Hirofumi Oyama

A Systematic Review of Elderly Suicide Prevention Programs

BACKGROUND Suicide rates are highest among the elderly, yet research on suicide prevention in old age remains a much-neglected area. AIMS We carried out a systematic review to examine the results of interventions aimed at suicidal elderly persons and to identify successful strategies and areas needing further exploration. METHODS Searches through various electronic databases yielded 19 studies with an empirical evaluation of a suicide prevention or intervention program designed especially for adults aged 60 years and older. RESULTS Most studies were centered on the reduction of risk factors (depression screening and treatment, and decreasing isolation), but when gender was considered, programs were mostly efficient for women. The empirical evaluations of programs attending to the needs of high-risk older adults seemed positive; most studies showed a reduction in the level of suicidal ideation of patients or in the suicide rate of the participating communities. However, not all studies used measures of suicidality to evaluate the outcome of the intervention, and rarely did they aim at improving protective factors. CONCLUSIONS Innovative strategies should improve resilience and positive aging, engage family and community gatekeepers, use telecommunications to reach vulnerable older adult, and evaluate the effects of means restriction and physicians education on elderly suicide.

Stress buffering effects of social support on depressive symptoms in middle age: reciprocity and community mental health

Abstract  Little is known about the association between depression and the buffering effects of social support in mid‐life crisis. The aim of this study is to determine the buffering effects of social support on depression concerning middle‐aged individuals, while also taking reciprocity and gender differences into careful consideration. A cross‐sectional survey of all middle‐aged individuals (40–69 years of age) using a large sample (n = 4558) from a community‐living population, who resided in Rokunohe town, Aomori prefecture in northern Japan (response rate = 69.8%), was undertaken. This town recently had a lot of suicides. Two‐way anova was used to analyze the effects of stressor and social support on the Center for Epidemiologic Studies Depression scale scores. The authors found a stress buffering effect of social support on the depressive symptoms occurring in middle age, however, a significant difference in the stress buffer effect was only observed in male subjects. Moreover, when the authors take reciprocity into account, the effect of the buffer on depression was found not only in males receiving support but in males providing support as well. In conclusion, pertaining to males, social support reduces depressive symptoms under stressful circumstances in middle age, not only when they receive such support but also when they provide it. Therefore, these findings suggest that reciprocal social support is important for males in relation to community mental health.

Effect of Community-based Intervention Using Depression Screening on Elderly Suicide Risk: A Meta-analysis of the Evidence from Japan

A systematic review was undertaken to quantify the effect of community-based depression screening (CDS) with follow-up on the completed suicide risk for residents aged 65 and over. Five quasi-experimental studies in Japanese regions with high suicide rates were included in the meta-analysis. Combined incidence rate ratios (95% confidence intervals) by the Mantel–Haenszel method and by the DerSimonian–Laird method in two homogenous studies implementing the follow-up conducted by psychiatrists were 0.30 (0.13–0.68) and 0.33 (0.14–0.80) in men, and 0.33 (0.19–0.58) and 0.33 (0.19–0.60) in women, respectively; and those in three homogenous studies implementing the follow-up conducted by general practitioners were 0.73 (0.45–1.18) and 0.74 (0.45–1.23) in men, and 0.36 (0.21–0.60) and 0.39 (0.22–0.66) in women, respectively. There are very few studies included, however, to demonstrate an association between CDS and the reduced risk, suggesting gender difference in the effectiveness.

Key considerations for preventing suicide in older adults: consensus opinions of an expert panel.

BACKGROUND The number of older adults is growing rapidly. This fact, combined with the high rates of suicide in later life, indicates that many more older adults will die by their own hands before rigorous trials can be conducted to fully understand the best approaches to prevent late life suicide. AIMS To disseminate key considerations for interventions addressing senior suicidal behavior. METHODS An international expert panel has reviewed and discussed key considerations for interventions against suicide in older adults based on existing evidence, where available, and expert opinion. RESULTS A set of new key considerations is divided into: universal, selective, and indicated prevention as well as a section on general considerations. CONCLUSIONS The suggestions span a wide range and are offered for consideration by local groups preparing new interventions, as well as large scale public health care planning.

