Ativan* LORAZE PAM
Clinically 'different'... Pharmacokinetically 'distinct'. COMPOSITION: Ativan 1 mg-Each white, oblong, scored tablet contains: Lorazepam 1 mg. (Dl N 348325) Ativan 2 mg-Each white, ovoid, scored tablet contains: Lorazepam 2 mg. (DIN 348333) INDICATlONS: Ativan is useful for the short-term relief of manifestations of excessive anxiety in patients with anxiety neurosis. CONTRAINDICATIONS: Ativan is contraindicated in patients with known hypersensitivity to benzodiazepines and in patients with myasthenia gravis or acute narrow angle glaucoma. DOSAGE: The dosage of ATI VAN must be individualized and carefully titrated in order to avoid excessive sedation or mental and motor impairment. As with other anxiolytic sedatives, it is not recommended to prescribe or administer ATIVAN for periods in excess of six weeks, without followup and establishing the need for more prolonged administration ii, individual patients. Usual Adult Dosage: The recommended initial adult daily dosage is 2 mg in divided doses of 0.5 mg, 0.5 mg and 1.0 mg, or of 1 mg and 1 mg. The daily dosage should be carefully increased or decreased by 0.5 mg depending upon tolerance and response. The usual daily dosage is 2 to 3 mg. However, the optimal dosage may range from 1 to 4 mg daily in individual patients. Usually, a daily dosage of 6 mg should not be exceeded. Elderly and Debilitated Patients: The initial daily dose in these patients should not exceed 0.5 mg and'should be very carefully and gradually adjusted, depending upon tolerance and response. PRECAUTIONS: Use in the Elderly: Elderly and debilitated patients, or those with organic brain syndrome, have been found to be prone to CNS depression after even low doses of benzodiazepines. Therefore, medication should be initiated in these patients with very low initial doses, and increments should be made gradually, depending on the response of the patient, in order to avoid oversedation or neurological impairment. Dependence Liability: Ativan should not be administered to individuals prone to drug abuse. Caution should be observed in patients who are considered to have potential for psychological dependence. It is suggested that the drug should be withdrawn gradually if it has been used in high dosage. Use in Mental and Emotional bisorders: Ativan is not recommended for the treatment of psychotic or depressed patients. Since excitement and other paradoxical reactions can result from the use of these drugs in psychotic patients, they should not be used in ambulatory patientssuspected of having psychotic tendencies. ADVERSE EFFECTS: The side effect most frequently reported was drowsiness. Other reported side effects were dizziness, weakness, fatigue and lethargy, disorientation, ataxia, anterograde amnesia, nausea, change in appetite, change in weight, depression, blurred vision and diplopia, psychomotor agitation, sleep disturbance, vomiting, sexual disturbance, headache, skin rashes, gastrointestinal, ear, nose and throat, musculoskeletal and respiratory disturbances. REFERENCES: 1. Singh, A.N., and Saxena, B.: "A Comparison of Lorazepam, Diazepam and Placebo in the Treatment of Anxiety States:' Curr. Ther. Res. 1974, 16, 149. 2. Nanivadekar, A.S. et al,: "A Multicenter Investigation of Lorazepam in Anxiety Neurosis.' Curr. Ther. Res. 1973, Vol. 15, No. 7, p. 505. 3. Okasha, A., Sadek, A.: "A Comparison of Lorazepam, Diazepam and Placebo in Anxiety States." J. Int. Med. Res. 1: 162-165, 1973. 4. Haider, I.: "A Comparative Trial of Lorazepam and Diazepam" Brit. J. Psychiat. 119: 599-600, 1971. 5. Greenblatt, D.J.etal,:"Clinical Pharmacokinetics of Lorazepam." Clin. Pharmacol. and Therapeutics, 1976, Vol. 20, No. 3, p. 338. 6. Ibid. p. 333. 7. Greenblatt, D.J., and Shader, RI., (1974) "Benzodiazepines in Clinical Practice" New York: Raven Press, 4, p. 78. Full product information available on request.
Wyeth AA Wyelh Lid. Reg d Trade Mark
in the Museum for the History of Medicine, at the Academy of Medicine, Toronto, and together with relevant material has become part of a teaching paleopathologic exhibit dedicated to disease in ancient times, sponsored by the ROM and the Academy of Medicine, Toronto.
