Suicide in the elderly: a psychological autopsy study in a North Italy area (1994-2004)

Use of Psychoactive Medications and Risk of Suicide in Late Life (75+): A Total Population Study

BACKGROUND

Psychoactive medications play an important role for the mental health and risk of suicidal behaviour in the oldest segment of the population (75+). A better understanding of psychoactive medication use is advocated to prevent suicide in this age group.

PURPOSE

We investigated the risk of suicide associated with the use of psychoactive medications in the total population aged ≥ 75 years, with and without exposure to antidepressants.

METHOD

A national population-based register study, including all Swedish residents aged ≥ 75 years between 2006 and 2014 (N = 1,413,806). A nested case-control design was used to investigate psychoactive medications associated with suicide among users and non-users of antidepressants. Risk estimates were calculated in adjusted conditional logistic regression models for the entire cohort and by gender.

RESULTS

Suicide occurred in 1305 persons (907 men and 398 women). Among them, 555 (42.5%) were on an antidepressant at the time of suicide. Adjusted incidence rate ratio (aIRR) for suicide was increased in those who were on hypnotics in the total cohort (aIRR 2.05, 95% confidence interval 1.74 to 2.41), in both users and non-users of antidepressants and for both genders. Elevated suicide risk was observed in those who concomitantly used anxiolytics with antidepressants (1.51, 1.25 to 1.83). Decreased risk of suicide was observed among those who were on anti-dementia drugs, in the total cohort (0.33, 0.21 to 0.52) and in both users and non-users of antidepressants. Use of antipsychotics and mood stabilisers showed no effect on suicide risk.

CONCLUSION

Use of hypnotics and concomitant use of anxiolytics with antidepressants was associated with increased risk of late-life suicide. Our findings suggest the need for careful evaluation of the benefit-risk balance of psychoactive medications as well as their availability as a possible suicide means. Future research should consider the indication of use of the psychoactive medications and the severity of psychiatric and medical illnesses of the patients.

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.

Suicide among older adults: Interactions among key risk factors

OBJECTIVE

The present study aimed to understand how key risk factors of older adult suicide interact to ultimately lead to death by suicide using data collected post-mortem.

METHOD

A psychological autopsy was used to gather detailed information about psychiatric diagnosis, medical problems, social isolation, and negative attitudes expressed by the individual during the six months prior to their death. Interviews with next-of-kin, medical and psychiatric records, and the Cumulative Illness Rating Scale for Geriatrics were used. Subjects included 32 older adults who died by suicide and 45 older adults who died by natural causes.

RESULTS

Hopelessness, depression, and negative health attitudes were strongly correlated with suicide. Older age was associated with social isolation, suggesting an indirect relationship with suicide via hopelessness, depression, and negative health attitudes. Physical illness did not increase risk. Multivariate analyses suggested that hopelessness fully mediated the effects of social isolation, negative health attitudes, and depression on suicide.

CONCLUSIONS

Psychological factors played the largest role in suicide deaths compared to social isolation and physical illness. Suicide interventions aimed at older adults should ensure hopelessness, depression, and negative health attitudes are primary targets.

Mental health status of Italian elderly subjects during and after quarantine for the COVID-19 pandemic: a cross-sectional and longitudinal study

BACKGROUND

The elderly are more vulnerable to COVID-19 and therefore need to adopt long-term social distancing measures. The duration of quarantine impacts the psychological status of the general population. However, until now no study has explored the psychological impact of the pandemic and quarantine together with longitudinal changes in the mental health status of Italian elderly.

METHODS

An online questionnaire including an assessment of depression, anxiety, anger, post-traumatic stress, subjective cognitive failures, resilience, coping style, and other dimensions related to the pandemic was completed by participants during (T0) and two months after the end (T1) of the quarantine.

RESULTS

The sample recruited at T0 included 334 elderly participants. About 45% of the participants experienced depression, anxiety, or anger. Moreover, more fear of getting infected was related to more severe depression, anxiety, and anger, but resilience was found to mediate these relationships. More severe depressive and anger symptoms were related to more severe cognitive failures. No significant difference was observed in mental health scores between T0 and T1. Finally, more severe depression at T0 was associated with the development of post-traumatic stress symptoms at T1.

CONCLUSIONS

The fear of getting infected, probably due to perceived vulnerability to disease, seems to play a crucial role in the development of psychological symptoms in the elderly, but resilience seems to mediate the impact of fear. The presence of long-term psychological consequences and the possible risk of developing PTS symptoms in the elderly suggest the need for targeted interventions to reduce possible long-term psychological and cognitive consequences.

Finitude, choice and the right to die: age and the completed life

This paper explores the concept of the completed life outlined in recent writing in the Netherlands on euthanasia and assisted suicide and its implications for ageing studies. Central to this theme is the basic right of people to self-determine the length of their later life, linked with the subsidiary right to assistance in achieving such self-determination. Although the notion of weariness with life has a long history, the recent advocacy of a self-limited life seems shaped by the new social movements presaged upon individual rights together with what might be called a distinctly third-age habitus, giving centre stage to autonomy over the nature and extent of a desired later life, including choice over the manner and timing of a person's ending. In exploring this concept, consideration is given to the notion of a ‘right to die’, ‘rational suicide’ and the inclusion of death as a lifestyle choice. While reservations are noted over the unequivocal good attached to such self-determination, including the limits to freedom imposed by the duty to avoid hurt to society, the article concludes by seeing the notion of a completed life as a challenge to traditional ideas about later life.

Risk factors for suicide in rural Italy: a case-control study

PURPOSE

Increased frequency of suicide in rural areas of Tuscany has been described since the 1970s. A case-control study was conducted in 2014 and 2015. The objective of this study was to identify major individual risk factors related to suicides in six rural districts of Tuscany.

METHODS

Cases were identified as all 128 suicides occurred in six rural districts between 2009 and 2013. Controls (three for each case) were matched for age, sex, and general practice. Information was collected from GPs using a structured questionnaire. Univariate and multivariate analyses were carried out to investigate the association between individual risk factors and suicide.

