Late life psychache – who cares?

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Late life psychache – who cares?. by John Snowdon “After age 60, suicide accounts for an inconsequential proportion of all deaths” !!!!!!!!!!!!!!. Late life psychache – who cares?. What is psychache? - PowerPoint PPT Presentation

Text of Late life psychache – who cares?

ENGLAND & WALES Males (2002)

Late life psychache who cares?

by John Snowdon

After age 60, suicide accounts for an inconsequential proportion of all deaths!!!!!!!!!!!!!!

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. PsychacheShneidman (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 oldSuicide 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 FranciscoQuestions to ask about late life suicideIs 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, whats the cause?What evidence have we got about causation of suicide?MALE: Suicide rate per 100,000 per year in New ZealandMALE: Suicide rate per 100,000 per year in New ZealandMALE: Suicide rate per 100,000 per year in New ZealandMALE: Suicide rate per 100,000 per year in New ZealandFEMALE: Suicide rate per 100,000 per year in N.Z.FEMALE: Suicide rate per 100,000 per year in N.Z.FEMALE: Suicide rate per 100,000 per year in N.Z.PsychacheShneidman (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 oldSuicide 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

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

SOURCE: Ji J, Kleinman A & Becker AE (2001). Harvard Rev. Psychiatry 9, 1-12.16

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

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

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

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]?

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. 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.

Henriksson et al (1995), Int. Psychogeriat. PSYCHOLOGICAL AUTOPSY STUDY

DSM-III-R diagnoses of suicide victimsUnder 60 years( n=186 )60 years+( n=43 )MAJOR DEPRESSION (including bipolar)60 (32%)19 (44%)DEPRESSION n.o.s.43 (23%)9 (21%)DYSTHYMIA31ADJUSTMENT DISORDERS7 (3%)4 (9%)DEPRESSIVE SYNDROMES (including all Axis I disorders with depression)120 (65%)32 (74%)Conwell et al (1996), Am J Psych 153, 1001-8 PSYCHOLOGICAL AUTOPSY STUDY

DSM-III-R diagnoses of 141 (male 113) suicide victims21-34( n=46 )35-54( n=45 )55-74( n=36 )75-92( n=14 )* MOOD DISORDERS14 (30%)19 (42%)23 (64%)10 (71%)* major 4%31%47%57%other25%17%22%21%* SUBSTANCE USE DISORDER70%76%50%36%* SCHIZOPHRENIA / PSYCHOSIS22%22%6%0OTHER AXIS I15%16%20%14%NO AXIS I DISORDER13%2%8%29%* = significant

Suicides in older adults: a case-control psychological autopsy study in Australia (De Leo, Draper, Snowdon and Klves, J.Psychiatric Research 2013)Response rate of n.o.k. of suicides 46.6%

Suicides (73 aged 60+)Psychiatric diagnoses in 62% Mood disorders 46.6%

Major depression 18%Melancholic depression 20.5%Other depression 8%

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%

Mood disorders in cases of suicideSmaller % among female than male suicides in ChinaSmaller % among male and female suicides in China than in NZ etc.Smaller % among rural (than urban) dwellers who killed themselves in ChinaSmaller % among middle-aged than late life suicides in some studies but not in others (De Leo et al, etc) 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 ( to ) didnt 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. Were 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.Suicide risk factors(R.Goldney, Chad Buckle address)MalePrevious history of suicidal behaviourFamily history of suicideMental disorders -- depression, substance abuse, schizophreniaHopelessness, despair, guiltSocial isolation e.g. by separation/divorce (but not in China!)Childhood deprivation parent loss, violence, sexual abuseChronic physical illnessCustody/prisonIndigenousSexual identity issuesLets add (and we could classify as proximal and distal)Personality and individual vulnerabilitiesImpulsivity, perfectionism, neuroticism, sensitivityCognitive rigidity and rumination; unfulfilled needsLow extroversion: being socially disconnected, with thwarted belongingness. Feeling a burden on others; helplessness Interpersonal stressors, and inability to escape: trapped!Other negative life events: stressNeurobiological 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.

So whats 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. Theyve lost their friends, theyre 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.NZ comparison of late life suicide and attempted suicide cases versus controls (Beautrais, 2002)Adults age