Suicide after hospitalization in the elderly: a population based study of suicides in Northern...

INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2008; 23: 135–141.

Published online 21 June 2007 in Wiley InterScience

(www.interscience.wiley.com) DOI: 10.1002/gps.1853

Suicide after hospitalization in the elderly: a populationbased study of suicides in Northern Finland between1988–2003

Kaisa Karvonen1*, Pirkko Rasanen2, Helina Hakko1, Markku Timonen3,V. Benno Meyer-Rochow4,5, Terttu Sarkioja6 and Hannu J. Koponen7

1Department of Psychiatry, Oulu University Hospital, Finland2Department of Psychiatry, University of Oulu, Finland3University of Oulu, Department of Public Health Science and General Practice, Oulu Health Center, Finland4Jacobs University (formerly known as International University Bremen), School of Engineering and Science,Bremen, Germany5Departments of Physiology and Biology, University of Oulu, Finland6Department of Forensic Medicine, University of Oulu, Finland7Department 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 todepression and other axis I psychiatric disorders. However, little is known about the preferred suicide method, effect ofprimary psychiatric diagnosis, and length of time between discharge from psychiatric hospitalization and suicide. The lack ofinformation 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 50–64, 65–74 andover 75 year-olds (Total n¼ 564) with regard to suicide method, history of psychiatric hospitalization and primary diagnosesgathered from the Finnish Hospital Discharge Register. Study population consisted of all suicides committed between 1988and 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 3months after being discharged from hospital and 83% used a violent method. Both elderly males and females were less oftenunder the influence of alcohol, but used more often violent methods than middle-aged persons.Conclusions Suicide rates within the first 3 months following discharge from hospital in the 65–74 and the over 75 yearolds were substantial and should influence post-hospitalization treatment strategies. To reduce the risk of suicides in elderlypatients discharged from hospital, close post-hospitalization supervision combined with proper psychoactive medication andpsychotherapy, are possible interventions. Copyright # 2007 John Wiley & Sons, Ltd.

key words — depression; age; hospitalization; violent

INTRODUCTION

In many countries the oldest age groups have thehighest suicide rates (WHO, 2005). Suicide has beenpredicted to become the tenth most common cause ofdeath 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: [email protected]

Copyright # 2007 John Wiley & Sons, Ltd.

nishing rates in the elderly of some regions have alsorecently been reported (Pritchard and Hansen 2005;Koponen et al., 2006). Suicide frequencies differ indifferent age-groups and the suicide rate of the oldestold in a population (i.e. the over 75 year olds) may notfollow the declining trend seen in the 65 to 74 yearsolds (Harwood et al., 2000).

In psychological autopsies a psychiatric disorder,most commonly depression, has been observed in75–97% of the cases (Conwell and Brent, 1995;

Received 7 January 2007Accepted 4 May 2007

136 k. karvonen ET AL.

Henriksson et al., 1995; Waern et al., 2002). Suicideappears to be more strongly associated with depres-sion in the elderly than in the younger age groups(Conwell and Brent, 1995). Although the role ofalcohol misuse may be smaller in the elderly than inthe younger people (Conwell and Brent, 1995), alco-holism and rigid or restrictive personal coping stylesare also associated with suicidal behavior in the aged(Henriksson et al., 1995; Harwood et al., 2001; Waern,2003). Multiple psychiatric disorders have beenobserved in one-third of the elderly suicide victims(Waern et al., 2002).

In the general population a substantially increasedrisk has been observed within the first weeks afterdischarge from psychiatric hospitalization (Ho, 2003;Qin and Nordentoft, 2005) and the same phenomenonhas recently been reported in the oldest old (Erlangsenet al., 2005). In the general population, suicide risksrelated to affective disorders and schizophrenia declinequickly after treatment, but risks that involve substanceuse disorders decline more slowly (Qin and Nordentoft,2005). Significantly higher suicide risks have also beenreported in patients who received less than the averageduration of hospital treatment or experienced areduction in treatment frequency (Appleby et al.,1999b). As comparable data from aged people arescant, we focused in this study on suicide rates inelderly patients by scrutinizing their previous historiesof psychiatric hospitalizations. We examined in detailhow suicide rates in the elderly (in this study defined asaged 65–74 years), the oldest old (over 75), and themiddle-aged (50–64) varied in relation to the length oftime spent outside the hospital after their last dischargefrom psychiatric care. In addition, we examined theeffects of gender and the primary psychiatric diagnoseson the suicide rates. Finally, we also studied the suicidemethods employed.

