Suicide and children,adolescents, youth and the Elderly

SUICIDE OVER THE LIFE SPAN


ADOLESCENTS AND YOUTHS Brian L. Mishara

CHILDREN Brian L. Mishara

THE ELDERLY Diego De Leo


ADOLESCENTS AND YOUTHS



Suicides of the young, those who have most of life's highlights to experience, are profoundly challenging to cultural systems. Considerable soul searching was triggered in the United States when, between the mid-1960s and mid-1980s, the suicide rates of its ten- to fourteen-year-olds nearly tripled while doubling among those aged fifteen to nineteen. Although the suicide rates for adolescents in the United States and Canada are lower than for other age groups because adolescents die infrequently from physical illnesses, by the end of the twentieth century suicide was the second greatest cause of death in adolescence, after (mainly automobile-related) accidents.

The term youth is often considered to end several years after adolescence, with twenty-first-century tendencies setting the upper limit for "youth" at age twenty-five or older. In the United States, males aged fifteen to twenty-five commit suicide at least five times as often as females, although females are much more likely to attempt suicide. This difference has been explained in different ways, including male preferences for more violent and more lethal methods; male tendencies to keep problems to themselves and not confide in others nor use health and mental health services as frequently; increased male vulnerability to mental health problems; socialization into male stereotypes and "macho" role expectations. During the 1990s suicide rates began to decrease among those aged fifteen to nineteen except among African Americans. The decrease may be attributed to better identification and treatment of mental disorders in youth, increased awareness of suicide and access to suicide prevention resources, or other sociocultural changes in American society.
Risk Factors Related to Adolescent and Youth Suicide

Mental health professionals have identified those factors that pose the greatest risk to adolescents and youth suicides. Youths who attempt and commit suicide generally have several risk factors, which are combined with the ready availability of a lethal means and the lack of suitable sources of help.

Social and economic environments. The family is one of the earliest and most significant influences in a young person's development. There have been numerous studies of family troubles associated with youth suicidal behavior, including early parental loss, parental mental health problems, parental abuse and neglect, and a family history of suicide. In addition to chronic family troubles, there are usually precipitant events closer in time to a suicide attempt, many of which involve the family. These precipitants include serious conflicts with family members or divorce of parents, perceived rejection by one's family, and failure of family members to take an adolescent's talk about suicide seriously.

The school constitutes an important influence on youth. It is therefore not surprising that a history of school problems and the stress of disruptive transitions in school are potential risk conditions for youth suicidal risk behavior, as well as failure, expulsion, and overwhelming pressure to succeed.

The influence of peers on young people's behavior can sometimes be greater than that of family and school. There is a risk of copycat suicidal behavior in adolescents who have been exposed to a peer's suicide. This contagion effect is most pronounced for vulnerable youths who tend to identify strongly with someone who has committed suicide in their environments or in mass media. Common precipitating events in youth suicidal behavior include rejection from peers, the breakup of a significant relationship, or the loss of a confidant. Furthermore, adolescents and young people who fail to act when confronted with a suicidal peer, by dismissing it as insignificant or failing to inform an adult, can increase the risk of suicide.

Poverty in children and youth heightens the risk conditions for suicide, including school problems and failures, psychiatric disorders, low self-esteem, and substance abuse, all of which can increase vulnerability to suicide and suicidal behavior.

Physical environment. Having immediate and easy access to lethal means to kill oneself increases the risk that a suicide will occur. Firearms are common methods of male suicides in the United States, and young women are increasingly using guns to kill themselves. Having such an instantly lethal method available increases the risk that vulnerable young people may kill themselves impulsively.

Additional risk factors. The researcher Jerome Motto suggested that the increased use of alcohol and drugs might have been a significant factor related to the rise of youth suicide since the 1970s. According to David Brent, at least one-third of adolescents who kill themselves are intoxicated at the time of their suicide and many more are likely to be under the influence of drugs.

