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. Author manuscript; available in PMC: 2025 May 1.
Published in final edited form as: J Women Aging. 2023 Dec 13;36(3):210–224. doi: 10.1080/08952841.2023.2292164

Depression in Older Women Who Died by Suicide: Associations with Other Suicide Contributors and Suicide Methods

Namkee G Choi 1,*, C Nathan Marti 1
PMCID: PMC11062817  NIHMSID: NIHMS1966189  PMID: 38090746

Abstract

Suicides among older women have received little research attention. In this study based on the 2017–2019 National Violent Death Reporting System data, we examined prevalence of depression in older female suicide decedents (N=3,061), associations between depression and other suicide precipitants, and the associations between suicide methods and depression. Descriptive statistics and generalized linear models (GLM) for a Poisson distribution with a log link were used to examine the research questions. Of the decedents, 15.0% had depressed mood without a reported diagnosis and 41.8% had a depression diagnosis. Nearly one half of the decedents with reported depression were receiving mental health/substance use treatment at the time of injury. The likelihood of depression was lower among those who were age 85 and older compared to those were age 65–74, but higher among those who had anxiety disorder (IRR=1.50, 95% CI=1.33–1.69), history of suicidal ideation (IRR=1.22, 95% CI=1.10–1.35), history of suicide attempt (IRR=1.27, 95% CI=1.14–1.41), and bereavement problems (IRR=1.45, 95% CI=1.27–1.65). Those who had depression were less likely to have used firearms (IRR=0.85, 95% CI=0.75–0.97) but more likely to have used hanging/suffocation (IRR=1.37, 95% CI=1.13–1.67). The findings show that gun ownership was likely an important factor for firearm use. The high prevalence of depressed mood and/or depression diagnosis among older female suicide decedents at the time of their fatal injury underscores the importance of assessing depression and providing evidence-based depression treatment as an essential suicide prevention approach.

Keywords: Suicide, Depression, Anxiety disorder, Suicide attempt, Firearms, Poisoning

INTRODUCTION

The U.S. Centers for Disease Control and Prevention (CDC) reported that the number of suicide deaths, after declining in 2019 and 2020, increased approximately 5% in 2021 and 2.6% in 2022, with the biggest percentage increase (8.1%; from 9,652 decedents in 2021 to 10,433 decedents in 2022) among those age 65 and older (CDC, 2023). The percentage increase in 2022 was also higher in women (3.8%) than in men (2.3%), although suicide rates have always been higher among men than women regardless of age group (CDC, 2023; Garnett & Curtin, 2023). Suicide rates among women age 65–74 increased significantly from 2004 to 2017, decreased from 2017 to 2020, and then increased again in 2021 and 2022 (Garnett & Curtin, 2023; CDC Wonder, 2023). Rates among women age 75 and older had periods of decline and stability since 2005; however, there was a significant increase between 2020 and 2022 (Garnett & Curtin, 2023; CDC Wonder, 2023).

Research has shown depression, especially depression with severe symptom severity, and psychiatric comorbidity (anxiety disorder, bipolar disorder, and/or alcohol and other substance use disorders) to be strong risk factors for suicidal ideation and behaviors among older adults in general (Beghi et al., 2021; Bruce et al., 2004; Fernandez-Rodrigues et al., 2022; Oude Voshaar et al., 2016; Raue et al., 2014; Sachs-Ericsson et al, 2014; Van Orden & Conwell, 2011). Research has also shown that women tend to have persistently higher rates of depression than men through middle and late life (Abrams & Mehta, 2021; Best et al., 2021; Luo et al., 2023). However, older women’s suicidal behaviors, compared to older men’s suicidal behaviors, have received relatively little research attention. With increasing suicide rates among older women, more research on the association between depression and suicide is needed.

Depression and Suicidality

The link between depression and suicide has often been explicated with psychological and neurocognitive factors that are common dimensions in both depression and suicidal thoughts and behaviors. These include hopelessness (i.e., pervasive negative and fatalistic views of the future and immutability of one’s situation; Beck et al., 1990), perceived defeat or entrapment, psychological pain, and cognitive control deficit. A meta-analysis found that hopelessness, as an important symptom dimension of depression, was associated with increased odds of suicidal ideation, suicide attempts, and death by suicide, regardless of the age of the study samples (Ribeiro et al, 2018). Hopelessness often leads to perceptions of defeat or entrapment, and these perceptions have been found to be strongly linked to depression and suicidality (Siddaway et al., 2015; Taylor et al., 2011). Hopelessness in late life can also be a result of feeling tired of life or perception of life not worth living that are often exacerbated by physical pain and loss of independence due to functional and/or cognitive impairment (Appel & van Wijngaarden, 2021). Faced with immutable physical health problems and other life stressors, older adults may feel that their life no longer has meaning or purpose. Further, hopelessness in late life can stem from loneliness or engender loneliness, which, along with reduced social support, has been found to be significantly associated with an elevated suicide risk (Fernandez-Rodrigues et al., 2022; Niu et al., 2020). Research has shown that trait hopelessness, i.e., enduring emotion of hopelessness, rather than state hopelessness, in particular, was significantly associated with suicide attempt (Burr et al., 2018).

Psychological pain or psychache – a perception of inability or deficiency of the self, as well as frustrated psychological needs and social disconnection – is a prominent dimension of depression that can lead to suicide as a means of escaping from pain (Meerwijk & Weiss, 2014; Shneidman, 1993). Depressed older adults, compared to non-depressed age peers, were found to exhibit heightened sensitivity to both psychological and physical pain and increased motivation to avoid both types of pain and decreased motivation to experience hedonia, which could be strong predictors of suicidal behavior (Conejero et al., 2018a; Xie et al., 2014). A meta-analysis found that the intensity of psychological pain was significantly higher among those with a history of suicidal ideation and suicide attempt (Conejero et al., 2018a; Ducasse et al., 2018). A recent study also found that motivation to avoid intolerable psychological pain, coupled with impaired decision-making bias toward under-valuing life’s worth was highly predictive of suicide attempts (Ji et al., 2022).

Suicide attempters with late-life depression were also found to have significantly higher global and periventricular white matter hyperintensities and to have significantly lower executive function, which could be an underlying mechanism for cognitive decline in older adults with suicidality (Lin et al., 2021; Sachs-Ericsson et al., 2014). Cognitive control deficits and a dysfunctional reward system likely undermining the search for alternative solutions predicted fatal and near-fatal suicidal behavior among older adults with depression (Dombrovski et al., 2019; Szanto et al., 2018; 2020).

Other Suicide Precipitants and Contributors in Late Life

While a significant proportion of older adults who died by suicide suffered from depression, suicidality in late life can occur in the absence of depression (Raue et al., 2010). A study of older suicide decedents based on the 2003–2016 National Violent Death Reporting System data found that 69% of older male and 50% of older female suicide decedents did not have a known mental illness (Schmutte & Wilkinson, 2020). As suicidal behavior is a multifactorial phenomenon, complex interactions among individual biological, social, and environmental factors and stress-coping skills throughout life can underlie the pathophysiology of suicidal behavior (Brådvik, 2018; Lengvenyte et al., 2021).

