Suicides in older adults: a case-control psychological autopsy study in Australia

Interpersonal Relationship and Suicide Attempt: The Role of Family and Social Relationship

ABSTRACT

This study investigates the role of family and social relationships in cases of attempted suicide in China. Studies, mostly analyzing data from developed countries, have indicated that interpersonal relationships are important predictors of suicidal behaviors. This study's data were derived from a case-control study in China. Family relationships included relationships with spouses, parents, and parents-in-law. Poor family and social relationships were significantly associated with increased risk of attempted suicide in women and men. Depression and social support significantly mediated the association between interpersonal relationship and attempted suicide. Poor relationship with spouse was significantly associated with an elevated risk of attempted suicide. Relationship with parents-in-law was also significantly associated with attempted suicide in women, whereas family relationships played a more important role than social relationships in suicidal behaviors, especially in men. The findings imply that suicide prevention in China could be conducted from the perspective of improving family relationships, especially husband/wife and parents/daughters-in-law relationships.

Late-life suicide: machine learning predictors from a large European longitudinal cohort

Background

People in late adulthood die by suicide at the highest rate worldwide. However, there are still no tools to help predict the risk of death from suicide in old age. Here, we leveraged the Survey of Health, Ageing, and Retirement in Europe (SHARE) prospective dataset to train and test a machine learning model to identify predictors for suicide in late life.

Methods

Of more than 16,000 deaths recorded, 74 were suicides. We matched 73 individuals who died by suicide with people who died by accident, according to sex (28.8% female in the total sample), age at death (67 ± 16.4 years), suicidal ideation (measured with the EURO-D scale), and the number of chronic illnesses. A random forest algorithm was trained on demographic data, physical health, depression, and cognitive functioning to extract essential variables for predicting death from suicide and then tested on the test set.

Results

The random forest algorithm had an accuracy of 79% (95% CI 0.60-0.92, p = 0.002), a sensitivity of.80, and a specificity of.78. Among the variables contributing to the model performance, the three most important factors were how long the participant was ill before death, the frequency of contact with the next of kin and the number of offspring still alive.

Conclusions

Prospective clinical and social information can predict death from suicide with good accuracy in late adulthood. Most of the variables that surfaced as risk factors can be attributed to the construct of social connectedness, which has been shown to play a decisive role in suicide in late life.

Psychogeriatric experts' experiences with risk factors of non-suicidal and suicidal self-injury in older adults: A qualitative study

While research has highlighted potential age-related differences in risk factors for non-suicidal and suicidal self-injury ((N)SSI), studies on such distinct risk factors among older adults are scarce. The present study addresses this gap by gaining insights into the experiences of psychogeriatric experts who work with older adults who engage in (N)SSI. In total, nine experts were interviewed about factors associated with (N)SSI in older adults. The responses were thematically analyzed using the biopsychosocial framework. We located a range of biological, psychological, and social factors contributing to (N)SSI, which largely align with previous findings regardless of age. Nonetheless, according to the experts cognitive and physical decline, advancing age, various experiences of loss, and social isolation were observed as particularly significant risk factors for older adults. These results emphasize the need for tailored preventive measures, interventions, and screening tools to address the unique challenges faced by older adults at risk of (N)SSI. Additionally, future research should investigate (N)SSI experiences in older age with a more diverse sample, including mapping the perspective of older adults themselves, healthcare providers, and other informants, to enhance our comprehension of this phenomenon among older adults.

Age and sex differences in the annual and seasonal variation of Australia's suicide rate, 2000-2020

Suicide is a major public health concern both globally and in Australia. But in Australia the extent of substantive annual and seasonality trends since 2000 through the first two decades of the 21st Century, by age and sex, has not been formally reported. The current paper sought to identify annual and within-year (seasonality) trajectories in age-sex standardized suicide rates between 2000 and 2020. The annual and within-year (seasonality) trajectories of suicide were estimated from generalised regression analyses of Australia's mortality database. No systematic variation in Australia's suicide rate since 2000 was reported and was consistent between sex and age cohorts. Seasonal variation in rates were identified, with peaks in the new year (January), declines in late Summer/Autumn, stability in Winter, increases in Spring, but with a notable decline in early summer (November-December). These trends were driven men only. Interpretation of current suicide rates need to consider systematic long-term historical context. Despite a historical focus on youth suicide especially, working-aged and very old men have consistently reported higher standardized suicide rates over the first two decades of the 21st Century. Seasonal variation was reported but only reported by men, potentially because across the lifespan, suicide rates for females were a comparatively low incidence event. Particularly after recent successive national and international crises, we emphasise that surveillance and interpretation of current suicide rate requires careful consideration as to the extent any immediate variation may otherwise fall within otherwise normal historical norms.

Older adults coping with critical life events - results of the revised demoralization scale in a representative sample of older adulthood

Background

High suicide rates in older adults are a relevant public health concern. Social isolation or widowhood as well as physical decline play a crucial role for suicidality in older adulthood. Previous evidence suggested that demoralization is an important risk factor for suicide. Whether demoralization is a relevant phenomenon in older adulthood which possibly could account for high suicide rates remains unclear.

Methods

Demoralization Scale II (DS-II) scores assessed in a survey of the German general population were investigated with respect to older adults (aged ≥ 65 years). DS-II scores were compared between older (≥ 65 years) and younger (< 65 years) adulthood and between young-old (65-74y), middle-old (75-84y), and old-old (85+y) individuals. We tested the impact of sociodemographic factors on DS-II scores within older adults.

Results

The sample comprised N = 545 adults ≥ 65 years and N = 1922 adults < 65 years. DS-II scores increased in older compared to younger adults (F(1,2465) = 6.1; p = 0.013; d = 0.09) and further from young-old to old-old (Mdiff = 2.7; 95% CI 0.45, 5.46; p = 0.034). One-fourth of individuals ≥ 65 years and almost half of old-old individuals reported DS-II scores above the cut-off > 5. Living with a partner protected from demoralization in old-old individuals.

Discussion

This study provides first evidence for an increased rate of demoralization in very old adults, in particular women, which is partly related to partnership status. We suggest that demoralization is considered as a crucial entity in older adulthood which can be missed by standard psychological screenings.

A Lonelier World after COVID-19: Longitudinal Population-Based Study of Well-Being, Emotional and Social Loneliness, and Suicidal Behaviour in Slovenia

Background and Objectives: The impact of coronavirus disease 2019 (COVID-19) goes beyond the consequences of the infectious disease, especially as the measures taken to prevent the spread of the virus have had a very profound impact on people's social relationships and everyday lives. Several studies have investigated these effects, but there is a lack of longitudinal studies in Central Europe. Objective: The aim of our study was to observe changes in well-being, loneliness, and suicidal behaviour before, during, and after the COVID-19 pandemic using the same population-based cohort. Materials and Methods: A representative sample of 440 participants completed online questionnaires at four time points: 2019 (wave 0), 2021 (wave 1), 2022 (wave 2), and 2023 (wave 3). Results: The results show significant changes in the levels of well-being and loneliness over these periods. In particular, both social and emotional loneliness increased during the pandemic, while emotional loneliness increased to a greater extent without further decreases. Well-being appeared to increase after pandemic-related restrictions diminished but decreased again one year later. No significant changes concerning suicidal ideation were observed. Conclusions: Our study suggests that the COVID-19 pandemic changed the way in which people perceive their well-being and especially their relationships with others. From the data, we can conclude that people's worldview is now lonelier than before the pandemic.

Death by suicide among aged care recipients in Australia 2008-2017

OBJECTIVE

To characterize the features of aged care users who died by suicide and examine the use of mental health services and psychopharmacotherapy in the year before death.

DESIGN

Population-based, retrospective exploratory study.

SETTING AND PARTICIPANTS

Individuals who died while accessing or waiting for permanent residential aged care (PRAC) or home care packages in Australia between 2008 and 2017.

MEASUREMENTS

Linked datasets describing aged care use, date and cause of death, health care use, medication use, and state-based hospital data collections.

RESULTS

Of 532,507 people who died, 354 (0.07%) died by suicide, including 81 receiving a home care package (0.17% of all home care package deaths), 129 in PRAC (0.03% of all deaths in PRAC), and 144 approved for but awaiting care (0.23% of all deaths while awaiting care). Factors associated with death by suicide compared to death by another cause were male sex, having a mental health condition, not having dementia, less frailty, and a hospitalization for self-injury in the year before death. Among those who were awaiting care, being born outside Australia, living alone, and not having a carer were associated with death by suicide. Those who died by suicide more often accessed Government-subsidized mental health services in the year before their death than those who died by another cause.

