Is Late-Onset Suicidal Behavior a Distinct Subtype?

This clinical viewpoint article aims to draw attention to a yet unexplored factor influencing suicidal behavior: age of onset of suicidal behavior. To tackle the substantial heterogeneity among depressed older attempters, we suggest consideration of at least two distinct pathways to suicidal behavior in late life based on when the first suicidal crisis occurred. Specifically, we discuss the current state of research and the rationale behind the suggested early-late-onset categorization of late-life suicidal behavior. We summarize available evidence so far on early-onset and late-onset attempters, and the potential heterogeneity in the interplay of risk/precipitating factors. Certain risk factors for suicide, such as impulsivity and borderline traits, decrease with age, while memory and broader cognitive impairments increase with age. Research indicates that familial/social exposure to suicidal behavior, childhood trauma, impulsivity, maladaptive personality traits, longstanding interpersonal difficulties, and legal problems are found predominantly in attempters experiencing their first suicidal crisis between youth and early midlife. In contrast, dementia prodrome is one of the most promising but understudied candidates for late-onset suicide risk, especially in the context of other risk factors. Moreover, personality traits conferring increased vulnerability to late-onset suicidal behavior (such as high conscientiousness) are not the same as ones classically identified in younger attempters and in older suicide attempters who have early-onset suicidal behavior (such as neuroticism and Cluster B traits). We discuss methodological points about studying age of onset of suicidal behavior, outline clinical implications, share ideas for future directions, and call for research on this understudied topic.

Diligent for better or worse: Conscientiousness is associated with higher likelihood of suicidal behavior and more severe suicidal intent in later life.

BACKGROUND: Contradictory findings link trait conscientiousness in mid- and late life to increased healthspan and lifespan, as well as to death by suicide. It remains unclear whether conscientiousness is associated with higher odds of attempting suicide or with more severe suicidal behavior among attempters, and whether its relationship to suicide risk varies with aging-related stressors, such as declining health. METHODS: In this cross-sectional study comprising 313 depressed adults aged ≥40 years and participating in the Longitudinal Research Program in Late-Life Suicide (Pittsburgh, USA), we employed logistic and linear regression to test whether conscientiousness was associated with the presence of recent suicidal behavior (≤2 years) and with intent severity in recent attempters (n = 84). We further tested whether the above relationships varied based on mental, cognitive, and physical health status, measured as depression severity, cognitive functioning, and the presence/absence of severe physical illness. RESULTS: Participants were 62.1 years old on average (SD = 7.6), 85% White, and 53% female. Recent attempters had a mean age of 61.8 years at their most recent attempt (SD = 8.5), had lower cognitive functioning and were more likely severely physically ill than comparisons. Conscientiousness was positively associated with a higher likelihood of recent suicidal behavior overall (adjusted OR = 1.44, 95% CI = 1.09, 1.90, p = .010), but not in case of co-occurring severe physical illness (interaction OR = 0.54, 95% CI = 0.30, 0.97, p = .039). Conscientiousness was also positively associated with suicidal intent at the most recent attempt (adjusted ß = 1.60, SE = 0.62, p = .012), explaining 7% of its variance, although this association lost significance after adjusting for other personality dimensions. CONCLUSIONS: Highly conscientious middle-aged and older adults may be at increased risk of resolute suicidal behavior, although conscientiousness may not confer additional suicide risk among those severely physically ill.

Life-Satisfaction, Engagement, Mindfulness, Flourishing, and Social Support: Do they Predict Depression, Suicide Ideation, and History of Suicide Attempt in Late Life?

OBJECTIVE: Suicide is an outcome arising from a combination of risk and protective factors. Examining psychological resilience traits associated with successful aging may help to better understand late-life suicide and depression. We examined self-reported protective factors including mindfulness, life satisfaction and engagement, flourishing, and subjective and objective social support in a high suicide-risk sample of depressed older adults. METHODS: Participants were 297 individuals aged 55+ (mean age: 64.2): 92 depressed suicide attempters, 138 depressed individuals who never attempted suicide, and 67 non-psychiatric comparisons. Using linear and binomial logistic regression, we examined the effects of a combined Protective Factor value on presence and severity of depression and suicidal ideation, and history of suicide attempt. RESULTS: Relative to the non-psychiatric comparison group, all depressed participants had significantly lower Protective Factor values. Higher Protective Factor value was associated with lower likelihood of depression, depression severity, and likelihood of ideation, but was not associated with ideation severity or history of suicide attempt. Participants with one standard deviation higher Protective Factor had lower odds of ideation incidence by a factor of OR=0.68 (95%CI=0.48-0.96). CONCLUSION: Resiliency characteristics relevant to psychological wellbeing and successful aging may mitigate the emergence of depression and suicidal ideation, as well as the severity of depression in late-life. The Resilience Factor used in this study can help clinicians nuance their appraisal of depression and suicide risk.

