East Asian Arch Psychiatry 2011;21:17-21

ORIGINAL ARTICLE

Dr Mimi MC Wong, MBBS, MRCPsych, Castle Peak Hospital, Tuen Mun, Hong Kong SAR, China.
Dr CF Tsui, MBBS, DCPsyc RCP&S, MPH, Castle Peak Hospital, Tuen Mun, Hong Kong SAR, China.
Dr SW Li, MBBS, MRCPsych, FHKAM (Psychiatry), Castle Peak Hospital, Tuen Mun, Hong Kong SAR, China.
Dr CF Chan, MBChB, FHKAM (Psychiatry), Castle Peak Hospital, Tuen Mun, Hong Kong SAR, China.
Ms YM Lau, Dip RMN, MBA HCA, Castle Peak Hospital, Tuen Mun, Hong Kong SAR, China.

Address for correspondence: Dr Mimi MC Wong, Castle Peak Hospital, 1/F, Block F, 15 Tsing Chung Koon Road, Tuen Mun, Hong Kong SAR, China.
Tel: (852) 2456 7111; Fax: (852) 2463 1644; Email: wmc009@ha.org.hk

Submitted: 27 September 2010; Accepted: 29 November 2010

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Introduction

It is well known that people aged 65 years or above have a high rate of suicide (30 per 100,000) in 2005 which is about 2 to 3 times higher than that in the general population (11 per 100,000) in Hong Kong.¹ Different measures have been instituted to address this problem, one of which was the implementation of the territory-wide Elderly Suicide Prevention Programme (ESPP) in different psychiatric centres under the auspices of the Hong Kong Hospital Authority.²

The ESPP was founded in Hong Kong in 2002; its aim was the early detection of elderly at risk of suicide and provision of effective and adequate management to this patient group. It depended on a case management approach in which each patient was managed by a community psychiatric nurse (CPN) and a case doctor. Previous studies indicated that suicides in the elderly were consistently associated with a number of risk factors, including a history of attempted suicide,³ physical illness,^4-6 psychiatric (particularly depressive) illness,³ and certain personality traits.⁷ It was believed that if modifiable risk factors (e.g. depressive illness) were properly managed, suicide could be prevented. Therefore, The ESPP aims at identifying patients with suspected depression and / or previous suicidal attempt as early as possible, so that timely intervention can be provided. The Castle Peak Hospital (CPH) is 1 of the 7 centres with an ESPP, and its team caters to all referrals of elderly persons, with suspected depression with or without a history of suicidal attempts, living in the New Territories West Cluster of Hong Kong. The Hospital serves a population of about 1.1 million.

A case series of all the completed suicides whilst under the active care of the service was carried out to define the characteristics of such patients, and to identify risk factors associated with suicide in these depressed elderly.

Methods

The patients who actually committed suicide whilst under the active care of ESPP of CPH from its establishment on 1 July 2002 up to 31 March 2010 were identified. The doctors and CPNs monitoring all the patients closely would actively trace patients who did not attend follow-up as scheduled, by means of telecheck or home visits. Those who had committed suicide could therefore be identified. The ESPP also has an established mechanism to trace details about elderly persons aged over 64 years, who were classified by Hong Kong Coroners to be suicide cases, which also helped to identify any remaining cases missed by the service.

Information about demographic characteristics (age, gender, marital status and living conditions) were collected for all patients recruited into the ESPP service. Mini-Mental State Examination (MMSE) score and Geriatric Depression Score (GDS) were also obtained during their first assessment by the case CPN. The clinical diagnosis was made by the case doctor after thorough psychiatric assessment.

A review was performed of the deaths, with reference to their case notes, mortality reports and hospital records. Phone contacts were undertaken by the CPN with the patient’s family members, or the persons who were in contact with them prior to the suicide (e.g. social worker, meal delivery volunteers). Unstructured interviews were performed with such persons to retrieve information about the suicide and the mental state of the patient before the act.

This entire study was approved by the New Territories West Cluster Clinical and Research Ethics Committee, and consent was obtained from the relatives of patients.

Results

From 1 July 2002 till 31 March 2010, 1230 cases with suicide risks were under the care of the ESPP of CPH, of whom 8 persons committed suicide during that period.