RESULTS

Informants for 91 cases of the 128 identified cases were successfully interviewed (response rate 71.1%). About 40.5-65.9% suicide cases and 11.4-20.0% of controls had some psychiatric pathology, accordingly to different definitions. Univariate conditional regression analysis showed that living in isolated houses (OR 2.48), living alone (OR 2.97), not being married (OR 2.63), low income (OR 2.73), psychiatric pathology (OR 9.70), psychotropic medication (OR 5.58), problems with relatives (OR 14.78), psychiatric family history (OR 5.67), and suicidal ideation (OR 15.61) were all risk factors. Practising religion (OR 0.27) was the only protective factor identified. Multivariate regression identified two independently and significantly associated variables namely, psychiatric pathology (OR 8.87) and living alone (OR 2.30).

CONCLUSIONS

Results of this study showed, similarly to recent research, that not all suicide events are the results of psychiatric pathology. Prevention strategies should, therefore, target both socio-economic and clinical risk factors.

Suicide in the elderly: a 37-years retrospective study

BACKGROUND

The rates of suicide increase with age and reach their highest levels in the oldest age groupings and are sufficiently large for them to constitute a public health concern. The number of deaths due to suicides after the age of 60 years in Italy is 1,775 (41.36%) in 2013; there is a constant increase of elder population over the last ten years and elderly are almost twice of young. It is in this context that suicide arises, a risk factor during old age.

METHOD

This is a retrospective study of autopsy and police reports of suicide from January 1979 through December 2015. Data about suicides after the age of 60 years was collected from the Archives of the Legal Medicine of the University of Parma, a Northern Italian city. Trend and characteristics (age, sex, marital status, pathological factors and method of suicide) were assessed.

RESULTS

A total of 538 cases (394 males, 144 females) were identified. Male sex correlates to a higher suicidal risk, with a male-female ratio of 2.74:1. The highest risk of suicide is observed in the age between 70 and 79 years. Pathological factors were revealed in 427 cases (physical state for 194 cases, mental state for 233 cases); mental illness was related significantly to suicidal risk. Hanging is the most common suicide method (175 cases), followed by fall from height (130 cases), drowning (101 cases) and use of firearms (56 cases); differences regarding methods employed were detected between males and females. The choice of method sometimes is indicative of a clear decision, while other times it is strictly linked to the availability of the means.

CONCLUSIONS

Suicidal behavior seems to be the product of the interaction of many factors, such as biological or psychological diseases or painful events. The presence of chronic and debilitating diseases, often accompanied by profound psychological suffering, is a powerful stimulus for suicide among men, whereas mental state is a significant risk factor for women, with the majority suffering from depression. The psychological and the biological changes, the cognitive deficits and the common diseases facilitate the structuring of depressive characteristics.

Lifestyle Interventions and Prevention of Suicide

Over the past years, there has been a growing interest in the association between lifestyle psychosocial interventions, severe mental illness, and suicide risk. Patients with severe mental disorders have higher mortality rates, poor health states, and higher suicide risk compared to the general population. Lifestyle behaviors are amenable to change through the adoption of specific psychosocial interventions, and several approaches have been promoted. The current article provides a comprehensive review of the literature on lifestyle interventions, mental health, and suicide risk in the general population and in patients with psychiatric disorders. For this purpose, we investigated lifestyle behaviors and lifestyle interventions in three different age groups: adolescents, young adults, and the elderly. Several lifestyle behaviors including cigarette smoking, alcohol use, and sedentary lifestyle are associated with suicide risk in all age groups. In adolescents, growing attention has emerged on the association between suicide risk and internet addiction, cyberbullying and scholastic and family difficulties. In adults, psychiatric symptoms, substance and alcohol abuse, weight, and occupational difficulties seems to have a significant role in suicide risk. Finally, in the elderly, the presence of an organic disease and poor social support are associated with an increased risk of suicide attempt. Several factors may explain the association between lifestyle behaviors and suicide. First, many studies have reported that some lifestyle behaviors and its consequences (sedentary lifestyle, cigarette smoking underweight, obesity) are associated with cardiometabolic risk factors and with poor mental health. Second, several lifestyle behaviors may encourage social isolation, limiting the development of social networks, and remove individuals from social interactions; increasing their risk of mental health problems and suicide.

A naturalistic 1 year follow-up study of the elderly patients with depression visiting the psychiatric outpatient services for the first time

This naturalistic study aimed to assess treatment dropout pattern, course of symptoms and outcome of depression among the elderly. This study aimed to assess the course and outcome of depression and treatment dropout pattern of patients with depression in old age. Additionally an attempt was made to study the predictors of outcome and dropout. 140 elderly patients (≥ 60 years) were followed up at 6 months and 1 year to evaluate the status of their depression and treatment pattern. Out of the 140 patients recruited at the baseline, 58 (41.4%) patients did not return to the clinic after the first visit. 65.7%, 75% and 90% patients dropped out from the clinic by 3 months, 6 months and 1 year after registration with the clinic. At 1 year, about two-third (65%) of patients achieved improvement in symptoms to the extent of 81-100% and only 10% did not show any improvement throughout the study period. To conclude present study suggests that large proportion of the elderly patients with depression attending a mental health service dropout of treatment. Despite the high dropouts rate, more than three-fourth of the patients improve to the extent of 81-100% and very few patients have worsening of symptoms or persistent symptoms.

Measuring elderly people's quality of life through the Beck Hopelessness Scale: a study with a Spanish sample

OBJECTIVES

Hopelessness is a key element of suicidal intent. It can instill a pessimistic outlook on the future, leading an individual to believe that suicide is the only answer to their problems. Hopelessness operates as a modulating variable between depression and suicidal behavior. The aim of this study was to confirm the factor structure of the Beck Hopelessness Scale (BHS) in a non-clinical sample.

METHOD

Three hundred and sixty-two Spanish individuals, aged over 60, free of cognitive impairment and depressive symptoms, completed the BHS scale. Participants were tested using confirmatory factor analysis (CFA), using one-, two- and three-factor models.

