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Suicidal tendencies in late life depression

Suicides in elderly, suicides in elderly depression

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Suicidal tendencies in late life depression

  1. 1. Suicidal tendencies in elderly and suicide prevention in general Dr Ravi Soni DM-SR II Dept. of Geriatric Mental Health KGMU, LKO
  2. 2. 2 38.1 29.1 29.6 28.5 28.6 29.5 29.4 18 17.9 17.2 16.8 15.2 15.3 14.3 14.7 14.2 14.3 14.8 14.8 5.8 5.4 5.4 4.8 4.8 4.7 4.3 4 3.9 4.1 3.8 3.8 4 3.9 3.9 4.1 4 36.5 36.2 29.8 31.831.431.132.2 33.8 34.235.1 18.9 15.6 14.6 16.7 15.8 0 5 10 15 20 25 30 35 40 45 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Ratesper100,000 Males All Genders Females Centers for Disease Control, WISQARS. http://www.cdc.gov/injury/wisqars/index.html U.S Suicide Rates by Gender, Age 65+
  3. 3. 3 0 5 10 15 20 25 30 35 40 45 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year Rateper100,000 Males 65+ Male All Ages Total 65+ All Ages & Gender Female All Ages Females 65+ U.S Suicide Rates of All Ages and Those 65+, by Gender Centers for Disease Control, WISQARS. http://www.cdc.gov/injury/wisqars/index.html
  4. 4. 4 Attitudes Towards Elderly Suicide • Society is more accepting of death and dying with the elderly compared to adolescents: years of potential life lost much greater • Less media attention towards elderly suicides • Less attention in research and literature compared to adolescents and young adults PubMed search of almost 10,000 articles from 1966-1999 21.4% included Ages 65+ (of these, 3.1% were 80+) Conwell, Y., & Duberstein, P. (2001). Suicide in Elders, Annals NY Academy of Science, 932: 132-47.
  5. 5. Elderly suicides in India: Statistics • Completed suicides for ages 65 and over comprise nearly 10% of all suicides – This age group is 10% of total Indian population [CENSUS 2011] • In India, there is low prevalence of Suicides in elderly because – Aged are well-integrated and respected in the family – Children take responsibility for their care – Life expectancy in the elderly is lower in India than elsewhere, contributing to the comparatively lower suicide rate. • The ratio of completed suicide to attempted suicide in India is about 1:7 in the elderly, which is double the ratio of 1:15 in lower age groups.
  6. 6. Elderly suicides in India: Statistics • Male:Female suicide ratio in elderly in India is 1.4:1 • Mode of suicide: – Poisoning [33.6%] – Hanging [31.5%] – Self immolation [9.2%] – Drowning [6.1%] – Jumping from the building [1.5%] • As 70% of elderly men who die by suicide do not have history of previous suicide attempt it is said that elderly are at a very high risk for completed suicide and it is difficult to detect them as they do not have history of previous attempts.
  7. 7. 7 Characteristics of Elderly Suicide • Fewer warnings of intent • Attempts are more planned, determined 2/3 have high suicide intent scores • Less likely to survive a suicide attempt due to use of more violent and immediate methods • More likely to have suffered from a depressive diagnosis prior to their suicide compared to younger counterparts • Suicidal ideation less common in elderly (studies range from 1 to 36%) • Ratio of attempts to completed suicide range from 7:1 Conwell Y, Duberstein PR, Cox C, Herrmann J, Forbes N, & Caine ED. Age differences in behaviors leading to completed suicide. American Journal of Geriatric Psychiatry, 1998 6(2), 122-6.
  8. 8. 8 Risk Factors • Previous suicide attempt • Psychiatric disorders [depression, substance use disorders, dementia (conflictual data)] (77% of suicides, 63% of those were depressed) • Physical illness and functional impairment • Other illnesses associated with an increased risk are: severe pain congestive heart failure chronic lung disease seizures but not: diabetes, breast cancer, prostate cancer • A patient with three or more illnesses had a three-fold increase in risk for suicide • Personality traits of neuroticism • Social isolation and decreased social support
  9. 9. Risk factors contd….. • The effect of spousal loss on suicidality is most pronounced in elderly men. Oldest old men (age 80+) experience highest increase in suicide risk immediately after the loss • In the 60–90 year old age group, the rates of suicide attempts associated with untreated mood disorders increase with each subsequent decade. • Causes of suicidal ideation in elderly with medical illness: – Untreated or undertreated pain, – anticipatory anxiety regarding the progression of medical illness, – fear of dependence and burdening the family • Suicidal ideation is less without depression in the terminally ill. • Adequate management of chronic pain decreases the request to die among cancer patients.
