Original Paper Psychopathology 1992:25:183-188
E- Niew F Viptn
L. Lázaro C. Gastó E. Cirera
Serious Suicide Attempts in the Elderly
Department of Psychiatry. Hospital Clinic i Provincial de Barcelona. School of Medicine, University of Barcelona. Spain
Abstract A retrospective study was carried out including all those patients who, over the last 6 years (n = 257), required admis sion to our hospital for medical or surgical reasons following attempted suicide. The authors examined a series of clinical and demographic variables. Thirty-eight patients over 65 years of age were compared with 120 patients aged between 30 and 64 years and 99 aged under 30 years. When compared with the other two groups, a significantly higher proportion of elderly patients were widowed and showed affective disorders and concurrent physical illness.
Introduction During the past several years suicidal be havior has been the focus of increasing atten tion and research. Nevertheless, studies on suicidal behavior in the elderly have been sur prisingly scarce. Thus, Merrill and Owens [1] point out that their study done in 1990 was the first one since the sixties to compare, according to age-group, the characteristics of people who attempted suicide. This negli gence in studying attempted suicide in the elderly does not seem justifiable, as this is pre cisely the age-group that presents higher sui
cide rates [2], Besides, in view of the progres sive aging of the world’s population, we shall no doubt see a considerable increase in the absolut number of geriatric suicides. Previous works indicate that suicidal be havior in the elderly is generally serious, both in intent to die and lethality [3]. Thus, the number of suicide attempts for every com pleted suicide is much lower than in other age-groups. In Spain, while the elderly ac count for under 5% of total patients seen to in casualty departments for minor suicide at tempts [4] they represent over a third of all completed suicides in the city of Barcelona
Hvaristo Nieto. MD Hospital Clinic i Provincial dc Barcelona Departmen: of Psychiatry C/Villarrocl 170 E-08036 Barcelona (Spain)
€> 1992 S. Karger AG. Basel 0254-4962/92/ 0254-0183S2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 10:16:37 AM
Key Words Attempted suicide Elderly Depression Physical illness
Material and Method Patients The 257 (5.3%) patients studied were selected from a total of 4,850 patients who had been seen by the Con sultation and Liaison Psychiatric Unit between June 1984 and June 1990. All 257 had been admitted to the Medical and Surgical Departments of the Hospital Clinic de Barcelona as a result of attempted suicide. The Hospital Clinic is a 1,000-bed university hospital in Barcelona where almost 500 suicide attempts arc seen in the casualty department every year. Neverthe less, most of these patients are not admitted to medical or surgical departments, as admission criteria are very restrictive because of the great attendance pressure, and many remain in the casualty area for 24-48 h until discharge. Admission is decided following exclusively criteria of medical seriousness. All the patients who are admitted as a result of self-harm are seen by the Unit of Consultation and Liaison Psychiatry'. The study sam ple, therefore, includes the whole subgroup of suicide attempters of higher medical seriousness. Thirty-eight (14.8%) of these 257 serious suicide attempters were older than 65. Material The data were obtained from the revision of each patient’s official psychiatric case history, plus exami nation of the case histories in the medical/surgical department and the psychiatric hospitalization unit, in those cases in which psychiatric admission was indi cated after medical discharge. Method At the time of their admission, all 257 patients had been seen by at least 2 psychiatrists (all suicide patients are seen routinely by a 4th-year psychiatry resident and a faculty member) and diagnosed according to
184
Table 1. Main diagnosis of the elderly suicide at tempters n
%
28 20 6 1 1
73.7 52.6 15.7 2.6 2.6
Nonaffective psychosis Schizophrenia
1 1
2.6 2.6
Other Adaptive disorder, depressed Substance abuse Personality disorder
8 5 1 2
21.0 13.1 2.6 5.2
No psychiatric disorder
1
2.6
Affective disorders Major depression, single episode Major depression, recurrent Bipolar disorder, depressed Dysthymia
