A Study of Elderly Suicide Attempters Admitted to an Inpatient Psychiatric Unit

A Study of Elderly Suicide

Attempters Admitted to an Inpatient psychiatric Unit A. Hind Rifai, M.D., Benoit H. Mulsant, M.D. Robert A. Sweet, M.D., Rona E. Pasternak, M.D. Jules Rosen, M.D., George S. Zubenko, M.D., Ph.D. The authors distinguish demographic and clinical characteris-

tics of elderly suicide attenlpters admitted to an inpatient psychiatn·c unit within 4 weeks ofa suz"cide attempt. Of560patients admitted, 28 (5%) were recent attempters, 32 (6%) had a past history ofsuicide attempt, and 500 (89%) were nonattempters. Of the 28 recent attempters, 21 (75%) were diagnosed with a mood disorder, 4 (14%) with an organic mental disorder, and 3 (11%) with other mental disorders. Among the nonattempters, the distribution alnong the three diagnostic categories was 188 (38%), 251 (50%), and 61 (12%), respectively. Of 166 patients with a diagnosis of major depression, 18 (11%) were recent attempters, 14 (8%) were past attelnpters, and 134 (71 %) were

nonattempters. Recent attempts were significantly associated with alcohol abuse. This study confirms earlier reports of high rates of major depression in elderly attempters.

T

he rate of completed suicide is highest in individuals age 65 years or older. In this age group suicide ranks as the 13th most common cause of death. 1 A dramatic increase in the number of elderly suicides has been predicted for the beginning of the twenty-first century. This expected increase is attributed to the aging of the Ubaby boomer" generation, which has been characterized by high rates of mood disorders,

and the rise in the percentage of population represented by the elderly. It is thus estimated that the annual number of suicides for individuals over age 5S may double, reaching 17,000 in the year 2030. 213 Most of the available information on suicide in late life has been derived from case reports and psychological autopsies.4-B Elderly suicide victims in these reports are characterized by a preponderance of white

This article has been awarded an honorable mention as a submission for the 1992 AAGP Junior Investigator Award. The winning article will be published in a future issue of the Journal. Received July 22, 1992j revised October 27, 1992; accepted November 13, 1992. From the Geriatric Health Services, Department of Psychiatry and Western Psychiatric Institute and Clinic, School of Medicine, University of Pittsburgh, Pittsburgh, PA. Address reprint requests to Dr. Rifai, Geriatric Health Services, Western Psychiatric Institute and Clinic, Room 1234,3811 O'Hara St., Pittsburgh, PA 15213. Copyright © 1993 American Association for Geriatric Psychiatry 126

VOLUME 1 • NUMBER 2 • SPRING 1993

Rifai et al. males, seriousness of intent, and use of violent and lethal methods. Although epidemiologic surveys have revealed demographic and clinical characteristics that differentiate groups of patients who commit suicide from those who do not, attempts to employ these factors to predict the likelihood of suicide in individual cases have consistently failed. 9 This result is not surprising considering the low frequency of suicide even among populations at increased risk for suicide attempt. Nonetheless, the search continues for more sensitive and specific predictors that could be used to estimate the risk of suicide in a specific patient at a specific time. A history of a failed suicide attempt is one of the strongest predictors of suicide in all age groupsl0 with the greatest increase in risk within the first few years following the attempt. 11 Although the ratio of the number of individuals who attempt suicide to the number of those who succeed varies widely and ranges from 10:1 to as high as 200:1 in younger populations, this ratio is only 4:1 in the elderly.6 Studies of suicide attempters in late life are rare. 12•13 Harkey and Hyer14 state "there is virtually no validated research on older suicidal inpatients." In an effort to distinguish potential characteristics of elderly suicide attempters, we conducted a study to identify the demographic and clinical correlates of attempted suicide among patients admitted to an acute geriatric psychiatric research unit. Our study is based on an analysis of data collected prospectively as part of the Late-Life Mental Disorder Core of the Mental Health Clinical Research Center for the Study of Affective Disorders at Western Psychiatric Institute and Clinic.

