INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY Int J Geriatr Psychiatry 2008; 23: 135141.

Published online 21 June 2007 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/gps.1853

Suicide after hospitalization in the elderly: a population based study of suicides in Northern Finland between 19882003
sa nen 2, Helina Hakko 1, Markku Timonen 3, Kaisa Karvonen 1*, Pirkko Ra 4,5 rkioja 6 and Hannu J. Koponen 7 V. Benno Meyer-Rochow , Terttu Sa
1 2

Department of Psychiatry, Oulu University Hospital, Finland Department of Psychiatry, University of Oulu, Finland 3 University of Oulu, Department of Public Health Science and General Practice, Oulu Health Center, Finland 4 Jacobs University (formerly known as International University Bremen), School of Engineering and Science, Bremen, Germany 5 Departments of Physiology and Biology, University of Oulu, Finland 6 Department of Forensic Medicine, University of Oulu, Finland 7 Department of Psychiatry, University of Kuopio, Academy of Finland

SUMMARY
Objective Elderly people commit suicide more often than people under the age of 65. An elevated risk is also attached to depression and other axis I psychiatric disorders. However, little is known about the preferred suicide method, effect of primary psychiatric diagnosis, and length of time between discharge from psychiatric hospitalization and suicide. The lack of information is most apparent in the oldest old (individuals over 75 years). Methods On the basis of forensic examinations, data on suicide rates were separately examined for the 5064, 6574 and over 75 year-olds (Total n 564) with regard to suicide method, history of psychiatric hospitalization and primary diagnoses gathered from the Finnish Hospital Discharge Register. Study population consisted of all suicides committed between 1988 and 2003 in the province of Oulu in Northern Finland. Results Of the oldest old, females had more frequent hospitalizations than males in connection with psychiatric disorders (61% vs 23%), of which depression was the most common (39% vs 14%). In this age group, 42% committed suicide within 3 months after being discharged from hospital and 83% used a violent method. Both elderly males and females were less often under the inuence of alcohol, but used more often violent methods than middle-aged persons. Conclusions Suicide rates within the rst 3 months following discharge from hospital in the 6574 and the over 75 year olds were substantial and should inuence post-hospitalization treatment strategies. To reduce the risk of suicides in elderly patients discharged from hospital, close post-hospitalization supervision combined with proper psychoactive medication and psychotherapy, are possible interventions. Copyright # 2007 John Wiley & Sons, Ltd. key words depression; age; hospitalization; violent

INTRODUCTION In many countries the oldest age groups have the highest suicide rates (WHO, 2005). Suicide has been predicted to become the tenth most common cause of death of older people in the world, although dimi*Correspondence to: Dr K. Karvonen, Department of Psychiatry, Oulu University Hospital, BOX 26, 90029 OYS, Finland. E-mail: kaisa.karvonen@oulu. Copyright # 2007 John Wiley & Sons, Ltd.

nishing rates in the elderly of some regions have also recently been reported (Pritchard and Hansen 2005; Koponen et al., 2006). Suicide frequencies differ in different age-groups and the suicide rate of the oldest old in a population (i.e. the over 75 year olds) may not follow the declining trend seen in the 65 to 74 years olds (Harwood et al., 2000). In psychological autopsies a psychiatric disorder, most commonly depression, has been observed in 7597% of the cases (Conwell and Brent, 1995;
Received 7 January 2007 Accepted 4 May 2007

