Anxiety symptoms and suicidal feelings in a population sample of 70-year-olds without dementia

Determinants of suicidal behavior in dementia: A Swedish national register-based study

OBJECTIVES

To examine predictors of suicidal behavior (SB) in adults aged 75 years and above with dementia.

DESIGN

Longitudinal national register-based study.

PARTICIPANTS AND SETTING

Swedish residents aged ≥75 years with dementia identified in the Swedish Dementia Registry (SveDem) between 1 January 2007 and 31 December 2017 (N = 59 042) and followed until 31 December 2018. Data were linked with numerous national registers using personal identity numbers.

MEASUREMENTS

Outcomes were nonfatal self-harm and suicide. Fine and Gray regression models were used to investigate demographics, comorbidities, and psychoactive medications associated with fatal and nonfatal SB.

RESULTS

Suicidal behavior was observed in 160 persons after dementia diagnosis; 29 of these died by suicide. Adjusted sub-hazard ratio (aSHRs) for SB was increased in those who had a previous episode of self-harm (aSHR = 14.42; 95% confidence interval [CI] = 7.06-29.46), those with serious depression (aSHR = 4.33, 95%CI = 2.94-6.4), and in those born outside Sweden (aSHR = 1.53; 95% CI = 1.03-2.27). Use of hypnotics or anxiolytics was also associated with a higher risk of SB; use of antidepressants was not. Milder dementia and higher frailty score also increased risk of SB. Risk was decreased in those who received home care (aSHR = 0.52; 95%CI = 0.38-0.71) and in the oldest group (aSHR = 0.35; 95%CI = 0.25-0.49).

CONCLUSION

In addition to established targets for suicidal behavior prevention (improved identification and treatment of depression and previous self-harm), several new risk factors were suggested. There is a need for innovative public health strategies to meet the needs of older dementia patients with a foreign background. Home care may have a potential positive effect to prevent SB in people with dementia, but this needs to be further explored.

Passive and active suicidal ideation in a population-based sample of older adults: Associations with polygenic risk scores of relevance for suicidal behavior

INTRODUCTION

There are few studies investigating genetic factors related to suicidal ideation or behavior in older adult populations. Our aim was to test associations between passive and active suicidal ideation and polygenic risk scores (PRSs) for suicidality and other traits of relevance for suicidality in old age (i.e. depression, neuroticism, loneliness, Alzheimer's disease, cognitive performance, educational attainment, and several specified vascular diseases) in a population-based sample aged 70 years and older.

METHODS

Participants in the prospective H70 study in Gothenburg, Sweden, took part in a psychiatric examination that included the Paykel questions on active and passive suicidal ideation. Genotyping was performed with the Neurochip (Illumina). After quality control of the genetic data the sample included 3467 participants. PRSs for suicidality and other related traits were calculated based on summary statistics from recent GWASs of relevance. Exclusion of persons with dementia or incomplete data on suicidal ideation yielded 3019 participants, age range 70-101 years. Associations between past year suicidal ideation (any level) and selected PRSs were analysed using general estimation equation (GEE) models, adjusted for sex and age.

RESULTS

We observed associations between passive/active suicidal ideation and PRSs for depression (three versions), neuroticism, and general cognitive performance. After excluding individuals with current major depressive disorder (MDD), similar associations were seen with PRS for neuroticism, general cognitive performance and two PRSs for depression. No associations were found between suicidal ideation and PRSs for suicidality, loneliness, Alzheimer's disease, educational attainment, or vascular disease.

DISCUSSION

Our results could indicate which types of genetic susceptibility that are of importance for suicidality in old age, and these findings can help to shed light on potential mechanisms that may be involved in passive and active suicidal ideation in late-life, also in those with no current MDD. However, due to the limited sample size, the results need to be interpreted with caution until replicated in larger samples.

An Emotion Regulation Tablet App for Middle-Aged and Older Adults at High Suicide Risk: Feasibility, Acceptability, and Two Case Studies

OBJECTIVE

The unique features of technological applications may improve the treatment of people at risk of suicide. In this article, we present feasibility and acceptability data as well as two case studies demonstrating the use of WellPATH, a tablet app that aims to help suicidal patients during emotionally-charged situations outside of therapy sessions. The WellPATH app was part of a 12-week psychotherapy intervention (CRISP - Cognitive Reappraisal Intervention for Suicide Prevention) for middle-aged and older adults after their discharge from a suicide-related hospitalization.

DESIGN

The use of WellPATH includes three stages: preparation and practice, incorporation, and actual use.

