Suicide in Older Adults With and Without Known Mental Illness: Results From the National Violent Death Reporting System, 2003–2016

Published:January 28, 2020DOI:


      Suicide risk increases with age, and evidence exists for the underdiagnosis and undertreatment of suicide risk in older adults. Recent data suggest that many U.S. adults who die from suicide do not have a known mental health condition. This study compares the characteristics and precipitating circumstances of geriatric suicide decedents with and without known mental illnesses.


      This study was a retrospective analysis of suicide deaths for adults aged ≥65 years from the National Violent Death Reporting System, 2003–2016 (n=26,884). ORs compared sociodemographic and clinical characteristics, cause of death, and precipitating circumstances based on coroner/medical examiner and law enforcement reports. Data were collected and analyzed in 2019.


      Most older male (69.1%) and female (50.2%) suicide decedents did not have a known mental illness. A physical health problem was the most prevalent precipitating circumstance but was more common among older adults without known mental illness. Past suicide attempt, disclosure of suicidal intent, depressed mood, and substance use were more common among those with a known mental illness. More than three fourths of suicide decedents did not disclose their suicidal intent. Most suicide deaths involved firearms, which were disproportionately used by decedents without known mental illness (81.6% of male and 44.6% of female decedents) compared with those with known mental illness (70.5% of male and 30.0% of female decedents).


      Most older adults who die from suicide do not have a known mental health condition. The rapidly growing U.S. geriatric population calls for more effective methods to identify and treat at-risk older adults, particularly those who are male.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hedegaard H
        • Curtin SC
        • Warner M
        Suicide rates in the United States continue to increase.
        NCHS Data Brief. 2018; ( Accessed October 11, 2019): 1-8
      1. Administration on Aging, HHS. A profile of older Americans: Published 2017. Accessed November 20, 2019.

