With knowledge of the epidemiology of suicide in older adults and the settings best suited for case finding, the next step in the prevention research cycle involves the design and testing of preventive interventions. These may be characterized as addressing suicide at one or more of three levels: indicated, selective, and universal [64
]. provides a definition and general example for each, and lists published studies in which the impact of an intervention on suicidal ideation or completed suicide in older adults was the specific outcome of interest. The authors are not aware of any studies with attempted suicide as the targeted outcome.
Levels of preventive intervention
Studies of elderly suicide prevention programs
Two studies represent indicated preventive interventions. Both targeted older adults in primary care practices who had symptomatic affective illness, and were based on the collaborative, stepped-care model in which expertise in the diagnosis and treatment of affective illness is incorporated into the practice. The Prevention of Suicide In Primary Care Elderly: Collaborative Trial (PROSPECT study) compared usual care by the primary care providers with algorithm-driven antidepressant treatment; interpersonal psychotherapy when indicated; physician, patient, and family education about the illness; and care management by a depression specialist (social worker, nurse, or psychologist) [65
]. In a sample of 598 subjects older than 60 years who had depression, Bruce and colleagues [65
] found that rates of suicidal ideation declined significantly faster in the intervention than comparison condition.
Unü tzer and colleagues [66
] took a similar approach with the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) study. They compared a collaborative depression care management intervention with usual care of 1801 patients aged 60 years or older who had major depression, dysthymic disorder, or both. As in PROSPECT, the IMPACT intervention included a depression care manager collaborating with a psychiatrist and primary care provider to offer patient and family education, facilitation of antidepressant treatment, and the option of brief problem-solving psychotherapy. In addition to significantly greater improvements in depressive symptoms, intervention subjects had significantly lower rates of suicidal ideation than controls for up to 24 months [67
Unfortunately, neither trial could assess the effectiveness of the intervention on suicidal behavior. Furthermore, given that approximately 70% of subjects in each trial were women and therefore at far lower risk for completed suicide than men, the impact that collaborative care models may have on late-life suicide at the population level remains to be established. Nonetheless, the most appropriate clinical position is certainly that screening for depressive illness in older adults should be routine and its diagnosis and treatment assertively pursued. When suicidal ideation is detected, aggressive indicated interventions should be initiated.
Examples of selective and universal preventive interventions applied to late-life suicide are also rare. The Telehelp/Telecheck service evaluated by DeLeo and colleagues [68
] represents a selective late-life suicide preventive intervention because the targeted population is older adults who are socially isolated and functionally impaired. Telehelp/Telecheck, based in Padua, Italy, provided telephone-based outreach, evaluation, and support services to more than 18,600 seniors with a mean age of 80 years; 84% were women. Over 11 years of service delivery, significantly fewer suicides occurred among clients than would have been expected in the elder population of that region. In subsequent analyses, however, no specific effect of the intervention on suicide in men could be shown; the intervention seemed to be effective in reducing suicide only in elderly women.
Experience in the United Kingdom indicates that means restriction may be an effective universal approach to preventing suicide. Hawton and colleagues [69
] reported that after legislation limited the pack size of paracetamol and salicylates sold over the counter, morbidity and mortality from overdose with these medications decreased significantly.
One study was found that suggests a specific effect of means restriction on suicide among older adults. Ludwig and Cooke [70
] examined whether implementation of the Brady Handgun Violence Prevention Act in the United States in 1994 was associated with changes in total and firearm-specific homicide and suicide rates in the general adult (≥21 years) and later late (≥55 years) populations. The Brady Act required that licensed firearm dealers observe a waiting period and initiate a background check before selling a handgun. States that already had this legislation established constituted the control group, whereas states newly instituting the legislation served as the experimental condition. Changes in rates of homicide and suicide in experimental and control states were not significantly different, except for firearm suicides among persons aged 55 years or older, which showed a significant reduction in the intervention states. Consistent with Miller’s [49
] observation that older male suicides were more likely than controls to have purchased the gun used to kill themselves in the week preceding death, the observed effect of the Brady legislation was much stronger in states that had instituted waiting periods and background checks than in states that only changed background check requirements. In the United States, where older men are at far higher risk than other groups and more than 75% die of self-inflicted gunshot wounds, these findings are particularly notable. Because of the complex social and political implications of gun control legislation, however, this promising approach to late-life suicide prevention will be difficult to test.
A basic tenet of prevention science is that interventions that combine approaches are more likely to have an effect at the population level than any single preventive intervention. Oyama and colleagues [71
] recently reported results of a series of five studies that test, in a quasi-experimental design, combinations of universal, selective, and indicated preventive interventions referred to in as a multilayered approach. Subjects included all residents aged 65 years and older who lived in small towns in rural Japan. Implemented over 5- to 10-year periods, these complex interventions typically included public education and socialization programs for seniors held in community centers; either a self-assessment or structured screening for depression; and follow-up referral with primary care or mental health care providers for those who screened positive. The investigators measured changes in the relative risk for suicide in older adults before and after the program’s implementation and relative to a neighboring reference town of similar size and character. In all five of these separate studies, a significant reduction (64%–76%) was seen in the risk for suicide in elderly women. However, only one of the five towns showed a significant risk reduction for men [71