METHODS

Study sample

The database consisted of all suicide victims (n¼1877, of which 564 were older than 50 years of age)from the province of Oulu in northern Finland andcovered the years 1988–2003. The annual meanpopulation of the province, which included both ruraland urban areas, was approximately 445, 000 (�40%of which were 50 years of age or older) over the studyperiod. In order to first evaluate the suicide rates andmethods in the elderly and then to compare them withthe middle-aged, the present study included all of thesuicides committed in three age groups: the ‘middle-


aged’ (50–64 years, n¼ 370), the ‘elderly’ (65–74years, n¼ 134), and the ‘oldest old’ (over 75 years,n¼ 60).

In addition, we used data from the Finnish HospitalDischarge Register (FHDR) that included lifetimehistories of hospital-treated psychiatric patients. TheFHDR covers all treatments in general, private,mental, military and prison hospitals, as well as theinpatient wards of local health centres nation-wide. Itcontains personal and hospital identification codes,data on age, gender, length of stay, and primarydiagnosis at discharge, together with three subsidiarydiagnoses. Coverage and validity of such data havebeen shown to be reliable (Poikolainen, 1983). Diag-noses in the FHDR during the period 1969–1986 werecoded according to the ICD-8 classification, for1987–1995 with ICD-9 along with DSM-III-R criteria(Kuoppasalmi et al., 1989), and since year 1996according to ICD-10.

Psychiatric diagnoses of suicide victims were con-verted to ICD-10 classification according to Nationaland Development Centre for Welfare and Healthinstructions (STAKES, 2006) as follows: Schizo-phrenia and other psychoses: F20-F29, Depressionand other mood disorders: F30-F33 (DepressionF32–F34.1), Substance related disorders: F10–F19and Other psychiatric diagnoses: F00–F09, F40–F61.

Assigning the elderly, according to age, to twogroups (65–74 and over 75 years) has also been used inprevious studies as these groups contain individualsthat may differ in lifestyles and health status (Pritchardand Hansen, 2005). The study protocol was approvedby the ethics committee of Oulu University.

Suicide information from the death certificates

In Finland, the law requires that in every case ofviolent, unnatural, sudden or unexpected death thepossibility of suicide is assessed by police andmedico-legal examinations. The decision to classifya death as a suicide is made by the forensic examiner.Our data contained only cases which were classified assuicides. During the study period the forensic defi-nition of suicide remained the same and there were nodifferences within the country. Data on age, gender,suicide method (violent: hanging, drowning, shooting,jumping from a height, traffic and other methods;non-violent: poisoning and gas) (Hakko et al., 1998),previous suicide attempts, and whether or not a victimwas under the influence of alcohol at the time ofthe suicide were based on the information from theforensic medico-legal autopsy investigations. Data inconnection with elderly and oldest old suicide victims


DOI: 10.1002/gps

suicide after hospitalization in the elderly 137

were compared with those of adult victims aged 50–64years from the same area.

Statistical methods

Statistical significance of group differences incategorical variables was examined with Pearson’sChi-square test or Fisher’s Exact test and in con-tinuous variables with Kruskal-Wallis’ test. In victimsaged 65 or older, Cox proportional hazards model wasused to compare the survival estimates between

Table 1. Suicide and clinical characteristics of the middle-aged, eld

(

AllViolent suicide method

HangingShootingDrowning

Non-violent suicide method: poisoningUnder the influence of alcohol at the time of suicidea

Previous suicide attemptsa

History of any psychiatric diagnosisHistory of hospital treated depressionHistory of hospital treated substance related diagnosisMedian (IQR) duration of last psychiatric hospitalization (days)

MalesViolent suicide method



Previous suicide attemptsa


FemalesViolent suicide method



Previous suicide attempta


*Group differences were assessed with Pearson’s Chi-Square test or Fisin continuous variables.aInformation gathered from death certificates.


different psychiatric diagnosis groups. Time from lastpsychiatric hospitalization to suicide was noted andage at death and histories of physical illnesses ofthe suicide victims were used as covariates. Statisticalsoftware used in the analyses was the SPSS version 13.

RESULTS

Gender-specific distributions of various suicides andclinical characteristics are presented in Table 1 by

erly and oldest old victims

Age-group of suicide victim Groupdifference

Middle-aged50–64 years)

Elderly(65–74 years)

