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Walker AR, Srasuebkul P, Trollor JN, Wand AP, Draper B, Cvejic RC, Moxey A, Reppermund S. Mortality in people living with dementia who self-harmed: An Australian data linkage study. Aust N Z J Psychiatry 2024:48674241278243. [PMID: 39252467 DOI: 10.1177/00048674241278243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
OBJECTIVES This study aimed to examine mortality for people living with dementia/mild cognitive impairment who self-harmed. METHODS We conducted a retrospective cohort study in New South Wales, Australia, using data ranging from 2001 to 2015. From people who accessed hospital services in the study period, we identified 154,811 people living with dementia/mild cognitive impairment, 28,972 who self-harmed and 1511 who had a record of both dementia/mild cognitive impairment and self-harm. We examined rates, causes and predictors of death for people with dementia/mild cognitive impairment and/or self-harm diagnoses using flexible parametric survival analyses. We explored rates of repeat self-harm in people living with dementia who self-harmed. RESULTS Circulatory disorders accounted for 32.0% of deaths in people with a living with dementia who self-harmed, followed by neoplasms (14.7%), and mental and behavioural disorders (9.6%). Death was more likely for someone who had self-harmed if they developed dementia/mild cognitive impairment. Predictors of death included male sex, greater physical comorbidity, a history of delirium, more previous emergency department presentations and fewer previous mental health ambulatory service days. Greater engagement with outpatient mental health services predicted a decreased likelihood of repeat self-harm. DISCUSSION We found that mortality increases when people who self-harm develop dementia. We argue post-diagnosis support offers a potential opportunity to reduce mortality rates in people with both dementia and self-harm diagnoses.
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Affiliation(s)
- Adrian R Walker
- Department of Developmental Disability Neuropsychiatry, Faculty of Medicine & Health, UNSW Sydney, Sydney, NSW, Australia
- Centre for Big Data Research in Health, Faculty of Medicine & Health, UNSW Sydney, Sydney, NSW, Australia
| | - Preeyaporn Srasuebkul
- National Centre of Excellence in Intellectual Disability Health, Faculty of Medicine & Health, UNSW Sydney, Sydney, NSW, Australia
| | - Julian N Trollor
- National Centre of Excellence in Intellectual Disability Health, Faculty of Medicine & Health, UNSW Sydney, Sydney, NSW, Australia
- Centre for Healthy Brain Ageing, Faculty of Medicine & Health, UNSW Sydney, Sydney, NSW, Australia
| | - Anne Pf Wand
- Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
- Discipline of Psychiatry & Mental Health, Faculty of Medicine & Health, UNSW Sydney, Sydney, NSW, Australia
- Older People's Mental Health Service, Concord Centre for Mental Health, Sydney Local Health District, Concord, NSW, Australia
| | - Brian Draper
- Centre for Healthy Brain Ageing, Faculty of Medicine & Health, UNSW Sydney, Sydney, NSW, Australia
- Discipline of Psychiatry & Mental Health, Faculty of Medicine & Health, UNSW Sydney, Sydney, NSW, Australia
- Eastern Suburbs Older Persons Community Mental Health Service, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Rachael C Cvejic
- Department of Developmental Disability Neuropsychiatry, Faculty of Medicine & Health, UNSW Sydney, Sydney, NSW, Australia
| | | | - Simone Reppermund
- Department of Developmental Disability Neuropsychiatry, Faculty of Medicine & Health, UNSW Sydney, Sydney, NSW, Australia
- Centre for Healthy Brain Ageing, Faculty of Medicine & Health, UNSW Sydney, Sydney, NSW, Australia
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Walker AR, Srasuebkul P, Trollor JN, Wand APF, Draper B, Cvejic RC, Moxey A, Reppermund S. Risk factors for dementia and self-harm: A linkage study. Alzheimers Dement 2023; 19:5138-5150. [PMID: 37126409 DOI: 10.1002/alz.13080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/22/2023] [Accepted: 03/11/2023] [Indexed: 05/02/2023]
Abstract
INTRODUCTION People living with dementia experience poor mental health and high rates of self-harm. We investigated risk factors for self-harm in people aged > 40 years living with dementia and risk factors for dementia after self-harm. METHODS Using linked hospital data from New South Wales, Australia, we defined a dementia cohort (n = 154,811) and a self-harm cohort (n = 28,972). Using survival analyses, we investigated predictors of self-harm for the dementia cohort, and predictors of dementia for the self-harm cohort. RESULTS We found self-harm or dementia diagnoses occurred most often within 24 months of a dementia diagnosis or initial self-harm presentation, respectively. Men living with dementia, and people with complex psychiatric profiles, had the greatest risk of self-harm. Men who had self-harmed had the greatest risk of dementia diagnoses. DISCUSSION Men and people with complex psychiatric profiles and dementia may particularly benefit from post-diagnosis mental and behavioral support to reduce risk of self-harm.
