Journal of Affective Disorders 132 (2011) 185191

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Journal of Affective Disorders

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d

Research report

Suicide in later life: A comparison between cases with early-onset and late-onset depression
Richard C. Oude Voshaar a,b,c, Nav Kapur d, Harriet Bickley d, Alyson Williams d, Nitin Purandare a,
a b c d

University of Manchester, Psychiatry Research Group, School of Community, Based Medicine, Manchester, UK University Medical Center Groningen, University Center of Psychiatry, Groningen, The Netherlands Program on Aging, Trimbos Institute, Utrecht, The Netherlands University of Manchester, Centre for Suicide Prevention, Manchester, UK

a r t i c l e

i n f o

a b s t r a c t
Background: Suicide rates are high in elderly people with depressive disorder. We compared behavioural, clinical and care characteristics of depressed elderly patients, aged 60 years and over at the time of death by suicide, with an early-onset depression (EOD, onset before 60 years) with those patients with a late age of onset (LOD). Method: From a 10-year national clinical survey of all suicides in England and Wales (n = 13066) we identied 549 LOD cases, and 290 EOD cases. EOD and LOD cases were compared by logistic regression adjusted for age at suicide. Results: Method of suicide did not differ by age of onset of depression. LOD cases were significantly less likely to have a history of psychiatric admissions (OR = 0.2 [0.10.3]), alcohol misuse (OR = 0.6 [0.40.9]) and self-harm (0.6 [0.40.8]). LOD cases also had a lower prevalence of a psychiatric co-morbid diagnosis (0.6 [0.40.7]) and a lower prescription rate for psychotropic drugs other than antidepressants. Furthermore, the number of recent life-events was signicantly higher (OR = 1.4 [1.01.9]) in LOD while the frequency of recent self-harm was similar to EOD. Conclusion: Although our study suggests that psychopathology of suicide among elderly depressed patients differs between EOD and LOD, the final pathway (via recent self-harm) to suicide may be similar in up to a quarter of patients in both groups. Our results suggest that strategies to enhance coping abilities and provision of support to negate the effects of lifeevents might be especially important in the prevention of suicide in LOD. 2011 Elsevier B.V. All rights reserved.

Article history: Received 13 August 2010 Received in revised form 12 February 2011 Accepted 12 February 2011 Available online 21 March 2011 Keywords: Early-onset depression Inquiry case Late-onset depression Suicide Aged Aged, 80 years and over

1. Introduction Suicide rates are highest in elderly people in most countries (Hawton and van Heeringen, 2009), although over the past 50 years rates have decreased in this group (Gunnell et al., 2003; Pritchard and Hansen, 2005). About 90% of all suicides are preceded by axis I psychiatric disorders, in later life most often a depressive disorder (Conwell et al., 1996; Chiu et al., 2004). In more than half of elderly patients diagnosed to have major depression by the mental health services the rst episode starts in later life (Fiske et al., 2009). Substantial consensus exists that elderly patients with late-onset depression (LOD), dened as an age of onset after the age of 60 years, have distinctive risk factors and presentation

GRANT SUPPORT: The National Condential Inquiry receives funding from the National Patient Safety Agency of the Department of Health in England and Wales, the Scottish Executive, and the Department of Health, Social Security and Public Services in Northern Ireland. The funding parties had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. NP and NK also receive support by the Manchester Mental Health and Social Care Trust. Corresponding author at: Room 3.316, Psychiatry Research Group, School of Community Based Medicine, The University of Manchester, University Place (3rd Floor East), Oxford Road, Manchester M13 9PL, UK. Tel.: + 44 161 3067943; fax: + 44 161 3067945. E-mail address: nitin.purandare@manchester.ac.uk (N. Purandare). 0165-0327/$ see front matter 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2011.02.008