Childhood trauma is associated with early-onset but not late-onset suicidal behavior in late-life depression.

OBJECTIVES: To examine the relationship between childhood traumatic experiences and early and late-onset suicidal behavior among depressed older adults. DESIGN: Cross-sectional study. SETTING: Inpatient and outpatient psychiatric services in Pennsylvania. PARTICIPANTS: Our sample included 224 adults aged 50+ (M ± SD = 62.5 ± 7.4) recruited into three depressed groups: (1) 84 suicide attempters, (2) 44 suicide ideators, and (3) 58 non-suicidal comparisons, and a non-psychiatric healthy comparison group (N = 38). MEASUREMENTS: The Childhood Trauma Questionnaire measured experiences of childhood trauma such as emotional abuse, physical abuse, emotional neglect, physical neglect, and sexual abuse. RESULTS: Attempters were separated into early- and late-onset based on age of first attempt using a statistical algorithm that identified a cutoff age of 30 years old. Overall, we found group differences in emotional and physical abuse and neglect in both genders and sexual abuse in females, but not in males. Early-onset attempters experienced more childhood emotional abuse and neglect than late-onset attempters and were more likely to have experienced multiple forms of abuse. They also experienced more emotional abuse and neglect than all comparison groups. Consistently, early-onset attempters more often met criteria for current or lifetime PTSD relative to late-onset attempters and most comparison groups. Late-onset attempters had similar levels of childhood trauma as other depressed groups. CONCLUSIONS: Our study reaffirms that there are distinct pathways to suicidal behavior in older adults based on their age of first suicide attempt and that trauma experienced in childhood has long-lasting emotional and behavioral consequences, even into late life.

Comparison of approximate intermolecular potentials for ab initio fragment calculations on medium sized N-heterocycles.

The ground state intermolecular potential of bimolecular complexes of N-heterocycles is analyzed for the impact of individual terms in the interaction energy as provided by various, conceptually different theories. Novel combinations with several formulations of the electrostatic, Pauli repulsion, and dispersion contributions are tested at both short- and long-distance sides of the potential energy surface, for various alignments of the pyrrole dimer as well as the cytosine-uracil complex. The integration of a DFT/CCSD density embedding scheme, with dispersion terms from the effective fragment potential (EFP) method is found to provide good agreement with a reference CCSD(T) potential overall; simultaneously, a quantum mechanics/molecular mechanics approach using CHELPG atomic point charges for the electrostatic interaction, augmented by EFP dispersion and Pauli repulsion, comes also close to the reference result. Both schemes have the advantage of not relying on predefined force fields; rather, the interaction parameters can be determined for the system under study, thus being excellent candidates for ab initio modeling.

The Role of Perceived and Objective Social Connectedness on Risk for Suicidal Thoughts and Behavior in Late-Life and Their Moderating Effect on Cognitive Deficits.

OBJECTIVE: Impaired cognition increases suicide risk while social connectedness protects against suicide risk in late life. We examined the independent and interactive effects of social connectedness and cognition on suicide risk in late life. METHODS: Participants included 570 individuals aged 50+ from a late-life suicide study. The Interpersonal Support Evaluation List and Social Network Index were used to assess perceived and objective social connectedness, respectively, while the Mattis Dementia Rating Scale and Executive Interview were used to assess cognition. RESULTS: Suicide attempters and ideators reported lower perceived social connectedness and exhibited worse executive function than non-suicidal depressed and healthy comparison participants, while only attempters had worse objective social connectedness relative to the other groups. Executive dysfunction was linked to low objective social connectedness in attempters but higher objective social connectedness in healthy comparisons. CONCLUSION: Interventions targeting suicide risk may consider bolstering social connectedness, particularly in those with low cognitive health.

