Sociodemographic and Clinical Characteristics of Older Adults With Suicide-Related Emergency Department Presentations

Abstract

Objectives

To identify characteristics of older adult emergency department (ED) patients aged ≥65 with suicidal ideation and/or behavior.

Methods

A single center retrospective chart review analyzed 392 patients (≥65) with suicidal ideation and/or behavior (2013–2019). Comprehensive full-text searches were used. Subgroup analyses for age and gender were conducted.

Results

Depressive disorder was documented in 50% of cases. Notably, 54% of all women were prescribed antidepressants, compared to only 31% of men. Most patients had general medical conditions (74.5%) and chronic multimorbidity (71.2%). Social stress affected 40.1%; 35.7% were intoxicated upon presentation. Alcohol abuse was more common in the 65–74 age group, while dementia impacted 20% of those ≥75. Men had a six-fold higher 30-day post-discharge mortality.

Discussion

Older ED patients with suicidal ideation and/or behavior exhibit typical characteristics. The dementia prevalence suggests tailored care for those ≥75, and the heightened post-discharge mortality rate in older men requires further research.

Keywords

older adults suicidal ideation suicidal behavior emergency department characteristics

Introduction

Elevated suicide rates among older adults are a concerning global phenomenon. Forecasts are indicating that, by 2030, approximately twenty percent of the population will surpass the age of 65 (Conwell et al., 2011). These changes not only result in a larger population of older adults but also extend retirement periods and may lead to increased numbers of persons living alone (Lindner et al., 2014). Given these societal trends in aging, it is reasonable to anticipate a surge in both suicidal thoughts and behaviors, as well as an absolute rise in suicides among older individuals in the coming decades (Yip et al., 2022).

Older adults with suicidal ideation and/or behavior share typical characteristics (Romero et al., 2021; Fässberg et al., 2016; Waern et al., 2002, 2003). These are, for example, physical health problems, social isolation, loss and grief, gender, (comorbid) psychiatric disorders, chronic physical health conditions, functional impairments, or pain. In addition, life events such as bereavement, retirement, or loss of independence can trigger crisis thoughts. Loneliness, social isolation, and lack of social support networks are risk factors for suicidal ideation and behavior in older adults.

A significant proportion of individuals who die by suicide seek medical assistance in the period leading up to their deaths. Nearly half of the persons who die by suicide had contact with an emergency department (ED) within the year preceding their deaths (Laanani et al., 2020; Stauffacher et al., 2022). This establishes the ED as a potential locus for targeted suicide prevention interventions aimed towards older adults. Paradoxically, though, research has indicated that older adults are less likely to undergo screening for suicidality and evaluation of lethal means in the ED (Arias et al., 2017; Betz et al., 2016).

We need to improve our understanding of older adults visiting the ED after self-harm or suicidal behavior. This is of utmost importance because the risk of subsequent suicidal behavior and suicide remains alarmingly high (Bostwick et al., 2016; Troya et al., 2019), and the identification of older adults at risk seems to be difficult. Improving our understanding in this regard could enable us to identify vulnerable older adults and develop tailored strategies for preventing suicide in this age group. Today, there is a lack of data on the clinical and sociodemographic characteristics of older adults admitted to the ED. Therefore, the aim of our study is to investigate clinical and sociodemographic factors for patients aged ≥65 years who present at the ED with suicidal ideation and/or behavior.

Moreover, in almost all industrialized countries, suicide rates are higher in older adults aged ≥75 years compared to younger older adults (65–74 years) (Naghavi, 2019; Waern et al., 2003). This may be associated with an increase in losses (e.g., health, status, autonomy, roles, and relations). In sight of reported age- and gender-related differences within the older adult population experiencing suicidal ideation and/or behavior (Conwell et al., 2002; Grande et al., 2022; Lee et al., 2018; Vasiliadis et al., 2012), an additional research aim is to compare clinical and sociodemographic characteristics in younger (65–74 years) and older (≥75 years) ED patients with suicidal ideation and/or behavior. In addition, potential gender differences are tested, based on prior findings on older adults of a Swiss population suggesting that female gender is associated with higher rates of suicide attempts than for males (Peter & Tuch, 2019).

Methods

Procedure and Participants

A single center retrospective study was conducted with suicide-related data over seven years. From January 1, 2013 to December 31, 2019 data was collected at the University Emergency Department, Inselspital Bern (Switzerland), which is a certified Level I adult trauma center affiliated to Bern University. This interdisciplinary ED has resources to provide rapid care for all critical emergencies; there is an open operating room, an in-house trauma surgeon and on-call specialists available. The study site is an interdisciplinary emergency department that includes psychiatry specialists 24/7. Psychiatrists (on site residents and on call consultants) provide evaluations and care to walk in patients and patients referred from other disciplines within the ED. Residents, also known as junior doctors, were involved in patient care under the supervision of senior doctors. Patients with critical psychiatric conditions are evaluated by psychiatrists upon referral, but patients with less severe mental health issues are primarily seen by internal medicine or surgery, depending on the current psychiatry resources on site. If patients need to be referred to psychiatric inpatient treatment, the psychiatrists organize the admission in the psychiatric hospital close by. The annual patient volume of the Emergency Department (ED) from 2013 to 2019 ranged from 38,027 in 2013 to 50,033 in 2019.

All data were extracted from medical records and files stored in the clinical database system (E.care, BVBA, ED 2.1.3.0, Turnhout, Belgium). This medical database allows the retrieval of past diagnostic reports, consultations, and other relevant medical documents. Cases were retrieved using a comprehensive full-text search algorithm, with the search terms “suicide,” “suicide attempt,” “suicidal behavior,” “self-inflicted death,” or “self-immolation” (i.e., the corresponding German terms “Suizid,” “suizidales Verhalten,” “Selbsttötung,” and “Freitod”) as search terms in the diagnosis, case history, other history, and triage fields of the emergency reports. Each of the 1245 cases identified by the full-text search was manually reviewed for the above inclusion criteria. Classification into the four categories was then based on interpretation of the medical history and third-party information recorded in the case files. In the next step, patients were selected who had given general consent for the anonymous analysis of medical data. Accordingly, no individual informed consent was obtained. The analysis was carried out with anonymized data. Cases were included if the person was aged 65 or older and his or her emergency case history contained one or more of the following conditions: (1) active or passive suicidal ideation; (2) suicidal behavior(s); (3) suicide intentions or plans; and (4) suicide warnings or threats. In the present study, persons with any of these four phenomena were considered “patients with suicidal ideation and/or behavior.” A few individuals who died in the emergency department or on a hospital ward were included in the analyses in the same manner as all others. The selection was performed manually. If a person had multiple events during the period of investigation, all information from these cases was combined and treated as one case.

