The Consideration of Age and Critical Risk Factors
W hen Working with the Suicidal Patient
Bruce Bongar
Pacific Graduate School of Psychology
and
Department of Psychiatry and Behavioral Sciences
Stanford University School of Medicine
Karin Cleary and Glenn Sullivan
Pacific Graduate School of Psychology

While the overall suicide rate has remained fairly stable over the past four and a half decades, there have been significant changes in the rates for specific age groups (NCHS, 1998). The suicide rate for adults has remained fairly stable, but the adolescent suicide rate has increased by 200% since the 1950s (NCHS, 1998). The current rate of adolescent suicide is approximately 10.6 per 100,000 (NCHS, 2001). At present, suicide is the eighth most common cause of death in older adults (over age 65) (NCHS, 1999). In fact, older adults constitute the age group at highest risk for suicide (NCHS, 1999). In 1997, elderly individuals comprised approximately 13% of the population in the United States but accounted for nearly 20% of all suicide deaths (Conwell, 1994; Moscicki, 1995; NCHS, 1999; NIMH, 2000). Approximately one of every five individuals who commit suicide is 65 years of age and older (Gallagher-Thompson & Osgood, 1997; NCHS, 1999).

Adolescents often present with numerous risk factors that make them more vulnerable to suicide (Eyman, Mikawa, & Eyman, 1990). The risk factors associated with living with one’s family of origin are more often encountered in adolescent populations. Their cognitive abilities are not as mature as adults; they are still developing their ability for abstract reasoning, cognitive and behavioral flexibility, and integrated identity, and are often less able to generate alternative solutions to problems. Furthermore, they tend to respond to crisis situations with less control and objectivity than are adults; as a result, difficult situations are easily overexaggerated and quickly become overwhelming to the adolescent with limited problem-solving skills (Eyman et al., 1990).

Risk factors for suicide can often be classified into different categories, including demographic categories (e.g. age, gender), psychosocial (e.g. recent interpersonal loss, socially isolated), psychiatric (e.g. presence or history of a psychiatric illness), and medical (e.g. presence of chronic medical illness) (Bongar, 2002). With older adults, however, the category of indirect self-destructive behaviors (e.g. drinking toxic liquids) must also be included (Brown, 2001). Indirect self-destructive behaviors create a significant number of risk factors for this population that are not relevant to suicide risk assessment in adults or in adolescents (Brown, 2001).

The typical practicing psychologist treating adolescent patients sees, on average, three female and two male patients per month for whom suicide is an issue, and approximately one in six practicing psychologists report losing an adolescent patient to suicide, while that patient was under their care (Cleary, 2002). Psychologists working with older adult clients report seeing a monthly average of one to two female and one to two male older adult patients for whom suicide is an issue (Brown, 2001). One in twelve psychologists working with older adult patients reports having lost a patient under their care to suicide (Brown, 2001). These data show that when working with either adolescent or older adult patients, there is a higher likelihood of suicide risk, and that the psychologist is at risk (over the span of their professional career) of having one of their patients commit suicide.

Several recent studies have examined what practicing psychologists believe to be critical risk factors for the prediction of risk for completed suicide for adults (Canapary, 1999; Peruzzi & Bongar, 1999; Reynolds, 2000), adolescents (Cleary, 2002), and older adults (Brown, 2001). While the top three critical risk factors were the same across adult diagnostic categories and across age groups, there were a significantly greater number of critical risk factors identified for adolescents (Cleary, 2002) and for older adults (Brown, 2001). There were eight critical risk factors identified for adult patients with a diagnosis of Major Depression (Peruzzi & Bongar, 1999), 12 for patients with a diagnosis of Alcohol Dependence (Canapary, 1999), 13 for a diagnosis of Schizophrenia (Reynolds, 2000), 17 for older adult patients (Brown, 2001), and 18 for adolescent patients (Cleary, 2002). Table 1 lists the top risk factors identified by psychologists for the adult diagnostic categories and the two age groups that have been studied so far (see page 10).

The identification of risk factors for adolescents, adults, and older adults makes assessing risk for completed suicide a more manageable task. Although risk assessment for all age groups can begin with the five items listed in the behind table, it is important to note the special considerations needed in working with youth and older adults who present at increased risk (i.e., there are significantly more critical risk factors that are relevant to these age populations than are relevant for adults).

Table 1

Risk Factor	Adolescents	Older Adults	Major Depression	Schizophrenia	Alcohol Dependence
History of suicide attempts	1	1	2	2	2
Severe hopelessness	2	2	4	5	3
Medical seriousness of previous attempt	3	3	1	1	1
Acute suicidal ideation	4	4	3	3	Not measured
Family history of completed suicide	5	8	6	7	6

Note: Numbers in the table represent the rank that was given to the item as to their importance for predicting suicide risk for the various populations.

References

Bongar, B. (2002). The Suicidal Patient: Clinical and Legal Standards of Care, 2nd edition. Washington, DC: American Psychological Association.

Brown, L. M. (2001) Suicidal Risk Factors with an Elderly Population: Standard of Care Practices. Unpublished doctoral dissertation, Pacific Graduate School of Psychology, Palo Alto, CA.

Canapary, A. (1999). Suicidal Risk Factors with an Alcoholic Population: Standard of Care Practices. Unpublished doctoral dissertation, Pacific Graduate School of Psychology, Palo Alto, CA.

Cleary, K. (2002). Risk Factors for Completed Suicide in Adolescents: Implications for Prevention. Unpublished doctoral dissertation, Pacific Graduate School of Psychology, Palo Alto, CA.

Conwell, Y. (1994). Suicide in elderly patients. In L. S. Schneider, C. F. Reynolds, B. D. Lebowitz, & A. J. Friedho(Eds.), Diagnosis and treatment of depression in late life: Results of the NIH Consensus Development Conference. (pp. 397-418). Washington, DC, USA: American Psychiatric Press, Inc.

Eyman, J. R., Mikawa, J. K., & Eyman, S. K. (1990) The problem of adolescent suicide: Issues and assessment. In P. McReynolds, J. Rosen, G. Chelune (Eds.), Advances in Psychological Assessment (vol. 7) (pp.165-201). New York: Plenum Press

Gallagher-Thompson, D., & Osgood, H. J. (1997). Suicide in later life. Behavior Therapy, 28, 23 - 41.

Moscicki, E. K. (1995). Epidemiology of suicide. International Psychogeriatrics, 7, 137-148.

National Center for Health Statistics (1999). Deaths: Final data for 1997. NCHS Monthly Vital Statistics Report, 47(Number 19).

National Center for Health Statistics (NCHS). (2001). Preliminary data for 1999. National Vital Statistics Report, 49(3).

Peruzzi, N. & Bongar, B. (1999). Assessing risk for completed suicide in patients with major depression: Psychologists’ views of critical factors. Professional Psychology: Research and Practice, 30, 576-580.

Reynolds, N. (2000). Suicidal Risk Factors with a Schizophrenic Population: Standard of Care Practices. Unpublished doctoral dissertation, Pacific Graduate School of Psychology, Palo Alto, CA.