Surveillance-based demographic characteristics for older adult suicides are understandably different from other types of studies, primarily due to small sample sizes and lack of random sampling in the other studies. The NVDRS surveillance system relies on the capturing of all suicides in funded states and thus is not subject to either of those limitations. One important demographic difference in the NVDRS is the percent of male and female decedents. In previous studies male sex ranged from approximately 45% to 95%, [5
] while NVDRS more closely mirrors, but is still not representative of the entire U.S. population due to the fact its data collection only covers seventeen states. Because so few studies compare male and female differences, and have defined age groups and circumstance variables inconsistently, comparison of their findings with NVDRS is difficult. Despite these differences, there are clear similarities in non-demographic surveillance data and data obtained from other types of studies.
Similar to previous research, this study found that the home was the most common location of injury among older adults [2
] and of both sexes [37
]. Firearms were the most common mechanism with nearly twice as many males using this method than females [1
]. Poisoning and hanging/strangulation/asphyxiation were also common [41
]. Also consistent with previous research, physical illness was a common precipitator [2
] while financial or legal problems were evident in only a small percentage of cases [17
]. Less than one in four older adult suicide decedents have made known prior attempts [9
] and disclosure of intent to take their own life was infrequent [2
]. Canetto [3
] notes that the percent disclosing intent to take their lives may be similar among males and females. Mental health problems, especially depression [40
], were common and alcohol and drug use disorders were noted with less frequency [2
]. Females were more likely to seek psychiatric treatment than males [3
] and females are more likely to have a history of mental health treatment [5
]. Few studies report on actual diagnosis by sex [3
]. Death of someone close to the suicide decedent was noted as a contributor in a small percentage of cases [17
Data that are reported separately for males and females in other studies closely mirror NVDRS data in many ways. For example, Turvey [8
] presented data on 20 suicide decedents 60 years of age or older, only one of whom was female. The study does not separate the one female from the males but, with that limitation, found that precipitating circumstance data are consistent with NVDRS male only data; that is, economic/financial problems (7% for each) and legal problems ranging from 2% to 3%. In addition, males and females are similar in disclosure of their intent to end their lives [3
], a finding also noted in NVDRS (28% and 25% respectively). Additionally, a separate study reports an average of 1.99 stressors per male and 1.98 for female decedents [19
]. NVDRS notes 1.65 for males and 1.56 for females; similar ratios of male to female stressors.
Additional precipitating interpersonal and life stressor circumstance information was more difficult to compare due to varying definitions of similar terms and the inconsistent collapsing of multiple circumstances into broad categories; for instance, in one study financial problems includes not only monetary issues but also job and unemployment problems [17
] while in other studies, and NVDRS, those are evaluated separately. Using Carney’s definition, financial problems were noted in 12% of suicides over the age of 60 while in NVDRS, combining the financial and job problem circumstances resulted in 11% [17
Adding to the literature, the differences in demographic, incident and precipitating circumstance data for older males and females who take their own lives are presented on a population-based level with large sample sizes and consistent definitions across states. Significant differences in proportions of older male and female suicide decedents are noted for age group, race ethnicity, marital status, method of injury, place of injury, place of death, toxicology, and problems with mental health and substance abuse, interpersonal relationships, physical health, jobs, and legal issues. These data were previously unavailable on a large scale.
Comparability of these findings to other studies looking at sex differences is complicated by differing case finding and variable definitions. For instance, NVDRS captures the manner of death (i.e.
, suicide, undetermined, unintentional firearm, homicide and legal intervention) in a standardized way from both the DC and CME and retains them in separate variables. Manners of death can be analyzed separately or in aggregate without jeopardizing the size of the study. In other research differences were noted among studies in their inclusion of numerous combinations of manner of death in assessing suicide. For some, determination of suicide and thus inclusion in a study was based only on a DC manner of suicide. Other studies include a CME determination of suicide, while still others include suicides, undetermined and accidental deaths that appeared as though they could have been suicides [7
]. Standardization of case finding and variable definitions in a large scale study enables the analysis not only of sex differences at a sizeable aggregate level but also in conjunction with other variables such as state or county of occurrence where prevention programming and legislative support can be provided.
Active surveillance methods overcome a number of other limitations of controlled studies and can substantially increase death counts for study, especially with marginalized groups such as older adults who take their own lives. The NVDRS takes advantage of the availability of existing documents and, by consolidating the information into single case records, produces a more complete picture of suicide incidents than would be obtained by single source or limited access systems. Although CME [46
] and PR are not standardized at the agency level, the NVDRS methodology of multiple source documents improves our ability to understand the circumstances surrounding older adult suicides.
The differences found in this study between older adult males and females who take their lives may be related to the gender roles and the unique experiences of aging. The National Strategy for Suicide Prevention, Goals and Objectives for Action suggests a number of strategies to reduce suicidal behavior including promoting awareness, reducing the stigma of seeking care for mental health and substance abuse problems, implementing community based programs, reducing access to lethal means, and providing training for practitioners who care for the elderly [47
]. Older adult males in particular may benefit greatly from programs that seek to keep them active in later life, facilitate their access to mental health services, assist them in dealing with immediate crises, and evaluate their access to highly lethal weapons. Older adult females on the other hand, may benefit greatly from services to assist them in the earlier stages of the aging process, dealing with widowhood, and close monitoring of prescription medications, particularly opiates. Regardless of sex, an immediate and comprehensive response to suicidal ideation and previous suicide attempts is critical as nearly one in four older adults disclose their intent to take their lives before doing so. The effectiveness of programs designed to mitigate or respond to these issues is key to prevention.
Evaluation of the effectiveness of prevention programs for older adult suicide remains challenging for the methodological reasons presented earlier in this paper. Public health entities employing primary and secondary prevention strategies and utilizing strict scientific methods are ideal partners in bridging this knowledge gap in the future.
Primary prevention strategies that have been explored include efforts such as training professional and lay persons having frequent contact with older adults on risk and protective factors, community resources, and recognition of the warning signs of potential suicidal behavior; promoting physical activity and ensuring affordable medical coverage for physical and mental health needs; reducing isolation among elders by promoting participation in community events; and balancing work and relationship commitments as well as others [3
]. More targeted than primary prevention efforts, secondary prevention efforts have included the provision of therapeutic interventions for mental health and other life crises, case management services, transportation assistance to reach service providers, and monitoring of prescription drug and substance abuse. First and foremost however, is the need to identify which of the many potential strategies are the most effective for suicide prevention among older adult males and for females to ensure the unique needs of these two groups are met; a challenge for the field of public health.
The results from this study are subject to at least six limitations. First, while we identified precipitating circumstances for both males and females, we were not able to discern the intensity of those circumstances or which circumstances were most contributory. Second, it was not possible to determine if male and female suicide decedents have more life stressors than the other male and female older adults who do not die by suicide. Third, the inability to request additional follow-up detail on specific circumstances and to understand chronological sequencing of circumstances inhibits temporal analysis for both sexes. Fourth, there are other potentially important aspects of suicide circumstances that are not included in the NVDRS. The concepts of social isolation, personality traits and level of functional impairment, for example, have all been suggested as contributory in other suicide studies among the elderly but are often not measures reported in CME or PR [2
]. Fifth, toxicology results are limited to decedents who were tested for each substance and are not generalizable to all suicide decedents. Sixth, NVDRS surveillance data represent only 17 U.S. states, comparisons in this paper are limited only to other studies using U.S. data. Results from international studies [40
], while just as important, may reflect differing cultural factors, aging experiences, life course events, effects of demography and differences in clinical profiles and divergent motivations that make them fundamentally different than U.S. data.