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Evaluation of attempted older adults suicides admitted to a University Hospital Emergency Department: Izmir study
Asian Journal of Psychiatry 30 (2017) 196–199
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Evaluation of attempted older adults suicides admitted to a University Hospital Emergency Department: Izmir study
MARK
⁎
Duygu Keskin Gokcellia, Pınar Tosun Tasarb,f, , Nur Ozge Akcama, Sevnaz Sahinb, Funda Karbek Akarcac, Ekin Ozgur Aktasd, Soner Dumane, Fehmi Akcicekb, Aysin Noyana a
Ege University Hospital, Department of Psychiatry, Izmir, Turkey Ege University Hospital, Department of Internal Medicine, Division of Geriatrics, Izmir, Turkey c Ege University Hospital, Department of Emergency Medicine, Izmir, Turkey d Ege University Hospital, Department of Forensic Medicine, Izmir, Turkey e Ege University Hospital, Department of Internal Medicine, Izmir, Turkey f Erzurum Regional Training and Research Hospital, Division of Geriatrics, Erzurum, Turkey b
A R T I C L E I N F O
A B S T R A C T
Keywords: Elderly Suicide Suicide attempt Risk factors
Introduction: Advanced age is one of the risk factors for attempting suicide. Suicide attempts are one of the reasons for elderly patients to admit emergency services. The aim of this study was to investigate the relationship between suicidal behavior and sociodemographic factors and concurrent somatic diseases. Methods: The medical records of patients aged 60 years and over who presented to the emergency department of our university hospital for attempted suicide between the dates of January 1, 2007 and December 31, 2015 were screened retrospectively. Individuals recorded as cases of suicide on the forensic case report form were identified, the data recorded at our hospital were obtained, and telephone interviews were conducted to acquire any missing data. Results: A total of 63 patients with a mean age of 65.88 years were included in the study. A large proportion of the suicide attempts occurred in the years 2014 and 2015. Overall, 23.8% of the patients had a previous history of suicide attempt. Overdose was the method in 74.6% of the suicide attempts, and 70.2% were impulsive; 63.5% of the patients had a history of psychiatric disease. The most common psychopathology was major depressive disorder. Conclusion: We found that suicide attempts were more common among older adults with a history of depression, that approximately one in four had previously attempted suicide, and that the majority of individuals attempting suicide chose to use their own medication.
1. Introduction Attempted suicide involves self-destructive behavior performed with the intention of dying, while in completed suicides, the individual takes their life in one of various ways. Each year, one million people die of suicide worldwide (WHO, 2014). According to data from the Turkish Statistical Institute, the number of suicide attempts and crude suicide rate in Turkey were 2301 suicide attempts and 3.49 per 100,000 in 2002, versus 3246 suicide attempts and 4,15 per 100,000 in 2015, respectively (Türkiye İstatistik Kurumu, 2001). Whatever the cause, every initiative should be carefully considered and carefully assessed. In the majority of completed suicides, there are initiatives that are unsuccessful and have a message quality. People may resort to make a suicide attempt to get rid of the unbearable emotional anguish
⁎
Corresponding author. E-mail address: [email protected] (P. Tosun Tasar).
http://dx.doi.org/10.1016/j.ajp.2017.10.002 Received 19 May 2017; Received in revised form 6 July 2017; Accepted 13 October 2017 1876-2018/ © 2017 Elsevier B.V. All rights reserved.
associated with various problems. Emergency departments are places where people are most in need of medical and surgical as well as psychosocial help. The first encounter with suicide attempts is the emergency services. Therefore, evaluation of cases showing any suicidal behavior evaluated in the emergency care is important in prognosis and treatment planning. Suicidal behavior in younger ages has been linked to type-B personality pathologies classified as antisocial, narcissistic, histrionic and borderline personality disorders (McGirr et al., 2008; Kim et al., 2003), while middle-aged suicidal behavior have been associated with alcohol/substance abuse, high anxiety, and comorbid depression (Akechi et al., 2006; Park et al., 2014). A strong association was found between suicidal behavior and psychopathology, especially major depressive disorder, in elderly individuals (Conwell et al., 1996). Although elderly
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D. Keskin Gokcelli et al.
