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Original Investigation
February 22, 2023

Association of Frailty With Risk of Suicide Attempt in a National Cohort of US Veterans Aged 65 Years or Older

Author Affiliations
  • 1San Francisco VA Health Care System, San Francisco, California
  • 2Northern California Institute for Research and Education, San Francisco
  • 3Hoag Memorial Hospital Presbyterian, Newport Beach, California
  • 4Division of Geriatrics, Department of Medicine, University of California, San Francisco
  • 5Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia
  • 6Department of Psychiatry and Medicine, University of California, San Francisco
JAMA Psychiatry. 2023;80(4):287-295. doi:10.1001/jamapsychiatry.2022.5144
Key Points

Question  Is frailty a factor associated with risk for suicide attempts?

Findings  In this cohort study of 2 858 876 US veterans aged 65 years or older, risk of suicide attempt was higher in patients with all levels of frailty (prefrailty and mild, moderate, and severe frailty) compared with those without frailty. Risk of lethal suicide attempt was associated with lower levels of frailty.

Meaning  The findings suggest that additional suicide prevention efforts should be directed toward patients with frailty complications associated with risk for suicide attempts and lethality.


Importance  Frailty is associated with reduced physiological reserve, lack of independence, and depression and may be salient for identifying older adults at increased risk of suicide attempt.

Objectives  To examine the association between frailty and risk of suicide attempt and how risk differs based on components of frailty.

Design, Setting, and Participants  This nationwide cohort study integrated databases from the US Department of Veterans Affairs (VA) inpatient and outpatient health care services, Centers for Medicare & Medicaid Services data, and national suicide data. Participants included all US veterans aged 65 years or older who received care at VA medical centers from October 1, 2011, to September 30, 2013. Data were analyzed from April 20, 2021, to May 31, 2022.

Exposures  Frailty, defined based on a validated cumulative-deficit frailty index measured using electronic health data and categorized into 5 levels: nonfrailty, prefrailty, mild frailty, moderate frailty, and severe frailty.

Main Outcomes and Measures  The main outcome was suicide attempts through December 31, 2017, provided by the national Suicide Prevention Applications Network (nonfatal attempts) and Mortality Data Repository (fatal attempts). Frailty level and components of the frailty index (morbidity, function, sensory loss, cognition and mood, and other) were assessed as potential factors associated with suicide attempt.

Results  The study population of 2 858 876 participants included 8955 (0.3%) who attempted suicide over 6 years. Among all participants, the mean (SD) age was 75.4 (8.1) years; 97.7% were men, 2.3% were women, 0.6% were Hispanic, 9.0% were non-Hispanic Black, 87.8% were non-Hispanic White, and 2.6% had other or unknown race and ethnicity. Compared with patients without frailty, risk of suicide attempt was uniformly higher among patients with prefrailty to severe frailty, with adjusted hazard ratios (aHRs) of 1.34 (95% CI, 1.27-1.42; P < .001) for prefrailty, 1.44 (95% CI, 1.35-1.54; P < .001) for mild frailty, 1.48 (95% CI, 1.36-1.60; P < .001) for moderate frailty, and 1.42 (95% CI, 1.29-1.56; P < .001) for severe frailty. Lower levels of frailty were associated with greater risk of lethal suicide attempt (aHR, 1.20 [95% CI, 1.12-1.28] for prefrail veterans). Bipolar disorder (aHR, 2.69; 95% CI, 2.54-2.86), depression (aHR, 1.78; 95% CI, 1.67-1.87), anxiety (aHR, 1.36; 95% CI, 1.28-1.45), chronic pain (aHR, 1.22; 95% CI, 1.15-1.29), use of durable medical equipment (aHR, 1.14; 95% CI, 1.03-1.25), and lung disease (aHR, 1.11; 95% CI, 1.06-1.17) were independently associated with increased risk of suicide attempt.

Conclusions and Relevance  This cohort study found that among US veterans aged 65 years or older, frailty was associated with increased risk of suicide attempts and lower levels of frailty were associated with greater risk of suicide death. Screening and involvement of supportive services across the spectrum of frailty appear to be needed to help reduce risk of suicide attempts.

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