Recognising inaccuracies in Australian suicide and 'hidden suicide' data.

OBJECTIVE: To examine the effects of revision of Australian mortality statistics every year since 2007 on numbers and rates of suicide and 'hidden suicide'. METHOD: Nine months after the end of each year, the Australian Bureau of Statistics releases preliminary statistics concerning deaths registered in that year, together with revised and finalised data regarding previous years. Numbers and rates of suicide and of deaths coded to selected categories of accidental, undetermined and unknown cause deaths were tabled. RESULTS: Upward revision of suicide and accidental drug poisoning death numbers, three years after first release, show that true rates are substantially higher than initially released data suggested. Concomitant downward revision of rates of undetermined and unknown cause deaths supports evidence that at first release some suicides are coded to these categories. CONCLUSIONS: Australia's finalised suicide data are likely to be more accurate than equivalent data from nations that do not revise mortality data. More comprehensive investigation (including verbal or psychological autopsy) in doubtful cases in Australia and elsewhere would probably lead to reported suicide rates being higher.

Drug overdose death rates in different countries: Who should be alarmed?

OBJECTIVES: This study aims to assess how many nations, in addition to the United States and Canada, report alarmingly high drug overdose death rates, and to compare how those rates have changed. CONCLUSIONS: Drug overdose death rates exceed four per 100,000 in over 10% of the world's nations, including Libya (where rates are increasing) and in Russia (where rates have fallen). A comparison of data from five well-resourced nations with high drug death rates showed recently accelerated and alarming increases in rates in the United States and Canada (attributed to influx of fentanyl, plus increased stimulant use). A reported recent fall in Canada's drug suicide rate may be attributable to misclassification of some suicides as accidents. There is an urgent need to ensure accuracy and better understanding concerning drug overdose deaths and how to prevent them.

Spain's suicide statistics: do we believe them?

PURPOSE: There is a widespread belief that suicides around the world are under-counted. A substantial proportion of suicides may have been inappropriately registered as accidental or of undetermined cause or intent. There is reason to explore to what extent low suicide rates in some nations could be partly attributable to under-counting. METHODS: Mortality statistics of most countries are available on-line. Numbers of suicide deaths in Spain, and in England and Wales (E & W), in male and female 5-year age groups, in each year between 2014 and 2018, were documented, along with deaths coded to ICD-10 accident or 'undetermined death' categories. Crude mortality rates were calculated using official population figures. Single year suicide, undetermined death, and non-transport accidental death rates of 12 other nations were calculated. RESULTS: Spain's crude suicide rate per 100,000 remains low (7.89) compared to other nations; its event of undetermined intent (EUI) death rate was 0.09 (contrasting with E & W's 1.74). Its accidental poisoning rate is much lower than that of E & W. The study showed much higher rates of ill-defined/unknown cause deaths in late life in Spain (both genders) than in E & W, and age-associated increases in accidental drowning rates parallel with increased suicide by drowning. CONCLUSIONS: Reportedly low suicide rates in Spain could be partly attributable to increased rates of 'hidden suicide' (accidental drowning, male accidental poisoning, and possibly ill-defined/unknown cause deaths, but not EUIs). It would be appropriate (and not just in Spain) to increase numbers of verbal and/or forensic autopsies in questionable 'undetermined' cases.

An Australian study of delusional disorder in late life.

OBJECTIVES: There is a paucity of available research to guide clinical practice in delusional disorder (DD), particularly in late life. This study aimed to evaluate antipsychotic use and treatment outcomes in patients with DD aged 65 years and older. Secondarily, we sought to examine associated clinical features and socio-demographic variables. DESIGN AND SETTING: This descriptive study reviewed all consecutive cases of DD referred to an Australian old age psychiatry service over a 12-year period. Fifty-five patients were assessed in the inpatient and/or community setting, with data verified from a review of all individual medical records. MEASUREMENTS: Data were collected with respect to antipsychotic use, outcomes, and clinical features. Socio-demographic variables of DD cases were compared to a non-matched comparison group (n=278) and an age and gender matched comparison group with a 1:1 ratio (n=55). RESULTS: The predominant type of DD was persecutory (87%). Non-prominent hallucinations were experienced by 18%, and depressive symptoms occurred in 22%. There was a statistically significant association between having DD and social isolation (χ2= 11.04 (DF=1) p<0.001; McNemar's test p<0.001). Atypical antipsychotic medication was prescribed in 32 cases, with follow-up permitted in 51 of the 55 cases (mean duration 36.6 months). Sustained recovery occurred in 20%, and improvement in an additional 35% of the study sample. Four patients subsequently developed dementia, and two developed mild cognitive impairment. CONCLUSIONS: Clinical improvement, including sustained recovery, occurred in more than half of those with late life DD. The majority of those who improved (96%) received atypical antipsychotics.