individuals with depression are less expressive of suicidal thoughts, the rate of completed suicide is higher among the elderly. As the average lifespan increases and the birth rate falls, the elderly population grows in number and in proportion to the general population. In Turkey, life expectancy at birth is 78 years overall, 75.3 years for males and 80.7 years for females (Türkiye İstatistik Kurumu Haber Bülteni, 2017). Advanced age is one of the risk factors for attempting suicide, and suicide attempt is among the reasons elderly patients are admitted to emergency departments. The main risk factors for attempted suicide among the elderly include male gender, loss of spouse or other loved ones, living alone, weak religious and family ties, being in a minority, loss of economic and social status as a result of aging, and the presence of physical and mental illnesses (Jeste, 2009; Apfeldorf and Alexopoulos, 2003). Evaluation of mental disorders in the elderly reveals that depressive symptoms are one of the main causes of suicidal behavior. Furthermore, persistent feelings of despair despite treatment for depressive symptoms, and an individual’s perception of having few reasons to continue living are independent risk factors that increase the risk of suicidal behavior. Studies investigating the frequency of attempted suicide in the elderly population of Turkey are limited; there are only a few studies with limited patient numbers. Because it serves a large region and a wide range of patients, the Ege University School of Medicine Hospital has a vast accumulation of data. Our aim in this study was to reveal the sociodemographic and certain clinical characteristics of elderly patients in the Izmir region presenting to the emergency department for attempted suicide.
Table 1 Demographic data of the elderly.
2. Materials and methods The medical records of patients aged 60 years and over who presented to the emergency department of the Ege University School of Medicine Hospital for attempted suicide between the dates of January 1, 2007 and December 31, 2015 were screened retrospectively. Demographic data (age, gender, education level, marital status) and data regarding chronic diseases were obtained from the patients’ files. The subjects were divided by age into three groups: young-old (60–74 years), middle-old (75–84 years) and old–old (85 years and over). Data regarding methods of suicide attempt (chemical agent, cutting implement, jumping, firearm), premeditation, outcome (completed or attempted suicide), neuropsychiatric diagnosis (major depression, alcoholism, dementia, psychotic disorder, etc.), and history of previous suicide attempts were recorded. Whether the suicidal behavior was associated with chronic disease was determined based on the evaluation forms of the psychiatrist who assessed the patients in the emergency department. Data were analyzed using SPSS version 16.0. Numerical data were expressed as mean ± standard deviation. The Pearson chi-square test was used in comparisons of categorical values. Categorical data were expressed as number and percentage. Data were analyzed with a 95% confidence interval, and statistical outcomes with p ≤ 0.05 were considered significant. The study was approved by the Ege University Ethics Committee (decision dated 05/16/2016, ethics committee number: 15–81/2).
Variable
n (%)
Mean age (years) Age Group Young-old Middle-old Old-old Gender Female Male Marital status Married Widowed Divorced Single Unknown Children (+) (−) Unknown Residence Home Nursing home Education status Illiterate Literate Elementary school Middle school High school University/Graduate school Unknown Mean number of chronic diseases Chronic diseases Hypertension Diabetes CAD* CVD** COPD*** Arrhythmia Malignancy Chronic kidney disease Hyperlipidemia Osteoporosis Gonarthrosis Other Mean number of drugs used
65.88 52 (82.5) 8 (12.7) 3 (4.8) 33 (52.4) 30 (47.6) 35 (79.5) 4 (9.1) 3 (6.8) 1 (2.3) 19 44 (97.8) 1 (2.2) 18 62 (98.4) 1 (1.6) 3 (9.7) 2 (6.5) 13 (41.9) 2 (6.5) 4 (12.9) 7 (22.6) 32 2.104 ± 1.604 23 (50.0) 19 (40.4) 10 (21.3) 7 (15.2) 6 (12.8) 4 (8.5) 3 (6.4) 4 (8.7) 4 (8.9) 2 (4.4) 1 (2.1) 14 (31.8) 3.35 ± 2.83
*CAD, Coronary artery disease; CVD**, Cerebrovascular Disease; COPD***, Chronic Obstructive Pulmonary Disease.
were living alone. The mean number of chronic diseases was 2.10 ± 1.60; the most common chronic disease was hypertension (50.0%). The demographic data of the elderly patients is shown in Table 1. A large proportion (22.2%) of the suicide attempts occurred in 2014 and 2015 (Fig. 1). A history of psychiatric disease was noted in 63.5% of the cases. The most common psychiatric diseases were major depression (n = 25, 40.3%), alcoholism (n = 9, 14.5%), and psychotic disorders (n = 4, 6.5%) (Fig. 2). We found that 23.8% of the patients (30.3% of women and 16.7% of men) had previously attempted suicide. Of these, 2 patients had attempted suicide 4 times, 11 had attempted twice, 1 had attempted 3 times, and 1 patient had attempted suicide 13 times. The suicide attempts were performed using drugs in 74.6% of cases (n = 47), with a chemical agent in 14.3% (n = 9), with a sharp object in 4.8% (n = 3), by jumping from a height in 4.8% (n = 3), and with firearm in just 1.6% (n = 1). There were no significant differences between methods of suicidal behavior based on gender (p > 0.612) (Table 2). Suicidal behavior was impulsive in 70.2% of the elderly patients. Only 2% informed their relatives prior to the suicide attempt, and a large proportion (59.4%) did not inform their relatives after the suicide attempt.
3. Results There were 73 individuals who presented to the emergency department of our university hospital for attempted suicide between the dates of January 1, 2007 and December 31, 2015. However, the data were incomplete for 10 of those patients, resulting in a total of 63 patients (33 women and 30 men) included in the study. The mean age was 65.88 years (range 60–91 years); 82.5% were young-old, 52.4% were female, 79.5% were married, and 41.9% were elementary school graduates. The majority of the patients lived at home; only one patient came from a nursing home. Only 20.9% of those who lived at home 197
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Fig. 1. Number of elderly suicide attempts by year.
detected between chronic diseases and suicidal behavior; only gonarthrosis was significantly associated with suicidal behavior (p = 0.004). 4. Discussion According to data from the Turkish Statistical Institute for 2015, the suicidal behaviors rate among individuals aged 60–64 was 4.4%, while this rate increased to 5.6% in people over the age of 75. These data also indicate that the female:male ratio for completed suicide is approximately 1:2 (Türkiye İstatistik Kurumu İntihar İstatistikleri, 2015). Although male gender is considered a risk factor for suicidal behaviors among the elderly (Sudak, 2009), our study population was predominantly female. In fact, though the rate of completed suicide is higher among men compared to women (De Leo, 1999; Draper, 2014), the female:male ratio for attempted suicide is 3:2 (Draper, 2014). We believe this result is attributable to the fact that males have a higher probability of completing suicide, and that it was not possible to definitively determine cause of death in patients who were dead on arrival to the emergency department. Most of the attempted suicides in the present study were married. In some studies, being married seemed to be protective against suicidal attempts (Sadock and Sadock, 2003; Qin et al., 2003; Sağınç et al., 2000); however, a more recent study reported a higher rate of suicidal behavior among married individuals compared to those who were unmarried (Şevik et al., 2012). Evaluation of marital status has revealed that suicidal attempt is more frequent among the divorced, widowed, and individuals living alone (De Leo, 1999; Sadock and Sadock, 2003). However, according to the 2015 data from the Turkish Statistical Institute, 50.5% of suicidal behavior were listed as ‘married’, 37.7% were ‘never married’, and 7.2% were ‘divorced’ (Türkiye İstatistik Kurumu İntihar İstatistikleri, 2015). In 2015, 39.3% of divorces occurred within the first 5 years of marriage and 21.5% within 6–10 years of marriage (Türkiye İstatistik Kurumu Boşanma İstatistikleri, 2015). This shows that divorce among the elderly is much less frequent compared to the other age groups. As these data are obtained by scanning individuals’ identification cards, they do not represent cohabitation without being fully married. Because this can only be confirmed by face-to-face interviews, discussing these results is only speculative. Depressive episodes are the foremost psychopathological disorder leading to attempted suicide. It is known that most elderly individuals who attempt suicide have prior depressive symptoms and are in these
Fig. 2. Neuropsychiatric disesases in the elderly who attempt suicide.
Table 2 Methods of suicidal behavior. Methods of suicidal behavior
Total n (%)
Female n (%)
Male n (%)
p value
Drugs Chemical agent Jumping Firearm Cutting/stabbing object
47 (74.6) 9 (14.3) 3 (4.8) 1 (1.6) 1 (1.6)
27 (81.8) 4 (12.1) 1 (3.0) 0 (0.0) 1 (3.0)
20 (66.7) 5 (16.7) 2 (6.7) 1 (3.3) 2 (6.7)
0.612
Analysis of the drugs used during the suicide attempts revealed that patients had most commonly ingested drugs of different types (33.3%), followed by psychotropic drugs (31.3%) and antidepressants (16.7%). The majority (69.7%) of those who attempted suicide by overdose used their own medications. Only 3 of the patients (2 males and 1 female) successfully completed suicide. The rate of completed suicide was higher among males (7.1%) than females (3%). No relationship was 198
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prognosis. It will make it easier to plan treatment steps. Besides, for further investigation assessing the rapports of autopsy and preventing missing data by prospectively designed studies will help developing new knowledge on the topic.