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Affiliation(s)
- Adrian R Walker
- The Department of Developmental Disability Neuropsychiatry, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Preeyaporn Srasuebkul
- The Department of Developmental Disability Neuropsychiatry, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Julian N Trollor
- The Department of Developmental Disability Neuropsychiatry, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Centre for Healthy Brain Ageing, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Anne P F Wand
- Speciality of Psychiatry, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
- Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Brian Draper
- Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Eastern Suburbs Older Persons Mental Health Service, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Rachael C Cvejic
- The Department of Developmental Disability Neuropsychiatry, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Annette Moxey
- Dementia Australia, Griffith, Australian Capital Territory, Australia
| | - Simone Reppermund
- The Department of Developmental Disability Neuropsychiatry, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Centre for Healthy Brain Ageing, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
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Salvatore T. Dying by Suicide in Nursing Homes: A Preventable End of Life Outcome for Older Residents. OMEGA-JOURNAL OF DEATH AND DYING 2023; 88:20-37. [PMID: 34404260 DOI: 10.1177/00302228211038798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Suicide research and suicide prevention have given comparatively little attention to the older adult residents of nursing homes. This population is characterized by advanced age, significant infirmity, limited autonomy and social connections, and other factors associated with high suicide risk such as self-neglect. However, little is known of the actual incidence and prevalence of suicide in older adults in such residential care settings, partly because of how such deaths are reported. Suicide risk screenings are nominal, facility staff lack training to identify signs of suicidality, and suicide prevention programs are not common in the nursing home industry. These deficits can be remedied by increasing awareness among family members, facility caregivers, contracted providers, community aging services, accrediting and regulatory agencies, and residents.
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Affiliation(s)
- Tony Salvatore
- Montgomery County Emergency Service, Norristown, Pennsylvania, United States
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Wand AP, Karageorge A, Browne R, Jessop T, Peisah C. A qualitative study of multiple voices to inform aftercare services for older persons following self-harm. Int J Geriatr Psychiatry 2023; 38:e5876. [PMID: 36655812 PMCID: PMC10108272 DOI: 10.1002/gps.5876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Self-harm and suicide are closely related in older adults, highlighting the opportunity for Aftercare interventions in targeted suicide prevention. The study aims were to explore strengths and shortfalls of current Aftercare services for older adults from the perspective of key stakeholders and researchers; and inform a set of guiding principles for older persons' Aftercare. METHODS Semi-structured interviews were undertaken with a convenience sample of older people with lived experience of self-harm, clinicians and suicide researchers (n = 22). Interviews were focussed on current practice (strengths and limitations), potential improvements, and identifying the core components of an acceptable Aftercare model. Interviews were audio-recorded, transcribed and subjected to a reflexive thematic analysis grounded in interpretive description. RESULTS Current practice strengths included validation, a person-centred approach and optimising aftercare delivery. Limitations included ageism, practical limitations (lack of service awareness, fragmented service provision, barriers to access, and traumatising approaches), and limited services, funding and training. Overarching themes included anti-ageism; anti-stigma; empowerment and agency; conveying hope; patience and pace; accessible; and finding purpose: connections and meaningful activity. CONCLUSIONS Older people who have self-harmed have complex, individualised needs. They sit within intersecting systems traversing healthcare, support services, family, and the social environment. Systemic, coordinated Aftercare founded upon core principles of anti-ageism, anti-stigma, partnership, empowerment, accessibility and provision of connections and meaning are needed.