The Cantonal Ethics Committee of Bern approved this study (reference number: BE 2020–00,590), in accordance with the guidelines of the Declaration of Helsinki and ethical principles for conducting medical research with human subjects. Data were handled according to the standards of the Ethics Committee and Swiss law.

Exposure Variables

In each case, the patient’s history, diagnosis, medication, clinical examination, and consultation entries were used to classify the exposure variables. If the sociodemographic and clinical variables under study were reported as present, then they were coded as yes. In accordance with procedures for recording emergency medicine data, missing variables were coded as not recorded. For each identified case, the reason for presentation to the ED was documented, with multiple options possible per case. This could be suicidal ideation, attempted suicide, planned or intended suicide and/or warnings or threats of suicide. To investigate clinical and sociodemographic characteristics of suicidal ideation and/or behavior in older adults, data on age, sex, living situation, current/past life events, and psychiatric disorders as well as type of referral at the ED were collected, among others. Two age groups were employed in the analyses; those aged 65–74 years were considered as younger older adults and those aged ≥75 years were considered older old adults. In terms of the type of referral to the ED, a distinction was made between referral by an outpatient clinic, self-referral, or referral by a general practitioner, a psychiatric clinic, another hospital, another university hospital clinic, the outpatient psychiatrist, the emergency doctor, or unspecified referral. Settings after discharge from the ED were classified as: in-patient stay in a psychiatric clinic (54%), inpatient stay at the university hospital (29.3%), transfer to another hospital (1.5%), discharge to home (14.3%), or death (0.5%).

Social parameters, physical and mental illnesses were examined, including substance abuse, use of various medications, past suicide attempts, method of the current suicide attempt, as well as the Glasgow Coma Scale (GCS; Teasdale & Jennett, 1976), a tool to measure the patient’s level of consciousness. If the GCS was not documented, it was calculated from the existing clinical data when possible. The following social factors were examined: the influence of the housing situation, that is, alone, with a partner, with a family or a nursing home), the effect of acute social stress situations (e.g., relationship problems with partner/family members, financial problems/loss of job, work overload/everyday overload, and loss of property), early traumatic experiences (e.g., physical or sexual violence, neglect/mental abuse or early loss/separation of family members) up to the age of 18 years, social isolation, a current or feared loss of autonomy and partner's need for long-term care. Current psychiatric disorders were categorized as major depressive disorder, bipolar disorder, personality disorder, psychotic disorder, sleep disorder, and other disorders, such as adjustment and anxiety disorder. If any of these psychiatric disorders were present, then the variable any psychiatric disorder was recorded. A patient could have multiple disorders. Dementia and comorbidity or multimorbidity were also considered. Substance abuse was categorized as follows: alcohol, benzodiazepines, Z-drugs, insulin, opiates, antidepressants, antipsychotics, class I painkillers, and other substances. The date of initial diagnosis of dementia was not usually reported in medical records. Typically, results of follow-up tests, such as the Mini-Mental State Examination are reported. Regularly taken prescription medications were also categorized, including antidepressants, antipsychotics, lithium, antidementia drugs, benzodiazepines, and Z-drugs. Multiple medications could be documented for one person.

Past suicide attempts were divided into one suicide attempt and multiple suicide attempts. If there was a current suicide attempt, methods were classified as intentional overdose/poisoning, cutting, jumping from height, strangulation, gunshot wound, electrocution, vehicular exposure, drowning, or other. On this basis, it was coded whether a person used a single or multiple methods. Date of death is routinely recorded in the hospital information system (SAP) and matched weekly with the report of the federal office, and mortality rates after 30, 60, and 90 days after ED contact were calculated.

Statistical Analysis

Statistical analyses were performed using Stata® 16.1 (StataCorp, The College Station, Texas, USA). The distribution of the categorical variables is presented with the absolute number and percentage. Univariable logistic regression analysis was used to detect differences in categorical variables between the two age groups and between males and females. Odds ratios (ORs) with 95% confidence intervals (CI) for all parameters were calculated with logistic regression. To account for multiple testing, the p-value for significance was set to p < .001.

Results

Descriptive Characteristics

From January 1, 2013 to December 31, 2019, a total of 310,073 ED consultations were documented (see enrolment, Figure 1). Of these, 26.2 % (81,138) involved people older than 65 years. After the full-text search for patients older than 65 years with suicidal ideation and/or behavior, 34% of the potential ED cases fulfilled inclusion and exclusion criteria. After merger of cases with multiple events the proportion was 31% (392 unique individuals), see Figure 1. The proportional incidence of suicidal ideation and/or behavior in older adults at the ED was 1.26 (95% CI: 1.14–1.40) per 1000 ED consultations. The investigated sample consisted of 188 (48%) females (mean age 75.3 years, SD = 8.4) and 204 (52%) males (mean age 75.0 years, SD = 7.7).

Suicidal ideation was recorded as the reason for ED presentation in 50.3% of the total study cohort and a suicide attempt was noted in 47.4% of the cases. Moreover, 18.4% of the investigated ED patients described suicidal intentions; suicide warnings and threats were recorded in 6.1%.

Among patients visiting an ED in connection with a suicide attempt, intentional overdose/poisoning was employed by 47.8%, making it the most commonly documented method. Only a small percentage (1.4%) of the data indicated that multiple methods were used. Slightly over one quarter (27.4%) of patients employed cutting, while jumping from a height was employed by 12.4%. Multiple suicide methods were used by 5.9%. Any psychiatric disorder was recorded in 74% of all of the ED patients with suicidal ideation and/or behavior. These included depressive disorders (50%), sleep disorders (20%), bipolar disorders (3%), psychotic disorders (10%), personality disorders (2%) or other disorders (adjustment, anxiety disorder; 23%). At least one general medical disorder was recorded in 74.5% of the ED cases. Cardiovascular diseases (48.7%) were highly prevalent and chronic multimorbidity was documented in 71.2%. Furthermore, a clinical diagnosis of dementia was noted in 11% of the study cohort.

At the time of admission, 42% of the older ED patients with suicidal ideation and/or behavior were prescribed antidepressants; one fifth were on antipsychotics, and 30% were on benzodiazepines (29%). Just over a third (36%) were intoxicated upon presentation to the ED. Most intentional overdose/poisoning involved alcohol use (18.6%), followed by benzodiazepines (10.7%), Z-drugs (6.9%), and antidepressants (3.3%). The majority of patients (89%) exhibited GCS scores 13–15, corresponding to mild traumatic brain injury, whereas 4.6% had moderate (GCS score 9–12), and 6.4% severe traumatic brain injury (GCS score< 9).