MEmODS The Geriatric Clinical Research Unit (GCRU) is an acute care unit for the assessment and treatment of late-life mental disorders at Western Psychiatric Institute and Clinic. THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

The GCRU serves primarily the urban elderly population of the city of Pittsburgh; it is also a tertiary referral center for elderly patients from western Pennsylvania. On admission, each patient undergoes a detailed evaluation, including a complete physical, neurological, and psychiatric history and examination. IS-I? Baseline laboratory tests, including complete blood count, chemistry profile and serum electrolytes, liver function tests, serum B 12 and folate levels, rapid plasma reagin test for syphilis, thyroid function tests, urinalysis, chest radiography, and an electrocardiogram, are obtained, as well as electroencephalography (EEG) and magnetic resonance imaging (MRI) of the brain. A detailed social history is obtained, and significant family members are interviewed when available. Four measures of psychopathology are administered on admission by a trained rater. The Mini-Mental State Examination (MMSE), 18 the 17-item Hamilton Rating Scale for Depression (Ham-D),19 the Brief Psychiatric Rating Scale (BPRS),20 and the Delirium Rating Scale (DRS).21 For each patient, all the information obtained during admission is reviewed during a consensus conference attended by at least three faculty psychiatrists and by research staff, all with special expertise in geriatric psychiatry. Axis I and II psychiatric diagnoses are established according to DSM-III-R criteria. 22 The primary psychiatric diagnosis is defined as the diagnosis for which the patient required hospitalization. Axis III diagnoses are coded according to ICD-9. 23 A history of suicide attempt is recorded separately. A suicide attempt is defined as the performance of a clear-cut act that may result in physical damage, with an intent to die. Attempts that took place within 1 month of admission are defined as recent; others are defined as past attempts. For the purpose of this study, patients who had both a past history of attempt and a recent attempt are included in the group of recent attempters. Recent attempts were reviewed and scored for seriousness of resulting medical damage using the Lethality Score. 24 127

Elderly Suicide We conducted two principal analyses. In the first analysis, we considered three diagnostic groups: mood disorders (major depression, bipolar disorder, dysthymia, cyclothymia, depressive disorder not otherwise specified), organic mental disorders (substance-induced organic disorders, dementias, and other DSM-III-R organic mental disorders), and all other mental disorders (including schizophrenia, delusional disorders, other psychotic disorders, anxiety disorders, and adjustment disorders). None of the patients were admitted with a primary diagnosis of a psychoactive substance use disorder. The distributions of the primary psychiatric diagnoses, classified accord-

ingtothesethree diagnostic groups, among recent attempters, past attempters, and nonattempters were compared using the chi-square test. In the second analysis, we focused exclusively on the largest diagnostic group within the recent suicide attempters, namely patients who had a primaI)' diagnosis of major depression (nonbipolar, single or recurrent episode, with or without psychotic features). Among these patients, we compared recent attempters, past attempters, and nonattempters admitted during the same time period along demographic and clinical variables: age at admission, race and gender distribution, marital status, highest

TABLE 1. Characteristics of recent suicide attempters Age, years

Gender

65

F M

79

F

71

F F F F

62

60 67 68

69

90 61 70

M M

F F

64 85

M

81

M

M

Race W W W

B W W W B

W W W W W

6S

M

W B W W W W W

69

F

W

82

M M M F

69

71

72 59 53

84 75 61

73

50

73

F F F

M M

W W W

F

W B

M

W

F

W

Method

LethaUty

Drug on

CO poison Drug 00

6 3 7

DrugOD DrugOD

3 6

OrogOO Drug on

7

Drug on DrugOD

3 7

Drowning, suffocation

Jumping

Drug on

Throat slashing Jumping Cutting Drug on

7

3 6 3 0

a

4 4

Drug on

1 5

DrugOD+

CO poison Strangulation

Drug 00

Car accident DrugOD

DrugOD Drug

on

DnlgOD

Drug 00

Axisn

MDR with psychosis MDR with psychosis MDR without psychosis MDR without psychosis MDR without psychosis MDR without psychosis MDR without psychosis MDR without psychosis

+

Past Suicide Attempt

+

+

+

+

+

2

DrugOD

Hanging

Axis I

3

2

7 0

4

6 4 2

7

MDR without psychosis

MDR \vithout psychosis

MDS without psychosis MDS without psychosis MDS without psychosis

+

+

MDS without psychosis + MDS without psychosis MDS without psychosis + MDS without psychosis MDS without psychosis Depressive disorder NOS Dysthymia

+

Bpn~Depressed

+

with psychosis PDD with depression POD with depression Deliriulll Organic mood disorder Adjustment disorder Schizophrenia, paranoid, chronic Schizoaffective disorder

+ +

Note: Drug 00 = drug overdose; CO poison == carbon monoxide poisoning; MDR = major depression, recurrent; MDS = major depression, single episode; NOS;: not othenvise specified; PDD = primary degenef'Jtive dementia; BPD = bipolar disorder. 128

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Rifai et at. level of education, occupation, financial status, living arrangement, presence of additional diagnoses on Axis I, alcohol abuse at admission, presence of an Axis II diagnosis, number of diagnoses on Axis III, age at onset of major depression, scores on psychopathology scales at admission, presence of abnormalities on electroencephalography, and the presence ofMRI abnormalities. Chi-square analyses (or Fisher's exact test when appropriate) were used to compare categorical data, and (-tests or one-way analyses of variance (ANOVAs) were used to compare continuous data. Tukey's Honest Significant Difference test was used on the AN0 VAs that were found to be significant.

RESULTS Over a period of 26 months (September 1, 1989-November 1, 1991), 560 patients age 50 or older were admitted to the GCRU. Of these patients, 28 (5%) were recent suicide attempters, 32 (6%) were past attempters, and 500 (89%) were nonattempters. Nine of the 28 recent attempters (33%) also had a prior histoty of attempts. Table 1 presents the demographic and clinical characteristics of the recent attempters. Table 2 lists the methods of attempt.

Distribution of Primary Psychiatric Diagnoses The proportions of mood disorders, organic mental disorders, and other diagnoses in recent, past, and nonattempters is shown in Figure 1. The difference in the distributions of recent, past, and nonattempters among the three diagnostic groups was highly significant (X 2 = 25.02; df = 4; P< 0.0001). Recent attempters and past attempters had a predominance of mood disorders (75% and 660/0, respectively). In contrast, nonattempters had a predominance of organic and other disorders (62%). THE AMERICAN JOURNAL OF GERIATIUC PSYCHIATRY

Characteristics of Attempters With Major Depression One hundred sixty-six patients were given a primary diagnosis of major depression. Among these 166 patients, 18 (110/0) were recent attempters, 14 (8%) were past attempters, and 134 (81%) were nonattempters. There were no statistically significant differ-

ences among the three groups on any of the demographic variables: age at admission, gender, race, living arrangement, marital status, and level of education crable 3). Similarly, the presence of an additional diagnosis on Axis I, age at onset of depressive illness, measures of psychopathology at admission (MMSE, Ham-D, BPRS, DRS), or the presence of EEG or MRI abnormalities did not distinguish any of the three groups (Table 4). In contrast, significant effects were found for alcohol abuse and number of medical problems on admission. Recent attempters had a significantly higher rate of alcohol abuse than both past attempters or nonattempters (Fisher's exact test, P= 0.03). The mean number of medical problems was higher in past (6.4 ± 3.4) and recent attempters (5.2 ± 3.7) than in nonattempters (4.5 ± 2.5). Only the difference between past attempters and nonattempters reached TABLE 2. Methods of suicide attempts In 28 elderlyattempters Method of Attempt

Number of Patients

Drug overdose· Benzodiazepines Tricyclic antidepressants Antipsychotics Phenobarbital

19

CO poisoning Stabbing Hanging Drowning and suffocation Jumping from heights Intentional car accident

2

Other

7

6 2

3

4 2 1 1

2 1

Note: Other = nonsteroidals, antibiotics t meclozine; CO poisoning = carbon monoxide poisoning; alcohol was involved in two attempts. Nine of 19 involved a combination of drugs.

129

Elderly Suicide significance (p== 0.02). Finally there was a trend among past attempters to have an Axis II diagnosis (Fisher's exact test, P = 0.052) compared with nonattempters.

DISCUSSION Distribution of Primary Psychiatric Diagnoses Our results higWight several issues of clinical relevance to the study of suicide in the elderly. Among 560 patients admitted to an acute geriatric psychiatry unit, suicide attempters were significantly more likely to have a diagnosis of mood disorders than patients without a history of suicide attempts.

Organic mental disorders were rare among attempters. Several authors have tried to link suicide attempts with organicity in the elderly.13,25.26 Data from biological snJdies of suicide have revealed the presence of alterations in the serotonergic system in suicide attempters and completers of all ages. 27128 Serotonergic system abnonnalities have also been found in patients with Alzheimer's and Huntington's diseases where higher suicide rates have been reported. 29130 These findings have increased the interest in the study of the relationship between degenerative brain changes and the increased vulnerability to suicide in the elderly. However, Pierce 12 found only a 3% rate of dementia in elderly attempters and attributed previous reports of a stronger association between suicide and

FIGURE 1. Distribution of diagnostic categories among elderly psychiatric inpatients

28 RECENT ATTEMPTERS

500 NONATTEMPTERS

~ Mood Disorders • ;..;..;. ;.

;~;~;:;:

Organic Mental Disorders Others 32 PAST ATTEMPTERS

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Rifai et all organic disorders to patient selection bias. Similarly, in our patients, suicide attempts were strongly associated with mood disorders and not with organic mental disorders. Moreover, within the subgroups of patients with major depression there were no differences between attempters and nonattempters with regard to the presence of gross EEG or brain MRI abnormalities or in measures of cognitive impairment. Our results confirm the findings ofFrierson, 31 who reported that major depression was the most common diagnosis in recent elderly suicide attempters admitted to a general hospital and referred for psychiatric consultation. Our results also agree with Merrill and Owens,32 who reported that depression accounted for 960/0 of psychiatric diagnoses made in elderly attempters admitted to a poison center. Our data also support the findings of psychological autopsies, which have consistently reported depressive disorders to be the most common psychiatric disorders in suicide completers. 4...g.33

attempt: 13% of recent attempters had a diagnosis of alcohol abuse compared with 2% of nonattempters. Frierson 31 reported that 10% of hospitalized elderly attempters required treatment for alcohol abuse at discharge. CattellS found alcohol to be present in the tissues of 29OA> of 104 elderly suicide completers at postmortem. Alcohol has been postulated to disinhibit suicidal urges in certain depressed patients, while in others it is used to potentiate the lethality of suicide attempt. Cullberg et a1. 34 found that among attempters of all ages, alcohol and substance abuse are the highest predictors of future completion. Thus, accurate detection and treatment of alcohol abuse in elderly attempters may be one of the most significant intelVentions to decrease the rate of future completion. Personality Disorders

In our study, there was a trend for past attempters with major depression to present with a higher rate of personality disorders than recent attempters or nonattempters. Increased rates of suicide attempt and completion have been documented in specific personality disorders in the younger age groups and linked to measures of aggression and to biological abnormalities of the serotonin system. 35 The diagnosis of a personality disorder in elderly inpatients admit-

Characteristics of Attempters With Major Depression: Alcohol Abuse In the subgroup of patients with major depression, we found a significant association between alcohol abuse and suicide

TABLE 3. Demographic characteristics of recent attempters, past attempters, and nonattempters with major depression Characteristic Mean age at admission ± SD Gender; female:male (%female:%male) Race; white:black (%white:%black) Education ( ~ 12 years), Il

(0/0)

Never married, divorced, widowed, n (0/0) Living at home at admission, 11 (0,1)

Recent Attempters ( " 1:1

18)

70.2 ± 8.7

Past Attempters (n

1:1

14)

69.7 ± 3.9

11 :7(61%:39)

9:5(64 0.4:36)

15:3(83%:17)

12:2(86%:14)

Nonattempters (n

1:1

134)

p=

71.1 ± 8.8

0.70

93:41(690/0:31)

0.74

124:10(930/0:7)

0.34

9(50)

9(65)

80(61)

0.78

8(44)

6(43)

66(50)

0.85

9(50)

5(36)

59(44)

0.72

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131

Elderly Suicide ted with Axis I disorders is difficult to achieve with confidence. I? Future studies of suicide in late life should assess the presence of personality disorder using structured diagnostic interviews in patients who have recovered from an episode of major depression to better clarify the relationship among personality disorders, major depression, and suicide in the elderly. I?

Physical dlness Numerous investigators have stressed the relationship between suicide and physical illness in the elderly.3()-3H Physical illness appears to be more frequently a precipitating factor for suicide in men than in women. 36 In our sample, recent and past attempters had a greater number of medical problems than nonattempters, although the difference reached significance only in past attempters. However, the number of medical diagnoses may not

be a sensitive measure of physical illness and disability.39 40 Furthermore, Murphy 41 and Conwell et a1. 42 have reported that the "threat" of severe illness (especially cancer) rather than its "presence't may precipitate suicide attempts in some patients. Future studies would benefit from a more sophisticated approach to the measurement of health concerns and functional impairment resulting from physical illness in elderly attempters. 1

Demographic Characteristics Data from epidemiologic studies consistently report the highest rates of suicide completion in elderly white males. In our sample, 12 of 28 attempters fit this profile. However in patients with major depression, the distribution of age, gender, and race did not differ between attempters and nonattempters. Similarly, marital status and living arrangement were not different in recent

TABLE 4. CUnJcal characteristics of recent attempters, past attempters, and nonattempters with major depression Characteristic Mean age at onset of first episode of depression ± SD Secondmy Axis I diagnosis, n (0/0) Axis II diagnosis Mean number of Axis III diagnoses ± SD Alcohol abuse, n (0/0) Admission testing Ham-D

BPRS

MMSE GAS DHS MRI findings, 11 (%) Cortical atrophy Cortical inf~trcts Subcortical infarcts Periventricular hyperintensities Deep \vhite matter hyperintensities AbnonnalEEG

