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Keywords:

  • cardiovascular disease;
  • elderly;
  • non malignant neoplasm;
  • orthopedic disorder;
  • psychiatric disorders;
  • suffering from physical illness;
  • suicide

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Background:  The aim of the present study is to show the causative factors of suicide among the elderly (over 65) in Mie Prefecture, Japan, and to discuss the prevention of the suicidal influences in elderly patients.

Methods:  We investigated all inquest records during the 14-year period 1989–2002 in cooperation with the First Department of Criminal Investigation of Mie Prefectural Police Headquarters. From all cases classified as suicides, we extracted data on age, sex and background, and we focused on suicide in the elderly group.

Results:  During the test period, there were 5048 suicides (3276 male and 1772 female suicides) of which 1513 (691 male and 822 female) were in the elderly group. The rate of suicide in the elderly group was approximately 30% of the total in all age groups. The rate of female suicides in the elderly group was approximately 46.3%. The major causative factors of suicide among the elderly were ‘suffering from physical illness’, and ‘psychiatric disorders’. ‘Physical diseases’ were not negligible backgrounds in middle and elderly groups. Among physical diseases, the number of malignant neoplasm was clearly less than the other diseases. Notably, ‘cardiovascular disease’ and ‘orthopedic disorders’ were most frequent causative factors of suicide other than malignant neoplasm.

Conclusion:  It is consequently concluded that improvements in the system of home nursing and health care should be involved in the suicidal prevention of the elderly who ‘suffer from physical illness’. The patients who ‘suffer from physical illness’ should be given physical and mental support. In order to prevent suicide, not only psychiatrists but also general practitioners as well as medical staff and general public should be provided with education regarding depression among ‘psychiatric disorders’.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Mie Prefecture is located in the center of Japan. The population is approximately 1.8 m with a population density of approximately 320 per km2. According to a report by Yoshioka,1 Mie Prefecture showed intermediate levels of suicide relative to Japan as a whole during the seven years from 1989 to 1995. In addition, he showed that ‘suffering from physical illness’ was the most serious issue in elderly (over 65), followed by ‘psychiatric disorders’ among the research. In recent years our country has become an increasingly aging society, so it is useful to investigate causative factors of suicide among the elderly. We were able to obtain and analyze detailed Mie Prefectural data on suicides to investigate the causes, which we presumed would reflect national trends in Japan. Therefore, since the rate of suicide in Mie Prefecture is similar to that for all of Japan, we considered our findings on suicidal behavior in this prefecture to be applicable to Japan as a whole. In the present study, we examined the incidence and the circumstances of all suicidal cases during the 14-year period, 1989–2002, and we focused on causative factors of suicide in the elderly.

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

We investigated all inquest records during the 14-year period 1989–2002 in cooperation with the First Department of Criminal Investigation of Mie Prefectural Police Headquarters. The records concerning suicide were assessed by inquest doctors carefully. In addition, other medical doctors of our group confirmed them again at the time of investigation. We assessed completed suicides in our investigation from the cases regarded as suicide by inquest doctors. From all cases classified as suicides, we extracted data on age, sex and background, and we focused on suicide in the elderly. The First Department of Criminal Investigation of Mie Prefectural Police Headquarters collects information on suicides, such as the social backgrounds of each case. We re-confirmed the information of the First Department of Criminal Investigation of Mie Prefectural Police Headquarters in all suicide cases. We stored all these data in our database.

  • 1
    Three age groups were established: younger (under 39), middle aged (40–64), and elderly (over 65).
  • 2
    The case backgrounds – the causative factors and medical histories, as diagnosed by medical professionals – were classified into six groups: suffering from physical illness (malignant neoplasm, diseases of the central nervous system, cardiovascular disease, digestive organ disease, diabetes mellitus, orthopedic disorder, urinary organ/generative organ disease and other), pessimism, economic difficulties, personal relationships, psychiatric disorders, and others.

The statistical analysis was performed using Fisher’s exact test.