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compared to elderly patients with early-onset depression (EOD) in whom the onset of depression is before the age of 60 years (Brodaty et al., 2001; Krishnan et al., 1995). For example, LOD is associated with a lower family load for depressive disorder, fewer premorbid personality disturbances, and more vascular risk factors, white matter hyperintensities on neuroimaging, concomitant cognitive decits and resistance to initial antidepressant mono-therapy (Fiske et al., 2009; Alexopoulos, 2005; Baldwin, 2005; Brodaty et al., 2001; Krishnan et al., 1995). With respect to the phenomenology of depression, patients with LOD are less likely to endorse cognitiveaffective symptoms, including dysphoria, worthlessness/guilt (Alexopoulos, 2005) and suicidal ideation (Zisook et al., 2007). The above differences suggest that the behavioural, clinical and care characteristics of suicide among older people may also differ between LOD and EOD. However, this has not been examined previously and was the primary aim of the current study. 2. Methods The study was carried out as part of the National Condential Inquiry into Suicide and Homicide by People with Mental Illness (Appleby et al., 2001), a complete national clinical sample of all people that had been in contact with mental health services in the 12 months prior to their death by suicide. The Inquiry has research ethics approval (South Manchester Research Ethics Committee ERP/96/2771) and approval under Section 60 of the Health and Social Care Act to process patient-identiable data without consent. The data collection on suicides involved three stages: 1) collection of a comprehensive national sample, irrespective of mental health history; 2) identication of people in the sample who had been in contact with mental health services in the 12 months before death; and 3) collection of clinical data about these individuals. Data collection has been described in detail elsewhere (Hunt et al., 2006), and is summarised below. 2.1. Comprehensive national sample Information on all deaths in England and Wales receiving a suicide or an open verdict at coroner's inquest was obtained from the Ofce for National Statistics (ONS). The cases presented here consist of those deaths, which occurred between January 1, 1997 and December 31, 2006. In the rst 3 years of the study, this information was cross-checked against equivalent data from the health authorities in England and Wales; inconsistencies were rare. Open verdicts, recorded as deaths from undetermined external cause, are often reached in cases of suicide in the UK. Open verdicts are conventionally included in research on suicide and in ofcial suicide statistics (O'Donnell and Farmer, 1995; Neeleman and Wessely, 1997; Lindsley et al., 2001). In this study, open verdicts were included unless it was clear that suicide was not considered at inquest for example, in deaths from an unexplained medical cause. 2.2. Identication of mental health service contact and collection of clinical data Identifying details on each individual who had died by suicide were submitted to the main hospital and community NHS trusts

who provided mental health services to people living in the deceased's district of residence. When NHS records showed that contact had occurred in the 12 months before the suicide, the person became an "Inquiry case". For each Inquiry case, the consultant psychiatrist was sent a questionnaire and asked to complete it based on their knowledge of the patient, psychiatry case-notes, and in discussion with other members of the mental health team. The questionnaire consisted of sections covering social/demographic characteristics, clinical history, details of suicide, aspects of care, details of nal contact with mental health services and clinicians' views on suicide prevention. Clinicians were also asked for the ICD-10 primary diagnosis and also any ICD-10 secondary diagnoses (or previous versions) for which the patient was in contact with mental health services (WHO, 1992). The social and clinical items reected many of the most frequently reported risk factors for suicide. The majority of items were factual but some (for example, adherence to treatment) were based on the judgments of clinicians. 2.3. Case-ascertainment Patients aged 60 years or over at the time of suicide who were given a primary diagnosis of depressive disorder based on ICD-10 criteria (or previous version) by the responding clinician were selected for the present study (WHO, 1992). Patients with a co-morbid diagnosis of dementia or organic brain disorder were excluded. Patients were classied as having an early onset of depressive illness (EOD) or late onset (LOD) based on the information about their rst contact with mental health services. A cut-off of 60 years to distinguish between EOD and LOD was chosen for consistency with previous studies (Krishnan et al., 1995; Brodaty et al., 2001; Zisook et al., 2007; Corruble et al., 2008; Fiske et al., 2009). 2.4. Statistical analysis All data are presented as absolute numbers and percentages within groups. If an item of information was not known for a case, the case was removed from the analysis of that item; the denominator in all estimates is therefore the number of valid cases for the item. As the study was mainly explorative, differences between EOD and LOD cases are presented as odds ratios (OR) with 95% condence intervals (CI) based on logistic regression analyses. These analyses were corrected for age, as the mean age at time of suicide differed signicantly between EOD cases (mean (SD) of 67.2 (6.6) years) and LOD cases (72.4 (8.2) years) (t=9.4, df=837, p b 0.001). Finally, two post-hoc analyses were conducted. First, we changed the age cut-off for LOD to 65 years and over in line with UK old age psychiatry services. Second, we excluded patients with an onset of depression before the age of 40 years (very early onset) to check if the differences between EOD and LOD groups were primarily driven by this group. 3. Results 3.1. Sample characteristics Over the 10 year study period, the Inquiry received notications of 50,352 deaths by suicide, including 34,891 (69%) cases in which the coroner's verdict was suicide and

