10/26/2021 1 New findings from the Pittsburgh Longitudinal Research Program in Late-Life Suicide: Implications for identification and treatment • Presenters: • Katalin Szanto, MD, Professor of Psychiatry Department of Psychiatry University of Pittsburgh, Pittsburgh, PA • Emma J O'Brien, BA, Research Specialist University of Pittsburgh Medical Center, Pittsburgh, PA • Elizabeth Schumacher, BS, Research Specialist University of Pittsburgh Medical Center, Pittsburgh, PA gsuicide.pitt.edu 'A silent epidemic' About 800,000 people die by suicide annually worldwide 48,000 in the US: 130 suicide per day 1 2
Transcript
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New findings from the Pittsburgh Longitudinal Research Program in Late-Life Suicide: Implications for identification and treatment
• Presenters:• Katalin Szanto, MD, Professor of Psychiatry Department of Psychiatry
University of Pittsburgh, Pittsburgh, PA
• Emma J O'Brien, BA, Research Specialist University of Pittsburgh Medical Center, Pittsburgh, PA
• Elizabeth Schumacher, BS, Research Specialist University of PittsburghMedical Center, Pittsburgh, PA
gsuicide.pitt.edu
'A silent epidemic'
About 800,000 people die by suicide annually worldwide
48,000 in the US: 130 suicide per day
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In most countries suicide rate is highest among the elderlyWhich of the following populations has the highest suicide rate?
•Men aged 85-89
•Women aged 25-30
•Women aged 60-65
•Men aged 35-40
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True 0r False?In late-life
•Depression is expected
•Quality of life declines
• Satisfaction with life increases
•Decline in crystalized intelligence is expected
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Late-life suicide attempts:"Failed suicides”
• Elderly suicide attempts best in vivo window to death by suicide
• high proportion of medically serious (high lethality) attempts
• Attempt/suicide rate: 4:1 in elderly;
• 10-100: 1 in general population
High mediclate-life
al severity in attempts
Participants: unipolar, non-psychotic,in- and outpatients
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Affective disorder
50-70% of those who die by suicide have current affective disorder (i.e. depression, bipolar)
20-45% of those who die by suicide have
prior suicide attempt
Suicide attempt
Suicide
10% life-time suicide
10% of the attempters die by suicide within 10 years
12 months after an attempt, rates of suicide 37x higher than in matched general population cohort (Olfson, 2017)
Pittsburgh Longitudinal Study for Late-Life Suicide
• Decision-making processes and cognition in late-life suicidal behavioral• Depression, suicidal ideation, suicide attempt, physical health changes over
time
• Attempters, Ideators, Depressed controls, Healthy controls• 70% of those who die by suicide have mood disorder at time of attempt
• Inclusion:• 55+ years of age
• Current depression with or without current suicidal ideation
• MMSE > 21
• No history of stroke, neurological disorder
• No history of psychotic d/o or bipolar
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Socio-CulturalProcesses
Family / EnvironmentalFactors
Intra-Psychic Mechanisms / Temperament
CognitiveNeuroscience
SystemsNeuroscience
Genetics / Molecular Neuroscience
Neuropathology / Neurochemistry
Level of investigations to suicidal behavior
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Who is vulnerable and when?Stress-Diathesis
Model of Suicide (j. Mann)
Cognitive deficits and Late-Life Suicide
• Cognitive and decision-making deficits may contribute to the accumulation of stressors and the perceived/actual inability to solve them.
• Particularly important role due to both normal age-related cognitive decline and dementia
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Early observations/Lab findings:
Williams: Entrapment limits ability to problem solve
Gibbs: Older attempters self-describe as deficient problem solvers
2015
Lower IQ/School performance - attempted and completed suicide decades later (Gunnel 2004, Andersson 2008; Batty
2010, Sorberg 2012, Hung 2015).
Bartfai: Suicidal pts had significantly lower scoresin verbal anddesign fluency.