Of other late-life suicide precipitants, with or without depression or other mental health problems, physical health problems and related pain and functional impairment, as aforementioned, have been most commonly examined, although compared to older male decedents, older female decedents had a lower rate of physical health problems as a suicide precipitant (Bickford et al., 2021; Choi et al., 2019; Conejero et al., 2018b; Fässberg et al., 2016; Kuffel et al., 2023; Lutz & Fiske, 2018). Physical health problems in late life that are perceived to be hopeless and burdensome to family members are especially significant contributors to depressive mood and suicidal behaviors (Choi et al., 2019). Additionally, loss of a loved one and bereavement-related stressors, financial difficulty, and limited social connectedness or relationship conflict have been found to contribute to older adults’ suicidal behaviors (Beghi et al., 2021; Choi et al., 2022a; Fässberg et al., 2012).

Examination of depression and other late-life suicide precipitants and contributors is important for identifying older women who may be at risk of suicide. In order to develop effective suicide prevention strategies, it is also important to examine associations between suicide methods and depression. A recent study found that firearms, poisoning, and hanging/suffocation were used by 75%, 8%, and 12%, respectively, of older male suicide decedents, and 34%, 41%, and 16%, respectively, of older women (Choi et al., 2022b). The associations between different suicide method choices and depression among older female suicide decedents have not yet been examined.

Research Questions

In this paper, using data on female suicide decedents age 65 and older, we examined: (1) prevalence of depression (depressed mood prior to suicide and/or depression diagnosis) in different age groups of older female decedents; (2) whether or not those who had depression were different from those who did not have depression with respect to other demographic factors, mental disorders, substance use problems, history of suicidal ideation and attempts, and suicide precipitants including problems with physical health, finance/housing, relationship, and bereavement; and (3) the associations between suicide methods that the older women used and depression and these other characteristics.

METHODS

Data Source

Data came from the 2017–2019 National Violent Death Reporting System (NVDRS). NVDRS is the only state-based violent death reporting system in the US that provides information and context on when, where, and how violent deaths occur and who is affected (National Center for Injury Prevention and Control [NCIPC], 2021). NVDRS links data from death certificates and reports from coroners/medical examiners (CME) and law enforcement (LE) agencies on cases of violent deaths--suicides, homicides, deaths from legal intervention (i.e., victim killed by LE acting in the line of duty), deaths of undetermined intent, and unintentional firearm deaths. CME/LE reports are from the injury/death scene, ongoing investigations, or family/friend accounts and often serve as the basis of the circumstances of death and the NVDRS variables that were “calculated” (i.e., coded “Yes” when endorsed by the CME and/or LE reports vs. “No/not available/unknown”).

We used 2017–2019 NVDRS data because the number of participating states increased from 27 in 2016 to 37 in 2017 and to 43 states, the District of Columbia, and Puerto Rico in 2019, although not all states provided complete data for all three years (NCIPC, 2021). Our preliminary analysis showed that some important results vary depending on the number of participating states. We were granted access to de-identified NVDRS data for this study by the Centers for Disease Control’s NVDRS-Restricted Access Data Review Committee.

The 2017–2019 NVDRS provided data on a total of 94,457 (74,042 male, 20,412 female, and 3 unknown sex) suicide decedents, ages 18–105 at the time of death. Of these, 17,917 were age 65 and older (14,856 [82.9%] male, 3,061 [17.1%] female ). The 3,061 older female decedents became this study’s focus. This study, based on deidentified data on deceased individuals, was exempt from the authors’ institutional review board’s review.

Measures

Demographic variables:

Data on age at the time of death, sex, race/ethnicity, marital status, and level of education were from the death certificates and CME/LE reports. In this study, decedents were categorized into 65–74, 75–84, and 85+ age groups to examine age group differences, and the 65–74 age group was used as the reference category in multivariable models. We also included the decedents’ residential region (Northeast, Midwest, South, West, Puerto Rico or missing) to control for possible geographic differences in suicide methods.

Depression:

In the NVDRS, depression is reported as depressed mood at the time of injury referring to “sad, despondent, down, blue, low, and/or unhappy” mood, perceived by self or others, without the need to have a clinical diagnosis or any indication that the depression directly contributed to the death. Depression is also noted as any depressive disorder listed in DSM-5 diagnosis (American Psychiatric Association, 2013) at the time of death, without the need for any indication that they directly contributed to the death. Depression in this study was defined as depressed mood at the time of injury or any depressive disorder (yes=1; no/not available/unknown=0). Depression in older adults tends to be underdiagnosed (Morichi et al., 2015), and thus, many may not have had a depression diagnosis despite depressive symptoms. Moreover, some family/friends may not have been aware of the decedents’ diagnoses.

Other mental disorders and substance use problems:

Other diagnosed mental disorders and syndromes listed in DSM-5 at the time of death that were examined in this study included anxiety and bipolar disorders. Because of their low rates, other mental disorders (schizophrenia, post-traumatic stress disorders, and dementia) were excluded. NVDRS also notes self or others’ perception of alcohol problem/addiction and other substance misuse/addiction (e.g., prescription drug misuse, chronic/abusive/problematic marijuana use, any use of other illicit drugs or inhalants), without requiring that the alcohol or drug problem directly contributed to the death. We included mental health or substance use treatment within the preceding two months and the history of such treatment for descriptive purposes only.

History of suicidal thoughts/plans and attempts:

In NVDRS, history of suicidal thoughts was coded “Yes,” if the decedent had at any time in her life expressed suicidal thoughts or plans. History of suicide attempts refers to any previous suicide attempts before the fatal incident, regardless of the severity and injury status.

Suicide precipitants:

In NVDRS, these included physical health problems, relationship problems, suicide/death of family/friend, and job/finance/housing problems that directly contributed to the fatal injury. Physical health problems were recorded “Yes” only if any diagnosed or perceived physical health problem (e.g., terminal disease, debilitating condition, chronic pain) was relevant to the death (e.g., “despondent over recent diagnosis of cancer” or “complained that he could not live with the pain associated with a condition” even if the condition may not have been diagnosed or existed). Relationship problems refer to conflict with an intimate partner and/or other family members, arguments, other family stressors, caregiver burden, or abuse by a caregiver. Bereavement problems were coded “Yes” if the decedent was distraught over or reacting to a suicide or other death of spouse, family member or a friend or to an anniversary of the death/suicide. Job problems refer to job loss (fired or laid off) and/or difficulties finding/keeping a job or difficulties with demotion or serious conflict/stress at work. Financial problems refer to financial difficulties, e.g., bankruptcy, overwhelming debts, or foreclosure of a home or business. Housing problems refer to a recent eviction or other loss of the victim’s housing, or the threat of it. Although the NVDRS coded job, financial, and housing problems separately, we combined them into a single category (yes=1; no/not available/unknown=0) in this study given that these problems tend to occur in step with one another (i.e., job loss leading to financial problems and finally, loss of housing).

