Suicide more prevalent in older adults
Suicide rates are highest among the elderly, with more than 300 taking their life with a gun in the last decade in Connecticut, yet research on suicide prevention in old age remains a much-neglected area.
Medical crises, isolation and loss, depression and other mental health issues, and access to guns all can contribute to the decision a person makes to end their life with a gun, experts say
Jeremy Stein, executive director of Connecticut Against Gun Violence, knows how it feels to find out that a loved one has killed themself with a gun. When he was in graduate school, his uncle died by suicide with a gun.
“My first reaction was I felt this incredible sadness for my father, who was deeply affected by his suicide, and then the second thing was, Why? How could life be that bad that you would take your own life?” Stein said.
Other feelings and thoughts followed.
“How could you do this to us? There’s also this feeling that this person was being selfish,” he said. “At the same time, there’s this feeling of shame, this stigma that attaches to your family and nobody really talked about it for a long time.”
That stigma and shame are common among those who survive a loved one’s suicide, say mental health experts and others who study suicide. Those factors keep people from talking about the issue openly with someone
who they fear is suicidal, which could save the person’s life.
The chief state medical examiner’s office provided Hearst Connecticut Media with a database of adults who used a gun in suicide. It lists 321 people age 65 and older between 2010 and August of this year. Ninety were 80 and older. All but 18 were men, and the list includes 13 people of color: 10 Black men and three Hispanic men.
In the course of this story, families we contacted were reluctant to speak. Obituaries often go not list suicide as a cause of death. Stein, whose uncle died in the early ’90s and whose work is devoted to increasing gun safety and reducing gun violence, is willing to be open about suicide.
“People don’t like to talk about people taking their own life,” Stein said. “Even in the gun violence prevention world, survivors of suicide are even in a separate category.”
By survivors, Stein is referring to the family and friends left behind by a loved one’s suicide.
Stein said that, when his uncle died, he felt “guilt, of course, but I also think part of it was, you think, is there something you could have done to stop it? … Did we not do enough? Should we have been more involved in his life? Should we have noticed?”
Sarah Lowe, an assistant professor in social and behavioral sciences at the Yale School of Public Health, studies trauma, including gun violence, and mental health. She said suicide will bring “traumatic bereavement” to the family and other survivors, bringing “guilt over not knowing that the person is suffering, anger that the person has taken their own life. … In the trauma literature, we know that traumatic stress is the experience of violence or hearing something happened to a loved one.”
Curtailing access to firearms
Eighty percent of those who use a gun to attempt suicide succeed, but the decision often is an impulsive act, Stein said. That’s why removing guns from the home of anyone who is depressed or who has other mental health issues is the most effective way to prevent suicide.
“The No. 1 factor of why somebody chooses a gun is access to a gun,” Stein said. “If you have a gun in the home, that increases your chances of suicide.”
If there is concern about someone’s mental state, “getting the gun away from them can greatly increase their chances of survival and getting help to live a happier life,” he said.
Marcie Dimenstein, a social worker who focuses on seniors in her Hamden practice, Elder Pathways, said anyone who is at risk should have their guns removed. Once she knows someone who is suicidal has a gun, “I have an obligation as a social worker and a care manager,” she said. “I have to do something, and if they do have … dementia I make sure that the gun leaves the house.”
Dimenstein said removing guns from an older person’s house is “the best way to keep them safe. … Some people would be successful anyway, but I would guess … that without a gun they would not be at risk.”
Suicide is the end of a progression that begins with suicidal thoughts or ideation, then moves through intent to making a plan, Lowe said. “Availability of firearms and firearms that are stored in a way that’s not safe is a huge issue,” she said.
Diagnosis and treatment
Suicide rates are highest among men 75 and older, yet many health care professionals are unprepared to diagnose or treat it, according to a study in the journal Crisis.