CONCLUSIONS

Older men, those with diagnosed mental health conditions, those living alone and without an informal carer, and those hospitalized for self-injury are key targets for suicide prevention efforts.

Guiding principles for the implementation of a standardized psychological autopsy to understand and prevent suicide: a stakeholder analysis

Background

Around 700,000 people die by suicide each year. While the global number of suicides declined over the last decade, the rates remained unchanged in the Netherlands. With this study, we aimed to provide guiding principles for the implementation of a national standardized psychological autopsy to better understand and prevent suicide, by exploring stakeholder perceptions and needs, and barriers to implementation.

Methods

We interviewed 47 representative stakeholders from various fields (e.g., mental healthcare professionals, policy advisors, researchers). A semi structured interview design was used, based on the RE-AIM and Consolidated Framework for Implementation Research (CFIR) theoretical frameworks.

Results

Themes relating to stakeholder perceptions and needs for a standardized psychological autopsy included valorization, accountability, integrability and the needs of the bereaved. Stakeholders believed that participation in a psychological autopsy can help bereaved in their process of grief but noted that evidence to frame the psychological autopsy as postvention is insufficient. The primary focal point should accordingly be to better understand and prevent suicide. Several key limitations of the proposed psychological autopsy approach were detailed, both methodological and implementational.

Conclusion

The stakeholder analysis delineates guiding principles for implementation. Stakeholders believe that a standardized psychological autopsy has merit, provided that key considerations, including valorization and accountability, are integrated in its design. Routine evaluation should be ensured. The findings may guide policy makers and researchers in their endeavors to support a learning, community-based approach for suicide prevention based on a standardized psychological autopsy.

Impact of Position in Family on Suicide: A Case-Control Psychological Autopsy Study among Chinese Rural Youths

Introduction

Suicide remains an important public health issue in China. Existing literature on the relationship between individual-familial variables and suicide risk mainly focused on family socioeconomic status, and few studies analyzed the effect of position in family on suicide. In this study, we aimed to explore the association between position in family and suicide among Chinese rural youths.

Methods

We conducted a case-control psychological autopsy study. The data collection yielded 392 suicide cases aged 15-34 years and 416 community living controls within the same age range. Personal position in family was assessed by the question "How do you evaluate his/her position in the family?" and categorized as high, general, and low to reflect the relative position in family. Logistic regression models were conducted to explore the association between position in family and suicide risk.

Results

The results showed that compared with females (males) having a high position in family, females (males) with a low position in family were 7.1 (9.1) times more likely to commit suicide (p < 0.01). Mental disorders, social support, and coping strain were potentially important mediating factors linking position in family to suicide, with certain heterogeneity among males and females. Low coping strain played the most important role in underlying the association between a low position in family and suicide for both females and males, accounting for 55% (28%) of the contribution to the total effect for females (males). Subgroup analysis revealed that low position in family had more significant impacts on suicide risk among married youths and those with low education levels.

Conclusion

The effect of position in family on suicide should receive greater consideration when predicting suicide in rural China. Possible mechanisms underlying the effect of position in family on suicide include mental status, social support, and coping strain.

Men's Behavior and Communication in the Days Prior to a Suicide-A Psychological Autopsy Study

Men show a significantly higher suicide rate, are less often recognized as persons at risk, and are more difficult to reach for suicide prevention interventions. Warning signs and deterioration in mental health are often not recognized by their surroundings. This study aims to retrospectively analyze the behavior and communication of men before a suicide, how relatives noticed changes, and how the interaction was perceived. N = 15 individuals who lost a close male relative to suicide were interviewed using psychological autopsy interviews. The interviews were evaluated following a deductive-inductive approach while using a comprehensive category system. The majority of men showed changes in behavior before the suicide, especially social withdrawal, irritability, and generally a deterioration in mental health. In fact, men did communicate their suicidal thoughts before they died through suicide, but mainly indirectly. While only one-third of the deceased made preparations before suicide, the majority of relatives noticed a deterioration in the mental health of the individual as well as increased alcohol and substance use. Men show signs of suicide, which are little recognized by their surroundings. Suicide prevention interventions should be adapted more to the needs of men.

The UT health Psychological Autopsy Interview Schedule (UTH- PAIS) - Description and reliability of diagnoses and transdiagnostic personality measures

Few studies have used psychological autopsies to evaluate large and diverse populations on transdiagnostically relevant variables such as personality, temperament, and trauma exposure; rather, they tend to focus on specific psychiatric disorders or manner of death. We therefore developed the UT Health Psychological Autopsy Interview Schedule (UTH-PAIS). The measure is described, and our results show that the PAIS diagnoses and dimensions can be reliably assessed. Furthermore, we were able to show that our sample of donated brains overall matches the demographic characteristics of a larger pool of individuals receiving a medical autopsy. In the Discussion we review the strengths and potential limitations of the study and outline in which context the PAIS will prove to be useful.

Midlife suicide: A systematic review and meta-analysis of socioeconomic, psychiatric and physical health risk factors

Suicide is an increasing contributing cause of mortality in middle-aged adults; however, knowledge to guide prevention is limited. This first systematic review and meta-analysis of studies on midlife suicide has provided an overview of published research on this issue and synthesized the evidence on socioeconomic and physical and mental health factors associated with this mortality. Using PRISMA guidelines MEDLINE, Embase, PsycINFO, Scopus and Web of Science were searched for English-language publications that involved persons aged 35 to 65, used individual-level data, and reported prevalence of exposure(s) or relative risks. The search identified 62 studies on midlife suicides and associated factors (28 for SES, 22 for psychiatric disorder and 23 for physical illness). All studies were from high income countries, and most (80.6%) used data from population registries. Meta-analyses showed that the pooled prevalence of exposure in suicide decedents was 57.8% for psychiatric disorder, 56.3% for low income, 43.2% for unemployment, and 27.3% for physical illness. The associated pooled risk ratio was 11.68 (95% confidence intervals: 5.82-23.47) for psychiatric illness of any type, 12.59 (8.29-19.12) for mood disorders, 3.91 (2.72-5.59) for unemployment, 3.18 (2.72-3.72) for being separated or divorced, 2.64 (2.26-3.10) for cancer, 2.50 (0.96-6.38) for central nervous system illness, and 2.26 (1.16-4.41) for low income. In conclusion, midlife suicide is strongly associated with socioeconomic difficulties and physical and psychiatric illnesses that are common in this age population. Future investigations should consider the interactions between risk factors, the intersectionality of sex and ethnicity, and include data from low- and middle-income countries.

Identifying Points of Prevention in Firearm-Related Suicides: A Mixed-Methods Study Based on Coronial Records

PURPOSE

Firearm-related suicide is a noteworthy and preventable public health issue that has drawn limited attention in Australian research. Firearms are highly lethal and remain in the top three methods of suicide among Australian males. This study examines suicides occurring in Tasmania, the jurisdiction with the highest rate of firearm-related suicide, with the aim of aiding suicide prevention strategies.

METHODS

A mixed-methods approach was used to analyze data from the Tasmanian Suicide Register. The quantitative analysis examined socio-demographic factors, substance use, physical and mental health, and access to services for suicides occurring between January 1, 2012 and December 31, 2016. The qualitative analysis comprised firearm-related suicides occurring between January 1, 2012 and December 31, 2017.

RESULTS

Firearms users were more likely than those employing other means of suicide to be male, retired, and residing in remote areas but were less likely to have had a previous mental illness diagnosis or evidence of suicidal ideation or self-harming behaviors. There was some evidence of increased impulsiveness among firearm users. We found 54% of decedents were licensed to own a firearm at the time of death. Firearms most often belonged to the decedent (52%) and 26% sourced a firearm from family or friends. Only 58% of cases involved a firearm with a dedicated storage facility.

CONCLUSIONS

Prevention efforts need to take into account the unique profiles of those at risk of firearm-related suicide. Impulsiveness and the varying levels of adherence to firearms safety practices point to the need for strategies that limit physical access to firearms.HIGHLIGHTSFirearms-related suicides have a unique risk profile compared with other means of suicide.Mental illness diagnosis, suicidal thoughts, and self-harming behaviors were less commonly identified among firearms-related suicides than other means of suicide.Impulsiveness and the varying levels of adherence to firearms safety practices point to the need for strategies that limit physical access to firearms.

