1. Suicide in later life
Dr A BaldwinDr A Baldwin
Consultant in Later Life PsychiatryConsultant in Later Life Psychiatry
Associate Medical DirectorAssociate Medical Director
5 Boroughs Partnership NHS FT5 Boroughs Partnership NHS FT
Honorary LecturerHonorary Lecturer
Ashley.Baldwin@5bp.nhs.ukAshley.Baldwin@5bp.nhs.uk

3. Global suicide rates by gender and age 1995
33.3
41.0
66.9
24.9
18.9
0.9
14.2
27.6 29.7
22.1
16.4
12.411.612.612.0
0.5
0
10
20
30
40
50
60
70
5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 or
above
Suiciderateper100,000population
Male Female

4. Suicide rates of selected countries
18.6
19.6
22.7
26.0
15.9
13.9
11.7
13.4
17.8
11.9
6.0
5.14.4
8.0
9.19.5
14.8
3.3
0
5
10
15
20
25
30
Suiciderateper100,000population
Male Female
US
(1998)
Canada
(1997)
Australia
(1997)UK
(1998) China
(1998)
Singapore
(1998)
Korea
(1997)
Japan
(1997)HK
(1996)

5. Suicide:Age and Sex
20%
4%
7%
26%
7%
21%
14%
7%6%
10%
15%
22%
23%
17%
0
500
1000
1500
2000
2500
Under 25 25-34 35-44 45-54 55-64 65-74 75+
Age-group
Frequency
Male Female

6. Risk factors & suicide (2000-2004)
Hunt et al
Hanging ( n =2288): 43% of total
Male
<25
Short illness duration
Affective Disorder
Self poisoning ( n =1720): 32 %
Female
>25
Social isolation/adversity (unmarried,unemployed,living alone)
Self harm, alcohol misuse
Primary drug dependence
Co-morbidity
Carbon monoxide poisoning (n =281): 5%
Male
Age 25-44
Short illness duration
Affective disorder and personality disorder

7. Risk factors & suicide (cont’d)
Jumping (n = 901): 17% of total
<25
Ethnic minority
Schizophrenia
Non compliance with treatment
CPA
Recent contact with mental health services
Drowning (n =402):
Female
Older Age (>45)
Ethnic minority
Schizophrenia
Multiple previous inpatient admissions
Current psychiatric inpatient
Burning (n =119):
Ethnic minority
Multiple previous inpatient admission/ recent ward discharge

8. Suicide in males according to age
group(1978-2010)
75+
All males
25-34
35-49
0
5
10
15
20
25
30
35
1978-1980 1983-1985 1988-1990 1993-1995 1998-2000 2003-2005 2008-2010
Three-year average
Age standardised death rate per 100,000 population
Source: ONS (ICD9 E950-E959, E980-E989, excluding E988.8; and ICD10 X60-X84, Y10-Y34, excluding Y33.9 up to 2006)
Note: Deaths with a E988.8 or Y33.9 code were excluded to remove pending verdicts from the figures. This method may miss a small number of cases where there are pending
verdicts (assigned to codes other than E988.8 or Y33.9); it may also wrongly omit some cases where a verdict has been returned (included under codes E988.8 or Y33.9). We
expect the error caused by this methodology to be negligible for figures in years up to and including 2006 and there will be no effect on more recent figures due to new codes
introduced in 2007.

9. Characteristics of elderly suicide
completers
 Low attempt to completion ratio – 4:1Low attempt to completion ratio – 4:1
 Self poisoning more common and drowningSelf poisoning more common and drowning
 Fewer warning signsFewer warning signs
 Greater planning and resolveGreater planning and resolve
 Low contact with mental health servicesLow contact with mental health services
(11%)(11%)

10. Characteristics of elderly suicide
completers
 Elderly suicide completion is also associated with:Elderly suicide completion is also associated with:
 Past history of suicide attemptPast history of suicide attempt
 Mental disorder ( 90%),Depression ( 66%)Mental disorder ( 90%),Depression ( 66%)
 Physical illness and functional impairmentPhysical illness and functional impairment
 Social isolationSocial isolation
 Recent life event/bereavementRecent life event/bereavement
 Suicide pactsSuicide pacts