DSM-III criteria [6]. Subsequently, the authors exam ined retrospectively a series of clinical and demo graphic variables. Diagnosis was modified in accor dance with DSM-III-R criteria [7], resulting in 2 cases of adaptive disorder with depressed mood who met criteria for major depression and 6 cases of schizophre nia that received a final diagnosis of schizoaffective disorder. Thirty-eight patients over 65 years of age were compared with 120 patients aged between 30 and 64 years and 99 aged under 30 years. The statistical technique used w'as the x2 test with Yates’ correction. DSM-III-R criteria were used for the main psy chiatric diagnosis. To facilitate statistical analysis, all patients were split up into three large diagnostic groups: (1) affective, including single episode major depression, recurrent major depression, bipolar disor der, schizoaffective disorder, dysthymia and organic affective disorder; (2) nonaffective psychotics, includ ing schizophrenia, schizophreniform disorder, brief reactive psychosis, delusional disorder and organic hallucinatory or delusional disorder; (3) group consist ing of the remainder of axis I diagnoses (mainly psy choactive substance abuse or dependence and adaptive disorders) and of those axis II diagnoses (mainly personality disorders) in which there was no comorbidity on axis I. Method of suicide was classified following the cri teria of Arora and Meltzer [8], in accordance with the violence of the attempt: nonviolent methods being vol untary self-poisoning with drugs or other substances
Nieto/Vlcta/Lázaro/Gastó/Cirera
Suicide in the Elderly
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 10:16:37 AM
[5]. On the other hand, because of the difficul ties involved in studying completed suicides, the analysis of the more medically serious forms of suicidal behavior takes on particular importance. The aim of this work was to determine the specific characteristics of nonfatal serious sui cidal behavior (that requiring hospitalization for medical or surgical reasons) among the elderly population.
Table 2. Demographic and clinical characteristics of the suicidal inpatients by age-group 0-30 years (n = 99)
31 -64 years ( n - 120)
More than 65 vears ( n - 38)
n
%
n
%
n
%
Male Female
60 39
60.6 39.4
60 60
50.0 50.0
17 21
44.7 55.3
Marital status Single Married Separated Widowed
84 10 5 0
84.8 10.1 5.1 0.0
37 51 23 9
30.8 42.5 19.2 7.5
4 8 5 21
10.5 21.1 13.2 55.3
Psychiatric diagnosis Diagnostic subtypes Affective Psychotic Other
98
98.9
118
98.3
37
97.3
27 60
11.5 27.2 60.6
57 27 34
47.5 22.5 28.3
28 1 8
73.7 2.6 21.0
Personality disorder Substance abuse Method of attempt Violent Nonviolent
45 18
45.5 18.2
25 24
21.8 20.0
6 2
15.8 5.3
48 51
48.5 51.5
46 74
38.3 61.7
12 26
.31.6 68.4
Seriousness Very' serious Less serious
18 81
18.2 81.8
46 74
38.3 61.7
16 22
42.1 57.9
Family history of suicide Previous attempts Previous treatment Physical illness
10 39 36 5
10.1 .39.4 36.4 5.1
10 54 70 19
8.3 45.0 58.3 15.8
5 14 12 19
13.2 36.8 31.6 50.0
Sex
11
pa
pb
NS
NS
0.0001
0.0001
NS 0.0001
NS 0.006
0.003 NS NS
NS NS NS
0.01
NS
NS NS NS
NS NS 0.008
0.0001
0.0001
a Level of significance when comparing young (0- to 30-year-old) vs. elderly (more than 65 years old). b Level of significance when comparing adults (31- to 64-year-old) vs. elderly (more than 65 years old).
Results Elderly patients accounted for 14.8% of all those who made serious suicide attempts. The average age was 73.34 years. Table 1 sets out the main psychiatric diagnosis of the 38 el derly suicidal patients. Table 2 sets out the results of the comparison between the elderly suicidal patients and the suicidal patients be
185
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and single cuts in the nondominant arm. Other meth ods (jumping from a height or to tube trains, hanging, shooting, piercing, and a combination of methods) were considered as violent. Medical seriousness of the attempt was divided in two categories: very serious, in the cases of multiple injuries or coma severe enough to require intensive surveillance; serious, in the rest of cases. With regard to the family history of suicide, every completed suicide of immediate and close relatives was taken into consideration.
