Medical examiner and coroner reports: uses and limitations in the epidemiology and prevention of late-life suicide

Epidemiological characteristics and hospitalization trajectories prior to suicide in Galicia between 2013 and 2016

INTRODUCTION

Addressing suicide requires an understanding of regional patterns of epidemiology, with health variables being central. However, the clinical profile of people who commit suicide has received little attention. The objectives of this study were to analyze the sociodemographic, clinical, and forensic characteristics of persons who committed suicide in Galicia between 2013 and 2016, analyze suicide mortality rates, and identify trajectories of hospitalizations and associated variables.

MATERIAL AND METHODS

A population study was carried out on the 1354 people who died by suicide in Galicia.

RESULTS

The most common profile was a retired man, 57.9 years old (SD=18.5), from an urban and inner area. 43.6% had been previously hospitalized, 41.6% had been diagnosed with physical disorders, and 26.8% with mental disorders. 48.2% had been prescribed psychiatric medications and 29.6% had received outpatient psychiatric care. The highest prevalence of death by suicide (27.5%) was in 2014, with the predominant method being hanging (59.1%). The average raw rate was 12.3/100,000. Three trajectories of hospitalizations emerged: 94.83% had experienced few hospitalizations; 2.95% an increasing pattern; and 2.22% a decreasing pattern. These trajectories were associated with number of psychiatric appointments, prescription of psychiatric medications, and diagnoses of physical and mental disorders.

CONCLUSIONS

These findings are crucial for detection and prevention.

Risk factors for suicidal behavior in late-life depression: A retrospective preliminary clinical study

AIM

To explore the risk factors associated with suicidal behavior (SB) using logistic regression analysis and the propensity score matching (PSM) method among Chinese patients suffering from late-life depression (LLD).

METHOD

Patient information sheets were retrieved with the International Classification of Diseases, Tenth Revision (ICD-10) code from an electronic database that comprised patient medical information. Herein, we set SB as a dependent variable, and gender, marital status, monthly income, quality of interpersonal relationships, hobbies, impulsivity, severity of depression, psychiatric symptoms or not, and having histories of smoking, drinking, major mental trauma as independent variables according to clinical experience and previous findings. For uncertain independent risk factors associated with SB generated by logistic regression analysis, PSM was performed for further verification.

RESULTS

The differences between the SB group and non-SB group for marital status, severity of depression, a history of drinking, and a history of major mental trauma were found to be statistically significant in univariate comparisons (P < 0.05); binary logistic regression analysis and PSM analysis showed that the severity of depression, a history of drinking, and a history of major mental trauma were independent risk factors associated with SB of patients with LLD with an odds ratio greater than one.

CONCLUSION

The severity of depression, a history of drinking, and a history of major mental trauma were independently associated with the occurrence of SB of patients with LLD in China. Further longitudinal and prospective studies are warranted to examine the dynamic changes of confounding risk factors. Geriatr Gerontol Int 2021; 21: 849-854.

Comparisons between suicide in persons with serious mental illness, other mental disorders, or no known mental illness: Results from 37 U.S. states, 2003-2017

BACKGROUND

Suicide is a leading cause of death in persons with schizophrenia and other serious mental illnesses (SMI), however, little is known about the characteristics and circumstances of suicide decedents with SMI in the US compared to those with other or no known mental illness.

METHODS

This study was a retrospective analysis of suicide deaths in individuals aged ≥18 years from the National Violent Death Reporting System, 2003-2017. Odds ratios compared sociodemographic and clinical characteristics, cause of death, precipitating circumstances, and post-mortem toxicology results. All analyses were stratified by gender.

RESULTS

Of the 174,001 suicide decedents, 8.7% had a known SMI, 33.0% had other mental disorders, and 58.2% had no known mental illness. Relative to persons with other mental disorders, SMI decedents were younger and more likely to have previous suicide attempts and co-occurring drug use. Problems with intimate partners, poor physical health, and recent institutional release were the most common precipitating circumstances for SMI decedents. Firearms were the most common suicide method for males with SMI. Although 67.0% male and 76.0% of female SMI decedents were currently in treatment, toxicology results suggest many were not taking antipsychotic or antidepressant medications at the time of death.

