Skip to main content

Suicidal ideation and its related factors among older adults: a population-based study in Southwestern Iran



Suicidal ideation is a major risk factor for suicide and can negatively affect self-care and health behaviors among the older adults. There are limited data on the prevalence and risk factors of suicidal ideation among the older population during the COVID-19 pandemic. The aim of the present study was to examine the prevalence and risk factors of suicidal ideations among Iranian older adults during the COVID-19 pandemic.


A total of 803 older community adults in Shiraz (Southwestern Iran) were surveyed to determine potential factors influencing suicidal ideation, including demographic factors, physical health status, access to healthcare, current depression status, fear of COVID-19, perceived social support, and social engagement. Data were collected utilizing face-to-face interviews between November and December 2020. Multivariate logistic regression analysis was used to identify independent variables associated with suicidal ideations.


Among the 803 participants, 69 reported suicidal ideations (8.6%). Individuals with suicidal ideations were more likely to have greater fear of COVID-19. However, based on the results of multivariate logistic regression analysis, current depression (OR: 2.07, CI 95%: 1.18–3.65), not being married (OR: 1.82, CI 95%: 1.06–3.13), inability to pay for medical bills (OR: 2.16, CI 95%: 1.23–3.79), low perceived social support (OR: 2.03, CI95%: 1.11–3.71), and having limited social network (OR:1.77, CI 95%: 1.02–3.10) appeared to be more powerful influencing factors.


Suicidal ideation appears to be relatively common among Iranian older adults during the COVID-19 pandemic. A lack of longitudinal data makes it difficult to establish an association between suicidal ideations and the COVID-19 pandemic. Systematic monitoring of suicidal ideation is recommended among high-risk groups, particularly the older population.

Peer Review reports


Late life suicide remains a major global health problem, with those individuals aged 65 years and over constituting the demographic group with the highest suicide rate in most countries according to the World Health Organization [1, 2]. In addition to being a major risk factor for suicide [3, 4] suicidal ideation (SI) can lead to a number of negative consequences in older adults such as poor self-care and increased mortality irrespective of baseline depressive status [5]. Estimates of SI prevalence among older adults vary widely across the world and ranges from 3 to 25% [6,7,8,9]. Studies show that prevalence of SI is particularly high among older adults who are single, widowed, bereaved, living alone and/or being socially isolated, as well as having underlying physical and/or mental disorders [10]. There are no reports concerning the prognosis of SI among older adults. However, for individuals of different ages who report SI within the previous 12 months, one-year prevalence rates of suicidal acts have been estimated to be 15–20% [11].

Suicidal behavior (SB) has been described as deliberate injury to self with the purpose of ending one’s life. Suicidality exists along a spectrum of severity with different levels of suicidal thoughts representing different levels of suicide risk. It can range from passive desire for death, to active thoughts of killing oneself, and in the most extreme cases having a specified plan with the intention to die by suicide [11, 12] SI is a significant risk factor for future suicide and is associated with higher risk of suicidal attempt (SA) and death [13]. The global lifetime prevalence for suicidal thoughts and suicide attempts among all age groups combined have been estimated to be 9 and 3%, respectively [3].

The coronavirus disease 2019 (COVID-19) pandemic is another potential factor that might be a contributor to SI. Pandemics can be stressful and increase anxiety levels among healthy individuals and escalate the symptoms of individuals with pre-existing mental health conditions. Pandemics can trigger a wide range of psychosocial impacts such as extreme anxiety, anger, insomnia, social isolation, depression, somatization, and increased use of alcohol and tobacco [14, 15]. Moreover, older adults are also at an elevated risk of late life depression and suicide. Depressive symptoms among older adults may be accentuated by stressful events [16].

Another psychological consequence of pandemics is fear. Fear is an adaptive response to potentially threatening situations. However, it can contribute to development of psychiatric disorders when it is excessive or disproportionate to real risks [17]. Fear can facilitate coping with unfavorable or unanticipated situations. However, pathological anxiety can impede an individual’s ability to cope effectively with life challenges and crises and can lead to functional impairment and chronic psychiatric disorders. Susceptibility to pathological fear and anxiety appears to be the result of predisposing factors and traits [18, 19].

As an international health crisis, the COVID-19 pandemic has affected millions of individuals all around the world. It has evoked much public fear and anxiety and the psychological impacts of the crisis have been extensive [20]. Across different age groups, the geriatric population is particularly vulnerable to this viral respiratory infection. Older individuals account for the majority of COVID-related deaths and are at higher risk of developing severe symptoms. As a cohort, they are also more concerned about being infected and are more inclined to stay at home during pandemics [21].

