Download pptx - Late life psychache – who cares?

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.

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

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?

10 to 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80+0

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50NZ Males 1949-1958 NZ Females 1949-1958NZ Males 1999-2008NZ Females 1999-2008

5-year age-groups

Suic

ide

rae

per

100,

000

10 to 14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ 0

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1949-1958

2009-2011

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,000

AGE (5-year groups)

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

10 to 14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ 0

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1949-1958

1959-1968

1969-1978

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AGE (5-year groups)


10 to 14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ 0

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1949-1958

1969-1978

1979-1988

1989-1998

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10 to 14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ 0

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20

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50

60

1989-1998

1999-2008

2009-2011

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per

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AGE (5-year groups)


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

10 to 14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ 5-year AGE GROUPS

02468

101214161820

1949-1958 1959-1968 1969-1978



02468

1012

1989-1998 1999-2008 2009-2011



02468

101214161820

1959-1968 2009-2011

10 to 14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+0

5

10

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NZ Males 2009-11

NZ Females 2009-11

5-year age-groups

Suic

ide

rate

per

100

,000

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

0

5

10

15

20

25

30

35

40

45

50

SUIC

IDE R

ATE p

er 10

0,000

AGE (years)

THE AGE EFFECT (Australia) 1949-53 vs 2001-2

AUSTRALIA males 1949-53AUSTRALIA males 1979-83AUSTRALIA males 2001-2AUSTRALIA females 1949-53AUSTRALIA females 2001-2

Australia vs England & Wales :

MALES (1951 vs 2001)

0

10

20

30

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60

10_1

415

-1920

-2425

-2930

-3435

-3940

-4445

-4950

-5455

-5960

-6465

-6970

-7475

-7980

-84 85+

AGE (years)

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er 1

00,0

00

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

E & W 2001-2

OZ 2001-2

E&W 1951

OZ 1951

Suicide in CHINA (1992 )

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15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

AGE (years)

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ICID

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er 1

00,0

00

URBAN Male

URBAN Female

RURAL Male

RURAL Female

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

Suicide in JAPAN (1960+1990)

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15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

AGE (years)

SU

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er 1

00,0

00

MALES 1960

MALES 1990

FEMALES 1960

FEMALES 1990

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

MAORI and NON-MAORI male & female

age-specific suicide rates 1982-1991

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10

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404550

5 15 25 35 45 55 65 75

RA

TE

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r 10

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NON-MAORI maleMAORI maleNON-MAORI femaleMAORI female

AGE (years)

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

Suic ide rates by AGE, RACE and GENDER

United States, 1995

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10_14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+AGE (years)

RA

TE

S (

per

100,

000)

WHITE male

BLACK male

WHITE female

BLACK female

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 victims

Under 60 years( n=186 )

60 years+( n=43 )

MAJOR DEPRESSION (including bipolar)

60 (32%) 19 (44%)

DEPRESSION n.o.s. 43 (23%) 9 (21%)

DYSTHYMIA 3 1

ADJUSTMENT DISORDERS 7 (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 victims

21-34( n=46 )

35-54( n=45 )

55-74( n=36 )

75-92( n=14 )

* MOOD DISORDERS 14 (30%) 19 (42%) 23 (64%) 10 (71%)

* major 4% 31% 47% 57%

other 25% 17% 22% 21%* SUBSTANCE USE DISORDER

70% 76% 50% 36%

* SCHIZOPHRENIA / PSYCHOSIS

22% 22% 6% 0

OTHER AXIS I 15% 16% 20% 14%NO AXIS I DISORDER 13% 2% 8% 29%

* = significant

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+)

• 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 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)

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.

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

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.

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.

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)

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.

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.

How commonly is old age suicide attributable to depression?

Depression in old agePrevalence 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.

Depressive conditions:

1) Depression associated with loss/lack- of loved one- of source of self-esteem / morale or satisfaction

2) Depression associated with physical disorders- psychological- neurobiochemical

3) Depression related to drug/alcohol abuse or depressant substances

4) Depression associated with other functional disorders (e.g. schizophrenia)

5) Major depression with melancholia

6) Psychotic depression

7) Depression in cases of bipolar disorder

Prevalence of depression in association with physical/organic

illnessesGENERAL MEDICAL PATIENTS 10 to 20% majorCANCER 25% major/adjustment

STROKE 23% to 34% major

PARKINSON’S 45% depressed (most major or dysthymia)

DEMENTIA 23% depressive disorder11% major

DISABLED 35% significantly depressed

NON-DISABLED 12% significantly depressed

The male suicide rate in New Zealand and Australia

reaches a second peak at age 85+ years.

Is this attributable to “rational” suicide ?

SUICIDE: AUTOPSY STUDIES

Cattell H and Jolley DJOne hundred cases of suicide in elderly people (Central Manchester)British Journal of Psychiatry 1995, 166, 451-456 Cattell 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.

