense of older adults’ control over their emotions54. A limited-time perspective may also explain the increased focus on emotional coping strategies with age.
Stress factors are present throughout the course of life. For people who perceive time as more limited, the future appears less important, while the emotional meaning of present situations increases in relevance. An emotions-focused approach to managing stress can therefore be used more frequently and result in better psychological outcomes53. Even if the intensity of experienced negative emotions is similar across all ages of life, older people are faster in returning to positive states than younger people55. Greater emotional control with age may help to explain why older adults report high levels of life satisfaction, nonwithstanding the losses experienced later in life56. Furthermore, older people have lower rates of mental health disorders compared to younger people57.
Most often, suicide in old age is presumed to be a rational act. Shortened lifespans, lack of positive outlooks, frailty, dependence on others, loss of a partner and loneliness are reasons that can provide a possible explanation for many cases of suicide. The aggregation of several risk factors, such as bereavement over the death of a partner, experiencing dependence and experiencing illness, can reinforce the paradigm of the rationality of suicidal behavior. Along the same lines, suicide might be considered a rightful choice in light of experiences such as loss of personal reputation and dignity, or if there is a dramatic change in status and social role. Situations such as those described above are often conceived as inevitably characterized by severe forms of depression, but this view is also heavily imbued with prejudices about the value of life in old age.
‘Ageism’, as defined by the World Health Organization, is a set of stereotypes, prejudices and discrimination that are based on age4. Often the public portrayal of old age is characterized by psychophysical decline, helplessness and fragility. These detrimental representations of old age might impact care options for older people. Furthermore, internalization of ageist narratives can result in a negative view of life and in the perpetuation of the common view of older people belonging to a disadvantaged subgroup of the population58. These psychosocial processes are confounded by ageism as portrayed in the press and social media59,60.
The roots of ageism have a long tradition. More than 2,000 years ago, Terentius, in his Phormio, wrote that ‘senectus ipsa morbus est’ (old age is in itself a disease)61. The accumulation of life events, losses and physical illnesses has fueled the view that older people rationally choose, for ‘right reasons’, to prematurely end their lives. Over the years, this interpretation has been replaced by the conception of older people as being almost always overwhelmed by their emotions, depressed to the point of seeing suicide as the only opportunity to stop their pains. Therefore, the medical world has paid the utmost attention to the therapy of affective disorders. However, depression is not the obvious answer to any type of stress, such as a sudden decrease in physical health or the onset of financial difficulties. The term ‘depression’, therefore, should be reserved only to describe a pathological state and not the supposedly foreseeable response to certain stress factors.
While there are different forms of depression that have distinct etiologies, all are characterized by an increased risk of suicide62. The central concept in depression is ‘loss’, and, as such, depression seems to align particularly well with the perceived ‘fragility’ of old age, somatic disorders and cognitive deficits, experiences of loneliness and loss of interest63. Not infrequently, these emotional experiences lead the person to ‘tunnel vision’, with suicide appearing as the only viable alternative and, perhaps, the only form of control over one’s life (the ultimate power) still achievable, especially in those people (more often men) who have been ‘people of action’ throughout their life64.
However, while depression is clearly a major risk factor for suicidal behavior (including in old age), arguably its role has been generalized more than necessary and it has been turned into the scapegoat for any suicidal behavior. In fact, sadness, disappointment, bitterness, loneliness and lack of hope for the future are frequent travel companions throughout the life of any individual and not necessarily clinical symptoms of an illness. As such, their presence should not always be indicative of pathology, as they are quite common feelings, sooner or later experienced by most individuals. But, then, when does a common mood such as sadness turn into depression (that is, a mental disorder)? It has been hypothesized that this occurs when the psychological reaction to an unfavorable life event does not appear to be related to it or is disproportionate or when there is a particular qualitative dimension in the reaction; that is, when it constitutes a ‘gestalt’ (an entity that is more than the sum of the elements that compose it) or, for pragmatic reasons, when it is assumed that there is a continuum of severity that ranges from sadness to clinical depression65. Apparently, many psychiatrists tend to favor the latter interpretation in qualifying a condition as ‘depressive’ in psychiatric terms65. In old age, people tend to be more often viewed with this way of thinking, which reflects anti-aging attitudes that are still widespread, even among doctors themselves64.
Mental health is affected by a number of determinants over the course of life; these determinants can accumulate in old age. Social determinants of health (SDH) are the conditions in which people are born, grow up, work and age and are affected by socio-environmental circumstances. These SDH are related to depression as well as other mental disorders and contribute to their onset or course. SDH may alternatively have a role as risk factors (for example, poverty, loss, relocation, migration, stigma and discrimination) or as protective factors (for example, good quality of family interactions, good social protection and intense spiritual life). By leveraging the SDH, one can improve mental health of older people66. This type of strategy, in itself non-medical stricto sensu, is however central in the fight against ageism and essential to the prevention of suicide.
