Biology and personal history
In all age groups suicide attempts and suicidal ideation are the strongest predictors of completed suicide. There is a subgroup of patients who become suicidal in each or almost each subsequent depressive episodes, while other patients with similar levels of depression do not express suicidal ideation or attempt. According to the stress-diathesis model of suicidal behavior, the probability of a suicide attempt or completed suicide is determined by a biological vulnerability. This diathesis increases the vulnerability to depressive illness, stress response, manifested in persistent hopelessness and inward directed aggression. The most consistent biological finding in suicide attempters and completers is a low level of a serotonin metabolite (5-HIAA) in their cerebrospinal fluid. Cerebrospinal 5-HIAA levels has been found to be lower in suicide attempters with high lethality, well-planned attempts than in those with a history of low-lethality suicide attempts. This finding has been found across the different age groups and was confirmed in elderly suicide attempters.
Co-morbidity
Physical illness
Physical illness plays an important role in the suicidal behavior of the elderly. In some cases, the physical illness or the treating medications are directly causally related to the depressive symptoms. Most often, physical illness and suicidal behavior co-occur. Chronic physical illness has been associated with an increase suicide risk in depressed patients. However, a recent study reported that among depressed patients, greater severity of depression, and not physical illness or overall functioning, differentiated elderly suicide completers from non-completers.
Only 2-4 % of terminally ill elderly commit suicide. As discussed above, a higher but unknown number accelerate their death with indirect self-destructive behavior. Suicidal ideation is rare without depression even in the terminally ill. Untreated or under-treated pain, anticipatory anxiety regarding the progression of the physical illness, fear of dependence, and fear of burdening the family are the major contributing factors in the suicidality of elderly with physical illness. Clinical experience suggests that when pain and depression are adequately treated, most of the previously suicidal elderly express a wish to live. It is often more difficult to diagnose depression in the elderly because of the overlap between the vegetative symptoms of depression and the symptoms of co-morbid physical illness. In addition, many depressed elders present with somatic complaints and minimize their psychological distress (“masked depression”). Masked depression is even more common in cultures where the elderly more readily accepts physical illness than mental disorders.
Mood disorders
Suicide rates of depressed patients are far higher than those of the general population. The estimate of lifetime prevalence of suicide in depressed patients ever hospitalized after a suicide attempt or as a consequence of suicidal ideation was 8.6%, while it was less than 0.5 % in population not suffering from an affective disorder. According to a study that examined patients after a suicide attempt, in the 60-90-age group 16% had an earlier attempt and the rates of previous attempts associated with untreated mood disorders increased with each subsequent decade. Psychological autopsy studies have found depression to be the most common psychiatric diagnosis in elderly suicide victims, while alcoholism is the most common diagnosis in younger adults. For instance, in a study of elderly suicide victims, 76% had diagnosable psychopathology including 54% with major depression and 11% with minor depression. Major depression is also the most frequent diagnosis among elderly suicide attempters.
The clinical profile of depressed elderly suicide victims suggests that, if treated, these patients would have had a favorable prognosis. Studies have observed that depression in elderly suicide victims is often without comorbid substance abuse or personality disorders. These characteristics have been associated with good response to psychotherapy and medications.
Hopelessness
Hopelessness has been found to be a component of depression. A recent study of institutionalized elderly patients showed that hopelessness was strongly related to suicidal ideation. However, this relationship was dependent upon the level of depression. Elderly subjects with high severity of depression were more likely to have suicidal ideation with increasing hopelessness; hopelessness did not predict suicidal ideation in subjects with low severity of depression. High levels of hopelessness have been reported in elderly with a history of suicide attempt. It also has been observed that higher levels of hopelessness may persist in elderly even after the resolution of their depression. These findings suggest that hopelessness, suicide ideation, and depression should be taken into consideration when assessing suicide risk in the elderly.
Alcohol
Although substance abuse is not common disorder among suicides, there is some evidence that, for a subset of ‘young old’ suicide victims, alcohol abuse may play a role. For alcoholic men who have survived into their 50s and 60s, the combination of continued alcohol abuse and burn out of their social supports may be lethal. Furthermore, the loss of the last social support can provoke a suicide crisis in older male alcoholics. Increase in alcohol consumption may also signal worsening depressive symptoms and/or anxiety.
Anxiety
In a study of the risk factors for completed suicide in middle-age patients with a high rate of substance abuse, several factors, including psychic anxiety and panic attacks, were associated with suicide attempt within a year of the diagnosis of major affective disorder. In another study, panic disorder did not increase the risk for suicide attempt or completion in the absence of other risk factors. No study to date has examined the relationship between anxiety disorders and suicidality in a geriatric population. In a study with 180 elderly patients diagnosed with recurrent major depression, higher levels of anxiety were found in those with suicidal ideation before starting treatment than in non-suicidal depressed patients. Pretreatment anxiety was also negatively related to both remission and recovery.
Bereavement and Social Isolation
Painful losses that accompany aging have been shown to be risk factors for suicide.The effect of spousal loss on suicidality appears to be the most pronounced in elderly men. In the U.S., the highest suicide rate is among bereaved elderly Caucasian men (84/100,000). The risk of suicide is the highest in the first year of bereavement, but remains elevated until the fifth year after the loss. Complicated, or “traumatic” grief, which is distinct from bereavement-related depression, includes posttraumatic stress disorder-like symptoms. These symptoms may include intrusive thoughts about the deceased, avoidance of reminders of the deceased, survivor guilt, and attachment disturbance-like symptoms such as lack of acceptance of the death, symptoms of identification,eg, pain the same part of the body as the deceased experienced.
In a group of bereaved elderly who had lost their spouses, patients who had high scores on a scale of complicated grief were more likely to have suicidal ideation than patients who had low complicated grief scores. Elderly who had a prior suicide attempt were more likely to have suicidal ideation after a loss than patients who did not have a history of suicide attempt.
Sudden change in social relationships, such as bereavement and divorce increase the rate of suicide. Early studies found that elderly suicide victims were more likely to live alone compared to the community living elderly. A later report found that the rate of elderly suicide victims who lived alone at death did not increase with age and another did not find differences in the rates of social contacts and living arrangements between young and elderly suicide completers. Living alone does not equal social isolation and one can be socially isolated even if he or she lives with someone else, e.g., the caregiver of a seriously ill person. Comorbid conditions such as substance use can increase social isolation. Studies reported that elderly at age 85 were more likely to live alone if they used alcohol at age 50. One study reported that the reduction of social isolation and the easy availability of health care professionals by a TeleHelp/TeleCheck service may reduce suicide risk.
Adapted from IDENTIFICATION OF SUICIDAL IDEATION AND PREVENTION OF SUICIDAL BEHAVIOR IN THE ELDERLY by Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Drugs and Aging. In press |
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