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Affiliation(s)
- Anne P. Wand
- Specialty of PsychiatryFaculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
- Discipline of Psychiatry and Mental HealthFaculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
- Older Persons Mental Health ServiceSydney Local Health DistrictSydneyNew South WalesAustralia
| | - Aspasia Karageorge
- Brain and Mind CentreUniversity of SydneyCamperdownNew South WalesAustralia
| | - Roisin Browne
- Discipline of Psychiatry and Mental HealthFaculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
- ForeFront Motor Neuron Disease & Frontotemporal Dementia ClinicFaculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
- Capacity AustraliaSydneyNew South WalesAustralia
| | - Tiffany Jessop
- Discipline of Psychiatry and Mental HealthFaculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
- Capacity AustraliaSydneyNew South WalesAustralia
| | - Carmelle Peisah
- Specialty of PsychiatryFaculty of Medicine and HealthUniversity of SydneySydneyNew South WalesAustralia
- Discipline of Psychiatry and Mental HealthFaculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
- Capacity AustraliaSydneyNew South WalesAustralia
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Howland J, Stone A. Public health nurses for case finding, assessment and referral of community-dwelling socially isolated and/or lonely older adults. Front Public Health 2023; 11:1114792. [PMID: 37033035 PMCID: PMC10073688 DOI: 10.3389/fpubh.2023.1114792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Affiliation(s)
- Jonathan Howland
- Department of Emergency Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
- *Correspondence: Jonathan Howland
| | - Amanda Stone
- Massachusets Association of Public Health Nurses, Milton, MA, United States
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Wand AP, Browne R, Jessop T, Peisah C. A systematic review of evidence-based aftercare for older adults following self-harm. Aust N Z J Psychiatry 2022; 56:1398-1420. [PMID: 35021912 DOI: 10.1177/00048674211067165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Anne Pf Wand
- Specialty of Psychiatry, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,School of Psychiatry, Faculty of Medicine, University of NSW (UNSW) Sydney, NSW, Australia.,Older Peoples Mental Health Service, Jara Ward, Concord Centre for Mental Health, Sydney Local Health District, Concord, Australia
| | - Roisin Browne
- School of Psychiatry, Faculty of Medicine, University of NSW (UNSW) Sydney, NSW, Australia.,ForeFront Motor Neuron Disease & Frontotemporal Dementia Clinic, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Capacity Australia, Sydney, NSW, Australia
| | - Tiffany Jessop
- School of Psychiatry, Faculty of Medicine, University of NSW (UNSW) Sydney, NSW, Australia.,Capacity Australia, Sydney, NSW, Australia
| | - Carmelle Peisah
- School of Psychiatry, Faculty of Medicine, University of NSW (UNSW) Sydney, NSW, Australia.,Capacity Australia, Sydney, NSW, Australia
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Educating Crisis Supporters About Self-Harm and Suicide in Older Adults. Am J Geriatr Psychiatry 2022; 30:1212-1220. [PMID: 34799248 DOI: 10.1016/j.jagp.2021.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/01/2021] [Accepted: 10/12/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study aimed to describe existing knowledge of crisis supporters (volunteers responding to crisis calls/texts/messages) regarding self-harm and suicide in older adults and investigate knowledge translation through use of a novel online adaptive learning tool. METHODS The online educational tool was tested in an Australian national sample of crisis supporters (trained volunteers) aged 18+. Knowledge Transfer was evaluated utilizing a pre/post intervention methodology for data collection. The collaboratively developed online educational tool comprised a pre-test (10 questions), middle learning module (individualised for participant's incorrect pre-test responses) and post-test (10 questions) on suicidal behaviours in older adults. Data analysed included the demographic characteristics of the participants, individual question scores, and summed pre- and post-tests scores. Group differences in change scores were assessed with either one-way between subjects ANOVA or independent samples t-test, depending on the number of groups within each variable. Pre-post education comparisons on individual change in scores were made using a paired samples t-test. Statistical significance was defined as p <0.05. RESULTS 104 crisis supporters completed the tool (pre-test, middle lesson and post-test). There was significant improvement in knowledge of crisis supporters after the intervention (pre-test scores Mean (M) = 4.56, SD = 1.62 and post-test scores M = 7.61, SD = 1.60; t (103) = 17.242, p <0.001.). CONCLUSION Dedicated training about suicidal behaviors in older adults is needed given their high rates of suicide and differing underlying reasons and needs compared to younger adults.
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Longitudinal big data needs to meet the individual to inform self-harm and suicide prevention in older adults. Int Psychogeriatr 2022; 34:767-769. [PMID: 34127164 DOI: 10.1017/s1041610220004147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Predictive factors of nonfatal self-harm among community-dwelling older adults assessed for support services. Int Psychogeriatr 2022; 34:813-826. [PMID: 33336632 DOI: 10.1017/s1041610220003853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Older adults receiving support services are a population at risk for self-harm due to physical illness and functional impairment, which are known risk factors. This study aims to investigate the relative importance of predictive factors of nonfatal self-harm among older adults assessed for support services in New Zealand. METHODS interRAI-Home Care (HC) national data of older adults (aged ≥ 60) were linked to mortality and hospital discharge data between January 1, 2012 and December 31, 2016. We calculated the crude incidence of self-harm per 100,000 person-years, and gender and age-adjusted standardized incidence ratios (SIRs). The Fine and Gray competing risk regression model was fitted to estimate the hazard ratio (HR; 95% CIs) of self-harm associated with various demographic, psychosocial, clinical factors, and summary scales. RESULTS A total of 93,501 older adults were included. At the end of the follow-up period, 251 (0.27%) people had at least one episode of nonfatal self-harm and 36,333 (38.86%) people died. The overall incidence of nonfatal self-harm was 160.39 (95% CI, 141.36-181.06) per 100,000 person-years and SIR was 5.12 (95% CI, 4.51-5.78), with the highest incidence in the first year of follow-up. Depression diagnosis (HR, 3.02, 2.26-4.03), at-risk alcohol use (2.38, 1.30-4.35), and bipolar disorder (2.18, 1.25-3.80) were the most significant risk factors. Protective effects were found with cancer (0.57, 0.36-0.89) and severe level of functional impairment measured by Activities of Daily Living (ADL) Hierarchy Scale (0.56, 0.35-0.89). CONCLUSION Psychiatric factors are the most significant predictors for nonfatal self-harm among older adults receiving support services. Our results can be used to inform healthcare professionals for timely identification of people at high risk of self-harm and the development of more efficient and targeted prevention strategies, with specific attention to individuals with depression or depressive symptoms, particularly in the first year of follow-up.