A history of previous suicide attempts and the presence of a psychiatric disorder are among the most important and well-established risk factors for youth suicidal behavior. As many as 10 percent of suicide attempters eventually die in a later suicide attempt. Depression is a major mental health problem associated with suicide. In addition, impulsive behavior, poor problem-solving and coping skills, alcoholism, and homosexual orientation also increase the likelihood of suicidal behavior.
Prevention

No single risk factor alone is sufficient to result in a suicide. Youths who attempt and commit suicide generally have several risk factors that are combined with the ready availability of a lethal means and the lack of suitable sources of help.

Primary prevention. Primary prevention consists of actions to prevent suicidal behavior before people develop a high-risk or a suicidal crisis. Most youth and adolescent suicide prevention programs have focused on school-based activities where adolescents receive training in identifying signs of suicide risks and how to best react to suicidal peers. Some programs also identify resources to help with suicide and encourage young people to talk with adults if they feel that they or their friends are feeling suicidal. Young people are specifically encouraged not to keep a "secret" confession of suicidal intentions to themselves. Controversy surrounds the usefulness and effects of school-based suicide prevention programs. Few programs have been the subject of rigorous evaluations and not all programs have had positive results. Research indicates that programs that provide a variety of resources within the school and community, including specially trained teachers, mental health services and counselors, and information and training for parents, may be of more benefit in preventing suicidal behavior.

In addition to school-based programs, many primary prevention approaches have focused on key persons who may come in contact with potentially suicidal youth. These persons, called "gatekeepers," include school staff, child welfare workers, community volunteers, coaches, police, family doctors, and clergy members. Training usually involves information on taking suicide threats seriously and asking specific questions to assess suicide risk, identifying behavior changes that may indicate increased suicide risk, better identification and treatment of depression and other mental health problems, and providing information about resources to help with suicide and other community youth problems.
Intervention

Given their higher risk of suicide, particular treatment should be given to persons who attempt suicide. Unfortunately, many young suicide attempters do not receive adequate follow-up after they are discharged from the hospital. Successful programs for young people who are hospitalized for suicide attempts involve treatment in the community by counseling, therapy, and/or medication after their discharge. The most effective programs treat more than just the suicidal individual but also involve the person's family in developing a long-term strategy to reduce the factors associated with suicidal behavior. Very often, young people do not want to continue with treatment after an attempt and they may tell others that they are better or that they want to move on in their life and ignore the "mistake" they have made. Despite this, it is important to ensure that there is regular long-term follow-up after any suicide attempt in order to treat the underlying problems and reduce the likelihood of a subsequent attempt.

After a suicide occurs in a school setting, it is important that the school react in an appropriate manner to the suicidal death in order to allow other students to grieve the death and prevent a contagion effect of others imitating the suicidal behavior. Many schools have established protocols for "postvention" which often use a "critical debriefing" model to mobilize members of the community following a tragic event, including a suicide by a student. These protocols define who will act as a spokesperson for the school, how to identify students and family members who are particularly vulnerable or traumatized by the event, and how best to help them, as well as general activities in the school to allow for appropriate mourning and discussions in order to understand what has occurred. Each suicidal event is unique and any general protocol must be adapted to the specific circumstances and the school environment. After a suicide schools should provide information and help facilitate access to skilled individuals who may help those troubled by the event. However, it is also important for those in authority not to glorify the suicide by having long extended commemorative activities that may communicate to some vulnerable suicidal students that committing suicide is an effective means of having the entire school understand their grief or problems. It is important that commemorative events emphasize that suicide is a tragic event, that no one is better off for this having happened, that help is readily available, and that most suicides can be prevented.

See also: S UICIDE I NFLUENCES AND F ACTORS : G ENDER , M EDIA E FFECTS , R OCK M USIC ; S UICIDE OVER THE L IFE S PAN : C HILDREN ; S UICIDE T YPES : S UICIDE P ACTS
Bibliography

Brent, David. "Age and Sex-Related Risk Factors for Adolescent Suicides." Journal of the American Academy of Child and Adolescent Psychiatry 38, no. 12 (1999):1497–1505.