Suicide and 'hidden suicide': a comparison of rates in selected countries.

OBJECTIVE: To review rates of suicide and 'hidden suicide' in New Zealand (NZ), Australia, Ireland and Spain. METHOD: Using estimated population figures and online cause-of-death data from four countries, rates of suicide and 'hidden suicide' in 2014-2016 were calculated and compared. RESULTS: Age patterns and rates of suicide and 'hidden suicide' differ between these countries. The male suicide rate progressively rises across the age range in Spain but becomes lower in late life in Ireland. The male patterns in NZ and Australia are bimodal; male and female rates decrease in late life, with NZ lower than Australia. Maori age patterns are downward-sloping. Suicide rates of young Maori considerably exceed those of young non-Maori in NZ. CONCLUSIONS: The NZ youth suicide peaks are attributable to high rates of Maori youth suicide. Rates of 'hidden suicide' are relatively low in the four countries.

Accumulating too much stuff: what is hoarding and what is not?

OBJECTIVE: This paper considers the meaning of the terms hoarding, collecting and accumulation, with a focus on what is abnormal and what is not. CONCLUSIONS: Hoarding is an adaptive behaviour. When hoarding is excessive and interferes with people's lives, it is a disorder. A central feature of hoarding disorder is accumulation of items due to unwillingness to discard them. This must be distinguished from abnormal accumulation of material caused by poor motivation or unawareness concerning the need to discard.

Should psychomotor disturbance be an essential criterion for a DSM-5 diagnosis of melancholia?

BACKGROUND: The CORE measure has proved useful in rating observed psychomotor disturbance (PMD), which has been held to be a key feature of melancholic depression. However, studies have shown a substantial percentage of subjects fulfilling DSM criteria for melancholia do not have observable PMD. METHODS: A semi-structured interview schedule was used in assessing and diagnosing depressed older patients. DSM-IV diagnoses were made, and the CORE measure was used to rate PMD. Comparisons were made between melancholia inpatients who scored low and those scoring high on the CORE in relation to presentation and pattern of symptoms. RESULTS: Of 32 inpatients with melancholia, 10 scored 0-7, 8 scored 8-10, and 14 scored 15 or more on the CORE. Thirty-two inpatients with psychotic depression scored 13 or more. High-CORE participants manifested unvarying depression more often than did low-CORE participants, and were less likely to state that stress precipitated their depressive episode. CONCLUSIONS: High-CORE melancholia cases appear to have more in common with psychotic depression than do low-CORE cases. Designation of observable PMD as an essential criterion in making a diagnosis of melancholia could increase the utility of the DSM classification in relation to treatment planning.

Contacts with health professionals before suicide: missed opportunities for prevention?

AIM: This study aims to examine contacts with different health professionals in the three months prior to death in suicide cases compared to sudden death controls; and, to analyse contacts with health professionals among people who died by suicide having a diagnosable mental health disorder at the time of suicide compared to those who did not have such a diagnosis within four major groups of conditions. METHODS: The psychological autopsy method was utilised to investigate suicides of individuals over the age of 35years. A case-control study design was applied using sudden death cases as controls. Odds ratios with a 95% confidence interval were calculated. RESULTS: In total, 261 suicides and 182 sudden deaths were involved. In terms of contacts during the last three months prior to death, 76.9% of suicides and 81.9% of sudden deaths visited a general practitioner (GP). Persons who died by suicide had significantly more frequently contacts with mental health professionals than sudden death controls did. People with a diagnosable mental health disorder at the time of suicide attended GP surgeries with approximately the same frequency of people without a diagnosis at GP level. CONCLUSION: Similarly, approximately 90% of people who die by suicide and by sudden death seek for help from health care system, mainly from GPs in three months prior to their death. With reference to health care contacts, people who had or did not have a diagnosable psychiatric disorder are not distinguishable at the GP surgery level.

