Diego De Leo, MD, PhD

Suicide is a complex phenomenon that is observable, at varying rates, in every nation around the world. Often, self-suppressive events are influenced by the impact of ecological and environmental factors, social fabric, individual predispositions, and current circumstances--factors that may interact, co-depend and cumulate over time. Decades of scientific investigation also suggest that such causal factors interact profoundly with the contextual system of values, traditions and sources of support available to individuals. In fact, social and cultural variables have been found to amplify any biological and psychological predisposition to suicidal behavior, regardless of age and sex (De Leo et al., 2002). 

In many Latin and Asian countries, suicide among the elderly is an increasing phenomenon, compared to Anglo-Saxon nations, where rates have been declining substantially since the 1960s. From 1960 to 1989, important shifts in the elderly/youth ratio of suicides were also observed in countries such as Hungary, Lithuania and Latvia (Lester, 2001) and in Asian nations where marked increases in suicide among the elderly corresponded with declines in youth suicides (Gulbinat, 1995). During the same period, Gulbinat observed the opposite phenomenon in many Anglo-Saxon nations of the New World, such as Australia, New Zealand, Canada and the United States. However, not all Latin and Anglo-Saxon countries experienced changes to the age distribution of suicide rates in recent decades.

Many Asian nations have observed greater rates of suicide among older, rather than younger age groups, with elderly/youth suicide ratios as high as 8.7 in Japan, 7.3 in Hong Kong and 5.9 in Singapore (Pritchard and Baldwin, 2002). In particular, women of Asian nations exhibit significantly higher rates of suicide in older age compared to women residing in other countries, particularly Anglo-Saxon nations. Suicide among males age 75 and older in selected areas of mainland rural China are also the highest of all nations that report mortality data to the World Health Organization (WHO, 2003a).

Among Western countries, when the rank ordering of suicide rates for males and females are considered for successive age groups (Table 1 and Table 2), a prominent difference between New World Anglo-Saxon countries and Latin European countries is evident. For example, close Anglo-Saxon countries Australia and New Zealand have higher-ranking suicide rates among males and females in younger age groups (15 to 24, 25 to 34, 35 to 44, and 45 to 54) compared to Spain and Portugal, two contiguous Latin countries. In successively older age groups (65 to 74 and 75+), however, the rank ordering is reversed, and suicide rates among both males and females in such Latin nations are ranked much higher than the Anglo-Saxon countries mentioned. The same cultural pattern may be observed by considering the elderly/youth ratio of suicide in these Western countries (Table 3). From this, it can be seen that for both males and females in Anglo-Saxon countries (and females in Canada), the ratio of elderly/youth suicides approaches 1:1, whereas in Latin nations, the ratio is ranked much higher. For example, in Portugal, elderly males complete suicide more than 11 times as frequently as males age 15 to 24. 

It is not entirely understood why these differences among countries exist; however, the epidemiological trends mentioned lead to speculations that sociocultural, economic and religious factors may contribute to the phenomenon. It has been suggested that the progressive decline in suicide rates observed among the elderly in Anglo-Saxon countries over the last 30 years, particularly in the United States and among white males, may have come about through improved attitudes toward retiring; improved social services; and enhanced psychiatric care, greater economic security and greater sociopolitical activism for the elderly (De Leo, 1998). On the contrary, in most Latin countries, as well as in some Asian nations (e.g., Hong Kong), social changes and the collapse of traditional family structures may have contributed to increases in suicide rates in older age. In Asia, for example, industrialization and Westernization have retransformed traditional family life into nuclear family set-ups, which may confine many elderly once supported by the extended family in a state of social isolation. In the absence of formal support and education on coping with age, such sociocultural changes may combine to foster suicidality among the elderly. 

From the epidemiological data highlighted in Table 1, it is also evident that suicide rates in nations that are historically, culturally and linguistically alike experience similar rates of suicide in older age. For example, bordering nations Hungary, Slovenia and Austria report high rates of suicide across all age groups, and in older age, these countries occupy the three highest respective ranks among males 75 and older. It is likely that the similarities in suicide rates are attributable, to a significant extent, to shared sociocultural facets, including similar attitudes toward suicidal acts, style and norms of living, main values and beliefs, educational systems and the upbringing of children, problems with alcohol, and attitudes that contribute to the perception of the elderly as a traditionally high-risk population for suicide (Grad et al., 2001). 

Moreover, the cultural element of suicide in old age is revealed in studies of elderly immigrants to Hong Kong, the United Kingdom and Australia that suggest that the prevalence of suicide--particularly in elderly immigrants--is largely determined by their country of origin (Burvill, 1995; Raleigh and Balarajan, 1992; Yip et al., 2000).  

The impact of religious affiliation upon suicide in older age should also be considered. In a study by Koenig (1994), older people who practice their faith were found to have frequently lower rates of depression, alcoholism and hopelessness (factors that have been found to increase the risk of suicide in the elderly [Rifai et al., 1994]) than their non-religious counterparts. Moreover, religious communities may serve to moderate loneliness and isolation in late life by providing an active support network and meaningful voluntary work, which can enhance well-being and promote feelings of usefulness and purpose (Krause et al., 1992). The tendency for older aged women to be more religious than men, attend church more (Weaver and Koenig, 1996), and be more involved in relational activities may perhaps further influence the rates of elderly female suicide, which are lower than those for males in every country of the world. 