AIDAN COCKBURN, MD Paleopathology Association 18655 Parkside Detroit, MI N.B. MILLET, PH D Curator, Egyptian department Royal Ontario Museum Toronto, Ont. JOHN W. SCOTT, MD Department of physiology University of Toronto Toronto, Ont.
GERALD D. HART, MD Toronto East General and Orthopaedic Hospital Toronto, Ont.
Suicide and attempted suicide among the aged In general, the ratio of attempted to actual suicide is approximately 10 to 1, but this is not true of persons over 65 years of age. In this group, which constitutes 9% of the general population, the ratio is reversed: suicide by the elderly accounts for 25% of all suicides, and suicide attempts in the elderly make up only 5% of those among all ages.14 What is the reason for this, and does this statistical phenomenon shed light on the underlying disease processes that manifest themselves as suicide and attempted suicide? To answer these questions one must use a comprehensive method of study that is broad and meaningful on epidemiologic, psychiatric and psychologic bases. One such method is that used by Douglas,6 who has described a "building up of statistics". My colleagues and I endorse this method; we used it from 1963 to 1970 to study patients who attempted suicide, were in danger of dying and subsequently survived.7" It is tedious and expensive to collect and classify data for patients who attempt suicide in large enough samples to be statistically meaningful, and then have the same sample of material available for clinical, psychiatric, psychologic and medical study. But unhurried compilation and selection of data for all patients admitted to the medical and surgical units of a general hospital does dispel the emotional taboos frequently manifest after a "suicide study" with its inherent publicity and artificial time limits accorded by grants or funding agencies. This method of study has proved valuable in demonstrating the structure and composition of the demographic region that has provided the clinical material' and has permitted comparison of this material with the collected sample so as to provide information on the etiology of the disease under study. Comparison has shown that those who attempt suicide have the same characteristics as the normal population with respect to
418 CMA JOURNAL/SEPTEMBER 3, 1977/VOL. 117
age, sex, marital status, ethnic group, religion and social class. The origin of our sample is unmistakably evident from such similarities and gives credence to the view that attempted suicide among persons over 65 years of age is rare.7'10'11 This is also substantiated in the literature.3'5'12 Analysis of the age distribution spectrum of those who attempt suicide discloses an underrepresentation before the age of 15 years and an overrepresentation for both sexes between the ages of 15 and 35 and a trend towards underrepresentation thereafter. The underrepresentation is noteworthy among females.7 The importance of physical illness as a factor in suicide in the elderly has been noted.4A.ls1l.le Among those who attempt suicide a high proportion have medical illness by the age of 65 and appear to manifest more illness than the normal population of the same age. In fact, among older persons they have definite characteristics. They have more physical disorders of metabolic, cardiovascular and respiratory origin, and about half have organic brain disease, compared with only 5 to 10% in the normal population over age 60. Some investigators hold a different opinion - that, in the elderly, suicide attempts are not typical of organic brain syndrome. Also, manic-depressive illness (psychosis) becomes more evident in older persons than schizophrenia, which is rare in old age.11'" Psychopathologic elements of the presuicidal state of older patients can be considered serious.13'14 The method of attempt is usually exotic and bizarre; more jumping, cutting and violent acts are evident - for example, aimless wandering through rush-hour traffic. Such persons give no cry for help, no external communication; rather such signs are replaced by internal or delusional elements. Organic brain syndrome, it seems, actually interferes with the success of the plan for suicide,
