Recent developments: Suicide in older people
http://www.100md.com
《英国医生杂志》
1 Mercer's Institute for Research on Ageing, Hospital 4, St James's Hospital, Dublin 8, Republic of Ireland
Correspondence to: H O'Connell henryoconnell@hotmail.com
Introduction
We searched Medline and the Cochrane database for original research and review articles on suicide in elderly people using the search terms "suicide", "elderly", and "older".
Dispelling the myths (Greek and otherwise)
One model of the suicidal process is that suicidality exists along a continuum (figure). Following this model, the epidemiology of suicidal behaviours in elderly people can be described broadly under the headings of suicidal ideation, attempted suicide, and completed suicide.
Model of suicidality
The prevalence of hopelessness or suicidal ideation in elderly people varies from 0.7-1.2% up to 17% in different studies, depending on the strictness of criteria used.3 w2 A universal finding is the strong association with psychiatric illness, particularly depression. The prevalence of suicidal feelings in mentally healthy elderly people has been reported to be as low as 4%.w3 These findings are therefore contrary to the ageist assumption that hopelessness and suicidality are natural and understandable consequences of the ageing process.
Rates of completed suicide in elderly people vary between cultures, but pooled international data published by the World Health Organization show a steady rise in prevalence of completed suicide with age. For men, the rate increases from 19.2 per 100 000 in the 15-24 year old age group to 55.7 per 100 000 in the over 75s. For women, the respective rates are 5.6 per 100 000 and 18.8 per 100 000.1 The male to female ratio for completed suicide in the elderly is 3 or 4:1, similar to that of other age groups.
Although the prevalence for completed suicide in elderly people does not at first suggest a major public health problem, completed suicides are likely to represent only the tip of the iceberg for psychological, physical, and social health problems in older people.
According to a comprehensive review of psychological autopsy studies, 71-95% of elderly people who completed suicide had a psychiatric illness, most commonly depression.4 Major depressive disorder has been found to be more common in completed suicides among older people than among younger counterparts and may affect as many as 83% of elderly people who die as a result of suicide.5 The prevalence of completed suicide is, however, relatively low among elderly people with primary psychotic illnesses, personality disorders, anxiety disorders, and alcohol and other substance use disorders.4
Data for suicidal behaviours, especially attempted suicide, between elderly and younger people suggests that different phenomena are involved.
The ratio of parasuicides to completed suicides in elderly people is much lower than that among younger people and among the general population (200:1 in adolescents, 8:1-33:1 for the general population, and 4:1 in elderly people).4 Suicidal behaviour among elderly people is therefore more likely to carry a higher degree of intent. This is further supported by the reported increased use of lethal means by older people, such as firearms and hanging.w4-w7
Factors associated with suicide in elderly people: re-examining the files of usual suspects
Despite the higher risk of completed suicide in elderly people compared with younger age groups, the low absolute prevalence rate does not justify screening of the entire elderly population. Screening for suicidal ideation should be opportunistic, with high risk subgroups defined and targeted, based on knowledge of psychological, physical, and social factors. High risk subgroups include those with depressive illnesses, previous suicide attempts, or physical illnesses, and those who are socially isolated. Elderly people with multiple such factors warrant special attention.
Older people are less likely to volunteer that they are experiencing suicidal feelings.w22 Moreover, these feelings may be present in patients with few depressive symptoms, and feelings might not be manifest unless asked about directly. Healthcare professionals should be trained and encouraged to ask such questions directly. The presence of suicidal feelings in depressed patients also predicts a lower response to treatment and an increased need for augmentation strategies, thereby identifying a group of patients who may need secondary referral.
Management
World Health Organization, 2002. www.who.int/mental_health/prevention/suicide (accessed 1 Aug 2004).
Uncapher H, Arean PA. Physicians are less willing to treat suicidal ideation in older patients. J Am Geriatr Soc 2000;48: 188-92.
Kirby M, Bruce I, Radic A, Coakley D, Lawlor BA. Hopelessness and suicidal ideation among the community dwelling elderly in Dublin. Ir J Psychol Med 1997;14: 124-7.
Conwell Y, Duberstein PR, Caine ED. Risk factors for suicide in later life. Biol Psychiatry 2002;52: 193-204.
Conwell Y, Duberstein PR, Cox C, Hermann JH, Forbes NT, Caine ED. Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study. Am J Psychiatry 1996;153: 1001-8.
Waern M, Runenowitz E, Wilhelmson K. Predictors of suicide in the old elderly. Gerontology 2003;49: 328-34.
Ross RK, Bernstein L, Trent L, Henderson BE, Paganini-Hill A. A prospective study of risk factors for traumatic death in the retirement community. Prev Med 1990;19: 323-4.
Waern M. Alcohol dependence and alcohol misuse in elderly suicides. Alcohol Alcohol 2003;38: 249-54.
