Suicide in the elderly in Kaniyambadi block, Tamil Nadu, South India

BACKGROUND: Inefficient civil registration systems, non-report of deaths, variable standards in certifying death and the legal and social consequences of suicide are major obstacles in investigating suicide in the developing world. Very high rates of suicide have been recorded in the region in the general population and among younger people. OBJECTIVE: This paper describes the suicide rate among the elderly in Kaniyambadi block, Tamil Nadu, South India for the years 1994-2002 using verbal autopsies. METHOD: The setting for the study was a comprehensive community health program in a development block in rural South India. The main outcome measure was death by suicide diagnosed by a detailed verbal autopsy and census, birth and death data to identify the population base. RESULTS: The average annual suicide rate was 189 per 100,000 for people over 55 years of age. The ratio of male to female suicides was 1: 0.66. The age-specific suicide rate for men and women increased with age. Hanging (52%) and poisoning with organo-phosphorus compounds (39%) were the commonest methods employed for committing suicide. Significantly more women chose drowning or burning than men who preferred poisoning or hanging (chi2 19.75; df 1; p < 0.001). CONCLUSIONS: The suicide rate documented in this study among the elderly is very high. The reasons for the high suicide rate observed in older people are not known. There is a need to develop innovative strategies to reduce deaths by suicide.     

Sex differences in elderly suicide rates: Some predictive factors

In the USA the rate of suicide among individuals aged 65 and older is higher than that for any other age group.There is a marked sex difference, with men accounting for 86% of elderly suicides. Using a sample consisting of every reported suicide death of older individuals between 1986 and 1990 (N =31,541), it was found that a different pattern of variables was predictive of suicide rates for men and women. For elderly men, factors associated with financial and social status were the best predictors of suicide. For elderly women, the predictors were indexes of social and environmental stability and stress.These findings may be explainable by psychological theories which speak of sex differences in the personality domains known as agency and communion, and similar considerations may help to explain why the suicide rate for men tends to increase in old age, while that for women remains relatively constant.     

The effect of participation in religious activities on suicide versus natural death in adults 50 and older

This study tests the hypothesis that older persons dying by suicide, compared with natural death, are less likely to have participated in religious activities. Data from the 1993 National Mortality Followback Survey were used to compare the frequency of participation in religious activities of 584 suicides to those of 4279 natural deaths occurring among women and men ages 50 and older. Adjusting for sex, race, marital status, age, and frequency of social contact, the odds for having never participated in religious activities are greater among suicide victims, compared with natural deaths. Participation in religious activities does appear to reduce the odds of the occurrence of suicide. This effect remains even after controlling for the frequency of social contact. The identification of specific factors contributing to this intrinsic benefit of religious participation requires further investigation.     

High Early Suicide Risk in Elderly Patients After Self-Poisoning

This article reports the findings of a follow-up study of suicide mortality in elderly patients after an index episode of self-poisoning. A total of 222 consecutive patients (143 female) aged 65 years or older (mean age 76.5 years; range 65–100) presenting at the emergency department of the Karolinska University Hospital after self-poisoning during 1994–2000, were followed up for the cause of death by January 1, 2006. Survival analysis was applied to study suicide and death risk. Of the 15 suicides, 13 (87%) occurred during the first year after the index episode of self-poisoning (cumulative suicide risk 6.2%). The risk of dying of all causes during the first year was increased fourfold. Self-poisoning in both elderly men and women is associated with high early suicide risk.     

