Suicidal Behavior in the Elderly...

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Suicidal Behavior in the Elderly

by Katalin Szanto, M.D.

Psychiatric Times December 2003 Vol. XX Issue 13

------------------------------------------------------------------------

Assessment and treatment of suicidal patients is one of the most difficult

and anxiety-provoking tasks for mental health care professionals. In the

case of elderly patients who may often talk about death and dying, assessing

suicide risk is even more challenging.

Epidemiological data may help to understand risk and protective factors but

they cannot guide the evaluation of individual patients. Suicide rates vary

greatly with age, gender and ethnicity. The elderly population has the

highest suicide rates in almost all countries in the world where data are

available. Some countries follow the Hungarian pattern (i.e., suicide rate

increases with age in both genders), while others show the U.S. pattern

(i.e., suicide rate increases with age only in men). The elderly (65 and

over) made up 12.4% of the U.S. population in 2001 while they represented

17.6% of suicides (McIntosh, 2003). Men accounted for about four out of five

completed suicides in the 65 and older age group over the past two decades.

This is partly explained by the fact that men are more likely to use more

lethal methods of suicide. Seventy-six percent of men and 33% of women who

completed suicide used firearms, while 3% of men and 33% of women who

completed suicide overdosed on medications (McIntosh, 2003).

The suicide rate of white, Chinese-American, Japanese-American and

Filipino-American men increases with age. In comparison, the middle-aged

group of African-American, Hispanic, Native American and Alaskan Native men

have the highest suicide rate. As a consequence of the gender and ethnic

differences in the United States, the suicide rate by age 80 ranges from

3/100,000 among African-American women to 60/100,000 among white men

(McIntosh, 2003).

Investigating risk factors and protective factors across ethnic groups may

help to understand the unexplained striking differences in suicide rates.

Risk Factors

So far, identified risk factors for suicide attempts and completed suicides

in late-life include past history of suicidal behavior, depression,

substance abuse, hopelessness and certain personality characteristics (e.g.,

rigidity and lack of openness to new experience) (Duberstein et al., 1994).

The role of medical comorbidity is controversial, as medical illness in

general is frequent among the elderly; previous non-controlled studies may

have overestimated its role. One case-controlled study from New Zealand

failed to find differences in physical illness (Beautrais, 2002), while a

Swedish study found that visual impairment and neurological and malignant

disease were associated with suicide risk (Waern et al., 2002a).

Interestingly, this association was only true for men. This finding needs to

be replicated prior to further interpretation due to the small sample size

of women.

A preliminary unpublished data from a Hungarian psychological autopsy study

conducted by my colleagues and me indicated that fear of serious physical

illness plays an important role in late-life suicide. In addition to

anticipatory anxiety, change in functional status and pain may be better

correlates of suicidality than physical illness itself.

Physical illness may contribute to suicidality in another way. Waern and

colleagues (1999) found that physicians were less likely to discuss suicidal

feelings with patients in poor physical health. If depression is detected in

an elderly patient, suicidal feelings should also be evaluated.

The most robust predictor of completed suicide is a past history of suicide

attempt. According to data from middle-aged groups, up to 40% of individuals

who eventually committed suicide made a prior suicide attempt (owitz et

al., 2001). In addition, lethality and suicide intent increased in those who

repeatedly attempted suicide. Although the attempt to completion ratio is

much smaller in the elderly than in younger age groups (4:1 versus 10:1 in

the general population), 56% of elderly women and 30% of elderly men who

committed suicide had a prior suicide attempt. During their final year of

life, suicide attempts were made by 20% of the elderly who died by suicide

(15% males, 28% females). Suicide attempts by the elderly considered to be

" failed suicides " --as these attempts are often long-planned--involve highly

lethal methods that, in addition to the fact that older patients are

medically frail and frequently live alone, increase the probability of a

fatal outcome. The rare but highly lethal attempts and the fact that 70% of

elderly men who die by suicide did not have a prior suicide attempt have two

implications for clinical practice: 1) elderly patients who attempt suicide

in late-life are at a very high risk for completed suicide, 2) the suicide

risk of older men may be more difficult to detect than the risk of older

women as they are less likely to have had a history of previous attempts.

Depression

Depression is the most common diagnosis in elderly suicide attempters and

suicide completers. The association of mental disorders with risk for

completed suicide in the elderly is shown in the Table (Waern et al.,

2002b). (Due to copyright concerns, this table cannot be reprinted online.

Please see p52 of the print edition--Ed.) In the only U.S. case-controlled

psychological autopsy study, 71.4% of the elderly who died by suicide

suffered from mood disorders and 35.7% had a substance use disorder (Conwell

et al., 1996).

When patients report sad mood or loss of interest in previously pleasurable

activities, appear to be depressed, or have an increase in substance abuse,

questioning patients if they have been feeling sad to the point that they

were thinking about death or dying is helpful for evaluation. Direct

questions about suicidal ideation should also follow. Patients should also

be questioned if family members report changes in mood.

