Chapter 2: Medical examiner and coroner reports: Uses and limitations in the epidemiology and prevention of late-life suicide
In the introduction chapter, I highlighted that male suicide rates increase with age and men aged 85 years and over have one of the highest suicide rates among all age groups in New Zealand. However, local research in late-life suicidal behaviour is lacking. I decided the first step of my inquiry was to explore and learn about the international literature on suicide in older people.
I have examined completed suicide in older people using coroner records in the later chapters of my thesis. The purpose of this chapter was to review and synthesise the findings of international literature using similar methodologies (coroner and medical examiner records) to investigate late-life suicide. In particular, I have described the epidemiological, sociodemographic characteristics and clinical aspects of late-life suicide in this chapter. The knowledge gained from this literature review informed my understanding of late-life suicidal behaviour when I examined the New Zealand data.
Suicide is among the top 20 leading causes of death globally for all ages and is a major public health concern. In 2000, the World Health Organization (WHO) estimated the rates of suicide in men and women, aged 75 and older, to be 50 and 16 per 100,000 respectively indicating a clear relationship between increased suicide rates with age (World Health Organization, 2002). With longer life expectancy and ageing populations worldwide, the absolute number of deaths from suicide in older people is likely to rise. Understanding the factors contributing to this emerging problem and developing effective late-life suicide prevention programmes is therefore an international priority.
Suicide rates of older people vary significantly across countries. Shah (2011) found that suicide rates of older people were reported to be the lowest in Caribbean and Arabic/Islamic countries, and highest in central and eastern European countries emerging from the former Soviet Union, and in some Asian and west European countries. However, reporting for deaths in general varies across countries (and states) and this may introduce misleading variations in mortality rates. For example, within the United Kingdom, there is no uniformity in the registration, coding and analysis of suicides across England and Wales, Scotland and Northern Ireland (Brock et al., 2006). Timmermans (2005) suggested geographical variation of suicide rates could be a result of how suicide is medicolegally determined, reported and classified in different jurisdictions. The regularity of reporting on mortality is also a factor. For example, for the WHO data bank there is almost no data available from the African region (Bertolote & Fleischmann, 2002).
As in other age groups, suicide in older people involves a complex interaction between psychiatric, psychological, physical, social and cultural factors (Conwell et al., 2011; Erlangsen et al., 2011; Fässberg et al., 2012; Lapierre et al., 2011). Identifying risk and protective factors in a given population is a crucial step towards the development and implementation of suicide risk assessment and management strategies. In many countries, assessment of coroner/medical records is frequently used to elucidate these factors. From the seventeenth century, coroners in Anglo-Saxon countries have conducted death inquests (Timmermans, 2005). In the United States (U.S.) 22 states have a medical examiner system, 11 states have a coroner system and the rest have mixed systems (Hanzlick, 2003).
The aims of this review are to (1) synthesise the results of studies that used coroner or medical examiner records to investigate epidemiological, sociodemographic and clinical factors associated with late-life suicide; (2) identify opportunities for suicide prevention in older people; and (3) determine whether there is any variation in the standard of reporting suicide risk factors by these studies. As far as we can ascertain, there has been no similar reviews previously published in the literature
A literature search was performed at a single time-point on the 20th August 2013 using the following databases: SCOPUS, MEDLINE and PsycINFO. All years were included in the search (SCOPUS from 1960; MEDLINE from 1946; PsycINFO from 1806). The following terms were used for searching in the abstract field: (“suicid*”) and (“coron*” or “medical examiner” or “autopsy”) and (“elder*” or “geriat*” or “old*”). The search was limited to publications in English. This search strategy resulted in 1084 publications. The titles and abstracts were screened and only studies that used coroner files or medical examiner records were included. Studies were individually checked to ensure that only older people were included in the published articles. Studies were also included if they used control group comparisons. Studies that used psychological autopsy, a different suicide research methodology, were excluded. Other exclusion criteria were (i) a sample size of less than 50; studies that published secondary analysis of primary data; (iii) studies that investigated the association of suicide with a specific medical condition, suicide method or medication; (iv) studies primarily reporting suicide rates and no other epidemiological aspects of suicide; and homicide-suicide studies. Exclusion criteria (iii) was introduced because studies using coroner or medical examiner records have the advantage of capturing 100% of consecutive cases in a specific geographical location over a defined time period. Including studies with a specific medical condition, suicide method or method would undermine this purpose.