Late-Onset Suicide: A Dementia Prodrome?

OBJECTIVES: This study examined whether late-onset (versus early-onset) suicidal behavior is associated with worse cognition. METHODS: Participants included 278 adults aged 50+ years (56 nonpsychiatric comparison group; 67 nonsuicidal depressed older adults; 63 depressed suicide ideators; and 44 late-onset (55+ years) and 48 early-onset suicide attempters (<55 years). Using a case-control design, this study examined group differences in global cognition, episodic memory, information processing speed, and executive functioning, assessed using the Repeatable Battery of Neuropsychological Status and the Trail Making Test from the Delis-Kaplan Executive Function System. Linear regression was used for data analyses. RESULTS: Both attempter groups displayed worse executive functioning than nonsuicidal depressed older adults. Late-onset attempters additionally displayed poorer global cognition and processing speed than nonsuicidal depressed older adults and poorer memory than early-onset attempters. CONCLUSIONS: Late-onset suicidal behavior is associated with worse performance in a broad range of cognitive domains, possibly reflective of a dementia prodrome.

Personality of late- and early-onset elderly suicide attempters.

OBJECTIVES: While suicidal behavior often manifests in adolescence and early adulthood, some people first attempt suicide in late life, often with remarkable lethal intent and determination. Given these individuals' more adaptive functioning earlier in life, they may possess traits that hinder adjustment to aging, such as high conscientiousness, rather than impulsive-aggressive traits associated with suicidal behavior in younger adults. METHODS: A cross-sectional case-control study was conducted in older adults aged ≥50 (mean: 65), divided into early- and late-onset attempters (age at first attempt ≤ or >50, mean: 31 vs 61), suicide ideators as well as non-suicidal depressed and healthy controls. Personality was assessed in terms of the five-factor model (FFM, n = 200) and five DSM personality disorders analyzed on the trait level as continuous scores (PDs, n = 160). Given our starting hypothesis about late-onset attempters, the FFM dimension conscientiousness was further tested on the subcomponent level. RESULTS: All clinical groups displayed more maladaptive profiles than healthy subjects. Compared to depressed controls, higher neuroticism, and borderline traits characterized both suicide ideators and early-onset attempters, while only early-onset attempters further displayed lower extraversion and higher antisocial traits. Late-onset attempters were similar to depressed controls on most measures, but scored higher than them on orderliness, a conscientiousness subcomponent. CONCLUSIONS: While neuroticism, introversion, and cluster B traits are prominent in early-onset suicidal behavior, late-onset cases generally lack these features. In contrast, higher levels of orderliness in late-onset suicidal behavior are compatible with the age-selective maladjustment hypothesis. Key points Personality of elderly attempters differed between those with early- and late-onset first attempts. Early-onset attempters possessed personality traits generally found in younger suicidal populations (high neuroticism, low extraversion, antisocial, and borderline PD traits), supporting that constitutional suicide risk factors persist into late life in some individuals. Late-onset suicide attempters had higher levels of orderliness than non-suicidal depressed participants, suggesting that this generally adaptive trait may facilitate suicidal behavior in a subset of depressed elderly.

Neurocomputational mechanisms of adaptive learning in social exchanges.

Prior work on prosocial and self-serving behavior in human economic exchanges has shown that counterparts' high social reputations bias striatal reward signals and elicit cooperation, even when such cooperation is disadvantageous. This phenomenon suggests that the human striatum is modulated by the other's social value, which is insensitive to the individual's own choices to cooperate or defect. We tested an alternative hypothesis that, when people learn from their interactions with others, they encode prediction error updates with respect to their own policy. Under this policy update account striatal signals would reflect positive prediction errors when the individual's choices correctly anticipated not only the counterpart's cooperation but also defection. We examined behavior in three samples using reinforcement learning and model-free analyses and performed an fMRI study of striatal learning signals. In order to uncover the dynamics of goal-directed learning, we introduced reversals in the counterpart's behavior and provided counterfactual (would-be) feedback when the individual chose not to engage with the counterpart. Behavioral data and model-derived prediction error maps (in both whole-brain and a priori striatal region of interest analyses) supported the policy update model. Thus, as people continually adjust their rate of cooperation based on experience, their behavior and striatal learning signals reveal a self-centered instrumental process corresponding to reciprocal altruism.

