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In June, the body of Philip Merrill, a Maryland-based publisher and philanthropist who had donated tens of millions of dollars to his favorite causes and served on many high-profile diplomatic and intelligence assignments, was found in the Chesapeake Bay. An autopsy confirmed that Merrill, age 72, died of a self-inflicted gunshot wound.¹

Merrill—lauded at his memorial service as a vibrant man with a passion for life—was one of 31,000 people a year in the United States who die by suicide.² He was also one of a group associated with a substantially higher risk of suicide than any other—older white males.

While suicide is the 11th leading cause of death in the United States, with 11 suicide deaths per 100,000 Americans, white men over the age of 65 commit suicide at almost triple that overall rate.³ These men are also eight times more likely to kill themselves than are women of the same age group, and have almost twice the rate of all other groups of male contemporaries.⁴

Analysts are divided over how to explain the elevated risk of suicide for older white men. Some researchers point to a lack of resilience or coping ability. Others point to men’s choice of more lethal means of suicide. More generally, systemic obstacles related to the primary care system (as well as cultural bias that assumes depression is a natural feature of aging) also inhibit detection of older people at risk of suicide.

While more research is needed to determine why some groups who are at-risk for suicide actually attempt it more than others, possible prevention interventions, include:

• Public-health campaigns to help people recognize risk factors or symptoms; and
• Better detection and treatment of people at risk of suicide in late life, including more training for primary-health providers who are likely to come into contact with elderly at-risk individuals.

Grim Comparisons by Sex, Race, and Ethnicity

Overall, three times as many women as men in the United States report a history of attempted suicide.⁵ But men are four times more likely to actually kill themselves.⁶ Choice of method may play a role in explaining this gender disparity: White men tend to use more violent and more lethal means than other suicide victims. In 2001, 73 percent of all suicide deaths and 80 percent of all firearm suicide deaths were white males.⁷

Disparities along ethnic lines for elderly males are also substantial. Compared with white males ages 65 and older, African American males (9.2 suicides per 100,000), Hispanic or Latino males (15.6), and Asian or Pacific Islander males (17.5) in the same age range had significantly lower suicide rates.

And as black and white men age, the gap in suicide rates between the two groups widens considerably. White males in the 45-64 age range commit almost three times as many suicides (26.1 per 100,000) as their black male contemporaries (at 9.0 per 100,000). The disparity grows among those ages 75-84 (37.5 per 100,000 for whites, compared with 11.3 per 100,000 for black males).

And suicide grows as a risk for white elderly males as they age. White men ages 85 and older have the highest annual suicide rate of any group—51.4 deaths per 100,000. In contrast, the highest rate for white women peaks between ages 45 and 64 at 7.8 deaths per 100,000.

Resilience and Stereotyping

There is still no clear explanation for this phenomenon, says Marnin Heisel, a psychologist at the University of Western Ontario’s departments of psychiatry and epidemiology and biostatistics.

Some researchers argue that older white males lack the resilience and coping mechanisms that make older white women and older black people less prone to suicide.⁸ The lower suicide rates among women suggest that women are capable of more complex and flexible coping strategies than men, according to Silvia Canetto, a Colorado State University psychology professor who specializes in gender issues in suicidal behavior.

Unlike men, argues Canetto, women experience more changes in roles and body functioning during adulthood, perhaps preparing them for physical changes in late life. In contrast, men are socialized to be in control and shape the world according to their needs.

When a problem arises, they are encouraged to use force to assert their will. As a result, Canetto writes, men arrive at late life with unrealistic expectations and a limited range of coping strategies.⁹

Suicidal women and men have also been portrayed differently in suicide research, according to Canetto. Women’s suicidal behavior is usually conceived as a private problem—an expression of an individual disorder or deficiency, or as the outcome of a “mental breakdown.” On the other hand, Canetto has noticed that the research literature views men’s suicidal behavior as a “tragic but rational” response to a loss or adverse circumstances.

And because men’s suicidal behavior is often linked afterwards to external factors such as an illness, a business failure, or a forced retirement, suicide-prevention plans often fail to address individual internal or psychological factors such as feelings, personal shortcomings, or relationship concerns.

“Unfortunately, an exclusive focus on impersonal, external factors ignores the fact that the majority of persons who experience an adversity do not become suicidal,” writes Canetto. “Most persons experience some degree of limitation in health status as a result of aging; however, only a minority of older adult men die as a result of suicide. Clearly, individual variables play a role.”¹⁰

Factors Underlying Race/Ethnic Disparities

Researchers who have noted the disparity in suicide rates between Hispanics and non-Hispanic whites have said that familism—or an emphasis on close relationships with extended kinship—may offer Hispanics better protection against suicide. Experts say that Hispanics tend to maintain closer relationships with family members than do whites. And their cultural tendency toward fatalism (or the expectation of adversity) may also help Hispanics adapt to chronic stress, according to analysts.¹¹

Some researchers have also speculated that the white/black differential in suicide rates may be explained through major social institutions such as family, church, and social-support systems that in the African American community seem to offer a buffer against social forces that might otherwise promote suicide.¹²

In an exploration of beliefs about suicide in the African American community, researchers who interviewed pastors at black churches in the southeastern United States found that the “view of suicide as a white thing” by blacks may protect them against suicide.¹³ Through ongoing struggle, pastors said, black Americans developed a culture of resilience in which suicide was seen as a contradiction to the black experience.

