Suicide in the elderly

In the vast majority of countries the suicide rate of elderly persons (referring to those aged 65 years and above) is significantly higher than in younger age groups. In the US, by age 80 the suicide rate ranges from 3/100 000 among African American women to 60/100 000 among Caucasian men. Although in all age groups men have higher suicide rates than women, the difference is the most striking in older men living in industrialized countries. In the US the elderly have the highest suicide rate of all age groups, with men accounting for 81% of completed suicides in late-life. It seems that certain life events such as widowhood pose a higher risk for suicide on men than women. It is also possible that the aging process has different effects among men than women and/or elderly women may possess distinct protective factors that could explain the dramatic gender difference. The clinical profile of depressed elderly suicide victims suggests that, if treated for depression, these patients would have had a favorable prognosis. In older people suicidal ideation, suicide attempt, and completed suicide occur most frequently in the context of major depression. Studies have observed that depression in elderly suicide victims is more often without comorbid substance abuse or personality disorders than in younger age groups. Furthermore, while the elderly carry out high lethality attempts, the time to intervene may be longer as the elderly are less impulsive, contemplating suicide for months. Psychological autopsy studies may overestimate the number of elderly suicides that occur in the first episode of late onset depression. It is possible that in a subgroup of suicidal elderly men previous depressive episodes may have been undetected. The detection of suicide in the elderly (especially in men) is more challenging, as they are less likely to communicate their depressed mood and overt suicide intent and are often present with symptoms of masked depression. Although 50% of elderly suicide victims visited their GP the month before their death, more than half of the visits were exclusively for physical complaints. Following an overview of epidemiology and risk factors, we report data on the development and preliminary testing of the Yale Evaluation of Elderly Suicidality Scale and summarize interventions that can be effective in treating suicidal elderly. Finally, we briefly describe two prevention and treatment studies that are currently underway in primary care settings. The aim of these studies is to determine whether the improved detection of depression, improved compliance, and state of-art pharmacotherapy and/or psychotherapy will reduce the prevalence of depressive symptoms, hopelessness and suicidal ideation. These studies aim to investigate whether all the above decrease the rate of suicide attempts and lethal suicide in older adults.     

Suicide attempts in an adolescent female twin sample.

OBJECTIVE: To examine suicide attempts in an epidemiologically and genetically informative youth sample. METHOD: 3,416 Missouri female adolescent twins (85% participation rate) were interviewed from 1995 to 2000 with a telephone version of the Child Semi-Structured Assessment for the Genetics of Alcoholism, which includes a detailed suicidal behavior section. Mean age was 15.5 years at assessment. RESULTS: At least one suicide attempt was reported by 4.2% of the subjects. First suicide attempts were all made before age 18 (and at a mean age of 13.6). Major depressive disorder, alcohol dependence, childhood physical abuse, social phobia, conduct disorder, and African-American ethnicity were the factors most associated with a suicide attempt history. Suicide attempt liability was familial, with genetic and shared environmental influences together accounting for 35% to 75% of the variance in risk. The twin/cotwin suicide attempt odds ratio was 5.6 (95% confidence interval [CI] 1.75-17.8) for monozygotic twins and 4.0 (95% CI 1.1 -14.7) for dizygotic twins after controlling for other psychiatric risk factors. CONCLUSIONS: In women, the predisposition to attempt suicide seems usually to manifest itself first during adolescence. The data show that youth suicide attempts are familial and possibly influenced by genetic factors, even when controlling for other psychopathology.     

Rates and correlates of suicide attempts in first-admission psychotic patients

The relationship of attempted suicide to demographic characteristics, current and lifetime psychiatric diagnoses, clinical history, and current symptoms was assessed in a sample of 184 recently hospitalized psychotic patients. Forty-three patients (23%) had an attempt history, and 28 (15% of sample; 65% of attempters) made an attempt during the episode for which they were hospitalized. Demographic characteristics did not distinguish attempters from nonattempters. Variables significantly associated with having ever attempted suicide were current diagnosis of unipolar major depressive disorder but not bipolar; lifetime major depressive episode; a history characterized by a less acute onset, lower pre-admission psychosocial functioning, and episodes of physical violence; and a symptom picture characterized by greater depression, hopelessness, negative symptoms, hallucinations and less thought disorder. Those with a current attempt had significantly higher rates of lifetime history of major depression and less physical violence than those with past attempts only. The potential importance of the data for predicting future suicidal acts is discussed.     