Brent, David, et al. "Psychiatric Sequelae to the Loss of an Adolescent Peer to Suicide." Journal of the American Academy of Child and Adolescent Psychiatry 32, no. 3 (1993):509–517.

Brent, David, et al. "Risk Factors for Adolescent Suicide." Archives of General Psychiatry 45 (1988):581–588.

Dyck, Ronald J., Brian L. Mishara, and Jennifer White. "Suicide in Children, Adolescents and Seniors: Key Findings and Policy Implications." In National Forum on Health Determinants of Health, Vol. 3: Settings and Issues. Ottawa: Health Canada, 1998.

Gould, Madeline, et al. "Suicide Clusters: An Examination of Age-Specific Effects." American Journal of Public Health 80, no. 2 (1990):211–212.

Groholt, Berit, et al. "Youth Suicide in Norway, 1990–1992: A Comparison between Children and Adolescents Completing Suicide and Age- and Gender-Matched Controls." Suicide and Life-Threatening Behavior 27, no. 3 (1997):250–263.

Motto, Jerome. "Suicide Risk Factors in Alcohol Abuse." Suicide and Life-Threatening Behavior 10 (1980):230–238.

Pfeffer, Cynthia, et al. "Suicidal Children Grow Up: Demographic and Clinical Risk Factors for Adolescent Suicide Attempts." Journal of the American Academy of Child and Adolescent Psychiatry 30, no. 4 (1991):609–616.

Shaffer, David, and Madeline Gould. "Suicide Prevention in Schools." In Keith Hawton and Kees van Heeringen eds., The International Handbook of Suicide and Attempted Suicide. Chichester: John Wiley & Sons, 2000.

Spirito, Anthony, et al. "Attempted Suicide in Adolescence: A Review and Critique of the Literature." Clinical Psychology Review 9 (1989):335–363.

BRIAN L. MISHARA
CHILDREN

Children develop an understanding of suicide at an early age and that follows their understanding of what it means to die and to be dead. Although children very rarely commit suicide before adolescence, they almost invariably witness suicide attempts and suicide threats on television. In addition, they talk about suicide with other children.
Children's Understanding of Suicide

Research indicates that by age seven or eight almost all children understand the concept of suicide. They can use the word suicide in conversations and name several common methods of committing suicide. Younger children, as young as ages five and six, are generally able to talk about "killing oneself," even if they do not know the meaning of suicide, and learn the unsettling effects of such talk on adults. By age seven or eight almost all children report that they have discussed suicide with others on at least one occasion, and these discussions are almost invariably with children their own age. In one 1999 study conducted by Brian Mishara, half of all children in first and second grade and all children above second grade said that they had seen at least one suicide on television. These suicides usually occur in cartoons and involve the "bad guy" who kills himself when he has lost an important battle with the "good guy." Children also experience suicide attempts and threats in soap operas and adult television programs. Surveys of parents have found that 4 percent of children have threatened to kill themselves at some time.

In Western cultures, children ages five to twelve rarely have positive attitudes toward suicide. At all age levels, children consider suicide an act that one should not do; few feel that people have a right to kill themselves. When there is a suicide in the family, children usually know about it, despite parents' attempts to hide the fact by explaining that the death was an accident. For example, in studies conducted in Quebec, Canada, by Mishara, 8 percent of children said that they knew someone who had committed suicide, but none of the children said they were told about the suicidal death by an adult.
Children's Understanding of Death

Although children understand death and suicide at a young age, their conceptions of death often differ from an adult understanding. Very young children do not see death as being final (once someone is dead, he or she may come back to life), universal (everyone does not necessarily die someday), unpredictable (death cannot just happen at any given time), nor inescapable (taking the right precautions or having a good doctor may allow someone to avoid dying). Furthermore, for the youngest children, once someone is dead he or she may have many characteristics that most adults reserve for the living, such as being able to see, hear, feel, and be aware of what living people are doing. These immature understandings of death change fairly rapidly, with children learning at a young age that death is a final state from which there is no return. Also, children learn at an early age that all people must die someday. However, as many as 20 percent of twelve-year-olds think that once a person has died, he or she is able to have feelings or perceptions that living people experience.
Children's View of Suicide