Suicide methods:

In the NVDRS, suicide methods were identified from the International Classification of Diseases, 10th Revision (ICD-10), codes for intentional self-harm (X60-X84) for underlying cause of death in death certificates and/or from the underlying cause descriptions in CME reports. They included the following: firearms; hanging/suffocation; drug poisoning (including any type of drug/medicine/alcohol/chemical overdose); gas (e.g., carbon monoxide, nitrogen) poisoning; laceration/sharp instruments; blunt objects; jumping from heights; contact with moving objects (train/other vehicles); drowning; and other (fire, hypothermia, electrocution, starvation, dehydration, not adhering to or refusing medical care, or undetermined causes). We classified them into four categories in this study: firearms, drug poisoning, hanging/suffocation, and all other means.

Analysis

All statistical analyses were performed using Stata/MP 18. First, we used cross-tabulations with Pearson’s χ2 tests to describe the rates of depression in three age groups. Second, we used χ2 tests to compare those with and without depression with respect to demographic characteristics, other mental disorders and substance use problem, history of suicidal ideation and attempt, suicide precipitants, and suicide methods. Third, we fit a generalized linear model (GLM) for a Poisson distribution with a log link to examine the associations of depression with demographic characteristics, other mental disorders and substance use problem, history of suicidal ideation and attempt, and suicide precipitants. Finally, we fit four GLMs to examine the associations of each suicide method (dependent variable) with depression and other covariates (demographic characteristics, other mental disorders and substance use problem, history of suicidal ideation and attempt, and suicide precipitants). As dichotomous categorization of depression status (i.e., depression vs. no depression) and tri-categorization of depression (depression diagnosis and depressed mood without a diagnosis vs. no depression) did not impact the conclusions, we report results from GLMs with the dichotomous measure of depression status. We used the Poisson distribution with a log link rather than logistic regression models because odds ratios exaggerate the true relative risk to some degree when the event (i.e., depression in this study) is a common (i.e., >10%) occurrence (Grimes & Schulz, 2008). As a preliminary diagnostic, we used variance inflation factor, using a cut-off of 2.50 (Allison, 2012), from linear regression models to assess multicollinearity among covariates. Variance inflation factor diagnostics indicated that multicollinearity was not a concern. GLM results are reported as incidence rate ratios (IRRs) with 95% confidence intervals (CIs). Significance was set at p<.05.

RESULTS

Prevalence of Depression

Table 1 shows that 56.8% of older female suicide decedents had depression; 15.0% had depressed mood without a reported diagnosis and 41.8% had a depression diagnosis. The prevalence of depression differed significantly among three age groups, with 60.1% in the 65–74 age, 54.7% in the 75–84 age group, and 38.4% in the 85+ age group, and the percentage of depression diagnosis in the 65–74 age group (46.2%) was more than twice that in the 85+ age group (22.1%). Additional analysis showed no significant difference in the prevalence of depression among three study years (χ2[2]=5.73, p=.057).

Table 1.

Prevalence of depression among older female suicide decedents by age group, 2017–2019 (%)

All
3,061 (100%)		 65–74
2,027 (66.2%)		 75–84
740 (24.2%)		 85+
294 (9.6%)
No depressed mood or depression diagnosis1 43.2 39.9 45.3 61.6
Depression (depressed mood or depression1 diagnosis) 56.8 60.1 54.7 38.4
Depressed mood only, no diagnosis 15.0 13.9 17.6 16.3
Depression diagnosis 41.8 46.2 37.1 22.1
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1

Age group differences were significant: Pearson χ2 (df=2)=50.89, p<.001

Characteristics of Decedents by Depression Status

Table 2 shows that among those who had depression, a little more than a quarter had depressed mood without a reported diagnosis, and nearly three quarters had a diagnosis. Compared to those who were not reported to have had depression, those who had depression included higher proportions of the 65–74 age group, Hispanics, and those with anxiety and bipolar disorders. Overall, compared to 19.9% of those who did not have depression, 78.3% of those who had depression had at least one mental disorder including any depressive disorder. Those who had depression also included higher proportions of individuals with alcohol and other substance use problems, history of suicidal ideation and attempt, relationship problems, bereavement problems, and job/finance/housing problems. Nearly 30% of those who had depression, compared to 13.9% of those who did not have depression, had attempted suicide before the fatal injury. About one half of those who had depression, compared to one of ten without depression, were receiving treatment for their mental health and/or substance use problems. Those who had depression also included a lower proportion of individuals who used firearms (30.3% vs. 38.1% of those without depression) but higher proportions of individuals who used drug poisoning (39.0% vs. 34.8%) and hanging or suffocation (17.7% vs. 13.6%).

Table 2.

Decedent’s characteristics by depression status (%)

No depression
1,324 (43.2%)		 Depression
1,737 (56.8%)		 p
Depression category n/a
Depressed mood only, no diagnosis 26.4
Depression diagnosis 73.6
Age group <.001
65–74 61.0 70.2
75–84 25.3 23.3
85+ 13.7 6.5
Race/ethnicity .032
Non-Hispanic White 89.8 90.2
Black 3.5 2.2
Hispanic 1.7 3.1
Asian 4.2 3.8
Other 0.8 0.7
Marital status .115
Married 32.3 35.1
Divorced/separated 29.0 28.8
Widowed 29.8 29.5
Never married 7.7 5.8
Missing 1.2 0.8
Education .777
≥ High school 47.1 46.8
Some college or AB 21.7 23.1
Bachelor’s degree or higher 28.2 27.4
Missing 3.0 2.8
US Census region .165
Northeast 16.8 18.5
Midwest 20.6 22.9
South 26.9 26.5
West 34.9 31.1
Puerto Rico or missing 0.8 1.0
Other mental disorders
Anxiety disorder 4.5 21.1 <.001
Bipolar disorder 5.2 7.5 <.001
Schizophrenia 2.7 1.5 .017
PTSD 0.6 1.1 .151
Dementia 1.2 0.3 .002
Any mental disorder diagnosis (including depression) 19.9 78.3 <.001
Alcohol use problem/addiction 5.3 7.7 .009
Other substance use problem 4.5 6.3 .029
Mental health/substance use treatment receipt
At the time of injury 10.5 46.9 <.001
History 14.4 56.4 <.001
History of suicidal thoughts 24.3 39.9 <.001
History of suicide attempt 13.9 29.2 <.001
Suicide precipitants
Physical health problem 40.9 41.1 .925
Relationship problem 10.3 16.0 <.001
Bereavement problem 6.4 17.8 <.001
Job, finance, or housing problem 7.1 9.7 .012
Suicide method <.001
Firearm 38.1 30.3
Drug poisoning 34.8 39.0
Hanging/suffocation 13.6 17.7
Other 13.5 13.1
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Associations of Depression with Demographic and Other Suicide Contributors: Multivariable GLM Results

Table 3 shows that the likelihood of depression was lower among those who were age 85 and older (IRR=0.69, 95% CI=0.56–0.85) compared to those were age 65–74 and those who lived in the West region (IRR=0.86, 95% CI=0.74–0.99) compared to those in the Northeast region, but was higher among those who had anxiety disorder (IRR=1.50, 95% CI=1.33–1.69), history of suicidal ideation (IRR=1.22, 95% CI=1.10–1.35), history of suicide attempt (IRR=1.27, 95% CI=1.14–1.41), and bereavement problems (IRR=1.45, 95% CI=1.27–1.65).