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A Qualitative Study Exploring Negative Affect in Older Adults Residing in Long-Term Care Facilities. Res Theory Nurs Pract 2022. [DOI: 10.1891/rtnp-2021-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Purpose: To explore the experience of negative affect amongst older adults residing in long-term care facilities (LTCFs).Methods: A total of 38 participants aged 65 years or above from seven LTCFs in the Henan Province were interviewed in an unstructured manner by using the phenomenological research method. Data were analyzed by the Colaizzi method with NVivo11.0 software.Results: Three main themes emerged: (a) loneliness (lack of family affection, no common topic, and few entertainment activities), (b) chronic anxiety (suffering from disease, fear of death, and interpersonal tension), (c) subthreshold depression (diminished self-care ability, high economic pressure, and spousal bereavement).Conclusions: Older adults residing in LTCFs experienced the negative affect of loneliness, chronic anxiety, and subthreshold depression. By identifying the specific psychological issues of older adults, tailored practical initiatives need to be developed in order to reduce negative affect, improve psychological resilience, and enhance subjective well-being of older adults.
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Wand A, McKay R, Pond D. Towards Zero Suicide: need and opportunities to improve implementation of clinical elements for older adults. Australas Psychiatry 2022; 30:290-293. [PMID: 34839743 DOI: 10.1177/10398562211054034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The Zero Suicide (ZS) framework is increasingly used in Australia, but without published adaptations for older people, and limited access by older people when implemented. The aim of this paper is to inform Towards Zero Suicide (TZS) implementations to benefit older adults by considering the key differences in older adults at risk of suicide according to each clinical component of the ZS framework. CONCLUSION TZS aspires to reduce deaths by suicide for people within healthcare by refocusing interventions on suicidality rather than diagnosis alone, emphasising evidence-based practices and cultural change. For TZS to be effective for older people, it is essential to ensure practices are based upon evidence relevant to older people and to ensure ageism is effectively counteracted. Older adults have distinct patterns of help seeking and service use, accompanied by differences in risk factors, presentations, and outcomes of suicidal behaviours. Ageism affects assessment, decision-making and actions to address self-harm and suicide for older people. Immediate and longer-term actions are essential to effectively implement TZS in this population.
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Affiliation(s)
- Anne Wand
- Faculty of Medicine and Health, University of Sydney, Australia; and Faculty of Medicine, University of New South Wales, Australia
| | - Roderick McKay
- NSW Health Education and Training Institute, North Parramatta, NSW, Australia
| | - Dimity Pond
- The University of Newcastle, Callaghan, NSW, Australia
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Wand APF, Peisah C. The Development of an Online Training Tool for Crisis Supporters on Late Life Suicide: Improving Knowledge While Promoting Empowerment. Arch Suicide Res 2022; 26:968-974. [PMID: 33076767 DOI: 10.1080/13811118.2020.1833798] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Telephone crisis services have an increasing role in suicide prevention yet existing interventions have not empowered crisis supporters with adequate education targeting the needs of older people in crisis. An existing educational intervention was adapted for crisis supporters through collaboration between a crisis support service, clinician researchers, and an eLearning technology company. Empowering crisis supporters, through improving knowledge and highlighting their strengths and expertise, was emphasized. The adaptive learning technology featured a pretest, middle learning module (educational content), and post-test individualized to the participant's incorrect pretest answers. The online training tool on suicidal behaviors in late-life combined clinician researcher expertise and evidence, insights from crisis supporters, and adaptive learning technology to create a purpose-built educational tool addressing an unmet need.