and more unsuccessful attempts result. In those in whom organic brain syndrome is superimposed on their illness, compared with those without organic brain syndrome, even fewer precipitating stressful events trigger the suicide attempt. They are thus less able to sustain stress and change. Multiple losses, such as loss of status, spouse and health, in rapid sequence are particularly hard to endure, epecially in old age.11 Organic brain syndrome can be detected clinically when, at the time of the suicidal act, clouding of consciousness or an acute confusional state supervenes. This state can be transient, lasting from 2 to 3 days to a few weeks or longer. The poor medical condition of these patients may contribute to the bewilderment, stupor and hallucination. In cooperative persons with less obvious organic brain syndrome, the Minnesota Multiphasic Personality Inventory may establish the degree of suicidal risk with accuracy.18 Such findings suggest that successful suicide usually requires coordination, planning, determination and reality testing. Therefore individuals devoid of these abilities and with impaired judgement and deterioration of intellectual capacities will tend to be unsuccessful in committing suicide. Their judgement then may be so poor that they may even deny having attempted suicide in the face of obvious evidence. The elderly survivors seem to be more helpless and hopeless, having a generally negative approach towards life. They may ruminate about death a great deal. At times, having the same physical illness that contributed to a parent's death, together with the mystique of the death date (anniversary), drives a person to "rejoin" loved ones in the life hereafter. To such a person this is not attempted suicide and any such thoughts will be denied, the person only waiting for a chance to do it again. There is general agreement about the need for early detection of depression in the elderly to prevent suicide. Barraclough,19 who reported a study of 26 cases of suicide in persons over 65 years of age, noted that the intensity of symptoms was not severe and that the patients were not regarded as being actively suicidal by their relatives or doctors. We are thus faced with a paradox. It appears that those who attempt suicide manifest a more severe psychopathologic disorder and a higher incidence of psychosis than those who succeed. This highlights the seriousness of both groups in trying to kill themselves, and the interference of psychopathologic factors in the success of the attempt. Careful evaluation of the findings indicates that older people are faced
with a finality of life and do not have to make up their minds about dying. Gestures or ambivalent suicide attempts are therefore not the rule. An aged body racked with an untreated or Untreatable illness and a serious, usually affective, psychiatric disorder certainly can hasten thoughts of termination of life. One might think that Spencer was wrong - that here it is a case of survival of the unfittest. This is only an illusion, however, because survival of the elderly is based on our recognition of the problem and vigorous medical and psychiatric treatment. An attempt at suicide that is made unsuccessful by the organic brain syndrome should be considered as a distorted call for help or a second chance for the medical profession to rectify matters. J.M. SENDBUEHLER, MD Royal Ottawa Hospital and University of Ottawa Ottawa, Ont.
References 1. LEVIN S: Depression in the aged, in Geriatric Psychiatry: Grief, Loss and Emotional Disorders in the Aging Process, BEREGIN MA, CATH S (eds), New York, Intl Univs Pr, 1967 2. CATH 5: A survey of selected geriatricpsychiatric facilities in northern Europe. II. Scandinavia. III. Holland and France. IV.
3. 4. 5. 6. 7.
Summary. I Am Geriatr Soc Ii: 682, 1963 WOLF FK: Depression and suicide in the geriatric patient. I Am Geriatr Soc 17: 668, 1969 World Health Organization: Psycho eriatrics: report on a WHO scientific group. Tech Rep Ser no 507, 1970 REsNICK H, CANTOR J: Suicide and aging. I Am Geriatr Soc 18: 152, 1970 DouGLAs J: The Social Meaning of Suicide, Princeton, Princeton U Pr, 1967, pp 163-231 SENDBUEHLER JM, BLAND A. NEMETH 0: Attempted suicide: some statistical and psychiatric parameters. Part I. Dis Nerv Sys
31 (GWAN suppl): 59, 1970 8. SENDBUEHLER JM: Attempted suicide: facts and theories. Dis Nerv Sys 30 (GWAN
suppi): 111, 1969 9. Montreal Council of Social Agencies: Sixty Major Study Areas and Their Comparative Socio-economic Profiles, Research dept spec rep ser NR 672, July 1968 10. SENDBUEHLER JM, BERNSTEIN J, NEMETH G: Attempted suicide and social class. I. Can