There is limited evidence on the effect of the COVID-19 pandemic on mental health and SB of older adults at the population level. However, to date, most published findings imply that older adults may be less negatively affected by mental health outcomes of the pandemic than other age groups [22]. According to a study conducted examining more than 5000 people in the United States, older adults reported lower rates of SI in the preceding 30 days than other age groups [23]. A population-based study conducted during the initial phase of COVID-19 pandemic in Spain also showed that being older (aged 60 to 80 years) was negatively associated with symptoms of both depression and anxiety [24]. Another study that assessed loneliness and mental health status among Dutch older adults during early phase of the pandemic showed that although social and emotional loneliness increased, mental health issues remained unchanged during the pandemic compared to pre-pandemic months [25].

Analysis of suicide statistics from several countries showed that during the pandemic, suicide death rates initially declined or remained unchanged [26]. However, in the case of Japan, after an initial decline there was an increase in suicide deaths, particularly among young female workers who had experienced job loss [27]. A longitudinal study across the pandemic waves in UK reported an increased rate of suicidal thoughts, especially among young female adults and those with preexisting mental health problems [28]. There have also been case reports of COVID-related suicides among older adults with a history of preexisting mental illnesses [29].

The current pandemic period is a unique timeframe in human history when an international health crisis has affected physical and mental well-being of millions of individuals globally. This unprecedented situation can be considered as an influential social phenomenon that may interact with psychological variables to increase vulnerability or resilience to mental illnesses [16]. However, it has been shown that SI can be influenced by various social and cultural factors [2]. Therefore, the aim of the present study was to examine the prevalence and risk factors of SI among a sample of Iranian older adults in Shiraz, Southwestern Iran during the COVID-19 pandemic.


Study setting and participants

The present study was conducted in Shiraz, a city located in the Fras Province in Southwestern Iran which has a population of approximately 2 million inhabitants of which approximately 160,000 are aged over 60 years. Participants were recruited utilizing a household survey conducted through face-to-face interviews within urban neighbourhoods of the city using a multi-stage cluster sampling. The inclusion criteria were being Iranian, aged 60 years and older, and being able to understand and respond to the survey questions. All participants said they were cognitively capable of participating in an interview in Persian and no-one was excluded from participating in the study in relation to this criterion. Participation was voluntary and no financial remuneration was provided. The sampling approach was based on clusters from municipal areas, then neighborhoods. In the first stage, municipal areas were numbered and six (out of 11) regions were randomly selected. In the next stage, a total of 17 neighborhoods were randomly selected from municipal regions proportional to their population size. In the final stage, 50 participants were randomly selected from each neighborhood. Within the neighborhoods, a list of households who had eligible members according to age was prepared and a simple random selection procedure was applied. For each selected household, if there was more than one eligible person, one of them was randomly selected. A total of 850 older adults were invited to be interviewed and 803 participated in the study (response rate: 94.5%). The mean age of participants was 68.1 years (SD = 4.73). Participants provided verbal consent to participate prior to commencing the study. Data were collected from the 24 November to 20 December 2020, during the COVID-19 pandemic in Iran. The survey took approximately 45 min for every participant to complete. Interviews were conducted outdoors while maintaining adequate physical distance (at least two meters) and wearing face masks. The protocol was approved by the Shiraz University’s Ethics Committee (Ref: Written informed consent was obtained from all participants, after they had been informed of the study’s goals. Complete anonymity and data confidentiality was guaranteed. The research conducted in this study was performed in accordance with the Declaration of Helsinki.



Basic demographic data included age, gender, marital status, working status and educational level were collected.

Access to healthcare

Self-reported access to healthcare was assessed using three questions. Questions included whether participants had (i) medical insurance coverage, (ii) easy access to a physician, (iii) problems in paying for medical bills during past 12 months.

Physical health status

Self-reported physical health status was assessed using a single question: (“How would you generally rate your current physical health?”) rated on scale from 1 (very poor) to 5 (excellent). Participants were also asked if they had any of the following common chronic medical conditions that necessitated regular medical visits and medication use: hypertension, heart disease, stroke, cancer, chronic lung disease and/or chronic kidney disease.

Current depression

The Persian version of the two-item Patient Health Questionnaire-2 (PHQ-2) was used to assess the presence of depression among participants [30]. The questions ask participants if they had “Little interest or pleasure in doing things” and/or were “Feeling down, depressed or hopeless” during the past 2 weeks. The responses are rated from 0 to 3 (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day) with the total score ranging from 0 to 6. A score of 3 or more is 83% sensitive and 90% specific for a diagnosis of major depression. Both the PHQ-9 and PHQ-2 are reliable and valid tools for screening and assessment of depressive symptoms [31, 32]. Cronbach’s alpha in the present study was 0.838.