Suicide Risk Assessments: A Scientific and Ethical Critique

There are widely held premises that suicide is almost exclusively the result of mental illness and there is "strong evidence for successfully detecting and managing suicidality in healthcare" (Hogan and Grumet, 2016). In this context, 'zero-suicide' policies have emerged, and suicide risk assessment tools have become a normative component of psychiatric practice. This essay discusses how suicide evolved from a moral to a medical problem and how, in an effort to reduce suicide, a paternalistic healthcare response emerged to predict those at high risk. The evidence for the premises is critiqued and shown to be problematic; and it is found that strong paternalistic interventions are being used more often than acknowledged. Using a Principles approach, the ethics of overriding autonomy in suicide prevention is considered. Ethical concerns are identified with the current approach which are potentially amplified by the use of these risk assessments. Furthermore, it is identified that the widespread use of risk assessments in health settings is equivalent to screening without regard to the ethical principles of screening. The essay concludes that this is unethical; that we should abandon the use of standardized suicide risk assessments and 'zero-suicide' policy; and that this may improve outcomes.

Physical diseases and elderly suicide in rural China: A case-control psychological autopsy study

OBJECTIVES

Physical diseases are well-established risk factor for suicide, particularly among older adults. However, little is known about the underlying mechanism of the association. This study aimed to describe the prevalence of physical diseases and their influences on the elderly in rural China and to examine the underlying mechanisms of the relationship between physical diseases and suicide.

METHODS

This matched case-control psychological autopsy study was conducted from June 2014 to September 2015. Consecutive suicide cases (242) among people aged 60 years or above were identified in three Chinese provinces. The suicide cases were 1:1 matched with living comparisons based on age, gender and residential area. Two informants for each participant were interviewed to collect data on their demographic characteristics, the severity index of physical diseases, depressive symptoms, feelings of hopelessness, mental disorders and social support.

RESULTS

A significant difference was found between suicide cases and living comparisons regarding the prevalence of physical diseases (83.5% vs 66.5%, p < 0.001) and their severity (11.3 ± 6.2 vs 6.7 ± 5.3, p < 0.001). Independent risks of suicide included the following: not currently married (OR = 2.81, 95% CI = [1.04, 7.62]), mental disorders (OR = 7.18, 95% CI = [1.83, 28.13]), depressive symptoms (OR = 1.15, 95% CI = [1.05, 1.26]) and feelings of hopelessness (OR = 1.51, 95% CI = [1.20, 1.90]). The structural equation model indicated that the relationship between the severity index of physical diseases and suicide was mediated by depressive symptoms, feelings of hopelessness and mental disorders.

CONCLUSION

The severity and number of physical diseases were found to be correlated with suicide among the elderly in rural China, after controlling for demographic characteristics. Physical diseases elevate one's suicide risk by increasing depressive symptoms, feelings of hopelessness and mental disorders. Efforts for suicide prevention should be integrated with strategies to treat physical diseases along with psychological interventions.

Assessing suicide ideation among older adults: a systematic review of screening and measurement tools

OBJECTIVES

Rates of suicide in older adults may be higher than reported due to poor understandings of presentation of suicide ideation in this group. The objectives of this paper were to (i) review current measurement tools designed for older adults to detect suicide ideation and (ii) assess their psychometric properties.

DESIGN

We used a systematic review approach to identify measurement tools developed specifically for older adults without cognitive decline or impairment.

RESULTS

Ten articles that reported on a total of seven different measurement tools were identified. These included tools that focused on resiliency to suicide and those that measured risk of suicide behavior. There was wide variation across the articles: some were adaptations of existing scales to suit older populations, others were developed by authors; they varied in length from four to 69 items; a range of settings was used, and there was a mix of self-report and clinician-administered measures. Most displayed good psychometric properties, with both approaches showing similar quality. Limitations in terms of samples, settings, and measurement design are discussed.

CONCLUSION

The case for specific measures for older adults is clear from this review. There appear to be unique factors that should be considered in understanding suicide ideation and behavior among older adults that may not be directly assessed in non-specific measurements. However, there is a need to expand the diversity of individuals included in measurement development to ensure they are appropriate across gender, culture and minority status, and for the views of professionals to be considered.

Suicide Risk among Older Adults: The Moderating Role of Hope

OBJECTIVES

The current study investigated whether hope and its two components (agency and pathways) acted as protective factors by weakening the relations between perceived burdensomeness, thwarted belongingness, and acquired capability for suicide and suicide risk among older adults.

METHODS

A community sample of 594 older Australians aged from 60 to 95 years (Mage = 68.72, SDage = 6.67) completed the Suicidal Behaviors Questionnaire-Revised, Interpersonal Needs Questionnaire-Revised, Acquired Capability for Suicide Scale-Fearlessness about Death Scale, Adult Hope Scale, and Geriatric Depression Scale-short form.

RESULTS

After controlling for depressive symptoms and sociodemographic variables, hope and agency moderated the thwarted belongingness-suicide risk relation, and hope, agency, and pathways moderated the acquired capability for suicide-risk relation.

CONCLUSIONS

Hope may play an important role in reducing suicide risk among older adults experiencing thwarted belongingness and who have acquired the capability for suicide. Research is required to identify ways of reducing suicide risk among older adults who experience perceived burdensomeness.

CLINICAL IMPLICATIONS

Increasing hope may reduce suicide risk among older adults experiencing thwarted belongingness and who have acquired the capability for suicide.

The Social Hopelessness Questionnaire (SHQ): Psychometric properties, distress, and suicide ideation in a heterogeneous sample of older adults

BACKGROUND

Older adults have high rates of suicide, necessitating attention to psychological factors that confer risk for suicide. Hopelessness is significantly associated with psychological despair and suicide risk factors; however, research has been limited by unidimensional treatment of the construct. The purpose of the present study was thus to investigate the psychometric properties of the Social Hopelessness Questionnaire (SHQ; Flett et al., 2021), a 20-item measure of hopelessness in the interpersonal domain, in a heterogeneous sample of older adults.

METHODS

Ninety adults 65 years of age or older were recruited from community, residential, or healthcare facilities in the context of a validation study of the Geriatric Suicide Ideation Scale (GSIS; Heisel & Flett, 2006). Participants voluntarily completed the SHQ, a demographics form, and concurrent measures of global hopelessness, depressive symptom severity, suicide ideation, and subjective well-being.

RESULTS

The SHQ demonstrated strong internal consistency, construct validity by way of significant positive associations with negative psychological factors and negative associations with positive factors, and differentiated older adults recruited from community and mental health settings. It also explained significant variability in depression, suicide ideation, and subjective well-being beyond that accounted for by an age-specific measure of global hopelessness.

LIMITATIONS

Findings were limited by a small clinical sub-sample, relatively few male participants, cross-sectional analysis, and focus on suicide ideation rather than suicide behavior.

CONCLUSION

These findings suggest that the SHQ is a reliable and valid measure of an interpersonal form of hopelessness for use with older adults across diverse settings.

Self-inflicted injury and the older trauma patient: a 20 year review of suicide attempts and outcomes

PURPOSE

Older patients (Older) have complex health management needs often requiring additional resources. Mental health disorders are common among trauma patients, yet minimal information on older suicidal related injury and outcomes exists. A review of trauma patients with intentional self-inflicted injury at one trauma center was done to describe and identify unique elements of this cohort of patients.

METHODS

Trauma registry data from 2000 to 2019 were reviewed for intentional injury and data abstracted included demographics, injury severity, diagnoses, comorbidities and outcomes. Cohorts by age were compared: Older (65 +) vs Younger (< 65). Values considered significant at p ≤ 0.05.

RESULTS

557 suicide attempts were identified with 9% among Older patients. Most patients were male with median age of 75 years for Older and 35 years for Younger cohort, with similar length of stay (LOS) and injury severity scores (ISS). Penetrating injury was more common among Older patients with firearm used most often, 34% vs 14% for Younger. Differences were evident between male and female Older patients with ISS 16.7 vs 5, p < 0.01 and mortality, p = 0.03. The outcome of discharge to home was significantly different between Older and Younger, 6% vs 20% (p < 0.05). A difference in mortality was evident, Older 38% vs Younger 18% (p < 0.05).

