Suicide in older adults: current perspectives

Determinants of suicidal history before assisted versus self-initiated suicide late in life: an observational study

BACKGROUND

Older adults are at risk of assisted and self-initiated suicide. The links between prior attempts and assisted suicide in the elderly have not been investigated. Hence, we aimed to investigate and describe the occurrence, timing and determinants of suicide attempts prior to assisted and self-initiated suicide.

METHODS

We developed a retrospective study of all assisted and self-initiated suicides among people over 65 years in the canton of Geneva, Switzerland, for a 10-year period (2010-2019). Cases were identified by cross-referencing hospitals' routinely collected electronic data and a forensic report database. Cases were characterised in terms of sociodemographic factors, mental health disorders, main comorbidities, temporal sequence, methods of injury, medical complications and disclosure rates of previous attempts. The study used descriptive statistics.

RESULTS

A total of 26 of 497 (5.2%) and 20 of 149 (13.4%) older adults had made previous attempts before assisted and self-initiated suicide, respectively. More than half of them had made a single attempt, mostly by medication poisoning, sometimes more than 10 years before dying. Individuals who made two attempts were significantly more represented among the assisted suicide decedents. One self-initiated suicide decedent and half of the assisted suicide cases had disclosed that they had considered suicide. Individual characteristics were similar, except for assisted suicide decedents, who were eight years older than self-initiated suicide decedents. Almost all the individuals had mental disorders. Depression, anxiety and chronic pain were particularly prevalent among decedents of assisted suicide. The substantial representation of women in both groups may be an indication of their vulnerability, possibly related to chronic pain and life stressors.

CONCLUSIONS

Our results show commonalities between older assisted and self-initiated suicide decedents who made an attempt (s) before suicide. Further research is needed to demonstrate the overlap between the determinants of assisted suicide and other forms of suicidality and to support a suicide prevention strategy applicable to both types of suicide.

Identifying the suicidal ideation risk group among older adults in rural areas: Developing a predictive model using machine learning methods

AIMS

The aim of this study was to develop a predictive model that can identify the suicidal ideation risk group among older adults in rural areas using machine learning methods.

DESIGN

This study applied an exploratory, descriptive and cross-sectional design.

METHODS

The participants were older adults (N = 650) aged over 65 living in rural areas of South Korea. Self-report questionnaires were used to collect the demographics, suicidal ideation, depression, socioeconomic information and basic health information from September to October 2020. The collected data were analysed using machine learning methods with R statistical software 4.1.0.

RESULTS

The predictive models indicated that depression, pain, age and loneliness were significant factors of suicidal ideation. Good performance was observed based on the area under the receiver operating characteristic curve in the decision tree, random forest and logistic regression. Finally, the evaluation of model performance indicated moderate to high sensitivity and specificity.

CONCLUSION

The predictive models using machine learning methods may be useful to predict the risk of suicidal ideation. Furthermore, depression with pain, age and feelings of loneliness should be included in the initial screening to assess suicide risk among older adults in rural areas.

IMPACT

Identifying suicidal risk among older adults is challenging. Thus, employing predictive models that can assess depression, pain, age and loneliness can enable public healthcare providers to detect suicidal risk groups. Particularly, the presented models from this study can facilitate healthcare providers with initiating early interventions to prevent suicide among older adults in clinical and community nursing care settings.

REPORTING METHOD

The reporting of this study (Observational, cross-sectional study) conforms to the STROBE statement.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. This study did not involve patients, service users, caregivers or members of the public.

IMPLICATION FOR THE PROFESSION AND/OR PATIENTS CARE

Applying this model may help to prevent geriatric suicide because the nursing staff will have a greater awareness regarding the suicide ideation risk of older adults, thereby reducing the possibility of their suicide.

Suicide Risk Help-Seeking Among Middle- to Old-Age Adults: A Systematic Review

Background and Objectives

Suicide has become a major public health concern worldwide and in the United States. Rates of suicide increase during the life course and are highest among middle- to old-age adults. Help-seeking represents a crucial coping mechanism that can mitigate suicide risk. Yet, less is known about suicide risk help-seeking, especially among these age groups. To address this knowledge gap, a systematic review of existing literature was performed to obtain a refined understanding of help-seeking for suicide risk among middle- to old-age adults.

Research Design and Methods

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, electronic databases and key journals with suicide and/or gerontology focuses were searched to identify peer-reviewed publications in English between 2010 and 2020. A total of 4 732 unduplicated publications were screened for relevance based on titles and abstracts, of which 52 were reviewed in full text.

Results

Twenty-four articles met inclusion criteria and were included in the qualitative synthesis. These articles discussed a range of topics, including the prevalence of service utilization, service use prior to a suicide death, and correlates of help-seeking. In general, the prevalence of service utilization was low and varied by suicidal history (eg, higher prevalence among individuals with a history of suicide attempts than those with suicide ideation only). Key facilitators (eg, current or history of suicidal thoughts, plans, or attempts) and barriers (eg, stigma) for service use and help-seeking were also identified.

Discussion and Implications

Findings highlight the need for future studies and tailored services to improve age-appropriate and culturally responsive suicide prevention and intervention strategies for middle- to old-age adults.

Leveraging network analysis to determine sex differences in factors associated with frailty among older adults living alone

BACKGROUND

Frailty is a complex geriatric syndrome typically characterized by multiple underlying etiological factors. We determined the contributing factors, by sex, using a network analysis.

METHODS

The study sample consisted of a cross-sectional cohort of community-dwelling older adults aged ≥ 65 years living alone in a Korean city (N = 1,037). Frailty was assessed via the Korean Frailty Index. Participants were assessed for sociodemographic, health-related, mental and cognitive, and social characteristics. Mixed graphical models including all variables were estimated using the R-package mgm discretely by sex. We also used the Walktrap cluster algorithm to identify differences in the network structure in terms of connectivity around frailty between the sex groups for further insights.

RESULTS

In both the networks for males and females, frailty correlated most strongly with nutritional status, presence of complex chronic disease, and self-efficacy, and exhibited proximity to decreased sleep quality and loneliness. However, frailty showed an association with suicidal ideation and the number of falls per year only in males, whereas it showed an association with functional disabilities only in females. The overall network connectivity around frailty was stronger with dense interactions (more edges) in the network for females than for males.

CONCLUSIONS

The results signify the need for sex-group customized multi-domain assessments and interventions for the prevention and improvement of frailty among community-dwelling older adults.

A comprehensive study of medically serious suicide attempts in France: incidence and associated factors

AIMS

People who make medically serious suicide attempts (MSSAs) share a number of features with those who die by suicide, and are at a high risk of suicide themselves. Studies to date have mostly focused on clinical samples of MSSAs. An epidemiological examination at a national level can help to identify risk profiles and pathways of care in this population.

METHODS

We explored the French nationwide hospital discharge database (Programme de Médicalisation des Systèmes d'Information, PMSI) to identify any MSSA taking place between 2012 and 2019. Relevant demographic and medical information was collected about the first MSSA of each attempter. Data from 2010 and 2011 were used to verify the absence of prior attempts.

RESULTS

First occurrences of MSSAs amounted to 81 959 cases over 8 years, with a mean age of 45.8 years, and 53.6% women. Incidence was higher in women (18.1 v. 17.3 per 1 00 000). The most common suicide method was deliberate self-poisoning (64.9% of cases). In comparison, violent methods associated higher mortality and comorbidity and were more frequent in men. The most common mental disorders were mood disorders (55.6%) and substance use disorders (46.2%). A minority of MSSA survivors were hospitalised in psychiatry (32.5%), mostly women.

CONCLUSIONS

MSSAs are frequent and easy to identify. There is a need to reinforce the continuity of psychiatric care for this population given the high risk of subsequent suicide, and the low rates of psychiatric hospitalisation after an MSSA even if violent methods are used. Specific care targeting this population could reduce treatment gaps.

