Prevalence of suicide ideation and attempts among Black Americans in later life

Abstract

This article provides the first national estimates of the prevalence and correlates of nonfatal suicidal behavior among older Black Americans. There is a lack of national data on suicide ideation and attempts across ethnic classifications of Blacks in a nationally representative sample. Data are a subsample from the National Survey of American Life (NSAL), a national U.S. adult household probability sample of 5,191 Black Americans. The WHO Composite International Diagnostic Interview (CIDI) was used to assess older Blacks for nonfatal suicidal behavior and 14 DSM-IV disorders. Bivariate and multivariate logistic regression analyses were employed to delineate patterns and correlates of nonfatal suicidal behavior. The estimated lifetime prevalence of suicidal ideation and attempts among older Blacks in the United States was 6.1% and 2.1%, respectively. On an average it took 2.5 and 5.7 years respectively to go from ideation to attempts or from planning to attempts. Surprisingly, among older Black adults, men reported attempting suicide and seriously consider taking their own lives more than women. Older Blacks at higher risk for suicide attempts were middle aged, had poorer health, were anxious, and had multiple DSM-IV disorders. The results also show that approximately 1 in 4 attempters and 2 in 5 ideators have never sought treatment for their emotional or psychological problems. Preventative care, particularly screening in primary care settings, should consider these findings when treating older Black Americans for psychiatric-related risk.

Keywords

Black American elderly risk factors suicide attempts suicide ideation

Among all Americans, suicide is the 11th leading cause of death and the rates vary by race and age, with older adults bearing the highest burden (Anderson & Smith, 2003). Older Americans are 12% of the U.S. population but account for 15.9% of the suicide deaths (Heron et al., 2009). Across race and gender, it is the elderly, particularly White men 85 and older that have the highest suicide rates (48.4 per 100,000 populations; Centers for Disease Control and Prevention, 2006). In 2007, the rate of suicide among Whites was 4 times higher than Blacks (4.1 per 100,000 populations). Although suicide has traditionally been viewed as a problem that affects Whites more, the patterns of suicide among Blacks have changed significantly since the mid-1980s, such that older Blacks have the second highest suicide rates for the population (Griffith & Bell, 1989). Despite the public health significance of these changes, no study to date has examined the psychiatric risk for suicide and the prevalence of nonfatal suicidal behavior among older Black Americans with a nationally representative sample.

Prior research on older Black suicidal behavior has used less generalizable clinical or community samples (Bartels et al., 2002; Cohen, Coleman, Yaffee, Casimir, 2008; Mahgoub & Kotbi, 2008) often focusing on a single risk factor (e.g., depression), related constructs (e.g., thought of death or wish to die), or bereft of other known psychiatric as well as sociocultural risk factors. These studies yield prevalence estimates for suicide ideation less than 1% up to 17%, depending on the definitions employed (Kim, Bogner, Brown, Gallo, 2006). The epidemiology of suicidal behaviors in the elderly is often viewed along a continuum ranging from death ideation, suicidal ideation, attempted suicide, and to suicide. Death ideation refers to a recurrent wish to die and thoughts of death by passive means, while suicidal ideation represents seriously thinking about or planning to commit suicide (Kim et al., 2006). Estimates of the wish to die in some studies for Blacks or ethnic minorities are from 21% to a high of 36% (Kim et al., 2006; Raue et al., 2010). The most recent epidemiologic studies, the two National Comorbidity Surveys (NCS and NCS-R; Kessler, Berglund, Borges, Nock, & Wang, 2005; Kessler, Borges, & Walters, 1999), provide national prevalence estimates of nonfatal suicidal behavior (4.6%), but not by race, ethnicity, or age group. More recent epidemiological research using the National Survey of American Life (NSAL; Jackson et al., 2004), does provide national prevalence estimates for Black (4.1%) and Black adolescents (2.3%), and highlights the importance of disaggregating the data by ethnicity (Joe, Baser, Breeden, Neighbors, & Jackson, 2006; Joe, Baser, Neighbors, Caldwell, & Jackson, 2009), but like the NCS studies they also lack information on the prevalence of suicide attempts, ideation, and planning as well as data on the robust sociocultural correlates that contextualizes the role of psychiatric risk factors associated with nonfatal suicidal behaviors among older Blacks (e.g., religion, region). Research on the occurrence and correlates of nonfatal suicidal behavior (e.g., ideation and attempts) is needed to further our understanding of whether the prevention and treatment of antecedents to suicide are effective in reducing risk among this population and for cross-national comparisons with other samples of Whites as well as Black and other minoities.