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15,461 (31%) open verdicts or deaths from undetermined cause. Of these, 13,331 (26%) were conrmed to have been in contact with mental health services in the year prior to death. Completed questionnaires were received on 13,066 cases, a response rate of 98%. Of these, 4645 (36%) received a clinical diagnosis of depression from their psychiatrist, of which 1353 (29%) patients were aged 60 years or above. Of these patients, 36/1353 (2.7%) were excluded because of co-morbid diagnoses of dementia or organic brain disorder, leaving an eligible sample of 1317 cases with late-life depression. In 478 (36.3%) cases the age of onset of depression could not be ascertained reliably from the psychiatric history. Therefore, the nal study population comprised 839 cases with primary diagnosis of depression who were aged 60 year or over at the time of suicide; 290 (34.6%) cases with EOD and 549 (65.4%) cases with LOD. Compared to included patients, excluded patients (n = 478) were more often widowed (p = 0.009), but did not differ with respect to age at time of suicide, sex, marital status and living arrangements (all p-values N 0.11). The mean (SD) age at time of suicide was 70.6 (8.1) years, with 472/839 (56%) males. The sample consisted primarily of people of white ethnicity. People from non-white ethnic groups made up only 3.8% of the sample (Indian, n=16; mixed race, n=7; and other, n=8). Table 1 presents the demographic characteristics by age of onset group, showing that patients with LOD who died by suicide were more commonly male, and married or co-habiting than patients with EOD who died by suicide, and less often lived alone.

followed by paracetamol either in pure form or combined with codeine (39/196, 18.7%), other pain medication (31/196, 15.8%) and sedative-hypnotic drugs (21/196, 10.7%).

3.3. Behavioural, clinical and care characteristics Patients with LOD who died by suicide were signicantly less likely to have a history of psychiatric admission and alcohol misuse compared to those with EOD who died by suicide (Table 2). More than half of the patients had a history of self-harm; LOD cases less often than EOD cases (57% versus 68%; ORage adjusted = 0.6 [0.40.8], p = 0.001). However, this latter difference was not found when looking specically at self-harm during the 3 months preceding suicide (EOD: 67/ 286 (23%) versus LOD: 131/547 (24%); ORage adjusted = 0.8 [0.51.2], p = 0.21). Patients with LOD who died by suicide were less likely to have an additional co-morbid psychiatric diagnosis, in particular anxiety disorders, alcohol dependence or misuse and personality disorders, but more often received a secondary diagnosis of adjustment disorder. Although the incidence of adverse life-events in the 3 months prior to suicide was higher among patients with LOD compared to those with EOD, none of the individual life-event categories differed between both groups. Neither did we nd any differences with respect to the psychiatric symptoms that were noted during the last contact with mental health services. Overall, the key predictors of subsequent suicidal behaviour were noted in only a minority of patients during their last contact, i.e. suicidal ideation (80/804, 9.5%), hopelessness (121/799, 14.4%) and recent self-harm (72/817, 8.6%). Table 3 presents characteristics of the care received by the elderly patients with late-life depression who died by suicide, by age at the onset of depression. Overall, most (705/839, 84.0%) patients were not receiving inpatient psychiatric treatment at the time of suicide. Of the 134/839 (16.0%) patients who died by suicide during a psychiatric hospitalisation, 37/134 (27.6%) took place on the ward. Of those patients who died by suicide outside the ward, 81/97 (83.5%) were off the ward with agreement of staff. The place of suicide did not differ between EOD and LOD groups. A total of 718/804 (89.3%) of patients were prescribed antidepressants at the time of suicide, with no differences

3.2. Method of suicide The method of suicide or the substances used in case of self-poisoning did not differ between EOD and LOD patients who died by suicide (data not shown, all p-values between 0.07 and 0.83). Therefore the following results are reported for EOD and LOD cases combined (n = 837). The commonest method of suicide was hanging or strangulation (303, 36.1%), followed by self-poisoning (214, 25.5%) and drowning (108, 12.9%). All other methods were used by less than 10% of the sample: jumping from a height (56, 6.7%), jumping in front of a moving vehicle (43, 5.1%), suffocation (31, 3.7%), cutting or stabbing (27, 3.2%), CO-poisoning (16, 1.9%) or other methods (39, 4.7%). The most common drugs used in selfpoisoning were antidepressants, taken by 61/196 (31.1%),

Table 1 Socio-demographic characteristics of elderly depressed patients who died by suicide by age of onset. Variable Age of onset Early (n = 290) Age, mean (SD) Male sex, n (%) Marital/civil status - Divorced, n (%) - Married/co-habiting, n (%) - Single, n (%) - Widowed, n (%) Living in the community (house or at), n (%) Living alone, n (%)
a

Comparison EODLOD a Late (n = 549) 72 (8) 320 (58%) 68 (12%) 271 (49%) 38 (7%) 168 (31%) 510 (93%) 235 (43%) OR [95% CI] 1.1 [1.11.1] 1.4 [1.01.8] 0.8 1.6 0.8 0.8 1.4 0.7 [0.51.1] [1.12.1] [0.41.3] [0.51.1] [0.72.5] [0.51.0] p-value b0.001 0.046 0.19 0.005 0.29 0.20 0.32 0.021

67 (7) 152 (52%) 57 (20%) 132 (46%) 27 (9%) 69 (24%) 270 (93%) 130 (45%)

Logistic regression corrected for age.

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Table 2 Clinical and behavioural characteristics of elderly depressed patients who died by suicide by age of onset. Variable Age of onset Early (n = 290) Psychiatric history: Previous psychiatric admissions History of self-harm History of violence History of alcohol misuse History of drug misuse Psychiatric co-morbidity: Presence of any secondary diagnosis: - Anxiety disorder - Alcohol dependence or misuse - Drug dependence or misuse - Personality disorder - Adjustment disorder/reaction - Other Major physical illness b Life-event (in 3 months before suicide): Any life-event, n (%) Interpersonal problems Bereavement Health problems in patient Material (nancial/housing) problems Legal of crime related problems Other problems Psychiatric symptoms noted at last contact: Emotional distress Delusions or hallucinations Hostility Recent self-harm Hopelessness Suicidal ideas
a b