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Dávila-Cervantes CA. Suicide burden in Latin America, 1990–2019: findings from the Global Burden of Disease Study 2019. Public Health 2022; 205:28-36. [PMID: 35219840 DOI: 10.1016/j.puhe.2022.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 01/12/2022] [Accepted: 01/18/2022] [Indexed: 02/05/2023]
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Toye F, Jenkins C, Barker K. Understanding the experience of living well, beyond the age of 85 years: a qualitative analysis using themes from a meta-ethnography. Age Ageing 2021; 50:2238-2245. [PMID: 34673923 DOI: 10.1093/ageing/afab179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 07/12/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Increase in life-expectancy is not necessarily matched by an increase in quality of life. OBJECTIVE (1) To explore the quality of life of patients over the age of 85 in the second decade following unicompartmental knee replacement surgery (2) To understand the usefulness of a priori themes from an evidence synthesis as a framework for primary qualitative analysis. DESIGN Qualitative Research. A hermeneutic phenomenological approach, using a priori themes as sensitising concepts. PARTICIPANTS Adults over the age of 85 who were part of an outcomes study in the second decade following unicompartmental knee joint replacement. METHODS Semi-structured interviews in people's homes. Transcripts were coded and data sorted using a priori themes as sensitising concepts. Data that did not fit these themes, or that added nuance, were analysed thematically through constant comparison. RESULTS We interviewed seven white women and five white men, aged 85-100. Data resonated with a priori themes and supported additional themes that help us to understand older peoples' experience: (1) losing our autonomy can be challenging, so be kind; (2) we must take care of our own bodies and the NHS; (3) I am more afraid of not dying. CONCLUSIONS Findings indicate that health outcomes for older people should incorporate measures of participation and well-being; they highlight the importance of kindness in healthcare; they indicate that older people do not want to place additional burden on the NHS, and this can act as a barrier to care; they support the need for open conversations about dying well.
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Affiliation(s)
- Francine Toye
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX37LD, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Cathy Jenkins
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karen Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX37LD, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Wand A, Verbeek H, Hanon C, de Mendonça Lima CA, Rabheru K, Peisah C. Is Suicide the End Point of Ageism and Human Rights Violations? Am J Geriatr Psychiatry 2021; 29:1047-1052. [PMID: 34272155 DOI: 10.1016/j.jagp.2021.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 11/19/2022]
Abstract
Ageism and human rights violations may pervade each of the potential factors underlying suicidal ideation or behavior in older persons, including physical and mental health, disability, relationships, and social factors. We outline how infringements of human rights and ageism may create or exacerbate risk factors associated with suicide in older persons. Strategies to address these issues are discussed, including tackling ageism, psychosocial interventions and education. A United Nations convention on the rights of older persons would create a uniform standard of accountability across health and social systems. Future studies are needed to evaluate the effects of alleviating ageism and human rights violations on suicide.
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Affiliation(s)
- Anne Wand
- Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney (AW), NSW, Australia; School of Psychiatry, Faculty of Medicine, University of New South Wales (AW, CP), Australia; Ageing Futures Institute, University of New South Wales (AW, CP), Australia.
| | - Hilde Verbeek
- Department of Health Services Research, CAPHRI, Faculty of Health, Medicine and Life Sciences (HV), Maastricht, The Netherlands
| | - Cecile Hanon
- Regional Resource Centre of old age Psychiatry - AP-HP Centre - Université de Paris (CH), France
| | | | | | - Carmelle Peisah
- School of Psychiatry, Faculty of Medicine, University of New South Wales (AW, CP), Australia; Ageing Futures Institute, University of New South Wales (AW, CP), Australia; Capacity Australia (CP), New South Wales, Australia
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Beghi M, Butera E, Cerri CG, Cornaggia CM, Febbo F, Mollica A, Berardino G, Piscitelli D, Resta E, Logroscino G, Daniele A, Altamura M, Bellomo A, Panza F, Lozupone M. Suicidal behaviour in older age: A systematic review of risk factors associated to suicide attempts and completed suicides. Neurosci Biobehav Rev 2021; 127:193-211. [PMID: 33878336 DOI: 10.1016/j.neubiorev.2021.04.011] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 11/28/2022]
Abstract
In older age, several observational studies investigated risk factors for suicide attempts/completed suicides; however, contrasting evidence came from population-based setting. In the present systematic review, we described through a narrative synthesis the significant associations existing among risk factors and suicide attempts/completed suicides in subjects aged >65 years. From the 39 population-based studies selected in six different databases until February 15, 2021, we analyzed the most frequent 28 risk factors for suicidal behaviour. The risk factors more associated to suicide attempts than other variables frequently related to suicidal behavior in older age were: depressive disorders, methods employed to self-harm (particularly poisoning), and psychotropic drug utilization followed by psychological factors and disability. Moreover, male sex, violent methods to self-harm, any psychiatric disorder (depression, anxiety and bipolar disorders), a poor medical condition, stressors/bereavement, and living alone appeared to be more significant for predicting completed suicides in late life. In older age, efforts for suicide prevention should be based on strategies to assess and treat psychiatric disorders along with psychological interventions, particularly in males.