Forty percent of the study cohort lived alone and 36% lived with a partner (36%). Only a 10th resided in a nursing home, and 2% lived with family. Regarding current/past life events, 40% of the older adults with suicidal ideation and/or behavior were suffering from an acute situation of social stress. Furthermore 15% indicated current or feared limitation of autonomy and 11% social isolation. Only 6% reported early traumatic experiences and 3% long-term care needs of partner. Just over half (54%) were discharged to a psychiatric hospital and 29% received further somatic treatment.

Age Groups

No differences were found between the younger (65–74 years) and the older (≥75 years) older adults regarding the presence of suicidal ideation and/or behavior as the reason for ED presentation (see Table 1). Furthermore, no age-group differences were found regarding the method of suicide attempt, psychiatric disorders, psychiatric medication upon admissions, current or past life events, and chronic multi-morbidity (see Table 1). While patients ≥75 years had numerically larger proportions with any chronic physical illness, physical restrictions or disabilities, cardiovascular diseases, previous or current cancer and other chronic diseases (diabetes mellitus, hypercholesterolaemia, and thyroid disease), only the group difference for cardiovascular diseases was significant. As expected, patients in the older subgroup were significantly more likely to suffer from dementia. Age differences in substance overdose were only found regarding alcohol. For the older group, alcohol use was documented significantly less often than in the younger group. Mortality rates were higher in the 75+ group, but associations did not endure correction for multiple testing. Patients aged ≥75 years were more likely to live in a nursing home than those aged 65–74 years.

Table 1.

Age Group Comparisons Between Emergency Department Patients With Suicidal Ideation/Behavior Aged 65–74 years and ≥75 years.

Characteristics	65–74 years n = 205	≥75 years n = 187	OR (95% CI)^a	p-Value^b
Sex, n (%)
Female	96 (46.8)	92 (49.2)	0.91 (0.61–1.35)	.639
Male	109 (53.2)	95 (50.8)	1.13 (0.77–1.68)	.531
Reason for ED presentation, n (%)
Suicidal thoughts (active, passive)	108 (52.7)	89 (47.6)	0.82 (0.55–1.21)	.314
Suicide attempt	94 (45.9)	92 (49.2)	1.14 (0.77–1.7)	.508
Suicide intentions	39 (19.0)	33 (17.6)	0.91 (0.55–1.52)	.725
Suicide warnings and threats	14 (6.8)	10 (5.3)	0.77 (0.33–1.78)	.542
Suicide attempt method, n (%)
overdose/poisoning	53 (25.9)	36 (19.3)	0.68 (0.42–1.10)	.120
Cutting	22 (10.7)	29 (15.5)	1.53 (0.84–2.76)	.162
Jumping from a height	13 (6.3)	8 (4.3)	0.66 (0.27–1.63)	.368
Hanging	3 (1.5)	3 (1.6)	1.10 (0.22–5.51)	.910
Shooting	5 (2.4)	12 (6.4)	2.74 (0.95–7.94)	.063
Electrocution	1 (0.5)	0 (0.0)	- (--)	-
Vehicular impact	2 (1.0)	2 (1.1)	1.10 (0.15–7.87)	.926
Drowning	1 (0.5)	4 (2.1)	4.46 (0.49–40.26)	.183
Multiple	8 (3.9)	3 (1.6)	0.40 (0.10–1.54))	.183
Living situation, n (%)
Alone	62 (30.2)	71 (38.0)	1.41 (0.93–2.15)	.107
With partner	82 (40.0)	57 (30.5)	0.66 (0.43–1.00)	.05
With family	4 (2.0)	2 (1.1)	0.54 (0.10–3.00)	.484
Nursing home	9 (4.4)	31 (16.6)	4.33 (2.00–9.36)	<.001
Current/past life events, n (%)
Acute social stress situation	91 (44.4)	66 (35.3)	0.68 (0.45–1.03)	.067
Early traumatic experiences <18 yrs	12 (5.9)	11 (5.9)	1.01 (0.43–2.34)	.99
Social isolation	26 (12.7)	18 (9.6)	0.73 (0.39–1.39)	.34
Current/feared limitation of autonomy	27 (13.2)	31 (16.6)	1.31 (0.75–2.29)	.344
Long-term care needs of partner	5 (2.4)	7 (3.7)	1.56 (0.49–4.99)	.457
Psychiatric disorders, n (%)
Any psychiatric disorder	159 (77.6)	131 (70.1)	0.68 (0.43–1.07)	.091
Depressive disorder	107 (52.2)	88 (47.1)	0.81 (0.55–1.21)	.310
Bipolar disorder	7 (3.4)	6 (3.2)	1.1 (0.35–3.47)	.872
Psychoses	18 (8.8)	13 (7.0)	0.78 (0.37–1.63)	.504
Personality disorder	5 (2.4)	3 (1.6)	0.65 (0.15–2.77)	.562
Sleeping disorder	40 (19.5)	37 (19.8)	1.02 (0.62–1.68)	.946
Other (adjustment, anxiety disorder)	54 (26.3)	35 (18.7)	0.64 (0.4–1.04)	.073
Psychiatric medication at admission, n(%)
Antidepressants	83 (40.5)	81 (43.3)	1.12 (0.75–1.68)	.571
Antipsychotics	42 (20.5)	35 (18.7)	0.89 (0.54–1.47)	.659
Benzodiazepines	62 (30.2)	50 (26.7)	0.84 (0.54–1.31)	.443
Z-drugs	33 (16.1)	35 (18.7)	1.2 (0.71–2.03)	.494
Lithium	4 (2.0)	3 (1.6)	0.82 (0.18–3.71)	.796
Antidementia	6 (2.9)	10 (5.3)	1.87 (0.67–5.26)	.233
Substance overdose, n (%)
Any overdose/poisoning	89 (43.4)	51 (27.3)	0.49 (0.32–0.75)	.001
Alcohol	52 (25.4)	21 (11.2)	0.37 (0.21–0.65)	<.001
Benzodiazepines	25 (12.2)	17 (9.1)	0.72 (0.38–1.38)	.323
Z-drug	15 (7.3)	12 (6.4)	0.87 (0.4–1.91)	.725
Insulin	2 (1.0)	1 (0.5)	0.55 (0.05–6.07)	.622
Opiate	8 (3.9)	3 (1.6)	0.4 (0.1–1.54)	.183
Antidepressant	10 (4.9)	3 (1.6)	0.32 (0.09–1.17)	.085
Antipsychotic	7 (3.4)	1 (0.5)	0.15 (0.02–1.25)	.079
Non-opioid analgesics (WHO, class I)	6 (2.9)	6 (3.2)	1.1 (0.35–3.47)	.872
Other	13 (6.3)	9 (4.8)	0.75 (0.31–1.79)	.513
Chronic illness, n (%)
Any chronic physical illness	140 (68.3)	152 (81.3)	2.02 (1.26–3.23)	.004
Pain	53 (25.9)	47 (25.1)	0.96 (0.61–1.52)	.87
Physical restriction/disabilities	33 (16.1)	42 (22.5)	1.51 (0.91–2.51)	.111
Cardiovascular diseases	79 (38.5)	112 (59.9)	2.38 (1.59–3.57)	<.001
Previous or current cancer	19 (9.3)	38 (20.3)	2.5 (1.38–4.51)	.002
Other (diabetes mellitus, hypercholesterolaemia, thyroid disease)	96 (46.8)	113 (60.4)	1.73 (1.16–2.59)	.007
Chronic multimorbidity, n (%)	139 (67.8)	140 (74.9)	1.41 (0.91–2.20)	.124
Dementia, n (%)	13 (6.3)	33 (17.6)	3.16 (1.61–6.22)	<.001
Mortality rate, n (%)
30 days	7 (3.4)	21 (11.2)	3.01(1.23–7.39)	.016
60 days	9 (4.4)	24 (12.8)	3.21 (1.45–7.09)	.005
90 days	9 (4.4)	26 (13.9)	3.43 (1.52–7.76)	.003

