Tom Rote, 70, lives alone on his property in Harrisburg. Many of his friends and family members have died in recent years, and he can no longer do some of the activities he used to enjoy, like flying in hot air balloons, now that he’s older.

Rote’s circumstances check every box when it comes to risk factors for depression.

He’s a white male, over the age of 65, living alone in a life full of loss. While these factors can increase the risk for depression in all people, for older adults they pose a bigger threat — silent suicide.

Among older adults, suicide prevalence is already high — and drastically underreported

Adults 65 and older make up only 12% of the population but account for 18% of all suicides, according to the American Association of Marriage and Family Therapy.

In Missouri, the suicide rate for adults over 85 is almost 50% higher than the national average. This statistic could be higher because suicide can be difficult to identify in the elderly.

It’s not always clear whether people forgot their medication or intentionally disregarded it, whether they were too sick to eat and drink or just didn’t want to.

Slipping away

“Silent suicide is the intention, often masked, to kill oneself by nonviolent means through self-starvation or noncompliance with essential medical treatment,” according to forensic psychiatrist and author Robert I. Simon, who taught at Georgetown University and conducted one of the only published studies on silent suicide among the elderly.

David Fleming, who specializes in geriatric medicine at MU Health, said that intervention can be difficult. If patients stop caring for themselves, doctors can only do so much.

If he notices a patient is knowingly and willfully not eating, for example, he can’t ethically force them to use a feeding tube if that patient has decision-making capacity.

“There are times we have to say, ‘OK, we’ll support you in that.’ And we let them do it,” Fleming said.

Senior living specialist Samantha McCay said she’s seen many elderly people become depressed because they feel useless or just “old and in the way,” as Rote describes himself. For people who have struggled with substance abuse in the past like Rote, this feeling can trigger a relapse.

“Silent suicide definitely is an issue because … some people, if they used to be alcoholics, maybe at a certain point, they start drinking again,” McCay said. “There’s just a lack of care for themselves.”

Lonely struggle

Rote struggled with alcoholism after his wife was injured in a car accident on the way home from their honeymoon decades ago.

“She was in a coma for nine months, and I got a couple of DWIs trying to drown my sorrow, and I went to a mental health center,” Rote said.

His wife woke up from the coma, but she had no memory of him. They eventually divorced, and while he’s had a few girlfriends since, he never remarried.

He now lives in a small house surrounded by photographs and memories of his adventurous past life. Rote said he enjoys going to bars and coffee shops in Columbia, but that’s a 20-minute drive from his home.

During snowy winter months, just getting out of his long gravel driveway can be difficult. He never had children and spends most of his time alone, looking at old pictures or chopping firewood.

This sort of isolation from the community is another risk factor for depression. Rote likes to spend time in a local senior center, but even there he can often be found sitting alone. The grief of losing relatives, combined with little to no interaction with others, makes it even more likely that he will experience depression.

Warning signs

There are many warning signs of depression in the elderly besides isolation, such as withdrawal from activities and changes in sleep and appetite. However, they are not always easy for doctors to recognize.

In fact, 70% of seniors who die by suicide visit their primary medical care provider within a month of their death, according to the American Association of Marriage and Family Therapy.

Peter Koopman is an associate professor of clinical family and community medicine at MU who has taught about geriatric depression for more than a decade. One reason it can be difficult to diagnose depression in elderly people is that they’re often more apathetic in describing their emotions.

Younger patients are much more likely to come in and say they feel depressed, he said, but older adults usually do not. Additionally, the majority of patients over 65 have at least one chronic illness, and doctors treat those physical illnesses as the highest priority for older patients.

“It’s easier for depression to go unnoticed because you’re dealing with their hypertension, their diabetes, and often as physicians, appropriately, we want to deal with their chronic physical diseases and make that part of our agenda,” Koopman said.

The best way for physicians and family members alike to check for depression is by asking what’s going on if there’s a change in behavior, even though it may be uncomfortable, he added.

“Most of the medical literature would talk about how you have to be direct about it if you’re going to ask about it,” Koopman said. “And you have to ask about it if you’re worried about depression.”

Treatment options

After depression is diagnosed, treatment can be a little more complicated for the elderly population as well because some antidepressants interact negatively with other medications. Cynthia Baker, a licensed clinical social worker with a certified specialty in gerontology at The Bluffs, a senior living center in Columbia, said a combined approach including cognitive behavioral therapy is the best option.

“What we’re finding is, and the research absolutely supports, the combination of the counseling or the psychotherapy with an antidepressant or mood related medication has the best outcome for reducing depressive symptoms,” Baker said.

While aging often requires adapting to a different lifestyle, depression is not a normal part of getting older, according to the Centers for Disease Control and Prevention. Depression is highly treatable, and elderly individuals experiencing depressive symptoms are encouraged to reach out to family members and their medical care providers to receive proper treatment.