Waern M, Runeson B, Allebeck P, Beskow J, Rubenowitz E, Skoog I, et al. Mental disorder in elderly suicides: a case-control study. Am J Psychiatry 2002;159: 450-5.
Duberstein PR, Conwell Y, Caine ED. Age differences in the personality characteristics of suicide completers: preliminary findings from a psychological autopsy study. Psychiatry 1994;57: 213-24.
Hepple J, Quinton C. One hundred cases of attempted suicide in the elderly. Br J Psychiatry 1997;171: 42-6.
Chiu HF, Yip PS, Chi I, Chan S, Tsoh J, Kwan CW, et al. Elderly suicide in Hong Kong—a case-controlled psychological autopsy study. Acta Psychiatr Scand 2004;109: 299-305.
Suominen K, Henriksson M, Isometsa E, Conwell Y, Heila H, Lonnqvist J. Nursing home suicides—a psychological autopsy study. Int J Geriatr Psychiatry 2003;18: 1095-101.
Conwell Y, Lyness JM, Duberstein P, Cox C, Seidlitz L, Di Giorgio A, et al. Completed suicide among older patients in primary care practices: a controlled study. J Am Geriatr Soc 2000;48: 23-9.
Conwell Y, Olsen K, Caine ED, Flannery C. Suicide in later life: psychological autopsy findings. Int Psychogeriatr 1991;3: 59-66.
Cattell H. Suicide in the elderly. Adv Psychiatr Treatment 2000;6: 102-8.
Rubenowitz E, Waern M, Wilelmson K, Allbeck P. Life events and psychosocial factors in elderly suicides—case-control study. Psychol Med 2001;31: 1193-202.
Barraclough BM. Suicide in the elderly: recent developments in psychogeriatrics. Br J Psychiatry 1971;(suppl 6): 87-97.
McClain, Rosenfeld B, Breitbart W. Effect of spiritual wellbeing on end of life despair in terminally ill cancer patients. Lancet 2003;361: 1603-7.
Bertolote JM, Fleischmann A, De Leo D, Wasserman D. Suicide and mental disorders: do we know enough? Br J Psychiatry 2003;183: 382-3.
World Health Organization. Mental health: new understanding, new hope. World health report 2001. Geneva: WHO, 2001.
Gunnell D, Frankel S. Prevention of suicide: aspirations and evidence. BMJ 1994;308: 1227-33.
Fischer LR, Wei F, Solberg LI, Rush WA, Heinrich RL. Treatment of elderly and other adult patients for depression in primary care. J Am Geriatr Soc 2003;51: 1554-62.(Henry O'Connell, research)
Correspondence to: H O'Connell henryoconnell@hotmail.com
Introduction
We searched Medline and the Cochrane database for original research and review articles on suicide in elderly people using the search terms "suicide", "elderly", and "older".
Dispelling the myths (Greek and otherwise)
One model of the suicidal process is that suicidality exists along a continuum (figure). Following this model, the epidemiology of suicidal behaviours in elderly people can be described broadly under the headings of suicidal ideation, attempted suicide, and completed suicide.
Model of suicidality
The prevalence of hopelessness or suicidal ideation in elderly people varies from 0.7-1.2% up to 17% in different studies, depending on the strictness of criteria used.3 w2 A universal finding is the strong association with psychiatric illness, particularly depression. The prevalence of suicidal feelings in mentally healthy elderly people has been reported to be as low as 4%.w3 These findings are therefore contrary to the ageist assumption that hopelessness and suicidality are natural and understandable consequences of the ageing process.
Rates of completed suicide in elderly people vary between cultures, but pooled international data published by the World Health Organization show a steady rise in prevalence of completed suicide with age. For men, the rate increases from 19.2 per 100 000 in the 15-24 year old age group to 55.7 per 100 000 in the over 75s. For women, the respective rates are 5.6 per 100 000 and 18.8 per 100 000.1 The male to female ratio for completed suicide in the elderly is 3 or 4:1, similar to that of other age groups.
Although the prevalence for completed suicide in elderly people does not at first suggest a major public health problem, completed suicides are likely to represent only the tip of the iceberg for psychological, physical, and social health problems in older people.
According to a comprehensive review of psychological autopsy studies, 71-95% of elderly people who completed suicide had a psychiatric illness, most commonly depression.4 Major depressive disorder has been found to be more common in completed suicides among older people than among younger counterparts and may affect as many as 83% of elderly people who die as a result of suicide.5 The prevalence of completed suicide is, however, relatively low among elderly people with primary psychotic illnesses, personality disorders, anxiety disorders, and alcohol and other substance use disorders.4
Data for suicidal behaviours, especially attempted suicide, between elderly and younger people suggests that different phenomena are involved.
