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. Author manuscript; available in PMC: 2022 Dec 1.
Published in final edited form as: J Affect Disord. 2021 Aug 27;295:243–249. doi: 10.1016/j.jad.2021.08.042

Risk factors associated with suicidal ideation in newly admitted working-age nursing home residents

Julie Hugunin a, Yiyang Yuan a, Anthony J Rothschild b, Kate L Lapane c, Christine M Ulbricht d
PMCID: PMC8551025  NIHMSID: NIHMS1737742  PMID: 34482055

Abstract

Introduction:

Suicide is a leading cause of mortality in the United States and recent initiatives have sought to increase monitoring of suicide risk within healthcare systems. Working-age adults (22-64 years) admitted to nursing homes may be at risk for suicidal ideation, yet little is known about this population.

Methods:

The national nursing home database, Minimum Dataset 3.0, was used to identify 323,436 working-age adults newly admitted to a nursing home in 2015. This cross-sectional study sought to describe sociodemographic and clinical characteristics, examine behavioral health treatment received, and determine resident characteristics associated with suicidal ideation at nursing home admission using logistic regression and reports adjusted odds ratios (aOR).

Results:

Suicidal ideation was present among 1.27% of newly admitted working-age residents. Almost 25% of those with suicidal ideation had no psychiatric diagnosis. Factors associated with increased odds of suicidal ideation included younger age (aOR 1.90), admission from the community (aOR 1.92) or a psychiatric hospital (aOR 2.38), cognitive impairments (aOR 1.46), pain (aOR 1.40), rejection of care (aOR 1.91), and psychiatric comorbidity (aOR depression: 1.91, anxiety disorder: 1.11, bipolar disorder: 1.62, schizophrenia: 1.32, post-traumatic stress disorder: 1.17).

Limitations:

Due to the cross-sectional nature of this study, no causal inferences about suicidal ideation and the explored covariates can be made. The Minimum Dataset 3.0 has only one measure of suicidal ideation the Patient Health Questionnaire.

Conclusion:

Factors other than psychiatric diagnosis may be important in identifying newly admitted working-age nursing home residents who require on-going suicide screening and specialized psychiatric care.

Keywords: Suicide, suicidal ideation, nursing homes

1. Introduction

Around 800,000 people in the world die by suicide each year, making suicide a leading cause of mortality (World Health Organization, 2019). While prediction of suicide remains elusive, screening for suicidal ideation and suicide plans are currently the standard in identifying individuals at risk for suicide (Fazel and Runeson, 2020). In the United States, 4.8% of those aged ≥18 years experienced suicidal ideation in 2019 (National Survey on Drug Use and Health, 2020). Of the 12 million adults who experienced ideation in 2019, 3.5 million made suicide plans and 1.4 million attempted suicide (National Survey on Drug Use and Health, 2020). Because healthcare visits commonly precede suicide attempts and deaths (Ahmedani et al., 2019), the Zero Suicide framework (“Zero Suicide Framework,” 2020) focuses on the role of the healthcare system in screening for and preventing suicide. This framework emphasizes that persons within a healthcare setting, such as a nursing home, should be appropriately monitored for suicide risk throughout the duration of the healthcare visit. Transitions of care represent a particularly important period of high risk for suicide, particularly after discharge from inpatient care (Bickley et al., 2013; Goldman-Mellor et al., 2019; Riblet et al., 2018). Admission to a nursing home may be a critical time when suicide risk is high (Mezuk et al., 2019), however, little is known about the prevalence of suicidal ideation in nursing home residents.

