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LONELINESS, LIVING ALONE and SOCIAL
ISOLATION
IN ELDERLY SUICIDE
Analysis of Coroner's inquests of 200
cases of elderly suicide
in Cheshire 1989-2001
George El-Nimr MB MSc MRCPsych
Specialist Registrar in Old Age
Psychiatry
Manchester
*Emad Salib Msc MRCPI FRCPsych
Honorary Senior Lecturer,
Liverpool University
Consultant Psychiatrist, Hollins
Park Hospital, Warrington
Background:
Available data suggests
that social isolation is an important correlate of late life suicide. Some
studies have considered loneliness to be a risk factor of suicide that can
be independent of depression. Leading a socially active life was studied as
a potential protective factor against suicide in the elderly.
Methods:
Data was extracted from
the records of coroner's inquests into all unexpected deaths of persons aged
60 and over, in Cheshire over a period of 13 years 1989-2001. The Coroner's
office covers the whole county of Cheshire (1,000,000 of population).
Verdicts of accidental death, misadventure and open verdicts were not
included in data collection.
Findings:
The study found no
significant gender difference in "living alone" in elderly suicide victims
(P>0.05). Significantly more widowed men who committed suicide were living
alone (OR 5.3, 95% CI 3-10, P<0.001). Females who were living alone showed a
lower tendency to contact their GP prior to suicide and also to be known to
psychiatric services compared to those who lived with, at least, another
person. Elderly suicide victims who lived alone showed a significantly
higher likelihood to leave an evidence of intent (OR1.7, 95% CI 0.9-2.9,
P<0.05). Men who lived alone were more likely to be suffering from a
physical illness (P<0.05).
Conclusion:
Men who are living
alone, although are at higher risk of physical illness, are much less likely
to be known to psychiatric services or to have made any contact with their
GP prior to their suicide. Childless status appears higher amongst female
victims who were living alone than those who lived in the company of another
person. Elderly suicide victims seem to be less likely to use a violent
suicidal method if they were living alone.
Further studies are
needed to evaluate the role of social isolation as a risk factor in elderly
suicide.
Key words:
Elderly suicide
Social isolation in old
age
Loneliness in old age
Suicide prevention in
old age
INTRODUCTION
Depression
affects 10 - 15% of people over 65 living at home in the United Kingdom. It
is the commonest and the most reversible mental health problem in old age.
Social isolation and loneliness are amongst the common associations of
depression in old age. Depression in old age carries an increased risk of
suicide and natural mortality. Recognition and simple intervention can
reduce morbidity, demand on Health and Social Services and the cost of
community care (Anderson, 2001). Models of suicide among the elderly suggest
that depressive symptoms, hopelessness, loneliness, anxiety and lowered
self-esteem are associated with the onset of suicidal ideation (Witzel,
1996). Characteristics of elderly suicide and deliberate self-harm in the
United Kingdom suggest that depression, social isolation and loss, and
physical illness are all risk factors (Dennis & Lindesay 1995). Available
data from the States suggests that social isolation is an important
correlate of late life suicide (Conwell & Duberstein 2001). Some studies
(Lantz, 2001), have considered loneliness to be a risk factor of suicide
that can be thought of as a factor that is not always associated with
depression. Although such studies have considered loneliness as a distinct
risk factor to elderly suicide, others looked at social deprivation and
loneliness as mere consequences of depression that can still increase the
risk of suicide amongst older adults (Palsson & Skoog 1997). Apart from
depression, pain, grief, alcoholism and carer stress, loneliness is
certainly one of the treatable contributing factors in elderly suicide
(Draper, 1995). Stressful circumstances and social isolation have often been
considered as possible risk factors for late life suicide, which may
definitely be altered (Conwell & Duberstein 1995). Nevertheless social
isolation was not found by some studies (Bell, 2001) to be a prominent
factor in elderly suicide.
According
to Conwell & Duberstein 2001, it is not only living alone that is a suicide
risk among older persons, but also the lack of openness to experience that
could be considered as another contributing factor in this regard.