Table 3.

Association of depression with demographic and other characteristics: Generalized linear modeling results (N=3,061)

Depression vs. No depression
IRR (95% CI)
Age group: vs. 65–74
75–84 0.92 (0.82–1.03)
85+ 0.69 (0.56–0.85)***
Race/ethnicity: vs. Non-Hispanic White
Black 0.85 (0.61–1.17)
Hispanic 1.27 (0.94–1.72)
Asian 1.05 (0.81–1.34)
Other 0.98 (0.55–1.76)
Marital status: vs. Married
Divorced/separated 0.98 (0.87–1.10)
Widowed 0.97 (0.85–1.10)
Never married 0.88 (0.71–1.08)
Missing 0.92 (0.52–1.62)
Education: vs. ≥ High school
Some college or associate degree 1.02 (0.90–1.15)
Bachelor’s degree or higher 1.01 (0.90–1.13)
Missing 1.02 (0.75–1.40)
Region: vs. Northeast
Midwest 0.98 (0.85–1.14)
South 0.96 (0.83–1.11)
West 0.86 (0.74–0.99)*
Puerto Rico or missing 0.90 (0.53–1.54)
Anxiety disorder 1.50 (1.33–1.69)***
Bipolar disorder 1.07 (0.89–1.28)
Alcohol use problem/addiction 1.05 (0.87–1.26)
Other substance use problem 0.98 (0.80–1.19)
History of suicidal thoughts 1.22 (1.10–1.35)***
History of suicide attempt 1.27 (1.14–1.41)***
Suicide precipitants
Physical health problem 1.06 (0.96–1.17)
Relationship problem 1.12 (0.98–1.28)
Bereavement problem 1.45 (1.27–1.65)***
Job, finance, or housing problem 1.07 (0.90–1.27)
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*

p<.05

**

p<.01

***

p<.001

Associations of Suicide Methods with Depression: Multivariable GLM Results

Table 4 shows that those who had depression were less likely to have used firearms (IRR=0.85, 95% CI=0.75–0.97) but more likely to have used hanging/suffocation (IRR=1.37, 95% CI=1.13–1.67). Of the covariates, compared to non-Hispanic White decedents, Hispanic and Asian decedents were less likely to have used firearms but more likely to have used hanging/suffocation. Asians were also less likely to have used drug poisoning, and Black and Asian decedents were more likely to have used other methods than firearms, drug poisoning, and hanging/suffocation. Compared to married women, divorced or widowed women were less likely to have used firearms, but more likely to have used drug poisoning. Those with a college degree were less likely to have used firearms. Compared to residence in the Northeast region, residence in the Midwest, South, or West regions were associated with 2–3 times higher likelihood of firearm use. Anxiety disorder, other substance use problems, and history of suicide attempt were associated with a higher likelihood of drug poisoning use. History of suicide attempt was associated with a lower likelihood of firearm use. Physical health problems were associated with a higher likelihood of firearm and drug poisoning use but a lower likelihood of hanging/suffocation and other method use.

Table 4.

Associations of suicidal intent disclosure and suicide methods with depression: Generalized linear modeling results (N=3,061 for each model)

Firearms vs. All other Drug poisoning vs. All other Hanging/suffocation vs. All other All other methods vs. Firearms, drug poisoning, and hanging/suffocation
IRR (95% CI) IRR (95% CI) IRR (95% CI) IRR (95% CI)
Depression vs. No depression 0.85 (0.75–0.97)* 1.02 (0.90–1.16) 1.37 (1.13–1.67)** 0.99 (0.80–1.23)
Age group: vs. 65–74
75–84 1.00 (0.86–1.16) 0.94 (0.81–1.09) 1.06 (0.85–1.32) 1.15 (0.91–1.46)
85+ 0.82 (0.64–1.04) 1.02 (0.82–1.27) 1.27 (0.93–1.74) 1.24 (0.87–1.75)
Race/ethnicity: vs. Non-Hispanic White
Black 0.65 (0.43–1.00) 0.86 (0.57–1.28) 1.50 (0.90–2.49) 2.04 (1.30–3.21)**
Hispanic 0.55 (0.31–0.99)* 0.87 (0.56–1.36) 2.05 (1.29–3.24)** 1.17 (0.64–2.16)
Asian 0.15 (0.07–0.32)*** 0.23 (0.12–0.42)*** 4.45 (3.42–5.78)*** 1.97 (1.34–2.89)**
Other 0.61 (0.23–1.64) 1.10 (0.58–2.08) 0.94 (0.29–3.11) 1.74 (0.66–4.58)
Marital status: vs. Married
Divorced/separated 0.67 (0.57–0.79)*** 1.35 (1.16–1.57)*** 1.08 (0.85–1.36) 1.17 (0.91–1.50)
Widowed 0.75 (0.64–0.89)** 1.38 (1.17–1.62)*** 0.96 (0.74–1.23) 0.95 (0.72–1.26)
Never married 0.77 (0.59–1.02) 1.14 (0.88–1.49) 1.04 (0.72–1.49) 1.30 (0.89–1.88)
Missing 0.45 (0.20–0.99)* 1.72 (0.93–3.18) 0.93 (0.35–2.48) 1.49 (0.56–3.91)
Education: vs. ≥ High school
Some college or associate degree 0.96 (0.82–1.12) 0.91 (0.78–1.06) 1.28 (1.01–1.62)* 1.12 (0.86–1.46)
Bachelor’s degree or higher 0.80 (0.68–0.94)** 1.04 (0.90–1.19) 1.20 (0.94–1.49) 1.25 (0.99–1.57)
Missing 1.39 (0.98–1.97) 0.63 (0.40–1.01) 1.35 (0.80–2.25) 0.82 (0.41–1.66)
Region: vs. Northeast
Midwest 1.95 (1.51–2.51)*** 0.91 (0.76–1.10) 0.79 (0.61–1.03) 0.66 (0.49–0.88)**
South 2.96 (2.33–3.74)*** 0.75 (0.63–0.90)** 0.47 (0.36–0.63)*** 0.49 (0.37–0.66)***
West 2.13 (1.67–2.72)*** 0.95 (0.80–1.12) 0.63 (0.49–0.80)*** 0.62 (0.47–0.81)***
Puerto Rico or missing 0.71 (0.17–3.01) 0.19 (0.05–0.78)* 1.35 (0.71–2.56) 1.36 (0.61–3.02)
Anxiety disorder 0.92 (0.76–1.12) 1.19 (1.01–1.39)* 0.86 (0.65–1.13) 0.87 (0.63–1.18)
Bipolar disorder 0.95 (0.72–1.25) 1.15 (0.92–1.43) 0.76 (0.50–1.14) 0.97 (0.65–1.44)
Alcohol use problem/addiction 0.88 (0.67–1.17) 1.20 (0.97–1.49) 0.77 (0.49–1.20) 0.80 (0.50–1.27)
Other substance use problem 0.74 (0.53–1.02) 1.44 (1.16–1.79)** 0.65 (0.38–1.12) 0.65 (0.37–1.14)
History of suicidal thoughts 0.97 (0.85–1.12) 0.95 (0.84–1.09) 1.06 (0.87–1.29) 1.14 (0.92–1.42)
History of suicide attempt 0.58 (0.49–0.70)*** 1.37 (1.20–1.57)*** 1.07 (0.86–1.33) 1.07 (0.85–1.37)
Suicide precipitants
Physical health problem 1.17 (1.03–1.32)* 1.15 (1.02–1.30)* 0.67 (0.55–0.82)*** 0.67 (0.54–0.84)***
Relationship problem 1.16 (0.98–1.39) 1.16 (0.98–1.37) 0.61 (0.44–0.84)** 0.67 (0.48–0.95)*
Bereavement problem 1.01 (0.82–1.23) 1.02 (0.86–1.22) 0.85 (0.63–1.14) 1.18 (0.87–1.60)
Job, finance, or housing problem 1.15 (0.92–1.44) 0.84 (0.67–1.05) 1.16 (0.83–1.62) 1.00 (0.68–1.46)
Open in a new tab
*