Note. In accordance with recording procedures for emergency medicine data; missing variables were coded as not recorded.

^aOR predicting ≥75 years group.

^bp-value was set to p < .001 (corresponding to a Bonferroni adjusted p-value of 0.05 to take into account multiple testing).

Gender Differences

Proportions with suicidal ideation and/or behavior as the reason for ED-treatment were similar in men and women (see Table 2). No gender differences were found in living situation, chronic illness and/or multimorbidity, dementia, or psychiatric disorder. Women were more likely than men to be on psychoactive medication with antidepressants, benzodiazepines, and Z-drugs upon admission. Less than one-third of the male participants were prescribed antidepressant medications. Women were also more likely to employ intentional overdose/poisoning as a mean of suicide attempt. Furthermore, women were more likely to exhibit substance use with benzodiazepines than men.

Table 2.

Gender Differences of Emergency Department Patients Aged 65+ With Suicide Ideation And/or Behavior.

Characteristics	Women n = 188	Men n = 204	OR (95%CI)^a	p-Value
Reason for ED presentation, n (%)
Suicidal thoughts (active, passive)	92 (48.9)	105 (51.5)	1.11 (0.74–1.65)	.616
Suicide attempt	94 (50.0)	92 (45.1)	0.82 (0.55–1.22)	.332
Suicide intentions	32 (17.0)	40 (19.6)	1.19 (0.71–1.99)	.509
Suicide warnings and threats	8 (4.3)	16 (7.8)	1.91 (0.80–4.58)	.145
Suicide attempt method, n (%)
Overdose/poisoning	62 (33.0)	27 (13.2)	0.31 (0.19–0.51)	<.001
Cutting	19 (10.1)	32 (15.7)	1.65 (0.90–3.03)	.103
Jumping from a height	12 (6.4)	9 (4.4)	0.68 (0.28–1.65)	.389
Hanging	1 (0.5)	5 (2.5)	4.70 (0.54–40.59)	.160
Shooting	0 (0.0)	17 (8.3)	- (--)	-
Electrocution	0 (0.0)	1 (0.5)	- (--)	-
Vehicular impact	2 (1.1)	2 (1.0)	0.92 (0.13–6.60)	.935
Drowning	3 (1.6)	2 (1.0)	0.61 (0.10–3.69)	.591
Multiple	7 (3.7)	4 (2.0)	0.52 (0.15–1.80)	.299
Living situation, n (%)
Alone	72 (38.3)	61 (29.9)	0.69 (0.45–1.05)	.080
With partner	60 (31.9)	79 (38.7)	1.35 (0.89–2.04)	.160
With family	5 (2.7)	1 (0.5)	0.18 (0.02–1.56)	.119
Nursing home	21 (11.2)	19 (9.3)	0.82 (0.42–1.57)	.545
Current/past life events, n (%)
Acute social stress situation	65 (34.6)	92 (45.1)	1.55 (1.03–2.34)	.034
Early traumatic experiences <18 yrs	16 (8.5)	7 (3.4)	0.38 (0.15–0.95)	.038
Social isolation	23 (12.2)	21 (10.3)	0.82 (0.44–1.54)	.544
Current/feared limitation of autonomy	20 (10.6)	38 (18.6)	1.92 (1.07–3.44)	.028
Long-term care needs of partner	6 (3.2)	6 (2.9)	0.92 (0.29–2.90)	.886
Psychiatric disorders, n (%)
Any psychiatric disorder	145 (77.1)	145 (71.1)	0.73 (0.46–1.15)	.173
Depressive disorder	101 (53.7)	94 (46.1)	0.74 (0.49–1.10)	.131
Bipolar disorder	6 (3.2)	7 (3.4)	0.92 (0.29–2.90)	.886
Psychoses	17 (9.0)	14 (6.9)	0.74 (0.35–1.55)	.426
Personality disorder	2 (1.1)	6 (2.9)	2.82 (0.56–14.14)	.208
Sleep disorder	38 (20.2)	39 (19.1)	0.93 (0.57–1.54)	.785
Other (adjustment, anxiety disorder)	41 (21.8)	48 (23.5)	1.1 (0.69–1.77)	.685
Psychiatric medication upon admission, n (%)
Antidepressants	101 (53.7)	63 (30.9)	0.38 (0.25–0.58)	<.001
Antipsychotics	40 (21.3)	37 (18.1)	0.82 (0.50–1.35)	.435
Benzodiazepines	79 (42.0)	33 (16.2)	0.27 (0.17–0.43)	<.001
Z-drugs	45 (23.9)	23 (11.3)	0.40 (0.23–0.70)	<.001
Lithium	5 (2.7)	2 (1.0)	0.36 (0.07–1.89)	.228
Antidementia	7 (3.7)	9 (4.4)	1.19 (0.44–3.27)	.731
Substance overdose, n (%)
Any overdose/poisoning	80 (42.6)	60 (29.4)	0.56 (0.37–0.85)	.007
Alcohol	25 (13.3)	48 (23.5)	2.01 (1.18–3.41)	.01
Benzodiazepine	36 (19.1)	6 (2.9)	0.13 (0.05–0.31)	<.001
Z-drug	20 (10.6)	7 (3.4)	0.3 (0.12–0.72)	.007
Insulin	0 (0.0)	3 (1.5)	- (--)	-
Opiate	6 (3.2)	5 (2.5)	0.76 (0.23–2.54)	.658
Antidepressant	10 (5.3)	3 (1.5)	0.27(0.07–0.98)	.047
Antipsychotic	5 (2.7)	3 (1.5)	0.55 (0.13–2.32)	.412
Non-opioid analgesics (WHO, class I)	9 (4.8)	3 (1.5)	0.3 (0.08–1.11)	.072
Other	15 (8.0)	7 (3.4)	0.41 (0.16–1.03)	.057
Chronic illness, n (%)
Any chronic physical illness	142 (75.5)	150 (73.5)	0.90 (0.57–1.42)	.650
Pain	50 (26.6)	50 (24.5)	0.90 (0.57–1.41)	.636
Physical restriction/disabilities	36 (19.1)	39 (19.1)	1 (0.6–1.65)	.994
Cardiovascular diseases	86 (45.7)	105 (51.5)	1.26 (0.85–1.87)	.257
Previous or current cancer	25 (13.3)	32 (15.7)	1.21 (0.69–2.13)	.503
Other (diabetes mellitus, hypercholesterolemia, thyroid disease)	104 (55.3)	105 (51.5)	0.86 (0.58–1.27)	.446
Chronic multimorbidity, n (%)	134 (71.3)	145 (71.1)	0.99 (0.64–1.53)	.965
Dementia, n (%)	19 (10.1)	27 (13.2)	1.36 (0.73–2.53)	.338
Mortality rate, n (%)
30 days	4 (2.1)	24 (11.8)	6.13 (2.09–18.02)	<.001
60 days	8 (4.3)	25 (12.3)	3.14 (1.38–7.15)	.006
90 days	8 (4.3)	27 (13.2)	3.4 (1.52–7.76)	.003