Understanding changes in mental health symptoms from young-old to old-old adults by sex using multiple-group latent transition analysis

Older adults are classified into three homogeneous groups: young-old (age 65-74), old-old (age 75-84), and oldest-old (age 85 and over). Mental health symptoms are likely to change over time, especially when older adults transition from one age group to another. Yet, little is known on changes in mental health symptoms as they transition to another age group, and if these changes differ by sex. This is a secondary data analysis using the longitudinal data from the National Social Life, Health, and Aging Project. A total of 1183 young-old adults at wave 1 was included. Mental health symptoms were depression, anxiety, loneliness, perceived stress, and happiness. Multiple-group latent transition analysis was conducted to model the transition probabilities of latent classes and to compare these differences between sex. Descriptive and inferential statistics were conducted to obtain demographic characteristics and to test for differences. Three latent classes were identified based on severity: class 1-mild, class 2-moderate, and class 3-severe. Regardless of sex, young-old adults remained in the same class from waves 1 to 2. However, they moved to a less severe group when transitioning into the old-old from waves 2 to 3. Statistically significant differences were found in their demographic characteristics among the latent classes. Older adults, when transitioning from young-old to old-old, are likely to transition to latent classes with less severe mental health symptoms in both sex. Clinicians need to provide a comprehensive assessment to all older adults, regardless of the severity of their mental health symptoms, to promote well-being.

Existential ageing and dying: A scoping review

BACKGROUND

After significant early interest in aging and dying, recent empirical studies have been few and theoretically fragmented.

OBJECTIVE

The aims of this review were to map what is empirically known about the intersections between existential aging (a sense of passing years that evoke a sense of nearness-to-death) and dying identity and to describe the available evidence.

METHOD

Articles were reviewed employing PRISMA guidelines. Seven data bases were searched resulted in 165 records. Of these 165 records a final selection of 24 studies that met the criteria were examined.

RESULTS

Evidence from the review found that the formation of the identity of dying alongside existential aging was associated with personal changes related to self/gerotranscendence, self-concerns about the inevitability of death (mortality salience), self-concerns about the prospect of death (death anxiety), attitudes toward the older self as a moderator of attitudes to death (aging attitudes), or simply anticipating the death of self (the future). Collectively, these studies found that death and dying were threats or challenges to life as an increasingly aging identity and that this seems to require compensation or accommodation.

CONCLUSION

These studies confirm the importance of nearness-to-death on identity formation and psychological change in older populations. However, most of the studies were quantitative and tested for pre-existing ideas and concepts. There is a need for more qualitative studies to search for wider or parallel meanings about identity change in the face of aging and death, more longitudinal designs, and greater attention to mixed methods approaches, especially for populations for whom talk or writing may be restrictive.

Spatial patterns and epidemiological characterization of suicides in the Chapecó micro-region, Santa Catarina, Brazil: an ecological study, 1996-2018

OBJECTIVE

to identify spatial clusters of suicide and its epidemiological characteristics in the Chapecó (SC) micro-region from 1996 to 2018.

METHODS

this was an exploratory ecological study, using data from the Mortality Information System; specific suicide rates and relative risks (RR) were calculated with a 95% confidence interval (95%CI); the scan statistic was used for spatial analysis.

RESULTS

there were 1,034 suicides (13.7/100,000 inhabitants), with a male/female ratio of 3.79; the ≥ 60 age group was at higher risk for both sexes; a high risk cluster was found in the southwest region (RR = 1.57) and a low risk cluster in the southeast region, including Chapecó itself (RR = 0.68); risk of suicide among widowed (RR = 3.05; 95%CI 1.99;4.67), separated (RR = 2.48; 95%CI 1.44;4.27), and married (RR = 1.97; 95%CI 1.54;2.51) people was higher than among single people. The main methods were hanging (81.2%) and firearms (9.7%).

CONCLUSION

there was a higher risk of suicide in the elderly, male and widowed people. Hanging was the most frequent method and risk clustering was found in the southwest.

Physical multimorbidity, suicidal ideation, and suicide attempts among adults aged ≥50 years from low- and middle-income countries

OBJECTIVES

The association between physical multimorbidity and suicidal ideation or suicide attempts among older adults from low- and middle-income countries (LMICs) is largely unknown. We aimed to assess this association as well as its mediators using nationally representative data from six LMICs.

METHODS

Cross-sectional, community-based data from the Study on Global Aging and Adult Health were analyzed. A total of 11 chronic physical conditions were assessed. Self-reported information on past 12-month suicidal ideation and suicide attempts was also collected. Multivariable logistic regression and mediation analyses were conducted.

RESULTS

The final sample consisted of 34,129 adults aged ≥50 years (mean [SD] age 62.4 (16.0) years; maximum age 114 years; 52.1% females). In the overall sample, physical multimorbidity was associated with increased odds for suicidal ideation (OR = 2.99; 95% CI = 2.06-4.34) and suicide attempts (OR = 2.79; 95% CI = 1.58-4.95), with the association being stronger in males than females. The association between multimorbidity and suicidal ideation or suicide attempts was largely mediated by pain/discomfort (mediated% 33.3%-44.2%), sleep/energy (28.2%-33.8%), and mobility limitations (26.6%-34.8%).

CONCLUSIONS

Physical multimorbidity among older adults in LMICs was associated with a substantially increased risk for suicidal ideation and suicide attempts. Addressing the identified mediators in people with physical multimorbidity may aid in the prevention of suicidal ideation and suicide attempts.

Apolipoprotein E genotype, inflammatory biomarkers, and non-psychiatric multimorbidity contribute to the suicidal ideation phenotype in older age. The Salus in Apulia Study

BACKGROUND

Possible relationships between suicidal ideation and biopsychosocial predictors in older age are unclear. In the population-based Salus in Apulia Study, we investigated the relationships among biomarkers, socio-demographic, psychopathological, inflammatory and metabolic characteristics and suicidal ideation in 1252 older subjects.

METHODS

Suicidal ideation was evaluated with the brief version of the Columbia-Suicide Severity Rating Scale. Apolipoprotein E (APOE) genotype and inflammatory profile [interleukin (IL)-6, tumor necrosis factor (TNF)-α, C-reactive protein (CRP)] were evaluated. A machine learning algorithm, the Random Forest (RF), selected potential biopsychosocial factors associated to suicidal ideation.

RESULTS

Suicidal ideators accounted for 2.32 % of subjects, were female, smokers, and obese with multimorbidity. After adjusting for age, gender, education and social dysfunction, logistic regression analyses revealed that suicidal ideation was associated to late-life depression (LLD) (odds ratio:21.71,95 % confidence interval:9.22-51.14). In the full RF model, asthma was the most important contributor to suicidal ideation. In the final RF model, education, age, and mild cognitive impairment followed by gender and global cognition were considered the most important contributors. Among biomarkers, in the final RF model, IL-6 followed by TNF-α, APOE ε4 allele presence, CRP and high-density lipoprotein cholesterol contributed most to suicidal ideation.

LIMITATIONS

A relatively small number of older subjects with suicidal ideation (2.3 %); we did not distinguish between active and passive suicidal ideation.

CONCLUSIONS

Although LLD is a strong determinant of suicidal ideation, other non-psychiatric factors, i.e., serum inflammation biomarkers, APOE ε4 allele, and multimorbidity, should be taken into account when evaluating a suicidal ideation phenotype in older age.

A Qualitative Analysis of Suicide Notes to Understand Suicidality in Older Adults

OBJECTIVE

Suicide is a complex multifactorial process influenced by a variety of biological, psychological, and social stressors. Many older adults face a characteristic set of challenges that predispose them to suicidal ideation, suicide-related behavior, and death by suicide. This study explored the subjective experience of suicidality through the analysis of suicide notes from older adults.

DESIGN

Qualitative study analyzing written suicide notes.

SETTING

Written notes for suicide deaths in Toronto, Canada, between 2003 and 2009 were obtained from the Office of the Chief Coroner for Ontario.