CONCLUSION

With the growing aging population, it is important to acknowledge the resultant increase in concomitant mental health issues and suicidality among older patients, where depression may be undiagnosed and untreated. Providing care within this cohort may reduce future attempts and lessen the burden on the health care system.

The Potential Impact of Adjunct Digital Tools and Technology to Help Distressed and Suicidal Men: An Integrative Review

Suicidal men feel the need to be self-reliant and that they cannot find another way out of relationship or socioeconomic issues. Suicide prevention is of crucial importance worldwide. The much higher rate of suicide in men engenders action. The prelude is a subjective experience that can be very isolating and severely distressing. Men may not realize a change in their thinking and behaviors, which makes it more difficult to seek and get help, thereby interrupting a "downward spiral". Stoicism often prevents men from admitting to their personal struggle. The lack of "quality" connections and "non-tailored" therapies has led to a high number of men "walking out" on traditional clinical approaches. But there are complicated relationships in motivations and formative behaviors of suicide with regards to emotional state, psychiatric disorders, interpersonal life events and suicidal behavior method selection. Middle-aged and older men have alternated as the most at-risk of suicide. There is no one solution that applies to all men, but digital tools may be of assistance (e.g., video conferences, social networks, telephone calls, and emails). Digital interventions require higher levels of effectiveness for distress and suicidality but self-guided approaches may be the most suitable for men especially where linked with an integrated online suicide prevention platform (e.g., quick response with online chats, phone calls, and emails). Furthermore, technology-enabled models of care offer promise to advance appropriate linking to mental health services through better and faster understanding of the specific needs of individuals (e.g., socio-cultural) and the type and level of suicidality experienced. Long-term evidence for suicidality and its evaluation may benefit from progressing human computer-interaction and providing impetus for an eminent integrated digital platform.

Late-life suicide in an aging world

Suicide is an important problem among older adults and in particular older men. Risk factors for suicide in older adults include the loss of a loved one, loneliness and physical illness. Suicide in older adults is often attributed to the development of depression due to bereavement or loss of physical health and independence. However, suicide prevention in old age requires avoiding overly simplistic therapeutic approaches. This Perspective discusses the impact of social determinants of health, cultural narratives and the coronavirus disease 2019 (COVID-19) pandemic on suicide among older adults and proposes strategies for a multifaceted approach to suicide prevention.

Non-Constructive Ruminations, Insomnia and Nightmares: Trio of Vulnerabilities to Suicide Risk

OBJECTIVE

Nightmare distress, nightmare frequency and anxiety are related to suicidal risk. Ruminations are a factor maximizing the risk of suicide. Research has identified two types of ruminations: constructive ruminations and non-constructive ruminations. As per our knowledge, no study has verified the links between non-constructive ruminations and sleep disorders and their role in the development of suicidal risk. We aimed to highlight the impact of non-constructive ruminations on nightmares, anxiety and insomnia in the development of suicidal risk.

METHODS

A total of 429 French participants responded to an anonymous online survey using the Qualtrics^® software. To assess variables, we used the Mini Cambridge-Exeter Repetitive Thought Scale, the Suicide Behaviors Questionnaire-Revised, the Nightmare Distress Questionnaire, the Beck Anxiety Inventory, and the Sleep Condition Indicator. Nightmare frequency was assessed by subjective evaluation through a question. We tested the possible effects of confounding variables such as age, gender, marital status and depression (Beck Depression Inventory-II).

RESULTS

Nightmare frequency was found to mediate the link between anxiety and suicidal risk (32.9%). Nightmare distress (37%) and non-constructive thoughts (48%) were also seen to mediate this link. Additionally, we found a moderating effect of insomnia on the link between non-constructive ruminations and suicidal risk (Z = 7.42, p < 0.001).

CONCLUSION

Our results showed that the frequency of nightmares, distress and non-constructive ruminations are closely related to suicidal risk. The interoperability between these elements and insomnia has thus been newly explored. The processes related to nightmares and suicidal risk as well as the underlying cognitive processes between sleep disorders and suicidal risk have been shed light upon.

Psychological Autopsy: A Method to Assist in the Identification of Risk and Protective Factors for Intimate Partner Femicide

The most common form of violence experienced by women is that perpetrated by intimate partners, and the gendered nature of intimate partner femicide (IPF) has received particular attention. Few studies to date have delved into the limitations associated with methods used in IPF research, and particularly the methods used to study homicide victims (rather than homicide perpetrators). This article outlines dominant methodologies used to study IPF, and considers a novel method of investigation-the "psychological autopsy"-that may help to improve existing knowledge about IPF.

Suicide in late life: A viewpoint

Suicide in old age represents a sad public health concern. Despite the global decline in rates of suicide and the general amelioration of quality of life and access to health care for older adults, their rates of suicide remain the highest virtually in every part of the world. With the aging of the world population and the growing number of mononuclear families, the risk of an increase in isolation, loneliness and dependency does not appear ungrounded. The Covid-19 pandemic is claiming the life of many older persons and creating unprecedented conditions of distress, particularly for this segment of the population. This article briefly examines the main characteristics of suicidal behavior in late life, including observations deriving from the spread of the Sars-2 coronavirus and possible strategies for prevention.

Suicide among older adults: Interactions among key risk factors

OBJECTIVE

The present study aimed to understand how key risk factors of older adult suicide interact to ultimately lead to death by suicide using data collected post-mortem.

METHOD

A psychological autopsy was used to gather detailed information about psychiatric diagnosis, medical problems, social isolation, and negative attitudes expressed by the individual during the six months prior to their death. Interviews with next-of-kin, medical and psychiatric records, and the Cumulative Illness Rating Scale for Geriatrics were used. Subjects included 32 older adults who died by suicide and 45 older adults who died by natural causes.

RESULTS

Hopelessness, depression, and negative health attitudes were strongly correlated with suicide. Older age was associated with social isolation, suggesting an indirect relationship with suicide via hopelessness, depression, and negative health attitudes. Physical illness did not increase risk. Multivariate analyses suggested that hopelessness fully mediated the effects of social isolation, negative health attitudes, and depression on suicide.

CONCLUSIONS

Psychological factors played the largest role in suicide deaths compared to social isolation and physical illness. Suicide interventions aimed at older adults should ensure hopelessness, depression, and negative health attitudes are primary targets.

Prevalence of Major Depressive Disorder and Correlates of Thoughts of Death, Suicidal Behaviour, and Death by Suicide in the Geriatric Population-A General Review of Literature

Background: There has been an increase in deaths by suicide in old age in the last decade. Depression and suicide in the elderly, 60 years and above, is a major global public health concern. Determining the prevalence of depression, and correlates of death by suicide in the geriatric population, is an important first step toward addressing this public health concern. This literature review aims to determine the prevalence of major depressive disorders and the correlates of death by suicide in the geriatric population. Methods: This general review of the literature was performed using relevant search terms to determine both the prevalence of depression and the correlates of death by suicide among the geriatric population. Databases such as MEDLINE, PsycINFO, CINAHL, and PubMed were searched. Relevant and current articles were extracted, reviewed, and analyzed. The elderly population was defined as individuals 60 years and above. Only full texts articles in English were reviewed. Findings: The prevalence estimates of major depressive disorder in the elderly ranged from 5.37 to 56%. Adults aged 60 years and older have a high risk of depression that exposes them to suicide. Moreover, elderly women are more likely to experience depression than elderly men, but successful suicide is more common in men. Depression and other mental health conditions (schizophrenia, anxiety disorders) and perceived stress were found to be predictors of suicide in the elderly. Other predictors included physical illnesses such as malignancies, financial constraints, cuckoldry, and sexual dysfunction, and also social factors like living alone triggers depressive symptoms and increases suicidal risk in the elderly. Hanging was found to be the most common method of death by suicide for both sexes. While elderly women preferred poisoning, elderly men in Western countries preferred firearms. Differences in gender, the aging process and social issues were also contributing factors to methods used for suicide. Conclusions: Depression and debilitating physical illnesses were identified as significant contributors to suicide risk in the elderly population, and emphasis should be placed on identifying these factors early and treating them. Recognizing and addressing factors that predict suicide in the elderly will help to improve the mental wellbeing of the elderly.