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Affiliation(s)
| | - Elisa Butera
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | | | | | - Francesca Febbo
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | - Anita Mollica
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Giuseppe Berardino
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Daniele Piscitelli
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy; School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - Emanuela Resta
- Translational Medicine and Management of Health Systems, University of Foggia, Foggia, Italy
| | - Giancarlo Logroscino
- Center for Neurodegenerative Diseases and the Aging Brain, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari Aldo Moro, Bari, Italy; Department of Clinical Research in Neurology, Pia Fondazione Cardinale G. Panico, Tricase, Lecce, Italy
| | - Antonio Daniele
- Institute of Neurology, Catholic University of Sacred Heart, Rome, Italy; Institute of Neurology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mario Altamura
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Antonello Bellomo
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Francesco Panza
- Healthy Aging Phenotypes Research Unit, "Salus in Apulia Study", National Institute of Gastroenterology "Saverio de Bellis" Research Hospital, Castellana Grotte, Bari, Italy.
| | - Madia Lozupone
- Center for Neurodegenerative Diseases and the Aging Brain, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari Aldo Moro, Bari, Italy.
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Wand APF, Draper B, Brodaty H, Hunt GE, Peisah C. Evaluation of an Educational Intervention for Clinicians on Self-Harm in Older Adults. Arch Suicide Res 2021; 25:156-176. [PMID: 31941427 DOI: 10.1080/13811118.2019.1706678] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
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.
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18
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Yang K, Petersen KJ, Qualter P. Undesirable social relations as risk factors for loneliness among 14-year-olds in the UK: Findings from the Millennium Cohort Study. INTERNATIONAL JOURNAL OF BEHAVIORAL DEVELOPMENT 2020. [DOI: 10.1177/0165025420965737] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In the current study, data collected from Wave 6 of the Millennium Cohort Study ( n = 11,872), a nationally representative sample survey of youth aged 14 years in the UK, are used to examine the prevalence of loneliness among this age-group, investigate the feelings associated with the experience of loneliness among youth, explore the risk factors for loneliness among young people, and learn how they coped with loneliness. Given recent findings that youth are vulnerable to loneliness, the study assesses the prevalence of loneliness among adolescents across some important sociodemographic characteristics, such as nation of residence, gender, and ethnicity. We also identify the kinds of social experiences that accompany loneliness during adolescence, exploring friendship, relations with parents, social support, and bullying. Our key finding is that, in addition to the absence of desired social relationships, which has been typically identified as the ultimate source of loneliness, the presence of undesirable and even harmful social relationships is a major source of loneliness. This study uniquely brings together psychological and sociological perspectives to understand the experience of youth loneliness.
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20
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Cervantes CAD, Montaño AMP. Study of suicide burden of mortality in México 1990-2017. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2020; 23:e200069. [PMID: 32638855 DOI: 10.1590/1980-549720200069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 09/11/2019] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE The primary goal was to analyze the level and trend of the burden of suicide mortality in Mexico between 1990 and 2017 at a national and state scale. METHODS A secondary analysis based on the 2017 global burden of disease study. Mortality rates and years of life lost due to premature death (YLL) were reported here. A joinpoint regression analysis based on a log-linear model was used to analyze the trend of YLL. RESULTS The burden of disease due to suicides increased in Mexico, mainly in young males and females; though the raise that happened in the elderly is an additional challenge for the health system. The burden of disease varied substantially between states. The male mortality rates were higher than those of females during the whole period under study, nonetheless with a trend to reduce the difference between the sexes. A bimodal pattern of the burden of disease due to suicide in Mexico was also observed, with the higher rates located in those aged between 15 and 19 years, and an important increase in people older than 85 years of age. CONCLUSION These results show a worrisome picture, not only from a social, economic and health point of view but also from the needs of public policies. This situation represents a wake-up call about the need to implement timely identification actions, a comprehensive multisectoral prevention strategy and the detailed study of suicide associated risk factors.
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21
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Peisah C, Sheahan L, White BP. Biggest decision of them all - death and assisted dying: capacity assessments and undue influence screening. Intern Med J 2020; 49:792-796. [PMID: 30693625 DOI: 10.1111/imj.14238] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/22/2018] [Accepted: 08/22/2018] [Indexed: 12/01/2022]
Abstract
Arguably, deciding the timing and manner of one's death is the biggest decision of all. With the Victorian Voluntary Assisted Dying Act 2017 commencing in 2019, assessing capacity to choose Voluntary Assisted Dying (VAD) becomes a critical issue for clinicians in Victoria, and elsewhere with on-going efforts to change the law across Australia and in New Zealand. We consider how capacity assessment and undue influence screening can be approached for VAD, the role and risks of supported decision-making, and argue for the importance of training to ensure health care professionals are educated about their role.
