Characteristics of young rural Chinese suicides: a psychological autopsy study.

BACKGROUND: Patterns of suicide rates in China differ in many ways from those in the West. This study aimed to identify the risk factors characteristic for young rural Chinese suicides. METHOD: This was a case-control psychological autopsy (PA) study. The samples were suicides and living controls (both aged 15-34 years) from 16 rural counties of China. We interviewed two informants for each suicide and each control with pretested and validated instruments to estimate psychosocial, psychiatric and other risk factors for suicides. RESULTS: The prevalence of mental disorders was higher among the young Chinese who died by suicide than among the living controls, but was lower than among suicides in the West. Marriage was not a protecting factor for suicide among young rural Chinese women, and never-married women who were involved in relationships were about three times more likely to commit suicide than single women who were unattached. Religion/religiosity was not a protecting factor in Chinese suicide, as it tended to be stronger for suicides than for controls. Impulsivity was significantly higher for suicides than for controls. Psychological strain, resulting from conflicting social values between communist gender equalitarianism and Confucian gender discrimination, was associated significantly with suicide in young rural Chinese women, even after accounting for the role of psychiatric illness. CONCLUSIONS: Risk factors for suicide in rural China are different from those in the West. Psychological strain plays a role in suicide. Suicide prevention programs in China should incorporate culture-specific considerations.

Screening for depression in elderly primary care patients. A comparison of the Center for Epidemiologic Studies-Depression Scale and the Geriatric Depression Scale.

BACKGROUND: Later-life depressive disorders are a major public health problem in primary care settings. A validated screening instrument might aid in the recognition of depression. However, available findings from younger patients may not generalize to older persons, and existing studies of screening instruments in older patient samples have suffered substantial methodological limitations. METHODS: One hundred thirty patients 60 years or older attending 3 primary care internists' practices participated in the study. Two screening scales were used: the Center for Epidemiologic Studies-Depression Scale (CES-D) and the Geriatric Depression Scale (GDS). The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. Third Edition, Revised, was used to establish "gold standard" diagnoses including major and minor depressive disorders. Receiver operating curve analysis was used to determine each scale's operating characteristics. RESULTS: Both the CES-D and the GDS had excellent properties in screening for major depression. The optimum cutoff point for the CES-D was 21, yielding a sensitivity of 92% and a specificity of 87%. The optimum cutoff point for the GDS was 10, yielding a sensitivity of 100% and a specificity of 84%. A shorter version of the GDS had a sensitivity of 92% and a specificity of 81% using a cutoff point of 5. All scales lost accuracy when used to detect minor depression or the presence of any depressive diagnosis. CONCLUSIONS: The CES-D and the GDS have excellent properties for use as screening instruments for major depression in older primary care patients. Because the GDS's yes or no format may ease administration, primary care clinicians should consider its routine use in their practices.

Adrenal weight and morphology in victims of completed suicide.

Several lines of evidence have implicated hypothalamic-pituitary-adrenal (HPA) axis dysfunction in major depression and suicidal behavior. In the present study, the weight and morphology of postmortem adrenal glands were compared between suicide victims and sudden death, nonpsychiatric controls. The mean adrenal weight of the combined left and right glands was significantly higher in the suicide group; this difference was accounted for specifically by increases in left adrenal weight of suicides compared with the control group. There was a positive correlation between adrenal weight and total cortical thickness in both left and right glands, providing direct evidence that increased adrenal weight in suicide victims is due to cortical hypertrophy. The finding of left-right adrenal weight asymmetry in suicides is consistent with the hypothesis of abnormal lateralized input from higher control centers of the HPA axis.

Suicide and Alzheimer's pathology in the elderly: a case-control study.

BACKGROUND: The single most important risk factor for Alzheimer's pathology is age. Elderly individuals are also at increased risk for suicide, but comprehensive studies of the association between Alzheimer's pathology and suicide are lacking. We designed the current study to determine if Alzheimer's disease changes are overrepresented in elderly people committing suicide. METHODS: The design is a case-control study. Cases (n = 28) were subjects older than 60 years of age who completed suicide. For each case, two age- and gender-matched individuals who died naturally were selected as control subjects (n = 56). Neuropathologic examination of hippocampal sections was performed blindly and included a modified Braak scoring system and semiquantitative assessment of neurofibrillary tangles, amyloid deposition, Lewy bodies, and Lewy-associated neurites. Data were analyzed by conditional logistic regression. RESULTS: The brains of individuals who committed suicide had higher modified Braak scores than those of matching control subjects (p =.0028). The number of neurofibrillary tangles in CA1 was not an independent predictor of suicide status in the statistical analysis (p =.16), although the distribution was more highly skewed among the cases (75th percentile of 10.5 for cases, vs. 2 for control subjects). CONCLUSIONS: Severe Alzheimer's disease pathology is overrepresented in elderly patients who complete suicide.

