One of the fundamental goals in this area of research is to identify constructs associated with suicide ideation that are potentially malleable, such that clinicians and other health care providers can engage in preventive efforts. Based on the interpersonal-psychological theory (Joiner, 2005
), this study points to the importance of perceived burdensomeness, a theoretically linked construct that is related to suicide ideation in older adults. According to the theory, perceived burdensomeness is a proximal, causal risk factor for suicide ideation and desire. As such, this construct should be significantly associated with suicide ideation. Results from these two studies indicate that perceived burdensomeness accounted for unique variance in suicide ideation after accounting for the variance related to a large number of correlates of suicide ideation in older adults.
Support was not found for the hypothesis that perceived burdensomeness exerts a greater impact on suicide ideation in males compared to females. This study included older adults recruited from a primary care environment, many of whom had few perceptions of burdensomeness and few thoughts of suicide. Thus, it is possible that gender differences in the impact of perceived burdensomeness on suicide ideation are more apparent among older adults with greater symptom severity in both domains. It is also possible that this association is greater among those engaging in suicidal behavior, rather than ideation. Thus, future research will aim to test the moderation effect of gender in samples with more proximal risk for suicide.
There are, however, several limitations to the studies. First, both samples were largely Caucasian, female, and highly educated. The gender distribution of the Study 2 sample reflected the gender ratio of patients in a primary care clinic (63% women, 37% men); however, our recruitment of 26% men suggests a lower rate of participation by men than women. Most studies of older adults have included a much higher proportion of women, limiting the ability to identify variables of specific importance to suicide in older Caucasian men (De Leo et al., 2002
; Unützer et al., 2006
) and this remains a difficulty with these samples. This is a limitation that should be addressed in future studies. The rate of agreement to participate in this study was 24%. Although we cannot examine whether those who participated differed in meaningful ways from those who did not on study-related variables, it is possible that older adults with greater physical and psychological difficulties may have declined participation, leading to a sample with less frequent elevation on study variables, including suicide ideation. To more fully understand suicide ideation in older adults, it is important to conduct research with underrepresented older adults, including older adults of various ethnic backgrounds and educational levels. Education level covaries with financial status, and it is possible that individuals from lower SES have particular stressors that relate to perceived burdensomeness. Similarly, individuals with cultural identities that stress family and interpersonal relationship goals above independence and achievement goals may be particularly vulnerable to changes in perceived burden.
A second characteristic of the sample that influences the interpretation of the results is that the participants were not members of a group particularly at risk for suicide, other than their age status and presentation to primary care (Study 2). Although this can be considered a strength of the study (a significant minority of individuals who end their lives do not fall into an identifiable risk group), it also limits the ability to generalize these findings to older adults potentially most at risk for suicide (e.g., depressed, widowed, loss of independence). Future investigation in this area would benefit from research efforts focused particularly on at-risk groups within the older adult population.
The data presented in both studies are cross-sectional and rely on self-report. Although the results support the theoretical model, they do not provide information about the prospective unfolding of these relationships. For example, it is impossible to determine whether suicide ideation precedes, follows, or occurs simultaneously with perceived burdensomeness. Further, it is possible that biases may be present wherein participants underreport thoughts of suicide or the extent to which they feel like a burden on others. Future research with longitudinal designs will help to elucidate the nature of these relationships, adding both to the complexity of the theoretical model and potential intervention models.
In addition to research that addresses the delineated limitations of the current studies, research that examines the degree to which perceived burdensomeness is a malleable construct will be of significant benefit to efforts aimed at preventing suicide in older adults. The first step is determining whether or not this construct can be changed, and the second step is determining the degree to which change in this construct is associated with change in suicide ideation. The perception of burden on loved ones is a class of thoughts that might be particularly amenable to interventions involved in cognitive therapy. In a recently published book, Joiner, Van Orden, Witte, and Rudd (2009)
described strategies for targeting perceptions of burdensomeness. For example, they suggested collaborating with the individual to generate evidence indicating the patient’s death is not worth more than his or her life. This may begin with the therapeutic relationship, wherein the clinician provides facts demonstrating the patient’s contribution to loved ones and society. The clinician further suggests that the patient begin to collect information from others that provides counterevidence to the perceptions of burdensomeness. Additional modifications to other empirically based approaches to the treatment of suicidal behavior to reduce perceptions of burdensomeness are described by Joiner et al. (2009)
. Although these strategies remain untested, researchers have demonstrated success in treating geriatric depression with cognitive-behavioral therapy (e.g., Pinquart, Duberstein, & Lyness, 2006
); thus, perceptions of burden on others may also be treated successfully in psychotherapy.
In sum, the two studies presented lend initial support to the importance of perceived burdensomeness as a correlate of suicide ideation in two older adult samples recruited from both the community and primary care physician offices. Given the risk of death by suicide in older adults and the increasing proportion of older adults in the United States, it is necessary to understand risk factors for suicidal desire and, ultimately, for suicidal behavior and death by suicide. The interpersonal-psychological theory of suicide allows for specific hypotheses about the necessary conditions for suicidal desire and the pathways through which developed desire may combine with acquired capability to result in suicide. Continuing to test this model may lead to development of assessment, prevention, and intervention strategies to reduce this significant public health concern.