Aging & Mental Health, 2016

Vol. 20, No. 2, 113 122, http://dx.doi.org/10.1080/13607863.2015.1012045

Understanding suicide among older adults: a review of psychological and sociological theories
of suicide
Ian H. Stanley*, Melanie A. Hom, Megan L. Rogers, Christopher R. Hagan and Thomas E. Joiner, Jr.
Department of Psychology, Florida State University, Tallahassee, FL, USA
(Received 30 October 2014; accepted 21 January 2015)

Objectives: Older adults die by suicide at a higher rate than any other age group in nearly every country globally. Suicide
among older adults has been an intractable clinical and epidemiological problem for decades, due in part to an incomplete
understanding of the causes of suicide, as well as imprecision in the prediction and prevention of suicidal thoughts and
behaviors in later life. Theory-driven investigations hold promise in addressing these gaps by systematically identifying
testable, and thus falsifiable, mechanisms that may better explain this phenomenon and also point to specific interventions.
Method: In this article, we comprehensively review key extant psychological and sociological theories of suicide and
discuss each theory’s applicability to the understanding and prevention of suicide among older adults.
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Results: Despite a modest number of theories of suicide, few have undergone extensive empirical investigation and
scrutiny, and even fewer have been applied specifically to older adults.
Conclusion: To advance the science and contribute findings with a measurable clinical and public health impact, future
research in this area, from conceptual to applied, must draw from and integrate theory.
Keywords: suicide; theory; older adults

Introduction F€assberg et al., 2012), physical illness (Duberstein,

Worldwide, across the lifespan, approximately 800,000 Conwell, Conner, Eberly, & Caine, 2004; Erlangsen, Vach,
individuals die by suicide each year, and rates are consis- & Jeune, 2005), and poor subjective sleep quality and
tently the highest among older adults (World Health Orga- insomnia (Bernert, Turvey, Conwell, & Joiner, 2014;
nization [WHO], 2014). In the United States, specifically, Nadorff, Fiske, Sperry, Petts, & Gregg, 2013). While psy-
nearly 10,000 older adults, aged 60 years and older, die chiatric illness, particularly depression, represents the most
by suicide annually (Centers for Disease Control and Pre- potent risk factor (Conwell et al., 2002), the vast majority
vention [CDC], 2014). For every suicide death in later of older adults who are depressed neither think about nor
life, it is estimated that at least four older adults make an attempt suicide. Thus, it is important to move beyond psy-
attempt (Conwell, 2013). This is in contrast to younger chiatric risk factors alone in considering why older adults
populations, in which each death by suicide is matched by die by suicide and in identifying how to intervene.
approximately 25 attempts (Institute of Medicine, 2002). Moving forward, it is a critical public health priority to
These disparate findings illustrate the lethality of suicidal increase understanding of the etiology, course, and pre-
thoughts and behaviors in later life. Older adults are more vention of suicidal thoughts and behaviors in later life. An
likely to use a firearm than any other method (Conwell explanatory framework a theory will help explain the
et al., 2002; McIntosh & Santos, 1985), report being more phenomenon, identify mechanisms that point to clinical
determined to die from an attempt (Conwell et al., 1998), interventions, expose gaps in our knowledge, and point to
and have fewer opportunities to be saved from an attempt future areas for scientific inquiry. In the field of suicidol-
(due in part to greater physiological frailty and likelihood ogy, however, few research studies have used theory-
of living alone). Globally, a similar epidemiological pat- driven approaches (Prinstein, 2008; Van Orden et al.,
tern emerges: across variegated cultural, political, and 2010). Furthermore, little is known about the use of theory
sociological settings, older adults die by suicide at dispro- specifically within the context of studying and preventing
portionate rates (Nock et al., 2008; WHO, 2014). In some suicide in later life.
cultures, however, suicide rates among older adults are We begin with a review of the major psychological
relatively low compared with younger populations, such and sociological theories of suicide, evaluating each the-
as among indigenous people (Beautrais & Fergusson, ory’s core constructs, assumptions, and scientific utility,
2006; Hunter & Harvey, 2002). with our discussion focused on findings from quantitative
A constellation of modifiable factors has been identi- studies. Theories of suicide were identified through an
fied that confer increased risk for suicide in later life. These examination of previous reviews (e.g., Selby, Joiner, &
include psychiatric illness (Conwell, Duberstein, & Caine, Ribeiro, 2014); however, distinguishing the current article
2002), social disconnectedness (Duberstein et al., 2004; from past work is its inclusion of how these individual