High symptomatic levels of depression, hopelessness, complicated grief and

anxiety, and lower levels of perceived support are associated with suicidal

ideation (Szanto et al., 1998, 1997). A secondary analysis of 395 elderly

subjects treated for a current major depressive episode found that, at the

beginning of treatment, 77.5% of patients reported suicidal ideation,

thoughts of death or feelings that life is empty (Szanto et al., 2003). By

week 12, suicidal ideation had resolved in all treated patients although

4.6% still reported thoughts of death. While suicidal ideation resolved

early in treatment, many of the patients who reported suicidal ideation at

the beginning of treatment had recurrent thoughts of death that lasted for

weeks. Thoughts of death persisted in 8% of the participants up to 12 weeks.

Patients who had suicidal ideation or had recurrent thoughts of death had

poorer treatment response than non-suicidal patients. These moderate- to

high-risk patients had a median time to response of six and five weeks,

respectively, compared to low-risk patients with a median time to response

of three weeks. Patients received antidepressant treatment with a tricyclic

antidepressant (nortriptyline [Aventyl, Pamelor]) or a selective serotonin

reuptake inhibitor (paroxetine [Paxil]) in combination with weekly

interpersonal psychotherapy. Rates of remission were significantly lower in

the moderate- to high-risk patients than the low-risk patients. These

findings show that it is crucial to develop a more focused suicide

intervention that will target clinical characteristics that are associated

with suicidality.

It is striking that another study at the other end of the life span found

similar results. In a clinical trial, the impact of suicidality on treatment

course and outcome of adolescents with depression was studied (Barbe et al.,

in press). The results showed that adolescents who are suicidal and

depressed had a higher dropout rate and were more likely to be depressed at

the end of treatment. The relationship between suicidality and treatment

response was mediated by severity of depression and hopelessness at intake.

Conclusion

Suicide-specific treatments that target not only depression, but also

hopelessness, anxiety and substance use are needed. Treatment should involve

a significant other whenever possible to help motivate the patient to remain

in treatment, comply with pharmacotherapy and psychotherapy, and abstain

from alcohol. When working with suicide attempters, clinicians should

inquire whether there was suicidal communication before the suicide attempt.

In a non-blaming manner, clinicians should explore how the significant other

felt about this and how they reacted to this communication. It is frequent

for significant others to deliberately ignore suicidal communication and

this may be a significant factor that further increases a sense of isolation

and despair in a suicidal elderly person.

Dr. Szanto is assistant professor of psychiatry at the University of

Pittsburgh Medical Center. She worked in Hungary at the Budapest Crisis

Intervention Center treating suicide attempters prior to joining the faculty

at the University of Pittsburgh. Her research and clinical work focuses on

the prevention and treatment of suicidal behavior.

References

Barbe RP, Bridge J, Birmaher B et al. (in press), Suicidiality and its

relationship to treatment outcome in depressed adolescents. Suicide Life

Threat Behav.

Beautrais AL (2002), A case control study of suicide and attempted suicide

in older adults. Suicide Life Threat Behav 32(1):1-9.

Conwell Y, Duberstein PR, C et al. (1996), Relationships of age and axis

I diagnoses in victims of completed suicide: a psychological autopsy study.

Am J Psychiatry 153(8):1001-1008.

Duberstein PR, Conwell Y, Caine ED (1994), Age differences in the

personality characteristics of suicide completers: preliminary findings from

a psychological autopsy study. Psychiatry 57(3):213-224.

McIntosh JL (2003), U.S.A. Suicide: 2001 Official Final Data. Available at:

www.suicidology.org/associations/1045/files/2001datapg.pdf. Accessed Oct.

28.

owitz E, Waern M, Wilhelmson K, Allebeck P (2001), Life events and

psychosocial factors in elderly suicides-a case-control study. Psychol Med

31(7):1193-1202.

Szanto K, Mulsant BH, Houck P et al. (2003), Occurrence and course of

suicidality during short-term treatment of late-life depression. Arch Gen

Psychiatry 60(6):610-617.

Szanto K, Prigerson HG, Houck P et al. (1997), Suicidal ideation in elderly

bereaved: the role of complicated grief. Suicide Life Threat Behav

27(2):194-207.

Szanto K, Reynolds CF 3rd, Conwell Y et al. (1998), High levels of

hopelessness persist in geriatric patients with remitted depression and a

history of suicide attempt. J Am Geriatr Soc 46(11):1401-1406.

Waern M, Beskow J, Runeson B, Skoog I (1999), Suicidal feelings in the last

year of life in elderly people who commit suicide. Lancet 354(9182):917-918

[letter].

Waern M, owitz E, Runeson B et al. (2002a), Burden of illness and

suicide in elderly people: case-control study. BMJ 324(7350):1355 [see

comments].

Waern M, Runeson BS, Allebeck P et al. (2002b), Mental disorder in elderly

suicides: a case-control study. Am J Psychiatry 159(3):450-455.

_________________________________________________________________

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[Guest guest]

http://www.psychiatrictimes.com/p031252.html

Suicidal Behavior in the Elderly

by Katalin Szanto, M.D.

Psychiatric Times December 2003 Vol. XX Issue 13

------------------------------------------------------------------------

Assessment and treatment of suicidal patients is one of the most difficult

and anxiety-provoking tasks for mental health care professionals. In the

case of elderly patients who may often talk about death and dying, assessing

suicide risk is even more challenging.