In the United States, 83.5% of nursing home residents are over the age of 65 years, 64.6% are women, and 75.1% are non-Hispanic white (Harris-Kojetin et al., 2019). Typically, nursing homes in the U.S. specialize in caring for functionally and cognitively impaired older adults. Of all U.S. nursing home residents, 47.8% have Alzheimer’s disease or other dementias, 92% need assistance in walking or locomotion, and 96.7% need assistance in bathing (Harris-Kojetin et al., 2019). A substantial number of working-age adults (22-64 years) are admitted to nursing homes each year (Grabowski et al., 2009) and about 16.5% of nursing home residents in the U.S. are under the age of 65 years (Harris-Kojetin et al., 2019). These residents may have many risk factors for suicidal ideation. Suicide is the 2nd leading cause of death among those aged 25-34 years, the 4th leading cause of death among those 35-54 years, and the 8th leading cause of death among those 54-64 years (National Center for Injury Prevention and Control, 2019). Many working-age nursing home residents have psychiatric diagnoses, medical comorbidities, and the presence of pain, all of which are associated with suicidal ideation (Fegg et al., 2016). A study of deaths of Australian residential aged care facility residents found that 13.2% of deaths among those aged 20-64 years were from suicide, compared to 4.1% of those over 65 years, indicating that suicide is of particular concern among working-age adults in nursing homes (Eastwood et al., 2019). These residents likely have different care needs than the typical older nursing home residents, which may not be adequately addressed by the nursing home.

Nursing homes have a responsibility to appropriately monitor suicidal ideation among residents and to provide proper treatment to alleviate the associated suffering. However, despite initiatives by the Joint Commission and other organizations to increase monitoring of suicide risk in healthcare systems, suicidal ideation, care needs, and psychiatric treatment among working-age nursing home residents remain overlooked (Centers for Medicare & Medicaid Services, 2019; The Joint Commission, 2019). The objectives of this study were to estimate the prevalence of suicidal ideation among working-age adults newly admitted to U.S. nursing homes in 2015, describe the sociodemographic and clinical characteristics of these residents, examine behavioral health treatment received, and determine resident characteristics associated with suicidal ideation at admission.

2. Methods

2.1. Study design

This was a cross-sectional study approved by the Institutional Review Board of the University of Massachusetts Medical School.

2.2. Data sources

The Minimum Data Set (MDS) 3.0 is a comprehensive, government mandated assessment for every resident in a Medicare-/Medicaid-certified nursing home in the U.S. (Centers for Medicare & Medicaid Services, 2015). This assessment is completed at admission, quarterly, annually, and when significant health changes occur. Nursing home staff and residents’ complete questions pertaining to demographic, clinical, cognitive, and functional characteristics. These assessments also include general information on pharmacological and nonpharmacological therapies received by residents.

2.3. Eligibility criteria

The focus of this study is working-age (22-64 years) residents newly admitted to a nursing home in 2015 (Figure 1). MDS 3.0 admission assessments were identified using Centers for Medicare & Medicaid Services’ definition (Centers for Medicare & Medicaid Services, 2015): 1.) must be documented as “admission” and not “re-entry,” and 2.) must be an Omnibus Budget Reconciliation Act required admission assessment. An admission was considered new if the resident did not have a prior nursing home stay within 90 days of the admission assessment. For residents with more than one eligible admission assessment in 2015 (n=5,630), the first admission assessment was used. Because the Patient Health Questionnaire (PHQ-9) containing the outcome measure has decreased specificity in those with cognitive impairment (Boyle et al., 2011), we excluded residents who did not have a resident-reported Patient Health Questionnaire–9 (PHQ-9) due to communication and comprehension difficulties (n=27,901) and those with severe cognitive impairment as measured by the Cognitive Function Scale (n=1,833) (Saliba et al., 2012). Residents missing other key MDS 3.0 items (suicidal ideation status, age, race/ethnicity, and marital status) were excluded (n=41,093). The final sample included 323,436 working-age residents.

Figure 1. Eligibility criteria.

Figure 1.

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a First admission was selected if a resident had multiple eligible nursing home episodes (n=5,630]

bKey Minimum Dataset 3.0 items: suicidal ideation, age, race/ethnicity, marital status

2.4. Outcome measure

Suicidal ideation was defined as an affirmative response to the ninth item of the resident-reported PHQ-9 in the MDS 3.0 at admission. The PHQ-9 is a 9-item assessment of depression symptoms based on DSM-IV criteria for depression (Spitzer et al., 1999). The ninth item asks if the respondent has experienced thoughts of death or self-harm during the previous two weeks.