Suicidal ideation and behaviors

To evaluate the presence of SI, three questions adapted from Ask Suicide-Screening Questionnaire (ASQ) [33] were used. This five-item scale assesses recent SI (first three questions) and lifetime and present SB (final two questions). The ASQ items are responded to either ‘yes’ or ‘no’ and comprise: “1=In the past few weeks, have you wished you were dead?”, “2=In the past few weeks, have you felt that you or your family would be better off if you were dead?”, “3=In the past week, have you been having thoughts about killing yourself?”, “4=Have you ever tried to kill yourself?” and “5=Are you having thoughts of killing yourself right now?”, with the final question assessing severity [27]. A ‘yes’ answer to the any of the first three questions were considered as recent suicidal ideation state. Previous studies have shown that the ASQ tool has robust psychometric properties among a wide range of ages. For example, in a sample of 727 adults (mean age: 50 years, range: 18–93 years), the ASQ showed a high sensitivity and specificity for screening of SI (100 and 89%, respectively) [34]. Following the cross-cultural scale translation and validation guidelines by Sousa and Rojjanasrirat (2011) [35], the items were translated into Persian and backward translated to English by two independent Persian-speaking individuals who were proficient in English. Discrepancies between the original questions and the back-translated version were discussed and resolved by the research team. Face validity and content validity were assessed by five experts including one linguist and construct validity was evaluated by factor analysis. The internal consistency was measured utilizing Cronbach’s alpha. The means for the content validity index and the content validity ratio were 0.89 and 0.85, respectively. Cronbach’s alpha value was 0.762. The translated Persian version of the questions were therefore internally consistent, reliable, and valid. The strong psychometric properties in relation to validity and reliability were consistent with previous studies [33, 34, 36].

Fear of COVID-19

The seven-item Fear of COVID-19 Scale (FCV-19S) [37] originally validated using an Iranian sample was used to assess fear of COVID-19. Items (e.g., “I am afraid of losing my life because of COVID-19”) are rated on a five-point scale from 1 (strongly disagree) to 5 (strongly agree) with total scores ranging from 7 to 35. Higher scores denote greater COVID-19-related fear. The FCV-19S was used because it has been validated in many languages with good psychometric properties [38]. Cronbach’s alpha in the present study was 0.918.

Social engagement

The Persian version of the six-item Lubben Social Network Scale (LSNS-6) [39] was used to assess social engagement among family and friends. Items (e.g., “How many relatives do you see or hear from at least once a month?”) are rated on a five-point scale from 0 (none) to 5 (nine or more) with total scores ranging from 0 to 30. A lower score indicates an increased risk for social isolation [38, 40]. Cronbach’s alpha in the present study was 0.871.

Perceived social support

The Persian version of 12-item Multidimensional Scale of Perceived Social Support (MSPSS) [41] was used to assess perceived social support from three different sources (family, friends and a significant other) on three subscales Items (e.g., “I get the emotional help and support I need from my family”) are rated on a seven-point scale ranging from 1 (very strongly disagree) to 7 (very strongly agree) with total scores ranging from 12 and 84. A higher score indicates greater social support perceived by an individual. Cronbach’s alpha in the present study was 0.914.

Statistical analysis

Descriptive statistics were used to calculate the main sample characteristics of the study participants. Demographic factors were calculated as frequencies and percentages for categorical variables, and means and standard deviations for numerical variables. Chi-square tests and the independent sample t-tests were used to calculate statistical differences between those who reported and those who did not report SI. To assess effect of social engagement, and perceived social support on the risk of SI, LSNS-6 and MSPSS scores were dichotomized into two categories using the median value as a cutoff point. Multivariate logistic regression was utilized to determine independent variables associated with increased risk of SI. When building the multivariate models, each of the variables listed above were evaluated in univariate models, and those with p-values <.10 were considered for inclusion in the backwards stepwise logistic regression. SPSS version 28 (IBM, United States) was used for all statistical analysis and significance level was set at p < .05.


Of the 803 participants, 69 reported SI in the past few weeks (8.6%), 12 had thoughts of killing themselves at the time of interview (1.5%), and 16 had previously attempted suicide at least one during their lives (2%). Table 1 shows the characteristics of older adults who did and did not report SI. Those reporting SI were significantly more likely to (i) be female (61% vs. 48%), (ii) be unmarried (42% vs. 24%), (iii) be unable to pay medical bills in the past 12 months (38% vs. 18%), (iv) have poor to moderate physical health (71% vs. 53%), (v) have a history of chronic disease (55% vs. 35%), (vi) be experiencing current depression (35% vs. 16%), (vii) have greater fear of COVID-19, (viii) have low social engagement (70% vs. 53%), and (ix) have low perceived social support (77% vs. 58%).