        • Conwell Y
        Suicide later in life: challenges and priorities for prevention.
        Am J Prev Med. 2014; 47: S244-S250
        • Stone DM
        • Simon TR
        • Fowler KA
        • et al.
        Vital Signs: trends in state suicide rates‒United States, 1999–2016 and circumstances contributing to suicide‒27 states, 2015.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 617-624
        • Ahmedani BK
        • Simon GE
        • Stewart C
        • et al.
        Health care contacts in the year before suicide death.
        J Gen Intern Med. 2014; 29: 870-877
        • Ahmedani BK
        • Stewart C
        • Simon GE
        • et al.
        Racial/ethnic differences in healthcare visits made prior to suicide attempt across the United States.
        Med Care. 2015; 53: 430-435
        • Ahmedani BK
        • Westphal J
        • Autio K
        • et al.
        Variation in patterns of health care before suicide: a population case-control study.
        Prev Med. 2019; 127105796
        • Simons K
        • Van Orden K
        • Conner KR
        • Bagge C
        Age differences in suicide risk screening and management prior to suicide attempts.
        Am J Geriatr Psychiatry. 2019; 27: 604-608
        • Arias SA
        • Boudreaux ED
        • Segal DL
        • Miller I
        • Camargo CA
        • Betz ME
        Disparities in treatment of older adults with suicide risk in the emergency department.
        J Am Geriatr Soc. 2017; 65: 2272-2277
        • Betz ME
        • Arias SA
        • Segal DL
        • Miller I
        • Camargo CA
        • Boudreaux ED
        Screening for suicidal thoughts and behaviors in older adults in the emergency department.
        J Am Geriatr Soc. 2016; 64: e72-e77
        • Betz ME
        • Kautzman M
        • Segal DL
        • et al.
        Frequency of lethal means assessment among emergency department patients with a positive suicide risk screen.
        Psychiatry Res. 2018; 260: 30-35
        • Uncapher H
        • Areán PA
        Physicians are less willing to treat suicidal ideation in older patients.
        J Am Geriatr Soc. 2000; 48: 188-192
        • Fischer LR
        • Wei F
        • Solberg LI
        • Rush WA
        • Heinrich RL
        Treatment of elderly and other adult patients for depression in primary care.
        J Am Geriatr Soc. 2003; 51: 1554-1562
        • Waitzfelder B
        • Stewart C
        • Coleman KJ
        • et al.
        Treatment initiation for new episodes of depression in primary care settings.
        J Gen Intern Med. 2018; 33: 1283-1291
        • Mitchell AJ
        • Rao S
        • Vaze A
        Do primary care physicians have particular difficulty identifying late-life depression? A meta-analysis stratified by age.
        Psychother Psychosom. 2010; 79: 285-294
        • Akincigil A
        • Matthews EB
        National rates and patterns of depression screening in primary care: results from 2012 and 2013.
        Psychiatr Serv. 2017; 68: 660-666
        • Rockett IRH
        • Caine ED
        • Stack S
        • et al.
        Method overtness, forensic autopsy, and the evidentiary suicide note: a multilevel National Violent Death Reporting System analysis.
        PLOS ONE. 2018; 13e0197805
        • Blair JM
        • Fowler KA
        • Jack SP
        • Crosby AE
        The National Violent Death Reporting System: overview and future directions.
        Inj Prev. 2016; 22: i6-i11
        • De Leo D
        • Draper BM
        • Snowdon J
        • Kõlves K
        Suicides in older adults: a case–control psychological autopsy study in Australia.
        J Psychiatr Res. 2013; 47: 980-988
        • Morgan C
        • Webb RT
        • Carr MJ
        • et al.
        Self-harm in a primary care cohort of older people: incidence, clinical management, and risk of suicide and other causes of death.
        Lancet Psychiatry. 2018; 5: 905-912
        • Ngamini Ngui A
        • Vasiliadis HM
        • Préville M
        Individual and area-level factors correlated with death by suicide in older adults.
        Prev Med. 2015; 75: 44-48
        • Mackenzie CS
        • Reynolds K
        • Cairney J