*Corresponding author. Email: [email protected]

Ó 2015 Taylor & Francis

 114 I.H. Stanley et al.

theories may apply to later life. We selected to review the- can help frame society-level phenomena such as seasonal
ories of suicide that have varying degrees of scientific variation in suicide (Christodoulou et al., 2012), increases
rigor in order to present the trajectory of theory develop- in suicide surrounding media reporting of a celebrity’s
ment in this area over time. To identify studies that tested death by suicide (Joiner, 1999), and decreases in suicide
the theories reviewed, we conducted searches within Goo- during times of ‘coming together’ (e.g., Super Bowl
gle Scholar and PubMed. Search terms included various Sunday) (Joiner, Hollar, & Van Orden, 2006). Impor-
permutations of specific theory names (e.g., hopelessness tantly, societal-level phenomena may explain differential
theory), articles citing seminal publications related to cross-national and cross-cultural suicide rates (Shah,
each theory, and suicide among older adults. Bhat, McKenzie, & Koen, 2007). Nonetheless, these
strengths are also a critical weakness in that individual
factors are minimized.
Theories of Suicide
Durkheim’s sociological theory Implications for older adults
Overview In terms of the theory’s relevance to suicide in later life,

In 1897, Emile Durkheim published one of the first com- there exists empirical support that a lack of social con-
prehensive theories of suicide (Durkheim, 1897). At the nectedness and integration with society may elevate risk.
heart of Durkheim’s theory is the belief that suicide is a For instance, a community-based study of older adults
result of social and structural factors rather than individual found that those who reported fewer social support resour-
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ones. He conceptualizes these forces in two domains: ces were more likely to endorse greater levels of suicidal
social integration (i.e., the social ties one has with others ideation (Vanderhorst & McLaren, 2005). Another study
and with society) and moral regulation (i.e., the effects of examining older adults with mood disorders found that
societal rules and norms on individuals). those with stronger family connectedness and those who
Among the key observations that Durkheim makes are lived with others were less likely to report suicidal idea-
that suicide rates are higher among men than women, tion (Purcell et al., 2012). Indeed, among suicide attemp-
those who are single than those who are married, those ters over the age of 60, loneliness and social isolation are
without children than those with children, and Protestants common characteristics (Lebret, Perret-Vaille, Mulliez,
than Catholics. He concludes from these observations that Gerbaud, & Jalenques, 2006). Furthermore, a recent study
when individuals are not integrated into society or lack found that in a primary care sample of adults over the age
structure from a social group, they experience feelings of of 60, an elevated sense of thwarted belongingness and
meaninglessness and depression, ultimately resulting in lack of meaningful social connections predicted increased
suicide. To illustrate this idea, he explains the lower sui- suicidal ideation (Cukrowicz, Jahn, Graham, Poindexter,
cide rate among Catholics by suggesting that Catholics & Williams, 2013). Finally, in residential communities
have a higher degree of social control and integration than and long-term care, where older adults may feel less inte-
Protestants. Durkheim also asserts that suicide rates grated with mainstream society, rates of suicide also
increase at the other end of the spectrum when there is appear to be elevated (Mezuk, Prescott, Tardiff, Vlahov,
excessive social control or regulation, especially to the & Galea, 2008; Podgorski, Langford, Pearson, & Conwell,
point that it may be oppressive. 2010). Despite these findings, in some cultures, the appli-
According to Durkheim, manifestations at the cability of Durkheim’s theory among older adults may be
extremes of either social or moral integration result in limited, especially given its highly specific focus on social
four specific types of suicide: altruistic, egoistic, anomic, structures over individual differences.
and fatalistic. Altruistic suicide occurs when individuals
are so highly integrated with a society that they believe
their death by suicide would be a societal contribution. In
Hopelessness theory
contrast, egoistic suicide is described as the result of a
lack of social integration, such as an individual lacking Overview
social bonds to family or friends. Anomic suicide takes Beck and colleagues (1985) proposed a theory of suicide
place when society does not provide adequate regulation, in which hopelessness is the core causal mechanism.
for instance, during a time of economic crisis when there Hopelessness is characterized by pervasive negative and
is great uncertainty regarding individuals’ current and fatalistic views about the future and immutability of one’s
future roles in their society. Lastly, at the opposite end of situation (Beck & Steer, 1988). In this model, hopeless-
the moral regulation spectrum, fatalistic suicide is thought ness is viewed as a stand-alone putative cause of suicidal
of as the result of excessive regulation and oppressive dis- ideation. A later iteration of Beck’s theory includes the
cipline, which, for example, might occur among prisoners idea of modal processing (Beck, 1986), in which five cog-
or slaves. nitive systems (i.e., cognitive, affective, motivational and
As the first comprehensive theory of suicide, behavioral, physiological, and conscious control) are
Durkheim’s work laid a foundation for scientific inquiry implicated in suicidal behavior. For example, thoughts of
into the complexities of suicide. The theory’s strengths lie hopelessness are purported to activate the cognitive sys-
in its contextualization of individual deaths within the tem. If one of these systems is activated, then the other
greater society in which one lives. This conceptualization systems are also activated (e.g., the activation of the
 Aging & Mental Health 115