11. Service utilisation of elderly
suicide completers
 But 54 % >75 known to services had contactBut 54 % >75 known to services had contact
within last 7 dayswithin last 7 days
 51 % under CPA51 % under CPA
 Only 6% reported suicidal ideation at last contactOnly 6% reported suicidal ideation at last contact
 7% inpatients7% inpatients
 19 % 3 months post discharge19 % 3 months post discharge
 21 % viewed as preventable21 % viewed as preventable
 Majority see PCP within one month of suicideMajority see PCP within one month of suicide

12. Risk factors
Genetics
Family Hx
Psychiatric disorder
PersonalitySocial milieu

13. Studies on suicidal ideations
 Among 516 elderly aged 70 or above inAmong 516 elderly aged 70 or above in
Berlin (Linden & Barnow, 1997):Berlin (Linden & Barnow, 1997):
 14.7% said that life is not worth living14.7% said that life is not worth living
(77.5% had depression)(77.5% had depression)
 5.4% wished to be dead or thought about5.4% wished to be dead or thought about
suicide (95.7% had depression)suicide (95.7% had depression)
 1.0% showed suicidal ideas or gestures1.0% showed suicidal ideas or gestures
(100% had depression)(100% had depression)

14. Completer- 30/100,000
Attempter – 100/100,000
Suicidal Intentions – 1-5%
Life not worth living – 15-19%
Normal – 80%

15. Normal
Slightly
depressed
Life
Not
Worth
Living
Suicidal
Intentions
Attempters Completers
TIME-LINE

16. Evidence-based means and tools
 Gotland study (RihmerGotland study (Rihmer et alet al, 1995):, 1995):
 depression-related suicide rates decreased withdepression-related suicide rates decreased with
training programme for general practitioners ontraining programme for general practitioners on
the diagnosis and treatment of depressionthe diagnosis and treatment of depression
 In UK negative correlation between antiIn UK negative correlation between anti
depressant prescribing and suicidedepressant prescribing and suicide
 TeleHelp-TeleCheck service (De LeoTeleHelp-TeleCheck service (De Leo et alet al, 2002):, 2002):
 reduction in elderly suicide rates afterreduction in elderly suicide rates after
introduction of tele-help serviceintroduction of tele-help service

17. What do we know about elderly
suicide?
5.5. Low utilisation rate of psychiatric service among elderly suicideLow utilisation rate of psychiatric service among elderly suicide
completers may reflect lack of awareness and stigmatisation in thecompleters may reflect lack of awareness and stigmatisation in the
community (Chiucommunity (Chiu et alet al, 2004), 2004)
6.6. Suicidal ideations and intentions are highly correlated withSuicidal ideations and intentions are highly correlated with
depressive disorder and are useful key markers for identification ofdepressive disorder and are useful key markers for identification of
at-risk individuals (Linden & Barnow, 1997)at-risk individuals (Linden & Barnow, 1997)
7.7. Programme aimed at educating primary care physicians aboutProgramme aimed at educating primary care physicians about
depression has been shown to reduce suicide rate, e.g. Gotlanddepression has been shown to reduce suicide rate, e.g. Gotland
study (Rihmerstudy (Rihmer et alet al, 1995), 1995)
8.8. Telecheck shown to be a useful tool in providing care for elderly atTelecheck shown to be a useful tool in providing care for elderly at
risk of suicide and reduce suicide rate (De Leorisk of suicide and reduce suicide rate (De Leo et alet al, 2002), 2002)
9.9. Relevant and locally validated instruments are available, e.g. GDSRelevant and locally validated instruments are available, e.g. GDS

18. Strategies in suicide prevention
 Universal preventionUniversal prevention
 Selective preventionSelective prevention
 Indicated/targeted preventionIndicated/targeted prevention

20. Important features of Service
 Improved access:Improved access:
 Increased capacity for detection through theIncreased capacity for detection through the
use of standardised instruments and traininguse of standardised instruments and training
of non-medical personnel ( Columbia )of non-medical personnel ( Columbia )
 Free-flow of patients betweenFree-flow of patients between
primary/secondary care according to needsprimary/secondary care according to needs
assessmentassessment

