Clinical Geriatrics

Introduction
Suicidality is a serious clinical concern that influences mental health treatment in the elderly. It manifests across a continuum that spans from suicidal ideation to completed suicide and is an urgent public health problem; both the rate and lethality of suicide attempts in geriatric age groups are increased relative to younger persons. Recent concern about a relationship between antidepressant use and suicidality raises questions about the risks associated with this treatment modality for depression and other mood disorders. This review delineates the known risk correlates of suicidality, summarizes studies on the relationship between antidepressants and suicidal manifestations, and concludes with a practical management strategy given the current evidence base.

Suicidality in the Elderly
Suicide is the eleventh leading cause of death in the United States, with rates for the general population of 10.4/100,000.1 Its prevalence increases in late life and reaches a rate of 17.6/100,000 for the population age 75-84 years. In addition, the lethality of suicide attempts increases in late life. Among all adults, the elderly are most likely to die as a result of their attempts,2 with the ratio of completed to attempted suicides increasing from 1:200 in young adult women to 1:4 in elderly persons.3

Suicidality is a complex and incompletely understood phenomenon. Its manifestations range from suicidal ideation to attempted suicide and completed suicide. Conwell et al4 reviewed the correlates of suicidal behaviors in late life that are described in the literature. In addition to demographic characteristics, factors associated with increased prevalence of suicidality fell into three categories: (1) mental health factors, (2) physical health factors, and (3) social factors.

Among mental health factors, the presence of a mood disorder (most notably depression) has been consistently demonstrated in studies of suicidality in the elderly.3,5-8 In addition, a prior history of suicide attempts has been shown to be a significant predictor of completed suicide,3,7 and investigations have found suicidal ideation to predict completed suicide.9 Many studies have linked a greater severity of depressive symptoms and recurrent major depressive disorder with a higher risk of attempted or completed suicide.5,8,10-11 On the other hand, substance use disorders have shown a less consistent association with suicidality in older patient samples.5,8,11-12 Other mental health factors associated with increased suicidality have included hypersomnia (> 9 hr/night),5 hopelessness,13,14 comorbid anxiety or panic disorder,15,16 and higher neuroticism and lower openness to experience on the revised NEO Personality Inventory (NEO PI-R).17 Most studies have not associated dementia with suicidality.4,8

Physical health factors correlated with suicidality include current smoking5 and higher medical comorbidity.3,8 The evidence for an association of functional impairment with suicidality has been mixed.3,10-11 This is likely reflective of the coexistence of impairment with serious physical illness, and also the resultant limitation on one’s ability to attempt or complete suicide.