Comparison EODLOD a Late (n = 549) 354 308 14 60 15 164 77 29 11 24 45 13 98 211 49 38 74 32 12 53 162 12 16 50 76 47 (65%) (57%) (3%) (11%) (3%) (30%) (14%) (5%) (2%) (4%) (8%) (2%) (42%) (40%) (9%) (7%) (14%) (6%) (2%) (10%) (30%) (2%) (3%) (9%) (15%) (9%) OR [95% CI] 0.2 0.6 0.9 0.6 0.7 [0.10.3] [0.40.8] [0.42.1] [0.40.9] [0.31.6] p-value b0.001 0.001 0.84 0.023 0.40 b0.001 b0.001 0.042 0.54 0.002 0.035 0.41 0.24 0.041 0.98 0.67 0.083 0.12 0.26 0.44 0.70 0.37 0.16 0.37 0.79 0.27

263 194 11 53 12

(91%) (68%) (4%) (19%) (4%)

131 (45%) 75 (26%) 30 (10%) 5 (2%) 27 (9%) 15 (5%) 4 (1%) 50 (40%) 90 (34%) 35 (13%) 17 (6%) 19 (7%) 12 (5%) 4 (2%) 22 (8%) 90 (32%) 9 (3%) 2 (1%) 22 (8%) 45 (16%) 33 (12%)

0.6 [0.40.7] 0.5 [0.30.7] 0.6 [0.31.0] [0.54.3] 0.4 [0.20.7] 2.0 [1.13.7] 1.7 [0.55.4] 0.8 [0.51.2] 1.4 1.0 1.1 1.6 1.7 2.0 1.2 [1.01.9] [0.61.6] [0.62.1] [0.92.8] [0.93.5] [0.66.3] [0.72.1]

0.94 [0.681.30] 0.65 [0.261.66] 2.98 [0.6613.4] 1.29 [0.742.24] 0.95 [0.621.44] 0.76 [0.461.24]

Logistic regression corrected for age. Only available for patients who died by suicide after 2005.

between patients with EOD and LOD. However, patients with LOD who died by suicide received signicantly less often prescriptions for antipsychotics, benzodiazepines and lithium compared to patients with EOD who died by suicide. Furthermore, the number of different classes of psychotropic drugs (i.e. antipsychotics, antidepressants, mood stabilisers, and sedativehypnotics) prescribed for the patients at the time of death was signicantly lower in patients with a LOD compared to those with an EOD who died by suicide (2=24.8, df=4, p b 0.001), with only 65/518 (12.6%) of the patients with LOD using 3 or more classes simultaneously versus 69/277 (24.9%) for those with an EOD. Post-hoc analyses showed that the differences in prescription rates were not affected by treatment setting (i.e. adult versus old age psychiatric services). Only a minority of patients with late-life depression (58/839, 7%) received formal cognitive-behavioural therapy at the time of suicide (with no between group differences). With respect to the last contact with psychiatric services, no differences were found, except that patients with LOD who died by suicide were more often cared for by old age psychiatry services. In the UK old age psychiatry services were set up specically to address the needs of elderly patients aged 65 years and above. Hence, we repeated the analysis excluding patients aged 6064 years, where after the difference disappeared (under the care of old age psychiatrist: EOD 98/154 (63.6%) versus LOD 368/643 (67.8%); ORage adjusted = 1.2 [0.71.8], p = 0.50).

3.4. Post-hoc analyses First, reanalysing our data using an age cut-off of 65 years for LOD revealed similar results although somewhat less pronounced. Interestingly, the presence of life-events did not differ anymore between EOD and LOD (37.0% versus 39.1%; OR [95% CI] = 1.2 [0.81.6] p = 0.41), which could be explained by differential effects of specic life-events. The prevalence of interpersonal life-events was signicantly higher in EOD compared to LOD cases (14.8% versus 5.7%; OR [95% CI] = 0.5 [0.30.8], p = 0.007), whereas the prevalence of health problems remained signicantly lower in EOD compared to LOD cases (8.0% versus 16.1%; OR [95% CI] = 1.6 [1.02.6], p = 0.070). Second, analyses excluding patients with an age of onset before the age of 40 years (n=75, 9%) yielded primarily the same results, perhaps a little more pronounced. In particular, the effect of life-events became more signicant (OR [95% CI]=1.8 [1.22.6], p=0.003). 4. Discussion 4.1. Main ndings Comparison of patients with early-onset depression (EOD) who died by suicide with patients with late-onset

R.C.O. Voshaar et al. / Journal of Affective Disorders 132 (2011) 185191 Table 3 Care characteristics of elderly depressed patients who died by suicide by age of onset. Variable Age of onset Early (n = 290) Clinical care: Inpatient at time of suicide Subject to enhanced CPA Within 3 months post discharge Pharmacological treatments: - All antipsychotics (AP) combined B Classical AP B Atypical AP - All antidepressants combined B Tricyclic antidepressants B SSRI or SNRI B Other antidepressants - Lithium augmentation - Benzodiazepines Non-compliance with drug treatment Psychological treatment - Cognitive-behavioural therapy - Group psychotherapy (not CBT) - Supportive therapy - Other Last contact with services: Last contact within 7 days Last contact face-to-face Last contact was a routine care contact Missed last appointment Under old age psychiatry services View on prevention: Preventable (by patient's psychiatrist)
a

189

Comparison EODLOD a Late (n = 549) 81 (15%) 141 (26%) 96 (21%) 138 (26%) 35 (7%) 109 (21%) 466 (89%) 72 (14%) 367 (70%) 63 (19%) 37 (7%) 197 (38%) 49 (10%) 252 (47%) 34 (6%) 14 (3%) 189 (34%) 10 (1%) 321 (59%) 490 (90%) 423 (78%) 65 (14%) 368 (68%) 84 (17%) OR [95% CI] 0.8 [0.51.2] 0.7 [0.51.0] 0.9 [0.61.3] 0.7 [0.51.0] 0.6 [0.41.0] 0.8 [0.61.2] 0.8 [0.61.6] 0.7 [0.41.0] 1.2 [0.81.6] 1.8 [1.13.2] 0.5 [0.30.8] 0.6 [0.50.8] 0.8 [0.51.4] 1.00 0.8 [0.51.5] 0.9 [0.42.2] 1.2 [0.81.7] 0.6 [0.21.1] 1.0 1.2 0.9 0.9 2.3 [0.71.3] [0.71.9] [0.61.3] [0.61.4] [1.53.4] p-value 0.26 0.051 0.40 0.022 0.040 0.24 0.79 0.053 0.40 0.026 0.003 0.002 0.47 0.46 0.53 0.78 0.31 0.22 0.76 0.50 0.68 0.59 b0.001 0.66

53 (18%) 93 (33%) 59 (25%) 105 (38%) 34 (12%) 75 (27%) 252 (91%) 52 (19%) 190 (68%) 23 (13%) 35 (13%) 133 (48%) 22 (8%) 130 (47%) 22 (8%) 9 (3%) 82 (28%) 12 (4%) 269 252 229 40 100 (59%) (88%) (80%) (17%) (35%)

44 (16%)

1.1 [0.71.7]

Logistic regression corrected for age.

depression (LOD) who died by suicide showed that both groups used similar methods of suicide, but differed with respect to socio-economic, clinical and care characteristics. Compared to EOD cases, LOD cases were more often male, more often married and less often lived alone. Two explanations can be put forward to explain the observed sex differences. First, the prevalence of depression in the population show a decreasing female to male ratio with increasing age (Djernes, 2006), possibly caused by a higher frequency of cardiovascular risk factors in males leading to interruption of mood regulating brain circuits. Secondly, the effect of the decreasing female to male ratio on the sex difference between EOD and LOD cases may become more pronounced by the fact that males more often succeed in committing suicide, partly due to the use of more lethal methods (Vrnik et al., 2008; Stack and Wasserman, 2009). The fact that LOD cases were more often married and less often lived alone compared to EOD cases, probably reects the high burden that depression places on interpersonal relationships in early life in case of EOD (Bulloch et al., 2009). LOD cases were signicantly less likely to have a history of psychiatric admissions, alcohol misuse and self-harm, as well as less likely to have psychiatric co-morbidity at the time of suicide compared to EOD cases. The higher frequency of a psychiatric history as well as more psychiatric co-morbidity among EOD cases compared to LOD cases was not seen in the frequency of psychiatric symptoms noted in the last contact with psychiatric services. This suggests that the actual mental state, presumably indicating severity of depression, was

comparable between both groups, despite the differences with respect to past psychiatric history. A quarter of the patients had harmed themselves in the 3 months prior to suicide and more than half had a life-time history of self-harm. Knowing that self-harm is a relatively rare phenomenon in later life, as only 510% of all episodes of self-harm can be accounted for by elderly people (Hawton and Fagg, 1990; Lawrence et al., 2000), this suggests that selfharm is an important risk factor for suicide in late-life depression irrespective of the age of onset of the depression. A history of self-harm, therefore, might be a primary target in preventing late-life suicide. Although it has been suggested that preventive strategies focusing on self-harm in adults have not proven successful (Crawford et al., 2007), this may be because of lack of power. The lower frequency of previous self-harm in LOD cases compared to EOD cases, indicates that patients with lateonset depression more often succeed in their rst attempt at suicide. It is known that the ratio of rates of self-harm to suicide is much lower in people aged over 60 years compared to their younger counterparts (Hawton and Harriss, 2008). Our data extends these ndings by showing that this ratio within the depressed elderly subgroup is also affected by age of onset of the depression. In contrast to the lower psychiatric disease burden, LOD cases were more likely to have experienced a life-event within 3 months preceding suicide when compared to EOD cases. We are not aware of studies evaluating life-events as a determinant of age of onset of latelife depression. Assuming similar rates of life-events in

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patients with EOD and LOD, patients suffering from LOD are more likely to react with suicide after experiencing lifeevents compared to those suffering from EOD. This is in line with our nding of a higher prevalence of a secondary diagnosis of adjustment disorder in patients with LOD. One possible hypothesis might be that executive dysfunction, which is generally more severe in LOD compared to EOD, limits the coping abilities of patients (Arean et al, 2010). Overall, 90% were on an antidepressant drug regime at the time of suicide. In comparison, only 47% of our sample received any kind of psychological therapy. According to treatment guidelines in the UK (NICE, 2009), cognitivebehavioural therapy is the rst-choice psychotherapy for depression. However, this was delivered to a minority of the cases, with most cases being offered non-specied supportive therapy. Although the protective effect of psychotherapy on suicide in later life has not rmly been established, the rst evidence points towards a protective effect of (sustained) collaborative care intervention that increases both the prescription of antidepressants as well as the delivery of psychotherapy (mainly interpersonal psychotherapy) (Alexopoulos et al., 2009; Untzer et al., 2006). Although the frequency of antidepressant drugs and CBT did not differ between LOD and EOD cases, those with LOD were prescribed signicantly less psychotropic drug classes, with signicant differences for all classes. This is particularly interesting as LOD is known to be resistant to initial antidepressant mono-therapy (Baldwin, 2005) and one would have expected to see evidence of augmentation by pharmacological or psychological therapies. The overall prescription rate of lithium (7% in LOD cases, 13% in EOD cases), was low. Lithium reduces the risk of death and suicide in patients with mood disorders by 60% (Cipriani et al., 2005) and population studies show that the suicide protective effect of lithium is independent of age (Kessing et al., 2005). Furthermore, available evidence does not show differential effects of lithium augmentation in younger and older patients with treatment resistant depression (Kok et al., 2007; Bauer et al., 2003). Due to the lack of a control group of elderly depressed patients who did not die by suicide as well as the lack of prescription data of lithium to depressed elderly patients in the UK, it remains unknown whether the low prescription rate in our sample points to the protective effects of lithium (only those without lithium have died by suicide) or whether there really is undertreatment. As it has been reported that elderly patients receive lithium augmentation in case of treatment resistance signicantly less often compared to their younger counterparts (Valenstein et al., 2006), the latter explanation seems more likely. It may be that co-morbid physical, especially renal, illnesses lead to a more cautious approach [by old age psychiatrist] when considering augmentation by Lithium (Ephraim and Prettyman, 2009). However, our ndings suggest that any potential risk associated with lithium augmentation needs to be weighed against potential risk of suicide in LOD. 4.2. Methodological considerations Despite a large sample size and almost complete data collection, the ndings of this study need to be interpreted in the context of certain methodological issues.