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.

45 (21%) had alcohol in their blood at death Of 20 labelled as alcoholic, 17 had depression as well.

Of 15 labelled as dementia, 12 had depression as well.

43 (20%) had antidepressants in their blood at the time of death + 3 lithium, 1 carbamazepine

122 (58%) had a disability or illness that we identified as a major factor contributing to the suicide

40 (19%) had cancer at death or treatment for cancer in the last year

10 were in hospital

5 were in nursing homes

5 were in hostels at the time of death

4 had said they’d rather die than go into a nursing home

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

• Delusional/endogenous depression• Non-melancholic “reactive’ depression• Bereavement• Depression with physical illness or disability

Dementia

Schizophrenia

“Rational”

Untenable situation

Undetermined or multi-factorial

Depression

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.

Untenable situation

Where the person couldn’t tolerate currentcircumstances,

e.g. rejection by spousee.g. lost self-esteem following migration to a different cultural milieue.g. shame, guilte.g. inability to give up alcohole.g. financial disaster

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.

The primary reasons why (we deduced) 210 people killed themselves

37

40

13

0 10 20 30 40 50

Multifactorial / undetermined aetiology

Untenable situation

Understandable (?) decision to avoideffects of illness or being a burden

Schizophrenia

Dementia / delirium

Depression plus physical illness/disability

Bereavement ( within one year )

Depressive ( commonly loss-related )

Endogenous / delusional depression

NUMBER OF CASES

DEFINITELY DEPRESSED

NOT DEFINITELY DEPRESSED

37

40

13

21

96

3

31 19

11 17 28

9

Issues to discuss

• Understandable? To whom? Rational? Who decides?

• Do some personality characteristics make it difficult to tolerate disability, loss, insults, pain, diminished self-regard ?

• Are some suicides altruistic (re burden) ?• Is it reasonable, understandable and rational for

people to request euthanasia when there is persisting intolerable psychache (‘mental pain’) or not? Is assisted suicide ever an option?

Adapting to age-related physical and cognitive changes:some people can’t/don’t, and this can lead to mental suffering…

• Re psychotherapy: “Suicidal behaviour can result from extreme psychological pain associated with an inability to meet previously achieved goals, responsibilities or physical accomplishments”

Baumeister R.F. (1990) Psychol. Rev. 97, 90-113

• “Older adults having difficulty adapting to the transitions of aging may succumb to a narcissistic despair that can heighten depressive pathology and engender suicidal behaviour.”

Maltsberger J.T. (1991) J.Geriatr Psychiatry 24, 217-234

• Prado C.G. (1998) in ‘The Last Choice: Preemptive Suicide in Advanced Age’ distinguished between suicide because of unbearable agony and ‘preemptive’ suicide to avoid demeaning decline and needless suffering.

Rational suicideWerth & Cobia (1995) (Suicide & Life-Threatening Behavior 25, 231-240):

• (1) An unremittingly hopeless condition• (2) Suicidal condition made as a free choice• (3) Informed decision-making process

Margaret Battin, ethicist and prof of philosophy (1984), argued that people have the right to shape the ends of their lives.

A note was written by a 66-year-old man suffering from terminal kidney and bowel cancer. He

committed suicide by carbon monoxide poisoning:

Dear… I will always love you. I have gone to your pussy cat and we will both wait for you. I am getting worse and I would like you to remember me as I am.

Soon I would be just a ‘vegetable’ and in pain…..

The Glebe study (1994-8)Why older MALES killed themselves

“Reason” 65-79 yearsNUMBER

80+ yearsNUMBER (%)

“Rational” 23 (18%) 17 (42%)

Depression + physical disorder or dementia

134

55

Loss-related depression(including bereavement)

23 9

Endogenous depression 22 1Untenable situation 19 1Schizophrenia or debatable reasons

9 2

TOTAL 113 40

The Glebe study (1994-8)Why older FEMALES killed themselves

“Reason” 65-79 yearsNUMBER

80+ yearsNUMBER (%)

“Rational” 6 (15%) 4 (25%)

Depression & physical 3 0Loss-related depression (including bereavement)

14 7

Endogenous depression 10 4Untenable situation 7 1 Schizophrenia 1 0

TOTAL 41 16

Only a few of those who commit suicide are free of the veil of depression that distorts and dictates choices that would not be elected if they truly acted rationally.

