Progress in identifying risk and protective factors in older suicidal adults.

In 2002, an American Journal of Geriatric Psychiatry theme issue of suicidal behaviors in older adults highlighted expanding research on possible risk and protective factors in later-life suicidality. The annual national suicide statistics available at that time (1999) indicated a suicide rate of 15.9 per 100,000 persons aged 65 and older. Rates from 2003 (the most recent available) indicate that 14.6 per 100,000 persons aged 65 and older died by suicide. The highest risk group among the elderly are white males aged 85 and older who have a suicide rate of 51 per 100,000, which is nearly five times the average national rate of 10.7 per 100,000. Although these rates have shown albeit a very small but decreasing trend, a number of the articles here propose that the absolute number of older adults dying by suicide in the United States will increase in the upcoming years simply because the proportion of older adults in the United States will increase. Indeed, many of the papers in this special issue define persons aged 50 and older as “the elderly,” casting a broader net that includes older middle-aged groups who also have substantial suicide rates. Several articles included in this issue provide refinements in assessment of risk and protective factors that can be used to anticipate possible shifts in risk and protective factors as the babyboomer cohort continues to age. Both descriptive and intervention research in suicide prevention remains a challenge as a result of the relatively low base rate of suicide deaths and attempts. It is rare to have research opportunities that can address an age-specific cohort with sufficient numbers of suicide deaths to examine risk and protective factors. The report on suicide decedent characteristics of all Danish psychiatric inpatients aged 60 and older by Erlangsen and her colleagues is a critical and unique registry study. Despite a relatively short window of follow-up time (defined by time at admission to a psychiatric hospital and one week after discharge), the suicide decedents, compared with other inpatient controls, had a significantly increased risk if they had an affective disorder. This registry study complements the consistent psychologic autopsy finding that affective disorders are the most common psychiatric diagnoses among elderly decedents. What is unique about the Danish study is its ability to capture all individuals with psychiatric hospitalizations in a nationwide healthcare system and link their treatment history with death records. This linkage is nearly impossible to accomplish in the United States, with the exception of some comprehensive healthcare systems such as the Veterans Administration. Although such linked data in the United States are difficult to come by, we do know that suicide deaths and attempts are events of serious concern for many healthcare facilities. The Joint Commission on Accreditation of Health care Organizations (JCAHO) has reported for some time that suicide is the leading sentinel event in healthcare facilities. As a step toward reducing suicides, JCAHO recently issued 2007 national patient safety goals that include assessment of suicide risk for clients for all mental health facilities. Adequate assessment of suicidal risk may be particularly important for the elderly. Counter to the logic that older patients with repeated hospitalizations may be at greatest risk (longer and possibly more severe course of illness), Erlangsen and associ-