Part 1 here.
The point of the editorial in AJP is that since everybody knows the elderly kill themselves at higher rates, we should go Orange Alert and mobilize America in preparation. Ok.
There are a total of 30000 suicides a year. As
you can see, the only group who commit suicide at higher rates as they age are
white males. Granted, I don't want white people to die any more than
George Bush does, but this increase applies only to them.
Now reread that quote in AJP:
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.
There's your sleight of hand. If the elderly kill themselves at a given rate, the fact that there are more of them coming shouldn't change the rate, only the number. The trick is that "the suicide rate in the elderly is four times higher" is the only thing dramatic enough to get you NIH grants. If it was reported as an increase in the number of suicides-- a number that in the most apocalyptic scenario would be in the hundreds-- no one would care, and certainly no one would pay for it.
Q: Why do the elderly kill themselves at higher rates?
A: "Ummm.... because they are old and there is nothing left to live for?" That culture-bound moronity exemplifies my point. The old must be more depressed and pessimistic, after all they're too old to enjoy life... or something... (God knows the young are enjoying it all so much.)
And maybe many do feel that way, but maybe they aren't any more intent on dying than the young (who have more non-lethal attempts) but are simply physically weaker and thus more susceptible to dying- even during what they hoped would be a non-lethal attempt?
Q: Why do we expect an increase in the number of elderly people to suicide? Is it a stable suicide rate coupled with an increasing population?
Well, the suicide rate has mostly fallen. Also note that the greatest change in rates occurred before the psychopharmacology era. The gazillions spent everywhere post 1960 have done nothing. But as anyone with experience using technical analysis will tell you, we don't know what the hell direction those lines are going next. The above blog discussed the opinion that the rate declined with the creation of Social Security. Or was it the war? Or...
It's hard enough to understand what happened in the past. How is AJP so confident about the future?
First, the suicide rates from different decades are not even comparable. An elderly person today will probably have little resemblance to an elderly person of 2030. Consider:
- will economic pressures push the elderly to live longer with their kids/extended families (or vise versa)
- will family units continue their trajectories towards looser, smaller, and more disjointed (e.g. divorces) affiliations?
- will better physical health/sex/financial security lead to more satisfaction in later life
- will promised better health/sex/financial security not materialize, leading to great pessimism?
- will narcissists cling to their lives/youth no matter what; Sex In The City VIII begins filming
- will narcissists suffer the ultimate of narcissistic injuries?
The chief reason that suicide rate predictions fail is that they are based, primarily, on absolutely nothing. Psychological autopsy is a biased interview occurring in a specific historical and cultural moment (e.g. the three generations before the current 40 year olds) not generalizable to the next one. Look at 1930 vs. 1960.
Psychiatric illness is a changing construct. What was MDD in 1930 may in some ways be similar to 2009, but in others it is not. If it is madness to conclude a 2009 suicide must have been mentally ill, it is complete and utter madness to take this conclusion and apply it to 1930, let alone 2030.
Instead of asking how the the hypothetical elderly might act in 30 years, you'd be better to ask how we will act in 30 years.
Q: Assuming that there is actually a suicide epidemic on the edge of the horizon, what can be done about it?
A: Nothing. As with all complex behaviors, nothing works reliably across a given population. No drug (I'll leave aside lithium for a moment) or therapy has been reliably shown to reduce the suicide rate across the population. "But I've saved so many of my patients..." You can only change the rates of a complex behavior such as suicide, violence, styles, opinions, at an individual level, or through society-- the culture. If you want to lower the suicide rate, you can't target "at risk" populations, you have to make suicide less of an option for all of society.
- if you want to reduce terrorism, you cannot round up all terrorists and change their thinking. You must either a) kill individual terrorists; b) make terrorism less viable/interesting/acceptable/easy for all of society.
- if you want to reduce teen drinking, you can't target the population of at risk teens and make them drink less. You must either target a) individual teens, one at a time; b) make teen drinking less viable/interesting/acceptable/easy for all of society.
- if you want to reduce the suicide rate, you can't find the depressed people and create a population based treatment. You must either a) target each individual suicider; b) make suicide less viable/interesting/acceptable/easy for all of society.
Simply: you will reduce the suicide rate much more if you take all guns off the earth than if you "improve access to healthcare." (There may be other reasons why taking away all guns is not a good idea, that's not the immediate point.)
Q: Why is there so much focus on the coming suicide epidemic, if there isn't any logical reason to assume one is coming?
A: Please understand I am not dismissing suicide, I am fully aware of its devastation. But this is the creation of a hysteria that will generate a
lot of activity (and money), and this-- not the reduction of suicide per se-- is the hysteria's chief purpose. The mobilization of the mental health army will ultimately have no demonstrable
effect on the suicide rate.
The future revenue streams in psychiatry won't be from billing for the treatment (Pharma) but from billing for the evaluation (insurance.)
You would do better-- and I mean this in complete earnestness; not that this should be done, but that it would be more effective-- to take all the money devoted to this problem, and giving the money to the "at-risk" patients as a pension.