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Suicidality-based prediction of suicide attempts in a community-dwelling elderly population: Results from the Osan Mental Health Survey
Journal of Affective Disorders 184 (2015) 286–292
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Research report
Suicidality-based prediction of suicide attempts in a community-dwelling elderly population: Results from the Osan Mental Health Survey Dae Jong Oh a, Jae Young Park b, Miyoung Oh c, Kayoung Kim b, Jongwoo Hong b, Taehyun Kim b, Ji Won Han a,b, Tae Hui Kim d, Ki Woong Kim a,b,e,n a
Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam, Republic of Korea Osan Mental Health Center, Osan, Republic of Korea d Department of Psychiatry, Yonsei University Wonju Severance Christian Hospital, Wonju, Republic of Korea e Department of Brain and Cognitive Science, Seoul National University College of Natural Sciences, Seoul, Republic of Korea b c
art ic l e i nf o
a b s t r a c t
Article history: Received 25 March 2015 Received in revised form 9 June 2015 Accepted 9 June 2015 Available online 17 June 2015
Background: Data on outcomes of suicidality in the community-dwelling elderly are scarce. We investigated the association of suicidality with the suicide attempts in a community-dwelling elderly cohort. Methods: In the Osan Mental Health Survey, 848 randomly sampled elderly Koreans participated in the baseline evaluation, 623 completed 2-year follow-up evaluation and 32 died during the follow-up period. The survey was conducted between February 2010 and January 2013. We evaluated suicidality using the Mini-International Neuropsychiatric Interview suicidality module that includes both suicidal ideation and attempts. Results: The incidences of suicidality and suicide attempts were 70.7 and 13.1 per 1000 persons per year, respectively. Suicidality was associated with increased risk of suicide attempts (odds ratio (OR) ¼ 3.84, 95% CI¼ 1.06–13.87). Two men with suicidality committed suicide by self-poisoning. Moderate to high intensity daily exercise decreased the risk of suicidality to become persistent or recurrent (OR ¼ 0.32, 95% CI¼ 0.12–0.81). Low education level (OR¼ 2.41, 95% CI ¼1.21–4.77) and depression (OR¼ 3.02, 95% CI¼ 1.65–5.53) were associated with risk of incident suicidality. Limitations: Study sample was enrolled from a single city of Korea, and the size of the study sample was small. Conclusions: We may reduce suicide attempts by screening for suicidality and implementing exercise programs in community-dwelling elderly people. & 2015 Elsevier B.V. All rights reserved.
Keywords: Suicide Suicide attempted Geriatric psychiatry Incidence Korea
1. Introduction According to a report by the WHO, over 800,000 people die from suicide every year, and suicide rates are universally highest in people aged 70 years and over (World Health Organization, 2014). South Korea (hereafter, Korea) has registered the highest suicide rate in the Organization for Economic Cooperation and Development (OECD) for more than a decade. In 2012, the suicide rate of the general population in Korea was 29.1 per 100,000, which was much higher than the average rate among OECD countries of 12.4 per 100,000 (OECD, 2013). In particular, the suicide rate in the n Corresponding author at: Department of Neuropsychiatry, Seoul National University Bundang Hospital, 82 Gumiro 173 Beongil, Bundanggu, Seongnamsi, Gyeonggido 463-707, Republic of Korea. E-mail address: [email protected] (K.W. Kim).
http://dx.doi.org/10.1016/j.jad.2015.06.010 0165-0327/& 2015 Elsevier B.V. All rights reserved.
elderly aged 70 or above in Korea was 116.2 per 100,000, far higher than that in other OECD countries (5.8–42.3 per 100,000) (World Health Organization, 2014). In the past two decades, the increase in suicide among the elderly has been exceptionally steep in Korea. The age-standardized suicide rate in Korean people over the age of 65 was 64.2 per 100,000 in 2013, which was three times higher than that in 1990 (Statistics Korea, 2013). Considering that Korea is one of the most rapidly aging countries in the world and that it will become one of the oldest countries by 2040 (Statistics Korea, 2014), development of a comprehensive and coordinated strategy for preventing suicide in the elderly is urgently needed. Timely identification of persons at risk of suicide is a prerequisite for providing suicide prevention programs. Previous suicidal behaviors, such as suicidal ideation, plans or attempts, are well-replicated predictors of suicide in general populations (Borges et al., 2008; Kessler et al., 1999). In a previous study, we found
D.J. Oh et al. / Journal of Affective Disorders 184 (2015) 286–292
that the age- and gender-standardized prevalence rates of current suicidal ideation without a plan or attempt, and current suicidal ideation with a plan or attempt, were 19.6% and 2.24%, respectively in elderly Koreans (Park et al., 2013). Fortunately, these suicidal behaviors do not inevitably lead to death by suicide. Thus, it is important to find a way to identify people who have risk factors that may aggravate their suicidal ideation to the point that they attempt suicide. However, suicidality usually fluctuates over time, interacting with various biological, psychological, and environmental factors and may result in suicide. This fluctuation of suicidality makes it difficult to identify people urgently in need of suicide prevention programs, particularly in community settings. According to a previous report, 86% of suicides occurred in the low-risk groups (University of Manchester, 2006), suggesting that suicidal behaviors over a lifetime or in a year may not accurately reflect the risk of imminent suicidality that should be a prime target for reduction by suicide intervention programs. As a part of the Osan Mental Health Survey (OMHS), we have been evaluating suicidality in an elderly Korean community-based cohort every two years since 2010 using the Korean version of the MiniInternational Neuropsychiatric Interview Suicidality Module (MINISM) (Yoo et al., 2006). The MINI-SM evaluates current suicidality by checking suicidal behaviors within the past month. The aims of this study were to examine the outcomes of suicidality such as incidence, persistence or recurrence, and to identify the predictors of suicide attempts through a 2-year follow-up evaluation of this cohort.
2. Methods 2.1. Design and data collection We conducted the baseline assessment of the OMHS on suicidality from February 2010 to February 2011. We randomly sampled 1588 people from the residential roster of 14,051 Koreans aged over 60 years who lived in Osan, Gyeonggido, Korea. We invited them to participate in the suicidality survey by home visits and 848 responded. Trained nurses implemented surveys including assessment of suicidality. They took a 180-min training program that included 90-min education on conducting interview with MINI-SM and 90-min education on suicide and depression in the elderly. Details of the design and assessments of the OMHS were described in our previous report (Park et al., 2013). We carried out the first 2-year follow-up assessment on suicidality from January 2012 through January 2013. Among the 848 individuals who participated in the baseline assessment, 623 (73.4%) responded to the follow-up assessment, and a further 32 (3.8%) were found to have died since the baseline study. Compared with responders, there were more women (66.8% vs 58.3%, p ¼0.033), spouseless (48.9% vs 37.2%, p ¼0.015), low education level (32.1% vs 18.3%, p ¼0.001) and cognitive impairment indicated by lower Mini-Mental State Examination (MMSE) scores (22.60 75.2 vs 25.15 73.2, p o0.001) in the 193 surviving individuals who did not participate in the follow-up. We included in the analysis the 655 participants who were followed up successfully or who died during the follow-up period. The study protocol was approved by the Institutional Review Board of the Seoul National University Bundang Hospital.
3. Assessment 3.1. Suicidality We evaluated suicidality at the baseline and follow-up assessments using the MINI-SM (Sheehan et al., 1998; Yoo et al., 2006).
