Journal of Gerontological Social Work
ISSN: 0163-4372 (Print) 1540-4048 (Online) Journal homepage: https://www.tandfonline.com/loi/wger20
Depression, Hopelessness, and Suicidal Ideation
Among the Elderly
A Comparison Between Men and Women Living in Nursing Homes and in
Pnina Ron PhD
To cite this article: Pnina Ron PhD (2004) Depression, Hopelessness, and Suicidal Ideation
Among the Elderly, Journal of Gerontological Social Work, 43:2-3, 97-116, DOI: 10.1300/
To link to this article: https://doi.org/10.1300/J083v43n02_07
Published online: 04 Oct 2008.
Submit your article to this journal
Article views: 2165
View related articles
Citing articles: 37 View citing articles
Full Terms & Conditions of access and use can be found at
and Suicidal Ideation Among the Elderly:
A Comparison Between Men
and Women Living in Nursing Homes
and in the Community
Pnina Ron, PhD
ABSTRACT. This study attempts to compare levels of depression,
hopelessness, and suicidal ideation among elderly males and females, in
reference to their living arrangement, i.e., community vs. nursing homes.
For many elderly people, old age is characterized by various losses:
physiological, functional, social, cognitive, financial, etc. The outcomes
of such losses often include, more often than not, environmental isolation, a subjective feeling of loneliness, anxiety, depression, and frequently, loss of motivation to continue living. In light of the rise in life
expectancy and the multitude of losses which can be associated with the
aging process, it is probable that one out of five elderly persons will
spend part of his/her life in a long term care institute. Such living arrangements may have negative effects on the mental health of its residents, because placement is often accompanied by feelings of lack of
control over one’s own life, and inability to make decisions regarding
daily issues. Elderly persons living in the community (227: 78 men, 149
women) and 91 living in nursing homes (33 men, 58 women), in both independent and frail functional status (ADL), participated in the study.
Findings show significantly more hopelessness, helplessness, and dePnina Ron is affiliated with the School of Social Work and Faculty of Social Welfare and Health Studies, University of Haifa.
Journal of Gerontological Social Work, Vol. 43(2/3) 2004
© 2004 by The Haworth Press, Inc. All rights reserved.
Digital Object Identifier: 10.1300/J083v43n02_07
JOURNAL OF GERONTOLOGICAL SOCIAL WORK
pression among residents of nursing homes compared to those living in
the community, differences between men and women living in both environments, and a correlation between other demographic variables and
the three dependent variables of the study. The conclusions of the study
indicate a need to pay interdisciplinary attention to the mental health of
elderly residents of nursing homes, particularly in the preliminary stages
of placement and adjustment. [Article copies available for a fee from The
Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address:
© 2004 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Elderly, gender, community, nursing home, depression,
hopelessness, suicidal ideation, losses, environmental isolation, loneliness, anxiety
Factors Affecting the Development of Depression Among the Elderly
Old age is characterized by various losses. Physiological losses may be due
to sickness and functional disabilities; sociological losses include retirement
from work, loss of social and family networks; and personal losses are related
to personality components, a reduced sense of control over one’s life, diminished self-esteem and self image, and increased difficulty when coping with
stress and crisis situations (Goldberg & Huxley, 1992; Jorm, 1995; Lovestone &
Howard, 1997). These losses create a dependence on others (in different life
aspects and to varying degrees) as well as a subjective sense of loneliness
(Achte, 1988). Coping with these losses ad their effects may lead to depressive
Among the outcomes of losses in old age, we can find different kinds of disturbances including mental, behavioral, emotional, etc. (Bar-Tor & Lomerantz,
1997). Mental disturbances include psychotic symptoms, such as paranoid delusions, the various types of depression, and especially reactive depression
(Goldberg & Huxley, 1992; Katona, 1994). Researchers argue that somatic
symptoms of depression are more frequent among the aged population because of reduced quality of life, fear of death or dementia, and accumulation of
non-channeled anger (Tolchin, 1989; McIntosh, 1992).