Table 1 Characteristics of study participants

Table 2 shows the association between predisposing factors and the risk of SI. Independent factors for SI among Iranian older adults were current depression (OR: 2.07, CI 95%: 1.18–3.65), being unmarried (OR: 1.82, CI 95%: 1.06–3.13), having financial problems in paying for medical bills (OR: 2.16, CI 95%: 1.23–3.79), having low perceived social support (OR: 2.03, CI 95%: 1.11–3.71), and having a limited social network (OR:1.77, CI 95%: 1.02–3.10).

Table 2 Factors associated with suicidal ideation


The present study examined the prevalence and factors associated with SI among older adults in an urban Shiraz community. To our best of the present authors’ knowledge, this is the first study in Iran to assess SI among older people. The prevalence of suicidal thoughts among the studied population during the COVID-19 pandemic was 8.6%. There is a dearth of population-based studies assessing SI among Iranian older adults. Pre-pandemic studies from other countries show a diverse range of prevalence rates. The prevalence of SI have been reported to be 23% among older individuals of rural Bangladesh [42], 19.6% among Korean older adults [43], and 16.5% among community dwelling Taiwanese older people [44]. In a cross-sectional population-based survey in Mexico, the lifetime prevalence of SI among individuals aged 65 years and over was 13.5 and 4.5% in the past 2 weeks [45]. Two studies from Western countries (United States and the United Kingdom) reported prevalence rates of ever having had suicidal thoughts among older adults to be 6 to 7% [46]. Also, a Swedish study reported a prevalence rate of 16% among individuals 80 years and older [46]. However, it should be noted that these different studies have used different tools which that makes direct comparison difficult.

Considering SI is a pivotal component of the suicidal process, global differences in suicidal behaviors can also be observed in suicide death rates across the world. Globally, there is a considerable inter-country variability in suicide rates [11]. Whole population suicide rates range from approximately 20 per 100,000 across Eastern Europe, South Korea, Zimbabwe, Guyana, and Suriname to less than five per 100,000 across North Africa, the Middle East, Indonesia, Peru, and some Mediterranean countries [47]. According to WHO reports, the Eastern Mediterranean region has the lowest age-standardized suicide rates (four per 100,000 population, 2016) among world WHO regions [48]. This has been attributed to cultural, religious, and social factors in this region [49]. Cultural diversity may account for a part of significant variations in suicide rates across the world. It is also assumed that family support is a strong predictor of maintaining psychosocial health and mental well-being [50]. Social support prevents the negative mental outcomes of stressful life events and a high level of social support decreases the risk of suicide [51]. The findings of the present study showed low perceived social support as an independent risk factor for SI among Iranian older adults.

Based on the findings of the present study, inability to pay for medical bills in the past 12 months was another independent variable influencing SI among Iranian older adults. Although the present study considered this as a measure of access to healthcare, it may also reflect the economic status of the study participants. It is well known that low economic status is a risk factor for suicide among the general population [11].

While the findings of the present study showed that SI was more common among female than male older adults, gender was not identified as an independent factor associated with SI. Most studies on gender differences of SI have compared suicide death rates and SA. Death rates from suicides are four to five times higher for males than female, and females demonstrate a disproportionately higher rate of SA compared to males [52]. Although reports on gender difference in SI are less explicit, a majority show a female preponderance [8, 53].

The findings of the present study showed that current depression was a significant risk factor for SI in the target population. SI among older adults is mostly seen in the context of mental disorders. In a US study of the older people aged 65 years and over in primary care settings, almost half of those with depression or anxiety reported SI [54]. In a cross-sectional study across 17 countries, the presence of any anxiety disorder increased the risk of SI threefold and mood disorder increased the risk fivefold [3].

Historically, international crises have been associated with increase in suicide rates. Rises in national suicide rates following the 2008 global economic crisis were particularly seen among young and middle-aged men and appeared to be associated with a significant increase in unemployment [55]. It is expected that under socially stressful conditions like a fatal pandemic disease, older individuals are more likely to feel scared and be worried about possible consequences and perceive social problems as impossible to resolve and therefore they might experience increased SI and SB [56]. An increase in SA among older individuals was reported after the severe acute respiratory syndrome (SARS) epidemic in Hong Kong in 2003–2004 [57]. Although participants in the present study who reported SI were more likely to report fear of COVID-19 pandemic, this variable was not a robust independent influencing factor based on multivariable regression analysis. Given the study’s limitations, this finding should be treated cautiously. One interpretation is that fear of COVID-19 mostly affects people with pre-existing mental health conditions, such as depression. Another explanation refers to Iranian cultural context. Traditionally, Iranian families strongly provide support to family members [58]. Family cohesion and support has also been suggested as a protective factor in coping with psychological distress in some other cultures such as Latino families [59]. However, caution is warranted given the cross-sectional design of the present study.

