Abstract
Objectives: To conduct a systematic review of studies that examined associations between physical illness/functional disability and suicidal behaviour (including ideation, nonfatal and fatal suicidal behaviour) among individuals aged 65 and older.
Method: Articles published through November 2014 were identified through electronic searches using the ERIC, Google Scholar, PsycINFO, PubMed, and Scopus databases. Search terms used were suicid* or death wishes or deliberate self-harm. Studies about suicidal behaviour in individuals aged 65 and older with physical illness/functional disabilities were included in the review.
Results: Sixty-five articles (across 61 independent samples) met inclusion criteria. Results from 59 quantitative studies conducted in four continents suggest that suicidal behaviour is associated with functional disability and numerous specific conditions including malignant diseases, neurological disorders, pain, COPD, liver disease, male genital disorders, and arthritis/arthrosis. Six qualitative studies from three continents contextualized these findings, providing insights into the subjective experiences of suicidal individuals. Implications for interventions and future research are discussed.
Conclusion: Functional disability, as well as a number of specific physical illnesses, was shown to be associated with suicidal behaviour in older adults. We need to learn more about what at-risk, physically ill patients want, and need, to inform prevention efforts for older adults.
Introduction
Older adults have higher rates of suicide than younger age groups in most countries that report mortality data to the World Health Organization (Värnik, Citation2012), with those 85–90 years old constituting the age group with the highest rates (Shah, Bhat, Zarate-Escudero, De Leo, & Erlangsen, Citation2015). According to the US data, for each suicide in the general population, there are 25 episodes of nonfatal suicidal behaviour. This ratio approaches 1:4 in older adults (Drapeau & McIntosh, for the American Association of Suicidology, Citation2015).
Physical illness and functional disability are common in late life and may lead to loss of autonomy, isolation, pain, increased burden on social networks, and the development of depression. Older adults who die by suicide often consult their physicians within weeks of their death (Ahmedani et al., Citation2014; Innamorati et al., Citation2014). Physical ailments are often the focus of these visits, and mental distress and suicidal feelings are often unaddressed (Waern, Beskow, Runeson, & Skoog, Citation1999).
Although prior reviews have considered the role of physical illness and functional disability (Conwell, van Orden, & Caine, Citation2011; O'Connell, Chin, Cunningham, & Lawlor, Citation2004), no systematic review has explicitly studied this in older adults. We aimed to systematically review the evidence of a relationship between physical illness and functional disability and (1) death wishes, (2) suicidal ideation, (3) nonfatal suicidal behaviour, and (4) suicide in older adults (age 65 and older). The following questions were addressed:
Which physical conditions are associated with death wishes, suicidal ideation, nonfatal suicidal behaviour, and/or suicide in older adults?
What are the implications for the prevention of suicidal behaviour in older adults?
What areas are in need of research?
Methods
Guidelines from the Cochrane Collaboration were used (Higgins, Green, & Cochrane Collaboration., Citation2008). Eligibility criteria included (1) peer-reviewed publication in English, (2) focused on persons >64 years of age, (3) examined (a) death wishes, suicidal ideation, nonfatal suicidal behaviour/self-harm, or suicide, and (b) an indicator of physical health. Studies focusing on cognitive disorders, including dementia, were excluded as these were considered mental disorders in accordance with the DSM IV/ICD 10 diagnostic systems. Quantitative studies that lacked relevant comparison groups were also excluded.
Studies were identified through electronic searches using the ERIC, Google Scholar, PsycINFO, PubMed, and Scopus databases. Search terms used were suicid* or death wishes or deliberate self-harm. No search terms relating to physical health were applied. All publication years were considered. Carried out during October–November 2014, the combined searches yielded 31,985 references. If a title or an abstract appeared to describe a study that included older persons, physical illness/functional disability, and suicidal behaviour, the full article was retrieved and examined for relevance. The authors also found several studies not obtained through the search. A total of 65 articles (based on 61 samples) met the inclusion criteria. These studies were subsequently classified as population-based, register-based, clinical cohort, or post-mortem.
Results
– provide details regarding the quantitative studies.
Table 1. Population-based studies.
Table 2. Register-based studies.
Table 3. Clinical studies.
Table 4. Post-mortem studies.