Epidemiological data may help to understand risk and protective factors but

they cannot guide the evaluation of individual patients. Suicide rates vary

greatly with age, gender and ethnicity. The elderly population has the

highest suicide rates in almost all countries in the world where data are

available. Some countries follow the Hungarian pattern (i.e., suicide rate

increases with age in both genders), while others show the U.S. pattern

(i.e., suicide rate increases with age only in men). The elderly (65 and

over) made up 12.4% of the U.S. population in 2001 while they represented

17.6% of suicides (McIntosh, 2003). Men accounted for about four out of five

completed suicides in the 65 and older age group over the past two decades.

This is partly explained by the fact that men are more likely to use more

lethal methods of suicide. Seventy-six percent of men and 33% of women who

completed suicide used firearms, while 3% of men and 33% of women who

completed suicide overdosed on medications (McIntosh, 2003).

The suicide rate of white, Chinese-American, Japanese-American and

Filipino-American men increases with age. In comparison, the middle-aged

group of African-American, Hispanic, Native American and Alaskan Native men

have the highest suicide rate. As a consequence of the gender and ethnic

differences in the United States, the suicide rate by age 80 ranges from

3/100,000 among African-American women to 60/100,000 among white men

(McIntosh, 2003).

Investigating risk factors and protective factors across ethnic groups may

help to understand the unexplained striking differences in suicide rates.

Risk Factors

So far, identified risk factors for suicide attempts and completed suicides

in late-life include past history of suicidal behavior, depression,

substance abuse, hopelessness and certain personality characteristics (e.g.,

rigidity and lack of openness to new experience) (Duberstein et al., 1994).

The role of medical comorbidity is controversial, as medical illness in

general is frequent among the elderly; previous non-controlled studies may

have overestimated its role. One case-controlled study from New Zealand

failed to find differences in physical illness (Beautrais, 2002), while a

Swedish study found that visual impairment and neurological and malignant

disease were associated with suicide risk (Waern et al., 2002a).

Interestingly, this association was only true for men. This finding needs to

be replicated prior to further interpretation due to the small sample size

of women.

A preliminary unpublished data from a Hungarian psychological autopsy study

conducted by my colleagues and me indicated that fear of serious physical

illness plays an important role in late-life suicide. In addition to

anticipatory anxiety, change in functional status and pain may be better

correlates of suicidality than physical illness itself.

Physical illness may contribute to suicidality in another way. Waern and

colleagues (1999) found that physicians were less likely to discuss suicidal

feelings with patients in poor physical health. If depression is detected in

an elderly patient, suicidal feelings should also be evaluated.

The most robust predictor of completed suicide is a past history of suicide

attempt. According to data from middle-aged groups, up to 40% of individuals

who eventually committed suicide made a prior suicide attempt (owitz et

al., 2001). In addition, lethality and suicide intent increased in those who

repeatedly attempted suicide. Although the attempt to completion ratio is

much smaller in the elderly than in younger age groups (4:1 versus 10:1 in

the general population), 56% of elderly women and 30% of elderly men who

committed suicide had a prior suicide attempt. During their final year of

life, suicide attempts were made by 20% of the elderly who died by suicide

(15% males, 28% females). Suicide attempts by the elderly considered to be

" failed suicides " --as these attempts are often long-planned--involve highly

lethal methods that, in addition to the fact that older patients are

medically frail and frequently live alone, increase the probability of a

fatal outcome. The rare but highly lethal attempts and the fact that 70% of

elderly men who die by suicide did not have a prior suicide attempt have two

implications for clinical practice: 1) elderly patients who attempt suicide

in late-life are at a very high risk for completed suicide, 2) the suicide

risk of older men may be more difficult to detect than the risk of older

women as they are less likely to have had a history of previous attempts.

Depression

Depression is the most common diagnosis in elderly suicide attempters and

suicide completers. The association of mental disorders with risk for

completed suicide in the elderly is shown in the Table (Waern et al.,

2002b). (Due to copyright concerns, this table cannot be reprinted online.

Please see p52 of the print edition--Ed.) In the only U.S. case-controlled

psychological autopsy study, 71.4% of the elderly who died by suicide

suffered from mood disorders and 35.7% had a substance use disorder (Conwell

et al., 1996).

When patients report sad mood or loss of interest in previously pleasurable

activities, appear to be depressed, or have an increase in substance abuse,

questioning patients if they have been feeling sad to the point that they

were thinking about death or dying is helpful for evaluation. Direct

questions about suicidal ideation should also follow. Patients should also

be questioned if family members report changes in mood.

High symptomatic levels of depression, hopelessness, complicated grief and

anxiety, and lower levels of perceived support are associated with suicidal

ideation (Szanto et al., 1998, 1997). A secondary analysis of 395 elderly

subjects treated for a current major depressive episode found that, at the

beginning of treatment, 77.5% of patients reported suicidal ideation,

thoughts of death or feelings that life is empty (Szanto et al., 2003). By

week 12, suicidal ideation had resolved in all treated patients although

4.6% still reported thoughts of death. While suicidal ideation resolved

early in treatment, many of the patients who reported suicidal ideation at

the beginning of treatment had recurrent thoughts of death that lasted for

weeks. Thoughts of death persisted in 8% of the participants up to 12 weeks.

