Paul R. Duberstein

Risk factors for suicide in later life.

Suicide rates are higher in later life than in any other age group. The design of effective suicide prevention strategies hinges on the identification of specific, quantifiable risk factors. Methodological challenges include the lack of systematically applied terminology in suicide and risk factor research, the low base rate of suicide, and its complex, multidetermined nature. Although variables in mental, physical, and social domains have been correlated with completed suicide in older adults, controlled studies are necessary to test hypothesized risk factors. Prospective cohort and retrospective case control studies indicate that affective disorder is a powerful independent risk factor for suicide in elders. Other mental illnesses play less of a role. Physical illness and functional impairment increase risk, but their influence appears to be mediated by depression. Social ties and their disruption are significantly and independently associated with risk for suicide in later life, relationships between which may be moderated by a rigid, anxious, and obsessional personality style. Affective illness is a highly potent risk factor for suicide in later life with clear implications for the design of prevention strategies. Additional research is needed to define more precisely the interactions between emotional, physical, and social factors that determine risk for suicide in the older adult.

Depression and cancer mortality: a meta-analysis.

BACKGROUND The goal of the present study was to analyze associations between depression and mortality of cancer patients and to test whether these associations would vary by study characteristics. METHOD Meta-analysis was used for integrating the results of 105 samples derived from 76 prospective studies. RESULTS Depression diagnosis and higher levels of depressive symptoms predicted elevated mortality. This was true in studies that assessed depression before cancer diagnosis as well as in studies that assessed depression following cancer diagnosis. Associations between depression and mortality persisted after controlling for confounding medical variables. The depression-mortality association was weaker in studies that had longer intervals between assessments of depression and mortality, in younger samples and in studies that used the Beck Depression Inventory as compared with other depression scales. CONCLUSIONS Screening for depression should be routinely conducted in the cancer treatment setting. Referrals to mental health specialists should be considered. Research is needed on whether the treatment of depression could, beyond enhancing quality of life, extend survival of depressed cancer patients.

Patient trust: Is it related to patient-centered behavior of primary care physicians?

Background:Patients’ trust in their health care providers may affect their satisfaction and health outcomes. Despite the potential importance of trust, there are few studies of its correlates using objective measures of physician behavior during encounters with patients. Methods:We assessed physician behavior and length of visit using audio tapes of encounters of 2 unannounced standardized patients (SPs) with 100 community-based primary care physicians participating in a large managed care organization. Physician behavior was assessed via 3 components of the Measure of Patient-Centered Communication (MPCC) scale. The Primary Care Assessment Survey (PCAS) trust subscale was administered to 50 patients from each physicians practice and to SPs. We used multilevel modeling to examine the associations between physicians’ Patient-Centered Communication during the SP visits and ratings of trust by both patients and SPs. Results:Component 1 of the MPCC, which explored the patients experience of the disease and illness, was independently associated with patients rating of trust in their physician. A 1 SD increase in this score was associated with 0.08 SD increase in trust (95% confidence interval 0.02–0.14). Each additional minute spent in SP visits was also independently associated with 0.01 SD increase in patient trust. (95% confidence interval 0.0001–0.02). Component 1 and visit length were also positively associated with SP trust ratings. Conclusions:Physician verbal behavior during an SP encounter is associated with trust reported by SPs and patients. Research is needed to determine whether interventions designed to enhance physicians’ exploration patients’ experiences of disease and illness improves trust.

Completed suicide among older patients in primary care practices: a controlled study.

OBJECTIVE: To determine whether physical and psychiatric illness, functional status, and treatment history distinguish older primary care patients who committed suicide from those who did not.

Dementia care: mental health effects, intervention strategies, and clinical implications

Caring for elderly people with dementia is associated with well-documented increases in burden, distress, and decrements in mental health and wellbeing. More severe behavioural, cognitive, and functional impairments in a patient are associated with higher levels of burden and distress. Distress increases with care hours per week, number of tasks, and declining coping and support resources. Demographic factors also affect levels of burden and distress. Promising, evidence-based interventions exist, but substantial economic and policy barriers preclude their widespread dissemination. Health-care policy makers should consider addressing these barriers; clinicians and families must campaign for reimbursement; and clinical researchers must develop more potent preventive interventions. In this article we review how dementia care affects the mental health of the carer and identify interventions that might be useful in mitigating carer burden and distress.