Lithium augmentation of combined neuroleptic-tricyclic treatment in delusional depression.

Recent clinical studies have reported rapid improvement following administration of lithium to depressed patients who are unresponsive to tricyclic antidepressants. The clinical value of lithium augmentation would be greatest in subtypes of depression refractory to tricyclic treatment, such as delusional depression. The authors describe the results of a preliminary study of lithium augmentation in six patients with delusional depression who were unresponsive to combined neuroleptic-tricyclic treatment. Of the six, three had a dramatic response, two had a more gradual response, and one was unresponsive. The authors discuss alternative mechanisms of lithium action in these patients.

Age at onset in late-life delusional depression.

Mean age at onset was not significantly different in 39 delusional and 70 nondelusional unipolar depressed patients over 60 years of age. The finding was unchanged when sex, concurrent dementia, and medical illness were examined.

Depressive symptoms, medical illness, and functional status in depressed psychiatric inpatients.

OBJECTIVE: There is evidence that both psychiatric (especially affective) and medical illnesses contribute to physical disability. However, the differential contributions of specific psychiatric disorders and of medical pathology to functional status in psychiatric populations have not been studied. The authors therefore examined the contributions of depressive symptoms and medical illness to functional disability in depressed inpatients. METHOD: This prospective investigation included 109 psychiatric inpatients with DSM-III-R major depression. Regression techniques were used to examine the contribution of demographic variables (age, sex, education), depressive symptom severity (Hamilton Rating Scale for Depression score), psychiatric function (Global Assessment of Functioning Scale score), organ system pathology (Cumulative Illness Rating Scale score), and medical disability (Karnofsky Performance Status Scale score) to overall functional status (Instrumental Activities of Daily Living and Physical Self-Maintenance scores). These relationships were also examined in older and younger subgroups. RESULTS: Greater age, female sex, and illness factors all contributed to poorer functional status. Of the illness factors, psychiatric pathology contributed more to low functional status than did medical illness. The predictive power came specifically from the functionally based measures of psychiatric and medical illness; a quantitative measure of symptoms (Hamilton depression scale) or organ pathology (Cumulative Illness Rating Scale) did not significantly predict overall functional status. CONCLUSIONS: Clinicians and researchers should recognize that symptomatic and functional assessments tap related but different domains and that both psychiatric and medical illnesses contribute to overall disability.

Violence, alcohol, and completed suicide: a case-control study.

OBJECTIVE: Violent behavior may represent a risk factor for suicide. The authors tested the hypothesis that violent behavior in the last year of life is associated with completed suicide, even after controlling for alcohol use disorders. METHOD: The authors analyzed data from the 1993 National Mortality Followback Survey, a nationally representative survey conducted by telephone interview with decedents' next of kin. Data on 753 victims of suicide were compared with data on 2,115 accident victims. Decedents ranged in age from 20 to 64. Dichotomous measures of violent behavior in the past year and history of alcohol misuse were derived by using the four-item CAGE questionnaire. Multiple logistic regression was used to evaluate the interactions of violent behavior with alcohol misuse, gender, and age, respectively, in predicting suicide versus accidental death. Education and race were included as covariates. RESULTS: Violent behavior in the last year of life was a significant predictor of suicide; the relationship was especially strong in individuals with no history of alcohol misuse, those who were younger, and women. CONCLUSIONS: Violent behavior distinguished suicide victims from accident victims, and this finding is not attributable to alcohol use disorders alone. Given that violent behavior increases the risk of suicide, violence prevention initiatives may serve to decrease the risk of suicide as well.

Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study.

