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Invited Commentary
Public Health
June 14, 2019

Suicide in Long-term Care Facilities—The Exception or the Norm?

Author Affiliations
  • 1Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
JAMA Netw Open. 2019;2(6):e195634. doi:10.1001/jamanetworkopen.2019.5634

Almost 30 years ago, Loebel and colleagues1 demonstrated that anticipation of nursing home placement may be a precipitant of suicide in elderly people, especially among married older adults. Surprisingly, fewer than 20 studies that we know of have been published since then focusing on suicide associated with nursing homes. In a 2015 systematic review2 of completed suicides among nursing home residents, 8 studies were identified, with only 101 suicides in nursing homes having detailed information available for analysis.

Suicide in older adults is a major public health issue. Suicide rates increase during the life course and are highest among older white men in the United States. Specific health conditions and stress factors increase the complexity of the explanatory model for suicide in older adults. Psychiatric and neurocognitive disorders, social exclusion, bereavement, cognitive impairment, decision making and cognitive inhibition, physical illnesses, and physical and psychological pain have all been noted as risk variables associated with suicide in older adults. Specific stress factors, such as disability and feelings of social disconnectedness, in suicide among older adults are directly associated with transition into long-term care. There is a dire need to fill the gap existing in our knowledge of the consequences of transition into long-term care.

Despite the scarcity of studies focusing on nursing home–associated suicide, some of the notable findings include seeing suicide “…as an expression of autonomy, a response to the suffering associated with aging and the living conditions imposed on older people in our society, particularly in nursing homes….”3(p424) Most studies indicate that suicidal thoughts are common among nursing home residents, although completed suicide is rare. Men are at a higher risk, depression is common, and the decedents had resided in the nursing home for less than 6 months. However, it needs to be stressed that some researchers, including Mezuk and colleagues,4,5 whose recent work is published in JAMA Network Open,5 have emphasized that the rate of completed suicides in nursing homes is no greater than that among the general older adult population.

This study by Mezuk and colleagues5 is the latest and most comprehensive of studies focusing on nursing home completed suicides. In addition to their observational epidemiological report, the authors developed a natural language processing algorithm to identify suicides associated with long-term care. The study’s notable strengths include the long duration captured and novel data linkage. Because the researchers used 2 approaches to data analyses, they were able to examine the association between nursing home residence and completed suicide risk more comprehensively than could be achieved with either approach alone.

However, the study by Mezuk and colleagues5 has some structural limitations related to the nature of any such data linkage study. The authors could not go beyond the data that existed within the database used; in particular, they were not able to ascertain the baseline rate of suicide among older adults either in the community or in rest homes given the variability of follow-up between states. This makes the estimation of the predictive value or influence of any risk factor virtually impossible to appraise. One of the drawbacks to generalization of their presented findings is the age gap between all deaths not associated with long-term care (median, 64 years) compared with all deaths associated with long-term care (median, 79 years). As the authors note, generalization of the data beyond similar states or outside of the United States would be a challenge because it appears that the suicide rate, at least in Denmark,6 increases with age and infirmity. In particular, the use of firearms in the community is not shared in other countries.7 We note that in the article by Mezuk and colleagues5 pain and disability were not associated with completed suicide; in contrast, within a Korean population (with a much higher baseline rate of suicide), both were associated with completed suicide.8 As in most epidemiological research, context matters in the elderly population. This calls into question the feasibility of suicide prevention in nursing homes.

We wish to highlight the additional public health threat of loneliness in people transitioning to long-term care. Social isolation and loneliness foretell increased odds of premature mortality, and it is well known that the World Health Organization notes “social support networks” as a “determinant of health.” While the mechanisms by which loneliness affects mental and physical health remain largely unclear, the anguish expressed by individuals as they leave their homes and loved ones and move into care facilities is well known to psychiatrists and allied health professionals.

What the article by Mezuk and colleagues5 does give us is information over a longer term that would be available with case-control studies and at a more granular level than that from national case registers. The size of residential units, the rate of depression, and the variation in licensing between states may allow for an ecologic approach comparing similar states to elucidate if changes in regulations and training may modify these risks.

Mezuk and colleagues5 correctly state that more surveys, more studies, and more data and testing of interventions are needed. Our older people deserve the best care we can provide. Moreover, for the surviving relatives, suicide is always tragic. Our aim should be that it remains the rare exception.

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Article Information

Published: June 14, 2019. doi:10.1001/jamanetworkopen.2019.5634

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Barak Y et al. JAMA Network Open.

Corresponding Author: Yoram Barak, MD, MHA, Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand (yoram.barak@otago.ac.nz).

Conflict of Interest Disclosures: None reported.

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