Obtaining national estimates of nonfatal suicidal behavior among older Black Americans is an important public health objective, given that the Black population is projected to double by 2050 (U.S. Census Bureau, 2004), and that suicidal thoughts and behaviors are among the strongest predictors of suicide (Harris & Barraclough, 1997). For instance, among geriatric psychiatry outpatients, the sensitivity and predictive value of suicidal ideation for the prediction of suicide is 80% and 5.4%, respectively (Beck, Brown, Steer, Dahlsgaard, & Grisham, 1999). Also prior research clearly reveals that there is a greater likelihood that an elderly person who attempts suicide will die, despite the fact that they make fewer attempts per completed suicide (Goldsmith, Pellmar, Kleinman, & Bunney, 2002). Suicide attempts among the elderly are more likely to lead to a death than in any other age groups, that is, 6% versus 2% for those younger than 55 years of age (Goldsmith et al., 2002). The putative reasons for the increased mortality following a suicide attempt is believed to be due to fact that the elderly are more likely to live alone and they are also more likely to be medically fragile, which increases the probability of a fatal outcome (Conwell, 2009; Conwell et al., 1996; Goldsmith et al., 2002). Therefore, generating more reliable and more extensive scientific data on nonfatal suicidal behaviors is a critical first step in developing and testing preventive interventions aimed at reducing both suicide morbidity and mortality (Goldsmith et al., 2002; U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention, 2012; U.S. Public Health Service, 2000, 2001). This article seeks to provide for the first time national estimates of the prevalence and correlates of nonfatal suicidal behavior among Black Americans aged 55 years and older from the National Survey of American Life (NSAL). We hypothesize that the risk for suicide ideation and attempts would not increase with advancing age, social ties (e.g., religiosity) would reduce the risk for Blacks, and health status would be a significant risk after controlling for psychiatric disorder. The NSAL is the first national study specifically designed to measure prevalence of psychiatric disorders, suicidal behavior, and mental health treatment in Black adults (Jackson et al., 2004).

Methods

Study population and data collection

The NSAL is part of the National Institute of Mental Health (NIMH) Collaborative Psychiatric Epidemiology Surveys (CPES) initiative that includes three nationally representative surveys—the NSAL, the National Comorbidity Survey Replication (NCS-R), and the National Latino and Asian American Study (NLAAS; Pennell, Bowers, & Carr, 2004) The NSAL is a nationally representative household survey of 3,570 African Americans, 1,621 Blacks of Caribbean descent (Caribbean Blacks), and 891 non-Hispanic Whites, aged 18 and over (Jackson et al., 2004). This analysis was limited to a subsample of 1,141 adults in the NSAL that were aged 55 and older. The Institutional Review Board of the University of Michigan approved the recruitment, consent, and data collection procedures. The non-Hispanic Whites, however, were not administered the full interview and were not asked the suicidality questions. Thus, the present report focuses on the African American and Caribbean Black samples. The African American sample, the largest segment of the NSAL sample, is nationally representative of households located in the 48 coterminous states with at least one Black adult 18 years or over who did not identify ancestral ties to the Caribbean. The Caribbean Black sample was selected from two area probability sample frames: 265 were selected from the households in the core sample, while 1,356 were selected from an area probability sample of housing units from geographic areas with a relatively high density of persons of Caribbean descent (more than 10% of the population; Heeringa et al., 2004). The NSAL analysis weights for the African American and Caribbean Black samples were designed to provide population representation for these populations in the 48 coterminous states.

Demographic description of the sample

The respondents in this older Black American sample ranged from 55 to 94 years of age (mean: 66.58; SD 6.39), with about two thirds (58.8%) of them being women (see Table 1). In regards to marital status, almost four out of 10 (40.9%) are married and the remaining 59.1% unmarried (i.e., widowed, divorced, separated, or never married). More than half (54.3%) of the respondents reside in the south part of the nation. Approximately seven out of 10 (68.3%) NSAL respondents report being in good to excellent health in contrast to only 31.7% saying they were in either fair to poor health. The average imputed family income is $33,420 (SD $28,928) and the average years of education is 11.54 (SD 2.63). More than one third of the respondents (35.0%) are currently employed, whereas only 4.5% are unemployed and 60.4% are not in the labor force. A majority of older Black Americans are attending religious services (50.3%) at least once a week. However, there were no significant differences between African Americans and Caribbean Blacks in religious participation.

Table 1.

Weighted distributions of sociodemographic distributions of the National Survey of American Life (NSAL) sample by ethnicity for ages 55 and older.

African American		Caribbean Black				Total
N = 837		N = 304				N = 1141
n (%) [SE]‡		n (%) [SE]‡		Significance test	n (%) [SE]‡
Gender
Female	537 (59.6) [1.8]		171 (47.0) [6.0]		$χ_{1}^{2}$ = 4.2		708 (58.8) [1.7]
Male	300 (40.4) [1.8]		133 (53.0) [6.0]		*p = .04		433 (41.2) [1.7]
Marital status†
Married	252 (39.9) [2.2]		134 (55.0) [7.4]		$χ_{1}^{2}$ = 3.9		386 (40.9) [2.2]
Unmarried	577 (60.1) [2.2]		170 (45.0) [7.4]		p = .05		747 (59.1) [2.2]
Education status
Less than high school		360 (38.2) [2.1]		91 (34.7) [5.1]		$χ_{1}^{2}$ = 0.4		451 (38.0) [2.0]
HS graduate and higher		477 (61.8) [2.1]		213 (65.3) [5.1]		p = .5		690 (62.0) [2.0]
Region§
Other	312 (44.4) [3.2]		207 (65.1) [12.5]		$χ_{1}^{2}$ = 2.3		519 (45.7) [3.1]
South	525 (55.6) [3.2]		97 (34.9) [12.5]		p = .1		622 (54.3) [3.1]
Elderly age
55--64	417 (50.3) [2.3]		164 (52.1) [4.7]		$χ_{1}^{2}$ = .1		581 (50.4) [2.2]
65+	420 (49.7) [2.3]		140 (47.9) [4.7]		p = .7		560 (49.6) [2.2]
Self-reported health†
Good to excellent		515 (68.2) [2.0]		201 (71.1) [5.0]		$χ_{1}^{2}$ = .3		716 (68.3) [1.9]
Fair or poor		272 (31.8) [2.0]		93 (28.9) [5.0]		p = .6		365 (31.7) [1.9]
Church attend
Less than once per year		106 (13.7) [1.5]		45 (16.2) [5.9]		$χ_{2}^{2}$ = 1.3		151 (13.9) [1.4]
A few times per year		304 (36.4) [1.7]		90 (27.7) [5.9]		p = .5		394 (35.8) [1.6]
At least once per week		427 (49.9) [1.7]		169 (55.1) [9.4]		596 (50.3) [1.7]

‡

All estimates represent row frequencies and percentage; all estimates, except sample sizes, are weighted to be nationally representative. Standard errors and Rao-Scott chi-square statistics are adjusted for the sampling stratification, clustering, and weighting of the data.

p < .05 by a two-sided test.