PARTICIPANTS

The analysis comprised 29 suicide notes (mean words per note: 221; range: 6-1095) written by individuals 65 years and older (mean ± SD age: 76.2 ± 8.3).

MEASUREMENTS

We employed a constructivist grounded theory framework for the analysis, conducted through line-by-line open coding, axial coding, and theorizing of data to establish themes.

RESULTS

Suicide notes elucidated the writers' conception of suicide and their emotional responses to stressors. Expressed narratives contributing to suicide centered on burdensomeness or guilt, experiences of mental illness, loneliness or isolation, and poor physical health or disability. Terms related to pain, poor sleep, apology, and inability to go on were recurrent.

CONCLUSIONS

Suicide notes enrich our understanding of the thoughts and emotions of those at highest risk of suicide, and they inform potential interventions for reducing suicide risk in older adults.

Distinctions between depression and anxiety with fear of being a burden in late life

Objectives: The perception of being a burden is a well-known risk factor for dying by suicide. Research on factors that precede the state of perceived burdensomeness, such as fearing being a burden, is necessary. We investigated the extent to which health status, elevated depressive symptoms, and elevated anxiety symptoms are associated with fear of being a burden in late life.Method: Older adult participants (N = 155) completed the Geriatric Anxiety Scale (GAS), Patient Health Questionnaire (PHQ-8), and demographic and health questions. Fear of being a burden, assessed with a supplemental item on the GAS, was categorically grouped as 'no fear' or 'some fear'. Using logistic regression, we examined predictors of fear of being a burden.Results: In the first step, elevated depression was associated with fear of being a burden (OR = 2.30, 95% CI: 1.09, 4.89, p = .03), but health status was not significant. In the second step, elevated anxiety was significant (OR = 2.63, 95% CI: 1.15, 5.99, p = .02); depression was no longer significant.Conclusion: Contrary to expectations, anxiety more strongly predicted fear of being a burden than depression. Future research should further investigate the role of anxiety in fear of being a burden and ways of intervening.

Opioid poisoning cases aged 50+ in the 2015-2020 National Poisoning Data System: suspected suicides versus unintentional poisoning and other intentional misuse/abuse

High rates of opioid overdose and suicide among the 50+ age group call for an examination of suicidal intent in overdose incidents. Using 2015-2020 National Poison Data System opioid poisoning cases aged 50+ (n = 83 153), we examined the types of opioids and other substances associated with suspected suicides compared to intentional misuse/abuse without suicidal intent. During the six years, prescription opioid cases decreased, while illicit opioid cases increased. Among both types of opioid poisoning cases, the proportions of suspected suicides decreased and those of intentional misuse/abuse without suicidal intent increased. However, due to the large increase in illicit opioid cases, the number of suspected suicide cases involving illicit opioids increased. Multivariable analyses showed that among prescription opioids, acetaminophen with opioid (IRR = 1.17, 95% CI = 1.11-1.24) and tramadol (IRR = 1.12, 95% CI = 1.06-1.47) were associated with higher risk of suspected suicides than intentional misuse/abuse without suicidal intent. Among illicit opioid cases, fentanyl poisoning cases were associated with lower risk of suspected suicides (IRR = 0.40, 95% CI = 0.17-0.94). Of other medications, use of benzodiazepines and antipsychotics was consistently associated with higher risk of suspected suicides in both prescription and illicit opioid cases. Alcohol and cocaine were also associated with higher risk of suspected suicide. Along with continued reductions in opioid prescribing, more effective monitoring of individual patient misuse/abuse behaviors and suicide risk assessment are needed. Healthcare professionals should also review other prescription medications frequently co-prescribed with opioids that may have additive effects on suicidal behaviors among older adults.

A systematic review of evidence-based aftercare for older adults following self-harm

OBJECTIVE

Self-harm is closely associated with suicide in older adults and may provide opportunity to intervene to prevent suicide. This study aimed to systematically review recent evidence for three components of aftercare for older adults: (1) referral pathways, (2) assessment tools and safety planning approaches and (3) engagement and intervention strategies.

METHODS

Databases PubMed, Medline, PsychINFO, Embase and CINAHL were searched from January 2010 to 10 July 2021 by two reviewers. Empirical studies reporting aftercare interventions for older adults (aged 60+) following self-harm (including with suicidal intent) were included. Full text of articles with abstracts meeting inclusion criteria were obtained and independently reviewed by three authors to determine final studies for review. Two reviewers extracted data and assessed level of evidence (Oxford) and quality ratings (Alberta Heritage Foundation for Medical Research Standard Quality Assessment Criteria for quantitative and Attree and Milton checklist for qualitative studies), working independently.

RESULTS

Twenty studies were reviewed (15 quantitative; 5 qualitative). Levels of evidence were low (3, 4), and quality ratings of quantitative studies variable, although qualitative studies rated highly. Most studies of referral pathways were observational and demonstrated marked variation with no clear guidelines or imperatives for community psychiatric follow-up. Of four screening tools evaluated, three were suicide-specific and one screened for depression. An evidence-informed approach to safety planning was described using cases. Strategies for aftercare engagement and intervention included two multifaceted approaches, psychotherapy and qualitative insights from older people who self-harmed, carers and clinicians. The qualitative studies identified targets for improved aftercare engagement, focused on individual context, experiences and needs.

CONCLUSION

Dedicated older-adult aftercare interventions with a multifaceted, assertive follow-up approach accompanied by systemic change show promise but require further evaluation. Research is needed to explore the utility of needs assessment compared to screening and evaluate efficacy of safety planning and psychotherapeutic approaches.

How to measure mental pain: a systematic review assessing measures of mental pain

QUESTION

Although mental pain is present in many mental disorders and is a predictor of suicide, it is rarely investigated in research or treated in care. A valid tool to measure it is a necessary first step towards better understanding, predicting and ultimately relieving this pain.

STUDY SELECTION AND ANALYSIS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review to identify all published standardised measures of mental pain. We used qualitative content analysis to evaluate the similarity of each measure, quantified via Jaccard Index scores ranging from no similarity (0) to full similarity (1). Finally, using the Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology, we evaluated each measure's development (assessing 35 features), its content validity (31 features) and if the latter was rated at least adequate, its other psychometric properties.

FINDINGS

We identified 10 self-reported scales of mental pain in 2658 screened studies relying on diverse definitions of this construct. The highest average similarity coefficient for any given measure was 0.24, indicative of weak similarity (individual pairwise coefficients from 0 to 0.5). Little to no information was provided regarding the development and the content validity of all 10 scales. Therefore, their development and content validity were rated 'inadequate' or 'doubtful'.

CONCLUSIONS AND CLINICAL IMPLICATIONS

There is not enough evidence of validity to recommend using one measure over others in research or clinical practice. Heterogeneous use of disparate measures across studies limits comparison and combination of their results in meta-analyses. Development by all stakeholders (especially patients) of a consensual patient-reported measure for mental pain is needed.

PROSPERO REGISTRATION NUMBER

CRD42021242679.

Mental Health Emergency Hotlines in the United States: A Scoping Review (2012-2021)

OBJECTIVE

Mental health emergency hotlines provide clinical supports and connection to services. This scoping review describes the current literature on hotlines in the United States, including which populations they do and do not reach, typical call volumes and engagement levels, barriers to and facilitators of implementation, and common call outcomes. The review also identifies gaps in the literature and presents recommendations.

METHODS

A systematic search of peer-reviewed articles on U.S.-based telephone, text, and chat hotlines published between January 2012 and December 2021 retrieved 1,049 articles. In total, 96 articles met criteria for full-text review, of which 53 met full inclusion criteria.

RESULTS

Approximately half of the included studies (N=25) focused on descriptive information of callers, most of whom were females, younger adults, and White; veteran hotlines typically reached older men. Common reasons for calling were suicidality, depression, and interpersonal problems. Of studies examining intervention effects (N=20), few assessed hotlines as interventions (N=6), and few evaluated caller behavioral outcomes (N=4), reporting reduced distress and suicidality among callers after hotline engagement. However, these studies also suggested areas for improvement, including reaching underrepresented high-risk populations. Six studies reported implementation needs, such as investments in data collection and evaluation, staff training, and sustainable funding.