affective system manifests in depressive symptomatol- that greater perceived responsibility to family and higher
ogy), creating a toxic environment in which suicidal levels of hopelessness are associated with the greatest
thoughts and behaviors can develop. A few studies cor- severity of suicidal ideation.
roborating Beck’s hopelessness theory of suicide suggest In an early test of the Beck Hopelessness Scale among
that, in the prediction of suicidal ideation among adults, community-dwelling older adults with major depressive
hopelessness may be a better predictor than depression disorder, depression accounted for the greatest predictive
(Beck, Brown, Berchick, Stewart, & Steer, 1990; Beck, variance of suicidal behavior, followed by hopelessness
Steer, Kovacs, & Garrison, 1985). (Hill, Gallagher, Thompson, & Ishida, 1988). Taken
Notwithstanding the strengths of the aforementioned together with perceived health, these variables only
studies demonstrating the power of hopelessness to longi- accounted for 27% of the predictive variance for suicidal
tudinally predict suicide attempts, it is important to con- ideation, which confirms the need for a theoretical expla-
sider the entire mosaic in which suicide occurs. There are nation for suicide that takes into account a constellation of
many different risk factors for suicide, and it is unlikely factors.
that any single factor accounts for all of the variance in
suicidal thoughts and behaviors (Van Orden et al., 2010).
Escape theory
This is true for hopelessness as well, as it is not a suffi-
cient cause for suicide. While hopelessness is an impor- Overview
tant risk factor and hope is a protective factor (Anestis, Baumeister (1990) proposed an escape theory of suicide,
Moberg, & Arnau, 2014) hopelessness alone has low
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consisting of a causal chain of six main steps: (1) falling

specificity. For example, in a meta-analytic review of the short of standards due to either unrealistic expectations or
Beck Hopelessness Scale (Beck & Steer, 1988), findings recent problems or setbacks; (2) negative internal attribu-
revealed a pooled specificity of only 0.42 (McMillan, Gil- tions of self-blame and low self-esteem; (3) an aversive
body, Beresford, & Neilly, 2007). state of high self-awareness stemming from comparison
of the self with relevant standards; (4) negative affect fol-
lowing the self-awareness of falling short on important
Implications for older adults standards; (5) cognitive deconstruction, such that the indi-
Nonetheless, hopelessness may be an indicator of suicide vidual tries to escape negative affect by rejecting and
risk in later life. Szanto, Reynolds, Conwell, Begley, and avoiding meaningful thought; and (6) consequences of
Houck (1998) found that, after older adults were treated in deconstruction, including disinhibition, passivity, absence
an outpatient setting for mood disorders, only the level of of emotion, and irrational cognitions. These consequen-
unremitting hopelessness (and not depression, anxiety, or ces, particularly disinhibition, are thought to be relevant
global functioning) was significantly associated with sui- to the suicide process and provide insight into the suicidal
cide attempt status. Among individuals living in a retire- mental state. According to this theory, suicide is an
ment community, a single item assessing hopelessness attempt to escape aversive self-awareness and intense
(i.e., ‘not feeling hopeless about the future’ [reversed]) negative emotions. By this model, suicide should be a rare
was found to predict death by suicide (Ross, Bernstein, occurrence, as it requires a particular set of decisions
Trent, Henderson, & Paganini-Hill, 1990). In 1984, Fry stemming from each step of the causal chain.
developed the Geriatric Hopelessness Scale (GHS) to cre- Components of Baumeister’s theory falling short of
ate a developmentally appropriate assessment of the con- important standards (Chatard & Selimbegovic, 2011), per-
struct of hopelessness in later life (Fry, 1984), although fectionism (Dean, Range, & Goggin, 1996; Hewit, Flett, &
there is some doubt regarding its psychometric properties Weber, 1994; O’Connor, 2007), negative affect (Conner,
(Heisel & Flett, 2005). Notably, the GHS has an 11-item Duberstein, Conwell, Seidlitz, & Caine, 2001), future ver-
suicide risk subscale (GHS-SR). Compared with the full sus present-focused cognitions (Hirsch et al., 2006), and
30-item GHS, GHS-SR has been found to correlate more disinhibited behaviors (Barrios, Everett, Simon, & Brener,
strongly with a criterion standard assessment of suicide 2000) are all risk factors for suicide-related thoughts,
risk (Heisel & Flett, 2005). ideation, and behavior individually; however, longitudinal
Another study found that among older men institutional- research linking these constructs causally in support of
ized in a nursing home, the effect of hopelessness on sui- escape theory is still needed. Furthermore, the third step of
cidal ideation was moderated by levels of depressive the chain, heightened self-awareness, has yet to be investi-
symptomotalogy (Uncapher, Gallagher-Thompson, Osgood, gated separately in relation to suicidal ideation and behav-
& Bongar, 1998). This finding stands in contrast to a study iors. Thus, although empirical support exists for the
utilizing a sample of younger adults (Beck et al., 1985), relationship between various components of the escape the-
which found that hopelessness predicted suicidal ideation ory individually, evidence for the model as a whole is less
‘better’ than depression. Adding incremental evidence to clear. It is noteworthy that the emphasis in this model on
the need to consider hopelessness within a larger system of disinhibition may be problematic given emerging evidence
risk factors is Britton et al.’s (2008) finding that the effect demonstrating that the relationship between suicidal behav-
of hopelessness on suicidal ideation among older adults is ior and impulsivity is indirect and distal (Anestis, Soberay,
moderated by feelings of responsibilities to family, such Gutierrez, Hernandez, & Joiner, 2014).
 116 I.H. Stanley et al.