Eighteen studies fulfilled these criteria. I then manually searched the bibliography of these 18 studies and an additional seven studies were found. The final number of studies included in this review is 25.
Data were extracted from the 25 studies on (i) demographics; (ii) medical, psychiatric and psychosocial factors; (iii) contact with primary care and mental health services prior to suicide; and (iv) suicide methods. The mean rate of these factors was calculated by pooling the total number of people included in the studies; while the rates of these factors reported in individual studies were used to calculate the range and median.
Thirteen of the 25 studies were conducted in North America (Conwell, Rotenberg, & Caine, 1990; Copeland, 1987; Duckworth & McBride, 1996; Juurlink, Hermann, Szalai, Kopp, & Redelmeir, 2004; Kaplan, McFarland, Huguet, & Valenstein, 2012; Karch, 2011; Mezuk, Prescott, Tardiff, Vlahov, & Galea, 2008; Purcell, Thrush, & Blanchette, 1999; Quan & Arboleda-Florez, 1999; Shields, Hunsaker, & Hunsaker III, 2006; Wanta, Schlotthauer, Guse, certificates; coroner/medical examiner reports; police reports; and crime laboratories (Centers for Disease Control and Prevention USA, 2013).
The study by Kaplan et al. (2012) included male veterans aged 18 years and older. They performed analyses on different age groups (age ranges: 18–34, 35–44, 45–64, >65). Only results on the >65 group are presented in this review. Similarly, the two studies by Tadros and Salib (2000; 2007) and the study by Abrams, Marzuk, Tardiff, and Leon (2005) included younger age groups and only the results in the elderly group are presented here.
The demographic data are shown in Table 2.2. All except two studies used age 60 or 65 years and over as their inclusion criteria: Quan and Arboleda-Florez (1999) included cases aged ≥55 years with more than half (51.2%) of their cases in the 55 to 64 age group; Conwell et al. (1990) included cases aged ≥50 but divided their analyses by age ranges e.g. age 64–73 and age ≥74 groups. The study by Wanta et al. (2009) is the only other study that divided their older people into young elder (65–74), middle elder (75–84) and older elder (≥85) age groups. They found increasing age in the male population was a significant risk factor for suicide. In those studies using ≥65 years as their inclusion criteria, the mean age ranged from 73 to 76.3 years.
The findings of suicide rates among ethnic groups are mixed. A number of studies reported that there were no significant increases in suicide rates among ethnic groups (Abrams et al., 2005; Cattell, 1988; Cattell & Jolley, 1995; Conwell et al., 1990; Copeland, 1987; Harwood et al., 2000; Karch, 2011; Mezuk et al., 2008; Quan & Arboleda-Florez, 1999; Salib et al., 2005). Three studies found white Americans were over-represented, while black Americans and ethnic minorities were under-represented in their samples (Bennett & Collins, 2001; Purcell et al., 1999; Shields et al., 2006). The two studies in Singapore reported suicide rate was highest among Chinese and lowest among Malays (Ko & Kua, 1995; Kua & Ko, 1992). The authors hypothesised the protective role of the Islam religion in suicide.
Medical, psychiatric and psychosocial factors
Thirteen studies reported on rates of overall physical illnesses (Bennett & Collins, 2001; Cattell, 1988; Cattell & Jolley, 1995; Conwell et al., 1990; Duckworth & McBride, 1996; Kaplan et al., 2012; Karch, 2011; Osuna et al., 1997; Purcell et al., 1999; Quan & Arboleda-Florez, 1999; Salib et al., 2005; Snowdon & Baume 2002; Tadros & Salib, 2007) (see Table 2.3). Of note, 78% of the cases in Purcell et al.’s (1999) study had newly identified medical problems within six months prior to suicide. 33% of their cases had an identified malignancy that was recently discovered, while 9% of them perceived they had a catastrophic illness even though none was identified. Concern over health was also the most common reason for depression in Copeland’s (1987) study; while physical illness was considered to be the main stressor leading to suicide in 30% of the cases in Quan and Arboleda-Florez’s (1999) study and 34% of the cases in Snowden and Baume’s (2002) study.
Dementia was reported in six studies but the severity of dementia was not routinely reported (Cattell, 1988; Cattell & Jolley, 1995; Duckworth & McBride, 1996; Osuna et al., 1997; Salib et al., 2005; Snowdon & Baume, 2002). Four studies reported on pain. Cattell (1988) and Cattell & Jolly (1995) reported 21% and 27% of their cases complained of pain respectively. Juurlink et al. (2004) found 26.2% of the cases had moderate pain and 4.7% had severe pain. Almost half (44%) of Purcell et al.’s (1999) cases had pain complaints and pain was considered as a major concern affecting their quality of life and comfort in 48% of them.