Psychiatr Assoc 1 17 (suppi 2): SS185, 1972 11. SENDBUEHLER JM, GOLDsTEIN 5: Attempted suicide among the aged. I Am Geriatr Soc 25: 245, 1977 12. GARDNER E, BAHN A, MACK M: Suicide and psychiatric care in the aging. Arch Gen Psychiatry 10: 547, 1964 13. SENDBUEHLER JM: Attempted suicide: a description of the pre and post suicidal states. Can Psychiatr Assoc 1 18: 113, 1973 14. SENDBUEHLER JM, KINCEL RL, NEMETH G: Attempted suicide: varieties of the pre- and post-suicidal state. Paper presented at VI World Conference of Psychiatry, Honolulu, Aug 28-Sept 3, 1977 15. KAY DWK, WALK A (eds): Recent developments in psycho-geriatrics. Br I Psychiatry spec pubi 6, 1971 16. MURPHY GE, RosINs E: Social factors in
suicide. JAMA 199: 303, 1967 17. BEAUREJOUR P, SaNDauamas JM, HOGAN T, et al: Attempted Suicide and Physical Illness,
Woodstock, Ontario Gov Pubis, 1973 18. SENDBUEHLER JM, KINCEL RL, NEMETH G, et al: Dimensions of seriousness in attempted suicide - the significance of the Mf scale in suicidal MMPI profiles. Paper presented at IX International Congress on Suicide Prevention and Crisis Intervention, Helsinki, June 1977 19. BARRACLOUGH BM: Suicide in the elderly, in KAY DWK, WALK A (eds): Recent developments in psycho-geriatrics. Br I Psychiatry
spec publ 6: 87, 1971
ATASOL
Non-ASA Analgesic/Antipyretic With or Without Codeine Acetaminophen INDICATIONS For the relief of mild to moderate pain of various causes as in: headache, migraine, dental pain, dysmenorrhea, myalgias and neuralgias. Also useful as an antipyretic when fever accompanies painful conditions. CONTRAINDICATIONS Repeated administration to patients with anemia or with cardiac, pulmonary, renal or hepatic disease is contraindicated. PRECAUTIONS It has been reported that acetaminophen potentiates the action of warfarin-type anticoagulants if administered several times daily over a two-week period. This should be borne in mind if the two drugs are administered concurrently. Renal damage has not been reported following the use of acetaminophen in therapeutic doses, but the chemical relationship of this drug to phenacetin cautions against its use in large amounts over protracted periods of time. Although tolerance and addiction to codeine are rare, S Atasol-iS and@ Atasol-30 should be prescribed cautiously to addiction-prone individuals. The drug should be administered with caution since the depressant effects of codeine may be enhanced by concurrent administration of sedatives and tranquilizers. ADVERSE REACTIONS These are usually mild and rare. GI. upset, usually rarer than after salicylate administration, and skin reactions are known, and anemia has been reported after chronic ingestion. Usually after larger doses, codeine may cause gi. symptoms of nausea, vomiting and constipation. DOSAGE AND ADMINISTRATION ATASOL TABLETS 325 mg acetaminophen Adults: 1-3 tablets daily Children: 10-14 years, one-half tablet, 3 times daily ATASOL FORTE TABLETS 500 mg acetaminophen Adults: 1-2 tablets as directed by a physician, up to a maximum of 5 tablets daily ATASOL LIQUID 108 mg acetaminophen/5 ml Children: 5-9 years, usual dose, 1 teaspoon 3 times daily or as directed by a physician to a maximum of 2 teaspoonsful 4 times daily 2-4 years, usual dose, one-half teaspoon 3 times daily or as directed by a physician up to a maximum of 1 teaspoon 4 times daily ATASOL DROPS 54 mg acetaminophen/0.6 ml Children: 2-4 years, usual dose 0.6 ml 3 times daily or as directed by a physician up to a maximum of 1.2 ml 4 times daily 1-2 years, as directed by a physician up to a maximum of 0.6 ml 4 times daily under 1 year, as directed by a physician up to a maximum of 0.3 ml 4 times daily * ATASOL-8 325 mg acetaminophen 8 mg codeine phosphate 30 mg caffeine citrate Adults: usual dose, 1 tablet 3 times daily or as directed by a physician up to a maximum of 2 tablets 4 times daily Children: 10-14 years, usual dose, one-half tablet 3 times daily or as directed by a physician up to a maximum of 1 tablet 4 times daily * ATASOL-15 325 mg acetaminophen 15 mg codeine phosphate 30 mg caffeine citrate Adults: 2 to 4 tablets daily or as directed by a physician * ATASOL-30 325 mg acetaminophen 30 mg codeine phosphate 30 mg caffeine citrate Adults: 2 to 4 tablets daily or as directed by a physician Full information available on request