Leading a
socially active life was studied as a potential protective factor against
suicide in the elderly. In a case control study on life events and
psychosocial factors in elderly suicides, active participation in
organisations and having a hobby were considered to be factors that are
associated with a decreased risk of suicide in later life. Obviously,
feelings of loneliness were regarded as an important risk factor of suicide
in older adults (Rubenowitz, Waern, Wilhelmson & Allebeck 2001). The
potential usefulness of social networks in a nursing home setting was also
studied. One study (Fessman & Lester 2000) explored the role of family
social support networks and support networks formed in the nursing home in
predicting depression and loneliness in elderly nursing home residents. In
addition to the use of a loneliness scale that was administered to the
nursing home patients, residents were also asked to identify close friends
among the nursing home residents and to describe the frequency of
interaction with outside visitors. Results indicated that the number of
visits from friends and family were not related to depression or
loneliness. However, social support within the nursing facility was a
significant predictor of depression and loneliness; nursing home residents
with more close relationships with other residents reported less depression
and loneliness. These results seem to suggest that the emotional and
psychological state of nursing home residents may be best improved by
helping them develop relationships with other residents of the institution.
Given the
fact that social isolation is a risk factor with potential implications for
prevention of late life suicide, preliminary indications were thought to be
that community outreach to elders at risk and educational programmes for
primary care providers on the identification and treatment of late life
depression are effective at lowering suicide rates (Conwell, 1997). As a
therapeutic attempt, the social work service over the telephone, under the
auspices of the suicide prevention hotline agency, was provided. The
programme targeted the elderly at increased risk of suicide by virtue of
depression, social isolation and unmet needs. When this was evaluated there
was a significant improvement in the care of this group of older persons
(Morrow & Becker 1998).
Studying
the marital status in the elderly suicide has indeed attracted the attention
of some researchers. In a study on the attempted and completed suicides in
older subjects (results from the WHO/EURO Multi-centre Study of Suicidal
Behaviour), in most centres the majority of the elderly who attempted
suicide were widow(ers) and often living alone (De-Leo, Padoani, Scocco,
Lie, Bille, Arensman et al 2001). One study (Byrne & Raphael 1997)
investigated the psychological symptoms experienced by recently widowed
older men. It was hypothesised that conjugal bereavement in this group
would be characterised by a mixture of depression, anxiety and loneliness.
Nevertheless, widowers reported more state anxiety and general psychological
distress, but not more depression or loneliness than married men. Studies of
attempted suicide (parasuicide, deliberate self-harm) in the old age
population between 1985 and 1994 were critically reviewed with reference to
demography, suicide methods, stressors, psychiatric features and outcome
(Draper, 1996). The studies consistently identified a number of factors
long regarded as being associated with suicidal behaviour in old age. These
included being unmarried and social isolation. Life expectancy of women is
greater than that of men at every age. Thus, an older woman is more likely
than a man to be living without a spouse and living alone. Studies that took
gender differences into account, revealed some rather interesting results.
Although the risk of suicide is lower, older women are more likely to be
depressed than older men, regardless of race, ethnic background or economic
status (Messinger-Rapport & Thacker 2001). Despite the existing informative
data on elderly suicide and social isolation, researchers are often faced
with a considerable numbers of dilemmas that can indeed affect the clarity
of the interpretation of their results and certainly the external validity
of the findings. The potential discrepancy between the subjective feelings
of loneliness and the objective 'fact' of living alone is only one of the
difficulties. The lack of an agreed operational definition for "social
isolation" is yet another obvious example.
In this
study, we attempt to explore whether living alone has any significant
association with elderly suicide and whether this differs in women and men.
The
findings and possible clinical implications are discussed.
METHOD
Data was
extracted from the records of coroner's inquests into all unexpected deaths
of persons aged 60 and over, in Cheshire over a period of 13 years
1989-2001. The Coroner's office if Cheshire is based at Warrington and
covers the whole county of Cheshire (1,000,000 of population).
The
Coroner will return a suicide verdict when there is evidence beyond
reasonable doubt that death was self-inflicted and the deceased had the
intention to take his/her own life. An open verdict is returned when the
evidence is for these two conditions cannot be proven to be beyond all
reasonable doubt. Verdicts of accidental death, misadventure and open
verdicts were not included in data collection.
A standard
form was designed and used to extract the data from the inquests' files
consistently for the whole. Information recorded for all cases included;
demographic details, method of death, circumstances leading to the death and
previous history of psychiatric and physical morbidity, social isolation and
evidence of intent.