In summary, the present study estimates that 1 in 12 Iranian older adults experienced SI during the COVID-19 pandemic. After conducting multivariable logistic regression analysis, the main influencing factors were interconnected and mostly related to social and economic domains. Based on these findings, it is recommended that Iranian health policymakers should focus on strategies to identify and address factors contributing to the socio-economic inequalities in access to healthcare and social support services among vulnerable groups, particularly the older population. Strategies should therefore be directed at improving the usability and availability of social facilities, activities, and resources for underserved older adults, all of which are generally associated with improved mental health outcomes [15, 60, 61]. Practical examples of such strategies might include facilitating access to healthcare by providing older adult-specific health insurance, ensuring healthcare provider availability and continuity, home visiting programs, facilitating access to public spaces by providing older adult-friendly transportation services and enhancing community safety (particularly for those with functional disabilities), peer support programs, and providing information and communication technologies such as applications and social media platforms to promote social engagement. Moreover, such strategies must be customized to address the socio-cultural needs and preferences of the older adults at both country and sub-country levels. Given the commonality of SI among Iranian older adults, investigating its presence in primary care practice settings is warranted.

There are some limitations that should be noted. The present study was conducted utilizing a modest sample size of individuals in a province of Iran, so the study findings may be not generalizable to all Iranian older adults. A further limitation is the aforementioned cross-sectional design of the study. The present study only reported risk factors associated with SI among Iranian older adults during the pandemic and cannot say anything about causation. Longitudinal studies are needed to confirm the associations found between variables in the present study. However, despite its limitations, the data provided an estimate of the prevalence of SI in the target population and provided some preliminary inferences in the absence of longitudinal data. Insomnia has also been suggested as a risk factor for late life depression and suicide [62]. However, the present study did not assess this variable among the studied population. The single item self-reported physical health status has been shown to be predictive of future morbidity and mortality [63]. However, it does not focus on specific health aspects during a specific timeframe, but rather provides individuals’ own judgments of their perceived general health. Moreover, all of the data were self-report which are subject to a number of well-known methods biases. This should also be taken into account when interpreting the study’s main findings.


SI are relatively common among Iranian older adults during COVID-19 pandemic. A lack of longitudinal data makes it difficult to establish an association between SI and the COVID-19 pandemic. Implications for health policy include developing and implementing strategies to increase social connectedness, particularly during the pandemic setting, and to improve social support for Iranian underserved older adults. Also we recommend systematic monitoring of SI among the older population. This policy can be integrated into existing comprehensive geriatric assessment in primary health care.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.



Patient Health Questionnaire-2


Ask Suicide-Screening Questionnaire


Fear of COVID-19


Lubben Social Network Scale


Multidimensional Scale of Perceived Social Support


Severe Acute Respiratory Syndrome


  1. Conwell Y, Van Orden K, Caine ED. Suicide in older adults. Psychiatr Clin North Am. 2011;34(2):451–ix.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Fässberg MM, van Orden KA, Duberstein P, Erlangsen A, Lapierre S, Bodner E, et al. A systematic review of social factors and suicidal behavior in older adulthood. Int J Environ Res Public Health. 2012;9(3):722–45.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry. 2008;192(2):98–105.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Arria AM, O'Grady KE, Caldeira KM, Vincent KB, Wilcox HC, Wish ED. Suicide ideation among college students: a multivariate analysis. Arch Suicide Res. 2009;13(3):230–46.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Raue PJ, Morales KH, Post EP, Bogner HR, Have TT, Bruce ML. The wish to die and 5-year mortality in elderly primary care patients. Am J Geriatr Psychiatry. 2010;18(4):341–50.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Nie Y, Hu Z, Zhu T, Xu H. A cross-sectional study of the prevalence of and risk factors for suicidal ideation among the elderly in nursing homes in Hunan Province, China. Front Psychiatry. 2020;11:339.

    PubMed  PubMed Central  Google Scholar 

  7. Wei J, Zhang J, Deng Y, Sun L, Guo P. Suicidal ideation among the Chinese elderly and its correlates: a comparison between the rural and urban populations. Int J Environ Res Public Health. 2018;15(3):422.

    Article  PubMed Central  Google Scholar 

  8. Lu L, Xu L, Luan X, Sun L, Li J, Qin W, et al. Gender difference in suicidal ideation and related factors among rural elderly: a cross-sectional study in Shandong, China. Ann General Psychiatry. 2020;19:2.