CONCLUSIONS

Hotlines appear to be more effective at reaching some populations than others, indicating that more intensive outreach efforts may be necessary to engage underrepresented high-risk populations. The findings also indicated limited evidence on the relationship between use of hotlines-particularly local text and chat hotlines-and caller outcomes, highlighting an area for further investigation.

Intent disclosure in late-life suicide: Age group differences in correlates and associations with suicide means

Age-adjusted suicide rates declined from 2018 to 2020. However, suicide rates among older adults, particularly males 75 and older, have continued to rise, and the evidence base for effective interventions to prevent suicide in late life remains limited. One strategy to prevent older adults' suicidal behavior is to intervene when they reveal suicide intent. Previous research found that a significant proportion of older suicide decedents disclosed their suicide intent close to the fatal incident. In this study, based on the 2017-2019 United States National Violent Death Reporting System (NVDRS) data, we examined: (1) correlates of intent disclosure among three age groups (65-74, 75-84, and 85+) of older suicide decedents (N = 17,917; 14,856 men and 3,061 women); and (2) associations of suicide means with intent disclosure and suicide contributing factors. The results show that 19.9% of all suicide decedents aged 65+ (18.7%, 21.0%, and 22.0% in the 65-74, 75-84, and 85+ age groups, respectively) disclosed their suicide intent to their partner, family/friends, and healthcare providers within a month of their death. Multivariable analyses using generalized linear models for a Poisson distribution with a log link showed that physical and mental health, substance misuse, addiction problems, and relationship/other life stressors were associated with a higher likelihood of intent disclosure in the 65-74 and 75-84 age groups. However, only physical health problems were associated with a higher likelihood of intent disclosure among those aged 85 and older. Intent disclosure was not associated with using firearms and poisoning as suicide means but with a lower likelihood of hanging or suffocation. Mental health and substance misuse problems were associated with higher odds of hanging or suffocation and poisoning, and physical health problems and male sex in the 85+ age group were associated with higher odds of firearm use. Suicide prevention strategies for those who have disclosed their suicide intent or are at risk of suicidal behavior should include more patient-centered comfort and palliative care, mental health/substance misuse/addiction treatment, and restriction of access to potential suicide means. More research on older adults who disclose suicide intent and late-life suicide prevention strategies is needed.

What distinguishes high and low-lethality suicide attempts in older adults? A systematic review and meta-analysis

Those making suicide attempts with highly lethal medical consequences are arguably the best proxy for those who die by suicide and represent a qualitatively different population from those making lower lethality attempts. Different factors influence the likelihood of a suicide attempt occurring and the lethality of that attempt. Both are important dimensions of risk. Older adults represent a distinct group in suicide research with unique risk factors that influence the lethality of their suicide attempts. This systematic review and meta-analysis summarises factors distinguishing those making high and low-lethality suicide attempts in older adulthood. Databases PsycINFO, PubMed (MEDLINE), Embase and CINAHL were systematically searched with seven of 1182 unique records included. Random effects meta-analyses were conducted on 18 variables in addition to a narrative synthesis regarding executive function. Only increased suicidal intent and planning meaningfully distinguished high from low-lethality attempters in meta-analyses. A large effect size was additionally observed for white ethnicity. Diminished alcohol use disorder prevalence and depression severity, and greater cognitive impairment, may be associated with high lethality attempters but further research is needed. Age and gender were not associated with lethality, contrary to adult populations. A narrative synthesis of studies exploring differences in executive functioning suggested high-lethality attempters were less likely to impulsively act on suicidal urges, allowing them to better plan suicide attempts that are more lethal, and are less likely to alter suicidal plans. Key limitations were that meta-analyses were underpowered to detect small effect sizes, and samples were largely white and limited to the USA.

Police-reported suicides during the first 16 months of the COVID-19 pandemic in Ecuador: A time-series analysis of trends and risk factors until June 2021

Background

There are widespread concerns that the COVID-19 pandemic may increase suicides. Few studies have analysed effects beyond the pandemic's early months or examined changes in known suicide risk factors.

Methods

Using time series models fit with Poisson regression, we analysed monthly police-reported suicides in Ecuador from January 2015 to June 2021. Treating March 2020 as the start of the pandemic, we calculated rate ratios (RRs) comparing the observed to the expected number of suicides for the total population and by age and sex groups. We investigated changes in risk factors, precipitants, geographic distribution, and suicide methods.

Findings

There was no evidence that suicide rates were higher than expected during the pandemic (RR 0·97 [95% CI 0·92–1·02]). There was some evidence of fewer than expected male suicides (RR 0·95 [95% CI 0·90–1·00]). The proportion of suicides occurring in urban and coastal areas increased but decreased amongst indigenous and other minorities. The proportions of suicides with evidence of alcohol consumption, disability, and amongst married and cohabiting individuals decreased, whereas suicides where mental health problems were considered contributory increased. There were relative increases in the proportion of suicides by hanging but decreases in self-poisoning and other suicide methods.

Interpretation

The pandemic did not appear to adversely impact overall suicide numbers nationwide during the first 16 months of the pandemic. Reduced alcohol consumption may have contributed to the decline in male suicides.

Funding

None.

The Applicability of Linehan Risk Assessment Scale: a Cross-Sectional Study from Alexandria Poison Centre, Egypt, During the COVID-19 Pandemic

Background/Objective

Suicide is a critical health problem that is significantly rising during the COVID-19 pandemic worldwide, yet it is still under-reported in Egypt. To date, a deficiency of a reliable scale to probe the risk factors underlying suicide liability among patients with deliberate self-poisoning. The study’s objective was to offer a snapshot of the pattern of self- poisoning in Egypt during the COVID-19 pandemic.

Methods

Using the Linehan Risk Assessment and Management Protocol LRAMP, a psychological assessment was applied to evaluate vulnerable patients needing urgent psychiatric support and emphasize the influence of previous suicidal behaviors. A cross-sectional study was conducted on all patients admitted to Alexandria Poison Centre with deliberate self-poisoning biosocial and poisoning data that were recorded in a specially designed sheet. All patients were interviewed for underlying risk factors and protective factors for suicidal behavior.

Results

Significant relation was recorded between previous suicidal attempts and psychiatric diseases. CNS depressant drugs and rodenticides recorded the highest frequency. The calculated score (suicide and protective factors) was higher in patients with previous suicidal attempts.

Conclusion

The study was the first to test the applicability of Linehan scale in Alexandria Poison Centre. The results are promising; however, multicenter replication of the concluded findings will be valuable.

Poisoning in older adults: characterization of exposures reported to the Dutch Poisons Information Center

Introduction: The annual number of patients > 65 years old about whom the Dutch Poisons Information Center (DPIC) was consulted has more than doubled in the last decade. We aimed to gain insight in the type and circumstances of exposures reported to the DPIC involving older patients, in order to help prevent future poisonings. Methods: Enquiries to the DPIC involving patients > 65 years old were prospectively included from January 2019 to June 2019. Data were collected on patient characteristics (e.g., age, gender, and living situation) and exposure characteristics (e.g., type and exposure scenario). Results: In the first half of 2019, the DPIC was consulted about 1051 patients > 65 years old. The median age of the patients was 77 years old (range: 66-104 years) and women were over-represented (61%). A total of 1650 different substances were reported, 1213 pharmaceutical exposures (74%) and 437 non-pharmaceutical exposures (26%), mostly household products (n = 162). Most pharmaceutical exposures involved cardiovascular agents (n = 367, 30%), central and peripheral nervous system agents (n = 354, 29%), and analgesics (n = 152, 13%). In 71% of the patients exposed to pharmaceuticals, the drugs were taken unintentionally (n = 471), frequently caused by medication errors made by the patients themselves (n = 357, 76%). Most common scenarios included inadvertently taken/given a double (n = 140, 30%) or more than double (n = 94, 20%) dose or the wrong medication (n = 124, 26%). The most common scenario for unintentional exposure to non-pharmaceuticals was "mistook product for food/drink" (n = 122, 37%). Conclusions: The majority of intoxications in older adults are accidental and often involve medication errors. Unintentional poisoning is often preventable. If patients are cognitively impaired, potentially harmful substances should be kept out of their reach and medication should only be administered under direct supervision. Clear labelling, simplified drug regimens and the use of automatic medication dispensers could reduce the risk of medication errors in older patients.