It is naive to think that young children do not know about suicide. However, the image that children get from television is different from what occurs in the vast majority of suicides in the real world. Those who commit suicide on television almost never suffer from severe depression or mental health problems, they are almost never ambivalent about whether or not they should kill themselves, and it is rare that children see suicidal persons receiving help or any form of prevention. This contrasts with the reality in which mental health problems are almost always present—where there is tremendous ambivalence and the fact that persons who consider suicide rarely do so, as most find other ways to solve their problems.
Prevention and Intervention Approaches

To counter such misconceptions and to reduce suicidal behavior later in life, several preventive strategies have been tried. One provides accurate information about suicide to children in order to correct erroneous conceptions that children may develop from their television experiences or discussions with other children. Another focuses upon children's coping abilities. Research on adolescents and young adults who attempt suicide indicates that they have fewer effective coping strategies to deal with everyday problems. Although it may take many years before programs begin teaching young children that there is a link between effective coping and long-term suicide prevention effects, this approach has had promising short-term effects in increasing children's abilities to find solutions to their problems and improve their social skills. For example, the Reaching Young Europe program, called "Zippy and Friends," is offered by the Partnership for Children in different European countries. Developed by the prevention organization Befrienders International (and now run by Partnership for Children), Zippy and Friends is a twenty-four-week, story-based program for children in kindergarten and first grade that teaches through games and role play on how to develop better coping skills. Short-term evaluation results indicate that, when compared to a control group of children who did not participate in the program, participants had more coping strategies, fewer problem behaviors, and greater social skills.

Research results suggest that it may not be appropriate to ignore self-injurious behavior in children and suicide threats because of the belief that children do not understand enough about death and suicide to engage in "true" suicidal behavior. According to official statistics, children almost never commit suicide. However, perhaps more children commit suicide than coroners and medical examiners indicate in reports. They may classify some deaths as accidental because of the belief that children are too young to know about death and suicide and are only "playing," or to spare parents the stigma of suicide. Nevertheless, there are numerous case histories and several investigations of factors related to suicidal behavior in children. Studies on the social environment generally focus on the greater likelihood of suicidal behavior in children from families where there is parental violence or sexual abuse, or have family histories of alcohol and drug abuse, depression, and suicidal behavior.

Depression in children appears to be a risk factor for suicide, although depressive symptoms in children are difficult to recognize and diagnose. Symptoms of depression in children include long-lasting sadness, which may be linked with frequent crying for little or no apparent reason, monotone voice, and seeming to be inexpressive and unemotional. Other possible symptoms include the development of inabilities to concentrate and do schoolwork, being tired and lacking energy, social withdrawal and isolation, refusing to continue to participate in games and group activities, not answering questions or having long delays before answering, and a variety of "somatic" complaints. These somatic complaints include sleep difficulties such as insomnia, frequent nightmares, and incontinence, anorexia, stomach pains, and complaints of physical difficulties that seem unfounded. Often depressed children seem anxious and may have multiple phobias or fears. Some children try to fight against depression by acting out or being angry a lot of the time. In these cases, the depressive symptoms are generally also present. If a child has several of the preceding symptoms, or symptoms are intense and long lasting, consultation with a professional is indicated. This is particularly true if a child threatens to commit suicide or becomes interested in suicide methods, such as tying nooses or playing suicide games with other children or with dolls.

It can also be beneficial to ask direct questions to a child who talks about suicide. Questions might include: "Are you thinking of killing yourself?" "Have you thought about how you would do it?" "Do you think you might really commit suicide?" Despite common adult beliefs that asking questions might "put ideas" in a child's head, if a child threatens suicide, the child almost always knows about suicide and it is impossible to suggest suicide behavior by talking about it. It is also important to ask suicidal children what they think will happen after a person dies. If the child gives the impression that one can return from the dead or being dead is like being alive, it may be useful to correct this impression or describe in some detail what it means to die and be dead.