Motivations for attempting suicide in mid- and late-life.

ABSTRACTObjectives:To understand pathways to suicide by investigating the association between personality and suicidal motivations in mid- and late-life attempts. DESIGN: In a two-study approach, we measured different components of suicidal motivations using an existing self-report investigating reasons for suicide and a semi-qualitative assessment of motivational states preceding attempts. SETTING: Inpatient and outpatient psychiatric services in Pittsburgh, PA. PARTICIPANTS: Study 1 (n = 50, mean age at attempt = 60.4) was a smaller sample of suicide attempters included in Study 2 (n = 69, mean age at attempt = 60.9). Non-psychiatric healthy controls (n = 50, mean age = 67.1) were used as benchmarks for dispositional measures. MEASUREMENTS: Motives for suicide were measured by the Reasons for Attempting Suicide Questionnaire (RASQ). Participants' written descriptions of the thoughts and feelings preceding their attempt captured motivational states. Measures of personality for both studies included assessments of impulsivity, five-factor model, interpersonal dysfunction, and borderline traits. RESULTS: In study 1, escape/self-punishment motives on the RASQ were associated with multiple attempts and borderline pathology, while interpersonal motives were less frequently endorsed and associated with poorly planned attempts. In study 2, experiences of defeat (i.e. powerlessness, poor coping to threats to autonomy/status) were more frequently endorsed by men and associated with disagreeableness. CONCLUSIONS: Study 1 revealed that attempters high in dysfunctional psychopathology were more likely to report self-oriented escape motives for suicide, while study 2 identified a putative pathway to suicide in men involving antagonism and the experience of defeat.

Losing the battle: Perceived status loss and contemplated or attempted suicide in older adults.

OBJECTIVE: While loss of socioeconomic status (SES) has been linked to suicidal behavior, it is unclear whether this experience is merely a downstream effect of psychopathology ("downward drift"), a sign of hardship, or an independent psychological contributor to suicide risk. We examined the association between the subjective experience of status loss and suicidal behavior and ideation in old age, while accounting for potential confounders. We were also interested in whether status loss was associated with mere thoughts of suicide vs. suicidal behavior. METHODS: Fifty older (55+) depressed suicide attempters, 29 depressed suicide ideators with no history of attempted suicide, 38 nonsuicidal depressed participants, and 45 nonpsychiatric controls underwent detailed clinical characterization and reported their current and highest lifetime SES. RESULTS: Suicide attempters were more likely to report a decline in their SES compared to healthy controls and nonsuicidal depressed older adults, while not differing from suicide ideators. This difference was not explained by objective predictors of SES, including education, financial difficulties, and the presence of addiction. Interestingly, while the current SES of suicide attempters was much lower than that of comparison groups, their reported highest lifetime SES was just as high, despite the differences in education. CONCLUSION: In older adults, the experience of status loss is associated with contemplated and attempted suicide even after accounting for objective indicators of social status and psychopathology. It is possible that suicidal individuals retrospectively inflate their previous status, making their current standing appear even worse by comparison.

Perceived burdensomeness is associated with low-lethality suicide attempts, dysfunctional interpersonal style, and younger rather than older age.

OBJECTIVES: Perceived burdensomeness is thought to contribute to suicide risk. However, suicidal behavior is clinically and psychologically heterogeneous. Does a high level of perceived burdensomeness differentiate medically serious suicidal acts, most closely resembling death by suicide, from less serious ones? How is perceived burdensomeness related to dysfunctional personality dimensions implicated in suicide? We sought to answer these questions in a cross-sectional, case-control study of adults, aged 42 years or older (n = 165). METHODS: Participants were suicidal depressed with history of high-lethality and low-lethality attempts, depressed with serious suicidal ideation, depressed non-suicidal, and psychiatrically healthy controls. Following detailed clinical characterization, we assessed perceived burdensomeness, the Big Five, impulsivity, and anger rumination. RESULTS: Low-lethality attempters reported the highest levels of perceived burdensomeness, followed by ideators, high-lethality attempters, non-suicidal depressed, and healthy controls. Group differences were robust to confounders, including demographics, severity of depression, and physical illness burden. In suicide attempters, perceived burdensomeness scaled positively with neuroticism, impulsivity, and anger and negatively with extraversion, conscientiousness, and age. CONCLUSIONS: Our findings suggest that perceived burdensomeness is most prominent in a subgroup of younger individuals with lower-lethality suicide attempts and a dysfunctional interpersonal style. Older adults with high-lethality attempts are surprisingly more resilient to the feelings of burdensomeness. Copyright © 2016 John Wiley & Sons, Ltd.

