Paolo Scocco

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.

Predictors and moderators of time to remission of major depression with interpersonal psychotherapy and SSRI pharmacotherapy.

BACKGROUND Although many studies suggest that, on average, depression-specific psychotherapy and antidepressant pharmacotherapy are efficacious, we know relatively little about which patients are more likely to respond to one versus the other. We sought to determine whether measures of spectrum psychopathology are useful in deciding which patients with unipolar depression should receive pharmacotherapy versus depression-specific psychotherapy. METHOD A total of 318 adult out-patients with major depression were randomly assigned to escitalopram pharmacotherapy or interpersonal psychotherapy (IPT) at academic medical centers at Pittsburgh, Pennsylvania and Pisa, Italy. Our main focus was on predictors and moderators of time to remission on monotherapy at 12 weeks. RESULTS Participants with higher scores on the need for medical reassurance factor of the Panic-Agoraphobic Spectrum Self-Report (PAS-SR) had more rapid remission with IPT and those with lower scores on the psychomotor activation factor of the Mood Spectrum Self-Report (MOODS-SR) experienced more rapid remission with selective serotonin reuptake inhibitor (SSRI) pharmacotherapy. Non-specific predictors of longer time to remission with monotherapy included several panic spectrum and mood spectrum factors and the Social Phobia Spectrum (SHY) total score. Higher baseline scores on the 17- and 25-item Hamilton Depression Rating Scales (HAMD-17 and HAMD-25) and the Work and Social Adjustment Scale (WSAS) also predicted a longer time to remission, whereas being married predicted a shorter time to remission. CONCLUSIONS This exploratory study identified several non-specific predictors but few moderators of psychotherapy versus pharmacotherapy outcome. It offers useful indicators of the characteristics of patients that are generally difficult to treat, but only limited guidance as to who benefits from IPT versus SSRI pharmacotherapy.

Quality of life assessment: validation of the Italian version of the WHOQOL-Brief

OBJECTIVE To test the psychometric properties of the Italian version of the WHOQOL-BRIEF (e.g., construct and internal validity, concurrent validity with the MOS SF-36 and test-retest reliability). The WHOQOL-BRIEF is a 26-items self-report instrument which assesses four domains assumed to represent the Quality Of Life (QOL) construct: physical domain, psychological domain, social relationships domain and environment domain, plus two facets for assessing overall QOL and general health. METHODS Data have been collected in three sites (Bologna, Modena and Padua), located in the North of Italy, in the framework of the international WHOQOL project. According to the study design, the sample had to include about 50% males and 50% females, 50% of subjects below and 50% above the age of 45, all in contact with various health services. A subsample has been re-interviewed after 2-3 weeks in order to study test-retest reliability. After the WHOQOL-BRIEF, most subjects have also been administered the MOS-SF36 in order to test the concurrent validity between these two instruments. RESULTS The instrument was administered to 379 subjects (1/6 healthy and 1/6 sick), chosen to be representative of a variety of different medical conditions. Seventy patients, who displayed stable health conditions, have been reassessed after 2-3 weeks to study test-retest reliability. The WHOQOL-BRIEF domains has shown good internal consistency, ranging from 0.65 for the social relationships domain to 0.80 for the physical domain; it has been able to discriminate between in- and out-patients and between the two age groups considered in the present study (< 45, > or = 45 years). Only physical and psychological domains were found to discriminate between healthy and ill subjects. No gender differences in the mean scores for the four domains were found. Concurrent validity between the WHOQOL-Brief and the MOS-SF-36 was satisfactory, and specific for the physical and psychological health domains. Test-retest reliability values were also good, ranging from 0.76 for the environment domain to 0.93 for the psychological domain. CONCLUSIONS This study shows that the WHOQOL-BRIEF is psychometrically valid and reliable, and that it is also potentially useful in discriminating between subjects with different health conditions in clinical settings.

Death ideation and its correlates: survey of an over-65-year-old population

The presence of dissatisfaction with life or thoughts of death or suicide has been variously surveyed in adolescent samples and in the general population, but there is a paucity of research on the elderly. The aim of this study was to assess, in an elderly community-dwelling population: a) the prevalence of death and/or suicidal feelings and thoughts and any attempted suicides; and b) factors associated with these experiences. A total of 611 over-65-year-old subjects were interviewed at home. Seventeen percent of the total (F:M = almost 2:1) responded affirmatively to at least one of the questions on suicidality. Elderly people reporting suicidal feelings presented markedly higher levels of physical and psychological distress, such as depression, anxiety, and hostility. Results indirectly confirm that depressive symptomatology is not adequately treated. Greater attention is warranted in psychological evaluation of the elderly to take into account those risk factors that, if identified and managed, could reduce the frequency of suicidal thoughts and, probably, associated actions.