    Article  Google Scholar 

  9. Kim SH. Suicidal ideation and suicide attempts in older adults: influences of chronic illness, functional limitations, and pain. Geriatr Nurs. 2016;37(1):9–12.

    Article  PubMed  Google Scholar 

  10. Conejero I, Olié E, Courtet P, Calati R. Suicide in older adults: current perspectives. Clin Interv Aging. 2018;13:691–9.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet. 2016;387(10024):1227–39.

    Article  PubMed  Google Scholar 

  12. Raue PJ, Ghesquiere AR, Bruce ML. Suicide risk in primary care: identification and management in older adults. Curr Psychiatry Rep. 2014;16(9):466.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Brown GK, Steer RA, Henriques GR, Beck AT. The internal struggle between the Wish to die and the Wish to live: a risk factor for suicide. Am J Psychiatr. 2005;162(10):1977–9.

    Article  PubMed  Google Scholar 

  14. Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations. Psychiatry Clin Neurosci. 2020;74(4):281–2.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Costanza A, Di Marco S, Burroni M, Corasaniti F, Santinon P, Prelati M, et al. Meaning in life and demoralization: a mental-health reading perspective of suicidality in the time of COVID-19. Acta Bio Med. 2020;91(4):e2020163.

    CAS  Google Scholar 

  16. Fiske A, Wetherell JL, Gatz M. Depression in older adults. Annu Rev Clin Psychol. 2009;5:363–89.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Graham BM, Milad MR. The study of fear extinction: implications for anxiety disorders. Am J Psychiatry. 2011;168(12):1255–65.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Steimer T. The biology of fear-and anxiety-related behaviors. Dialogues Clin Neurosci. 2002;4(3):231.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Garcia R. Neurobiology of fear and specific phobias. Learn Mem. 2017;24(9):462–71.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Rajkumar RP. COVID-19 and mental health: a review of the existing literature. Asian J Psychiatr. 2020;52:102066.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Meng H, Xu Y, Dai J, Zhang Y, Liu B, Yang H. Analyze the psychological impact of COVID-19 among the elderly population in China and make corresponding suggestions. Psychiatry Res. 2020;289:112983.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Vahia IV, Jeste DV, Reynolds CF. Older adults and the mental health effects of COVID-19. JAMA. 2020;324(22):2253.

    Article  CAS  PubMed  Google Scholar 

  23. Czeisler MÉ, Lane RI, Petrosky E, Wiley JF, Christensen A, Njai R, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic - United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049–57.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. González-Sanguino C, Ausín B, Castellanos MÁ, Saiz J, López-Gómez A, Ugidos C, et al. Mental health consequences during the initial stage of the 2020 coronavirus pandemic (COVID-19) in Spain. Brain Behav Immun. 2020;87:172–6.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  25. Van Tilburg TG, Steinmetz S, Stolte E, van der Roest H, de Vries DH. Loneliness and mental health during the COVID-19 pandemic: a study among Dutch older adults. J Gerontol B Psychol Sci Soc Sci. 2021;76(7):e249–e55.

    Article  PubMed  Google Scholar 

  26. Pirkis J, John A, Shin S, DelPozo-Banos M, Arya V, Analuisa-Aguilar P, et al. Suicide trends in the early months of the COVID-19 pandemic: an interrupted time-series analysis of preliminary data from 21 countries. Lancet Psychiatry. 2021;8(7):579–88.

    Article  PubMed  Google Scholar 

  27. Ueda M, Nordström R, Matsubayashi T. Suicide and mental health during the COVID-19 pandemic in Japan. J Public Health (Oxf). 2021:fdab113.

  28. O'Connor RC, Wetherall K, Cleare S, McClelland H, Melson AJ, Niedzwiedz CL, et al. Mental health and well-being during the COVID-19 pandemic: longitudinal analyses of adults in the UK COVID-19 Mental Health & Wellbeing study. Br J Psychiatry. 2021;218(6):326–33.

    Article  PubMed  CAS  Google Scholar 

  29. Asthana NK, Mehaffey E, Sewell DD. COVID-19 associated suicidal ideation in older adults: two case reports with a review of the literature. Am J Geriatr Psychiatry. 2021;29(11):1101–16.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Maroufizadeh S, Omani-Samani R, Almasi-Hashiani A, Amini P, Sepidarkish M. The reliability and validity of the patient health Questionnaire-9 (PHQ-9) and PHQ-2 in patients with infertility. Reprod Health. 2019;16(1):137.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Park LT, Zarate CA Jr. Depression in the primary care setting. N Engl J Med. 2019;380(6):559–68.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Costantini L, Pasquarella C, Odone A, Colucci ME, Costanza A, Serafini G, et al. Screening for depression in primary care with patient health Questionnaire-9 (PHQ-9): a systematic review. J Affect Disord. 2021;279:473–83.