Course of cognitive impairment following attempted suicide in older adults.

OBJECTIVE: Cognitive impairment has been associated with late-life suicidal behavior. Without longitudinal data it is unclear whether these are transient features of a depressive state or stable impairments. We examined longitudinally the course of cognitive impairment in older adults with depression and a history of suicide attempt. METHODS: We investigated the persistence of cognitive impairment over time in 198 depressed older adults (age >60); 91 suicide attempters, 39 depressed individuals with suicidal ideation (ideators), and 68 non-suicidal depressed adults assessed over a 2-year period at four time points. We used linear mixed effects modeling to examine group differences in trajectories of cognitive decline over 2 years, using the Mini-Mental State Examination (MMSE), Mattis Dementia Rating Scale (DRS), and Executive Interview (EXIT). RESULTS: Over the 2-year period, suicide attempters performed significantly worse than both suicide ideators and non-suicidal depressed older adults on the MMSE (mean difference: from ideators: -0.88, p = 0.02; from non-suicidal depressed: -1.52, p < 0.01), while on the EXIT and DRS, suicide attempters performed significantly worse than non-suicidal depressed older adults (mean difference: in EXIT: -1.75, p = 0.01; in DRS: 3.04, p < 0.01; in MMSE: 1.15, p < 0.01). Cognitive impairment in suicide attempters partly resolved, as indicated by a group × time interaction on the DRS (p = 0.039), but not the EXIT (p = 0.58) or the MMSE (p = 0.08). CONCLUSIONS: Cognitive impairment in late-life suicidal behavior appears to involve both a stable and a state-related component.

Insomnia is associated with suicide attempt in middle-aged and older adults with depression.

BACKGROUND: Insomnia increases in prevalence with age, is strongly associated with depression, and has been identified as a risk factor for suicide in several studies. The aim of this study was to determine whether insomnia severity varies between those who have attempted suicide (n = 72), those who only contemplate suicide (n = 28), and those who are depressed but have no suicidal ideation or attempt history (n = 35). METHODS: Participants were middle-aged and older adults (age 44-87, M = 66 years) with depression. Insomnia severity was measured as the sum of the early, middle, and late insomnia items from the Hamilton Rating Scale for Depression. General linear models examined relations between group status as the independent variable and insomnia severity as the dependent variable. RESULTS: The suicide attempt group suffered from more severe insomnia than the suicidal ideation and non-suicidal depressed groups (p < 0.05). Differences remained after adjusting for potential confounders including demographics, cognitive ability, alcohol dependence in the past month, severity of depressed mood, anxiety, and physical health burden. Moreover, greater insomnia severity in the suicide attempt group could not be explained by interpersonal difficulties, executive functioning, benzodiazepine use, or by the presence of post-traumatic stress disorder. CONCLUSIONS: Our results suggest that insomnia may be more strongly associated with suicidal behavior than with the presence of suicidal thoughts alone. Accordingly, insomnia is a potential treatment target for reducing suicide risk in middle-aged and older adults.

Impulsive traits and unplanned suicide attempts predict exaggerated prefrontal response to angry faces in the elderly.