2.5. Covariate measures

Sociodemographic covariates included age, sex, race/ethnicity, marital status, and admission location. Age was categorized into four groups: 22-34, 35-44, 45-54, and 55-64 years. Male and female categories were included in the sex measure, and race/ethnicity included non-Hispanic White, non-Hispanic Black, Hispanic, or a composite category including American Indian, Alaska Native, Asian, Native Hawaiian, Pacific Islander, or multiracial. Marital status included those never married, married, widowed, or separated/divorced. Residents were admitted from the community (private home/apartment, board/care, assisted living, group home), another nursing home, acute hospital, psychiatric hospital, or other (inpatient rehabilitation facility, intellectual/developmental disabilities facility, hospice).

Functional covariates included physical and cognitive function. Physical function was defined using the activities of daily living self-performance hierarchy scale (Morris et al., 1999). Three levels of dependency in performing activities of daily living (ADLs) were defined as independent/limited assistance required (scores: 0-2), extensive assistance required (3-4), dependent/total dependence (5-6). The Cognitive Function Scale was used to indicate intact cognitive function, mild, or moderate impairment (Thomas et al., 2017).

Clinical characteristics focused on psychiatric and other physical comorbidities. Psychiatric disorders assessed in the MDS 3.0 include depression, anxiety disorder, bipolar disorder, schizophrenia, psychotic disorder other than schizophrenia, and post-traumatic stress disorder. Physical comorbidities prevalent in the working-age population and thought to be associated with suicidal ideation were explored, including hypertension, diabetes mellitus, asthma, chronic obstructive pulmonary disorder, arthritis, thyroid disorders, stroke, heart failure, seizure disorders, hemiplegia/paraplegia/quadriplegia, and cancer (Fegg et al., 2016). A physical comorbidity index was created using the sum of physical comorbidities present in each resident. A cut off value of ≥3 comorbidities was used to indicate a higher level of physical comorbidity. Existing MDS-based mortality risk scores were developed for older adults and do not include disorders relevant to our study population (Ogarek et al., 2018; Thomas et al., 2019).

Behavioral health treatment was defined as receipt of antidepressants, antianxiety medication, antipsychotics, hypnotics, and/or psychological therapy received in the previous 7 days/since admission. Other covariates explored include any pain documented (resident or staff reported) and any rejection of care.

2.6. Statistical analysis

Characteristics of working-age residents were examined, stratified by the presence/absence of suicidal ideation at admission. An absolute difference of ≥5 percentage points was considered notable as statistical significance was not considered useful given the large sample size.

Previously identified risk factors for suicidal ideation at admission to a nursing home were then explored using logistic regression analysis (Franklin et al., 2017; Temkin-Greener et al., 2020). Sociodemographic, functional, and clinical covariates were sequentially added to a logistic model. The final model included all sociodemographic and functional covariates, any pain documented, rejection of care, psychiatric comorbidities, and presence of ≥3 comorbidities. Complete case analysis was used to handle missing data. We present adjusted odds ratios (aOR) and 95% confidence intervals (CIs).

3. Results

Of the 323,436 working-age residents newly admitted to a nursing home in 2015, half were female, 68.6% were non-Hispanic White, and 66.5% were 55-64 years old. Of all the newly admitted working-age residents, 1.27% reported suicidal ideation.

3.1. Characteristics of working-age residents with suicidal ideation

Prevalence differences in age and sex were not observed by presence of ideation in working-age residents (Table 1). More residents with ideation were divorced/separated as compared to those without ideation (31.0% vs 25.5%), though differences in the other marital statuses were not observed. Nearly 80% of residents with ideation were non-Hispanic white compared to 68.5% of those without ideation. Eighty-one percent of those with and 89.5% of those without ideation were admitted from an acute hospital. Intact or mild impairment in cognitive function was seen in over 90% of residents (with ideation: 92.8%, without ideation: 94.4%).

Table 1.