Note. In accordance with procedures for recording emergency medicine data, missing variables were coded as not recorded.

^aOR predicting male.

^bp-value was set to p < .001 (corresponding to a Bonferroni adjusted p-value of 0.05 to take into account multiple testing).

Men and women did not differ regarding current/past life events. Men were more likely to show substance use with alcohol than women. The risk of death within 30 days was more than six-fold greater for men compared to women (see Table 2).

Discussion

The findings derived from our research into older adults who have presented with suicidal ideation and/or behavior at the emergency department reveal some significant patterns. Some of these correspond to the expected characteristics of older patients with suicidal ideation and/or behavior. Notably, about half of these individuals had documented depressive disorders, with a substantial gender difference in the use of antidepressants. Over half of the women were prescribed antidepressants, in contrast to less than a third of the men. Furthermore, the majority of patients were found to have general medical disorders, chronic multimorbidity, and a quarter of them reported pain, emphasizing the complex health challenges this population faces. Social stressors were prevalent among 40.1% of cases, and 35.7% were intoxicated at the time of presentation. Subgroup analysis revealed higher rates of alcohol use in the 65–74 age group. Importantly, there were no gender differences in the prevalence of suicidal ideation and behavior, but men exhibited a striking six-fold increase in mortality within 30 days following admission. Additionally, one-fifth of individuals aged ≥75 who presented with suicidal ideation and/or behavior were found to have dementia, highlighting the importance of neurodegenerative disorders in this age group.

Older adults in the ED with suicidal ideation and/or behavior were commonly diagnosed with psychiatric disorders, especially depressive disorders, aligning with previous research (Almeida et al., 2012; Beghi et al., 2021; Carlsten et al., 1999; Waern et al., 2003). Sleep disorders were also notable, with a higher prevalence compared to earlier studies (Schmutte et al., 2020). Unlike younger populations, older adults’ suicide attempts are closely linked to depression (Conwell & Brent, 1995; Conwell et al., 2002; Rostami et al., 2018; Wiktorsson et al., 2010). They often exhibit subthreshold depression, depression related to physical discomfort, and undiagnosed psychiatric conditions (Minder et al., 2018; Waern et al., 2003; Ólafsdóttir et al., 2001). Some individuals in our study might have had subthreshold depression severity, not identified due to our study’s limitations. Clinicians should consider these nuances in depression presentation among the elderly during ED assessments.

Most older adults with suicidal ideation/and or behavior at the ED received psychotropic medications including antidepressants, antipsychotics, or benzodiazepines. Upon ED arrival, these patients were often found to be intoxicated, mainly from alcohol, followed by benzodiazepines, Z-drugs, and antidepressants. Notably, older adults struggling with addiction face a significantly higher suicide risk, up to 40 times higher (Schneider, 2009; Waern et al., 2003). Many older adults admitted to the ED after suicide attempts do overdose on their own medications, underscoring the importance of considering medication choices for older adults with suicidal tendencies (Keskin Gokcelli et al., 2017).

Multimorbidity was highly prevalent with three quarters of the older adults presenting at the ED with suicidal ideation and/or behavior along with a general medical condition. Chronic multimorbidity was also highly prevalent. Somatic diseases, which tend to increase with age and are often followed by a decline in autonomy and quality of life, are closely linked to suicidal ideation and behavior (Greune, 2007). In fact, serious somatic illness can triple the risk of suicide in individuals aged 75 and older (Waern et al., 2003). In our study, approximately 25% of individuals with suicidal ideation and/or behavior reported experiencing physical pain, which is consistent with the findings of Schmutte et al. (2020), who also observed similar proportions of pain in this context.

A significant portion of patients who presented with suicidal ideation and/or behavior were concurrently dealing with acute social stress, the actual or anticipated restriction of their autonomy, or social isolation. Notably, social isolation emerged as a prominent factor associated with suicidal ideation and behavior among older adults, as highlighted by Heuser and Howe (2018). In the later stages of life, there is a measurable reduction in the size of an individual’s social network (Lindner et al., 2014; Tesch-Römer, 2010). This loss of social interaction may explain the increased prevalence of suicide among older adults who are widowed, single, or divorced, a phenomenon well-documented by Canetto (1992) and Steck et al. (2016). Therefore, when systematically assessing suicide risk in older adults, it becomes imperative to deliberately explore their current social circumstances, levels of isolation, and the presence of loneliness.