Repetition of suicidal behaviour in elderly Europeans : a prospective longitudinal study.

The aim of this study was to assess any predictive factors for repeated attempted suicide and completed suicide in a 1-year follow-up on a sample of elderly European suicide attempters (60 years and over). From 1990 to 1993, 63 subjects completed the first interview and were recontacted after 1 year. At follow-up, eight subjects (12.7%) had taken their lives and seven (11.1%) had repeated at least one suicide attempt. On comparison of repeaters and non-repeaters, differences emerged in terms of death of the father in childhood and for mean Suicidal Intent Score. At the end of follow-up period, repeaters reported a more frequent desire to repeat suicidal behaviour and judged their mental health and social assistance received to be worse. Suicides and non-repeaters differed especially in relation to death of father during childhood and number of contacts with General Practitioner. Interpretation of the results must take into account the smallness of the test sample, the difficulties in obtaining complete data for the follow-up interview, the lack of a control group and a diagnosis formulated in a hospital consultation setting. The study confirms, however, the high risk of repetition of suicidal behaviour in the elderly. In old age suicidal ideation is often sustained over long periods of time and requests for help are addressed to relatives and GPs. An interesting finding is the more frequent death of the father during childhood among repeaters.

Physical illness and parasuicide: evidence from the European Parasuicide Study Interview Schedule (EPSIS/WHO-EURO).

Objective: The aim of this research was to identify psychosocial characteristics which might predict future suicidal behavior in parasuicidal subjects in Europe. Method: The interview utilized for the survey (European Parasuicide Study Interview Schedule—EPSIS) was administered to 1269 parasuicides aged fifteen years and over, within one week of hospital admission after a suicide attempt, and is part of a longitudinal multicenter study. EPSIS included a brief medical questionnaire, scales rating depression, hopelessness, self-esteem, suicide intention, questions on sociodemographic characteristics, an interview on life events and social support, a description of the parasuicidal act, and an evaluation of factors precipitating the index parasuicide. Results: Physical illness proved to be very frequent among suicide attempters. One in two subjects suffered from an acute, chronic, or chronic disorder in relapse at the time of the parasuicide. Subjects with a physical illness were significantly more depressed, particularly subjects from the intermediate age band and ones affected by a chronic physical disease in relapse. Forty-two percent of patients with physical illness rated their somatic problem as a factor precipitating the attempt and 22 percent judged it to be major one. Furthermore, subjects with physical illnesses considered psychiatric symptoms and disorders to be relevant factors in triggering suicidal behavior, to a greater extent than non-sufferers. The importance of physical illness in contributing to suicidal behavior increased with advancing age. Conclusions: More careful attention to somatic conditions and their subjective implications would probably augment chances of effectively preventing suicide.

Parental Psychopathology and the Risk of Suicidal Behavior in their Offspring: Results from the World Mental Health Surveys

Previous research suggests that parental psychopathology predicts suicidal behavior among offspring; however, the more fine-grained associations between specific parental disorders and distinct stages of the pathway to suicide are not well understood. We set out to test the hypothesis that parental disorders associated with negative mood would predict offspring suicide ideation, whereas disorders characterized by impulsive aggression (for example, antisocial personality) and anxiety/agitation (for example, panic disorder) would predict which offspring act on their suicide ideation and make a suicide attempt. Data were collected during face-to-face interviews conducted on nationally representative samples (N=55 299; age 18+) from 21 countries around the world. We tested the associations between a range of parental disorders and the onset and persistence over time (that is, time since most recent episode controlling for age of onset and time since onset) of subsequent suicidal behavior (suicide ideation, plans and attempts) among offspring. Analyses tested bivariate and multivariate associations between each parental disorder and distinct forms of suicidal behavior. Results revealed that each parental disorder examined increased the risk of suicide ideation among offspring, parental generalized anxiety and depression emerged as the only predictors of the onset and persistence (respectively) of suicide plans among offspring with ideation, whereas parental antisocial personality and anxiety disorders emerged as the only predictors of the onset and persistence of suicide attempts among ideators. A dose-response relation between parental disorders and respondent risk of suicide ideation and attempt was also found. Parental death by suicide was a particularly strong predictor of persistence of suicide attempts among offspring. These associations remained significant after controlling for comorbidity of parental disorders and for the presence of mental disorders among offspring. These findings should inform future explorations of the mechanisms of intergenerational transmission of suicidal behavior.