Characteristics of working-age residents newly admitted to US nursing homes in 2015, by presence of suicidal ideation

Characteristic Residents with
suicidal ideation
(n = 4,118)		 Residents without
suicidal ideation
(n = 319,318)
Sociodemographic covariates Percentage
Age in years
 22-34 4.9 3.1
 35-44 7.8 6.4
 45-54 25.5 24.0
 55-64 61.9 66.6
Female 51.7 50.0
Race/ethnicity
 Non-Hispanic White 79.4 68.5
 Non-Hispanic Black 12.7 21.9
 Hispanic 5.1 7.1
 American Indian, Alaska Native, Asian, Native Hawaiian, Pacific Islander, or Multi-racial 2.9 2.6
Marital status
 Never married 36.7 39.1
 Married 24.0 28.0
 Widowed 8.4 7.4
 Divorced/separated 31.0 25.5
Admitted from
 Community 7.48 3.7
 Another nursing home 5.3 3.9
 Acute hospital 81.0 89.5
 Psychiatric hospital 4.3 1.5
 Other (inpatient rehab, ID/DD, hospice) 1.9 1.3
Functional covariates
Physical function
 Independent/ limited assistance required for ADLs 29.9 28.7
 Extensive assistance required for ADLs 51.2 54.8
 Dependent/ total dependence for ADLs 18.9 16.5
Cognitive function
 Intact 71.9 80.8
 Mild impairment 20.9 13.6
 Moderate impairment 7.3 5.6
Clinical covariates
Physical comorbidities
 Hypertension 61.1 63.4
 Diabetes mellitus 41.5 39.6
 Asthma/ Chronic obstructive pulmonary disorder 29.4 24.7
 Arthritis 16.7 18.8
 Thyroid disorders 16.5 13.5
 Stroke 13.0 10.4
 Coronary artery disease 15.6 14.3
 Heart failure 13.1 13.1
 Seizure 13.4 10.7
 Hemiplegia/paraplegia/quadriplegia 11.8 8.8
 Cancer 8.8 8.5
 ≥3 physical comorbidities 45.0 40.5
Any pain documented 74.4 69.5
Any rejection of care 13.0 6.1
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*

ID/DD: intellectual/developmental disability facilities; ADL: activities of daily living

Missing data for admission from (suicidal ideation n=53, without n=3091), physical function (suicidal ideation n=4, without n=238), hypertension (without suicidal ideation n=48), diabetes mellitus (suicidal ideation n=1, without n=27), asthma/COPD (without suicidal ideation n=27), arthritis (without suicidal ideation n=26), thyroid disorders (suicidal ideation n=1, without n=12), stroke (suicidal ideation n=1, without n=8), coronary artery disease (suicidal ideation n =1, without n=21), heart failure (without suicidal ideation n=28), seizure (without suicidal ideation n=10), hemiplegia/paraplegia/quadriplegia (without suicidal ideation n=11), cancer (without suicidal ideation n=52), pain presence (suicidal ideation n=136, without n=8953), rejection of care (suicidal ideation n=5 without n=166).

Half required extensive assistance for ADLs (with ideation: 51.2%, without ideation: 54.8%). Forty-five percent of those with ideation and 40.5% of those without ideation had ≥3 physical comorbidities. Hypertension, diabetes mellitus, and asthma/ chronic obstructive pulmonary disorder were the most commonly observed comorbidities. Pain was documented for 74.4% of those with ideation and 69.5% of those without ideation. Rejection of care was reported in 13.0% and 6.1% of those with and without ideation, respectively.

3.2. Psychiatric comorbidities and treatment of working-age residents with suicidal ideation

As compared to those without ideation at admission, a greater percentage of residents with ideation had diagnoses of depression (57.1% versus 37.6%), anxiety disorder (36.4% versus 25.4%), and bipolar disorder (14.7% versus 7.6%) (Table 2). No psychiatric diagnosis was documented in 24.2% of those with ideation and 46.7% of those without ideation. Of those with ideation, 82.7% received behavioral health treatment, compared to 62.1% of those without ideation (Table 3). A combination of treatments was the most common (49.3%) for those with ideation, followed by antidepressants only (23.0%). Antianxiety and antidepressant medications were the most common combination treatment (14.6%), followed by antidepressant and antipsychotic (10.9%). Psychological therapy was received by 3.7% of those with ideation, usually in combination with pharmacological treatment.

Table 2.

