Elderly suicide in Hong Kong--a case-controlled psychological autopsy study

Differences Between Suicide Victims Who Leave Notes and Those Who Do Not

Background: Whether differences exist between those who do leave a suicide note and those who do not has not yet been comprehensively answered. Leaving a suicide note is not a random phenomenon: A minority, varying between 3–42%, of all suicide victims leave a note. Aims: To compare the group of suicide victims who leave notes with the ones who do not, using data from the Athens Department of Forensic Medicine, the largest in Greece. Methods: We examined sex, age, nationality, religious beliefs, marital and residential status, history of prior psychiatric disorder and psychiatric attempt(s), suicide method, physical disease, recent hospitalization, and existence of suicide notes. We completed psychological autopsy questionnaires after phone interviews with relatives of the suicide victims of a 2-year period (November 2007–October 2009). Results: Note writers, 26.1% of our sample, differed in the following: they died by hanging or shooting (p = .007), had no history of psychiatric illness (p < .001) or recent (i.e., within 12 months of the suicide) psychiatric hospitalization (p = .005). Conclusions: Our study showed that there are indeed differences between suicide victims who leave a note and those who do not. We also suggest some explanations for these differences, which could represent a valuable starting point for future research on this topic.

Outpatient health care utilization of suicide decedents in their last year of life

The characteristics of health care utilization during the last year of life by Taiwanese who died by suicide were analyzed. The degree of health services utilization was evaluated by extracting the data of National Health Insurance (NHI) outpatient cohort records in 2006. A total of 4,406 fatal suicide cases were matched with the 17,587,901 subjects in the NHI beneficiary registry file. Rate of visit of the suicide decedents for all NHI outpatient services during their last year before death was 85%, and that for mental disorders service only was 30.2%. Average number of visits per person-year of the suicide decedents was 24.5 visits per year, two times higher than that of the survivors. The average numbers of visits (ANV) of male suicide decedents who used the mental disorders services was increased 6.8 times compared to that for all survivors. The increase in female decedents, in contrast, was 2.7 times. The increase in ANV for 15-24 age group was 14.6 times, significantly higher than that for the other age groups (<4 times). Effective prediction or prevention of potential suicides through increased awareness and surveillance of medical care resource utilization is possible, especially for male and young adult patients under mental disorder health care.

The next generation of psychological autopsy studies: part 2. Interview procedures

The psychological autopsy (PA) is a systematic method of assessing the psychological and contextual circumstances preceding suicide. The method requires interviews with one or more proxy respondents (i.e., informants) of suicide decedents. Procedural challenges that need to be addressed to conduct PA interviews are described in this article and recommendations for meeting these challenges in future PA investigations are made. Procedures addressed include determining the timing of PA interviews after suicide, designing the structure and flow of interviews, selection of proxy respondents, integrating interview data with information gathered from records, and selecting and training interviewers. This methodological article is the second in a two-part series-the first article focused on interview content.

The next generation of psychological autopsy studies. Part I. Interview content

The psychological autopsy (PA) is a systematic method to understand the psychological and contextual circumstances preceding suicide. The method requires interviews with one or more proxy respondents (i.e., informants) of decedents. The methodological challenges that need to be addressed when determining the content of these research interviews for PA studies are described and recommendations are made for meeting these challenges in future PA investigations. Ways to improve the data collected about mental disorders and life events--domains that are assessed in almost all PA studies--are discussed at length. Other understudied content areas considered include the role of personality traits, medical illness and functional limitations, availability of lethal agents, medications, and select distal variables including child maltreatment and family history of mental disorders and suicide. The benefits and challenges to using common protocols across studies are also discussed.

Gambling and completed suicide in Hong Kong: a review of coroner court files

BACKGROUND

Previous studies have established a positive relationship between gambling and suicidal ideation and suicide attempts. Limited studies have investigated the role of gambling in completed suicide. This study aimed to determine the prevalence of gambling behavior among suicides and to compare the correlates of nongambling and gambling with and without related debt suicides.

METHOD

The death records from the coroner's court files of suicides (N = 1,201) in Hong Kong in 2003 were reviewed. Logistic regression models were used to investigate relevant correlates in suicides with gambling behavior and debt due to gambling compared to suicides with gambling behavior but no debt and nongamblers.

RESULTS

Of the suicide victims, 233 (19.4%) showed evidence of gambling behavior prior to death; 110 of the 233 gambling suicides (47.2%) involved individuals who were indebted due to gambling. In comparison with the other 2 groups, the gambling with debt suicide victims were more likely to be male, aged 30-49 years old, married, and employed and to have died by charcoal burning (carbon monoxide poisoning). These individuals also had fewer recorded medical and psychiatric problems in the past year and lifetime. When comparing suicides with gambling behavior with and without gambling-related debt, the indebted victims were more likely to also have had debt problems not attributed to gambling (OR = 149.66, P < .001) and to have been disturbed by loan sharks prior to death (OR = 28.14, P < .001) but were less likely to have recorded psychiatric disorders during their lifetime (OR = 0.41, P < .05) and at the time of death (OR = 0.26, P < .05).

CONCLUSIONS

Gambling and indebted suicides have a distinct profile and may be difficult to predict using standard risk factors as references. This finding suggests the need for improved detection and suicide prevention efforts related to gambling in individuals with gambling-related debt.

Prospective cohort study of suicide attempters aged 70 and above: one-year outcomes

BACKGROUND

Most elderly persons who attempt suicide suffer from depression. This study aimed to investigate one-year outcomes in suicide attempters aged 70+, and to identify predictors of these outcomes.

METHODS

101 persons (mean age 80) who were hospitalized after a suicide attempt were interviewed at baseline and followed for one year by record linkage. Face-to-face interviews were carried out with 71% of those who were alive after one year (60 out of 85). Outcome measures included major/minor depression, Montgomery-Asberg Depression Rating Scale (MADRS) score, repeat non-fatal/fatal suicidal behavior and all-cause mortality.