21. Early detection
1.1. Raising the awareness of target referrers andRaising the awareness of target referrers and
general public:general public:
a.a. Promotional and bibliographic materialPromotional and bibliographic material
b.b. Liaison with target medical referrersLiaison with target medical referrers
c.c. Liaison with non-medical target referrersLiaison with non-medical target referrers
d.d. EducationEducation

22. Early detection
2.2. Improving access to serviceImproving access to service
a.a. Setting-up of Fast Track ClinicSetting-up of Fast Track Clinic
b.b. Early intervention serviceEarly intervention service
c.c. Non-medical referral ?Non-medical referral ?

23. Effective and adequate
management
1.1. Individual biopsychosocial assessment withIndividual biopsychosocial assessment with
early intervention serviceearly intervention service
2.2. Multidisciplinary approach includingMultidisciplinary approach including
involvement of referrerinvolvement of referrer
3.3. Regular case conferenceRegular case conference
4.4. Adequate biological and psychosocial treatmentAdequate biological and psychosocial treatment
5.5. Coordination of psychosocial support andCoordination of psychosocial support and
mobilising resources from the communitymobilising resources from the community
6.6. Intensive follow-up by home visitsIntensive follow-up by home visits
7.7. Dedicated In-patient facilityDedicated In-patient facility

24. Assessment of suicidal risk
 Asking about suicidal inclinations does notAsking about suicidal inclinations does not
make suicidal behaviour more likelymake suicidal behaviour more likely
 Willingness to make tactful but direct
enquiries about a patient’s intention
 Be alert to factors that signify an increased
risk of suicide

25. Assessment of suicidal risk
 Consider known risk factorsConsider known risk factors
 Assess current suicidal riskAssess current suicidal risk
 Assess suicidal intent – planning,Assess suicidal intent – planning,
preparation, precaution against discovery,preparation, precaution against discovery,
final rite, verbal cues, suicide notefinal rite, verbal cues, suicide note
 Collateral informationCollateral information

26. Suggested questioning sequence
 Whether the patient:Whether the patient:
 hopes things turn out wellhopes things turn out well
 gets pleasure out of lifegets pleasure out of life
 feels hopeful from day to dayfeels hopeful from day to day
 feels able to face each dayfeels able to face each day
 ever despairs about thingsever despairs about things
 feels life to be a burdenfeels life to be a burden
 wishes it would all endwishes it would all end

27. Suggested questioning sequence
 Whether the patient:Whether the patient:
 knows why he/she feels this wayknows why he/she feels this way
 has thought of ending lifehas thought of ending life
 has thought about the possible methodshas thought about the possible methods
 has ever acted on any suicidal thoughts orhas ever acted on any suicidal thoughts or
intentionsintentions
 feels able to resist any suicidal thoughtsfeels able to resist any suicidal thoughts

28. Data Collection Method Face-to-face interviews
Sample Design A random sample of 917 ethnic
Chinese people aged 60 and
above living in Hong Kong
Fieldwork Period October 1999 - February 2000
RESPONSE RATE : 73%

29. Significant factors to Suicidal Wishes
Factors Odd
ratio
95% CI p-value Factors Odd
ratio
95% CI p-value
Female 1.00 PSMS 1.26 1.08 1.48 0.0037
Widowed 1.94 1.03 3.65 0.0401 Freq. of
seeing doctor
1.17 1.08 1.27 0.0003
Self-rated
financially
insufficient
2.37 1.32 4.27 0.0041 Life event
Self-rated health
as unhealthy
2.90 1.63 5.16 0.0003 Relationship 1.61 1.01 2.56 0.0438
Incontinence 5.83 2.61 13.06 <0.0001 Robbed 5.41 1.44 20.36 0.0124
Vision problem 1.82 1.30 2.56 0.0005 Court case 11.89 1.94 72.84 0.0074
Hearing problem 1.59 1.15 2.20 0.0049 Active coping 0.86 0.79 0.93 0.0001
IADL 1.11 1.03 1.18 0.0043 Depressed 13.48 7.34 25.76 <0.0001