†

There were eight African American respondents with missing data for marital status, 50 African American and 10 Caribbean Black respondents with missing data for self-reported health. Due to this, the variables do not add up to the total.

§South denotes Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; other denotes the rest of states (Alaska and Hawaii are not included in this study).

Suicidal behavior

Suicidality is assessed in its own section of the World Mental Health Composite International Diagnostic Interview (WMH-CIDI) by a series of questions about lifetime suicidal behaviors including ideation, planning, and attempts (Kessler & Ustun, 2004). Respondents were screened into the suicidality section of the WMH-CIDI if they answered affirmatively to the question “Have you ever seriously thought about committing suicide?” These respondents are said to have engaged in suicidal ideation and will be referred to as ideators in this report, while those answering negatively will be referred to as nonideators. Only the ideators went on to answer questions to determine if they ever made plans to commit suicide (“Have you ever made a plan for committing suicide?”) and if they ever attempted suicide (“Have you ever attempted suicide?”). To gain a better understanding of the progression from ideation to attempt, we also examined three conditional associations corresponding to different pathways individuals may follow from suicidal ideation to attempted suicide: plan given ideation, attempt given ideation but no plan, and attempt given ideation and a plan (Kessler et al., 1999).

Psychiatric diagnosis and treatment experience

We present and discuss risks for various suicidal behaviors associated with the mental disorders assessed in the NSAL. The World Mental Health Composite International Diagnostic Interview (WMH-CIDI), a fully structured diagnostic interview based on the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV; American Psychiatric Association, 1994), was used to assess a wide range of serious mental disorders and conditions, including suicidality. We present and discuss risks for various suicidal behaviors associated with the mental disorders assessed in the NSAL: mood disorders (major depressive disorder, dysthymia, Bipolar I & II disorders), anxiety disorders (panic disorder, agoraphobia, social phobia, generalized anxiety disorder, probable obsessive compulsive disorder, posttraumatic stress disorder), substance disorders (alcohol abuse, alcohol dependence, drug abuse, drug dependence), disorders usually diagnosed in childhood (separation anxiety disorder, oppositional defiant disorder, conduct disorder, attention deficit/hyperactivity disorder), and eating disorders (anorexia, bulimia, binge-eating).

We also examined suicidal respondents’ treatment experiences for mental disorders assessed in the NSAL. All respondents were asked if they had contact with anyone from an extensive list of treatment providers for problems with their emotions, nerves, mental health, or use of alcohol or drugs in their lifetime. Health care treatment providers were categorized into a mental health sector (psychiatrists, psychologists, counselors and social workers seen in mental health settings, other mental health professionals, mental health hotlines) and a general medical sector (general practitioners, family doctors, nurses, occupational therapists, and other health professionals). A nonhealth care sector included the use of human services (religious and spiritual advisors, counselors and social workers seen in nonmental health settings) and complementary-alternative treatments (herbalists, chiropractors, spiritualists, self-help groups, Internet support groups). Lifetime service use was defined as making at least one visit to a service provider prior to the respondent’s interview.

Sociodemographic correlates

We investigated sociodemographic factors to ascertain which groups are potentially at elevated risk of suicidal behaviors. Sociodemographic correlates included ethnicity (African American and Caribbean Black), sex, marital status (married, unmarried), highest level of education attained (0–11 years, 12+ years), region (south, other regions), age (55–64, 65+), frequency of religious service attendance (less than once per year, few times, at least once per week), and self-reported health (good to excellent, fair or poor).

Statistical analysis

Bivariate cross-tabulations are presented to illustrate ethnic and the lifetime suicidal behavior differences by sociodemographic factors. Unweighted frequencies but weighted percentages were reported. Standard errors were adjusted for the sampling stratification, clustering, and weighting of the data. The Rao-Scott chi-square statistic, a complex design-corrected measure of association, was used to test for associations across categorical variables. A single model was estimated for each of the lifetime suicidal behavior outcomes. To test the hypothesized relationships between NSAL/DSM-IV-R disorders and suicide ideation and suicide attempts, logistic multiple regression analyses were conducted. In these analyses, 14 disorder variables were tested individually as predictors of suicide ideation and suicide attempts. All logistic regression models were adjusted for age, gender, race, family income, education, marital status, and self-reported health. Odds ratios were obtained by exponentiating the coefficients and 95% CIs were given along with design-corrected Wald chi-square measures. Throughout the analyses, the .05 level on a two-sided design-based test of significance represented the cut-off value for assessing statistical significance. The p values of these statistics were adjusted to control for the false discovery rate, because 28 models (14 models for each of the two outcomes) were constructed as in Table 4, which required a total of 45 statistically tested comparisons (Benjamini & Hochberg, 1995). This method is preferable to controlling for the family-wise error rate when the multiple comparisons are not independent (Benjamini & Yekutieli, 2001). Although 95% confidence intervals remain unadjusted, asterisks indicate which estimates in the tables are significant according to the more stringent adjusted p values. All analyses were conducted with SAS 9.13, which uses the Taylor expansion approximation technique for calculating the complex design-based estimates of variance.