RESULTS

The one- and two-factor models presented adequate fit indices. Specifically, the indices of the two-factor models were better than those of the one-factor model. The two-factor model, without items 4, 9 and 14, provided the best fit, given that the indices obtained in the CFA and their internal consistency were better than those of the other models.

CONCLUSION

The validation of the BHS for a population of Spanish older adults provides a reliable and valid measure of hopelessness and could be useful in clinical practice and research as an effective tool for the early detection of suicidal behaviors.

Age and sex-related differences in risk factors for elderly suicide: Differentiating between suicide ideation and attempts

OBJECTIVE

The purpose of this study was to analyze the age and sex-related differences in socio-demographic factors that influence suicide ideation and attempts in the elderly.

METHODS

The total number of subjects was 93 151, of whom 8441 belonged to the high suicide-risk group (2064 male; 6377 female). Following this identification, we investigated their socio-demographic information, health status, and depressive symptoms, which might have influenced their suicide ideation and attempts.

RESULTS

Residence in an urban area was identified as a risk factor for both male and female elderly in their 60s and 70s and female elderly in their 80s. Marital status showed a different influence on suicide ideation depending on age and sex. A negative perception of one's own health status was a significant risk factor that increased the likelihood of suicide ideation in all ages, except the female elderly in their 60s. No factor was identified that significantly influenced suicide attempts in the male elderly. However, in the female elderly, residence in an urban area and a negative perception of one's own health status were identified as significant risk factors.

CONCLUSIONS

This study revealed that factors known to influence suicide ideation in the elderly from previous studies, such as residence area, separation from a spouse, education level, religion, and drinking, show changed influence as the elderly reach their 70s and 80s. However, a negative perception of one's own health status was a risk factor that encompassed most ages and sexes.

Elderly suicide in Eskisehir, Turkey

Old age should be examined separately from other stages of life in terms of ratio, method and motives for suicide. With some variation, epidemiological studies suggest suicides increase with age in virtually every society. This study examines demographic data (age, sex and marital status), and other factors related to 20-years (1997-2016) of completed elder suicides in Eskisehir, Turkey. The 74 cases of those 65 and over were evaluated with regard to method, tool and location of the suicide. Annual distributions illustrate gradual increases in this fatal self-harm over time. The vast majority of cases were male (74.3%), compared to female (25.6%). Elders in the 80-84 age range were most likely to kill themselves. Deaths were frequently caused by hanging, followed by other methods and took place in the home. Reasons associated with suicidal behavior included despair as a result of bereavement, mental illnesses, chronic physical conditions and living alone. The researchers cite potential prevention strategies through the use of early mental health treatment for elders, along with inclusion in social services and activities.

Suicide in older men: The health in men cohort study (HIMS)

Suicide rates are high in later life, particularly among older men. Mood disorders are known risk factors, but the risk of suicide associated with poor physical health remains unclear. We completed a cohort study of a community representative sample of 38,170 men aged 65-85 in 1996 who were followed for up to 16years. Data on suicide attempts and completion were obtained from the Western Australia Data Linkage System, as was information about medical and mental health diagnoses. 240 (0.6%) participants had a recorded history of past suicide attempt, most commonly by poisoning (85%). Sixty-nine men died by suicide during follow up (0.3% of all deaths), most often by hanging (50.7%). Age-adjusted competing risk regression showed that past suicide attempt was not a robust predictor of future suicide completion (sub-hazard ratio, SHR=1.58, 95% CI=0.39, 6.42), but bipolar (SHR=7.82, 95% CI=3.08, 19.90), depressive disorders (SHR=2.26, 95% CI=1.14, 4.51) and the number of health systems affected by disease (SHR for 3-4 health systems=6.02, 95% CI=2.69, 13.47; SHR for ≥5 health systems=11.18, 95% CI=4.89, 25.53) were. The population fraction of suicides attributable to having 5 or more health systems affected by disease was 79% (95% CI=57%, 90%), and for any mood disorder (bipolar or depression) it was 17% (95% CI=3%, 28%). Older Australian men with multiple health morbidities have the highest risk of death by suicide, even after taking into account the presence of mood disorders. Improving the overall health of the population may be the most effective way of decreasing the rates of suicide in later life.

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

OBJECTIVE

The relationship between older adult suicide rates and population-level variables has been examined in a few studies. Therefore, the objective of the present study is to analyse the extent to which population-level factors are associated with suicide by older persons in Australia, from an ecological perspective.

METHODS

Suicide rates for older adults aged 65 years and over were calculated for 68 observation units at Statistical Areas Level 4 in Australia for 2002-2011. The 2011 Census of Population and Housing was used for population-level variables. Analysis on standardised suicide mortality ratios and Poisson regression were performed to examine geographical and gender differences.

RESULTS

Between 2002 and 2011, a total of 3133 suicides of persons aged 65 years and above (men: n = 2418, 77.1%) was identified with an average annual rate of 10.1 per 100,000 persons. Suicide rates in older adults vary widely between different geographical regions in Australia. The multivariate estimates of contextual factors showed that the risk of suicide was positively associated with the sex ratio (incidence risk ratio (IRR) = 1.053, 95%CI = 1.016-1.092), the proportion of those in tenant household (IRR = 1.120, 95%CI = 1.081-1.160) and Australian residents born in North-West Europe (IRR = 1.058, 95%CI = 1.022-1.095). Significant gender variations were found.

CONCLUSIONS

Specific factors increasing risk of suicide for older adults on SA4 level in Australia were living in areas with a higher proportion of male population, a higher proportion of tenant household dwellers and a higher proportion of immigrants from North-West Europe. The different influences of population-level factor on suicide between older men and women indicate the need for targeted suicide prevention activities.

A systematic review of physical illness, functional disability, and suicidal behaviour among older adults

OBJECTIVES

To conduct a systematic review of studies that examined associations between physical illness/functional disability and suicidal behaviour (including ideation, nonfatal and fatal suicidal behaviour) among individuals aged 65 and older.

