Older Suicide Completers Israel 2014

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Psychosocial and medical aspects of older suicidecompleters in Israel: a 10-year survey

Assaf Shelef1,2, Jehuda Hiss3,2, Gali Cherkashin1,2, Uri Berger4, Dov Aizenberg2,5, Yehuda Baruch1,2

and Yoram Barak1,2

1Abarbanel Mental Health Center, Bat-Yam, Israel2Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel3The National Institute of Forensic Medicine, Assaf Harofe Medical Center, Tel-Aviv, Israel4Department of Psychology, Bar-Ilan University, Ramat-Gan, Israel5Geha Mental Health CenterPetah-Tikva, IsraelCorrespondence to: Dr A. Shelef, E-mail: [email protected]

Objectives: The rate of completed suicide among the elderly continues to be the highest of any age groupworldwide. The aim of the present study was to investigate the sociodemographic data, mental andphysical health characteristics, and suicide methods of the elderly population who completed suicidein Israel.

Methods:A national retrospective record-based case series study of consecutive elder (50 years or older)suicide completers who had undergone autopsy over a 10-year period was conducted.

Results:Three hundred and fourteen consecutive records of suicide completers, 69.6% males, andmean age 64.7 were analyzed. The largest group (38%) emigrated from the Former Soviet Unionand 19% emigrated from East Europe. Immigrants from East Europe committed suicide at anolder age.Hanging was the predominant suicide method. Jumping from height increased more than three-fold in the old-old(older than 75 years) group. Hanging and rearms were more frequently used

by males. Females were more likely to employ poisoning and suffocation.A signicant minority (30%) had been diagnosed as suffering from psychiatric morbidity. Mostcommon diagnoses were depression and alcohol abuse or dependence. Physical disorders (mainlycardiovascular disease and malignancy) were present in 27% of cases. Subjects with psychiatric illnesswere more likely to complete suicide at a younger age compared with subjects with physical illness.

Conclusions:Findings of male predominance, psychiatric morbidity, and physical illness are consistentwith previously published studies. Immigrants from East Europe completed suicide at an older age andthe older victims had used more lethal methods of suicide. Copyright # 2014 John Wiley & Sons, Ltd.

Key words: elderly; suicide; methods; psychiatric morbidity; immigrantsHistory: Received 17 May 2013; Accepted 11 December 2013; Published online 14 January 2014 in Wiley Online Library(wileyonlinelibrary.com)DOI:10.1002/gps.4070

Introduction

Old age is a predictor of completed suicide and recentstudies demonstrate that in many countries, suiciderates among the elderly are higher than those among

young adults (Chanet al., 2007; Shah, 2007). Despitethese ndings, suicide in old age remains a much-neglected area of research.

Risk and protective factors provides additionalguidance for clinicians as to which patients are at ele-vated risk of committing suicide. Psychiatric illness(especially depression), social isolation, functionalimpairment, physical illness, and pain represent aconstellation of risk factors that characterize olderadults at greatest risk of suicide (Van Orden andConwell, 2011). Further, past suicide attempts, feelings

Copyright#

2014 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry2014;29: 846851

RESEARCH ARTICLE


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of hopelessness, and alcohol addiction have all beenshown to be associated with suicidal ideation, thoughtsof death, and completed suicide in the elderly(Alexopoulos et al., 1999; Bartels et al., 2002; Caineand Conwell, 2001; Conwell, 1996). It is of note that

major depressive disorder is more common amongolder people who commit suicide than among theiryounger counterparts (Skoog, 2011).

Completed suicide rates are relatively low in Israel incomparison with other industrialized nations (Haklai,2011). Compared with 27 European countries, Israelsrates of completed suicide were found to be secondlowest for women and third lowest for men.

The aim of the present study was to investigate thesociodemographic data, mental and physical health char-acteristics, and suicide methods of the elderly populationwho completed suicide in Israel over a 10-year period.

Subjects and methods

Data sources

This study was designed as a case series of autopsies thathad been performed at Israels sole National Institute ofForensic Medicine over a 10-year period. Informationwas collected on all suicide completers between January1995 and December 2004. Data were examined for allcompleted suicides 50 years or older who underwentautopsy to assess the cause and mechanism of death.

Medical, psychiatric, and sociodemographic data werecollected from necropsy reports and pertinent policereports. Medical and drug abuse history was retrievedfrom hospital, clinic, and health insurance organizationsrecords. In Israel, because of religious beliefs, not all thebodies of alleged suicidal victims are delivered to theinstitute of forensic medicine, and only less than half ofthem are submitted for complete autopsy. All suicidalcases determined by necroscopic and police investigationover a decade are included in the present analysis.

Suicide method was classied into the followingsubcategories: hanging, shooting byrearm, poisoningand medication overdose, jumping from heights,suffocation, stabbing, and other means.