RESULTS

One half (52%) of all those who were interviewed scored <10 on the MADRS at follow-up. Among those with major depression at baseline, two thirds (26 out of 39) no longer fulfilled criteria for this disorder. Factors associated with non-remission of major depression (MADRS ≥ 10) included higher baseline depression and anxiety scores, higher suicide intent and lower Sense of Coherence. There were two suicides and six non-fatal repeat attempts. The relative risk of death (any cause) was 2.53 (95% CI = 1.45-4.10, p<0.001).

LIMITATIONS

This is a naturalistic study; participants received non-uniform treatment as usual. The proportion with repeat suicidal behavior was lower than anticipated and the study was thus underpowered with regard to this outcome.

CONCLUSIONS

Half of the surviving attempters were free from depressive symptoms at one-year follow-up and there were relatively few repeat attempts. However, all cause mortality remained high in this elderly cohort.

Suicide in later life: a comparison between cases with early-onset and late-onset depression

BACKGROUND

Suicide rates are high in elderly people with depressive disorder. We compared behavioural, clinical and care characteristics of depressed elderly patients, aged 60years and over at the time of death by suicide, with an early-onset depression (EOD, onset before 60years) with those patients with a late age of onset (LOD).

METHOD

From a 10-year national clinical survey of all suicides in England and Wales (n=13066) we identified 549 LOD cases, and 290 EOD cases. EOD and LOD cases were compared by logistic regression adjusted for age at suicide.

RESULTS

Method of suicide did not differ by age of onset of depression. LOD cases were significantly less likely to have a history of psychiatric admissions (OR=0.2 [0.1-0.3]), alcohol misuse (OR=0.6 [0.4-0.9]) and self-harm (0.6 [0.4-0.8]). LOD cases also had a lower prevalence of a psychiatric co-morbid diagnosis (0.6 [0.4-0.7]) and a lower prescription rate for psychotropic drugs other than antidepressants. Furthermore, the number of recent life-events was significantly higher (OR=1.4 [1.0-1.9]) in LOD while the frequency of recent self-harm was similar to EOD.

CONCLUSION

Although our study suggests that psychopathology of suicide among elderly depressed patients differs between EOD and LOD, the final pathway (via recent self-harm) to suicide may be similar in up to a quarter of patients in both groups. Our results suggest that strategies to enhance coping abilities and provision of support to negate the effects of life-events might be especially important in the prevention of suicide in LOD.

Suicide in older adults

This article makes the case that late-life suicide is a cause for great concern that warrants ongoing attention from researchers, health care providers, policy makers, and society at large. It reviews the evidence for factors that place older adults at risk for suicide, or protect them from it. The authors introduce the notion that suicide preventive interventions target individuals or groups at different levels of risk at different points on the developmental trajectory toward death by suicide, offering examples and recommending their strategic, combined application to create an effective, community-level response to the mounting problem of suicide in older adults.

Outcomes of a two-tiered multifaceted elderly suicide prevention program in a Hong Kong Chinese community

OBJECTIVES

1) To compare the 2-year completed suicide and reattempt rates in a preintervention group of Hong Kong Chinese suicide attempters (aged 65 years and older) who received standard care and a postintervention group enrolled in a regional elderly suicide prevention program (ESPP) that adopts a two-tiered multifaceted care management model and 2) to examine the trend of suicide rates in older adults aged 65 years and older in the pre- and postintervention periods.

DESIGN

The first part is an observational cohort study with baseline, follow-up, and outcome data being identified from a clinical electronic registry. The second part examines changes in suicide rates from official mortality statistics.

SETTING

A government-funded suicide intervention program serving catchment population (852,796 people aged 65 years and older) in Hong Kong, China.

PARTICIPANTS

Suicide attempters (aged 65 years and older) presenting to old-age psychiatric service in the pre- and postintervention phases.

MEASUREMENTS

1) Two-year rates of completed suicide and suicide reattempt and 2) changes in population suicide rates in the pre- and postintervention periods.

RESULTS

The 2-year completed suicide rate was 7.58% in the preintervention group (N = 66) and 1.99$% in the ESPP group (N = 351) Χ = 6.192; p value: 0.028; df = 1). Reattempt rates were not different. At a population level, suicide rate dropped significantly only in women aged 85 years and older, relative to the preintervention period.

CONCLUSIONS

The ESPP was associated with a reduced rate of completed suicide in old-age suicide attempters and might have contributed to a fall of suicide rate in women aged 85 years and older.

Social inclusion affects elderly suicide mortality

BACKGROUND

National attitudes towards the elderly and their association with elderly suicide mortality in 26 European countries were assessed, and Eastern and Western European countries compared.

METHODS

For each country, mean age-adjusted, gender-specific elderly suicide rates in the last five years for which data had been available were obtained from the WHO European Mortality Database. Questions about citizens' attitudes towards the elderly were taken from the European Social Survey. Correlations between attitudes and suicide rates were analyzed using Pearson's test. Differences between mean scores for Western and Eastern European attitudes were calculated, and data on labor-market exit ages were obtained from the EUROSTAT database.

RESULTS

Perception of the elderly as having higher status, recognition of their economic contribution and higher moral standards, and friendly feelings towards and admiration of them are inversely correlated with suicide mortality. Suicide rates are lower in countries where the elderly live with their families more often. Elderly suicide mortality and labor-market exit age are inversely correlated. In Eastern European countries, elderly people's status and economic contribution are seen as less important. Western Europeans regard the elderly with more admiration, consider them more friendly and more often have elderly relatives in the family. The data also show gender differences.

CONCLUSIONS

Society's attitudes influence elderly suicide mortality; attitudes towards the elderly are more favorable among Western European citizens; and extended labor-market inclusion of the elderly is a suicide-protective factor.

Prison inmates' suicidal ideation in China: a study of gender differences and their impact

Suicide is one of the leading causes of inmate death, and many studies have explored suicidal risks among inmates in Western countries. Such studies, however, have been extremely rare in China. Because of China's unique cultural and social conditions, suicide displays many distinctive features and one of them is the greater percentage of women (than men) who commit suicide. With data collected from three adult prisons in China, this study tests gender differences on prison inmates' suicidal risk factors and explores the correlation of gender's impact with other factors. Findings show that male and female inmates present distinctive patterns of suicidal ideation, although gender fails to exert a significant direct impact on the outcome. The results call for different approaches and treatments toward both gender groups for suicide prevention in Chinese correctional facilities.