Results

Prevalence

Table 2 presents the estimated lifetime prevalence of the suicidal behaviors among Blacks in later life. The estimated lifetime prevalence of suicidal ideation and attempts among older Blacks in the United States was 6.1% and 2.1%, respectively. On an average it took 2.5 and 5.7 years respectively to go from ideation to attempts or from planning to attempts. Among older Black that had an attempted suicide, only a quarter had two or more attempts in their lifetime. Among the ideators, only 38.7% made a suicide plan. Statistically significant differences (

χ_{1}^{2}

= 14.0, p ≤ .001) were found between those middle aged (55–64) and elderly (65 and older), with suicide attempts being more prevalent among middle aged Blacks (3.6%) than for the elderly (0.5%). The analyses by gender reveal additional important differences in the prevalence of suicidal behaviors. Men were more likely to report suicide ideation than women (p < .05), 7.9% to 4.8% respectively. Overall, the amount of time it took to go from ideation to attempts was shorter for women than men, whereas men took a shorter time to go from planning to actually making an attempt (gender difference of 2.5 years). Surprisingly, we found no significant differences in attempts by self-reported health, ethnicity, frequency of church attendance, or marital status. Older Blacks reporting poorer health (9.3%) consider seriously taking their own lives more often than those with excellent health (4.6%,

χ_{1}^{2}

= 6.20, p < .01).

Table 2.

Estimated weighted prevalence of suicidal behaviors by sociodemographic characteristics and disaggregated through pathways involving attempts and ideation for ages 55 and older.

Attempt	Ideation	Plan among ideators
(n = 17)†	(n = 62)†	(n = 22)‡
% (SE)§	% (SE)§	% (SE)§
Overall ethnicity	2.1(0.6)	6.1(0.7)	38.7(4.7)
African American	2.0(0.6)	6.0(0.7)	37.1(5.0)
Caribbean Black	3.6(3.1)	6.2(4.5)	62.5(0.0)
Significance test	$χ_{1}^{2}$ = 0.4; p = .5	$χ_{1}^{2}$ = 0.0006, p = 1.0	$χ_{1}^{2}$ = 20.4; *p = < .0001
Gender
Female	1.3(0.6)	4.8(0.7)	34.9(7.3)
Male	3.3(1.2)	7.9(1.6)	42.0(5.7)
Significance test	$χ_{1}^{2}$ = 2.6; p = .1	$χ_{1}^{2}$ = 3.8; p = .05	$χ_{1}^{2}$ = 0.6; p = .4
Marital status
Married	1.8(0.7)	5.5(1.2)	33.1(7.3)
Unmarried	2.3(0.9)	6.5(1.0)	42.1(6.7)
Significance test	$χ_{1}^{2}$ = 0.2; p = .7	$χ_{1}^{2}$ = 0.4; p = .5	$χ_{1}^{2}$ = 0.7; p = .4
Education status
Less than high school	2.0(0.8)	7.7(1.3)	29.4(5.0)
HS graduate and higher	2.2(0.8)	5.0(1.0)	47.5(6.6)
Significance test	$χ_{1}^{2}$ = 0.03; p = .9	$χ_{1}^{2}$ = 2.3; p = .1	$χ_{1}^{2}$ = 6.3; *p = .01
Region
Other	2.4(1.0)	6.8(1.2)	42.7(7.4)
South	1.9(0.7)	5.5(0.9)	34.6(5.9)
Significance test	$χ_{1}^{2}$ = 0.2; p = .6	$χ_{1}^{2}$ = 0.8; p = .4	$χ_{1}^{2}$ = 0.7; p = .4
Elderly age
55-64	3.6(1.1)	8.7(1.4)	46.7(6.6)
65+	0.5(0.3)	3.2(0.7)	16.0(7.8)
Significance test	$χ_{1}^{2}$ = 14.0; *p = .0002	$χ_{1}^{2}$ = 11.2; *p = .0008	$χ_{1}^{2}$ = 5.0; *p = .02
Self-reported health
Good to excellent	1.4(0.6)	4.6(0.8)	28.4(9.4)
Fair or poor	3.5(1.4)	9.3(1.9)	49.6(6.0)
Significance test	$χ_{1}^{2}$ = 2.6; p = .1	$χ_{1}^{2}$ = 6.2; *p = .01	$χ_{1}^{2}$ = 2.4; p = .1

§All estimates represent row percentage; standard errors and Rao-Scott chi-square statistics are adjusted for the sampling stratification, clustering, and weighting of the data.

p < .05 by a two-sided test.

†

The behavioral categories of “attempt” and “ideation” present the risks for the unconditional behaviors.

‡

The behavioral category of “plan among ideators” presents the risks for the conditional behaviors.

Sociodemographic risk factors

Risk of a suicide attempt and risk of suicidal ideation were significantly associated with being younger, male, and having poor health (Table 3). Middle-age Blacks were 8.5 times (

χ_{1}^{2}

= 9.73, p < .01) more likely to attempted suicide and 3.6 times (

χ_{1}^{2}

= 15.01, p < .01) more likely to engage in suicide ideation than the elderly. Respondents with fewer than 12 years of formal education, unmarried, or residing in nonsouthern regions were more likely to attempt suicide or engage in suicide ideation, but these findings were not statistical significant. Frequency of religious involvement had no significant effect on suicide risk among older Blacks.