OBJECTIVE: Psychiatric illness is a potent risk factor for suicide, rates of which differ markedly with age. The purpose of this study was to examine whether the psychiatric diagnoses of suicide victims vary predictably with age. METHOD: DSM-III-R axis I diagnoses of 141 persons aged 21 to 92 years who had completed suicide were established by the psychological autopsy method. Multiple logistic regression analyses were used to determine whether age, gender, or their interaction predicted the presence of specific disorders. RESULTS: One or more axis I conditions were diagnosable in 90.1% of the suicide victims. Substance use disorders were most frequent, followed by mood disorders and primary psychotic illness. Younger age at death was a significant predictor of substance abuse or dependence and primary psychoses, while older age predicted major mood disorders. Comorbidity of substance use and mood disorders was common. Among victims with substance abuse or dependence, older age at death predicted major depression; among victims with mood disorders, younger age at death predicted comorbid substance abuse or dependence. CONCLUSIONS: The distribution of psychiatric illnesses in suicide victims differs across the life course. Age-related patterns of addictive and psychotic disorders echo their prevalence in the general population. In contrast, the relationship between age and mood disorders among suicide victims is distinctly different from that of the general population. These findings suggest that risk for suicide increases with age in individuals with major affective illness. Depressed elderly men are particular targets for suicide prevention strategies.

Cerebrovascular risk factors and 1-year depression outcome in older primary care patients.

OBJECTIVE: A model in which cerebrovascular disease contributes to the pathogenesis of depression in later life was the basis of the authors' hypothesis that cerebrovascular risk factors at intake are independently associated with depression at 1-year follow-up. METHOD: The subjects were 247 patients aged 60 years or older in primary care practices. The study measures were completed at intake and 1-year follow-up. Multiple regression techniques were used to determine the independent association of initial cerebrovascular risk factors with depressive symptoms and diagnoses at 1 year. RESULTS: The authors found that the severity of initial cumulative cerebrovascular risk factors was significantly independently associated with 1-year depressive symptoms and diagnoses, but not after also controlling for overall medical burden. CONCLUSIONS: The results lend some support to the cerebrovascular model of depression.

Completed suicide at age 50 and over.

The authors present data abstracted from medical examiners' investigative reports of 246 completed suicides of persons over the age of 50 years classified into four age groups. The sample population conformed to epidemiologic studies with regard to sex distribution. With increasing age, more suicide victims were widowed, and significantly fewer were single, separated, or divorced. Violent methods of suicide were more prevalent and alcohol use and psychiatric histories less common with aging. Physical illness and loss became the most common definable precipitants to suicide, whereas job, financial, and family relationship problems became less frequent with increasing age. The indications for future research and intervention in primary care settings are discussed.

Suicide attempts in elderly psychiatric inpatients.

OBJECTIVE: To describe the psychopathological characteristics of elderly suicide attempters admitted to an inpatient psychiatric unit. DESIGN: Retrospective chart review. PATIENTS: All 168 patients age 60 years and over treated on the adult psychiatric inpatient unit of Yale-New Haven Hospital from 1979 to 1984. Twenty-five made a suicide attempt. MAIN OUTCOME MEASURES: Presence and severity of suicide attempts were rated and compared with demographic, clinical, and functional data. RESULTS: (1) Eighty percent of the attempters had a major depressive syndrome; (2) among patients with affective disorders, presence of an attempt was significantly associated with a later age of onset; (3) patients who had made more severe attempts were more likely to be diagnosed as psychotic depression, although this trend was not significant; (4) substance abuse and dementia were uncommon diagnoses; (5) symptomatic and functional outcome of hospitalization was as favorable for the attempters as for the entire elderly cohort. CONCLUSIONS: Affective illness, especially late-onset major depression, was the major association with suicide attempts.

Validation of a measure of physical illness burden at autopsy: the Cumulative Illness Rating Scale.

OBJECTIVE: To further validate an objective measure of physical illness burden, the Cumulative Illness Rating Scale (CIRS). DESIGN: Survey with correlation of CIRS ratings made from physician interviews and review of medical records with post-mortem ratings made independently at tissue autopsy. SUBJECTS: Victims of completed suicide investigated by both psychological and tissue autopsy (n = 72). RESULTS: CIRS ratings made by examination of tissue at autopsy were highly predictive of analogous ratings based on historical data, accounting for 75% of the variance in CIRS scores. Taking autopsy findings as the gold standard of objective health assessment, historical ratings tend to underestimate physical illness at high levels of tissue pathology and to overestimate burden at lower levels. CONCLUSIONS: The CIRS score, when derived from all available sources of medical information, is a valid objective measure of physical illness burden and has broad applicability to research in geriatrics.

Attitudes of older people toward suicide and assisted suicide: an analysis of Gallup Poll findings.