.HORflER Montreal. Canada
Prepared by: F.H. HayhUrst Ad No: FWH-77-117E
CMA JOURNAL/SEPTEMBER 3, 1977/VOL. 117 419
Clinically 'different'... Pharmacokinetically 'distinct'. COMPOSITION: Ativan 1 mg-Each white, oblong, scored tablet contains: Lorazepam 1 mg. (Dl N 348325) Ativan 2 mg-Each white, ovoid, scored tablet contains: Lorazepam 2 mg. (DIN 348333) INDICATlONS: Ativan is useful for the short-term relief of manifestations of excessive anxiety in patients with anxiety neurosis. CONTRAINDICATIONS: Ativan is contraindicated in patients with known hypersensitivity to benzodiazepines and in patients with myasthenia gravis or acute narrow angle glaucoma. DOSAGE: The dosage of ATI VAN must be individualized and carefully titrated in order to avoid excessive sedation or mental and motor impairment. As with other anxiolytic sedatives, it is not recommended to prescribe or administer ATIVAN for periods in excess of six weeks, without followup and establishing the need for more prolonged administration ii, individual patients. Usual Adult Dosage: The recommended initial adult daily dosage is 2 mg in divided doses of 0.5 mg, 0.5 mg and 1.0 mg, or of 1 mg and 1 mg. The daily dosage should be carefully increased or decreased by 0.5 mg depending upon tolerance and response. The usual daily dosage is 2 to 3 mg. However, the optimal dosage may range from 1 to 4 mg daily in individual patients. Usually, a daily dosage of 6 mg should not be exceeded. Elderly and Debilitated Patients: The initial daily dose in these patients should not exceed 0.5 mg and'should be very carefully and gradually adjusted, depending upon tolerance and response. PRECAUTIONS: Use in the Elderly: Elderly and debilitated patients, or those with organic brain syndrome, have been found to be prone to CNS depression after even low doses of benzodiazepines. Therefore, medication should be initiated in these patients with very low initial doses, and increments should be made gradually, depending on the response of the patient, in order to avoid oversedation or neurological impairment. Dependence Liability: Ativan should not be administered to individuals prone to drug abuse. Caution should be observed in patients who are considered to have potential for psychological dependence. It is suggested that the drug should be withdrawn gradually if it has been used in high dosage. Use in Mental and Emotional bisorders: Ativan is not recommended for the treatment of psychotic or depressed patients. Since excitement and other paradoxical reactions can result from the use of these drugs in psychotic patients, they should not be used in ambulatory patientssuspected of having psychotic tendencies. ADVERSE EFFECTS: The side effect most frequently reported was drowsiness. Other reported side effects were dizziness, weakness, fatigue and lethargy, disorientation, ataxia, anterograde amnesia, nausea, change in appetite, change in weight, depression, blurred vision and diplopia, psychomotor agitation, sleep disturbance, vomiting, sexual disturbance, headache, skin rashes, gastrointestinal, ear, nose and throat, musculoskeletal and respiratory disturbances. REFERENCES: 1. Singh, A.N., and Saxena, B.: "A Comparison of Lorazepam, Diazepam and Placebo in the Treatment of Anxiety States:' Curr. Ther. Res. 1974, 16, 149. 2. Nanivadekar, A.S. et al,: "A Multicenter Investigation of Lorazepam in Anxiety Neurosis.' Curr. Ther. Res. 1973, Vol. 15, No. 7, p. 505. 3. Okasha, A., Sadek, A.: "A Comparison of Lorazepam, Diazepam and Placebo in Anxiety States." J. Int. Med. Res. 1: 162-165, 1973. 4. Haider, I.: "A Comparative Trial of Lorazepam and Diazepam" Brit. J. Psychiat. 119: 599-600, 1971. 5. Greenblatt, D.J.etal,:"Clinical Pharmacokinetics of Lorazepam." Clin. Pharmacol. and Therapeutics, 1976, Vol. 20, No. 3, p. 338. 6. Ibid. p. 333. 7. Greenblatt, D.J., and Shader, RI., (1974) "Benzodiazepines in Clinical Practice" New York: Raven Press, 4, p. 78. Full product information available on request.
Wyeth AA Wyelh Lid. Reg d Trade Mark
in the Museum for the History of Medicine, at the Academy of Medicine, Toronto, and together with relevant material has become part of a teaching paleopathologic exhibit dedicated to disease in ancient times, sponsored by the ROM and the Academy of Medicine, Toronto.