Oldest old(Over 75 years)

n (%) n (%) n (%) p-value*

n¼ 370 n¼ 134 n¼ 60275 (74.3) 118 (88.1) 50 (83.3) 0.003131 (35.4) 62 (46.3) 26 (43.3) 0.06598 (26.5) 26 (19.4) 10 (16.7) 0.10125 (6.8) 22 (16.4) 11 (18.3) 0.00179 (21.4) 14 (10.4) 10 (16.7) 0.019124 (33.5) 31 (23.1) 6 (10.0) <0.00137 (10.0) 19 (14.2) 3 (5.0) 0.137195 (52.7) 62 (46.3) 21 (35.0) 0.029117 (31.6) 39 (29.1) 13 (21.7) 0.28785 (23.0) 18 (13.4) 1 (1.7) <0.0015 (2–11) 4 (1–9) 7 (3–14) 0.079

n¼ 284 n¼ 104 n¼ 42228 (80.3) 97 (93.3) 35 (83.3) 0.009106 (37.3) 53 (51.0) 19 (45.2) 0.04796 (33.8) 26 (25.0) 10 (23.8) 0.14913 (4.6) 12 (11.5) 6 (14.3) 0.01140 (14.1) 6 (5.8) 7 (16.7) 0.058102 (35.9) 27 (26.0) 6 (14.3) 0.00722 (7.7) 11 (10.6) 2 (4.8) 0.466

139 (48.9) 42 (40.2) 10 (23.8) 0.00679 (27.8) 22 (21.2) 6 (14.3) 0.10073 (25.7) 16 (15.4) 1 (2.4) 0.0019 (3–27) 4.5 (2–27.25) 18 (7.5–35.75) 0.311

n¼ 86 n¼ 30 n¼ 1847 (54.7) 21 (70.0) 15 (83.3) 0.04425 (29.1) 9 (30.0) 7 (38.9) 0.7112 (2.3) — — 0.567

12 (14.0) 10 (33.3) 5 (27.8) 0.05139 (45.3) 8 (26.7) 3 (16.7) 0.02922 (25.6) 4 (13.3) — 0.02815 (17.4) 8 (26.7) 1 (5.6) 0.17956 (65.1) 20 (66.7) 11 (61.1) 0.92538 (44.2) 17 (56.7) 7 (38.9) 0.39712 (14.0) 2 (14.3) — 0.158

11.5 (5–40) 8 (4–12.75) 5 (4–20) 0.456

her’s Exact test in categorical variables and with Kruskal-Wallis’ test


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age-group. In males a history of any hospital-treatedpsychiatric diagnosis was statistically significantlyless frequent in the oldest old (24%) than in themiddle-aged (49%). Also substance-related diagnoseswere rare among the oldest old menfolk (2% and 26%correspondingly). Additional analyses addressing gender-differences within each age-group revealed that theoldest old females had had more hospitalizations inconnection with psychiatric disorders (61% vs 23%,p¼ 0.006) and depression than any of the males hadhad (39% vs 14%, p¼ 0.034).

As also seen in Table 1, a violent method of suicidewas used statistically significantly most often byelderly males (93%), but a percentage of 83%, seen inoldest old males, was also substantial and even a littlehigher than the comparable figure for middle-agedmale victims (80%). With regard to the specific type ofsuicide method, hanging was by far the most commonmethod amongst the elderly victims (40%), whereasit was drowning (14%) for the oldest of the old. Infemales, violent methods of suicide increased drama-tically with increasing age: while 55% of the middle-

Table 2. Diagnosis of last psychiatric hospitalization of the middle-

Primary diagnosis of lastpsychiatric hospitalization

Middle-aged(50–64 yrs)

n¼ 370n (%)

AllSchizophrenia and other psychosesa 28 (14.4)Depression and other mood disordersb 85 (43.6)Substance related disordersc 60 (30.8)Other psychiatric disordersd 22 (11.3)Total 195 (100.0)

MalesSchizophrenia and other psychosesa 17 (12.2)Depression and other mood disordersb 52 (37.4)Substance related disordersc 53 (38.1)Other psychiatric disordersd 17 (12.2)Total 139 (100.0)

FemalesSchizophrenia and other psychosesa 11 (19.6)Depression and other mood disordersb 33 (58.9)Substance related disordersc 7 (12.5)Other psychiatric disordersd 5 (8.9)Total 58 (100.0)

*Fisher’s Exact test, df¼ 6.aICD-10: F20–F29.bICD-10: F30–F33.cICD-10: F10–F19.dICD-10: F00–F09, F40–F61.


aged female victims had chosen to end their livesviolently, the respective proportion was as high as 83%amongst the oldest of the old female victims. Withregard to the specific kind of suicide method, drown-ing (28%) was most common in elderly femalevictims and poisoning (45%) in middle-aged ones.Suicide committed under the influence of alcohol waslowest amongst the oldest old (males 14% and females0%).

Table 2 presents the distribution of primary psy-chiatric diagnoses assessed during the last psychiatrichospitalization. Diagnoses of depression and mooddisorders were most common in every age-group.Gender-specific analyses did not reveal any significantdifferences in the diagnoses between the differentage-groups.

