|Year : 2020 | Volume
| Issue : 1 | Page : 29-32
Identifying suicidal risk and its association with depression in the elderly population
Susmita Halder, Shreya Manot
Department of Clinical Psychology, Amity University, Kolkata, West Bengal, India
|Date of Submission||23-Apr-2020|
|Date of Decision||31-May-2020|
|Date of Acceptance||04-Jun-2020|
|Date of Web Publication||29-Jun-2020|
Dr. Susmita Halder
Department of Clinical Psychology, Amity University, Major Arterial Road (South-East), Action Area II, Newtown, Kolkata - 700 135, West Bengal
Source of Support: None, Conflict of Interest: None
Background: With increased life expectancy and improved health-care facilities, the number of elderly persons is on the rise worldwide. According to the population census 2011, there are nearly 104 million elderly persons in India, who face several physical and mental health challenges, suicide being one of them. Increased life expectancy, rapid urbanization, sociocultural factors, changing family setups, and lifestyle changes have led to an emergence of varied problems, the most alarming being suicide among the elderly, which often goes unnoticed due to inadequate expression. Further, the risk of suicide increases with depression, which tends to be common among elderly people. Many a times, the indicative signs of depression in the elderly are missed and attributed to usual complaints associated with aging. It has become important to understand the suicidal ideation and behaviors in the elderly, for identifying the risk factors and further facilitating prevention. The present study aims to explore suicidal ideation and behavior among the elderly population. Materials and Methods: A total of 110 individuals of both genders aged 60 years and above were included in the study. The General Health Questionnaire-12 was administered for screening, the Geriatric Depression Scale, and Suicidal Behaviors Questionnaire-R were administered to assess the presence of depression and suicidal behavior, respectively. Results: The results of the study show the presence of suicidal ideation and behavior in 42.72% of the individuals; it was also found to be more among males. Conclusions: Thus, these findings implicate that the elderly are at a considerable risk for suicidal behaviors, which warrants attention for early identification and subsequent psychosocial intervention.
Keywords: Depression, elderly, suicideDepression, elderly, suicide
|How to cite this article:|
Halder S, Manot S. Identifying suicidal risk and its association with depression in the elderly population. J Geriatr Ment Health 2020;7:29-32
|How to cite this URL:|
Halder S, Manot S. Identifying suicidal risk and its association with depression in the elderly population. J Geriatr Ment Health [serial online] 2020 [cited 2020 Oct 31];7:29-32. Available from: https://www.jgmh.org/text.asp?2020/7/1/29/288234
| Introduction|| |
With increased life expectancy and improved health-care facilities, the number of elderly persons is on the rise worldwide. Aging is also exponentially increasing due to the impressive gains that society has made in terms of increased life expectancy. According to the population census 2011, there are nearly 104 million elderly persons (aged 60 years or above) in India: 53 million females and 51 million males.
Old age tends to be accompanied by many stressors that might lead to an increased risk of mental disorders. These may include, but are not limited to: loss of spouse, loss of friends, loss of health in the elderly themselves and in their relatives, loss of social support, loss of job, financial losses, loss of independence, loss of intellectual capacity, loss of future dimension, and the approach of death. However, life stressors might be better tolerated in old age because they are expected. Old age may also have a positive dimension, with freedom of time, less stressors of work, and less competition. Although late-life depression tends to a severe and debilitating condition, there is a common misconception that it is a normal feature of aging. Poor physical health has long been recognized to be one of the most important risk factors for depression in older adults.
Suicide in elderly population is a growing problem. The gravity of the problem might be more severe than perceived because of under-reporting. The suicidal behavior in the elderly often goes unnoticed due to lack of direct communication of any such intent on their part. The World Health Organization (WHO) estimated the suicide rate for men and women aged 75 and above to be 50 for 100,000 and 16 for 100,000, respectively. With the emerging prevalence of nuclear family setups in recent years, the elderly are likely to be exposed to emotional, physical, and financial insecurity in the years to come. There is an upward trend in the living arrangement pattern of the elderly staying alone or with spouse only from 9.0% in 1992 to 18.7% in 2006. Further, the risk of suicide increases with depression, which tends to be common among elderly people. The indicative signs of depression in the elderly tend to be missed and attributed to usual complaints associated with aging. This is often aggravated by the fact that the depression often presents in a different way in the elderly which is often confused with other concomitant medical conditions, thereby hindering the identification of suicidal intentions.
