CGPR: Can you please tell us about the work that you do? 
Dr. Schechter: I’m the chair of the psychiatry department at Mass General Brigham Salem Hospital. I’m also a psychoanalyst and, over the last almost 20 years, I’ve developed an interest in various aspects of suicide—risk assessment, risk management, and working with suicidal patients across different populations. One of my interests is integrating what we know about suicidality from various perspectives—biological, suicide research, psychodynamic, and dialectical behavior therapy approaches.

CGPR: How do risk factors for suicide differ between younger and older adults?
Dr. Schechter: Older adults, particularly White men, have much higher suicide completion rates than younger people (Kulak-Bejda A et al, Front Psychiatry 2021;12:695286). While younger people may make more attempts, older adults make fewer attempts but use more lethal means—their attempt-to-completion ratio is about 4:1 compared to 20:1 in younger populations (Conwell Y et al, Psychiatr Clin North Am 2011;34(2):451–468). We also know that while suicide attempts are one of the strongest risk factors we have, most suicides happen without a prior attempt (Coon H et al, Psychiatry Res 2025;347:116391). We shouldn’t be reassured simply because someone is 75 or 80 years old and has never attempted suicide before. That alone doesn’t reduce the risk, especially when other concerning factors are present. 

CGPR: How can understanding suicide risk factors improve prevention efforts in older adults?
Dr. Schechter: Suicide prevention requires looking beyond diagnosed psychiatric conditions, as CDC data show that more than half of individuals who die by suicide have no known preexisting mental illness (Stone DM et al, MMWR Morb Mortal Wkly Rep 2018;67(22):617–624). While psychological autopsies might later reveal undiagnosed conditions, this highlights the need to assess broader risk factors. In older adults, depression can manifest more through physical symptoms rather than obvious mood changes, making it essential for us to be vigilant in trying to recognize depression and treat it effectively. However, suicide risk isn’t solely tied to depression—social isolation, a lack of belonging, and a perceived loss of purpose play significant roles.

CGPR: What should clinicians be aware of when working with suicidal older adults?
Dr. Schechter: It’s important for us to be aware of subtle ageism—for example, assuming that depression and suicidal thoughts are normal or expected in older people, especially those with serious illnesses (Editor’s note: For more on ageism, see CGPR Oct/Nov/Dec 2024). Patients, families, and clinicians can all fall into thinking, “This person’s old; they have cancer. Of course they’re depressed or suicidal.” We need to recognize these thoughts in ourselves and reframe them. Suicidal ideation is never “normal,” even in the context of terminal illness or advanced age. It always deserves our full clinical attention and therapeutic engagement. Additionally, it’s important that we don’t jump to assuming depression and psychiatric illness for every older person with suicidal thoughts. While depression is an important factor to assess and treat, suicidal thoughts in these populations often stem from existential distress. Instead of reacting with anxiety or immediately resorting to medication or hospitalization, we should engage in open, compassionate conversations that validate the patient’s emotions. 

CGPR: How should clinicians manage their own anxiety when discussing suicide?
Dr. Schechter: First, recognize that anxiety is normal when working with suicidal patients. If you’re engaged in this work and don’t think you have any anxiety about it, you may not be acknowledging your feelings. This unrecognized anxiety can lead us to inadvertently shut down important conversations or resort to false reassurance. The key is to be aware of your anxiety without letting it drive your clinical response. Practice staying present with patients even when discussions are uncomfortable. Our ability to tolerate these difficult conversations often determines whether patients will feel safe enough to share their honest thoughts and feelings.

CGPR: How do you identify true suicidal intent?
Dr. Schechter: Statements like “If I have to do chemo, I just want to kill myself” often aren’t expressing active suicidal intent but rather communicating fear, panic about losing control, or anxiety about suffering. Fears about loss of control and dignity at the end of life are understandable and can be validated and worked through psychotherapeutically. For some patients, these thoughts serve as a psychological escape valve—having a theoretical “way out” helps them cope with their current reality. Suicidal thoughts can sometimes serve as a psychological coping mechanism—helping individuals manage uncertainty and maintain a sense of agency—and suicidal fantasy can have a self-regulatory function that can paradoxically mitigate the need for action (Maltsberger JT et al, J Am Acad Psychoanal Dyn Psychiatry 2010;38(4):611–623). The key distinctions involve specificity of plan, preparations for death, timeline, intent to act, and emotional tone during assessment. Someone talking about suicide as a way to express distress typically responds well to empathic exploration of their underlying fears, while someone with active intent requires immediate safety intervention.

CGPR: What assessment questions help you determine suicide risk in older adults?
Dr. Schechter: Beyond the standard questions about ideation, plan, and intent, I explore contributing factors especially relevant to older adults: “Have you started to feel like you’re a burden to your family?” “Are you afraid of what is coming—of losing control of how things go, losing your dignity?” “Who do you have in your life? Have you lost someone important to you?” “What still brings meaning to your life?” I also assess specific risk factors for older adults—recent losses, physical illness, pain, functional decline, social isolation, and access to lethal means, particularly firearms. The context of their thoughts often reveals more about risk than the thoughts themselves.

CGPR: How do you use suicide screening tools in your practice?
Dr. Schechter: In the hospital setting, we screen patients with standard tools like the Columbia Suicide Severity Rating Scale (C-SSRS), but I view these tools as conversation starters, not endpoints. They help ensure I cover important areas and provide structure to the assessment. After using a screening tool, I follow up on positive responses: “You mentioned having these thoughts daily. Can you tell me more about what that’s like for you?” This transforms a checklist into a meaningful clinical dialogue that often reveals much more than the formal assessment alone.