Table 3.

Multivariate sociodemographic predictors of suicidal behaviors by ethnicity and gender, and disaggregated through pathways involving attempts and ideation for ages 55 and older.

Attempt†		Ideation†
n = 17		n = 62
OR	[95% CI]	OR	[95% CI]
Ethnicity
African American	1.00	1.00
Caribbean Black	1.79	[0.37, 8.59]	0.88	[0.24, 3.30]
Significance test	$χ_{1}^{2}$ = 0.52	p = .47	$χ_{1}^{2}$ = 0.04	p = .85
Gender
Female	1.00	1.00
Male	3.16	[0.82, 12.15]	1.93	[1.06, 3.52]
Significance test	$χ_{1}^{2}$ = 2.82	p = .09	$χ_{1}^{2}$ = 4.67	*p = .03
Marital status
Married	1.00	1.00
Unmarried	2.02	[0.59, 6.90]	1.44	[0.77, 2.70]
Significance test	$χ_{1}^{2}$ = 1.25	p = .26	$χ_{1}^{2}$ = 1.27	p = .26
Education status
Less than high school	0.94	1.76
HS graduate	1.00	[0.28, 3.17]	1.00	[0.88, 3.50]
Significance test	$χ_{1}^{2}$ = 0.01	p = .91	$χ_{1}^{2}$ = 2.57	p = .11
Region
Other	1.30	1.49
South	1.00	[0.42, 4.03]	1.00	[0.89, 2.52]
Significance test	$χ_{1}^{2}$ = 0.21	p = .64	$χ_{1}^{2}$ = 2.27	p = .13
Elderly age
55-64	8.56	3.60
65+	1.00	[2.22, 33.00]	1.00	[1.88, 6.89]
Significance test	$χ_{1}^{2}$ = 9.73	*p = .002	$χ_{1}^{2}$ = 15.01	*p = .0001
Self-reported health
Good to excellent	1.00	1.00
Fair or poor	3.05	[0.85, 10.92]	2.13	[1.10, 4.11]
Significance test	$χ_{1}^{2}$ = 2.93	p = .09	$χ_{1}^{2}$ = 5.06	*p = .02

Abbreviations: OR, odds ratio; CI, confidence interval. Odds ratios were obtained by exponentiating the coefficients from logistic regression models. The 95% confidence intervals were obtained using a modified method of balanced repeated replications to adjust for stratification, clustering, and weighting of the data. A single model was estimated for each of the seven outcomes that included all of the predictor variables. Wald chi-square values were obtained from design-based variance–covariance matrices to adjust for the stratification, clustering, and weighting of the data. The first two columns present the risks for the unconditional behaviors. The last five columns present the risks for the conditional behaviors.

p < .05 by a two-sided test.

†

The behavioral categories of “attempt” and “ideation” present the risks for the unconditional behaviors.

Psychiatric risk factors

Multivariate logistic regression models controlling for all of the sociodemographic variables included in Table 2 were used to assess the risks of engaging in the suicidal behaviors associated with the 14 DSM-IV disorders assessed in the NSAL. Table 4 presents the odds ratios and 95% confidence intervals for these disorders. Respondents with any of the 14 DSM-IV disorders assessed in the NSAL were 4.1 times (95% CI [1.31, 12.58]) more likely to attempt suicide and more than 4 times more likely to develop suicidal ideation (adjust odds ratio [AOR] = 4.37, 95% CI [2.31, 8.27]) than were those with no disorder. Among the summary variables for the diagnostic classes (e.g., any mood disorder, any anxiety disorder), only having any anxiety disorder was significantly associated with elevated risks of attempting suicide (AOR = 8.87).

Table 4.

Multivariate associations of NSAL/DSM-IV-R disorders with subsequent first onset of attempted suicide in the total sample and disaggregated through pathways involving Onset of Ideation and Attempts for aged 55 and older*.

Attempt^‡ (n = 17)		Ideation^‡ (n = 62)
OR	95% CI	OR	95% CI
I. Mood disorders
Major depressive disorder	2.92	[0.94, 9.05]	5.34	[2.62, 10.90^*]
Dysthymia	5.93	[0.86, 40.83]	6.86	[2.74, 17.17^*]
Bipolar I-II disorder (Includes subthreshold)	5.68	[0.42, 76.96]	1.55	[0.18, 13.19]
Any mood disorder	2.89	[0.94, 8.86]	4.95	[2.43, 10.08^*]
II. Anxiety disorders
Panic disorder	4.20	[0.57, 30.89]	4.29	[1.14, 16.14^*]
^†Agoraphobia without panic	<0.001	[<0.001, <0.001]	4.78	[1.23, 18.64^*]
Social phobia	0.80	[0.09, 7.49]	0.71	[0.15, 3.30]
Generalized anxiety disorder	5.21	[1.38, 19.70^*]	2.91	[1.08, 7.87^*]
^†Obsessive compulsive disorder	<0.001	[<0.001, <0.001]	1.25	[0.19, 8.38]
Posttraumatic stress disorder	8.97	[2.55, 31.53^*]	4.33	[1.63, 11.55^*]
Any anxiety disorder(of 6)	6.87	[2.24, 21.12^*]	4.13	[1.96, 8.71^*]
III. Substance disorders
Alcohol abuse	2.66	[0.73, 9.68]	2.22	[1.09, 4.52^*]
Alcohol dependence	1.79	[0.27, 11.93]	2.34	[0.78, 7.01]
Drug abuse	9.81	[1.48, 65.26^*]	3.28	[0.64, 16.90]
Drug dependence	31.31	[2.58, 380.11^*]	8.18	[0.76, 88.53]
Any substance disorder	2.31	[0.61, 8.79]	1.92	[0.91, 4.04]
IV. Eating disorders
^†Bulimia	<0.001	[<0.001, <0.001]	1.94	[0.17, 21.64]
Binge-Eating	3.33	[0.64, 17.41]	3.36	[1.19, 9.54^*]
Any eating disorder	3.33	[0.64, 17.41]	3.36	[1.19, 9.54^*]
V. Any disorder	4.06	[1.31, 12.58^*]	4.37	[2.31, 8.27^*]
VI. Number of comorbid disorders
0	1.00	1.00
1	2.67	[0.61, 11.70]	2.86	[1.34, 6.09^*]
2	2.54	[0.46, 14.00]	5.84	[2.54, 13.43^*]
3+	8.36	[1.90, 36.83^*]	5.92	[2.06, 17.04^*]

