November 23, 2006
A thought provoking article. I have to admit this never occurred to me, and that's exactly the problem.
First, a question, and you must commit to an answer: why do the elderly suicide at higher rates? Write in your answer here: _________________________. No, don't read on without answering.
General theory is that they are hopeless, pessimistic, and their intent to die is high. That's what you wrote, right? Me, too.
But what if they died at higher rates not because they wanted to die, but because they were more susceptible to dying, even by a half-hearted, low-lethality attempt?
Using Sri Lanka's most common poisoning, yellow oleander overdose (= cholinergic toxicity), 94/1900 suicde attempters studied died. Elderly were 13 times more likely to die than those under 25-- even when the number of seeds was controlled. And the number of seeds was often low (median was 3). In other words, the elderly were not dying at higher rates because they ingested more seeds; they were dying because they couldn't survive even a few seeds.
Wow. Ok, my previous bias had been to worry most about the intent in the elderly, not so much the means; once they decided to die, they'd find any way they could. Whereas in, say, teens, the bias was to worry about the means, because (often) their intent to die was low, but they might take something that was much more lethal than they thought it would be. A common question I ask is, "which is more lethal, an OD of Zoloft or Tylenol?" Because many believe psych meds are lethal, while Tylenol, an OTC, shouldn't be.
But it may be that I was wrong, and that the elderly have vague attempts just as frequently as others, but actually die from them. Maybe I need to be more careful about prescribing them meds that even in mild overdose could result in their death (Elavil, Tylenol, narcotics, etc)?
What's against this is that 60% of people under 65 use a gun to kill themselves, while 73% of those over 65 use a gun-- suggesting that intent is pretty high after all. But that's not my point here.
What's interesting is why this all never occurred to me. Where did I get the idea that the elderly were more intent on death than the younger people? Certainly, the popular psychiatric literature constantly reminds us the elderly have higher risk; but perhaps a culture which places so much value on youth, and which is incessantly and publicly debating doctor assisted suicide (always for the elderly), the right of family to withdraw care, etc-- maybe all those notions recursively reinforce the premise on which they are based: that old people want to die? Of course a 20 year old doesn't really want to die because he doesn't "understand" death, he has his whole life ahead of him, hasn't learned impulse control, etc. But the old guy "knows" there's nothing to live for...(?)
Yet another reason why doctors should not become social policy analysts. We are too much in the thick of it, and never question our assumptions because we believe them to be axioms.