Patients who had suicidal ideation or had recurrent thoughts of death had

poorer treatment response than non-suicidal patients. These moderate- to

high-risk patients had a median time to response of six and five weeks,

respectively, compared to low-risk patients with a median time to response

of three weeks. Patients received antidepressant treatment with a tricyclic

antidepressant (nortriptyline [Aventyl, Pamelor]) or a selective serotonin

reuptake inhibitor (paroxetine [Paxil]) in combination with weekly

interpersonal psychotherapy. Rates of remission were significantly lower in

the moderate- to high-risk patients than the low-risk patients. These

findings show that it is crucial to develop a more focused suicide

intervention that will target clinical characteristics that are associated

with suicidality.

It is striking that another study at the other end of the life span found

similar results. In a clinical trial, the impact of suicidality on treatment

course and outcome of adolescents with depression was studied (Barbe et al.,

in press). The results showed that adolescents who are suicidal and

depressed had a higher dropout rate and were more likely to be depressed at

the end of treatment. The relationship between suicidality and treatment

response was mediated by severity of depression and hopelessness at intake.

Conclusion

Suicide-specific treatments that target not only depression, but also

hopelessness, anxiety and substance use are needed. Treatment should involve

a significant other whenever possible to help motivate the patient to remain

in treatment, comply with pharmacotherapy and psychotherapy, and abstain

from alcohol. When working with suicide attempters, clinicians should

inquire whether there was suicidal communication before the suicide attempt.

In a non-blaming manner, clinicians should explore how the significant other

felt about this and how they reacted to this communication. It is frequent

for significant others to deliberately ignore suicidal communication and

this may be a significant factor that further increases a sense of isolation

and despair in a suicidal elderly person.

Dr. Szanto is assistant professor of psychiatry at the University of

Pittsburgh Medical Center. She worked in Hungary at the Budapest Crisis

Intervention Center treating suicide attempters prior to joining the faculty

at the University of Pittsburgh. Her research and clinical work focuses on

the prevention and treatment of suicidal behavior.

References

Barbe RP, Bridge J, Birmaher B et al. (in press), Suicidiality and its

relationship to treatment outcome in depressed adolescents. Suicide Life

Threat Behav.

Beautrais AL (2002), A case control study of suicide and attempted suicide

in older adults. Suicide Life Threat Behav 32(1):1-9.

Conwell Y, Duberstein PR, C et al. (1996), Relationships of age and axis

I diagnoses in victims of completed suicide: a psychological autopsy study.

Am J Psychiatry 153(8):1001-1008.

Duberstein PR, Conwell Y, Caine ED (1994), Age differences in the

personality characteristics of suicide completers: preliminary findings from

a psychological autopsy study. Psychiatry 57(3):213-224.

McIntosh JL (2003), U.S.A. Suicide: 2001 Official Final Data. Available at:

www.suicidology.org/associations/1045/files/2001datapg.pdf. Accessed Oct.

28.

owitz E, Waern M, Wilhelmson K, Allebeck P (2001), Life events and

psychosocial factors in elderly suicides-a case-control study. Psychol Med

31(7):1193-1202.

Szanto K, Mulsant BH, Houck P et al. (2003), Occurrence and course of

suicidality during short-term treatment of late-life depression. Arch Gen

Psychiatry 60(6):610-617.

Szanto K, Prigerson HG, Houck P et al. (1997), Suicidal ideation in elderly

bereaved: the role of complicated grief. Suicide Life Threat Behav

27(2):194-207.

Szanto K, Reynolds CF 3rd, Conwell Y et al. (1998), High levels of

hopelessness persist in geriatric patients with remitted depression and a

history of suicide attempt. J Am Geriatr Soc 46(11):1401-1406.

Waern M, Beskow J, Runeson B, Skoog I (1999), Suicidal feelings in the last

year of life in elderly people who commit suicide. Lancet 354(9182):917-918

[letter].

Waern M, owitz E, Runeson B et al. (2002a), Burden of illness and

suicide in elderly people: case-control study. BMJ 324(7350):1355 [see

comments].

Waern M, Runeson BS, Allebeck P et al. (2002b), Mental disorder in elderly

suicides: a case-control study. Am J Psychiatry 159(3):450-455.

_________________________________________________________________

Tired of slow downloads and busy signals? Get a high-speed Internet

connection! Comparison-shop your local high-speed providers here.

https://broadband.msn.com

[Guest guest]

I find it interesting that the cure is the cause. The only solution psychiatry

has is substances that

alter the mental functions and are abused on the street where ever possible for

a high.

" Suicide-specific treatments that target not only depression, but also

hopelessness, anxiety and substance use are needed " .

My best friend in high school's mother told me this amazing

story about how when she was pregnant with my friend her

doctor wanted her to go into labor while under the influence

of this new wonder drug that would help with the delivery

called LSD. Luckily she refused!!

Suicidal Behavior in the Elderly...

http://www.psychiatrictimes.com/p031252.html

Suicidal Behavior in the Elderly

by Katalin Szanto, M.D.

