Low Depression Scores May Miss Seniors With Suicidal Intent

Batya Swift Yasgur, MA, LSW

August 19, 2021

Older adults may have a high degree of suicidal intent yet still have low scores on scales measuring psychiatric symptoms, such as depression, new research suggests.

In a cross-sectional cohort study of more than 800 adults who presented with self-harm to psychiatric emergency departments in Sweden, participants aged 65 years and older scored higher than younger and middle-aged adults on measures of suicidal intent.

However, only half of the older group fulfilled criteria for major depression, compared with three quarters of both the middle-aged and young adult–aged groups.

"Suicidal older persons show a somewhat different clinical picture with relatively low levels of psychopathology but with high suicide intent compared to younger persons," lead author Stefan Wiktorsson, PhD, University of Gothenburg, Gothenburg, Sweden, told Medscape Medical News.

"It is therefore of importance for clinicians to carefully evaluate suicidal thinking in this age group. Safety issues and need for treatment might otherwise be underestimated," he said.

The findings were published online August 9 in the American Journal of Geriatric Psychiatry.

Research by Age Groups "Lacking"

"While there are large age differences in the prevalence of suicidal behavior, research studies that compare symptomatology and diagnostics in different age groups are lacking," Wiktorsson said.

He and his colleagues "wanted to compare psychopathology in young, middle-aged, and older adults in order to increase knowledge about potential differences in symptomatology related to suicidal behavior over the life span."

The researchers recruited patients aged 18 years and older who had sought or had been referred to emergency psychiatric services for self-harm at three psychiatric hospitals in Sweden between April 2012 and March 2016.

Among all patients, 821 fit inclusion criteria and agreed to participate. The researchers excluded participants who had engaged in nonsuicidal self-injury (NNSI), as determined on the basis of the Columbia Suicide Severity Rating Scale (C-SSRS). The remaining 683 participants, who had attempted suicide, were included in the analysis.

The participants were then divided into the following three groups:

  • Older (n = 96; age, 65 to 97 years; mean age, 77.2 years; 57% women)

  • Middle-aged (n = 164; age, 45 to 64 years; mean age, 53.4 years; 57% women)

  • Younger (n = 423; age, 18 to 44 years; mean age, 28.3 years; 64% women)

Mental health staff interviewed participants within 7 days of the index episode. They collected information about sociodemographics, health, and contact with healthcare professionals. They used the C-SSRS to identify characteristics of the suicide attempts, and they used the Suicide Intent Scale (SIS) to evaluate circumstances surrounding the suicide attempt, such as active preparation.

Investigators also used the Mini International Neuropsychiatric Interview (MINI), the Suicide Assessment Scale (SUAS), and the Karolinska Affective and Borderline Symptoms Scale.

Greater Disability, Pain

Of the older patients, 75% lived alone; 88% of the middle-aged and 48% of the younger participants lived alone. A higher proportion of older participants had severe physical illness/disability and severe chronic pain compared with younger participants (all comparisons, P < .001).

Physical illness/disability
  • Older: 65%

  • Middle-aged: 40%

  • Younger: 22%

Chronic pain
  • Older: 38%

  • Middle-aged: 31%

  • Younger: 17%

Older adults had less contact with psychiatric services, but they had more contact than the other age groups with primary care for mental health problems. Older adults were prescribed antidepressants at the time of the suicide attempt at a lower rate compared with the middle-aged and younger groups (50%, vs 73% and 66%).

Slightly less than half (44%) of the older adults had a previous history of a suicide attempt ― a proportion considerably lower than was reported by patients in the middle-aged and young adult groups (63% and 75%, respectively). Few older adults had a history of a previous NNSI (6%, vs 23% and 63%).

Three quarters of older adults employed poisoning as the single method of suicide attempt at their index episode, compared with 67% and 59% of the middle-aged and younger groups.

Notably, only half of older adults (52%) met criteria for major depression, determined on the basis of the MINI, compared with three quarters of participants in the other groups (73% and 76%, respectively). Fewer members of the older group met criteria for other psychiatric conditions.

Psychiatric condition Distribution by group
Generalized anxiety disorder
  • Older: 10%

  • Middle-aged: 23%

  • Younger: 24%

Posttraumatic stress disorder
  • Older: 5%

  • Middle-aged: 17%

  • Younger: 22%

Alcohol use disorder
  • Older: 11%

  • Middle-aged: 36%

  • Younger: 35%

Substance use disorder
  • Older: 1%

  • Middle-aged: 3%

  • Younger: 24%


Clouded Judgment

The mean total SUAS score was "considerably lower" in the older adult group than in the other groups. This was also the case for the SUAS subscales for affect, bodily states, control, coping, and emotional reactivity.

Importantly, however, older adults scored higher than younger adults on the SIS total score and the subjective subscale, indicating a higher level of suicidal intent.

The mean SIS total score was 17.8 in the older group, 17.4 in the middle-aged group, and 15.9 in the younger group. The SIS subjective suicide intent score was 10.9, vs 10.6 and 9.4.

"While subjective suicidal intent was higher, compared to the young group, older adults were less likely to fulfill criteria for major depression and several other mental disorders and lower scores were observed on all symptom rating scales, compared to both middle-aged and younger adults," the investigators write.

"Low levels of psychopathology may cloud the clinician's assessment of the serious nature of suicide attempts in older patients," they add.

"Silent Generation"

Commenting on the findings for Medscape Medical News, Marnin Heisel, PhD, CPsych, associate professor, Departments of Psychiatry and of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada, said an important take-away from the study is that if healthcare professionals look only for depression or only consider suicide risk in individuals who present with depression, "they might miss older adults who are contemplating suicide or engaging in suicidal behavior."

Heisel, who was not involved with the study, observed that older adults are sometimes called the "silent generation" because they often tend to downplay or underreport depressive symptoms, partially because of having been socialized to "keep things to themselves and not to air emotional laundry."

He recommended that, when assessing potentially suicidal older adults, clinicians select tools specifically designed for use in this age group, particularly the Geriatric Suicide Ideation Scale and the Geriatric Depression Scale. Heisel also recommended the Center for Epidemiological Studies Depression Scale–Revised Version.

"Beyond a specific scale, the question is to walk into a clinical encounter with a much broader viewpoint, understand who the client is, where they come from, their attitudes, life experience, and what in their experience is going on, their reason for coming to see someone and what they're struggling with," he said.

"What we're seeing with this study is that standard clinical tools don't necessarily identify some of these richer issues that might contribute to emotional pain, so sometimes the best way to go is a broader clinical interview with a humanistic perspective," Heisel concluded.

The study was funded by the Swedish Research Council, the Swedish Research Council for Health, Working Life and Welfare, and the Swedish state, Stockholm County Council and Västerbotten County Council. The investigators and Heisel have reported no relevant financial relationships.

Am J Geriatr Psychiatry. Published online August 9, 2021. Full article

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