p<.05

**

p<.01

***

p<.001

DISCUSSION

In this study, we compared two groups of older women who died by suicide: those who were reported to have shown depressed mood or had a depression diagnosis at the time of injury (56.8%), and those who did not have such a report (43.2%). Multivariable analysis showed that the decedents who had depression were less likely to have been 85 years or older but depression was not associated with other demographic factors, i.e., race/ethnicity, marital status, and education. However, those who had depression were more likely to have had psychiatric and substance use problems, prior suicidal thoughts and attempt, and bereavement-related stressors as a suicide precipitant. Comorbid anxiety disorder was a significant factor among those with depression, which is not surprising. In a study of suicide decedents who had depression, a comorbid anxiety disorder was identified in one out of six cases and associated with a higher prevalence of several suicide risk factors (Oude Voshaar et al., 2016). The associations between depression and suicidal thoughts and attempts are not surprising, either; however, the fact that nearly 30% of the decedents who had depression had a history of suicide attempt indicates that these women’s intent to die may have been persistent, likely due to hopelessness, tiredness of living from physical and/or psychological pain, perceptions of defeat, dysfunctional psychopathology, and escape motives (Alessi et al., 2019). It also shows that these women may not have received any suicide prevention services or such services were not effective.

The high prevalence of depressed mood and/or depression diagnosis at the time of their fatal injury among these older female suicide decedents underscores the importance of treating depression. The fact that nearly one half of the decedents with reported depression were receiving mental health/substance use treatment implies that the treatment may not have been effective for these women. While the NVDRS did not provide detailed data on the types of treatment, the most common depression treatment for older adults is pharmacotherapy (Kok & Reynolds, 2017), which may have had limited or no effect on alleviating suicidal ideation (KoKoAung et al., 2015; Laflamme et al., 2022). KoKoAung et al.’s review of five observational studies (2015) also found an increased risk of suicide attempts with antidepressants (selective serotonin reuptake inhibitors) versus no treatment. Physical activity and behavioral activation or other psychotherapeutic interventions may have been more effective in reducing suicidal thoughts and behaviors (Laflamme et al., 2022; Meerwijk et al., 2016). However, there still is insufficient evidence for the assumption that suicidality in depressed patients can be reduced with psychotherapy for depression (Cuijpers et al., 2013). Given that prior suicide attempt is an especially lethal risk factor for completed suicide (Bostwick et al., 2016), our findings point out the critical importance of assessing and treating depression among those with prior suicide attempts.

Our findings show that those with depression had a lower likelihood of firearm use and a higher likelihood of hanging/suffocation. However, suicide method choices among older female decedents appear to have been influenced by many other factors: race/ethnicity, marital status, region of residence, other psychiatric problems, and physical health problems besides depression. For example, the likelihood of firearm use was higher among White and married women and in the rest of the country than the Northeast region, which implies that gun ownership was an important factor. National survey data showed that gun ownership was higher among non-Hispanic Whites, in households of married people, and in the Midwest, South, and West regions than in the Northeast region (Jones, 2013; Schaeffer, 2021). Firearms in the home increase firearm suicide rates beyond and above other risk factors for suicidal behaviors (Miller et al., 2013). The higher likelihood of hanging/suffocation among Hispanic and Asian women may be a reflection of the overall lower gun ownership rates among Hispanics and Asian/Pacific Islanders compared to non-Hispanic Whites (Schaeffer, 2021). The higher likelihood of firearm use among those with physical health problems may be due to the fact that those who had experienced severe physical pain leading to strong suicidal intent had a higher degree of physical pain tolerance and fearlessness about death—the element of the capability of suicide—especially if they had prior experiences of firing a gun (Anestis & Capron, 2018; Van Orden et al., 2010). The higher likelihood of drug poisoning among those with depression and anxiety disorder, other substance use problems, and physical health problems may be due to the fact that these women had easy access to psychotropic medicines and other substances.

The study has a few limitations due to NVDRS data constraints, including the uncertain validity of depression reporting in NVDRS and limited generalizability of the findings to NVDRS non-participating states. Depression and suicide precipitants and contributors in NVDRS were based on reports from decedents’ family/friends and other informants and/or suicide notes and could not be independently verified. The actual rate of depression may have been higher. Some members in the informal system may not have been aware of depression diagnosis or depressed mood especially if they had not had close contact. Decedents, including those without any informal support system, with “unknown” or “not available” depression state may have had depression but were not reported as such. Although 43 states, District of Columbia, and Puerto Rico participated in the 2017–2019 NVDRS, some states did not provide data on all three observation years and others provided only partial data limited to some counties.