Clinical treatment and suicide prevention
Ageism deteriorates care options for older adults: from normalizing depression in late life to fostering reluctance to intervene clinically, given the fragility of health of older patients and the fear of harmful drug–drug interactions67,68. These attitudes and misunderstandings can lead to underappreciation of the severity of a depressive disorder and simultaneously minimizing the complexity of an older person’s problems, flattening prospects for appropriate care66.
From the perspective of suicide prevention, there may be contradictory aspects in qualifying a condition as depressive. In clinical practice, approaching patient care with attention and prudence is better than to presume that life stressors, as well as all reactions connected to them, are inevitable. However, there are cultural scripts and common attitudes that can interfere with the best possible clinical management. These attitudes are particularly dangerous especially in the clinical management of older patients also because biopsychosocial stress factors (for example, chronic diseases, bereavement, social invisibility and so on) easily aggregate, multiplying their power19.
On the contrary, assuming that attitude in which every difficulty reported by the patient becomes attributable to a depressive illness implies an oversimplification of the problems and can lead to a hasty prescribing approach, often limited to the sole indication of an antidepressant drug. In this way, appreciation of the multifactorial nature and complexity of a given patient’s situation becomes too modest and the chances of countering a dangerous suicidal progression may be reduced. If there are no known miracle remedies for depression, there certainly are no ‘one-size-fits-all’ solutions for suicidal behavior. Furthermore, older people experiencing mental disorders are less likely to seek out psychiatrists and specialist services but rather prefer to approach their general practitioner to discuss health problems69.
In any case, prescription drugs alone may rarely be enough to make a difference for a person contemplating suicide. Pharmacological treatments should very often be supplemented (and sometimes replaced) by psychological treatments. Equally often, if not always, appropriate psychosocial interventions should be arranged. Unfortunately, these remedies do represent a traditionally problematic area for doctors: they are usually not part of their professional training and often tend to be considered of secondary importance, a kind of ‘soft therapy’. For this reason, these remedies are generally delegated to psychologists and social workers. On the contrary, in my opinion, the ‘social prescriptions’ of the UK national health system may represent an important complement to traditional care. Even if further research is needed to understand how social prescriptions can be applied efficiently to a variety of conditions70,71, social prescriptions appear to be promising health care interventions, useful in integrating the traditional biomedical model of care72,73.
As far as training in the area of suicidal behavior prevention is concerned, this remains a need of primary importance: certainly much more could be achieved in this area with adequate preparation74,75. Preventing suicide should be a shared commitment, and multidisciplinary teamwork appears today to be the most logical approach. The task of respecting the dignity of old people and fighting ageist views of old age remains problematic; equal determination should be involved in the fight against the stigma associated with mental disorders and suicidal behaviors76.
A fatalistic attitude toward the problem of suicide in late life conveys a materialistic and dismissive message to younger members of society, who instead need examples of courage and determination to live a meaningful life and nurture an authentic sense of belonging to the community.
Combating stigma and discrimination against older people, as well as promoting basic SDH, would help to prevent suicide76. However, these issues are still very under-represented in the global agenda of health care. While having an effective impact on the numerous forms of discrimination would require legal interventions by governments, fighting stigma would primarily involve education aimed at changing beliefs and attitudes77. Actions against stigma and discrimination must be sensitive to the local culture; their main objective must be the promotion of human rights, with particular regard to protection against abandonment, abuse and violence (especially deleterious aspects in old age)76. A human rights-based approach for older individuals essentially aims at their personal empowerment. Once they become more powerful, older people would also become more capable of defending their interests in terms of quality of life and protection against risk factors for suicide78.
Suicide prevention in old age should greatly expand its portfolio of interventions and direct more attention to the numerous socio-environmental conditions that can be particularly worrisome in old age, such as decreased physical health, social isolation and loneliness and financial insecurity. All of this could be crucial to counter suicidal ideation and behavior. The goal should not only be preventing suicide but also improving the quality of life of older adults to reduce factors that contribute to depression and suicidal ideation. While not all problems should be interpreted as symptoms of depression, both identification and early treatment of affective disorders and improvement of social support remain key interventions to reduce the risk of suicide in old age79.
It is crucial that governments continue to improve retirement programs, facilitate access to health care (in particular, mental health services), and create supportive social systems. The problem of loneliness with its many facets must be tackled and certainly with enhanced determination80. It remains a categorical imperative to test the real validity of any actions taken, with particular attention to identifying individual components of each prevention program and their respective impact and to ensure that they are tailored to different cultural contexts.
The fight against stigma and the ageist way of thinking, which is pervasive in society, including among health professionals, must be pursued with great vigor81. Additionally, successful aging requires promoting a culture of resilience and adaptation to the different stages of life as well as to the changes that come with advancing age. Promoting human rights of older people is an essential step in the path leading to this success.
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De Leo, D. Late-life suicide in an aging world. Nat Aging 2, 7–12 (2022). https://doi.org/10.1038/s43587-021-00160-1