Depression was the most common psychiatric illness reported. This finding is consistent across the 18 studies that reported on psychiatric diagnoses (Bennett & Collins, 2001; Cattell, 1988; Cattell & Jolley, 1995; Conwell et al., 1990; Copeland, 1987; Duckworth & McBride, 1996; Eilertsen et al., 2007; Harwood et al., 2000; Juurlink et al., 2004; Kaplan et al., 2012; Karch, 2011; Osuna et al., 1997; Purcell et al., 1999; Quan & Arboleda-Florez, 1999; Salib et al., 2005; Snowdon & Baume, 2002; Tadros & Salib, 2007; Wanta et al., 2009) (see Table 2.3).
Internationally recognised psychiatric and addiction diagnostic classification systems were infrequently used. As a result, a wide range of prevalence was reported. For example, psychiatric illnesses were present in 26% of Bennett and Collins’s (2011) cases where they reviewed files in the coroner system in South Carolina for psychiatric history and no additional information (e.g. hospital medical record, general practitioner record) was sought. In contrast psychiatric diagnoses were made in 80.4% of Snowdon and Baume’s (2002) sample. In this study the authors reached consensus for a diagnosis of depressive disorder at the time of death in 129 of the 170 cases after carefully reviewing the coroner files. Approaches used in the other studies to determine the presence of depression included depression as diagnosed by a psychiatrist or general practitioner; clinical profile of depression as described by relatives/witnesses; cross reference with a psychiatric case register; treatment with an antidepressant medication; and antidepressant medication found in blood samples at autopsy.
In the two studies that included a control group, it was found that suicide cases were more likely to have a history of depression, previous suicide attempt(s) and depression prior to suicide than accidental death cases (Cattell, 1988); and anxiety disorders, depression, psychotic disorders and bipolar disorder were associated with suicide completers when compared to alive controls (Juurlink et al., 2004).
Chapter 1 : Introduction
1.1 New Zealand late-life suicide statistics
1.2 Growing old in New Zealand: A snapshot of the 2013 census
1.3 Suicidality on a continuum
1.4 Death wishes and older people
1.5 Suicide attempts and older people
1.6 Physical illness and suicidal behaviour
1.7 The health of older New Zealanders: The New Zealand Health Survey
1.8 Suicide prevention: Universal, selected and indicated strategies
1.9 Overview of thesis
Chapter 2 : Medical examiner and coroner reports: Uses and limitations in the epidemiology and prevention of late-life suicide
2.6 Strengths and limitations
2.7 Suicide reporting and recording in New Zealand
Chapter 3 : Death wishes among older people assessed for home support and long-term aged residential care
3.6 Strengths and limitations
Chapter 4 : Predictors for repeat self-harm and suicide among older people within 12 months of a self-harm presentation
4.6 Strength and limitations
Chapter 5 : Do suicide characteristics differ by age in older people?
Chapter 6 : Late-life suicide: Insight on motives and contributors derived from suicide notes
6.6 Strengths and limitations
Chapter 7 : Understanding the progression from physical illness to suicidal ,behaviour: A case study based on a newly developed conceptual model
7.2 Case presentation
7.4 Clinical implications
Chapter 8 : Rational suicide, euthanasia and physician-assisted dying: A literature review
8.1 Definition of rational suicide
8.3 Age and ageing
8.5 Marital status
8.10 Social support
8.11 Physical problems and ill health
8.12 Depression and euthanasia/PAS
8.13 Personality factors
8.14 Psychological factors: Life satisfaction and burden on others
Chapter 9 : Late-life suicide in terminal cancer: A rational act or underdiagnosed depression?
9.5 Strengths and limitations
Chapter 10 : Late-life Homicide-suicide: A national case series in New Zealand
Chapter 11 : Evidence-based elderly suicide prevention programmes: An updated literature review
11.2 Primary care interventions
11.3 Community-based outreach
11.4 Clinical treatment
11.5 Universal prevention
11.6 Telephone counselling and improving resilience
Chapter 12 : Discussion
12.1 Thesis major findings: A summary
12.2 Implications for clinical practice
12.3 Implications for policy
12.4 Implications for future research
12.5 Strengths and weaknesses of this thesis
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