One should seek advice from a mental health professional if a child has symptoms of depression and/or threatens suicide. It is also important to talk about what occurred when a child experiences a suicide in the family or in the family of friends or at school. Such discussions may begin by asking a child what he or she thinks about what occurred, including why the child thinks the person committed suicide and what the child thinks it is like to be dead. Often children have a good understanding of what has occurred, a fairly realistic notion of what happens when one dies, and a negative attitude toward suicidal behavior. However, in the event that a child glorifies or trivializes a death by suicide or feels that the suicide victim is "better off" now, it is important to continue the discussion to clarify the nature of what occurred and if necessary seek counseling or professional help. It is also important for children to be able to express their feelings about a loss by suicide (even if those feelings include "unacceptable" feelings such as anger at the person for having left). It is important for children to develop an understanding of the suicide as being a tragic avoidable death and not a situation with which the child can easily identify.

Although suicidal behavior in children is rare, one should not minimize suicidal threats and attempts in children, and it is important to be aware of persistent indications of depression in children.

See also: C HILDREN AND A DOLESCENTS' U NDERSTANDING OF D EATH ; C HILDREN AND M EDIA V IOLENCE ; L ITERATURE FOR C HILDREN
Bibliography

Dyck, Ronald J, Brian L. Mishara, and Jennifer White. "Suicide in Children, Adolescents and Seniors: Key Findings and Policy Implications." In National Forum on Health Determinants of Health, Vol. 3: Settings and Issues. Ottawa: Health Canada, 1998.

Garfinkel, Barry D., Art Froese, and Jane Hood. "Suicide Attempts in Children and Adolescents." American Journal of Psychiatry 139 (1982):1257–1261.

Mishara, Brian L. "Conceptions of Death and Suicide in Children Aged 6 to 12 and Their Implications for Suicide Prevention." Suicide and Life-Threatening Behavior 29, no. 2 (1999):105–118.

Mishara, Brian L. "Childhood Conceptions of Death and Suicide: Empirical Investigations and Implications for Suicide Prevention." In Diego De Leo, Armi N. Schmidtke, and Rene F. W. Diekstra eds., Suicide Prevention: A Holistic Approach. Boston: Kluwer Academic Publishers, 1998.

Mishara, Brian L., and Mette Ystgaard. "Exploring the Potential of Primary Prevention: Evaluation of the Befrienders International Reaching Young Europe Pilot Programme in Denmark." Crisis 21, no. 1 (2000):4–7.

Normand, Claude, and Brian L. Mishara. "The Development of the Concept of Suicide in Children." Omega: The Journal of Death and Dying 25, no. 3 (1992): 183–203.

Pfeffer, Cynthia R. The Suicidal Child. New York: The Guilford Press, 1986.

BRIAN L. MISHARA
THE ELDERLY

Until the 1970s suicide was most common among the elderly, while in the twenty-first century younger people have the highest suicide rate in one-third of all countries. Reasons for such a change are unclear; however, many countries of different cultures have registered an increase in youth suicide that has been paralleled by a decline in elderly rates. Since the 1970s, the decline in elderly suicide has been particularly evident in Anglo-Saxon countries, and especially among white males in United States (around 50%). Proposed explanations have considered improved social services, development of elderly political and social activism, changing attitudes toward retirement, increased economic security, and better psychiatric care. By contrast, the lack of specific services for the elderly in Latin American countries may account for the increase in suicide rates in recent years. Moreover, the spontaneous support provided by traditional family structure has been progressively declining without being replaced by alternative sources of formal support or any better education on coping with age.

Despite tremendous cultural variability across nations, suicide rates in the elderly remain globally the highest for those countries that report mortality data to the World Health Organization (WHO), as shown in Figure 1. In general, rates among those seventy-five years and older are approximately three times higher than those of youth under twenty-five years of age. This trend is observed for both sexes, and it is steeper for males. Suicide rates actually present several distinct patterns in females. In some nations, female suicide rates rise with age, in others female rates peak in middle age while, particularly in developing nations and minority groups, female suicide rates peak in young adults. Based on 2001 data, half of all suicides reported in women worldwide occur in China.