The role of psychopathology and suicidal intention in predicting suicide risk: a longitudinal study

Objective: In this study, we describe psychological symptoms, any relationship with suicidal intention in a sample of subjects recently attempting suicide and the predictive value of this association in later completed suicide. Methods: An assessment was made of 467 suicidological consultations carried out by the Suicidology Unit of the Department of Neurology and Psychiatry, University of Padua, on 421 patients admitted to hospital following attempted suicide in the 5-year period 1990–1994. Suicidal intention was appraised by the Intent Score Scale (ISS). Suicide mortality was assessed after a mean follow-up period of 3.5 years. Results: Psychiatric evaluation was completely negative in only 8% of cases. The most commonly identified symptom was depressed mood (79% of cases, 22% severe depression), followed by anxiety (43% of cases, 32% severe anxiety). From the study, it emerged that psychopathology seemed to influence suicidal intent, where this was characterized by severe depression. Anxiety and other symptoms appeared to have a secondary role. Assessments of suicidal intent showed that intention heightened as the number of symptoms increased. The symptom ‘anxiety’ did not prove to have a significant bearing on assessment of the seriousness of suicidal intention, whereas severely depressed mood did. The total number of subsequent suicide victims was 5.5%. During consultation relating to the index parasuicide, these subjects did not manifest a discriminate psychopathological profile (the only distinguishing characteristic was anxiety, which was less frequently identified in suicide victims), but did present a more positive personal and family psychiatric history. Conclusions: In subjects who had recently attempted suicide, the psychopathological profile appeared to be related to suicidal intent, where this was characterized by severe depression. Anxiety and other symptoms seemed to have a secondary role. Nonetheless, both total scores and subscores should be taken into consideration when assessing suicidal intention through the ISS. The psychopathological profile and ISS score following attempted suicide do not appear to permit prediction, in the medium to long term, of subsequent completed suicide.

Feasibility and Effectiveness of a Multi-Element Psychosocial Intervention for First-Episode Psychosis: Results From the Cluster-Randomized Controlled GET UP PIANO Trial in a Catchment Area of 10 Million Inhabitants

Integrated multi-element psychosocial interventions have been suggested to improve the outcomes of first-episode psychosis (FEP) patients, but they have been studied primarily in experimental settings and in nonepidemiologically representative samples. Thus, we performed a cluster-randomized controlled trial, comparing an integrated multi-element psychosocial intervention, comprising cognitive behavioral therapy, family intervention, and case management, with treatment as usual (TAU) for FEP patients in 117 community mental health centers (CMHCs) in a large area of northern Italy (10 million inhabitants). The randomized units (clusters) were the CMHCs, and the units of observation the patients (and, when available, their family members). The primary hypotheses were that add-on multicomponent intervention: (1) results in greater improvements in symptoms, as assessed with positive and negative syndrome scale and (2) reduces in-hospital stay, based on days of hospitalization over the 9-month follow-up. Four hundred and forty-four FEP patients received the intervention or TAU and were assessed at baseline and 9 months. Based on the retention rates of patients (and families) in the experimental arm, multi-element psychosocial interventions can be implemented in routine mental health services. Regarding primary outcomes, patients in the experimental arm showed greater reductions in overall symptom severity, while no difference could be found for days of hospitalization. Among the secondary outcomes, greater improvements were detected in the experimental arm for global functioning, emotional well-being, and subjective burden of delusions. No difference could be found for service disengagement and subjective burden of auditory hallucinations. These findings support feasibility and effectiveness of early interventions for psychosis in generalist mental health services.

Stigma of Suicide Attempt (STOSA) scale and Stigma of Suicide and Suicide Survivor (STOSASS) scale: Two new assessment tools

This study aimed at validating two new assessment tools, the Stigma of Suicide Attempt (STOSA) scale and the Stigma of Suicide and Suicide Survivor (STOSASS) scale. The Devaluation-Discrimination scale of Link et al. was translated into Italian and adapted to measure stigma towards suicidal behavior. Both scales were administered to a mixed sample including members of the general population (n=282), patients with a mental disorder (n=113), suicide attempters (n=57) and people who had lost a significant other to suicide (n=75). Reliability of the scales was good in terms of both internal coherence and test-retest stability. Factor analysis produced an acceptable solution for the STOSA-scale. Items were distributed into two factors, one grouping items to measure supportive, respectful and caring attitudes, the other factor grouping items oriented towards stigmatizing attitudes and beliefs. The clinical populations were more inclined towards stigmatization of suicide than were people from the general population, who might be less aware of the stigma attached to suicide. The two scales may be helpful to quantify stigma at individual level in order to provide targeted supportive interventions, and at population level to measure changes in the beliefs and attitudes of the general population.