Late life psychache – who cares?

1. Late life psychache –who cares? by John Snowdon “After age 60, suicide accounts for an inconsequential proportion of all deaths” !!!!!!!!!!!!!!

2. Late life psychache – who cares? • What is psychache? • Rates and age patterns of male and female suicide in different countries, across time. Why the differences? • Causation of late life suicide. Mental illness? Distress? Emotional reaction? Importance of psychache. • Older people requesting assisted suicide or euthanasia. • Prevention of late life suicides. Reducing psychache. Optimising self-esteem and mental health in old age.

3. Psychache • Shneidman (1999) coined the term ‘psychache’ to describe intensely felt psychological pain – a hurt, anguish or ache that takes hold of the mind … introspectively felt mental pain of negative emotions such as guilt, shame, humiliation, fear, panic, angst, loneliness, helplessness, dread of growing old… • Suicide occurs when the psychache is deemed to be unbearable – to stop the unceasing flow of intolerable consciousness. Shneidman E (1999) ‘Perturbation and lethality. In D.G.Jacobs (ed.) The Harvard Medical School Guide to Assessment and Intervention. Jossey-Bass, San Francisco

4. Questions to ask about late life suicide • Is suicide always or usually due to psychache? • How commonly is suicide attributable to mental disorder (in particular, depression)? • If not a result of mental disorder, what’s the cause? • What evidence have we got about causation of suicide?

6. MALE: Suicide rate per 100,000 per year in New Zealand

7. MALE: Suicide rate per 100,000 per year in New Zealand

8. MALE: Suicide rate per 100,000 per year in New Zealand

9. MALE: Suicide rate per 100,000 per year in New Zealand

10. FEMALE: Suicide rate per 100,000 per year in N.Z.

11. FEMALE: Suicide rate per 100,000 per year in N.Z.

12. FEMALE: Suicide rate per 100,000 per year in N.Z.

14. Psychache • Shneidman (1999) coined the term ‘psychache’ to describe intensely felt psychological pain – a hurt, anguish or ache that takes hold of the mind … introspectively felt mental pain of negative emotions such as guilt, shame, humiliation, fear, panic, angst, loneliness, helplessness, dread of growing old… • Suicide occurs when the psychache is deemed to be unbearable – to stop the unceasing flow of intolerable consciousness. Shneidman E (1999) ‘Perturbation and lethality. In D.G.Jacobs (ed.) The Harvard Medical School Guide to Assessment and Intervention. Jossey-Bass, San Francisco

15. E&W 1951 OZ 1951 OZ 2001-2 E & W 2001-2

16. SOURCE: Ji J, Kleinman A & Becker AE (2001). Harvard Rev. Psychiatry 9, 1-12.

17. SOURCE: Takahashi Y et al (1995). Int. Psychogeriatrics 7, 239-251.

18. SOURCE: Skegg K et al (1995). Acta Psych Scand 92, 453-9 AGE (years)

19. SOURCE: Mosciki EK (1999), page 42, Harvard Medical School Guide to Suicide Assessment & Intervention (ed DG Jacobs). Jossey-Bass, San Francisco.

20. Why the big difference between male & female rates ?Why the difference in ratio of male to female rates betweenNZ, Australia, E&W and China ?Why the differing ratios between age-groups & across time ?

21. Why the differences? • Do we think that mental illness is three times more common in men than women? (in NZ and Australia, but not in China?) • Do we think that mental illness became much more common in young people in NZ in the 1980s (but not in China) – and much less common among people aged 60 to 79 in NZ over the last few decades…..?

22. Why the differences? • Statistical bias in collection of data? • Differences between countries and over time in the way data are collected? • Changes in the rates of being able to determine whether suicide was the cause of death (“undetermined”, “open verdict”) [UK, Australia]?

23. Yang, Phillips, Zhou et al (2005) • Psychological autopsy study of 895 suicide victims from 23 representative locations around China, 90% response rate. • Pesticide ingestion accounted for 519 (58%). • 63% of suicide victims had a mental illness, in contrast to 17% of control accidental death victims. • 40% of the suicide victims had mood disorders, 9% psychotic disorders, 14% other mental disorders. • Higher rate of mental disorder in men who died by suicide (67% v. 58%) and in urban dwellers (75% v. 60%). • Young rural females who died from suicide had the highest rates of pesticide ingestion (79%) and lowest prevalence of mental illness (39%). Distress. Personality-related emotional reactions.