"Is Life Worth Living?": The Role of Masculinity in the Way Men Aged Over 80 Talk About Living, Dying, and Suicide

Men aged 85 years and over have the highest rate of suicide of any age or gender group in Australia. However, little is known about their trajectory toward suicide. The objective of this study was to understand the role of masculine norms and other life factors in the suicidality of older men. Thirty-three men aged 80 years or more took part in a semistructured focus group or interview, and/or completed a survey. Participants were asked about the issues facing older men, well-being and aging, physical health challenges, social support, mental health and help-seeking, and suicide and suicide prevention. Five themes emerged: "finding out we're not invincible," "active and tough," "strong silent types," "decision makers," and "right to die." Participants spoke about masculine norms that had influenced their lives as providers and decision makers, and now influenced how they coped with aging and their journey toward death. For some participants, suicide was seen to be a rational alternative to dependence in their final years. Suicide prevention should adopt a gendered approach and be cognizant of the influence of gender roles and masculinity in older men's lives. Further research and prevention efforts should be mindful of the impact of masculine norms of self-reliance and control on an older man's decision to end his life. Suicide prevention efforts should work to reduce stigma around the challenges of aging, maximize opportunities for control, facilitate social connection, and improve residential aged care.

Suicide prevention in older adults

BACKGROUND

Suicide among older adults is a multifactorial problem with several interrelated factors involved that vary with age, gender and culture. The number of suicides is highest in those aged 70 years or older in almost all regions of the world. With the increase in life expectancy, and the decrease in mortality due to other causes of death, we could expect the absolute number of older adults' suicide continue increasing.

METHODS

Review of the literature on suicide protective factors of suicide among older adults.

RESULTS

Improvements on social determinants of health and the timely detection and early treatment of affective disorders are key interventions. Prevention based on community actions and training of gatekeepers may have positive impact. Community programs that promote a sense of usefulness, belonging and that contribute to preserve social integration should be encouraged. Governments should develop the improvement of retirement programs and the development of support systems. The access to general health and mental health services should be facilitated and Primary Care professionals should receive proper training to detect and manage older persons at risk. Actively promoting a culture of coping to different stages of life and to the changes imposed by the advancing of age should form the essential part of a process bringing to better successful aging avenues.

CONCLUSIONS

Suicide prevention in older adults should broaden its focus and pay attention to the many socio-environmental conditions that may be relevant in older age, especially social isolation, financial security and physical health.

Development and initial validation of the Hopelessness Inventory for Later Life (HILL)

OBJECTIVES

Hopelessness is associated with depression, physical illness, and mortality. It is a key risk factor for suicidality in later life. Limitations have been identified in available hopelessness assessment measures regarding their use with older adults. The current study describes the development and initial psychometric evaluation of a content-valid, self-report scale for late-life hopelessness (i.e. the Hopelessness Inventory for Later Life; HILL).

METHODS

A sample of 265 older adults (ages 60-99, M = 71.1, SD = 6.7) was recruited through a combination of in-person, online, and mailed solicitations. Participants completed a survey battery containing the preliminary HILL and measures of related constructs (e.g. depression, anxiety, suicide risk, social support) to examine its psychometric properties.

RESULTS

Multiple analytic item selection strategies resulted in two viable versions of the scale: the HILL and the HILL-Shortened (HILL-S). Both exhibited strong item response characteristics and preliminary evidence of unidimensionality (via factor analysis), internal consistency (α = .96 and α = .89, respectively), and construct validity (via correlations with related constructs).

CONCLUSION

Findings provide preliminary psychometric support for both the HILL and HILL-S. Advantages for use of the HILL and the HILL-S over existing measures of hopelessness are discussed.

Introducing the Psychological Autopsy Methodology Checklist

OBJECTIVE

Case-control psychological autopsy studies are the research standard for the postmortem, quantitative study of ongoing or recent risk factors for suicide. We aimed to develop a reliable checklist of methodological quality of these studies.

METHOD

We adapted items from a validated checklist to address general methodological elements and created novel items to address the unique aspects of psychological autopsy research to generate a 16-item checklist assessing reporting, external validity, internal validity, and power. We used percent agreement and kappa to evaluate inter-rater reliability of the items and overall checklist based on independent ratings of 26 case-control psychological autopsy studies conducted internationally. We also summed the items to generate overall quality ratings, assessing internal consistency with coefficient alpha (α).

RESULTS

Inter-rater reliability for the overall checklist was high (percent agreement, 86.5%) and that based conservatively on kappa was substantial (κ .71) whereas internal consistency was low (α = 0.56). The inter-rater reliability of the individual items showed acceptable to high agreement.

CONCLUSION

A novel checklist provides a reliable means to assess the methodological quality of specific elements of quantitative case-control psychological autopsy studies, providing detailed guidance in planning such studies. Lower internal consistency may limit its utility as a summary measure of study quality.

Suicide Risk in Medicare Patients With Schizophrenia Across the Life Span

Importance

Although adults with schizophrenia have an increased risk of suicide, sample size limitations of previous research have hindered characterizations of suicide risk across the life span.

Objective

To describe suicide mortality rates and correlates among adults with schizophrenia across the life span and standardized mortality ratios (SMRs) for suicide compared with the general US population.

Design, Setting, and Participants

Five national retrospective longitudinal cohorts of patients with schizophrenia in the Medicare program from January 1, 2007, to December 31, 2016, were identified by age: 18 to 34, 35 to 44, 45 to 54, 55 to 64, and 65 years or older. Death record information was obtained from the National Death Index. The total cohort included 668 836 Medicare patients with schizophrenia, 2 997 308 years of follow-up, and 2218 suicide deaths. Data were analyzed from September 30, 2020, to March 10, 2021.

Main Outcomes and Measures

For each age group, suicide mortality rates per 100 000 person-years and adjusted hazard ratios (aHRs) with 95% CIs of suicide were determined. Suicide SMRs were estimated for the total cohort and by sex and age cohorts standardized to the general US population by age, sex, and race/ethnicity.

Results

The study population of adults 18 years and older included 668 836 Medicare recipients with schizophrenia (52.5% men, 47.5% women). The total suicide rate per 100 000 person-years was 74.00, which is 4.5 times higher than that for the general US population (SMR, 4.54; 95% CI, 4.35-4.73) and included a rate of 88.96 for men and 56.33 for women, which are 3.4 (SMR, 3.39; 95% CI, 3.22-3.57) and 8.2 (SMR, 8.16; 95% CI, 7.60-8.75) times higher, respectively, than the rates for the general US population. Suicide rates were significantly higher for men (aHR, 1.44; 95% CI, 1.29-1.61) and those with depressive (aHR, 1.32; 95% CI, 1.17-1.50), anxiety (aHR, 1.15; 95% CI, 1.02-1.30), drug use (aHR, 1.55; 95% CI, 1.36-1.76), and sleep disorders (aHR, 1.22; 95% CI, 1.07-1.39), suicidal ideation (aHR, 1.41; 95% CI, 1.22-1.63), and suicide attempts or self-injury (aHR, 2.48; 95% CI, 2.06-2.98). The adjusted hazards of suicide were lower for Hispanic patients (aHR, 0.66; 95% CI, 0.54-0.80) or Black patients (aHR, 0.29; 95% CI, 0.24-0.35) than White patients. The suicide rate declined with age, from 141.95 (SMR, 10.19; 95% CI, 9.29-11.18) for patients aged 18 to 34 years to 24.01 (SMR, 1.53; 95% CI, 1.32-1.77) for patients 65 years or older. The corresponding declines per 100 000 person-years were from 153.80 (18-34 years of age) to 34.17 (65 years or older) for men and from 115.70 (18-34 years of age) to 18.66 (65 years or older) for women. In the group aged 18 to 34 years, the adjusted hazards of suicide risk were significantly increased for patients with suicide attempt or self-injury (aHR, 2.57; 95% CI, 18.20-2.04) and with comorbid drug use disorders (aHR, 1.48; 95% CI, 1.17-1.88), but not with comorbid depressive disorders (aHR, 0.99; 95% CI, 0.38-1.26) during the year before the start of follow-up.

Conclusions and Relevance

In this cohort study of adult Medicare patients with schizophrenia, suicide risk was elevated, with the highest absolute and relative risk among young adults. These patterns support suicide prevention efforts with a focus on young adults with schizophrenia, especially those with suicidal symptoms and substance use.