Suicide and suicide attempts in adolescent-onset psychotic disorders

Eighty-eight subjects with adolescent-onset psychotic disorders (mean age±standard deviation 15.7±1.5?years), mainly schizophrenia and affective disorders, were followed up 10.6±3.6?years later, rediagnosed (DSM-IV) and assessed with the Positive and Negative Symptom Scale, abuse of drugs including nicotine, the Lancashire Quality of Life Profile and occurrence of suicide or suicide attempts. Four males (4.5% of subjects) had died from suicide while another 25% of the subjects had attempted suicide. Suicide attempts were associated to more depressive symptoms but fewer negative symptoms at first episode, and to number of admissions and to dependence on nicotine at follow-up in a logistic regression. Satisfaction with religion, health, family relations and safety at follow-up were inversely associated to attempting suicide but only satisfaction with religious belief remained after controlling for concurrent symptoms of anxiety and depression.     

Suicide and suicide attempts in adolescent-onset psychotic disorders

Eighty-eight subjects with adolescent-onset psychotic disorders (mean age+/-standard deviation 15.7+/-1.5 years), mainly schizophrenia and affective disorders, were followed up 10.6+/-3.6 years later, rediagnosed (DSM-IV) and assessed with the Positive and Negative Symptom Scale, abuse of drugs including nicotine, the Lancashire Quality of Life Profile and occurrence of suicide or suicide attempts. Four males (4.5% of subjects) had died from suicide while another 25% of the subjects had attempted suicide. Suicide attempts were associated to more depressive symptoms but fewer negative symptoms at first episode, and to number of admissions and to dependence on nicotine at follow-up in a logistic regression. Satisfaction with religion, health, family relations and safety at follow-up were inversely associated to attempting suicide but only satisfaction with religious belief remained after controlling for concurrent symptoms of anxiety and depression.     

Depressed Suicide Attempters with Posttraumatic Stress Disorder

Posttraumatic stress disorder and major depressive disorder are well-established risk factors for suicidal behavior. This study compared depressed suicide attempters with and without comorbid posttraumatic stress disorder with respect to additional diagnoses, global functioning, depressive symptoms, substance abuse, history of traumatic exposure, and suicidal behavior. Adult patients consecutively admitted to a general hospital after a suicide attempt were interviewed and assessed for DSM-IV diagnosis and clinical correlates. Sixty-four patients (71%) were diagnosed with depression; of them, 21 patients (32%) had posttraumatic stress disorder. There were no group differences in social adjustment, depressive symptoms, or suicidal intent. However, the group with comorbid depression and posttraumatic stress disorder had more additional Axis I diagnoses, a higher degree of childhood trauma exposure, and more often reported previous suicide attempts, non-suicidal self-harm, and vengeful suicidal motives. These findings underline the clinical importance of diagnosis and treatment of posttraumatic stress disorder in suicide attempters.     

Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study

OBJECTIVE: Suicidal behavior is highly prevalent in borderline personality disorder and major depressive episode, although the characteristics of suicide attempts in the two disorders are believed to differ. Comorbidity of borderline personality disorder and major depressive episode may obscure characteristics of suicide attempts that are uniquely related to the psychopathology of each disorder. We compared suicidal behavior in patients with borderline personality disorder, major depressive episode, and borderline personality disorder plus major depressive episode to determine whether characteristics of suicide attempts differed between groups and if aspects of core psychopathology predicted specific attempt characteristics. METHOD: Eighty-one inpatients with borderline personality disorder, including 49 patients with borderline personality disorder plus major depressive episode, were compared to 77 inpatients with major depressive episode alone on measures of depressed mood, hopelessness, impulsive aggression, and suicidal behavior, including lifetime number of attempts, degree of lethal intent, objective planning, medical damage, and degree of violence of suicide methods. RESULTS: No significant differences were found in the characteristics of suicide attempts between patients with borderline personality disorder and those with major depressive episode. However, patients with both disorders had the greatest number of suicide attempts and the highest level of objective planning. An increase in either impulsive aggression or hopelessness or a diagnosis of borderline personality disorder predicted a greater number of attempts. Hopelessness predicted lethal intent in all three groups and predicted objective planning in the group with both disorders. Medical damage resulting from the most serious lifetime suicide attempt was predicted by number of attempts. CONCLUSIONS: Comorbidity of borderline personality disorder with major depressive episode increases the number and seriousness of suicide attempts. Hopelessness and impulsive aggression independently increase the risk of suicidal behavior in patients with borderline personality disorder and in patients with major depressive episode.     

Suicide attempts in bipolar patients.

BACKGROUND: Between 25% to 50% of patients with bipolar disorder make suicide attempts during their lives, but there are some controversies about factors related to suicide attempts in this group of patients. The aim of this study is to investigate the association between suicide attempts and the predictive factors previously described in the literature. METHOD: The sample included all 169 patients with DSM-III-R bipolar I disorder identified in a delimited area (northern Spain). Sociodemographic, clinical, and family history variables measured by Research Diagnostic Criteria-Family History were analyzed. Significant variables were introduced in a logistic regression analysis to control for the effects of other variables. RESULTS: There were 56 patients (33%) who had one or more suicide attempts. Early age at onset, history of hospital admission during depressive episodes, drug abuse, and family history were significantly associated with suicide in the univariate analyses (p < .05). A much higher proportion of patients with onset at or before 25 years of age than patients with onset after 25 years of age attempted suicide (23% vs. 10%). The age at onset was no longer significant after controlling for the other 3 variables included in the logistic regression analysis. CONCLUSION: Suicide attempts are highly prevalent in bipolar patients and are related to drug abuse, family history of affective disorders, and severe depressive episodes. This study suggests that the risk of suicide in patients with an early age at onset could reflect other variables such as drug abuse, a history of hospital admissions for depression, or family history.     

Sex differences in clinical predictors of suicidal acts after major depression: a prospective study

OBJECTIVE: Whether sex differences exist in clinical risk factors associated with suicidal behavior is unknown. The authors postulated that among men with a major depressive episode, aggression, hostility, and history of substance misuse increase risk for future suicidal behavior, while depressive symptoms, childhood history of abuse, fewer reasons for living, and borderline personality disorder do so in depressed women. METHOD: Patients with DSM-III-R major depression or bipolar disorder seeking treatment for a major depressive episode (N=314) were followed for 2 years. Putative predictors were tested with Cox proportional hazards regression analysis. RESULTS: During follow-up, 16.6% of the patients attempted or committed suicide. Family history of suicidal acts, past drug use, cigarette smoking, borderline personality disorder, and early parental separation each more than tripled the risk of future suicidal acts in men. For women, the risk for future suicidal acts was sixfold greater for prior suicide attempters; each past attempt increased future risk threefold. Suicidal ideation, lethality of past attempts, hostility, subjective depressive symptoms, fewer reasons for living, comorbid borderline personality disorder, and cigarette smoking also increased the risk of future suicidal acts for women. CONCLUSIONS: These findings suggest that the importance of risk factors for suicidal acts differs in depressed men and women. This knowledge may improve suicide risk evaluation and guide future research on suicide assessment and prevention.     