Preventing Elderly Suicide Through Primary Care by Community-Based Screening for Depression in Rural Japan

Depression is a major cause of suicide among the elderly. Few previous community-based interventions against depression have reduced the suicide rate. This study aims to evaluate outcomes of a community-based program to prevent suicide among the elderly using a quasi-experimental design with a neighboring reference group. The program, including depression screening with follow-up and health education through primary care and public health nursing, was implemented for 10 years in Matsudai town, a rural area of Japan (population 6,015; suicide rate per 10(5) [65-year-olds] for males 290.6, and for females 361.3). Changes in the suicide risk were estimated by the incidence rate ratio (IRR). The female risk of completing suicide in the intervention area was reduced by 70% (age-adjusted IRR: 0.30; 95% CI: 0.14-0.67), while there was no change in the risk for males in the intervention area nor for males or females in the reference area (Kawanishi town: population 9,425; elderly suicide rate for males 212.2, females 151.9). A ratio of the female IRR in the intervention area to that in its prefecture was also estimated at 0.45 (95% CI: 0.19-0.97), showing that the reduction of suicide risk in the intervention area was greater than the historical trend. A community intervention against suicide using management of depression with nonpsychiatric, primary health care would be effective for elderly females, but not males.

Local community intervention through depression screening and group activity for elderly suicide prevention.

Abstract  This study aims to evaluate outcomes of a community‐based program to prevent suicide among the elderly (≥65 years old) using a quasi‐experimental design with two neighboring references. During 1999–2004, the program including depression screening and group activity was conducted by the public health nurses in the Minami district (population 1685) of Nagawa town, rural Japan. Pre‐post changes in the risk of completing suicide were estimated by the incidence rate ratios (IRR). The risk for Minamis elderly females was reduced by 74% (age‐adjusted IRR, 0.26; 90% CI, 0.07–0.98) more than the historical trend, while there was no change in the risk of Minamis males and nor in the male or female references. The local intervention using public health nursing would be effective against suicide for elderly females without diffusing to the surroundings.

A community intervention trial of multimodal suicide prevention program in Japan: A Novel multimodal Community Intervention program to prevent suicide and suicide attempt in Japan, NOCOMIT-J

BackgroundTo respond to the rapid surge in the incidence of suicide in Japan, which appears to be an ongoing trend, the Japanese Multimodal Intervention Trials for Suicide Prevention (J-MISP) have launched a multimodal community-based suicide prevention program, NOCOMIT-J. The primary aim of this study is to examine whether NOCOMIT-J is effective in reducing suicidal behavior in the community.Methods/DesignThis study is a community intervention trial involving seven intervention regions with accompanying control regions, all with populations of statistically sufficient size. The program focuses on building social support networks in the public health system for suicide prevention and mental health promotion, intending to reinforce human relationships in the community. The intervention program components includes a primary prevention measures of awareness campaign for the public and key personnel, secondary prevention measures for screening of, and assisting, high-risk individuals, after-care for individuals bereaved by suicide, and other measures. The intervention started in July 2006, and will continue for 3.5 years. Participants are Japanese and foreign residents living in the intervention and control regions (a total of population of 2,120,000 individuals).DiscussionThe present study is designed to evaluate the effectiveness of the community-based suicide prevention program in the seven participating areas.Trial registrationUMIN Clinical Trials Registry (UMIN-CTR) UMIN000000460.