287
This module includes three questions on suicidal ideation within the past month (‘Did you think you would be better off dead or wish you were dead?’ [1 point], ‘Did you want to harm yourself?’ [2 points] and ‘Did you think about suicide?’ [6 points]), one question on suicide plans within the past month (‘Did you have a suicide plan?’ [10 points]), one question on suicide attempts within the past month (‘Did you attempt suicide?’ [10 points]) and one question on lifetime history of suicide attempts (‘In your lifetime, did you ever make a suicide attempt?’ [4 points]). Based on the total score of this module, we classified the severity of suicidality into four levels as follows: none (total score 0), low (1–5 points), moderate (6–9 points) and high (Z10 points). In addition, we also classified suicidality into passive suicidal ideation, active suicidal ideation and suicide plan. We defined passive suicidal ideation as answering ‘YES’ to ‘Did you think you would be better off dead or wish you were dead?’, active suicidal ideation as answering ‘YES’ to ‘Did you want to harm yourself?’ or ‘Did you think about suicide?’, and suicide plan as answering ‘YES’ to ‘Did you have a suicide plan?’. 3.2. Risk factors The socio-demographic and clinical characteristics of the participants were obtained as follows. We evaluated depressive symptoms using the Korean version of the Geriatric Depression Scale (GDS). We defined depression as having GDS score of 10 points or higher according to the previous observations (Wancata et al., 2006), and lifetime history of depression as ‘YES’ response of each subject to a simple question; ‘Have you ever been diagnosed with depression?’. We used the Korean version of the MMSE for evaluating global cognition (Kim et al., 2010), and the Korean version of the Alcohol Use Disorders Identification Test (AUDIT) for evaluating problem drinking (Lee et al., 2000). Cut-off points for cognitive impairment and problem alcohol drinking were 24 points and 8 points, respectively (Isaacson et al., 1994; Lee et al., 2002). We evaluated participants’ level of physical exercise using the Korean version of International Physical Activity Questionnaire (IPAQ), short-form (Chun, 2012). Based on the IPAQ, we transformed the amount of daily exercise into metabolic equivalent task (MET) values (Ainsworth et al., 2000). Finally, following the IPAQ guidelines (International Physical Activity Questionnaire Group, 2005), we categorized the level of exercise into the following four categories: none, mild, moderate and high. All participants were fully informed of the study protocol and subsequently provided a written consent statement signed by themselves or their legal guardians.
4. Statistical analysis Descriptive statistics of the baseline socio-demographic and clinical data were compared by Pearson's chi-squared test or Student's t-test. Standardized incidences of suicide completion and attempt were estimated. To standardize the incidence rates, we stratified the samples with age of 5 years (60–64, 65–69, 70–74, 75–79, 80–84, and 85 þ), and then weighed the proportion based on the age- and gender-distribution of Korean population from 2010 Korean National Census (Statistics Korea, 2010). The 95% confidence intervals were calculated for the incidences by the Wald method. Multiple logistic regression analysis was used to evaluate risk factors of suicidality computing suicidality and depression in the first block and other risk factors in the second block. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for each variable. Backward elimination method was used in multivariate analysis. All statistical analyses were performed using the SPSS 21.0 statistical package.
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5. Results
5.2. Incidence rates of suicide attempts and completion
5.1. Baseline characteristics
Among the 655 participants in the baseline assessment, 17 participants had attempted suicide during the follow-up period. Of these 17 attempters, 11 had had suicidality at the baseline assessment. Among these 11 attempters with suicidality at baseline, two men who had shown low suicidality at the baseline assessment committed suicide by self-poisoning. In addition to these two men who died by suicide, 30 elders were found to have passed away at the follow-up assessment. The age- and genderstandardized incidence rate of suicide attempt without completion was 11.7 per 1000 persons per year (95% CI ¼10.0–13.4), whereas the rate of suicide attempt or completion was 13.1 per 1000 persons per year (95% CI ¼11.2–15.0) in the elderly Korean aged 60 years or older. The age- and gender- standardized incidence rate of suicide completion was 115 per 100,000 persons per year (95% CI ¼68.7–161.3).
Among the 655 participants (the 623 responders to the followup assessment and the 32 participants who died during the follow-up period), 182 (27.8%) had shown suicidality at the baseline assessment (low 111; moderate 40; high 31). Among them, 66 (10.1%) had passive suicidal ideation, 58 (8.9%) had active suicidal ideation, 16 (2.4%) had suicide plans in the past month, and 42 (6.4%) reported lifetime history of suicide attempt without recent suicidality. Their baseline characteristics are summarized in Table 1. Compared with those without suicidality, there were more women (65.4% vs 54.8%, p ¼0.014), spouseless (44.8% vs 34.5%, p ¼0.016), low education level (72.5% vs 56.4%, p o0.001), economic disadvantage (58.1% vs 42.8%, p o0.001), living alone (21.4% vs 14.0%, p ¼0.021) and mild-intensity daily exercise or less (80% vs 65.0%, p o0.001) in the individuals with suicidality at baseline. They were also more likely to be cognitively impaired (34.1% vs 24.8%, p ¼0.017) and depressed (75.3% vs 37.9%, p o0.001), and to have a history of depression (8.3% vs 3.2%, p ¼ 0.005).
Table 1 Baseline demographic and clinical characteristics of participants. Suicidality measured by MINI
Age (yrs) o80 (%) Z80 (%) Gender Men (%) Women (%) Marital status Married (%) No spouse (%) Cohabitants No (%) Yes (%) Education (yrs) o7 (%) Z7 (%) Economic status Not disadvantaged (%) Disadvantaged (%) Smoking No (%) Yes (%) Exercise None-mild (%) Above moderate (%) History of depression No (%) Yes (%) AUDIT o8 (%) Z8 (%) MMSE Z24 (%) o24 (%) GDS o10 (%) Z10 (%)
Pn
None (N ¼ 473)
Positive (N¼ 182)
87.7 12.3
83.5 16.5
0.165
45.2 54.8
34.6 65.4
0.014
65.5 34.5
55.2 44.8
0.016
14.0 86.0
21.4 78.6
0.021
56.4 43.6
72.5 27.5
o0.001
57.2 42.8
41.9 58.1
o0.001
60.3 39.7
61.5 38.5
0.763
65.0 35.0
80.0 20.0
o0.001
96.8 3.2
91.7 8.3
0.005
82.4 17.6
86.8 13.2
0.173
75.2 24.8
65.9 34.1
0.017
62.1 37.9
24.7 75.3
o0.001
Pearson’s chi-squared test.
Suicidality measured by the MINI-SM was not associated with the risk of all-cause mortality (OR ¼1.90, 95% CI ¼0.64–5.69). However, in the multiple logistic regression analysis that computed the presence of depression as a covariate, suicidality was a significant risk factor for suicide attempts (OR¼ 3.84, 95% CI ¼1.06–13.87, p ¼0.040). In addition to suicidality, living alone (OR¼ 6.40, 95% CI ¼1.88–21.79, p¼ 0.003) and problem drinking (OR¼ 6.77, 95% CI ¼1.02–44.78, p ¼0.047) were also found to be independent risk factors of suicide attempts (Table 2). When we classified the severity of suicidal behaviors into passive suicidal ideation, active suicidal ideation and suicide plan, ORs for incident suicide attempts were 1.20 (95% CI ¼0.12–11.83, p ¼0.877), 15.86 (95% CI ¼3.27–77.08, p ¼ 0.001) and 6.87 (95% CI ¼0.58–81.06, p¼ 0.126), respectively. We could not analyze the risk factors for suicide completion since only two participants took their own lives during the follow-up period. Both were male and showed low-level suicidality at the baseline assessment. One man was a problem drinker (AUDIT ¼20) and had a lifetime history of suicide attempts, and the other was depressed (GDS ¼18) at the baseline assessment. 5.4. Risk factors for suicidality
MINI, Mini-International Neuropsychiatric Interview; AUDIT, Alcohol Use Disorders Identification Test; MMSE, Mini-Mental State Examination; GDS, Geriatric Depression Scale. *
5.3. Risk factors for suicide attempts
Among the 168 survivors with suicidality at the baseline assessment, 79 (47.0%) had suicidality at the 2-year follow-up assessment, which may indicate persistent or recurring suicidality. The economically disadvantaged elders were about 2.3 times more likely to have suicidality at the follow-up assessment (OR¼ 2.26, 95% CI ¼ 1.10–4.65) (Table 2). Interestingly, the participants who engaged in moderate- to high-intensity daily exercise showed a lower risk of persistent or recurring suicidality than those who had engaged in only mild intensity or no daily exercise (OR ¼0.32, 95% CI ¼0.12–0.81) (Table 2). Suicidality was no longer reported in follow-up assessments in 25 out of 32 participants (78.1%) who had engaged in moderate- to high-intensity daily exercise, whereas this happened in only 58 out of 124 participants (46.8%) who had engaged in only mild-intensity daily exercise or less. Among the 457 survivors without suicidality at the baseline assessment, 68 (14.9%) had suicidality at the 2-year follow-up assessment. The age- and gender-standardized incidence rate of suicidality was estimated to be 70.7 per 1000 persons per year (95% CI ¼66.0–75.4). Depression (OR ¼3.02, 95% CI ¼1.65–5.53) and low education level (OR ¼2.41, 95% CI ¼1.21–4.77) were associated with risk of incident suicidality (Table 2). The incidence of suicidality in participants who had engaged in moderate- to
D.J. Oh et al. / Journal of Affective Disorders 184 (2015) 286–292
289
Table 2 Factors related to incidence, persistence or recurrence of suicidal behaviors.