Can cognition help predict suicide risk in patients with major depressive disorder? A machine learning study

BACKGROUND

Previous studies suggest that deficits in cognition may increase the risk of suicide. Our study aims to develop a machine learning (ML) algorithm-based suicide risk prediction model using cognition in patients with major depressive disorder (MDD).

METHODS

Participants comprised 52 depressed suicide attempters (DSA) and 61 depressed non-suicide attempters (DNS), and 98 healthy controls (HC). All participants were required to complete a series of questionnaires, the Suicide Stroop Task (SST) and the Iowa Gambling Task (IGT). The performance in IGT was analyzed using repeated measures ANOVA. ML with extreme gradient boosting (XGBoost) classification algorithm and locally explanatory techniques assessed performance and relative importance of characteristics for predicting suicide attempts. Prediction performances were compared with the area under the curve (AUC), decision curve analysis (DCA), and net reclassification improvement (NRI).

RESULTS

DSA and DNS preferred to select the card from disadvantageous decks (decks "A" + "B") under risky situation (p = 0.023) and showed a significantly poorer learning effect during the IGT (F = 2.331, p = 0.019) compared with HC. Performance of XGBoost model based on demographic and clinical characteristics was compared with that of the model created after adding cognition data (AUC, 0.779 vs. 0.819, p > 0.05). The net benefit of model was improved and cognition resulted in continuous reclassification improvement with NRI of 5.3%. Several clinical dimensions were significant predictors in the XGBoost classification algorithm.

LIMITATIONS

A limited sample size and failure to include sufficient suicide risk factors in the predictive model.

CONCLUSION

This study demonstrate that cognitive deficits may serve as an important risk factor to predict suicide attempts in patients with MDD. Combined with other demographic characteristics and attributes drawn from clinical questionnaires, cognitive function can improve the predictive effectiveness of the ML model. Additionally, explanatory ML models can help clinicians detect specific risk factors for each suicide attempter within MDD patients. These findings may be helpful for clinicians to detect those at high risk of suicide attempts quickly and accurately, and help them make proactive treatment decisions.

Suicidality in the geriatric population

Suicide in older adults is a major global concern in both public and mental health. With an ageing population on the rise, a surge in suicidal deaths is predicted in the coming years. The objectives of this paper are to review the risk factors, protective factors, assessment rating scales and current prevention strategies in the geriatric population. The identification of modifiable risk factors and strengthening of protective factors as well as staging according to suicidal ideation, behaviors and/or attempt(s) are necessary to devise appropriate personalized interventions in vulnerable older adults. A history or current psychiatric illness particularly depression, physical illnesses, previous suicide attempt, substance abuse, loneliness, marital status, financial stress, a family history of psychiatric illnesses or suicide in 1st degree relatives and low social support most commonly increase suicidal susceptibility in older adults. Conversely, factors that increase resilience in older adults include a good physical health and cognitive function, religiousness, good quality of life and life satisfaction, ability to perform activities of daily living, marital status, having friends and social connectedness. While the risk factors associated with suicide in the geriatric population are complex and multidimensional in nature, the current preventive strategies have provided no substantial decline in suicidal risk. Therefore, a combination of strategies applied via a multilevel prevention program at a primary, mental healthcare, societal and community level could mitigate suicidal risk. Further research and better preventive measures are warranted to diminish suicidal risk in older adults.

Suicide Rates and Differences in Rates Between Non-Hispanic Black and Non-Hispanic White Populations in the 30 Largest US Cities, 2008-2017

OBJECTIVES

Suicide is a leading cause of death in the United States, and rates vary by race and ethnicity. An analysis of suicide across large US cities is absent from the literature. The objective of this study was to examine suicide rates among the total population, non-Hispanic Black population, and non-Hispanic White population in the United States and in the 30 largest US cities.

METHODS

We used data from the National Vital Statistics System to calculate non-Hispanic White, non-Hispanic Black, and total age-adjusted suicide rates for the 30 largest US cities and for the entire nation during 2 periods: 2008-2012 and 2013-2017. We also examined absolute and relative differences in suicide rates among non-Hispanic White populations and non-Hispanic Black populations in each city.

RESULTS

The overall age-adjusted suicide rate per 100 000 population in the United States increased significantly from 12.3 in 2008-2012 to 13.5 in 2013-2017. Total suicide rates were stable in most cities; rates increased significantly in only 1 city (Louisville), and rates decreased significantly in 2 cities (Boston and Memphis). The non-Hispanic White suicide rate was significantly higher-1.3 to 4.3 times higher-than the non-Hispanic Black suicide rate in 24 of 26 study cities during 2013-2017. From 2008-2012 to 2013-2017, non-Hispanic White suicide rates decreased significantly in 3 cities and increased significantly in 3 cities; non-Hispanic Black suicide rates increased significantly in 5 cities and decreased in none. Absolute differences in suicide rates among non-Hispanic White populations and non-Hispanic Black populations increased significantly in 1 city (Louisville) and decreased significantly in 2 cities (Memphis and Boston).

CONCLUSIONS

Our study may inform the use of evidence-based programs and practices to address population-level risk factors for suicide.

Determinants of Suicide Ideation in the Romanian Population

BACKGROUND

Suicide ideation and behaviors are directly linked to the risk of death by suicide. In Romania, as well as worldwide, increased suicide rates were observed in the recent past, more so in the context of the COVID-19 pandemic. The purpose of this study was to investigate the influence of psychosocial factors, quality of life (QOL), and loneliness dimensions and adverse life antecedents on suicide ideation (SI) and prolonged sadness (PS).

METHODS

This cross-sectional quantitative research study used a CATI data gathering method to investigate 1102 randomly selected individuals over 18 years of age regarding various determinants of SI and PS. Data were collected in June 2021. Descriptive, inferential, and multivariate statistics were used for data analysis.

RESULTS

SI was negatively correlated with all the assessed psychosocial factors, more significantly with family relationships, wealth, health, social relationships, and affective life. Stronger correlations were observed when investigating the state of prolonged sadness, sex, and affective lives along with health and income, which were more influential. SI was negatively correlated with QOL and positively correlated with adverse life events and total loneliness scores. Lesser educated youngsters with reduced overall happiness and a history of depression, self-harm, and trauma were at greater risk of developing SI.

CONCLUSIONS

This is the first national study exploring the suicide ideation and prolonged sadness in relation to psychosocial factors, quality of life, and adverse life events. These results have important implications for suicide prevention programs, which should be designed in accordance with similar studies.

Factors Related to Suicidal Ideation and Prediction of High-Risk Groups among Youngest-Old Adults in South Korea

(1) Background: The suicide of older adults shows different factors between the youngest-old adults and the old-old adults. This study aimed to identify factors predicting suicidal ideation among youngest-old adults (ages 65 to 74 years) and predict high-risk groups’ characteristics. (2) Methods: The subjects of this study were 970 youngest-old adults who participated in the Korean National Health and Nutrition Examination Survey (KNHANES VIII Year 1, 2019). Logistic regression analysis identified factors related to suicidal ideation, and decision tree analysis identified combined characteristics among high-risk groups. Data were analyzed using SPSS 27.0. (3) Results: Suicidal ideation became more common among those with relatively lower income levels (OR = 1.48, 95% CI = 1.04−2.12), those whom had experienced depression (OR = 9.28, 95% CI = 4.57−18.84), those with relatively higher stress levels (OR = 2.42, 95% CI = 1.11−5.28), and those reporting a relatively worse perceived health (OR = 1.88, 95% CI = 1.23−3.11). Complex characteristics that combined depression, low personal income level, and low perceived health predicted a high risk of suicidal ideation (64.6%, p < 0.05). (4) Conclusions: The findings indicate that this high-risk group should be prioritized when developing suicide prevention strategies.