Implications for older adults Implications for older adults

Components of this theory have been supported in various Despite the elevated rate of suicide deaths among older
studies, such that depression and hopelessness mediate adults, later life is characterized by an increase in positive
the relationship between cognitive functioning and sui- affectivity (Charles & Carstensen, 2010). Older adults
cidal ideation among older adults (Heisel, Flett, & Besser, report feeling a greater proportion of positive (versus neg-
2002), and cognitive biases, such as perceptions of poor ative) emotions, and when confronted with interpersonal
health and negative expectancies toward the future, influ- stressors, older adults report smaller increases in distress
ence the relationship between depression and suicidal ide- reactivity compared with their younger counterparts
ation (Uncapher, 2000). However, to our knowledge, no (Birditt, Fingerman, & Almeida, 2005). Indeed, older
direct empirical tests have been conducted to investigate adults prioritize emotion regulation and report better regu-
suicide ideation and behaviors in older adults through the lation of their emotions than their younger counterparts
lens of the escape theory of suicide. This is an important (Carstensen, Fung, & Charles, 2003; Gross et al., 1997).
area for future research, given that age-related physical or In examining suicide through the lens of Linehan’s emo-
cognitive limitations may propel an older adult along a tion dysregulation model, it is thus important to ask why
trajectory towards suicide as a means to escape these aver- later life is characterized by greater emotional regulation
sive states. In this sense, the escape theory may be infor- and positive affectivity, yet older adults die by suicide at
mative in understanding why persons with dementia and disproportionately high rates.
their family caregivers exhibit elevated levels of suicidal- In a randomized pilot trial testing the efficacy of psy-
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ity (Erlangsen, Zarit, & Conwell, 2008; Haw, Harwood, chiatric medication alone versus psychiatric medication
& Hawton, 2009; O’Dwyer, Moyle, & van Wyk, 2013; plus DBT, DBT was found to augment the effects of psy-
O’Dwyer, Moyle, Zimmer-Gembeck, & De Leo, 2013). chiatric medication in reducing depression among older
adults (Lynch, Morse, Mendelson, & Robins, 2003). How-
ever, in post hoc analyses, no differences were found in
Emotion dysregulation theory post-treatment suicidal ideation scores among the two
groups. It should be noted that this was a randomized pilot
Overview
study that was likely not sufficiently powered to detect
In a theory of suicidal behavior originally developed in differences in suicidal ideation, and thus should be viewed
the context of patients with borderline personality disor- in the context of the literature in younger samples that
der (BPD), Linehan (1993) proposes that the pathogenesis demonstrates the efficacy of DBT in reducing suicidal ide-
of suicidal behavior is in the interaction of emotional dys- ation and behaviors (e.g., Rathus & Miller, 2002). The
regulation and emotional invalidation. Suicidal behaviors findings suggest, however, that factors beyond emotional
are posited to be a distraction mechanism from the nega- dysregulation may be a more salient mechanism account-
tive intense emotional states (emotional dysregulation) ing for suicide in older adults.
and critical environment (emotional invalidation) in
which an individual lives.
Dialectical behavior therapy (DBT), the treatment for
Psychache theory
BPD that was derived from this theory, targets deficits in
emotion regulation the core feature of BPD by Overview
employing traditional cognitive-behavioral techniques as Edwin Shneidman developed a theory of suicide in which
well as principles of emotional validation. There is a psychache is the causative agent accounting for suicidal
growing empirical base for DBT’s efficacy in reducing thoughts and behavior. Shneidman (1993) defined psy-
self-injurious and suicidal behaviors. For example, in a chache as a psychological pain, hurt, or anguish that over-
randomized controlled trial of women with BPD and both takes the mind. This type of pain is deeply emotional and
a past (i.e., within five years) and recent (i.e., within eight may be characterized by intense feelings of shame, guilt,
weeks) suicide attempt history, patients receiving DBT fear, anxiety, or loneliness. He notes that this pain is inti-
were half as likely as the control group to have made a mately connected with a person’s psychological needs,
suicide attempt at one-year follow-up (Linehan et al., and that when these needs are blocked, thwarted, or frus-
2006). Nonetheless, the problem of specificity discussed trated, psychache arises. Shneidman proposes that suicide
for the other theories presented in this review also applies is more likely to occur when individuals find their psy-
to Linehan’s model. Namely, emotion dysregulation is an chache to be intolerable and unbearable. In short, he
underlying feature of many psychiatric disorders (Gross argues that suicide is a way by which individuals escape
& Mu~ noz, 1995), yet, as noted, the vast majority of people deep psychological pain. Although Shneidman acknowl-
with a psychiatric disorder neither think about, attempt, edges that there are biological, cultural, sociological,
nor die by suicide. It is also important to note that, while interpersonal, and other factors that may play a role in
emotion dysregulation is a risk factor for suicidal ideation, conferring risk for suicide, he asserts that psychache is the
it may in fact be a protective factor against lethal self- essential element underlying risk.
harm because suicide is daunting and fearful (see Van Shneidman’s theory is illustrated by his cubic model
Orden et al., 2010) and data suggest that emotionally dys- of suicide (Shneidman, 1987), which uses three primary
regulated individuals may not be able to overcome this dimensions to provide an integrated model for suicide
(adaptive) fear (Anestis, Bagge, Tull, & Joiner, 2011). risk: degree of psychache, degree of stress, and degree of
 Aging & Mental Health 117

