Influences of population-level factors on suicides in older adults: a national ecological study from Australia

Mental pain as a mediator in the association between avoidant attachment and suicidal ideation among older men

OBJECTIVES

In the present study, our aim was to deepen the understanding of suicidality in older men by adopting a biopsychosocial approach. The study focused on older men as they face an elevated risk of suicide, surpassing not only other age groups but also exhibiting higher rates compared to women. We examined the contribution of mental pain as a mediator in the association between attachment avoidance and suicidal ideation among older men, taking into consideration the severity of their physical illnesses.

METHODS

Participants were 200 men in Israel, aged ≥65 years, living in the community and without cognitive impairment. Data collection was based on self-report measures of suicidal ideation (Beck Scale for Suicidal Ideation, BSSI), attachment (Experience in Close Relationships, ECR-R), mental pain (Orbach and Mikulincer Mental Pain Scale, OMMP), and the severity of physical illnesses (Cumulative Illnesses Rating Scale, CIRS).

RESULTS

Mental pain was found to mediate the association between attachment avoidance and suicidal ideation, but only among participants with higher levels of physical illnesses.

CONCLUSIONS

Mental pain should be considered as a complication of an avoidant coping strategy, which increases the risk of suicide among older men, especially those suffering from significant physical illnesses. The theoretical and clinical implications of these findings are discussed.

Changes in mortality of Polish residents in the early and late old age due to main causes of death from 2000 to 2019

Purpose

The aim of the study was to assess mortality trends in Poland between 2000 and 2019 in the early and late old age population (65-74 years and over 75 years).

Methods

The work used data on all deaths of Polish residents aged over 65 years (N = 5,496,970). The analysis included the five most common major groups of causes of death: diseases of the circulatory system, malignant neoplasms, diseases of the respiratory system, diseases of the digestive system and external causes of mortality. The analysis of time trends has been carried out with the use of joinpoint models. The Annual Percentage Change (APC) for each segments of broken lines, the Average Annual Percentage Change (AAPC) for the whole study period (95% CI), and standardized death rates (SDRs) were calculated.

Results

The percentage of deaths due to diseases of the circulatory system decreased in all the studied subgroups. Among malignant neoplasms, lung and bronchus cancers accounted for the largest percentage of deaths, for which the SDRs among men decreased, while those among women increased. In the early old age, the SDR value increased from 67.8 to 76.3 (AAPC = 0.6%, p > 0.05), while in the late old age group it increased from 112.1 to 155.2 (AAPC = 1.8%, p < 0.05). Among men, there was an upward trend for prostate cancer (AAPC = 0.4% in the early old age group and AAPC = 0.6% in the late old age group, p > 0.05) and a downward trend for stomach cancer (AAPC -3.2 and -2.7%, respectively, p < 0.05). Stomach cancer also showed a decreasing trend among women (AAPC -3.2 and -3.6%, p < 0.05). SDRs due to influenza and pneumonia were increasing. Increasing trends in mortality due to diseases of the digestive system in women and men in the early old age group have been observed in recent years, due to alcoholic liver disease. Among the external causes of mortality in the late old age group, the most common ones were falls.

Conclusions

It is necessary to conduct further research that will allow to diagnose risk and health problems of the elderly subpopulation in order to meet the health burden of the aging society.

The Potential Impact of Adjunct Digital Tools and Technology to Help Distressed and Suicidal Men: An Integrative Review

Suicidal men feel the need to be self-reliant and that they cannot find another way out of relationship or socioeconomic issues. Suicide prevention is of crucial importance worldwide. The much higher rate of suicide in men engenders action. The prelude is a subjective experience that can be very isolating and severely distressing. Men may not realize a change in their thinking and behaviors, which makes it more difficult to seek and get help, thereby interrupting a "downward spiral". Stoicism often prevents men from admitting to their personal struggle. The lack of "quality" connections and "non-tailored" therapies has led to a high number of men "walking out" on traditional clinical approaches. But there are complicated relationships in motivations and formative behaviors of suicide with regards to emotional state, psychiatric disorders, interpersonal life events and suicidal behavior method selection. Middle-aged and older men have alternated as the most at-risk of suicide. There is no one solution that applies to all men, but digital tools may be of assistance (e.g., video conferences, social networks, telephone calls, and emails). Digital interventions require higher levels of effectiveness for distress and suicidality but self-guided approaches may be the most suitable for men especially where linked with an integrated online suicide prevention platform (e.g., quick response with online chats, phone calls, and emails). Furthermore, technology-enabled models of care offer promise to advance appropriate linking to mental health services through better and faster understanding of the specific needs of individuals (e.g., socio-cultural) and the type and level of suicidality experienced. Long-term evidence for suicidality and its evaluation may benefit from progressing human computer-interaction and providing impetus for an eminent integrated digital platform.