Discussion Our study suffers from the classic limita tions of retrospective studies. Nevertheless, the risk of biases is probably reduced by the ‘hardness’ of the variables finally selected and the way they had been collected (this is, sys tematically). The percentage of elderly patients (14.8%) among the total admitted to medical and sur gical units as a result of attempted suicide falls between the figure pertaining to the suicide attempters seen in casualty departments (un der 5%) and that found in samples of com pleted suicide (30%) [9]. It seems clearly that as the lethality of suicidal behavior increases, so too does the percentage of elderly in the total sample. When comparing the marital status of the elderly suicidal patients with the marital sta tus of the other two groups’ patients, there were significant differences between the three groups, particularly with regard to the propor tion of widowed patients. These differences are probably related to age. Only 1 of the 38 elderly suicidal patients did not fulfil DSM-III-R criteria for any psy chiatric diagnosis. Of the remaining 37 pa tients, 35 received an axis 1 diagnosis, and 2 were diagnosed as suffering from personality disorder without diagnosis on axis 1. These figures seem to confirm previous studies indi cating that elderly peopple making nonfatal serious suicide attempts suffer almost all from a psychiatric disorder.
186
Almost 3 out of every 4 elderly patients who made a serious suicide attempt were suf fering from an affective disorder. This pro portion indicates clearly that in this group, clinical depression is absolutely, and sig nificantly - in comparison with other agegroups -, of prime importance as a determin ing factor in suicidal behavior. Similar results were found by Barraclough et al. [9] and by Robins et al. [10] in their studies on com pleted suicides. Only 1 of the 38 patients was suffering from a nonaffective psychotic disorder (2.6%). The importance of nonaffective psy chotic disorders (mainly schizophrenia) as a determining factor in suicidal behavior in the elderly population is therefore minimum, and significantly much less than that found in the other age-groups, where the percentages are over 20%. The presence of personality disorders in suicidal elderly patients (15.8%) is signifi cantly lower than that found in suicidal pa tients under 30 years of age (45.5%) and is also lower, although not significantly so, than that found in the 30- to 65-year-old group ( 21 . 8 % ). In our study we did not come across any elderly patient suffering from delirium or de mentia prior to the suicidal act. Our results are similar to those found by Pierce [11] and Merrill and Owens [ 1] and very different from those found in the first works [12-14]. Such discrepancies do not seem to be justifiable, although they could be due to several reasons. One is the lack of suitable diagnostic criteria at the time those works were done, with possi ble overlapping between the diagnoses of de mentia and depressive pseudodementia. Moreover, mental organic disorder could be the result of the suicidal act and not exist beforehand (we did not take these cases of postattempt mental organic disorders into consideration).
Nieto/Vieta/ Lázaro/Gastó/Ci rera
Suicide in the Elderly
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 10:16:37 AM
longing to other age-groups. Elderly suicide patients used the following methods of sui cide: 16(42 %) drug overdose. 8(21 %) domes tic poison (liquid or gas), 7 (18%) jumping. 4 (10%) jumping in front of tube train, 2 (5%) wrist cut and 1 (2.5%) piercing.
1990, unpubl. data] ideas of death were very infrequent (10.5%) and were very signifi cantly related (p < 0.0003) to psychiatric con ditions (affective or adaptive disorder with depressed mood being the main diagnoses). In our sample of elderly suicide attempters, 95% of those suffering from an organic illness pre sented depressive symptoms. Given the asso ciation between organic illness and depres sion in the elderly population [18], and be tween depression and suicidal behavior [19], it seems likely that the determining factor in suicidal behavior is ultimately the change in mood, and not the existence of a physical ill ness.
Conclusions Nonfatal serious suicidal behavior in the elderly is generally the result of a clinically sig nificant and treatable affective disorder. It should not, in principle, be attributed to phys ical illness, loneliness or just age. If one should not be nihilistic with any suicidal patient, par adoxically with the elderly there is even less reason to be so, as their suicidal behavior is usually secondary to a mental disorder (de pression) which has good prognosis if treated. Diagnosing affective disorders in the elderly is more difficult than in other times of life. To prevent suicidal behavior in the elderly, it would be a great help if general practitioners, as well as geriatric specialists and, of course, psychiatrists, were adequately trained and practiced in the diagnosis and treatment of depression, such a common disorder among this group of population.