Suicidality measured by MINI Positive Depression GDS Z 10 Age Z 80 (yrs) Gender Men Marital status No spouse (vs married) Cohabitants No Education (yrs) o7 Economic status Disadvantaged Smoking Yes Exercise Above moderate History of depression Yes AUDIT score Z8 MMSE score o 24 Lifetime suicide attempt Yes
Incidence of suicide attempt
Incidence of suicidality
Persistence/recurrence of suicidality
Univariate modela
Multivariate modelb
Univariate model
Multivariate model
Univariate model
Multivariate model
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
5.01**
1.82–13.75
3.84*
1.06–13.87
–
–
–
–
–
–
–
–
2.63
0.92–7.55
1.05
0.28–3.97
3.41***
1.99–5.84
3.02***
1.65–5.53
1.85
0.98–3.47
1.45
0.71–2.99
0.85
0.19–3.77
–
–
1.21
0.56–2.61
–
–
1.66
0.71–3.87
–
–
1.21
0.46–3.18
–
–
0.77
0.45–1.29
–
–
1.13
0.59–2.16
–
–
1.52
0.58–3.99
–
–
1.82*
1.08–3.08
1.79
0.97–3.30
1.28
0.69–2.36
–
–
3.83**
1.42–10.30
6.40**
1.88–21.79
1.66*
1.17–4.21
–
–
1.25
0.61–2.56
–
–
1.21–4.77
1.35
0.69–2.66
–
1.19
0.44–3.26
–
–
2.83
***
1.56–5.14
2.41
0.75
0.26–2.12
–
–
1.17
0.68–2.00
–
1.07
0.40–2.86
–
–
0.94
0.55–1.59
–
1.34
0.22–8.09
–
–
0.62
0.34–1.15
1.31
0.17–10.19
–
–
0.95
1.59
0.51–4.98
6.77*
1.02–44.78
1.47
0.54–4.04
–
–
–
–
*
*
– *
2.36
1.21–4.59
2.26
–
1.21
0.65–2.26
–
–
–
–
0.25**
0.10–0.61
0.32*
0.12–0.81
0.21–4.35
–
–
0.74
0.25–2.18
–
–
1.01
0.51–1.98
–
–
1.04
0.43–2.50
–
–
–
2.14**
1.24–3.69
–
–
1.13
0.59–2.16
–
–
–
–
–
–
–
1.49
0.80–2.77
–
–
1.10–4.65
OR, Odds ratio; CI, Confidence Interval; AUDIT, Alcohol Use Disorders Identification Test; MMSE, Mini-Mental State Examination; GDS, Geriatric Depression Scale; MINI, MiniInternational Neuropsychiatric Interview. a
Univariate logistic regression analysis. Multivariate logistic regression analysis with backward elimination, after adjusting depression as covariate. p o 0.05. ** po 0.01. *** p o 0.001. b *
high-intensity daily exercise (16 out of 148 participants, 10.8%) was not different from that in participants who had engaged in only mild-intensity daily exercise or less (44 out of 271 participants, 16.2%), (p ¼0.127). The two risk factors for incident suicide attempts (living alone and problem drinking) were not associated with incident, persistent or recurring suicidality.
6. Discussion We found that suicidality measured by trained nurses using the MINI-SM could predict the risk of suicide attempts within the following two years in community-dwelling elderly people. In elderly Koreans, the incidences of suicidality and suicide attempts were 70.7 per 1000 persons per year (95% CI ¼66.0–75.4) and 13.1 per 1000 persons per year (95% CI ¼11.2–15.0). The risk of incident suicidality was associated with depression and low education level whereas that of persistent or recurrent suicidality was associated with poverty and level of daily exercise. In addition to suicidality, living alone and problem alcohol drinking conferred risk of suicide attempts independently of suicidality. Most of the previous studies on suicide or suicide attempts have been case-control studies of individuals who visited mental health services after attempting suicide or of those psychologically autopsied after completed suicide (Conwell et al., 2002; Nordentoft, 2007), since suicide or suicide attempts are a rare outcome in
community settings (Conwell et al., 2002, 2011). However, these case-control studies have limited generality for several reasons such as the low rate of referral to mental health services of those who eventually complete suicide (Luoma et al., 2002). To our knowledge, the present study is the first prospective study on the prediction of suicide attempt by suicidality in a community-based elderly cohort. In the elderly, suicide attempts are as potent a predictor of suicide as in younger adults but are more lethal on the first attempt than in younger adults (De Leo et al., 2001; Goldstein et al., 1991; Nordentoft, 2007). We found that community-dwelling elderly individuals with suicidality as measured by the MINISM were about 4 times more likely to attempt suicide within 2 years than those without suicidality. Although the prediction of future suicidal behaviors by MINI-SM was reported in one prospective study on younger adults admitted to an acute psychiatric unit (Roaldset et al., 2012), it has never been validated in a community-dwelling general elderly population until now. Predictability of suicidality for incident suicide attempt was also low in previous studies on general populations; 15.4% in 10-year followup among respondents with lifetime history of suicidal ideation (Borges et al., 2008) and 10.3% in 13-year follow-up among respondents with lifetime history of suicidal ideation (Kuo et al., 2001). In line with these studies, the positive predictive value of suicidality for suicide attempts was found to be low (positive predictive value ¼6.04%, 95% CI ¼3.06%–10.56%). However, screening the risk of suicide attempt using the MINI-SM still seems to be useful since the incidence of suicide attempt in the
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community-dwelling elderly was very low (13.1 per 1000 persons per year). The MINI-SM has several strengths in evaluating elderly suicidality in community settings. First, it directly evaluates suicidality regardless of the presence of mental disorders. About 18% of elderly people with suicidal ideation have been found not to have any mental disorder in primary care settings (Raue et al., 2010), and more than two-thirds of elderly people with suicidal ideation in community settings do not meet the criteria of any mental disorder (Corna et al., 2010). In many previous studies, suicidality has been evaluated using a part or an item from an instrument for evaluating specific mental disorders like depressive disorder (Cheng et al., 2010; Sirey et al., 2008). Second, the MINI-SM is simple and easy to administer in either primary care or community settings (de Azevedo Marques and Zuardi, 2008). In the present study, trained nurses administered the instrument in a community setting, and their evaluations were valid in predicting future risk of suicide attempts. Thus, its use will enable primary physicians or community gatekeepers to increase the rate of referral of elderly individuals with suicidality to mental health specialists. In the present study, active suicidal ideation was associated with high risk of incident suicidal attempt, but passive suicidal ideation was not. Since the suicidality group defined by MINI-SM included a part of subjects with passive suicidal ideation, OR of suicidality for incident suicide attempt was lower than those of active suicidal ideation or suicide plan. However, passive suicidal ideations may not be clearly distinguished from active suicidal ideation and share many clinical correlates in common with active suicidal ideation (Szanto et al., 1996). Furthermore, the risk for lifetime suicide attempt of the people with passive suicidal ideation was not different from that with active suicidal ideation (Baca-Garcia et al., 2011). Old people with passive suicidal ideation only may have more distant histories of serious suicidal ideation (Van Orden et al., 2013; Beck et al., 1999; Joiner et al., 2003). As the suicidal ideation can fluctuate overtime, the elderly with recent passive suicidal ideation should also be monitored for the progression to more severe suicidal behaviors. In this aspect, the assessment of suicidality using MINI-SM may have strengths by concerning the suicidal ideation as a floating target along a continuum of severity. Elderly suicide rate in Korea is highest among OECD countries, which might have also contributed to the higher suicidality prevalence of the current study than that from the previous studies overseas. In the previous reports from overseas, the prevalence of suicidal ideation was estimated widely from 1% to 10% depending on the methods and the time-windows of assessments (Schulberg et al., 2004). However, the rate of suicidality in the present study was also higher than that of previous studies on elderly Koreans. This difference may be attributed to a couple of reasons. First, methodological differences might have contributed to the discrepancy. For example, in the study conducted by Kang et al. that had reported one-month prevalence rate of suicidal ideation to be 11.5% in elderly aged 65 years or older, the researchers did not include suicide plans, attempts, and the lifetime history of suicide attempt in their assessments of suicidality (Kang et al., 2014). In our population, the prevalence of lifetime history of suicidal attempt without current suicidality was 6.4% (95% CI ¼4.5–8.3). In the 2011 Korean National Epidemiological Survey reported by Park et al., the prevalence of suicidality in the past one year was only 4.0%. However, this study did not include passive suicidal ideation and lifetime history of suicide attempt (Park et al., 2014). In the current study, the prevalence of active suicidal ideation in the past one month was 10.7% (95% CI ¼ 8.3–13.0). Secondly, Osan city where this mental health survey was conducted, showed relatively higher rate of suicide than other regions of Korea. The suicide rate
of elders above 65 years in this areas was 72.7 per 100,000, which was higher than the national average 64.2 per 100,000 (Statistics Korea, 2013). We found that 47.0% of the elders with suicidality at baseline (79 of 168) also had suicidality at follow-up. This persistent or recurrent suicidality is a well-established high-risk condition for suicide attempt or completion (Borges et al., 2008; Hintikka et al., 2001; Kessler et al., 1999) that should be a target of communitybased suicide prevention programs. In addition to the risk of suicide-related outcomes, suicidality could be related to poor medical outcomes like the health-related quality of life (Goldney et al., 2001; Ostamo and Lönnqvist, 2001). Considering that suicidality usually fluctuates over time interacting with various biological, psychological, and environmental factors, clinicians working with old people with suicidality may need to be aware not only of potential risk of suicide attempt, but also of the risks of other adverse outcomes and aggravation of suicidality. In this study, poverty increased the risk of persistent or recurrent suicidality. These results are consistent with those of the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study. In the PROSPECT study, poor elderly people with poverty were more likely to have suicidal ideation at the 2-year follow-up assessment than those without poverty (Gilman et al., 2013). These results would suggest that suicidality might be more likely to become chronic or recurrent in the economically disadvantaged elderly. In Korea, old-age poverty has increased from about 45% in the mid2000s to 47.2% in 2013, which was among the highest in the OECD countries (OECD, 2013). Thus, impoverished elderly individuals with suicidality should be the first target of community-based suicide prevention programs in Korea. Our data also suggest that moderate levels of daily exercise or above may reduce the risk of persistent or recurrent suicidality. Two studies on young inpatients with mental disorders have examined suicidality changes as an outcome of exercise (Davidson et al., 2013; Sturm et al., 2012). One study revealed that exercise reduced suicidality in young inpatients with post-traumatic stress disorder (Davidson et al., 2013), and the other revealed that 9 weeks of hiking reduced suicidal ideation in patients at high risk for suicide (Sturm et al., 2012). Robust, randomized studies have shown the benefits of exercise for ameliorating depressive symptoms in elders with depressive disorder, which is a strong risk factor for suicidal behaviors (Sjosten and Kivela, 2006). We found that exercise may reduce the risk of suicide directly, or indirectly by improving depression. An increase in circulating brain-derived neurotrophic factor (BDNF) may possibly play a role in mediating the direct effect of exercise on the risk of suicide attempts. Peripheral BDNF levels in suicidal patients were found to be lower than in non-suicidal depressed patients or in healthy controls (Lee et al., 2007). Brain BDNF was also lower in suicidal patients than in healthy controls (Dwivedi et al., 2003). In many randomized trials, physical activity increased the BDNF level in both healthy controls and in elderly individuals with various illnesses (Coelho et al., 2013). Moderate-intensity exercise in particular seemed to be effective in increasing peripheral BDNF levels in the elderly (Coelho et al., 2013). In addition to suicidality, we found that living alone and problem drinking conferred risk of suicide attempts independently of suicidality. Disrupted social connectedness has been considered a major risk factor for suicide and suicide attempts in the elderly (Almeida et al., 2012; Wiktorsson et al., 2010). Support from family members or community peer groups has a significant protective effect against suicide. According to our nationwide survey in Korea (Park et al., 2012), living alone was also a risk factor for late-life depression, which may be a key link between living alone and suicide attempts. Despite mixed results due to cultural differences (Conwell et al., 2011), problem alcohol drinking is known to be an
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important risk factor for suicidal behaviors as it can increase impulsivity, aggressiveness and psychological distress (Hufford, 2001). Considering the higher prevalence of problem drinking (estimated as 10.6%) in Korean compared with Caucasian elders (Kim et al., 2009), intervention targeted to elders with problem drinking could be useful for reducing suicide attempts. In the present study, incident suicide attempt, suicidality and persistent/recurrent suicidality are all suicidal behaviors but had different risk factors. These differences in the risk factors of suicidal behaviors may reflect the complexity and broad spectrum of suicidality in the elderly. Suicidal ideation, in particular, can range from normative perspective on death to imminent intent to suicide (Scocco et al., 2001; Szanto et al., 2013). In the National Comorbidity Survey which was a prospective study on general population (Borges et al., 2008), incident suicidal ideation was related to the marital status, employment status whereas incident suicidal plan and attempt were not. Interestingly, that study also showed that mental illness such as depressive disorder could only mediate the onset of ideation rather than attempts, which was consistent with our results. In another longitudinal study in elderly Koreans (Kang et al., 2014), incident suicidal ideation was related to marriage status, social support, severe pain and depression, whereas persistent suicidal ideation was related to baseline stressful life event and depression. Therefore, incident suicidality, recurrent/persistent suicidality and incident suicide attempts, although can be described as an umbrella term ‘suicidal behavior’, may have different etiologies or risk factors.
7. Limitations Our study has several limitations. Firstly, the study sample was enrolled from a single city, and the size of the study sample was small. Secondly, assessments of depression, level of exercise and other clinical variables largely relied on self-reported information, and were thus subject to recall bias. Thirdly, some factors that may influence the risk of suicidality, such as recent stressful life events or comorbid medical conditions, were not evaluated. Fourthly, there was no information about the history of mental health treatment. Finally, we could not find any report on how the relative scoring weight of each MINI-SM item was determined. Since the relative scoring weights of MINI-SM items considerably influence the level of suicidality and may be different according to the characteristics of study populations, further studies are warranted to validate them in various clinical and community populations. In spite of these limitations, this study showed that we may briefly screen suicidality using the MINI-SM and predict suicide attempts based on suicidality in community-dwelling elderly individuals. Our data also suggested that above-moderate level of exercise may be effective for reducing suicidality of elderly individuals in community settings.
Financial disclosure All authors have no financial relationships relevant to this article to disclose.
Role of the funding source This work was supported by the National Research Foundation of Korea grant funded by the Korean government (MEST; Grant no. 2010-0029382), and by the grant of the Korean Health Technology
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R&D Project, Ministry of Health, Welfare and Family Affairs, Republic of Korea (Grant no. A092077). Conflict of interest None.
