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Are Men an Endangered Species? A Look at Suicide and Vascular Depression
by Arline Kaplan
Geriatric Times September/October 2001 Vol. II Issue 5
In Los Angeles, prominent defense attorney Barry Levin, age 54, reportedly upset over a debilitating illness, dies from a self-inflicted gunshot wound to the head. In Michigan, millionaire auto parts entrepreneur Heinz C. Prechter, age 59, reportedly suffering from depression, also dies from an apparent suicide.
These July news stories, reported in the Washington Post and the Los Angeles Times, reveal an often hidden epidemic--suicide in older men. Steven P. Roose, M.D., professor of clinical psychiatry at Columbia University's College of Physicians and Surgeons and director of the Neuropsychiatry Research Clinic at New York State Psychiatric Institute, recently pointed out, "The suicide cohort in the United States is overwhelmingly white, male and old."
Speaking at an industry-supported symposium at the 154th Annual Meeting of the American Psychiatric Association in New Orleans on "Men Over 50: An Endangered Species," Roose discussed the scope of the suicide epidemic and sought to raise physicians' awareness about their role in preventing suicides.
Suicide takes the lives of more than 30,000 Americans each year, making it the eighth leading cause of death in the country. According to Roose, the pattern of completed suicides differs between men and women. "Women have many more attempts than men, but, per attempt, a man is four times more likely to die than [is] a woman," he said.
In males, he added, there is a rapid increase in the rate of suicide in late adolescence and the early 20s. After that, the suicide rate levels off until men reach their mid-50s. Then, for Caucasian males only, the suicide rate starts to "astronomically rise." Although people aged 65 years and older represent only 13% of the population, they account for 20% of the reported suicides, Roose said. "And as age increases, the suicide rate increases. So among those aged 85 years and older, there is an astoundingly high rate," he added.
According to the National Strategy for Suicide Prevention (NSSP), older adults who are divorced or widowed are at a higher risk for suicide than those who are married (NSSP, 2001).
Worldwide Problem
Being old and male are not risk factors for suicide only among Americans, but also among people throughout the world.
"Whether it is in Europe, Asia or South America, and irrespective of what the baseline suicide rate is for the entire population, in every place that [suicide rate] is reported, you have a significant increase in suicide once the population goes past the age of 65. What is also true internationally is the difference in suicide rates between men and women," Roose said.
Even more disturbing, Roose said, is the fact that in the United States, 20% of older people who committed suicide saw a physician on the day that they committed suicide, 41% had seen a physician within one week and 75% within one month (NSSP, 2001).
Despite advances in treatments for depression, the suicide rate in the United States is not decreasing. Roose noted, "We are not focusing on the patients who are at greatest risk for suicide... the older patients. And that is backed up by the fact that the [number] of treatment studies in older Americans with depressive illness is significantly restricted. There are no large systematic outcome studies of patients over 75 years of age."
Roose and colleagues recently completed the largest study of treatment of depression in patients over the age of 75. They randomized 178 patients to citalopram (Celexa) versus placebo. The study included magnetic resonance imaging evaluations, along with an extensive neuropsychological battery and assessment of platelet function.
The study "will give us data about the impact of treatment of depression in the group that is at greatest risk for suicide," Roose said. He hopes that eventually a psychobiology of the risk factors of suicide in this vulnerable population will be developed. He said, "We want to call attention to it and make this one of the research agendas for the elderly."
Vascular Depression
One of the acknowledged risk factors for suicide among older people is the higher prevalence of depression and more physical illnesses than in younger adults (NSSP, 2001).
K. Ranga R. Krishnan, M.D., chair of the department of psychiatry at Duke University, also spoke at the Endangered Species symposium. He pointed out that when psychiatrists examine patients who develop depression late in life, they often find "subtle signs of vascular disease."
He defined vascular depression as a distinct subtype of late-life depression, usually characterized by the presence of major depression; specific characteristics such as psychomotor retardation and apathy; older age of onset or change in character of symptoms if early-onset; presence of non-central nervous system vascular disease; and documentation of brain damage through neuroimaging findings or by evaluating the patient neurologically.