Suicide Risk in Survivors of Acute Respiratory Distress Syndrome: A Nationwide Cohort Study in South Korea

OBJECTIVE

We aimed to examine the prevalence and risk factors of suicide among patients with acute respiratory distress syndrome (ARDS).

METHODS

Data were extracted from the National Health Insurance Service database in South Korea. This study included all adults admitted to intensive care units with a diagnosis of ARDS from January 1, 2010 to December 31, 2019, who survived ≥365. The primary endpoint in this study was suicide within 1 year of an ARDS diagnosis, which was determined as death by a suicide attempt or self-harm.

RESULTS

Analysis included 9,928 patients identified as ARDS survivors. One-year all-cause mortality occurred in 5,021 patients, 186 (1.9%) of which died by suicide. In multivariable Cox regression, older age, continuous renal replacement therapy, cardiopulmonary resuscitation incidence, history of self-harm or attempted suicide and concurrent substance abuse were associated with a higher risk of death by suicide among ARDS survivors.

CONCLUSION

During the 1-year follow-up period, 1.9% of ARDS survivors died by suicide in South Korea, and some factors were identified as potential risk factors for death by suicide. Knowledge of the factors associated with suicide might allow for earlier intervention to potentially reduce the death by suicide among ARDS survivors.

Relationship between handgrip strength, depression and cognitive functioning among older adults: Evidence from longitudinal ageing study in India

BACKGROUND

Handgrip strength (HGS) is a frequent and general indicator of muscle strength and it may affect several aspects of mental health among older people. This study explored the association of HGS with depression and cognitive impairment among community-dwelling older adults in resource-constrained setting of India.

METHOD

Data were drawn from the Longitudinal Ageing Study in India (LASI), and the analysis was conducted on 27,707 older adults aged 60 years and above. Outcome measures included depression (assessed by the Short Form Composite International Diagnostic Interview (CIDI-SF) and the Center for Epidemiological Studies-Depression (CES-D) scales) and cognitive impairment. Descriptive statistics and mean scores of HGS were reported and multivariable linear regression analyses were conducted to test the research hypotheses of the study.

RESULTS

Mean score of HGS was 24.33 (SD: 7.22) for males and 15.94 (SD: 5.14) for females. Mean age was 68.86 (SD: 7.19) and 68.40 (SD: 7.31) years among males and females respectively. Older participants who had weak HGS were significantly more likely to be depressed in CIDI-SF scale (B: 0.06, CI: 0.01-0.13) and CES-D scale (B: 0.02, CI: 0.01-0.03) in comparison to those who had strong HGS after adjusting for a large number of confounders. Older participants who had weak HGS were significantly more likely (B: 0.92, CI: 0.76-1.07) to have cognitive impairment compared to those who had strong HGS.

CONCLUSION

The findings highlight the independent association of HGS with major depression, depressive symptoms and cognitive impairment that have implications on promoting resistance-training programs among aged population.

Association between Loneliness and Depression among Community-Dwelling Older Women Living Alone in South Korea: The Mediating Effects of Subjective Physical Health, Resilience, and Social Support

Social isolation and loneliness are the key risk factors for depression in late life. Older adults living alone and socially isolated are at greater risk for physical and mental health. This study aims to examine the mediating effects of subjective physical health, resilience, and social support on the association between loneliness and depression among the elderly female population living alone in South Korea. We included a total of 308 older women aged 60 years or older who live alone in a medium-sized city in South Korea. The survey data was collected using the validated survey instruments between November 2015 and April 2016. A parallel mediation model was performed to investigate whether physical health, resilience, and social support had mediating effects on the association of loneliness with depression. The findings of this study showed that loneliness was directly and indirectly associated with depression through its association with the subjective physical health, resilience, and social support among the older female population living alone. Our results suggest the importance of supporting community-based programs to improve physical and mental health of the elderly people as a way to minimize the level of loneliness and prevent depression.

Suicidal ideation and suicide attempts among older recipients of public welfare assistance in Japan

BACKGROUND

The high suicide rate among older adults is an important public health issue. Financial insecurity has been linked to suicidal behaviour. Despite this, as yet, there has been little research on suicide-related behaviours among older recipients of public welfare. This study will examine if suicidal ideation and suicide attempts are more prevalent in older recipients of public welfare assistance in Japan.

METHODS

This cross-sectional study analysed data from 16 135 adults aged ≥65 years who participated in the 2019 wave of the Japan Gerontological Evaluation Study. Information was obtained on receiving public welfare assistance, lifetime suicidal ideation and attempts, and a variety of covariates. Poisson regression analysis with robust variance estimates was used to examine associations.

RESULTS

Suicidal ideation was reported by 4.8% of the participants, while the corresponding figure for attempted suicide was 2.2%. In fully adjusted analyses public welfare recipients had an almost 1.5 times higher prevalence of lifetime suicidal ideation (prevalence ratio, PR 1.47, 95% CI 1.02 to 2.13), and an almost two times higher prevalence of attempted suicide (PR 1.91, 95% CI 1.20 to 3.04) when compared with their counterparts not receiving public welfare assistance.

CONCLUSION

Older recipients of public welfare have a higher prevalence of suicidal behaviour in Japan. An urgent focus is now warranted on this vulnerable population to determine the specific factors underlying this association.

Association of food insecurity with suicidal ideation and suicide attempts in adults aged ≥50 years from low- and middle-income countries

BACKGROUND

The aim of the present study was to investigate associations between food insecurity with suicidal ideation and suicide attempts in adults aged ≥50 years from six low- and middle-income countries (LMICs).

METHODS

Cross-sectional, community-based data from the World Health Organisation's Study on Global Aging and Adult Health were analyzed. Self-reported information on past 12-month suicidal ideation and suicide attempts was collected. Past 12-month food insecurity was assessed with two questions on frequency of eating less and hunger due to lack of food. Multivariable logistic regression analysis was conducted to assess the association between food insecurity and suicidal ideation or suicide attempts.

RESULTS

The final analytical sample included 34,129 individuals aged ≥50 years [mean (SD) age 62.4 (16.0) years; 52.1% females]. Compared to no food insecurity, severe food insecurity was associated with a significant 2.78 (95%CI = 1.73-4.45) times higher odds for suicidal ideation, while moderate and severe food insecurity were associated with 2.59 (95%CI = 1.35-4.97) and 5.15 (95%CI = 2.52-10.53) times higher odds for suicide attempts, respectively.

LIMITATIONS

The cross-sectional design, the use of self-reported wish to die as a measure of suicide ideation, and that suicidal ideation and suicide attempts were only assessed among those who had depressive symptoms, could be considered limitations of our study.

CONCLUSIONS

Food insecurity was positively associated with suicidal ideation and suicide attempts. Targeting food insecurity among older adults in LMICs may lead to reduction in suicidal ideation and suicide attempts, although future longitudinal studies are warranted to confirm this.

Impact of COVID-19 on the social relationships and mental health of older adults living alone: A two-year prospective cohort study

Background

Owing to the COVID-19 outbreak, older adults living alone, who can only connect socially outside their homes, are at risk of social isolation and poor mental health. This study aimed to identify the changes, before and after COVID-19, by sex and age, in social relationships (social activity, social network, and social support) and mental health (depression and suicide ideation) among older adults living alone.

Methods

This is a prospective cohort study of community-dwelling older adults who were at least 65 years old and living alone in South Korea. The study was conducted during 2018–2020 with 2,291 participants (795, 771, and 725 for the 1st to 3rd waves, respectively). The data were collected via face-to-face interviews. A generalized linear mixed modeling framework was used to test for changes over three years.