Acknowledgments None.
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Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
Suicidality-based prediction of suicide attempts in a community-dwelling elderly population: Results from the Osan Mental Health Survey Dae Jong Oh a, Jae Young Park b, Miyoung Oh c, Kayoung Kim b, Jongwoo Hong b, Taehyun Kim b, Ji Won Han a,b, Tae Hui Kim d, Ki Woong Kim a,b,e,n a
Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam, Republic of Korea Osan Mental Health Center, Osan, Republic of Korea d Department of Psychiatry, Yonsei University Wonju Severance Christian Hospital, Wonju, Republic of Korea e Department of Brain and Cognitive Science, Seoul National University College of Natural Sciences, Seoul, Republic of Korea b c
art ic l e i nf o
a b s t r a c t
Article history: Received 25 March 2015 Received in revised form 9 June 2015 Accepted 9 June 2015 Available online 17 June 2015
Background: Data on outcomes of suicidality in the community-dwelling elderly are scarce. We investigated the association of suicidality with the suicide attempts in a community-dwelling elderly cohort. Methods: In the Osan Mental Health Survey, 848 randomly sampled elderly Koreans participated in the baseline evaluation, 623 completed 2-year follow-up evaluation and 32 died during the follow-up period. The survey was conducted between February 2010 and January 2013. We evaluated suicidality using the Mini-International Neuropsychiatric Interview suicidality module that includes both suicidal ideation and attempts. Results: The incidences of suicidality and suicide attempts were 70.7 and 13.1 per 1000 persons per year, respectively. Suicidality was associated with increased risk of suicide attempts (odds ratio (OR) ¼ 3.84, 95% CI¼ 1.06–13.87). Two men with suicidality committed suicide by self-poisoning. Moderate to high intensity daily exercise decreased the risk of suicidality to become persistent or recurrent (OR ¼ 0.32, 95% CI¼ 0.12–0.81). Low education level (OR¼ 2.41, 95% CI ¼1.21–4.77) and depression (OR¼ 3.02, 95% CI¼ 1.65–5.53) were associated with risk of incident suicidality. Limitations: Study sample was enrolled from a single city of Korea, and the size of the study sample was small. Conclusions: We may reduce suicide attempts by screening for suicidality and implementing exercise programs in community-dwelling elderly people. & 2015 Elsevier B.V. All rights reserved.
Keywords: Suicide Suicide attempted Geriatric psychiatry Incidence Korea
1. Introduction According to a report by the WHO, over 800,000 people die from suicide every year, and suicide rates are universally highest in people aged 70 years and over (World Health Organization, 2014). South Korea (hereafter, Korea) has registered the highest suicide rate in the Organization for Economic Cooperation and Development (OECD) for more than a decade. In 2012, the suicide rate of the general population in Korea was 29.1 per 100,000, which was much higher than the average rate among OECD countries of 12.4 per 100,000 (OECD, 2013). In particular, the suicide rate in the n Corresponding author at: Department of Neuropsychiatry, Seoul National University Bundang Hospital, 82 Gumiro 173 Beongil, Bundanggu, Seongnamsi, Gyeonggido 463-707, Republic of Korea. E-mail address: [email protected] (K.W. Kim).
http://dx.doi.org/10.1016/j.jad.2015.06.010 0165-0327/& 2015 Elsevier B.V. All rights reserved.
elderly aged 70 or above in Korea was 116.2 per 100,000, far higher than that in other OECD countries (5.8–42.3 per 100,000) (World Health Organization, 2014). In the past two decades, the increase in suicide among the elderly has been exceptionally steep in Korea. The age-standardized suicide rate in Korean people over the age of 65 was 64.2 per 100,000 in 2013, which was three times higher than that in 1990 (Statistics Korea, 2013). Considering that Korea is one of the most rapidly aging countries in the world and that it will become one of the oldest countries by 2040 (Statistics Korea, 2014), development of a comprehensive and coordinated strategy for preventing suicide in the elderly is urgently needed. Timely identification of persons at risk of suicide is a prerequisite for providing suicide prevention programs. Previous suicidal behaviors, such as suicidal ideation, plans or attempts, are well-replicated predictors of suicide in general populations (Borges et al., 2008; Kessler et al., 1999). In a previous study, we found
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that the age- and gender-standardized prevalence rates of current suicidal ideation without a plan or attempt, and current suicidal ideation with a plan or attempt, were 19.6% and 2.24%, respectively in elderly Koreans (Park et al., 2013). Fortunately, these suicidal behaviors do not inevitably lead to death by suicide. Thus, it is important to find a way to identify people who have risk factors that may aggravate their suicidal ideation to the point that they attempt suicide. However, suicidality usually fluctuates over time, interacting with various biological, psychological, and environmental factors and may result in suicide. This fluctuation of suicidality makes it difficult to identify people urgently in need of suicide prevention programs, particularly in community settings. According to a previous report, 86% of suicides occurred in the low-risk groups (University of Manchester, 2006), suggesting that suicidal behaviors over a lifetime or in a year may not accurately reflect the risk of imminent suicidality that should be a prime target for reduction by suicide intervention programs. As a part of the Osan Mental Health Survey (OMHS), we have been evaluating suicidality in an elderly Korean community-based cohort every two years since 2010 using the Korean version of the MiniInternational Neuropsychiatric Interview Suicidality Module (MINISM) (Yoo et al., 2006). The MINI-SM evaluates current suicidality by checking suicidal behaviors within the past month. The aims of this study were to examine the outcomes of suicidality such as incidence, persistence or recurrence, and to identify the predictors of suicide attempts through a 2-year follow-up evaluation of this cohort.
2. Methods 2.1. Design and data collection We conducted the baseline assessment of the OMHS on suicidality from February 2010 to February 2011. We randomly sampled 1588 people from the residential roster of 14,051 Koreans aged over 60 years who lived in Osan, Gyeonggido, Korea. We invited them to participate in the suicidality survey by home visits and 848 responded. Trained nurses implemented surveys including assessment of suicidality. They took a 180-min training program that included 90-min education on conducting interview with MINI-SM and 90-min education on suicide and depression in the elderly. Details of the design and assessments of the OMHS were described in our previous report (Park et al., 2013). We carried out the first 2-year follow-up assessment on suicidality from January 2012 through January 2013. Among the 848 individuals who participated in the baseline assessment, 623 (73.4%) responded to the follow-up assessment, and a further 32 (3.8%) were found to have died since the baseline study. Compared with responders, there were more women (66.8% vs 58.3%, p ¼0.033), spouseless (48.9% vs 37.2%, p ¼0.015), low education level (32.1% vs 18.3%, p ¼0.001) and cognitive impairment indicated by lower Mini-Mental State Examination (MMSE) scores (22.60 75.2 vs 25.15 73.2, p o0.001) in the 193 surviving individuals who did not participate in the follow-up. We included in the analysis the 655 participants who were followed up successfully or who died during the follow-up period. The study protocol was approved by the Institutional Review Board of the Seoul National University Bundang Hospital.
3. Assessment 3.1. Suicidality We evaluated suicidality at the baseline and follow-up assessments using the MINI-SM (Sheehan et al., 1998; Yoo et al., 2006).