CONCLUSIONS

Persons with SMI are over-represented in suicide deaths. Efforts to improve treatment of co-occurring substance use disorders, continuity of care following hospitalization, medication adherence, and to reduce access to firearms are important suicide prevention strategies.

Evaluation of an Educational Intervention for Clinicians on Self-Harm in Older Adults

Clinicians may lack knowledge and confidence regarding self-harm in older adults and hold attitudes that interfere with delivering effective care. A 1-hour educational intervention for hospital-based clinicians and general practitioners (GPs) was developed, delivered, and evaluated. Of 119 multidisciplinary clinicians working in aged care and mental health at two hospitals, 100 completed pre/post-evaluation questions. There were significant improvements in knowledge, confidence in managing, and attitudes regarding self-harm in late life, and the education was rated as likely to change clinical practice. No GP education sessions could be conducted. A brief educational intervention had immediate positive impacts for hospital-based clinicians albeit with high baseline knowledge. The sustainability of these effects and effectiveness of the intervention for GPs warrant examination.

Mental Disorders, Cognitive Impairment and the Risk of Suicide in Older Adults

More than 600 million people are aged 60 years and over are living in the world. The World Health Organization estimates that this number will double by 2025 to 2 billion older people. Suicide among people over the age of 60 is one of the most acute problems. The factors strongly associated with suicide are mentioned: physical illnesses, such as cancer, neurologic disorder, pain, liver disease, genital disorders, or rheumatoid disorders. Moreover, neurologic conditions, especially stroke, may affect decision-making processes, cognitive capacity, and language deficit. In addition to dementia, the most common mental disorders are mood and anxiety disorders. A common symptom of these disorders in the elderly is cognitive impairment. This study aimed to present the relationship between cognitive impairment due to dementia, mood disorders and anxiety, and an increased risk of suicide among older people. Dementia is a disease where the risk of suicide is significant. Many studies demonstrated that older adults with dementia had an increased risk of suicide death than those without dementia. Similar conclusions apply to prodromal dementia Depression is also a disease with a high risk of suicide. Many researchers found that a higher level of depression was associated with suicide attempts and suicide ideation. Bipolar disorder is the second entity in mood disorders with an increased risk of suicide among the elderly. Apart from suicidal thoughts, bipolar disorder is characterized by high mortality. In the group of anxiety disorders, the most significant risk of suicide occurs when depression is present. In turn, suicide thoughts are more common in social phobia than in other anxiety disorders. Suicide among the elderly is a serious public health problem. There is a positive correlation between mental disorders such as dementia, depression, bipolar disorder, or anxiety and the prevalence of suicide in the elderly. Therefore, the elderly should be comprehensively provided with psychiatric and psychological support.

Impact of COVID-19 on the health and psychosocial status of vulnerable older adults: study protocol for an observational study

BACKGROUND

Many countries around the world have adopted social distancing as one of the public health measures to reduce COVID-19 transmissions in the community. Such measures could have negative effects on the mental health of the population. The aims of this study are to (1) track the impact of COVID-19 on self-reported mood, self-rated health, other health and psychosocial indicators, and health services utilization of people who have an interRAI assessment during the first year of COVID-19; (2) compare these indicators with the same indicators in people who had an interRAI assessment in the year before COVID-19; and (3) report these indicators publicly as soon as data analysis is completed every 3 months.

METHODS

interRAI COVID-19 Study (iCoS) is an observational study on routinely collected national data using the interRAI Home Care and Contact Assessment, which are standardized geriatric assessment tools mandated for all people assessed for publicly funded home support services and aged residential care in New Zealand. Based on the 2018/19 figures, we estimated there are 36,000 interRAI assessments per annum. We will compare the four post-lockdown quarters (from 25th March 2020) with the respective pre-lockdown quarters. The primary outcomes are self-reported mood (feeling sad, depressed or hopeless: 0 = no, 1 = yes) and self-rated health (0 = excellent, 1 = good, 2 = fair, 3 = poor). We will also analyze sociodemographics, other secondary health and psychosocial indicators, and health services utilization. Descriptive statistics will be conducted for primary outcomes and other indicators for each of the eight quarters. We will compare the quarters using regression models adjusted for demographic characteristics using weights or additional variables. Key health and psychosocial indicators will be reported publicly as soon as data analysis is completed for each quarter in the 12-month post-lockdown period by using a data visualization tool.