Psychiatric diagnoses among newly admitted working-age residents to US nursing homes in 2015, by presence of suicidal ideation

Diagnosis Residents with suicidal
ideation
(n = 4,118)		 Residents without suicidal
ideation
(n = 319,318)
Percentage
Depression 57.1 37.6
Anxiety disorder 36.4 25.4
Bipolar disorder 14.7 7.6
Schizophrenia 11.1 7.0
Psychotic disorder 4.9 3.3
Post-traumatic stress disorder 3.4 1.2
No psychiatric diagnosis 24.2 46.7
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Missing data for depression (without suicidal ideation=26), anxiety disorder (suicidal ideation n=1, without n=17), bipolar disorder (without suicidal ideation n=8), schizophrenia (without suicidal ideation n=8), psychotic disorder (without suicidal ideation n=14), post-traumatic stress disorder (without suicidal ideation n=6).

Table 3.

Behavioral health treatments received in the previous 7 days/since admission in newly admitted working-age residents to US nursing homes in 2015, by presence of suicidal ideation

Residents with
suicidal ideation
(n = 4,118)		 Residents without suicidal
ideation
(n = 319,318)
Percentage
No treatment 17.3 37.9
Pharmacologic treatment (monotherapy)
 Antidepressants 23.0 20.6
 Antianxiety 5.7 6.5
 Antipsychotics 3.5 4.4
 Hypnotics 1.1 2.3
Psychological therapy only <1 <1
Any combination of treatment 49.3 28.0
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3.3. Sociodemographic risk factors for suicidal ideation at admission

In the fully adjusted model (Table 4), relative to residents aged 55-64 years, those aged 22-34 years had 90% excess odds of reporting ideation (95% CI: 1.62-2.21), those aged 35-44 had 34% excess odds (95% CI: 1.19-1.52), and those aged 45-54 had 15% excess odds (95% CI: 1.07-1.24). Compared to non-Hispanic white residents, non-Hispanic Black and Hispanic residents had decreased odds of reporting ideation (respectively: aOR 0.59; 95% CI: 0.53-0.65; aOR 0.71; 95% CI: 0.62-0.82). Compared to those who were married, having never been married was not notably associated with ideation at admission, however, being widowed (aOR 1.25; 95% CI: 1.10-1.42) or being divorced/separated (aOR 1.26; 95% CI: 1.15-1.37) was associated with greater odds of reporting ideation.

Table 4.

Risk factors for suicidal ideation among newly admitted working-age nursing home residents using a logistic model, in 2015

Predictors Adjusted
Odds ratio		 95%
Confidence interval
Sociodemographic covariates
Age in years
 22-34 1.90 1.62-2.21
 35-44 1.34 1.19-1.52
 45-54 1.15 1.07-1.24
 55-64 ref
Female 0.95 0.90-1.02
Race/ethnicity
 Non-Hispanic White ref
 Non-Hispanic Black 0.59 0.53-0.65
 Hispanic 0.71 0.62-0.82
 American Indian, Alaska Native, Asian, Native Hawaiian, Pacific Islander, or Multi-racial 1.19 0.98-1.44
Marital status
 Never married 1.02 0.94-1.12
 Married ref
 Widowed 1.25 1.10-1.42
 Divorced/separated 1.26 1.15-1.37
Admitted from
 Community 1.92 1.70-2.17
 Another nursing home 1.13 0.98-1.31
 Acute hospital ref
 Psychiatric hospital 2.38 2.01-2.83
 Other (inpatient rehab, ID/DD, hospice) 1.40 1.11-1.76
Functional covariates
Physical function
 Independent/ limited assistance required for ADLs ref
 Extensive assistance required for ADLs 0.98 0.91-1.05
 Dependent/ total dependence for ADLs 1.20 1.09-1.33
Cognitive function
 Intact ref
 Mild 1.63 1.50-1.77
 Moderate 1.46 1.28-1.66
Any pain documented 1.40 1.30-1.51
Any rejection of care 1.91 1.74-2.11
Psychiatric comorbidities
 Depression 1.91 1.78-2.04
 Anxiety disorder 1.11 1.03-1.19
 Bipolar disorder 1.62 1.47-1.78
 Schizophrenia 1.32 1.18-1.47
 Psychotic disorder 1.00 0.86-1.16
 Post-traumatic stress disorder 1.76 1.47-2.11
≥3 physical comorbidities 1.17 1.10-1.25
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*

ID/DD: intellectual/developmental disability facilities; ADL: activities of daily living

The fully adjusted model included all sociodemographic and functional covariates, any pain documentation, rejection of care, psychiatric comorbidities, and a proxy measure of physical comorbidity.