Rates and factors associated with suicide in Kaniyambadi Block, Tamil Nadu, South India, 2000-2002

BACKGROUND: Inefficient civil registration systems, non-report of deaths, variable standards in certifying death and the legal and social consequences of suicide are major obstacles to investigating suicide in the developing world. OBJECTIVE: The aim of this study was to prospectively determine the suicide rate in Kaniyambadi Block, Tamil Nadu, South India, for the years 2000-2002 using verbal autopsies. METHOD: The setting for the study was a comprehensive community health programme in a development block in rural South India. The main outcome measure was death by suicide, diagnosed by a detailed verbal autopsy and census, and birth and death data to identify the population base. RESULTS: The average suicide rate was 92.1 per 100,000. The ratio of male to female suicides was 1:0.66. The age-specific suicide rate for men increased with age while that for women showed two peaks: 15-24 years and over 65 years of age. Hanging (49%) and poisoning with organo-phosphorus compounds (40.5%) were the commonest methods of committing suicide. Acute and/or chronic stress was elicited for nearly all subjects. More men suffered from chronic stress while more women had acute precipitating events (chi2 = 4.58; p < 0.04). People less than 44 years of age had more acute precipitating events before death while older subjects reported more chronic stress (chi2 = 17.38; p < 0.001). CONCLUSION: The study replicates findings of an earlier study from the area. The suicide rate documented in this study is very high and is a major public health concern. There is a need for sentinel centres in India and in developing countries to monitor trends and to develop innovative strategies to reduce deaths by suicide.     

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.     

Gender and age differences in suicide mortality in the context of violent death: Findings from a multi-state population-based surveillance system

Objective

Males are more likely than females to die by all forms of violent death, including suicide. The primary purpose of the present study was to explore whether the gender difference in suicide rates is largely accounted for by males' general greater tendency to experience violent deaths. The current study examined gender and age differences in suicides and other violent deaths, using data from a population-based surveillance system.

Method

Pearson's chi-square tests and logistic regression analyses were conducted with data for 32,107 decedents in the 2003–2005 National Violent Death Reporting System (NVDRS). Decedents were categorized by gender, age, and death by suicide versus other violent means.

Results

When suicides were examined in the greater context of violent death, the total proportion of violent deaths due to suicide did not differ across gender. When deaths were examined by age group, after controlling for ethnicity, marital status, and U.S. location in which the death occurred, males in early to mid childhood were significantly more likely than same-aged females to die by suicide relative to all other violent deaths. The portion of deaths due to suicide was for the most part equal across both genders in late childhood, young adulthood, and mid-adulthood. Older males were more likely than older females to die by suicide relative to other violent deaths.

Conclusion

Our findings suggest that that the risk of dying by suicide relative to other violent deaths may be more pronounced at certain developmental stages for each gender. This knowledge may be valuable in tailoring prevention strategies.     

Contacts with health professionals before suicide: Missed opportunities for prevention?

AimThis study aims to examine contacts with different health professionals in the three months prior to death in suicide cases compared to sudden death controls; and, to analyse contacts with health professionals among people who died by suicide having a diagnosable mental health disorder at the time of suicide compared to those who did not have such a diagnosis within four major groups of conditions.MethodsThe psychological autopsy method was utilised to investigate suicides of individuals over the age of 35 years. A case–control study design was applied using sudden death cases as controls. Odds ratios with a 95% confidence interval were calculated.ResultsIn total, 261 suicides and 182 sudden deaths were involved. In terms of contacts during the last three months prior to death, 76.9% of suicides and 81.9% of sudden deaths visited a general practitioner (GP). Persons who died by suicide had significantly more frequently contacts with mental health professionals than sudden death controls did. People with a diagnosable mental health disorder at the time of suicide attended GP surgeries with approximately the same frequency of people without a diagnosis at GP level.ConclusionSimilarly, approximately 90% of people who die by suicide and by sudden death seek for help from health care system, mainly from GPs in three months prior to their death. With reference to health care contacts, people who had or did not have a diagnosable psychiatric disorder are not distinguishable at the GP surgery level.     