Effectiveness of a Multimodal Community Intervention Program to Prevent Suicide and Suicide Attempts: A Quasi-Experimental Study

Background Multilevel and multimodal interventions have been suggested for suicide prevention. However, few studies have reported the outcomes of such interventions for suicidal behaviours. Methods We examined the effectiveness of a community-based multimodal intervention for suicide prevention in rural areas with high suicide rates, compared with a parallel prevention-as-usual control group, covering a total of 631,133 persons. The effectiveness was also examined in highly populated areas near metropolitan cities (1,319,972 persons). The intervention started in July 2006, and continued for 3.5 years. The primary outcome was the incidence of composite outcome, consisting of completed suicides and suicide attempts requiring admission to an emergency ward for critical care. We compared the rate ratios (RRs) of the outcomes adjusted by sex, age group, region, period and interaction terms. Analyses were performed on an intention-to-treat basis and stratified by sex and age groups. Findings In the rural areas, the overall median adherence of the intervention was significantly higher. The RR of the composite outcome in the intervention group decreased 7% compared with that of the control group. Subgroup analyses demonstrated heterogeneous effects among subpopulations: the RR of the composite outcome in the intervention group was significantly lower in males (RR = 0.77, 95% CI 0.59–0.998, p = 0.0485) and the RR of suicide attempts was significantly lower in males (RR = 0.39, 95% CI 0.22–0.68, p = 0.001) and the elderly (RR = 0.35, 95% CI 0.17–0.71, p = 0.004). The intervention had no effect on the RR of the composite outcome in the highly populated areas. Interpretation Our findings suggest that this community-based multimodal intervention for suicide prevention could be implemented in rural areas, but not in highly populated areas. The effectiveness of the intervention was shown for males and for the elderly in rural areas. Trial Registration ClinicalTrials.gov NCT00737165 UMIN Clinical Trials Registry UMIN000000460

A Community-Based Survey and Screening for Depression in the Elderly

BACKGROUND In addition to implementing a depression screening program, conducting a survey beforehand might contribute to suicide risk reduction for the elderly. AIMS This study evaluates outcomes of a community-based program to prevent suicide among individuals aged 60 and over, using a quasiexperimental design with an intervention region (41,337 residents, 35.1% aged 60 and over) and a neighboring reference region. METHODS Our 2-year intervention program included an anonymous survey by random sample in the entire intervention region and, in the second year, a depression screening with follow-up by a psychiatrist in the higher-risk districts. Changes in the risk of completed suicide were estimated by the incidence-rate ratio (IRR). RESULTS The risk for men in the intervention region was reduced by 61% (age-adjusted IRR = 0.39; 90% CI = 0.18-0.87), whereas there was a (statistically insignificant) 51% risk reduction for women in the intervention region, and no risk reduction for either men or women in the reference region. The ratio of the crude IRR for elderly men in the intervention region to that for all elderly men in Japan was estimated at 0.42 (90% CI = 0.18-0.92), showing that the risk reduction was greater than the national change. CONCLUSIONS The management of depression through a combination of an initial survey and subsequent screening holds clear promise for prompt effectiveness in the prevention of suicide for elderly men, and potentially for women.

Long-Term Effects of a Screening Intervention for Depression on Suicide Rates among Japanese Community-Dwelling Older Adults

OBJECTIVES To explore the long-term impact of a universal screening intervention for depression on suicide rates among older community-dwelling adults, with gender as an effect modifier. DESIGN Controlled cohort study reporting long-term follow-up of previous research. SETTING Two sets of three municipalities in Japan were assigned as intervention and control regions and compared with the surrounding zone and prefecture. PARTICIPANTS Intervention area residents aged 60 years and older (14,291) were invited to participate in a 2-year intervention (2005-2006). Four population-based dynamic cohorts of residents aged 65 years and older (1999-2010) were included as subjects, 6 years before and after the intervention started. INTERVENTION At-risk residents within the intervention region (4,918) were invited for a two-step screening program; 2,552 participated in the program linked with care/support services for 2 years. An education program open to the public was held. MEASUREMENTS Changes in suicide from a 6-year baseline to the 2-year intervention and a 4-year follow-up in the intervention region (11,700 adults ≥65 years) were compared with a matched control and two comparison areas using mixed-effects negative binomial regression models. Suicide rates among older adults exposed to screening were compared with those of the control region. RESULTS Suicide rates in the intervention region decreased by 48%, which was significantly greater than in the three comparison areas. The programs benefits lasted longer for women than men. Screening exposure may be associated with decreased suicide risk over the 4-year follow-up. CONCLUSIONS Universal screening may decrease suicide rates among older adults, with potential gender differences in treatment response.