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Elderly patients admitted as a result of attempted suicide showed a preference for nonviolent modes of suicidal behavior, al though the differences with the other agegroups were not significant. These results dif fer from those found by Conwell et al. [15] in completed suicides, as these authors point out that the elderly use violent methods. A possi ble explanation is that the choice of a violent method by elderly patients would imply a greater risk of death, which might determine a high rate of violent attempts in samples of completed suicide and a low rate in samples of noncompleted suicide. The elderly showed a more serious suicidal behavior in terms of lethality. This significantly higher medical se riousness could be related, in the elderly, to a higher intent to die [3] and to increased vul nerability to physical and chemical injuries [16]. Only 31 % of the elderly patients had been treated previously, while in the intermediate age-group this percentage rose to 58%, with a significant difference between both groups (p < 0.008). These figures show that major psychiatric disorders, especially the affective ones, are not adequately detected in the el derly population [17], Half of the elderly patients with serious suicidal behavior are suffering from some rel evant organic illness. These figures are signifi cantly higher than those found in the other two age-groups. This high incidence of or ganic illness in suicidal elderly people is com mon in most studies, both on attempted sui cide [1] and completed suicide [9], Since the incidence of physical illness increases with age, these results should not be considered as if suicidal behavior was a logical, common attitude in seriously ill elderly patients. They would rather indicate a relationship between aging and physical illness. In fact, in a recent study with a sample of 95 old people hospital ized due to physical illness [Lázaro et al.,
1 Merrill J. Owens J: Age and at tempted suicide. Acta Psychiatr Scand 1990:82:385-388. 2 Blazer DG. Bachar JR. Mantón KG: Suicide in late life. Review and com mentary. J Am Geriatr Soc 1986:34: 519-525. 3 Pierce DW: Suicidal intent in selfinjury. Br J Psychiatry 1977:130: 377-385. 4 Rodríguez F, De las Cuevas C, Henry M. Morilla J. Frugoni A. Al amo V. González de Rivera JL: Variables socio-demográficas y psi quiátricas de las tentativas de sui cidio atendidas en un hospital gen eral. Psiquis 1989:10:293-299. 5 Martí G: Epidemiología del suicidio consumado en Barcelona durante el año 1983. Rcv Psiquiatr Psicol Méd 1984;16:576-583. 6 American Psychiatric Association: Diagnostic and Statistical Manual of Psychiatric Association, ed 3. Wash ington. American Psychiatric Press, 1980. 7 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 3 revised. Washington, American Psychiatric Press, 1987.
8 Arora RC, Meltzer HY: Serotoner gic measures in the brain of suicidal victims: 5-HT2 binding sites in the frontal cortex of suicide victims and control subjects. Am J Psychiatry 1989:146:730-736. 9 Barraclough B. Bunh J, Nelson B. Sainsbury P: A hundred cases of sui cide: Clinical aspects. Br J Psychia try' 1974:125:355-373. 10 Robins E, Murphy GE. Wilkinson RH Jr, Gassncr S. Kays J: Some clinical considerations in the pre vention of suicide based on a study of 134 successful suicides. Am J Public Health 1959;49:888-899. 11 Pierce D: Deliberate self-harm in the elderly. Int J Geriatr Psychiatry 1987;2:105-110. 12 Batchelor IRC, Napier MB: At tempted suicide in old age. Br Med J 1953;ii: 1186. 13 O’Neill P. Robins E, Schmidt E: A psychiatric study of attempted sui cide in persons over sixty years of age. Arch Neurol Psychiatry 1965; 75:275-284.
14 Sendbuehler JM. Goldstein S: At tempted suicide among the aged. J Am Geriatr Soc 1977:252:245-248. 15 Conwell Y, Rotenberg M. Caine ED: Completed suicide at age 50 and over. J Am Geriatr Soc 1990:38: 640-644. 16 Davidson J: The pharmacologic treatment of psychiatric disorders in the elderly; in Busse EW, Blazer DG (eds): Geriatric Psychiatry. Wash ington, American Psychiatric Press. 1989. pp 5 16-517. 17 Lázaro L. Dc Pablo J. Nieto E. Vieta E, Vilalta J. Cirera E: Morbididad psiquiátrica en ancianos ingresados en un hospital general: Estudio prevalencia-día. Med Clin (Bare) 1991: 97:206-210. 18 Kennedy GJ, Kelman HR. Thomas C: Persistence and remission of de pressive symptoms in late life. Am J Psychiatry 1991:148:174-178. 19 Sainsbury P: Depression, suicide, and suicide prevention; in Roy A (ed): Suicide. Baltimore, Williams & Wilkins, 1986, pp 73-88.
