Suicide in geriatric depressed patients in Turkish Culture

Işın Baral Kulaksızoğlu, M.D.

Department of PsychiatryIstanbul Medical Faculty

- Population over 65 in

Turkey %8.6 (U.S.A %26)

- Life expectancy w=71.4 , m=66.8

year (DPT 1999)

After Japan and Mexico Turkey has the 3rd increasing the elderly population in the world according to WHO statistics.

Geriatric depression in Turkey

• In Black Sea Region; MDD over 60 is %29» Bekaroglu et al (1991)

• In Mediterranean Region; MDD is %5,9 , depressive symptoms are %11

» Ucku et al (1992)

Geriatric Depression Prevalance Study

• 1018 community dwelling elderly • GDS and MMSE scores obtained

Depressive(14) Normal(<14) Total

n=163 n =855 n=1018

%16,0 %84,0 %100

» Kulaksizoğlu IB et all. Int J Psychiatry 2005

Risks for geriatric depression in İstanbul

• Age:75-79• female gender• no education• 4 or more kids• Only 7% were on AD

• Similiar rates of geriatric depressive symptoms as other countries in the world

• Female gender- Universal truth• Social factors are closely related with

depression in a developing country; Türkiye

– education, multiparity,child caring..

• Elderly depression is unrecognised and untreated by medical staff

Suicide rates of eldely depressed

patients?• Culture effects elderly suicide rates

• Higher in old age in USA, Hungary,Japan, ChinaFrance, Spain, Italy, Austria…..• Lower in old age;Norway, netherland Denmark

Sweden, Poland, Australia….

• İdeation or action?• Factors associated with elderly suicide?• Other ways: Passive suicide?

For Turkey

• WHO-EURO multicentre study; in a 4 year of period between 1998-2001, suicide attempts– 46.89/100.000 for men– 112.89/100.000 for women

» Devrimci-özgüven Can J psychiatry 2003

Suicide Rates in Turkish population among age

groups

15-24(%)

25-35(%)

65-74(%)

>75(%)

1999 32.6 24.4 5.8 2.8

2000 34.5 21.1 5.3 2.5

Data obtained from the official Turkish State Statistics Institute

• Between 2002 and 2004; only 3 elderly patients admitted to emergency department of İU.İstanbul Medical Faculty with a suicide attempt.

• Since last 5 years there is no admission of any elderly person to psychiatry department of the same hospital after a suicide attempt

• In the Government suicide statistics; 47 suicide in 1974 to 139 suicide in 1996 were reported over 65. İncreasing rates but still below the European average.

Questions then..

• Are suicides under-reported?

• Are suicide ideations different in our elderly patients than young ones?

• Are there other ways of committing for old age suicide?

Are Suicides underreported?• In Islam, suicide is strictly forbidden

– Religious funeral or prayers are not allowed– They belive he/she will go directly to hell– It is a shame for the family to have a

member who committed suicide

– Medical staff or authorities are inclined to report suicides as accidents or intoxications to protect the families from the convicting attitude of the society, therefore statistic may not reflect the exact rates. But still low comparing other western and some eastern countries

Are suicide ideations different between young and

old?• 30 young and 30 elderly consecutive patients with

major depression and admitted to Pscyhiatry and Geriatric Psychiatry were included in the study

• DSM-IV criteria were used for M.Depression • The young group was between the ages of 14-40

and the elderly were above 60 years old. • Sociodemografic data form, a questionnare for

suicidal ideation( beliefs, plans, attempts…were asked) Hamilton Depression Scale, Geriatric Depression Scale, Beck anxiety scale and MMSE were given

• Elderly group was followed up for a 12 month period.

• Mean age of the ED group was 71.1+ 7.6 years and YD group was 28.6 +6.8 .

• Female gender was predominant in both patients group and percentages were as high as 83.3 % for YD and 80 % for ED.

• Income level, sex and education level were matched between the groups

• All were Caucasians and Muslims.