Suicide is a growing public health issue in the United States, and older people are more likely to kill themselves with a gun than younger people. Of the 40,000 people who die by gun violence each year, six in 10 are suicides, according to the Centers for Disease Control and Prevention. Several studies have linked stricter gunpossession laws to lower homicide and suicide rates.
The congressional Joint Economic Committee reported that the oldest of the old, those 85 and older, are even more at risk.
“People see suicide as a young person’s issue … and that is not borne out in the research,” Lowe said. “If you look at absolute numbers, I believe there is an increase in suicidality in older adults as opposed to middle-aged adults.”
One reason is older people are more likely to be diagnosed with a chronic, debilitating medical condition, such as Parkinson’s disease, which “can put someone over the edge and lead them to take their own life.”
The ‘why’
“There are a few reasons that people decide to kill themselves,” according to Dimenstein. “Either undiagnosed or untreated depression [or] a chronic or acute disease that they’re going to die from at some point.” Dementia, before it becomes so advanced the person isn’t able to attempt suicide, is another underlying cause.
Depression resulting from retirement can lead to other health problems, too, said Dr. Michael Norko, a psychiatrist in the Yale School of Medicine and director of forensic services for the state Department of Mental Health and Addiction Services.
“Retirement is actually a stressor for a lot of people, and people will develop illness as a consequence of the stress of retirement,” including heart attacks, Norko said.
People resort to suicide to end what seems like unending pain, either physical or psychological, Norko said, and men will use a gun more often than women, partly because they are more likely to own them.
Stein said that in his uncle’s case, there was “a belief that he may have been diagnosed with early Alzheimer’s or dementia. Nobody knows for sure,” Stein said. His uncle was a Marine Corps veteran who had suffered from depression.
Ultimately, Stein said, “I don’t think anybody has any answers why somebody does or somebody doesn’t, but there are risk factors,” including depression and other mental health disorders, isolation, loss of family and friends. “The bottom line is we need to educate more people that just owning a firearm puts you more at risk for all injuries,” Stein said.
The COVID-19 pandemic is exacerbating the issues that bring on depression, Dimenstein said. “Right now, isolation is a terrible thing, and it’s killing people left and right,” she said.
Risk warrants
If a gun owner refuses to hand over his or her weapons, family members can ask police to apply for an extreme risk protection order. Connecticut was the first state to enact such a law, after the 1998 shooting at state lottery headquarters in which the gunman killed four people and then himself.
“It’s used more for harm to self than it is harm to others,” Stein said.
When police apply for an order, which may be on the family’s behalf, the judge will hold a hearing and can order the guns removed from the home for up to a year.
Stein sees the one-year limit as a flaw in the law, because “there is no hearing to determine whether this person is still a risk to themselves or others. It should trigger an automatic hearing before the guns are automatically given back to this person.” Now, a new order must be applied for
When an order is approved, notice is given to the state Department of Public Health or Mental Health and Addiction Services. But the law only applies to gun owners. There is no provision to revoke a permit or prevent someone from acquiring weapons in the first place, Stein said.
Often, family members don’t realize someone has a gun in the house, which they may have had for years, said Jill Harkavy-Friedman, vice president of research for the American Foundation for Suicide Prevention. But the risk of suicide is three times greater when someone owns a gun.
Norko has studied data drawn from more than 700 applications for the extreme risk protection orders, also known as risk warrants. The study found at least one person was prevented from suicide for every 10 to 20 firearms seizures.
Causes
“There’s never one cause of suicide,” even though people will try to determine one, Harkavy-Friedman said. “That’s not really how suicide works.”
In addition to depression, other mental health issues, substance use, a head injury and genetics can play a role in suicidal ideation, she said. Isolation and a decrease in physical ability can lead to depression, but “people don’t realize depression is not a natural part of aging and it’s treatable,” she said.
“When someone’s in a suicidal crisis, their thinking is different, they don’t have access to their usual coping. They can’t switch gears well,” Harkavy-Friedman said. What results is tunnel vision and what’s needed is “time for somebody to intervene but also time for the situation to de-escalate,” she said.