Results

Social activity was reduced after the COVID-19, with an interaction effect of sex: older women (odds ratio [OR], 0.19; 95% confidence interval [CI], 0.15–0.23; p < .001) showed greater reduction than older men (OR, 0.50; 95% CI, 0.34–0.75; p < .001). Interaction with neighbors also reduced after the pandemic, but there was no significant evidence of interaction effects. Interaction with family members increased in both sexes during the pandemic, with the interaction effect of sex: older women (OR, 1.40; 95% CI, 1.11–1.76; p = .004) showed greater increase than men (OR, 1.55; 95% CI, 1.13–2.14; p = .007). Social support increased in both sexes during the pandemic, but there was no significant evidence of interaction effects. Depression and suicide ideation showed no significant differences before and after the pandemic.

Conclusions

The findings provide health administrators and health providers with explorative insights into the impact of the COVID-19 on social relationships and mental health among older adults living alone and can guide further studies of interventions considering specific properties of social relationships.

Psychotherapy with older adults: Ageism and the therapeutic process

Objective This study explores how ageism in therapists is manifested in psychotherapy with older adults and how therapists deal with its impact on their therapeutic work. Method: Semi-structured interviews were conducted with 14 therapists and analyzed using grounded theory methodology. Results: Findings clustered around two themes: (i) maintaining openness to change while acknowledging limitations; (ii) dealing with manifestations of ageism inside therapy by going beyond relating to older patients only in terms of their chronological age. Conclusions: Our findings indicate that while therapists maintain an optimistic view regarding the possibility of therapeutic change, the therapeutic encounter with older patients triggers certain ageist therapeutic biases and behaviors in therapists, even in experienced therapists who have competency in working with older adults. Our findings also indicate that dealing with therapists' ageism in psychotherapy with older patients requires therapists not only to be aware in advance of their ageist attitudes but also to continuously engage in the management of the manifestations of ageism inside treatment. We use the conceptual framework of countertransference to suggest an understanding of the relationship between therapists' ageism and the therapeutic process. Implications for training and practice are discussed.

Social isolation among older veterans: findings from the National Health and Aging Trends Study

OBJECTIVES

Social isolation is a critical public health issue that affects multiple domains of well-being among older adults, but little is known about social isolation among older military veterans. As such, the purpose of this study was to estimate the prevalence of social isolation among older veterans and to examine risk factors for social isolation among older veterans.

METHOD

Data were derived from Round 1 of the National Health and Aging Trends Study, which is an annual, longitudinal panel survey of Medicare beneficiaries aged 65 and older. The sample included 1,683 veterans, who were primarily White and male. Weighted logistic regression models were used to predict severe social isolation (having no social participation) and social isolation (having only one source of social participation) among older veterans, while controlling for age, sex, race, marital status, education, income, and metropolitan residency.

RESULTS

After accounting for other predictors, results show that veterans who are 85 and older, male, White, unmarried or unpartnered, with lower educational attainment and lower income are greatly at risk of both severe social isolation and social isolation.

CONCLUSION

The results of this study support past research showing that veterans with limited social and economic capital are at great risk of experiencing adverse outcomes in older adulthood, including social isolation. Interventions should therefore aim to improve social connectedness among this population and should address the risk-factors that contribute to social isolation among older veterans.

A scoping review exploring the ‘grey area’ of suicide-related expression in later life: Developing a conceptual framework for professional engagement

As the body of research on suicide in later life has developed, so has its vocabulary. This has generated a high level of overlap in concepts and terminology used to articulate suicide and how it might present, as well as ‘grey area’ behavioural terms that are both specific to older adults and less well-defined (e.g. ‘hastening of death’ or ‘completed life’). A better understanding of individual experiences and pathways to suicide can help to inform assessment and interventions, and increase the potential to relate any theoretical concepts to the implementation of such. Here, we adopted a scoping review to search systematically literature on specific presentation, features, circumstances and outcomes of these grey areas of suicide in later life. Fifty-three articles (quantitative, qualitative and theoretical) were reviewed. A narrative approach was used to merge and translate this body of knowledge into a new conceptual framework based on four key themes: (a) a sense of completed life or existential loneliness; (b) death thoughts, wishes and ideation; (c) death-hastening behaviour and advanced directives; and (d) self-destructive or self-injurious behaviour. We discuss the importance of integrating this understanding into current knowledge and suicide prevention strategies for older adults. Recommendations are made for unifying research with policy themes on healthy ageing, person-centredness within service provision and citizen participation.

Characteristics of suicide among farmers and ranchers: Using the CDC NVDRS 2003-2018

BACKGROUND

Suicide is among the top 10 causes of premature death in the United States. This study provides details on farmer and rancher suicide decedents, including demographic information, mental health status, history of suicidal thoughts and attempts, and circumstances associated with death.

METHODS

Data for this study were obtained from the Centers for Disease Control and Prevention's National Violent Death Reporting System Restricted Access Database for the years 2003-2018. Descriptive statistics and adjusted odds ratios are presented for farm and nonfarm populations in addition to farm populations by age groups and sex.

RESULTS

This study found that almost half of the farmer suicide decedents were over 65 years old. Firearms were the most widely used method for farmers and ranchers regardless of age and sex. Young farmers and ranchers that died by suicide were more likely to have had relationship problems and older farmers and ranchers that died by suicides were more likely to have had a physical health problem. Male farmer and rancher suicide decedents were more likely to die by firearm than females, and female farmer and rancher suicide decedents were likely to have resided in a small metropolitan area, however, due to small numbers and suppression in the data, most sex comparisons were not able to be presented.

CONCLUSIONS

While no clear risk factor for suicide among farmers and ranchers emerged, results underscore the complex nature of suicide and the need for multifaceted, culturally competent interventions and campaigns that address suicide risk and prevention at the individual and community levels.

Suicide mortality among the elderly population in Italy: A nationwide cohort study on gender differences in sociodemographic risk factors, method of suicide, and associated comorbidity

OBJECTIVES

This study aimed at investigating gender differences in the relationship between sociodemographic factors and suicide mortality, as well as in the method used for suicide and the presence of comorbidities in an older population in Italy.

METHODS/DESIGN

We conducted a historical cohort study based on individual record linkage across the 15th Italian Population Census, the Italian Population Register, and the National Register of Causes of Death. Suicides among people aged 75 years or older from 2012 to 2017 were analyzed. Crude mortality rates were computed, and cause-specific mortality rate ratios were estimated using negative binomial regression models. Chi-square tests were used to evaluate significant gender differences in suicide methods and comorbidities associated with suicide.

RESULTS

The study included 9,686,698 individuals (41% men, 59% women). Compared to living alone, living with children or partners reduced suicide mortality, especially among men. Having high or medium educational levels was associated with lower mortality than low educational levels among men. Foreign citizens had lower mortality among men, but not among women. Living in urban areas was associated with lower suicide rates in men and higher rates in women. Methods of suicide significantly differed by gender: leading methods were hanging, strangulation, and suffocation in men, and falling from height in women. Mental comorbidity was significantly more frequent among women, especially at ages 75-84 years.

CONCLUSIONS

We believe that our findings might help to promote public health strategies taking gender differences in old age into account to improve social support and quality of life of older men and women.

Suicide mortality after a nonfatal suicide attempt: A systematic review and meta-analysis

INTRODUCTION

Deliberate self-harm and suicide attempts share common risk factors but are associated with different epidemiological features. While the rate of suicide after deliberate self-harm has been evaluated in meta-analyses, the specific rate of death by suicide after a previous suicide attempt has never been assessed. The aim of our study was to estimate the incidence of death by suicide after a nonfatal suicide attempt.