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Henriksson et al., 1995; Waern et al., 2002). Suicide appears to be more strongly associated with depression in the elderly than in the younger age groups (Conwell and Brent, 1995). Although the role of alcohol misuse may be smaller in the elderly than in the younger people (Conwell and Brent, 1995), alcoholism and rigid or restrictive personal coping styles are also associated with suicidal behavior in the aged (Henriksson et al., 1995; Harwood et al., 2001; Waern, 2003). Multiple psychiatric disorders have been observed in one-third of the elderly suicide victims (Waern et al., 2002). In the general population a substantially increased risk has been observed within the rst weeks after discharge from psychiatric hospitalization (Ho, 2003; Qin and Nordentoft, 2005) and the same phenomenon has recently been reported in the oldest old (Erlangsen et al., 2005). In the general population, suicide risks related to affective disorders and schizophrenia decline quickly after treatment, but risks that involve substance use disorders decline more slowly (Qin and Nordentoft, 2005). Signicantly higher suicide risks have also been reported in patients who received less than the average duration of hospital treatment or experienced a reduction in treatment frequency (Appleby et al., 1999b). As comparable data from aged people are scant, we focused in this study on suicide rates in elderly patients by scrutinizing their previous histories of psychiatric hospitalizations. We examined in detail how suicide rates in the elderly (in this study dened as aged 6574 years), the oldest old (over 75), and the middle-aged (5064) varied in relation to the length of time spent outside the hospital after their last discharge from psychiatric care. In addition, we examined the effects of gender and the primary psychiatric diagnoses on the suicide rates. Finally, we also studied the suicide methods employed. METHODS Study sample The database consisted of all suicide victims (n 1877, of which 564 were older than 50 years of age) from the province of Oulu in northern Finland and covered the years 19882003. The annual mean population of the province, which included both rural and urban areas, was approximately 445, 000 (40% of which were 50 years of age or older) over the study period. In order to rst evaluate the suicide rates and methods in the elderly and then to compare them with the middle-aged, the present study included all of the suicides committed in three age groups: the middleCopyright # 2007 John Wiley & Sons, Ltd.

aged (5064 years, n 370), the elderly (6574 years, n 134), and the oldest old (over 75 years, n 60). In addition, we used data from the Finnish Hospital Discharge Register (FHDR) that included lifetime histories of hospital-treated psychiatric patients. The FHDR covers all treatments in general, private, mental, military and prison hospitals, as well as the inpatient wards of local health centres nation-wide. It contains personal and hospital identication codes, data on age, gender, length of stay, and primary diagnosis at discharge, together with three subsidiary diagnoses. Coverage and validity of such data have been shown to be reliable (Poikolainen, 1983). Diagnoses in the FHDR during the period 19691986 were coded according to the ICD-8 classication, for 19871995 with ICD-9 along with DSM-III-R criteria (Kuoppasalmi et al., 1989), and since year 1996 according to ICD-10. Psychiatric diagnoses of suicide victims were converted to ICD-10 classication according to National and Development Centre for Welfare and Health instructions (STAKES, 2006) as follows: Schizophrenia and other psychoses: F20-F29, Depression and other mood disorders: F30-F33 (Depression F32F34.1), Substance related disorders: F10F19 and Other psychiatric diagnoses: F00F09, F40F61. Assigning the elderly, according to age, to two groups (6574 and over 75 years) has also been used in previous studies as these groups contain individuals that may differ in lifestyles and health status (Pritchard and Hansen, 2005). The study protocol was approved by the ethics committee of Oulu University. Suicide information from the death certicates In Finland, the law requires that in every case of violent, unnatural, sudden or unexpected death the possibility of suicide is assessed by police and medico-legal examinations. The decision to classify a death as a suicide is made by the forensic examiner. Our data contained only cases which were classied as suicides. During the study period the forensic denition of suicide remained the same and there were no differences within the country. Data on age, gender, suicide method (violent: hanging, drowning, shooting, jumping from a height, trafc and other methods; non-violent: poisoning and gas) (Hakko et al., 1998), previous suicide attempts, and whether or not a victim was under the inuence of alcohol at the time of the suicide were based on the information from the forensic medico-legal autopsy investigations. Data in connection with elderly and oldest old suicide victims
Int J Geriatr Psychiatry 2008; 23: 135141. DOI: 10.1002/gps

suicide after hospitalization in the elderly were compared with those of adult victims aged 5064 years from the same area. Statistical methods Statistical signicance of group differences in categorical variables was examined with Pearsons Chi-square test or Fishers Exact test and in continuous variables with Kruskal-Wallis test. In victims aged 65 or older, Cox proportional hazards model was used to compare the survival estimates between

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different psychiatric diagnosis groups. Time from last psychiatric hospitalization to suicide was noted and age at death and histories of physical illnesses of the suicide victims were used as covariates. Statistical software used in the analyses was the SPSS version 13.