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Affiliation(s)
- Carmelle Peisah
- University New South Wales, Sydney, New South Wales, Australia.,Sydney University, Sydney, New South Wales, Australia.,Capacity Australia, Sydney, New South Wales, Australia
| | - Linda Sheahan
- University New South Wales, Sydney, New South Wales, Australia.,Sydney University, Sydney, New South Wales, Australia
| | - Ben P White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
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22
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Toye F, Jenkins C, Barker KL. The Experience of Living to an Extreme Age: A Meta-Ethnography. QUALITATIVE HEALTH RESEARCH 2020; 30:3-22. [PMID: 31631748 DOI: 10.1177/1049732319880537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Advances in health care mean that we can now treat diseases that once cut lives short. However, the increase in life expectancy has not been matched by improvements in quality of life. The World Health Organization warns us that all countries should prepare to meet the challenges of an aging population and this is integral to the United Nations 2030 Agenda for Sustainable Development. This may require a shift in attitude toward aging. We aimed to use meta-ethnography to explore the experience of adults living beyond the age of 80. Our conceptual model illuminates the phenomenon of connection in older age and reflects on the paradox of time: ephemeral, yet interminable. Our findings encourage us to reflect on the influence of enlightenment philosophies that underpin the desire for autonomy at all costs. Our study challenges the stereotypes of old age and has the potential to influence people's perspectives toward aging.
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Affiliation(s)
- Francine Toye
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Cathy Jenkins
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Karen L Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
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Abstract
OBJECTIVES To follow-up a cohort of older people who self-harmed, their carer, and general practitioner (GP) and examine their reflections on the self-harm, care experiences, and outcomes. DESIGN Qualitative in-depth interviews. SETTING Two teaching hospitals and associated community services. PARTICIPANTS Twelve-month follow-up of participants aged 80 or older who self-harmed, their nominated carers, and GPs. MEASUREMENTS A geriatric psychiatrist gathered data through patient and carer interviews using a narrative inquiry approach and from medical records. Interviews were audio recorded and transcribed. N-VIVO facilitated data organization for thematic analysis. Questionnaires sent to the patient's GP examined their perspectives and aspects of care relating to the self-harm. RESULTS Nineteen patients (63% baseline sample), 29 carers (90.6%), and 11 GPs (36.7%) were available at follow-up. Themes emerging from patients were "denial and secrets;" "endless suffering;" "more invalidation;" "being heard;" and "miserable in care." Themes from carer interviews were "denial and secrets;" "patient's persistent wish to die;" "abandonment by clinicians;" "unending burden for the carer;" and "distress regarding placement." General practitioner themes were "the problem is fixed;" "the troops have arrived;" and "I understand." CONCLUSIONS Factors contributing to self-harm persisted at follow-up. Positive and negative responses were identified in the older person's system, highlighting areas for potential intervention. A conceptual framework for understanding self-harm in the very old was derived that emphasized the importance of understanding individual needs, the interpersonal context of the older person, and carer burden. Interventions should improve communication, facilitate shared understanding of perspectives, and provide support at all levels.
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24
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Wand APF, Peisah C, Draper B, Brodaty H. Carer insights into self-harm in the very old: A qualitative study. Int J Geriatr Psychiatry 2019; 34:594-600. [PMID: 30592092 DOI: 10.1002/gps.5057] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 12/20/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To examine the insights of carers to better understand self-harm in their older relatives. METHODS An in-depth interview was conducted with the nominated relative/friend (carer) of a person over 80 who had self-harmed within the last month. Carer interpretation and experience of the self-harm and clinical care were explored qualitatively. Audio recordings were transcribed and the content thematically analyzed using N-VIVO. RESULTS Thirty-two carers of 30 older people who self-harmed were interviewed. Physical, social, and psychological issues were identified as contributory to self-harm. Themes relating to the perceived barriers to seeking help included "they can't communicate," "suicide and secrets," and "invalidation." Themes for the intent of self-harm were "attention seeking" and "wanting to die." Themes which emerged for consequences of self-harm for carers were "anger," "guilt and self-blame," and "it made us ill." Themes for solutions to address the underlying factors leading to self-harm were "more practical support and structure," "improving communication," "removing means of self-harm," "advance care directives as a solution for suffering," and "ignoring self-harm." Clinical care themes were "shared shame and stigma," "safety and supervision vs being locked up," "clinicians dismissing the carer," and "relief and support." CONCLUSIONS Validation of carer perspectives and understanding family dynamics may improve communication at various system levels and inform interventions for older persons, concurrently support families, and potentially reduce risk of repeat self-harm. Good care must be holistic, be person-centred, and relieve carer burden. A shared understanding and psychotherapeutic approaches to management of self-harm in late life should be considered.