The odds of a working-age resident reporting ideation at admission, after adjusting for covariates, was 2.38 times higher (aOR: 2.38; 95% CI: 2.01-2.83) among those admitted from a psychiatric hospital and 1.92 times higher (aOR: 1.92; 95% CI: 1.70-2.17) among those admitted from the community, compared to those admitted from an acute hospital.

3.4. Functional and comorbidity risk factors for suicidal ideation at admission

Relative to those with complete independence or limited assistance required for ADLs, those with dependence or total dependence had 20% excess odds of reporting ideation (95% CI: 1.09-1.33). Those with mild and moderate cognitive impairment had 63% (95% CI: 1.50-1.77) and 46% (95% CI: 1.28-1.66) excess odds, respectively, of reporting ideation compared to those with intact cognitive function, after adjusting for confounders.

The odds of having ideation at admission was 1.40 times higher (aOR: 1.40; 95% CI: 1.30-1.51) among residents with pain documented, and 1.91 times higher (aOR: 1.91; 95% CI: 1.78-2.04) among residents rejecting care, after adjusting for potential confounders. Those with ≥3 physical comorbidities had 17% excess odds in having ideation at admission (95% CI: 1.10-1.25), adjusting for potential confounders. Residents with psychiatric comorbidity (other than psychotic disorders) had increased odds of having ideation at admission, relative to those without psychiatric comorbidity (depression: aOR: 1.91; 95% CI: 1.78-2.04; anxiety disorder: aOR: 1.11; 95% CI: 1.03-1.19; bipolar disorder: aOR: 1.62; 95% CI: 1.47-1.78; schizophrenia: aOR: 1.32; 95% CI: 1.18-1.47; post-traumatic stress disorder: aOR: 1.76; 95% CI: 1.47-2.11).

4. Discussion

Suicidal ideation was present among 1.27% of working-age adults upon admission to a nursing home in 2015. This is lower than the estimated 4% of U.S. adults in 2015 with suicidal ideation (Piscopo K, Lipari RN, Cooney J, 2016), however it is closer to the estimated 1.6% of adults in inpatient hospital units reporting suicidal ideation (Roaten et al., 2018). Notable characteristics associated with suicidal ideation at admission to a nursing home among these residents include younger age, admission from the community or a psychiatric hospital, mild or moderate cognitive impairment, any pain documented, rejection of care, and psychiatric comorbidity. These factors may be important in identifying newly admitted working-age residents who require on-going suicide screening and specialized psychiatric care. Additionally, about one quarter of residents reporting suicidal ideation did not have a documented psychiatric diagnosis. A recent study found that of persons aged ≥18 years who died by suicide, 58.2% had no known mental illness (Schmutte et al., 2021). This highlights the need to look beyond presence of psychiatric diagnoses to identify suicide risk.