Physical illness
Population and register studies
Thirteen population-based studies were retrieved. Associations between physical illness and death wishes were observed in a Canadian study (Lapierre et al., Citation2015) and in one that utilized pooled data from 11 European countries (Fässberg et al., Citation2014). In population studies from Sweden (Fässberg, Östling, Börjesson-Hanson, Skoog, & Waern, Citation2013; Skoog et al., Citation1996) and Italy (Scocco, Meneghel, Caon, Dello Buono, & De Leo, Citation2001), questions regarding suicidal feelings also encompassed life-weariness and death wishes (Paykel, Myers, Lindenthal, & Tanner, Citation1974). Two (Scocco et al., Citation2001; Skoog et al., Citation1996) of the three studies reported associations of suicidal feelings with physical illness. Associations between physical illness and suicidal ideation did not persist in multivariate models in Taiwanese (Yen et al., Citation2005) and South Korean (Kang et al., Citation2014) studies.
Studies focusing on associations between physical illness and suicide mortality also showed mixed results. No association was found between the number of chronic illnesses and suicide in a US population-based study (Turvey et al., Citation2002). Having any of nine specific physical illnesses was not associated with suicide in a register study conducted in the United States (Miller, Mogun, Azrael, Hempstead, & Solomon, Citation2008), but having been hospitalized on a medical ward during the past two years was associated with increased risk of suicide in a Danish register study (Erlangsen, Vach, & Jeune, Citation2005).
Clinical studies
Medical comorbidity was associated with suicidal ideation in a US-based study of homecare recipients (Raue, Meyers, Rowe, Heo, & Bruce, Citation2007), but no association was found between medical conditions and suicidal thinking in Singaporean patients with depressive symptoms (Tan & Wong, Citation2008). Total illness burden was greater in US primary care patients with suicidal ideation, as compared to those without suicidal ideation (Hirsch, Duberstein, Chapman, & Lyness, Citation2007). A similar result was found among psychiatric inpatients in Israel who had engaged in nonfatal suicidal behaviour prior to hospitalization (Levy, Barak, Sigler, & Aizenberg, Citation2011).
Post-mortem studies
Three psychological autopsy studies examined the relationship between physical illness and suicide. Having any serious physical condition, as rated by the Cumulative Illness Rating Scale-Geriatrics (CIRS-G), associated strongly with suicide in a study conducted in Sweden, and the relationship remained after adjusting for depression (Waern et al., Citation2002). Associations between the number of physical illnesses and both nonfatal suicidal behaviour and suicide were shown in a Hong Kong-based study (Tsoh et al., Citation2005). Increased odds of suicide were found among older adults with one and two physical illnesses in a Chinese study (Jia, Wang, Xu, Dai, & Qin, Citation2014).
Subjective health
Population studies
In studies from four continents, poorer self-rated health was associated with wish to die (Jorm et al., Citation1995; Lapierre et al., Citation2015), death wishes/suicidal ideation/nonfatal suicidal behaviour (Barnow, Linden, & Freyberger, Citation2004), suicidal ideation (Chan, Liu, Chau, & Chang, Citation2011), remote suicidal feelings (Scocco et al., Citation2001), and suicide (Turvey et al., Citation2002). Poor subjective health was associated with current suicidal ideation in a Japanese study (Awata et al., Citation2005), but results did not remain in the multivariate model. No relationship was observed between poor perceived health and suicidal feelings among Swedish 97-year-olds without dementia (Fässberg et al., Citation2013Citation), nor was an association found between poor/very poor self-rated health and past year suicidal ideation among community dwelling older adults in South Korea (Park, Citation2014).
Functional disability
Population studies
Eleven studies were retrieved. Associations between functional disabilities and death wishes were found in an Australian study (Jorm et al., Citation1995), and in a study based on pooled data from 11 sites across Europe (Fässberg et al., Citation2014). Relationships with suicidal ideation were observed in studies conducted in Taiwan (Chan et al., Citation2011) and South Korea (Kang et al., Citation2014; Lee, Hahm, & Park, Citation2013; Park, Citation2014). In Japan, impaired physical functioning was associated with current suicidal ideation in univariate, but not multivariate analyses (Awata et al., Citation2005).
