Treating Suicidal Elders
by Leslie Knowlton| Geriatric Times |  |
September/October 2000 | |
Vol. I | |
Issue 3 |
Suicide among the elderly was the topic of a recent talk given in New York City by Yeates Conwell, M.D., professor of psychiatry and co-director of the Center for the Study and Prevention of Suicide at the University of Rochester School of Medicine and Dentistry. The presentation was part of a two-day conference sponsored by the American Foundation for Suicide Prevention.
Conwell told attendees that Americans over the age of 70 are at higher risk for suicide than any other group, with elderly white males facing the highest risk. He explained that he uses a public health-model framework to address geriatric suicide, which focuses on four general disease-prevention guidelines.
The first is that prevention goals must be based on what beneficial outcome is most meaningful to the individual and society. "Attitudinal research recently done...says that, in general, our society tends to regard suicide among older adults as more acceptable than suicide among younger people," Conwell said. "Is this another reflection of ageism in our culture? It's certainly something we need to continue thinking carefully about."
The second guideline is that potential benefit of a preventive measure is proportional both to prevalence of the disease and severity of its associated morbidity. Regarding prevalence, Conwell noted that in 1997, suicide was the 14th leading cause of death among older people, accounting for almost 6,000 deaths. Furthermore, between 1980 and 1992, overall geriatric suicide rates rose 9%, and among men and women aged 80 to 84, rates rose by 35% and 36%, respectively. Regarding severity of morbidity, data indicate that suicidal behavior is more lethal among older people than younger people, Conwell said.
"Among the general population...there are around 10 suicide attempts for each completed suicide, but among the elderly... there are only about four suicide attempts for each completed suicide," he said. "It's much less common behavior [to have] failed suicide in older people."
One reason for a higher lethality is that older people are more frail and therefore more likely to die from self-injury. Also, because the elderly are generally more socially isolated than younger people, they are less likely to be rescued in a timely manner. Finally, the elderly are more planned and determined in suicide attempts, and they are far less likely than younger people to have a history of previous suicide attempts to evaluate as a risk factor.
The third prevention guideline is that to be effective in older people, preventive care must take into account multiple dimensions that impact their health. "Suicide in many cases, and...in particular among older people, is oversimplified in this country," said Conwell. "You'll see headlines that there is a prominent older person who has committed suicide and the issue is often boiled down to 'he killed himself because of his physical illness, unbearable pain and suffering, his bereavement,' this kind of thing. Well, of course, the story is much more complicated."
Conwell said there are many different domains of risk. As those factors come together at the same place and time, overall risk for suicide rises dramatically. "This presents both challenges as well as potentials for suicide prevention. The challenge of course is that it's really complicated to think about suicide, why it happens and how to intervene. The promise is, however, that these are inextricably linked events...The likelihood is that if one intervenes at any one point in the causal chain, the suicide can be prevented. There are, therefore, many opportunities and means to improve outcomes."
Conwell said that the various intersecting domains of risk include medical illness factors, social factors, psychiatric and psychological factors, and biological factors. He noted that stressful life events clearly cluster in the days and weeks before the suicide of an older person.
"We know for bereavement, for example, that risk for suicide is increased...for up to four years following the death of a spouse," he said. Bereaved people with a history of psychiatric illness, substance use disorder and a history of early life loss rekindled by the bereavement are at special risk.
Regarding the link between suicide and physical illness and functional impairment, Conwell cited a review (Harris and Barraclough, 1994) that found very good evidence to suggest increased risk for completed suicide for most disorders of the central nervous system, in addition to HIV disease, peptic ulcer disease, kidney disease, systemic lupus and most cancers.
"It's also important to note [that] clearly there are many, many people with these illnesses who don't kill themselves," he said. "We need to know what it is that puts an individual at risk in the face of these conditions." Conwell noted that studies of terminally ill patients suggest that suicidal ideation is quite rare in the absence of concurrent depressive symptoms and syndromes, so it's likely that affective illness mediates the relationship between medical illness and suicide.
Another issue is personality traits, said Conwell. "People who committed suicide...had significantly more neuroticism than a control population...and significantly lower openness to experience," he said.
The strongest risk factor for suicide is psychiatric illness, Conwell said. "To boil this down from our own data [Conwell et al., 1996] from psychological autopsies studied comparing completed suicides with controls over the age of 50, almost 90% had a diagnosable Axis-I condition in the suicides," he said.
That relates to the fourth and final prevention guideline: the effectiveness of a prevention measure depends on identification of risk factors characteristic of the individual or group; the strength of the causal relationship between the risk factor and disease; and the alterability of the causal risk factor. Seventy percent of older adults who have committed suicide saw their primary care provider within 30 days previous to death, making that setting a critical venue for intervention.
One existing collaborative care model that received a lot of attention is a Swedish study (Rutz et al., 1989, 1992a, 1992b), in which all primary care providers on the island of Gotland were educated about the recognition and treatment of depression. Over the next two to three years, the suicide rate dropped to 30% of baseline.
Conwell reported on an outreach model called Tele-Help/Tele-Check (De Leo et al., 1995), in which more than 12,000 vulnerable elderly clients were provided call-in services and support over several years. The number of suicides in that group was significantly lower than the number of suicides expected in that population over time.
"So there are two methods of intervention," said Conwell. "In primary care, we need to educate people regarding recognition and treatment of affective disorders and suicidal states...Then [we need] to establish outreach programs that help us contact, identify older people at risk and integrate [them] into effective, comprehensive prevention programs."
References
Conwell Y, Duberstein PR, Cox C et al. (1996), Relationships of age and axis I diagnosis in victims of completed suicide: a psychological autopsy study. Am J Psychiatry 153(8):1001-1008.
De Leo D, Carollo G, Dello Buono M (1995), Lower suicide rates associated with a Tele-Help/Tele-Check service for the elderly at home. Am J Psychiatry 152(4):632-634.
Harris EC, Barraclough BM (1994), Suicide as an outcome for medical disorders. Medicine (Baltimore) 73(6):281-296 [see comment].
Rutz W, Carlsson P, von Knorring L, Walinder J (1992a), Cost-benefit analysis of an educational program for general practitioners by the Swedish Committee for the Prevention and Treatment of Depression. Acta Psychiatr Scand 85(6):457-464.
Rutz W, von Knorring L, Walinder J (1992b), Long-term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression. Acta Psychiatr Scand 85(1):83-88.
Rutz W, Walinder J, Eberhard G et al. (1989), An educational program on depressive disorders for general practitioners on Gotland: background and evaluation. Acta Psychiatr Scand 79(1):19-26.