Two main
categories of suicide will be referred to in the text as non-violent death
which included: (E950 = Self-poisoning by solid or liquid; E951 = Gas in
domestic use & E952 = other gases and vapour) and predominantly violent
death which included all methods other than self poisoning (E953 = Hanging,
strangulation and suffocation; E954 = Drowning: E955 = Firearms and
explosives; E056 = Cutting or piercing instruments; E957 = Jumping from a
high place; E958 = Other methods).
SPSS was
used in the statistical analysis and cross tabulation. EPI INFO statistical
packages were used to compute Chi square, odds ratios and P value.
RESULTS:
This study
included 200 suicide recorded by the Cheshire Coroner between 1989 and 2001
of person aged 60 and above that reside within the County of Cheshire. The
mean age of the entire sample was 71 years (SD= 8, range 60-86). One hundred
and seventeen (58.5 % )of the sample were men and eighty three (41.5%) were
women with mean ages of 70 (SD 7) and 74 (SD 8) respectively. Of the 200
deaths, 106 (53 %) of suicide victims lived alone (men: 58(54 %) and women:
48 (45 %) while 94 (47%) lived with at least another person (men: 59 (63 %)
and women: 35(37 %). Variables that showed statistical significant
difference between the two groups included: method of suicide, marital
status, childlessness, previous contact with primary and secondary services
and evidence of intent (table 1). The study found no significant difference,
in terms of living alone, between both sexes. Widowed elderly victims were
significantly more likely to be living alone than those who lived with
others (OR 5.3, 95% CI 3-10, P<0,001). Elderly suicide victims were found to
be significantly less likely to use a violent suicidal method (methods other
than self-poisoning such as hanging/ strangulation/ suffocation, drowning,
firearm/explosives, cutting/ piercing instruments, jumping from high place
and other methods) if they were living alone (OR 0.5, 95% CI 0.3 - 0.9,
P<0.05). Sex comparison revealed no significant difference (P>0.05).
Childless status was found to be significantly higher amongst elderly
suicide victims who were living alone (OR 2, 95% CI 1-3.4, P<0.05).
Interestingly, when gender was taken into account, statistical significance,
in this regard, was found only amongst female victims (P<0.05). Only forty
three percent (n = 46) of the elderly suicide victims who lived alone had
made some form of contact with their GP at least once over a period of 3
months prior to their death. This was found to be significantly lower than
those who were not living alone (57% n =54), (OR 0.5, 95% CI 0.3 - 0.9,
P<0.05). Similarly, elderly suicide victims who lived alone were
significantly less known to Psychiatric services compared to the other study
group (OR 0.3, 95% CI 0.2 - 0.6, P<0.001).
When
gender difference was taken into account, utilisation of both primary and
secondary services was found to be statistically significant only among
females (P<0.01).
DISCUSSION:
Interpretation of findings:
Despite the fact that
the study found that females who lived alone were not at a statistically
significant higher risk of committing suicide than their male counterpart,
looking at the absolute frequencies suggests some degree of difference in
that direction. Although this is a rather unexpected finding, this can be
explained on the basis of the assumption that females may have a higher
expectation in terms of gaining more support from their families and from
the community as a whole. Failing to receive such level and or quality of
care can, arguably, give rise to a more painful and rather stressful sense
of social isolation and poor self worth.
Based on
the literature, although the risk of suicide is lower, older women are more
likely to be depressed than older men (Messinger-Rapport & Thacker 2001).
Women are likely to suffer more from the potentially deleterious
consequences of social isolation. The longer periods of social isolation,
giving the longer life expectancy of females in general can indeed be
considered as another plausible explanation if one was to take into account
the possible "cumulative" agony of living in a perceived "increasingly
different" world with an increasing sense of "alienation". The finding that
elderly suicide victims are less likely to use violent suicide methods if
they were living alone is an interesting one. In one respect, it seems that
by doing so, an elderly individual who is living with another person can
communicate his/her stress to their perceived failing care-givers in a more
dramatic way; even though it was for the last time. In psycho-dynamic terms
this can be considered as a means of introjecting one's extreme hostility
he/she feels towards the outside world and redirecting those painful
feelings against one's self. One assumption can be that some of the people
who live alone for such a long time might have adopted the role of being
"non-significant" to others. As they lived in an "unnoticed" social
isolation, they tend to put an end to such a life in a similarly "quiet",
"peaceful" and rather "unnoticed" way.
