By Kelsey Harnisch, Megan Yarck and Kiva Hanson
Oregon’s elderly population has the highest rate of suicide in the state. According to data from the National Violent Death Reporting System, the suicide rate for Oregonians aged 65 and older is nearly twice as high as the rate for young people.
“We have an enormous amount of work being done around youth suicide prevention,” says Roger Brubaker, suicide prevention coordinator for Lane County. However, “the vast, vast majority of people who are dying and who are at greatest risk of death by suicide are middle-aged and older adults, and not youth.”
In Oregon, funding for suicide awareness has often gone toward youth programs. In 2019, four pieces of legislation were passed addressing youth suicide.
The five bills that would have addressed older adult suicide didn’t pass.
Researchers and advocates agree that funding for youth suicide is needed, though some worry that older adult suicide prevention is being ignored.
“That’s not surprising nor would we debate it,” says Dr. Jim Davis, chair of the Older Adults and People with Disabilities Behavioral Health Advisory Council, of funding for youth suicide. “What we’re asking for more is that there be actual acceptable and appropriate recognition of the problems that elders are facing.”
Appropriate recognition of older adult suicide has been an issue in Oregon for decades.
“It’s been a problem going back to the days in the ’70s when I was a gerontologist in the state mental health division,” Davis says.
A report from the Oregon Department of Human Resources (DHS), published in 1997, shows that rates for older adult suicide remained steadily above the national average since the 1950s — roughly 60 percent higher.
More recently, the rate of suicide among Oregon’s older adults climbed to 66 percent above the national rate for the same age group, according to 2016 data from the National Violent Death Reporting System.
So why are so many older Oregonians taking their own lives?
Researchers, advocates and those working within the senior behavioral health community agree on some main factors: Older adults in Oregon often have access to firearms and are often isolated in rural communities — both socially and from mental health resources.
These issues, coupled with elder mental health care being low on state legislators’ priority lists, have created an environment for high rates of depression and suicide among Oregon’s older adults.
Very Deadly Means
The vast majority of suicides among older adults in Oregon are carried out using firearms. Seventy-six percent of suicide deaths among older adults in Oregon involved a gun, according to a 2015 report from the OHA.
Last year, of the 465 incidents of gun violence within Oregon, 83 percent were suicide related. Thirty-nine percent were by white males over the age of 65.
“Older adults use what we call very deadly means,” says Nirmala Dhar, Oregon’s statewide older adult behavioral health coordinator. It is “much more final when you use a gun in suicide,” Dhar adds, because guns, as opposed to other mechanisms of death like suffocation or poisoning, have a higher rate of fatality.
The high rate of suicide by firearm among older adults may signal a stronger intent to die.
A 2012 article in the American Journal of Public Health states, “the elderly may be more intent on killing themselves because they are more likely than younger persons to use a firearm, which has the highest case fatality rate of any suicide method,” at 91 percent.
Self-inflicted gunshots have an even greater risk of fatality in seniors because of their physical frailty. According to a 2002 article from the American Journal of Geriatric Psychiatry, older adults have “greater frailty and decreased ability to survive the physical insult” of a self-inflicted gunshot wound.
Gun deaths in America have been difficult to study, however, due to a decrease in Centers for Disease Control funding earmarked for firearm injury research — what’s known as the Dickey Amendment.
In 1996, lawmakers, urged by the National Rifle Association, established the Dickey Amendment, which prohibited the CDC from studying gun violence by reducing its funding. In 2018, in the wake of the Marjory Stoneman Douglas High School shooting in Florida, Congress loosened the regulations, allowing gun violence research but still prohibiting “funding to advocate or promote gun control.”
In an attempt to work around the regulations of the Dickey Amendment, The Oregonian collected data from a variety of sources, including concealed-carry licenses and homicide and suicide rates in Oregon counties, to find a correlation between gun ownership and gun deaths.
The data show that Oregon’s more rural counties have a higher rate of gun ownership than urban counties as well as a higher rate of suicide.
But some who work in the field of older adult behavioral health don’t believe access to guns is a main indicator of suicide risk. Many believe the greater threat is social isolation.
“You have individuals that are socially isolated and have become depressed,” says Rod Harwood, an older adult behavioral health specialist who covers some of the state’s most rural counties in eastern Oregon. “Having a firearm in itself is not a threat.”
Oregon is a largely rural state, and many rural counties have an older-than-average population. Wheeler County, for example, has the oldest population in Oregon — the median age there is 57.9, while the median age for the state is 39 — and it’s the least populated. Rural counties like Wheeler also have a higher than average suicide rate.
“In Oregon, suicide disproportionately impacts our rural communities,” says David Westbrook, the chief operating officer at Lines for Life in his February 2019 testimony before the Oregon House Committee on Health Care. “Nearly every one of our rural counties have higher suicide death rates than our urban counties.”
A 2016 report from Oregon State University and the La Pine Community Health center in Central Oregon says: “Residents in rural areas of the U.S. are 1 1/2 times more likely to die by suicide compared with their counterparts in U.S. cities.”
Those involved in older adult behavioral health believe the higher rates of suicide in rural counties can be attributed to social isolation and loneliness.
“You have an older gentleman who his whole life has been his job. That’s his social connection. That’s his identity,” Harwood says. Now, “he’s isolated and alone, and there’s a real high risk that that individual’s going to end up committing suicide.”
Studies have shown that social isolation is a risk factor for suicide, particularly among older adults.