The impact of epidemic outbreak: the case of severe acute respiratory syndrome (SARS) and suicide among older adults in Hong Kong

BACKGROUND

Previous studies revealed that there was a significant increase in suicide deaths among those aged 65 and over in 2003. The peak coincided with the majority of SARS cases being reported in April 2003.

AIMS

In this paper we examine the mechanism of how the SARS outbreak resulted in a higher completed suicide rate especially among older adults in Hong Kong.

METHODS

We used Qualitative data analysis to uncover the association between the occurrence of SARS and older adult suicide. Furthermore, we used a qualitative study based on the Coroner Court reports to provide empirical evidence about the relationship between SARS and the excessive number of suicide deaths among the elderly.

RESULTS

SARS-related older adult suicide victims were more likely to be afraid of contracting the disease and had fears of disconnection. The suicide motives among SARS-related suicide deaths were more closely associated with stress over fears of being a burden to their families during the negative impact of the epidemic. Social disengagement, mental stress, and anxiety at the time of the SARS epidemic among a certain group of older adults resulted in an exceptionally high rate of suicide deaths.

CONCLUSIONS

We recommend that the mental and psychological well-being of the community, in particular older adults, be taken into careful account when developing epidemic control measures to combat the future outbreak of diseases in the community. In addition, it is important to alert family members to vulnerable individuals who are at potential risk because of their illnesses or anxieties.

The WHO/START Study: Promoting suicide prevention for a diverse range of cultural contexts

The WHO/Start Study is introduced and described in its four main components. The study originated as a response to growing concerns about trends of suicide, the prevalence of which in the Western Pacific Region of the World Health Organization is the highest among the six regions of the WHO. So far, nineteen centers have joined the study. This ambitious project is expected to provide important transcultural perspectives on both fatal and nonfatal suicidal behaviors, together with increased awareness for these phenomena and the growth of culture-sensitive prevention programs.

Health status and suicide in the second half of life

OBJECTIVE

To examine the associations of suicide in the second half of life with medical and psychiatric illness, functional limitations, and reported use of inpatient, ambulatory, and home health care services.

METHOD

A retrospective case-control design was used to compare 86 people over age 50 years who died by suicide with a comparison group of 86 living community participants that were individually matched on age, gender, race, and county of residence.

RESULTS

Suicide decedents had more Axis I diagnoses, including current mood and anxiety disorders, worse physical health status, and greater impairment in functional capacity. They were more likely to have required psychiatric treatment, medical, or surgical hospitalization in the last year, and visiting nurse or home health aide services. In a multivariate model, the presence of any active Axis I disorder and any impairment in instrumental activities of daily living (IADL) made independent contributions to suicide risk.

CONCLUSIONS

Mental illness, physical illness, and associated functional impairments represent domains of risk for suicide in this age group. In addition to individuals with psychiatric illness, those with severe or comorbid physical illness and functional disability who require inpatient and home care services should be targeted for screening and preventive interventions.

Suicidal behavior and alcohol abuse

Suicide is an escalating public health problem, and alcohol use has consistently been implicated in the precipitation of suicidal behavior. Alcohol abuse may lead to suicidality through disinhibition, impulsiveness and impaired judgment, but it may also be used as a means to ease the distress associated with committing an act of suicide. We reviewed evidence of the relationship between alcohol use and suicide through a search of MedLine and PsychInfo electronic databases. Multiple genetically-related intermediate phenotypes might influence the relationship between alcohol and suicide. Psychiatric disorders, including psychosis, mood disorders and anxiety disorders, as well as susceptibility to stress, might increase the risk of suicidal behavior, but may also have reciprocal influences with alcohol drinking patterns. Increased suicide risk may be heralded by social withdrawal, breakdown of social bonds, and social marginalization, which are common outcomes of untreated alcohol abuse and dependence. People with alcohol dependence or depression should be screened for other psychiatric symptoms and for suicidality. Programs for suicide prevention must take into account drinking habits and should reinforce healthy behavioral patterns.

A Community-Based Survey and Screening for Depression in the Elderly

Background: In addition to implementing a depression screening program, conducting a survey beforehand might contribute to suicide risk reduction for the elderly. Aims: This study evaluates outcomes of a community-based program to prevent suicide among individuals aged 60 and over, using a quasiexperimental design with an intervention region (41,337 residents, 35.1% aged 60 and over) and a neighboring reference region. Methods: Our 2-year intervention program included an anonymous survey by random sample in the entire intervention region and, in the second year, a depression screening with follow-up by a psychiatrist in the higher-risk districts. Changes in the risk of completed suicide were estimated by the incidence-rate ratio (IRR). Results: The risk for men in the intervention region was reduced by 61% (age-adjusted IRR = 0.39; 90% CI = 0.18–0.87), whereas there was a (statistically insignificant) 51% risk reduction for women in the intervention region, and no risk reduction for either men or women in the reference region. The ratio of the crude IRR for elderly men in the intervention region to that for all elderly men in Japan was estimated at 0.42 (90% CI = 0.18–0.92), showing that the risk reduction was greater than the national change. Conclusions: The management of depression through a combination of an initial survey and subsequent screening holds clear promise for prompt effectiveness in the prevention of suicide for elderly men, and potentially for women.

The geriatric depression scale as a screening tool for depression and suicide ideation: a replication and extention

OBJECTIVES

To examine a) whether the Geriatric Depression Scale (GDS) can predict clinician-rated suicide ideation and depression, using the 15-, 5-, and 4-item versions, b) whether an additional suicide-ideation item would improve the performance, and c) whether the results vary by age groups.

METHODS

First-time psychiatric outpatients responded to the GDS. They were subsequently assessed by psychiatrists blind to the GDS, who also indicated whether suicide ideation was present. The performance of the GDS scales was evaluated using receiver operating characteristic curves. Analyses were conducted separately for young-old (aged 60-74 years) and old-old (aged 75 years or older) adults.

RESULTS

Areas under the curves showed that the different GDS versions were comparable in detecting depression and suicide ideation. For identifying depression, thresholds of 7, 2, and 2 for the 15-, 5-, and 4-item versions were optimal, respectively. In terms of detecting suicide ideation, all measures performed better in old-old than in young-old adults. A single, self-report suicide-ideation item performed better than all multiitem GDS measures.