OBJECTIVES: To describe the older population's attitudes toward suicide and assisted suicide, and to determine whether lenient attitudes are associated with known demographic and psychosocial risk factors for completed suicide. DESIGN: Telephone survey conducted by the Gallup Organization in November 1992. PARTICIPANTS: A sample of 802 adults in the United States (541 women and 261 men) aged 60 years and older. MEASUREMENTS: The dependent variables, attitudes toward suicide, were assessed with five attitude statements. Participants rated their agreement with each statement on 4-point Likert-type scales, subsequently dichotomized for use in univariate analyses and logistic regressions. The independent variables included income and demographic and psychosocial risk factors for suicide: age, gender, race, marital status, religiousness, self-rated health, and satisfaction with family relationships. RESULTS: The majority of respondents did not express lenient attitudes. In comparison with survey findings of physicians and the general population, a relatively smaller percentage (41%) of these older respondents believe that physician-assisted suicide should be legalized. Agreement with one or more of the attitudes presented was associated with age, gender, race, marital status, and religiousness in univariate analyses (P < .05), and race, religiousness (P < .001), gender, self-rated health, and satisfaction with family relations (P < .08) in logistic regressions. CONCLUSIONS: The hypothesized relations between risk factors for suicide and lenient attitudes toward suicide were supported. Although none of the risk factors was associated with all five attitudes, in combination the results suggested that a common set of variables predict both lenient attitudes toward suicide and suicidal behavior. Future research is necessary to determine the role of depression and other factors that may mediate the observed relationships and to determine whether the presence of specific, strongly held attitudes sanctioning suicide in an older person signals the need to assess suicide risk.

Elderly patients admitted to the psychiatric unit of a general hospital.

Elderly psychiatric patients who are cared for in general hospital psychiatric settings have not been clearly characterized in the literature in terms of demographics, primary diagnoses, hospital course, and outcome. The authors reviewed charts of 168 patients over the age of 60 years admitted to a general hospital inpatient psychiatry unit over a 5-year period in order to develop a demographic and clinical profile of this patient population. Results indicated that the large majority of patients had affective syndromes; dementia was the second most common diagnosis. Length of stay correlated with severity of depressive illness, while a diagnosis of dementia was associated with a shorter hospitalization. Outcome measures showed favorable response to treatment in three-fourths of this population of elderly psychiatric patients. These data suggest that the general hospital acute inpatient setting is well suited to care for the combined medical and mental illnesses of elderly psychiatric patients.

Older age and the underreporting of depressive symptoms.

OBJECTIVE: To determine whether older age is associated with a decrease in self-reported depressive symptoms, independent of examiner-rated symptoms, in inpatients with major depression. DESIGN: Survey study. SETTING: Inpatient psychiatric units at a university medical center. PATIENTS: Eligible subjects were those over 20 years of age with a primary diagnosis of DSM-III-R major depression. Participation was sought from all subjects over 60 years of age and from every second or every third younger subject, depending on rater availability. Of 137 eligible subjects, 97 completed all study measures. MEASUREMENTS: The Beck Depression Inventory (BDI), as a measure of self-reported depressive symptoms, was the dependent variable. The Hamilton Rating Scale for Depression (Ham-D) was used to assess examiner-rated symptoms. MAIN RESULTS: Older age (P = .03) was associated negatively and examiner-rated depressive symptoms (P = .0001) were associated positively with BDI score. Other variables, including gender, education, age of depression onset, and medical illness burden, were not independently associated with BDI. Examination of depressive symptom subtotals (psychologic/affective vs. somatic/neurovegetative) revealed that only the self-reported psychologic/affective subtotal was significantly associated with age (P = .0018). CONCLUSIONS: Some older patients with clinically significant depression underreport their symptoms. When asking older patients about depressive symptoms, clinicians should view negative responses only within larger clinical contexts and should obtain information from other sources as needed. Similar concerns must temper interpretation of research that relies on subject self-report to study depression in late life.

Attitudes toward self-determined death: a survey of primary care physicians.