Approximately half of the ED patients displaying suicidal ideation and/or behavior were subsequently admitted to a psychiatric hospital. This rate is somewhat lower than the findings in a large US study (Schmutte et al., 2020). Our figure indicates that nearly half of the patients who presented at the ED with suicidal ideation and/or behavior did not receive referrals for inpatient psychiatric care. This observation may in part reflect concerns about being involuntarily admitted to a psychiatric hospital due to their suicidal ideation and/or behavior. These fears could potentially influence a patient’s willingness to disclose the severity of their suicidal ideation, possibly leading clinicians to underestimate the necessity for psychiatric follow-up care. Given these considerations, healthcare providers must pay special attention to whether older adults who are not referred to psychiatric inpatient care after their ED visit can access adequate support for their mental health needs. Other explanations for lack of referral to inpatient psychiatric care might be that psychiatric outpatient care had been established, or that suicidal ideation had resolved. Fluctuations in suicidal feelings have been shown to be more common among older women than among older men (Fässberg et al., 2020).

Age Differences in ED Patients with Suicidal Ideation And/or Behavior

No notable differences emerged between younger old adults (aged 65–74) and older old adults (age group ≥75) in their rates of ED visits related to suicidal ideation and/or behavior. Likewise, age did not appear to influence the choice of suicide attempt methods. This lack of age-related disparities, given that suicidal ideation typically increases with age in the older adult population (Fässberg et al., 2020), is somewhat surprising but may be specific to the ED setting. In addition, 11 of 392 patients used multiple methods. This overall small number is in contrast to other findings (Muheim et al., 2013) in which approximately 30% reported using more than one suicide method. This may reflect an ascertainment problem in the ED setting, but it could in part be related to the age group studied. The study of Muheim et al. (2013) covered all age groups.

However, both age groups share a common concern regarding potential loss of autonomy if their circumstances change. This finding is especially noteworthy, particularly since older patients (aged ≥75 years) presenting at the ED were more likely to reside in nursing homes compared to those aged 65–74 years. The fear of losing autonomy appears to be a significant concern for older individuals, extending beyond their living situations. In some instances, this fear may be linked to worries about involuntary psychiatric hospitalization due to their suicidal ideation and/or behavior, potentially impacting referrals for psychiatric care.

Within the cohort of patients with suicidal ideation and/or behavior, 11% also had dementia. As expected, dementia was more prevalent in the ≥75 age group. Notably, one-fifth of these older old ED patients with suicide-related presentations suffered from dementia. The literature still lacks a comprehensive understanding of dementia’s relevance as a suicide risk factor (Cipriani et al., 2013; Hedna et al., 2023). This age discrepancy may stem from the unique nature of the emergency setting, where older adults with dementia, especially those in nursing homes, might receive heightened attention for suicidal ideation and behavior, potentially leading to more frequent referrals to emergency units. Given that the date of the initial diagnosis of dementia is typically missing from medical records, and that only results of follow-up tests are documented, there is no basis for assuming a direct correlation between the initial diagnosis of dementia and the suicidal crisis. There is evidence of an increased risk of passive suicidal ideation already in people with mild cognitive impairment (Rymo et al., 2023).

Gender Differences in ED Patients with Suicidal Ideation And/or Behavior

The prevalence of patients with suicidal ideation and/or behavior was comparable between men and women presenting at the ED. This finding was somewhat unexpected, given the higher occurrence of suicidal ideation among women in the general older adult population (Fässberg et al., 2020). Moreover, numerous studies have consistently reported higher rates of suicidal ideation among women compared to men (Koo et al., 2014; Lu et al., 2020; Shiraly et al., 2022; Vasiliadis et al., 2012). It’s noteworthy that women were more inclined to choose intentional overdose/poisoning as the method for their suicide attempts, aligning with previous research findings from the general population (Bostwick et al., 2016).

Highlighting the relatively low rate of antidepressant prescriptions in men, at just 30%, is crucial. This discrepancy may be explained by men’s tendency to delay seeking help for mental health issues, as indicated by previous research (Affleck et al., 2018; Pattyn et al., 2015). Our study aligns with this trend, revealing similar rates of mental disorders in both genders but a noticeable difference in the use of psychiatric medication upon admission, with a higher prevalence among women. The reduced prescription rate of psychotropic medications may suggest lower utilization of psychiatric treatments (e.g., by general practitioners or psychiatrists) among men. Our data revealed a significantly higher mortality rate in men compared to women during the first 30 days post-hospital admission, with a six-fold greater risk. This highlights the elevated risk faced by older men after admission, necessitating enhanced vigilance during this vulnerable period. Incorporating this knowledge into emergency management protocols holds promise for improving the identification of unmet needs of older adults in the ED at high risk for suicidal behavior. Subsequently, these patients can be directed toward appropriate follow-up mental health interventions after their ED visits for suicidal ideation and/or behavior.

Strengths and Limitations

The primary strength of our study was investigating a well-characterized sample from the Swiss older adult population, specifically those presenting with suicidal ideation and/or behavior in emergency settings. This enabled us to compare characteristics between younger and older adults in this context and explore potential gender differences. However, our study does have several inherent limitations.

Firstly, it’s important to note that general consent for the anonymous processing of medical data was obtained from only about one-third of the cases selected from the emergency cohort. This raises concerns about potential selection bias, as individuals with stigmatized conditions such as substance abuse, mental health issues, or suicidal thoughts may be more inclined to withhold their consent. This leads to questions about whether this reluctance to provide consent is more common among older adults, possibly due to greater concerns about stigmatization and data misuse. Unfortunately, the limited available literature on this topic did not provide sufficient context to interpret the high rate of denial of general consent in a broader sense. This is consistent with the relatively small number of patients included, which raises additional concerns about the possibility of missing cases of suicidal ideation and/or behavior in the overall sample. The problem of underreporting of suicidal crises or behaviors in emergency departments is well known, with false-negative cases potentially biasing the data by masking suicidal ideation or behavior as accidents. Factors contributing to this phenomenon include fear of social stigma, perceived ineffectiveness of treatment, and fear of involuntary hospitalization. This trend appears to exist across all age groups, suggesting that there is a subgroup of people who do not seek or receive help. Secondly, because our data was collected in an ED setting and retrospectively coded based on medical records, it was only possible to determine whether certain information was reported or not. Thus, the absence of reported information does not necessarily indicate the absence of the underlying condition. This potential reporting bias means that certain sociodemographic and clinical characteristics may not have been accurately documented.