perturbation. Each dimension is rated from low (1) to high two dynamic psychological states thwarted belonging-
(5) for an individual. He posits that when an individual is ness and perceived burdensomeness. Dimensions of
a 5-5-5 on the cube that is, when they are experiencing thwarted belongingness include loneliness (e.g., lack of
deep psychological pain that they perceive to be intolera- friends, living alone) and the absence of reciprocal care
ble, alongside great stress and agitation then they are at (e.g., having friends on whom one can rely to give and
elevated risk for suicide. Thus, many of the treatments receive support). Furthermore, dimensions of perceived
and interventions that he outlines focus on addressing burdensomeness include the belief that one is a burden to
these three dimensions. Shneidman emphasises the need his or her loved ones (e.g., in times of illness or unem-
to engage with an individual’s psychological and emo- ployment) and self-hate. Central to this construct is the
tional experiences, and offers questions such as ‘Where term ‘perceived’, that is, individuals think their death
do you hurt?’ and ‘How can I help you?’ as key starting would be worth more than their life to others. The theory
points in reducing psychache (Shneidman, 1998). states that the presence of these two constructs is suffi-
A number of studies have found that psychache cient for the development of passive suicidal ideation, and
is a unique predictor of suicidal ideation. For example, a hopelessness about the mutability of these states is the cri-
2-year prospective study of 41 high-risk undergraduates terion of demarcation between passive and active suicidal
found that psychache was a unique predictor of change in ideation (Van Orden et al., 2010). Nonetheless, these
suicidal ideation, over depression or hopelessness social disconnectedness constructs are not proposed to be
(Troister & Holden, 2012). This study was followed up sufficient for the emergence of suicidal behavior (Van
with a longitudinal study following 683 high-risk under- Orden, Witte, Gordon, Bender, & Joiner, 2008), a point to
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graduates across 5 months (Troister, Davis, Lowndes, & which we now turn.
Holden, 2013); again, change in psychache was signifi- Unique to this theory is the recognition that suicidal
cantly associated with change in suicidal ideation, even behavior defies a human’s biological instinct for survival
when controlling for depression and hopelessness. dying by suicide is not easy. Termed acquired capability,
Another study found that psychache was associated with dimensions of this construct include a lowered fear of death
intensity and frequency of suicidal ideation among a sam- and elevated physical pain tolerance. The exposure to pain-
ple of patients hospitalized for a major depressive episode ful and provocative experiences over time contributes to the
(Olie, Guillaume, Jaussent, Courtet, & Jollant, 2010). development of acquired capability, and thus the interper-
Patients with a history of suicide attempts also reported sonal theory could explain why a family history of suicide,
higher levels of psychological pain and suicidal ideation combat exposure, childhood maltreatment, sexual abuse,
than patients without a history of attempts. and bullying all confer increased risk for suicide (Van
Orden et al., 2010). In contrast to thwarted belongingness
and perceived burdensomeness, acquired capability may
Implications for older adults have a genetic component (Smith et al., 2012) and is not
There are no studies to our knowledge directly examining proposed to be a dynamic state that is amenable to clinical
Shneidman’s theory among older adults, although it is interventions.
plausible that the intense psychological pain central in These three constructs are interactive and are all
Shneidman’s theory is applicable to understanding suicide assumed to be necessary, but not individually sufficient,
in later life as well. Shneidman himself has argued that, for the emergence of lethal suicidal behavior. It is impor-
despite phenotypic differences in suicide across the life- tant to highlight that the theory proposes that thwarted
span, demographic partitions in the understanding of sui- belongingness and perceived burdensomeness are related
cide may not be useful: ‘In my analyses of suicide, there to suicidal ideation, whereas acquired capability is related
are no separate youth suicides, adult suicides, geronto- to suicidal behavior. This distinction is critical because
logic suicides; there is only human suicide and all of it is many more people have suicidal ideation than make an
to be understood in terms of the same principles [that is, attempt, and the interpersonal theory holds that this is
psychache]’ (Shneidman, 1991, p. 40). What this view because, as noted, suicidal behavior is daunting and goes
does not resolve, however, are the findings outlined at the against a human’s biological instinct for survival. Hith-
outset of this article that is, in most countries around erto, no theory of suicide has been able to account for
the world, older adults die by suicide at higher rates, and both ideation and behavior by proposing distinct mecha-
at least in the United States, older adults use more lethal nisms. As noted above, several earlier theories of suicide
methods and are more likely to die when they attempt. point to specific individual risk factors as the core etiolog-
ical constructs (e.g., hopelessness in Beck’s theory).
Unique to the interpersonal theory is its ability to account
for a large constellation of risk factors for suicide (Van
Interpersonal-psychological theory of suicide
Orden et al., 2010). A limitation of the theory, however, is
Overview that relatively few studies have examined one of the the-
The interpersonal-psychological theory of suicide (Joiner, ory’s core postulates that thwarted belongingness and
2005; Van Orden et al., 2010) proposes that individuals perceived burdensomeness are implicated in active sui-
will die by suicide if they have both the desire and the cidal desire only when an individual simultaneously feels
ability to enact lethal self-injury. According to this theory, hopelessness regarding the mutability of these two states
the desire to die by suicide manifests in the presence of (Van Orden, in press).
 118 I.H. Stanley et al.