AIDAN COCKBURN, MD Paleopathology Association 18655 Parkside Detroit, MI N.B. MILLET, PH D Curator, Egyptian department Royal Ontario Museum Toronto, Ont. JOHN W. SCOTT, MD Department of physiology University of Toronto Toronto, Ont.
GERALD D. HART, MD Toronto East General and Orthopaedic Hospital Toronto, Ont.
Suicide and attempted suicide among the aged In general, the ratio of attempted to actual suicide is approximately 10 to 1, but this is not true of persons over 65 years of age. In this group, which constitutes 9% of the general population, the ratio is reversed: suicide by the elderly accounts for 25% of all suicides, and suicide attempts in the elderly make up only 5% of those among all ages.14 What is the reason for this, and does this statistical phenomenon shed light on the underlying disease processes that manifest themselves as suicide and attempted suicide? To answer these questions one must use a comprehensive method of study that is broad and meaningful on epidemiologic, psychiatric and psychologic bases. One such method is that used by Douglas,6 who has described a "building up of statistics". My colleagues and I endorse this method; we used it from 1963 to 1970 to study patients who attempted suicide, were in danger of dying and subsequently survived.7" It is tedious and expensive to collect and classify data for patients who attempt suicide in large enough samples to be statistically meaningful, and then have the same sample of material available for clinical, psychiatric, psychologic and medical study. But unhurried compilation and selection of data for all patients admitted to the medical and surgical units of a general hospital does dispel the emotional taboos frequently manifest after a "suicide study" with its inherent publicity and artificial time limits accorded by grants or funding agencies. This method of study has proved valuable in demonstrating the structure and composition of the demographic region that has provided the clinical material' and has permitted comparison of this material with the collected sample so as to provide information on the etiology of the disease under study. Comparison has shown that those who attempt suicide have the same characteristics as the normal population with respect to
418 CMA JOURNAL/SEPTEMBER 3, 1977/VOL. 117
age, sex, marital status, ethnic group, religion and social class. The origin of our sample is unmistakably evident from such similarities and gives credence to the view that attempted suicide among persons over 65 years of age is rare.7'10'11 This is also substantiated in the literature.3'5'12 Analysis of the age distribution spectrum of those who attempt suicide discloses an underrepresentation before the age of 15 years and an overrepresentation for both sexes between the ages of 15 and 35 and a trend towards underrepresentation thereafter. The underrepresentation is noteworthy among females.7 The importance of physical illness as a factor in suicide in the elderly has been noted.4A.ls1l.le Among those who attempt suicide a high proportion have medical illness by the age of 65 and appear to manifest more illness than the normal population of the same age. In fact, among older persons they have definite characteristics. They have more physical disorders of metabolic, cardiovascular and respiratory origin, and about half have organic brain disease, compared with only 5 to 10% in the normal population over age 60. Some investigators hold a different opinion - that, in the elderly, suicide attempts are not typical of organic brain syndrome. Also, manic-depressive illness (psychosis) becomes more evident in older persons than schizophrenia, which is rare in old age.11'" Psychopathologic elements of the presuicidal state of older patients can be considered serious.13'14 The method of attempt is usually exotic and bizarre; more jumping, cutting and violent acts are evident - for example, aimless wandering through rush-hour traffic. Such persons give no cry for help, no external communication; rather such signs are replaced by internal or delusional elements. Organic brain syndrome, it seems, actually interferes with the success of the plan for suicide,