RESULTS Gender-specic distributions of various suicides and clinical characteristics are presented in Table 1 by

Table 1. Suicide and clinical characteristics of the middle-aged, elderly and oldest old victims Age-group of suicide victim Middle-aged (5064 years) n (%) All Violent suicide method Hanging Shooting Drowning Non-violent suicide method: poisoning Under the inuence of alcohol at the time of suicidea Previous suicide attemptsa History of any psychiatric diagnosis History of hospital treated depression History of hospital treated substance related diagnosis Median (IQR) duration of last psychiatric hospitalization (days) Males Violent suicide method Hanging Shooting Drowning Non-violent suicide method: poisoning Under the inuence of alcohol at the time of suicidea Previous suicide attemptsa History of any psychiatric diagnosis History of hospital treated depression History of hospital treated substance related diagnosis Median (IQR) duration of last psychiatric hospitalization (days) Females Violent suicide method Hanging Shooting Drowning Non-violent suicide method: poisoning Under the inuence of alcohol at the time of suicidea Previous suicide attempta History of any psychiatric diagnosis History of hospital treated depression History of hospital treated substance related diagnosis Median (IQR) duration of last psychiatric hospitalization (days) n 370 275 (74.3) 131 (35.4) 98 (26.5) 25 (6.8) 79 (21.4) 124 (33.5) 37 (10.0) 195 (52.7) 117 (31.6) 85 (23.0) 5 (211) n 284 228 (80.3) 106 (37.3) 96 (33.8) 13 (4.6) 40 (14.1) 102 (35.9) 22 (7.7) 139 (48.9) 79 (27.8) 73 (25.7) 9 (327) n 86 47 (54.7) 25 (29.1) 2 (2.3) 12 (14.0) 39 (45.3) 22 (25.6) 15 (17.4) 56 (65.1) 38 (44.2) 12 (14.0) 11.5 (540) Elderly (6574 years) n (%) n 134 118 (88.1) 62 (46.3) 26 (19.4) 22 (16.4) 14 (10.4) 31 (23.1) 19 (14.2) 62 (46.3) 39 (29.1) 18 (13.4) 4 (19) n 104 97 (93.3) 53 (51.0) 26 (25.0) 12 (11.5) 6 (5.8) 27 (26.0) 11 (10.6) 42 (40.2) 22 (21.2) 16 (15.4) 4.5 (227.25) n 30 21 (70.0) 9 (30.0) 10 (33.3) 8 (26.7) 4 (13.3) 8 (26.7) 20 (66.7) 17 (56.7) 2 (14.3) 8 (412.75) Oldest old (Over 75 years) n (%) n 60 50 (83.3) 26 (43.3) 10 (16.7) 11 (18.3) 10 (16.7) 6 (10.0) 3 (5.0) 21 (35.0) 13 (21.7) 1 (1.7) 7 (314) n 42 35 (83.3) 19 (45.2) 10 (23.8) 6 (14.3) 7 (16.7) 6 (14.3) 2 (4.8) 10 (23.8) 6 (14.3) 1 (2.4) 18 (7.535.75) n 18 15 (83.3) 7 (38.9) 5 (27.8) 3 (16.7) 1 (5.6) 11 (61.1) 7 (38.9) 5 (420) p-value* 0.003 0.065 0.101 0.001 0.019 <0.001 0.137 0.029 0.287 <0.001 0.079 0.009 0.047 0.149 0.011 0.058 0.007 0.466 0.006 0.100 0.001 0.311 0.044 0.711 0.567 0.051 0.029 0.028 0.179 0.925 0.397 0.158 0.456 Group difference

*Group differences were assessed with Pearsons Chi-Square test or Fishers Exact test in categorical variables and with Kruskal-Wallis test in continuous variables. a Information gathered from death certicates. Copyright # 2007 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2008; 23: 135141. DOI: 10.1002/gps