A sociological autopsy lens on older adult suicide in rural Australia: Addressing health, psychosocial factors and care practices at the intersection of policies and institutions

This paper examines the interrelationship between suicide, health, socioeconomic, and psychosocial factors in contributing to suicide in older adults in rural Australia. Drawing on a coronial dataset of suicide cases and a mixed methods sociological autopsy approach, our study integrated a quantitative analysis of 792 suicide cases with a qualitative analysis of medico-legal reports from 30 cases. The sociological autopsy provided novel insights into the entanglement of policy and service provision at the state-level with individual end-of-life decisions. Particular attention is drawn to age and gendered dimensions of suicide, especially in relation to health and social issues. The study showed a continuity between suicide and the patterning of an individual's life course, including experiences and consequences of inequality and marginality; a desire to meet culturally-normative ideals of autonomy; and a fragmented, under-funded, and intimidating social care system that offered limited options.

Estimating the risk of suicide associated with mental disorders: A systematic review and meta-regression analysis

BACKGROUND

Mental disorders (MDs) are known risk factors for suicide. This systematic review updates the evidence base for this association and improves upon analytic approaches by incorporating study-level and methodological variables to account for measurement error in pooled suicide risk estimates.

METHODS

A systematic review was conducted to review studies on MDs as risk factors for suicide. Relevant studies were searched using PubMed, Embase, PsychINFO, and existing reviews from 2010 to 19. Studies were eligible if they were longitudinal/case-control studies, representative of the general population, used diagnostic instruments, and quantified suicide risk. The outcome assessed was relative risks (RRs) for suicide due to MDs. A multi-level meta-regression approach was used to obtain pooled RRs adjusted for covariates and between-study effects.

FINDINGS

We identified 20 eligible studies yielding 69 RRs. Disorder type, age, sex, use of psychological autopsy, study design, and adjustment for confounders were tested as predictors of pooled suicide risk. Overall, all disorders were significant predictors of suicide with predicted adjusted RRs ranging from 4·11 [2·09, 8·09] for dysthymia to 7·64 [4·3, 13·58] for major depressive disorder.

INTERPRETATION

Our results indicate that MDs are important risk factors for suicide. This systematic review provides pooled RRs that have been adjusted for methodological sources of bias. Findings from our paper may inform suicide prevention strategies as part of national health agendas.

The relationship of frailty and disability with suicidal ideation in late life depression

OBJECTIVES

Frailty and disability are commonly found in Late Life Depression (LLD) and have been associated with increased depression severity, health comorbidities and mortality. Additionally, physical frailty has been associated with suicide in later life, independent of presence of a mood disorder. The objective of our study was to assess the associations of physical frailty and functional disability with suicidal ideation, controlling for depression severity and demographic factors, in an older depressed sample.

METHODS

This study used data from community-dwelling older adults with major depression. Eligible participants were ≥ 65 years old, completed measures of depression symptom severity (Hamilton Depression Rating Scale-24 item; HDRS-24), current suicidal ideation (Geriatric Suicide Ideation Scale; GSIS), and physical frailty/functional capacity measures.

RESULTS

Participants were 88 older adults with a mean age of 71.5 (SD = 6.0) and 66% of the sample was female. Poorer performance on frailty measures of gait speed (B = .239, p = .003) and muscle weakness (B = -.218, p = .01) were significantly associated with higher levels of suicidal ideation, independent of depression severity and demographic factors. Functional disability was also significantly related to suicide ideation, specifically impairment in financial capacity (B = -.290, p = .008), social interaction (B = .408, p < .001), and communication skills (B = .373, p = .001).

CONCLUSION

Our findings show that, in LLD, frailty and functional disability are significantly associated with higher levels of suicide ideation, independent of depression symptom severity.

Development of a Suicide Prevention Toolkit for VA Home-Based Primary Care Teams

The U.S. Department of Veterans Affairs Home-Based Primary Care program (HBPC) serves Veterans with multiple comorbid physical and psychological conditions that can increase suicide risk. HBPC teams are uniquely able to implement suicide risk assessment and prevention practices, and the team's mental health provider often trains other team members. An online suicide prevention toolkit was developed for HBPC mental health providers and their teams as part of a quality improvement project. Toolkit development was guided by a needs assessment consisting of first focus group and then data from surveys of HBPC program directors (n = 53) and HBPC mental health providers (n = 56). Needs identified by both groups included training specific to the HBPC patient population and more resources if mental health needs could not be fully managed by the HBPC team. HBPC mental health providers within integrated care teams play a key role in clinical intervention, policy development, and interprofessional team education on suicide prevention. HBPC teams have specific learning and support needs around suicide prevention that can be addressed with a feasible, easily accessible clinical and training resource.

Clinical validation of the nursing diagnosis risk for suicide in the older adults

OBJECTIVE

To clinically validate risk factors for the nursing diagnosis risk for suicide in older adults.

METHODS

Case-control study (105 older adults). The strength of the association between variables was assessed using odds ratio (OR). Risk factors were grouped into hierarchical blocks according to the Integrated Motivational-Volitional Model of Suicidal Behaviour.

RESULTS

Anxiety; guilt; divorce; hostility; inability to express feelings; loss of important relationship; financial problems; apathy; low self-esteem; hopelessness; dependence and functional incapacity; unhappiness; failure; frustration; marked change in attitude and behavior; sadness; self-neglect; stockpiling medication; depression; ideation and suicidal plans; and mental disorders were associated with risk for suicide.

CONCLUSIONS

It is expected that this study will contribute to clinical nursing practice by the identification of this diagnosis in a safer and more precise manner. Descriptors: clinical judgment, nursing diagnosis, psychiatric nursing, suicide, older adult.

Suicide in Older Adults With and Without Known Mental Illness: Results From the National Violent Death Reporting System, 2003-2016

INTRODUCTION

Suicide risk increases with age, and evidence exists for the underdiagnosis and undertreatment of suicide risk in older adults. Recent data suggest that many U.S. adults who die from suicide do not have a known mental health condition. This study compares the characteristics and precipitating circumstances of geriatric suicide decedents with and without known mental illnesses.

METHODS

This study was a retrospective analysis of suicide deaths for adults aged ≥65 years from the National Violent Death Reporting System, 2003-2016 (n=26,884). ORs compared sociodemographic and clinical characteristics, cause of death, and precipitating circumstances based on coroner/medical examiner and law enforcement reports. Data were collected and analyzed in 2019.

RESULTS

Most older male (69.1%) and female (50.2%) suicide decedents did not have a known mental illness. A physical health problem was the most prevalent precipitating circumstance but was more common among older adults without known mental illness. Past suicide attempt, disclosure of suicidal intent, depressed mood, and substance use were more common among those with a known mental illness. More than three fourths of suicide decedents did not disclose their suicidal intent. Most suicide deaths involved firearms, which were disproportionately used by decedents without known mental illness (81.6% of male and 44.6% of female decedents) compared with those with known mental illness (70.5% of male and 30.0% of female decedents).

CONCLUSIONS

Most older adults who die from suicide do not have a known mental health condition. The rapidly growing U.S. geriatric population calls for more effective methods to identify and treat at-risk older adults, particularly those who are male.

Reliability and validity of short Beck Hopelessness Scale in psychological autopsy study among Chinese rural elderly

BACKGROUND

Older adults represent the segment of population most exposed to the risk of suicide nearly everywhere in the world. Previous studies showed that hopelessness was an important risk factor for suicide.

AIMS

This study aimed to evaluate the reliability and validity of the four-item Beck Hopelessness Scale (BHS-4) in psychological autopsy study among Chinese rural elderly.

METHOD

Two-stage stratified cluster sampling method was used to select research sites. Using case-control psychological autopsy study, face-to-face interviews were conducted to collected information.

RESULTS

A total of 242 elderly suicide deaths and 242 matched living comparisons were investigated, including 135 males and 107 females for each group. Intraclass Correlation Coefficients (ICC) of the controls were 0.682-0.713. The median score of BHS-4 among suicides was significantly higher than that among controls. The corrected correlation coefficient between items and total score were 0.184-0.723. Cronbach's Alphas coefficient was 0.834. Only one common factor was precipitated by exploratory factor analysis and the cumulative variance contribution rates were 59.558% for suicides and 52.722% for living controls. The correlation coefficient between hopelessness and depression were 0.481 among suicide death and 0.617 among living controls.