OBJECTIVE: Abnormal responses to social stimuli are seen in people vulnerable to suicidal behavior, indicating possible disruptions in the neural circuitry mediating the interpretation of socioemotional cues. These disruptions have not been empirically related to psychological and cognitive pathways to suicide. In the present study of older suicide attempters, we examined neural responses to emotional faces and their relationship to impulsivity, one of the components of the suicidal diathesis. METHODS: Using functional magnetic resonance imaging, we recorded neurohemodynamic responses to angry faces in a carefully characterized sample of 18 depressed elderly with history of suicide attempts, 13 depressed nonsuicidal patients, and 18 healthy individuals, all aged 60+. Impulsivity was assessed with the Social Problem Solving Inventory Impulsivity/Carelessness Style subscale and Barratt Impulsiveness Scale. The Suicide Intent Scale planning subscale was used to describe the degree of planning associated with the most lethal attempt. RESULTS: Depression and history of attempted suicide were not associated with neural responses to angry faces, failing to replicate earlier studies. Higher impulsivity, however, predicted exaggerated responses to angry faces in fronto-opercular and dorsomedial prefrontal cortex (pcorr <0.05). Poorly planned suicide attempts also predicted increased fronto-opercular responses. Results were robust to effects of medication exposure, comorbid anxiety and addiction, severity of depression, burden of physical illness, and possible brain injury from suicide attempts. CONCLUSION: Impulsive traits and history of unplanned suicide attempts partly explain the heterogeneity in neural responses to angry faces in depressed elderly. Displays of social emotion command excessive cortical processing in impulsive suicide attempters.

Cognitive inhibition in older high-lethality suicide attempters.

BACKGROUND: People who attempt suicide often display cognitive impairments, particularly poor cognitive control. Could poor cognitive control contribute to high suicide rates in old age? A component of cognitive control, cognitive inhibition-active suppression of task-irrelevant processing-is very sensitive to aging and has been linked to attempted suicide. We investigated cognitive inhibition in older high-lethality suicide attempters, closely resembling suicide victims, as well as low-lethality attempters, and control groups with and without depression and suicidal ideation. METHODS: A total of 102 participants aged 60 years and older (17 psychiatrically healthy control subjects, 38 depressed control subjects, 16 suicide ideators, 14 low-lethality suicide attempters, and 17 high-lethality suicide attempters) underwent comprehensive clinical and cognitive assessments. They completed the Delis-Kaplan Executive Function System Color-Word Interference Test, a validated modification of the Stroop test. RESULTS: High-lethality suicide attempters demonstrated a distinct pattern of cognitive inhibition deficits. Compared with psychiatrically healthy control subjects and suicide ideators, high-lethality attempters took longer to complete inhibition trials, even after accounting for potential confounding factors (age, education, Mini mental state examination score, information processing speed, and accuracy). Compared with non-suicidal depressed and healthy control subjects, low-lethality suicide attempters committed more uncorrected errors; however, this difference was not specific to the inhibition condition. CONCLUSIONS: Older suicide attempters are a cognitively heterogeneous group. Poor cognitive control in high-lethality attempters may undermine their ability to solve real-life problems, precipitating a catastrophic accumulation of stressors. Meanwhile, low-lethality attempters' poor performance may reflect a careless approach to the task or faulty monitoring.

Impaired Executive Function in Contemplated and Attempted Suicide in Late Life.

OBJECTIVE: Executive deficits may play an important role in late-life suicide. Yet, current evidence in this area is inconclusive and does not indicate whether these deficits are broadly associated with suicidal ideation or are specific to suicidal behavior. This study examined global cognition and specifically executive function impairments as correlates of suicidal ideation and suicidal behavior in depressed older adults, with the goal of extending an earlier preliminary study. DESIGN: Case-control study. SETTING: University-affiliated psychiatric hospital. PARTICIPANTS: All participants were age 60+: 83 depressed suicide attempters, 43 depressed individuals having suicidal ideation with a specific plan, 54 nonsuicidal depressed participants, and 48 older adults with no history of psychiatric disorders. MEASUREMENTS: Global cognitive function was assessed with Dementia Rating Scale (DRS) and executive function with Executive Interview (EXIT). RESULTS: Both suicide attempters and suicide ideators performed worse than the two comparison groups on the EXIT, with no difference between suicide attempters and suicide ideators. On the DRS total score, as well as on Memory and Attention subscales, suicide attempters and ideators and nonsuicidal depressed subjects performed similarly and were impaired relative to nonpsychiatric control subjects. Controlling for education, substance use disorders, and medication exposure did not affect group differences in performance on either the EXIT or the DRS. CONCLUSIONS: Executive deficits, captured with a brief instrument, are associated broadly with suicidal ideation in older depressed adults but do not appear to directly facilitate suicidal behavior. Our data are consistent with the idea that different vulnerabilities may operate at different stages in the suicidal process.