Jill Manthorpe looks at research on suicide and depression among older people

THE RESEARCH 

Title: Older People and suicide (2006)
Authors: Derek Beeston.
Institutions: Centre for Ageing and Mental Health, Staffordshire University, published by Care Services Improvement Partnership (CSIP), West Midlands Development Centre.

OBJECTIVES

This review pulls together the findings of UK and international studies on suicide among older people. Although the risk factors are sometimes tentative and numerous, Beeston summarises approaches to reducing suicide risks among older people and outlines work on prevention of suicide relevant to health and social care practitioners.

The review informs practitioners, especially nurses and general practitioners, about older people and suicide. The conclusion is that the subject’s complexity means that “quick fix” solutions are unlikely to be effective but social care and health services practitioners have the potential to reduce risk factors. While this review is directed to nurses and general practitioners it may inform social work practice, social care commissioning, and integrated services.

FINDINGS

By their nature, reviews of literature do not generally make significant discoveries. However, they are useful in exploring what is known and what remains uncertain or uncharted. This review draws together statistics on suicide among older people in the West Midlands, covered by the regional office of the Care Services Improvement Partnership (CSIP). From 1994 to 2004, there were about 699 deaths by suicide among people aged over 60 in this region. This is possibly an underestimate and, of course, does not reflect the harm and distress that affect those bereaved.

Like other reviewers of this subject, Beeston notes that depression is one of the major factors in common between people who commit suicide, that rates are higher among men and that people can take their own lives at any age. He draws attention to features that distinguish suicidal behaviour and suicide among older people from that of other adults particularly the much greater likelihood that a suicide attempt will be fatal among older people. The implication of this is that the strongest predictor of a suicide among older people is a previous attempt. Nonetheless, the review shows that thinking about or making plans to take your own life is not the only predictor. Many older people show no signs of suicidal ideation (thinking) and some who do express such thoughts may not follow them through.

Verbal clues cover direct talk about death, or ending life, as well as indirect references. The person may talk about putting affairs in order, making a will or not being around for certain events. Of course, some of these are matters that professionals would be pleased to hear about as they might suggest a sensible or even empowered way of planning for the future.

Behavioural clues can also be picked up on in day-to-day communications, such as observing that a person is “tidying up” or giving things away. Other behaviours can also suggest depression, such as not taking part in social activities so much or so frequently.

Situational factors can include many of the factors that are linked to depression, such as diagnosis of a serious illness, or loss or sudden change for the worse. And syndromatic factors may group around depression, guilt and isolation. Some researchers think of these as personality factors or the characteristics of an individual.

Beeston makes the point that depression is frequently seen as an important marker for suicide. He cites several studies that show that depression was unrecognised, neither managed nor treated, despite the contacts that many depressed older people have with primary care practitioners.

Beeston summarises that prevention may be assisted by improved health monitoring, more social contacts, greater participation with and by older people in social activities and more vigilance among practitioners about older people’s talk of “ending it all” or similar. There is some evidence that serious illness has particular impact on men, but relationship problems, money problems and family disputes may also be important. Social support, a very loose term, is one that research often identifies as a key risk factor and social connectedness appears to be protective.

This review concludes with brief mentions of prevention and interventions, noting that treating depression is likely to be the most effective. The review also gives examples of projects that appear to make a difference to suicide rates but which have rarely gone beyond project status. As Beeston concludes, there is a wealth of reliable data on suicide and older people, and concerted and lasting action is needed. At the moment, however, isolated and depressed older people are not a priority group.

Analysis

This report has all the advantages and disadvantages of a systematic review. It is clear about many of these limits – the research covered is only that published in English (but that is a large amount) and the time and resources available were limited. What is not acknowledged is the concentration on medical, nursing and psychological literature (to the extent that Social Care Online was not searched) or the use of a hierarchy of evidence that grades research by quality of the science and therefore misses accounts of practice, let alone experiences from older people and carers. Social workers in England (it is a largely English study) will need to seek out the elements that relate to social care. These are many, because older people with depression are major users of social care services, even if their primary reason may be something else (Manthorpe and Iliffe 2005).

But social care is not the only loser from an approach that creates a document for nurses and GPs as if they are the only partnership in town. When the review says that we do not have much evidence of what are, in effect, good neighbour schemes, this is not so. Nebraska likewise did not invent these (this is an example given) and we do not need to turn to an Italian experiment to learn about telephone-based networks of support.

Many social workers know about these at local level indeed many good neighbour schemes and telephone networks are paid for out of social care budgets. This is why this research is recommended to social workers with a “health warning”. It reports health focused literature in a health focused way. But this state of affairs also should serve as a prompt to social work researchers to be more assertive in arguing that they too need more reviews that are multi-faceted.

PRACTICE IMPLICATIONS

Identifying depression

For those new to work with older people, the nature and scale of depression may be surprising. Dementia receives much attention but depression little by comparison (see the Age Concern Inquiry on Mental Health). The implication of this research is that skills to communicate with older people with depression in the context of suicide risks will be important in making decisions about eligibility criteria, in arguing for extra social care support and in constructing acceptable care plans. Reviews like this can be used when making the case that depression may be very serious.

Knowing local trends

How do the figures for West Midlands compare to your area and what is said about suicide prevention for older people in the local strategy? Local suicide prevention strategies are one way to consider trends and to make arguments for resources for activities that are thought to work in reducing suicide risks. Strategies are also one way of making sure that interagency training is given some priority. They may also be a way of assessing the responsiveness to bereavement by suicide.

Joining in networks

Practitioners may welcome what is likely to be growing interest in CSIP networks in the welfare of older people’s mental health, and may want to join local initiatives on suicide prevention. This literature review is a good starting base for thinking about areas that can be targeted, skill sharing and local resources. It can also be used to follow up studies that were conducted outside the UK to think about how far they are transferable. The review of social work research by Joe and Niedermeier says that social workers have not yet written much about suicide prevention that will equip social workers with examples of what works in prevention. However, risk factors are relatively well established and can be discussed with social care practitioners.

Reading around

The emergent policy and practice focus on prevention fits well with the prevention of suicide. The Age Concern Inquiry provides accessible reviews that touch on mental health services and practice examples. The inquiry is a useful background document to mental health promotion and initiatives, applicable in areas where mental health services are organised along age divisions (older and adult mental health) or by mental health problems (dementia and other problems).

Equity between user groups

The risk factors for suicide among older people are higher for men, people who are socially isolated and people who are in pain. Social workers should be more aware of risk factors such as the use of drugs and access to medication as a matter that they can assess, or draw to the attention of social care providers in some cases. They can also encourage people to seek help with pain control and help them build up social networks. Joe and Niedermeier suggest that access to firearms should be considered as a risk factor in the US and perhaps even in the UK among some groups.

LINKS & RESOURCES
● Joe, S and Niedermeier, D (2006 advance access) “Preventing Suicide: a neglected social work research agenda“, British Journal of Social Work doi:10.1093/bjsw/hcl353
● Godfrey M, Townsend J, Surr C, Boyle G, and Brooker D, (2006) Literature and policy review on prevention and services
● Manthorpe J, and Iliffe S, (2005) Depression in Later Life, London, Jessica Kingsley
● McLaren S, Gomez R, Bailey M, and van der Horst R, (2007), “The association of depression and sense of belonging with suicidal ideation among older adults: applicability of resiliency models”, Suicide and Life-Threatening Behavior 37(1) 89-102

Jill Manthorpe is professor of social work and director of the social care workforce research unit at King’s College, London

This article appeared in the 10 May issue under the headline “Lifting the depression”