Figure 1 presents the survival estimates in victimsaged 65 or older after the last psychiatric hospital-ization according to primary psychiatric diagnosesmade at that time. In females an increased likelihoodfor shorter survival was found in victims with mooddisorders (HR 2.79, 95% CI 1.28–6.10, p¼ 0.010)

aged, elderly, and oldest old suicide victims

Age-group of suicide victims

Elderly(65–74 yrs)

Oldest old(over 75 yrs)

Overaldifference

n¼ 134 n¼ 60n (%) n (%) p-value*

8 (12.9) 3 (14.3)30 (48.4) 13 (61.9)16 (25.8) 1 (4.8)8 (12.9) 4 (19.0)

62 (100.0) 21 (100.0) 0.197

4 (9.5) —16 (38.1) 7 (70.0)15 (35.7) 1 (10.0)7 (16.7) 2 (20.0)

42 (100.0) 10 (100.0) 0.365

4 (20.0) 3 (27.3)14 (70.0) 6 (54.5)1 (5.0) —1 (5.0) 2 (18.2)

20 (100.0) 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 indifferent diagnosis groups of the last hospitalization.


compared with those suffering from other disorders; inmales no differences were seen. We noticed that in42% of the cases the suicide was committed within thefirst 3 months after hospitalization.

DISCUSSION

We found a 42% suicide proportion within 3 monthsafter discharge from a psychiatric hospitalization in the


two age-groups, designated as the elderly and the oldestold. The rate was similar to that reported in connectionwith middle-aged persons, suggesting that the high-riskperiod extends into old age. The high rates wereassociated with acute episodes of psychiatric illness,earlier psychiatric hospitalization, recent hospitaldischarge, reduction in care, social factors such asliving alone or bereavement, and history of sub-stance 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 insuicide completers with mood disorders.

Suicide in elderly men appears to be more stronglyassociated with depression than in younger age groups(Conwell and Brent, 1995). In a previous Finnishstudy, in which a lower cut-off limit of 60 years wasused and psychological autopsy diagnoses were takeninto consideration (Henrikson et al., 1995), 58% of thesuicide victims had had major depression, dysthymiaor depressive disorders not otherwise specified. Ourresults are in accordance with previous results thatshowed a substantial risk of suicide in connection withdepression (Waern et al., 2002).

Alcohol dependence clearly increases the suiciderisk in the general population. However, in the elderlyalone, lower rates of alcohol dependence are usuallyreported, but perhaps this is due in part to underdetec-tion and misdiagnoses (O’Connell et al., 2003). Inprevious studies prevalence figures for alcoholism,ranging from 5 to 35%, have been reported inconnection with elderly suicide victims (Harwoodet al., 2000; Harwood et al., 2001; Waern, 2003). Inthis study, the observed rate for alcoholism in theelderly was of the same range as that of earlier studies.However, the observed proportion of elderly peoplewith a positive post-mortem screening for ethanol wassmaller than in the study of Waern (29%: Waern,2003). The observed lower rate of suicides committedunder the influence of alcohol in the elderly (as com-pared with the middle-aged), suggests that a relaxedimpulse control, due to acute alcohol intoxication,does not significantly contribute to the suicide act.

The methods used in the suicides were related towhat was available and accessible at the time thesuicides were committed, but in a proportionatelylarge number of cases violent methods were used bythe elderly and oldest old (Henriksson et al., 1995). Inour study, violent methods were used more often bythe Elderly than the Middle aged. Violent suicide wasespecially common in Elderly males, reaching rateshigher than those of violent suicide for the whole ofFinland (70.3% for the whole population, 83.2% formale and 39.8% for female subjects: Hakko et al.,1998). Violent suicides in elderly females were sub-stantially more frequent than in younger age-groups,suggesting that a violent frame of mind and aggressivenature are also risk factors for elderly females. Theobserved trend of increasingly violent suicides withincreasing age suggests that suicidal behaviour amongthe elderly is more likely to be related to a higherdegree of intent. Living alone and physical frailty arealso likely to represent contributing factors.


There are no well-known programs or guidelinesthat can be used to prevent (or at least reduce) suicidesin the elderly. The higher rates of suicide within thefirst 3 months after being discharged from hospitalmay implicate an insufficient treatment response orsuggest that outpatient treatment has started tardily orhas proved unacceptable for the patient (Qin andNordentoft, 2005). A closer monitoring of the patientduring and immediately following the dischargeperiod, use of effective psychotherapy and/or psy-choactive medication as well as avoidance of knowntoxic compounds, such as tricyclic antidepressants,might represent possible interventions (Ho, 2003;Pinquard et al., 2006). Certainly greater attentionshould be given to the potential role of lay networksin alleviating psychological distress and loweringsuicidal ideation (Conwell et al., 2002). Furthermore,there is no doubt that additional research is neededto assess personality traits as predisposing factorsfor completed suicides in the elderly (Useda et al.,2007).

ACKNOWLEDGEMENTS

The study has been supported by grant number 113760 from the Academy of Finland (HKO).

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