Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-083Suicidal BehaviourHoward CattellWrexham Maelor Hospital, Wrexham, UKThis chapter concerns itself with completed and attempted suicidein the elderly. It is a major public health problem and the clinicianhas a crucial influence in determining outcome in suicidal patients.We shall discuss the epidemiological, social, physical andpsychiatric factors involved and conclude with a considerationof preventive measures.EPIDEMIOLOGYAlthough there are significant international variations in theofficial completed suicide rates reported by countries throughoutthe world, the overall rates continue to remain among the highestin the elderly, as rates increase with age. Males aged 75 and overhave the highest rates of suicide in nearly all industrializedcountries, with rates for men throughout the elderly lifespanexceeding those for women. However, suicide rates in the elderly,for both sexes, have declined in recent years in many countries,with rates declining by over 30%, for example, in the UK for bothsexes between 1982 and 1996 1 . Explanations for such trends arelargely speculative.The prevalence of suicidal thoughts in the elderly has beeninvestigated in some recent studies. Skoog et al. examined apopulation of non-demented 85-year-olds with the finding thatamong the mentally well, none had seriously considered suicide,but that the presence of mental disorder, especially majordepression, was strongly correlated with suicidal feelings 2 . Thestudy by Forsell et al. 3 of almost 1000 over-75-year-olds similarlyfound that those with frequent suicidal thoughts had a strongassociation with major depression. The conclusion from studiessuch as these is similar, notably that a careful assessment of themental state, focused especially on the possibility of depression, isessential before any rational basis for suicidal thoughts beconsidered.Little attention has been focused on non-fatal suicidal acts inthe elderly, due probably to the phenomenon in recent decadesbeing one of younger people. No countries keep nationalstatistics, but data from centres with well-defined catchmentareas allow examination of numbers, rates and trends. Cases ofelderly self-harm account for about 5% of the total number ofself-harm admissions to general hospitals in the UK and NorthAmerica.SOCIAL FACTORSStudies of individual elderly suicides have drawn attention to anumber of social variables. With regard to marital status,widowed, single or divorced individuals seem to be more at risk,with marriage appearing to offer a protective factor. The greatmajority of elderly suicides occur in a community setting, usuallyin the person’s home. The method of suicide varies over time, withage, gender and other sociocultural factors. It is generally foundthat men adopt more violent methods than women, e.g. deathsdue to hanging and firearms are commoner in men. In the USA,firearms are used by over 60% of all completed suicides, withelderly White men employing this method most frequently.The role of social isolation as a risk factor has traditionallybeen considered an important variable 4 , although several subsequentstudies 5,6 have found no difference between living aloneand number of social contacts compared to younger suicides.Bereavement appears as a significant risk factor, with studies ofattempted and completed suicide citing its relevance. The first yearof widowhood seems to be a vulnerable period, with elderlywidowed men being at greater relative risk.The antecedents in terms of precipitating life events appear todiffer in the elderly population compared with younger andmiddle-aged groups. The latter are associated more closely withinterpersonal and relationship problems, financial, legal andoccupational difficulties, and less with physical illness, fear ofdependency and loss of function, as is often the situation in theelderly. Although complaints of ‘‘loneliness’’ are frequent, arecent Scandinavian study revealed that a similar proportion ofyounger victims (around 38%) also complained of this difficulty 7 .PSYCHIATRIC ILLNESSThe major finding in the clinical studies of suicide and attemptedsuicide in the elderly is the presence of psychiatric disorder in theperiod prior to the event. Among the elderly, however, depressiveillness is the most important predictor of suicide and this needs tobe emphasized. Most comprehensive studies of completed suicideemploying the psychological autopsy method report the prevalenceof major depression and other mood disorders to be 60–90%. For example, Conwell et al. 8 , examining the relationshipbetween age and Axis 1 diagnoses in a sample of 141 completedsuicides aged 21–92 years, found 71% and 64% of the 75–92- and55–77-year-old cohorts, respectively, to exhibit mood disorders,compared with 30% of the 21–34-year-old group. Majordepression was diagnosed in almost 60% of the most elderlysuicides, with other mood disorders accounting for 10–20% of thesample in this study. The elderly constituted the most homogeneousgroup, in which non-affective psychoses were rare,addictive disorders less common and late-onset depression therule.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd