Late life psychache –
who cares?
by
John Snowdon
“After age 60, suicide accounts for an
inconsequential proportion of all deaths”
!!!!!!!!!!!!!!
Late life psychache – who cares?
• What is psychache?
• Rates and age patterns of male and female suicide in
different countries, across time. Why the differences?
• Causation of late life suicide. Mental illness? Distress?
Emotional reaction? Importance of psychache.
• Older people requesting assisted suicide or
euthanasia.
• Prevention of late life suicides. Reducing psychache.
Optimising self-esteem and mental health in old age.
Psychache
• Shneidman (1999) coined the term ‘psychache’
to describe intensely felt psychological pain – a
hurt, anguish or ache that takes hold of the
mind … introspectively felt mental pain of
negative emotions such as guilt, shame,
humiliation, fear, panic, angst, loneliness,
helplessness, dread of growing old…
• Suicide occurs when the psychache is deemed
to be unbearable – to stop the unceasing flow
of intolerable consciousness.
Shneidman E (1999) ‘Perturbation and lethality. In D.G.Jacobs (ed.)
The Harvard Medical School Guide to Assessment and Intervention. Jossey-Bass, San Francisco
Questions to ask about late life suicide
• Is suicide always or usually due to
psychache?
• How commonly is suicide attributable to
mental disorder (in particular, depression)?
• If not a result of mental disorder, what’s
the cause?
• What evidence have we got about
causation of suicide?
50
NZ Males 1949-1958
NZ Females 1949-1958
NZ Males 1999-2008
NZ Females 1999-2008
45
40
Suicide rae per 100,000
35
30
25
20
15
10
5
0
10 to 14 15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
5-year age-groups
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80+
MALE: Suicide rate per 100,000 per year in New Zealand
50
1949-1958
45
2009-2011
40
RATE per 100,000
35
30
25
20
15
10
5
0
10 to 14 15-19
20-24
25-29
30-34
35-39
40-44
45-49 50-54 55-59
AGE (5-year groups)
60-64
65-69
70-74
75-79
80+
MALE: Suicide rate per 100,000 per year in New Zealand
RATE per 100,000
50
45
1949-1958
40
1959-1968
35
1969-1978
30
25
20
15
10
5
0
10 to 14 15-19
20-24
25-29
30-34
35-39
40-44
45-49 50-54 55-59
AGE (5-year groups)
60-64
65-69
70-74
75-79
80+
MALE: Suicide rate per 100,000 per year in New Zealand
60
1949-1958
1969-1978
50
1979-1988
RATE per 100,000
1989-1998
40
30
20
10
0
10 to 14 15-19
20-24
25-29
30-34
35-39
40-44
45-49 50-54 55-59
AGE (5-year groups)
60-64
65-69
70-74
75-79
80+
MALE: Suicide rate per 100,000 per year in New Zealand
60
1989-1998
50
1999-2008
RATE per 100,000
2009-2011
40
30
20
10
0
10 to 14 15-19
20-24
25-29
30-34
35-39
40-44
45-49 50-54 55-59
AGE (5-year groups)
60-64
65-69
70-74
75-79
80+
FEMALE: Suicide rate per 100,000 per year in N.Z.
20
1949-1958
1959-1968
1969-1978
15
10
5
0
10 to 14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
5-year AGE GROUPS
55-59
60-64
65-69
70-74
75-79
80+
FEMALE: Suicide rate per 100,000 per year in N.Z.
1989-1998
12
10
8
6
4
2
0
1999-2008
2009-2011
FEMALE: Suicide rate per 100,000 per year in N.Z.
20
1959-1968
15
2009-2011
10
5
0
10 to 14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
5-year AGE GROUPS
55-59
60-64
65-69
70-74
75-79
80+
50
NZ Males 2009-11
45
NZ Females 2009-11
40
Suicide rate per 100,000
35
30
25
20
15
10
5
0
10 to 14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
5-year age-groups
50-54
55-59
60-64
65-69
70-74
75-79
80+
THE AGE EFFECT (Australia) 1949-53 vs 2001-2
50
SUICIDE RATE per 100,000
•
45
Psychache
AUSTRALIA males 1949-53
AUSTRALIA males 1979-83
AUSTRALIA males 2001-2
AUSTRALIA females 1949-53
AUSTRALIA females 2001-2
Shneidman (1999) coined the term ‘psychache’
40 to describe intensely felt psychological pain – a
35 hurt, anguish or ache that takes hold of the
30 mind … introspectively felt mental pain of
25 negative emotions such as guilt, shame,
humiliation, fear, panic, angst, loneliness,
20
helplessness, dread of growing old…
15
• Suicide occurs when the psychache is deemed
10
5 to be unbearable – to stop the unceasing flow
0 of intolerable consciousness.
Shneidman E (1999) ‘Perturbation and lethality.
In D.G.Jacobs (ed.)
The Harvard Medical School Guide to Assessment and Intervention. Jossey-Bass, San Francisco
AGE (years)
Au stra lia vs En g la n d & Wa le s :
MAL ES (1 9 5 1 vs 2 0 0 1 )
60
E&W 1951
OZ males 1951
OZ males 2001-2
E&W males 1951
E&W males 2001-2
40
OZ 1951
30
20
OZ 2001-2
10
E & W 2001-2
AGE (years)
85
+
15
-1
9
20
-2
4
25
-2
9
30
-3
4
35
-3
9
40
-4
4
45
-4
9
50
-5
4
55
-5
9
60
-6
4
65
-6
9
70
-7
4
75
-7
9
80
-8
4
0
10
_1
4
SUICIDE RATE per 100,000
50
180
Suicide in CHINA (1992 )
SOURCE: Ji J, Kleinman A & Becker AE (2001). Harvard Rev. Psychiatry 9, 1-12.
160
SUICIDE RATE per 100,000
140
120
URBAN Male
URBAN Female
RURAL Male
100
RURAL Female
80
60
40
20
0
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84
AGE (years)
85+
100
Suicide in JAPAN (1960+1990)
SOURCE: Takahashi Y et al (1995). Int. Psychogeriatrics 7, 239-251.
90
MALES 1960
SUICIDE RATE per 100,000
80
70
MALES 1990
FEMALES 1960
FEMALES 1990
60
50
40
30
20
10
0
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84
AGE (years)
85+
RATE (per 100,000)
MAORI and NON-MAORI male & female
50
45
40
age-specific suicide rates 1982-1991
SOURCE: Skegg K et al (1995). Acta Psych Scand 92, 453-9
NON- MAORI male
MAORI male
NON- MAORI female
MAORI female
35
30
25
20
15
10
5
0
5
15
25
AGE
35 (years)
45
55
65
75
Su ic id e ra te s b y AGE, RACE a n d GENDER
70
United States, 1995
SOURCE: Mosciki EK (1999), page 42, Harvard Medical School Guide to
Suicide Assessment & Intervention (ed DG Jacobs). Jossey-Bass, San Francisco.
60
RATES (per 100,000)
WHITE male
50
BLACK male
WHITE female
40
BLACK female
30
20
10
0
10_14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
AGE (years)
Why the big difference between
male & female rates ?
Why the difference in ratio of
male to female rates between
NZ, Australia, E&W and China ?
Why the differing ratios between
age-groups & across time ?
Why the differences?
• Do we think that mental illness is three times
more common in men than women? (in NZ and
Australia, but not in China?)
• Do we think that mental illness became much
more common in young people in NZ in the
1980s (but not in China) – and much less
common among people aged 60 to 79 in NZ
over the last few decades…..?
Why the differences?
• Statistical bias in collection of data?
• Differences between countries and over time
in the way data are collected?
• Changes in the rates of being able to determine
whether suicide was the cause of death
(“undetermined”, “open verdict”) [UK, Australia]?
Yang, Phillips, Zhou et al (2005)
• Psychological autopsy study of 895 suicide victims from
23 representative locations around China, 90% response rate.
• Pesticide ingestion accounted for 519 (58%).
• 63% of suicide victims had a mental illness, in contrast to
17% of control accidental death victims.
• 40% of the suicide victims had mood disorders,
9% psychotic disorders, 14% other mental disorders.
• Higher rate of mental disorder in men who died by suicide
(67% v. 58%) and in urban dwellers (75% v. 60%).
• Young rural females who died from suicide had the highest
rates of pesticide ingestion (79%) and lowest prevalence of
mental illness (39%). Distress. Personality-related emotional reactions.
What do we understand from the China data?
• Phillips et al (2002): people refer to the low status and
limited opportunities for women in China, but women
in many developing countries have low social status and
are subject to domestic violence , without having
correspondingly high female suicide rates.
• Importance of acute stressors (e.g. family conflicts) as
suicidal precipitants in absence of mental disorder.
Impulsivity noted more commonly among completed
suicides. Impulsive pesticide use: China >> NZ.
• Instead of mental disorder, call it stress-related distress,
emotional turmoil: personality factors determine how
people react to mind-shattering circumstances.
Henriksson et al (1995), Int. Psychogeriat.
PSYCHOLOGICAL AUTOPSY STUDY
DSM-III-R diagnoses of suicide victims
Under 60 years
( n=186 )
60 years+
( n=43 )
MAJOR DEPRESSION
(including bipolar)
60 (32%)
19 (44%)
DEPRESSION n.o.s.
43 (23%)
9 (21%)
DYSTHYMIA
3
1
ADJUSTMENT DISORDERS
7 (3%)
4 (9%)
DEPRESSIVE SYNDROMES
(including all Axis I disorders
with depression)
120 (65%)
32 (74%)
Conwell et al (1996), Am J Psych 153, 1001-8
PSYCHOLOGICAL AUTOPSY STUDY
DSM-III-R diagnoses of
141 (male 113) suicide victims
21-34
( n=46 )
35-54
( n=45 )
55-74
( n=36 )
75-92
( n=14 )
14 (30%)
19 (42%)
23 (64%)
10 (71%)
* major
4%
31%
47%
57%
other
25%
17%
22%
21%
* SUBSTANCE USE
DISORDER
70%
76%
50%
36%
* SCHIZOPHRENIA /
PSYCHOSIS
22%
22%
6%
0
OTHER AXIS I
15%
16%
20%
14%
NO AXIS I DISORDER
13%
2%
8%
29%
* MOOD DISORDERS
* = significant
Suicides in older adults: a case-control psychological
autopsy study in Australia
(De Leo, Draper, Snowdon and Kõlves, J.Psychiatric Research 2013)
Response rate of n.o.k. of suicides 46.6%
Suicides (73 aged 60+)
Suicides (188 aged 35 to 59)
• Psychiatric diagnoses in 62%
•
Mood disorders 46.6%
• Psychiatric diagnoses in 80%
•
Mood disorders 58.1%
• Major depression 18%
• Melancholic depression 20.5%
• Other depression 8%
•
•
•
•
Major depression 18%
Melancholic depression 23.7%
Other depression 9%
Bipolar depression 4%
Mood disorders in cases of suicide
• Smaller % among female than male suicides in
China
• Smaller % among male and female suicides in
China than in NZ etc.
• Smaller % among rural (than urban) dwellers
who killed themselves in China
• Smaller % among middle-aged than late life
suicides in some studies but not in others (De
Leo et al, etc)
How often is suicide attributable to mood disorder?
• Although various psychological autopsy studies have shown high
rates of mental disorder, especially depression, among people in
high-income countries who killed themselves, others showed a
substantial proportion (⅓ to ½) didn’t have a diagnosable mental
disorder.
• Studies show that a multitude of factors (with or without
diagnosed mental disorders being present) may have
contributed to causation of suicide.
• Note that the prevalence of severe mental disorder in NZ is ? 5%,
with another 10%+ having less severe psych problems. Yet only
1% of us in NZ & Australia will die by suicide. We’re not good at
predicting which of the 5% (or the other 95%) will die by suicide.
• Personality factors contribute to causation. Precipitants differ for
men and women. What boosts/shatters their self-esteem?
• Cultural variation.
Suicide risk factors
(R.Goldney, Chad Buckle address)
•
•
•
•
•
•
•
•
•
•
•
Male
Previous history of suicidal behaviour
Family history of suicide
Mental disorders -- depression, substance abuse, schizophrenia
Hopelessness, despair, guilt
Social isolation – e.g. by separation/divorce (but not in China!)
Childhood deprivation – parent loss, violence, sexual abuse
Chronic physical illness
Custody/prison
Indigenous
Sexual identity issues
Let’s add (and we could classify as proximal and distal)
•
•
•
•
•
•
•
•
•
Personality and individual vulnerabilities
Impulsivity, perfectionism, neuroticism, sensitivity
Cognitive rigidity and rumination; unfulfilled needs
Low extroversion: being socially disconnected, with thwarted
belongingness.
Feeling a burden on others; helplessness
Interpersonal stressors, and inability to escape: trapped!
Other negative life events: stress
Neurobiological factors, including genetic: abnormal serotonin
system; frontal brain changes.
Diathesis (vulnerabilities)/stress model – distal/proximal
The diathesis model explains why so few of those exposed to psychiatric
disorders and other stressors will die by suicide.
So what’s different about late life suicide?
Unlike a majority of younger or middle-aged people,
• Commonly, the person lived alone, their partner having died or been
admitted to residential care. They’ve lost their friends, they’re no
longer involved in work and social groups, and may have had to
change accommodation. They feel socially disconnected. Depressing!
• Commonly the person had functional impairments due to disabilities
or chronic (often painful) illness. They worried about being a burden.
They may have felt useless. Depressing!
• Of those with depressive illnesses, half or more will have been of late
onset (age 65+), and may have had brain changes.
• The person is less likely to have been referred to a mental health
specialist or team, though 77% (in Australia) will have visited a GP in
the three months prior to death.
NZ comparison of late life suicide and attempted
suicide cases versus controls (Beautrais, 2002)
•
•
•
•
Adults aged 55 years or more.
269 controls, mean age 67.6 years
31 completed suicide (20 male, 11 female), mean age 65.2 years
22 attempted suicide (7 male, 15 female), 17/22 self-poisoning, mean age 66.3 years
•
•
•
•
•
•
Suicides versus controls:
Serious relationship problems: 17% v. 4% , p .001 (64% of each group were married)
Low social interaction in 26% versus 9%, p<.0001
Current serious physical illness: 26% versus 19% (not significant)
Current DSM-III-R mood disorder: 64.5% v. 1.5% , p<.0001
Any mental disorder: 74% versus 9%, p<.0001
Childhood sexual abuse: 11% versus 4%, p<.001
•
Risk of serious suicidal behaviour adjusted for confounding factors:
Mood disorder in prior month O.R. 179, psych admission in last year O.R. 24
Low social network O.R. 4.5 (p<.013)
Why the big fall in suicide rates of men aged 60+
( and reduced female rate 60-79 years ) ?
•
•
•
•
•
•
•
Do clinicians recognise and treat late life depression (and anxiety
and psychoses) better than they used to, with more effective
antidepressants, antipsychotics and talking treatments?
Are older people more likely than the young to have treatable
types of depression?
Are depressing physical problems being treated better?
Is there improved recognition and provision for the needs of
older people? Better services for disabled people?
Have there been changes in the way suicide data are gathered?
Are doctors less inclined to record deaths as suicides in cases of
terminal illness? Has there been an increase in deaths registered
as of undetermined cause? Reduced autopsy rates?
? Cohort effect.
Have older people changed to using less lethal suicide methods?
Changes in preferred method of suicide.
Why suicide rate of older persons has fallen,
though it remains higher among males
• Increased and improved use of antidepressants.
• Doctors recognise & treat late life depression better.
Less ageist.
• Better treatment of distressing (e.g. painful)
physical disorders.
• Environmental & socio-political improvements.
• But women maintain more satisfying roles and
networks.
How commonly is old age suicide
attributable to depression?
Depression in old age
Prevalence 13% in UK, US, NZ - but this includes:
 adjustment disorder with depressed mood
 ‘subthreshold’ depressions (often as disabling &
significant as ‘major’ depressions)
 Depressions associated with physical illness
(e.g. Parkinson’s, stroke, cancer, etc.) or with
dementia
 Older person commonly denies depression.