The baseline demographics and clinical characteristics of these 8 subjects are summarised in the Table. Five of them (63%) were male. Their mean age was 75 (standard deviation, 6) years. In all, 4 were living alone; 2 were married while the others were divorced, widowed or never married. All of them were diagnosed to have depressive illness and in 7 (88%) of them the depression was precipitated by physical illness. Four had made a previous suicidal attempt about 1 month earlier, in which 2 had attempted to jump from a height, 1 attempted to jump into the sea, and 1 tried to kill himself by taking a drug overdose and hanging. None of them had symptoms suggestive of dementia according to their clinical history or MMSE score. All patients used a lethal method of suicide, in which 5 (63%) involved jumping from a height.

All 8 patients committed suicide within 6 weeks of their first consultation with doctors or assessment by CPN of the ESPP; the interval ranged from 2 days to 6 weeks, with a mean of 3 weeks. The number of consultations with doctors from the ESPP ranged from 1 to 4, except for 1 patient who refused to see a doctor.

All but 1 of the patients were prescribed an antidepressant. They included citalopram, escitalopram, fluoxetine, paroxetine or mirtazapine, for about 3 to 4 weeks before their suicide. Some of the patients started to receive their antidepressant from other disciplines before being followed by the ESPP. Six of them tolerated the medication; 4 patients showed improvement of either mood, sleep and energy level after commencing treatment. One of them had complained of dizziness and headache on starting the antidepressant.

All of the patients had stayed in either a mental or general hospital for about 1 month before they committed suicide. Two had been admitted to a mental hospital for the treatment of their depression and discharged shortly before the suicide, and 4 others had been sent to the Accident and Emergency Department for earlier suicidal attempts. The remaining 2 patients had been admitted to a general hospital for a physical condition, 1 for an exacerbation of chronic obstructive airway disease (COAD), and 1 for constipation.

There was an unexpected relationship between the day of suicide and festive holidays. One of the patients committed suicide on the day of the Dragon Boat Festival, 1 on the day following the Mid-Autumn Festival, and 1 around the Winter Solstice, all of which commemorate traditional Chinese festivals. One of the patients committed suicide during the Christmas period.

Case Presentations

Case 4 was an 80-year-old married man, who was noted by his family to have a depressed mood, and lacking in energy, interest, appetite, and motivation. He was perpetually tired and slept both day and night. He felt hopeless and attempted to jump from a height 1 month before presentation. The depressive symptoms were likely precipitated by deterioration in physical health; an unexplained slowness in movement significantly limited ambulation. Mental state examination revealed psychomotor retardation and negative cognition. He was diagnosed to have a severe depressive episode. Escitalopram 10 mg daily was initiated; later he was suspected to have Parkinson’s disease and was referred to the medical department for further assessment. He was able to tolerate escitalopram well, and his family noted that he was more motivated to carry out daily chores. There was also slight improvement in mood. Treatment for Parkinson’s disease was started for him by the medical unit, with improvement in his movements. He eventually committed suicide by jumping from a height when left alone at home, while his family perceived that his condition had improved. The interval between his first assessment by an ESPP doctor and his suicide was less than 1 month.

Case 7 was an 82-year-old widow who presented with low mood, negative ruminations, loss of appetite and weight loss after undergoing a cholecystectomy. She was troubled by a frequent sensation of bloating after her surgery. She slept poorly and had lack of interest and motivation. She attempted to kill herself by taking a drug overdose and jumping from a height but was discovered and restrained by her family. The patient later presented and was diagnosed to have a moderate depressive episode, and treatment with mirtazapine was initiated. However, she continued to have insomnia and started having dizziness and headaches that she blamed on the medication. Three days later she saw an ESPP doctor and the therapy with mirtazapine was switched to escitalopram. She was also given sleeping pills. However, the next day she committed suicide by jumping from a height when there was no one at home. She died within 1 week of her first assessment by an ESPP doctor.

Discussion

From the review of all the patients who committed suicide whilst under the care of the ESPP, it was striking that all suicides occurred in the initial stage of treatment, i.e. within the first 2 months of being involved with the service. The core common feature was that they all presented in crisis, which was their reason for hospital attendance or admission owing to a significant mental or physical disturbance. Four of them had recently attempted suicide and had been recently discharged after their hospital admission for their suicidal attempt. Another 2 patients were recently discharged from a mental hospital where they had just started treatment for depression. Recent discharge from hospital was indicative of the severity of their symptoms, and this feature together with previous suicidal attempt were risk factors of suicide.^3,8,9 This was also the time these patients were referred to the ESPP and constituted a group with high suicidal risk.