Abbreviations: DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; NSAL, National Survey of American Life.

Abbreviations: OR, odds ratio; CI, confidence interval. Odds ratios were obtained by exponentiating the coefficients from logistic regression models. The 95% confidence intervals were obtained using a modified method of balanced repeated replication to adjust for stratification, clustering, and weighting of the data. Each column presents the results from 21 models. Each of these models controlled for the sociodemographic variables presented in Table 2. In addition, each model contained exactly one of the 15 individual disorders, exactly 1 of the 5 summary measures (any disorder, any mood disorder, etc.), or the set of dummy variables representing the number of comorbid disorders. The first two columns present the risks for the unconditional behaviors, the last four the conditional behaviors. All disorders were defined without diagnostic hierarchy rules.

†

Only a small number of respondents met criteria for agoraphobia without panic, obsessive compulsive disorder and bulimia with attempt. As such, these risk coefficients tend to be artificially high, low, or inestimable.

‡

The behavioral categories of “attempt” and “ideation” present the risks for the unconditional behaviors.

Indicates odds ratio estimates that are significantly different from 1.00. For the 46 tests in this tables, this significance criterion was p < 0.05.

Note: Anorexia was not included in the model due to no case.

The effects of comorbidity are presented at the bottom of Table 4. Having three or more disorders was strongly associated with suicide attempts and suicide ideation. Persons with three or more disorders were 8 times (8.36; 95% CI [1.90, 36.83]) more likely to attempt suicide and about 6 times (5.92; 95% CI [2.06, 17.04]) more likely to develop suicidal ideation than respondents with no psychiatric disorder. The risks of suicide ideation are greater for persons with one disorder than for persons with no disorder, and slightly greater for persons with two disorders than for persons with only one disorder.

Treatment for mental disorders

Table 5 presents information on the lifetime history of receiving treatment for emotional problems among suicide attempters and ideators with no history of an attempt. The results show that approximately one in four attempters and two in five ideators have never sought treatment for emotional problems. When older adults who have thoughts of suicide sought treatment for their mental health problems many report contacting a mental health professional (40%, SE 5.2), namely a psychiatrist (30%, SE 5.2). Approximately two thirds of suicide attempters also report seeking treatment for their emotional problems in the general medical sector. In addition, the treatment preferences of older Black American suicide attempters vary, with a third of them also reporting having gone to nonhealth service professionals, such as religious or spiritual advisors or massage therapists, for their emotional problems.

Table 5.

Prevalence of lifetime services utilization by service sector among NSAL respondents with and without suicide related behaviors for ages 55 and over.

Service sector†	Ideators w/no attempt history	Attempters	NSAL respondents with no reported ideation history
Service sector†	(n = 45)	(n = 17)	(n = 1013)
	% (SE)*	% (SE)*	% (SE)*
Any treatment	63.6(8.1)	76.1(10.4)	2.65(2.0)
Health service provider	55.6(7.9)	76.1(10.4)	25.2(2.0)
General medical	35.6(9.3)	60.0(13.6)	17.4(1.7)
Mental health specialty	40.6(5.2)	38.9(14.4)	12.1(1.5)
Psychiatrist	30.5(5.2)	38.9(14.4)	7.8(1.3)
Nonpsychiatrist	20.0(6.3)	32.2(14.3)	7.3(1.4)
Nonhealth service	24.4(8.9)	35.8(15.2)	6.1(1.1)
Complementary-alternative	18.8(7.9)	21.8(12.9)	3.1(0.8)
Human service	12.6(7.7)	18.2(12.9)	3.3(0.8)

Note. Due to the small size of the sample, the standard errors of attempters are adjusted for the weighting of the data. They are not corrected for complex sample survey data. Abbreviations: NSAL = National Survey of American Life.

All estimates represent row percentage; all prevalence estimates are weighted to be nationally representative. Standard errors are adjusted for the sampling stratification, clustering, and weighting of the data.