Smoking and the risk of suicide

OBJECTIVE: To estimate the relationship between cigarette smoking and the risk of suicide. METHOD: The mortality of 36527 adult men and women was monitored for the mean 14.4 years. Information on deaths caused by suicide was obtained from the National Mortality Register. Suicides were subclassified by the level of violence used. Current smokers of 1-20 cigarettes per day were considered light/moderate smokers and heavy smokers were defined as those smoking > or =21 cigarettes per day. RESULTS: There were 134 suicides among 17798 men and 31 suicides among 18729 women. The most common suicide methods were hanging, firearms and drug overdose. According to the Cox model the adjusted relative risk of both violent and non-violent suicide was significantly and linearly increased among light/moderate and heavy smokers compared with non-smokers. CONCLUSION: Smoking was associated with an increased risk of suicide irrespective of the level of violence used.     

Method availability and the prevention of suicide – a re-analysis of secular trends in England and Wales 1950–1975

  Background: In England and Wales in the 1960s there were marked declines in suicide rates. These reductions were partly attributable to the detoxification of the domestic gas supplies; however, their extent varied by age and gender, with the most striking effects seen in older men. The objective of this study was to investigate method-specific trends in suicide between 1950 and 1975 to elucidate possible explanations for the patterns seen in different demographic groups. Methods: An analysis of age-standardised method-specific suicide rates for England and Wales between 1950 and 1975 was carried out using routinely available mortality and population statistics. Results: As has previously been shown, there were marked reductions in suicides by gassing in men and women of all ages between 1960 and 1975. In women and younger men, the effects of these reductions on overall suicide rates were partially offset by rises in drug overdose deaths (method substitution), but there were no immediate increases in the use of other suicide methods. In contrast, in older men, reductions in suicide by gassing were accompanied by only a slight increase in overdose suicides as well as reductions in rates of suicide using all other methods. The modest rise in overdose fatalities in older men occurred despite the fact that they were more often prescribed barbiturates and tricyclic antidepressants than younger men. Conclusions: Accessibility to and the lethality of particular methods of suicide may have profound effects on overall suicide rates. Such effects appear to depend upon the popularity of the method and the extent to which alternative methods that are acceptable to the individual are available. Social and psychological interpretations of fluctuations in suicide rates should only be made after assessing the possible contribution to these of changes in method availability and lethality. Accepted: 5 June 2000     

Characteristics of Chinese rural young suicides: Who did not have a strong intent to die

BackgroundIn exploration of the risk factors of the Chinese rural young suicide, previous researchers found low prevalence of mental problems, high degree of impulsivity, and great proportion of lethal pesticide consumption. It noticed that some of the young suicides in rural China did not intend to die from the suicidal behavior which was only instrumentally used for certain gains.AimsThis study aims to look into the characteristics of those young suicides who did not really intend to die and compare them with those young suicides who had a strong intent to die.MethodsSubjects were 386 suicides aged 15–34 years in the rural areas of three provinces in China. The data were obtained by psychological autopsy method. The degree of suicidal intent of the subjects was evaluated by the first 8 items of Beck's Suicide Intent Scale (SIS).ResultsIt was found that those suicides that had a strong intent of death were more likely to have higher age, more years of education, live alone, and suffer mental disease. On the other hand, the low intent suicides were more likely to have pesticides at home and to be impulsive. In other words, pesticides and impulsivity killed some Chinese rural young men and women who did not really want to die by suicide.ConclusionFindings of the study may be translated into practical measures in suicide prevention in China as well as elsewhere in the world.     

Patterns of suicide mortality in England and Wales before and after the suicide of the actor Robin Williams

Purpose

There is international evidence supporting an association between sensational reporting of suicide and a subsequent increase in local suicide rates, particularly where reporting the death of a celebrity. We aimed to explore whether the observed increase in suicides in the United States, Canada and Australia in the 5 months following the 2014 suicide of the popular actor Robin Williams was also observed in England and Wales.

Method

We used interrupted time-series analysis and a seasonal autoregressive integrated moving averages (SARIMA) model to estimate the expected number of suicides during the 5 months following Williams’ death using monthly suicide count data for England and Wales from the UK Office for National Statistics (ONS) 2013–2014.