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N ieto/Vieta/Lázaro/Gastó/Circra
Suicide in the Elderly
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References
E- Niew F Viptn
L. Lázaro C. Gastó E. Cirera
Serious Suicide Attempts in the Elderly
Department of Psychiatry. Hospital Clinic i Provincial de Barcelona. School of Medicine, University of Barcelona. Spain
Abstract A retrospective study was carried out including all those patients who, over the last 6 years (n = 257), required admis sion to our hospital for medical or surgical reasons following attempted suicide. The authors examined a series of clinical and demographic variables. Thirty-eight patients over 65 years of age were compared with 120 patients aged between 30 and 64 years and 99 aged under 30 years. When compared with the other two groups, a significantly higher proportion of elderly patients were widowed and showed affective disorders and concurrent physical illness.
Introduction During the past several years suicidal be havior has been the focus of increasing atten tion and research. Nevertheless, studies on suicidal behavior in the elderly have been sur prisingly scarce. Thus, Merrill and Owens [1] point out that their study done in 1990 was the first one since the sixties to compare, according to age-group, the characteristics of people who attempted suicide. This negli gence in studying attempted suicide in the elderly does not seem justifiable, as this is pre cisely the age-group that presents higher sui
cide rates [2], Besides, in view of the progres sive aging of the world’s population, we shall no doubt see a considerable increase in the absolut number of geriatric suicides. Previous works indicate that suicidal be havior in the elderly is generally serious, both in intent to die and lethality [3]. Thus, the number of suicide attempts for every com pleted suicide is much lower than in other age-groups. In Spain, while the elderly ac count for under 5% of total patients seen to in casualty departments for minor suicide at tempts [4] they represent over a third of all completed suicides in the city of Barcelona
Hvaristo Nieto. MD Hospital Clinic i Provincial dc Barcelona Departmen: of Psychiatry C/Villarrocl 170 E-08036 Barcelona (Spain)
€> 1992 S. Karger AG. Basel 0254-4962/92/ 0254-0183S2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 10:16:37 AM
Key Words Attempted suicide Elderly Depression Physical illness
Material and Method Patients The 257 (5.3%) patients studied were selected from a total of 4,850 patients who had been seen by the Con sultation and Liaison Psychiatric Unit between June 1984 and June 1990. All 257 had been admitted to the Medical and Surgical Departments of the Hospital Clinic de Barcelona as a result of attempted suicide. The Hospital Clinic is a 1,000-bed university hospital in Barcelona where almost 500 suicide attempts arc seen in the casualty department every year. Neverthe less, most of these patients are not admitted to medical or surgical departments, as admission criteria are very restrictive because of the great attendance pressure, and many remain in the casualty area for 24-48 h until discharge. Admission is decided following exclusively criteria of medical seriousness. All the patients who are admitted as a result of self-harm are seen by the Unit of Consultation and Liaison Psychiatry'. The study sam ple, therefore, includes the whole subgroup of suicide attempters of higher medical seriousness. Thirty-eight (14.8%) of these 257 serious suicide attempters were older than 65. Material The data were obtained from the revision of each patient’s official psychiatric case history, plus exami nation of the case histories in the medical/surgical department and the psychiatric hospitalization unit, in those cases in which psychiatric admission was indi cated after medical discharge. Method At the time of their admission, all 257 patients had been seen by at least 2 psychiatrists (all suicide patients are seen routinely by a 4th-year psychiatry resident and a faculty member) and diagnosed according to
184
Table 1. Main diagnosis of the elderly suicide at tempters n
%
28 20 6 1 1
73.7 52.6 15.7 2.6 2.6
Nonaffective psychosis Schizophrenia
1 1
2.6 2.6
Other Adaptive disorder, depressed Substance abuse Personality disorder
8 5 1 2
21.0 13.1 2.6 5.2
No psychiatric disorder
1
2.6