30. Significant multiple risk factors to Suicidal Wishes
Factors Odd ratio 95% CI p-value
Number of
diseases
1.76 1.07 2.90 0.0260
Vision problem 3.34 1.24 9.04 0.0173
Hearing problem 2.74 1.13 6.64 0.0255
Court case 57.42 1.29 2557.90 0.0365
Depressed 7.23 1.52 34.38 0.0129

31. Significant factors to Depression
Factors Odd
ratio
95% CI p-value Factors Odd
ratio
95% CI p-value
Divorced 3.76 1.38 10.23 0.0095 Vision problem 1.85 1.47 2.35 <0.0001
Living alone 1.00 Hearing problem 1.22 0.96 1.53 0.0981
Spouse only 0.38 0.19 0.73 0.0039 IADL 1.14 1.09 1.20 <0.0001
Spouse & children 0.36 0.21 0.61 0.0002 PSMS 1.36 1.17 1.57 <0.0001
Children only 0.36 0.20 0.64 0.0005 Freq. of seeing
doctor
1.11 1.04 1.19 0.0021
CSSA 2.31 1.44 3.72 0.0005 LSNS 0.93 0.91 0.95 <0.0001
Self-rated
financially
insufficient
5.01 3.35 7.51 <0.0001 Life event
Self-rated health as
unhealthy
3.52 2.37 5.24 <0.0001 Relationship 1.71 1.22 2.40 0.0019
Memory (cognition) 0.78 0.69 0.88 <0.0001 Financial
problems
1.55 1.17 2.06 0.0021
Number of diseases 1.28 1.10 1.50 0.0015 Active coping 0.83 0.78 0.88 <0.0001
Chronic pain 2.84 1.90 4.25 <0.0001

32. Data Collection Method Face-to-face interviews
Sample Design
Control group: a random sample
of 100 elderly people aged 60 and
above, with age and sex matched
to the suicide group
Fieldwork Period March 2000 – June 2001
Suicide group: 62 cases of people
aged 60 and above who had
committed suicide
RESPONSE RATE : 76%

33. Significant factors to predicting suicide
Factors Odd
ratio
95% CI p-value Factors Odd
ratio
95% CI p-value
No. of diseases 2.18 1.56 3.05 <0.0001Life events w/in
1 yr
Cancer 9.14 2.5 33.35 0.0008 Change of living
arrangements
6.53 2.37 17.99 0.0003
IADL 1.28 1.15 1.43 <0.0001 Death/illness 15.13 4.95 46.26 <0.0001
PSMS 1.53 1.13 2.07 0.0058 Relationship 21.97 2.79 173.05 0.0033
Pain 23.66 6.75 82.96 <0.0001Constipation 29.99 3.85 233.86 0.0012
Last seen a doctor 0.0002 NEO-PI
Less than a month 9.31 2.99 28.93 0.0001 Neuroticism 1.17 1.09 1.25 <0.0001
1 to <2months 4.34 1.15 16.45 0.0307 Extraversion 0.87 0.8 0.94 0.0007
Hospitalised due to
psychiatric disease
24.20 5.43 107.91 <0.0001  Openness to
experience
0.83 0.74 0.92 0.0009
Suicide attempt 20.77 4.63 93.17 0.0001 Agreeableness 0.89 0.81 0.97 0.0104
At least 1 Life
diagnosis
16.54 4.68 58.48 <0.0001 Conscientious-
ness
0.79 0.71 0.88 <0.0001
Major depression
diagnosis
10.32 2.85 37.39 0.0004 Current major
depression
diagnosis
41.91 11.96 146.84 <0.0001
At least 1 current
diagnosis
68.2524.85 187.40 <0.0001

34. Summary
 Suicide rate fallen in elderly over last 20 yrsSuicide rate fallen in elderly over last 20 yrs
 No gender difference in elderly suicideNo gender difference in elderly suicide
 Most mentally ill, >70 % depressedMost mentally ill, >70 % depressed
 Risks include isolation, physical illness andRisks include isolation, physical illness and
bereavementbereavement
 Self poisoning/hanging commonest methodSelf poisoning/hanging commonest method
 Suicide pacts (marital) more commonSuicide pacts (marital) more common
 Least engaged with mental health servicesLeast engaged with mental health services