There are several important risk factors for suicide in older adults. These include, among others:
- Prior suicide attempts
- Feelings of hopelessness
- Comorbid general medical conditions
- Social isolation
- Family discord
- Impulsivity in the context of cognitive impairment.
Even after these substantial findings, still study on suicide in old age is a neglected area. As the proportion of the elderly age group in the population will increase all over the world in the coming decades, the number of suicides among older adults is also consequently expected to be on the rise. Therefore, proper identification of the elderly at risk is important for early intervention in consideration with the policies of the public health maintenance. Hence, knowledge regarding the suicidal risk factors specific to the elderly population could be considered as a first step in the formulation of suitable interventions for suicide prevention in the elderly in keeping with reference to the Indian context. Various comprehensive studies and researches are conducted with respect to suicidal ideation and behaviors, but works related to the suicidal intent and behavior in the elderly are very limited. Thus, the present study aims at identifying suicidal risk behavior among the elderly.
| Methods|| |
This is a cross-sectional, exploratory study conducted to identify the presence of suicidal risk behavior among the elderly population residing in urban areas of Kolkata, who were selected using a purposive sampling method. The elderly included individuals within the age range of 60–80 years. The study explores the suicidal risk behavior among 110 elderly individuals.
- Sociodemographic and clinical datasheet – A sociodemographic and clinical datasheet was prepared for this work with a view of eliciting relevant information
- General Health Questionnaire-12 (GHQ-12): The GHQ is a screening device for identifying minor psychiatric disorders in the general population. The GHQ-12, which is a short form of the GHQ, was used for the present study. The reliability of the GHQ-12 in the older Indian population is 0.90, and the GHQ-12 shows adequate reliability among the older population in India
- The Geriatric Depression Scale, Short (GDS-S): The GDS is a 30-item self-report assessment used to identify depression in the elderly. The GDS was found to have a 92% sensitivity and an 89% specificity when evaluated against diagnostic criteria. The validity and reliability of the tool have been supported through both clinical practice and research. A Short-Form GDS consisting of 15 questions was developed in 1986. Scores of 0–4 are considered normal, depending on age, education, and complaints; 5–8 indicate mild depression; 9–11 indicate moderate depression; and 12–15 indicate severe depression
- Suicidal Behaviors Questionnaire-Revised (SBQ-R): The SBQ-R was developed to be used as a measure of suicidal behavior in clinical and nonclinical populations. The SBQ-R consisted of four items. The internal consistency coefficients of the SBQ-R are 0.76–0.88.
To conduct the study, participants from the community setting, staying with family in a residential area in urban Kolkata, were included. After taking informed consent, they were briefed about the study. Then, the selected tests were administered following a sequence, beginning with the GHQ-12, followed by GDS-S and SBQ-R. The sufficient amount of rest was provided in between, whenever required, to prevent the creeping of fatigue, boredom, and monotony on the part of the subject. In case of individuals with even minimal suicidal intentions and behaviors, the family was informed and brief counseling was provided. Ethical consideration and confidentiality were maintained. The data thus obtained are subjected to the following statistical treatment.
| Results|| |
The present study aims at exploring and assessing suicidal behavior among a total of 110 elderly people (60+ years of age) in Kolkata. Descriptive statistics will help to show the mean age, along with the percentage of elderly people scoring below and above the cutoff points.
From [Table 1], it is seen that the total number of elderly persons comprised 49.09% of males and 50.90% of females in the current study. The mean age of the sample is 68 years.
[Table 2] showed that 42.72% of the sample scored above cut-off on SBQ-R and 39.09% scored above cut-off on GDS.
From [Table 3], it is seen that 33% of them had lifetime suicidal ideation and 10.90% of them had a likelihood of suicidal behavior in the future.
|Table 3: Distribution of the participants scoring high on the Suicidal Behaviors Questionnaire-Revised domains|
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| Discussion|| |
The present study aims to explore the suicidal risk behavior of elderly people. In the present study, as shown in [Table 2], it is found that suicidal risk behavior and intent tend to be present in 42.72% of the sample undertaken for the study, 49.09% of which comprise males and 50.90% of them tend to be females. Further, as shown in [Figure 1] among these individuals with suicidal ideation and risk behavior, 38 % of the individuals tend to have depressive features. This is in line with the findings of a study by Halder and Mahato, wherein it was found that mental illness is known to be one of the highest risk factors for suicide and 4% of the sample was diagnosed with depressive illness. In almost all countries, individuals aged 65 years and older have greater rates of suicidal behavior. Prior studies also suggest that clinicians often underdiagnose or undertreat depression (a robust risk factor for suicide) and suicide ideation among older adults. This might stem partly from difficulties in distinguishing between normal reactions to the changes associated with aging and suicidal thoughts triggered by hopelessness, any physical or mental illness. In addition, older suicidal individuals are more likely to be planned long ahead of time and involve more lethal methods. Further, in the present study, it was found that neither do all elderly with depression tend to have suicidal ideation, nor do elderly with suicidal behaviors necessarily have depression, thereby highlighting their exclusivity in the elderly population.
|Figure 1: Percentage of participants with suicidal ideation scoring above the cutoff on the Geriatric Depression Scale|
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International data which are published by the WHO show a steady rise in the prevalence of completed suicide with age. Among those that make attempts, it has been seen that the geriatric patients rank higher in measures of suicidal intent and are at far greater risk of completed suicide. According to a comprehensive review of psychological autopsy studies, 71%–95% of elderly people who completed suicide had a psychiatric illness, most commonly depression. Even in the present study, many participants who had suicidal risk behavior tended to have depressive features, and there was a significant correlation between scores on SBQ-R and GDS.
Further, suicide risk increases with general medical illness, including asthma, cancer, chronic obstructive pulmonary disease, coronary artery disease, diabetes mellitus, spine disorders (e.g., disc disorders), stroke, recent surgery, and chronic or terminal diseases. In the present study, most individuals who scored above the cutoff on GDS and SBQ-R tended to have the presence of diabetes and chronic pain.
Although several social factors associated with suicide in elderly people are nonmodifiable, they may give clues as to the underlying biological processes involved in suicidal ideation and behavior, as has been found in the present study. Decreased social support and social isolation are generally associated with increased suicidal feelings in elderly people. In general, widowed, single, and divorced elderly people have been seen to have a higher risk of suicide, with marriage seeming to be protective factor. It has also been seen that men seem especially vulnerable after the loss of a spouse, with a relative risk three times that of married men. In contrast, widowed and married elderly women seem to have a similar risk. Many participants in the present study who scored above the cutoff on SBQ-R reported feeling lonely as a result of demise of spouse or being left alone by children who had settled elsewhere.
Further analysis of the domains of SBQ-R indicates that the elderly tended to differ with respect to lifetime suicide ideation, frequency of suicidal ideation, threat of suicide attempt, and likelihood of suicidal behavior in the future. As shown from [Table 3], the elderly had a higher percentage of suicidal ideation (33.63%), followed by increased frequency of such ideations (27.27%), threat of suicidal attempt (20.9%), and likelihood of suicidal behavior (10.9%). Studies have established that among elderly individuals with the presence of suicidal ideation, the probability of ever making a plan is approximately 33%, and the probability of ever making a suicide attempt is approximately 30%. In the present study, the presence of suicidal ideation and threats of suicidal attempt, though present in less than half of the sample, tends to be alarming enough to warrant early/timely identification and proper intervention.
Gender is one of the most important predictors of suicide in the elderly. There tend to be differences between the two genders with respect to suicidal ideation, threat of attempt, actual attempt, and method of attempt. Females report higher rates of attempting suicide, yet males are more likely to die from suicide, possibly because males use more lethal means. In the present study, it was seen that a greater number of males scored above the cutoff on SBQ-R as compared to females, however, no significant differences between the two groups were found with respect to their suicidal risk behaviors. Further it was seen that the presence of such ideations and behaviors tended to be greater among the males, going in line with established studies which predict higher suicidal ideations and completed suicides among the males.
Having established presence of suicidal risk behavior among the elderly to such a significant level, the need of early identification and suicide prevention becomes extremely important. Older people are less likely to reveal that they are experiencing suicidal feelings. Moreover, these feelings may be present in patients with few depressive symptoms, which might not be apparent without direct probing. For the elderly with suicidal behaviors, screening procedures should be made more opportunistic, focusing on individuals in high-risk groups as defined and targeted keeping in mind the knowledge of psychological, physical, and social factors. High-risk subgroups include those with depressive illnesses, previous suicide attempts, or physical illnesses and those who are socially isolated. Suicide prevention efforts targeted for old adults are rare. Most programs have been targeted toward adolescents in high school, and these programs generally do not extend to include old adults. Interventions tailored for these individuals are likely to improve social contact, support, and integration in the community and are also thus likely to be effective in ensuring a richer quality of life.
The present study included only urban population, which is a limitation for generalization of the findings. Further, other associated psychosocial variables such as loneliness, social isolation, and hopelessness could be included to get a wider understanding of risk factors of suicide behavior in the elderly.
| Conclusion|| |
Suicide in elderly people tends to be a complex and multifactorial phenomenon. Suicide and its prevention remain a significant concern in general. However over the years suicide in the elderly has received little priority in terms of specific preventive strategies tailored for the population, despite the fact that elderly suicide rates are among the highest. Further, elderly suicidal behavior tends to be more closely related to depression in particular and other physical health problems. There is a need for the prioritization of awareness among health professionals and society in general that the act of suicide in late life is not an unavoidable tragedy or a reasonable and well-thought act. Further, the psychological reaction to suicide of a close person thus creates a risk and need for the intervention for the suicide survivor. To address the risk factors in the elderly population and also importantly the suicide risk in the survivors itself, a customized plan may be used, whereby principles and strategies from several therapies that are effective are incorporated. Thus, to shed more light on the suicidal behaviors in the elderly, future studies can focus upon other variables associated with suicidal behaviors and ideation in the elderly, especially in terms of their coping, loneliness, hopelessness, and the like. Further, a comparative study between individuals from different age groups could have provided more clarity on the uniqueness of suicidal behaviors in the elderly.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Kinsella KG, Velkoff VA. An Aging World: 2001. Washington, DC: Bureau of Census; 2001.
Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R. Psychoneuroimmunology: Psychological influences on immune function and health. J Consult Clin Psychol 2002;70:537-47.
Gurland B, Golden RR, Teresi JA, Challop J. The SHORT-CARE: An efficient instrument for the assessment of depression, dementia and disability. J Gerontol 1984;39:166-9.
Heisel MJ, Flett GL, Duberstein PR, Lyness JM. Does the geriatric depression scale (GDS) distinguish between older adults with high versus low levels of suicidal ideation? Am J Geriatr Psychiatry 2005;13:876-83.
Alam M, James KS, Gridhar G, Sathyanarayana KM, Kumar S, Raju SS, et al
. Report on the Status of Elderly in Select States of India, 2011. New Delhi: United Nations Population Fund; 2012.
Goldberg D, Williams P. General health questionnaire (GHQ). Swindon, Wiltshire, UK: nferNelson. 2000.
Yesavage JA, Sheikh JI. 9/Geriatric depression scale (GDS) recent evidence and development of a shorter version. Clin Gerontol 1986;5:165-73.
Osman A, Bagge CL, Gutierrez PM, Konick LC, Kopper BA, Barrios FX. The Suicidal Behaviors Questionnaire-Revised (SBQ-R): Validation with clinical and nonclinical samples. Assessment 2001;8:443-54.
Halder S, Mahato AK. Socio-demographic and clinical characteristics of patients who attempt suicide: A hospital-based study from Eastern India. East Asian Arch Psychiatry 2016;26:98-103.
Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF 3rd
. Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs Aging 2002;19:11-24.
O'Connell H, Chin AV, Cunningham C, Lawlor BA. Recent developments: Suicide in older people. BMJ 2004;329:895-9.
Barber CW, Miller MJ. Reducing a suicidal person's access to lethal means of suicide: A research agenda. Am J Prev Med 2014;47:S264-72.
Chakraborty S, Halder S. Psychological sequelae in suicide survivors: A brief overview. Indian J Soc Psychiatry 2018;34:105. [Full text]
[Table 1], [Table 2], [Table 3]