Affective disorders Major depression, single episode Major depression, recurrent Bipolar disorder, depressed Dysthymia
DSM-III criteria [6]. Subsequently, the authors exam ined retrospectively a series of clinical and demo graphic variables. Diagnosis was modified in accor dance with DSM-III-R criteria [7], resulting in 2 cases of adaptive disorder with depressed mood who met criteria for major depression and 6 cases of schizophre nia that received a final diagnosis of schizoaffective disorder. Thirty-eight patients over 65 years of age were compared with 120 patients aged between 30 and 64 years and 99 aged under 30 years. The statistical technique used w'as the x2 test with Yates’ correction. DSM-III-R criteria were used for the main psy chiatric diagnosis. To facilitate statistical analysis, all patients were split up into three large diagnostic groups: (1) affective, including single episode major depression, recurrent major depression, bipolar disor der, schizoaffective disorder, dysthymia and organic affective disorder; (2) nonaffective psychotics, includ ing schizophrenia, schizophreniform disorder, brief reactive psychosis, delusional disorder and organic hallucinatory or delusional disorder; (3) group consist ing of the remainder of axis I diagnoses (mainly psy choactive substance abuse or dependence and adaptive disorders) and of those axis II diagnoses (mainly personality disorders) in which there was no comorbidity on axis I. Method of suicide was classified following the cri teria of Arora and Meltzer [8], in accordance with the violence of the attempt: nonviolent methods being vol untary self-poisoning with drugs or other substances
Nieto/Vlcta/Lázaro/Gastó/Cirera
Suicide in the Elderly
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 10:16:37 AM
[5]. On the other hand, because of the difficul ties involved in studying completed suicides, the analysis of the more medically serious forms of suicidal behavior takes on particular importance. The aim of this work was to determine the specific characteristics of nonfatal serious sui cidal behavior (that requiring hospitalization for medical or surgical reasons) among the elderly population.
Table 2. Demographic and clinical characteristics of the suicidal inpatients by age-group 0-30 years (n = 99)
31 -64 years ( n - 120)
More than 65 vears ( n - 38)
n
%
n
%
n
%
Male Female
60 39
60.6 39.4
60 60
50.0 50.0
17 21
44.7 55.3
Marital status Single Married Separated Widowed
84 10 5 0
84.8 10.1 5.1 0.0
37 51 23 9
30.8 42.5 19.2 7.5
4 8 5 21
10.5 21.1 13.2 55.3
Psychiatric diagnosis Diagnostic subtypes Affective Psychotic Other
98
98.9
118
98.3
37
97.3
27 60
11.5 27.2 60.6
57 27 34
47.5 22.5 28.3
28 1 8
73.7 2.6 21.0
Personality disorder Substance abuse Method of attempt Violent Nonviolent
45 18
45.5 18.2
25 24
21.8 20.0
6 2
15.8 5.3
48 51
48.5 51.5
46 74
38.3 61.7
12 26
.31.6 68.4
Seriousness Very' serious Less serious
18 81
18.2 81.8
46 74
38.3 61.7
16 22
42.1 57.9
Family history of suicide Previous attempts Previous treatment Physical illness
10 39 36 5
10.1 .39.4 36.4 5.1
10 54 70 19
8.3 45.0 58.3 15.8
5 14 12 19
13.2 36.8 31.6 50.0
Sex
11
pa
pb
NS
NS
0.0001
0.0001
NS 0.0001
NS 0.006
0.003 NS NS
NS NS NS
0.01
NS
NS NS NS
NS NS 0.008
0.0001
0.0001
a Level of significance when comparing young (0- to 30-year-old) vs. elderly (more than 65 years old). b Level of significance when comparing adults (31- to 64-year-old) vs. elderly (more than 65 years old).
Results Elderly patients accounted for 14.8% of all those who made serious suicide attempts. The average age was 73.34 years. Table 1 sets out the main psychiatric diagnosis of the 38 el derly suicidal patients. Table 2 sets out the results of the comparison between the elderly suicidal patients and the suicidal patients be
185
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and single cuts in the nondominant arm. Other meth ods (jumping from a height or to tube trains, hanging, shooting, piercing, and a combination of methods) were considered as violent. Medical seriousness of the attempt was divided in two categories: very serious, in the cases of multiple injuries or coma severe enough to require intensive surveillance; serious, in the rest of cases. With regard to the family history of suicide, every completed suicide of immediate and close relatives was taken into consideration.
