Older adults have high rates of suicide in Canada and worldwide,1,2
necessitating preventive interventions for those at risk. Late-life suicide often occurs in the context of untreated depression.3
Although few older adults who die by suicide have seen a mental health specialist in the days and weeks before their deaths,4
as many as 50% to 75% see a primary health care provider in that time frame,5
creating an opportunity for clinical detection of suicide risk.6
Effective detection of suicide risk is vital to clinical suicide prevention initiatives3,6
and to safe clinical treatment with older adults.
Expression of suicide ideation is associated with risk for death by suicide,7,8
and is thus an important clinical risk indicator.9
Adults 55 years of age or older who presented to hospital following self-harm had a high risk for suicide in the following year; risk for suicide remained elevated during the next 15 years.10
Swedish researchers, reporting on a retrospective study8
of adults 65 years of age or older who died by suicide, indicated that nearly 75% were reported to have communicated a wish to die or suicide ideation to a family member or acquaintance in the year prior to suicide.
Although expression of suicide ideation is associated with risk for suicide,1
the absence of expressed suicide ideation is not evidence of the absence of suicide risk.11,12
Some at-risk patients deny suicide ideation to health care providers,8
impeding risk detection.13,14
In one study,15
only 11% of patients seen in primary care in the month prior to dying by suicide communicated suicidal intent. In another study,16
78% of patients receiving or recently discharged from mental health care services denied suicide ideation minutes to hours prior to taking their lives.16
Given that older adults tend to deny or underreport depressive symptoms,13,14
clinicians are advised to interview their social supports. Canadian national guidelines for assessment and intervention with older adults at risk for suicide identify social supports as potential proxies for collection of collateral information when assessing patient suicide risk.17
However, evidence is limited regarding the concordance of patient and proxy reports of suicide ideation,18,19
and little is known about the potential impact of patient depression symptom severity on patient–proxy concordance.
A Swedish study18
of depression symptom reporting among adults 90 years of age or older indicated that social supports identified significantly less suicide ideation than was revealed during patient examination by a physician. A US study19
among home care patients 65 years of age or older similarly indicated that social supports identified less suicide ideation than did clinical interviewers. Previous studies assessed suicide ideation with a single global suicide ideation item derived from structured diagnostic interview measures, potentially limiting detection of patient suicide ideation.
Although available data suggest that clinicians do a better job of detecting suicide ideation than do collateral informants,18
researchers have yet to explore self-proxy concordance of suicide ideation among older recipients of mental health services. This information may be clinically useful, given that older adults are often accompanied to health care appointments by social supports, and may help identify at-risk older adults who underreport suicide ideation. The purpose of our study was to assess the concordance in suicide ideation as self-reported by mental health patients 50 years of age or older and proxy-reported by their social supports, and to investigate whether self- and proxy reports of patient depression symptom severity are associated with concordance in reports of patient suicide ideation. We assessed concordance of patient–proxy reporting using a variable assessing presence of suicide ideation based on self-report and interviewer rating scales assessing suicide ideation to serve as a higher bounds estimate of the presence of patient suicide ideation. We hypothesized that concordance would be positively associated with patient depressive symptom severity, such that patients with greater depression symptom severity would be more likely to report suicide ideation and to be reported by proxies as being suicidal relative to those with lower levels of depression symptom severity.