In terms of cost savings, suicide among the elderly would be quite effective. Perhaps “suicide panels” would be as successful as the imaginary ”death panels” that caused so much consternation as healthcare reform was being processed. A ready-made theme song for “suicide panels” could be “Suicide is Painless“, the theme song from the hit TV show, Mash.
As ghoulish as this sounds, this is not a one-time Halloween trick. Indeed, something like this was even predicted by the outstanding pioneer in studying suicide, the psychiatrist Herbert Hendin, M.D. In his classic book, Suicide in America, Hendin discussed the unique challenges of suicide in the elderly. He pointed out that the history of large birth cohorts, like we have had with the “baby boomers”, usually manifests with increased stress through life and correspondingly higher suicide rates at every age level. When the stressors of aging are added on, the suicide rate will predictably be even higher.
The rate of known suicide is highest today in the Caucasian male elderly, rivaled only by adolescents. For these men, the particular stress is often the loss of status and authority that has given their lives meaning. For all elderly, among other increased risk factors are prior suicide attempts, severe depression, dual disorders of substance abuse and/or anxiety, antidepressant and/or anticholinergic medication exposure, prior Electroconvulsive Therapy, vascular disease, and beginning dementia. New research suggests that these factors can cause alterations to reward systems in the brain, increasing vulnerability for impulsive suicides.
Given these factors, it may not be surprising that the success of suicide attempts also increases in the elderly. While the overall known ratio of attempted suicides to actual suicides is about 10 attempts for every completed suicide, among the elderly suicide attempts and completed suicides are estimated to occur at the same rate. A typical sequence is a non-serious attempt followed in a relatively short time by a potentially lethal attempt, often by a gun.
Dr. Hendin took a strong stand against so-called physician-assisted suicide and euthanasia, sensing that these could be used against those viewed as a burden to society, such as the elderly. He was especially concerned about euthanasia for psychiatric patients who are suicidal, given the distorting influence of the depression that is almost invariably concomitant in the suicidal elderly.
These subtle, and not so subtle, pressures toward suicide have confronted me more than once in my career, even though I was not a geriatric psychiatrist. I recall when I was Director of our not-for-profit managed behavioral healthcare system, as described in my book The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare (1997), that when we had high cost, treatment resistant, suicidally depressed patients, our administrator more than once exasperatedly exclaimed: “Just withdraw support, it’s hopeless, and we’ll overspend our capitation with more of these”. Dr. Hendin has also described similar scenarios in non managed care situations.
I was more recently reminded of how suicide is viewed differently in the elderly when I was part of a panel on suicide on Yom Kippur, the Jewish High Holy Day when most religious Jews pray to be put into the “Book of Life”. I presented for the first time publicly a patient who had died by suicide under my care during the initial stage of my psychiatric training. He was an elderly man who had lost his job and was in a loveless marriage. In his second session, he seemed a bit better. Later, I was to learn to be wary of this brief time of looking better, as the patient may have the energy to now decide and plan a suicide. The next week he walked into Lake Michigan and drowned.
As I began to speak, I sobbed instead, only to be comforted by the father of a teenager who recently died by suicide. Nevertheless, the lively discussion that followed was all about preventing suicide in the young, not at all about the elderly.
Yet, there is much that we can probably do to prevent suicide in the elderly, if we value that stage of life enough to give the attention and to spend the resources. Akin to those who survive suicide attempts at any stage of life, people often decide they want to live, especially if helpful treatment is provided to relieve the frequent unbearable psychological and/or physical pain.
Primary care physicians, in particular, have an opportunity to intervene, as they often have seen patients within the prior month before a suicide. The elderly grew up at a time when mental illness was even more stigmatized than today, so that they don’t readily admit to depression or ask for help. These doctors can also be on the lookout for the more passive suicidal behavior. Self-starvation, poor medication compliance, and frequent accidents can be a mask for a slow suicidal process.
Community services can reduce the risk. More and better community supports are necessary replacements for important losses. Perhaps even the robots that Jim Sabin discussed in his recent post on Grandma and Her Robot, will help when humans aren’t sufficiently available.
All this is not to say that some suicides in the elderly could be concluded to be rational ones and therefore not be prevented. However, we should do everything in our power to make sure that they are not irrational suicides that could be prevented. Otherwise, we will be allowing de facto suicide panels, will we not?
H. Steve Moffic, M.D., 67, retired from clinical practice at 65. He was fondly deemed a “psychiatric gadfly” by the Chair of the Department of Psychiatry where he first trained. His book The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare, published in 1997, was the first extended discussion of the ethics of managed mental health care.