    Article  PubMed  Google Scholar 

  33. Horowitz LM, Snyder DJ, Boudreaux ED, He J-P, Harrington CJ, Cai J, et al. Validation of the ask suicide-screening questions for adult medical inpatients: a brief tool for all ages. Psychosomatics. 2020;61(6):713–22.

    Article  PubMed  Google Scholar 

  34. Aguinaldo LD, Sullivant S, Lanzillo EC, Ross A, He J-P, Bradley-Ewing A, et al. Validation of the ask suicide-screening questions (ASQ) with youth in outpatient specialty and primary care clinics. Gen Hosp Psychiatry. 2021;68:52–8.

    Article  PubMed  Google Scholar 

  35. Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline. J Eval Clin Pract. 2011;17(2):268–74.

    Article  PubMed  Google Scholar 

  36. Horowitz LM, Bridge JA, Teach SJ, Ballard E, Klima J, Rosenstein DL, et al. Ask suicide-screening questions (ASQ): a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med. 2012;166(12):1170–6.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Ahorsu DK, Lin C-Y, Imani V, Saffari M, Griffiths MD, Pakpour AH. The fear of COVID-19 scale: development and initial validation. Int J Ment Heal Addict. 2020:1–9.

  38. Pakpour AH, Griffiths MD, Chang K-C, Chen Y-P, Kuo Y-J, Lin C-Y. Assessing the fear of COVID-19 among different populations: a response to Ransing et al. (2020). Brain Behav Immun. 2020;89:524–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Tavakoli Ghouchani H, Lashkardoost H, Khankolabi M, Asghari D, Nabavi SH. Validity and reliability of persian version of lubben social netwok-6 scale in elderly adult. J North Khorasan Univ Med Sci. 2020;12(2):64–9.

    Google Scholar 

  40. Lubben J, Blozik E, Gillmann G, Iliffe S, von Renteln KW, Beck JC, et al. Performance of an abbreviated version of the Lubben social network scale among three European Community-dwelling older adult populations. The Gerontologist. 2006;46(4):503–13.

    Article  PubMed  Google Scholar 

  41. Sararoudi RB, Sanei H, Baghbanian A. The relationship between type D personality and perceived social support in myocardial infarction patients. J Res Med Sci. 2011;16(5):627.

    PubMed  PubMed Central  Google Scholar 

  42. Wahlin Å, Palmer K, Sternäng O, Hamadani JD, Kabir ZN. Prevalence of depressive symptoms and suicidal thoughts among elderly persons in rural Bangladesh. Int Psychogeriatr. 2015;27(12):1999–2008.

    Article  PubMed  Google Scholar 

  43. Park JY, Han JW, Jeong H, Jeong H-G, Kim TH, Yoon I-Y, et al. Suicidal behaviors in elderly Koreans: one-month-point prevalence and factors related to suicidality. J Affect Disord. 2013;150(1):77–83.

    Article  PubMed  Google Scholar 

  44. Yen Y-C, Yang M-J, Yang M-S, Lung F-W, Shih C-H, Hahn C-Y, et al. Suicidal ideation and associated factors among community-dwelling elders in Taiwan. Psychiatry Clin Neurosci. 2005;59(4):365–71.

    Article  PubMed  Google Scholar 

  45. Borges G, Acosta I, Sosa AL. Suicide ideation, dementia and mental disorders among a community sample of older people in Mexico. Int J Geriatr Psychiatry. 2014;30(3):247–55.

    Article  PubMed  Google Scholar 

  46. Garand L, Mitchell AM, Dietrick A, Hijjawi SP, Pan D. Suicide in older adults: nursing assessment of suicide risk. Issues Ment Health Nurs. 2006;27(4):355–70.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Death rate from suicides 2017. Available from: [cited 23 Jul 2021]

  48. Organization WH. Suicide rate estimates, crude estimates by WHO region. Available from: [cited 23 Jul 2021]

  49. Rezaeian M. Age and sex suicide rates in the eastern Mediterranean region based on global burden of disease estimates for 2000. East Mediterr Health J. 2007;13(4):953–60.

    CAS  PubMed  Google Scholar 

  50. Ozbay F, Johnson DC, Dimoulas E, Morgan C III, Charney D, Southwick S. Social support and resilience to stress: from neurobiology to clinical practice. Psychiatry (Edgmont). 2007;4(5):35.

