Late-life suicidal behaviours among new users of antidepressants: a prospective population-based study of sociodemographic and gender factors in those aged 75 and above

OBJECTIVE

To investigate sociodemographic and gender factors associated with suicide and suicide attempts among new users of antidepressants aged 75 and above.

DESIGN

Register-based cohort study.

SETTING

National population-based cohort of Swedish residents aged ≥75 years.

PARTICIPANTS

185 225 patients who initiated antidepressant medication between 1 January 2007 and 31 December 2013 were followed until 31 December 2014.

MAIN OUTCOME MEASURES

Suicide and suicide attempts. Fine and Gray regression models were used to analyse the sociodemographic factors (age, country of birth, marital status, education level, last occupation, income and social allowance) associated with suicidal behaviours in the entire cohort and by gender.

RESULTS

During follow-up, 295 suicides and 654 suicide attempts occurred. Adjusted sub-hazard ratios (aSHRs) for suicide were lower among older age groups (aSHR 0.73, 95% CI 0.53 to 0.99 for those 85-89 years; and aSHR 0.53, 95% CI 0.33 to 0.86 for those ≥90 years). A similar pattern was observed for suicide attempts. Suicide attempts were more common among those born in foreign countries (aSHR 1.58, 95% CI 1.16 to 2.15 for those born in another Nordic country; and aSHR 1.43, 95% CI 1.06 to 1.93 for those born in non-Nordic countries). In the gender-stratified analyses, being single or divorced, and born in another Nordic country was associated with a higher risk of suicide among men. Educational and occupational history and being born in a non-Nordic country influenced risk of suicidal behaviours in women.

CONCLUSION

Suicidal behaviours occurred more commonly among new users who were 'younger' old adults and those with foreign background, suggesting that those groups might require greater support when initiating antidepressant therapy. Our findings suggest the need for gender-specific, multifaceted approaches to the prevention of suicidal behaviours in late life.

Suicide risk in long-term care facilities: a systematic review

OBJECTIVE

Suicide risk is highest in later life; however, little is known about the risk of suicide among older adults in long-term care facilities (e.g., nursing homes and assisted living facilities). The goal of this paper is to review and synthesize the descriptive and analytic epidemiology of suicide in long-term care settings over the past 25 years.

METHODS

Four databases (PubMed, CINAHL Plus, Web of Knowledge, and EBSCOHost Academic Search Complete) were searched for empirical studies of suicide risk in nursing homes, assisted living, and other residential facilities from 1985 to 2013. Of the 4073 unique research articles identified, 37 were selected for inclusion in this review.

RESULTS

Of the included reports, 21 were cross-sectional, 8 cohort, 3 qualitative, and 5 intervention studies. Most studies indicate that suicidal thoughts (active and passive) are common among residents (prevalence in the past month: 5-33%), although completed suicide is rare. Correlates of suicidal thoughts among long-term care residents include depression, social isolation, loneliness, and functional decline. Most studies examined only individual-level correlates of suicide, although there is suggestive evidence that organizational characteristics (e.g., bed size and staffing) may also be relevant.

CONCLUSIONS

Existing research on suicide risk in long-term care facilities is limited but suggests that this is an important issue for clinicians and medical directors to be aware of and address. Research is needed on suicide risk in assisted living and other non-nursing home residential settings, as well as the potential role of organizational characteristics on emotional well-being for residents.

The Destructiveness of Perfectionism Revisited: Implications for the Assessment of Suicide Risk and the Prevention of Suicide

Although perfectionism is recognized as a factor that is linked with suicide, we maintain that the role of perfectionism as an amplifier of the risk of suicide has been underestimated due to several factors. In the current article, contemporary research on the role of perfectionism in suicide is reviewed and summarized. Several themes are addressed, including: (a) consistent evidence linking suicide ideation with chronic exposure to external pressures to be perfect (i.e., socially prescribed perfectionism); (b) the roles of perfectionistic self-presentation and self-concealment in suicides that occur without warning; and (c) how perfectionism contributes to lethal suicide behaviors. We also summarize data showing consistent links between perfectionism and hopelessness and discuss the need for a person-centered approach that recognizes the heightened risk for perfectionists who also tend to experience hopelessness, psychache, life stress, overgeneralization, and a form of emotional perfectionism that restricts the willingness to disclose suicidal urges and intentions. It is concluded that when formulating clinical guidelines for suicide risk assessment and intervention and public health approaches to suicide prevention, there is an urgent need for an expanded conceptualization of perfectionism as an individual and societal risk factor. We also discuss why it is essential to design preventive programs tailored to key personality features with specific components that should enhance resilience and reduce levels of risk among perfectionists who hide behind a mask of apparent invulnerability.

Screening and brief intervention for substance misuse among older adults: the Florida BRITE project

OBJECTIVES

We developed and examined the effectiveness of the Florida Brief Intervention and Treatment for Elders (BRITE) project, a 3-year, state-funded pilot program of screening and brief intervention for older adult substance misusers.

METHODS

Agencies in 4 counties conducted screenings among 3497 older adults for alcohol, medications, and illicit substance misuse problems and for depression and suicide risk. Screening occurred in elders' homes, senior centers, or other selected sites. Individuals who screened positive for substance misuse were offered brief intervention with evidence-based practices and rescreened at discharge from the intervention program and at follow-up interviews.

RESULTS

Prescription medication misuse was the most prevalent substance use problem, followed by alcohol, over-the-counter medications, and illicit substances. Depression was prevalent among those with alcohol and prescription medication problems. Those who received the brief intervention had improvement in alcohol, medication misuse, and depression measures.

CONCLUSIONS

The BRITE program effectively shaped state policy by responding to legislative mandates to address the needs of an increasing, but underserved, elder population. The pilot paved the way for obtaining a federally funded grant to expand BRITE to 27 sites in 17 counties in Florida.

Risk for suicide among medicaid beneficiaries

Demographic, diagnostic, and service expenditure characteristics of Florida Medicaid enrollees who died by suicide were investigated. Among persons receiving Medicaid and Supplemental Security Income (SSI), findings indicate the most powerful predictors of suicide were involuntary psychiatric examination, mental health hospitalization, and high mental health service use. Among Medicaid enrollees not receiving SSI, strongest suicide predictors were mental health hospitalization, high expenditures for physical health medications, and involuntary psychiatric examination. Findings suggest reducing involuntary psychiatric examinations and mental health hospitalizations while improving physical health may reduce suicide in the Medicaid population. Comprehensive hospital discharge planning, adherence monitoring with follow-up care, training mental health providers in assessing suicide lethality, and providing adequate assessment time are all crucial to achieve these objectives.