Despite the certain impact of social and cultural variables upon suicide rates in old age, limited cross-cultural data are available to definitively tease out the actual contribution of such factors and the impact of other dynamics such as psychopathology, personality traits, previous suicidal behavior, stressful life events and physical illness (Steffens and Blazer, 1999). Nevertheless, anti-suicide strategies in old age must take into account the concomitance of factors that contribute to suicide risk, including an awareness of cultural/traditional aspects. 

The mainstay of suicide prevention initiatives targeted toward the aged is predominantly founded on the early detection and treatment of psychiatric disorders, mainly depressive illnesses. Notwithstanding, approximately 75% of all elderly suicide victims suffer from some sort of psychiatric disorder at the time of their death, with affective disorders representing the most common diagnosis (Henriksson et al., 1995; Waern et al., 2002). However, targeting depression in old age as a main strategy for preventing suicide may not be feasible in a number of countries. For example, vast differences exist across cultures with regard to the way in which individuals with psychiatric illnesses are perceived and thus integrated into the community. In some regions of the world, individuals with psychiatric illnesses are ostracized, and, as a consequence, the likelihood that individuals may seek professional assistance in response to psychological problems can be sternly reduced. The effects of stigma on the acceptance of a diagnosed psychiatric disorder appear to be more significant among men compared to women (Reynolds and Kupfer, 1999). Moreover, in many developing nations, mental health issues--including suicide--are not considered to be a matter of priority on governmental agendas and, as a result, financial provisions required to improve clinical diagnostic techniques and treatment regimens for psychiatric disorders may not be available.  

The conceptualization of psychological distress across cultures and in older age may also highlight difficulties related to the detection of depression in the clinical domain. Cross-culturally, Latin Americans in general may be more likely to conceptualize psychiatric symptoms in physical or medical terms than Anglo-Americans (Canino, 1982; Jenkins, 1988). In addition, ideas about the nature of mental illness in non-industrialized countries are poorly differentiated from those about physical illness, and the concepts of both usually overlap with or include religious and magical concepts (Cooper and Sartorius, 1977). 

In any case, regardless of culture, elderly individuals are more likely to complain of somatic symptoms than of psychological distress. Geriatric depression can and frequently does amplify physical symptoms; however, many elderly patients may deny psychological symptoms of depression or reject the diagnosis due to the stigma attached to it (Reynolds and Kupfer, 1999). Accordinaly, physicians seem to be able to detect depressive symptomatology in only 20% of depressed elderly patients (Vasilas and Morgan, 1994), and as few as 8% of elderly individuals who commit suicide may be treated adequately with antidepressant agents prior to death (Pitkala et al., 2000). However, it is important to acknowledge that even if the ability of physicians to detect depressive symptoms among the elderly were to improve, more than antidepressant treatment would be needed to avert suicide. Recent findings have shown that even by treating with (a 70% efficacy index) all depressed people, the obtainable reduction in suicide rates would not be higher than 12% (Bertolote et al., in press). 

Coupled with these clinical realities is also the tendency for older individuals, particularly men, not to communicate suicidal ideation and intent. Thus, relying on the emergence of depressive symptoms and/or communication of suicidality by elderly patients as indicators of suicide risk, together with the expectation that antidepressant agents may single-handedly prevent suicide, would be naive. Evidently, inquiry into other domains (e.g., personality traits, recent life events and losses, presence of physical illnesses, comorbidity, loneliness and social isolation, involuntary retirement, financial difficulties) and a greater emphasis on the sociocultural facet of suicide in late life may provide appropriate clues to suicide risk and prevention. 

Suicide among the elderly is undoubtedly a complex phenomenon, and the difficulty in preventing suicide, regardless of cultural delineation, is apparent. Across cultures, suicide in older age is more prevalent in Latin and Asian countries, compared to Anglo-Saxon nations. In all countries, primary care physicians and mental health care professionals face a common dilemma in detecting symptoms of depression and suicidality among the elderly. Ideally, in order to prevent suicide in late life, complete consideration should be paid to both the personal characteristics and circumstances and the sociocultural milieu of an elderly person. 

With reference to large-scale suicide prevention strategies for the aged, those that are formulated globally and implemented across cultures ought to take into account the unique sociocultural, economic and political structure of countries and the way in which suicide rates may hinge upon these constitutions. Thus, preventive efforts within societies must be adapted in a way that is sensitive to the cultural elements of suicide.

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Articles

A cross-cultural comparison of suicide in old age, including a discussion of recent epidemiological trends in suicide rates. The authors also discuss the impact of social and cultural variables on the detection of depression and the formulation of suicide prevention strategies.

Diego De Leo, MD, PhD

Articles

Culture and Suicide in Late Life