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age-group. In males a history of any hospital-treated psychiatric diagnosis was statistically signicantly less frequent in the oldest old (24%) than in the middle-aged (49%). Also substance-related diagnoses were rare among the oldest old menfolk (2% and 26% correspondingly). Additional analyses addressing genderdifferences within each age-group revealed that the oldest old females had had more hospitalizations in connection with psychiatric disorders (61% vs 23%, p 0.006) and depression than any of the males had had (39% vs 14%, p 0.034). As also seen in Table 1, a violent method of suicide was used statistically signicantly most often by elderly males (93%), but a percentage of 83%, seen in oldest old males, was also substantial and even a little higher than the comparable gure for middle-aged male victims (80%). With regard to the specic type of suicide method, hanging was by far the most common method amongst the elderly victims (40%), whereas it was drowning (14%) for the oldest of the old. In females, violent methods of suicide increased dramatically with increasing age: while 55% of the middle-

aged female victims had chosen to end their lives violently, the respective proportion was as high as 83% amongst the oldest of the old female victims. With regard to the specic kind of suicide method, drowning (28%) was most common in elderly female victims and poisoning (45%) in middle-aged ones. Suicide committed under the inuence of alcohol was lowest amongst the oldest old (males 14% and females 0%). Table 2 presents the distribution of primary psychiatric diagnoses assessed during the last psychiatric hospitalization. Diagnoses of depression and mood disorders were most common in every age-group. Gender-specic analyses did not reveal any signicant differences in the diagnoses between the different age-groups. Figure 1 presents the survival estimates in victims aged 65 or older after the last psychiatric hospitalization according to primary psychiatric diagnoses made at that time. In females an increased likelihood for shorter survival was found in victims with mood disorders (HR 2.79, 95% CI 1.286.10, p 0.010)

Table 2. Diagnosis of last psychiatric hospitalization of the middle-aged, elderly, and oldest old suicide victims Primary diagnosis of last psychiatric hospitalization Middle-aged (5064 yrs) n 370 n (%) All Schizophrenia and other psychosesa Depression and other mood disordersb Substance related disordersc Other psychiatric disordersd Total Males Schizophrenia and other psychosesa Depression and other mood disordersb Substance related disordersc Other psychiatric disordersd Total Females Schizophrenia and other psychosesa Depression and other mood disordersb Substance related disordersc Other psychiatric disordersd Total *Fishers Exact test, df 6. a ICD-10: F20F29. b ICD-10: F30F33. c ICD-10: F10F19. d ICD-10: F00F09, F40F61. Copyright # 2007 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2008; 23: 135141. DOI: 10.1002/gps 28 85 60 22 195 17 52 53 17 139 11 33 7 5 58 (14.4) (43.6) (30.8) (11.3) (100.0) (12.2) (37.4) (38.1) (12.2) (100.0) (19.6) (58.9) (12.5) (8.9) (100.0) Age-group of suicide victims Elderly (6574 yrs) n 134 n (%) 8 30 16 8 62 4 16 15 7 42 4 14 1 1 20 (12.9) (48.4) (25.8) (12.9) (100.0) (9.5) (38.1) (35.7) (16.7) (100.0) (20.0) (70.0) (5.0) (5.0) (100.0) Oldest old (over 75 yrs) n 60 n (%) 3 (14.3) 13 (61.9) 1 (4.8) 4 (19.0) 21 (100.0) (70.0) (10.0) (20.0) (100.0) Overal difference p-value*

0.197

7 1 2 10

0.365

3 (27.3) 6 (54.5) 2 (18.2) 11 (100.0)

0.753

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Figure 1. Survival time from the last psychiatric hospitalization to suicide among elderly (65 or older) male and female suicide victims in different diagnosis groups of the last hospitalization.

compared with those suffering from other disorders; in males no differences were seen. We noticed that in 42% of the cases the suicide was committed within the rst 3 months after hospitalization. DISCUSSION We found a 42% suicide proportion within 3 months after discharge from a psychiatric hospitalization in the
Copyright # 2007 John Wiley & Sons, Ltd.

