Suicide in Old Age

Margda Wrn, Professor/Senior psychiatrist

Neuropsychiatric Epidemiology Research Unit
And the AGECAP Center
University of Gothenburg, Sweden

Declaration of interest
Sahlgrenska Suicide Studies are funded
by the Swedish Research Council and
FORTE.
Conflict of interest: None

Controlled psychological autopsy

studies focusing on older adults

Waern M. Suicidologi 2011

High suicide rates in old age

Accelerating rates
in the Asian Pacific

South Korea
Men 65+
118/100 000
Women 65+
47/100 000
Cheong et al. J Prev Med Pub Health
2012

Greatly elevated risk of suicide

following an attempt
Prospective, population-based selfharm cohort (60+) from 3 general
hospitals was followed for 7 yrs.
Risk of death by suicide was 67
times that of the population.
Murphy et al. Brit J Psych 2012

History of attempted suicide

Indisputable risk factor in old age suicide.
However, proportions vary widely in different
settings (2-3% - 42%)
Risk estimates vary
OR= 40 (Chui et al.)
OR= 186 (Voaklander et al.)

Death ideation in 85-year-olds

In a population-based sample (n=345), a latent class
analysis revealed distinct groups. Individuals with
recent death ideation also reported either:
1) high levels of depression and anxiety or
2) more distant histories of serious suicidal ideation.

Both 1) and 2) may signal elevated risk for suicide.

Van Orden et al. Am J Ger Psych 2013

Depression
Depression was the
only factor associated
with suicide in ALL of
the psychological
autopsy studies.
65-75% of elderly
suicides suffer from
depression.

Age and diagnoses

in mental health service users
who die by suicide

Hunt IM et al. Br J Psychiatry, 2006: 188:135-142

Anxiety disorders
The late-life literature is sparse.
Anxiety disorder was associated with
increased risk in the Swedish study.
Waern et al. Am J Psych 2002

Anxiety and suicidality at seventy

In a Swedish population-based study (n= 560),
anxiety symptom burden was associated with
increased risk of suicidal feelings.
The association was independent of depression.
Jonson et al., Int Psychogeriatrics 2012

Do antidepressants increase suicide risk

in older adults?
Antidepressants do not increase
suicide risk in older adults (Kelly et
al 2003, Hall et al 2003), and there is
clinical evidence that they reduce
risk of suicidal behavior in this
age group (Barak et al 2006).

Attitudes to antidepressant treatment

one year after suicide attempt at age
70+ (n=60)
Benefits of being on an
antidepressant outweighed
disadvantages.

Lesn et al, Int Psychogeriatrics 2015

Attitudes to
antidepressant treatment (age 70+)
I sometimes worry about becoming
addicted to antidepressants.
Strongly agree/agree: 31%

Lesn et al, Int Psychogeriatrics, 2015

Can treatment with sedatives increase

suicide risk in the elderly?
A large cohort study from Canada
showed increased risk associated
with benzodiazepines
The authors pointed out that this could
be due to confounding by indication.
Voaklander et al., 2006

Late life suicid risk associated

with sedatives/hypnotics
OR

95% C.I.

Day
sedatives

14.1

(5.6-35.6)

Hypnotics

10.8

(5.4-21.5)

OR

11.8 a
4.2

95% C.I.

(4.6-30.6)
(1.6-10.9)

Adjusted for diagnosis of amood or anxiety disorder, bany Axis I

disorder
Carlsten & Waern, BMC Geriatrics 2009

Alcohol abuse/dependence

Waern M. Alcohol and Alcoholism 2003

Alcohol abuse/dependence

Waern M. Alcohol and Alcoholism 2003

Alcohol abuse/ dependence

Morin J et al. Am J Ger Psych 2013

Dementia
Most studies suggest that the rate of suicide
in dementia is lower than that in the
general population (Haw et al 2009).
In a Danish register study, risk was
increased when diagnosis was made
during hospitalisation (Erlangssen 2008).

Cognitive dysfunction
Dombrovski and colleagues (2008)
assessed cognitive function in suicidal
depressed and non-suicidal depressed
persons and found that poor
performance on tests of executive
function, attention and memory were
associated with suicidal behaviour.

Cognitive dysfunction
The same group went on to show that
older persons with suicidal depression
make poorer choices in a gaming task
compared to non-suicidal depressed
persons.

Dombrovski et al Am J Psych 2010

Suicide in first degree relatives

Suicide cases 15%
Control group 5%
Fourfold increase in odds ratio after adjustment
for depression

Waern M. Suicid life-threat behav 2005

Serious physical illness

Waern et al, BMJ 2002

Comorbidity
39 of the 85 suicide cases had
both serious physical
illness/disability and depression.
Which came first?

Waern et al, BMJ 2002

Comorbidity
39 of the 85 suicide cases had both
serious physical illness/disability
and depression. Which came first?
Physical illness first: 46%
Depression first: 51%
Waern et al, BMJ 2002

Specific illnesses associated with

suicide in older people
Neurological disorders, cancer, vision problems (Wrn
et al, 2002).
Congestive heart disease, chronic lung disease, seizures
(Juurlink et al 2004).
Stroke, cancer and liver disease (Voaklander et al 2006).
Elevated risk (12 fold) when receiving a cancer diagnosis
(Fang et al 2012). The risk decreased with time after
diagnosis.