Recent Attempters

58 ± 16.9

Past Attempters

Nonattempters

p=

52.0 ± 15.4

57.9 ± 17.9

0.46

41 (31) 27 (20)

0.90 0.052

6 (33) 6 (33)

5 (36) 6 (42)

5.2±3.7 3 (13)

6.4 ± 3.4 0

4.5 ± 2.5 3 (2)

0.02 0.03

22.2 ±4.6 32.5 ± 5.6 26.3 ±4.6 33.6± 11.1 4.8± 2.1

23.2 ± 3.89 33.5 ±6.63 27.7 ± 2.5 41.1 ±9.7 4.64 ± 2.1

22.1 ± 3.62 34 ±6.2 26.2 ±4.1 38.5 ± 10.1 4.8 ± 2.5

0.59 0.60

DAD

0.09 0.90

3 (19) 0 3 (19)

1 (11) 1 (12) 1 (12)

20 (20) 23 (23)

0.39 0.69

5 (31)

6 (67)

55 (54)

0.15

8 (50)

3 (33) 3 (23)

47 (54) 37 (30)

0.71 0.36

8 (45)

4 (4)

0.82

Note: SD=Standard deviation; I-Ianl-D = Hamilton Rating Scale for Depression; BPRS = Brief Psychiatric Rating Scale; MMSE = Mini-Mental State Examinationj GAS = Global Assessnlent Scale; DRS;::; Delirium Rating Scale.

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Rifai et at. attempters and nonattempters. Until recently, suicide completer studies have consistently reported higher rates of completion among the single or widowed with significant social isolation and loneliness. 8,12 Like Conwell et al.,6 we found the impact of social isolation in the elderly to be less than originally thought. For these variables, given the number and distribution of attempters and nonattempters, our analysis had a power (Le., a probability of getting significant results) of 0.80 for predicted differences of at least 130/0, 150/0, and 17% for gender, race, and marital status, respectively. Our subgroups showed a difference of < 10% on these measures. Thus the lack of significant differences between recent attempters and nonattempters on these variables in our sample is not likely to be due to a lack of power. The variability of demographic and clinical characteristics in our group of attempters is compatible with the understanding that among attempters there is a continuous spectrum of suicidality. Only a certain subgroup in that spectrum represents truly failed suicides. This subgroup is believed to be larger in elderly attempters than in attempters of all ages, hence the relevance of the study of elderly attempters to the understanding of suicide completion.

Measures of Psychopathology There was no significant difference between attempters and nonattempters on measures of cognitive impairment, depression severity, psychosis, or delirium. This observation is in accordance with the findings of Jones et a1.,43 who found no difference between elderly depressed attempters and nonattempters on similar measures of psychopathology. The intensity of hopelessness that has been found to be a measure of psychopathology correlated with increased suicide risk in depressed patients44 was not assessed during this stu'dy. THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

CONCLUSION In our study of elderly psychiatric inpatients we found that patients with organic mental disorders, which primarily consisted of degenerative and vascular dementias, were less likely to have attempted suicide than would have been expected from chance alone. There was a higher rate of major depression in recent and past suicide attempters than in nonattempters. Alcohol abuse was significantly associated with recent suicide in depressed attempters. Among patients with major depression, no demographic or clinical characteristic distinguished attempters from nonattempters. Future studies of elderly attempters should be designed prospectively to include a crosssectional assessment of the interactions among mood disorders, physical illness, hopelessness, and personality disorders and their contribution to increased suicide risk. These studies should also include a longitudinal phase of follow-up of suicide attempters to ascertain the correlates of reattempt and completion in elderly suicide attempters. Our failure to detect anatomical or electrophysiological differences between attempters and nonattempters highlights the desirability of exploring neurochemical parameters, specifically, abnormalities of biogenic amine indices that have been linked to suicidal behavior in younger attempters. This area of inquiry is uniquely important in the elderly, in whom age-related degenerative changes and increased prevalence of physical illness coincide with increased rates of suicide completion.

The contributions o/the clinicaland research staff of the Geriatric Clinical Research Unit are gratefully acknowledged. The authors thank Dr. }. john Mann for reviewing this manuscript and Ms. ConnieJohnston for assistance in thepreparation ofthe manuscript. 'This study was supported in part by the Mental Health Clinic Research Centerfor the Study of Affective Disorders (MH30915) 133

Elderly Suicide funded by the National Institute ofMental Health. Dr. Zubenko was the recipient of a Research Scientist Development Award

(MH00540) from the National Institute of

Mental Health.

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