Despite these limitations, the study findings have important clinical and policy implications for preventing suicide among older women. First, healthcare professionals, especially primary care physicians who have frequent contact with older women, should routinely assess depression, anxiety, and suicidal ideations. Second, older women who are at risk of suicide due to depression and other mental disorders should be provided evidence-based mental health treatments. Research has shown that multifaceted primary care-based depression screening and management programs are one of the most effective interventions for preventing suicidal behaviors in older adults (Ding & Kennedy, 2021; Okolie et al., 2017). Those with prior suicide attempt and psychiatric co-morbidity need continued treatment and monitoring that include strengthening resiliency, finding meaning in life and reasons for living, and reducing reasons for dying, and enhancing overall psychological and physical well-being as protective factors (Bagge et al., 2014; Brüdern et al., 2018; O’Brien et al., 2023). Given the complex and diverse suicide precipitants and contributors among older women, suicide prevention for older adults who are suffering from depression and suicidal thoughts need to be tailored to individual circumstances and needs. Third, older women who are at risk of suicide should be restricted from accessing lethal means such as firearms and large quantities of psychotropic medications and other substances. Family members and healthcare professionals at both primary care and mental health settings need to identify those at risk and should work together with older adults to develop safety protocols and restrict access to these means. While the Second Amendment curtails legislation broadly restricting firearm access in the U.S., we need to strengthen gun control and safety measures for those at risk of suicide.

Acknowledgments

The Centers for Disease Control and Prevention (CDC) administers the National Violent Death Reporting System (NVDRS) in conjunction with participating NVDRS states. CDC provided the NVDRS Restricted Access Data used in this study to the authors. Study findings and conclusions are those of the authors alone and do not necessarily represent the official position of CDC or of the participating NVDRS states.

Funding

This work was supported by the National Institute on Aging [P30AG066614], awarded to the Center on Aging and Population Sciences at The University of Texas at Austin.

Footnotes

Conflict of Interest

None for both authors.

Ethics Statement

This study based on de-identified/deceased individuals was exempt from the authors’ Institutional Review Board’s review.

Data Availability and Acknowledgments

The Centers for Disease Control and Prevention (CDC) administers the National Violent Death Reporting System (NVDRS) in conjunction with participating NVDRS states. CDC provided the NVDRS Restricted Access Data used in this study to the authors after reviewing the authors’ data request. Study findings and conclusions are those of the authors alone and do not necessarily represent the official position of CDC or of the participating NVDRS states.

