Suicide in late life: A viewpoint

Patterns of suicide intent disclosures among older adult decedents, 2016-2018: a qualitative analysis

OBJECTIVE

The aim of this work is to examine suicide intent disclosures to identify patterns to support an improved understanding of the impetus for suicidal behavior in late life, which may offer insight useful in aiding prevention efforts.

METHODS

Using restricted access data from the National Violent Death Reporting System for years 2016-2018, we conducted qualitative content analysis of included narrative descriptions of 2,969 cases in which the decedent was aged 65 years or older and disclosed their intent to die by suicide.

RESULTS

The majority of suicide intent disclosures were direct statements of intent to die by suicide (37.19%), followed by a smaller proportion of indirect (implied) statements (25.29%). When response of disclosure recipient was described, such disclosures were frequently dismissed as insincere. Uncontrolled or chronic pain was cited by 11.62% of decedents as the rationale for suicide.

CONCLUSION

Findings from this work suggest the content of suicide intent disclosures may vary considerably but demonstrate consistent patterns. Dismissal of such disclosures is a common response, likely due to inability to assess sincerity. Given the high rate of lethality among suicide attempts in late life, any intent disclosures should be critically evaluated.

A brief research report of suicide rates in the Brazilian elderly over a 12-year period: the lack of association of the "Setembro Amarelo" campaign for suicide prevention

Objectives

Aiming to disseminate information related to suicide prevention in Brazil, the "Setembro Amarelo" campaign has been conducted since 2015. The objective of this study is to assess the association between this campaign and elderly suicide rates over a 12-year period.

Methods

Data were gathered from the Mortality Information System and the Notifiable Diseases Information System, established by public institutions in Brazil. An interrupted time-series framework was applied to assess the association between the "Setembro Amarelo" campaign and suicide mortality rates in the elderly population (60 et plus) in the southeastern region of Brazil. We consider three monthly outcomes: all suicides, suicides in males and suicide in females. We operationalize the campaign assuming three effects: short-term, declining and sustained. The period of analysis was from 2011-2022.

Results

The suicide-mortality rate over time has remained stable; the average rate in the pre-campaign period was 0.028 and increased slightly to 0.035. Regardless of the campaign's operationalization and the outcome used, results show no significant associations between the campaign and elderly suicide rates. The campaign was associated with non-significant decreased effects of 15% (P=0.532) in the short term, and 16% (P=0.446) assuming the campaign was sustained.

Conclusions

There is a lack of association between the campaign and suicide rates, among the elderly in Brazil's southeastern region. As suicide is complex and multifactorial, more research is needed. The campaign, while raising awareness and reducing stigma, may not reduce suicides. To reduce the suicide rate in the elderly requires addressing social, economic and cultural factors, multisectoral interventions, and upholding basic human rights.

Childhood adversity and suicidal ideation in older Korean adults: unraveling the mediating mechanisms of mental health, physical health, and social relationships

BACKGROUND

Suicide rates in older adults are much higher than those in younger age groups. Given the rapid increase in the proportion of older adults in Korea and the high suicide rate of this age group, it is worth investigating the mechanism of suicidal ideation for older adults. Generally, adverse childhood experiences are positively associated with suicidal ideation; however, it is not fully understood what mediating relationships are linked to the association between these experiences and current suicidal ideation.

METHODS

The data from 685 older Korean adults were analyzed utilizing logistic regression, path analyses, and structural equation modeling. Based on our theoretical background and the empirical findings of previous research, we examined three separate models with mental health, physical health, and social relationship mediators. After that, we tested a combined model including all mediators. We also tested another combined model with mediation via mental health moderated by physical health and social relationships.

RESULTS

The univariate logistic regression results indicated that childhood adversity was positively associated with suicidal ideation in older adults. However, multivariate logistic regression results demonstrated that the direct effect of childhood adversity became nonsignificant after accounting all variables. Three path models presented significant mediation by depression and social support in the association between childhood adversity and suicidal ideation. However, combined structural equation models demonstrated that only mediation by a latent variable of mental health problems was statistically significant. Social relationships moderated the path from mental health problems to suicidal ideation.

CONCLUSIONS

Despite several limitations, this study has clinical implications for the development of effective strategies to mitigate suicidal ideation. In particular, effectively screening the exposure to adverse childhood experiences, early identification and treatment of depressive symptoms can play a crucial role in weakening the association between childhood adversity and suicidal ideation in older adults.

