September 22, 2009

As The Population Ages, Will Suicides Increase?

Don't bet your life on it.


An editorial in AJP opens,

In most countries of the world, older adults kill themselves at higher rates than any other age group. Given that the leading edge of the large post-World War II "baby boom" cohort will reach the age of 65 in 2011, demographers predict a rapid rise in the number of seniors taking their own lives in subsequent decades. The need for effective approaches to late-life suicide prevention is pressing.


No. 

First, I'd like to debunk the prevailing belief that almost all suicides are due to a psychiatric illness, a belief he supports using an article he himself wrote that references studies that don't actually show this.

Construction Of Pathology

Simply assuming anyone who commits suicide is therefore "somehow not normal"; or "only someone mentally ill would kill himself" is wrong.  

If a serial killer says, "kill yourself or I kill your kids" and you kill yourself, are you mentally ill?  Was Ajax mentally ill?

Consequently, the fact that you committed suicide is not proof of illness, in the exact same way that death cannot be proof of pancreatic cancer.

Attributing causality to a complex behavior is masturbation with words.  How is killing yourself from MDD different than killing yourself because of terminal pancreatic cancer?  Note that the syntactic construction forces me to say "from MDD" but "because of pancreatic cancer."  But is that a real, existent distinction?

Is it the same biological mechanism?  Different?  Note: "He was depressed, he killed himself, for no reason, his life was great." The presence of pathology is assumed because of the absence of causes; psychiatry abhors a vacuum. 

While it is clear that suicide is a risk in depression, the issue here is whether one can assume depression if they committed suicide?


Three Problems Of "Psychological Autopsy"

Hearsay:

The evidentiary support for the presence of mental illness in those who commits suicide is mostly determined not by a past history of diagnosed psychopathology, but by a post-mortem psychological evaluation ("tell me what he was like?") in which the deceased has drastically biased everyone around him by killing himself.

A psychological evaluation is basically interviewing "informants" (e.g. family), over three hours, asking psychiatric screening questions to determine diagnoses. Think about this, seriously think about this. The guy is dead, and you're asking the family if this guy ever exhibited signs of mental illness.

The closest analogy is doing a post-mortem of a marriage by only asking the ex-wife.   "The evidence strongly suggests 75% of divorced men are manipulative jerks."  Oh.

Validity of Symptoms Descriptions:


Example, from one of the sources of the above article:

Where subjects suffered both physical illness and depressive symptoms before death it was often difficult to judge whether a depressive episode was present. To ensure a consistent approach to diagnosis, we took possible depressive symptoms at face value; thus, if a subject was reported to suffer tiredness, this was included as a depressive symptom regardless as to whether it may have been due to physical illness.

Go figure: 77% of these people "had" a psychiatric diagnosis.


Generalizability:

So it's legitimate to ask, what percent of suicides have ever been diagnosed before they died? What percent have been to a psychiatrist or primary care doc for psychopathology? The answer varies from 30-60%, which is another way of saying 40-70% have never been. A full 75% had never attempted suicide in their lives-- this was their first and last attempt. It's important to keep this in mind because the point of the editorial is to offer the elderly "access through a care manager to algorithm-driven treatment"-- yes, that's what he wrote-- then you're going to help a maximum of 45% (the so far best response rate in psychiatry) of the 50% you actually ever meet.


Part 2 here.






Comments

A lot of suicides are also ... (Below threshold)

September 22, 2009 7:10 PM | Posted by Ben: | Reply

A lot of suicides are also deemed to be accidents. For example, a lot of single vechile auto accidents could very well be suicide. Furthermore, some family members remove evidence of suicide to make it look like an accident to avoid the stigma of having a suicide in the family.

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I plan on committing... (Below threshold)

September 22, 2009 8:19 PM | Posted by Paula: | Reply


I plan on committing suicide when I am too sick to bother fighting. If I knew I was going to get Alzheimer’s- I would kill myself. It is about personal choice and quality of life. We do not like people to have choice over their own body- prostitution is illegal and drugs are. If I am not hurting anyone else- I have a right to do BOTH. Puritan America does not understand basic BOUNDARIES.
Kevorkian is WAY ahead of his time- light years. As ate people who choose to not drag down everyone around them and committing suicide when their quality is stupid. Staying alive as a vegetable is really selfish.

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I wouldn't try mixing a pol... (Below threshold)

September 22, 2009 8:58 PM | Posted by Diego: | Reply

I wouldn't try mixing a political issue with a purely academic one. Also, I still don't see how debunking "Suicide is due to illness" makes that question anymore negative.
I do agree though: Studying "which ill old people commit suicide" is not the best way to study "why did old people commit suicide".