CONCLUSIONS

Both the 4- and the 5-item versions are excellent alternatives to the 15-item version, and all are reasonable tools for detecting the presence of suicide ideation also. However, to improve the effectiveness of screening, brief measures of suicide risk should also be included. Even a 1-item measure of suicide ideation can improve clinical decisions tremendously.

Suicidality and suicide in older people

Suicide is accepted as a major health problem worldwide, especially in the young and middle aged. It is, however, a significant health problem in older people as well, and those aged 65 years and over generally have the highest suicide rates compared with all other age groups. In research literature from the last decade, there has been an increased interest in disentangling the phenomenon of suicide in later life. This paper aims to critically review the literature on suicide and suicidality in later life published from 2000 to 2009. Prevalence rates as well as risk and protective factors are mapped and correlates reviewed. The association between suicidality and help-seeking behaviour is considered. Finally, potential prevention strategies are reviewed.

Attempted suicide in the elderly: characteristics of suicide attempters 70 years and older and a general population comparison group

OBJECTIVE

To identify factors associated with attempted suicide in the elderly.

DESIGN

Social, psychological, and psychiatric characteristics were compared in suicide attempters (70 years and older) and a representative population sample.

SETTINGS

Emergency departments at five hospitals in western Sweden and a representative sample of the elderly population.

PARTICIPANTS

Persons with Mini Mental State Examination (MMSE) score <15 were excluded. One hundred forty persons who sought hospital treatment after a suicide attempt were eligible and 103 participated (57 women, 46 men, and mean age 80 years). Comparison subjects matched for gender and age group (N = 408) were randomly selected among participants in our general population studies.

MEASUREMENTS

Symptoms were rated with identical instruments in cases and comparison subjects. The examination included the MMSE and tests of short- and long-term memory, abstract thinking, aphasia, apraxia, and agnosia. Depressive symptomatology was measured using the Montgomery-Asberg Depression Rating Scale, and major and minor depressions were diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, using symptom algorithms.

RESULTS

Factors associated with attempted suicide included being unmarried, living alone, low education level, history of psychiatric treatment, and previous suicide attempt. There was no association with dementia. Odds ratios were increased for both major (odds ratio [OR]: 47.4, 95% confidence interval [CI]: 19.1-117.7) and minor (OR: 2.6, 95% CI: 1.5-4.7) depressions. An association was observed between perceived loneliness and attempted suicide; this relationship was independent of depression (OR: 2.8, 95% CI: 1.3-6.1).

CONCLUSIONS

Observed associations mirrored those previously shown for completed suicide. Results may help to inform clinical decisions regarding suicide risk evaluation in this vulnerable and growing age group.

Case-control study of suicide attempts in the elderly

BACKGROUND

Prior studies have inadequately explored the relationship between late-life suicidal behavior and subclinical/clinical symptoms. This study aimed to assess the risk associated with subclinical symptoms, mild cognitive impairment and clinical factors among late-life suicide attempters.

METHOD

Forty-three elderly patients aged 60 years and older who sought emergency services in a university-affiliated general hospital for attempting suicide and 43 comparison subjects participated in this study between March 2005 and December 2006. The comparison group was recruited by advertising in the community around the hospital. DSM-IV based diagnostic interview and screening instruments including the GDS, MMSE, BSRS-5 and APGAR were applied. Adjusted odds ratios were measured in the final multiple logistic regression model.

RESULTS

Suicide attempters were more likely to meet a diagnosis of depressive disorder, after adjustments for BSRS-5 score and drinking habit. The adjusted odds of suicide among people with a BSRS-5 score of more than 5 points was 17.8 times higher than those with the BSRS score less than or equal to 5 points.

CONCLUSIONS

Our findings support the significant impact on late-life suicidal behavior from the assessment of subclinical symptoms, including anxiety, depression, hostility, sleep condition and interpersonal symptoms. The assessment of subclinical symptoms by the BSRS-5 may help in the future prevention of late-life suicidal behavior in primary care settings.

Risk factors for suicide in Bali: a psychological autopsy study

Background

The suicide rate in Bali has significantly increased in recent years. However, to date, there have been no case-control studies investigating risk factors for suicide.

Methods

A psychological autopsy study was conducted comparing 60 suicide cases and 120 living controls matched in age, sex, and area of residence.

Results

Multiple logistic regression analysis identified the following risk factors for suicide: at least one diagnosis of axis-I mental disorder (OR: 14.84 CI: 6.12 - 35.94); low level of religious involvement (OR: 7.24 CI: 2.28 - 22.95); and severe interpersonal problems (OR: 3.86 CI: 1.36 - 11.01). Forty-eight (80.0%) of the suicide cases were diagnosed with mental disorders; however, only 16.7% visited a primary care health professional and none received psychiatric treatment during the 1 month prior to death.

Conclusion

Clinical, religious, and psychosocial factors were associated with suicide. These results highlight the significance of early recognition and treatment of mental disorders, religious activities, and interpersonal problem-solving strategies for suicide prevention in Bali.

Unrecognised psychological problems impair quality of life and increase consultation rates in Chinese elderly patients

OBJECTIVE

Studies have shown that psychological problems in elderly patients are often unrecognised in primary care. The aim of this study was to investigate the quality of life and consultation rates of Chinese elderly patients with unrecognised psychological problems in primary care. The prevalence and risk factors of unrecognised psychological problems were also determined.

METHODS

A cross-sectional study on consecutive patients aged > or =60 with no known psychological diseases were screened by the Hospital Anxiety and Depression Scale (HADS) when they consulted at two primary care clinics in Hong Kong. Data on socio-demographic characteristics, chronic morbidity, consultation rates, and health-related quality of life (HROQL) were collected. Multivariable regressions were used to determine the effect of a positive HADS score on HRQOL scores and consultation rates, and the risk factors of unrecognised psychological problems.