Fatal Intoxications with Zopiclone-A Cause for Concern?

INTRODUCTION

Zopiclone, a controlled substance prescribed for insomnia, has become a common toxicological finding in forensic autopsy cases. This study investigated the role and extent of zopiclone use in fatal intoxications in Sweden.

METHODS

All forensic autopsy cases positive for zopiclone in femoral blood during 2012-2020 were selected. Among these cases, fatalities caused by intoxication according to the cause of death certificates issued by the forensic pathologist were identified. Intoxications where zopiclone contributed to the cause of death were included in the study. The Swedish Prescribed Drug Register was utilized to examine whether the included cases were prescribed zopiclone or not.

RESULTS

In total 7320 fatal intoxications underwent a forensic autopsy during the study period, 573 of them were caused by zopiclone. Among the zopiclone fatalities, 87% (n = 494) had a prescription for zopiclone, and 8% (n = 43) were monointoxications. Most fatalities, 62% (n = 354) were suicides, and zopiclone was involved in about 17% (n = 354) of all intoxication suicides in Sweden. Women were significantly (p < 0.01) overrepresented in suicides with zopiclone, comprising 56% (n = 291) of fatalities. The median age was 55 years among zopiclone intoxications compared with 44 years amongst all fatal intoxications.

CONCLUSION

This study demonstrates that the toxicity of zopiclone can be lethal both in combination with other substances and on its own. Most individuals dying in fatal zopiclone intoxications were prescribed zopiclone, which potentially indicates that a more restrictive prescribing rate could prevent future intoxication deaths, especially when caring for patients with an increased suicide risk.

A scientometric analysis and visualisation of elderly suicide research from 1951 to 2022

BACKGROUND

There are still many gaps in both national and international literature on elderly suicide. This study aimed to identify the most influential journals in elderly suicide, the countries and authors that contribute the most to the field, and the trends in the field.

MATERIAL AND METHODS

Studies published on elderly suicide between 1951 and 2022 were retrieved utilising the Web of Science Core Collection. Co-authorship analysis of countries and authors, as well as co-occurrence analysis of keywords, were conducted using VOSviewer 1.6.18.

RESULTS

There were 2864 articles retrieved, including 95 countries, 889 academic journals, 9162 authors and 4160 keywords. The number of publications in this field has significantly increased after the 2000s, and the United States is the most productive country (996). The most prolific author is Yeates Conwell, while the journal with the highest number of publications in this field is the International Journal of Geriatric Psychiatry. Other than 'suicide' and 'elderly', the most trending keywords are 'depression', 'primary care', 'treatment', 'antidepressant', 'loneliness', 'quality of life' and 'COVID-19'.

CONCLUSION

There has been an increase in both the thematic diversity and quantity of studies on elderly suicide over time. However, these publications predominantly originate from socioeconomically affluent countries with relatively low suicide rates. While the increasing numbers of publications from developing countries in recent years are promising, there is a greater need for publications from countries with lower socioeconomic status for the prevention or intervention of elderly suicides.

A narrative review: suicide and suicidal behaviour in older adults

Globally, suicide is a public health concern that claims the lives of many each year. The complex etiology and factors contributing to the risk of suicide make it hard to predict the likelihood of death by suicide. Suicide rates have been increasing over the past 25 years in patients aged 65 years and older, and with the expected increases in the size of the older adult population and the under-detection of suicide risk, these rates may continue to increase. To mitigate and attempt to limit this expected increase, it is important to understand the risk and protective factors of suicide in older adults. This narrative review focuses on individuals above the age of 65 and encompasses relevant peer-reviewed publications from the past 25 years to cover fatal and non-fatal suicidal behaviour. It summarizes several important risk factors for suicide and suicidal behaviors while considering how risk can be detected, assessed, prevented, and mitigated. Screening methods to detect suicide and depression in older adults were examined based on their effectiveness and suitability for use in this population. Lastly, the impacts of the COVID-19 pandemic on suicide rates in older adults were described.

Social disconnection and suicide mortality among Japanese older adults: A seven-year follow-up study

BACKGROUND

Few prospective studies have examined the association between social disconnection and late-life suicide. Therefore, we conducted a large-scale prospective study of older adults in Japan to examine differences in suicide mortality according to specific aspects of social disconnectedness.