two age-groups, designated as the elderly and the oldest old. The rate was similar to that reported in connection with middle-aged persons, suggesting that the high-risk period extends into old age. The high rates were associated with acute episodes of psychiatric illness, earlier psychiatric hospitalization, recent hospital discharge, reduction in care, social factors such as living alone or bereavement, and history of substance abuse as well as previous suicide attempts (Appleby et al., 1999a; Erlangsen et al., 2005, Harwood
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et al., 2006). In the aged females survival times, following discharge from hospital, were shortest in suicide completers with mood disorders. Suicide in elderly men appears to be more strongly associated with depression than in younger age groups (Conwell and Brent, 1995). In a previous Finnish study, in which a lower cut-off limit of 60 years was used and psychological autopsy diagnoses were taken into consideration (Henrikson et al., 1995), 58% of the suicide victims had had major depression, dysthymia or depressive disorders not otherwise specied. Our results are in accordance with previous results that showed a substantial risk of suicide in connection with depression (Waern et al., 2002). Alcohol dependence clearly increases the suicide risk in the general population. However, in the elderly alone, lower rates of alcohol dependence are usually reported, but perhaps this is due in part to underdetection and misdiagnoses (OConnell et al., 2003). In previous studies prevalence gures for alcoholism, ranging from 5 to 35%, have been reported in connection with elderly suicide victims (Harwood et al., 2000; Harwood et al., 2001; Waern, 2003). In this study, the observed rate for alcoholism in the elderly was of the same range as that of earlier studies. However, the observed proportion of elderly people with a positive post-mortem screening for ethanol was smaller than in the study of Waern (29%: Waern, 2003). The observed lower rate of suicides committed under the inuence of alcohol in the elderly (as compared with the middle-aged), suggests that a relaxed impulse control, due to acute alcohol intoxication, does not signicantly contribute to the suicide act. The methods used in the suicides were related to what was available and accessible at the time the suicides were committed, but in a proportionately large number of cases violent methods were used by the elderly and oldest old (Henriksson et al., 1995). In our study, violent methods were used more often by the Elderly than the Middle aged. Violent suicide was especially common in Elderly males, reaching rates higher than those of violent suicide for the whole of Finland (70.3% for the whole population, 83.2% for male and 39.8% for female subjects: Hakko et al., 1998). Violent suicides in elderly females were substantially more frequent than in younger age-groups, suggesting that a violent frame of mind and aggressive nature are also risk factors for elderly females. The observed trend of increasingly violent suicides with increasing age suggests that suicidal behaviour among the elderly is more likely to be related to a higher degree of intent. Living alone and physical frailty are also likely to represent contributing factors.
Copyright # 2007 John Wiley & Sons, Ltd.

There are no well-known programs or guidelines that can be used to prevent (or at least reduce) suicides in the elderly. The higher rates of suicide within the rst 3 months after being discharged from hospital may implicate an insufcient treatment response or suggest that outpatient treatment has started tardily or has proved unacceptable for the patient (Qin and Nordentoft, 2005). A closer monitoring of the patient during and immediately following the discharge period, use of effective psychotherapy and/or psychoactive medication as well as avoidance of known toxic compounds, such as tricyclic antidepressants, might represent possible interventions (Ho, 2003; Pinquard et al., 2006). Certainly greater attention should be given to the potential role of lay networks in alleviating psychological distress and lowering suicidal ideation (Conwell et al., 2002). Furthermore, there is no doubt that additional research is needed to assess personality traits as predisposing factors for completed suicides in the elderly (Useda et al., 2007). ACKNOWLEDGEMENTS The study has been supported by grant number 113 760 from the Academy of Finland (HKO). REFERENCES
Appleby L, Dennehy JA, Thomas CS, et al. 1999a. Aftercare and clinical characteristics of people with mental illness who commit suicide: a case-control study. Lancet 353: 13971400. Appleby L, Shaw J, Amos T, et al. 1999b. Suicide within 12 months of contact with mental health services: national clinical survey. BMJ 318: 12351239. Carlsten A, Waern M, Holmgren P, Allebeck P. 2003. The role of benzodiazepines in elderly suicide. Scand J Public Health 31: 224228. Conwell Y, Brent D. 1995. Suicide and aging I: Patterns of psychiatric diagnosis. Int Psychogeriatrics 7: 149164. Conwell Y, Duberstein PR, Caine ED. 2002. Risk factors for suicide in later life. Biol Psychiatry 52: 193204. Erlangsen A, Mortensed PB, Vach W, Jeune B. 2005. Psychiatric hospitalization and suicide in the very old in Denmark: population-based register study. Br J Psychiatry 187: 4348. sa nen P, Tiihonen J. 1998. Secular trends in the rates Hakko H, Ra and seasonality of violent and nonviolent suicide occurrences in Finland during 19801995. J Affect Disord 50: 4954. Harwood DMJ, Hawton K, Hope T, Jacoby R. 2000. Suicide in older people: mode of death, demographic factors, and medical contact before death. Int J Geriatr Psychiatry 15: 736743. Harwood D, Hawton K, Hope T, Jacoby R. 2001. Psychiatric disorder and personality factors associated with suicide in older people: a descriptive and case-control study. Int J Geriatr Psychiatry 16: 155165. Harwood D, Hawton K, Hope T, Jacoby R. 2006. Suicide in older people without psychiatric disorder. Int J Geriatr Psychiatry 21: 363367. Int J Geriatr Psychiatry 2008; 23: 135141. DOI: 10.1002/gps