Psychiatric Times December 2003 Vol. XX Issue 13

------------------------------------------------------------------------

Assessment and treatment of suicidal patients is one of the most difficult

and anxiety-provoking tasks for mental health care professionals. In the

case of elderly patients who may often talk about death and dying, assessing

suicide risk is even more challenging.

Epidemiological data may help to understand risk and protective factors but

they cannot guide the evaluation of individual patients. Suicide rates vary

greatly with age, gender and ethnicity. The elderly population has the

highest suicide rates in almost all countries in the world where data are

available. Some countries follow the Hungarian pattern (i.e., suicide rate

increases with age in both genders), while others show the U.S. pattern

(i.e., suicide rate increases with age only in men). The elderly (65 and

over) made up 12.4% of the U.S. population in 2001 while they represented

17.6% of suicides (McIntosh, 2003). Men accounted for about four out of five

completed suicides in the 65 and older age group over the past two decades.

This is partly explained by the fact that men are more likely to use more

lethal methods of suicide. Seventy-six percent of men and 33% of women who

completed suicide used firearms, while 3% of men and 33% of women who

completed suicide overdosed on medications (McIntosh, 2003).

The suicide rate of white, Chinese-American, Japanese-American and

Filipino-American men increases with age. In comparison, the middle-aged

group of African-American, Hispanic, Native American and Alaskan Native men

have the highest suicide rate. As a consequence of the gender and ethnic

differences in the United States, the suicide rate by age 80 ranges from

3/100,000 among African-American women to 60/100,000 among white men

(McIntosh, 2003).

Investigating risk factors and protective factors across ethnic groups may

help to understand the unexplained striking differences in suicide rates.

Risk Factors

So far, identified risk factors for suicide attempts and completed suicides

in late-life include past history of suicidal behavior, depression,

substance abuse, hopelessness and certain personality characteristics (e.g.,

rigidity and lack of openness to new experience) (Duberstein et al., 1994).

The role of medical comorbidity is controversial, as medical illness in

general is frequent among the elderly; previous non-controlled studies may

have overestimated its role. One case-controlled study from New Zealand

failed to find differences in physical illness (Beautrais, 2002), while a

Swedish study found that visual impairment and neurological and malignant

disease were associated with suicide risk (Waern et al., 2002a).

Interestingly, this association was only true for men. This finding needs to

be replicated prior to further interpretation due to the small sample size

of women.

A preliminary unpublished data from a Hungarian psychological autopsy study

conducted by my colleagues and me indicated that fear of serious physical

illness plays an important role in late-life suicide. In addition to

anticipatory anxiety, change in functional status and pain may be better

correlates of suicidality than physical illness itself.

Physical illness may contribute to suicidality in another way. Waern and

colleagues (1999) found that physicians were less likely to discuss suicidal

feelings with patients in poor physical health. If depression is detected in

an elderly patient, suicidal feelings should also be evaluated.

The most robust predictor of completed suicide is a past history of suicide

attempt. According to data from middle-aged groups, up to 40% of individuals

who eventually committed suicide made a prior suicide attempt (owitz et

al., 2001). In addition, lethality and suicide intent increased in those who

repeatedly attempted suicide. Although the attempt to completion ratio is

much smaller in the elderly than in younger age groups (4:1 versus 10:1 in

the general population), 56% of elderly women and 30% of elderly men who

committed suicide had a prior suicide attempt. During their final year of

life, suicide attempts were made by 20% of the elderly who died by suicide

(15% males, 28% females). Suicide attempts by the elderly considered to be

" failed suicides " --as these attempts are often long-planned--involve highly

lethal methods that, in addition to the fact that older patients are

medically frail and frequently live alone, increase the probability of a

fatal outcome. The rare but highly lethal attempts and the fact that 70% of

elderly men who die by suicide did not have a prior suicide attempt have two

implications for clinical practice: 1) elderly patients who attempt suicide

in late-life are at a very high risk for completed suicide, 2) the suicide

risk of older men may be more difficult to detect than the risk of older

women as they are less likely to have had a history of previous attempts.

Depression

Depression is the most common diagnosis in elderly suicide attempters and

suicide completers. The association of mental disorders with risk for

completed suicide in the elderly is shown in the Table (Waern et al.,

2002b). (Due to copyright concerns, this table cannot be reprinted online.

Please see p52 of the print edition--Ed.) In the only U.S. case-controlled

psychological autopsy study, 71.4% of the elderly who died by suicide

suffered from mood disorders and 35.7% had a substance use disorder (Conwell

et al., 1996).

When patients report sad mood or loss of interest in previously pleasurable

activities, appear to be depressed, or have an increase in substance abuse,

questioning patients if they have been feeling sad to the point that they

were thinking about death or dying is helpful for evaluation. Direct

questions about suicidal ideation should also follow. Patients should also

be questioned if family members report changes in mood.