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Affiliation(s)
- Anne Pamela Frances Wand
- Academic Department of Aged Care Psychiatry, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Discipline of Psychiatry, School of Medicine, University of New South Wales, Sydney, Australia
| | - Carmelle Peisah
- Discipline of Psychiatry, School of Medicine, University of New South Wales, Sydney, Australia.,Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Brian Draper
- Academic Department of Aged Care Psychiatry, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Discipline of Psychiatry, School of Medicine, University of New South Wales, Sydney, Australia
| | - Henry Brodaty
- Academic Department of Aged Care Psychiatry, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Dementia Centre for Research Collaboration and Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
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25
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Gender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990-2016. LANCET PUBLIC HEALTH 2018; 3:e478-e489. [PMID: 30219340 PMCID: PMC6178873 DOI: 10.1016/s2468-2667(18)30138-5] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 12/20/2022]
Abstract
Background A systematic understanding of suicide mortality trends over time at the subnational level for India's 1·3 billion people, 18% of the global population, is not readily available. Thus, we aimed to report time trends of suicide deaths, and the heterogeneity in its distribution between the states of India from 1990 to 2016. Methods As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016, we estimated suicide death rates (SDRs) for both sexes in each state of India from 1990 to 2016. We used various data sources for estimating cause-specific mortality in India. For suicide mortality in India before 2000, estimates were based largely on GBD covariates. For each state, we calculated the ratio of the observed SDR to the rate expected in geographies globally with similar GBD Socio-demographic Index in 2016 (ie, the observed-to-expected ratio); and assessed the age distribution of suicide deaths, and the men-to-women ratio of SDR over time. Finally, we assessed the probability for India and the states of reaching the Sustainable Development Goal (SDG) target of a one-third reduction in SDR from 2015 to 2030, using location-wise trends of the age-standardised SDR from 1990 to 2016. We calculated 95% uncertainty intervals (UIs) for the point estimates. Findings There were 230 314 (95% UI 194 058–250 260) suicide deaths in India in 2016. India's contribution to global suicide deaths increased from 25·3% in 1990 to 36·6% in 2016 among women, and from 18·7% to 24·3% among men. Age-standardised SDR among women in India reduced by 26·7% from 20·0 (95% UI 16·5–23·5) in 1990 to 14·7 (13·1–16·2) per 100 000 in 2016, but the age-standardised SDR among men was the same in 1990 (22·3 [95% UI 14·4–27·4] per 100 000) and 2016 (21·2 [14·6–23·6] per 100 000). SDR in women was 2·1 times higher in India than the global average in 2016, and the observed-to-expected ratio was 2·74, ranging from 0·45 to 4·54 between the states. SDR in men was 1·4 times higher in India than the global average in 2016, with an observed-to-expected ratio of 1·31, ranging from 0·40 to 2·42 between the states. There was a ten-fold variation between the states in the SDR for women and six-fold variation for men in 2016. The men-to-women ratio of SDR for India was 1·34 in 2016, ranging from 0·97 to 4·11 between the states. The highest age-specific SDRs among women in 2016 were for ages 15–29 years and 75 years or older, and among men for ages 75 years or older. Suicide was the leading cause of death in India in 2016 for those aged 15–39 years; 71·2% of the suicide deaths among women and 57·7% among men were in this age group. If the trends observed up to 2016 continue, the probability of India achieving the SDG SDR reduction target in 2030 is zero, and the majority of the states with 81·3% of India's population have less than 10% probability, three states have a probability of 10·3–15·0%, and six have a probability of 25·1–36·7%. Interpretation India's proportional contribution to global suicide deaths is high and increasing. SDR in India is higher than expected for its Socio-Demographic Index level, especially for women, with substantial variations in the magnitude and men-to-women ratio between the states. India must develop a suicide prevention strategy that takes into account these variations in order to address this major public health problem. Funding Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.
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The Interpersonal Context of Suicide and Self-Harm in Later Life: An Invited Commentary on "Why Do the Very Old Self-Harm? A Qualitative Study". Am J Geriatr Psychiatry 2018; 26:872-873. [PMID: 30100022 DOI: 10.1016/j.jagp.2018.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 05/21/2018] [Indexed: 11/23/2022]
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