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The old people will be too ... (Below threshold)

September 22, 2009 9:11 PM | Posted by Anonymous: | Reply

The old people will be too forgetful to be able to do suicide. Its work to organize and execute, while having a cup of tea/coffie they will go "Now what was I planning?". I predict the army of senile old people will drive their cars accidentally into people and places. Who is going to take away their drivers licence? Get off my lawn!

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" If a serial killer says, ... (Below threshold)

September 22, 2009 11:13 PM | Posted by Anonymous: | Reply

" If a serial killer says, "kill yourself or I kill your kids" and you kill yourself, are you mentally ill? Was Ajax mentally ill?
Consequently, the fact that you committed suicide is not proof of illness, in the exact same way that death cannot be proof of pancreatic cancer."

I don't think you really prove your point. It's not as if lots of folks who commit suicide are in the duress situation you describe. In fact, almost none are. So, your next step does not follow. Unless you can prove otherwise, I think it's reasonable to assume that most suicides involve mental disorders of some sort (and I say this as an avid fan of your site).

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I'm pretty sure Alone was j... (Below threshold)

September 23, 2009 2:51 AM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

I'm pretty sure Alone was just trying to show that if the author asserted:

People who kill themselves are/were depressed.

then by giving an (extreme) example of a person killing themselves without being depressed the original assertion isn't true. That depression and suicide are linked in many (most?) cases isn't the point: only that it's not the cause of all cases.

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Depression and/or existenti... (Below threshold)

September 23, 2009 3:23 AM | Posted by David Johnson: | Reply

Depression and/or existential crisis and/or proactive behavior. No serial killers were harmed in the creation of this post.

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Suicide can be lumped into ... (Below threshold)

September 23, 2009 5:02 AM | Posted by Anonymous: | Reply

Suicide can be lumped into three broad categories.
1) Physical causes (e.g. terminal cancer)
2) Situational causes (e.g. going bankrupt and having your family leave you)
3) Mental causes (e.g. depression, bipolar).

Or, a combination (depression + going bankrupt).

BTW, psychiatry is almost entirely useless so it is expected that less than the majority of suicide victims will have seen one. Most people who see psychiatrists aren't doing that badly, or else they wouldn't be in a position to see one. I think psychiatry tends to encapsulate the very sick and the very well. The former are forced into care by the state. The latter go of their own free will as a slightly more scientific version of calling a psychic hotline.


Anyway, back to the point.
I think if you can rule out terminal/chronic severe illness (1), and any major life devistations (2), it is fair to say that some kind of mental illness must have lead to suicide. People who are healthy, who have no situational adversity, don't kill themselves unless they are depressed and/or psychotic.

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Oh and if you disagree with... (Below threshold)

September 23, 2009 5:08 AM | Posted by Anonymous: | Reply

Oh and if you disagree with me, please, do elaborate on how you can put fourth it is POSSIBLE for a person who is physically healthy, who has a fine life with no major devastation, to KILL THEMSELVES without being mentally unwell? The definition of mental illness is when your mind, your perceptions and behaviors, are inappropriate to circumstance. Killing yourself for no reason = mental illness.

I think an exception can be made for people who are TEMPORARILY insane due to drug use (or non-use). E.g. kurt cobain's suicide was most likely induced by acute heroin withdrawal. If Kurt didn't have his endogenous endorphin system shut down without exogenous administration of heroin to compensate for those 3 days, he probably never would have killed himself.
But, this classification of suicides would technically fall under "mental" since the cause of the suicide is an abnormality of their mind, even if not mental illness.

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Anon 2:51... obviously not ... (Below threshold)

September 23, 2009 5:16 AM | Posted by Anonymous: | Reply

Anon 2:51... obviously not every single person who kills himself is mentally ill. Obviously, once or twice in history, someone has been forced into suicide for lack of a better option. One of my ancestors was a soldier in the french/algerian war. He killed himself due to circumstances surrounding this. He was obviously not mentally ill and if he could have arrived home safely he would have chosen that option.
Then again, I have an uncle on my fathers side who killed himself shortly after I was born. This, OTOH, is a more typical suicide and it is an example of mental illness induced suicide. My uncle was depressed and had a traumatic upbringing. He killed himself because my father started a family and it was the last support system he had left; he no longer saw a point in living as far as he could see.

I think a great deal of suicides, particularly in the elderly, are related to a combination of depression and loss of support systems (family), combined with physical illnesses which complicate their daily function. Depression is probably the crucial factor involved. There are many very sick people who are happy and don't want to die. I know I work with the elderly and sick as a registered nurse. There are many very healthy, attractive and successful people who are mad and commit suicide.

Everything else is just more weight. Depression, situational or organic, is the real cause.