depressive states at the time of suicide (Conwell, 1995). In a study recently conducted in Turkey, the risk of suicidal behavior was found to be higher in those who are at risk of anxiety and depression in their ages (Avci et al., 2017). We also found in the present study that the elderly patients exhibiting suicide attempts often had major depression. Unlike with younger adults, depression in the elderly is not characterized by crying and feelings of guilt; instead, patients experience introversion, appetite changes, sleep disturbances and somatic symptoms. Considering that past major depression is a highly predictive factor of elderly suicidal behavior, this point must not be overlooked during examination. We observed in our study that the method most commonly used in suicide attempts in the elderly is drug overdose. It was determined that the use of different drug groups was common and that most patients used their own medication when attempting suicide. Drugs and chemicals are the most common method in attempted suicide both in Turkey and in the rest of the world (Atli et al., 2014; Oral, 1997; Beautrais, 2000; Zlotnick et al., 1997; Özgüven, 2008). Therefore, it is of vital importance to keep in mind the possibility of suicidal behavior risk when selecting medications for elderly patients. Nevertheless, in Turkey a substantial proportion of prescribed medications are stored in the home after use. This suggests that suicide rates could be reduced if authorities took the necessary precautions. The probability of attempted suicides resulting in death is higher in the elderly compared to adolescents and the general population. One study reported that the suicide completion rate among the elderly was 1/4, compared to a rate of 1/200 among adolescents (McIntosh, 1985). In our study, only 3 cases were completed suicides. However, our study only included patients who presented directly to the emergency department for attempted suicide; individuals who were dead on arrival and were sent for forensic autopsy were not included. Our study is important because it is the first research conducted in patients admitted to an emergency department in our province for attempted suicide, and it draws attention to the geriatric emergency of elderly suicide. Although our findings will contribute to the existing literature, the study has certain limitations. Despite screening forensic files in our study, the sample size was insufficient due to missing data in the records system, including Turkish citizen identification numbers. This limits the degree to which our results reflect the general population. Keeping the data records system organized and up-to-date will add to the validity of future studies. Because the study was retrospective, face-to-face interviews with the patients were not conducted and it was not possible to obtain some data. Further studies on this topic using the prospective screening approach will yield more valid results. In conclusion, our study showed that suicide attempts were more common among older adults with a history of depression, that approximately one in three patients in the study population had previously attempted suicide, that the majority of individuals attempting suicide chose to use their own medication, and that they did not inform their families after attempting suicide. Moreover, it was noteworthy that there were completed suicide attempts in the patient group we were scanning. Considering these points, obtaining a very detailed history from patients will reduce the incidence of suicidal behavior among the elderly, and choosing to prescribe single drugs with broad therapeutic ranges will help avoid the completion of unavoidable suicide attempts. Identifying the elderly who have depressive symptoms and attempted suicide in their previous story will help to predict the
Conflict of interest None. References Akechi, T., et al., 2006. Alcohol consumption and suicide among middle-aged men in Japan. Br. J. Psychiatry 188, 231–236. Apfeldorf, W.J., Alexopoulos, G.S., 2003. Late-life mood disorders. In: Hazzard, W.R., Blass, J.P., Halter, J.B., Ouslander, J.G., Tinetti, M.E. (Eds.), Principles of Geriatric Medicine & Gerontology, 5th ed. Mc Graw Hill, New York, pp. 1451–1452. Atli, A., Uysal, C., Kaya, C.M., Bulut, M., et al., 2014. Acil Ünitesine İntihar Girişimi Nedeniyle Başvuran Olguların Değerlendirilmesi:Şanlıurfa Örneklemi. J. Mood Disord. 4 (3), 110–114. Avci, D., Selcuk, K.T., Dogan, S., 2017. Suicide risk in the hospitalized elderly in Turkey and affecting factors. Arch. Psychiatr. Nurs. 31 (1), 55–61. Beautrais, A.L., 2000. Risk factors for suicide and attempted suicide among young people. Aust. N. Z. J. Psychiatry 34 (3), 420–436. Conwell, Y., et al., 1996. Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study. Am. J. Psychiatry 153 (8), 1001–1008. Conwell, Y., 1995. Suicide among elderly persons. Psychiatr. Serv. 46 (6), 563–564. De Leo, D., 1999. Cultural issues in suicide and old age. Crisis 20 (2), 53–55. Draper, B.M., 2014. Suicidal behaviour and suicide prevention in later life. Maturitas 79 (2), 179–183. Jeste, D.V., 2009. Geriatric psychiatry: overview. In: Sadock, B.J., Sadock, V.A., Ruiz, P. (Eds.), Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Lippincott Williams Wilkins, Philadelphia, pp. 3595–3602. Kim, C., et al., 2003. Patterns of co-morbidity in male suicide completers. Psychol. Med. 33 (7), 1299–1309. McGirr, A., et al., 2008. Impulsive-aggressive behaviours and completed suicide across the life cycle: a predisposition for younger age of suicide. Psychol. Med. 38 (3), 407–417. McIntosh, J.L., 1985. Suicide among the elderly: levels and trends. Am. J. Orthopsychiatry 55 (2), 288–293. Oral, G., 1997. İntihar ve Adli Bilimler. Yeni Sypmosium Dergisi 35, 46–47. Özgüven, H.D., 2008. İntihar davranışının epidemiyolojisi. Türkiye Klinikleri Psikiyatri Özel Dergisi 1 (3), 1–7. Park, J.E., et al., 2014. Age-related differences in the influence of major mental disorders on suicidality: a Korean nationwide community sample. J. Affect. Disord. 162, 96–101. Qin, P., Agerbo, E., Mortensen, P.B., 2003. Suicide risk in relation to family history of completed suicide and psychiatric disorders. A nested case-control study. Ugeskr. Laeger 165 (25), 2573–2577. Sağınç, H., Kuğu, N., Akyüz, G., Doğan, O., 2000. Yatarak tedavi gören hastalarda intihar öyküsünün araştırılması. Anadolu Psikiyatri Dergisi 83–88. Sadock, B.J., Sadock, V.A., 2003. Suicide. Kaplan & Sadock’s Synopsis of Psychiatry, 9th ed. Lipincott Williams & Wilkins, Philadelphia (p. 914). Şevik, A.E., Özcan, H., Uysal, E., 2012. İntihar Girişimlerinin İncelenmesi:Risk Faktörleri ve Takip. Klinik Psikiyatri 15, 218–225. Sudak, H.S., 2009. Suicide. In: Sadock, B.J., Sadock, V.A., Ruiz, P. (Eds.), Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. Lippincott Williams Wilkins, Philadelphia, pp. 2717–2731. Türkiye İstatistik Kurumu İntihar İstatistikleri, 2015. Sayı: 21516. (17 Haziran 2016. Available from:www.tuik.gov.tr). Türkiye İstatistik Kurumu Boşanma İstatistikleri, 2015. Sayı: 21515. (02 Mart 2016. Available from:www.tuik.gov.tr). Türkiye İstatistik Kurumu Haber Bülteni. www.tuik.gov.tr/PreHaberBultenleri.do?id= 18618. Türkiye İstatistik Kurumu, Hayati İstatistikler, 2001–2014. http://www.tuik.gov.tr/ UstMenu.do?metod=temelist (erişim tarihi: 29.09.2015). WHO, 2014. Mental Health: Suicide Prevention. http://www.who. int/mental_health/ suicide-prevention/en/ (Accessed 5 November 2014). Zlotnick, C., et al., 1997. Affect regulation and suicide attempts in adolescent inpatients. J. Am. Acad. Child Adolesc. Psychiatry 36 (6), 793–798.
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Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Evaluation of attempted older adults suicides admitted to a University Hospital Emergency Department: Izmir study
MARK
⁎
Duygu Keskin Gokcellia, Pınar Tosun Tasarb,f, , Nur Ozge Akcama, Sevnaz Sahinb, Funda Karbek Akarcac, Ekin Ozgur Aktasd, Soner Dumane, Fehmi Akcicekb, Aysin Noyana a
Ege University Hospital, Department of Psychiatry, Izmir, Turkey Ege University Hospital, Department of Internal Medicine, Division of Geriatrics, Izmir, Turkey c Ege University Hospital, Department of Emergency Medicine, Izmir, Turkey d Ege University Hospital, Department of Forensic Medicine, Izmir, Turkey e Ege University Hospital, Department of Internal Medicine, Izmir, Turkey f Erzurum Regional Training and Research Hospital, Division of Geriatrics, Erzurum, Turkey b
A R T I C L E I N F O
A B S T R A C T
Keywords: Elderly Suicide Suicide attempt Risk factors
Introduction: Advanced age is one of the risk factors for attempting suicide. Suicide attempts are one of the reasons for elderly patients to admit emergency services. The aim of this study was to investigate the relationship between suicidal behavior and sociodemographic factors and concurrent somatic diseases. Methods: The medical records of patients aged 60 years and over who presented to the emergency department of our university hospital for attempted suicide between the dates of January 1, 2007 and December 31, 2015 were screened retrospectively. Individuals recorded as cases of suicide on the forensic case report form were identified, the data recorded at our hospital were obtained, and telephone interviews were conducted to acquire any missing data. Results: A total of 63 patients with a mean age of 65.88 years were included in the study. A large proportion of the suicide attempts occurred in the years 2014 and 2015. Overall, 23.8% of the patients had a previous history of suicide attempt. Overdose was the method in 74.6% of the suicide attempts, and 70.2% were impulsive; 63.5% of the patients had a history of psychiatric disease. The most common psychopathology was major depressive disorder. Conclusion: We found that suicide attempts were more common among older adults with a history of depression, that approximately one in four had previously attempted suicide, and that the majority of individuals attempting suicide chose to use their own medication.