All data were completely anonymous after encoding.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Suicide annual transition

During the 14-year period 1989–2002, 5048 (3276 male and 1772 female) suicides were reported to Mie Prefectural Police Headquarters (Table 1a), giving a male/female ratio of approximately 1.9:1. The suicide rates by sex were 26.2 men and 13.4 women per 100 000 (P < 0.05). The mean number of suicides per year was 360.6. During the test period, there were 1513 (691 male and 822 female) suicides in the elderly (Table 1b). Suicides in the elderly group constituted approximately 30% of suicides in all age groups. Interestingly, suicides in elderly women were approximately 46.3% of suicides in women of all age groups.

Table 1.  The number of suicides in for the years 1989–2002
 TotalMaleFemale
(a) In all age groups
1989 327 202 125
1990 276 160 116
1991 276 188  88
1992 300 180 120
1993 288 192  96
1994 299 171 128
1995 334 204 130
1996 326 204 122
1997 319 205 114
1998 501 325 176
1999 461 308 153
2000 425 289 136
2001 456 337 119
2002 460 311 149
Total504832761772
(b) In the elderly
1989 108  50  58
1990  92  34  58
1991  93  44  49
1992  95  41  54
1993  78  35  43
1994  94  38  56
1995 111  46  65
1996  98  44  54
1997  93  42  51
1998 129  56  73
1999 140  67  73
2000 121  64  57
2001 124  67  57
2002 137  63  74
Total1513 691 822

Age distributions for men and women and yearly changes

Age was strongly related to the rate of suicide, but different age distributions were found for men and women. The rate was highest in the 50–59 age group (1060 cases) followed by the 60–69 age group (883 cases). The pattern among men, exhibited throughout the 14 years showed a sharp peak in the 50–59 age group (781 cases) followed by the 40–49 age group (626 cases). The rate among women was highest in the 70–79 age group (374 cases) followed by the 60–69 age group (314 cases).

The age-adjusted suicide mortality rates showed relationships to age similar to that seen before with the unadjusted rates except that the adjusted rate was relatively higher in the very elderly. The adjusted number of suicides in men peaked in the elderly and 50–59 age group, while it increased progressively in females.

Causative factors and medical history as background

Among the various causative factors (Table 2), ‘suffering from physical illness’ was the most serious issue in all generations, accounting for 26.6% of the total cases, followed by ‘psychiatric disorders’, and then ‘economic difficulties’. In men, the most common causative factor was ‘suffering from physical illness’ (23.6%) in all age groups. The second most common one was ‘economic difficulties’ (20.2%), and then ‘psychiatric disorders’ (18.5%). The most common factor in elderly men was ‘suffering from physical illness’ (47.3%). The second most common one was ‘pessimism’ (14.3%) in elderly men. On the other hand, in women, the most common causative factor was ‘psychiatric disorders’ (32.9%) in all age groups, and the second most common one was ‘suffering from physical illness’ (32.0%). The most common one in elderly women was ‘suffering from physical illness’ (45.1%) and the second most common one was ‘psychiatric disorders’ (24.4%).

Table 2.  Causative factors of suicide
Age group, yearsTotal (%)Male (%)Female (%)
≤39 (Younger)40–64 (Middle)≥65 (Elderly)All ages≤39 (Younger)40–64 (Middle)≥65 (Elderly)All ages≤39 (Younger)40–64 (Middle)≥65 (Elderly)All ages
Suffering from physical illness1157028671684 80488403971 35214464713
Percentage  8.5 22.6 46.1  26.6  8.2 21.3 47.3 23.6  9.3 26.1 45.1 32.0
Pessimism170308263 741136253122511 34 55141230
Percentage 12.6  9.9 14.0  11.7 14.0 11.0 14.3 12.4  9.0  6.7 13.7 10.3
Economic difficulties164685 94 943149617 66832 15 68 28111
Percentage 12.2 22.0  5.0  14.9 15.3 26.9  7.7 20.2  4.0  8.3  2.7  5.0
Personal relationships262273 75 610182205 32419 80 68 43191
Percentage 19.4  8.8  4.0   9.9 18.7  8.9  3.8 10.2 21.3  8.3  4.2  8.6
Psychiatric disorders4187123641494253396113762165316251732
Percentage 31.0 22.9 19.4  23.6 26.0 17.3 13.3 18.5 43.9 38.5 24.4 32.9
Others219432217 868172332116620 47100101248
Percentage 16.2 13.9 11.5  13.7 17.7 14.5 13.6 15.1 12.5 12.2  9.8 11.1