References

  1. Abrams LR, & Mehta NK (2019). Changes in depressive symptoms over age among older Americans: Differences by gender, race/ethnicity, education, and birth cohort. SSM - Population Health, 7, 100399. 10.1016/j.ssmph.2019.100399 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Alessi M, Szanto K, & Dombrovski A (2019). Motivations for attempting suicide in mid- and late-life. International Psychogeriatrics, 31(1), 109–121. 10.1017/S1041610218000571 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Allison P (2012). Statistical horizons. When can you safely ignore multicollinearity? http://statisticalhorizons.com/multicollinearity [Google Scholar]
  4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 10.1176/appi.books.9780890425596 [DOI] [Google Scholar]
  5. Anestis MD, & Capron DW (2018). Deadly experience: The association between firing a gun and various aspects of suicide risk. Suicide & Life-threatening Behavior, 48(6), 699–708. 10.1111/sltb.12381 [DOI] [PubMed] [Google Scholar]
  6. Appel JE, & van Wijngaarden EJ (2021). Older adults who experience their lives to be completed and no longer worth living: A systematic mini-review into used terminology, definitions, and interpretations. Frontiers in Psychology, 12, 734049. 10.3389/fpsyg.2021.734049 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Bagge CL, Lamis DA, Nadorff M, & Osman A (2014). Relations between hopelessness, depressive symptoms and suicidality: mediation by reasons for living. Journal of Clinical Psychology, 70(1), 18–31. 10.1002/jclp.22005 [DOI] [PubMed] [Google Scholar]
  8. Beck AT, Brown G, Berchick RJ, Stewart BL, & Steer RA (1990). Relationship between hopelessness and ultimate suicide: A replication with psychiatric outpatients. American Journal of Psychiatry, 147(2), 190–195. 10.1176/ajp.147.2.190 [DOI] [PubMed] [Google Scholar]
  9. Beghi M, Butera E, Cerri CG, Cornaggia CM, Febbo F, Mollica A, Berardino G, Piscitelli D, Resta E, Logroscino G, Daniele A, Altamura M, Bellomo A, Panza F, & Lozupone M (2021). Suicidal behaviour in older age: A systematic review of risk factors associated to suicide attempts and completed suicides. Neuroscience and Biobehavioral Reviews, 127, 193–211. 10.1016/j.neubiorev.2021.04.011 [DOI] [PubMed] [Google Scholar]
  10. Best JR, Gan DRY, Wister AV, & Cosco TD (2021). Age and sex trends in depressive symptoms across middle and older adulthood: Comparison of the Canadian Longitudinal Study on Aging to American and European cohorts. Journal of affective disorders, 295, 1169–1176. 10.1016/j.jad.2021.08.109 [DOI] [PubMed] [Google Scholar]
  11. Bickford D, Morin RT, Woodworth C, Verduzco E, Khan M, Burns E, Nelson JC, & Mackin RS (2021). The relationship of frailty and disability with suicidal ideation in late life depression. Aging & Mental Health, 25(3), 439–444. 10.1080/13607863.2019.1698514 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Bostwick JM, Pabbati C, Geske JR, & McKean AJ (2016). Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. American Journal of Psychiatry, 173(11), 1094–1100. 10.1176/appi.ajp.2016.15070854 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Brådvik L (2018). Suicide risk and mental disorders. International Journal of Environmental Research & Public Health, 15(9):2028. doi: 10.3390/ijerph15092028. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Bruce ML, Ten Have TR, Reynolds CF 3rd, Katz II, Schulberg HC, Mulsant BH, Brown GK, McAvay GJ, Pearson JL, & Alexopoulos GS (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA, 291(9), 1081–1091. 10.1001/jama.291.9.1081 [DOI] [PubMed] [Google Scholar]
  15. Brüdern J, Stähli A, Gysin-Maillart A, Michel K, Reisch T, Jobes DA, & Brodbeck J (2018). Reasons for living and dying in suicide attempters: a two-year prospective study. BMC Psychiatry, 18(1), 234. 10.1186/s12888-018-1814-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Burr EM, Rahm-Knigge RL, & Conner BT (2018). The differentiating role of state and trait hopelessness in suicidal ideation and suicide attempt. Archives of Suicide Research, 22(3), 510–517. 10.1080/13811118.2017.1366960 [DOI] [PubMed] [Google Scholar]
  17. Centers for Disease Control and Prevention. (2023). Suicide data and statistics. https://www.cdc.gov/suicide/suicide-data-statistics.html
  18. Centers for Disease Control and Prevention, CDC Wonder (2023). Provisional mortality statistics, 2018 through last week results: suicide death. https://wonder.cdc.gov/controller/datarequest/ [Google Scholar]
  19. Choi NG, Marti CN, & Conwell Y (2016). Effect of problem-solving therapy on depressed low-income homebound older adults’ death/suicidal ideation and hopelessness. Suicide & Life-threatening Behavior, 46(3), 323–336. 10.1111/sltb.12195 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Choi NG, DiNitto DM, Marti CN, & Conwell Y (2019). Physical health problems as a late-life suicide precipitant: Examination of coroner/medical examiner and law enforcement reports. The Gerontologist, 59(2), 356–367. 10.1093/geront/gnx143 [DOI] [PubMed] [Google Scholar]
  21. Choi NG, Marti CN, & Choi BY (2022a). Job loss, financial strain, and housing problems as suicide precipitants: Associations with other life stressors. SSM - Population Health, 19, 101243. 10.1016/j.ssmph.2022.101243 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Choi NG, Marti CN, & Choi BY (2022b). Three leading suicide methods in the United States, 2017–2019: Associations with decedents’ demographic and clinical characteristics. Frontiers in Public Health, 10, 955008. 10.3389/fpubh.2022.955008 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Conejero I, Olié E, Courtet P, & Calati R (2018a). Suicide in older adults: current perspectives. Clinical Interventions in Aging, 13, 691–699. 10.2147/CIA.S130670 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Conejero I, Olié E, Calati R, Ducasse D, & Courtet P (2018b). Psychological pain, depression, and suicide: Recent evidences and future directions. Current Psychiatry Reports, 20(5), 33. 10.1007/s11920-018-0893-z [DOI] [PubMed] [Google Scholar]
  25. Cuijpers P, de Beurs DP, van Spijker BA, Berking M, Andersson G, & Kerkhof AJ (2013). The effects of psychotherapy for adult depression on suicidality and hopelessness: a systematic review and meta-analysis. Journal of Affective Disorders, 144(3), 183–190. 10.1016/j.jad.2012.06.025 [DOI] [PubMed] [Google Scholar]
  26. Ding OJ, & Kennedy GJ (2021). Understanding vulnerability to late-life suicide. Current Psychiatry Reports, 23(9), 58. 10.1007/s11920-021-01268-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Dombrovski AY, Hallquist MN, Brown VM, Wilson J, & Szanto K (2019). Value-based choice, contingency learning, and suicidal behavior in mid- and late-life depression. Biological Psychiatry, 85(6), 506–516. 10.1016/j.biopsych.2018.10.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Fässberg MM, van Orden KA, Duberstein P, Erlangsen A, Lapierre S, Bodner E, Canetto SS, De Leo D, Szanto K, & Waern M (2012). A systematic review of social factors and suicidal behavior in older adulthood. International Journal of Environmental Research and Public Health, 9(3), 722–745. 10.3390/ijerph9030722 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Fässberg MM, Cheung G, Canetto SS, Erlangsen A, Lapierre S, Lindner R, Draper B, Gallo JJ, Wong C, Wu J, Duberstein P, & Waern M (2016). A systematic review of physical illness, functional disability, and suicidal behaviour among older adults. Aging & Mental Health, 20(2), 166–194. 10.1080/13607863.2015.1083945 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Fernandez-Rodrigues V, Sanchez-Carro Y, Lagunas LN, Rico-Uribe LA, Pemau A, Diaz-Carracedo P, Diaz-Marsa M, Hervas G, & de la Torre-Luque A (2022). Risk factors for suicidal behaviour in late-life depression: A systematic review. World Journal of Psychiatry, 12(1), 187–203. 10.5498/wjp.v12.i1.187 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Garnett MF, & Curtin SC (2023). Suicide Mortality in the United States, 2001–2021. NCHS Data Brief, (464), 1–8. [PubMed] [Google Scholar]
  32. Grimes DA, & Schulz KF (2008). Making sense of odds and odds ratios. Obstetrics and Gynecology, 111(2 Pt 1), 423–426. 10.1097/01.AOG.0000297304.32187.5d [DOI] [PubMed] [Google Scholar]
  33. Ji X, Zhao J, Fan L, Li H, Lin P, Zhang P, Fang S, Law S, Yao S, & Wang X (2022). Highlighting psychological pain avoidance and decision-making bias as key predictors of suicide attempt in major depressive disorder-A novel investigative approach using machine learning. Journal of Clinical Psychology, 78(4), 671–691. 10.1002/jclp.23246 [DOI] [PubMed] [Google Scholar]