The ratio of parasuicides to completed suicides in elderly people is much lower than that among younger people and among the general population (200:1 in adolescents, 8:1-33:1 for the general population, and 4:1 in elderly people).4 Suicidal behaviour among elderly people is therefore more likely to carry a higher degree of intent. This is further supported by the reported increased use of lethal means by older people, such as firearms and hanging.w4-w7
Factors associated with suicide in elderly people: re-examining the files of usual suspects
Despite the higher risk of completed suicide in elderly people compared with younger age groups, the low absolute prevalence rate does not justify screening of the entire elderly population. Screening for suicidal ideation should be opportunistic, with high risk subgroups defined and targeted, based on knowledge of psychological, physical, and social factors. High risk subgroups include those with depressive illnesses, previous suicide attempts, or physical illnesses, and those who are socially isolated. Elderly people with multiple such factors warrant special attention.
Older people are less likely to volunteer that they are experiencing suicidal feelings.w22 Moreover, these feelings may be present in patients with few depressive symptoms, and feelings might not be manifest unless asked about directly. Healthcare professionals should be trained and encouraged to ask such questions directly. The presence of suicidal feelings in depressed patients also predicts a lower response to treatment and an increased need for augmentation strategies, thereby identifying a group of patients who may need secondary referral.
Management
World Health Organization, 2002. www.who.int/mental_health/prevention/suicide (accessed 1 Aug 2004).
Uncapher H, Arean PA. Physicians are less willing to treat suicidal ideation in older patients. J Am Geriatr Soc 2000;48: 188-92.
Kirby M, Bruce I, Radic A, Coakley D, Lawlor BA. Hopelessness and suicidal ideation among the community dwelling elderly in Dublin. Ir J Psychol Med 1997;14: 124-7.
Conwell Y, Duberstein PR, Caine ED. Risk factors for suicide in later life. Biol Psychiatry 2002;52: 193-204.
Conwell Y, Duberstein PR, Cox C, Hermann JH, Forbes NT, Caine ED. Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study. Am J Psychiatry 1996;153: 1001-8.
Waern M, Runenowitz E, Wilhelmson K. Predictors of suicide in the old elderly. Gerontology 2003;49: 328-34.
Ross RK, Bernstein L, Trent L, Henderson BE, Paganini-Hill A. A prospective study of risk factors for traumatic death in the retirement community. Prev Med 1990;19: 323-4.
Waern M. Alcohol dependence and alcohol misuse in elderly suicides. Alcohol Alcohol 2003;38: 249-54.
Waern M, Runeson B, Allebeck P, Beskow J, Rubenowitz E, Skoog I, et al. Mental disorder in elderly suicides: a case-control study. Am J Psychiatry 2002;159: 450-5.
Duberstein PR, Conwell Y, Caine ED. Age differences in the personality characteristics of suicide completers: preliminary findings from a psychological autopsy study. Psychiatry 1994;57: 213-24.
Hepple J, Quinton C. One hundred cases of attempted suicide in the elderly. Br J Psychiatry 1997;171: 42-6.
Chiu HF, Yip PS, Chi I, Chan S, Tsoh J, Kwan CW, et al. Elderly suicide in Hong Kong—a case-controlled psychological autopsy study. Acta Psychiatr Scand 2004;109: 299-305.
Suominen K, Henriksson M, Isometsa E, Conwell Y, Heila H, Lonnqvist J. Nursing home suicides—a psychological autopsy study. Int J Geriatr Psychiatry 2003;18: 1095-101.
Conwell Y, Lyness JM, Duberstein P, Cox C, Seidlitz L, Di Giorgio A, et al. Completed suicide among older patients in primary care practices: a controlled study. J Am Geriatr Soc 2000;48: 23-9.
Conwell Y, Olsen K, Caine ED, Flannery C. Suicide in later life: psychological autopsy findings. Int Psychogeriatr 1991;3: 59-66.
Cattell H. Suicide in the elderly. Adv Psychiatr Treatment 2000;6: 102-8.
Rubenowitz E, Waern M, Wilelmson K, Allbeck P. Life events and psychosocial factors in elderly suicides—case-control study. Psychol Med 2001;31: 1193-202.
Barraclough BM. Suicide in the elderly: recent developments in psychogeriatrics. Br J Psychiatry 1971;(suppl 6): 87-97.
McClain, Rosenfeld B, Breitbart W. Effect of spiritual wellbeing on end of life despair in terminally ill cancer patients. Lancet 2003;361: 1603-7.
Bertolote JM, Fleischmann A, De Leo D, Wasserman D. Suicide and mental disorders: do we know enough? Br J Psychiatry 2003;183: 382-3.
World Health Organization. Mental health: new understanding, new hope. World health report 2001. Geneva: WHO, 2001.
Gunnell D, Frankel S. Prevention of suicide: aspirations and evidence. BMJ 1994;308: 1227-33.
Fischer LR, Wei F, Solberg LI, Rush WA, Heinrich RL. Treatment of elderly and other adult patients for depression in primary care. J Am Geriatr Soc 2003;51: 1554-62.(Henry O'Connell, research)