Because of the multitude of losses experienced in old age, the time elapsed
between the adjustment to one loss and the occurrence of another is reduced
substantially. This reduction makes it difficult to distinguish incidences of abnormal depression and normal reactive depression (Rose, 1993).
Various research studies have investigated the correlation between depression and cognition, behavior, and suicidal tendencies (Robbins & Regier,
1991; Weyerer et al., 1995). Several researchers suggested five categories of
depressive symptoms that indicate suicidal tendency: general appearance and
behavior (uncombed, introverted, etc.); cognitive function (disorientation,
memory loss, etc.); content of thought patterns (disorganized thought, hopelessness, etc.); mood (sadness, anger, etc.); and somatic function, such as lack
of appetite, sleeplessness, etc. (Schmid, Menjee, & Shah, 1994). Other researchers found that hopelessness is the major element in suicidal ideation and
tendencies among depressed elderly (Rifai et al., 1994).
Lester (1994) reported the hints revealed by the depressed elderly population in regard to suicidal tendencies. These included situational hints, such as
frequent negative life events; loss of living environment, personal, and
inter-personal losses; hints of a psychological syndrome, such as anxiety and
guilt; behavioral hints, such as preparing for death and changes in lifestyle and
habits; and verbal hints, such as talk of personal death, suicide threats, and expressions of helplessness and hopelessness.
Characteristics of the Elderly Who Are “at Risk”
of Suicidal Ideation and Behavior
As in younger population groups, there is no “profile” describing the elderly who are “at risk” of suicidal ideation. Nevertheless, there do seem to be
several characteristics that are more frequent among those elderly who attempted or committed suicide.
White male widowers aged 65 and over are at higher risk than the remaining population groups. Since 1980, the rate of suicide among this group has
risen in the U.S. by 23% (Meeham, Saltzman, & Sattin, 1991). Atchley (1991)
further defined the population group with the highest potential to commit suicide, arguing that this white male aged 65 and up had also recently lost his
spouse and in addition suffers from a terminal illness or deteriorated physical
ability. The risk of suicide among these males rises with age and reaches its
peak at the age of 80. Other researchers focused on elderly females at risk
(Lovestone & Howard, 1997).
Most of the researchers dealing with suicide risk factors among the elderly
indicate physiological and the functional disabilities as the main reasons for
JOURNAL OF GERONTOLOGICAL SOCIAL WORK
suicide (McIntosh, 1992; Norris, Snow-Turek, & Blankenship, 1995). Frequent use of medication and sometimes overuse and a combination of different medications can also be a risk factor for suicide.
Mental and Inter-Personal Characteristics
The feeling of loneliness experienced by the elderly is subjective and may
result from lack of social bonds, loss of spouse, and feelings of alienation and
emptiness (Lowenstein & Rosen, 1989; Bondevik & Skogstad, 1996). This
feeling is accompanied in most cases, with the feeling of depression and low
self-esteem (Mullins & McNicholas, 1986), which might lead to the development of suicidal tendencies.
Glass and Reed (1993) added that most of the elderly with suicidal tendencies were not characterized by past suicidal attempts or other self-destructive
behaviors; rather, these elderly consider ending their lives following a realistic
assessment of their situation, in which they identify numerous possible reasons, such as the accumulating effect of loss they have experienced, reduction
in job, family and community roles, reduction in income level, a sense of worthlessness and uselessness, functional damage, tendency to develop chronic illnesses accompanied by pain and suffering, placement in nursing home, etc.
Achte (1988) argued that it was not evident whether the relatively high rate
of suicide among the elderly was the result of loneliness and financial insecurity in modern society or whether it should be attributed to cognitive-pathological processes frequently found in older age, which increase the risk of suicide.
Reviewing these suicide risk factors among the elderly, Achte supported the
multi-causal etiology composed of loneliness, isolation (withdrawing from
the environment), somatic illnesses, and depression.