Suicide and attempted suicide in general practice, 1979-1986

Using data from the Continuous Morbidity Registration Sentinel Stations over the period 1979-1986, the authors tried to determine the incidence and the characteristics of patients in general practice who attempted or committed suicide. Almost half of the suicide attempts and suicides had contacted their general practitioner (GP) shortly before the suicidal act. A minority of these cases were recognized by the GP as having a high suicide risk. In almost 70% of the suicides and 58% of the suicide attempters the GPs reported the existence, currently or previously, of a depressive episode. About half of both the suicides and the suicide attempters had been treated or seen by mental health professionals or social workers. Given the fact that suicide and suicide attempt are relatively rare events in general practice, and given the fact that for the patients who contact their GP shortly before the suicidal act, it is not at all certain whether they present clearly recognizable signs of suicide risk at that time, the authors conclude that GPs cannot play an important role in the prevention of suicidal behaviour.     

Psychopathological predictors of suicide in patients with major depression during a 5-year follow-up.

OBJECTIVE: It is widely known that the risk of suicide is higher in cases of major depressive disorders in comparison to the general population. The purpose of this study was to examine which psychopathologic symptoms during the index episode are predictors for an increased risk of suicide in the further course of major depression. METHOD: Mortality data were determined from a prospective study of 280 patients with major depression (DSM-III-R, single episode or recurrent) during a follow-up period of 5 years. The predictive power of different depressive symptoms including psychotic symptoms for suicide risk was investigated. RESULTS: Patients who committed suicide (N = 16) during the follow-up period had reported significantly more often hypochondriacal preoccupations or delusions (but not delusions or preoccupations of impoverishment, guilt or sin), suicidal thoughts and suicide attempts as well as feelings of severe hopelessness during the index episode than still living patients or patients who had died from natural causes. CONCLUSION: These symptoms seem to be helpful early predictors for the risk of suicide during the further course of illness. This should be taken into account for suicide prevention in the course of major depression.     

Suicide attempts in the Hungarian adult population. Their relation with DIS/DSM-III-R affective and anxiety disorders.

Prevalence of suicide attempts and their relationship with DIS anxiety and affective disorder diagnoses were investigated in a Hungarian adult community sample. Despite the high suicide mortality rate, the rate of suicide attempts was similar to that reported in other studies using similar methods. Suicide attempts occurred more frequently among women and previously married persons. Although the presence of any lifetime anxiety and/or affective disorder increased the rate of reported suicide attempts, the effect of co-morbidity, recurrence and chronicity might be considered significant predictors. The highest odds of an attempt were related to the diagnoses of dysthymic or bipolar disorders. Agitation was the only depressive symptom, which increased the odds of a suicide attempt.     

Suicide attempts in women with bulimia nervosa: frequency and characteristics

OBJECTIVE: This study aimed to estimate the lifetime frequency of suicide attempts in a large referred population of women with DSM-IV bulimia nervosa (BN), and to compare demographic and clinical characteristics of those who had attempted suicide and those who had not. METHOD: A total of 295 women (202 with BN purging type, 68 with BN non-purging type and 25 with anorexia nervosa binge/eating purging type) were assessed using a semi-structured interview and self-rated questionnaires. RESULTS: Suicide attempts were frequent (27.8% of women), often serious and/or multiple. Women who had attempted suicide differed significantly from those who had not for earlier onset of psychopathology, higher severity of depressive and general symptoms, and more impulsive disordered conducts, but not for the core symptoms or severity of BN. CONCLUSION: Interventions targeting depressive and impulsive features associated with BN are essential to reduce the risk of suicide attempt in women with this disorder.     

Posttraumatic stress disorder comorbid with major depression: factors mediating the association with suicidal behavior