RESULTS

One thousand eight hundred and fifty-four subjects (mean age 72.6 years and 52% male) were screened and the estimated prevalence of unrecognised psychological diseases was 23% (95% CI = 13.1-33.8%). A positive screening result was associated with poorer SF-36 HROQL scores and higher episodic consultation rates. An increased risk of unrecognised psychological problems was associated with the presence of more than two chronic diseases. Other risk factors included female gender, no formal education and having chronic pulmonary disease or heart disease. Living with a spouse increased the risk in elderly women.

CONCLUSIONS

Unrecognised psychological problems are common in Chinese elderly patients in primary care. They are clinically important because they impair quality of life and increase the utilization of consultations.

Suicide among the elderly in mainland China

Suicide in mainland China shows unique demographic patterns with age: the over-65 age group has the highest rate of completed suicide, reaching 44.3-200 per 100,000, which is four to five times higher than the Chinese general population. Rural suicide rates among the elderly are three to five times higher than the urban rates. The gender ratio of suicide in the elderly shows a reversal to those younger than 60 years of age in China. In addition, suicide methods and causes are different from those in Western countries. In the present paper, the profile of suicide among the elderly in China is delineated, including the prevalence, characteristics, underlying reasons and measures of preventing it.

Dementia and suicidal behavior: a review of the literature

BACKGROUND

While dementia is more common in older people and suicide rates in many countries are higher among the elderly, there is some doubt about the association between these two phenomena.

METHODS

A search of the major relevant databases was carried out to examine the evidence for this possible association.

RESULTS

The association between dementia and suicide and also non-fatal self-harm did not appear strong but many studies have significant methodological limitations and there are few studies of suicide or self-harm in vascular, frontotemporal, Lewy body and HIV dementia where such behavior might be expected to be more common. Rates of self-harm may be increased in mild dementia and are higher before than after predictive testing for Huntington's disease. Overall, the risk of suicide in dementia appears to be the same or less than that of the age-matched general population but is increased soon after diagnosis, in patients diagnosed with dementia during hospitalization and in Huntington's disease. Putative risk factors for suicide in dementia include depression, hopelessness, mild cognitive impairment, preserved insight, younger age and failure to respond to anti-dementia drugs. Large, good quality prospective studies are needed to confirm these findings.

CONCLUSIONS

Further research should be undertaken to examine how rates of suicide and self-harm change during the course of the illness and vary according to the specific sub-type of dementia.

Prevalence and socio-demographic correlates of major depressive episode in rural and urban areas of Beijing, China

OBJECTIVE

This study aimed to determine the 12-month and lifetime prevalence of major depressive episode (MDE) and their socio-demographic correlates in both the urban and rural areas of Beijing, China.

METHODS

A total of 4767 adults were randomly selected and interviewed in Beijing using the Composite International Diagnostic Interview (CIDI 1.0). Basic socio-demographic and clinical data were collected during the interviews.

RESULTS

The overall 12-month prevalence of MDE was 3.2%; 2.8% and 3.8% for men and women, respectively. The overall lifetime prevalence of MDE was 5.3%; 4.4% and 6.3% for men and women, respectively. Being older than 25 years of age was independently associated with increased risk of MDE. Sixteen point three percent of the subjects with lifetime MDE attempted suicide while the rate of suicide attempts was only 0.2% in subjects without MDE. The percentage of subjects with MDE who received any type of treatment from medical practitioners was 33.1%; of them, only 5.4% sought help from mental health professionals.

CONCLUSIONS

National epidemiologic surveys are needed to further explore the prevalence of MDE in China. The low percentage of subjects treated for MDE constitutes a major public health problem that should be urgently addressed.

Suicide

Suicide receives increasing attention worldwide, with many countries developing national strategies for prevention. Rates of suicide vary greatly between countries, with the greatest burdens in developing countries. Many more men than women die by suicide. Although suicide rates in elderly people have fallen in many countries, those in young people have risen. Rates also vary with ethnic origin, employment status, and occupation. Most people who die by suicide have psychiatric disorders, notably mood, substance-related, anxiety, psychotic, and personality disorders, with comorbidity being common. Previous self-harm is a major risk factor. Suicide is also associated with physical characteristics and disorders and smoking. Family history of suicidal behaviour is important, as are upbringing, exposure to suicidal behaviour by others and in the media, and availability of means. Approaches to suicide prevention include those targeting high-risk groups and population strategies. There are, however, many challenges to large-scale prevention, especially in developing countries.

Substance use disorders as risk factors for suicide in an Eastern and a Central European city (Tallinn and Frankfurt/Main)

Cultural and regional differences on the well-known elevated suicide risk in substance use disorders have not been clarified yet. Therefore, the suicide risk associated with substance use disorders in a society of transition and in a socially and economically stable society should be identified and compared. Data from two population-based matched case-control studies were used to analyse the association between alcohol and other substance consumption and the risk of suicide. Data in Frankfurt were obtained by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) in 163 suicides that occurred in 1999 and 2000, and data from Tallinn were collected according to DSM-IV criteria on 156 deceased persons who committed suicide in 1999 by using the psychological autopsy method and in each city in matched population-based control persons by personal interview. In both cities, substance use disorders were significantly associated with suicide. Odds ratios for suicide were higher in Tallinn than in Frankfurt. The highest risk was observed in Tallinn among men with alcohol use disorders, aged 35 to 59 years. Although substance use and, in particular, alcohol use disorders were confirmed as risk factors for suicide in Tallinn and in Frankfurt, the much higher suicide risk associated with alcoholism in Tallinn than in Frankfurt indicates the importance of cultural, socio-political, and regional impact of suicide risk in alcoholism.

Substance use disorders and risk for completed suicide

Substance use disorders are among the most frequent psychiatric disorders found in suicides. In psychological autopsy studies between 19% and 63% of all suicides suffered from substance use disorders, mostly from alcohol use disorders. Suicide risk is highly increased in substance use disorders, particularly in alcohol use disorders, and in co-morbid alcoholism and depression. So far, some risk factors for suicide have been identified in alcoholism. Nevertheless, various questions about the relationship between substance use disorders and suicide remain open, which indicate directions for future research.