        • Streiner DL
        • Sareen J
        Disorder‐specific mental health service use for mood and anxiety disorders: associations with age, sex, and psychiatric comorbidity.
        Depress Anxiety. 2012; 29: 234-242
        • Byers AL
        • Arean PA
        • Yaffe K
        Low use of mental health services among older Americans with mood and anxiety disorders.
        Psychiatr Serv. 2012; 63: 66-72
        • DiNapoli EA
        • Cully JA
        • Wayde E
        • Sansgiry S
        • Yu HJ
        • Kunik ME
        Age as a predictive factor of mental health service use among adults with depression and/or anxiety disorder receiving care through the Veterans Health Administration.
        Int J Geriatr Psychiatry. 2016; 31: 575-582
        • Garrido MM
        • Kane RL
        • Kaas M
        • Kane RA
        Use of mental health care by community‐dwelling older adults.
        J Am Geriatr Soc. 2011; 59: 50-56
        • Choi NG
        • DiNitto DM
        • Marti CN
        Mental health treatment use and perceived treatment need among suicide planners and attempters in the United States: between and within group differences.
        BMC Res Notes. 2015; 8: 305
        • Kato E
        • Borsky AE
        • Zuvekas SH
        • Soni A
        • Ngo-Metzger Q
        Missed opportunities for depression screening and treatment in the United States.
        J Am Board Fam Med. 2018; 31: 389-397
        • Hjelmeland H
        • Dieserud G
        • Dyregrov K
        • Knizek BL
        • Leenaars AA
        Psychological autopsy studies as diagnostic tools: are they methodologically flawed?.
        Death Stud. 2012; 36: 605-626
        • Valenstein M
        • Walters H
        • Pfeiffer PN
        • et al.
        Possession of household firearms and firearm-related discussions with clinicians among veterans receiving VA mental health care.
        Arch Suicide Res. 2019; : 1-20
        • Betz ME
        • Knoepke CE
        • Siry B
        • et al.
        ‘Lock to Live’: development of a firearm storage decision aid to enhance lethal means counselling and prevent suicide.
        Inj Prev. 2019; 25: i18-i24
        • Roszko PJ
        • Ameli J
        • Carter PM
        • Cunningham RM
        • Ranney ML
        Clinician attitudes, screening practices, and interventions to reduce firearm-related injury.
        Epidemiol Rev. 2016; 38: 87-110
        • Stanley IH
        • Hom MA
        • Rogers ML
        • Anestis MD
        • Joiner TE
        Discussing firearm ownership and access as part of suicide risk assessment and prevention: “means safety” versus “means restriction”.
        Arch Suicide Res. 2017; 21: 237-253
        • Slovak K
        • Pope N
        • Giger J
        • Kheibari A
        An evaluation of the counseling on access to lethal means (CALM) training with an area agency on aging.
        J Gerontol Soc Work. 2019; 62: 48-66
        • Slovak K
        • Pope ND
        • Brewer TW
        Geriatric case managers’ perspectives on suicide among community-dwelling older adults.
        J Gerontol Soc Work. 2016; 59: 3-15
        • Pope ND
        • Slovak KL
        • Giger JT
        Evaluating a training intervention to prepare geriatric case managers to assess for suicide and firearm safety.
        Educ Gerontol. 2016; 42: 706-716
        • Runyan CW
        • Brooks-Russell A
        • Betz ME
        Points of influence for lethal means counseling and safe gun storage practices.
        J Public Health Manag Pract. 2019; 25: 86-89
        • Betz ME
        • Azrael D
        • Barber C
        • Miller M
        Public opinion regarding whether speaking with patients about firearms is appropriate: results of a national survey.
        Ann Intern Med. 2016; 165: 543-550
        • Betz ME
        • Flaten HK
        • Miller M
        Older adult openness to physician questioning about firearms.
        J Am Geriatr Soc. 2015; 63: 2214-2215
      2. Parker K, Horowitz J, Igielnik R, Oliphant B, Brown A. America's Complex Relationship With Guns: an In-Depth Look at the Attitudes and Experiences of US Adults. Pew Research Published June 22, 2017. Accessed October 5, 2019.