287
This module includes three questions on suicidal ideation within the past month (‘Did you think you would be better off dead or wish you were dead?’ [1 point], ‘Did you want to harm yourself?’ [2 points] and ‘Did you think about suicide?’ [6 points]), one question on suicide plans within the past month (‘Did you have a suicide plan?’ [10 points]), one question on suicide attempts within the past month (‘Did you attempt suicide?’ [10 points]) and one question on lifetime history of suicide attempts (‘In your lifetime, did you ever make a suicide attempt?’ [4 points]). Based on the total score of this module, we classified the severity of suicidality into four levels as follows: none (total score 0), low (1–5 points), moderate (6–9 points) and high (Z10 points). In addition, we also classified suicidality into passive suicidal ideation, active suicidal ideation and suicide plan. We defined passive suicidal ideation as answering ‘YES’ to ‘Did you think you would be better off dead or wish you were dead?’, active suicidal ideation as answering ‘YES’ to ‘Did you want to harm yourself?’ or ‘Did you think about suicide?’, and suicide plan as answering ‘YES’ to ‘Did you have a suicide plan?’. 3.2. Risk factors The socio-demographic and clinical characteristics of the participants were obtained as follows. We evaluated depressive symptoms using the Korean version of the Geriatric Depression Scale (GDS). We defined depression as having GDS score of 10 points or higher according to the previous observations (Wancata et al., 2006), and lifetime history of depression as ‘YES’ response of each subject to a simple question; ‘Have you ever been diagnosed with depression?’. We used the Korean version of the MMSE for evaluating global cognition (Kim et al., 2010), and the Korean version of the Alcohol Use Disorders Identification Test (AUDIT) for evaluating problem drinking (Lee et al., 2000). Cut-off points for cognitive impairment and problem alcohol drinking were 24 points and 8 points, respectively (Isaacson et al., 1994; Lee et al., 2002). We evaluated participants’ level of physical exercise using the Korean version of International Physical Activity Questionnaire (IPAQ), short-form (Chun, 2012). Based on the IPAQ, we transformed the amount of daily exercise into metabolic equivalent task (MET) values (Ainsworth et al., 2000). Finally, following the IPAQ guidelines (International Physical Activity Questionnaire Group, 2005), we categorized the level of exercise into the following four categories: none, mild, moderate and high. All participants were fully informed of the study protocol and subsequently provided a written consent statement signed by themselves or their legal guardians.
4. Statistical analysis Descriptive statistics of the baseline socio-demographic and clinical data were compared by Pearson's chi-squared test or Student's t-test. Standardized incidences of suicide completion and attempt were estimated. To standardize the incidence rates, we stratified the samples with age of 5 years (60–64, 65–69, 70–74, 75–79, 80–84, and 85 þ), and then weighed the proportion based on the age- and gender-distribution of Korean population from 2010 Korean National Census (Statistics Korea, 2010). The 95% confidence intervals were calculated for the incidences by the Wald method. Multiple logistic regression analysis was used to evaluate risk factors of suicidality computing suicidality and depression in the first block and other risk factors in the second block. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for each variable. Backward elimination method was used in multivariate analysis. All statistical analyses were performed using the SPSS 21.0 statistical package.
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5. Results
5.2. Incidence rates of suicide attempts and completion
5.1. Baseline characteristics
Among the 655 participants in the baseline assessment, 17 participants had attempted suicide during the follow-up period. Of these 17 attempters, 11 had had suicidality at the baseline assessment. Among these 11 attempters with suicidality at baseline, two men who had shown low suicidality at the baseline assessment committed suicide by self-poisoning. In addition to these two men who died by suicide, 30 elders were found to have passed away at the follow-up assessment. The age- and genderstandardized incidence rate of suicide attempt without completion was 11.7 per 1000 persons per year (95% CI ¼10.0–13.4), whereas the rate of suicide attempt or completion was 13.1 per 1000 persons per year (95% CI ¼11.2–15.0) in the elderly Korean aged 60 years or older. The age- and gender- standardized incidence rate of suicide completion was 115 per 100,000 persons per year (95% CI ¼68.7–161.3).
Among the 655 participants (the 623 responders to the followup assessment and the 32 participants who died during the follow-up period), 182 (27.8%) had shown suicidality at the baseline assessment (low 111; moderate 40; high 31). Among them, 66 (10.1%) had passive suicidal ideation, 58 (8.9%) had active suicidal ideation, 16 (2.4%) had suicide plans in the past month, and 42 (6.4%) reported lifetime history of suicide attempt without recent suicidality. Their baseline characteristics are summarized in Table 1. Compared with those without suicidality, there were more women (65.4% vs 54.8%, p ¼0.014), spouseless (44.8% vs 34.5%, p ¼0.016), low education level (72.5% vs 56.4%, p o0.001), economic disadvantage (58.1% vs 42.8%, p o0.001), living alone (21.4% vs 14.0%, p ¼0.021) and mild-intensity daily exercise or less (80% vs 65.0%, p o0.001) in the individuals with suicidality at baseline. They were also more likely to be cognitively impaired (34.1% vs 24.8%, p ¼0.017) and depressed (75.3% vs 37.9%, p o0.001), and to have a history of depression (8.3% vs 3.2%, p ¼ 0.005).
Table 1 Baseline demographic and clinical characteristics of participants. Suicidality measured by MINI
Age (yrs) o80 (%) Z80 (%) Gender Men (%) Women (%) Marital status Married (%) No spouse (%) Cohabitants No (%) Yes (%) Education (yrs) o7 (%) Z7 (%) Economic status Not disadvantaged (%) Disadvantaged (%) Smoking No (%) Yes (%) Exercise None-mild (%) Above moderate (%) History of depression No (%) Yes (%) AUDIT o8 (%) Z8 (%) MMSE Z24 (%) o24 (%) GDS o10 (%) Z10 (%)
Pn
None (N ¼ 473)
Positive (N¼ 182)
87.7 12.3
83.5 16.5
0.165
45.2 54.8
34.6 65.4
0.014
65.5 34.5
55.2 44.8
0.016
14.0 86.0
21.4 78.6
0.021
56.4 43.6
72.5 27.5
o0.001
57.2 42.8
41.9 58.1
o0.001
60.3 39.7
61.5 38.5
0.763
65.0 35.0
80.0 20.0
o0.001
96.8 3.2
91.7 8.3
0.005
82.4 17.6
86.8 13.2
0.173
75.2 24.8
65.9 34.1
0.017
62.1 37.9
24.7 75.3
o0.001
Pearson’s chi-squared test.
Suicidality measured by the MINI-SM was not associated with the risk of all-cause mortality (OR ¼1.90, 95% CI ¼0.64–5.69). However, in the multiple logistic regression analysis that computed the presence of depression as a covariate, suicidality was a significant risk factor for suicide attempts (OR¼ 3.84, 95% CI ¼1.06–13.87, p ¼0.040). In addition to suicidality, living alone (OR¼ 6.40, 95% CI ¼1.88–21.79, p¼ 0.003) and problem drinking (OR¼ 6.77, 95% CI ¼1.02–44.78, p ¼0.047) were also found to be independent risk factors of suicide attempts (Table 2). When we classified the severity of suicidal behaviors into passive suicidal ideation, active suicidal ideation and suicide plan, ORs for incident suicide attempts were 1.20 (95% CI ¼0.12–11.83, p ¼0.877), 15.86 (95% CI ¼3.27–77.08, p ¼ 0.001) and 6.87 (95% CI ¼0.58–81.06, p¼ 0.126), respectively. We could not analyze the risk factors for suicide completion since only two participants took their own lives during the follow-up period. Both were male and showed low-level suicidality at the baseline assessment. One man was a problem drinker (AUDIT ¼20) and had a lifetime history of suicide attempts, and the other was depressed (GDS ¼18) at the baseline assessment. 5.4. Risk factors for suicidality
MINI, Mini-International Neuropsychiatric Interview; AUDIT, Alcohol Use Disorders Identification Test; MMSE, Mini-Mental State Examination; GDS, Geriatric Depression Scale. *
5.3. Risk factors for suicide attempts
Among the 168 survivors with suicidality at the baseline assessment, 79 (47.0%) had suicidality at the 2-year follow-up assessment, which may indicate persistent or recurring suicidality. The economically disadvantaged elders were about 2.3 times more likely to have suicidality at the follow-up assessment (OR¼ 2.26, 95% CI ¼ 1.10–4.65) (Table 2). Interestingly, the participants who engaged in moderate- to high-intensity daily exercise showed a lower risk of persistent or recurring suicidality than those who had engaged in only mild intensity or no daily exercise (OR ¼0.32, 95% CI ¼0.12–0.81) (Table 2). Suicidality was no longer reported in follow-up assessments in 25 out of 32 participants (78.1%) who had engaged in moderate- to high-intensity daily exercise, whereas this happened in only 58 out of 124 participants (46.8%) who had engaged in only mild-intensity daily exercise or less. Among the 457 survivors without suicidality at the baseline assessment, 68 (14.9%) had suicidality at the 2-year follow-up assessment. The age- and gender-standardized incidence rate of suicidality was estimated to be 70.7 per 1000 persons per year (95% CI ¼66.0–75.4). Depression (OR ¼3.02, 95% CI ¼1.65–5.53) and low education level (OR ¼2.41, 95% CI ¼1.21–4.77) were associated with risk of incident suicidality (Table 2). The incidence of suicidality in participants who had engaged in moderate- to
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Table 2 Factors related to incidence, persistence or recurrence of suicidal behaviors.