High symptomatic levels of depression, hopelessness, complicated grief and

anxiety, and lower levels of perceived support are associated with suicidal

ideation (Szanto et al., 1998, 1997). A secondary analysis of 395 elderly

subjects treated for a current major depressive episode found that, at the

beginning of treatment, 77.5% of patients reported suicidal ideation,

thoughts of death or feelings that life is empty (Szanto et al., 2003). By

week 12, suicidal ideation had resolved in all treated patients although

4.6% still reported thoughts of death. While suicidal ideation resolved

early in treatment, many of the patients who reported suicidal ideation at

the beginning of treatment had recurrent thoughts of death that lasted for

weeks. Thoughts of death persisted in 8% of the participants up to 12 weeks.

Patients who had suicidal ideation or had recurrent thoughts of death had

poorer treatment response than non-suicidal patients. These moderate- to

high-risk patients had a median time to response of six and five weeks,

respectively, compared to low-risk patients with a median time to response

of three weeks. Patients received antidepressant treatment with a tricyclic

antidepressant (nortriptyline [Aventyl, Pamelor]) or a selective serotonin

reuptake inhibitor (paroxetine [Paxil]) in combination with weekly

interpersonal psychotherapy. Rates of remission were significantly lower in

the moderate- to high-risk patients than the low-risk patients. These

findings show that it is crucial to develop a more focused suicide

intervention that will target clinical characteristics that are associated

with suicidality.

It is striking that another study at the other end of the life span found

similar results. In a clinical trial, the impact of suicidality on treatment

course and outcome of adolescents with depression was studied (Barbe et al.,

in press). The results showed that adolescents who are suicidal and

depressed had a higher dropout rate and were more likely to be depressed at

the end of treatment. The relationship between suicidality and treatment

response was mediated by severity of depression and hopelessness at intake.

Conclusion

Suicide-specific treatments that target not only depression, but also

hopelessness, anxiety and substance use are needed. Treatment should involve

a significant other whenever possible to help motivate the patient to remain

in treatment, comply with pharmacotherapy and psychotherapy, and abstain

from alcohol. When working with suicide attempters, clinicians should

inquire whether there was suicidal communication before the suicide attempt.

In a non-blaming manner, clinicians should explore how the significant other

felt about this and how they reacted to this communication. It is frequent

for significant others to deliberately ignore suicidal communication and

this may be a significant factor that further increases a sense of isolation

and despair in a suicidal elderly person.

Dr. Szanto is assistant professor of psychiatry at the University of

Pittsburgh Medical Center. She worked in Hungary at the Budapest Crisis

Intervention Center treating suicide attempters prior to joining the faculty

at the University of Pittsburgh. Her research and clinical work focuses on

the prevention and treatment of suicidal behavior.

References

Barbe RP, Bridge J, Birmaher B et al. (in press), Suicidiality and its

relationship to treatment outcome in depressed adolescents. Suicide Life

Threat Behav.

Beautrais AL (2002), A case control study of suicide and attempted suicide

in older adults. Suicide Life Threat Behav 32(1):1-9.

Conwell Y, Duberstein PR, C et al. (1996), Relationships of age and axis

I diagnoses in victims of completed suicide: a psychological autopsy study.

Am J Psychiatry 153(8):1001-1008.

Duberstein PR, Conwell Y, Caine ED (1994), Age differences in the

personality characteristics of suicide completers: preliminary findings from

a psychological autopsy study. Psychiatry 57(3):213-224.

McIntosh JL (2003), U.S.A. Suicide: 2001 Official Final Data. Available at:

www.suicidology.org/associations/1045/files/2001datapg.pdf. Accessed Oct.

28.

owitz E, Waern M, Wilhelmson K, Allebeck P (2001), Life events and

psychosocial factors in elderly suicides-a case-control study. Psychol Med

31(7):1193-1202.

Szanto K, Mulsant BH, Houck P et al. (2003), Occurrence and course of

suicidality during short-term treatment of late-life depression. Arch Gen

Psychiatry 60(6):610-617.

Szanto K, Prigerson HG, Houck P et al. (1997), Suicidal ideation in elderly

bereaved: the role of complicated grief. Suicide Life Threat Behav

27(2):194-207.

Szanto K, Reynolds CF 3rd, Conwell Y et al. (1998), High levels of

hopelessness persist in geriatric patients with remitted depression and a

history of suicide attempt. J Am Geriatr Soc 46(11):1401-1406.

Waern M, Beskow J, Runeson B, Skoog I (1999), Suicidal feelings in the last

year of life in elderly people who commit suicide. Lancet 354(9182):917-918

[letter].

Waern M, owitz E, Runeson B et al. (2002a), Burden of illness and

suicide in elderly people: case-control study. BMJ 324(7350):1355 [see

comments].

Waern M, Runeson BS, Allebeck P et al. (2002b), Mental disorder in elderly

suicides: a case-control study. Am J Psychiatry 159(3):450-455.

_________________________________________________________________

Tired of slow downloads and busy signals? Get a high-speed Internet

connection! Comparison-shop your local high-speed providers here.

https://broadband.msn.com

[Guest guest]

I find it interesting that the cure is the cause. The only solution psychiatry

has is substances that

alter the mental functions and are abused on the street where ever possible for

a high.

" Suicide-specific treatments that target not only depression, but also

hopelessness, anxiety and substance use are needed " .