    Google Scholar 

  51. Endo G, Tachikawa H, Fukuoka Y, Aiba M, Nemoto K, Shiratori Y, et al. How perceived social support relates to suicidal ideation: a Japanese social resident survey. Int J Soc Psychiatry. 2013;60(3):290–8.

    Article  PubMed  Google Scholar 

  52. Freeman A, Mergl R, Kohls E, Székely A, Gusmao R, Arensman E, et al. A cross-national study on gender differences in suicide intent. BMC Psychiatry. 2017;17(1):234.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Vasiliadis H-M, Gagné S, Préville M. Gender differences in determinants of suicidal ideation in French-speaking community living elderly in Canada. Int Psychogeriatr. 2012;24(12):2019–26.

    Article  PubMed  Google Scholar 

  54. Bartels SJ, Coakley E, Oxman TE, Constantino G, Oslin D, Chen H, et al. Suicidal and death ideation in older primary care patients with depression, anxiety, and at-risk alcohol use. Am J Geriatr Psychiatry. 2002;10(4):417–27.

    Article  PubMed  Google Scholar 

  55. Chang S-S, Stuckler D, Yip P, Gunnell D. Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ. 2013;347:f5239.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Szanto K, Dombrovski AY, Sahakian BJ, Mulsant BH, Houck PR, Reynolds CF 3rd, et al. Social emotion recognition, social functioning, and attempted suicide in late-life depression. Am J Geriatr Psychiatry. 2012;20(3):257–65.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Cheung YT, Chau PH, Yip PSF. A revisit on older adults suicides and severe acute respiratory syndrome (SARS) epidemic in Hong Kong. Int J Geriatr Psychiatry. 2008;23(12):1231–8.

    Article  CAS  PubMed  Google Scholar 

  58. Hajinejad F, Ebrahimi E, de Jong A, Ravanipour M. Factors promoting Iranian older adults' spirituality: a qualitative content analysis. BMC Geriatr. 2019;19(1):132.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Rivera FI, Guarnaccia PJ, Mulvaney-Day N, Lin JY, Torres M, Alegria M. Family cohesion and its relationship to psychological distress among Latino groups. Hisp J Behav Sci. 2008;30(3):357–78.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Costanza A, Amerio A, Aguglia A, Serafini G, Amore M, Macchiarulo E, et al. From “the interpersonal theory of suicide” to “the interpersonal trust”: an unexpected and effective resource to mitigate economic crisis-related suicide risk in times of covid-19? Acta Biomed. 2021;92:e2021417.

    CAS  PubMed  PubMed Central  Google Scholar 

  61. Costanza A, Ambrosetti J, Wyss K, Bondolfi G, Sarasin F, Khan RA. Prévenir le suicide aux urgences: de la «Théorie Interpersonnelle du Suicide» à la connectedness. Rev Méd Suisse. 2018;14(593):335–8.

    PubMed  Google Scholar 

  62. Nadorff MR, Fiske A, Sperry JA, Petts R, Gregg JJ. Insomnia symptoms, nightmares, and suicidal ideation in older adults. J Gerontol B Psychol Sci Soc Sci. 2013;68(2):145–52.

    Article  PubMed  Google Scholar 

  63. Miilunpalo S, Vuori I, Oja P, Pasanen M, Urponen H. Self-rated health status as a health measure: the predictive value of self-reported health status on the use of physician services and on mortality in the working-age population. J Clin Epidemiol. 1997;50(5):517–28.

    Article  CAS  PubMed  Google Scholar 

Download references


The authors very much appreciate the cooperation offered by the Health Vice Chancellor of Shiraz University of Medical Sciences. The Authors wish to thank Dr. Jin Han (Black Dog Institute, Sydney, Australia) for the useful comments on earlier version of this manuscript.


This article is based on the thesis (Grant No. 21980) prepared by Roya Zohrabi in fulfillment of the requirements for the medical doctor degree. The project was funded by Vice Chancellor for Research of the Shiraz University of Medical Science.

Author information

Authors and Affiliations



RS and RZ contributed in the study design, data gathering and writing the primary draft. HM contributed in data analysis and writing the manuscript. MDG contributed in reviewing and writing drafts and critically appraising the manuscript. All the authors read and approved the final manuscript.

Corresponding author

Correspondence to Hamideh Mahdaviazad.

Ethics declarations

Ethics approval and consent to participate

The protocol was approved by the Shiraz University’s Ethics Committee (Ref: Written informed consent was obtained from all participants, after they had been informed of the study’s goals. Complete anonymity and data confidentiality was guaranteed. The research conducted in this study was performed in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shiraly, R., Mahdaviazad, H., Zohrabi, R. et al. Suicidal ideation and its related factors among older adults: a population-based study in Southwestern Iran. BMC Geriatr 22, 371 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: