Middle-Aged Suicide on the Rise: What Are the Top Risk Factors? - BRIGID Magazine

Friday, June 15, 2018

Middle-Aged Suicide on the Rise: What Are the Top Risk Factors?

Image: Francisco Moreno
The suicides of fashion designer Kate Spade and chef Anthony Bourdain highlight the importance of paying attention to rising suicide rates. In the United States, the most dramatic increases in suicide deaths have been amongst the middle-aged.

The total suicide rate in the U.S. in 2016 was 13.5 per 100,000 people, up from 10.4 in 2000. (For comparison, the suicide rate in Canada, as of data published in 2015, was 11.3 per 100,000.)

Among the 45-64 age group, suicide rates rose from 6.2 per 100,000 in 2000 to 9.9 in 2016 for women, and from 21.3 per 100,000 in 2000 to 29.1 in 2016 for men. Suicide rates also rose in the 25-44 age group for both genders. For more information, read the Centers for Disease Control and Prevention's June 2018 suicide rates document.

What are the factors leading to this increase in suicide rate, specifically among American middle-aged individuals?

Samantha Boardman, a clinical instructor in medicine and psychiatry at Weill Cornell Medical College in New York City told The Wall Street Journal that "Life satisfaction hits an all-time low in middle age," and rates of depression are very high in this age group. Feelings common to the middle-aged include despair, lack of control, and a general sense of overwhelm. Newly-declining health can also be a major factor contributing to stress and depression.

Those who have had depression throughout their adult lives but were never treated can experience a worsening of symptoms in the fourth through sixth decades of their lives, according to Catherine Burnette, assistant professor at Tulane University School of Social Work in New Orleans.

Over 90% of those who die by suicide have been determined to have a mental illness. The four mental health conditions with the highest risk of suicide are borderline personality disorder, anorexia nervosa, depression, and bipolar disorder, according to a 2014 meta-review published in World Psychiatry.

Since depression is one of the features in bipolar disorder (formerly called manic depression), and since depression commonly co-occurs with both borderline personality disorder and anorexia nervosa, we will focus here on the risk factors for developing depression.


The Main Risk Factors for the Development of Depression


Cognitive Risk Factors for Depression


Image: Ian Espinosa
People react differently to adversity — this is a given. Early researchers of depression recognized that some individuals are "characteristically prone to preferentially focus on and exaggerate the negative, especially around themes of loss and depletion," wrote Constance Hammen, distinguished professor in the Department of Psychology and the Department of Psychiatry and Biobehavioral Sciences at the University of California, Los Angeles. This has been called depressive cognition.

However, depressive cognition is both a risk factor and a symptom of depression, and is not a direct cause of depression in itself. In other words, it takes far more than just a negative frame of mind to lead to depression.

It's clear that some individuals do appear to be born with a temperament that is more vulnerable to negative experiences, but we also learn coping and response strategies from family members and caregivers beginning very early in our lives. These are all factors that can add to depressive cognition and one's susceptibility to depression.

"Depressive disease is not, in itself, inherited; instead [...] individuals are born with, are exposed to, and acquire causal risk factors and mechanisms, such as temperament, cognitive and coping styles, reactivity to stress, and relational styles, that eventuate, through both environmental and biological processes, in depression." -Constance Hammen


Life Stress, Stressors, and Interpersonal Factors in Depression


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Negative events and life stress can trigger depression. Hammen said that "the environment as construed" is the proximal, or central, trigger of depression. This means that something negative and likely chronic often has to be going on in an individual's life in order for depression to develop. It's the stressor or set of stressors, in other words, along with the individual's judgment or perception of them, which leads to depression.

More than 80% of people who meet criteria for clinically significant depression report having experienced a recent major life event or ongoing stressor. And the great majority of these stressors were deemed "objectively severe stressors" — in other words, not merely stressful to the individual, but they would be stressful to anyone experiencing them.

That said, some traits and interpersonal styles can generate stress for an individual — such as rumination, neuroticism, and insecure attachment. These traits and interpersonal styles have genetic components, and can lead the individual to make choices that put them into more stressful situations. But it's important to never blame these individuals for their experiences of stress or for their depression. Depression is far more complex than that.

Childhood adversity (for example, sexual or physical abuse, or poverty) lowers the threshold of stress required to trigger depressive episodes. This can lead to a kind of cyclic nature of depression from very early in life. "Exposure to adverse conditions in childhood sensitizes individuals to be more likely to experience major depression," Hammen said.

Stress has a major impact on brain, endocrine, and hormonal development, which likely explains the susceptibility to developing depression and mental illness seen in many survivors of adverse childhood experiences.

One major source of stress for women is interpersonal conflict. Researchers who focus on the social origins of depression have found that depression in women can form over time in response to negative or painful interpersonal experiences, such as social rejection or loss of important relationships. Impaired or dysfunctional intimate relationships are major triggers of depression.


Parental Depression and Its Impact on Children 


Image: Joshua Rawson-Harris
When a parent is depressed, especially when that parent is a depressed mother, there is a high chance that the child will struggle with depression, according to a review by William R. Beardslee et al. that was published in the Journal of the American Academy of Child & Adolescent Psychiatry. The review found that by the age of 20, children of depressed parents had a 40% chance of experiencing a major depressive episode.

And another review conducted by Sherryl H. Goodman et al. looked at children of depressed mothers and found that these children had problems with overly internalizing or externalizing problems, and had increased rates of psychopathology. Other studies showed that children of depressed parents had significantly higher rates of "cognitive, social-interpersonal, academic, and health difficulties."

Depressed parents pass on the following risk factors of depression to their children:

  • Exposure to stressful life events and situations (like marital conflict, family discord, and general instability).
  • Maladaptive behaviours, beliefs, and cognitions expressing negative and damaging views of the self, the world, and the future.
  • Poor coping strategies for dealing with stress and adversity.


What To Do If You Suspect Someone You Know is Depressed


Image: Helena Lopes
Several articles and social media posts since the deaths of Spade and Bourdain have pleaded for those with depression to reach out for help. Unfortunately, it's often difficult for a depressed individual to reach out, since one of the main features of depression is a tendency to isolate and turn inward. And not all people who are depressed know that they are depressed.

What NOT to do: Do not shame the individual or make them feel bad for the way they feel. Depression is not their fault, and it is not something they chose. Depression is not a weakness or personal flaw. 

According to Angela Dee, shame can take many forms in the words we choose when talking to those with depression. Shame-filled words like these tend to increase the tendency to isolate (in other words, avoid saying them):

  • "You have such a great life and so much to be thankful for. Why are you so sad?"
  • "But you seem so sure of yourself and successful."
  • "Aren't you over it by now? Look how much you have to be happy about."
  • "You should have called me or texted. I would have helped."
  • "Have you tried meditating or yoga? How about cardio?"


The best way to help is to be there. Tell your loved one that you're here for them, you love them, and provide practical assistance if they want it. Psychologist Deborah Serani suggests first asking, "What can I do to help you feel better?" Offering unwanted advice or trying to fix the person can make them feel insulted and inadequate.

It's important to remember that "those who need the most help are usually the least capable of asking for it and the least likely to show their pain," hiding it instead behind humour or a cool and together exterior, Dee says.

by Kristen Hovet

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