Clinical studies
Higher mean number of limitations in activities of daily living (ADL) was observed among US recipients of home care with passive suicidal ideation (thoughts that life was not worth living or that one would be better off dead), as compared to those without suicidal ideation (Raue et al., Citation2007). Results did not persist, however, in the multivariate model. Limitations in instrumental ADL increased the odds of both nonfatal and fatal suicidal behaviour in Hong Kong (Tsoh et al., Citation2005).
Vision and hearing loss
Population and register studies
Significant associations between visual impairment and death wishes/suicidal feelings/thoughts were observed in some population studies (Forsell, Jorm, & Winblad, Citation1997; Jorm et al., Citation1995) but not in others (Fässberg et al., Citation2013; Lapierre et al., Citation2015). One hospital register study showed elevated suicide risk in those with cataract (Erlangsen, Stenager, & Conwell, Citation2015). Hearing loss was examined in two population-based studies; elevated risk of death wishes was observed in one (Jorm et al., Citation1995), but not in the other, which focused on 97-year-olds (Fässberg et al., Citation2013). Hearing loss did not predict suicide in a register-based study (Erlangsen et al., Citation2015).
Clinical studies
No association was found between vision impairment and suicidal ideation in a study that focused on homecare patients (Raue et al., Citation2007).
Post-mortem studies
A strong association between vision impairment and suicide was noted in one study (Waern et al., Citation2002).
Cardiovascular conditions
Population and register studies
A significant association between heart disease and past week suicidal ideation was noted in one population-based study (Chan et al., Citation2011). No association was found with past-year wish to die in another study (Lapierre et al., Citation2015). One register study reported no association between cardiovascular disease and suicide after adjusting for other predictive illnesses from the univariate analysis (Juurlink, Herrmann, Szalai, Kopp, & Redelmeier, Citation2004). Another study found no relationship between cardiac disease and suicide after adjustment for medical and psychiatric comorbidity (Voaklander et al., Citation2008). Null findings were observed in another register study that focused specifically on medicare recipients (Miller et al., Citation2008). A history of myocardial infarction (MI) was linked to suicidal feelings in a representative, population-based sample of 85-year-olds (Skoog et al., Citation1996), and to suicide in a hospital register study (Larsen, Agerbo, Christensen, Sondergaard, & Vestergaard, Citation2010).
Clinical studies
MI was linked to wishes to die in US primary care patients, also in multivariate models including a large number of factors (Kim, Bogner, Brown, & Gallo, Citation2006).
Post-mortem studies
Serious cardiac illness was observed in similar proportions (10 %) in suicide cases and matched population comparison individuals (Waern et al., Citation2002).
Results for several other specific cardiac conditions, as well as findings regarding hypertension and cholesterol are shown in –
Pulmonary conditions
Population and register studies
Respiratory problem was associated with wish to die in one population-based study (Lapierre et al., Citation2015), but the association did not hold in the adjusted model that included sex and depression. Asthma was associated with suicidal ideation in another population-based study (Chan et al., Citation2011). A slight increase in odds for suicide was observed in persons with chronic lung disease in one register study (Juurlink et al., Citation2004). Chronic obstructive pulmonary disease (COPD) was linked to suicide in three other studies (Erlangsen et al., Citation2015; Miller et al., Citation2008; Voaklander et al., Citation2008). However, adjusted results remained significant only for the study with the largest sample size (Erlangsen et al., Citation2015).
Post-mortem studies
COPD was associated with suicide risk in one study, but only univariate results were reported (Tsoh et al., Citation2005).
Gastrointestinal and renal disorders
Population and register studies
Self-reported digestive problems were linked to death wishes, but not in multivariate analyses (Lapierre et al., Citation2015). Peptic ulcer was associated with a threefold increase in odds for past month suicidal feelings in a population sample of 85-year-olds (Skoog et al., Citation1996). Having been prescribed medication for hyperacidity was not associated with suicide after adjustment for other predictive illnesses (Juurlink et al., Citation2004). Liver disease was linked to a higher risk of suicide in two register studies (Erlangsen et al., Citation2015; Voaklander et al., Citation2008). No association was found between renal disease and suicide in one register study (Voaklander et al., Citation2008), but another reported an association between endstage renal disease and suicide in adults aged 75 and older (Kurella, Kimmel, Young, & Chertow, Citation2005).
Genitourinary conditions
Population and register studies
In adjusted models, prostate and male genital disorders were associated with suicide in two register studies (Erlangsen et al., Citation2015; Voaklander et al., Citation2008), but not in a third which employed prescription data to detect these conditions (Juurlink et al., Citation2004).