Suicide is most prevalent among male subjects, and remarkably so at seventy-five and more years of age. Particularly in the Western world, this seems to contrast with the poor health and social status experienced by elderly women that results from more compromised psychophysical conditions secondary to greater longevity, poverty, widowhood, and abandonment. To explain this difference, social scientists have suggested that women might benefit from better established social networks, greater self-sufficiency in activities of daily living, and commitment to children and grandchildren.
General Characteristics of Suicide in the Elderly

There are characteristics that are particular to this age group. Older people are likely to suffer from a physical or mental illness, and in general tend to plan their suicides rather than act on impulsivity. The suicide methods chosen by elderly persons (including women) are generally violent with a high degree of lethality, expressing strong suicidal intention. The most common self-destructive methods are by hanging, firearms (particularly in the United States), jumping from high places (particularly in Asian metropolitan cities like Hong Kong and Singapore), self-poisoning (especially with medicine, benzodiazepines, and analgesics, among women), and drowning.

In most cases of elderly suicides, the act is performed at home alone. When suicide notes are left, they usually contain financial dispositions and burial instructions. The notes indicate a high degree of determination, accurate planning, and emotional detachment.
Underreporting of Suicidal Behavior in the Elderly

Suicide mortality data usually carry an underestimation of their real number, a phenomenon that is thought to be particularly frequent in the elderly. For a variety of reasons, there may be reluctance to call a death a suicide, particularly in those regions where religious and cultural attitudes condemn suicide. In general, a suicide may be voluntarily hidden to avoid public stigmatization for social convenience, for political reasons, to benefit from insurance, or because it was deliberately masked as an accident. Suicide can also be misclassified as an undetermined cause of death or as a natural cause (e.g., when people neglect to take life-sustaining medications).

Suicide can also go unrecognized when people overdose on drugs, starve themselves to death, or die some time after their suicide attempt (in these cases usually it is the clinical cause of death which is officially reported), or in cases of euthanasia or assisted suicide.
High-Risk Factors in Suicide among the Elderly

Although the majority of elderly persons may be suffering from psychiatric disorders at the time of suicide, the large majority of them who commit suicide do not have a history of previous suicidal behavior. In addition, researchers found that only a small percentage of psychologically healthy individuals have a "desire to die."

Psychopathology. Psychiatric pathology represents the most important risk factor for suicide in the elderly. Over three-fourths of elderly victims
FIGURE 1
FIGURE 1
are reported to suffer from some sort of psychiatric disorder at the time of their death. Mood disorders are highly associated with suicidal behavior at all ages but appear to play the most fundamental role in suicide in older adults. A study conducted by Harris and Barraclough in 1997 revealed that the mean suicide risk in subjects affected by major depressive disorder and dysthymia (a less severe form of mood disorder) was, respectively, twenty and twelve times higher than expected, in relation to the general population. An excess risk persists into old age, during which time the combined suicide risk is thirty-five times higher than expected. Most elderly victims suffered from major depression: 67 percent of suicides were aged fifty or over in a 1991 study by Yates Conwell and colleagues; 83 percent in those aged sixty-five and over in the 1993 study by Clark and Clark; and 44 percent of the over-sixty age group in the 1995 research by Markus Heriksson and colleagues.

The predominant role of mood disorders in increasing the risk of a serious suicide attempt suggests that elimination of these disorders could reduce the incidence of serious suicide attempts by up to 80 percent, particularly among older adults (sixty years and over), where the association between mood disorder and suicide attempts is stronger. However, the underrecognition and undertreatment of depression in older adults in the community is very common.

Older persons often do not present with the classic symptomatology. Nearly half of them lack a depressed mood (one of the most recognizable symptoms) in the clinical presentation. Furthermore, given the frequently simultaneous presence of a physical illness, often masking the symptoms of depression, older persons may deliberately deny symptoms such as suicidal ideation. The problem of underrecognition of elderly depression is exacerbated by very low rates of antidepressant treatment. Even if physicians recognize that the depression may need treatment, they are often concerned about adding to the already complex regimen of medications.