OBJECTIVE: The purpose of the study was to determine if patients with a history of major depressive episode and comorbid posttraumatic stress disorder (PTSD) have a higher risk for suicide attempt and differ in other measures of suicidal behavior, compared to patients with major depressive episode but no PTSD. In addition, to explore how PTSD comorbidity might increase risk for suicidal behavior in major depressive episode, the authors investigated the relationship between PTSD, cluster B personality disorder, childhood sexual or physical abuse, and aggression/impulsivity. METHOD: The subjects were 230 patients with a lifetime history of major depressive episode; 59 also had lifetime comorbid PTSD. The demographic and clinical characteristics of subjects with and without PTSD were compared. Multivariate analysis was used to examine the relationship between suicidal behavior and lifetime history of PTSD, with adjustment for clinical factors known to be associated with suicidal behavior. RESULTS: Patients with a lifetime history of PTSD were significantly more likely to have made a suicide attempt. The groups did not differ with respect to suicidal ideation or intent, number of attempts made, or maximum lethality of attempts. The PTSD group had higher objective depression, impulsivity, and hostility scores; had a higher rate of comorbid cluster B personality disorder; and were more likely to report a childhood history of abuse. However, cluster B personality disorder was the only independent variable related to lifetime suicide attempts in a multiple regression model. CONCLUSIONS: PTSD is frequently comorbid with major depressive episode, and their co-occurrence enhances the risk for suicidal behavior. A higher rate of comorbid cluster B personality disorder appears to be a salient factor contributing to greater risk for suicidal acts in patients with a history of major depressive episode who also have PTSD, compared to those with major depressive episode alone.     

Depression, desperation, and suicidal ideation in college students: results from the American Foundation for Suicide Prevention College Screening Project at Emory University

The objective of this investigation was to examine suicidal ideation and depression in undergraduate college students who participated in the American Foundation for Suicide Prevention-sponsored College Screening Project at Emory University. The principal measure of depressive symptoms was the nine-item depression module from the Patient Health Questionnaire (PHQ-9). Additional questions were focused on current suicidal ideation, past suicide attempts, and episodes of deliberate self-harm and on symptoms of anxiety and distress. Seven hundred and twenty-nine students participated over a 3-school-year interval (2002-2005). Most notably, 11.1% of the students endorsed current (past 4 weeks) suicidal ideation and 16.5% had a lifetime suicide attempt or self-injurious episode. Students with current suicidal ideation had significantly higher depression symptom severity than those without suicidal ideation (t = -9.34, df = 706, P<.0001, d = 1.9), and 28.5% of the students with PHQ-9 scores of 15 or higher reported suicidal ideation compared to 5.7% of those with lower scores (chi(2) = 56.29, df = 1, P<.0001, two-tailed). Suicidal ideation was prominently associated with symptoms of desperation (odds ratio 2.6, 95% CI 1.5-4.6, P<.001). The vast majority of students with moderately severe to severe depression (85%) or current suicidal ideation (84%) were not receiving any psychiatric treatment at the time of assessment. These results suggest that there is a strong relationship between severity of depressive symptoms and suicidal ideation in college students, and that suicidal feelings and actions are relatively common in this group. This underscores the need to provide effective mental health outreach and treatment services to this vulnerable population. As this analysis was based on data collected at a single institution, the results may not be representative of all college students or young adults.     

Violent and Nonviolent Methods of Suicide: Different Patterns May Be Found in Men and Women with Severe Depression

The objective of this study was to investigate violent and nonviolent suicidal acts in men and women with severe depression. The records of 98 suicide victims, who had been admitted to the Department of Psychiatry, Lund University Hospital, Sweden between 1956 and 1969, were evaluated and the subjects were monitored up to 1998. The female group displayed a significant linear trend for nonviolent completed suicide after one suicide attempt, and even more significantly, after repeated attempts. A switch from only nonviolent suicide attempts to completed violent suicide was significantly more common in men than in women. These different progressions may contribute to the expected finding that men used violent methods for completed suicide more often than women.     

Suicidal behavior in patients with schizophrenia and other psychotic disorders.