        • Ilgen MA
        • Zivin K
        • McCammon RJ
        • Valenstein M
        Mental illness, previous suicidality, and access to guns in the United States.
        Psychiatr Serv. 2008; 59: 198-200
        • Miller M
        • Barber C
        • Azrael D
        • Hemenway D
        • Molnar BE
        Recent psychopathology, suicidal thoughts and suicide attempts in households with and without firearms: findings from the National Comorbidity Study Replication.
        Inj Prev. 2009; 15: 183-187
        • Morgan ER
        • Gomez A
        • Rowhani-Rahbar A
        Firearm ownership, storage practices, and suicide risk factors in Washington State, 2013–2016.
        Am J Public Health. 2018; 108: 882-888
        • Morgan ER
        • Gomez A
        • Rivara FP
        • Rowhani-Rahbar A
        Household firearm ownership and storage, suicide risk factors, and memory loss among older adults: results from a statewide survey.
        Ann Intern Med. 2019; 171: 220-222
        • Anglemyer A
        • Horvath T
        • Rutherford G
        The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis.
        Ann Intern Med. 2014; 160: 101-110
        • Miller M
        • Azrael D
        • Barber C
        Suicide mortality in the United States: the importance of attending to method in understanding population-level disparities in the burden of suicide.
        Annu Rev Public Health. 2012; 33: 393-408
        • Miller M
        • Swanson SA
        • Azrael D
        Are we missing something pertinent? A bias analysis of unmeasured confounding in the firearm-suicide literature.
        Epidemiol Rev. 2016; 38: 62-69
        • Ivey-Stephenson AZ
        • Crosby AE
        • Jack SPD
        • Haileyesus T
        • Kresnow-Sedacca MJ
        Suicide trends among and within urbanization levels by sex, race/ethnicity, age group, and mechanism of death—United States, 2001–2015.
        MMWR Surveill Summ. 2017; 66: 1-16
        • Anderson TJ
        • Saman DM
        • Lipsky MS
        • Lutfiyya MN
        A cross-sectional study on health differences between rural and non-rural US counties using the County Health Rankings.
        BMC Health Serv Res. 2015; 15: 441
        • Andrilla CHA
        • Patterson DG
        • Garberson LA
        • Coulthard C
        • Larson EH
        Geographic variation in the supply of selected behavioral health providers.
        Am J Prev Med. 2018; 54: S199-S207
        • Siegel M
        • Rothman EF
        Firearm ownership and suicide rates among US men and women, 1981–2013.
        Am J Public Health. 2016; 106: 1316-1322
        • Fontanella CA
        • Saman DM
        • Campo JV
        • et al.
        Mapping suicide mortality in Ohio: a spatial epidemiological analysis of suicide clusters and area level correlates.
        Prev Med. 2018; 106: 177-184
        • Creighton G
        • Oliffe J
        • Ogrodniczuk J
        • Frank B
        “You've gotta be that tough crust exterior man”: depression and suicide in rural-based men.
        Qual Health Res. 2017; 27: 1882-1891
        • Canetto SS
        Suicide: why are older men so vulnerable?.
        Men Masc. 2017; 20: 49-70
        • Herbst DM
        • Griffith NR
        • Slama KM
        Rodeo cowboys: conforming to masculine norms and help-seeking behaviors for depression.
        Rural Ment Health. 2014; 38: 20-35
        • Pepper CM
        Suicide in the Mountain West region of the United States.
        Crisis. 2017; 38: 344-350
        • Cheung G
        • Merry S
        • Sundram F
        Medical examiner and coroner reports: uses and limitations in the epidemiology and prevention of late‐life suicide.
        Int J Geriatr Psychiatry. 2015; 30: 781-792
        • Kaplan MS
        • Caetano R
        • Giesbrecht N
        • et al.
        The National Violent Death Reporting System: use of the restricted access database and recommendations for the system's improvement.
        Am J Prev Med. 2017; 53: 130-133
        • Vahia IV
        • Ng B
        • Camacho A
        • et al.
        Telepsychiatry for neurocognitive testing in older rural Latino adults.
        Am J Geriatr Psychiatry. 2015; 23: 666-670
        • Dham P
        • Gupta N
        • Alexander J
        • Black W
        • Rajji T
        • Skinner E
        Community based telepsychiatry service for older adults residing in a rural and remote region-utilization pattern and satisfaction among stakeholders.
        BMC Psychiatry. 2018; 18: 316
        • Gellis ZD
        • Kenaley B
        • McGinty J
        • Bardelli E
        • Davitt J
        • Ten Have T
        Outcomes of a telehealth intervention for homebound older adults with heart or chronic respiratory failure: a randomized controlled trial.
        Gerontologist. 2012; 52: 541-552
        • Choi NG
        • Marti CN
        • Bruce ML
        • Hegel MT
        • Wilson NL
        • Kunik ME
        Six‐month postintervention depression and disability outcomes of in‐home telehealth problem‐solving therapy for depressed, low‐income homebound older adults.
        Depress Anxiety. 2014; 31: 653-661
        • Miller IW
        • Camargo Jr, CA
        • Arias SA
        • et al.
        Suicide prevention in an emergency department population: the ED-SAFE Study.
        JAMA Psychiatry. 2017; 74: 563-570
        • Lapierre S
        • Erlangsen A
        • Waern M
        • et al.
        A systematic review of elderly suicide prevention programs.
        Crisis. 2011; 32: 88-98
        • Okolie C
        • Dennis M
        • Simon Thomas E
        • John A
        A systematic review of interventions to prevent suicidal behaviors and reduce suicidal ideation in older people.
        Int Psychogeriatr. 2017; 29: 1801-1824
        • Hofstra E
        • Van Nieuwenhuizen C
        • Bakker M
        • et al.
        Effectiveness of suicide prevention interventions: a systematic review and meta-analysis.
        Gen Hosp Psychiatry. May 8, 2019; (In press. Online)
        • Henderson C
        • Robinson E
        • Evans-Lacko S
        • Thornicroft G
        Relationships between anti-stigma programme awareness, disclosure comfort and intended help-seeking regarding a mental health problem.
        Br J Psychiatry. 2017; 211: 316-322
        • Apesoa-Varano EC
        • Barker JC
        • Hinton L
        “If you were like me, you would consider it too”: suicide, older men, and masculinity.
        Soc Ment Health. 2018; 8: 157-173
        • Vannoy S
        • Park M
        • Maroney MR
        • Unützer J
        • Apesoa-Varano EC
        • Hinton L
        The perspective of older men with depression on suicide and its prevention in primary care: implications for primary care engagement strategies.
        Crisis. 2018; 39: 397-405
        • Seidler ZE
        • Dawes AJ
        • Rice SM
        • Oliffe JL
        • Dhillon HM
        The role of masculinity in men's help-seeking for depression: a systematic review.
        Clin Psychol Rev. 2016; 49: 106-118
        • Anestis MD
        • Anestis JC
        Suicide rates and state laws regulating access and exposure to handguns.
        Am J Public Health. 2015; 105: 2049-2058
        • Anestis MD
        • Selby EA
        • Butterworth SE
        Rising longitudinal trajectories in suicide rates: the role of firearm suicide rates and firearm legislation.
        Prev Med. 2017; 100: 159-166
        • Anestis MD
        • Houtsma C
        • Daruwala SE
        • Butterworth SE
        Firearm legislation and statewide suicide rates: the moderating role of household firearm ownership levels.
        Behav Sci Law. 2019; 37: 270-280