Thirdly, we were unable to compare the patients exhibiting suicidal ideation and/or behavior with a control group. This limitation stems from the standard practice in emergency departments, which focuses on collecting data relevant to the immediate visit. As a result, patients with suicidal ideation and/or behavior are more likely to be asked for a detailed medical and psychiatric history, including information about trauma and other life events, compared to patients with somatic presentations. Consequently, a case-control comparison was not feasible since controls were not asked for most of the relevant sociodemographic and clinical variables.

To address these limitations, future research efforts should consider establishing a standardized set of required information for all ED patients, regardless of their presenting condition. This would also enhance the study’s power for conducting distinct analyses on suicidal ideation and suicide attempts, potentially necessitating a larger participant cohort.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Anja Gysin-Maillart

David Bettschen

References

Affleck

Carmichael

Whitley

(2018). Men's mental health: Social determinants and implications for services. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 63(9), 581–589. https://doi.org/10.1177/0706743718762388

Almeida

O. P.

Draper

Snowdon

Lautenschlager

N. T.

Pirkis

Byrne

Sim

Stocks

Flicker

Pfaff

J. J.

(2012). Factors associated with suicidal thoughts in a large community study of older adults. The British Journal of Psychiatry, 201(6), 466–472. https://doi.org/10.1192/bjp.bp.112.110130

Arias

S. A.

Boudreaux

E. D.

Segal

D. L.

Miller

Camargo Jr

C. A.

Betz

M. E.

(2017). Disparities in treatment of older adults with suicide risk in the emergency department. Journal of the American Geriatrics Society, 65(10), 2272–2277. https://doi.org/10.1111/jgs.15011

Beghi

Butera

Cerri

C. G.

Cornaggia

C. M.

Febbo

Mollica

Berardino

Piscitelli

Resta

Logroscino

Daniele

Altamura

Bellomo

Panza

Lozupone

(2021). Suicidal behaviour in older age: A systematic review of risk factors associated to suicide attempts and completed suicides. Neuroscience and Biobehavioral Reviews, 127(10), 193–211. https://doi.org/10.1016/j.neubiorev.2021.04.011

Betz

M. E.

Arias

S. A.

Segal

D. L.

Miller

Camargo Jr

C. A.

Boudreaux

E. D.

(2016). Screening for suicidal thoughts and behaviors in older adults in the emergency department. Journal of the American Geriatrics Society, 64(10), e72–e77. https://doi.org/10.1111/jgs.14529

Bostwick

J. M.

Pabbati

Geske

J. R.

McKean

A. J.

(2016). Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. American Journal of Psychiatry, 173(11), 1094–1100. https://doi.org/10.1176/appi.ajp.2016.15070854

Canetto

S. S.

(1992). Gender and suicide in the elderly. Suicide and Life-Threatening Behavior, 22(1), 80–97.

Carlsten

Waern

Allebeck

(1999). Suicides by drug poisoning among the elderly in Sweden 1969–1996. Social Psychiatry and Psychiatric Epidemiology, 34(11), 609–614. https://doi.org/10.1007/s001270050182

Cipriani

Vedovello

Lucetti

Di Fiorino

Nuti

(2013). Dementia and suicidal behavior. Aggression and Violent Behavior, 18(6), 656–659. https://doi.org/10.1016/j.avb.2013.07.016

10.

Conwell

Brent

(1995). Suicide and aging I: Patterns of psychiatric diagnosis. International Psychogeriatrics, 7(2), 149–164. https://doi.org/10.1017/s1041610295001943

11.

Conwell

Duberstein

P. R.

Caine

E. D.

(2002). Risk factors for suicide in later life. Biological Psychiatry, 52(3), 193–204. https://doi.org/10.1016/s0006-3223(02)01347-1

12.

Conwell

Van Orden

Caine

E. D.

(2011). Suicide in older adults. Psychiatric Clinics of North America, 34(2), 451–468. https://doi.org/10.1016/j.psc.2011.02.002

13.

Fässberg

M. M.

Cheung

Canetto

S. S.

Erlangsen

Lapierre

Lindner

Draper

Gallo

J. J.

Wong

Duberstein

Wærn

(2016). A systematic review of physical illness, functional disability, and suicidal behaviour among older adults. Aging & Mental Health, 20(2), 166–194. https://doi.org/10.1080/13607863.2015.1083945

14.

Fässberg

M. M.

Vanaelst

Jonson

Sterner

T. R.

Ahlner

Wetterberg

Rydén

Kern

Sigström

Zettergren

Skoog

Waern

(2020). Epidemiology of suicidal feelings in an ageing Swedish population: From old to very old age in the Gothenburg H70 birth cohort studies. Epidemiology and Psychiatric Sciences, 29(s29), Article e26. https://doi.org/10.1017/S2045796019000143

15.

Grande

Vichi

Alicandro

Marchetti

Frova

Pompili

(2022). Suicide mortality among the elderly population in Italy: A nationwide cohort study on gender differences in sociodemographic risk factors, method of suicide, and associated comorbidity. International Journal of Geriatric Psychiatry, 37(6), 5726. https://doi.org/10.1002/gps.5726

16.

Greune

(2007). Der Alterssuizid in der Bundesrepublik Deutschland. Gefährdungspotentiale und Möglichkeiten der Prävention. GRIN Verlag.

17.

Hedna

Sigström

Johnell

Waern

(2023). Determinants of suicidal behavior in dementia: A Swedish national register-based study. International Psychogeriatrics, 36(5), 415–426. https://doi.org/10.1017/S1041610223000583

18.

Heuser

Howe

(2018). The relation between social isolation and increasing suicide rates in the elderly. Quality in Ageing and Older Adults, 20(1), 2–9. https://doi.org/10.1108/qaoa-06-2018-0026

19.

Keskin Gokcelli

Tosun Tasar

Akcam

N. O.

Sahin

Akarca

F. K.

Aktas

E. O.

Duman

Akcicek

Noyan

(2017). Evaluation of attempted older adults suicides admitted to a University Hospital Emergency Department: Izmir study. Asian Journal of Psychiatry, 30, 196–199. https://doi.org/10.1016/j.ajp.2017.10.002

20.

Koo

C. Y.

Kim

J. S.

(2014). A study on factors influencing elders' suicidal ideation: Focused on comparison of gender differences. Journal of Korean Academy of Community Health Nursing, 25(1), 24–32. https://doi.org/10.12799/jkachn.2014.25.1.24

21.