May be ‘masked’ and present as a physical
problem, or with apathy, irritability or being
demanding.
Depressive conditions:
1) Depression associated with loss/lack
- of loved one
- of source of self-esteem / morale or satisfaction
2) Depression associated with physical disorders
- psychological
- neurobiochemical
3) Depression related to drug/alcohol abuse or
depressant substances
4) Depression associated with other functional disorders
(e.g. schizophrenia)
5) Major depression with melancholia
6) Psychotic depression
7) Depression in cases of bipolar disorder
Prevalence of depression in association
with physical/organic illnesses
GENERAL MEDICAL PATIENTS
10 to 20% major
CANCER
25% major/adjustment
STROKE
23% to 34% major
PARKINSON’S
45% depressed
(most major or dysthymia)
DEMENTIA
23% depressive disorder
11% major
DISABLED
35% significantly
depressed
NON-DISABLED
12% significantly
depressed
The male suicide rate in
New Zealand and Australia
reaches a second peak
at age 85+ years.
Is this attributable to
“rational” suicide ?
SUICIDE: AUTOPSY STUDIES
Cattell H and Jolley DJ
One hundred cases of suicide in elderly people (Central Manchester)
British Journal of Psychiatry 1995, 166, 451-456
Cattell HR
Elderly suicide in London: an analysis of coroner’s inquests
International Journal of Geriatric Psychiatry 1988, 3, 251-261.
Harwood D et al
Coroner’s files (195 cases), with psychological autopsy of 100
International Journal of Geriatric Psychiatry 2001, 16, 155-165.
Of 210 suicides of older people whose files
we saw at Glebe Coroner’s Court,
we agreed that:
• 160 were definitely depressed
• 25 were possibly depressed
• 25 did not fulfil criteria for a depressive
disorder
3 schizophrenia or paranoid state
1 PTSD and 1 Delirium
Snowdon J, Baume P (2002). A study of suicides of older people in Sydney.
International Journal of Geriatric Psychiatry 17, 261-269.
45 (21%) had alcohol in their blood at
death
 Of 20 labelled as alcoholic, 17 had
depression as well.
 Of 15 labelled as dementia, 12 had
depression as well.
43 (20%) had antidepressants in their
blood at the time of death
 + 3 lithium, 1 carbamazepine
122 (58%) had a disability or illness
that we identified as a major factor
contributing to the suicide
40 (19%) had cancer at death or
treatment for cancer in the last year
10 were in hospital
5 were in nursing homes
5 were in hostels
at the time of death
4 had said they’d rather die
than go into a nursing home
We asked why
these 210 people
took the decision to
kill themselves
Dementia
Schizophrenia
“Rational”
Untenable situation
Undetermined or multi-factorial
Depression
•
•
•
•
Delusional/endogenous depression
Non-melancholic “reactive’ depression
Bereavement
Depression with physical illness or disability
Depression associated with a
physical condition
Where physical illness (e.g.
stroke or coronary bypass) had
precipitated a depression, and
then depressive perceptions
appeared to dominate the
person’s life.
Untenable situation
Where the person couldn’t tolerate current
circumstances,
e.g. rejection by spouse
e.g. lost self-esteem following migration to a
different cultural milieu
e.g. shame, guilt
e.g. inability to give up alcohol
e.g. financial disaster
What did we include as
‘rational’ decisions?
A decision was made that pain,
discomfort or handicap had made life
unbearable for themselves and/or a
burden for another person.
Up to half would have been expected to
die from their physical condition within
one year. Some owned ‘Final Exit’.
A majority were depressed because of
their physical condition.
The primary reasons why (we deduced) 210 people killed themselves
3737
Endogenous / delusional depression
40
40
Depressive ( commonly loss-related )
13
13
Bereavement ( within one year )
21
Depression plus physical illness/disability
Dementia / delirium
9
6
DEFINITELY DEPRESSED
3
Schizophrenia
Understandable (?) decision to avoid
effects of illness or being a burden
NOT DEFINITELY DEPRESSED
31
11
Untenable situation
19
17
28
9
Multifactorial / undetermined aetiology
NUMBER OF CASES
0
10
20
30
40
50
Issues to discuss
• Understandable? To whom? Rational? Who decides?