‘Psychiatric disorders’ was one of the most common medical predictors in all age groups and also in both sexes (Table 3). ‘Physical diseases’ were not negligible backgrounds in middle and elderly groups (Table 3). In physical diseases, there was clearly more non malignant neoplasm than malignant neoplasm. In particular, ‘cardiovascular disease’ and ‘orthopedic disorder’ were most frequent among non malignant neoplasms (Table 3).

Table 3.  The medical histories of suicide victims
Age groupTotal (%)Male (%)Female (%)
≥65 (Elderly)All ages≥65 (Elderly)All ages≥65 (Elderly)All ages
No hospitalization 157 (6.3)1231 (18.3) 88 (7.8) 996 (24.1) 69 (5.0) 235 (9.1)
Psychiatric disorders 602 (24.1)2161 (32.2)197 (17.5)1124 (27.2)405 (29.6)1037 (40.1)
Malignant neoplasm 121 (4.9) 243 (3.6) 72 (6.4) 150 (3.6) 49 (3.6)  93 (3.6)
Other diseases1436 (57.6)2513 (37.4)647 (57.6)1428 (34.6)789 (57.6)1085 (41.9)
Central nerve system 166 (11.6) 242 (9.6) 90 (13.9) 148 (10.4) 76 (9.6)  94 (8.7)
Cardiovascular disease 397 (27.6) 568 (22.6)177 (27.4) 303 (21.2)220 (27.9) 265 (24.4)
Digestive organ disease 164 (11.4) 345 (13.7) 81 (12.5) 228 (16.0) 83 (10.5) 117 (10.8)
Diabetes mellitus 106 (7.4) 253 (10.1) 42 (6.5) 157 (11.0) 64 (8.1)  96 (8.8)
Orthopedic disorder 241 (16.8) 429 (17.1) 77 (11.9) 209 (14.6)164 (20.8) 220 (20.3)
Urinary organ/Generative organ disease  73 (5.1) 139 (5.5) 48 (7.4)  85 (6.0) 25 (3.2)  54 (5.0)
Other 289 (20.1) 537 (21.4)132 (20.4) 298 (20.9)157 (19.9) 239 (22.0)
Unknown 177 (7.1) 566 (8.4)120 (10.7) 429 (10.4) 57 (4.2) 137 (5.3)

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

The number of suicides in Mie prefecture clearly increased since 1998 (Table 1a).2 This tendency was almost the same as in all of Japan.

The major causative factors of suicide among the elderly were ‘suffering from physical illness’, and ‘psychiatric disorders’. ‘Psychiatric disorders’ were the important causative factors for suicide in both sexes. ‘Suffering from physical illness’ was also an important factor in the elderly in both men and women.

‘Psychiatric disorders’ showed a high rate and were critical factors in suicide in both sexes among the elderly. Therefore, urgent suicide prevention addressing ‘psychiatric disorders’ is required. In the USA nationwide, the general public was educated about psychiatric disorders.3 This involved providing for education regarding psychiatric disorders not only to psychiatrists but also to general practitioners and medical staff.4,5 Therefore, the rate of patients with psychiatric disorders who go to medical institutions has increased, and the results of the diagnosis of psychiatric disorders by general practitioners have improved.6 In England nationwide, as in the USA, there has been a campaign for the prevention of ‘psychiatric disorders’. In particular, information regarding depression has been provided through books, cassette tapes and education through the media.7–9 Consequently, the suicide rate has decreased in one region of England. In Sweden, suicide rates have decreased after teaching general practitioners about psychiatric disorders.10 In Finland, lectures and workshops concerning to ‘psychiatric disorders’ have been conducted for the general public at the national level, as a result of which suicides have been reduced.2 In parts of Japan, measures for the early detection and treatment of psychiatric disorders with screening methods to prevent suicide associated with psychiatric disorders have been implemented, but the suicide rate has not decreased. Therefore, suicide prevention should urgently be conducted at the national level. Furthermore, both the general public and medical staff should understand psychiatric disorders, and should conduct early detection and treatment measures.