Mean Median SD Min Max U Z p

HDS

Genç 24.7 25.0 4.3 15 32 young vs. old 391.0 0.875 0.382

Yaşlı 26.3 27.0 6.2 16 40

GDS score

Yaşlı 20.0 20.0 4.1 13 30

BECK score

Genç 29.0 28.5 12.5 9 59young vs. old

224.0 3.347 0.001

Yaşlı 18.8 15.5 12.2 6 47

CGI

Genç 4.9 5.0 0.7 3 6young vs. old

421.5 0.443 0.658

Yaşlı 4.8 5.0 1.2 3 7

MMSE

Genç 28.2 29.0 2.6 17 30young vs. old depressives

268.0 2.736 0.006

Yaşlı 26.6 27.0 2.6 21 30Old dep vs.old

controls 270.5 2.699 0.007

Yaşlı 28.3 29.0 1.4 24 30

Yaşlı 21.1 18.5 6.3 17 44

"Hayat boş, yaşamaya değmez" diye düşündüğünüz oluyor mu?Do you have thoughts such as ‘Life is not worth living’?

yes % Total Chi Sq. SD p

Young 23 76.7 30 X2 0.341 1 0.559

Old 21 70.0 30 Yates 0.085 1 0.770

Ölürsem yakınlarım rahat eder" diye düşünüyor musunuz?Do you ever think that your family will be better off if you die ?

Yes % Total Chi Sq. SD p

Young 7 23.3 30 X2 0.341 1 0.559

old 9 30.0 30 Yates 0.085 1 0.770

("Keşke ölmüş olsaydım" diye düşündüğünüz oluyor mu?)Do you wish to die?

yes % Total Chi Sq SD p

young 15 50.0 30 X2 0.268 1 0.605

old 17 56.7 30 Yates 0.067 1 0.796

("Ölüm tek çare" diye düşündüğünüz oluyor mu?)Death is the only solution

yes % Total Chi Sq SD p

young 7 23.3 30 X2 3.590 1 0.058

old 14 46.7 30 Yates 2.637 1 0.104

(İntihar etmeyi düşündüğünüz oluyor mu?)Do you ever think of the idea of suicide

YES % Total CHİ sq. SD p

Young 11 36.7 30 X2 0.693 1 0.405

old 8 26.7 30 Yates 0.308 1 0.579

(İntihar etmek için bir tasarı ya da planınız var mı?)Do you have plans for committing suicide?

Yes % Total Chi Sq. SD p

Young 6 20.7 29 X2 0.150 1 0.698

Old 7 25.0 28 Yates 0.005 1 0.943

Results• Ideation and pre-occupation with suicide were not

statisticly different between young and elderly groups

• After one year of follow-up 25% of the elderly group had suicidal thoughts nevertheless none of them had an actual attempt

• Intra-familial conflicts and chronic disabling medical diseases were the main causes of suicidal ideation

• Hanging and jumping are the most common choices of suicide. Elderly prefers more lethal methods

• Religious and cultural diaproval were major barriers to do the act in the elderly depressed group.

Discussion • Affective illnesses , particularly unipolar and bipolar

depression, are the major risk factors that predispose to suicide across all age groups

• Islamic disapproval may be discouraging factor for lower rates of elderly suicide in Turkey.– In Ethiopia similar results were obtaioned among Muslims

Alem A et all Acta Psych Scan 1999

• Self killing is not an option for adults who had strong religious education.

Eskin M Soc.Psych.epidemiol. 2004

• Religiously unaffiliated subjects had significantly more lifetime suicide attempts and more first-degree relatives who committed suicide than subjects who endorsed a religious affiliation.

Dervic K Am J Psychiatr 2004

Other factors may be related to low suicide rates;

• ‘Self-anger’ and agressive behaviors may decline by age

• Those who prone to violence died early in life • Turkish culture may provide more of a role for

the elderly and elderly may have more prestige in the community. They stay in the familiy, There is a stigma of nursing home…

• Turkish elderly may experience less stressors in their daily life.

• Substance and alcohol abuse is a not a common problem in Turkish elderly

Are there other ways of committing suicide?

• Passive and Chronic suicidal behavior– Stoping medications– Malnutrition

• Stop eating or drinking water• Fasting to die

– Disobeying the medical advises; diet etc– Refusing any help for caring

• Osgood et all 1991 first mentioned ‘indirectly self-destructive behavior’ of elderly

• ‘Those over 75 are more likely to use passive forms of self-destructive behavior’

• ‘Elderly who acts in chronic a suicidal manner are less likely to be brought to the attention of authorities’

Conclusion• Suicide is an important risk for elderly depressed

patients despite both the İslam and Turkish culture

• Clinicians must be careful for passive suicidal attempts

• Psychosocial prevention programs are needed

• Governmental Support and new politics for Socio-medical programs for elderly care are needed

• Collaboration and multicentre studies are essential for understanding the effect of Muslim on elderly people for their attitudes for death and dying

Thank you for your attention