Two types of squalor: findings from a factor analysis of the Environmental Cleanliness and Clutter Scale (ECCS).

BACKGROUND: Most people who collect and hoard, and then have difficulty discarding items, do not live in squalor, even though accumulation of hoarded items can make cleaning very difficult. Commonly, people living in squalor accumulate garbage, but relatively few fulfill proposed criteria for "hoarding disorder." We examined the overlap between hoarding and squalor among people referred because of unacceptable living conditions. METHODS: Ongoing collection of data by a Squalor Project team, including ratings on the Environmental Cleanliness and Clutter Scale (ECCS), allowed (1) description of characteristics of cases and (2) examination of ratings of uncleanliness, and of the effect of accumulation of items or material on access within dwellings. Principal component analysis was used to examine latent variables underlying the ECCS. RESULTS: The mean age of the referred occupants (108 male, 95 female) was 61.9 years. The mean ECCS score in 186 rated cases was 18.5. Factor analysis of ECCS data showed a two-factor solution as the most plausible. Factor 1, comprising seven squalor items, accounted for 33.7% of the variance. Factor 2 comprised reduced accessibility and accumulation of items of little value (variance 17.6%). Accumulation of garbage loaded equally on the two factors. High levels of squalor and/or accumulation were recorded in 105 (56%) of the 186 dwellings. One-third scored high on accumulation/hoarding, while 38% scored high on squalor; 15% scored high on both squalor and accumulation. A quarter of those scoring high on squalor scored low on hoarding/accumulation. CONCLUSIONS: The ECCS is useful when describing whether referred cases show high levels of squalor, hoarding, or both.

Factors associated with suicidal thoughts in a large community study of older adults.

BACKGROUND: Thoughts about death and self-harm in old age have been commonly associated with the presence of depression, but other risk factors may also be important. AIMS: To determine the independent association between suicidal ideation in later life and demographic, lifestyle, socioeconomic, psychiatric and medical factors. METHOD: A cross-sectional study was conducted of a community-derived sample of 21 290 adults aged 60-101 years enrolled from Australian primary care practices. We considered that participants endorsing any of the four items of the Depressive Symptom Inventory -Suicidality Subscale were experiencing suicidal thoughts. We used standard procedures to collect demographic, lifestyle, psychosocial and clinical data. Anxiety and depressive symptoms were assessed with the Hospital Anxiety and Depression Scale. RESULTS: The 2-week prevalence of suicidal ideation was 4.8%. Male gender, higher education, current smoking, living alone, poor social support, no religious practice, financial strain, childhood physical abuse, history of suicide in the family, past depression, current anxiety, depression or comorbid anxiety and depression, past suicide attempt, pain, poor self-perceived health and current use of antidepressants were independently associated with suicidal ideation. Poor social support was associated with a population attributable fraction of 38.0%, followed by history of depression (23.6%), concurrent anxiety and depression (19.7%), prevalent anxiety (15.1%), pain (13.7%) and no religious practice (11.4%). CONCLUSIONS: Prevalent and past mood disorders seem to be valid targets for indicated interventions designed to reduce suicidal thoughts and behaviour. However, our data indicate that social disconnectedness and stress account for a larger proportion of cases than mood disorders. Should these associations prove to be causal, then interventions that succeeded in addressing these issues would contribute the most to reducing suicidal ideation and, possibly, suicidal behaviour in later life.

A randomized trial to reduce the prevalence of depression and self-harm behavior in older primary care patients.