METHOD

Articles published through November 2014 were identified through electronic searches using the ERIC, Google Scholar, PsycINFO, PubMed, and Scopus databases. Search terms used were suicid* or death wishes or deliberate self-harm. Studies about suicidal behaviour in individuals aged 65 and older with physical illness/functional disabilities were included in the review.

RESULTS

Sixty-five articles (across 61 independent samples) met inclusion criteria. Results from 59 quantitative studies conducted in four continents suggest that suicidal behaviour is associated with functional disability and numerous specific conditions including malignant diseases, neurological disorders, pain, COPD, liver disease, male genital disorders, and arthritis/arthrosis. Six qualitative studies from three continents contextualized these findings, providing insights into the subjective experiences of suicidal individuals. Implications for interventions and future research are discussed.

CONCLUSION

Functional disability, as well as a number of specific physical illnesses, was shown to be associated with suicidal behaviour in older adults. We need to learn more about what at-risk, physically ill patients want, and need, to inform prevention efforts for older adults.

Unpacking Sleep and Suicide in Older Adults in a Combined Online Sample

OBJECTIVE

Duration of insomnia symptoms and nightmares are related to suicidal risk in young adults independent of current symptoms of insomnia, nightmares, anxiety, depression, and PTSD. However, this relation has yet to be examined among older adults, despite older adults being at higher risk of suicidal behavior. Further, the current study aims to replicate previous research among younger adults showing that insomnia symptoms and nightmares are associated with suicide risk independent of the interpersonal psychological theory of suicide (IPTS).

METHODS

The present study utilized 167 participants age 55 and older obtained by combining two independent mTurk data collections of adults in the United States.

RESULTS

In the current sample, duration of nightmares was associated with suicide risk in older adults independent of symptoms of current insomnia and nightmares, duration of insomnia, and symptoms of PTSD, anhedonia, and the IPTS.

CONCLUSIONS

Our findings suggest that the duration of nightmares (i.e., how long someone has been experiencing nightmares) predict substantial variance in suicide risk among older adults in addition to the risk factors typically examined. Thus, assessment of sleep dysfunction is important when assessing suicide risk among older adults.

Somatic disorders and antidepressant use in suicides: A population-based study from the Friuli Venezia Giulia region, Italy, 2003-2013

BACKGROUND

Many somatic disorders are complicated by depression and increase the risk of suicide. Little is known about whether antidepressants might reduce the suicidal risk in patients with somatic disorders.

METHODS

Data on diagnoses and antidepressant prescriptions were derived from the Social and Health Information System of the Friuli Venezia Giulia Region. Cases were all suicides that occurred in the region during the years 2003-2013 and were sex- and age-matched to controls from the general population. Conditional logistic regression analysis was used to assess the association between suicide and somatic disorders.

RESULTS

The suicide rate in Friuli Venezia Giulia decreased from 11.3 to 10.7 per 100,000 inhabitants during the years 2003-2013, however patients with somatic disorder had a three times increased risk of suicide. Elderly somatic patients' suicide risk was twice as high as younger patients. The risk increased from 2.6 to 9.8 times as the number of comorbid disorders increased from 1 to 4 and over. Although no significant risk of suicide in patients with somatic disorders was found when patients were adherent to antidepressants, only 11.5% of the suicides was adherent in the year prior to death.

CONCLUSIONS

Medical illnesses and underlying depressive symptoms may have a synergy effect on the risk of suicide, particularly in older patients and in patients with multiple morbidities. Since medically ill subjects adherent to antidepressants did not show a significant risk of suicide, early identification and adequate treatment of depression in somatic patients should be considered in order to prevent suicide.

Acute and Chronic Risk Preceding Suicidal Crises Among Middle-Aged Men Without Known Mental Health and/or Substance Abuse Problems: An Exploratory Mixed-Methods Analysis

BACKGROUND

Suicides among men aged 35-64 years increased by 27% between 1999 and 2013, yet little research exists to examine the nature of the suicide risk within this population. Many men do not seek help if they have mental health problems and suicides may occur in reaction to stressful circumstances.

AIMS

We examined the precipitating circumstances of 600 suicides without known mental health or substance abuse (MH/SA) problems and with a recent crisis. Whether these suicides occurred within the context of an acute crisis only or in the context of chronic circumstances was observed.

METHOD

Using data from the National Violent Death Reporting System and employing mixed-methods analysis, we examined the circumstances and context of a census of middle-aged male suicides (n = 600) in seven states between 2005 and 2010.

RESULTS

Precipitating circumstances among this group involved intimate partner problems (IPP; 58.3%), criminal/legal problems (50.7%), job/financial problems (22.5%), and health problems (13.5%). Men with IPP and criminal/legal issues were more likely than men with health and/or job/financial issues to experience suicide in the context of an acute crisis only.

CONCLUSION

Suicides occurring in reaction to an acute crisis only or in the context of acute and chronic circumstances lend themselves to opportunities for intervention. Further implications are discussed.

Adapting interpersonal psychotherapy for older adults at risk for suicide

OBJECTIVE

To pilot a psychological intervention adapted for older adults at risk for suicide.

DESIGN

A focused, uncontrolled, pre-to-post-treatment psychotherapy trial. All eligible participants were offered the study intervention.

SETTING

Outpatient mental health care provided in the psychiatry department of an academic medical center in a mid-sized Canadian city.

PARTICIPANTS

Seventeen English-speaking adults 60 years or older, at risk for suicide by virtue of current suicide ideation, death ideation, and/or recent self-injury.

INTERVENTION

A 16-session course of Interpersonal Psychotherapy (IPT) adapted for older adults at risk for suicide who were receiving medication and/or other standard psychiatric treatment for underlying mood disorders.

MEASUREMENTS

Participants completed a demographics form, screens for cognitive impairment and alcohol misuse, a semi-structured diagnostic interview, and measures of primary (suicide ideation and death ideation) and secondary study outcomes (depressive symptom severity, social adjustment and support, psychological well-being), and psychotherapy process measures.