and more unsuccessful attempts result. In those in whom organic brain syndrome is superimposed on their illness, compared with those without organic brain syndrome, even fewer precipitating stressful events trigger the suicide attempt. They are thus less able to sustain stress and change. Multiple losses, such as loss of status, spouse and health, in rapid sequence are particularly hard to endure, epecially in old age.11 Organic brain syndrome can be detected clinically when, at the time of the suicidal act, clouding of consciousness or an acute confusional state supervenes. This state can be transient, lasting from 2 to 3 days to a few weeks or longer. The poor medical condition of these patients may contribute to the bewilderment, stupor and hallucination. In cooperative persons with less obvious organic brain syndrome, the Minnesota Multiphasic Personality Inventory may establish the degree of suicidal risk with accuracy.18 Such findings suggest that successful suicide usually requires coordination, planning, determination and reality testing. Therefore individuals devoid of these abilities and with impaired judgement and deterioration of intellectual capacities will tend to be unsuccessful in committing suicide. Their judgement then may be so poor that they may even deny having attempted suicide in the face of obvious evidence. The elderly survivors seem to be more helpless and hopeless, having a generally negative approach towards life. They may ruminate about death a great deal. At times, having the same physical illness that contributed to a parent's death, together with the mystique of the death date (anniversary), drives a person to "rejoin" loved ones in the life hereafter. To such a person this is not attempted suicide and any such thoughts will be denied, the person only waiting for a chance to do it again. There is general agreement about the need for early detection of depression in the elderly to prevent suicide. Barraclough,19 who reported a study of 26 cases of suicide in persons over 65 years of age, noted that the intensity of symptoms was not severe and that the patients were not regarded as being actively suicidal by their relatives or doctors. We are thus faced with a paradox. It appears that those who attempt suicide manifest a more severe psychopathologic disorder and a higher incidence of psychosis than those who succeed. This highlights the seriousness of both groups in trying to kill themselves, and the interference of psychopathologic factors in the success of the attempt. Careful evaluation of the findings indicates that older people are faced
with a finality of life and do not have to make up their minds about dying. Gestures or ambivalent suicide attempts are therefore not the rule. An aged body racked with an untreated or Untreatable illness and a serious, usually affective, psychiatric disorder certainly can hasten thoughts of termination of life. One might think that Spencer was wrong - that here it is a case of survival of the unfittest. This is only an illusion, however, because survival of the elderly is based on our recognition of the problem and vigorous medical and psychiatric treatment. An attempt at suicide that is made unsuccessful by the organic brain syndrome should be considered as a distorted call for help or a second chance for the medical profession to rectify matters. J.M. SENDBUEHLER, MD Royal Ottawa Hospital and University of Ottawa Ottawa, Ont.
References 1. LEVIN S: Depression in the aged, in Geriatric Psychiatry: Grief, Loss and Emotional Disorders in the Aging Process, BEREGIN MA, CATH S (eds), New York, Intl Univs Pr, 1967 2. CATH 5: A survey of selected geriatricpsychiatric facilities in northern Europe. II. Scandinavia. III. Holland and France. IV.
3. 4. 5. 6. 7.
Summary. I Am Geriatr Soc Ii: 682, 1963 WOLF FK: Depression and suicide in the geriatric patient. I Am Geriatr Soc 17: 668, 1969 World Health Organization: Psycho eriatrics: report on a WHO scientific group. Tech Rep Ser no 507, 1970 REsNICK H, CANTOR J: Suicide and aging. I Am Geriatr Soc 18: 152, 1970 DouGLAs J: The Social Meaning of Suicide, Princeton, Princeton U Pr, 1967, pp 163-231 SENDBUEHLER JM, BLAND A. NEMETH 0: Attempted suicide: some statistical and psychiatric parameters. Part I. Dis Nerv Sys
31 (GWAN suppl): 59, 1970 8. SENDBUEHLER JM: Attempted suicide: facts and theories. Dis Nerv Sys 30 (GWAN
suppi): 111, 1969 9. Montreal Council of Social Agencies: Sixty Major Study Areas and Their Comparative Socio-economic Profiles, Research dept spec rep ser NR 672, July 1968 10. SENDBUEHLER JM, BERNSTEIN J, NEMETH G: Attempted suicide and social class. I. Can