Suicide in late life: A viewpoint

Suicide in old age represents a sad public health concern. Despite the global decline in rates of suicide and the general amelioration of quality of life and access to health care for older adults, their rates of suicide remain the highest virtually in every part of the world. With the aging of the world population and the growing number of mononuclear families, the risk of an increase in isolation, loneliness and dependency does not appear ungrounded. The Covid-19 pandemic is claiming the life of many older persons and creating unprecedented conditions of distress, particularly for this segment of the population. This article briefly examines the main characteristics of suicidal behavior in late life, including observations deriving from the spread of the Sars-2 coronavirus and possible strategies for prevention.

Suicide prevention in older adults

BACKGROUND

Suicide among older adults is a multifactorial problem with several interrelated factors involved that vary with age, gender and culture. The number of suicides is highest in those aged 70 years or older in almost all regions of the world. With the increase in life expectancy, and the decrease in mortality due to other causes of death, we could expect the absolute number of older adults' suicide continue increasing.

METHODS

Review of the literature on suicide protective factors of suicide among older adults.

RESULTS

Improvements on social determinants of health and the timely detection and early treatment of affective disorders are key interventions. Prevention based on community actions and training of gatekeepers may have positive impact. Community programs that promote a sense of usefulness, belonging and that contribute to preserve social integration should be encouraged. Governments should develop the improvement of retirement programs and the development of support systems. The access to general health and mental health services should be facilitated and Primary Care professionals should receive proper training to detect and manage older persons at risk. Actively promoting a culture of coping to different stages of life and to the changes imposed by the advancing of age should form the essential part of a process bringing to better successful aging avenues.

CONCLUSIONS

Suicide prevention in older adults should broaden its focus and pay attention to the many socio-environmental conditions that may be relevant in older age, especially social isolation, financial security and physical health.

Suicide and Suicide Attempts in Elderly Patients: An Epidemiological Analysis of Risk Factors and Prevention

A number of elderly patients commit suicide due to the interaction of various factors, including, for example, feelings of loneliness, financial distress, alcohol abuse, chronic pain, progressive diseases, and personality disorders. The data from the EU countries with the highest rates of suicide and suicide attempts among people over 55 years of age warrant the consideration of new approaches to address this social problem.

METHODS

PubMed and other databases, including Polish National data, were used for the analyses.

RESULTS

The average European suicide-attempt rate is 18 per 100 thousand inhabitants. More cases of suicides were reported among those over 55 years of age. Suicide attempts from the year 2012 to 2014 and deaths in 2012 have been reviewed. The risk factors involved in these events, such as depression and social situations including loneliness, health condition, etc., have been discussed to suggest a plausible preventative approach for this important elderly problem.

CONCLUSION

The psychophysiology of elderly persons affected by retirement, socio-economic changes, limited personal autonomy, loneliness, lack of support by the family, and diseases ultimately may lead elderly patients to commit suicide. Thus, financial freedom, family support (respect, love, and care), proper medications, psychological and psychiatric interventions may help the elderly avoid suicidal thoughts and prevent attempts.

Loneliness and social integration as mediators between physical pain and suicidal ideation among elderly men

OBJECTIVES

Suicide in the elderly is a complex and significant public health problem. The purpose of our study was to examine the role of loneliness and social integration as potential mediators in the relationship between physical pain and suicidal ideation in the elderly.

DESIGN

Descriptive, bivariate correlations, and moderated mediation analyses were performed.

SETTING

Personal meetings were held with participants in their homes.

PARTICIPANTS

A total of 198 elderly men aged 65 and over.

MEASUREMENTS

Self-report measures: Beck Scale for Suicidal Ideation, Physical pain subscale, Multidimensional Social Integration in Later Life Scale, and University of California, Los Angeles (UCLA) Loneliness Scale (Version 3).

RESULTS

Our findings showed that the association between physical pain and suicidal ideation was mediated by loneliness and social integration. Further analyses revealed that this mediation model was significant among single, but not married, men.

CONCLUSIONS

Physical pain and social factors are both important in understanding suicidality in late life. Elderly single men who experience physical pain may be lonelier and less socially integrated, and these factors may contribute to higher risk of suicidal ideation.