  34. Jones J (2013). Men, married, Southerners most likely to be gun owners. https://news.gallup.com/poll/160223/men-married-southerners-likely-gun-owners.aspx#:~:text=Gender%20is%20an%20important%20factor,31%25%20who%20are%20not%20married. [Google Scholar]
  35. Kok RM, & Reynolds CF 3rd (2017). Management of depression in older adults: A review. JAMA, 317(20), 2114–2122. 10.1001/jama.2017.5706 [DOI] [PubMed] [Google Scholar]
  36. KoKoAung E, Cavenett S, McArthur A, & Aromataris E (2015). The association between suicidality and treatment with selective serotonin reuptake inhibitors in older people with major depression: a systematic review. JBI Database of Systematic Reviews and Implementation Reports, 13(3), 174–205. 10.11124/jbisrir-2015-2272 [DOI] [PubMed] [Google Scholar]
  37. Kuffel RL, Morin RT, Covinsky KE, Boscardin WJ, Lohman MC, Li Y, & Byers AL (2023). Association of frailty with risk of suicide attempt in a national cohort of US veterans Aged 65 years or older. JAMA Psychiatry, 80(4), 287–295. 10.1001/jamapsychiatry.2022.5144 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Laflamme L, Vaez M, Lundin K, & Sengoelge M (2022). Prevention of suicidal behavior in older people: A systematic review of reviews. PloS One, 17(1), e0262889. 10.1371/journal.pone.0262889 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Lengvenyte A, Conejero I, Courtet P, & Olié E (2021). Biological bases of suicidal behaviours: A narrative review. European Journal of Neuroscience, 53(1), 330–351. 10.1111/ejn.1463 [DOI] [PubMed] [Google Scholar]
  40. Lin C, Huang CM, Karim HT, Liu HL, Lee TM, Wu CW, Toh CH, Tsai YF, Yen TH, & Lee SH (2021). Greater white matter hyperintensities and the association with executive function in suicide attempters with late-life depression. Neurobiology of Aging, 103, 60–67. 10.1016/j.neurobiolaging.2020.12.016 [DOI] [PubMed] [Google Scholar]
  41. Luo M, Li L, Liu Z, & Li A (2023). Sociodemographic dynamics and age trajectories of depressive symptoms among adults in mid- and later life: a cohort perspective. Aging & Mental Health, 27(1), 18–28. 10.1080/13607863.2021.2010182 [DOI] [PubMed] [Google Scholar]
  42. Lutz J, & Fiske A (2018). Functional disability and suicidal behavior in middle-aged and older adults: A systematic critical review. Journal of Affective Disorders, 227, 260–271. 10.1016/j.jad.2017.10.043 [DOI] [PubMed] [Google Scholar]
  43. Meerwijk EL, Parekh A, Oquendo MA, Allen IE, Franck LS, & Lee KA (2016). Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: a systematic review and meta-analysis. Lancet. Psychiatry, 3(6), 544–554. 10.1016/S2215-0366(16)00064-X [DOI] [PubMed] [Google Scholar]
  44. Meerwijk EL, & Weiss SJ (2014). Toward a unifying definition: response to ‘The concept of mental pain’. Psychotherapy and psychosomatics, 83(1), 62–63. 10.1159/000348869 [DOI] [PubMed] [Google Scholar]
  45. Miller M, Barber C, White RA, & Azrael D (2013). Firearms and suicide in the United States: is risk independent of underlying suicidal behavior?. American journal of epidemiology, 178(6), 946–955. 10.1093/aje/kwt197 [DOI] [PubMed] [Google Scholar]
  46. National Center for Injury Prevention and Control, Division of Violence Prevention Centers for Disease Control and Prevention. (2021). National Violent Death Reporting System (NVDRS) Coding Manual. Revised [Online]. Centers for Disease Control and Prevention (producer). Available from URL: www.cdc.gov/injury. [Google Scholar]
  47. Niu L, Jia C, Ma Z, Wang G, Sun B, Zhang D, & Zhou L (2020). Loneliness, hopelessness and suicide in later life: a case-control psychological autopsy study in rural China. Epidemiology and Psychiatric Sciences, 29, e119. 10.1017/S2045796020000335 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. O’Brien E, Whitman K, Buerke M, Galfalvy H, & Szanto K (2023). Life-satisfaction, engagement, mindfulness, flourishing, and social support: Do they predict depression, suicide ideation, and history of suicide attempt in late life?. American Journal of Geriatric Psychiatry, 31(6), 415–424. 10.1016/j.jagp.2022.12.192 [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Okolie C, Dennis M, Simon Thomas E, & John A (2017). A systematic review of interventions to prevent suicidal behaviors and reduce suicidal ideation in older people. International Psychogeriatrics, 29(11), 1801–1824. 10.1017/S1041610217001430 [DOI] [PubMed] [Google Scholar]
  50. Oude Voshaar RC, van der Veen DC, Hunt I, & Kapur N (2016). Suicide in late-life depression with and without comorbid anxiety disorders. International Journal of Geriatric Psychiatry, 31(2), 146–152. 10.1002/gps.4304 [DOI] [PubMed] [Google Scholar]
  51. Raue PJ, Morales KH, Post EP, Bogner HR, Have TT, & Bruce ML (2010). The wish to die and 5-year mortality in elderly primary care patients. American Journal of Geriatric Psychiatry, 18(4), 341–350. 10.1097/JGP.0b013e3181c37cfe [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Raue PJ, Ghesquiere AR, & Bruce ML (2014). Suicide risk in primary care: identification and management in older adults. Current Psychiatry Reports, 16(9), 466. 10.1007/s11920-014-0466-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Ribeiro JD, Huang X, Fox KR, & Franklin JC (2018). Depression and hopelessness as risk factors for suicide ideation, attempts and death: meta-analysis of longitudinal studies. British Journal of Psychiatry, 212(5), 279–286. 10.1192/bjp.2018.27 [DOI] [PubMed] [Google Scholar]
  54. Sachs-Ericsson N, Hames JL, Joiner TE, Corsentino E, Rushing NC, Palmer E, Gotlib IH, Selby EA, Zarit S, & Steffens DC (2014). Differences between suicide attempters and nonattempters in depressed older patients: depression severity, white-matter lesions, and cognitive functioning. American Journal of Geriatric Psychiatry, 22(1), 75–85. 10.1016/j.jagp.2013.01.063 [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Schaeffer K (2021). Pew Research Center: Key facts about Americans and guns. https://www.pewresearch.org/short-reads/2021/09/13/key-facts-about-americans-and-guns/
  56. Schmutte TJ, & Wilkinson ST (2020). Suicide in older adults with and without known mental illness: Results from the National Violent Death Reporting System, 2003–2016. American Journal of Preventive Medicine, 58(4), 584–590. 10.1016/j.amepre.2019.11.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Shneidman ES (1993). Suicide as psychache. Journal of Nervous and Mental Disease, 181(3), 145–147. 10.1097/00005053-199303000-00001 [DOI] [PubMed] [Google Scholar]
  58. Siddaway AP, Taylor PJ, Wood AM, & Schulz J (2015). A meta-analysis of perceptions of defeat and entrapment in depression, anxiety problems, posttraumatic stress disorder, and suicidality. Journal of Affective Disorders, 184, 149–159. 10.1016/j.jad.2015.05.046 [DOI] [PubMed] [Google Scholar]
  59. Szanto K, Galfalvy H, Vanyukov PM, Keilp JG, & Dombrovski AY (2018). Pathways to late-life suicidal behavior: Cluster analysis and predictive validation of suicidal behavior in a sample of older adults with major depression. Journal of Clinical Psychiatry, 79(2), 17m11611. 10.4088/JCP.17m11611 [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Szanto K, Galfalvy H, Kenneally L, Almasi R, & Dombrovski AY (2020). Predictors of serious suicidal behavior in late-life depression. European Neuropsychopharmacology, 40, 85–98. 10.1016/j.euroneuro.2020.06.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Taylor PJ, Gooding P, Wood AM, & Tarrier N (2011). The role of defeat and entrapment in depression, anxiety, and suicide. Psychological Bulletin, 137(3), 391–420. 10.1037/a0022935 [DOI] [PubMed] [Google Scholar]
  62. Van Orden K, & Conwell Y (2011). Suicides in late life. Current Psychiatry Reports, 13(3), 234–241. 10.1007/s11920-011-0193-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. Van Orden KA, Witte TK, Cukrowicz KC, Braithwaite SR, Selby EA, & Joiner TE Jr (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600. 10.1037/a0018697 [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Xie W, Li H, Luo X, Fu R, Ying X, Wang N, Yin Q, Zou Y, Cui Y, Wang X, & Shi C (2014). Anhedonia and pain avoidance in the suicidal mind: behavioral evidence for motivational manifestations of suicidal ideation in patients with major depressive disorder. Journal of Clinical Psychology, 70(7), 681–692. 10.1002/jclp.22055 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The Centers for Disease Control and Prevention (CDC) administers the National Violent Death Reporting System (NVDRS) in conjunction with participating NVDRS states. CDC provided the NVDRS Restricted Access Data used in this study to the authors after reviewing the authors’ data request. Study findings and conclusions are those of the authors alone and do not necessarily represent the official position of CDC or of the participating NVDRS states.

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