“Social isolation has been linked with increased mortality rates for people aged over 65 years,” according to a 2003 article in the academic journal Aging and Society, and can increase risks of depression and suicide in older adults.
Rural isolation can also make it difficult for seniors to access health care resources because facilities are often few and far between.
“They’re out there all by themselves,” Harwood says. “But along with that, the resources in terms of addressing their medical needs is more challenging too. They have to drive hundreds of miles to get to the doctors they need to see.”
Further complicating access to mental health resources, Medicare, the government-run health insurance program for seniors, only reimburses for clinical psychologists and licensed clinical social workers, neither of which can prescribe antidepressant or antianxiety medications, forcing patients to pay out-of-pocket.
While accessing mental health care can be difficult for seniors living in rural areas, there is an opportunity for clinical intervention during primary care visits.
The Oregon Health Authority (OHA) found that between 2003 and 2012, 29 percent of older adults who committed suicide had seen a physician within 30 days of their death. Primary care physicians have an opportunity to intervene if they’re properly trained in identifying signs of depression in older adults.
An Opportunity for Intervention
In 2012, Dr. Jim Davis co-chaired a legislative workgroup tasked with understanding the scale of mental health and addiction issues in Oregon’s older adult community. In 2013, the group published its final report, which included recommendations to help bring down rates of older adult suicide in Oregon.
Those recommendations led to OHA partnering with Portland State University’s Institute on Aging and, in 2015, the Older Adult Behavioral Health Initiative was established. The initiative created 25 older adult behavioral health specialist positions across the state. These specialists train primary care providers on how to respond to and treat signs of depression and suicidal ideation in older adults.
The initiative is in place “to provide education to the community and to the workforce related to the different issues such as suicide prevention,” Harwood says.
These modules help primary care physicians understand and identify signs of depression in older adults. Due to a generational stigma around suicide, however, few of their older patients disclose any emotional issues they may be experiencing.
“There’s a generation of folks that believe that depression is a choice,” says Chris Eilers, an older adult behavioral health specialist in Lane County. “They don’t bring it to their doctor because they don’t see it as a medical issue.”
But older patients are not the only ones who carry a stigma around suicide among senior citizens.
“In one study, 75 percent of physicians were found to believe that depression in older persons is a ‘normal facet of old age,’” according to a 2006 report from Oregon DHS on older adult suicide in Oregon.
“I think there’s definitely some hesitancy for [doctors] to ask about suicidality,” says Dr. Angela Plowhead, a geriatric psychologist in Salem.
“They figure that if they ask about it that will put the idea in their head,” Plowhead continues. “But that’s not really what the research shows. The research shows that when you give people the opportunity to talk about it, then you can intervene.”
While the older adult behavioral health initiative has been successful in training primary care physicians, specialists say they need more support, especially as Oregon’s senior population continues to grow.
“In many of the counties I serve, we’re already hitting close to 30 percent are older adults. That’s only going to increase,” Harwood says. “You have that many more hitting that age group and you don’t see the state or federal government throwing more money into addressing the needs of these communities.”
“Until the state wants to commit real resources to mental health and addiction services and support systems, I don’t think it’s going to be addressed,” Davis says.
Several pieces of legislation addressing the high rates of older adult suicide have been introduced both in Oregon’s Senate and House in the last several years, but very few have gained the support needed to get passed.
In the 2019 session, the outcome was the same.
Senate Bill 173 would have appropriated $10 million to the Oregon Health Authority to enhance behavioral health programs for seniors.
Senate Bill 174 would have appropriated $2 million to OHA and DHS to establish a Center for Excellence on Behavioral Health for Older Adults and People with Disabilities.
House Bill 2667 would have declared adult suicide in Oregon an emergency and funded the position of an adult suicide intervention and prevention coordinator. House Bill 2667 did not move forward, but the position was included in a youth suicide prevention measure — a small victory in a decade’s-long battle, as the coordinator will focus on all adult suicides, those aged 24 years and older, and not specifically on older adults.
“You wonder if, when [legislators] are having this discussion, they’re even looking at elder suicides and that issue,” says Davis. “It’s a real problem, I think, getting recognition.”
While these measures were not passed, several measures that focused on youth suicide prevention were: A school district suicide prevention plan, a youth suicide intervention and prevention advisory committee and a “communication plan to respond to suspected suicides of persons 24 years or younger” were all enacted this year.
“We have to protect and support our future generations,” Davis says. “But it’s got to be more of an intergenerational approach. You’ve got to be caring about all ages.”
Other advocates say that, even more than any policy or piece of legislation, it’s the culture that has to change around the way we treat our older generations.
“It’s a matter of mental illness, but it’s also a matter of culture,” Brubaker says. “If we are able to shift that culture to be more compassionate, more kind, more supporting, that’s also suicide prevention.”
This story is part of Breaking the Silence, an effort by news organizations across Oregon to change the way we talk about the public health crisis of death by suicide. The National Suicide Prevention Hotline is a free service answered by trained staff 24 hours a day, every day. The number is 1-800-273-8255. Or text 273TALK to 839863.
This story was developed as part of the Catalyst Journalism Project at the University of Oregon School of Journalism and Communication. Catalyst brings together investigative reporting and solutions journalism to spark action and response to Oregon’s most perplexing issues. To learn more visit Journalism.UOregon.edu/Catalyst or follow the project on Twitter @UO_catalyst.
This story has been updated to reflect the correct rate at which rural Americans are more likely to die of suicide.