Chapter 21 THE OLDER PERSON WITH SUICIDAL THOUGHTS

INTRODUCTION

Some of the highest rates for suicide are found among older people, particularly men. Yet despite this fact, older people are often left out of discussions on suicide for a number of reasons (Mitty & Flores 2008). These include more emphasis given to youth suicide because the young carry a higher economic burden and, where ageist attitudes prevail, feelings of wanting to die and hopelessness are sometimes considered normal for older people. Unfortunately, these attitudes also manifest in clinical practice where it may not be considered important to ask an older person about suicidal feelings and, consequently, they are less likely to be offered assertive treatment (O’Connell 2005).

There has been a significant decline in late-life suicides over the last decade or so (Australian Bureau of Statistics 2007). However, the increased prevalence of depression and suicide attempts among middle-aged people, particularly the large number of baby boomers who are now beginning to reach the status of being older people, may be suggestive of a generational effect that will carry over into the coming decades, boding late-life suicide as a looming major public health concern. Suicide is a tragic event for all the people involved, including mental health workers. The purpose of this chapter is to highlight the trends and themes concerning suicide and older people, and create an awareness of risk factors and the role they have in the prevention of suicide. Effective interventions are also detailed to reduce the morbidity and mortality associated with suicide in older people.

CASE VIGNETTE

Tom is a 67-year-old, unmarried, retired farmer. He had been discovered by his neighbour early one morning preparing to hang himself from a tree in the backyard. The neighbour had rung the police who took Tom to the local hospital’s emergency department. Tom was admitted voluntarily to the psychiatric unit. He had been there for a week and was being discharged home. He had been referred to the older persons’ mental health service (OPMHS) on admission for intensive follow-up on discharge. Staff of the OPMHS had been involved in the treatment decisions. Tom was not cognitively impaired, he was diagnosed with a mild depression and had been prescribed an antidepressant medication.

During his admission, the following personal problems had been identified:

• Unresolved grief over the loss of his mother and farm life. Tom and his mother had sold their farm and moved to a regional town 5 years previously. His mother required ongoing medical treatment for cancer and Tom had cared for her by himself until she had died 9 months ago.

• Loneliness and limited social support. Tom had been asked to leave his local church because a female volunteer who had been visiting him after his mother’s death had interpreted a display of affection from Tom as being sexually motivated. Despite denying this was the intention, Tom continued to feel shame and embarrassment over this incident. Additionally, Tom’s neighbourhood consisted of working families and, although they were friendly, there was limited social interaction and common interests with neighbours.

Tom was a keen gardener, but a small yard and water restrictions hampered this activity and there was no one with whom to share this passion.

Tom’s treatment plan was aimed at addressing these issues. It consisted of support and gradual introduction into various therapeutic and social activities. These activities were:

• weekly interpersonal psychotherapy sessions for his grief and improvement of social skills

• attendance at an older men’s group and a senior citizen’s group (the latter was important to Tom because he enjoyed dancing and the company of women) for peer support and socialisation

• attendance at another church for spiritual needs and socialisation

• participation in a water-wise gardening cooperative that was run by the local council, and

• home visits by a mental health worker on the days he did not have any scheduled activities to establish his mental state, suicide risk, daily living skills, and to work through reactions or potential worries about scheduled activities.

Tom was also given a list of contacts to telephone if he felt suicidal and was asked to give an assurance that he would make contact.

After 3 months of interpersonal therapy and supported social interactions, Tom was able to come to better terms with his grief and build up a social support network that suited his needs. His suicidal thoughts and shameful feelings decreased and the mental health workers were able to gradually withdraw their support.

EPIDEMIOLOGY

The pattern of age-specific rates in 2005 for suicide in men and women is shown in Figure 21.1.

Figure 21.1 Age-specific rates in 2005 for suicide in men and women

Source: Australian Bureau of Statistics (2007).