METHODS

We conducted a nationwide baseline survey of functionally independent older adults (age ≥65 years) from 12 municipalities in Japan from 2010 to 2011. We followed the participants (n = 46,144) for cause of death through December 2017 using vital statistics. Social disconnection was assessed based on the indicators of eating alone, a lack of instrumental/emotional support, no participation in community activities, and no contact with friends. We adopted Cox regression models with multiple imputation for missing values and calculated the population-attributable fraction (PAF).

RESULTS

A total of 55 suicide deaths were recorded during an average follow-up of 7 years. Older adults with social disconnection had a marginally increased risk of suicide. The hazard ratio for eating alone vs. eating together was 2.81 (95% confidence interval [CI]: 1.47-5.37). The direction of these associations and point estimations did not largely change after controlling for depressive symptoms, an evident risk factor for suicidal behavior. The PAF indicated that eating alone was attributable to around 1800 (29%) of the suicide deaths among older adults annually in Japan.

CONCLUSION

Avoidance of not only depressive symptoms, but also social disconnection including eating alone, is useful in suicide prevention among older adults.

Understanding the Factors Contributing to Suicide Among the Geriatric Population: A Narrative Review

A critical health concern for older adults is suicide, particularly for those above the age of 60 years. Despite this, research on suicide in this age group is relatively scarce compared to studies on younger populations. This article is intended to summarize the existing literature on etiological/risk factors, including problems with one's physical and mental health, social isolation, money, and life changes like retirement and the death of a spouse and methods for preventing suicide specific to the geriatric population. We conducted a comprehensive literature search to identify the original reports and reviewed publications through various databases, including Google Scholar, PubMed, and the CDC. We gathered information on Google from reputable sources such as the WHO and the National Crime Records Bureau (NCRB). Our review found that the risk factor of suicide in the geriatric population includes physical illness, familial issues, financial issues, and hopelessness. The suicide rate for older adults declined, dropping from 16.17 per 100,000 individuals to 14.25 per 100,000 individuals aged 50 to 69 years and from 27.45 per 100,000 individuals to 24.53 per 100,000 individuals for those over 70 years. A more significant proportion of elderly suicide attempters come from rural than urban locations. Young individuals have better professional opportunities in urban areas, but older people are dispersed to underdeveloped or rural areas, where they are more likely to experience social isolation. By systematically identifying these risk factors, we can develop prevention and intervention strategies to decrease the suicide rates among the geriatric population.

Suicide in Later Life in Uruguay: A Suicide Note Analysis

Suicide is a significant public health challenge worldwide, with inconsistent behavioral patterns. This study examined the psychological processes underlying 191 suicide notes left by older adults in Uruguay, a country doubling global and regional suicide rates, with the highest prevalence among those aged 60+. Uruguay highlights in the region as a high-income country. Through content analysis with an inter-judge strategy, the notes revealed that loneliness, loss of interest, and loss of meaning for life, were prevalent. Financial hardship was not a primary reason for suicide. Social connectedness was highlighted as a factor for reducing suicide risk in older adults, particularly those with ill health and physical impairment. The study sheds light on the need to expand social services aimed at reducing loneliness and the need to combat ageism and social prejudice towards suicide in Uruguay, providing valuable insights into suicide prevention strategies for older adults in diverse social settings.

How to save a life: From neurobiological underpinnings to psychopharmacotherapies in the prevention of suicide

The impact of suicide on our societies, mental healthcare, and public health is beyond questionable. Every year approximately 700 000 lives are lost due to suicide around the world (WHO, 2021); more people die by suicide than by homicide and war. Although suicide is a key issue and reducing suicide mortality is a global imperative, suicide is a highly complex biopsychosocial phenomenon, and in spite of several suicidal models developed in recent years and a high number of suicide risk factors identified, we still have neither a sufficient understanding of underpinnings of suicide nor adequate management strategies to reduce its prevalence. The present paper first overviews the background of suicidal behavior including its epidemiology, prevalence, age and gender correlations and its association with neuropsychiatric disorders as well as its clinical assessment. Then we give an overview of the etiological background, including its biopsychosocial contexts, genetics and neurobiology. Based on the above, we then provide a critical overview of the currently available intervention options to manage and reduce risk of suicide, including psychotherapeutic modalities, traditional medication classes also providing an up-to-date overview on the antisuicidal effects of lithium, as well as novel molecules such as esketamine and emerging medications and further molecules in development. Finally we give a critical overview on our current knowledge on using neuromodulatory and biological therapies, such as ECT, rTMS, tDCS and other options.