CONCLUSION

The information provided by the informants through psychological autopsy method had high reliability to reflect the actual situation of suicides and controls. BHS-4 has good reliability and validity among Chinese rural elderly suicides. It is suitable for psychological autopsy study among Chinese rural elderly.

Personality of late- and early-onset elderly suicide attempters

OBJECTIVES

While suicidal behavior often manifests in adolescence and early adulthood, some people first attempt suicide in late life, often with remarkable lethal intent and determination. Given these individuals' more adaptive functioning earlier in life, they may possess traits that hinder adjustment to aging, such as high conscientiousness, rather than impulsive-aggressive traits associated with suicidal behavior in younger adults.

METHODS

A cross-sectional case-control study was conducted in older adults aged ≥50 (mean: 65), divided into early- and late-onset attempters (age at first attempt ≤ or >50, mean: 31 vs 61), suicide ideators as well as non-suicidal depressed and healthy controls. Personality was assessed in terms of the five-factor model (FFM, n = 200) and five DSM personality disorders analyzed on the trait level as continuous scores (PDs, n = 160). Given our starting hypothesis about late-onset attempters, the FFM dimension conscientiousness was further tested on the subcomponent level.

RESULTS

All clinical groups displayed more maladaptive profiles than healthy subjects. Compared to depressed controls, higher neuroticism, and borderline traits characterized both suicide ideators and early-onset attempters, while only early-onset attempters further displayed lower extraversion and higher antisocial traits. Late-onset attempters were similar to depressed controls on most measures, but scored higher than them on orderliness, a conscientiousness subcomponent.

CONCLUSIONS

While neuroticism, introversion, and cluster B traits are prominent in early-onset suicidal behavior, late-onset cases generally lack these features. In contrast, higher levels of orderliness in late-onset suicidal behavior are compatible with the age-selective maladjustment hypothesis. Key points Personality of elderly attempters differed between those with early- and late-onset first attempts. Early-onset attempters possessed personality traits generally found in younger suicidal populations (high neuroticism, low extraversion, antisocial, and borderline PD traits), supporting that constitutional suicide risk factors persist into late life in some individuals. Late-onset suicide attempters had higher levels of orderliness than non-suicidal depressed participants, suggesting that this generally adaptive trait may facilitate suicidal behavior in a subset of depressed elderly.

Family Functioning and Suicide Among the Elderly in Rural China: A Case-Control Psychological Autopsy Study

This study aimed to examine the association between family functioning and suicide among the elderly in rural China. This 1:1 paired case-control psychological autopsy study included 242 suicides at age 60 or more and an equal number of controls matched on age (±3 years), gender, and residency. Family functioning was assessed by the Family Adaptation Partnership Growth Affection Resolve Index. Family dysfunction was reported more frequently in suicides than in paired controls. Severe family dysfunction denoted a significant risk factor for suicide only in women after adjusting for potential confounding factors. Suicides with family dysfunction were prone to have unstable marital status, physical illness, mental disorders, family suicide history, and more stressful life events than those with good family functioning. The findings suggest that the intervention enhancing family functioning may be effective in decreasing suicide among the elderly in rural China.

Suicide and sudden death bereavement in Australia: A longitudinal study of family members over 2 years after death

OBJECTIVE

Grief reactions change over time. However, only a limited number of studies, and none in Australia, have analysed changes in individual grief reactions longitudinally. The aim is to examine changes in grief reactions, mental health and suicidality of close family members bereaved by suicide, 6, 12 and 24 months after their loss compared with those bereaved by other forms of sudden death, adjusting for confounding factors.

METHOD

Participants were 142 adult family members bereaved by suicide and 63 by other sudden death, followed up at 6, 12 and 24 months in Queensland, Australia. The Grief Experience Questionnaire, Depression Anxiety Stress Scale and Beck Scale for Suicide Ideation were used as main outcomes. Mixed-effects linear and logistic regressions were utilized for statistical analyses.

RESULTS

There were significant differences in rejection, stigmatization, shame and responsibility between the suicide and sudden death bereaved over the 2-year period, after adjusting for potential confounding factors. Rejection, stigmatization, search for explanation, somatic reactions and symptoms of depression and anxiety (Depression Anxiety Stress Scale) declined significantly over time in both groups. Rejection and somatic reactions showed group-by-time interaction effects, with a decrease in the suicide bereaved and no change in the sudden death bereaved. Loss of social support and suicidal ideation did not show a group or time effect.

CONCLUSION

Although our findings confirm that there are several common dimensions to experiencing a sudden death of a family member, several differences were found between the suicide and non-suicide sudden death bereaved including significantly higher levels of rejection, stigmatization, shame and responsibility remaining in the suicide compared to sudden death bereaved 2 years after their loss. These findings should be considered in clinical practice and when designing postvention services in Australia.

Meaning-Centered Men's Groups: Initial Findings of an Intervention to Enhance Resiliency and Reduce Suicide Risk in Men Facing Retirement

Objectives: To assess the preliminary effectiveness of Meaning-Centered Men's Groups (MCMG), a 12-session existentially-oriented, community-based, psychological group intervention designed to enhance psychological resiliency and prevent the onset or exacerbation of suicide ideation among men who are concerned about or struggling with the transition to retirement.Methods: We recruited 30 men (n= 10 per group), 55 years and older (M= 63.7, SD= 4.1) from community settings to participate in a course of MCMG to be delivered in a community center. Participants completed eligibility, pre-, mid-, and post-group assessments of suicide ideation and psychological risk and resiliency factors.Results: Participants experienced significant increases in attitudinal sources of meaning in life, psychological well-being, life satisfaction, retirement satisfaction, and general health, and decreases in depression, hopelessness, loneliness, and suicide ideation.Conclusions: Preliminary findings suggest that MCMG is a novel men's mental health intervention that may help to enhance psychological well-being and potentially reduce the severity or prevent the onset of symptoms of depression, hopelessness, and suicide ideation.Clinical Implications: Upstream psychological interventions may serve an important role in mental health promotion and suicide prevention with potentially vulnerable individuals facing challenging life transitions.

Validation by experts of Risk of suicide Nursing Diagnosis in the elderly

OBJECTIVE

to validate the conceptual and operational definitions content of factors for Risk of suicide Nursing Diagnosis in the elderly.

METHOD

this is validation of the conceptual and operational definitions content of factors for Risk of suicide in the elderly, performed by 15 experts, from November 2015 to March 2016. Risk factors were classified into three hierarchical chuncks. The data were analyzed by descriptive statistics and binomial test.

RESULTS

of the 54 validated risk factors, only eight presented problems regarding clarity, simplicity and accuracy: chronic pain, vision problems, retirement, frustration, medication neglect and depression. Only rigidity was not validated as relevant for the study diagnosis.

CONCLUSION

content validation of the risk factors for Nursing Diagnosis can guide the clinical practice of the nurse in the early detection of risk of suicide in the elderly.

Factors Associated with Suicide Attempts and Suicides in the General Population of Andalusia (Spain)

Discrepant results have been published by studies comparing deaths by suicide with attempted suicides. This study aimed to determine factors associated with suicides and attempted suicides in Andalusia (Spain) between 2007 and 2013, comparing sex, age, year, and suicide method between these populations. A retrospective study was conducted of data on deaths by suicide and attempted suicides over a seven-year period, calculating the sex and age rates for each behavior. Adjusted Poisson regression was used to analyze the association with study variables, and incidence rate ratios were estimated. During the seven-year study period, 20,254 attempted suicides and 5202 deaths by suicide were recorded. The prevalence of attempted suicide did not differ between the sexes, whereas the prevalence of deaths by suicide was three-fold higher among males than among females and increased with higher age. The most frequently used method was the same in males and females for suicide attempts, but differed between the sexes for suicides. The combined influence of sex and age was greater in the model for death by suicide than in the model for attempted suicide. The key differentiating factor was the method used, while the finding of greatest concern was the suicide behavior among the elderly. Preventive strategies should take these differences into account.

Suicide Means Used by the Older Adults in Rural China: A Comparison Between Those Using Pesticides and Other Means

BACKGROUND

The most frequently used means of committing suicide was pesticide poisoning in rural China, yet little is known about the characteristics and risk factors for suicides committed with pesticides compared to those committed via other means in older adults.

METHODS

The participants were 242 older adults (aged 60 or older) who had committed suicide in the rural areas of 3 provinces (Shandong, Hunan, and Guangxi) in China. This study was conducted using the psychological autopsy (PA) method.