†

Any mental health treatment includes treatment by a psychiatrist as well as by a nonphysician mental health specialist (e.g., psychologist, social worker in a mental health specialty setting). General medical treatment includes treatment by any nonpsychiatrist physician or a worker in a general medical setting (e.g., nurse in a primary care setting). In addition to including mental health and general medical treatment, the category of any treatment includes treatment in non-health-care settings including human services professionals (e.g., religious or spiritual advisors) and complementary-alternative treatments (e.g., massage therapy, chiropractic treatment, or participation in a self-help group).

Conclusion

Suicide is a growing public health concern among Black Americans across the life span as evidenced by the reported lifetime prevalence of 6.1% for suicide ideation and 2.1% for attempts among older Black Americans. We found no significant ethnic group differences in the prevalence of nonfatal suicidal behavior among Black Americans aged 55 and older, which contradicts previous NSAL studies that found ethnic differences among Blacks in earlier phases of life (Joe et al., 2006; Joe et al., 2009). The focus on ethnicity is important, because though there is only a limited amount of research on African Americans there is extremely little mental health research on Caribbean Blacks. The relevance of this point is the need to understand the role of ethnicity (African American and Black Caribbean) in suicidal risk among Black Americans and this type of information is needed to help researchers and clinicians’ understandings of which older Black Americans are most at risk for suicide. The findings that among older Blacks the risk for attempted suicide is highest among those middle aged, 55 to 64 years, are consistent with the mortality data that show that among Black Americans it is the younger generation that are at significantly higher suicide risk (Centers for Disease Control and Prevention, 1998; Garlow, 2002; Garlow, Purselle, & Heninger, 2005). The reasons for the higher suicide risk among younger Blacks have pointed to their increased access to lethal methods (Hawton, 2001; Shaffer, Gould, & Hicks, 1994), higher prevalence of psychiatric disorders, and more accepting attitudes toward suicide (Gibbs, 1988, 1997; Joe, 2003). This cohort explanation suggests that the observed higher vulnerability represents a suicide risk carried uniquely by those cohorts now occupying middle age related to changing social norms (e.g., attitudes toward suicidal behavior) between the generations. This cohort explanation also assumes that suicide acceptance plays an important role in regulating people’s consideration of suicide as a solution to life problems (Goldsmith et al., 2002; Neeleman, Wessely, & Lewis, 1998). Joe, Romer, and Jamieson (2007) found that adolescents and young adults who believe that it is okay to end your life are more than 14 times more likely to think about killing themselves than those who do not. A number of additional generational factors could be affecting the middle aged, including increasing need for them to take care of aging baby-boomer parents, or coping with substance abuse or unemployment.

Older Black American adult men reported more suicide ideation and attempts than women. Among the respondents in this study, men reported more attempted suicides and to seriously consider taking their own lives than women. This gender disparity favoring men among older NSAL respondents appears to be unique among other national representative and clinical studies of nonfatal suicide behavior among the elderly, but consistent with studies on the risk for suicidal behavior among Black Americans (Joe et al., 2006; Joe et al., 2009), as well as data on elderly men higher suicide rates (Cattell, 2000; Conwell, 2009). Finally, the fact that the time it takes to go from the onset of suicide ideation to an actual suicide attempt is shorter than what it takes to go from suicide planning to attempts, a difference of 3.2 years, suggests that older Black Americans engage in more impulsive suicide attempts. This is particularly troubling given that older adults often do not directly report thoughts of suicide, which can impede efforts to prevent suicide among this population (Heisel, Duberstein, Lyness, & Feldman, 2010).

The research on the relations between physical illness, health complaints, and suicide among the elderly is equivocal (Cattell, 2000; Crocker, Clare, & Evans, 2006), and few have examined this association among Black Americans in later life. Our finding that older Blacks at higher risk for suicide ideation reported poorer health is consistent with earlier studies that found that medical illness directly contributes to suicide in about seven out of 10 older adult suicides (Cattell, 2000). Older Blacks that reported poorer health were twice as likely to report suicidal thoughts and 3 times more likely to have attempted suicide in their lifetime. The reason the data on the relationship between self-reported health and suicide attempts is only trending toward significance might be due to either there is no relationship or there is not enough power given the lower frequency of cases, however, the magnitude of the odds ratio is worth noting. Future population-level inquiries with larger samples should explore whether the self-reported versus confirmed physical illness might better explain physical health relationship to suicide among older Blacks.

The relationship between the risk for suicide attempts and psychiatric disorder among older Black Americans is consistent with previous results with other ethnic groups that are based on cross-sectional surveys and clinical or community samples (Cattell, 2000; Crocker et al., 2006). Consistent with prior research, psychiatric disorders (Cattell, 2000; Cohen et al., 2008; Conwell, 2009; Crocker et al., 2006), including drug use and dependence diagnosis (Slap, Vorters, Chaudhuri, & Centor, 1989) and comorbid psychiatric disorders (Ialongo et al., 2002; Shaffer et al., 1996), were significant predictors of attempted suicide among older Black Americans. Our analyses showed that Blacks with any psychiatric disorder were 4 times more likely to attempt suicide, even when controlling for known protective factors such as religiosity (Chatters, Taylor, Lincoln, Nguyen, & Joe, 2011) and region (Walker, Lester, & Joe, 2006). Unlike previous research on older adults’ suicidal behavior, affective disorders were not significant predictors among NSAL respondents. Having an anxiety disorder increased the risk for attempted suicide 6 folds and was the strongest psychiatric suicide risk factor among Blacks in later life. Among anxiety disorders, the two that confer higher risk for attempted suicide for older Blacks were generalized anxiety disorder and posttraumatic stress disorder. These results on the role of anxiety disorder in nonfatal suicidal behavior among Blacks are consistent with other adult population studies (Joe et al., 2006). The greater the number of psychiatric disorders an individual has, the higher the risk of attempting suicide (Ialongo et al., 2002). According to our analyses, older Black Americans with three or more psychiatric disorders are 8 times more likely to attempt suicide and 5 times as likely to seriously consider taking their own lives. Despite the apparent need for psychiatric treatment among suicidal older Black Americans, we found that roughly one in four attempters and two in five ideators have never sought treatment for their emotional or psychological problems. Approximately two thirds of the suicide attempters in our study report seeking treatment for their emotional problems in the general medical sector, which is common among the elderly that engage in suicidal behavior (Cohen et al., 2008). In fact, Neighbors and colleagues found that older Black Americans tend to seek mental health care in the general medical sector more than the mental health sector (Neighbors et al., 2008).