24. What do we understand from the China data? • Phillips et al (2002): people refer to the low status and limited opportunities for women in China, but women in many developing countries have low social status and are subject to domestic violence , without having correspondingly high female suicide rates. • Importance of acute stressors (e.g. family conflicts) as suicidal precipitants in absence of mental disorder. Impulsivity noted more commonly among completed suicides. Impulsive pesticide use: China >> NZ. • Instead of mental disorder, call it stress-related distress, emotional turmoil: personality factors determine how people react to mind-shattering circumstances.

25. Henriksson et al (1995), Int. Psychogeriat. PSYCHOLOGICAL AUTOPSY STUDYDSM-III-R diagnoses of suicide victims

26. Conwell et al (1996), Am J Psych 153, 1001-8 PSYCHOLOGICAL AUTOPSY STUDYDSM-III-R diagnoses of 141 (male 113) suicide victims * = significant

27. Suicides in older adults: a case-control psychological autopsy study in Australia(De Leo, Draper, Snowdon and Kõlves, J.Psychiatric Research 2013)Response rate of n.o.k. of suicides 46.6% Suicides (73 aged 60+) Suicides (188 aged 35 to 59) Psychiatric diagnoses in 80% Mood disorders 58.1% Major depression 18% Melancholic depression 23.7% Other depression 9% Bipolar depression 4% • Psychiatric diagnoses in 62% • Mood disorders 46.6% • Major depression 18% • Melancholic depression 20.5% • Other depression 8%

28. Mood disorders in cases of suicide • Smaller % among female than male suicides in China • Smaller % among male and female suicides in China than in NZ etc. • Smaller % among rural (than urban) dwellers who killed themselves in China • Smaller % among middle-aged than late life suicides in some studies but not in others (De Leo et al, etc)

29. How often is suicide attributable to mood disorder? • Although various psychological autopsy studies have shown high rates of mental disorder, especially depression, among people in high-income countries who killed themselves, others showed a substantial proportion (⅓ to ½) didn’t have a diagnosable mental disorder. • Studies show that a multitude of factors (with or without diagnosed mental disorders being present) may have contributed to causation of suicide. • Note that the prevalence of severe mental disorder in NZ is ? 5%, with another 10%+ having less severe psych problems. Yet only 1% of us in NZ & Australia will die by suicide. We’re not good at predicting which of the 5% (or the other 95%) will die by suicide. • Personality factors contribute to causation. Precipitants differ for men and women. What boosts/shatters their self-esteem? • Cultural variation.

30. Suicide risk factors(R.Goldney, Chad Buckle address) • Male • Previous history of suicidal behaviour • Family history of suicide • Mental disorders -- depression, substance abuse, schizophrenia • Hopelessness, despair, guilt • Social isolation – e.g. by separation/divorce (but not in China!) • Childhood deprivation – parent loss, violence, sexual abuse • Chronic physical illness • Custody/prison • Indigenous • Sexual identity issues

31. Let’s add (and we could classify as proximal and distal) • Personality and individual vulnerabilities • Impulsivity, perfectionism, neuroticism, sensitivity • Cognitive rigidity and rumination; unfulfilled needs • Low extroversion: being socially disconnected, with thwarted belongingness. • Feeling a burden on others; helplessness • Interpersonal stressors, and inability to escape: trapped! • Other negative life events: stress • Neurobiological factors, including genetic: abnormal serotonin system; frontal brain changes. • Diathesis (vulnerabilities)/stress model – distal/proximal The diathesis model explains why so few of those exposed to psychiatric disorders and other stressors will die by suicide.

32. So what’s different about late life suicide?Unlike a majority of younger or middle-aged people, • Commonly, the person lived alone, their partner having died or been admitted to residential care. They’ve lost their friends, they’re no longer involved in work and social groups, and may have had to change accommodation. They feel socially disconnected. Depressing! • Commonly the person had functional impairments due to disabilities or chronic (often painful) illness. They worried about being a burden. They may have felt useless. Depressing! • Of those with depressive illnesses, half or more will have been of late onset (age 65+), and may have had brain changes. • The person is less likely to have been referred to a mental health specialist or team, though 77% (in Australia) will have visited a GP in the three months prior to death.

