Indirect self-destructive behavior in the elderly are particularly notable. In addition to overt suicide attempts, there are subtle behaviors especially in the elderly, with conscious or unconscious intent to die, such as refusal to eat or drink, noncompliance with treatment, or extreme self-neglect. Farberow (1980) used the term “sub-intentional suicide” to refer to indirect self-destructive behaviors which often lead to premature death, and are common in certain settings such as nursing homes (where more immediate means to complete suicide are limited), and among people whose religion forbids suicide. Osgood et al. (1991) found that the rate of completed suicide among elderly nursing home residents was 15.8/100,000 as compared to 19.2/100,000 for elderly living in the community. By contrast they estimated the rate of indirect self-destructive behavior leading to death to be 79.9/100,000 among nursing home residents, and the rate of such behavior not resulting in death to be 227/ 100,000. Kastenbaum and Mishara (1971) found that 44% of men and 22% of women who were hospitalized for chronic medical illnesses exhibited indirect self-destructive behavior during a 1-week period.

Bereavement is an important risk factor in the elderly. The effect of spousal loss on suicidality appears to be the most pronounced in elderly men. In the United States, the highest suicide rate is among bereaved elderly white men: 84/100,000 (NCHS, 1992). Rates of suicidal ideation are also elevated in elderly with complicated or traumatic grief, which differs from bereavement-related depression and includes PTSD-like symptoms (Szanto et al., 1997).

Although chronic physical illness has been associated with an increased suicide risk in depressed patients (Duggan et al., 1991), depression and not physical illness differentiated elderly suicide completers from non-completers (Conwell et al., 2000). A 1-year follow-up study of psychiatric register cases observed that depressed patients aged 55 years or older had more than twice the rate of suicide (475/100,000) than younger depressed patients (207/100,000) (Gardner et al., 1964). In the 60–90 year old age group, the rates of suicide attempts associated with untreated mood disorders increase with each subsequent decade (Bostwick and Pankratz, 2000). Psychological autopsy studies have found depression to be the most common psychiatric diagnosis in elderly suicide victims, while alcoholism is the most common diagnosis in younger adults (Conwell and Brent, 1996; Dorpat and Ripley, 1960). Conwell and Brent (1996) reported that 76 percent of elderly suicide victims had diagnosable psychopathology, including 54 percent with major depression and 11 percent with minor depression.

Seventy percent or more of elderly suicide victims were seen by their primary care physician within one month from their death (Barraclough et al., 1971; Conwell, 1994; Miller, 1976). Terminal illness needs to be



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