Suicidality measured by MINI Positive Depression GDS Z 10 Age Z 80 (yrs) Gender Men Marital status No spouse (vs married) Cohabitants No Education (yrs) o7 Economic status Disadvantaged Smoking Yes Exercise Above moderate History of depression Yes AUDIT score Z8 MMSE score o 24 Lifetime suicide attempt Yes
Incidence of suicide attempt
Incidence of suicidality
Persistence/recurrence of suicidality
Univariate modela
Multivariate modelb
Univariate model
Multivariate model
Univariate model
Multivariate model
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
5.01**
1.82–13.75
3.84*
1.06–13.87
–
–
–
–
–
–
–
–
2.63
0.92–7.55
1.05
0.28–3.97
3.41***
1.99–5.84
3.02***
1.65–5.53
1.85
0.98–3.47
1.45
0.71–2.99
0.85
0.19–3.77
–
–
1.21
0.56–2.61
–
–
1.66
0.71–3.87
–
–
1.21
0.46–3.18
–
–
0.77
0.45–1.29
–
–
1.13
0.59–2.16
–
–
1.52
0.58–3.99
–
–
1.82*
1.08–3.08
1.79
0.97–3.30
1.28
0.69–2.36
–
–
3.83**
1.42–10.30
6.40**
1.88–21.79
1.66*
1.17–4.21
–
–
1.25
0.61–2.56
–
–
1.21–4.77
1.35
0.69–2.66
–
1.19
0.44–3.26
–
–
2.83
***
1.56–5.14
2.41
0.75
0.26–2.12
–
–
1.17
0.68–2.00
–
1.07
0.40–2.86
–
–
0.94
0.55–1.59
–
1.34
0.22–8.09
–
–
0.62
0.34–1.15
1.31
0.17–10.19
–
–
0.95
1.59
0.51–4.98
6.77*
1.02–44.78
1.47
0.54–4.04
–
–
–
–
*
*
– *
2.36
1.21–4.59
2.26
–
1.21
0.65–2.26
–
–
–
–
0.25**
0.10–0.61
0.32*
0.12–0.81
0.21–4.35
–
–
0.74
0.25–2.18
–
–
1.01
0.51–1.98
–
–
1.04
0.43–2.50
–
–
–
2.14**
1.24–3.69
–
–
1.13
0.59–2.16
–
–
–
–
–
–
–
1.49
0.80–2.77
–
–
1.10–4.65
OR, Odds ratio; CI, Confidence Interval; AUDIT, Alcohol Use Disorders Identification Test; MMSE, Mini-Mental State Examination; GDS, Geriatric Depression Scale; MINI, MiniInternational Neuropsychiatric Interview. a
Univariate logistic regression analysis. Multivariate logistic regression analysis with backward elimination, after adjusting depression as covariate. p o 0.05. ** po 0.01. *** p o 0.001. b *
high-intensity daily exercise (16 out of 148 participants, 10.8%) was not different from that in participants who had engaged in only mild-intensity daily exercise or less (44 out of 271 participants, 16.2%), (p ¼0.127). The two risk factors for incident suicide attempts (living alone and problem drinking) were not associated with incident, persistent or recurring suicidality.
6. Discussion We found that suicidality measured by trained nurses using the MINI-SM could predict the risk of suicide attempts within the following two years in community-dwelling elderly people. In elderly Koreans, the incidences of suicidality and suicide attempts were 70.7 per 1000 persons per year (95% CI ¼66.0–75.4) and 13.1 per 1000 persons per year (95% CI ¼11.2–15.0). The risk of incident suicidality was associated with depression and low education level whereas that of persistent or recurrent suicidality was associated with poverty and level of daily exercise. In addition to suicidality, living alone and problem alcohol drinking conferred risk of suicide attempts independently of suicidality. Most of the previous studies on suicide or suicide attempts have been case-control studies of individuals who visited mental health services after attempting suicide or of those psychologically autopsied after completed suicide (Conwell et al., 2002; Nordentoft, 2007), since suicide or suicide attempts are a rare outcome in
community settings (Conwell et al., 2002, 2011). However, these case-control studies have limited generality for several reasons such as the low rate of referral to mental health services of those who eventually complete suicide (Luoma et al., 2002). To our knowledge, the present study is the first prospective study on the prediction of suicide attempt by suicidality in a community-based elderly cohort. In the elderly, suicide attempts are as potent a predictor of suicide as in younger adults but are more lethal on the first attempt than in younger adults (De Leo et al., 2001; Goldstein et al., 1991; Nordentoft, 2007). We found that community-dwelling elderly individuals with suicidality as measured by the MINISM were about 4 times more likely to attempt suicide within 2 years than those without suicidality. Although the prediction of future suicidal behaviors by MINI-SM was reported in one prospective study on younger adults admitted to an acute psychiatric unit (Roaldset et al., 2012), it has never been validated in a community-dwelling general elderly population until now. Predictability of suicidality for incident suicide attempt was also low in previous studies on general populations; 15.4% in 10-year followup among respondents with lifetime history of suicidal ideation (Borges et al., 2008) and 10.3% in 13-year follow-up among respondents with lifetime history of suicidal ideation (Kuo et al., 2001). In line with these studies, the positive predictive value of suicidality for suicide attempts was found to be low (positive predictive value ¼6.04%, 95% CI ¼3.06%–10.56%). However, screening the risk of suicide attempt using the MINI-SM still seems to be useful since the incidence of suicide attempt in the
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community-dwelling elderly was very low (13.1 per 1000 persons per year). The MINI-SM has several strengths in evaluating elderly suicidality in community settings. First, it directly evaluates suicidality regardless of the presence of mental disorders. About 18% of elderly people with suicidal ideation have been found not to have any mental disorder in primary care settings (Raue et al., 2010), and more than two-thirds of elderly people with suicidal ideation in community settings do not meet the criteria of any mental disorder (Corna et al., 2010). In many previous studies, suicidality has been evaluated using a part or an item from an instrument for evaluating specific mental disorders like depressive disorder (Cheng et al., 2010; Sirey et al., 2008). Second, the MINI-SM is simple and easy to administer in either primary care or community settings (de Azevedo Marques and Zuardi, 2008). In the present study, trained nurses administered the instrument in a community setting, and their evaluations were valid in predicting future risk of suicide attempts. Thus, its use will enable primary physicians or community gatekeepers to increase the rate of referral of elderly individuals with suicidality to mental health specialists. In the present study, active suicidal ideation was associated with high risk of incident suicidal attempt, but passive suicidal ideation was not. Since the suicidality group defined by MINI-SM included a part of subjects with passive suicidal ideation, OR of suicidality for incident suicide attempt was lower than those of active suicidal ideation or suicide plan. However, passive suicidal ideations may not be clearly distinguished from active suicidal ideation and share many clinical correlates in common with active suicidal ideation (Szanto et al., 1996). Furthermore, the risk for lifetime suicide attempt of the people with passive suicidal ideation was not different from that with active suicidal ideation (Baca-Garcia et al., 2011). Old people with passive suicidal ideation only may have more distant histories of serious suicidal ideation (Van Orden et al., 2013; Beck et al., 1999; Joiner et al., 2003). As the suicidal ideation can fluctuate overtime, the elderly with recent passive suicidal ideation should also be monitored for the progression to more severe suicidal behaviors. In this aspect, the assessment of suicidality using MINI-SM may have strengths by concerning the suicidal ideation as a floating target along a continuum of severity. Elderly suicide rate in Korea is highest among OECD countries, which might have also contributed to the higher suicidality prevalence of the current study than that from the previous studies overseas. In the previous reports from overseas, the prevalence of suicidal ideation was estimated widely from 1% to 10% depending on the methods and the time-windows of assessments (Schulberg et al., 2004). However, the rate of suicidality in the present study was also higher than that of previous studies on elderly Koreans. This difference may be attributed to a couple of reasons. First, methodological differences might have contributed to the discrepancy. For example, in the study conducted by Kang et al. that had reported one-month prevalence rate of suicidal ideation to be 11.5% in elderly aged 65 years or older, the researchers did not include suicide plans, attempts, and the lifetime history of suicide attempt in their assessments of suicidality (Kang et al., 2014). In our population, the prevalence of lifetime history of suicidal attempt without current suicidality was 6.4% (95% CI ¼4.5–8.3). In the 2011 Korean National Epidemiological Survey reported by Park et al., the prevalence of suicidality in the past one year was only 4.0%. However, this study did not include passive suicidal ideation and lifetime history of suicide attempt (Park et al., 2014). In the current study, the prevalence of active suicidal ideation in the past one month was 10.7% (95% CI ¼ 8.3–13.0). Secondly, Osan city where this mental health survey was conducted, showed relatively higher rate of suicide than other regions of Korea. The suicide rate