Suicide risk increases with

number of illnesses

Juurlink
2004

Cardiovascular fitness at 18 predicts

suicidal behavior in men (n=1,136,527)

berg et al. Psychological medicine 2014

EURODEP
Death wishes by disability category
(n=16 487)

Fssberg et al. Soc Psych Psych Epi 2014

Functional disability: more

important than illness itself?
In a large nationally representative US
sample (Kaplan et al 2007), physical illness
was no longer a risk factor when functional
limitation was included in the model.
In a psychological autopsy study, (Conwell et
al 2009) impairment in ADL was an
independent risk factor. Suicides were
more likely to be in contact with home care
nurses and home help providers.

Loneliness

Suicide group

61%

Control group 20%

Loneliness was associated with a fivefold increase
in odds for suicide
Waern et al. BMJ 2003

Loss of partner
and suicide in later life
Register study
Entire Danish population aged 50 and above

Loss of partner was associated with

increased risk of suicide and the highest
increase was observed in men 80+. In this
age group, risk remained elevated even
3 years after the partners death.
Erlangsen et al, 2004

Interpersonal conflict
Associated with a tenfold increase in odds of suicide
(age 65+) in the Swedish study
(Rubenowitz, et al Psychol Med 2003)

Significant association also after adjustment for

sociodemographics and mental health in a US
study (age 50+) .
(Duberstein et al, Psychol Med 2004)

Interpersonal conflict
Suggested to be the most common
negative life event prior to suicide in
rural mainland China, reported in 76%
(Li et al. 2009)

Interpersonal conflict
In a large Australian primary care-based
study, social disconnectedness and stress
were more strongly associated with
suicidal ideation than mood disorders.
Almeida OP, et al. Br J Psych 2012 .

Sense of Coherence in older adult suicide

attempters, aged 70 and above (n=80)
Low Sense of Coherence associated with:
Too little time spent with children
Too little time spent with grandchildren
Moved in the past five years
Perceived loneliness
Mellquist et al., Int Psychogeriatrics 2011

Experience of life in the period before

suicide
Loss of freedom of
action and selfdetermination
Losing control
meant losing
oneself.
Kjlseth 2009

Personality
Low Openess to Experience, and
higher Neuroticism (Duberstein et al.
1995)
Similar results were later shown in an
Asian setting (Tsoh et al, Am J
Geriatric Psych 2005).

Personality
Obsessive-compulsive and anxious
traits distinguished older persons
who died by suicide compared
with those who died of natural
causes (Harwood et al. 2001)

Personality characteristics in
older men who died by suicide
Action-oriented throughout their lives
Self-esteem linked to activity and acheivement
Wanted to be in control
Emptionally closed, kept a distance
Kjlseth et al. 2009

Attributions in physically ill older

adult suicide attempters
In all, 62 persons (61%) had at least one
serious illness or disability.
Only a third of these attributed their
suicide attempt to somatic distress
(health problems/ functional
disability/decreased autonomy).
Wiktorsson et al, 2014 Abstract,
Symposium

European Suicide

Age 70-79 (n=48)

Serious illness
yes

no

40%

22%

0.22

Psychological 84%
pain

48%

0.01

Cant explain

35%

0.03

Somatic
distress

8%

Attributions in attempters with and without serious physical illness.

Wiktorsson et al, 2014

Abstract, European Suicide Symposium

Age 70-79 (n=48)

Serious illness

Age 80+ (n=53)

Serious illness

yes

no

yes

no

40%

22%

0.22

44%

32%

0.54

Psychological 84%
pain

48%

0.01

57%

50%

0.77

Cant explain

35%

0.03

32%

38%

0.76

Somatic
distress

8%

Attributions in attempters with and without serious physical illness.

Abstract, European Suicide Symposium

Wiktorsson et al. 2014

Fssberg et al., 2013

Suicidal feelings
in the
twilight
of
life
Life not worth living: 8%
Death wishes 10%
Thoughts of taking own life 4%
Serious thoughts 1%
Most who reported such feelings had neither major
or minor depression.
Fssberg et al., BMJ open 2013

Suicidal feelings
in the twilight of life

Neither poor perceived health nor disability

(hearing, vision and motor function) were
associated with sucidial feelings.
Problematic sleep and deficient social
contacts were related to suicidal feelings
also after adjustment for depression.
Fssberg et al. BMJ open 2013

Ernst Josefsson: La joie de vivre

Sahlgrenska Suicide Studies

Post docs
Stefan Wiktorsson

Collaborators
Ingmar Skoog

Madeleine M. Fssberg

Svante stling

Silke Kern

Paul Duberstein

Ph Students

Kim van Orden

Dimitra Baklava
Anna-Maria Nilsson
Statisticians
Tom Marlow, Erik Joas

Bo Runeson