RESULTS

Participants experienced significant reductions in suicide ideation, death ideation, and depressive symptom severity, and significant improvement in perceived meaning in life, social adjustment, perceived social support, and other psychological well-being variables.

CONCLUSIONS

Study participants experienced enhanced psychological well-being and reduced symptoms of depression and suicide ideation over the course of IPT adapted for older adults at risk for suicide. Larger, controlled trials are needed to further evaluate the impact of this novel intervention and to test methods for translating and integrating focused interventions into standard clinical care with at-risk older adults.

Suicide in the old elderly: results from one Italian county

OBJECTIVES

To investigate factors differentiating old-old elderly (those aged 75 years and older) who died by suicide from middle-aged (those aged 50-64 years) and young-old (aged 65-74 years) adults who took their own lives, and from living psychiatric outpatients 75 years and older who had no suicidal behaviors in the last 12 months before assessment.

METHODS

Cases for psychological autopsy interviews were 117 old-old elderly who died by suicide between 1994 and 2009. Comparisons were 97 young-old adult and 98 middle-aged suicide victims and 117 psychiatric outpatients admitted to the Department of Psychiatry of the University of Parma (Parma, Italy) between 1994 and 2009. Information for suicide decedents was gathered through proxy-based interviews, and data regarding living comparison subjects were extracted from medical records.

RESULTS

A high number of old-old elderly were widowed and lived alone before death; widowhood was more prevalent in the old-old elderly than in the younger suicide groups and the psychiatric outpatients. In addition, old-old elderly were more frequently characterized by the presence of life stressors in the few months before death compared with the psychiatric outpatients.

CONCLUSIONS

Clinicians involved in the prevention of suicide in older adults should pay particular attention to loneliness and lack of social support, two conditions that may push the individual to feel hopeless, especially in those individuals who are facing stressful life events.

Personality and suicidal ideation in the elderly: factorial invariance and latent means structures across age

OBJECTIVES

Suicide among the elderly is a dramatic global health problem. Although fatal attempts are frequent in the elderly, research indicated that they rarely present long-term elaboration of suicidal ideation and communicate their intents. Consequently, risk factor detection and assessment are salient. Although evidence on the association between personality and suicidal ideation in young adults is accumulating, little is known about its relevance in the elderly. The purpose of the present study was to analyze the components of a measurement model that are invariant across young adults and older adults and then investigate the relations among dimensions of personality and suicide risk. We postulated a specific relation pattern a priori and tested the hypotheses statistically in order to examine the models for equivalency of the factorial measurement.

METHOD

We investigated 316 young adults and 339 older adults, who were administered self-report questionnaires to assess depression, hopelessness, alternative five-factor model of personality, and self-other perception.

RESULTS

Multigroup confirmatory factor analyses were conducted, yielding a final model with excellent fit to the data. This model showed a similar pattern of associations between suicidal ideation and personality across both groups.

CONCLUSIONS

Although the elderly are exposed to specific life stressors associated with suicidal ideation, our findings suggest that the elderly and young adults may be similar on personality and psychopathology variables predicting suicidal ideation than previously hypothesized. Implications are provided for enhanced assessment and intervention of the elderly high in neuroticism, depression, hopelessness, and with negative self-other perception.

Elderly deaths in Ankara, Turkey

According to World Health Organization, the life expectancy at birth is increasing. An increase in life expectancy might result in increased morbidity and mortality in elderly. The increase in the elderly population also leads to an increase in medico-legal problems, as well. Autopsy is of high importance for determination of cause of death in clinical and forensic cases. The purpose of this study was to find out general characteristics elderly deaths by examining forensic autopsy records. Out of 7033 forensic autopsies performed between years of 2007 and 2011, 1324 were elderly deaths and were included in the scope of the study. The records of public prosecutor office, crime scene investigation and autopsy findings were examined. The majority of victims (70.6%) were male, while 29.4% were female, with a male to female ratio of 2.4/1. Victims' ages ranged between 65 and 96 years, and the mean age was 74.8 years. A great number of presented elderly deaths were due to unnatural causes, followed by natural deaths cases. Out of unnatural deaths, 63.2% were related to accidents, 23.7% were suicides, and remaining 13.1% were homicides. More than half (56.6%) of all suicidal deaths were due to hanging. Of natural deaths, the majority (82.7%) were due to cardiovascular system disease. In the presented series the cause of death was determined in 90.9% of all elderly deaths, which validates the need for a forensic autopsy. Data obtained through autopsy procedures is of high importance for death statistics.

Suicidal behaviour and suicide prevention in later life

Despite a general decline in late life suicide rates over the last 30 years, older people have the highest rates of suicide in most countries. In contrast, non-fatal suicidal behaviour declines with age and more closely resembles suicide than in younger age groups. There are difficulties in the detection and determination of pathological suicidal ideation in older people. Multiple factors increase suicide risk ranging from distal early and mid-life issues such as child abuse, parental death, substance misuse and traumatic life experiences to proximal precipitants in late life such as social isolation and health-related concerns. Clinical depression is the most frequently identified proximal mental health concern and in many cases is a first episode of major depression. Recent studies have identified changes on neuroimaging and neurocognitive factors that might distinguish suicidal from non-suicidal depression in older people. Strategies for suicide prevention need to be ‘whole of life’ and, as no single prevention strategy is likely to be successful alone, a multi-faceted, multi-layered approach is required. This should include optimal detection and management of depression and of high risk individuals as available evidence indicates that this can reduce suicidal behaviour. How best to improve the quality of depression management in primary and secondary care requires further research.

The association between suicide and the utilization of mental health services in South Tirol, Italy: a psychological autopsy study

AIMS

The aim of the present study was to investigate potential differences between suicide decedents who had contact with a psychologist or psychiatrist before committing suicide and those individuals who had not had previous contact with a mental health professional prior to ending their lives.