Results

Compared with the observed 2051 suicide deaths in all age groups from August to December 2014, we estimated that we would have expected 1949 suicides over the same period, representing no statistically significant excess.

Conclusions

This finding is an outlier among previous studies and contrasts with the approximately 10% increase in suicides found in similar analyses conducted in other high-income English-speaking countries with established media reporting guidelines.

     

Suicide in patients with Parkinson's disease

The purpose of this study was to estimate the risk of suicide for patients with Parkinson's disease (PD) in Denmark compared with that in the background population. The study involved 458 patients with a PD diagnosis, 226 men and 232 women. The follow-up period to either death or end of follow-up on December 31, 1990 was 0 to 17 years, mean 5.7 years. Deaths in the follow-up period amounted to 254, 135 men and 119 women. Two women committed suicide. The number of expected suicides was 1.06 for men and 0.55 for women, a total of 1.62. Neither for men nor for women was the difference between expected and observed suicides statistically significant.     

Prostate cancer: a significant risk factor for late-life suicide.

OBJECTIVE: The authors sought to determine the incidence of suicide and its relevant correlates among men with prostate cancer. METHODS: This was a population-based, retrospective cohort review of men age 65 and older, residing in South Florida between 1983 and 1993. Average annual suicide rate was calculated for prostate cancer-related suicides and contrasted with age and gender-specific rates in the same geographic area. RESULTS: Of 667 completed suicides, 20 were prostate cancer-related (3% of the total male suicide sample). The average annual incidence of suicide for men was 55.32 per 100,000 persons, but for men with prostate cancer, the rate was 274.7 per 100,000. The risk of suicide in men with prostate cancer was 4.24 times that of an age- and gender-specific cohort. The clinical correlates included depression (70%), cancer diagnosis within 6 months of suicide (80%), physician visit within 1 month of suicide (60%), and being foreign-born (70%). CONCLUSION: The incidence of suicide among older men with prostate cancer is higher than previously recognized. Depression, recent diagnosis, pain, and being foreign-born are important clinical correlates. Screens for depression and suicide in older men with prostate cancer should be done after diagnosis and redone during the first 6 months regularly, particularly in the primary-care setting. Public education is needed to decrease the stigma associated with having a cancer diagnosis.     

Suicide or accident? a psychological autopsy study of suicide in youths under the age of 16 compared to deaths labeled as accidents

ABSTRACT: OBJECTIVE: In the present paper, we describe suicide in youths under 16 years of age and compare their risk factors for suicide to those of older adolescents as described in the literature. Furthermore, we evaluate the possible mislabeling of suicides as accidents, and vice versa. METHOD: We used the data from a nationwide psychological autopsy of youths 15 years and younger who had committed suicide or died in accidents in Norway from 1993 to 2004 (n = 84). We additionally constructed a suicide index to distinguish between the two causes of death. RESULTS: The young suicide victims presented, with little gender difference, fewer obvious risk factors and less suicide intent than commonly described for older adolescents. The suicide index distinguished quite well between suicides and accidents, with few cases indicating a possible mislabeling, although some suicide cases could have been labeled as uncertain. CONCLUSION: In line with previous research, suicides in 11-15-year-olds have many similarities to suicides in older adolescents in terms of external circumstances, but they present less apparent warning signs. In our total sample of 84 deaths, there were few indications of incorrect labeling.     

A Comparison of Suicides and Undetermined Deaths by Poisoning among Women: An Analysis of the National Violent Death Reporting System

The study compared the prevalence of common suicide risk factors between poisoning deaths classified as injuries of undetermined intent or suicides among women. Data were derived from the 2003–10 National Violent Death Reporting System. Multiple logistic regression assessed the factors associated with 799 undetermined deaths (relative to 3,233 suicides). Female decedents with lower education, a substance use problem, and a health problem were more likely to be classified as undetermined death. Older women, those with an intimate partner problem, financial problem, depressed mood, mental health problem, attempted suicide, and disclosed intent to die were less likely to be classified as undetermined death. The present study raises the possibility that many (perhaps most) undetermined female poisoning deaths are suicides.     