1. Introduction Attempted suicide involves self-destructive behavior performed with the intention of dying, while in completed suicides, the individual takes their life in one of various ways. Each year, one million people die of suicide worldwide (WHO, 2014). According to data from the Turkish Statistical Institute, the number of suicide attempts and crude suicide rate in Turkey were 2301 suicide attempts and 3.49 per 100,000 in 2002, versus 3246 suicide attempts and 4,15 per 100,000 in 2015, respectively (Türkiye İstatistik Kurumu, 2001). Whatever the cause, every initiative should be carefully considered and carefully assessed. In the majority of completed suicides, there are initiatives that are unsuccessful and have a message quality. People may resort to make a suicide attempt to get rid of the unbearable emotional anguish
⁎
Corresponding author. E-mail address: [email protected] (P. Tosun Tasar).
http://dx.doi.org/10.1016/j.ajp.2017.10.002 Received 19 May 2017; Received in revised form 6 July 2017; Accepted 13 October 2017 1876-2018/ © 2017 Elsevier B.V. All rights reserved.
associated with various problems. Emergency departments are places where people are most in need of medical and surgical as well as psychosocial help. The first encounter with suicide attempts is the emergency services. Therefore, evaluation of cases showing any suicidal behavior evaluated in the emergency care is important in prognosis and treatment planning. Suicidal behavior in younger ages has been linked to type-B personality pathologies classified as antisocial, narcissistic, histrionic and borderline personality disorders (McGirr et al., 2008; Kim et al., 2003), while middle-aged suicidal behavior have been associated with alcohol/substance abuse, high anxiety, and comorbid depression (Akechi et al., 2006; Park et al., 2014). A strong association was found between suicidal behavior and psychopathology, especially major depressive disorder, in elderly individuals (Conwell et al., 1996). Although elderly
Asian Journal of Psychiatry 30 (2017) 196–199
D. Keskin Gokcelli et al.
individuals with depression are less expressive of suicidal thoughts, the rate of completed suicide is higher among the elderly. As the average lifespan increases and the birth rate falls, the elderly population grows in number and in proportion to the general population. In Turkey, life expectancy at birth is 78 years overall, 75.3 years for males and 80.7 years for females (Türkiye İstatistik Kurumu Haber Bülteni, 2017). Advanced age is one of the risk factors for attempting suicide, and suicide attempt is among the reasons elderly patients are admitted to emergency departments. The main risk factors for attempted suicide among the elderly include male gender, loss of spouse or other loved ones, living alone, weak religious and family ties, being in a minority, loss of economic and social status as a result of aging, and the presence of physical and mental illnesses (Jeste, 2009; Apfeldorf and Alexopoulos, 2003). Evaluation of mental disorders in the elderly reveals that depressive symptoms are one of the main causes of suicidal behavior. Furthermore, persistent feelings of despair despite treatment for depressive symptoms, and an individual’s perception of having few reasons to continue living are independent risk factors that increase the risk of suicidal behavior. Studies investigating the frequency of attempted suicide in the elderly population of Turkey are limited; there are only a few studies with limited patient numbers. Because it serves a large region and a wide range of patients, the Ege University School of Medicine Hospital has a vast accumulation of data. Our aim in this study was to reveal the sociodemographic and certain clinical characteristics of elderly patients in the Izmir region presenting to the emergency department for attempted suicide.
Table 1 Demographic data of the elderly.
2. Materials and methods The medical records of patients aged 60 years and over who presented to the emergency department of the Ege University School of Medicine Hospital for attempted suicide between the dates of January 1, 2007 and December 31, 2015 were screened retrospectively. Demographic data (age, gender, education level, marital status) and data regarding chronic diseases were obtained from the patients’ files. The subjects were divided by age into three groups: young-old (60–74 years), middle-old (75–84 years) and old–old (85 years and over). Data regarding methods of suicide attempt (chemical agent, cutting implement, jumping, firearm), premeditation, outcome (completed or attempted suicide), neuropsychiatric diagnosis (major depression, alcoholism, dementia, psychotic disorder, etc.), and history of previous suicide attempts were recorded. Whether the suicidal behavior was associated with chronic disease was determined based on the evaluation forms of the psychiatrist who assessed the patients in the emergency department. Data were analyzed using SPSS version 16.0. Numerical data were expressed as mean ± standard deviation. The Pearson chi-square test was used in comparisons of categorical values. Categorical data were expressed as number and percentage. Data were analyzed with a 95% confidence interval, and statistical outcomes with p ≤ 0.05 were considered significant. The study was approved by the Ege University Ethics Committee (decision dated 05/16/2016, ethics committee number: 15–81/2).
