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Citation
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Costanza A, Amerio A, Radomska M, Ambrosetti J, Di Marco S, Prelati M, Aguglia A, Serafini G, Amore M, Bondolfi G, Michaud L, Pompili M. Front. Psychiatry 2020; 11: e558974. |
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Abstract
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Taking into account and evaluating the presence of a physical illness plays a crucial role in the clinical encounter with the elderly who may present suicidal ideation (SI) and suicidal behavior (SB) (1, 2).
On the one hand, physical illness is associated with greater suicidality risk in the elderly. This association has been inferred from both quantitative and qualitative findings based on population and registry cohorts (3-5), case-control studies (6-13), psychological autopsies (14, 15), coroners' reports (16, 17), and suicide notes (17, 18) [for reviews, see (19, 20)]. This applies to SI/wishes to die (20-22) and the entire span of SB, including suicide attempts (SAs) and completed suicides [for reviews, see (20, 23, 24)].
On the other hand, a physical illness may render the suicidality assessment of the elderly complex for multiple reasons (25): a) the possible presence of uncommon or masking clinical features of both SB (indirect or passive SB, e.g. self-starvation) and psychiatric disorders associated with SB (e.g. atypical depressive disorders with prevalent somatic or cognitive symptoms) (26-28); b) the risk of overlooking and missing SB when severe illnesses coexist (29); c) the frequent reticence among the elderly in externalizing SI as they place more emphasis on their physical conditions (30-33); and d) the eventual caregivers' representations of suicide as a more "understandable" act when facing greater physical fragilities and the intrinsic proximity of the end of life (34, 35). S. de Beauvoir wrote in the 1970s about the feeling of resignation or impotence of what may be considered an inexorable outcome: "Some suicides of elder people follow states of neurotic depression that one has not been able to heal; but most are normal reactions to an irreversible, desperate situation, experienced as intolerable" (36).
A large number of the elderly who died by suicide had had recent contact with primary healthcare professionals, including in emergency departments (EDs). Approximately 50 to 70% of individuals had consulted a healthcare professional in the 30 days preceding their death (32, 37), and more than 80% had done so in the six months prior to death (38). In most of these cases, the last consultation had focused on physical complaints in the absence of a psychiatric diagnosis (32, 37). Notably, affective disorders in the geriatric population can go undiagnosed by ED physicians (39).
The aim of this opinion paper is to point out the opportunity of assessing suicidality in the elderly when they present to the ED with physical illness. To this purpose, it could be useful to overview some both controversial and consensual key points on suicidality risk in the elderly...
Language: en |