Clinical studies
Urinary incontinence was associated with death wishes in primary care patients after adjustment for demographics, but not after functional status was included in the model (Kim et al., Citation2006).
Endocrine disorders
Population and register studies
Most population (Lapierre et al., Citation2015; Turvey et al., Citation2002) and register-based studies (Erlangsen et al., Citation2015; Juurlink et al., Citation2004; Kim et al., Citation2014; Miller et al., Citation2008) reported no association between diabetes and suicidal behaviour. A couple found univariate but not multivariate associations (Chan et al., Citation2011; Voaklander et al., Citation2008). Likewise, little evidence of a link between suicidal behaviour and thyroid or other endocrine disorders was found (Erlangsen et al., Citation2015; Lapierre et al., Citation2015).
Clinical and post-mortem studies
Similar null findings were noted in a clinical cohort of older adults with nonfatal suicidal behaviour (Tsoh et al., Citation2005), and in a post-mortem study (Waern et al., Citation2002).
Neurological conditions
Population and register studies
Two register studies demonstrated a two-threefold increase in suicide risk in older adults with seizure disorders (Erlangsen et al., Citation2015; Juurlink et al., Citation2004). Cerebrovascular disease/hemiplegia was also linked to suicide (Erlangsen et al., Citation2015). Associations with stroke were observed in adjusted analyses in two register studies (Teasdale & Engberg, Citation2001; Voaklander et al., Citation2008), but not in a third (Miller et al., Citation2008). One population-based study showed an association between migraine headache and suicidal ideation (Chan et al., Citation2011). A second examined a potential association between migraine headache and wish to die, but no relationship was found (Lapierre et al., Citation2015).
Post-mortem studies
Serious neurological disorders (dementia excluded) were associated with a nearly ninefold increase in odds for suicide in one study based on informant reports and medical record review (Waern et al., Citation2002).
Pain
Population and register studies
Pain was associated with wish to die (Jorm et al., Citation1995) and suicidal ideation (Awata et al., Citation2005) in older adult populations. Three pain levels (mild, moderate, and more severe) were all associated with baseline and incident past-month suicidal ideation, but not with persistent suicidal ideation (Kang et al., Citation2014). No association was found between aches and pains and suicidal feelings among 97-year-olds (Fässberg et al., Citation2013).
Clinical studies
An association between pain and suicidal ideation among home care recipients did not remain in adjusted analyses (Raue et al., Citation2007).
Musculoskeletal conditions
Population and register studies
A relationship between arthritis/rheumatism and past-year wish to die was observed in a population-based study (Lapierre et al., Citation2015). A link to suicide was also found in one register study (Erlangsen et al., Citation2015) but not three other studies (Juurlink et al., Citation2004; Miller et al., Citation2008; Voaklander et al., Citation2008). Osteoporosis was linked to excess risk of suicide among recently diagnosed hospitalized older adults (Erlangsen et al., Citation2015). Out of a range of fractures, only spinal fractures were found to be linked to suicide in adjusted analyses (Erlangsen et al., Citation2015; Turvey et al., Citation2002).
Clinical and post-mortem studies
An association between arthritis and nonfatal suicidal behaviour was reported in one study that compared a cohort of individuals hospitalized following a suicidal act and a population-based group (Tsoh et al., Citation2005). Parallel findings were demonstrated for the post-mortem cohort also included in that study ().
Cancer
Population and register studies
Nine register studies reported associations between cancer and various suicidal behaviours (Ahn et al., Citation2010; Crocetti, Arniani, Acciai, Barchielli, & Buiatti, Citation1998; Dormer, McCaul, & Kristjanson, Citation2008; Fang et al., Citation2012; Miccinesi, Crocetti, Benvenuti, & Paci, Citation2004; Miller et al., Citation2008; Misono, Weiss, Fann, Redman, & Yueh, Citation2008; Smailyte et al., Citation2013; Voaklander et al., Citation2008) while one showed no association (Tanaka et al., Citation1999). Lung cancer was linked to elevated risk of suicide in two studies (Erlangsen et al., Citation2015; Urban et al., Citation2013). Prostate and genital cancers were related to elevated suicide risk in males in three studies (Carlsson et al., Citation2013; Erlangsen et al., Citation2015; Fall et al., Citation2009).
