Loneliness and abuse as risk factors for suicide in older adults: new developments and the contribution of the <scp>WPA</scp> Section on Old Age Psychiatry
Authors: Carlos Augusto de Mendonça Lima, Diego De Leo, Gabriel Ivbijaro, Igor Svab
Journal: World Psychiatry (2021)

Suicide is a major public health problem, with 817,000 cases worldwide in 2016. The incidence is highest in those aged 70 years or older, among both men and women, in almost all regions of the world1. Effective interventions that mitigate iden­tified risk factors and sustain protective fac­tors are relevant across all age groups, but re­search specifically focused on suicide pre­vention in older adults is still in its early stag­es. The evidence on the effectiveness of suicide prevention interventions for older adults remains limited. The International Association for Suicide Prevention Interest Group on Suicide in Old Age2 recommended multi-component approaches, based on the available scientific evidence, with an organized system of distribution of resources and the monitoring of the effectiveness of each intervention. Loneliness occurs when a person feels disconnected from his/her closest social circle: partners, family members, peers, friends and significant others. It often affects older adults, particularly men when single, widowed or divorced3. It may result from the loss of an important intimate relationship or a social role that previously used to give a person his/her sense of self-esteem and dignity. In case of negative life events or other psychological stressful situations, when the person has nobody to share his/her feelings with, loneliness can have particularly negative consequenc­es. This, in combination with other risk factors, can lead to an increase of the risk for suicidal behaviour. A particular expression of loneliness among older adults is the fact that suicides more often occur when the person is alone at home4. The consequences of the COVID-19 pan­demic have resulted in new challenges for older adults, and we are just beginning to see the effects on morbidity, mortality and suicide rates worldwide5. Many government policies to tackle the pandemic that include social isolation, lockdown and social distancing have resulted in increased distress in older adults. We therefore need to develop strong primary care and commu­nity assets to support older adults. A rise in suicide deaths in older adults as a result of the pandemic is not inevitable6. The traditional approaches to suicide prevention need to be re-considered7, so that we can develop innovative ways to address this issue in older adults in the new context. The voices of people with lived experience should be heard to inform developments in strategies. Previous traumatic experiences (e.g., history of abuse during childhood, loss of a parent) can have consequences in later life and be associated with increased likelihood of suicidal behaviour. But present traumatic experiences may also increase the risk for suicide. According to the World Health Organization, around 1 in 6 older people experienced some form of abuse in the past year8. However, the prevalence rates reported in existing population-based elder abuse studies likely underestimate the true population prevalence. Not only this field of research suffers from methodological and comparability challenges, but elder abuse prevalence surveys also carry substantial participation bias, in that they exclude individuals with cognitive impairment, who could potentially be most vulnerable to abuse, especially in institutions. Older adults with mental health problems are at high risk for abuse. There are many forms of elder abuse, including psychological, physical, sexual, financial and social abuse, as well as neglect and abandonment. Abuse should never be condoned, whatever the mitigating circumstances. What may not be considered abusive towards a healthy, competent person may be so in a vulnerable older adult. This is mainly explained by the high risk of older adults to be dependent (financially, emotionally, physically) from the persons who perpetrate acts of violence, abuse or neglect against them. Each form of elder abuse represents a risk factor for suicide. Several psychosocial risk factors found in severely abused older adults are also frequently present in older adults who attempted or completed suicide. Abused older adults have been paid inadequate attention in suicide prevention efforts. This omission must be remedied, as the aged global population will dramatically increase in coming decades, which, in the absence of meaningful preventive efforts, may drive a sharp rise in the incidence of older adults' abuse and suicide9. Help to establish strong social relationships and an effective legal frame to protect the individual against any form of violence are common protective factors against suicide. However, in the case of older adults, we should recognize that efforts to sustain these protective factors have been weaker than for the younger population. Considering the high potential of loneliness as a risk factor for suicide, the WPA Section on Old Age Psychiatry has supported the establishment of an End Loneliness Day. The Section is also going to become partner of the Campaign to End Loneliness. Having the friendship and support we need is a fundamental part of our well-being. When loneliness becomes entrenched in later life, it can be hardest to overcome. The campaign aims to involve academics, front-line practitioners, decision-makers and businesses (see https://www.campaigntoendloneliness.org). Considering that all forms of elder a­buse are a violation of basic human rights, the WPA Section on Old Age Psychiatry is contributing to the effort to develop a new United Nations Convention on the Rights of Older Persons. A first action was a webinar organized in collaboration with the International Psychogeriatric Association on December 10, 2020, on the occasion of the Human Rights Day. The Section also organized an intersectional symposium on Threats to the Dignity of Older Adults with Mental Disorders during COVID-19 Pandemic within the 2020 WPA Thematic Meeting on Intersectional Collaboration. A Position Statement on Human Rights and Mental Health of Older Adults is now in preparation.