Implications for older adults adults. However, research does exist to support individual
Several studies have provided empirical corroboration for components of the model. Regarding the development
the interpersonal theory across the lifespan, including in and strengthening of suicidal motivation, the IMV postu-
later life. For example, Cukrowicz, Cheavens, Van Orden, lates that disengagement from goals that are unattainable,
Ragain, and Cook (2011) found that, among community- combined with low levels of engagement with other goals,
dwelling older adults, perceived burdensomeness is a risk factor for developing suicidal motivations
accounted for significant variance in suicidal ideation (O’Connor, 2011). Research has found that, particularly
above and beyond other important risk factors, including for older adults, this pattern of disengagement from goals
depressive symptoms and hopelessness; additionally, no without replacement goals to work towards leads to emo-
gender differences were found, which is important to tional distress and a higher probability of suicide attempts
highlight, given the differential suicide rates by gender in (O’Connor, O’Carroll, Ryan, & Smyth, 2012; Wrosch,
later life (CDC, 2014). For older adults presenting to a pri- 2010). Additionally, research has found that impairment
mary care setting, perceptions of being burdensome to in positive future thinking moderates the relationship
younger generations as opposed to peers or older gener- between feelings of entrapment and suicidal thoughts,
ations appear to have a more potent impact on suicidal independent of mood and mood disorders (MacLeod,
ideation (Jahn & Cukrowicz, 2011), although perceptions Pankhania, Lee, & Mitchell, 1997; Rasmussen et al.,
of burdensomeness on a spouse may also be particularly 2010); however, this has not yet been tested among older
toxic (Jahn, Van Orden, & Cukrowicz, 2013). Social dis- adults specifically.
O’Connor (2011) describes volitional moderators as
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connectedness, of which both perceived burdensomeness