For purposes of clarity and statistical analyses,we dened the following age groups: middle age(5064 years), young old (6574 years) and theold-old (75years and older). It is accepted that the6574 year-old rangethe young old populationwho live in the industrialized world are entering thethird ageand are likely to have different life styles andrelatively less age-related disabilities than their counter-parts in former years (Paraschakiset al., 2012).

The study was approved by the Abarbanel MentalHealth Center Human Subjects and Ethics Committee.

Measures

The following variables were used in the present analysis:

(1) Method and location of suicide. The principalmethod of suicide was identied as the methodresulting in death. The method of suicide wasidentied from medical examiners record andfrom autopsy results.

(2) Physical illness. Data were collected from pastmedical records and autopsy reports.

(3) Psychiatric morbidity. Data were collected frompast medical records.

(4) Sociodemographic information. The following data

were collected: age, place of birth, current address,and marital status.

Statistics

The following tests were used for statistical analysis ofthe data: Pearsons 2 test for comparison of percent-ages, independent sample t-test for comparison ofmeans of variables and one way analysis of variance(ANOVA). Statistical analysis of age group distribu-tion was carried separately for each suicide method

by a Pearsons Chi test, with a Bonferroni correctionfor multiple comparisons (= 0.007).

Results

During the 10-year study period, there were 314 com-pleted suicides aged 50 years and older. There were217 males (69.6%) and 95 (30.4%) females, meanage 64.7 years (range: 5097; SD = 11.5). It is of inter-est to note that only 20.3% of suicide victims wereborn in Israel (Table 1). A majority had emigratedfrom the Former Soviet Union (38.2%) as well as EastEurope (19.4%) and 9.2% came from West Europe,South Africa, and Australia.

ANOVA with age as the dependent variable and sub-ject origin as the independent variable revealed severalstatistically signicant effects (F5,301 = 7.9, p< 0.001).West Europe born suicide victims died at a signicantly

younger age compared with East Europe victims (meandifference 10.15 years, SE = 2.48,p< 0.05). East Europeborn suicide victims have died older than Israeli, NorthAfrica, and Asia born victims (p< 0.05). Israeli born

847Older suicide completers in Israel: a 10-year survey

Copyright # 2014 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry2014;29: 846851


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suicide victims died younger than Former Soviet Unionsuicide victims (mean difference 5.34 years, SE = 1.7,

p< 0.05).The largest number of victims were married, 157

(50%) followed by 63 (20%) who were widowed, 34(10.8%) divorced, whereas 13 (4.1%)were single (Table 2).There were missing values for 47 subjects (14.9%).ANOVA with age as the dependent variable and sub-

ject marital status as the independent variable wasconducted on all participants whose marital statuswas available (N= 267). The analysis found a signi-cant effect (F3,263 = 28.12.,p< 0.001). This effect wasattributed to the relatively older age in which widowerscommitted suicide (p< 0.05) (Table 2).

Suicide location and methods

The great majority of suicides took place at home 205(65.2%), 70 suicides (22.2%) occurred in public places(roads, the sea, forest, and public gardens), and 37

(11.7%) occurred in institutions (9 in jail/detentioncenters, nine in general hospitals, eight in psychiatricinstitutions, six in nursing homes, and ve at work).

Methods of suicide included: hanging 116 (36.9%), selfshooting 59 (18.7%), jumping from heights 54 (17.1%),poisoning and medication overdose 23 (6.3%), suf-focation 17 (5.4%), stabbing 4 (1.2%), and othermeans 41(13%).

Between groups comparisons

The study sample was divided into three categories: mid-

dle age(50

64 years), young-old

group (65

74 years),andold-old(over 75 years). Hanging and shooting were

much more frequent suicide methods in themiddle agegroup than in the old-old. Jumping from height in-creased threefold in the old-oldgroup (32%) comparedto the middle agegroup (11%). Poisoning and medica-tion overdose increased slightly with age across all agegroups. Suffocation as a suicide method (mainly using aplastic shopping bag) increased more than twofold inthe old-oldgroup (10%) compared to the middle agegroup (4%).

Despite these numerical differences statistical sign-icance was reached only for Jumping from heightmethod compared to all other methods in the elderlyversus middle-aged (2 = 12.76, df = 2,p< 0.01) (Table 3).