Despite the large sample size and having a nationally representative sample, the results reported here are limited by relatively small numbers, which might account for several nonsignificant associations with several socioeconomic (e.g., marital status and region) and psychiatric variables (e.g., affective disorders). However, the number of respondents reporting this fairly rare event is consistent with similar large-scale psychiatric epidemiological studies (Kessler et al., 2005; Kessler et al., 1999). However, the fact that we do not know the extent to which cultural attitudes and factors affected the willingness of our respondents to either admit or recall the presence of symptoms or suicide over their lifetime is of concern. The results may also be affected by recall bias associated with the respondents’ age and mental health status. The NSAL is cross-sectional, obtaining retrospective reports; thus the prevalence rates are likely to be lower bound estimates (Kessler et al., 1999). Despite these constraints, the effect of most of the limitations noted above is to make our prevalence estimates more conservative than might otherwise be the case. In view of current gaps in our understanding of the risk for suicidal behavior among older Blacks, these constraints seem acceptable in light of information concerning the prevalence and correlates of suicide risk in this diverse population sample of Black Americans.

The study provides the first nationally representative general population data on ethnic differences in lifetime suicide ideation and attempts among Black Americans in later life. Given our results that a majority of attempters went to a health professional for their emotional problems and about a third of them went to a general medical professional, physicians have an important role to play in the prevention of suicide among older Black Americans. The results of the study should influence clinicians who screen for risk for suicide. For instance, clinicians should focus on modifiable risk factors (e.g., anxiety). Physicians and mental health professionals should be skilled in talking with Black clients about the risk for suicide, providing interventions for those at imminent risk for suicidal behavior, and referring clients for expert assessment and treatment.

Funding

The data collection on which this study is based was supported by the National Institute of Mental Health (NIMH; U01-MH57716) with supplemental support from the Office of Behavioral and Social Science Research at the National Institutes of Health (NIH) and the University of Michigan. Drs. Joe, Taylor, and Chatters involvement in the preparation of this manuscript was supported by a grant from the National Institute of Mental Health (R01-MH082807).

Footnotes

Acknowledgements

We appreciate the assistance provided in all aspects of the NSAL study by the Program for Research on Black Americans (PRBA) faculty, and research staff, including Lili Deng and Myriam Torres. We appreciate the assistance of Katie Taylor, Mary Oliver, and Daniel Ureche from the Research Lab on Race and Self-Destructive Behavior.

Biographies

Sean Joe, PhD, holds a joint position as Associate Professor in the School of Social Work and Department of Psychiatry at the University of Michigan’s School of Medicine. He is the Associate Director for Research and Training at the Program for Research on Black Americans at the Institute for Social Research at the University of Michigan. Dr. Joe is the Principal Investigator of research projects focusing on the role of religion in Black American suicidal behavior (NIMH), adolescents mental health service use patterns, and salivary biomarkers for adolescent suicidal behavior. He has published in the areas of suicide, racial barriers to mental health service use, violence, and firearm-related violence.

Briggett C. Ford, PhD, focuses her work on mental illness and service young among older Black Americans. Her research interests also include examining the influence that exposure to violence and trauma has upon the mental health of African Americans. Currently she is involved in the analysis of data from the Detroit Psychiatric Institute Race and Diagnosis Study and the Ypsilanti Area Cognitive Interview Study. She is also involved in a clinical validation study which focuses on diagnostic comparisons between the Structured Clinical Interview for DSM-IV (SCID) and Composite International Diagnostic Interview (CIDI).

Robert Joseph Taylor, PhD, is the Sheila Feld Collegiate Professor of Social Work, University of Michigan. He is also the Director of the Program for Research on Black Americans at the Institute for Social Research. Professor Taylor has published extensively on the informal social support networks (i.e., family, friends, and church members) of adult and elderly Black Americans. He has been principal investigator of several grants from the National Institute on Aging that examine the role of religion in the lives of Black and White elderly adults. He has been coprincipal investigator with James Jackson on several grants from the National Institute of Mental Health on the correlates of mental health and mental illness among Black Americans.

Linda Chatters, PhD, has a joint appointment as Professor in the Department of Health Behavior and Health Education (School of Public Health) and in the School of Social Work. She is also a faculty associate with the Program for Research on Black Americans at the Institute for Social Research, University of Michigan. Dr. Chatters’ research focuses on adult development and aging as it relates to the mental and physical health status and functioning of older persons in a variety of social contexts (i.e., the family, church, and community). Dr. Chatters has been designated by Thomson-ISI as a highly cited researcher in the category of general social sciences. ISI Author Publication Number A0347-2004-0.

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