Slaby AE, 1999PSYCHIATRY SERVICES, 50, 1093

Glebe study findings• Most people who died by suicide were

depressed, but only a minority had melancholia. Most were reacting to loss or untenable situations. Psychache

• Personality a big factor• Multifactorial explanations for suicide• Health problems contributory in a majority of

old age suicides, but few were so bad and irremediable that requests for euthanasia seem justifiable

In the decade 1983 – 1992there was a reduction by one third in the

suicide rate of Dutch people over age fifty. Assisted suicide and euthanasia were made more easily available and

acceptable during this time, and most of those dying in this way were over 50

( 86% of male euthanasia , 78% of female euthanasia cases were aged over 50 years )

Patients who request euthanasia are usually asking in the strongest way they know for mental and

physical relief from suffering. When that request is made to a caring, sensitive and knowledgeable

physician who can address their fear, relieve their suffering, and assure them that he or she will remain with them to the end, most patients no longer want

to die and are grateful for the time remaining to them.

Hendin H, 1995CRISIS, 17, 90-93

Susan Stern’s documentary, ‘The Self-Made Man’

• Her father, Bob Stern, was 77, a tough individual who prided himself on his achievements.

• “I have my sanity and my reasoning capacity…….. I’m seriously considering an end to my very nice life.”

• Prostate cancer, a grapefruit-sized abdominal aortic aneurysm, and “now saw in his future only a fast and demoralising slide into total dependency.”

• He shot himself.

San Francisco Chronicle, 25/7/05

• The values of American masculinity are at increasing odds with the reality of ageing. A lot of times men don’t grieve. They don’t let people know how they feel. Depressed men often cover up pain with a take-charge attitude – just like Bob Stern.

• There is compelling evidence that depression can be driving the seemingly rational wish to die.

• Susan Stern: “Sometimes I wonder if my father was strong enough to get weak.”

Rousseau PPain Management in the terminally illJournal of the American Geriatrics Society 1994, 42, 1217

“Physicians must confront the historical malaise regarding the treatment of pain in terminal illness and afford deserving patients a pain-free and dignified death”

THE GOTLAND STUDY

During the early 1980s this study showed that it was possible to reduce the incidence of suicide through introduction of a comprehensive education programme aimed at GPs. The rate fell from 20 to 7 per 100,000 (Rutz et al, Acta, 1989)

Two additional one-day seminars for GPs in 1993 and 1995.

1990-1994 100% increase in antidepressant prescriptionand 15% reduction in suicide (especially women)

Can we prevent suicide?

• Chad Buckle’s death highlighted the importance of consistently implementing best practice techniques in the diagnosis, treatment, monitoring and ongoing care of psychiatric patients, including the recognition and treatment of those at risk.

• This talk has focused on suicide in late life, with the aim of highlighting the need for RECOGNITION of THOSE AT RISK, and appropriate INTERVENTION.

• A majority but not all people who die by suicide have mental disorders, but nearly all have PSYCHACHE.

• Our aim should be to recognise the psychache and suppress it, thereby preventing suicide.

Elderly suicide prevention programmes

• Various countries have published guidelines• There have been too few studies of the effectiveness of interventions

aimed at preventing late life suicide.• Studies have centred on depression screening and treatment, and

decreasing isolation. Best for women.• TeleHelp worked well for women (De Leo et al, 2002)

• “Improvement in detection, treatment and management of mood disorders should be the primary focus” (Lapierre et al, 2011) . Yes, but for some people, other factors need prime attention.

• No studies examined the differential impact of programmes on young-old (60-79) and old-old (80+) persons to see if the groups present different challenges.

• Older men could prefer programs that focus on action and problem solving rather than emotions and creating new relationships (Lapierre et al). Those depressed because of functional impairments, for example?

Lapierre S et al (2011). A systematic review of elderly suicide prevention programs. Crisis 32, 88-98.

Prevention of late life suicide

• Collaborative care models, using depression care managers, such as PROSPECT, can improve outcomes.

• So can community old age psychiatry services.• Lithium (depression and bipolar) and clozapine

(schizophrenia) have helped prevent suicide.• Late onset depression is commonly attributed to

vascular changes; hope to prevent it by limiting vascular damage.

• Rates of suicide in the 60-79 years age-groups in NZ and Australia have fallen, maybe largely due to availability of better antidepressant treatments and community services (mental health, home help).

Conclusions

• Good news! Rates of late life depression in NZ and Australia have fallen, but still with too high a peak among men aged 80+ years.

• Suicide is a consequence of an interplay of multiple factors, including mental disorder, brain changes, functional impairments, social circumstances, insecurity, personality, conflicts, cultural attitudes, and reactions to life events.

• Prevention of late life suicide needs special focus on connectedness, physical illness, and empowerment.

SENECA

I will not relinquish old age if it leaves my better part intact. But if it begins to shake my mind, if it destroys its facilities one by one, if it leaves me not life but breath, I will depart from the putrid or tottering edifice. I will not escape by death from disease so long as it may be healed, and leaves my mind

unimpaired. I will not raise my hand against myself on account of pain, for so to die is to be conquered. But if I know that I must

suffer without hope or relief, I will depart, not through fear of the pain itself, but because it prevents all for which I would live.

[ Lecky, 1869 ]