Post-mortem studies
Studies from Hong Kong and Sweden showed strong associations between malignancy and suicide (Tsoh et al., Citation2005; Waern et al., Citation2002).
Age and sex effects
Population and register studies reporting age effects
Recent history of hospitalization on a medical ward was associated with high suicide risk in men aged 80 and older (Erlangsen et al., Citation2005). Another register study showed elevated suicide risk in prostate and genital cancers in men aged 80 and older, but not among men aged 70 to 79 (Fang et al., Citation2010).
Population and register studies reporting sex effects
While sex differences were not directly examined, suicide risk was analysed separately in men and women for 21 physical health conditions in a large Danish study (Erlangsen et al., Citation2015). Both gastrointestinal cancer and cardiovascular disease diagnosed within the past three years were associated with suicide risk in men but not in women. In contrast, elevated risk was seen in women with brain cancer and glaucoma, but not in men with these conditions. In a South Korean study, having one or more physical illnesses increased the odds of past year suicidal ideation in community dwelling men, but not in women (Jeon, Jang, Rhee, Kawachi, & Cho, Citation2007). In that same study, the reverse was found for self-reported poor health. A Swedish cancer register study showed a twofold risk of suicide in the 80 and older men only (Allebeck, Bolund, & Ringback, Citation1989). Several register studies showed mixed results (Allebeck & Bolund, Citation1991; Oberaigner, Sperner-Unterweger, Fiegl, Geiger-Gritsch, & Haring, Citation2014).
Post-mortem studies
When Swedish data for women and men were analysed separately, both (1) any serious physical condition and (2) high overall physical-illness burden showed significant associations for men, but not for women (Waern et al., Citation2002). Age-stratified analyses (Waern et al., Citation2003) demonstrated that serious physical health problems were associated with a fourfold increase in suicide risk in those aged 75 and older.
Qualitative studies
In studies from Taiwan (Ku, Tsai, Lin, & Lin, Citation2009; Lee, Tsai, Chen, & Huang, Citation2014), the Netherlands (Rurup et al., Citation2011) and Sweden (Van Orden et al., Citation2014), older adults with a history of suicidal ideation or behaviour were interviewed about the reasons for their suicidality, while in a Canadian study (Clarke, Korotchenko, & Bundon, Citation2012), older adults were interviewed about preparing for death. Finally, a study from Norway (Kjølseth, Ekeberg, & Steihaug, Citation2010) used a psychological autopsy method to understand the suicide motives of a sample of older adults, from the point of view of their surviving significant others.
In one of the Taiwanese studies (Ku et al., Citation2009), male veterans (N = 19, ages 73–85) were asked to describe what triggered their suicidal act. Frustration with illness, disability, and pain were mentioned by 95 % of respondents. Their quotes reveal what made, from their perspective, the illnesses and disabilities unbearable and suicidogenic: ‘I couldn't accept that I needed to take more and more pills . . . . So I tried to hang myself,’ said one veteran (p. 749). ‘I used to be a military officer. . . . very concerned . . . about my appearance and dignity. But after the stroke, I needed help to go to the toilet . . . . I felt that I was living without dignity,’ said another veteran (p. 749). Explanations for nonfatal self-harm were given by 54 women and 47 men aged 70–91 in the Swedish study (Van Orden et al., Citation2014). Twenty-four per cent mentioned how disability impacted on their functioning and autonomy (‘I can no longer do the things I used to do’), and 16 % explicitly associated their suicidal act with their physical illness or pain (‘I wanted to get away from the pain. I decided, I've had enough’) (p. 539).
In the second Taiwanese study (Lee et al., Citation2014), 17 women and 7 men, aged 65–84, and in psychiatric outpatient care, were asked what they believed precipitated their first episode of suicidal ideation in the prior year, as well as what prevented them from ‘executing’ the suicide. Illness and physical discomfort were at the top of the list of reported reasons for the suicidal ideation, with death seen as ‘a good way to resolve . . . [the] health problems’ (p. 4).