MEASUREMENTS

Feasibility was measured by the overall use of WellPATH during 12 weeks, and acceptability was measured with the three items of the Client Satisfaction Questionnaire.

RESULTS

Twelve study participants were administered WellPATH as part of CRISP. The results provide preliminary evidence of feasibility and acceptability of WellPATH. Study participants and therapists reported high satisfaction with WellPATH and provided feedback for future research and development. The patients in the case studies reported a reduction in negative emotions and an increase in emotion regulation (i.e., cognitive reappraisal ability) after using techniques on the WellPATH app.

CONCLUSION

Our preliminary findings suggest that use of technology applications such as the WellPATH app is feasible and accepted among middle-aged and older adults at high suicide risk. Further research with an adequately powered sample is needed to further evaluate WellPATH's feasibility and accessibility, and test its efficacy with this high-risk population.

Passive and active suicidal ideation in Swedish 85-year-olds: Time trends 1986-2015

BACKGROUND

Older adults have high suicide rates. We investigated potential time trends in the prevalence of passive and active suicidal ideation in 85-year-olds. Further, we examined factors associated with such ideation in this age group.

METHODS

Population-based samples of 85-year-olds were interviewed in 1986 (N = 347), 2008 (N = 426) and 2015 (N = 320). Past-month passive/active suicidal ideation was evaluated with the Paykel questions.

RESULTS

Reporting any type of passive or active suicidal ideation was less common in 2008 (7.3%, p < 0.001) and 2015 (7.2%, p < 0.001) compared to 1986 (16.4%). The change was driven by decreases in passive ideation. Passive/active suicidal ideation was associated with higher MADRS score (OR: 1.2, 95% CI: 1.1-1.2, p < 0.001), institution residence (OR: 3.9, 95% CI: 1.7-8.9, p = 0.001) and feelings of loneliness (OR: 2.7, 95% CI: 1.4-5.2, p = 0.003). When stratified by sex, it was associated with institution residence (OR: 3.7, 95% CI: 1.4-9.9, p = 0.008) and feelings of loneliness (OR: 3.0, 95% CI: 1.4-6.3, p = 0.005) in women. In men, we observed a tenfold higher risk in those without partners (OR: 9.8, 95% CI: 2.9-33.5, p < 0.001).

LIMITATIONS

While differential three-year mortality was not observed in 1986, mortality was higher among non-participants in 2008 and 2015. This might have inflated cohort differences in passive/active suicidal ideation.

CONCLUSION

An initial decrease in the prevalence of passive/active suicidal ideation in 85-year-olds was observed but this positive trend did not persist. Results underline that preventive strategies targeting loneliness and focusing on institutional settings are needed, as are interventions for men without partners.

Antidepressant Use and Suicide Rates in Adults Aged 75 and Above: A Swedish Nationwide Cohort Study

Background: The treatment of depression is a main strategy for suicide prevention in older adults. We aimed to calculate suicide rates by antidepressant prescription patterns in persons aged ≥ 75 years. A further aim was to estimate the contribution of antidepressants to the change in suicide rates over time.

Methods: Swedish residents aged ≥ 75 years (N = 1,401,349) were followed between 2007 and 2014 in a national register-based retrospective cohort study. Biannual suicide rates were calculated for those with selective serotonin reuptake inhibitor (SSRI) single use, mirtazapine single use, single use of other antidepressants and use of ≥ 2 antidepressants. The contribution of antidepressants to the change in biannual suicide rates was analyzed by decomposition analysis.

Results: There were 1,277 suicides. About one third of these were on an antidepressant during their last 3 months of life. In the total cohort, the average biannual suicide rate in non-users of antidepressants was 13 per 100,000 person-years. The corresponding figure in users of antidepressants was 34 per 100,000 person-years. These rates were 25, 42 and 65 per 100,000 person-years in users of SSRI, mirtazapine and ≥ 2 antidepressants, respectively. In the total cohort, antidepressant users contributed by 26% to the estimated increase of 7 per 100,000 in biannual suicide rates. In men, biannual suicide rates increased by 11 suicides per 100,000 over the study period; antidepressant users contributed by 25% of the change. In women, those on antidepressant therapy accounted for 29% of the estimated increase of 4.4 per 100,000.

Conclusion: Only one third of the oldest Swedish population who died by suicide filled an antidepressant prescription in their last 3 months of life. Higher suicide rates were observed in mirtazapine users compared to those on SSRIs. Users of antidepressants accounted for only one quarter of the increase in the suicide rate. The identification and treatment of suicidal older adults remains an area for prevention efforts.