OBJECTIVE: Patients with schizophrenia are known to be at high risk for suicide attempts and dying by suicide. However, little research has been conducted to determine whether the risk for suicidal behavior is elevated among patients with psychosis in general. METHOD: This study evaluated 1-month and lifetime rates of suicidal behavior among 1,048 consecutively admitted psychiatric inpatients (ages 18 to 55 years) with DSM-III-R psychotic disorders. Demographic, clinical, and diagnostic correlates of suicidal behavior were examined. RESULTS: A high rate of suicidal behavior was found in the group: 30.2% reported a lifetime history of suicide attempts, and 7.2% reported a suicide attempt in the month before admission. The highest 1-month and lifetime rates were found in patients with schizoaffective disorder and major depression with psychotic features. Ratings of the medical dangerousness of the most recent suicide attempt on the basis of the extent of physical injury were higher in patients with schizophrenia spectrum psychoses. Agreement was high between emergency room assessments and semistructured interview assessments of suicidal behavior. CONCLUSIONS: Rates of suicidal behavior were high across a broad spectrum of patients with psychotic disorders; patients with a history of a current or past major depressive episode (as a part of major depressive disorder or schizoaffective disorder) were at a greater risk for suicide attempts, but patients with schizophrenia, on average, made more medically dangerous attempts. Risk factors for suicidal behavior in patients with psychosis appear to vary compared to those for the general population.     

伴自杀未遂双相障碍患者的血清脑源性神经营养因子水平

目的 分析伴自杀未遂的双相障碍（BD）患者与不伴自杀未遂患者及健康人群间血清BDNF水平的差异,探讨BDNF在预防BD患者自杀中的作用.方法 采用DSM-IV轴Ⅰ障碍用临床定式检查（患者版）（SCID-I/P）对临床诊断为心境障碍的患者进行评佑.纳入111例BD患者（26例有自杀未遂史）及41例健康对照.使用汉密尔顿抑郁量表（HAMD-17）及杨氏躁狂量表（YMRS）评估患者症状严重程度;使用酶联免疫吸附测定法测定所有研究对象的血清BDNF水平.结果 伴自杀未遂的BD患者血清BDNF水平（13.8±7.4） ng/ml显著低于无自杀未遂患者（18.7±11.9） ng/ml及健康对照组（26.0±12.9）ng/ml（F=9.371,P＜0.01）;伴自杀未遂的BD患者抑郁发作次数显著多于不伴自杀未遂患者,在控制抑郁发作次数后,两组间血清BDNF水平差异消失（P=0.236）;伴自杀未遂的BD患者血清BDNF水平和抑郁发作次数有相关性的倾向（r=-0.388,P=0.068）,与HAMD-17得分呈负相关（r=-0.585,P＜0.01）.结论 本研究提示BDNF在BD及BD患者自杀未遂的病理生理机制中起重要作用;伴自杀未遂的BD患者血清BDNF水平可能与抑郁发作次数、抑郁严重程度相关;通过有效治疗来提高BDNF水平可能通过减少抑郁发作次数,降低抑郁严重程度来降低自杀风险.     

Suicide attempts in schizophrenia: the role of command auditory hallucinations for suicide

BACKGROUND: We examined the presence of command auditory hallucinations for suicide (CAHS) in a sample of individuals with schizophrenia or schizoaffective disorder. We examined the relationship between CAHS and demographic and clinical variables. We also investigated the relationship between CAHS and suicide attempts. METHOD: 100 individuals with DSM-IV schizophrenia or schizoaffective disorder hospitalized on an inpatient research unit participated. Information was gathered using the Diagnostic Interview for Genetic Studies and the Harkavy Asnis Suicide Scale. Data were gathered from 1995 to 2001. RESULTS: CAHS were frequent in this sample (22%), as were suicide attempts (33%). Eight percent of the entire sample (36% of those who experienced CAHS) made at least 1 suicide attempt in response to the hallucinations. The presence of CAHS was not related to demographic or clinical measures assessed. The frequency of CAHS was not statistically different for suicide attempters (30%) and nonattempters (18%). However, 80% (8/10) of attempters with CAHS reported at least 1 attempt in response to CAHS. Three of 6 repeat attempters who made at least 1 suicide attempt in response to CAHS also made other attempts that were not in response to CAHS. The presence of CAHS was not associated with a history of depression or substance abuse/dependence. CONCLUSION: The presence of CAHS does not directly predict suicide attempts. However, individuals who are already at risk for suicidal behavior (e.g., past attempters) may be at increased risk for a suicide attempt when experiencing CAHS.