33. NZ comparison of late life suicide and attempted suicide cases versus controls (Beautrais, 2002) • Adults aged 55 years or more. • 269 controls, mean age 67.6 years • 31 completed suicide (20 male, 11 female), mean age 65.2 years • 22 attempted suicide (7 male, 15 female), 17/22 self-poisoning, mean age 66.3 years Suicides versus controls: • Serious relationship problems: 17% v. 4% , p .001 (64% of each group were married) • Low social interaction in 26% versus 9%, p<.0001 • Current serious physical illness: 26% versus 19% (not significant) • Current DSM-III-R mood disorder: 64.5% v. 1.5% , p<.0001 • Any mental disorder: 74% versus 9%, p<.0001 • Childhood sexual abuse: 11% versus 4%, p<.001 • Risk of serious suicidal behaviour adjusted for confounding factors: Mood disorder in prior month O.R. 179, psych admission in last year O.R. 24 Low social network O.R. 4.5 (p<.013)

34. Why the big fall in suicide rates of men aged 60+( and reduced female rate 60-79 years ) ? • Do clinicians recognise and treat late life depression (and anxiety and psychoses) better than they used to, with more effective antidepressants, antipsychotics and talking treatments? • Are older people more likely than the young to have treatable types of depression? • Are depressing physical problems being treated better? • Is there improved recognition and provision for the needs of older people? Better services for disabled people? • Have there been changes in the way suicide data are gathered? Are doctors less inclined to record deaths as suicides in cases of terminal illness? Has there been an increase in deaths registered as of undetermined cause? Reduced autopsy rates? • ? Cohort effect. • Have older people changed to using less lethal suicide methods? Changes in preferred method of suicide.

35. Why suicide rate of older persons has fallen, though it remains higher among males • Increased and improved use of antidepressants. • Doctors recognise & treat late life depression better. Less ageist. • Better treatment of distressing (e.g. painful) physical disorders. • Environmental & socio-political improvements. • But women maintain more satisfying roles and networks.

36. How commonly is old age suicide attributable to depression?

37. Depression in old age Prevalence 13% in UK, US, NZ - but this includes: adjustment disorder with depressed mood ‘subthreshold’ depressions (often as disabling & significant as ‘major’ depressions) Depressions associated with physical illness (e.g. Parkinson’s, stroke, cancer, etc.) or with dementia Older person commonly denies depression. May be ‘masked’ and present as a physical problem, or with apathy, irritability or being demanding.

38. Depressive conditions: • Depression associated with loss/lack • - of loved one • - of source of self-esteem / morale or satisfaction • Depression associated with physical disorders • - psychological • - neurobiochemical • Depression related to drug/alcohol abuse or depressant substances • Depression associated with other functional disorders (e.g. schizophrenia) • Major depression with melancholia • Psychotic depression • Depression in cases of bipolar disorder

39. Prevalence of depression in association with physical/organic illnesses

40. The male suicide rate in New Zealand and Australia reaches a second peak at age 85+ years. Is this attributable to “rational” suicide ?

41. SUICIDE: AUTOPSY STUDIESCattell H and Jolley DJOne hundred cases of suicide in elderly people (Central Manchester)British Journal of Psychiatry 1995, 166, 451-456Cattell HRElderly suicide in London: an analysis of coroner’s inquestsInternational Journal of Geriatric Psychiatry 1988, 3, 251-261.Harwood D et al Coroner’s files (195 cases), with psychological autopsy of 100International Journal of Geriatric Psychiatry 2001, 16, 155-165.

42. Of 210 suicides of older people whose files we saw at Glebe Coroner’s Court, we agreed that: • 160 were definitely depressed • 25 were possibly depressed • 25 did not fulfil criteria for a depressive disorder 3 schizophrenia or paranoid state 1 PTSD and 1 Delirium Snowdon J, Baume P (2002). A study of suicides of older people in Sydney. International Journal of Geriatric Psychiatry 17, 261-269.

44. 122 (58%) had a disability or illness that we identified as a major factor contributing to the suicide40 (19%) had cancer at death or treatment for cancer in the last year

45. 10were in hospital5were in nursing homes5were in hostelsat the time of death4had said they’d rather die than go into a nursing home

46. We asked why these 210 people took the decision to kill themselves

47. Dementia Schizophrenia “Rational” Untenable situation Undetermined or multi-factorial Depression • Delusional/endogenous depression • Non-melancholic “reactive’ depression • Bereavement • Depression with physical illness or disability

48. Depression associated with a physical condition Where physical illness (e.g. stroke or coronary bypass) had precipitated a depression, and then depressive perceptions appeared to dominate the person’s life.

49. Untenable situation

50. What did we include as ‘rational’ decisions? A decision was made that pain, discomfort or handicap had made life unbearable for themselves and/or a burden for another person. Up to half would have been expected to die from their physical condition within one year. Some owned ‘Final Exit’. A majority were depressed because of their physical condition.