Discussion Our study suffers from the classic limita tions of retrospective studies. Nevertheless, the risk of biases is probably reduced by the ‘hardness’ of the variables finally selected and the way they had been collected (this is, sys tematically). The percentage of elderly patients (14.8%) among the total admitted to medical and sur gical units as a result of attempted suicide falls between the figure pertaining to the suicide attempters seen in casualty departments (un der 5%) and that found in samples of com pleted suicide (30%) [9]. It seems clearly that as the lethality of suicidal behavior increases, so too does the percentage of elderly in the total sample. When comparing the marital status of the elderly suicidal patients with the marital sta tus of the other two groups’ patients, there were significant differences between the three groups, particularly with regard to the propor tion of widowed patients. These differences are probably related to age. Only 1 of the 38 elderly suicidal patients did not fulfil DSM-III-R criteria for any psy chiatric diagnosis. Of the remaining 37 pa tients, 35 received an axis 1 diagnosis, and 2 were diagnosed as suffering from personality disorder without diagnosis on axis 1. These figures seem to confirm previous studies indi cating that elderly peopple making nonfatal serious suicide attempts suffer almost all from a psychiatric disorder.
186
Almost 3 out of every 4 elderly patients who made a serious suicide attempt were suf fering from an affective disorder. This pro portion indicates clearly that in this group, clinical depression is absolutely, and sig nificantly - in comparison with other agegroups -, of prime importance as a determin ing factor in suicidal behavior. Similar results were found by Barraclough et al. [9] and by Robins et al. [10] in their studies on com pleted suicides. Only 1 of the 38 patients was suffering from a nonaffective psychotic disorder (2.6%). The importance of nonaffective psy chotic disorders (mainly schizophrenia) as a determining factor in suicidal behavior in the elderly population is therefore minimum, and significantly much less than that found in the other age-groups, where the percentages are over 20%. The presence of personality disorders in suicidal elderly patients (15.8%) is signifi cantly lower than that found in suicidal pa tients under 30 years of age (45.5%) and is also lower, although not significantly so, than that found in the 30- to 65-year-old group ( 21 . 8 % ). In our study we did not come across any elderly patient suffering from delirium or de mentia prior to the suicidal act. Our results are similar to those found by Pierce [11] and Merrill and Owens [ 1] and very different from those found in the first works [12-14]. Such discrepancies do not seem to be justifiable, although they could be due to several reasons. One is the lack of suitable diagnostic criteria at the time those works were done, with possi ble overlapping between the diagnoses of de mentia and depressive pseudodementia. Moreover, mental organic disorder could be the result of the suicidal act and not exist beforehand (we did not take these cases of postattempt mental organic disorders into consideration).
Nieto/Vieta/ Lázaro/Gastó/Ci rera
Suicide in the Elderly
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 10:16:37 AM
longing to other age-groups. Elderly suicide patients used the following methods of sui cide: 16(42 %) drug overdose. 8(21 %) domes tic poison (liquid or gas), 7 (18%) jumping. 4 (10%) jumping in front of tube train, 2 (5%) wrist cut and 1 (2.5%) piercing.
1990, unpubl. data] ideas of death were very infrequent (10.5%) and were very signifi cantly related (p < 0.0003) to psychiatric con ditions (affective or adaptive disorder with depressed mood being the main diagnoses). In our sample of elderly suicide attempters, 95% of those suffering from an organic illness pre sented depressive symptoms. Given the asso ciation between organic illness and depres sion in the elderly population [18], and be tween depression and suicidal behavior [19], it seems likely that the determining factor in suicidal behavior is ultimately the change in mood, and not the existence of a physical ill ness.
Conclusions Nonfatal serious suicidal behavior in the elderly is generally the result of a clinically sig nificant and treatable affective disorder. It should not, in principle, be attributed to phys ical illness, loneliness or just age. If one should not be nihilistic with any suicidal patient, par adoxically with the elderly there is even less reason to be so, as their suicidal behavior is usually secondary to a mental disorder (de pression) which has good prognosis if treated. Diagnosing affective disorders in the elderly is more difficult than in other times of life. To prevent suicidal behavior in the elderly, it would be a great help if general practitioners, as well as geriatric specialists and, of course, psychiatrists, were adequately trained and practiced in the diagnosis and treatment of depression, such a common disorder among this group of population.