In a Dutch study (Rurup et al., Citation2011), interviews were carried out with a sample of adults who had indicated a wish to die in a previous survey. Seventeen of the 31 participants were aged 71–99. Exemplary quotes from three older women were ‘You can't do anything . . . I dread every day. Life is so boring (p. 208)’; ‘It's not nice to be old . . . . I always did everything myself, but I can't no longer (p. 208); and, ‘You're no longer useful . . . . you're not needed anymore’ (p. 209). These quotes suggest that the illnesses and disabilities were suicidogenic when they were experienced as depriving the individuals of their independence, sense of usefulness, and pleasure with living.
The Canadian study (Clarke et al., Citation2012) focused on the end of life plans of 19 women and 16 men who had at least three chronic health problems. These respondents, who were between the ages of 73 and 91 and mostly of European descent, were not interviewed about suicide, but the topic of suicide came up. Women more often spoke ‘of not wanting to burden others’ (p. 1414) as a reason for their interest in hastening their death. ‘[M]y daughter having to look after me, that's a big worry to me . . . . that's why I feel that we really should [be able to have] euthanasia,’ said an 87-year-old woman (p. 1410). Men tended to emphasize illnesses as a threat to their wish to be independent, powerful, and in control. ‘I don't want someone . . . to look after me, wash me, clean me,’ said a 79-year-old widower. A 75-year-old man said, ‘If I was to have a stroke and have to go to the hospital, how would I get my pills to end it?’ For many men, suicide appeared to be a way to regain dignity and control: ‘The hell with it! Go home and get the gun out and blow your brains out,’ a 79-year-old man stated (p. 1411). According to the authors’ study, ‘a bad death was defined [by the men in their study] in terms of a loss of autonomy that challenged their view of themselves as active, independent and masculine’ (p. 1409).
The Norwegian psychological autopsy study (Kjølseth et al., Citation2010) of reasons for older adult suicide was based on interviews with 63 informants (relatives, physicians, and home-based care nurses) regarding suicide of 19 men and 4 women aged 65–90 the informants knew well. These interviews were conducted two to six months after the suicide. According to the informants, the older person suffered from illnesses and other strains, such that life had become a burden and death had come to be viewed as a relief. The informants also reported that prior to their suicide, the individuals had said that they were ‘tired of living’. The informants generally viewed the older adult suicide as understandable. For example, the physician of a nearly 87-year-old man said he could understand his patient's decision because ‘He was old enough to die’ (p. 211).
Discussion
This systematic review identified 59 quantitative and 6 qualitative studies exploring the link between a variety of physical illnesses and functional disabilities and suicidal behaviours. While somewhat divergent results were obtained for studies focusing on physical illness per se, results were more consistent regarding functional disability and certain specific physical conditions, including malignant diseases, neurological disorders, male genital disorders, arthritis/arthrosis, COPD, and liver disease. Little support was found for associations with cardiovascular diseases in general but several studies showed elevated risk for MI. Many studies examined a possible link between diabetes and suicide behaviour, but few found evidence for such a connection. While results for renal disease were inconclusive, it should be acknowledged that renal disease can involve clinical complexities (dialysis withdrawal) (Bostwick & Cohen, Citation2009) not addressed in this systematic review.
Five qualitative studies contributed the perspectives of older adults on the reasons for their suicidality. A further study reported on the beliefs and attitudes of family members and formal care providers about the recent suicide of an older person they knew well. A common theme across studies was that the illnesses and disabilities were experienced suicidogenic when they threatened the person's independence, sense of usefulness, value, dignity, and/or pleasure with life.
Before results of this review are discussed further, methodological considerations need to be highlighted. Due to variability in definitions of suicidal behaviours and the large variation in physical illness exposures, we were unable to perform a meta-analysis. Also, few clinical studies were found with our search strategy. An alternative search approach (for example, a search that included disease names and employed full-text searches) might have yielded more studies. Another issue is that the degree to which findings were adjusted for potential confounders varied widely among studies.
A cut-off at age 65 was employed in this review. We are aware, however, that older adulthood is a social construct. In some cultures, people in their 40s or 50s might be considered older adults. Furthermore, only a handful of the studies in this review provided age-stratified suicide risk estimates. It is likely that physical health differentially impacts the risk of suicidal behaviour in persons in their early 70s, as compared to persons in their upper 90s. Conventional risk factors may be of less relevance in extreme old age, as suggested by the findings of the Swedish study on suicidal feelings in dementia-free 97-year-olds (Fässberg et al., Citation2013).