Variable
n (%)
Mean age (years) Age Group Young-old Middle-old Old-old Gender Female Male Marital status Married Widowed Divorced Single Unknown Children (+) (−) Unknown Residence Home Nursing home Education status Illiterate Literate Elementary school Middle school High school University/Graduate school Unknown Mean number of chronic diseases Chronic diseases Hypertension Diabetes CAD* CVD** COPD*** Arrhythmia Malignancy Chronic kidney disease Hyperlipidemia Osteoporosis Gonarthrosis Other Mean number of drugs used
65.88 52 (82.5) 8 (12.7) 3 (4.8) 33 (52.4) 30 (47.6) 35 (79.5) 4 (9.1) 3 (6.8) 1 (2.3) 19 44 (97.8) 1 (2.2) 18 62 (98.4) 1 (1.6) 3 (9.7) 2 (6.5) 13 (41.9) 2 (6.5) 4 (12.9) 7 (22.6) 32 2.104 ± 1.604 23 (50.0) 19 (40.4) 10 (21.3) 7 (15.2) 6 (12.8) 4 (8.5) 3 (6.4) 4 (8.7) 4 (8.9) 2 (4.4) 1 (2.1) 14 (31.8) 3.35 ± 2.83
*CAD, Coronary artery disease; CVD**, Cerebrovascular Disease; COPD***, Chronic Obstructive Pulmonary Disease.
were living alone. The mean number of chronic diseases was 2.10 ± 1.60; the most common chronic disease was hypertension (50.0%). The demographic data of the elderly patients is shown in Table 1. A large proportion (22.2%) of the suicide attempts occurred in 2014 and 2015 (Fig. 1). A history of psychiatric disease was noted in 63.5% of the cases. The most common psychiatric diseases were major depression (n = 25, 40.3%), alcoholism (n = 9, 14.5%), and psychotic disorders (n = 4, 6.5%) (Fig. 2). We found that 23.8% of the patients (30.3% of women and 16.7% of men) had previously attempted suicide. Of these, 2 patients had attempted suicide 4 times, 11 had attempted twice, 1 had attempted 3 times, and 1 patient had attempted suicide 13 times. The suicide attempts were performed using drugs in 74.6% of cases (n = 47), with a chemical agent in 14.3% (n = 9), with a sharp object in 4.8% (n = 3), by jumping from a height in 4.8% (n = 3), and with firearm in just 1.6% (n = 1). There were no significant differences between methods of suicidal behavior based on gender (p > 0.612) (Table 2). Suicidal behavior was impulsive in 70.2% of the elderly patients. Only 2% informed their relatives prior to the suicide attempt, and a large proportion (59.4%) did not inform their relatives after the suicide attempt.
3. Results There were 73 individuals who presented to the emergency department of our university hospital for attempted suicide between the dates of January 1, 2007 and December 31, 2015. However, the data were incomplete for 10 of those patients, resulting in a total of 63 patients (33 women and 30 men) included in the study. The mean age was 65.88 years (range 60–91 years); 82.5% were young-old, 52.4% were female, 79.5% were married, and 41.9% were elementary school graduates. The majority of the patients lived at home; only one patient came from a nursing home. Only 20.9% of those who lived at home 197
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Fig. 1. Number of elderly suicide attempts by year.
detected between chronic diseases and suicidal behavior; only gonarthrosis was significantly associated with suicidal behavior (p = 0.004). 4. Discussion According to data from the Turkish Statistical Institute for 2015, the suicidal behaviors rate among individuals aged 60–64 was 4.4%, while this rate increased to 5.6% in people over the age of 75. These data also indicate that the female:male ratio for completed suicide is approximately 1:2 (Türkiye İstatistik Kurumu İntihar İstatistikleri, 2015). Although male gender is considered a risk factor for suicidal behaviors among the elderly (Sudak, 2009), our study population was predominantly female. In fact, though the rate of completed suicide is higher among men compared to women (De Leo, 1999; Draper, 2014), the female:male ratio for attempted suicide is 3:2 (Draper, 2014). We believe this result is attributable to the fact that males have a higher probability of completing suicide, and that it was not possible to definitively determine cause of death in patients who were dead on arrival to the emergency department. Most of the attempted suicides in the present study were married. In some studies, being married seemed to be protective against suicidal attempts (Sadock and Sadock, 2003; Qin et al., 2003; Sağınç et al., 2000); however, a more recent study reported a higher rate of suicidal behavior among married individuals compared to those who were unmarried (Şevik et al., 2012). Evaluation of marital status has revealed that suicidal attempt is more frequent among the divorced, widowed, and individuals living alone (De Leo, 1999; Sadock and Sadock, 2003). However, according to the 2015 data from the Turkish Statistical Institute, 50.5% of suicidal behavior were listed as ‘married’, 37.7% were ‘never married’, and 7.2% were ‘divorced’ (Türkiye İstatistik Kurumu İntihar İstatistikleri, 2015). In 2015, 39.3% of divorces occurred within the first 5 years of marriage and 21.5% within 6–10 years of marriage (Türkiye İstatistik Kurumu Boşanma İstatistikleri, 2015). This shows that divorce among the elderly is much less frequent compared to the other age groups. As these data are obtained by scanning individuals’ identification cards, they do not represent cohabitation without being fully married. Because this can only be confirmed by face-to-face interviews, discussing these results is only speculative. Depressive episodes are the foremost psychopathological disorder leading to attempted suicide. It is known that most elderly individuals who attempt suicide have prior depressive symptoms and are in these
Fig. 2. Neuropsychiatric disesases in the elderly who attempt suicide.