• Do some personality characteristics make it
difficult to tolerate disability, loss, insults, pain,
diminished self-regard ?
• Are some suicides altruistic (re burden) ?
• Is it reasonable, understandable and rational for
people to request euthanasia when there is
persisting intolerable psychache (‘mental pain’)
or not? Is assisted suicide ever an option?
Adapting to age-related physical and cognitive changes:
some people can’t/don’t, and this can lead to mental suffering…
• Re psychotherapy: “Suicidal behaviour can result from extreme
psychological pain associated with an inability to meet previously
achieved goals, responsibilities or physical accomplishments”
Baumeister R.F. (1990) Psychol. Rev. 97, 90-113
• “Older adults having difficulty adapting to the transitions of aging
may succumb to a narcissistic despair that can heighten depressive
pathology and engender suicidal behaviour.”
Maltsberger J.T. (1991) J.Geriatr Psychiatry 24, 217-234
•
Prado C.G. (1998) in ‘The Last Choice: Preemptive Suicide in Advanced Age’
distinguished between suicide because of unbearable agony and ‘preemptive’
suicide to avoid demeaning decline and needless suffering.
Rational suicide
Werth & Cobia (1995)
(Suicide & Life-Threatening Behavior 25, 231-240):
• (1) An unremittingly hopeless condition
• (2) Suicidal condition made as a free choice
• (3) Informed decision-making process
Margaret Battin, ethicist and prof of philosophy
(1984), argued that people have the right to shape
the ends of their lives.
A note was written by a 66-year-old man suffering
from terminal kidney and bowel cancer. He
committed suicide by carbon monoxide poisoning:
Dear… I will always love you. I have gone to your
pussy cat and we will both wait for you. I am getting
worse and I would like you to remember me as I am.
Soon I would be just a ‘vegetable’ and in pain…..
The Glebe study (1994-8)
Why older MALES killed themselves
“Reason”
65-79 years
NUMBER
80+ years
NUMBER (%)
“Rational”
Depression + physical disorder
or dementia
23
13
4
17 (42%)
5
5
Loss-related depression
23
9
22
19
9
1
1
2
(18%)
(including bereavement)
Endogenous depression
Untenable situation
Schizophrenia or debatable
reasons
TOTAL 113
40
The Glebe study (1994-8)
Why older FEMALES killed themselves
“Reason”
65-79 years
NUMBER
80+ years
NUMBER (%)
“Rational”
6
3
4
0
Depression & physical
(15%)
Loss-related depression
(including bereavement)
14
Endogenous depression
10
7
1
TOTAL 41
Untenable situation
Schizophrenia
(25%)
7
4
1
0
16
Only a few of those who commit
suicide are free of the veil of
depression that distorts and
dictates choices that would not be
elected if they truly acted rationally.
Slaby AE, 1999
PSYCHIATRY SERVICES, 50, 1093
Glebe study findings
• Most people who died by suicide were
depressed, but only a minority had
melancholia. Most were reacting to loss or
untenable situations. Psychache
• Personality a big factor
• Multifactorial explanations for suicide
• Health problems contributory in a majority of
old age suicides, but few were so bad and
irremediable that requests for euthanasia
seem justifiable
In the decade 1983 – 1992
there was a reduction by one third in the
suicide rate of Dutch people over age
fifty. Assisted suicide and euthanasia
were made more easily available and
acceptable during this time, and most of
those dying in this way were over 50
( 86% of male euthanasia , 78% of female euthanasia cases
were aged over 50 years )
Patients who request euthanasia are usually asking in
the strongest way they know for mental and physical
relief from suffering. When that request is made to a
caring, sensitive and knowledgeable physician who
can address their fear, relieve their suffering, and
assure them that he or she will remain with them to
the end, most patients no longer want to die and are
grateful for the time remaining to them.
Hendin H, 1995
CRISIS, 17, 90-93
Susan Stern’s documentary,
‘The Self-Made Man’
• Her father, Bob Stern, was 77, a tough individual who
prided himself on his achievements.
• “I have my sanity and my reasoning capacity…….. I’m
seriously considering an end to my very nice life.”
