Mohammed T. Abou-Saleh

SUICIDAL BEHAVIOUR 471RecognitionDespite the unique multifactorial precipitants that contribute toindividual cases of suicide, opportunities for recognition exist.Suicidal intent, for example, is frequently directly expressed, albeitin different contexts, and should be taken seriously. In the recentstudy from Finland 2 , for example, although nearly half of thevictims, men as often as women, had brought up their suicidalideation or intent to their next of kin, the same intent had onlybeen communicated to healthcare professionals in 18%, despitethe great majority (70%) being in contact with health services inthe month before their death. The study, however, also reportedthat in only 24% of the cases had the healthcare professionalseven asked about suicidal intentions. It is a misconception tosuppose that discussion of suicidal ideas generates attempts. Mostindividuals feel grateful for a discussion of their suicidal feelings,about which they may feel unduly guilty.The role of primary care services in suicide prevention is ofconsiderable interest. Most studies report substantial levels ofcontact: 40–70% of elderly suicides seeing their general practitioner(GP) in the month preceding their death and between 20–50% attending in the preceding week. This raises the importantissue of effective intervention at a time when the individual isparticularly vulnerable. The importance of training and educationprogrammes for GPs in the recognition and treatment ofdepression as a means of reducing the suicide rate arises fromthe Gotland Study 16 , in which in the year following training,suicide rates on the island fell significantly compared with otherparts of Sweden, and the fall was accounted for largely by theproportion of suicides with major depression. Although notspecific to the elderly, such research requires replication.Research evidence also suggests that a minority of elderlysuicides have been in contact with secondary psychiatric servicesprior to death. Several studies report that around 20% of theirseries of completed elderly suicides had contact within 6 monthsand around 10–15% in the preceding 1 month 17,18 . It is importantto realize that around 30–60% have no contact with healthprofessionals prior to death, despite the high prevalence ofpsychiatric disorder.The issue of treatment adequacy is of significance, given theimportance of depressive illness in completed and attemptedsuicide, with several studies revealing inadequate or inappropriatetreatment with psychotropic medication. Conwell 19 , for example,described the recognition and treatment of psychiatric symptomsin primary care settings for 51 elderly suicides and found only twowho had received adequate treatment, with men and those withcoexistent physical illness presenting the greatest challenge.Information from several Coroner’s Inquest studies reveal lowlevels of antidepressant treatment of around 10–25% 11,12,17 ,although a more optimistic finding has been reported fromSweden, where 50% of a cohort of 75 elderly suicides had adocumented history of treatment for affective disorder in the 6months prior to death 20 .Preventive StrategiesStrategies for the prevention of elderly suicide have been recentlyreviewed from an international perspective 21 . It would be fair tosay that there are limited data on the effectiveness of specificassertive outreach programmes targeting the elderly, althoughsome encouraging initiatives have been described. DeLeo et al. 22described a Tele-Help/Tele-Check service for a population of12 000 over-65-year-olds in Padua, Italy. The service providesactive contacts to clients by trained staff giving information,support and prompt intervention in medical and psychologicalemergencies. After 4 years of this service, only one suicide wasreported, which was significantly lower than expected.In the USA, the Gatekeepers Program of Spokane, Washington,addresses the need to contact non-self-referrals by trainingbusiness personnel in the recognition and referral to healthprofessionals of elderly distressed individuals. Such personnelinclude apartment managers, pharmacists, meter readers, etc. Inthe UK, the implementation of screening policies for the elderly,the development of community-based old age psychiatry servicesmaintaining close links with primary care facilities, improvededucation and liaison links with general hospital services, andlocal and national audit programmes, are likely to be useful.CONCLUSIONAlthough there has been a recent decline in elderly suicide rates inseveral Western countries, the rates remain among the highest forany age group in most societies throughout the world. Despitethis, the phenomenon receives little public attention. A commonassumption is that suicide in these individuals is an understandable,normal reaction to hopeless, irreversible situations andis consequently unavoidable. There is increasing debate over theindividual’s ‘‘right to die’’ and self-determination and euthanasiaadvocates have adopted a more prominent position.Whatever an individual’s personal views are towards themorality of suicidal behaviour, it is incumbent on the physicianto pay close attention to the mental and physical state. Availableevidence suggests that the great majority of individuals whoattempt or commit suicide suffer from both potentially treatablepsychiatric conditions (mainly depression) and associated physicaland social difficulties for which much can be done. To condemnthe elderly by adopting a negative approach is to succumb to thedangers of ‘‘ageism’’.REFERENCES1. Kelly S, Bunting J. Trends in suicide in England and Wales 1982–1996. Population Trends 1998; 92: 29–41.2. Skoog I, Aevarsson O, Beskow J et al. Suicidal feelings in apopulation sample of non-demented 85 year olds. Am J Psychiat1996; 153: 1015–20.3. Forsell Y, Jorm A, Winblad B. Suicidal thoughts and associatedfactors in an elderly population. Acta Psychiat Scand 1997; 95:108–11.4. Barraclough B. Suicide in the elderly. In Kay DWK, Walks A, eds,Recent Developments in Psychogeriatrics. Headley: Royal Medico-Psychological Association, 1971; 87–97.5. Heikkinen ME, Lonnqvist JK. Recent life events in elderly suicide: anationwide study in Finland. Int Psychogeriat 1995; 7: 287–300.6. Carney SS, Rich CL, Burke PA et al. Suicide over 60: the San DiegoStudy. J Am Geriat Soc 1994; 42: 174–80.7. Pitkala K, Isometsa ET, Henriksson MM, Lonnqvist JK. Elderlysuicide in Finland. Int Psychogeriat 200; 12: 209–20.8. Conwell Y, Duberstein PR, Cox C et al. Relationship of age and axis1 diagnoses in victims of completed suicide: a psychological autopsystudy. Am J Psychiat 1996; 153: 1001–8.9. Duberstein PR. Openness to experience and completed suicide acrossthe second half of life. Int Psychogeriat 1995; 7: 183–98.10. Jones JS, Stanley B, Mann JJ et al. 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