My best friend in high school's mother told me this amazing

story about how when she was pregnant with my friend her

doctor wanted her to go into labor while under the influence

of this new wonder drug that would help with the delivery

called LSD. Luckily she refused!!

Suicidal Behavior in the Elderly...

http://www.psychiatrictimes.com/p031252.html

Suicidal Behavior in the Elderly

by Katalin Szanto, M.D.

Psychiatric Times December 2003 Vol. XX Issue 13

------------------------------------------------------------------------

Assessment and treatment of suicidal patients is one of the most difficult

and anxiety-provoking tasks for mental health care professionals. In the

case of elderly patients who may often talk about death and dying, assessing

suicide risk is even more challenging.

Epidemiological data may help to understand risk and protective factors but

they cannot guide the evaluation of individual patients. Suicide rates vary

greatly with age, gender and ethnicity. The elderly population has the

highest suicide rates in almost all countries in the world where data are

available. Some countries follow the Hungarian pattern (i.e., suicide rate

increases with age in both genders), while others show the U.S. pattern

(i.e., suicide rate increases with age only in men). The elderly (65 and

over) made up 12.4% of the U.S. population in 2001 while they represented

17.6% of suicides (McIntosh, 2003). Men accounted for about four out of five

completed suicides in the 65 and older age group over the past two decades.

This is partly explained by the fact that men are more likely to use more

lethal methods of suicide. Seventy-six percent of men and 33% of women who

completed suicide used firearms, while 3% of men and 33% of women who

completed suicide overdosed on medications (McIntosh, 2003).

The suicide rate of white, Chinese-American, Japanese-American and

Filipino-American men increases with age. In comparison, the middle-aged

group of African-American, Hispanic, Native American and Alaskan Native men

have the highest suicide rate. As a consequence of the gender and ethnic

differences in the United States, the suicide rate by age 80 ranges from

3/100,000 among African-American women to 60/100,000 among white men

(McIntosh, 2003).

Investigating risk factors and protective factors across ethnic groups may

help to understand the unexplained striking differences in suicide rates.

Risk Factors

So far, identified risk factors for suicide attempts and completed suicides

in late-life include past history of suicidal behavior, depression,

substance abuse, hopelessness and certain personality characteristics (e.g.,

rigidity and lack of openness to new experience) (Duberstein et al., 1994).

The role of medical comorbidity is controversial, as medical illness in

general is frequent among the elderly; previous non-controlled studies may

have overestimated its role. One case-controlled study from New Zealand

failed to find differences in physical illness (Beautrais, 2002), while a

Swedish study found that visual impairment and neurological and malignant

disease were associated with suicide risk (Waern et al., 2002a).

Interestingly, this association was only true for men. This finding needs to

be replicated prior to further interpretation due to the small sample size

of women.

A preliminary unpublished data from a Hungarian psychological autopsy study

conducted by my colleagues and me indicated that fear of serious physical

illness plays an important role in late-life suicide. In addition to

anticipatory anxiety, change in functional status and pain may be better

correlates of suicidality than physical illness itself.

Physical illness may contribute to suicidality in another way. Waern and

colleagues (1999) found that physicians were less likely to discuss suicidal

feelings with patients in poor physical health. If depression is detected in

an elderly patient, suicidal feelings should also be evaluated.

The most robust predictor of completed suicide is a past history of suicide

attempt. According to data from middle-aged groups, up to 40% of individuals

who eventually committed suicide made a prior suicide attempt (owitz et

al., 2001). In addition, lethality and suicide intent increased in those who

repeatedly attempted suicide. Although the attempt to completion ratio is

much smaller in the elderly than in younger age groups (4:1 versus 10:1 in

the general population), 56% of elderly women and 30% of elderly men who

committed suicide had a prior suicide attempt. During their final year of

life, suicide attempts were made by 20% of the elderly who died by suicide

(15% males, 28% females). Suicide attempts by the elderly considered to be

" failed suicides " --as these attempts are often long-planned--involve highly

lethal methods that, in addition to the fact that older patients are

medically frail and frequently live alone, increase the probability of a

fatal outcome. The rare but highly lethal attempts and the fact that 70% of

elderly men who die by suicide did not have a prior suicide attempt have two

implications for clinical practice: 1) elderly patients who attempt suicide

in late-life are at a very high risk for completed suicide, 2) the suicide

risk of older men may be more difficult to detect than the risk of older

women as they are less likely to have had a history of previous attempts.

Depression

Depression is the most common diagnosis in elderly suicide attempters and

suicide completers. The association of mental disorders with risk for

completed suicide in the elderly is shown in the Table (Waern et al.,

2002b). (Due to copyright concerns, this table cannot be reprinted online.

Please see p52 of the print edition--Ed.) In the only U.S. case-controlled

psychological autopsy study, 71.4% of the elderly who died by suicide

suffered from mood disorders and 35.7% had a substance use disorder (Conwell

et al., 1996).

When patients report sad mood or loss of interest in previously pleasurable

activities, appear to be depressed, or have an increase in substance abuse,

questioning patients if they have been feeling sad to the point that they

were thinking about death or dying is helpful for evaluation. Direct

questions about suicidal ideation should also follow. Patients should also

be questioned if family members report changes in mood.