Prevalence and sociodemographic correlates of depression in an elderly population living with family members in Beijing, China

BACKGROUND

To date, there has been no large-scale survey of geriatric depression (GD) involving both rural and urban areas in China using standardized assessment tools and diagnostic criteria. This study aimed to determine the 12-month and lifetime prevalence rates of GD and sociodemographic correlates in urban and rural regions of Beijing, China.MethodA total of 1601 elderly patients (aged 60 years) were randomly selected and interviewed in Beijing using the Composite International Diagnostic Interview (CIDI 1.0). Basic sociodemographic and clinical data were also collected during the interviews.

RESULTS

The overall 12-month prevalence of GD was 4.33%, and the 12-month prevalence rates for men and women were 2.65% and 5.83% respectively. The overall lifetime prevalence of GD was 7.83%, and lifetime prevalence rates for men and women were 4.65% and 10.66% respectively. Female sex, lower educational level, monthly income, rural abode, and the presence of one or more major medical conditions were associated with increased risk of GD. Of the GD subjects interviewed, 25.2% were receiving some type of treatment, with only 4.7% preferring to seek treatment from mental health professionals.

CONCLUSIONS

Although still relatively low by international standards, there is an increasing trend in the prevalence of GD in China. The low percentage of subjects treated for GD is a major public health concern that should be addressed urgently.

Suicide in Asia

Suicide is a major problem worldwide, and suicides in Asian countries account for as much as 60% of all suicides in the world. There are many unique features in suicides within this ethnically-diverse continent, from the methods used, to the putative risk factors. Much research still needs to be done to guide efficacious and culturally relevant interventions in suicide prevention; existing literature suggests a strong focus for programmes that address restricting access to pesticides, increasing crisis counseling activities, improving the accessibility and delivery of mental health services, and promoting responsible media reporting of suicide and related issues. There is a need for coordinated national suicide plans to be developed that are sensitive to the socioeconomic and cultural factors in the local context.

A review on neurobiological and psychological mechanisms underlying the anti-depressive effect of qigong exercise

Elders with chronic medical conditions are vulnerable to depression. Mainstream interventions for treating their depression is however far from satisfactory which stimulates the interests of researchers to look for alternative therapies to alleviate geriatric depression. Qigong, a Chinese mindful exercise, is demonstrated to have anti-depressive effects. Results of our earlier studies shed light on the psychological mechanism underlying this effect. The neurobiological mechanism remains unclear. This article attempts to review extant evidence and suggests possible neurobiological pathways of the anti-depressive effect of qigong based on the neurotransmitter, neuroendocrine, and neurotropic perspectives. Further research to consolidate its scientific base is suggested.

Suicidal risk factors and completed suicide: meta-analyses based on psychological autopsy studies

The purpose of the present review is to evaluate the effects of common risk factors for suicide by meta-analyses using data extracted from studies based on the psychological autopsy method. We focused on five common risk factors of suicide: substance-related disorders, mood disorders, adverse marital status, adverse employment status, and self-harm behaviors. A total of 24 articles were identified from MEDLINE in which the crude odds ratio (OR) could be calculated for the above five risk factors through 30 April 2007, using such search keywords as "suicide," "psychological autopsy," and "case-control study." Overall, both substance-related disorders [OR = 5.24; 95% confidence interval (CI) = 3.30-8.31] and mood disorders [OR = 13.42; 95% CI = 8.05-22.37] were strongly associated with suicidal risk. Suicidal attempt and deliberate self-harm, which can directly lead to completed suicide, have been shown to be very strongly associated with suicidal risk [OR = 16.33; 95% CI = 7.51-35.52]. Effects of social factors such as adverse marital and employment status were relatively small. As substance-related disorders and mood disorders were strongly associated with an increased risk of completed suicide, the comorbidity of these two disorders should be paid a maximum attention. The effective prevention of suicide depends on whether we can successfully incorporate these personal factors as well as social factors into an adequate multi-factorial model.

Prevalence of clinically significant depressive symptoms in an epidemiologic sample of community-dwelling elders with milder forms of cognitive impairment in Hong Kong SAR

BACKGROUND

Depression and cognitive impairment in later-life have great bearings on public health. The two conditions often co-occur and have mutual implications on short-term risk and long-term prognosis.

METHOD

A two-phase epidemiologic survey on the prevalence of dementia in elders aged 60 and over was conducted in Hong Kong in 2005-2006. In the first phase, 6,100 randomly selected community dwelling elders were assessed with Cantonese version of Mini-Mental State Examination (C-MMSE) and Abbreviated Memory Inventory for Chinese (AMIC). Two thousand and seventy-three subjects were screened positive and invited for second phase cognitive and psychiatric assessment. 35.5% of screen-positive subjects participated in Phase 2 assessment conducted by psychiatrists for diagnosis of dementia. Severity of dementia was determined using Clinical Dementia Rating Scale (CDR). Cornell Scale for Depression in Dementia (CSDD) and a structured bedside cognitive battery were also administered to each subject.

RESULTS

1.7% of subjects with CDR 0.5 and 5.9% of subjects with CDR 1 had clinically significant depressive symptoms (>or= 8 on CSDD). Score on CSDD correlated positively with duration of cognitive symptoms, scores on CIRS and CMMSE in linear regression model. In a logistic regression model, male gender, duration of cognitive symptoms, CIRS and CMMSE was associated with increased risk for clinically significant depressive symptoms.

CONCLUSIONS

In our sample, milder forms of cognitive impairment were associated with increased risk for depression in the presence of other risk factors such as male gender, higher physical illness burden and longer duration of cognitive symptoms.

Suicidal behavior in elders

Suicide is a major public health concern for older adults, who have higher rates of completed suicide than any other age group in most countries of the world. Older men are at greatest risk. Reduction of suicide-related morbidity and mortality in this age group hinges on systematic study at each point in the suicide preventive intervention research cycle. Improvements in systems for surveillance of late-life suicidal behavior, particularly attempted suicide, are needed to further develop the foundation on which to evaluate differences in the elderly subgroup, over time, and in different locations, and to better assess changes in response to interventions. This article provides an overview of suicide in later life and a foundation on which to base decisions about the design and implementation of preventive interventions.