Psychiatr Assoc 1 17 (suppi 2): SS185, 1972 11. SENDBUEHLER JM, GOLDsTEIN 5: Attempted suicide among the aged. I Am Geriatr Soc 25: 245, 1977 12. GARDNER E, BAHN A, MACK M: Suicide and psychiatric care in the aging. Arch Gen Psychiatry 10: 547, 1964 13. SENDBUEHLER JM: Attempted suicide: a description of the pre and post suicidal states. Can Psychiatr Assoc 1 18: 113, 1973 14. SENDBUEHLER JM, KINCEL RL, NEMETH G: Attempted suicide: varieties of the pre- and post-suicidal state. Paper presented at VI World Conference of Psychiatry, Honolulu, Aug 28-Sept 3, 1977 15. KAY DWK, WALK A (eds): Recent developments in psycho-geriatrics. Br I Psychiatry spec pubi 6, 1971 16. MURPHY GE, RosINs E: Social factors in
suicide. JAMA 199: 303, 1967 17. BEAUREJOUR P, SaNDauamas JM, HOGAN T, et al: Attempted Suicide and Physical Illness,
Woodstock, Ontario Gov Pubis, 1973 18. SENDBUEHLER JM, KINCEL RL, NEMETH G, et al: Dimensions of seriousness in attempted suicide - the significance of the Mf scale in suicidal MMPI profiles. Paper presented at IX International Congress on Suicide Prevention and Crisis Intervention, Helsinki, June 1977 19. BARRACLOUGH BM: Suicide in the elderly, in KAY DWK, WALK A (eds): Recent developments in psycho-geriatrics. Br I Psychiatry
spec publ 6: 87, 1971
ATASOL
Non-ASA Analgesic/Antipyretic With or Without Codeine Acetaminophen INDICATIONS For the relief of mild to moderate pain of various causes as in: headache, migraine, dental pain, dysmenorrhea, myalgias and neuralgias. Also useful as an antipyretic when fever accompanies painful conditions. CONTRAINDICATIONS Repeated administration to patients with anemia or with cardiac, pulmonary, renal or hepatic disease is contraindicated. PRECAUTIONS It has been reported that acetaminophen potentiates the action of warfarin-type anticoagulants if administered several times daily over a two-week period. This should be borne in mind if the two drugs are administered concurrently. Renal damage has not been reported following the use of acetaminophen in therapeutic doses, but the chemical relationship of this drug to phenacetin cautions against its use in large amounts over protracted periods of time. Although tolerance and addiction to codeine are rare, S Atasol-iS and@ Atasol-30 should be prescribed cautiously to addiction-prone individuals. The drug should be administered with caution since the depressant effects of codeine may be enhanced by concurrent administration of sedatives and tranquilizers. ADVERSE REACTIONS These are usually mild and rare. GI. upset, usually rarer than after salicylate administration, and skin reactions are known, and anemia has been reported after chronic ingestion. Usually after larger doses, codeine may cause gi. symptoms of nausea, vomiting and constipation. DOSAGE AND ADMINISTRATION ATASOL TABLETS 325 mg acetaminophen Adults: 1-3 tablets daily Children: 10-14 years, one-half tablet, 3 times daily ATASOL FORTE TABLETS 500 mg acetaminophen Adults: 1-2 tablets as directed by a physician, up to a maximum of 5 tablets daily ATASOL LIQUID 108 mg acetaminophen/5 ml Children: 5-9 years, usual dose, 1 teaspoon 3 times daily or as directed by a physician to a maximum of 2 teaspoonsful 4 times daily 2-4 years, usual dose, one-half teaspoon 3 times daily or as directed by a physician up to a maximum of 1 teaspoon 4 times daily ATASOL DROPS 54 mg acetaminophen/0.6 ml Children: 2-4 years, usual dose 0.6 ml 3 times daily or as directed by a physician up to a maximum of 1.2 ml 4 times daily 1-2 years, as directed by a physician up to a maximum of 0.6 ml 4 times daily under 1 year, as directed by a physician up to a maximum of 0.3 ml 4 times daily * ATASOL-8 325 mg acetaminophen 8 mg codeine phosphate 30 mg caffeine citrate Adults: usual dose, 1 tablet 3 times daily or as directed by a physician up to a maximum of 2 tablets 4 times daily Children: 10-14 years, usual dose, one-half tablet 3 times daily or as directed by a physician up to a maximum of 1 tablet 4 times daily * ATASOL-15 325 mg acetaminophen 15 mg codeine phosphate 30 mg caffeine citrate Adults: 2 to 4 tablets daily or as directed by a physician * ATASOL-30 325 mg acetaminophen 30 mg codeine phosphate 30 mg caffeine citrate Adults: 2 to 4 tablets daily or as directed by a physician Full information available on request
.HORflER Montreal. Canada
Prepared by: F.H. HayhUrst Ad No: FWH-77-117E
CMA JOURNAL/SEPTEMBER 3, 1977/VOL. 117 419