Family structure and depressive symptoms among older adults in China: A marginal structural model analysis

BACKGROUND

Mental well-being in the aging population is inevitably linked to families due to the reliance of older adults on family members. This study investigates the causal relationship between family structure and depressive symptoms among Chinese older adults in general and between gender and residential areas.

METHODS

We used China Health and Retirement Longitudinal Study (CHARLS) panel data, covering four data collection rounds over seven years. Family structure was classified into single-member, couple, nuclear family, and extended family. Taking into account time-varying confounding, we estimated the causal effects of family structure on depressive symptoms using marginal structural models.

RESULTS

Older people with cumulative exposure to single-member family type had an increased odds of depressive symptoms by an average of 33 % (95 % CI: 1.22-1.44) than their counterparts who lived in the couple family. Additionally, older people living in extended families also had 6 % higher odds of experiencing depressive symptoms (95 % CI: 1.00, 1.11). The longitudinal associations were consistent across gender groups and residential areas (p-value for interaction is 0.6638 for gender and 0.7043 for the residential area).

LIMITATION

The time-varying confounders (e.g., chronic health conditions) included in the analysis are based on self-reported data, which may be subject to measurement errors.

CONCLUSION

The risk of depressive symptoms is greater for older individuals living alone and in extended families. Screening for depression in the older population, particularly those living in "at-risk" households, is recommended.

Elderly suicides in Turkey

Due to the unique physical and psychosocial characteristics of this age group, it is expected that the characteristics of elderly suicides are different from other groups. Knowing the characteristics of elderly suicides guides prevention strategies. The objective of this study was to evaluate the demographic characteristics, methods and reasons for suicide in elderly suicide cases using the data of the Turkish Statistical Institute between 2002 and 2019. Of the completed suicides among older adults, 4,208 (74%) cases were men and 1,481 (26%) were women. Crude suicide rates of all elderly age groups were higher than the general population. Illness was the most common reason for suicide. The second leading cause of suicide was marital conflicts in women, while financial difficulties were observed in men. Hanging was the most common method in both genders. It is remarkable that the use of gunshot considerably increases as years progress and the ratio of men (n:962) to women (n:16) reach 60. Considering these findings together with epidemiologic data predicting that this increase in the elderly population will almost double within less than 30 years, it is apparent that suicide is a major issue among older adults.

Does social pension buy improved mental health and mortality outcomes for senior citizens? Evidence from South Africa's 2008 pension reform

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The 2008 pension reform in South Africa improved access to healthcare.

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The 2008 pension reform improved mental health and 60-year-old deaths.

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The impact of the 2008 pension reform in averting 60-year-old deaths is higher in urban regions than rural regions.

In South Africa, men were traditionally eligible to receive government pensions at 65 years. However, that eligibility criterion was changed in 2008 to allow men to receive a pension payout at 60 years. This study is designed to quantify the impact of the 2008 pension reform on mental health outcomes (depression and traumatic stress) and deaths among 60-year-old men from disadvantaged households without advanced education. This analysis used secondary data issued by Statistic South Africa- General Household Survey. Men who reported earning a pension at 60 years from 2008 to 2014 were exposed to the 2008 pension reform and thus were classified as the treatment group. The 60-year-old men during 2002–2007 were ineligible to earn the pension, therefore considered the control group. We then used a Two-stage Least Squared Model (2SLS) to quantify the impact of the 2008 pension reform on healthcare utilization, depression cases, traumatic stress cases, and deaths among 60-year-old men. The model shows that the 2008 pension reform improved healthcare utilization by 3 % in the cohorts of men who benefitted from the 2008 reform. The 2008 pension reform averted depression cases, traumatic stress cases, and deaths among 60-year-old men by 3 %, 4 %, and 5 %, respectively. The impact of the 2008 pension reform in averting deaths among 60-year-old men was higher in urban regions than rural regions. We concluded that the 2008 pension reform successfully bought improved mental health outcomes and prevented depression, traumatic stress, and deaths among 60-year-old men.

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

OBJECTIVES

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

METHODS/DESIGN

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

RESULTS

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

CONCLUSIONS

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