DISCUSSION

This rapid translation of routinely collected national interRAI data will provide a means to monitor the health and psychosocial well-being of vulnerable older New Zealanders. Insights from this study can be shared with other countries that use interRAI and prepare health and social services for similar epidemics/pandemics in the future.

Measuring suicide risk in the elderly with non-institutionalized depression: an integrative review

OBJECTIVE

Analyze the state of the art about instruments, at national and international levels, for assessing the risk of suicide in elderly people with depression assisted in the community.

METHODS

Integrative review of 38 complete articles, published in journals indexed in the databases: US National Library of Medicine (PubMed Central), Scopus, CINAHL and Web of Science, located using controlled descriptors combined with Boolean operators: elderly OR aged OR older OR elder OR geriatric AND depression AND suicide AND risk assessment.

RESULTS

Six instruments were found, all international and published in the English language, in order to identify suicidal behavior and ideation in the elderly. Of these, two are specific scales for assessing the risk of suicide in the elderly in the community: 5-item GDS subscale and Geriatric Suicide Ideation Scale.

FINAL CONSIDERATIONS

With the scarcity of national instruments to assess such risk, research is recommended to cross-culturally adapt one of these scales to the Brazilian Portuguese language.

Suicide in Older Adults With and Without Known Mental Illness: Results From the National Violent Death Reporting System, 2003-2016

INTRODUCTION

Suicide risk increases with age, and evidence exists for the underdiagnosis and undertreatment of suicide risk in older adults. Recent data suggest that many U.S. adults who die from suicide do not have a known mental health condition. This study compares the characteristics and precipitating circumstances of geriatric suicide decedents with and without known mental illnesses.

METHODS

This study was a retrospective analysis of suicide deaths for adults aged ≥65 years from the National Violent Death Reporting System, 2003-2016 (n=26,884). ORs compared sociodemographic and clinical characteristics, cause of death, and precipitating circumstances based on coroner/medical examiner and law enforcement reports. Data were collected and analyzed in 2019.

RESULTS

Most older male (69.1%) and female (50.2%) suicide decedents did not have a known mental illness. A physical health problem was the most prevalent precipitating circumstance but was more common among older adults without known mental illness. Past suicide attempt, disclosure of suicidal intent, depressed mood, and substance use were more common among those with a known mental illness. More than three fourths of suicide decedents did not disclose their suicidal intent. Most suicide deaths involved firearms, which were disproportionately used by decedents without known mental illness (81.6% of male and 44.6% of female decedents) compared with those with known mental illness (70.5% of male and 30.0% of female decedents).

CONCLUSIONS

Most older adults who die from suicide do not have a known mental health condition. The rapidly growing U.S. geriatric population calls for more effective methods to identify and treat at-risk older adults, particularly those who are male.

[Suicidality in the elderly: socio-cultural and clinical risk factors]

Advanced age is a significant risk factor for a completed suicide. The review considers the patterns of suicidal behavior of older adults in the context of their gender, ethnicity as well as social and cultural factors. In terms of pro- and antisuicidal variables, special emphasis is made on the role of somatic and psychic disorders. The article looks at the features of committing a suicide peculiar to the older people and debates some specific issues of self-inflicted death by elderly people. The obtained data indicate the involvement of multilevel factors (biological, clinical, cultural, micro- and microsocial) in suicidal behavior in later life.

Late-life suicide in Asian people living in New Zealand: a qualitative study of coronial records

BACKGROUND

There has been no previous study examining the phenomenon of suicide in older Asians in New Zealand. The aim of this study was to identify common factors and gain a better understanding of late-life suicide in Asian people living in New Zealand.

METHODS

New Zealand Coronial Services provided records of all closed cases of late-life suicides (age ≥ 65 years) between July 2007 and December 2012. Out of the total of 225 cases, 15 were recorded as being of Asian ethnicity. These cases were reviewed in their entirety using a qualitative thematic analysis approach.