RESULTS

In univariate analyses, no statistically significant differences were found between those who committed suicide with pesticide or with other means in terms of demographic and clinical variables except age, prevalence of mental disorders, suicidal intent, number of recent life events, social support, hopelessness, impulsivity, and depressive symptoms (P > .05); age, history of suicide attempts, having pesticides available at home, the total number of life events, and the number of long-term life events were significantly different (P < .05) between the 2 groups. In multivariate logistic regression model, the factors associated with committing suicide with pesticides were the availability of pesticides at home (odds ratio [OR] = 3.48, 95% confidence interval [CI]: 1.99-6.08) and the number of long-term life events (OR = 0.87, 95% CI: 0.78-0.97).

CONCLUSION

The older adults who committed suicide by pesticides and those using other means are probably the same population. The main determinant of choosing pesticides as suicide means was likely the availability of pesticides at home. Suicide risk among older adults might be reduced by placing appropriate restrictions on access to pesticides.

Characteristics of patients with cancer who die by suicide: Coronial case series in an Australian state

OBJECTIVE

Suicide rates are elevated in epidemiological studies, but extrapolating population level data to the individual patient cancer is difficult, and there is a dearth of studies examining how suicidality might be linked to the cancer experience. We examine the cancer-suicide correlates to explore clinical implications and future research directions.

METHOD

We used a novel database to examine all suicide deaths reported to the Coroners Court of Victoria between 2009 and 2013 in individuals with active, diagnosed cancer. Cases were classified in relation to whether cancer had been a probable, possible, or unlikely influence on suicidal ideation. Sociodemographic, clinical, health service contacts, and suicide method data were analysed to describe the characteristics of individuals with cancer at the time of their suicide.

RESULTS

There were 2870 suicide deaths, and 118 cases met inclusion criteria. Clinically distinct patient subgroups emerged through a contrast between those cases where the data suggested a correlate between cancer and suicide, and those where the data did not. The former group had many more cancer-related health problems than the latter group, who had a higher burden of psychiatric illness that predated their cancer diagnosis. The intent to suicide was known to most clinicians.

CONCLUSIONS

All clinicians working with cancer patients should be prepared to explore suicidal ideation. Understanding how the patient conceptualises suicidality with respect to cancer experience and mental health may be of central importance in determining whether mental health care is best provided as part of cancer care, or through a separate mental health service.

Metaanalysis of Mood and Substance Use Disorders in Proximal Risk for Suicide Deaths

Evidence for proximal risk factors for suicide is based on case-control psychological autopsy studies, with these reports showing that mood and substance use disorders are the most prevalent mental disorders among suicide decedents worldwide and are associated with marked risk. However, moderators of risk and the degree of risk associated with (nonalcohol) drug use disorder are unknown. A comprehensive search was used to identify 35 case-control psychological autopsy studies published worldwide over a 30-year period that were metaanalyzed using random effects models. Major depression, odds ratio (95% confidence interval) = 9.14 (5.53, 15.09), and drug use disorder, OR (95% CI) = 7.18 (3.22, 16.01), had large effect sizes, among other results. Risk estimates associated with major depression were greater in studies with a larger proportion of women and those conducted in Asia compared with other regions. There was no evidence of publication bias or that any one study had a disproportionate impact on findings. Risk for suicide associated with major depression appears to be moderated by sex and/or world region. Drug use disorder is a potent risk factor, illustrating the importance of assessing drug use in clinical risk assessment.

Being left-behind, mental disorder, and elderly suicide in rural China: a case-control psychological autopsy study

BACKGROUND

Suicide rate among rural elderly is the highest among all age groups in China, yet little is known about the suicide risks in this rapidly growing vulnerable population.

METHODS

This matched case-control psychological autopsy study was conducted during June 2014 to September 2015. Consecutive samples of suicides aged 60 or above were identified in three provinces (Shandong, Hunan, and Guangxi) in China. Living comparisons were 1:1 matched with the suicides in age (±3 years old), gender, and living location. Risk factors included demographic characteristics, being left-behind, mental disorder, depressive symptoms, stressful life events, and social support.

RESULTS

A total of 242 suicides and 242 comparisons were enrolled: 135 (55.8%) were male, mean (s.d.) age was 74 (8) years. The most frequently used suicide means were pesticides (125, 51.7%) and hanging (95, 39.3%). Independent risks of suicide included unstable marital status [odds ratio (OR) 4.19, 95% confidence interval (CI) 1.61-10.92], unemployed (compared with employed, OR 4.43, 95% CI 1.09-17.95), depressive symptoms (OR 1.34, 95% CI 1.21-1.48), and mental disorder (OR 6.28, 95% CI 1.75-22.54). Structural equation model indicated that the association between being left-behind and suicide was mediated by mental disorder, depressive symptoms, stressful life events, and social support.

CONCLUSIONS

Unstable marital status, unemployed, depressive symptoms, and mental disorder are independent risk factors for suicide in rural elderly. Being left-behind can elevate the suicide risk through increasing life stresses, depressive symptoms, mental disorder, and decreasing social support. Elderly suicide may be prevented by restricting pesticides, training rural physicians, treating mental disorders, mitigating life stress, and enhancing social connection.

Suicide and other sudden death bereavement of immediate family members: An analysis of grief reactions six-months after death

INTRODUCTION

While suicide bereavement has been assumed to be different from bereavement following death by other modes, a number of studies have reported that there are several similarities, particularly for violent deaths. The aims of the current study are to test, using confirmatory factor analysis, the factor structure of Grief Experience Questionnaire (GEQ) that has been proposed in other studies; and to compare short term grief reactions, mental health, and suicidality six-months after bereavement in close family members bereaved by suicide versus sudden death.

METHODS

Participants were 142 adults who were bereaved following a suicide and 63 who were bereaved following the sudden death of a family member. Data were collected six-months after the death.

RESULTS

Analyses did not show good fits for the factor structures proposed for the GEQ in earlier studies. However, a relatively good fit was found for an 8-factor version of the originally proposed GEQ. Bereavement type (suicide vs. sudden death) significantly predicted rejection, somatic reactions, stigmatisation, responsibility and shame on the GEQ, after adjusting for kinship type, gender, age, pre-bereavement diagnosis of mental illness and self-harm behaviours of both the deceased and the bereaved, and current mental health and suicidal ideation of the bereaved.

LIMITATIONS

Different recruitment methods were used and response rates were relatively low.

CONCLUSIONS

The new knowledge of bereaved experiences specific to suicide loss at six-months post death, should be channelled into determining the most practical and satisfactory ways to alleviate the impacts of these potentially changeable states of experience.

Clinical and demographic characteristics of geriatric patients with acute poisoning in the state of Uttarakhand

Background:

Acute poisoning in geriatric age group is a clinical challenge due to multiple comorbidities and complications in this age group. There are very few studies done in the past, which have addressed this issue.

Materials and Methods:

This retrospective observational study was a carried out in the Department of Emergency Medicine of a tertiary care hospital of Uttarakhand over a period of 1 year from November 2017 to October 2018. Detailed demographic data and clinical history of patients with alleged history of acute poisoning was obtained from the hospital record section.

Results:

During the period of 1 year, 156 patients of acute poisoning attended the medical emergency department, of which 53 (33.9%) patients belonged to geriatric age group (>60 years). Maximum number of patients belonged to the age group of 71–80 years (n = 26, 16.6%). Males outnumbered female patients. The most common toxidrome in geriatric age group was alcohol intoxication followed by pesticide (organophosphorus) poisoning. Unintentional exposure of toxin in the form of drug over dosage encompassed more than one-third of poisonings in geriatric population. Nine (16.9%) geriatric patients succumbed to poisoning. Complications such as acute renal failure, shock, respiratory distress, acute liver injury, and need for ventilator support were more common in nonsurvivors as compared with survivors.

Conclusion:

The study demonstrated mortality of 16.9% (n = 9) among geriatric patients with alleged history of acute poisoning. The risk factors attributing to mortality were shock, aspiration pneumonia, and acute liver injury. Although cases of suicidal exposure outnumbered cases of unintentional exposure, the latter group comprised of a considerable number. Clearly, more attention is needed while managing a case of acute poisoning of geriatric age group as their pattern of presentation and complications differ from that of younger age group.