of elders above 65 years in this areas was 72.7 per 100,000, which was higher than the national average 64.2 per 100,000 (Statistics Korea, 2013). We found that 47.0% of the elders with suicidality at baseline (79 of 168) also had suicidality at follow-up. This persistent or recurrent suicidality is a well-established high-risk condition for suicide attempt or completion (Borges et al., 2008; Hintikka et al., 2001; Kessler et al., 1999) that should be a target of communitybased suicide prevention programs. In addition to the risk of suicide-related outcomes, suicidality could be related to poor medical outcomes like the health-related quality of life (Goldney et al., 2001; Ostamo and Lönnqvist, 2001). Considering that suicidality usually fluctuates over time interacting with various biological, psychological, and environmental factors, clinicians working with old people with suicidality may need to be aware not only of potential risk of suicide attempt, but also of the risks of other adverse outcomes and aggravation of suicidality. In this study, poverty increased the risk of persistent or recurrent suicidality. These results are consistent with those of the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study. In the PROSPECT study, poor elderly people with poverty were more likely to have suicidal ideation at the 2-year follow-up assessment than those without poverty (Gilman et al., 2013). These results would suggest that suicidality might be more likely to become chronic or recurrent in the economically disadvantaged elderly. In Korea, old-age poverty has increased from about 45% in the mid2000s to 47.2% in 2013, which was among the highest in the OECD countries (OECD, 2013). Thus, impoverished elderly individuals with suicidality should be the first target of community-based suicide prevention programs in Korea. Our data also suggest that moderate levels of daily exercise or above may reduce the risk of persistent or recurrent suicidality. Two studies on young inpatients with mental disorders have examined suicidality changes as an outcome of exercise (Davidson et al., 2013; Sturm et al., 2012). One study revealed that exercise reduced suicidality in young inpatients with post-traumatic stress disorder (Davidson et al., 2013), and the other revealed that 9 weeks of hiking reduced suicidal ideation in patients at high risk for suicide (Sturm et al., 2012). Robust, randomized studies have shown the benefits of exercise for ameliorating depressive symptoms in elders with depressive disorder, which is a strong risk factor for suicidal behaviors (Sjosten and Kivela, 2006). We found that exercise may reduce the risk of suicide directly, or indirectly by improving depression. An increase in circulating brain-derived neurotrophic factor (BDNF) may possibly play a role in mediating the direct effect of exercise on the risk of suicide attempts. Peripheral BDNF levels in suicidal patients were found to be lower than in non-suicidal depressed patients or in healthy controls (Lee et al., 2007). Brain BDNF was also lower in suicidal patients than in healthy controls (Dwivedi et al., 2003). In many randomized trials, physical activity increased the BDNF level in both healthy controls and in elderly individuals with various illnesses (Coelho et al., 2013). Moderate-intensity exercise in particular seemed to be effective in increasing peripheral BDNF levels in the elderly (Coelho et al., 2013). In addition to suicidality, we found that living alone and problem drinking conferred risk of suicide attempts independently of suicidality. Disrupted social connectedness has been considered a major risk factor for suicide and suicide attempts in the elderly (Almeida et al., 2012; Wiktorsson et al., 2010). Support from family members or community peer groups has a significant protective effect against suicide. According to our nationwide survey in Korea (Park et al., 2012), living alone was also a risk factor for late-life depression, which may be a key link between living alone and suicide attempts. Despite mixed results due to cultural differences (Conwell et al., 2011), problem alcohol drinking is known to be an
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important risk factor for suicidal behaviors as it can increase impulsivity, aggressiveness and psychological distress (Hufford, 2001). Considering the higher prevalence of problem drinking (estimated as 10.6%) in Korean compared with Caucasian elders (Kim et al., 2009), intervention targeted to elders with problem drinking could be useful for reducing suicide attempts. In the present study, incident suicide attempt, suicidality and persistent/recurrent suicidality are all suicidal behaviors but had different risk factors. These differences in the risk factors of suicidal behaviors may reflect the complexity and broad spectrum of suicidality in the elderly. Suicidal ideation, in particular, can range from normative perspective on death to imminent intent to suicide (Scocco et al., 2001; Szanto et al., 2013). In the National Comorbidity Survey which was a prospective study on general population (Borges et al., 2008), incident suicidal ideation was related to the marital status, employment status whereas incident suicidal plan and attempt were not. Interestingly, that study also showed that mental illness such as depressive disorder could only mediate the onset of ideation rather than attempts, which was consistent with our results. In another longitudinal study in elderly Koreans (Kang et al., 2014), incident suicidal ideation was related to marriage status, social support, severe pain and depression, whereas persistent suicidal ideation was related to baseline stressful life event and depression. Therefore, incident suicidality, recurrent/persistent suicidality and incident suicide attempts, although can be described as an umbrella term ‘suicidal behavior’, may have different etiologies or risk factors.
7. Limitations Our study has several limitations. Firstly, the study sample was enrolled from a single city, and the size of the study sample was small. Secondly, assessments of depression, level of exercise and other clinical variables largely relied on self-reported information, and were thus subject to recall bias. Thirdly, some factors that may influence the risk of suicidality, such as recent stressful life events or comorbid medical conditions, were not evaluated. Fourthly, there was no information about the history of mental health treatment. Finally, we could not find any report on how the relative scoring weight of each MINI-SM item was determined. Since the relative scoring weights of MINI-SM items considerably influence the level of suicidality and may be different according to the characteristics of study populations, further studies are warranted to validate them in various clinical and community populations. In spite of these limitations, this study showed that we may briefly screen suicidality using the MINI-SM and predict suicide attempts based on suicidality in community-dwelling elderly individuals. Our data also suggested that above-moderate level of exercise may be effective for reducing suicidality of elderly individuals in community settings.
Financial disclosure All authors have no financial relationships relevant to this article to disclose.
Role of the funding source This work was supported by the National Research Foundation of Korea grant funded by the Korean government (MEST; Grant no. 2010-0029382), and by the grant of the Korean Health Technology
291
R&D Project, Ministry of Health, Welfare and Family Affairs, Republic of Korea (Grant no. A092077). Conflict of interest None.
Acknowledgments None.
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