RESULTS

Eight Asian men and seven Asian women completed suicide during this period. The majority (93%) lived with their families, and 80% were found by family after having completed suicide at home. Three main themes emerged from the thematic analysis: (i) suicide occurring in the context of a family; (ii) declining physical health; and (iii) a violent method of suicide. The role of the family has not been previously identified in other studies of late-life suicide in New Zealand.

CONCLUSIONS

Further research is needed to identify ways Asian families can access culturally appropriate and accessible support and mental health services for their older members at risk of suicide. There is also a need for developing post-suicide interventions specifically for Asian families. The findings of this study have added to the growing evidence of declining physical health acting as a drive for late-life suicide.

Suicide in older adults: current perspectives

Suicidal behavior in older adults (65 years old and over) is a major public health issue in many countries. Suicide rates increase during the life course and are as high as 48.7/100,000 among older white men in the USA. Specific health conditions and stress factors increase the complexity of the explanatory model for suicide in older adults. A PubMed literature search was performed to identify most recent and representative studies on suicide risk factors in older adults. The aim of our narrative review was to provide a critical evaluation of recent findings concerning specific risk factors for suicidal thoughts and behaviors among older people: psychiatric and neurocognitive disorders, social exclusion, bereavement, cognitive impairment, decision making and cognitive inhibition, physical illnesses, and physical and psychological pain. We also aimed to approach the problem of euthanasia or physician-assisted suicide in older adults. Our main findings emphasize the need to integrate specific stress factors, such as feelings of social disconnectedness, neurocognitive impairment or decision making, as well as chronic physical illnesses and disability in suicide models and in suicide prevention programs in older adults. Furthermore, the chronic care model should be adapted for the treatment of older people with long-term conditions in order to improve the treatment of depressive disorders and the prevention of suicidal thoughts and acts.

Do suicide characteristics differ by age in older people?

ABSTRACTBackground:Suicide rates increase with age in the population aged over 65 years. The aims of this study were to (i) report the characteristics of older people who died by suicide; and (ii) investigate whether these characteristics differ in three age bands: 65-74 years, 75-84 years, and 85+ years.

METHODS

Using information from national coroner records, relevant socio-demographic and clinical factors in all suicides (age ≥ 65 years; n = 225) from July 2007 to December 2012 in New Zealand were analyzed and compared in the three age bands.

RESULTS

We found the older the person, the more likely they are to be widowed but the less likely to have a past psychiatric admission or recent contact with psychiatric services in the month prior to suicide. However, most of the older people (61.7% of 65-74 years, 65.6% of 75-84 years, and 77.3% of 85+ years) had contact with their general practitioner within one month of suicide. Women were less likely to use violent methods than men in all three age bands but with increasing age, men were less likely to use violent methods.

CONCLUSIONS

Suicide characteristics in older people differ by age. The oldest people who die by suicide are not necessarily under psychiatric services and may benefit from a primary care-based approach in which there is screening for depression and suicide risk.

Demographic and Clinical Characteristics of Completed Suicides in Mexico City 2014-2015

Objective: To analyze sex differences in demographic and clinical characteristics of individuals who died by suicide in Mexico City. Method: Statistical analysis of residents of Mexico City whose cause of death was suicide, during two years period from January 2014 to December 2015, with a coroner's report. Suicide mortality rates were calculated by age, sex, and location within the city. The Chi-squared test was used to assess statistical differences. Results: From January 2014 to December 2015, 990 residents of Mexico City died by suicide (men: 78.28%, women: 21.72%). Among males, the highest mortality rates were among the groups of 20-24 and 75-79 years old, whereas in women, the group with the highest mortality rate was 15 to 19 years old. 74% of the sample used hanging as suicide method. However, men had higher rates of a positive result in the toxicology test (40%) (p < 0.05). There was no concordance between male and female suicide by city jurisdictions. Conclusion: Our results provide evidence that the characteristics of Mexico City's residents who committed suicide had significant sex-related differences, including where they used to live. Understanding the contributory factors associated with completed suicide is essential for the development of effective preventive strategies.