Similarly, identification of persons at risk of suicide is also particularly problematic in the elderly. The lack of forewarning of suicide attempts in elderly suicide leads to particular importance being placed on the detection of suicidal ideation. Recent research examining suicidal ideation in seventy-three completed suicides found that 38 percent had expressed their suicidal intent to their doctor prior to their death. However, when consulting with friends and confidants of the deceased they found that 85 percent had communicated their intent. Several patients had denied their intent to suicide to their doctor. These figures highlight the difficulty in detecting suicidal ideation in older patients in a primary care setting, as well as advocating consultation with close ones when suicidal ideation is suspected.

Alcohol abuse and dependence are present according to different studies in 3 to 44 percent of elderly suicide victims, which is higher than the general population of the same age, and are more common among those aged sixty-five to seventy-four. The combination of drinking and depression may produce a very high risk of suicide in the elderly, especially where drinking is a maladaptive coping mechanism. Only a small number of elderly suicides were suffering from schizophrenia or other psychotic conditions, and the same holds true for personality disorders. Suicides may generally be associated with the personality trait of "lower openness to experience," inability to form close relationships, tendency to be helpless and hopeless, inability to tolerate change, inability to express psychological pain verbally, loss of control, and feelings of loneliness, despair, and dependence on others.

Finally, the role of anxiety disorders seems to be relevant only as an added condition, especially in conjunction with depression. Likewise, dementia hardly features on the diagnostic list of suicides. It has been proposed that in the early stages of Alzheimer's disease there could frequently be suicidal ideation, but cognitive impairment may impede realization. Loss of insight from the very beginning of the disorders is more marked among subjects with deeper involvement of frontal lobes.

Physical illness. There is controversy as to the influence exerted by physical illness on suicidal behavior. In a study by McKenzie and Popkin (1990), 65 percent of older adults were afflicted by a severe, chronic physical pathology at the time of suicide and 27 percent suffered from persistent, severe illness. Because these conditions were likely to reduce autonomy and necessitate a change of lifestyle, they may induce symptoms of depression, helplessness, and hopelessness, particularly among men and those over seventy-five. Lack of trust in medical intervention and endless suffering were commonly found in depressed elderly suicides. However, the constant co-presence of a structured depressive disorder or other psychiatric pathology (e.g., substance abuse) suggests that physical illness alone does not bring about suicide outside of a psychopathological context. Researchers have suggested that most physical illnesses presenting an increased risk of suicide were associated with mental disorders, substance abuse, or both, and that these factors may be a link between medical disorder and suicide.

Recent studies reported increased suicide rates across cancer patients, especially in the first months after diagnosis and in men. However, among them a high prevalence of psychopathology has also been identified (e.g., severe depression, anxiety, and thought disturbances). An important aspect of suicide risk in relation to physical illness has to do with how patients feel about their illness and their unique fears. In most cases their fears are a manifestation of a deeper psychological problem.

Life conditions and events. Widowed, single, or divorced people are overrepresented among elderly suicide victims, particularly among men. The relatively low suicide rates for married people may reflect not only the companionship of marriage, but also its outlet for aggressiveness.

Up to 50 percent of elderly suicide victims, particularly women, are reported to live alone and to be lonely. Generally speaking, suicidal elderly have been found to have fewer resources and supports and to have less contact with relatives and friends than the younger. However, some researchers claim that apart from more frequent losses and the presence of physical illness in the elderly, there is no particular excess of social isolation and stressful life events, compared to youth. Suicide in the elderly could be related to a narcissistic crisis due to the inability to tolerate the accumulation of minor day-to-day failures. Suicidal behavior may then be precipitated by these events in conjunction to depression or alcohol abuse.