“If they are at risk, they have a negative lens through which they see the world. They feel hopeless,” she said. “It’s usually about wanting to stop physical or emotional pain and feeling desperate.”
Suicidal thoughts can be caused by a medical condition or by medication. “That’s why you have to consider a person’s physical and mental health,” Harkavy-Friedman said.
Depression, Dimenstein said, “is ultimately treatable” with medication or, in severe cases, electroconvulsive therapy. But if depression is newly diagnosed there may be a physical reason, such as a sleeping issue or hormonal changes. It may even be a side effect of medication. One problem is men “don’t look into treatment half as often as women do.”
For those 85 and over, who are known as the “older old,” Dimenstein said, “I think the issues are the same” but more may be living alone and dealing with ailments that are getting worse.
“If you’re worried about someone, you should trust your gut” and have “a real conversation” with a person at risk of suicide, she said. “You can’t make someone suicidal by asking. It can help them feel better, more likely,” she said.
‘Related to loss’
Norko said “the death of a significant other and failing health” were prime causes of suicide. For white men, “the rates continue to increase over 65. The angle of the curve just keeps going up over 65 and it’s related to loss, basically,” he said.
“There were actually two blips” when the risk of suicide rose, Norko said. One was at 65, when many men retire. “For a lot of men, the job was when they got a lot of their social interaction,” he said. “Some people do well in retirement, but for a lot of people it’s a big loss.”
The other spike was about age 50, he said. “The theory was that it’s sort of a time of failures in people’s careers and loss, a midlife crisis.”
‘ Traumatic stress’
Nancy Varga, a clinical social worker in Middletown, treats older people who are dealing with depression, chronic illness or at the end of life. A misunderstanding of mental health treatment may lead many older people not to seek help, she said.
“The baby boomers and older people grew up in a time when treatment meant asylums” and electric shock therapy, she said.
“A lot of people think treatment is going to take them to a place [where] they do not want to go,” she said.
And it’s often difficult to know someone is planning suicide,. she said.
“If they’re serious about suicide … they don’t say anything, they won’t write notes, they won’t let you know. They’ll put on a face that they’re OK. The doctors don’t necessarily know because doctors aren’t necessarily trained in determining levels of depression.”
If a patient complains of depression, the doctor may minimize it, believing it is to be expected when a patient loses a spouse or is elderly, Varga said. Among the warning signs is “if there’s suicide in a family. It becomes an option,” she said.
An older person, especially a man, may be more at risk of suicide because “they don’t have the resiliency; they don’t have the coping mechanisms that wives have managed for them all their lives,” she said. “Once they’ve made that decision, they don’t want to be stopped.”
Jennifer Colby, a social worker based in Rye Brook, N.Y., who also is licensed in Connecticut, does not have her senior clients come to her. She goes to their homes, where she can see how they are doing in their environment.
“I deal with people that have suicidal ideation a lot because of the isolation. In older adults, it’s very common to ask the question, Why am I here?” she said. Suicidal thoughts can increase when there are health problems, or if the person is unable to walk or dress themselves. She said she has serious concerns about 10 percent of her clients.
“They don’t want anybody to feel that they have to take care of them,” Colby said. “People don’t think about somebody who’s old wanting to take their life but it’s pervasive.”
“I am extremely careful and I check in with them frequently,” she said.
So far, none of her clients has died by suicide.
“I know that probably one day that will happen. I know as a clinician I will ask myself, is there something I missed?” she said.
It’s important to listen to an older person, who may struggle with living day to day and is ready to die. Platitudes such as “you have a lot to live for” are not helpful, Colby said.
“When they lay out a logical argument and it makes sense from a logical perspective, you need to validate what they’re going through,” she said. “What they say makes a lot of sense,” particularly for the very old.
In that case, she’ll approach her client by saying, “Let’s talk about how you can better cope with it until it is your time,” she said.