Late-Life Suicide in Terminal Cancer: A Rational Act or Underdiagnosed Depression?

CONTEXT

Previous studies have reported significantly elevated standardized mortality rates in older people with cancer. Terminally ill people represent a unique group where suicide may be considered as rational.

OBJECTIVES

The aims of this study are to compare the sociodemographic and clinical characteristics of older people with and without terminal cancer who died by suicide and analyze the suicide motives of those with terminal cancer to determine whether they represent rational suicide.

METHODS

The New Zealand Coronial Services provided records of all older people (aged 65 years and older) who died by suicide between July 2007 and December 2012. Sociodemographic and clinical data were extracted from the records. Using the characteristics for defining rational suicide, we determined whether the motives in terminal cancer cases represented rational suicide.

RESULTS

Of the 214 suicide cases, 23 (10.7%) older people were diagnosed with a terminal cancer. Univariate analysis found that older people with terminal cancer who died by suicide were less likely to have a diagnosis of depression (8.7% vs. 46.6%; P = 0.001) or previous contact with mental health services (4.5% vs. 35.0%; P = 0.004) than those without terminal cancer. About 82.6% of the terminal cancer cases had a motivational basis that would be understandable to uninvolved observers.

CONCLUSION

A high proportion of those with terminal cancer had motives suggestive of rational suicide. Future studies are needed to clarify whether the low rate of depression is secondary to underdiagnosis of depression or people with terminal cancer choosing to end their life as a rational act to alleviate suffering.

Suicide in Illinois, 2005-2010: A reflection of patterns and risks by age groups and opportunities for targeted prevention

BACKGROUND

Suicide accounts for two thirds of all deaths from intentional or violence-related injury and is a leading cause of death in the United States. Patterns of suicide have been well described among high-risk groups, but few studies have compared the circumstances related to suicides across all age groups. We sought to understand the epidemiology of suicide cases in Illinois and to characterize the risks and patterns for suicide among different age groups.

METHODS

We used suicide data collected from the Illinois Violent Death Reporting System to assess demographics, method of suicide, circumstances, and mental health status among different age groups.

RESULTS

Between 2005 and 2010, 3,016 suicides were reported; 692 (23%) were female, and the median age (n = 3,013) was 45 years (range, 10-98 years). The most common method/weapon types were hanging/strangulation (33%), firearm (32%) and poisoning (21%). Hanging was more common (74%) among young people aged 10 to 19 years, while firearm use was more common among elderly persons age 65 years and older (55%). The percentage of victims within an age group experiencing a crisis within two weeks before committing suicide was highest among 10- to 14-year-olds, while the risk factor of having a family member or friend die in the past 5 years was highest among older victims.

CONCLUSION

The final analysis demonstrated age-related trends in suicide in Illinois, suggesting prevention programs should tailor services by age.

LEVEL OF EVIDENCE

Epidemiologic study, level IV.

Association of Suicidality and Depression With 5α-Reductase Inhibitors

IMPORTANCE

There have been concerns raised by patients and regulatory agencies regarding serious psychiatric adverse effects associated with 5α-reductase inhibitors.

OBJECTIVE

To determine if there is an increased risk of suicide, self-harm, or depression among older men starting a 5α-reductase inhibitor for prostatic enlargement.

DESIGN, SETTING, AND PARTICIPANTS

A population-based, retrospective, matched cohort study using linked administrative data for 93 197 men ages 66 years or older (median [IQR] age, 75 [70-80] years) in Ontario, Canada, who initiated a new prescription for a 5α-reductase inhibitor during the study period (2003 through 2013). Participants were matched (using a propensity score that included 44 of our 96 covariates that included medical comorbidities, medication usage, and health care system utilization) to an equal number of men not prescribed a 5α-reductase inhibitor.

EXPOSURES

Duration of finasteride or dutasteride usage.

MAIN OUTCOMES AND MEASURES

Suicide. Secondary outcomes were self-harm and depression.