In other
words, finding the least painful and quickest way of putting an end to it
all, might be the only task a suicidal elderly would be aiming to achieve in
the final few moments of his/her life. An expected finding is that more
elderly widowed suicide victims were living alone than those with a
different marital status. This is in to keeping with the finding from the
WHO/EURO Multi-centre study of social behaviour (De-Leo, Padoani, Scocco et
al 2001).
It appears
that an elderly person who is used to living with a partner for a long time,
has established a life style that is so hard to change by moving to a less
"socially isolating" type setting hence the more sense of isolation and
loneliness. Childlessness was found in this study to be significantly higher
amongst the elderly suicide victims who were living alone. This finding can
be explained in the light of the literature finding that the most common
barrier to suicide is the thoughts of the consequences to family members
(Bell 2001). Therefore, it may be reasonable to assume that having close
family members, such as spouse and children can be a significant protective
factor against suicide in this age group. Children are also expected to
facilitate some form of therapeutic contact between their parents and their
doctors. This can obviously explain the higher likelihood of an elderly
suicide victim who live with a potential carer to have had a recent contact
with primary health services and being known to psychiatric services.
Families seem to help their "dependent" elderly utilise relevant services by
early detection of ill-health, encouraging patients to make contact with
concerned professionals and indeed by alerting psychiatric or otherwise
relevant services. The fact that this was only found among female victims
might indicate that having children could be more protective for mothers who
will, arguably, draw more attention and support from their children. Another
assumption can be; for some men, having children might stop them from
leading an independent and private life that can be achieved by choosing to
live alone. The "usual" argument that females are "better" in utilising both
primary and secondary care services can easily apply here. Women tend to
more readily somatise their distress and therefore, seek more medical
advice.
The fact
that only men who lived alone had a significantly more physical morbidity,
is an interesting but rather unexpected finding of our study. One dilemma
will clearly be determination of the direction of causality.
One
argument could be that men who live alone are, in some ways, poor survivors
of social isolation who can barely lead a healthy life style that could,
expectedly, precipitate a physical illness.
Limitations of the study:
One
crucial limitation of this study is the lack of a control group that consist
of socially isolated elderly people who did not commit suicide.
The other
main limitations of this study include the small sample size and
confounding. The fact that the data were collected from only one county
might, at least partly affect the external validity of some of the findings
should the sample be not representative to the elderly population in the UK.
Collecting information about the circumstances surrounding elderly suicide
was rather difficult giving their social isolation and/or reluctance to talk
about their emotional difficulties.
Correspondence:
Hollins Park Hospital,
Warrington,
WA2 8WA
Tel: 01925 664123 , Fax: 01925 664145
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Table 1
Gender differences in elderly suicide and 'living alone' in Cheshire
1989-2001
========================================================
Living
alone Not living alone
106
(53%) 94 (47%)
mean age 74
(sd8) mean age 71 (sd 9)
Male
Female Male Female
58(55%) 48
(45%) 59 (63%) 35 (37%)
mean age 72 mean age
78 mean age 71 mean age 71
__________________________________________________________________________
MARITAL
STATUS
Widowed
27
(47%) 34 (70%) 8 (14%) 11 (31%)
P<001
__________________________________________________________________________
CHILDREN
No
Children
22
(38%) 22 (46%) 21 (36%) 5 (14%)
P<05
(women
only)
__________________________________________________________________________
GP
CONTACT
Yes
P<01
28
(48%) 18 (38%) 28 (48%) 26 (74%)
(women
only)
__________________________________________________________________________
METHOD
Violent
31
(53%) 19 (40%) 38 (64%) 21 (60%)
P>05
__________________________________________________________________________
EVIDENCE
OF
INTENT
yes
36
(62%) 24 (50%) 25 (42%) 16 (45%)
P>05
___________________________________________________________________________
PSYCHIATRIC
MORBIDITY
yes
33 (57%)
17 (35%) 24 (41%) 25 (71%)
P<001
(for
women only)
___________________________________________________________________________
HISTORY
OF DSH
yes
8
(14%) 9 (19%) 10 (17%) 12 (34%)
P>05
___________________________________________________________________________
PHYSICAL
MORBIDITY
Yes
32
(55%) 30 (63%) 43 (73%) 22 (63%)
___________________________________________________________________________
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