Control Strategies and Suicidal Ideation in Older Primary Care Patients with Functional Limitations

Suicide is an important public health problem that disproportionately affects older adults. In 2010, adults age 65 or older comprised 13.0% of the U.S. population but represented 15.6% of the suicides [1]. Risk of suicide is especially elevated in men aged 75 and older, whose rate is nearly triple the overall suicide rate in the United States [2]. Depression, the predominant risk factor for suicide among older adults, is implicated in the majority of suicides in this age group [3]. Nevertheless, it is a non-specific risk factor, as the vast majority of older adults with a depressive disorder do not die by suicide. Thus, there is a pressing need to identify factors independently associated with suicide risk in older adults. Physical illness and disability are associated with increased risk of suicide in late life, and effects appear to be partially independent of depression [4]. Although there may be multiple explanations for the link between physical health problems and suicide, evidence suggests that difficulties adapting to physical limitations may play a role. Among health problems associated with suicide in late life, many are chronic and potentially disabling conditions, including some types of cancer, neurological disorders, congestive heart failure, chronic pulmonary disorder, renal failure and impairments in vision and hearing [4]. Functional impairment has been linked to suicide risk in older adults [5, 6; cf. 7], although the possibility that functional impairment explains the relation between physical illness and suicide remains to be evaluated. Additional evidence comes from studies showing that among individuals with cancer, the risk of suicide is especially elevated early in the course of the disease [8], consistent with the possibility that suicide risk is related to problems adapting to the disease. Furthermore, qualitative reports suggest that older adults who died by suicide had pronounced problems adapting to loss of control, including limitations in physical functioning [9]. Taken together, these findings are consistent with the proposition that suicidal ideation in late life may be related, in part, to problems of adaptation. The Motivational Theory of Life Span Development [10] provides a framework for understanding mental health outcomes in the context of age-associated limitations in physical functioning. According to this theory, individuals of all ages prefer to attain their goals by exerting control directly on their environment, but opportunities to exert control tend to decline with age. Individuals who exhibit flexibility in coping with their changed circumstances should have the most positive outcomes. Successful adaptation theoretically requires changing strategies for attaining goals as well as managing motivation through cycles of disengaging from unobtainable goals and reengaging with more feasible ones. Heckhausen and colleagues [10] define control strategies along two dimensions: selective versus compensatory and primary versus secondary. Selective strategies reflect investment of one’s own effort to attain a goal. In contrast, compensatory strategies involve recruitment of external resources, such as asking for help from others. Primary control strategies are those aimed at changing the environment, whereas secondary control strategies are focused on changing the self. The theory specifies that selective primary control strategies are preferred across the lifespan, but as individuals age and encounter limitations in the ability to exert primary control, use of other strategies becomes adaptive. Research supports the theory, showing that control strategies change in predicted ways with normal aging [e.g., 11], as well as following onset of health problems among older adults [12]. Furthermore, control strategies reflecting an active engagement in personal goals are associated with lower levels of depressive symptoms [13], and buffer the effects of health problems on both depressed mood and the stress response [14]. In addition, a growing literature has shown that disengagement from unobtainable goals (compensatory secondary control) is associated with better mental health outcomes relative to continued striving [e.g., 15, 16, 17]. Research also supports theoretical predictions that specific type of control strategy employed should be related to outcomes, as successful aging involves a match between opportunity for control and strategy used to exert control [10]. Similarly, Clark’s model of late life suicidal behavior suggests that individuals who have limited flexibility will have the greatest difficulty adapting to the losses associated with aging and will consequently be at risk of suicide [18]. Consistent with these theoretical frameworks, evidence shows that individuals who continue striving (selective primary control) without employing a more diverse repertoire of control strategies are at risk of poor outcomes when they encounter age-related limitations in their ability to exercise control [e.g., 15, 16, 19]. Compensatory primary control strategies, which involve the recruitment of external resources, may be particularly relevant for older adults facing health-related limitations. Among both older [20] and middle-aged adults [21] with vision impairment, compensatory primary control strategies were the most frequently endorsed strategies. Strategies related to seeking or accepting help from others were more often used by participants with more severe impairments, whereas use of technical aids was more frequently used by participants with the least severe impairments. These strategies may also be particularly adaptive. In a prospective study, older men with “health-induced task-related restrictions” who endorsed primary control striving (“persistence”) but did not endorse help seeking or task modification were at increased risk of subsequent hospitalization for medical or other reasons [19]. The Motivational Theory of LifeSpan Development also provides a basis for predicting suicidal outcomes in late life. For individuals who are not able to attain goals through direct effort (selective primary control), are not willing or able to seek help (compensatory primary control) and do not disengage from the goal (compensatory secondary control), hopelessness and suicidal thinking may ensue. Given this conceptual rationale, as well as previous research demonstrating that older adults who die by suicide are characterized by an inability to adapt to age-related losses in functioning [9], endorsement of a diverse set of control strategies in the face of independence-limiting conditions should be associated with less suicidal ideation than continued striving alone. In summary, specific profiles of control strategies have been shown to predict mental and physical health outcomes in older adults with health problems, but the relation between control strategies and suicidal ideation has not yet been tested. The purpose of the present study was to examine this relation in older primary care patients with functional limitations. Our first hypothesis, based on existing research, was that greater endorsement of compensatory primary control strategies would be associated with lower levels of both depressive symptoms and suicidal ideation, controlling for other types of control strategies. Given our conceptualization that failure to adapt to limitations may lead specifically to a hopeless state, we also anticipated that the relation between compensatory primary control strategy endorsement and suicidal ideation would be partially independent of the effects of depressive symptoms. Our second hypothesis, also based in prior empirical literature, was that greater endorsement of secondary control strategies (both selective and compensatory) would be associated with lower levels of depressive symptoms and suicidal ideation.