RESULTS

Men who used 5α-reductase inhibitors were not at a significantly increased risk of suicide (HR, 0.88; 95% CI, 0.53-1.45). Risk of self-harm was significantly increased during the initial 18 months after 5α-reductase inhibitor initiation (HR, 1.88; 95% CI, 1.34-2.64), but not thereafter. Incident depression risk was elevated during the initial 18 months after 5α-reductase inhibitor initiation (HR, 1.94; 95% CI, 1.73-2.16), and continued to be elevated, but to a lesser degree, for the remainder of the follow-up period (HR, 1.22; 95% CI, 1.08-1.37). The absolute increases in the event rates for these 2 outcomes were 17 per 100 000 patient-years and 237 per 100 000 patient-years, respectively. The type of 5α-reductase inhibitor (finasteride or dutasteride) did not significantly modify the observed associations with suicide, self-harm, and depression.

CONCLUSIONS AND RELEVANCE

In a large cohort of men ages 66 years or older, we did not demonstrate an increased risk of suicide associated with 5α-reductase inhibitor use. However, the risk of self-harm and depression were increased compared with unexposed men. This is in keeping with postmarketing experience and patient concerns, and discontinuation of the medication in these circ umstances may be appropriate.

Understanding the Progression from Physical Illness to Suicidal Behavior: A Case Study Based on a Newly Developed Conceptual Model

Suicide in older people is a significant public health issue given the aging population and increasing suicide rates with age in many parts of the world. Depression and physical illness are two factors consistently associated with suicidal behavior in older people; however, their inter-relationships are not well understood. We present here a case study based on a newly developed conceptual model illustrating the various medical, psychological, social and resilience factors involved in the progression of physical illness to suicidal behavior. This model provides a framework for clinicians to understand protective factors and address late-life suicide risk.

Convergent Validity, Concurrent Validity, and Diagnostic Accuracy of the interRAI Depression Rating Scale

AIMS

Depression Rating Scale (DRS) is one of the clinical outcome measures of the International Resident Assessment Instrument (interRAI) assessment. The primary aim of this study is to investigate the diagnostic accuracy and concurrent validity of the 3-day assessment window version of the DRS.

METHODS

The performance of DRS was compared with a gold standard clinical diagnosis of depression in 92 patients (age ≥65) who had interRAI version 9.1 Home Care assessment completed within 30 days of discharge from psychogeriatric inpatient care or memory clinic assessment.

RESULTS

The DRS had poor diagnostic accuracy for depression diagnosis with an area under the curve of 0.68 (95% confidence interval [CI] = 0.57-0.77). The DRS score had a poor to moderate correlation with the Health of the Nation Outcome Scale 65+ depression item score ( r_s = 0.30, 95% CI = 0.09-0.48, P = .006).

CONCLUSION

This study and the existing literature raise concerns that the DRS is not an adequate measure of depression.

Late-life suicide: Insight on motives and contributors derived from suicide notes

OBJECTIVES

The aims of this study were: (i) to investigate the proportion of older people writing suicide notes in New Zealand; (ii) to compare the socio-demographic and clinical variables of older suicide note writers and non-note writers; and (iii) to perform a thematic analysis of the content of suicide notes.

METHODS

The Coronial Services provided records of all suicide cases aged 65 years and over (n=225) between July 2007 and December 2012. We were able to determine whether there was a suicide note written in 212 cases. The content of 39 coroners/medical examiners' excerpts and 5 suicide notes was available for thematic analysis using a general inductive approach.

FINDINGS

88 (41.5%) older people left a suicide note. Logistic regression showed that female gender (OR=2.8, 95% CI=1.4-5.7, p=0.005) and Caucasian ethnicity (OR=13.7, 95% CI=1.7-111.0, p=0.014) are significantly associated with older people writing suicide notes. 33.3% of those who left a suicide note gave health-related reasons for their suicide and a significant proportion (73.3%) of them had underlying medical conditions. Another common theme is around people leaving specific instructions and wishes.

CONCLUSIONS

Apart from gender and ethnicity, suicide note writers are similar to non-writers on broad socio-demographic and clinical factors. Suicide notes indicated free will in and reasons for their suicide and emotional/farewell messages to their loved ones. Many documented poor quality of life or physical illness but the progression of these factors to suicide in older people should be further researched.