According to Dykstra (1993; 1995), the highest risk of suicide stems from
the feeling of failure and lack of support. These feelings usually originate from
changes and transitions experienced by the elderly during a time when their
adjustment powers are diminished (Osgood, 1991; Peters & Liefbroer, 1997).
Findings show that in Israel, only 5% of the elderly aged 65 to 79, 10% of
the elderly aged 80 to 84, and 20% of the elderly aged 85 and up live in nursing
homes (Bergman, Factor, & Kaplan, 1986). In light of the rise in life expectancy, the number of persons aged 80 and over is constantly increasing; hence,
the percent of elderly residing in nursing homes is also rising (Lowenstein &
Yakivitz, 1995; Bar-Tor & Lomerantz, 1997).
Various research studies have indicated low mental well being among elderly residents of nursing homes (Estes, 1980; Berkowitz, Waxman, & Yabbe,
1988). On the other hand, other research studies have reported an increase in
quality of life and personal welfare experienced by the elderly upon placement
in nursing homes (Sherwood, Glassman, Sherwood, & Morris, 1974; Carp,
Bar-Tor and Lomerantz (1997) found that mental and physical expressions
of depression are frequent among elderly residents of nursing homes. The
mental symptoms included melancholia, lack of general interest in life, fears
and isolation, and the physical symptoms included lack of appetite and sleeplessness. Suicidal ideation and tendencies are defined as thoughts and feelings
characterized by helplessness, lack of direction and significance in life, and
hopelessness. Suicidal behavior is an expression of these feelings and
thoughts and includes irregular intake or complete cessation of medication,
ceasing to eat leading to drastic weight loss, sleeplessness, activity reduced to
a minimum, personal, and hygienic negligence, etc. A large part of these
symptoms also characterize depression.
In the United Kingdom, the rate of depression among the elderly population
residing in the community is about 15%, and it is higher among women than
men. The rate of depression rises to 40% among the elderly population residing in nursing homes or geriatric hospitals, in similar states of functionality
and health (Lovestone & Howard, 1997).
Empirical studies carried out in the United States indicate similar rates of
depression (in its various types) among elderly residents in the community and
in nursing homes (Lester, 1994).
In general, few comparative studies have been made investigating the rate
of depression among the elderly residing in nursing homes and in the community. One study addressed the issue of differences in health and functioning
levels between the two population groups as research limitations (Stuck et al.,
1993). Another study, investigating health background and the consumption
of sleep medication and anti-depressive drugs, found that elderly women living in the community consumed more anti-depressive drugs than did men in
similar living conditions, whereas in nursing homes, the consumption rate of
these drugs is similar among men and women, with only slightly higher usage
by men (Rubenstein et al., 1984).
In a comparison regarding the frequency and different rates of depression, it
is necessary to address the health history of the research participants, which
may precede placement in the nursing home (Baldwin & Jolley, 1986; Green
et al., 1992).
In Israel, no research studies have compared the mental health of elderly residing in the community with that of a similar population group residing in
nursing homes. Moreover, there is no data comparing suicidal behavioral expressions, suicidal attempts, or suicides among the two population groups. It is
difficult to locate sampling groups of elderly persons living in both types of
JOURNAL OF GERONTOLOGICAL SOCIAL WORK
environments who also share basic characteristics, such as functional level,
marital status, etc. Clearly, the mental state of an elderly person who arrives at
a nursing home due to unwillingness to continue living at home after the loss
of a spouse does not resemble that of a widowed elderly person who chooses to
remain at home. The emotional vulnerability of elderly individuals who chose
the nursing home is more intense, as they need to adjust both to the loss of the
spouse as well as to the nursing home.
The Statistical Almanac does not differentiate between suicides committed
by elderly living in the community and in the nursing home (Israel Central Bureau of Statistics, 1986, 1990, 1994). The reasons for this include institutes’
unwillingness to publish data that might damage their image, Judaism’s attitude towards suicide, the religious sanction placed upon those committing suicide in regard to place of burial, commemoration, etc.