OBJECTIVE: To survey physicians to determine whether sociodemographic and practice-related variables are predictive of their attitudes toward suicide. DESIGN: Mailed questionnnaire survey. SETTING: Monroe County, New York. PARTICIPANTS: A 50 percent random sample of practicing primary care physicians. Of 186 potential respondents, 114 (61.3%) physicians returned questionnaires. MEASUREMENT: In addition to age and gender, independent variables included medical specialty, practice composition defined in terms of patient age, and textbook knowledge of depression and suicide. The dependent variable, attitude toward suicide, was measured using four standard opinion survey questions and six items based on a case vignette. Dependent variables were rated on a Likert-type scale and subsequently dichotomized for use in logistic regression analysis. RESULTS: Approximately 61 percent of the respondents believe that suicide can be rational under certain circumstances, 51 percent believe that physicians should not assist suicides under any circumstances, and 31 percent support legalization of assisted suicide under certain circumstances. Regression analyses revealed that gender was a significant predictor for three of the ten attitude items. Medical specialty, clinical and epidemiological knowledge of depression and suicide, and physician age significantly predicted one attitude item. CONCLUSIONS: These results suggest that physicians' attitudes toward suicide are multidetermined. Although gender, age, medical specialty, and knowledge of depression and suicide predict certain attitudes, the logistic regression analyses were not highly successful in predicting respondents' attitudes. Given the power of physicians to command public attention and to influence public and legal opinion, it is vital that future research continue to explore the determinants of physicians' attitudes toward self-determined death.

High levels of hopelessness persist in geriatric patients with remitted depression and a history of attempted suicide.

OBJECTIVE: To determine whether a high level of hopelessness after treatment of a depressive episode is an indicator of a history of lifetime suicide attempts in older people. DESIGN: Groups of suicide attempters, suicidal ideators, and nonsuicidal patients were compared via analysis of variance with respect to levels of hopelessness, depression, anxiety, and global functioning before and after treatment of depression. SETTING: An outpatient research clinic providing two treatment protocols of late-life mood disorders. PARTICIPANTS: A total of 107 consecutive outpatients (mean age 67) with major depression who responded to treatment. MEASUREMENTS: Levels of hopelessness, severity of depression, anxiety, and global functioning were compared across the three groups at the beginning of treatment and at remission. RESULTS: After remission there were no differences between the three groups in depression severity, anxiety, and global functioning. Hopelessness remained significantly higher in the attempter group than among ideators or nonsuicidal patients. CONCLUSIONS: Suicide attempts, the most important risk factor for subsequent suicide, are associated with persistent, high levels of hopelessness following remission of depression in late-life patients. These findings suggest that treatments designed specifically to lower hopelessness (such as cognitive, behavioral or interpersonal therapy) may be effective in reducing suicide risk.

Completed suicide among older patients in primary care practices: a controlled study.

OBJECTIVE: To determine whether physical and psychiatric illness, functional status, and treatment history distinguish older primary care patients who committed suicide from those who did not. DESIGN: A case-control study using data collected by psychological autopsies of suicides and prospective patient interviews for controls. SETTING: Primary care practices in Monroe County, NY. PARTICIPANTS: Forty-two suicides aged 60 years and older who visited a primary care provider within 30 days of death and 196 patients aged 60 years and older from a group practice of general internal medicine (n = 115) or family medicine (n = 81). MEASUREMENTS: Psychiatric diagnosis; depressive symptom severity; physical health and function; psychiatric treatment history. RESULTS: Completed suicides had more depressive illness (P = .001), physical illness burden (P = .0002), and functional limitations (P = .0001) than controls and were more likely to be prescribed antidepressants (P = .004), anxiolytic agents (P = .0001), and narcotic analgesics (P = .022). Among depressed subjects, affective symptom severity (P< .0001) and emotional dysfunction (P<.0001) distinguished suicide completers. However, physical health, overall function, and treatments received did not differ between groups. CONCLUSIONS: The primary care setting is an important venue for late life suicide prevention. Primary care providers should be well prepared to diagnose and treat depression in their older patients. Additional research is needed concerning the interactions of physical health, functional status, and depressive symptoms in determining suicide risk.

Suicide in elders.

Older persons in the United States are at higher risk for suicide than any other segment of the population. The epidemiology and risk factors for suicide in later life and the most promising approaches to its prevention are reviewed. Available data suggest that psychiatric and physical illnesses, functional impairment, personality traits of neuroticism and low openness to experience, and social isolation are important correlates of late-life suicide. Affective illness is the risk factor with the strongest association. As treatable conditions in most cases, mood disorders are critical targets for preventive interventions. Because 70% of older adults who committed suicide saw their primary care provider within 30 days of death, the primary care setting is an important venue for intervention. Mood disorders are common in primary care practice, but often go undiagnosed and inadequately treated. One important approach to late-life suicide prevention, therefore, is to optimize the ability of primary care providers to diagnose and treat late-life mood disorders and suicidality effectively. Other elders at high risk have no active relationship to primary care. Strategies designed to identify this group and provide them with preventive services through outreach to the community have shown promise as late-life suicide prevention measures as well.