Another explanation may be related to the use of antidepressants. As these patients were new attendees of the mental health service, they had just started antidepressant therapy. It is known that depression is a disorder with a constellation of symptoms and after treatment the various symptoms do not resolve at the same time. The physical symptoms of depression including lack of energy, difficulty concentrating, sleeping and eating disturbances usually resolve first, whilst the depressed mood resolves last.¹⁰ As a result, patients treated for depression can have increased energy and increased functionality during partial recovery, but still feel depressed. This increases their suicide risk as they may lack energy and ability to attempt suicide before starting treatment, but as they begin to recover they regain ability and motivation before they enjoy a subjective improvement in mood. The fact that antidepressants take time to work may also add to the sense of hopelessness of these patients. As they struggle for a while before reaching a psychiatrist, to them, this might appear to be their last chance / hope of relief. They might therefore have very high expectations of the medication given to them during their first visit and expect immediate mood improvement after starting their medication. Regrettably the therapeutic effect of antidepressants takes time and the dosage often needs titration. At the same time, antidepressant side- effects may be distressing and increase associated feelings of restlessness that compound their disappointment.

Other than the effects of antidepressants, the psychological support and trusting relationship with the doctor and CPN takes time to establish. Once these elements are successfully established, the effect of the programme to prevent suicide in the elderly starts to take place. Thus, if the patient is able to survive through the initial stage, it has been postulated that their depressive symptoms improve and the risk of suicide diminishes.

In this group of patients, all except 1 had their depressive episode precipitated by a deterioration in their physical health. They either underwent an operation or were recently diagnosed to have a major physical illness that could be regarded as experiencing an important life event, and / or 1 or more distressing chronic symptoms (particularly pain). This was compatible with overseas^4-6 and Chinese¹¹ findings associating physical illness and major life events with suicides in the elderly. In particular, cancer and COAD were mentioned in different studies^12-14 as associated with suicide in the elderly. Besides generating a feeling of hopelessness, such recent changes in their health appeared to trigger a catastrophic reaction and excessive anxiety. As a result, they became preoccupied with the physical symptoms they endured.⁶ This might result in a negative effect with respect to their response to antidepressants, whilst also becoming more aware of their side-effects.

In this case series the patients relatively preserved cognitive functioning, compatible with a previous local study on elderly suicide.¹⁵ There was also a higher proportion of males among those who committed suicide, as described previously.¹⁶

Regarding the relationship between suicide and festivals, 3 of them ensued around traditional Chinese festivals. Young people in Hong Kong could be classified as westernised, as they are more influenced by the western culture. However, the elderly adhere more fervently to traditional Chinese culture. They are therefore more likely to value traditional Chinese festivals as times for family reunion and celebration. This too might exacerbate feelings of isolation and the notion that they were a burden on the family with which they lived. Such occasions may also exacerbate quarrels with others, whilst direct access to their case worker may not be readily available during such public holidays. These type of factors may precipitate suicidal attempts during these vulnerable periods. Nevertheless, it was notable that there was a lower rate of local suicides around the Chinese New Year period.¹⁷ The possible reason may be the belief that this most important of all festival represents the beginning of a year and new beginning. Traditionally, in this period only good and happy events should ensue and ‘bad’ words and unhappiness are to be avoided. In this sense the Chinese New Year period may differ from other festivals.

In reviewing this case series there are a number of limitations. First, only the GDS was used to screen for depressive symptoms and cannot accurately reflect their severity. Moreover, there was no serial rating of the depressive symptoms, though little variation in their severity was expected within such short treatment periods. Second, only patients who committed suicide when under the active care of the ESPP were included; those who committed suicide when not under the care of that service were left out. However, this was likely to be a small number, as intensive nursing support for the ESPP has successfully kept the default rate low. Persons deemed at high risk of suicide are very likely closely monitored by the CPN through telechecks or home visits. Only those deemed at low risk of suicide would have been referred back to general psychogeriatric clinics or discharged from the mental health service. Third, no suitable controls were available to elucidate the differences in risk factor profiles or protective factors that could explain differences in clinical outcomes. Lastly, all the cases were taken from only 1 cluster, so the findings may not be generalised to elsewhere in Hong Kong as the distribution of socio-economic backgrounds may differ depending on the region.

Conclusion

In this case series, we have observed that the first 2 months of treatment is associated with the highest risk of suicide in patients treated by an ESPP. Particularly high-risk cases are persons recently discharged from hospital and having to cope with new / recent physical and / or mental conditions. Traditional Chinese festivals together with lack of supervision from relatives and case workers may render patients vulnerable. However, after the initial stage and once the effects of antidepressants and trusting relationship with staff become established, depressive symptoms seem to improve and the risk of suicide appears to be substantially reduced.

Declaration

The authors declared no financial support nor conflicts of interest in this study.

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