Persons within a healthcare setting, such as a nursing home, should be appropriately monitored for suicide risk. At admission to a Medicaid-/Medicare-certified nursing home, each resident receives the PHQ-9 screener for depression as part of a federal mandate that requires the completion of the MDS 3.0 (Centers for Medicare & Medicaid Services, 2015). The next mandated PHQ-9 screening on the MDS 3.0 occurs 90 days post-admission or when a significant health change occurs. The relatively small, measured prevalence of working-age adults with suicidal ideation at admission to a nursing home (1.27%) compared to that in the general U.S. adult population (4%) indicates that the current suicide risk screening mechanisms required in the nursing home setting may be inadequate (Piscopo K, Lipari RN, Cooney J, 2016). It is also possible that the prevalence of suicidal ideation among working-age adults admitted to nursing homes is more similar to the that among adults in inpatient hospital settings (1.6%) (Roaten et al., 2018). However, the predictive value of the PHQ-9 for suicide risk remains unclear and evidence indicates it is an insufficient assessment tool for suicide screening (Thom et al., 2020). The PHQ-9 should serve as an initial screen for suicidal ideation (Ryan and Oquendo, 2020), with residents responding affirmatively to item 9 followed by targeted screening with a validated suicide risk assessment, such as the Columbia Suicide Severity Rating Scale, as well as clinical assessment of suicide risk (Na et al., 2018; Viguera et al., 2015). It is unknown to what extent this occurs in nursing homes. Given the severity and far-reaching implications of suicide, the high-risk nature of transition to a nursing home, and initiatives by the Joint Commission and other organizations to increase monitoring of suicide risk in healthcare systems, we recommend additional research examining suicide risk screening in working-age adults admitted to nursing home which utilizes validated tools, such as the Columbia Suicide Severity Rating Scale. Additionally, we recommend that nursing homes require follow-up screening among those who respond affirmatively to item 9 of the PHQ-9 and that agencies, such as the Centers for Medicare and Medicaid Services or the Joint Commission, consider reporting this information as a quality measure.

Working-age nursing home residents with suicidal ideation have a unique set of psychiatric care needs that may not be adequately addressed during the nursing home stay. Among those with suicidal ideation, 75% had a psychiatric diagnosis and 45% had 3 or more physical comorbidities. The majority were cognitively intact with relatively few physical limitations, similar to previous findings (Aschbrenner et al., 2011). While psychiatric comorbidity was common, almost one in five working-age residents experiencing suicidal ideation at admission received no behavioral health treatment. Despite evidence indicating that cognitive behavioral therapy can reduce suicidal ideation and attempts (D’Anci et al., 2019), only 3.7% of those with suicidal ideation in our study received any form of psychological therapy. Recent recommendations in the Zero Suicide Toolkit, which outlines key elements for addressing suicide within healthcare systems, highlight that suicide prevention frameworks need to be expanded to specifically include those residing in institutional settings such as nursing homes (Jain et al., 2020). As in other healthcare facilities, it is important to appropriately monitor for suicidal ideation, improve identification and connection to appropriate care, engage at-risk individuals with a suicide care management plan, and provide care in the least restrictive settings possible (“Zero Suicide ToolkitSM,” 2021). Better access to mental health services for nursing home residents, such as through increased referral or integrating services into the nursing home care system, could help alleviate the suffering related to psychiatric illness and suicidal ideation (Jain et al., 2020). Additionally, “gatekeeper” training for nursing home staff, which helps to develop the knowledge, attitudes, and skills to prevent suicide among high-risk individuals (Chauliac et al., 2020) would likely aid in connecting working-age nursing home residents with suicidal ideation to appropriate care. Future research on interventions to address ideation in nursing homes should be rigorously evaluated and consider the influence of a resident’s age.

In the U.S., nursing homes generally specialize in caring for functionally and cognitively impaired older adults. Thus, the admission of working-age residents who are cognitively intact, have few physical limitations, and have a high prevalence of psychiatric comorbidity requires further exploration. Little is known as to what precipitates transfer to a nursing home among this population. A shortage in psychiatric beds, resulting from widespread closure of state psychiatric hospitals, may have led to the warehousing of working-age adults with psychiatric disorders in nursing homes (National Council on Disabilities, 2002). Additionally, following deinstitutionalization, some nursing homes have gained a reputation for specifically treating those with psychiatric illness (Mor et al., 2004). Our results indicate that residents admitted to the nursing home from the community or a psychiatric hospital have increased odds of suicidal ideation, relative to admission from an acute hospital. There is a general consensus that nursing homes often fail to be a place where most people would be happy to live (Jain et al., 2020), and discontentment with nursing home life may be a particular stressor for working-age residents. Understanding these transitions of care may be key to preventing suicide in this population and improving access to more appropriate settings of care.