"One of the first things that you will find when you do CT [computerized tomography] scans or MRIs in elderly patients with depression is that many of these patients often demonstrate strokes in the brain," Krishnan said. "These strokes are present mostly in the frontal lobe or basal ganglia regions of the brain. These are silent strokes or silent ischemic episodes. You do not usually find motor signs or symptoms or sensory signs and symptoms. What happens is that in these patients the stroke involves nonmotor and nonsensory areas of the brain... primarily related to cognition and mood regulation."
There is a relationship between vascular disease and depression even in the absence of full-blown depression, Krishnan said. He discussed evidence from the Cardiovascular Health Study (Steffens et al., 1999).
As part of their standardized clinical evaluation, 3,657 men and women have undergone brain MRI. Steffens and colleagues (1999) also conducted detailed interviews with the subjects and assessed cognitive function and the presence of depression using the Center for Epidemiological Studies of Depression Scale (CES-D). On the MRI scans, the researchers graded the presence of silent strokes using a standardized system. They found that there was a relationship between even mild depression, as measured by the CES-D, and cerebrovascular disease, especially when lesions were in the basal ganglia region.
To help answer the question, "Where in the brain are these lesions located such that one could specifically relate them to depression?" Krishnan described a study he and colleagues conducted involving 88 elderly patients who were depressed and 47 controls.
"We identified the lesions and then mapped them, using a technique called Statistical Parametric Mapping [SPM]. The SPM analysis basically identified regions in the brain where there was an increased lesion density in the depressed group compared to controls--the medial-orbital prefrontal white matter," he said. He added that severity of depression among depressed patients was correlated with lesions in this region.
When considering the consequences of depression in patients with these types of vascular changes, Krishnan said that studies show these patients do not respond as well to medications and that they may be more prone to cognitive decline and dementia. There is also an increased risk of stroke and an increased risk of mortality probably related to the concomitant vascular disease.
With regard to suicide attempts, he cited a study by colleagues Eileen Ahearn, M.D., Ph.D., and David C. Steffens, M.D., at Duke. The investigators looked at 19 patients with suicide attempt history and age- and gender-matched them to 19 patients without such a history. Individuals with lesions seemed to have a slightly higher rate of suicide attempts.
Treatment Considerations
Treatment options for vascular depression include behavioral intervention, stress management, exercise training and pharmacological approaches, according to Krishnan.
"Pharmacological treatment involves a number of medications--the two major classes being tricyclics and serotonin reuptake inhibitors," he said. "There are a couple of things to keep in mind when treating this group of patients. The first is to protect them from drug/drug interactions. Remember that the elderly often receive between seven and 11 prescriptions per year, and they are usually taking between four and seven drugs. So you need to be aware of protein binding and enzyme effects through the cytochrome P450 [CYP] system.
"One should also remember that many patients with cardiac disease may have other medical conditions that could affect the use of drugs, such as liver disease and renal failure," he said.
Because of tricyclics' well-known cardiac side effects (e.g., orthostatic hypotension, Type 1 antiarrhythmic properties, conduction disturbance and increased heart rate), Krishnan said he tends to favor the use of selective serotonin reuptake inhibitors (SSRIs) in this population (Krishnan et al., 2001).
He explained there is no evidence of orthostatic hypotension or pro/antiarrhythmic properties with SSRIs. Additionally, they are associated with a modest decrease in heart rate and they usually do not affect blood pressure, pulse rate, electrocardiogram QRS waves or QT intervals (Glassman, 1998).
References
Glassman AH (1998), Cardiovascular effects of antidepressant drugs: updated. J Clin Psychiatry 59(suppl 15):13-18.
Krishnan KR, Doraiswamy PM, Clary CM (2001), Clinical and treatment response characteristics of late-life depression associated with vascular disease: a pooled analysis of two multicenter trials with sertraline. Prog Neuropsychopharmacol Biol Psychiatry 25(2):347-361.
NSSP (2001), At a glance--suicide among the elderly. Available at: www.mentalhealth.org/suicideprevention/elderly.htm. Accessed Aug. 1.
Steffens DC, Helms MJ, Krishnan KR, Burke GL (1999), Cerebrovascular disease and depression symptoms in the Cardiovascular Health Study. Stroke 30(10):2159-2166.