Contact of mental and nonmental health care providers prior to suicide in Taiwan: a population-based study

OBJECTIVE

Higher rates of health care service use prior to suicide were previously reported in Western countries; however, these studies have tended to suffer from small sample sizes. This nationwide, population-based study examines the distribution and patterns of health care service use among suicide victims in Taiwan.

METHOD

A retrospective cohort study was conducted using linked population-based data to determine the proportion of health care service use among suicide victims aged 15 years and older within the 1-year and 1-month period prior to their deaths. After adjusting for demographic, socioeconomic and health care indices, the differences in health care service use patterns were assessed for age and sex.

RESULTS

Among the 19 426 suicide victims in the sample, 83.1% had used nonmental health care services within the 1-year period prior to their death, while only 22.2% had used mental health care services. Men, and suicide victims aged 55 years and older, were less likely to have had any contact with mental health care professionals prior to their deaths (P < 0.001).

CONCLUSIONS

In line with prior studies, similarly high rates and distinct patterns of health care service use were found in Taiwan prior to suicide. These findings will be of practical interest and should support designing appropriate methods of suicide intervention and effective preventive strategies.

Suicide among adults aged 30-49: a psychological autopsy study in Hong Kong

Background

A surge in suicide rates in middle age people in Hong Kong and many Asian countries was recently observed. However, there is a paucity of suicide research on this subgroup of people in Asia.

Methods

The next-of-kin of 85 suicide cases and 85 community subjects aged 30–49 years were interviewed by a psychological autopsy approach. Information was triangulated by interview notes, coroner's court files, and police investigation reports.

Results

A multiple logistic regression analysis identified the following risk factors for suicide among the middle age people in Hong Kong: the presence of at least one psychiatric disorder (OR = 37.5, 95% CI 11.5–121.9, p < 0.001), indebtedness (OR = 9.4, 95% CI 2.2–40.8, p < 0.01), unemployment (OR = 4.8, 95% CI 1.3–17.5, p < 0.05), never married (OR = 4.2, 95% CI 1.1–16.3, p < 0.05), and lived alone (OR = 3.9, 95% CI 1.2–13.4, p < 0.05).

Conclusion

The data show that socio-economical factors had a strong impact on suicide in the target group. Further research is needed to explore any positive qualities that protect the middle-aged from suicide. The prevention of suicide in the middle-aged requires multiple strategies.

Completed suicide among Sinhalese in Sri Lanka: a psychological autopsy study

Sri Lanka has the one of highest rates of suicide. Important factors associated with suicide were determined via the psychological autopsy approach (which had not been carried out previously in Sri Lanka). Over a 3-month period, in a catchment area, 31 suicides among Sinhalese were identified and 27 were investigated. Males were more likely to commit suicide and alcohol abuse and domestic violence were reported as contributory factors. We found it possible to use psychological autopsy methods to obtain information which can inform planned prevention measures.

Gender differences in suicidal behavior in Korea

OBJECTIVE

To examine gender differences in the characteristics of suicidal behavior in South Korea.

METHODS

Between August 2003 and December 2006, 344 suicide attempters (116 men, 228 women) participated in this study. The attempters were interviewed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), and the lethality of the attempt was measured using the Lethality Suicide Attempt Rating Scale-II (LSARS-II) and Risk-Rescue Rating Scale (RRRS).

RESULTS

Significantly more women than men were admitted to emergency rooms due to attempted suicide during the study period. The male attempters were older and had a higher rate of employment than the females. Depression was the most common psychiatric disorder in both genders. The lesion/toxicity scores of the RRRS indicated that the male suicide attempters used higher doses or more toxic agents than the female attempters. The most common methods of suicide were ingestion and cutting in both sexes. Although there were significant gender differences in the RRRS risk score and RRRS total scores, there was no gender difference in the LSARS-II scores, which suggests that patients of both sexes share a similar ambivalence regarding suicide completion or death.

CONCLUSION

Our study should be understood within the context of the specific cultural background of South Korea. We found that males and females use similar methods when attempting suicide and share a similar ambivalence regarding the outcome of the attempt; however, there was a difference in severity of the attempt between the two groups. Our findings may aid in the identification of more effective methods of intervention to prevent suicide.

Psychiatric assessment of suicide attempters in Japan: a pilot study at a critical emergency unit in an urban area

BACKGROUND

The incidence of suicide has increased markedly in Japan since 1998. As psychological autopsy is not generally accepted in Japan, surveys of suicide attempts, an established risk factor of suicide, are highly regarded. We have carried out this study to gain insight into the psychiatric aspects of those attempting suicide in Japan.

METHODS

Three hundred and twenty consecutive cases of attempted suicide who were admitted to an urban emergency department were interviewed, with the focus on psychosocial background and DSM-IV diagnosis. Moreover, they were divided into two groups according to the method of attempted suicide in terms of lethality, and the two groups were compared.

RESULTS

Ninety-five percent of patients received a psychiatric diagnosis: 81% of subjects met the criteria for an axis I disorder. The most frequent diagnosis was mood disorder. The mean age was higher and living alone more common in the high-lethality group. Middle-aged men tended to have a higher prevalence of mood disorders.

CONCLUSION

This is the first large-scale study of cases of attempted suicide since the dramatic increase in suicides began in Japan. The identification and introduction of treatments for psychiatric disorders at emergency departments has been indicated to be important in suicide prevention.

Studies from emerging countries: an encouraging development

PURPOSE OF REVIEW

To summarize the findings of recent psychogeriatric research conducted in emerging countries.

RECENT FINDINGS

During the review period there have been new reports on the prevalence, clinical characteristics and pathogenic mechanisms of dementia in its various forms, epidemiological findings on depression, and psychological autopsy analyses of suicidal behaviors and psychiatric morbidities. New studies in social psychiatry have been conducted, especially on the trends of transgenerational support of the elderly and of interventions that may reduce psychiatric disease burdens and promote mental health in later life.

SUMMARY

These research findings support a better understanding of the prevalence, nature, and underlying risk and protective factors of the major psychiatric morbidities in the studied regions. Further exploration of the epidemiological profile of mental disorders in rural areas, research on the direct and indirect costs of psychogeriatric conditions, and evaluation of the cost-effectiveness and financial sustainability of early detection programs, treatment and rehabilitation models are warranted.