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Elderly patients admitted as a result of attempted suicide showed a preference for nonviolent modes of suicidal behavior, al though the differences with the other agegroups were not significant. These results dif fer from those found by Conwell et al. [15] in completed suicides, as these authors point out that the elderly use violent methods. A possi ble explanation is that the choice of a violent method by elderly patients would imply a greater risk of death, which might determine a high rate of violent attempts in samples of completed suicide and a low rate in samples of noncompleted suicide. The elderly showed a more serious suicidal behavior in terms of lethality. This significantly higher medical se riousness could be related, in the elderly, to a higher intent to die [3] and to increased vul nerability to physical and chemical injuries [16]. Only 31 % of the elderly patients had been treated previously, while in the intermediate age-group this percentage rose to 58%, with a significant difference between both groups (p < 0.008). These figures show that major psychiatric disorders, especially the affective ones, are not adequately detected in the el derly population [17], Half of the elderly patients with serious suicidal behavior are suffering from some rel evant organic illness. These figures are signifi cantly higher than those found in the other two age-groups. This high incidence of or ganic illness in suicidal elderly people is com mon in most studies, both on attempted sui cide [1] and completed suicide [9], Since the incidence of physical illness increases with age, these results should not be considered as if suicidal behavior was a logical, common attitude in seriously ill elderly patients. They would rather indicate a relationship between aging and physical illness. In fact, in a recent study with a sample of 95 old people hospital ized due to physical illness [Lázaro et al.,
1 Merrill J. Owens J: Age and at tempted suicide. Acta Psychiatr Scand 1990:82:385-388. 2 Blazer DG. Bachar JR. Mantón KG: Suicide in late life. Review and com mentary. J Am Geriatr Soc 1986:34: 519-525. 3 Pierce DW: Suicidal intent in selfinjury. Br J Psychiatry 1977:130: 377-385. 4 Rodríguez F, De las Cuevas C, Henry M. Morilla J. Frugoni A. Al amo V. González de Rivera JL: Variables socio-demográficas y psi quiátricas de las tentativas de sui cidio atendidas en un hospital gen eral. Psiquis 1989:10:293-299. 5 Martí G: Epidemiología del suicidio consumado en Barcelona durante el año 1983. Rcv Psiquiatr Psicol Méd 1984;16:576-583. 6 American Psychiatric Association: Diagnostic and Statistical Manual of Psychiatric Association, ed 3. Wash ington. American Psychiatric Press, 1980. 7 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 3 revised. Washington, American Psychiatric Press, 1987.
8 Arora RC, Meltzer HY: Serotoner gic measures in the brain of suicidal victims: 5-HT2 binding sites in the frontal cortex of suicide victims and control subjects. Am J Psychiatry 1989:146:730-736. 9 Barraclough B. Bunh J, Nelson B. Sainsbury P: A hundred cases of sui cide: Clinical aspects. Br J Psychia try' 1974:125:355-373. 10 Robins E, Murphy GE. Wilkinson RH Jr, Gassncr S. Kays J: Some clinical considerations in the pre vention of suicide based on a study of 134 successful suicides. Am J Public Health 1959;49:888-899. 11 Pierce D: Deliberate self-harm in the elderly. Int J Geriatr Psychiatry 1987;2:105-110. 12 Batchelor IRC, Napier MB: At tempted suicide in old age. Br Med J 1953;ii: 1186. 13 O’Neill P. Robins E, Schmidt E: A psychiatric study of attempted sui cide in persons over sixty years of age. Arch Neurol Psychiatry 1965; 75:275-284.
14 Sendbuehler JM. Goldstein S: At tempted suicide among the aged. J Am Geriatr Soc 1977:252:245-248. 15 Conwell Y, Rotenberg M. Caine ED: Completed suicide at age 50 and over. J Am Geriatr Soc 1990:38: 640-644. 16 Davidson J: The pharmacologic treatment of psychiatric disorders in the elderly; in Busse EW, Blazer DG (eds): Geriatric Psychiatry. Wash ington, American Psychiatric Press. 1989. pp 5 16-517. 17 Lázaro L. Dc Pablo J. Nieto E. Vieta E, Vilalta J. Cirera E: Morbididad psiquiátrica en ancianos ingresados en un hospital general: Estudio prevalencia-día. Med Clin (Bare) 1991: 97:206-210. 18 Kennedy GJ, Kelman HR. Thomas C: Persistence and remission of de pressive symptoms in late life. Am J Psychiatry 1991:148:174-178. 19 Sainsbury P: Depression, suicide, and suicide prevention; in Roy A (ed): Suicide. Baltimore, Williams & Wilkins, 1986, pp 73-88.
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References