First, we dened LOD as onset of depression after the age of 60 years in keeping with the previous literature on LOD (Krishnan et al., 1995; Brodaty et al., 2001; Zisook et al., 2007; Corruble et al., 2008; Fiske et al., 2009). However, in the UK old age psychiatry services provide services to those aged 65 years and over. When we reanalysed our data using an age cut-off of 65 years for LOD in a post-hoc analysis, our results were similar although somewhat less pronounced. Second, data collection relies on clinical reports and respondents are not blind to outcome. However, most information is factual and previous studies have shown good reliability and validity of Inquiry questionnaire data (Appleby et al., 1999). Furthermore, it is unlikely that a systematic bias would have occurred due to knowledge of the age of onset of the depressive illness of the suicide victim by the respondent. A third limitation might be misclassication of patients according to age of onset. Methodologically, onset of depression is difcult to identify, especially when mild (Wiener et al., 1997). We based age of onset on previous contacts with psychiatric services and subsequently did not include prior episodes of depression for which no contact with adult psychiatric services had been sought. Furthermore, a third of our population of interest had to be excluded due to insufcient data with respect to their psychiatric history. Although, this procedure may have weakened the external generalisability, excluding all patients with any doubt about the age of onset increases the validity of the comparison of EOD and LOD cases, which was the primary aim of our paper. As the psychiatric history is more likely to be complete in cases of late-onset disorders (with a less complicated psychiatric history), the proportion of LOD in our study sample might be overestimated. Nevertheless, the proportion of LOD (65%) in our sample is in line with those reported by others (Fiske et al., 2009), e.g. 52% of depressed patients at a geriatric mood disorders unit (Brodaty et al., 2006) and 71% of depressed home-care patients (Bruce et al., 2002). Finally, this study is a survey of the clinical circumstances preceding suicide, and we are unable to make causal inferences. A control group of depressed patients who had not died by suicide would have been relevant for identication of suicide risk factors specic for EOD and LOD cases separately. Therefore conclusions are limited to the relative differences between EOD and LOD. 4.3. Final conclusion/clinical implications This study is the rst to describe similarities and differences between older patients with LOD and EOD who died by suicide. Major differences were that patients with LOD who died by suicide were signicantly less likely to have a history of comorbid psychiatric disorders such as anxiety disorders and alcohol misuse disorders, less likely to have a history of self-harm, and were prescribed signicantly less psychotropic drugs. In contrast, LOD cases were somewhat more likely to have experienced a stressful life-event in the 3 months prior to their suicide while recent self-harm was equally frequent as in EOD cases. Our study suggests that psychopathology of suicide differs between EOD and LOD. However, the nal pathway (via recent self-harm) to suicide may be similar in up to quarter of patients in both groups, offering a potential target for prevention. Prevention strategies may include strategies to enhance coping abilities and support to negate the effects of life-events (most important in

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LOD) and augmentation of antidepressant treatment by psychological and/or pharmacological means to tackle treatment resistance.
Role of funding source Nothing declared. Conict of Interest None of the authors do have any conict of interest to declare with respect to the manuscript.

Acknowledgements We would like thank all clinicians who provide the data for the National Condential Inquiry into Suicide and Homicide by People with Mental Illness. References
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