PURPOSE: We wanted to determine whether an educational intervention targeting general practitioners reduces the 2-year prevalence of depression and self-harm behavior among their older patients. METHODS: Our study was a cluster randomized controlled trial conducted between July 2005 and June 2008. We recruited 373 Australian general practitioners and 21,762 of their patients aged 60 years or older. The intervention consisted of a practice audit with personalized automated audit feedback, printed educational material, and 6 monthly educational newsletters delivered over a period of 2 years. Control physicians completed a practice audit but did not receive individualized feedback. They also received 6 monthly newsletters describing the progress of the study, but they were not offered access to the educational material about screening, diagnosis and management of depression, and suicide behavior in later life. The primary outcome was a composite measure of clinically significant depression (Patient Health Questionnaire score ≥10) or self-harm behavior (suicide thoughts or attempt during the previous 12 months). Information about the outcomes of interest was collected at the baseline assessment and again after 12 and 24 months. We used logistic regression models to estimate the effect of the intervention in a complete case analysis and intention-to-treat analysis by imputed chain equations (primary analysis). RESULTS: Older adults treated by general practitioners assigned to the intervention experienced a 10% (95% CI, 3%-17%) reduction in the odds of depression or self-harm behavior during follow-up compared with older adults treated by control physicians. Post hoc analyses showed that the relative effect of the intervention on depression was not significant (OR = 0.93; 95% CI, 0.83-1.03), but its impact on self-harm behavior over 24 months was (OR = 0.80; 95% CI, 0.68-0.94). The beneficial effect of the intervention was primarily due to the relative reduction of self-harm behavior among older adults who did not report symptoms at baseline. The intervention had no obvious effect in reducing the 24-month prevalence of depression or self-harm behavior in older adults who had symptoms at baseline. CONCLUSIONS: Practice audit and targeted education of general practitioners reduced the 2-year prevalence of depression and self-harm behavior by 10% compared with control physicians. The intervention had no effect on recovery from depression or self-harm behavior, but it prevented the onset of new cases of self-harm behavior during follow-up. Replication of these results is required before we can confidently recommend the roll-out of such a program into normal clinical practice.

An evaluation of a national program to implement the Cornell Scale for Depression in Dementia into routine practice in aged care facilities.

BACKGROUND: Screening tools have been recommended for use in aged care to improve the detection and treatment of depression. This study aimed to evaluate the impact of a program for the routine implementation of the Cornell Scale for Depression in Dementia in Australian facilities, to determine whether use of the instrument by nurses led to further monitoring of depressive symptoms, medical referral, and changes in treatments prescribed for depression. METHODS: A file review was completed for 412 participants out of a total of 867 older people (47.5%) who resided in ten aged care facilities. The review examined Cornell Scale assessment data, medication charts, medical history, nursing progress notes, and resident care plans. Nursing staff who administered the Cornell Scale to each participant were also interviewed, and ten facility managers took part in an interview to determine barriers to the effective implementation of the instrument. RESULTS: The Cornell Scale had been administered to 46.8% of the sample in the previous 12 months, with 25% of these participants scoring 9-13 and 27% scoring 14 and above. Less than one third of the residents with high scores were monitored by the staff following the assessment. Only 18% of residents with high scores were referred for further assessment of depression, while 10% received a treatment change. CONCLUSIONS: The absence of a protocol for responding to high Cornell Scale scores limited the potential of this program to result in widespread improved treatment of depressed older people. The use of the Cornell Scale by aged care nurses with limited training raised concern.

Anxiety, depression, and comorbid anxiety and depression: risk factors and outcome over two years.

BACKGROUND: This study aimed to determine: (1) the prevalence of depression, anxiety, and depression associated with anxiety (DA); (2) the risk factor profile of depression, anxiety, and DA; (3) the course of depression, anxiety, and DA over 24 months. METHODS: Two-year longitudinal study of 20,036 adults aged 60+ years. We used the Patient Health Questionnaire and the Hospital Anxiety and Depression Scale anxiety subscale to establish the presence of depression and anxiety, and standard procedures to collect demographic, lifestyle, psychosocial, and clinical data. RESULTS: The prevalence of anxiety, depression, and DA was 4.7%, 1.4%, and 1.8%. About 57% of depression cases showed evidence of comorbid anxiety, while only 28% of those with clinically significant anxiety had concurrent depression. There was not only an overlap in the distribution of risk factors in these diagnostic groups but also differences. We found that 31%, 23%, and 35% of older adults with anxiety, depression, and DA showed persistence of symptoms after two years. Repeated anxiety was more common in women and repeated depression in men. Socioeconomic stressors were common in repeated DA. CONCLUSIONS: Clinically significant anxiety and depression are distinct conditions that frequently coexist in later life; when they appear together, older adults endure a more chronic course of illness.

Unanticipated Changes in Drug Overdose Death Rates in Canada During the Opioid Crisis.