In an attempt to explain the possible differences between residents of nursing homes and the elderly living in the community, in terms of frequency and
levels of depression, Henderson et al. (1994) focused on the change of environment. In addition to separating the elderly individual from his/her physical
surroundings, in most cases, a separation forced due to a deteriorated functional-health situation or loss of a spouse is often accompanied by emotional-social separation. This separation causes isolation and seclusion of the
elderly individual and, hence, depression.
Other researchers indicated that family support was the most effective factor influencing the sense of depression experienced by residents of nursing
homes (Burvill et al., 1991; Green et al., 1992; Peters & Liefbroer, 1997). According to their findings, placement in a nursing home creates a sense of alleviated responsibility, since it is henceforth shared among family members,
friends, and the nursing home staff. This sense of a lessened burden in turn affects the frequency of visits, and the degree of support provided by the elderly
individual’s informal support systems. However, this behavior may be construed by the elderly as a rejection, which leads to feelings of depression.
Bar-Tor and Lomerantz (1997) indicated five factors affecting the deteriorated mental welfare of nursing home residents. These factors include negative stereotypes of nursing home staff; society’s negative stereotypical
attitude towards nursing home residents; lack of control in a nursing home
framework; insecurity and lack of privacy; disconnection from family and
friends. Solitary elderly people, as well as those lacking any informal support
system, who live in the community but are not in touch with family and
friends, express similar high levels of depression, and the rate of attempted
suicide among them is high.
The following research attempted to compare the levels of depression and
suicidal behavior between two population groups: frail elderly people residing
in nursing homes and those living in the community. An additional point of
comparison was between men and women. In the course of the research, a
comparison was made between these groups in regard to three dimensions:
level of depression, level of hopelessness, and level of suicidal ideation.
The contribution of this research lies in its comparison between two parallel
populations and in its specific focus on elderly who exhibit high rates of suicide. Identifying the characteristics of these risk groups may enlighten professionals and contribute to the planning, assessment, and application of suicide
prevention programs for the elderly in the community and those residing in
The research population consisted of two groups categorized according to
living environment: community and nursing homes (see Table 1).
1. The group living in the community consisted of 149 elderly women and
78 elderly men, in frail condition. The participants, insured in the general health insurance fund (Kupat Holim Klalit), defined themselves as
in need of partial assistance in their ADL function. All were interviewed
while waiting for their appointment at clinics treating a high percentage
of elderly patients.
The clinics were sampled at random from a list of clinics treating the elderly population, within a certain geographical urban area. In the clinic,
the participants were sampled by convenience sampling. Defining characteristics of the two research groups included variables such as knowledge of the Hebrew language, perceived functional situation, and
present place of residence. These factors were determined before conducting the interview.
2. The group residing in nursing homes consisted of 91 elderly persons (58
women; 33 men) aged 67-86 living in “independent and frail” quarters
at three nursing homes within the same geographical area as the sampled clinics and the community participants. The residents were sampled at random. One of three residents defined was selected from a list
of 214 fluent Hebrew speakers corresponding to the research population. One of the nursing homes on the list had only 12 residents, so addi-
JOURNAL OF GERONTOLOGICAL SOCIAL WORK
tional residents were interviewed by convenience sampling in order to
maintain a balance between residents of all three nursing homes.
Table 1 shows that most of the demographic variables of the subjects in
both groups have a similar distribution. The proportion of men and women in
both research groups is similar and closely resembles that of the elderly population in Israel. Most of the participants are European-American (this datum
relates to the fact that the majority of participants were Holocaust survivors).
Most participants subjectively described their socio-economic status as moderate, and none had attempted suicide in the past. The two groups were not
matched on some variables. Most of the elderly living in nursing homes were
widowed, whereas most of the participants living in the community were married. It is possible that being widowed constitutes an accelerating factor for
TABLE 1. Characteristics of the populations.
Elders in the
(N = 227)
(N = 91)
Marital Status %
Country of Origin
Socioeconomic Status %
Previous Suicide Attempts
Previous Mental Therapy %
Holocaust Survivor %
Average Ag ...
Purchase answer to see full