Retirement does not constitute an important suicide risk factor per se, unless it is abrupt and involuntary, particularly in the case of white men under seventy-five and in subjects who lack the flexibility to deal with role change or health and social support. Socioeconomic decline does not appear to be as important a risk factor for the elderly suicide as it is in younger populations. Conversely, bereavement very frequently represents a stressful life event in late life, and the death of a close relative or friend is a very important factor in precipitating suicide. Risk appears to be higher when it concerns the loss of a spouse, especially if it is sudden. Men seem to be more exposed than women.

Biological factors. The study of aging brain processes showed alterations of synaptic conduction and neurotransmitters systems, such as a reduction in dopamine and norepinephrine content in various areas of the brain of the elderly and an increase in monoamine-oxidases, the enzymes that eliminate those neuro-hormones. The hypothesized higher vulnerability of elderly people to depression and suicide could be related to a defective compensatory mechanism, which may favor onset and chronic course of psychopathological process. It has been suggested that impaired regulation of the hypothalamus-pituitary-adrenal axis and alterations in the circadian rhythm, both common in the elderly, may in turn play a part in inducing suicidal behavior.
Prevention and Intervention of Suicidal Behavior

Preventative initiatives include the introduction of social security programs, reduction in the percentage of elderly persons living below the poverty line, the development of flexible retirement schemes, and improved health care availability. Greater opportunities for relations with peers and better access to recreational facilities may provide support for urban elderly people and facilitate role transition typical of old age, including retirement and children leaving home. A systematic monitoring of physical health seems to be particularly important, in the light of its possible impact on suicidal behavior.

Identifying suicidal ideas and tendencies among the elderly is a first goal of fundamental importance. Abilities to detect mental suffering should be improved by appropriate training and educational programs, addressed particularly to general practitioners and other health professionals, such as nurses and social workers. Particular emphasis should be placed on recognition of early and atypical symptoms of psychopathology in the elderly (particularly depression in men) and on the need to eradicate passive therapeutic attitude and old-fashioned fears about psychotropic drugs to allow adequate treatment of potentially reversible mental illness. Some nonpharmacological approaches to the treatment of senile depression might also be considered, particularly cognitive therapy and interpersonal psychotherapy.

Suicide prevention programs and general mental health facilities are underutilized by elderly suicide victims. Reasons range from poor information available to the public, conviction that these services are costly, and the low credibility given by older adults to all types of agencies or institutions. An attempt to overcome elderly people's reticence to contact centers for collecting alarm signals has been through the use of active outreach programs. One such program is the "Tele-Help/Tele-Check Service" established in the Veneto region of Italy, where most disadvantaged elderly people (by loss of autonomy, social isolation, poverty, and/or poor mental health) are actively selected within the community by general practitioners and social workers. They are then assisted with at least two phone calls per week from well-trained personnel. This program is associated with a statistically significant decrease in the number of expected deaths among the elderly.

Ongoing strategies are more successful with female subjects. A possible explanation for success involves the generally more pronounced attitude of women to communicate their inner feelings and receive emotional support. Especially in Western cultures, men are less willing to express their emotions. Thus, it is more likely that males at risk are more often underdiagnosed and undertreated, especially by general practitioners, than their female counterparts. The most promising avenues include the development of crisis intervention techniques that are able to modify the male client attitude and environment in a way that promotes in them more adaptive strategies.

Individuals affected by the suicide of a relative or close friend experience emotional stress requiring special attention, as they too are at high risk for suicide. The most important differences in the grief experience of suicide survivors compared to survivors of accidental or natural deaths concern the associated stigma of the suicide and its ramifications: feelings of guilt, blame, embarrassment, shame, loneliness, and social isolation. Supportive interventions should therefore pay special attention to the elderly, be they survivors of peer suicides or younger individuals (children, grandchildren), bearing in mind that older adults rarely take advantage of formal crisis intervention and support facilities. A particularly important role in identifying needs and organizing the feasibility of such intervention could be assumed by general practitioners, who are often the only contact elderly people actively seek or request of health and social services.

See also: S UICIDE B ASICS : E PIDEMIOLOGY ; S UICIDE I NFLUENCES AND F ACTORS : G ENDER , M ENTAL I LLNESS ; S UICIDE T YPES : T HEORIES OF S UICIDE
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