Gender

Several signicance between genders differences werefound. Hanging was the leading suicide method in

Table 1 Place of birth and age of suicide victims

SDMean

age % N Place of birth

12.57 66.02 38.2 120 Former Soviet Union10.18 70.08 19.4 61 East Europe

9.14 60.68 20.3 64 Israel9.92 60.80 8.2 26 North Africa and Asia8.97 59.93 9.2 29 West Europe ( includes North

and South America, SouthAfrica, and Australia)

12.92 67.58 3.8 12 Other 11.48 64.78 312 All

Table 2 Marital status and age of suicide victims

Marital status NumberMean age of

suicide victim Standard deviation

Married 156 63 10.2Widowed 63 75 11.4Divorced 33 59 8.2Bachelor 13 60 10.2

Table 3 Comparison of method of suicide of middle ageversus young-oldand versus old-old

Overall Age 75 years and above Age 6574 years Age 5064 years

Methods of suicide% N % N % N % N

36.9 116 28.1 20 32.3 21 42.1 75 Hanging18.7 59 14 10 15.3 10 21.9 39 Shooting13 41 7 5 18.4 12 13.4 24 Other 17.1 54 32.3 23 18.4 12 10.6 19 Jumping6.3 23 8.4 6 7.6 5 6.7 12 Poisoning and

medications overdose5.4 17 9.8 7 4.6 3 3.9 7 Suffocation1.2 4 0 0 3 2 1.1 2 Stabbing

314 71 65 178 All

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males and females, although males (41.1%) used itsignicantly more frequently than females 27.1%)(2 = 3.86, df = 1, p< 0.05). Women used rearmssignicantly less frequently than men (8.3 vs 23.3%)(2 = 8.06, df = 1,p< 0.01) and jumping from heights

was more common among females (22.9%) than males(14.6%) albeit not reaching signicance. Women usedpoisoning and medication overdose (13.5%) more thanmen (4.6%) (2 =7.27, df=1, p< 0.01). Furthermore,women employed suffocation (10.4%) more than males(3.2%) (2 = 6.37, df = 1,p< 0.05) (Table 4).

Psychiatric history

Nearly one-in-three of suicide victims had psychiatrichistory95 (30.2%); most commonly depression 54(17.1%) followed by alcohol/substance abuse or depen-

dence 33 (10.5%), schizophrenia 6 (1.9%), Alzheimersdementia 4 (1.2%) and adjustment disorder 1 (0.3%).

Of the 33 suicide victims that had alcohol/substanceabuse or dependence, 28 (84.8%) were chronic alco-holics, 4 (12%) were on opiates, and 1 (3%) abusedbarbiturates.

Subjects with psychiatric illness (mean age = 61.21,SD = 9.18) committed suicide at a signicantly youngerage (t= 3.65, df = 310, p< 0.001) in comparison tosubjects without psychiatric illness (mean age = 66.26,SD = 12.03).

Medical comorbidity

One comorbid physical illness was reported in 85 sub-jects (27%), the most frequent being cardiovascular48 (15.3%); particularly having suffered myocardialinfarction. Malignancy was detected in 25 suicidevictims (8%) with the most common site beingcolon and pancreatic carcinomas. A small minority,

8 (2.5%), of the suicide victims had hepatic cirrhosis(Table 5).

Subjects with physical illness (mean age = 69.85,SD = 11.63) committed suicide at a signicantly olderage (t=4.99, df = 312, p< 0.001) in comparison

with subjects without physical illness (mean age =62.83, SD = 10.88).

Discussion

Suicide is most prevalent in men aged 75 years andolder (Skoog, 2011; Baraket al., 2005). In Israel, oldage has consistently been shown to be a signicant riskfactor for completed suicide. Those aged 75 years andolder have the highest suicide rate of all age groupsin the country: 23.2 per 100 000 among men and 4.3per 100 000 among women (Haklai, 2011). These pub-

lications are in line with World Health Organizationstatistics reporting that worldwide suicide rates ofmales are highest among those aged 75 years and older(Shah, 2007).

The mean age of suicide victims in our study was64.7 (range from 50 to 97) years, and as expected,the majority (69.6%) were males. Most of the subjectswere born in the Former Soviet Union (38.2%) andEastern Europe (19.4%). This is in line with reportsof higher suicide rates among Ashkenazi Jews (Haklai,2011; Levav and Aisenberg, 1989). Over-representationof Former Soviet Union emigrates in our study can also

Table 4 Comparison of suicidal methods by gender

Females Males

Methods% N % N

27.1 26 41.1 90 Hanging8.3 8 23.3 51 Self shooting16.7 16 11.9 26 Other 22.9 22 14.6 32 Jumping13.5 13 4.6 10 Poisoning and

medications overdose10.4 10 3.2 7 Suffocation1 1 1.4 3 Stabbing

96 219 All

Table 5 Physical illness

% N Diagnosis % N System

10.8 34 Old myocardialinfarction

15.3 48 Cardiovascular

2.2 7 Ischemic heartdisease

0.95 3 Cardiacarrhythmia

1.3 4 Other 0.95 3 Colon 8 25 Malignancy0.9 3 Pancreas0.6 2 Lymphoma0.6 2 Ovary0.6 2 Hepatic1.6 5 Other 2.2 7 Unknown2.2 7 Metastatic

cancer2.5 8 Cirrhosis 2.5 8 Hepatic0.9 3 Parkinsons

disease1.5 5 Neurologic

0.6 2 Other 0.9 3 Diabetes 0.9 3 Metabolic2.2 7 2.2 7 Other




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be related to the fact that immigration induces a majorstress, enhancing the risk for depressive disorders,resulting in more common suicidal behavior (Mirskyet al., 2011; Shoval et al., 2007). Completed suiciderates are reportedly higher among Former Soviet

Union immigrants than in the general Israeli popula-tion, the largest risk being among young-adult maleimmigrants (Mirskyet al., 2011).