and thwarted belongingness are manifestations, is com- any factor that affects the strength of the connection
mon among suicides in later life (Van Orden & Conwell, between suicidal intentions and behaviors. Access to
2011). There are fewer data examining acquired capability means for a suicide attempt (e.g., firearms) and fearless-
among older adults an important area for future ness regarding death are two of the most important voli-
research, especially given that older adults are more likely tional moderators. This is especially notable for older
to die on their first suicide attempt. adults, as some research has demonstrated that, compared
with younger adults, older adults report less fear of dying
(Cicirelli, 2001) and use more lethal methods when
Integrated motivational volitional (IMV) model of
attempting suicide (Conwell et al., 2002). As fearlessness
suicidal behavior
about death is one of the crucial components for predict-
Overview ing suicidal behavior (Ribeiro et al., 2014), attention to
The integrated motivational volitional (IMV) model of this factor and other volitional moderators are relevant
suicidal behavior (O’Connor, 2011) was designed to map when studying and working with older adults.
the development of motivational facets of suicide (i.e., Although much more research is necessary on the
thoughts, desire, and intent) into volitional aspects (i.e., IMV, including its potential applications to older adults,
plans and actions) within the biopsychosocial context of its focus on moderating factors that facilitate movement
diatheses and instigating stressors. Compared to other mod- from the pre-motivational stage to the motivational stage
els, such as the interpersonal theory, this is a broader model to the volitional stage appears to be a useful guiding heu-
of suicide that describes the entire range of suicidality; ristic when assessing and conceptualizing suicidal risk
however, these theories are not incompatible. Indeed, the across the lifespan.
interpersonal theory is included within the IMV as part of
the process of developing suicidal behavior.
The IMV describes three phases of suicidal behavior: Conclusions
the pre-motivational phase, composed of background risk The public health significance of increasing our under-
and protective factors and triggering events; the motiva- standing of the causes and prevention of suicidal thoughts
tional phase, when suicidal thoughts, desires, and inten- and behaviors among older adults is immense (Conwell,
tions develop; and the volitional phase, where suicidal 2014). The evidence is clear no single risk factor can
behaviors occur. The IMV asserts that suicidal thoughts account for suicidal ideation, attempts, and death among
turn into intentions to act due to perceptions of entrapment individuals, including older adults. A theory of suicide
triggered by feelings of inescapable defeat and humilia- can reconcile this by providing a testable and parsimoni-
tion. The transition between these three phases is moder- ous multifaceted explanatory framework that both
ated by relevant factors including, but not limited to, explains the phenomenon and points to clinical applica-
perceptions of a threat to one’s core sense of self posed by tions. In this review, we presented extant theories of sui-
the humiliation or defeat, motivational moderators such as cide, outlined their core constructs and proposed
perceived burdensomeness and social support, and voli- etiological pathways, and discussed the applicability and
tional moderators such as access to means and the capabil- implications of each theory for the scientific study and
ity to face death. prevention of suicide among older adults. Although the
current review is limited in that it is not a systematic syn-
thesis of the literature (e.g., it is exclusive of qualitative
Implications for older adults reports) and is largely limited to studies published in
As this theory was recently developed, there have not yet English and conducted in the United States, it remains
been any direct tests of the theory, including among older notable that few direct empirical tests of these theories
 Aging & Mental Health 119