‘Suffering from physical illness’ causes many suicides, especially in the elderly. Cardiovascular diseases and orthopedic disorders were frequent diseases reported as the causes of suicide. Among non malignant neoplasms, cardiovascular diseases and orthopedic disorders are chronic and long-term, and result in a depressed condition and mental as well as physical exhaustion for patients. According to the report of Perlis et al. they researched the prevalence of significant levels of irritability among the first 1456 outpatients with non-psychotic major depressive disorders entering the Sequenced Treatment Alternatives to Relieve Depression study.11 They found that the risks of cardiovascular diseases were one of the prevalent complaints of depressed outpatients and were associated with a greater likelihood of suicide attempts.11 Walsh and Sage showed the relevance of depression and chronic orthopedic disorders through a case report of suicide.12 In addition, they speculated that the chronic course or long-term course of the disease in cases of chronic diabetic foot disability might induce depressed mental status.12 In ‘suffering from physical illness’ consequently, improvements in the system of home nursing and health care should be involved in the prevention of suicide. In addition, patients ‘suffering from physical illness’ should be given physical and mental support.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

We thank all the staff of the Department of Forensic Medicine and Sciences and the Department of Psychiatry, Mie University Graduate School of Medicine, and the First Department of Criminal Investigation of Mie Prefectural Police Headquarters, for their enthusiastic cooperation.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. MATERIALS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES
  • 1
    Yoshioka N. Present Status of Suicide in Japan, and the Preventive Application: Report of a Grant-in-Aid for Scientific Research (Ministry of Education, Culture, Sports, Science, and Technology of Japan).]; Akita: Author published, 1997. (In Japanese.)
  • 2
    Yoshioka N. Epidemiological study of suicide in Japan- is it possible to reduce committing suicide? Jpn J Legal Med 1998; 52: 286293. (In Japanese, English abstract.)
  • 3
    Regier DA, Hischfeld RM, Goodwin FK et al. The NIMH Depression Awareness, Recognition, and Treatment Program: structure, aims, and scientific basis. Am J Psychiatry 1988; 145: 13511357.
  • 4
    O’Hara MW, Gorman LL, Wright EJ. Description and evaluation of the lowa depression awareness, recognition, and treatment program. Am J Psychiatry 1996; 153: 645649.
  • 5
    Greenfield SF, Reizes JM, Magruder KM et al. Effectiveness of community-based screening for depression. Am J Psychiatry 1997; 154: 13911397.
  • 6
    Greenfield SF, Reizes JM, Muenz LR et al. Treatment for depression following the 1996 National Depression Screening Day. Am J Psychiatry 2000; 157: 18671869.
  • 7
    Paykel ES, Tylee A, Wright A et al. The Defeat Depression Campaign: psychiatry in the public arena. Am J Psychiatry 1997; 154: 5965.
  • 8
    Paykel ES, Hart D, Priest RG. Changes in public attitudes to depression during the Defeat Depression Campaign. Br J Psychiatry 1998; 173: 519522.
  • 9
    Rix S, Paykel ES, Lelliott P et al. Impact of a national campaign on GP education: an evaluation of the Defeat Depression Campaign. Br J Gen Pract 1999; 49: 99102.
  • 10
    Rutz W, Walinder J, Eberhard G et al. An education programme for depressive disorders on Gotland: background and evaluation. Acta Psychiatr Scand 1989; 79: 1926.
  • 11
    Perlis RH, Fraguas R, Fava M et al. Prevalence and clinical correlates of irritability in major depressive disorder: a preliminary report from the Sequenced Treatment Alternatives to Relieve Depression study. J Clin Psychiatry 2005; 66: 159166.
  • 12
    Walsh SM, Sage RA. Depression and chronic diabetic foot disability. A case report of suicide. Clin Podiatr Med Surg 2002; 19: 493508.