Stigma towards people with mental illness in developing countries in Asia

BACKGROUND

There is a wide range of literature on stigmatization and discrimination of people with mental illness. Most studies, however, derive from Western countries. This review aims at summarizing results from developing countries in Asia published between 1996-2006.

METHOD

Medline search focusing on English-speaking literature.

RESULTS

Comparable to Western countries, there is a widespread tendency to stigmatize and discriminate people with mental illness in Asia. People with mental illness are considered as dangerous and aggressive which in turn increases the social distance. The role of supernatural, religious and magical approaches to mental illness is prevailing. The pathway to care is often shaped by scepticism towards mental health services and the treatments offered. Stigma experienced from family members is pervasive. Moreover, social disapproval and devaluation of families with mentally ill individuals are an important concern. This holds true particularly with regards to marriage, marital separation and divorce. Psychic symptoms, unlike somatic symptoms, are construed as socially disadvantageous. Thus, somatisation of psychiatric disorders is widespread in Asia. The most urgent problem of mental health care in Asia is the lack of personal and financial resources. Thus, mental health professionals are mostly located in urban areas. This increases the barriers to seek help and contributes to the stigmatization of the mentally ill. The attitude of mental health professionals towards people with mental illness is often stigmatizing.

CONCLUSION

This review revealed that the stigmatization of people with mental illness is widespread in Asia. The features of stigmatization-beliefs about causes of and attitudes towards mental illness, consequences for help-seeking-have more commonalities than differences to Western countries.

Planning of suicide attempts among depressed inpatients ages 50 and over

BACKGROUND

Suicidal behavior is heterogeneous; suicide attempts can be impulsive (lower planned) or reflect forethought and preparation (higher planned). Lower planned and higher planned attempts may have different correlates that require different prevention strategies. Based on a model of suicide planning relevant to middle-aged and older adults, we tested the following hypotheses: physical illness burden, decreased functional capacity, hopelessness, and living alone are associated with suicide attempts that are more extensively planned; lower cognitive functioning is associated with suicide attempts that are more impulsive.

METHODS

Subjects were 117 inpatients ages 50 and over diagnosed with major depression based on semi-structured clinical research interviews, the medical record, plus other records when available. All subjects had attempted suicide within 1 month of admission. The degree of planning prior to the suicide attempt was quantified using Beck's Suicide Intent Scale. Multivariate linear regression analysis identified correlates of planning.

RESULTS

As hypothesized, lower cognitive functioning was associated with lower levels of planning. Contrary to the hypothesis, impaired physical self-care was associated with lower (not higher) planning. Results pertaining to living alone were equivocal.

LIMITATIONS

The study was limited by the cross-sectional research design and unclear generalizability to completed suicide or to racial/ethnic minorities.

CONCLUSIONS

Depressed patients with lower cognitive functioning and impairments in physical self-care may be especially vulnerable to impulsive suicidal behavior. The potential role of living alone in higher planned suicidal acts requires further investigation.

Identification of suicide risk factors in Medellín, Colombia: a case-control study of psychological autopsy in a developing country

The incidence, methods and risk factors for suicide may vary among the different cultures, which makes necessary to study the risk factors for suicide in specific settings in order to design adequate intervention strategies. This study aims to determine the risk factors for suicide in Medellín (Colombia). It is a case-control study conducted among 108 individuals who committed suicide and 108 deceased in accidents, matched for age and gender. Both cases and controls were examined by means of psychological autopsy. Conditional logistic regression analysis identified the following factors: Adverse life events in the last six months (OR=11.81, 95% CI: 4.29-32.52), family history of suicide (OR=10.82, 95% CI: 2.23-52.47), major depressive episode (OR=4.58, 95% CI: 1.53-13.67) and expression of a wish to die (OR=3.54, 95% CI: 1.25-10.06). These findings may suggest that risk factors for suicide are similar across cultures.

Critical issues in psychological autopsy studies

This paper reviews research based on the psychological autopsy (PA) method applied to the study of suicide. It evidences the presence of a number of methodological problems. Shortcomings concern sampling biases in the selection of control subjects, confounding influences of extraneous variables, and reliability of the assessment instruments. The absence of homogeneity among studies in the procedure employed, as well as the lack of defined guidelines for performing this type of inquiry are emphasized. Questions needing empirical investigation in the future are pointed out. It is concluded that the validity and reliability of findings emerging from the use of this method of investigation would benefit from a standardization of its application.

Risk of depression in patients with chronic respiratory diseases: results from two large cohort studies in Chinese elderly from Hong Kong

OBJECTIVE

Although it has been suggested that depression is common in patients with chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), few studies on the association between chronic respiratory diseases and depression have been conducted in the community.

METHOD

Data from the baseline examination of two cohort studies, Mr and Ms Os, Hong Kong were used. Three thousand nine hundred and ninety-eight Hong Kong men and women aged 65 to 92 were recruited. Depression was assessed by face-to-face interview, using the short-form of a validated Chinese version of the Geriatric Depression Scale (GDS). Chronic respiratory disease was assessed by subjects' self reports of chronic respiratory disease (chronic bronchitis, emphysema and asthma) diagnosed by medical doctors. Adjusted odds ratios (ORs) and corresponding 95% confidence intervals (CI) for depression among subjects with chronic respiratory diseases relative to those without (controls) were calculated, after adjustments were made for potential confounders.

RESULTS

Chronic respiratory disease was associated with a higher prevalence of depressive disorders with an odds ratio of 1.58 (95% CI = 1.12-2.13) after adjustment was made for age, sex, cigarette smoking, alcohol drinking and history of cardiovascular diseases when compared with controls. For those subjects with self report of chronic respiratory disease and who screened positive for depression (n = 44), none were on antidepressants. Among subjects who screened positive for depression without self-report of chronic respiratory disease (n = 328), only 2.74% (n = 9) were on antidepressants.

CONCLUSIONS

We conclude that chronic respiratory disease is independently associated with depression in Chinese elderly. Moreover, depression in the elderly is under-treated in those with and without chronic respiratory disease. Clinicians, especially primary care physicians in the community, should be more aware of increased prevalence of depression in patients with chronic respiratory disease.