• Prostate cancer, a grapefruit-sized abdominal aortic
aneurysm, and “now saw in his future only a fast and
demoralising slide into total dependency.”
• He shot himself.
San Francisco Chronicle, 25/7/05
• The values of American masculinity are at increasing
odds with the reality of ageing. A lot of times men
don’t grieve. They don’t let people know how they
feel. Depressed men often cover up pain with a takecharge attitude – just like Bob Stern.
• There is compelling evidence that depression can be
driving the seemingly rational wish to die.
• Susan Stern: “Sometimes I wonder if my father was
strong enough to get weak.”
Rousseau P
Pain Management in the terminally ill
Journal of the American Geriatrics Society 1994, 42, 1217
“Physicians must confront the
historical malaise regarding the
treatment of pain in terminal illness
and afford deserving patients a
pain-free and dignified death”
THE GOTLAND STUDY
During the early 1980s this study showed that it
was possible to reduce the incidence of suicide
through introduction of a comprehensive
education programme aimed at GPs. The rate fell
from 20 to 7 per 100,000 (Rutz et al, Acta, 1989)
Two additional one-day seminars for GPs
in 1993 and 1995.
1990-1994
and
100% increase in antidepressant prescription
15% reduction in suicide (especially women)
Can we prevent suicide?
• Chad Buckle’s death highlighted the importance of
consistently implementing best practice techniques in
the diagnosis, treatment, monitoring and ongoing care
of psychiatric patients, including the recognition and
treatment of those at risk.
• This talk has focused on suicide in late life, with the
aim of highlighting the need for RECOGNITION of
THOSE AT RISK, and appropriate INTERVENTION.
• A majority but not all people who die by suicide have
mental disorders, but nearly all have PSYCHACHE.
• Our aim should be to recognise the psychache and
suppress it, thereby preventing suicide.
Elderly suicide prevention programmes
• Various countries have published guidelines
• There have been too few studies of the effectiveness of
interventions aimed at preventing late life suicide.
• Studies have centred on depression screening and treatment,
and decreasing isolation. Best for women.
• TeleHelp worked well for women (De Leo et al, 2002)
• “Improvement in detection, treatment and management of
mood disorders should be the primary focus” (Lapierre et al,
2011) . Yes, but for some people, other factors need prime attention.
• No studies examined the differential impact of programmes
on young-old (60-79) and old-old (80+) persons to see if the
groups present different challenges.
• Older men could prefer programs that focus on action and
problem solving rather than emotions and creating new
relationships (Lapierre et al). Those depressed because of functional
impairments, for example?
Lapierre S et al (2011). A systematic review of elderly suicide prevention programs. Crisis 32, 88-98.
Prevention of late life suicide
• Collaborative care models, using depression care
managers, such as PROSPECT, can improve outcomes.
• So can community old age psychiatry services.
• Lithium (depression and bipolar) and clozapine
(schizophrenia) have helped prevent suicide.
• Late onset depression is commonly attributed to
vascular changes; hope to prevent it by limiting
vascular damage.
• Rates of suicide in the 60-79 years age-groups in NZ
and Australia have fallen, maybe largely due to
availability of better antidepressant treatments and
community services (mental health, home help).
Conclusions
• Good news! Rates of late life depression in NZ and
Australia have fallen, but still with too high a peak
among men aged 80+ years.
• Suicide is a consequence of an interplay of multiple
factors, including mental disorder, brain changes,
functional impairments, social circumstances,
insecurity, personality, conflicts, cultural attitudes,
and reactions to life events.
• Prevention of late life suicide needs special focus on
connectedness, physical illness, and empowerment.
SENECA
I will not relinquish old age if it leaves my better part intact.
But if it begins to shake my mind, if it destroys its facilities one
by one, if it leaves me not life but breath, I will depart from the
putrid or tottering edifice. I will not escape by death from
disease so long as it may be healed, and leaves my mind
unimpaired. I will not raise my hand against myself on account
of pain, for so to die is to be conquered. But if I know that I
must suffer without hope or relief, I will depart, not through
fear of the pain itself, but because it prevents all for which I
would live.
[ Lecky, 1869 ]