  10. 10. The reasons for this low attempt to completion ratio • The elderly are more medically fragile and may live alone and thereby increase the probability of a fatal outcome. • Suicides in older people are often with high intent, long-planned and involve highly lethal methods. • Suicide methods selected by the elderly are less likely to be affected by short-term modeling effects, such as suicide epidemics. • Older people are less likely to directly communicate their intent to die. • As the elderly are often preoccupied with death and dying, it is more likely to miss the indirect warning that they give.
  11. 11. Greater prevalence of indirect self destructive behavior • Indirect self-destructive behavior as – Refusal to eat or drink, – Noncompliance with treatment, – Extreme self-neglect, • Conscious or unconscious intent to die lead to premature death and are common in nursing homes (where the availability of suicidal methods is limited) and where religion forbids suicide. • Rate of completed suicide among elderly nursing home residents is 15.8/ lac • Rate of indirect self-destructive behavior is 79.9/lac
  12. 12. Elderly suicide and depression • 97% of elderly suicide victims fulfilled criteria of at least one DSM-IV axis I diagnosis in a study by waern et al. 2002. • 65% of elderly suicide victims have depression • Prevalence of major depression is between 60 to 90% in elderly. • Barraclough’s study (1971) reported following prominent symptoms prior to elderly suicide – Insomnia [90%] – Weight loss [75%] – Guilt feeling [50%] – Hypochondriasis [50%] • Medications in elderly may cause symptoms of depression. – Antihypertensive, Arthritis Medication, Hormones, Steroids are some of the medication commonly prescribed to the elderly that may cause depression. • Enquiries about suicidal ideation and hopelessness do not precipitate suicidal acts and should be assessed in detail.
  13. 13. Suicide warning signs in elderly • Statements about death and suicide. • Reading material about death and suicide. • Stockpiling medications. • Rush to complete or revise a will. • Increased alcohol or prescription drug use. • Sudden interest in firearms. • Overt suicide threats.
  14. 14. 14 Treatment with SSRIs and the Elderly • Most studies on risk of suicide with SSRI use focus on youth or middle aged participants • Study of Ontario residents who completed suicide, age 66 or older, from 1992-2000, and with matched living controls • 1,329 cases (4,552 comparison subjects) • 68% received no antidepressant therapy within 6 months prior to suicide • 32% were on antidepressant therapy within 6 months prior to suicide Juurlink, D. N., Mamdani, M. M., Kopp, A., & Redelmeier, D. A. (2006). The risk of suicide with selective serotonin reuptake inhibitors in the elderly. American Journal of Psychiatry 163(5), 813-821.
  15. 15. 15 Treatment with SSRIs and the Elderly (cont.) • 5 fold risk of completed suicide in first month of SSRI treatment, but not in subsequent months (in suicide cases initiating therapy, SSRI N=62 and non-SSRI N=17) • Associated with more violent methods • Absolute risk of suicide was low in first month for people taking an SSRI as well as for those on other antidepressants • Risk of suicide in first month may increase due to improvement in symptoms, which “energize patient to suicide” • Conclusion: There is a low risk of suicide for elderly patients who are taking an SSRI, and the benefits outweigh the risks (future research is necessary) Juurlink, D. N., Mamdani, M. M., Kopp, A., & Redelmeier, D. A. (2006). The risk of suicide with selective serotonin reuptake inhibitors in the elderly. American Journal of Psychiatry 163(5), 813-821.
  16. 16. 16 Goals For Suicide Prevention • Increase community awareness that suicide is a preventable public health problem • Increase awareness that depression is the primary cause of suicide • Change public perception about the stigma of mental illness, especially about depression and suicide • Increase the ability of the public to recognize and intervene when someone they know is suicidal
  17. 17. THE END “healthy children will not fear life if their elders have integrity enough not to fear death.”

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Suicides in elderly, suicides in elderly depression

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