METHOD

We developed and followed a standard meta-analysis protocol (systematic review registration-PROSPERO 2021: CRD42021221111). Randomized controlled trials and cohort studies published between 1970 and 2020 focusing on the rate of suicide after suicide attempt were identified in PubMed, PsycInfo and Scopus and qualitatively described. The rates of deaths by suicide at 1, 5 and 10 years after a nonfatal suicide attempt were pooled in a meta-analysis using a random-effects model. Subgroup analysis and meta-regressions were also performed.

RESULTS

Our meta-analysis is based on 41 studies. The suicide rate after a nonfatal suicide attempt was 2.8% (2.2-3.5) at 1 year, 5.6% (3.9-7.9) at 5 years and 7.4% (5.2-10.4) at 10 years. Estimates of the suicide rate vary widely depending on the psychiatric diagnosis, the method used for the suicide attempt, the type of study and the age group considered.

CONCLUSION

The evidence of a high rate of suicide deaths in the year following nonfatal suicide attempts should prompt prevention systems to be particularly vigilant during this period.

Microglia as a Hub for Suicide Neuropathology: Future Investigation and Prevention Targets

Suicide is a complex public health challenge associated worldwide with one death every 40 s. Research advances in the neuropathology of suicidal behaviors (SB) have defined discrete brain changes which may hold the key to suicide prevention. Physiological differences in microglia, the resident immune cells of the brain, are present in post-mortem tissue samples of individuals who died by suicide. Furthermore, microglia are mechanistically implicated in the outcomes of important risk factors for SB, including early-life adversity, stressful life events, and psychiatric disorders. SB risk factors result in inflammatory and oxidative stress activities which could converge to microglial synaptic remodeling affecting susceptibility or resistance to SB. To push further this perspective, in this Review we summarize current areas of opportunity that could untangle the functional participation of microglia in the context of suicide. Our discussion centers around microglial state diversity in respect to morphology, gene and protein expression, as well as function, depending on various factors, namely brain region, age, and sex.

Elder suicides: A reminder from the forgotten generation ……

Elder suicide is a significant public health issue in many countries. This reflects the complex underlying psychosocial, mental and physical health issues that older adults face. Increased life expectancy in developing countries has resulted in a gradual transition to an ageing population. Furthermore, in countries such as Sri Lanka, the transition occurs at a lower per capita income than in developed countries. This will negatively impact the availability of resources and service delivery to at-risk individuals. Thus, addressing elder suicide and concerns of elders are timely issues. This paper looks at the underlying risk factors associated with elder suicide and strategies that can be implemented in preventing elder suicide in the South Asian context, with reference to Sri Lanka.

The hidden stigma of aging and COVID-19: aggravating factors and strategies to mitigate the impact of the pandemic in older adults, a text mining analysis

OBJECTIVE

To identify factors associated with mental health of older adults during the pandemic and to provide strategies to mitigate their psychosocial impact in the elderly.

METHOD

An integrative text mining analysis in Medline was performed to identify studies on the mental health of older adults during the pandemic. Subsequently, statistical topic modeling was performed to identify the most prevalent terms and topics discussed in included studies.

RESULTS

A total of 29 studies were retrieved until July 1st 2020, including a majority of letters (12 studies) and commentaries (8 studies). The most frequent terms overall were: loneliness (n = 137), support (n = 132), home (n = 102), suicide (n = 96) and help (n = 94). The most prevalent terms were then divided in five topics: home (33%), suicide (32%), apps (15%), loneliness (12%) and physical activity (9%). Additionally, a section focused on low- and middle-income countries was included. A summary of strategies to mitigate the effects of pandemic in mental health of older adults was also provided.

CONCLUSION

These factors demonstrate the importance of developing strategies for psychosocial support that take into consideration the particularities of the elderly. Different levels of care are immediately necessary to diminish the devastating impact of the pandemic in the mental health of older adults.

Assessing suicide ideation among older adults: a systematic review of screening and measurement tools

OBJECTIVES

Rates of suicide in older adults may be higher than reported due to poor understandings of presentation of suicide ideation in this group. The objectives of this paper were to (i) review current measurement tools designed for older adults to detect suicide ideation and (ii) assess their psychometric properties.

DESIGN

We used a systematic review approach to identify measurement tools developed specifically for older adults without cognitive decline or impairment.

RESULTS

Ten articles 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. There was wide variation across the articles: some were adaptations of existing scales to suit older populations, others were developed by authors; they varied in length from four to 69 items; a range of settings was used, and there was a mix of self-report and clinician-administered measures. Most displayed good psychometric properties, with both approaches showing similar quality. Limitations in terms of samples, settings, and measurement design are discussed.

CONCLUSION

The case for specific measures for older adults is clear from this review. There appear to be unique factors that should be considered in understanding suicide ideation and behavior among older adults that may not be directly assessed in non-specific measurements. However, there is a need to expand the diversity of individuals included in measurement development to ensure they are appropriate across gender, culture and minority status, and for the views of professionals to be considered.

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

Objectives

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.

Methods

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.

Results

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.

Conclusion

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.

Gender and the Subjective Well-Being of Older Widows and Widowers

Previous research on older adults who are widowed often focuses on the immediate subjective impacts of spousal loss, and how gender might influence this. Our interest here is on the factors that influence subjective well-being after a period of at least two years' post-bereavement, and how this might differ for men and women. We draw on theoretical considerations from previous research on gender and on widowhood and use two different measures-life satisfaction and happiness-to assess possible differences in this subjective outcome. We used data from the 2014 Health and Retirement Study on 692 widowed adults aged 65 and over (578 females and 114 males) and employed regression and postestimation analyses to examine whether and how gender influences their subjective well-being. Our findings show that gender did not affect overall levels of subjective well-being, regardless of measure. However, gender did influence the predictors, such as total household income, total wealth, and social support from children and friends, for life satisfaction and happiness somewhat differently. Our study highlights the importance of examining gender differences among older widows and widowers and also underlines the importance of introducing different measures of subjective well-being that might yield different yet valuable findings.

Attempted Suicide in the Older Adults: A Case Series From the Psychiatry Ward of the University Hospital Maggiore Della Carità, Novara, Italy

Introduction: As suicide rates increase with age, it is mandatory to carefully assess old age suicidal behaviors. Our aim was to describe the main socio-demographic and clinical features of a sample of suicide attempters aged 65 years and older, and to assess differences within the sample (men vs. women; patients with vs. without a previous history of suicide attempt; patients with vs. without a previous psychiatric history).

Methods: Retrospective study conducted at the Maggiore della Carità University Hospital, Novara, Italy.

Results: A higher percentage of female patients in our sample were treated by or referred to mental health services, while a greater percentage of male patients required a prolonged clinical observation in the Emergency Room (ER) or in non-psychiatric wards before psychiatric admission. The percentage of patients without previous psychiatric history taking anxiolytic and sedative medications was 25%.

Conclusion: It is likely that different clusters and types of suicide attempters exist. Women in our sample appeared more proactive in asking for help, and more likely to be already treated by or referred to a psychiatric service, suggesting the need to facilitate the access to psychiatric services for the male population aged 65 years and older, or to offer support and care for the non-psychiatric reasons (comorbidities, pain, and loss of autonomy) possibly underlying suicidal behavior in this specific group. The use of medications deserves more attention considering the possible critical diagnostic issues in this age group.

An Audit of Mental Health Care Plans in Community Mental Health Services for Older Persons in Rural Communities in a State in Australia

Mental health care planning is an important part of holistic, patient-centred care provision. Rural older adults represent a vulnerable population with unique and complex care needs requiring robust care planning approaches. This study's aim was to audit care plan documentation for rural older Australians against quality standards. A retrospective review of the care plans from electronic case records was performed for all patients who were 65 years or older and managed by rural community mental health teams over a 12-month period. 72.1% of patients had a care plan available. Multiple assessment areas were sparsely documented, such as cognition (32%), self-harm risk assessments (29.8%), visual impairment (5.5%), hearing issues (5%) and Advance Care Directives (35.4%). This study highlighted the need for the development and implementation of a care plan template specific to rural older patients. Further research into care planning processes and barriers to implementation is also required for this population.