Overdose deaths in young substance abusers: accidents or hidden suicides?

Of 1969 earlier adolescent psychiatric inpatients, 1792 (91%) were traced after a mean follow-up period of 15 years. Thirty-nine patients, 2.3% of the men and 2.0% of the women had died from drug overdoses. An additional 16 drug- and alcohol-related deaths had occurred. The overdose death rate increased significantly during the observation period. At the time of death, 28 (72%) of the 39 overdose cases received a diagnosis of opioid dependence, the rest had polysubstance dependence. Death was most often caused by opioids. Comparing the 39 overdose cases with 39 surviving controls and 35 suicides from the same patient population, we found that the suicide cases had more psychotic symptoms, suicidal ideation, learning difficulties and somatic disorders. The suicide cases received less follow-up treatment on discharge from hospital, did not enter specific drug treatment programs, and were the only ones to be discharged to the street. We found no significant differences between the overdose cases and their surviving controls. Both groups showed poor impulse control and risk-taking behavior more often than the suicide group. The study lends support to the hypothesis that the majority of overdose deaths in young drug addicts are accidental poisonings and not misclassified suicides.     

Elderly suicide in Finland

Suicide mortality among the elderly is high in most Western countries. We investigated the characteristics of suicide victims 65 years or older in a nationwide psychological autopsy study, the research phase of the National Suicide Prevention Project in Finland. This study population included all completed suicides (N = 1,397, of whom 211 were 65 years or older) that occurred in Finland during a 12-month research period in 1987-1988. The elderly suicide victims were found to have used violent suicide methods more often than the young. Although almost 70% of the elderly persons who had committed suicide had been in contact with health care services during the month before their death, their suicidal intentions were rarely communicated in these contacts. They had been referred to psychiatric services less often than the young, and only 8% had received adequate antidepressive medication. The fact that most elderly suicides have contact with health care services during their final month suggests a potential for suicide prevention. However, the major obstacle to this is the poor recognition of mental disorders and suicidal ideation among the elderly.     

Hospitalization for suicide attempt and completed suicide: epidemiological features in a managed care population

BACKGROUND: Understanding factors that contribute to high suicide risk holds important implications for prevention. We aimed to examine the sociodemographic and medical predictors of attempted suicide (severe enough to require hospitalization) and of completed suicide in a large population-based sample from a health maintenance organization (HMO) in northern California, USA. METHOD: We designed a cohort study, including 87,257 women and 70,570 men aged 15 through 89 years old at baseline (in 1977-1985) with follow-up for hospitalizations and mortality through the end of 1993. RESULTS: After a median of 10 years, 169 first hospitalizations for attempted suicide (111 among women, 58 among men) and 319 completed suicides (101 among women, 218 among men) were identified. There was a greater incidence of hospitalization for suicide attempt in women than in men and, conversely, a greater incidence of completed suicide in men than in women. The predominant methods of attempted and completed suicides were ingestion of psychotropic agents and use of firearms, respectively. In gender-specific multivariate analysis of hospitalization for suicide attempt, statistically significant associations were seen for age 15-24 years (women), 65-89 years (men), white race (women), 12th grade or less education (both genders), technical/business school education (men), never being married (men), history of emotional problems (both genders), history of family problems (women), history of job problems (men) and presence of one or more comorbidities (men). The independent predictors of completed suicide were: age 15-24 years (both genders), Asian race (women), Caucasian race (both genders), never being married (both genders), being separated/divorced (women), prior inpatient hospitalization for suicide attempt (both genders) and history of emotional problems (both genders). CONCLUSION: These findings could help health professionals be more effective in the prevention of suicide morbidity and mortality.