Older men have the highest rates of suicide in the United States; the overall rate of suicide among men over 65 is about 30 per 100,000 population (Chapter 2). These figures underscore the urgency of examining the barriers to treatment for older people, especially men. The barriers range from general ones—cost of services and stigma—to more specific barriers posed by clinicians and patients.
For older people, the major financier of health services is Medicare. In comparison with private insurance, Medicare carries fewer benefits for mental health services via lower coverage of office visits and limits on hospitalization (US DHHS, 1999).5 Prescription drugs are not covered at all, although this may change under new policy initiatives. One-quarter of older people report that, because of Medicare restrictions, they would not seek mental health services if they needed them (Mickus et al., 2000). Other general barriers to treatment include limited transportation and stigma (Unutzer et al., 1999; US DHHS, 1999). Older people are less likely to accept a diagnosis of a mental disorder and they are less receptive to treatment than are other adults (Gallo et al., 1999; Leaf et al., 1988). They also perceive greater situational barriers to care (Leaf et al., 1988). If they enter treatment, they are more likely to discontinue prematurely because of stigma (Sirey et al., 2001). The significance of these barriers is borne out in overall patterns of utilization. Older persons are less likely to use mental health services than are other adults, and older males are less likely than older females (Burns et al., 2001; Leaf et al., 1987; Olfson and Pincus, 1996; Swartz et al., 1998). Thus, the demographic group most likely to complete suicide—older men—is the least likely to use services.
Several additional barriers, discussed below, relate specifically to suicidality: “ageism” in social attitudes; problems with detection and treatment of depression, the foremost risk factor for suicide in older people (Conwell et al., 1996); and problems in detection of suicidality.
Ageism refers to societal attitudes that devalue life as people age. It is manifest in stereotypes held by the public, older people, and clinicians. Members of the public, for example, perceive suicide in older people as less tragic than suicide in youth (Marks, 1988-1989). Clinicians, family members, and older adults report that suicidal ideation and depression