Table 2 Methods of suicidal behavior. Methods of suicidal behavior
Total n (%)
Female n (%)
Male n (%)
p value
Drugs Chemical agent Jumping Firearm Cutting/stabbing object
47 (74.6) 9 (14.3) 3 (4.8) 1 (1.6) 1 (1.6)
27 (81.8) 4 (12.1) 1 (3.0) 0 (0.0) 1 (3.0)
20 (66.7) 5 (16.7) 2 (6.7) 1 (3.3) 2 (6.7)
0.612
Analysis of the drugs used during the suicide attempts revealed that patients had most commonly ingested drugs of different types (33.3%), followed by psychotropic drugs (31.3%) and antidepressants (16.7%). The majority (69.7%) of those who attempted suicide by overdose used their own medications. Only 3 of the patients (2 males and 1 female) successfully completed suicide. The rate of completed suicide was higher among males (7.1%) than females (3%). No relationship was 198
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prognosis. It will make it easier to plan treatment steps. Besides, for further investigation assessing the rapports of autopsy and preventing missing data by prospectively designed studies will help developing new knowledge on the topic.
depressive states at the time of suicide (Conwell, 1995). In a study recently conducted in Turkey, the risk of suicidal behavior was found to be higher in those who are at risk of anxiety and depression in their ages (Avci et al., 2017). We also found in the present study that the elderly patients exhibiting suicide attempts often had major depression. Unlike with younger adults, depression in the elderly is not characterized by crying and feelings of guilt; instead, patients experience introversion, appetite changes, sleep disturbances and somatic symptoms. Considering that past major depression is a highly predictive factor of elderly suicidal behavior, this point must not be overlooked during examination. We observed in our study that the method most commonly used in suicide attempts in the elderly is drug overdose. It was determined that the use of different drug groups was common and that most patients used their own medication when attempting suicide. Drugs and chemicals are the most common method in attempted suicide both in Turkey and in the rest of the world (Atli et al., 2014; Oral, 1997; Beautrais, 2000; Zlotnick et al., 1997; Özgüven, 2008). Therefore, it is of vital importance to keep in mind the possibility of suicidal behavior risk when selecting medications for elderly patients. Nevertheless, in Turkey a substantial proportion of prescribed medications are stored in the home after use. This suggests that suicide rates could be reduced if authorities took the necessary precautions. The probability of attempted suicides resulting in death is higher in the elderly compared to adolescents and the general population. One study reported that the suicide completion rate among the elderly was 1/4, compared to a rate of 1/200 among adolescents (McIntosh, 1985). In our study, only 3 cases were completed suicides. However, our study only included patients who presented directly to the emergency department for attempted suicide; individuals who were dead on arrival and were sent for forensic autopsy were not included. Our study is important because it is the first research conducted in patients admitted to an emergency department in our province for attempted suicide, and it draws attention to the geriatric emergency of elderly suicide. Although our findings will contribute to the existing literature, the study has certain limitations. Despite screening forensic files in our study, the sample size was insufficient due to missing data in the records system, including Turkish citizen identification numbers. This limits the degree to which our results reflect the general population. Keeping the data records system organized and up-to-date will add to the validity of future studies. Because the study was retrospective, face-to-face interviews with the patients were not conducted and it was not possible to obtain some data. Further studies on this topic using the prospective screening approach will yield more valid results. In conclusion, our study showed that suicide attempts were more common among older adults with a history of depression, that approximately one in three patients in the study population had previously attempted suicide, that the majority of individuals attempting suicide chose to use their own medication, and that they did not inform their families after attempting suicide. Moreover, it was noteworthy that there were completed suicide attempts in the patient group we were scanning. Considering these points, obtaining a very detailed history from patients will reduce the incidence of suicidal behavior among the elderly, and choosing to prescribe single drugs with broad therapeutic ranges will help avoid the completion of unavoidable suicide attempts. Identifying the elderly who have depressive symptoms and attempted suicide in their previous story will help to predict the
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