The following are some interesting facts and figures about suicide in older people in Australia (Australian Bureau of Statistics 2007, Caldwell et al 2004, Cantor et al 1999, de Leo et al 1999, 2001, Fairweather et al 2007, Goldney & Harrison 1998):

• Suicide rates among older people have generally declined across Australia over recent decades. In 2005, the rate of 11 suicides per 100,000 of older people was less than the 12.9 per 100,000 recorded in 1995. Possible reasons cited for this have been changes in medical prescribing habits, improved access to healthcare including psychiatric services, better income support, greater acceptance of mental health problems and illnesses such as depression, and migration from countries with lower suicide rates.

• Approximately 283 older people commit suicide each year, accounting for 13.5% of all suicides in Australia. Nearly 80% of these deaths are men. However, this is thought to be an underestimate because of a high level of comorbidity issues in this age group, which may confound the cause of death, and it is sometimes difficult to know whether a death was intentional or accidental.

• Men aged 80 years of age and older have exceptionally higher rates of suicide, at just over 30 per 100,000 of population per year. The impact of poor physical and mental health resulting in dependency is thought to be a strong contributing factor to suicide for men of this age.

• In older men, for every completed suicide there are 0.9 attempts recorded and in older women for every completed suicide there are 3.1 attempts recorded. When completed suicide numbers are greater, as in the case for older men, this indicates that a suicidal act is more likely to end in death than not.

• International studies have indicated that between 2.3% and 17% of older people have recently considered suicide, and although the rates of suicidal ideation decrease with age, completion rates normally increase with age.

• Suicide rates for older people in Australia are marginally lower than suicide rates for older people in other similar English-speaking countries. The Australian suicide rate is higher than rates in the European nations of origin of the major immigrant groups, but similar to rates in other countries also recently colonised by Europeans (New Zealand, Canada and the United States).

• The suicide rate among older Aboriginal and Torres Strait Islander Australians is low. However, as a smaller number of Aboriginal and Torres Strait Islander people live to old age, it is difficult to draw clear conclusions from this. The majority of Aboriginal and Torres Strait Islander suicides are by hanging or firearms.

• Suicide rates in rural and remote areas are higher for older men with 27.7 per 100,000 of population per year compared with 22.1 in metropolitan areas. For older women, the rate is slightly higher in metropolitan areas at 6.1 per 100,000 per year compared with 4.9 in rural and remote areas.

TYPES OF SUICIDAL BEHAVIOURS

Suicidal behaviour in older people has been categorised as thoughts of hopelessness or suicidal ideation, indirect self-destructive behaviour, deliberate self-harm and completed suicide (Harwood 2002). Some very old or terminally ill people may have thoughts of hopelessness or suicidal ideation and may express statements such as ‘I wish I was dead’, but if questioned will vehemently deny any thought of self-harm. More serious suicidal thoughts are usually found when a person is single, has depression, physical disability, pain, sensory impairments or is institutionalised. Indirect self-destructive behaviour, sometimes known as subintentional suicide, such as failing to eat and drink or non-compliance with life-saving medication, occurs frequently in older women and in very old institutionalised people. The older person in this situation will deny that it is an act of suicide, but the likelihood of dying is increased. Deliberate self-harm differs from suicidal thoughts and indirect self-destructive behaviour because there is a definite, more determined and immediate response.

METHODS OF SUICIDE

In Australia (de Leo et al 2001), older men tend to use more violent and lethal means such as hanging, shooting and carbon monoxide poisoning (car exhaust fumes). This use of highly lethal means is thought to account in part for the higher rate of completed suicides in older men. Older women tend to use drug overdose, hanging and carbon monoxide poisoning. Drug overdoses are usually with commonly prescribed medications such as paracetamol, analgesics and antidepressants. Large-scale government policies, such as gun control laws, changing household gases to less toxic varieties and changing prescribing practices, have reduced the use of these popular methods for suicide; however, there have been compensatory rises in other methods, leading to the conclusion that limiting access to means of suicide to suicidal people who are ambivalent may be effective, but it does not change the behaviour of those people who are intent on committing suicide.