METHODS

Psychological autopsy interviews (N = 396) were conducted for individuals who died by suicide between 1997 and 2007 in South Tirol, Italy.

RESULTS

The study found that suicide decedents known to mental health professionals were more frequently women and more frequently unemployed or with unstable employment. These decedents were significantly more likely than those unknown to mental health professionals to have a family history of mental illness, one or more past suicide attempts, and more frequent substance abuse, and likely to have frequent alcohol abuse. They more often had visited a physician in the last four weeks before dying and more frequently complained about psychological symptoms. In the prediction of group membership, individuals whom were known to mental health professionals prior to their suicidal act were 3 times more likely to have a family history of mental illness, 5.8 times more likely to have one past suicide attempt, 9.7 times more likely to have two or more past suicide attempts and 3.5 times more likely to have visited a physician in the four weeks prior to their death.

CONCLUSION

Our findings indicate that suicide decedents who had contact with mental health services can be distinguished from those who were not known to mental health professionals.

Unemployment as a risk factor for completed suicide: a psychological autopsy study

This study adopts a psychological autopsy method to compare (1) unemployed suicides, (2) other suicides who were either employed or not in the labor force, and (3) psychiatric outpatients without any prior suicidal behavior. A total of 245 consecutive suicides from Province of Parma (Italy) with recorded employment status were included in the analysis. The control group included 41 psychiatric outpatients aged 18 to 64 years, who had not engaged in any previous suicidal act, and who were unemployed. The unemployed suicides had a risk 17 times higher to have had financial problems in the last 12 months (95% confidence interval [CI]: 2.0/149.5; p < 0.01) than other suicides. Unemployed suicides (compared to living unemployed controls) were 10 times more likely to have had poor social support (95% CI: 1.7/56.1; p < 0.01), 16 times more likely to have had any stressful life events in the past 12 months (95% CI: 2.5/103.9; p < 0.01), and 22 times more likely to have a diagnosis of borderline personality disorder (95% CI: 2.4/203.2; p < 0.01). New suicide prevention strategies for those who are facing job loss need to focus on social support and personality disorders, as well as hopelessness and despair.

Attempted and completed suicide: not what we expected?

BACKGROUND

Suicide attempters and suicide completers are two overlapping but distinct suicide populations. This study aims to present a more accurate characterization by comparing populations of suicide attempters and completers from the same geographical area.

METHODS

Samples and procedure: All cases of attempted suicide treated at the emergency room of the Corporacio Sanitària i Universitària Tauli Parc de Sabadell in 2008 (n=312) were compared with all completed suicides recorded in the same geographical area from 2008 to 2011 (n=86). Hospital and primary care records were reviewed for sociodemographic and clinical variables.

STATISTICAL ANALYSIS

Chi-square, ANOVA, and Mann-Whitney U tests were used to identify characteristics related to suicide completion.

RESULTS

Compared to suicide attempters, suicide completers were more likely to be male (73.3% vs. 37.8%; p<0.001), pensioners (73.7% vs. 23.4%; p<0.001), and people living alone (31.8% vs. 11.4%; p=0.006). Suicide completers more frequently presented somatic problems (71.7 vs. 15.7; p<0.001), Major Depressive Disorder (54.7% vs. 27.9%; p<0.001), and made use of more lethal methods (74.1 vs. 1.9; p<0.001). Suicide completers were more likely to have been followed by a primary care provider (50.0% vs. 16.0%; p<0.001). 92.3% of the suicides committed were completed during the first or second attempt.

LIMITATIONS

Suicide completers were not evaluated using the psychological autopsy method.

CONCLUSIONS

Despite presenting a profile of greater social and clinical severity, suicide completers are less likely to be followed by Mental Health Services than suicide attempters. Current prevention programs should be tailored to the specific profile of suicide completers.

Suicide in the absence of mental disorder? A review of psychological autopsy studies across countries

BACKGROUND

While numerous past reviews of psychological autopsy (PA) studies have examined the relationship between mental disorder and suicide, there has been little systematic investigation of suicide occurring in the absence of any identifiable psychiatric condition.

AIM

This article reviews available literature on the topic by considering Axis I, sub-threshold, mild disorders and personality disorders.

METHOD

We conducted a systematic review of PA studies from 2000 onwards. Studies included in the review had to clearly describe the proportion of suicide cases without a classifiable mental disorder or sub-threshold condition.

RESULTS

Up to 66.7% of suicide cases remained without diagnosis in those studies that only examined Axis I disorders (n = 14). Approximately 37.1% of suicide cases had no psychiatric condition in research papers that assessed personality and Axis I disorders (n = 9), and 37% of suicides had no Axis I, sub-threshold/mild conditions (n = 6). In general, areas in China and India had a higher proportion of suicides without a diagnosis than studies based in Europe, North America or Canada.

CONCLUSION

Variation in the proportion of suicide cases without a psychiatric condition may reflect cultural specificities in the conceptualization and diagnosis of mental disorder, as well as methodological and design-related differences between studies.

[Suicide in the elderly: age-related specificities?]

Suicide in the elderly raises the question of our relationship with aging and death. Suicide rate is relatively high in this group and is significantly related to depression widely under-diagnosed in the elderly. Suicidal behaviour in the elderly has clinical specificities including high intentionality and lethality, usually little personal history of suicidal behaviour and low levels of impulsivity-aggression. Suicidal vulnerability could rely on etiopathogenic mechanisms both common and different according to age; for example, a preponderance of early developmental factors and impulsivity-aggression in adolescents and young adults vs. pathological aging in older adults, but partly similar neurocognitive deficits leading individuals not to respond adequately to their environment (itself different with age). Direct comparisons between elderly and younger subjects would be required. The article concludes with a summary of the principles of recognition and management of suicide risk.

Suicides in older adults: a case-control psychological autopsy study in Australia

AIM

The present study aims to analyse predicting factors of suicide among older adults compared to sudden death controls and middle-aged suicides.