Epidemiology of suicidal feelings in an ageing Swedish population: from old to very old age in the Gothenburg H70 Birth Cohort Studies

AIMS

The first aim of this study was to provide prevalence suicidal feelings over time (past week, past month, past year and lifetime) in a population-based sample of old to very old adults without dementia. Does prevalence change with rising age? The second aim was to examine the fluctuation of suicidal feelings over time. How does this coincide with depression status?

METHODS

Data were derived from the Gothenburg H70 Birth Cohort Studies (the H70 studies) which are multidisciplinary longitudinal studies on ageing. A representative sample of adults in Gothenburg, Sweden with birth years 1901-1944 were invited to take part in a longitudinal health study on ageing and participated at one or more occasions during 1986-2014. The sample consisted of 6668 observations originating from 3972 participants without dementia between the ages of 70 and 108, including 1604 participants with multiple examination times. Suicidal feelings were examined during a psychiatric interview using the Paykel questions (life not worth living, death wishes, thoughts of taking own life, seriously considered taking life, attempted suicide).

RESULTS

Prevalence figures for suicidal feelings of any severity were as follows: past week 4.8%, past month 6.7%, past year 11.2% and lifetime 25.2%. Prevalence rates increased with age in the total group and in women but not in men. Suicidal feelings were common in participants with concurrent major or minor depression, but over a third of the participants who reported suicidal feelings did not fulfil criteria for these diagnoses nor did they present elevated mean depressive symptom scores. The majority of participants consistently reported no experience of suicidal feelings over multiple examination times, but fluctuation was more common in women compared with men.

CONCLUSION

Suicidal feelings in late-life are uncommon in individuals without depression indicating that such behaviour is not a widespread, normative phenomenon. However, such feelings may occur outside the context of depression.

Life weariness and suicidal thoughts in late life: a national study in Sweden

OBJECTIVES

This study aimed at investigating the point prevalence of life weariness and suicidal thoughts and their relationship with socio-demographic characteristics in a population of older adults in Sweden.

METHOD

Data from 7913 individuals aged 60 years and older were drawn from the Swedish National Study on Aging and Care, a collaborative study in Sweden. Life weariness and suicidal thoughts were measured by one item derived from the Montgomery-Åsberg Depression Rating Scale. A multinomial regression model was used to investigate the relationships of socio-demographic characteristics with life weariness and suicidal thoughts.

RESULTS

Living in urban and semi-urban areas, being of advanced age, being divorced and having lower educational levels were related to life weariness. Living in a residential care facility, being widowed or unmarried, being born in a non-Nordic European country and experiencing financial difficulties were related to both life weariness and suicidal thoughts. Sex was found to be unrelated to either life weariness or suicidal thoughts.

CONCLUSION

This study found that several socio-demographic variables were associated with life weariness and suicidal thoughts among older adults. Specific attention to older individuals with these characteristics may be warranted as they might be more vulnerable to life weariness and suicidal thoughts.

Nursing diagnosis for Risk of Suicide in elderly: integrative review

OBJECTIVE

To analyze the specialized literature regarding the risk factors in nursing diagnosis for suicide risks in elderly.

METHOD

This is an integrative literature review carried out during June 2015 in the following databases with no time limit: MEDLINE, PsycINFO and CINAHL.

RESULTS

A total of 80 full papers were analyzed. It was suggested the inclusion of 23 risk factors in NANDA-I taxonomy: apathy; unrest; low self esteem; carelessness with medication; Inability to ask for help; Inability to express feelings; suicidal plan; rigidity; functional disability; visual problems; sadness; hostility; anxiety; failure; frustration; unhappiness; dishonor; frequent visits to a physician with unclear symptoms; social deprivation; social devaluation; psychological violence; Interfamilial violence; and financial violence.

CONCLUSION

The risks for suicide presented in NANDA-I taxonomy need to be refined and adapted to the elderly reality. Furthermore, a review is also recommended for the risk factors not included in this classification.

Antidepressants and suicidal behaviour in late life: a prospective population-based study of use patterns in new users aged 75 and above

Purpose

To investigate associations between antidepressant use patterns and risk of fatal and non-fatal suicidal behaviours in older adults who initiated antidepressant therapy.

Method

A national population-based cohort study conducted among Swedish residents aged ≥ 75 years who initiated antidepressant treatment. Patients who filled antidepressant prescriptions between January 1, 2007 and December 31, 2013 (N = 185,225) were followed until December 31, 2014. Sub-hazard ratios of suicides and suicide attempts associated with use patterns of antidepressants, adjusting for potential confounders such as serious depression were calculated using the Fine and Gray regression models.