CGPR: What role does validation play when working with suicidal older adults?
Dr. Schechter: Validation is an experience of nonjudgmental acceptance, even in the context of needing to work toward change. It means accepting a person’s feelings, even their suicidal ideation or behavior, as understandable given their circumstances and experiences (Schechter M, J Am Psychoanal Assoc 2007;55(1):105–130). It is not agreeing that suicide is an appropriate solution. Rather, it communicates, “I understand why you might feel this way given your illness, pain, and losses” while helping the person come to see the negative consequences of suicide—for example, by exploring with them how their death might affect loved ones or how some problems might still be solvable with support. Validation counters the harsh self-criticism and shame many suicidal patients feel. When patients experience validation, they’re more likely to engage in therapeutic work and less likely to hide their thoughts out of fear of judgment or overreaction.

CGPR: How might one counteract an older adult’s feeling that they “no longer matter”? 
Dr. Schechter: The feeling that one no longer matters is central to suicide risk in older adults (Flett GL et al, Int J Ment Health Addict 2021;19(6):2443–2469). When people feel that their life means something and that they matter to someone else, even to a therapist, it becomes a metacommunication: “You matter. You are important.” This potentially mitigates a patient’s wish to end their life. 

CGPR: What strategies can help older adults who feel they’ve become “a burden” to their families?
Dr. Schechter: First, I directly challenge the “burden assumption” by encouraging family meetings where loved ones can express their actual feelings, which almost always differ from what the patient imagines. Patients are often surprised to discover that family members don’t experience caregiving as the burden they feared, and that their loved ones would be devastated by their suicide. Second, I help patients recognize the gifts they still offer—wisdom, love, connection, family history—that have nothing to do with physical capability. Finding ways that they can still contribute, even small gestures like sharing stories or expressing gratitude, helps counter the “burden narrative” that drives many suicidal thoughts.

CGPR: Can you share an example of how repairing relationships can impact a patient’s outlook on life?
Dr. Schechter: I worked with a man who had taken an extremely serious overdose, fully aware of its consequences due to his medical knowledge. He carried deep remorse over his alcohol use disorder and the ways it had made him a terrible father, leading to estrangement from his daughter. During our consultation, I could feel this man’s pain about his daughter and how much he loved her. I asked him why had he never tried to reach out to her. As we explored this, he realized that it was he who had distanced himself out of guilt and shame—she had not actually completely estranged herself from him. Together, we set a goal for his hospitalization: to reach out to her and see what was realistically possible. And he did. That single step mattered. She came to a family meeting, which meant so much to him. That one connection may have been the difference between him choosing to end his life and realizing that there was still meaning, still hope. He recognized that he had been trapped in his past, unable to see what was possible in the present. Once he stepped out of his own head and dismantled the walls he had built, he saw that life could still offer him something worth living for. 

“Suicidal ideation is never ‘normal,’ even in the context of terminal illness or advanced age. It always deserves our full clinical attention and therapeutic engagement.”

Mark Schechter, MD

CGPR: How can clinicians discuss firearm safety with older adults at risk of suicide?
Dr. Schechter: Firearms are involved in most suicides in the US, and the percentage is higher among older adults—around 70% (Price JH and Khubchandani J, J Community Health 2021;46(5):1050–1058). Having a gun in the home significantly increases suicide risk, particularly for men (Studdert DM et al, N Engl J Med 2020;382(23):2220–2229). While removing firearms entirely is the safest option, this isn’t always feasible due to personal rights and preferences. For individuals experiencing severe depression, a simple conversation can help reduce risk: “You’re struggling right now; can we move the gun out of the house for the time being?” Families should also consider firearm safety when cognitive decline begins. If complete removal isn’t accepted, discuss graduated options: removing ammunition, storing guns and ammunition separately, using trigger locks, or giving keys to gun safes to a family member. It may also be helpful to ask about access to firearms—even those who don’t currently own a gun may know how to obtain one quickly. Taking steps to delay access and create space for intervention can ultimately reduce the likelihood of suicide—whether by firearm, overdose, or other means. 

CGPR: How do you help older adults rebuild a sense of hope when facing terminal illness?
Dr. Schechter: Hope is an expectation, even if uncertain, that there’s a future that can hold some good or some meaning that is realistically possible. But what that means changes for people over time. You can divide hope into at least two components: agency (the belief one can still take meaningful action) and pathways (seeing a route to achieve modified goals) (Snyder CR et al, J Pers Soc Psychol 1991;60(4):570–585). Hope changes form in terminal illness. Initially, patients hope for a cure, but when that’s no longer possible, hope needs to shift to other meaningful goals—repairing relationships, creating legacy projects, ensuring comfort and dignity at the end of life, or making meaningful memories with loved ones. By helping patients identify achievable goals and supporting their sense of agency in reaching them, we can build a different kind of hope even in the face of death.

CGPR: How do you approach hospitalization decisions for suicidal older adults with terminal illness?
Dr. Schechter: For terminally ill patients, hospitalization is at the bottom of the list, not the top. The harm of psychiatric hospitalization can outweigh the benefits unless there’s an acute mental illness or imminent suicide risk. Removing someone from home at the end of life can cause significant distress with little evidence it changes long-term outcomes. 

CGPR: Thank you for your time, Dr. Schechter.