METHODS

During the period 2006-2008, at two Australian sites, the psychological autopsy method was utilised to investigate suicides of individuals over the age of 35 by interviewing next-of-kin and healthcare professionals. A case-control study design was applied using sudden death cases as controls. Initial information was gathered from coroner's offices. Potential informants were approached and interviews were conducted using a semi-structured format.

RESULTS

In total, 261 suicides (73 aged 60+) and 182 sudden deaths (79 aged 60+) were involved. Older adult suicides showed a significantly lower prevalence of psychiatric diagnoses (62%) when compared to middle-aged suicide cases (80%). In both age groups, subjects who died by suicide were significantly more likely to present a psychiatric diagnosis, compared to controls; however, diagnosis did not remain in the final prediction model for older adults. Hopelessness and past suicide attempts remained in the final model for both age groups. In addition, living alone was an important predictor of suicide in older adults.

CONCLUSION

Although mood disorders represent an important target for suicide prevention in old age, there should be increased attention for other risk factors including psychosocial, environmental, and general health aspects of late life.

Depression, suicidal ideation, and associated factors: a cross-sectional study in rural Haiti

BACKGROUND

Since the 2010 earthquake in Haiti, there has been increased international attention to mental health needs throughout the country. The present study represents one of the first epidemiologic studies of depression symptomatology, suicidal ideation, and associated factors in Haiti's Central Plateau.

METHODS

We conducted a cross-sectional, zone-stratified household survey of 408 adults in Haiti's Central Plateau. Depression symptomatology was assessed with a culturally-adapted Kreyòl version of the Beck Depression Inventory (BDI). Multivariable linear and logistic regression models were built using backward elimination, with the outcomes being continuous BDI scores and endorsing suicidal ideation, respectively.

RESULTS

The mean BDI score was 20.4 (95% confidence interval [CI]: 19.3-21.5), and 6.13% (N = 25) of participants endorsed current suicidal ideation. Factors associated with BDI scores were: continuous age (adjusted beta [aβ]: 0.14, CI: 0.06-0.22), female gender (aβ: 2.1, CI: 0.18-4.0), suicidal ideation (aβ: 11.1, CI: 7.3-14.9), death in family (aβ: 2.7, CI: 0.57-4.9), and prior life-threatening illness (aβ: 2.6, CI: 0.77-4.5). Education was a risk factor for depression among women but not among men, and employment was a risk factor for both genders. Factors associated with endorsing suicidal ideation were: BDI score (ten point change) (adjusted odds ratio [aOR]: 2.5, CI: 1.7-3.6), lack of care if sick (aOR: 5.5, CI: 1.1-28.6), alcohol use (aOR: 3.3, CI: 1.3-8.2), and ever having been to a Vodou priest (aOR: 3.2, CI: 1.1-9.5).

CONCLUSIONS

A large proportion of Haiti's Central Plateau may be experiencing high levels of depression symptomatology and/or current suicidal ideation. Screening could be conducted in biomedical, religious, and Vodou healing contexts. For prevention, poverty reduction and improved healthcare access are key elements. For treatment, general psychiatric services, psychosocial services for the medically ill and their families, and substance abuse interventions should be explored. Paradoxical associations related to education and employment require further exploration.

[Recommendations for the prevention and management of suicidal behaviour]

INTRODUCTION

Suicidal behaviour is a major public health issue. Suicidal behaviour is one of the main causes of years of life lost and it is the third leading cause of death among young adults. This project was initiated by the Spanish Society of Psychiatry and the Spanish Society of Biological Psychiatry with the aim of providing a document containing the main recommendations on the prevention and management of suicidal behaviour; these recommendations should be based on the best available evidence and the experts' opinion.

MATERIAL AND METHODS

In this article we summarize the review of the available evidence on the epidemiology and impact of suicidal behaviour, risk and protective factors, evaluation tools for the assessment of suicide risk, international and local preventive protocols, educational interventions for health professionals, and potential interventions for at risk populations.

RESULTS

Based on this review, a panel of psychiatrists summarized and agreed a set of recommendations about the impact, prevention and management of suicidal behaviour.

CONCLUSION

The recommendations on the prevention and management of suicidal behaviour were summarized in the ten conclusions reported in this article.

Impact of employment status and work-related factors on risk of completed suicide. A case-control psychological autopsy study

The objective of this study was to determine the impact of work-related factors on risk for completed suicide. Psychiatric disorders and socio-demographic factors including work-related factors were assessed by a semi-structured interview using the psychological autopsy method in 163 completed suicide cases and by personal interview in 396 living population-based control persons. Unemployment (in particular, for more than six months), (early) retirement, or homemaker status were associated with highly significantly increased suicide risk, independently of categorized psychiatric diagnosis. In addition, adverse psychosocial working conditions, such as monotonous work, increased responsibility and pronounced mental strain due to contact with work clients, significantly increased suicide risk as well, again independently of categorized psychiatric diagnosis. These findings demonstrate that negative consequences of unemployment, homemaker status with no outside occupation, or (early) retirement, as well as adverse psychosocial working conditions, present relevant risk factors contributing to suicidal behavior, independently of diagnosed psychiatric disorders. Employment and a positive modification of working conditions, may possibly be preventive to important adverse mental health outcomes, including suicidality.

The relationship between loneliness and passive death wishes in the second half of life

BACKGROUND

Both passive death wishes and loneliness are prevalent in old age and both have been shown to be associated with a variety of detrimental effects. The overall goal of the present study was to evaluate the relationship between loneliness and passive death wishes in the general population of Europeans over the age of 50 years.

METHODS

Passive death wishes were evaluated in waves 1 and 2 of the Survey of Health, Ageing and Retirement in Europe, using the question "in the past month, have you felt that you would rather be dead?" Loneliness was evaluated by the question: "how frequently have you felt lonely over the past week?" taken from the Center for Epidemiological Studies of Depression questionnaire. All predictors were gathered in wave 1. Analysis was stratified into three age groups (50-65, 66-75, >75 years).