Results

During follow-up, 295 suicides and 654 suicide attempts occurred. Adjusted sub-hazard ratios (aSHRs) were increased for both outcomes in those who switched to another antidepressant (aSHR for suicide 2.42, 95% confidence interval 1.65 to 3.55, and for attempt 1.76, 1.32 to 2.34). Elevated suicide risks were also observed in those who concomitantly filled anxiolytics (1.54, 1.20 to 1.96) and hypnotics (2.20, 1.69 to 2.85). Similar patterns were observed for the outcome suicide attempt. Decreased risk of attempt was observed among those with concomitant use of anti-dementia drugs (0.40, 0.27 to 0.59).

Conclusion

Switching antidepressants, as well as concomitant use of anxiolytics or hypnotics, may constitute markers of increased risk of suicidal behaviours in those who initiate antidepressant treatment in very late life. Future research should consider indication biases and the clinical characteristics of patients initiating antidepressant therapy.

Electronic supplementary material

The online version of this article (10.1007/s00228-017-2360-x) contains supplementary material, which is available to authorized users.

Negative Emotions and Suicidal Ideation during Psychosocial Treatments in Older Adults with Major Depression and Cognitive Impairment

OBJECTIVE

To examine the relationship of negative emotions with suicidal ideation during 12 weeks of Problem Adaptation Therapy (PATH) versus Supportive Therapy of Cognitively Impaired Older Adults (ST-CI), hypothesizing that improved negative emotions are associated with reduced suicidal ideation, PATH improves negative emotions more than ST-CI, and improved negative emotions, rather than other depression symptoms, predict reduction in suicidal ideation.

METHODS

In a randomized controlled trial of two home-delivered psychosocial interventions, 74 older participants (65-95 years old) with major depressive disorder and cognitive impairment were recruited in collaboration with community agencies. The sample reported less intense feelings than suicidal intention. Interventions and assessments were conducted in participants' homes. PATH focuses on improving emotion regulation, whereas ST-CI focuses on nonspecific therapeutic factors, such as understanding and empathy. Improved negative emotions were measured as improvement in Montgomery Asberg's Depression Rating Scales' (MADRS) observer ratings of sadness, anxiety, guilt, hopelessness, and anhedonia. Suicidal ideation was assessed with the MADRS Suicide Item.

RESULTS

MADRS Negative Emotions scores were significantly associated with suicidal ideation during the course of treatment (F_[1,165] = 12.73, p = 0.0005). PATH participants had significantly greater improvement in MADRS emotions than ST-CI participants (treatment group by time: F_[1,63.2] = 7.02, p = 0.0102). Finally, improved negative emotions, between lagged and follow-up interview, significantly predicted reduction in suicidal ideation at follow-up interview (F_{[1, 96]} = 9.95, p = 0.0022).

CONCLUSION

Findings thatimprovement in negative emotions mediates reduction in suicidal ideation may guide the development of psychosocial interventions for reduction of suicidal ideation (clinicaltrials.gov; NCT00368940).

Age-related differences in the influence of major mental disorders on suicidality: a Korean nationwide community sample

BACKGROUND

We compared the influence of major mental disorders on suicidality according to age, adjusting for suicide-related correlates.

METHODS

This study was based on the Korean national epidemiological survey of mental disorders including community-dwelling adults between 18 and 74 years of age (n=6022). Subjects were classified into three age groups; young (18-39), middle-aged (40-59), and late adulthood (60-74). Face-to-face interviews were conducted using the Korean version of the Composite International Diagnostic Interview. According to age groups, the influence of major depressive disorder (MDD), anxiety disorder, and alcohol use disorder on risk for suicidality were investigated by multiple logistic regression models adjusting for sex, years of education, marital status, income, employment, presence of chronic medical illness, and lifetime history of suicide attempt.

RESULTS

After including MDD as a covariate, anxiety disorder remained a risk factor only in the middle-aged group (adjusted OR: 2.83, 95% CI: 1.54-5.22), and alcohol use disorder was a risk factor for suicidality only in the young group (adjusted OR: 2.81, 95% CI: 1.06-7.43). Conversely, MDD was the only mental disorder that significantly increased suicidality in all age groups.

LIMITATIONS

This was a cross-sectional study and did not include subjects over 75 years of age.

CONCLUSION

This study showed that the contribution of psychiatric disorders to risk for suicidality varied according to age group. Therefore, strategies for suicide prevention should be specifically designed for different age groups.