Age Differences in Behaviors Leading to Completed Suicide

The authors described retrospectively the premorbid self destructive behaviors of suicide victims to determine whether these behaviors differ with age. One hundred forty one suicide victims, age 21-92 years, were studied by psychological autopsy. Older age was significantly associated with more determined and planful self-destructive acts, less violent methods, and fewer warnings of suicidal intent. Age differences in the behaviors leading to suicide indicate that intervention in the midst of a suicidal crisis may be less effective in elderly persons than in younger people. Primary prevention should be the focus of efforts to decrease suicide rates in late life.

Associations of social networks with cancer mortality: A meta-analysis

This meta-analysis integrates results of 87 studies on the associations of perceived social support, network size, and marital status with cancer survival. In controlled studies, having high levels of perceived social support, larger social network, and being married were associated with decreases in relative risk for mortality of 25%, 20%, and 12%, respectively. Moderator analyses revealed that never married patients had higher mortality rates than widowed and divorced/separated patients. Associations of social network with mortality were stronger in younger patients, and associations of marital status with mortality were stronger in studies with shorter time intervals, and in early-stage cancer. Relationships varied by cancer site, with stronger associations of social support observed in studies of patients with leukemia and lymphomas and stronger associations of network size observed in studies of breast cancer. Further randomized intervention studies are needed to test causal hypotheses about the role of social support and social network for cancer mortality.

Sexual Orientation and Risk Factors for Suicidal Ideation and Suicide Attempts Among Adolescents and Young Adults

Same-gender sexual orientation has been repeatedly shown to exert an independent influence on suicidal ideation and suicide attempts, suggesting that risk factors and markers may differ in relative importance between lesbian, gay, and bisexual individuals and others. Analyses of recent data from the National Longitudinal Study of Adolescent Health revealed that lesbian, gay, and bisexual respondents reported higher rates of suicidal ideation and suicide attempts than did heterosexual respondents and that drug use and depression were associated with adverse outcomes among heterosexual respondents but not among lesbian, gay, and bisexual respondents.

Suicide at 50 years of age and older: perceived physical illness, family discord and financial strain

BACKGROUND Mental disorders amplify suicide risk across the lifecourse, but most people with mental disorder do not take their own lives. Few controlled studies have examined the contribution of stressors to suicide risk. METHOD A case-control design was used to compare 86 suicides and 86 controls aged 50 years and older, matched on age, gender, race and county of residence. Structured interviews were conducted with proxy respondents for suicides and controls. RESULTS Perceived physical illness, family discord and employment change amplified suicide risk after controlling for sociodemographic covariates and mental disorders that developed > or = 1 year prior to death/interview. Only the effect of physical illness (OR 6.24, 95% CI 1.28-51.284) persisted after controlling for all active mental disorders. CONCLUSIONS Interventions to decrease the likelihood of financial stress and to help families manage discord and severe physical illness may effectively reduce suicides among middle-aged and older adults.

Access to Firearms and Risk for Suicide in Middle-Aged and Older Adults

Elderly white men are at the highest risk for suicide. Firearms are the most common method of suicide used by both men and women in later life, and a greater proportion of older than younger suicide victims use a gun. This psychological autopsy study aimed to test hypotheses concerning the risk for suicide associated with access to and storage of firearms. Subjects included 86 suicide victims age 50 years of age and over and 86 community control subjects individually matched on age, sex, race, and county of residence. Presence of a firearm in the home was associated with increased risk for suicide, even after controlling for psychiatric illness. Elevated risk was accounted for by access to handguns rather than long guns and was more pronounced in men than women. Among subjects who kept a gun in the home, storing the weapon loaded and unlocked were independent predictors of suicide. Findings support the potential benefit for suicide prevention of restricting access to handguns. Education programs for older persons, their families, and healthcare providers concerning the risks of having a gun in the home and reinforcement of rules for safe storage may contribute to reducing the rate of suicide in older people.