2001
Keilp: Late Life High-Lethality suicide attempters exhibit worse cognitive control
2005
Jollant: Impaired decision making in attempters
Overlapping contributors to low IQ - also risk factors for mental illness & suicide
Association between low IQ and suicidal behavior is mitigated but remains after adjusting for parental SES, the young adult’s alcohol abuse, smoking status, and mental illness (Batty, 2010)
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With age comes wisdom and cognitive changes,Late-onset depression – as behavioral symptom of dementia
From Dunn & Cassidy-Eagle, Eds (2020)
Depression
Dementia
Taiwan: Elderly who attempted suicide were prone
to developing dementia (Tu, 2016). Late-onset
attempters had a seven-fold increased risk for
subsequent dementia compared to older adults
without a late-life suicide attempt. (Tu, 2016).
Suicide attempters with greater white matter hyperintensities had impaired executive function. Elevated global and periventricular white matter hyperintensities in suicide attempters with LLD. (Li, 2021)
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Dementia and MCI
• Erlangsen, 2008: suicide rate elevated in those diagnosed with dementia, even after controlling for the effect of mood disorders. The risk is highest months after the diagnosis, but remains elevated for years.
• Gunak, 2021: Risk for attempt is significantly higher with a diagnosis of recent MCI (HR:1.73 (CI, 1.34-2.22), and with recent dementia (HR: 1.44 (CI,1.17-1.77).
"Robin's was one of the worst Lewy body pathologies [the doctors] had ever seen. […] The massive proliferation of Lewy bodies throughout his brain had done so much damage to neurons and neurotransmitters that in effect, you could say he had chemical warfare in his brain."
-Susan Schneider Williams, "The terrorist inside my husband's brain", Neurology 2016
In hippocampal sections larger number of amyloid deposition and Lewy bodies in suicide brains than in controls (Rubio, 2001)
Cognitive/DM deficits are risk factors that differentiate attempters from ideators - in contrast to most well-known risk
factors that do not
Low Self Esteem
High Neuroticism
Hopelessness
Lack of Belonging
Burdensomeness
Current Substance Use
• “Cognitive deficits may be a transdiagnostic risk factor for SB,especially alterations in cognitive control” (Huber, 2019)
• Accumulating evidence that cognitive deficits are trait biomarkers of suicidal behavior, that worsen with aging• More research is needed in adolescence
• Cognitive deficits and DM give information about subtypes of attempters that may need different treatment.
• Age at first suicide attempt is useful for understanding the clinical/cognitive and broader biological heterogeneity of suicidal behavior.
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Summary:
•Cognitive deficits include difficulty shifting attention from compelling but inappropriate stimuli, predisposition to attend to prepotent emotional states, narrowed view of the situation, and reduced consideration of alternatives in a crisis.
• Cognitive and decision-making deficits may contribute to the accumulation of stressors and the perceived inability to solve them.
COVID-19 and Suicide Rates,Perfect storm for mental health consequences?
• Neuroinflammation, Social isolation, Bereavement, Financial difficulties, Disruption in services related to mental health and physical health.
However:
• During the COVID-19 pandemic in the US, death by suicide declined
• In Japan, a 20% decrease in suicide rates was reported in the early months of the pandemic. Similarly to 12 other countries who reported data (Pirkis, 2021).
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Why do suicide rates decline during crises?
• Durkheim’s Anomie in a Time of Crisis speculates why suicide rates may decrease due to an "anomic division of labor" and sense of unity within communities (Durkheim, 1893)
• Increased social cohesion in crises so people who are otherwise marginalized may receive more social support
• Resilience in older adults?• (i.e. WWII, 1973 oil crisis, Vietnam War, 2008 housing crisis)
Why do suicide rates decline during crises?
• Large scale crises may lead to increased social cohesion short-term
• Marginalized people may receive more social support
• Previous life stressors may become less urgent
• Life may feel more precious
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Difficulties in Treatment Engagement during Covid
• Logistic challenges (i.e. technology barriers)
• COVID-19 health concerns in-person
• Ability to deliver services virtually
• Virtual assessment & rapport challenges
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Black –box warning - FDA meta-analysis conclusions
100,000 patients in RTCs
• Ages 65 and older: strong protective effect of antidepressants (Odds Ratio: 0.37, p=0.007)