have been conducted. Moreover, most of the theories that Barrios, L.C., Everett, S.A., Simon, T.R., & Brener, N.D. (2000).
were reviewed are untested among older adults, for whom Suicide ideation among US college students. Associations
suicidal ideation and behaviors have unique epidemiologi- with other injury risk behaviors. Journal of American College
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driven approaches. Organizing research questions and Beautrais, A.L., & Fergusson, D.M. (2006). Indigenous suicide
findings within the framework of one or more of the in New Zealand. Archives of Suicide Research, 10(2),
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Beck, A.T. (1986). Hopelessness as a predictor of eventual sui-
questions that will explain the heretofore unexplained. cide. Annals of the New York Academy of Sciences, 487,
For example, a critical and paramount question that 90 96. doi:10.1111/j.1749-6632.1986.tb27888.x
remains unanswered is how to effectively intervene to Beck, A.T., Brown, G., Berchick, R.J., Stewart, B.L., & Steer,
prevent the onset, persistence, and attendant sequelae of R.A. (1990). Relationship between hopelessness and ulti-
suicidal thoughts and behaviors among older adults mate suicide: A replication with psychiatric outpatients.
American Journal of Psychiatry, 147(2), 190 195.
(Conwell, 2014). In this sense, theories are especially use- Beck, A.T., & Steer, R.A. (1988). Manual for Beck Hopelessness
ful in intervention development because a theory can, by Scale. San Antonio, TX: Psychological Corportation.
definition, provide mechanistic explanations for a phe- Beck, A.T., Steer, R.A., Kovacs, M., & Garrison, B. (1985).
nomenon and implicate potential targets for intervention Hopelessness and eventual suicide: A 10-year prospective
(see Van Orden et al., 2013 for example). study of patients hospitalized with suicidal ideation. Ameri-
can Journal of Psychiatry, 142(5), 559 563.
In addition to older populations as a whole, it would
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Bernert, R.A., Turvey, C.L., Conwell, Y., & Joiner, T.E. (2014).
also be useful for future research to test these theories Association of poor subjective sleep quality with risk for
among subpopulations of older adults who may be at par- death by suicide during a 10-year period: A longitudinal,
ticularly elevated risk for suicide and have unique mental population-based study of late life. JAMA Psychiatry, 71
health treatment needs, including veterans (Fanning & (10), 1129 1137. doi:10.1001/jamapsychiatry.2014.1126
Birditt, K.S., Fingerman, K.L., & Almeida, D.M. (2005). Age
Pietrzak, 2013), sexual minorities (Fredriksen-Goldsen differences in exposure and reactions to interpersonal ten-
et al., 2011), and those living in long-term care facilities sions: A daily diary study. Psychology and Aging, 20(2),
(O’Riley, Nadorff, Conwell, & Edelstein, 2013). In sum- 330 340. doi:10.1037/0882-7974.20.2.330
mary, to advance the science of the understanding and Britton, P.C., Duberstein, P.R., Conner, K.R., Heisel, M.J.,
prevention of suicide among older adults, researchers and Hirsch, J.K., & Conwell, Y. (2008). Reasons for living,
hopelessness, and suicide ideation among depressed
clinicians should draw from and apply theories of suicide. adults 50 years or older. American Journal of Geriatric Psy-
chiatry, 16(9), 736 741. doi:10.1097/JGP.0b013e31817b
609a
Acknowledgements Carstensen, L.L., Fung, H.H., & Charles, S.T. (2003). Socioemo-
The authors have no financial relationships relevant to this article tional selectivity theory and the regulation of emotion in the
to disclose. Opinions, interpretations, conclusions and recom- second half of life. Motivation and Emotion, 27(2),
mendations are those of the authors and are not necessarily 103 123. doi:10.1023/A:1024569803230
endorsed by the Military Suicide Research Consortium (MSRC) Centers for Disease Control and Prevention (CDC). (2014).
or the Department of Defense. WISQARS: Web-based injury statistics query and reporting
system. Retrieved from http://www.cdc.gov/injury/wisqars/
Disclosure statement index.html.
Charles, S.T., & Carstensen, L.L. (2010). Social and emotional
No potential conflict of interest was reported by the authors. aging. Annual Review of Psychology, 61, 383 409.
doi:10.1146/annurev.psych.093008.100448
Chatard, A., & Selimbegovic, L. (2011). When self-destructive
Funding thoughts flash through the mind: Failure to meet standards
This work was in part supported by the Military Suicide affects the accessibility of suicide-related thoughts. Journal
Research Consortium (MSRC), an effort supported by the Office of Personality and Social Psychology, 100(4), 587 605.
of the Assistant Secretary of Defense for Health Affairs under doi:10.1037/a0022461
Award No. (W81XWH-10-2-0181). Christodoulou, C., Douzenis, A., Papadopoulos, F.C., Papado-
poulou, A., Bouras, G., Gournellis, R., & Lykouras, L.
(2012). Suicide and seasonality. Acta Psychiatrica Scandi-
navica, 125(2), 127 146. doi:10.1111/j.1600-0447.2011.
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