The impact of strengthening mental health services to prevent suicidal behaviour

OBJECTIVE

Successive suicide prevention frameworks and action plans in Australia and internationally have called for improvements to mental health services and enhancement of workforce capacity. However, there is debate regarding the priorities for resource allocation and the optimal combination of mental health services to best prevent suicidal behaviour. This study investigates the potential impacts of service capacity improvements on the incidence of suicidal behaviour in the Australian context.

METHODS

A system dynamics model was developed to investigate the optimal combination of (1) secondary (acute) mental health service capacity, (2) non-secondary (non-acute) mental health service capacity and (3) resources to re-engage those lost to services on the incidence of suicidal behaviour over the period 2018-2028 for the Greater Western Sydney (Australia) population catchment. The model captured population and behavioural dynamics and mental health service referral pathways and was validated using population survey and administrative data, evidence syntheses and an expert stakeholder group.

RESULTS

Findings suggest that 28% of attempted suicide and 29% of suicides could be averted over the forecast period based on a combination of increases in (1) hospital staffing (with training in trauma-informed care), (2) non-secondary health service capacity, (3) expansion of mental health assessment capacity and (4) re-engagement of at least 45% of individuals lost to services. Reduction in the number of available psychiatric beds by 15% had no substantial impact on the incidence of attempted suicide and suicide over the forecast period.

CONCLUSION

This study suggests that more than one-quarter of suicides and attempted suicides in the Greater Western Sydney population catchment could potentially be averted with a combination of increases to hospital staffing and non-secondary (non-acute) mental health care. Reductions in tertiary care services (e.g. psychiatric hospital beds) in combination with these increases would not adversely affect subsequent incidence of suicidal behaviour.

Self-harm in a primary care cohort of older people: incidence, clinical management, and risk of suicide and other causes of death

BACKGROUND

Self-harm is a major risk factor for suicide, with older adults (older than 65 years) having reportedly greater suicidal intent than any other age group. With the aging population rising and paucity of research focus in this age group, the extent of the problem of self-harm needs to be established. In a primary care cohort of older adults we aimed to investigate the incidence of self-harm, subsequent clinical management, prevalence of mental and physical diagnoses, and unnatural-cause mortality risk, including suicide.

METHODS

The UK Clinical Practice Research Datalink contains anonymised patient records from general practice that routinely capture clinical information pertaining to both primary and secondary care services. We identified 4124 adults aged 65 years and older with a self-harm episode ascertained from Read codes recorded during 2001-14. We calculated standardised incidence and in 2854 adults with at least 12 months follow-up examined the frequency of psychiatric referrals and prescription of psychotropic medication after self-harm. We estimated prevalence of mental and physical illness diagnoses before and after self-harm and, using Cox regression in a matched cohort, we examined cause-specific mortality risks.

FINDINGS

Overall incidence of self-harm in older adults aged 65 years and older was 4·1 per 10 000 person-years with stable gender-specific rates observed over the 13-year period. After self-harm, 335 (11·7%) of 2854 adults were referred to mental health services, 1692 (59·3%) were prescribed an antidepressant, and 336 (11·8%) were prescribed a tricyclic antidepressant (TCA). Having a diagnosed previous mental illness was twice as prevalent in the self-harm cohort as in the comparison cohort (prevalence ratio 2·10 [95% CI 2·03-2·17]) and with a previous physical health condition prevalence was 20% higher in the self-harm cohort compared to the comparison cohort (1·20 [1·17-1·23]). Adults from the self-harm cohort (n=2454) died from unnatural causes an estimated 20 times more frequently than the comparison cohort (n=48 921) during the first year. A markedly elevated risk of suicide (hazard ratio 145·4 [95% CI 53·9-392·3]) was observed in the self-harm cohort.

INTERPRETATION

Within primary care, we have identified a group of older adults at high risk from unnatural death, particularly within the first year of self-harm. We have highlighted a high frequency of prescription of TCAs, known to be potentially fatally toxic in overdose. We emphasise the need for early intervention, careful alternative prescribing, and increased support when older adults consult after an episode of self-harm and with other health conditions.

FUNDING

National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre.

Epidemiology of coronial deaths from pesticide ingestion in Australia

Pesticides in Australia are tightly regulated but it is unknown how this may affect the distribution of misuse and self-harm across Australia, both spatially and within subgroups in the population. We performed an observational study to examine spatial differences in suicide/deliberate poisonings with pesticides in Australia. We examined Coronial inquest cases of self-harm by pesticide ingestion for the years 2001-2013 (n=209). Coronial cases were older, more likely to be male, have lower SES status and live in outer regional areas as opposed to cities when compared to the general population. Case densities (cases/100,000 population) were lower in large capital cities and higher in agricultural areas: despite this half the cases occurred in major cities.