Finally, it is important to note that about one quarter of working-age residents reporting suicidal ideation did not have a documented psychiatric diagnosis. While a fraction of these individuals may have an undiagnosed psychiatric condition or missing information in the dataset, it is a common misconception that only those with a mental illness experience suicidal ideation. Many biopsychosocial risk factors are associated with suicidal ideation and are important to consider. Some of these factors include experiencing life stressors such as severe or debilitating physical illness, domestic/ relationship problems, financial pressures, and legal circumstances (Vilhjalmsson et al., 1998). Among the MDS 3.0 items, our results show that rejection of care, documented pain, and marital status may be more comprehensive indicators of suicide risk than presence of a psychiatric diagnosis. Stigma has consistently been associated with decreased help-seeking behavior among those with suicidal ideation, as well as those with mental health disorders (Carpiniello and Pinna, 2017). To identify suicide risk and help prevent suicide we must acknowledge that suicidal ideation can be experienced by anyone, regardless of psychiatric diagnosis.

To our knowledge, this is the first study to explore suicidal ideation in working-age adults in the nursing home setting. We used a contemporary, national dataset that allowed us to examine the relatively rare outcome of ideation. However, we were limited to items collected on the MDS 3.0 and thus were unable to explore additional potentially important factors, such as reason for admission to the nursing home and additional socioeconomic status and social support level factors, such as income and education level, occupational status, and family support. While more comprehensive suicide assessments exist (Runeson et al., 2017), the MDS 3.0 included only the PHQ-9. Evidence indicates that a positive response to the ninth item identifies outpatients at risk of suicidal behavior (Simon et al., 2013); less is known about its validity in inpatient settings. We also lacked details about suicide risk factors, such as resident history of ideation and/or suicide attempts. Data on attempts are not collected uniformly and not readily available within this dataset. We are unable to make causal inferences about suicidal ideation and the explored covariates due to the cross-sectional nature of this study. Even so, this study is an important contribution to understanding suicide risk in the nursing home population and to improving the identification of working-age adults with ideation.

This study is an essential first step in understanding newly admitted working-age adults nursing home residents reporting suicidal ideation, a population with unique suicide risk factors and care needs. More research is required to understand how to effectively manage suicide risk in working-age adults during and after their nursing home stay. In line with the recent Surgeon General’s call to action for suicide prevention (Department of Health and Human Services, 2021), research to better understand suicide risk identification in the nursing home setting, the effectiveness of suicide safe care pathways for individuals admitted to nursing homes, and what precipitates transitions of care for those admitted to nursing homes with suicidal ideation is urgently needed.

Highlights.

  • 1.3% of working-age adults had suicidal ideation at admission to a nursing home

  • 25% of residents with suicidal ideation did not have a psychiatric diagnosis

  • Rejection of care, pain, and marital status are indicators of suicide risk

  • Many residents with suicidal ideation received no behavioral health treatment

  • Only 3.7% of those with suicidal ideation received any psychological therapy

Acknowledgements:

The opinions expressed here do not necessarily represent the views of the National Institutes of Health, the Department of Health and Human Services, or the United States Government.

Funding

This research was supported by the National Institute of Mental Health, National Institutes of Health (R01MH117586), National Center for Advancing Translational Science TL1 Training Grant, National Institutes of Health (TR001454), and the National Institutes of General Medical Sciences Medical Scientist Training Program, National Institutes of Health, Ruth L. Kirschstein Institutional Predoctoral Training Grant (T32GM107000).

Footnotes

Conflicts of interest

Julie Hugunin, Yiyang Yuan, Dr. Ulbricht, and Dr. Lapane have no conflicts relevant to this research. Dr. Rothschild reports grants from Allergan, grants from Janssen, grants from National Institute of Mental Health, grants from Otsuka, non-financial support from Eli Lilly, non-financial support from Pfizer, grants from Irving S. and Betty Brudnick Endowed Chair of Psychiatry, personal fees from GlaxoSmithKline, personal fees from American Psychiatric Press, Inc., personal fees from University of Massachusetts Medical School, personal fees from Up-to-Date, personal fees from Sage Therapeutics, personal fees from Alkermes, personal fees from Wolters Kluwer, outside the submitted work.

Presentations: Preliminary results of this work were presented at the AcademyHealth 2020 annual conference.

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