High symptomatic levels of depression, hopelessness, complicated grief and

anxiety, and lower levels of perceived support are associated with suicidal

ideation (Szanto et al., 1998, 1997). A secondary analysis of 395 elderly

subjects treated for a current major depressive episode found that, at the

beginning of treatment, 77.5% of patients reported suicidal ideation,

thoughts of death or feelings that life is empty (Szanto et al., 2003). By

week 12, suicidal ideation had resolved in all treated patients although

4.6% still reported thoughts of death. While suicidal ideation resolved

early in treatment, many of the patients who reported suicidal ideation at

the beginning of treatment had recurrent thoughts of death that lasted for

weeks. Thoughts of death persisted in 8% of the participants up to 12 weeks.

Patients who had suicidal ideation or had recurrent thoughts of death had

poorer treatment response than non-suicidal patients. These moderate- to

high-risk patients had a median time to response of six and five weeks,

respectively, compared to low-risk patients with a median time to response

of three weeks. Patients received antidepressant treatment with a tricyclic

antidepressant (nortriptyline [Aventyl, Pamelor]) or a selective serotonin

reuptake inhibitor (paroxetine [Paxil]) in combination with weekly

interpersonal psychotherapy. Rates of remission were significantly lower in

the moderate- to high-risk patients than the low-risk patients. These

findings show that it is crucial to develop a more focused suicide

intervention that will target clinical characteristics that are associated

with suicidality.

It is striking that another study at the other end of the life span found

similar results. In a clinical trial, the impact of suicidality on treatment

course and outcome of adolescents with depression was studied (Barbe et al.,

in press). The results showed that adolescents who are suicidal and

depressed had a higher dropout rate and were more likely to be depressed at

the end of treatment. The relationship between suicidality and treatment

response was mediated by severity of depression and hopelessness at intake.

Conclusion

Suicide-specific treatments that target not only depression, but also

hopelessness, anxiety and substance use are needed. Treatment should involve

a significant other whenever possible to help motivate the patient to remain

in treatment, comply with pharmacotherapy and psychotherapy, and abstain

from alcohol. When working with suicide attempters, clinicians should

inquire whether there was suicidal communication before the suicide attempt.

In a non-blaming manner, clinicians should explore how the significant other

felt about this and how they reacted to this communication. It is frequent

for significant others to deliberately ignore suicidal communication and

this may be a significant factor that further increases a sense of isolation

and despair in a suicidal elderly person.

Dr. Szanto is assistant professor of psychiatry at the University of

Pittsburgh Medical Center. She worked in Hungary at the Budapest Crisis

Intervention Center treating suicide attempters prior to joining the faculty

at the University of Pittsburgh. Her research and clinical work focuses on

the prevention and treatment of suicidal behavior.

References

Barbe RP, Bridge J, Birmaher B et al. (in press), Suicidiality and its

relationship to treatment outcome in depressed adolescents. Suicide Life

Threat Behav.

Beautrais AL (2002), A case control study of suicide and attempted suicide

in older adults. Suicide Life Threat Behav 32(1):1-9.

Conwell Y, Duberstein PR, C et al. (1996), Relationships of age and axis

I diagnoses in victims of completed suicide: a psychological autopsy study.

Am J Psychiatry 153(8):1001-1008.

Duberstein PR, Conwell Y, Caine ED (1994), Age differences in the

personality characteristics of suicide completers: preliminary findings from

a psychological autopsy study. Psychiatry 57(3):213-224.

McIntosh JL (2003), U.S.A. Suicide: 2001 Official Final Data. Available at:

www.suicidology.org/associations/1045/files/2001datapg.pdf. Accessed Oct.

28.

owitz E, Waern M, Wilhelmson K, Allebeck P (2001), Life events and

psychosocial factors in elderly suicides-a case-control study. Psychol Med

31(7):1193-1202.

Szanto K, Mulsant BH, Houck P et al. (2003), Occurrence and course of

suicidality during short-term treatment of late-life depression. Arch Gen

Psychiatry 60(6):610-617.

Szanto K, Prigerson HG, Houck P et al. (1997), Suicidal ideation in elderly

bereaved: the role of complicated grief. Suicide Life Threat Behav

27(2):194-207.

Szanto K, Reynolds CF 3rd, Conwell Y et al. (1998), High levels of

hopelessness persist in geriatric patients with remitted depression and a

history of suicide attempt. J Am Geriatr Soc 46(11):1401-1406.

Waern M, Beskow J, Runeson B, Skoog I (1999), Suicidal feelings in the last

year of life in elderly people who commit suicide. Lancet 354(9182):917-918

[letter].

Waern M, owitz E, Runeson B et al. (2002a), Burden of illness and

suicide in elderly people: case-control study. BMJ 324(7350):1355 [see

comments].

Waern M, Runeson BS, Allebeck P et al. (2002b), Mental disorder in elderly

suicides: a case-control study. Am J Psychiatry 159(3):450-455.

_________________________________________________________________

Tired of slow downloads and busy signals? Get a high-speed Internet

connection! Comparison-shop your local high-speed providers here.

https://broadband.msn.com