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HELLO HELLO HELLO... (Below threshold)

September 23, 2009 6:26 AM | Posted by Hoola: | Reply

HELLO HELLO HELLO

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I LOVE YOU for pointing thi... (Below threshold)

September 23, 2009 10:09 AM | Posted by jessa: | Reply

I LOVE YOU for pointing this out!

I hate so much the assumption that committing suicide automatically equals being mentally ill. It steams me. Of course many people who commit suicide are mentally ill, duh, but that doesn't mean they ALL are.

I also hate the assumption that if you are a person who allows for the possibility that suicide can make sense, you are mentally ill. Yes, my position that suicide can be a rational choice is INFORMED by my experience with mental illness, but it is not a PRODUCT of mental illness (ie. I am not currently experiencing any symptoms of mental illness, and this position on suicide is not itself a symptom). I actually think that if my experience with mental illness and the extreme suffering I went through because of it did not affect my attitudes toward suicide, that would be more indicative of psychiatric-ly symptomatic thinking than the fact that my attitudes toward suicide are impacted by my experience with mental illness, because that would me that I had not learned from experience. Not that someone who goes through the suffering of mental illness must then hold the same view as I hold about suicide, but that going through such extreme suffering must temper that view.

Fact: I believe that there is a point at which suffering can be so great that all the wonderfulness possible in life does not outweigh that suffering. At that point, I believe suicide makes sense. Of course I don't want people to commit suicide in "the heat of the moment" where they might have otherwise found life worth the suffering, but I never want to force someone to live through such extreme suffering that they find no amount of life-wonderfulness to be worth that suffering. That is a subjective line, not in the same place for everyone. I can only hope that if I pass that line again, that my friends and family will respect my desire to end that suffering.

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I'm just about to turn 60. ... (Below threshold)

September 23, 2009 4:26 PM | Posted by Robert Porter: | Reply

I'm just about to turn 60. Many of my contemporaries have nothing to talk about. Unless it's about the good old days and how old age has slowed them down. They almost seem glad that it has. My wife tells me I should grow up - means act like our friends. Leave childish (means all) interests behind - serious interest in film, poetry, theater, what have you. Young people, even middle aged people, those that seem interesting and exiting to be around aren't much interested in the average old timer. Youth is a special time and only special oldsters need apply. SO you come home to a spouse that wants nothing for herself, AND FOR YOU, except a clean bath room and the bed made in the morning. And, like I said, friends are satisfied in their boredom and an evening of beer or good wine. One looks to the future and it looks pretty bleak. Despite exercise your body is old and looks it. I can see how thoughts of suicide might look appealing as one ages.

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Robert Porter,I kind... (Below threshold)

September 23, 2009 6:20 PM | Posted by Anonymous: | Reply

Robert Porter,
I kinda agree with your friends/wife. You come across as immature and self centered. Seems like you miss the good old days when narcissism was a somewhat acceptable part of growing up. Now you just stand out as childish.

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@ anonymous 6:20 pm: Immatu... (Below threshold)

September 23, 2009 11:14 PM | Posted by David Johnson: | Reply

@ anonymous 6:20 pm: Immature can't even begin to define your response to Robert Porter. Perhaps it's because you're so terribly young ... or somewhat lacking in imagination or empathy. Nice armchair diagnosis.

@ Robert Porter: according to NIMH, of every 100,000 people ages 65 and older, 14.2 died by suicide in 2006. This figure is higher than the national average of 10.9 suicides per 100,000 people in the general population.

I do believe some of the reasons you mention contribute to suicidal ideation and ... indirectly support Alone's contention that not all suicides are about depression. There are quality of life issues, existential issues ... it's not just depression (as defined by health care professionals).

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HMMMMM.....What is t... (Below threshold)

September 24, 2009 12:00 AM | Posted by Steve : | Reply


HMMMMM.....What is the point of this post? People kill themselves because they feel like shit.........

sometimes they feel like shit because of external factors like unemployment or a shitty marriage or a boring life or a missing set of legs......

Sometimes they feel like shit because of internal factors like a chemical imbalance, major depression, or both.

Last I checked nobody kills themselves because they won the lottery or because Pamela Anderson agreed to sleep with them 3 nights a week.

What the big mystery? Life sucks, some folks tough it out, some folks say "fuck it". I think both approaches have their merits.

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Maybe with all the therapie... (Below threshold)

November 2, 2009 3:57 PM | Posted by Herman: | Reply

Maybe with all the therapies that are available things may change in a few generations, but I bet new forms of disorders will emerge.
Herman
http://www.interpersonaltherapy.net/

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does this site have a maili... (Below threshold)

January 2, 2010 7:53 PM | Posted by Algerian TV Online: | Reply

does this site have a mailing list?

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