In our study, immigrants from Eastern Europe hadsignicantly older age of suicide compared with WestEurope born and Israeli born suicide victims. Largepercentage of East Europe born Jews are holocaustsurvivors and the tendency towards older age of sui-cide can be attributed to vulnerability to stressors ofaging amongst survivors implying residual or sub-threshold symptoms of posttraumatic stress disorder(Barak, 2005; Safford, 1995; Clarke et al., 2004). Inour study, only 47% of the elderly suicide victims were

married and a large minority (32.3%) were widowed.According to the Israel Central Bureau of Statistics(ICBS, 2009), in the year 2009, 57% of the generalpopulation above 65 years were married and 31.1%were widowed. In agreement with the literature onmarital status and suicide (Kposowa, 2000), these datasuggest that the suicide victims in our study had lessfamily and social support were living alone, lost aspouse and may have been suffering from loneliness,interpersonal discord, and low social support (VanOrden and Conwell, 2011).

The elderly often choose more lethal means of

suicide, give fewer warnings or indications of suicidalintent, and may more frequently engage in carefulplanning of the suicidal act (Elnour and Harrison,2008; Voaklander et al., 2008). In the present study,hanging was the most common method of suicide;shooting and jumping from heights were also usedfrequently.

Very little is known about self-destructive behaviorin long-term care facilities, and there is lack of informa-tion concerning suicides in nursing homes (Suominenet al., 2003). It is of interest to note that 11.8% of allsuicides in the present study occurred in institutions,including general hospitals and nursing homes.

Psychological autopsy studies indicate that psychi-atric morbidity is present in nearly 90% of older adultswho die by suicide, mostly affective disorders (Conwellet al., 1996; Skoog, 2011; Van Orden and Conwell,2011). In our study, depression was the leading psychi-atric disorder (17.1%). Alcohol or substance abuse ordependence had been recorded in 10.5% of victims inour samplein line with previous studies (Van Ordenand Conwell, 2011). The association between physicalillness and suicide is also marked among the elderly.

Severe pain, often associated with malignancies, is oftenrecorded (Van Orden and Conwell, 2011; Voaklanderet al., 2008 ). In our study, there was a high incidence(27%) of physical illness the most frequent disordersbeing cardiovascular and malignancy. The incidence of

suicide among cancer patients is almost twice that of theUS general population, and studies have demonstratedalmost a vefold increase in suicide rate among patientswith gastric malignancies (Voaklander et al., 2008, Turagaet al., 2011). In our study, the most frequent malignanciesof suicide victims were pancreatic and colon cancer.

The limitations of the present study are the fact thatit includes only individuals whose next of kinconsented to an autopsy, and the lack of an ade-quate control group. Our study sample representsonly 20% of completed suicides in Israel amongpersons 50 years or older during the studied period(Haklai, 2011). This unfortunately is inherent in

studies of completed suicide in a country wherereligious laws foster stigma and prevent higherrates of post mortem examinations. Finally, thetime span for data collection10 yearsis long.The potential for changes in suicide prole overthat time need be acknowledged. Despite theselimitations, to the best of our knowledge, this isthe rst attempt to clarify psychosocial and psychi-atric as well as medical features of older suicide-completing group in Israel. Our ndings may beuseful in suicide prevention both in Israel andcan be generalized to other countries.

In conclusion, the present study emphasizes that oldage and male gender are major risk factors for completedsuicide, especially when associated with low socialsupport, positive psychiatric history and physical illness.Early recognition and effective treatment of psychiatricdisorders, particularly depression, should be the corner-stone of all suicide prevention strategies in the elderly.

Conict of interest

None declared.

Key points

Male gender, depression and physical comorbidityassociated with completed suicide were replicatedin this study.

Immigrants from Eastern Europe were over-represented possibly reecting the complexstressors in this group.

The lethality of suicide methods increased withage.

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Author contributions

Yoram Barak, Dov Aizenberg Judea hiss, and YehudaBaruch designed the study. Gali Cherkashin collectedthe data, Uri Berger carried out the statistical analyses

of the data, and Assaf Shelef wrote the paper. YoramBarak and Judea Hiss reviewed the drafts of the paper.

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Older Suicide Completers Israel 2014