suicide after hospitalization in the elderly

nnqvist JK. 1995. Recent life events in elderly Heikkinen ME, Lo suicide: a nationwide study in Finland. Int Psychogeriatrics 7: 287300. ET, et al. 1995. Mental Henriksson MM, Marttunen MM, Isometsa disorders in elderly suicide. Int Psychogeriatrics 7: 275286. Ho T-P. v 2003. The suicide risk of discharged psychiatric patients. J Clin Psychiatry 64: 702707. Koponen H, Viilo K, Hakko H, et al. 2006. Rates and previous disease history in old age suicide. International Journal of Geriatric Psychiatry 22(1): 3846. nnqvist J, Pylkka nen K, Huttunen M. 1989. Kuoppasalmi K, Lo Classication of mental disorders in Finland. A comparison of the Finnish classication of mental disorders in 1987 with DSM-III-R. Psychiatria Fennica 20: 6581. OConnell H, Chin A-V, Cunningham C, Lawlor BA. 2003. Alcohol use disorders in elderly people-redening an age old problem in old age. BMJ 327: 664667. Pinquard M, Duberstein PR, Lyness JM. 2006. Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. Am J Psychiatry 163: 14931501. Poikolainen K. 1983. Accuracy of hospital discharge data: ve alcohol-related diseases. Drug Alcohol Depend 12: 315322.

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Pritchard C, Hansen L. 2005. Comparison of suicide in people aged 6574 and 75 by gender in England and Wales and the major Western countries. Int J Geriatr Psychiatry 20: 17 25. Qin P, Nordentoft M. 2005. Suicide risk in relation to psychiatric hospitalization. Arch Gen Psychiatry 62: 427432. STAKES (National and Development Centre for Welfare and Health). 2006. Conversion Table between ICD-10, ICD-9 and ICD-9 of Chapter V Mental and Behavioural Disorders. At http:// retki.stakes. /NR/rdonlyres/6B7F7D24-93BB-4AE5-84D1620183E81534/0/icd1098.pdf. Accessed 18.12.2006. Useda JD, Duberstein PR, Conner KR, et al. 2007. Personality differences in attempted suicide versus suicide in adults 50 years of age or older. J Consult Clin Psychol 75(1): 126133. Waern M. 2003. Alcohol dependence and misuse in elderly suicides. Alcohol Alcoholism 38: 249254. Waern M, Rubinowitz E, Runeson B, et al. 2002. Burden of illness and suicide in elderly people: case-control study. BMJ 324: 13551357. Waern M, Rubinowitz E, Wilhelmsson K. 2003. Predictors of suicide in the old elderly. Gerontology 49: 328334. World Health Organization. 2005. At www.who.int/mental_health/ prevention/suicide. Accessed 18.12.2006.

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Int J Geriatr Psychiatry 2008; 23: 135141. DOI: 10.1002/gps