RESULTS

Both passive death wishes (15.6%) and loneliness (mean (SE) = 1.68(0.03)) were highest in those over the age of 75, relative to the other two age groups (age 50-65: 4.6%, mean (SE) = 1.43(0.01); age 66-75: 7.3%, mean (SE) = 1.50(0.02), respectively). Loneliness remained a significant risk for passive death wishes, net of the effect of demographic, health, mental health, and various social indicators in those aged 50-65 years (OR = 1.47, 95%CI: 1.10-1.97) and 65-75 (OR = 1.74, 95%CI: 1.28-2.38), but not in those over the age of 75 (OR = 1.12, 95%CI: 0.84-1.47). None of the objective social indicators was associated with passive death wishes.

CONCLUSIONS

The present study emphasizes the differential role of loneliness across the lifespan. Any intervention to alleviate passive death wishes in the general population will benefit from addressing the subjective sense of loneliness more so than objective indicators of social interaction.

Age variation in the prevalence of DSM-IV disorders in cases of suicide of middle-aged and older persons in Sydney

Data concerning 127 persons aged 35 years or above who died by suicide (as determined in consecutive cases by a Sydney coroner) were analyzed. Psychological autopsy (PA) interviews were conducted in 52 cases, and details were compared with the 75 cases where data were available only from coroner's files (CF). Most characteristics of the two groups were similar, although more CF suicide victims were of Asian background and unable to speak English fluently. Consensus diagnoses were reached following detailed discussion about PA and CF cases. Logistic regression showed no significant difference between age-groups in the proportion diagnosed with major depression, which contrasts with the results of an earlier U.S. study.

Adverse life events proximal to adult suicide: a synthesis of findings from psychological autopsy studies

The objective of this review was to summarize and interpret data about adverse life events proximal to adult suicide from major psychological autopsy studies. A PubMed search was conducted. Nearly all suicides have experienced at least 1 (usually more) adverse life event within 1 year of death (concentrated in last few months). Controlled studies have revealed specific life events, notably interpersonal conflict, as risk factors for suicide with some evidence of a dose-response effect. Some of the risk is independent of mental disorder. The suicidogenic impact of adverse life events, especially interpersonal conflict, necessitates specific objectives in suicide prevention strategies. Cultural influences on relative contributions of adversity and mental disorder to suicide warrant further research. Limitations of psychological autopsy studies suggest the need for complementary research into life events prior to serious suicide attempts.

Differences between younger and older adults in the structure of suicidal intent and its correlates

OBJECTIVE

To analyze differences in the variables associated with severity of suicidal intent and in the main factors associated with intent when comparing younger and older adults.

DESIGN

Observational, descriptive cross-sectional study.

SETTING

Four general hospitals in Madrid, Spain.

PARTICIPANTS

Eight hundred seventy suicide attempts by 793 subjects split into two groups: 18-54 year olds and subjects older than 55 years.

MEASUREMENTS

The authors tested the factorial latent structure of suicidal intent through multigroup confirmatory factor analysis for categorical outcomes and performed statistical tests of invariance across age groups using the DIFFTEST procedure. Then, they tested a multiple indicators-multiple causes (MIMIC) model including different covariates regressed on the latent factor "intent" and performed two separate MIMIC models for younger and older adults to test for differential patterns.

RESULTS

Older adults had higher suicidal intent than younger adults (z = 2.63, p = 0.009). The final model for the whole sample showed a relationship of intent with previous attempts, support, mood disorder, personality disorder, substance-related disorder, and schizophrenia and other psychotic disorders. The model showed an adequate fit (chi²[12] = 22.23, p = 0.035; comparative fit index = 0.986; Tucker-Lewis index = 0.980; root mean square error of approximation = 0.031; weighted root mean square residual = 0.727). All covariates had significant weights in the younger group, but in the older group, only previous attempts and mood disorders were significantly related to intent severity.

CONCLUSIONS

The pattern of variables associated with suicidal intent varies with age. Recognition, and treatment of geriatric depression may be the most effective measure to prevent suicidal behavior in older adults.

Suicidality and suicide in older people

Suicide is accepted as a major health problem worldwide, especially in the young and middle aged. It is, however, a significant health problem in older people as well, and those aged 65 years and over generally have the highest suicide rates compared with all other age groups. In research literature from the last decade, there has been an increased interest in disentangling the phenomenon of suicide in later life. This paper aims to critically review the literature on suicide and suicidality in later life published from 2000 to 2009. Prevalence rates as well as risk and protective factors are mapped and correlates reviewed. The association between suicidality and help-seeking behaviour is considered. Finally, potential prevention strategies are reviewed.

When the solution is part of the problem: problem solving in elderly suicide attempters

OBJECTIVES

Depression, loss, and physical illness are associated with suicide in the elderly. However, the nature of individual vulnerability remains poorly understood. Poor problem solving has been suggested as a risk factor for suicide in younger adults. Unresolved problems may create an accumulation of stressors. Thus, those with perceived deficits in problem-solving ability may be predisposed to suicidal behavior. To test this hypothesis, we investigated whether elderly suicide attempters perceived their problem solving as deficient.

METHODS

Sixty-four individuals aged 60 and older participated in the study including depressed suicide attempters, depressed non-attempters, and non-depressed controls. The social problem solving inventory-revised: short-version was used to measure participants' perceived social problem solving, assessing both adaptive problem-solving dimensions (positive problem orientation and rational problem solving) and dysfunctional dimensions (negative problem orientation, impulsivity/carelessness, and avoidance).

RESULTS

Depressed elderly who had attempted suicide perceived their overall problem solving as deficient, compared to non-suicidal depressed and non-depressed elderly. Suicide attempters perceived their problems more negatively and approached them in a more impulsive manner. On rational problem solving and avoidant style sub-scales, suicide attempters did not differ from non-suicidal depressed. However, both depressed groups reported lower rational problem solving and higher avoidance compared to non-depressed controls.

CONCLUSIONS

A perception of life problems as threatening and unsolvable and an impulsive approach to problem solving appear to predispose vulnerable elderly to suicide attempts.