Obstacles to Detecting Depression in the Elderly

Analysts say that all elderly could be targeted more effectively by suicide prevention efforts. For instance, studies of suicide among elderly persons have found that 70 percent of elderly suicide victims saw their primary care provider within a month of death. Health care providers could use that knowledge to prevent suicides by improving the detection and treatment of mental disorders and other suicide risk factors in the primary care setting.¹⁴

But there are challenges. Study conditions for such collaborative approaches in which mental health care providers team up with primary care providers may not be realistic. “It doesn’t mirror resources in the real world,” says Paul Duberstein, professor of psychiatry at the University of Rochester.

For instance, not all physicians are comfortable with or adequately trained to identify which patients pose high suicide risks. With average visits to a primary care doctor running about 17 minutes long, according to data from the 2002 National Ambulatory Medical Care Survey, the primary care system is simply not set up for detecting, assessing, and treating mental health issues.

And even psychological clinicians may not be adequately trained in detecting suicidal thoughts and treatment.¹⁵ Depression can be more difficult to diagnose in the elderly because it may manifest itself as vague physical symptoms (such as fatigue) rather than more clear-cut symptoms.

In retrospect, friends of suicide victim Philip Merrill said that they had noticed that the usually energetic publisher had been feeling down in the months before his suicide. And his family had talked to his physicians about his change in behavior in the weeks before the suicide. It’s possible that Merrill’s dark mood was related to heart bypass surgery he underwent a year earlier; research shows that heart disease often leads to depression and vice versa.¹⁶

Finally, beliefs and attitudes that devalue life as people age may also interfere with the detection of depression, says Heisel. Many people perceive suicide in older people as less tragic then suicide by youths. Clinicians, family members, and older adults sometimes consider suicidal thoughts and depression as a natural part of aging.¹⁷

“If [clinicians] think that it’s just a natural consequence of aging, they’re not necessarily going to treat it as aggressively as they should,” says Heisel. “People need to be aware that depression and late-life depression are treatable.”

References

1. Elizabeth Williamson, “Merrill Suicide Confirmed; New Details of Case Released,” The Washington Post, June 24, 2006.
2. National Center for Health Statistics (NCHS), Self-Inflicted Injury/Suicide (Hyattsville, MD: NCHS, 2006), accessed online at www.cdc.gov, on July 17, 2006.
3. Arialdi M. Miniño, Melonie Heron, and Betty L. Smith, Deaths: Preliminary Data for 2004 (2006), accessed online at www.cdc.gov, on Aug. 2, 2006; and National Center for Health Statistics, Health, United States, 2005 (Hyattsville, MD: NCHS: 2005): table 46.
4. National Center for Health Statistics, Health, United States, 2005.
5. National Institute of Mental Health (NIMH), Suicide Facts and Statistics, accessed online at www.nimh.nih.gov, on July 20, 2006.
6. U.S. Preventive Services Task Force (USPSTF), Agency for Healthcare Research and Quality, Screening for Suicide Risk, accessed online at www.ahrq.gov, on July 20, 2006.
7. NIMH, Suicide Facts and Statistics.
8. Silvia S. Canetto, “Gender and Suicidal Behavior: Theories and Evidence,” in Review of Suicidology, 1997, ed. Ronald W. Maris, Morton M. Silverman, and Silvia S. Canetto (New York and London: The Guilford Press, 1997).
9. Silvia S. Canetto, “Gender and Suicide in the Elderly,” Suicide and Life-Threatening Behavior 22, no. 1 (1992): 92-93.
10. Canetto, “Gender and Suicidal Behavior.”
11. Maria A. Oquendo et al., “Ethnic and Sex Differences in Suicide Rates Relative to Major Depression in the United States,” American Journal of Psychiatry 158, no. 10 (2001): 1656.
12. Kevin E. Early and Ronald L. Akers, ” ‘It’s a White Thing’: An Exploration of Beliefs About Suicide in the African-American Community,” Deviant Behavior: An Interdisciplinary Journal 14, no. 4 (1993): 277-96.
13. Early and Akers, ” ‘It’s a White Thing’ “: 287.
14. Carolyn Levinson Miller and Benjamin Druss, “Datapoints: Suicide and Access to Care,” Psychiatric Services 52, no. 1566 (2001), accessed online at http://ps.psychiatryonline.org, on July 24, 2006; and NIMH, In Harm’s Way: Suicide in America (Bethesda, MD: NIMH, 2003).
15. Marnin J. Heisel and Paul R. Duberstein, “Suicide Prevention in Older Adults,” Clinical Psychology: Science and Practice 12, no. 3 (2005): 243.
16. Annie Linskey, “Friends Saw Mood Change in Merrill: Publisher’s Behavior Subdued After Surgery,” The Baltimore Sun, June 22, 2006; Mary A. Whooley, “Depression and Cardiovascular Disease: Healing the Broken-Hearted,” The Journal of the American Medical Association 295, no. 24 (2006): 2874-81; and David Kohn, “Depression Research Shows Head Heart Linked,” The Baltimore Sun, June 30, 2006.
17. Institute of Medicine, Reducing Suicide: A National Imperative (Washington, DC: The National Academies Press, 2002), accessed online at http://darwin.nap.edu, on July 24, 2006.