Relatively few studies presented sex-specific results. For many studies, the percentage of women in the sample was not reported. For those that did (see tables), proportions differed widely from study to study. There could be many reasons for this variability, including differing sex-ratios in the background population, in the rate of the particular physical condition being studied, geographical/cultural variations in the sex ratios for a particular type of suicidal behaviour, and differential reporting of suicide in women and men.
We acknowledge that any lack of association between suicidality and physical illness/functional disability might be due to inadequate power. This is less of a problem in register studies, which offer advantages in terms of large sample sizes, no loss to follow-up and objective information regarding dates of hospitalization. However, selection bias (many include hospitalized cases only) and lack of individual-level data are inherent disadvantages. Another limitation is that severity of conditions and time since diagnosis were rarely characterized. Adjustment to any medical condition takes time. Initial feelings of overwhelming hopelessness often abate.
A major limitation specific to the post-mortem studies is the use of proxy data. Informants, often next of kin, were interviewed shortly after the suicide. Their perspectives on the reasons for the suicide were therefore impacted by their recent loss as well as by their relation to the decedent. This is less of an issue in studies that also include data derived from medical records. Regarding the qualitative psychological autopsy study included in this review, it should be mentioned that the authors, who were also interviewers revealed that they considered older adult suicide to have been an acceptable choice for the older adults in their study. This position likely influenced what the authors asked of the informants and how they asked it, as well as the authors’ interpretations and conclusions.
Implications for families
This review of the literature provides risk estimates related to a large number of physical conditions, many of which may place significant strain on families and friends of the persons afflicted. While findings from the qualitative studies provide some clues about the thoughts and feelings of suicidal older adults with physical illnesses and/or disabilities, we need to know more about the consequences of specific types of physical conditions on individuals and their families, in order to inform interventions. The family is oftentimes the primary source of care for older persons living at home, even in countries like Sweden where municipalities have explicit obligations to provide care for their older adults (Triantafillou et al., Citation2010). Involving family members in the development and implementation of treatment plans for suicidal older persons should therefore be considered in both acute and long-term care settings (De Leo, Draper, & Krysinska, Citation2009; Fässberg et al., Citation2012).
Implications for non-government organisations (NGOs)
This study's findings can inform NGO suicide prevention centres to better map out, address, and plan services for suicidal older adults. An example of a suicide prevention model for older persons is the program developed by the CitationSamaritans of Singapore (SOS) (https://sos.org.sg/). In response to increasing suicide rates, the SOS started collaborating with similar NGOs, government bodies, and other service providers (e.g., day-care, hospitals, nursing homes). Their focus was on creating awareness of older adults with physical illness/disability who may be at heightened risk of suicide. This review identified a number of physical conditions that could be highlighted in educational interventions for staff working with older persons at NGOs, as well as other service providers.
Implications for clinicians
Quantifying the extent or severity of physical illness or functional disability in older patients will not identify potentially suicidal individuals. For example, a controlled psychological autopsy study that examined the last contact with a health professional of persons aged 60 and over who died of suicide or sudden death found that severity of physical illness and functional impairment did not distinguish the suicides from the sudden death cases (De Leo, Draper, Snowdon, & Kolves, Citation2013).
While this literature review found associations between suicidal behaviour and a number of physical illness and disability conditions, it should be pointed out that the risk estimates were rather modest, as compared to those reported for psychiatric illness (Waern et al., Citation2002). Comorbid physical and mental health problems are frequent, especially in older adults. A number of psychological autopsy studies focusing on older adults found that major depression was present in about half of cases (Conwell et al., Citation2011; Pompili et al., Citation2008). Therefore, clinicians working with suicidal older adults need to consider both medical and psychiatric morbidity when making choices regarding pharmacological treatment options. During the clinical consultation, asking older persons about how they are getting on with managing their medicines and activities needed for their medical conditions may provide clues to these older persons’ suicidal thoughts. Low self-efficacy and feelings of helplessness in dealing with the functional impairment and self-care activities interferes with the quality of life as well as adherence to medical regimens (Bane, Hughes, & McElnay, Citation2006; Chao, Nau, Aikens, & Taylor, Citation2005; Lindner, Foerster, & von Renteln-Kruse, Citation2014).