Escalating drug overdose death rates in Canada are of ever-increasing concern. To better understand the extent of this health threat, we obtained mortality statistics and population figures for the years 2000 to 2020, and examined rates of overdose deaths, coded (using ICD-10) as accidental, suicide or "undetermined intent." The drug deemed as primarily responsible for the death was categorized as opioid, non-opioid, or unspecified. Age patterns of drug deaths were graphed. Joinpoint analysis was used to test the significance of changes in death rates. Accidental opioid and stimulant overdose death rates in Canada have climbed faster since 2011, though not as high as corresponding US rates. Unknown cause death rates have increased. However, opioid and non-opioid suicide rates have decreased significantly since 2011, and there have been fewer drug deaths of undetermined intent. Increased attention to the possibility that some suicides are being misclassified is warranted.

A study of severe domestic squalor: 173 cases referred to an old age psychiatry service.

BACKGROUND: Although community psychiatric services commonly encounter cases where intervention is needed due to persons' unclean or cluttered living conditions, evidence concerning the referral rate and prevalence of severe domestic squalor is sparse. METHODS: Between 2000 and 2009, ratings of cleanliness and clutter have been made in all cases of people living in squalor who have been referred to an old age psychiatry service in Central Sydney. Where possible, one-year follow-up was arranged. RESULTS: 173 persons aged 65 years or more were referred to the service during the ten years and assessed as living in squalor (120 moderate or severe, two thirds of whom showed a moderate or severe degree of hoarding/clutter). Of 157 followed up after one year, 47% were still at home, 32% were in long-term care homes, 12% had moved elsewhere, and 9% had died. The annual new referral rate was close to 1 per 1000 elderly people in the catchment area, and of moderate or severe squalor was 0.66 per 1000. Limiting follow-up to those in moderate or severe squalor, 41% were still at home one year later. Current findings suggest that the minimum prevalence in the community of older people living in moderate or severe squalor in Sydney is 1 per 1000. CONCLUSIONS: The costs of intervening in cases of severe domestic squalor are considerable. Increased attention and funding are warranted, as the incidence and prevalence are higher than had previously been estimated.

Living in squalor: neuropsychological function, emotional processing and squalor perception in patients found living in squalor.

BACKGROUND: Patients living in squalor have a wide range of psychiatric diagnoses, but these may have a common neural basis involving frontal systems. This study investigated frontal executive function, theory of mind, emotional processing including disgust, and appreciation of squalor in elderly patients found living in squalor. METHODS: Six patients referred to an old age psychiatry service underwent a battery of neuropsychological tests, assessment of living conditions and awareness of self and others' squalor. RESULTS: All six patients showed impairment in frontal executive function, typically accompanied by amnesic deficits. Theory of mind and emotional processing were surprisingly preserved. While five of the patients could recognize severely unclean or cluttered living conditions in newspaper photographs, more than half did not appreciate that their own living conditions were squalid. CONCLUSION: Deficits in frontal executive function appear important in the genesis of squalor although functions linked to orbito-frontal ability appear preserved.

Patterns of psychotropic medication use in nursing homes: surveys in Sydney, allowing comparisons over time and between countries.

BACKGROUND: This study aimed to explore changes in patterns of use of psychotropic medication in Sydney nursing homes over recent years, and to compare current usage rates with those reported from other countries. METHODS: Data were obtained from 44 of the 48 nursing homes in a central Sydney health area. Researchers noted details from medication cards concerning residents' age, gender and all currently prescribed drugs, checking whether medication had been given as prescribed. Frequency of administration of "as required" drugs in the previous four weeks was noted. RESULTS: The pattern of use of psychotropic medication changed considerably between 1993 and 2009. The number of residents taking regularly administered antipsychotics increased by 24% during 1998-2009, though mean dosages decreased. In 2009, fewer residents took hypnotic and/or anxiolytic medications than in the 1990s, and fewer than in countries from which equivalent data have been reported. Antidepressant use increased over the 16 years but only to 25.6%. Only 3% of residents in Sydney nursing homes in 2009 took cognition-enhancing drugs. CONCLUSIONS: Compared to other countries, rates of use of hypnotic, anxiolytic and antidepressant medication in Sydney nursing homes are low. Benefits and disadvantages of these differences merit analysis. Antipsychotic medications were administered to similar percentages of survey residents in 1993 and 2009, but at lower mean dosages in 2009 compared to previous surveys, and with a change to using mainly atypical antipsychotic drugs. Compared to various other countries, cognition-enhancing and antidepressant medications are administered to proportionally fewer residents in Sydney nursing homes. Outcome analysis regarding the use and benefits of such drugs in nursing homes is desirable.