In Greek mythology, Sisyphus was the founder and king of Ephyra. Zeus punished him for cheating death twice by being forced to roll an immense boulder up a hill only for it to roll down every time it neared the top, repeating this action for eternity. Assessing suicide ideation as part of suicide prevention efforts is one of modern psychiatry’s ways of cheating death.

Gleeson and colleagues analyzed available screening and measurement tools for suicide ideation (Gleeson et al., Reference Gleeson, Roesch, Hafford-Letchfield and Ellmers2021). They used a systematic review approach to identify measurement tools developed specifically for older adults without cognitive decline or impairment identifying ten papers that reported on a total of seven different measurement tools were identified. These included tools that focused on resiliency to suicide and those that measured risk of suicide behavior. This is a laudable effort. However, the analysis does not present data on two major issues: what is the real-world efficacy of using these scales in the general older adult population and what are the benefits using these scales as part of indicated or selective prevention efforts.

Searching the National Library of Medicine PubMed database for studies that focused on evaluating the “efficacy” of assessing suicide ideation in older adults yields only 59 papers and full papers assessed for eligibility identifies only 2 relevant publications both published in the last 4 years. Painter and colleagues described a training program for pharmacists that was used to provide skills necessary to recognize a crisis and the warning signs of suicide. The training program was led by the QPR Institute plan and the “First Question” principle relied on a one question detection of suicidal ideation: “Have you ever experienced thoughts of death or suicide?” Findings from this project suggest that a suicide prevention training program helped pharmacist respondents build confidence in detection of suicide signs (Painter et al., Reference Painter, Kuo, Collins, Palomino and Lee2018). In keeping with recent research efforts, Alexopoulos and colleagues aimed to identify modifiable predictors of suicidal ideation through a machine learning approach. Convergent findings of the four machine learning models identified hopelessness, neuroticism, and low general self-efficacy as the strongest predictors of suicidal ideation in depressed older adults (Alexopoulos et al., Reference Alexopoulos2021). Despite these exciting approaches, we have yet to read of a scale that identifies suicide ideation and has shown clinical relevance.

What is clinical relevance when suicide ideation is flagged? Amongst older adults lifetime suicidal ideation is in the range of 4 % −6%, 12 months prevalence is in the range of 13 % -18% and may be as high as 40% in older adults suffering from clinically meaningful major depression (Cao et al., Reference Cao2015). Do these rates translate into a higher rate of death by suicide? Wenzel and colleagues in the longest ever, 30-year prospective study, looking at predictors of suicide relative to other deaths in patients with suicide ideation were unable to demonstrate an association between the two (Wenzel et al., Reference Wenzel, Berchick, Tenhave, Halberstadt, Brown and Beck2011). This is in line with evidence from studies of the Motivational-Volitional Model of suicidal behavior demonstrating that people who attempt suicide differ from those reporting suicide ideation on all volitional phase factors (Branley-Bell et al., Reference Branley-Bell, O'Connor, Green, Ferguson, O'Carroll and O'Connor2019).

“Where to?” in suicide research is the crucial question not answered by Gleeson and colleagues. Recent developments in suicide theory and research promise to meaningfully advance knowledge and prevention. The ideation-to-action framework, which stipulates that the development of suicidal ideation and the progression from ideation to suicide attempts are distinct phenomena with distinct explanations and predictors. A second key development is a growing body of research distinguishing factors that predict ideation from those that predict suicide attempts. Depression, hopelessness, most mental disorders, and even impulsivity predict ideation, but these factors struggle to distinguish those who have attempted suicide from those who have only considered suicide. These perceptions can and should inform the next generation of suicide research and prevention (Klonsky et al., Reference Klonsky, May and Saffer2016). Specifically in older adults loneliness and poverty cannot be ignored as are other social determinants of health when we advance suicide prevention strategies for the older adult population (Barak et al., Reference Barak, Fortune, Hobbs, Cheung, Johari and Zalsman2021; Cheung et al., Reference Cheung, Wright-St Clair, Chacko and Barak2019).