Integrating mental health care into primary care, medical specialty care, and geriatric health care can be an effective strategy for identifying and treating suicidal older people with physical conditions (Alexopoulos et al., Citation2009; Bensadon, Citation2015; Erlangsen et al., Citation2011; Gallo et al., Citation2013; Lindner, Foerster, & von Renteln-Kruse, Citation2013; Unützer et al., Citation2006; Williams et al., Citation2007). There is also a need for integrating mental health care and palliative care (Kasl-Godley, King, & Quill, Citation2014). Collaborative care models typically involve the following components: (1) improving routine screening and diagnosis of depressive disorders; (2) increasing provider use of evidence-based protocols for the proactive management of diagnosed depressive disorder; and (3) improving clinical and community support for patient engagement in treatment goal-setting and self-management (Thota et al., Citation2012). Promising findings notwithstanding (Alexopoulos et al., Citation2009; Gallo et al., Citation2013; Unützer et al., Citation2006), concerns have been raised about collaborative care's cost and sustainability (Almeida et al., Citation2012) and potential for disrupting workflow and undermining continuity of care (Wittink, Duberstein, & Lyness, Citation2013).
The findings of this review suggest that greater attention to, and expertise in suicide prevention is needed in specialty medical settings. Interventions involving specialty medical providers, particularly oncologists and neurologists, need to be developed. Although older adults seen in specialty medical care settings are also seen in primary care settings, those experiencing severe illnesses may be seen more frequently by specialists.
Future research
Most suicide prevention initiatives for older adults focus on depression screening and treatment (Lapierre et al., Citation2011). Such interventions may miss at-risk physically ill older adults who are distressed in ways not captured by conventional diagnostics (Epstein et al., Citation2010; Hjelmeland, Dieserud, Dyregrov, Knizek, & Leenaars, Citation2012; Kjølseth et al., Citation2010). We actually know little about what at-risk, physically ill patients want, and need, to help them relieve their distress. This paucity of data must be viewed in the context of the biomedical model's emphasis on diagnosis and treatment, which leaves little room for listening and empathically responding to the person's narrative (Duberstein & Wittink, Citation2015; Wittink et al., Citation2013). There is however cause for optimism. For example, advances in information technology could be used in connection with automated practice audits (Almeida et al., Citation2012) and for the facilitation of client-provider communication and decision-making (Duberstein & Wittink, Citation2015). A recent intervention study demonstrated increased clinician inquiry about suicide when older adults completed a brief computerized survey in the waiting room (Shah et al., Citation2014). More research is needed on whether eliciting and responding to older adults’ psychological needs in the context of medical care reduces the risk of suicidal behaviour and improves other health outcomes (Duberstein & Wittink, Citation2015).
While the topic of voluntary euthanasia was beyond the scope of the current review, it is likely that there is an overlap with suicide, especially in those with serious physical illness. The literature on the topic is sparse. One Australian psychological autopsy study focusing on persons aged 60+ addressed this issue, reporting that 8.5% of suicides belonged to a euthanasia group (De Leo et al., Citation2013). Many of the themes identified in the qualitative studies we reviewed (e.g., loss of autonomy, inability to engage in activities) were also observed among terminally ill persons of mixed ages who died under the Oregon Death with Dignity Act (Oregon Public Health Division, Citation2014). Relevant to the current paper is the finding that loss of control of bodily functions was endorsed by half of those who died in accordance with the Death with Dignity Act, highlighting the need for more research on the topic. There is also a need for more research on the withdrawal of life support, not just in renal disease (Bostwick & Cohen, Citation2009) but in other conditions as well.
Another question for future research is how and why suicide motivations may differ in older women and men, as well as, more generally, why older men in some cultures are more likely than older women to die by suicide under conditions of ill health and disability (Canetto, Citation1992; Citation1997). In this regard, we need to remember that there is significant variability, across cultures, in rates of older adult suicide as well as variability in female/male suicide rate ratios. Research on scripts of gender and aging, illness and suicide across cultures (Canetto & Lester, Citation1998; Stice & Canetto, Citation2008) would help make sense of the global variability in suicidality among older adult women and men, and would support the design of culture- and gender-grounded suicide prevention programmes.
Acknowledgements
This review involved a collaboration within the International Research Group on Suicide in Older Adults. Contact persons for the Interest Group are Annette Erlangsen ( [email protected]) and Sylvie Lapierre ( [email protected]).
Disclosure statement
No potential conflict of interest was reported by the authors.
Additional information
Funding
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