Laanani

Imbaud

Tuppin

Poulalhon

Jollant

Coste

Rey

(2020). Contacts with health services during the year prior to suicide death and prevalent conditions a nationwide study. Journal of Affective Disorders, 274, 174–182. https://doi.org/10.1016/j.jad.2020.05.071

22.

Lee

Seol

K. H.

Kim

J. W.

(2018). Age and sex‐related differences in risk factors for elderly suicide: Differentiating between suicide ideation and attempts. International Journal of Geriatric Psychiatry, 33(2), e300–e306. https://doi.org/10.1002/gps.4794

23.

Lindner

Hery

Schaller

Schneider

Sperling

(2014). Suizidgefährdung und Suizidprävention bei älteren Menschen: Eine Publikation der Arbeitsgruppe „Alte Menschen “im Nationalen Suizidpräventionsprogramm für Deutschland. Springer-Verlag.

24.

Luan

Sun

Qin

Zhang

Jing

Wang

Xia

Jiao

A. a.

(2020). Gender difference in suicidal ideation and related factors among rural elderly: A cross-sectional study in Shandong, China. Annals of General Psychiatry, 19(1), 2. https://doi.org/10.1186/s12991-019-0256-0

25.

Minder

Ajdacic-Gross

Hepp

(2018). Suicide de la personne âgée. In Swiss Medical Forum (Vol. 18, No. 10, pp. 230–235). EMH Media.

26.

Muheim

Eichhorn

Berger

Czernin

Stoppe

Keck

Riecher-Rössler

(2013). Suicide attempts in the county of Basel: Results from the WHO/EURO multicentre study on suicidal behaviour. Swiss Medical Weekly, 143, w13759.

27.

Naghavi

Global Burden of Disease Self-Harm Collaborators . (2019). Global, regional, and national burden of suicide mortality 1990 to 2016: Systematic analysis for the global burden of disease study 2016. BMJ, 364, l94. https://doi.org/10.1136/bmj.l94

28.

Ólafsdóttir

Marcusson

Skoog

(2001). Mental disorders among elderly people in primary care: The Linköping study. Acta Psychiatrica Scandinavica, 104(1), 12–18. https://doi.org/10.1034/j.1600-0447.2001.104001012.x

29.

Pattyn

Verhaeghe

Bracke

(2015). The gender gap in mental health service use. Social Psychiatry and Psychiatric Epidemiology, 50(7), 1089–1095. https://doi.org/10.1007/s00127-015-1038-x

30.

Peter

Tuch

(2019). Suicidal thoughts and Suicide attempts in the Swiss population. Obsan Bulletin, 7, 1–8. Aviable from. https://www.obsan.admin.ch/de/publikationen/2019-suizidgedanken-und-suizidversuche-der-schweizer-bevoelkerung

31.

Romero

D. E.

Muzy

Damacena

G. N.

Souza

N. A. D.

Almeida

W. D. S. D.

Szwarcwald

C. L.

Malta

D. C.

Barros

M. B. D. A.

Júnior

P. R. B. D. S.

Azevedo

L. O.

Gracie

de Pina Lima

M. G.

Machado

Í. E.

Gomes

C. S.

Werneck

A. O.

Silva

D. R. P. D.

(2021). Older adults in the context of the COVID-19 pandemic in Brazil: effects on health, income and work. Cadernos de saúde pública, 37, e00216620.

32.

Rostami

Younesi

S. J.

Shahboulaghi

F. M.

Malakouti

S. K.

Foroughan

(2018). Models of suicide in elderly: A protocol for a systematic review. BMJ Open, 8(10), Article e022087. https://doi.org/10.1136/bmjopen-2018-022087

33.

Rymo

Fässberg

M. M.

Kern

Zetterberg

Skoog

Waern

Sacuiu

(2023 Jul). Mild cognitive impairment is associated with passive suicidal ideation in older adults: A population-based study. Acta Psychiatrica Scandinavica, 148(1), 91–101. https://doi.org/10.1111/acps.13549

34.

Schmutte

Olfson

Xie

Marcus

S. C.

(2020). Self-harm, suicidal ideation, and attempted suicide in older adults: A national study of emergency department visits and follow-up care. American Journal of Geriatric Psychiatry, 28(6), 646–658. https://doi.org/10.1016/j.jagp.2019.12.003

35.

Schneider

(2009). Substance use disorders and risk for completed suicide. Archives of Suicide Research, 13(4), 303–316. https://doi.org/10.1080/13811110903263191

36.

Shiraly

Mahdaviazad

Zohrabi

Griffiths

M. D.

(2022). Suicidal ideation and its related factors among older adults: A population-based study in Southwestern Iran. BMC Geriatrics, 22(1), 371. https://doi.org/10.1186/s12877-022-03049-9

37.

Stauffacher

M. W. D.

Stiefel

Dorogi

Michaud

(2022). Observational study of suicide in Switzerland: Comparison between psychiatric in- and outpatients. Swiss Medical Weekly, 152, w30140. https://doi.org/10.4414/smw.2022.w30140

38.

Steck

Egger

Zwahlen

(2016). Assisted and unassisted suicide in men and women: Longitudinal study of the Swiss population. The British Journal of Psychiatry, 208(5), 484–490. https://doi.org/10.1192/bjp.bp.114.160416

39.

Teasdale

Jennett

(1976). Assessment and prognosis of coma after head injury. Acta Neurochirurgica, 34(1–4), 45–55. https://doi.org/10.1007/BF01405862

40.

Tesch-Römer

(2010). Soziale beziehungen alter menschen. Kohlhammer Verlag.

41.

Troya

M. I.

Babatunde

Polidano

Bartlam

McCloskey

Dikomitis

Chew-Graham

C. A.

(2019). Self-harm in older adults: Systematic review. British Journal of Psychiatry, 214(4), 186–200. https://doi.org/10.1192/bjp.2019.11

42.

Vasiliadis

H.-M.

Gagné

Préville

(2012). Gender differences in determinants of suicidal ideation in French-speaking community living elderly in Canada. International Psychogeriatrics, 24(12), 2019–2026. https://doi.org/10.1017/S1041610212001251

43.

Waern

Rubenowitz

Runeson

Skoog

Wilhelmson

Allebeck

(2002). Burden of illness and suicide in elderly people: Case-control study. BMJ, 324(7350), 1355. https://doi.org/10.1136/bmj.324.7350.1355

44.

Waern

Rubenowitz

Wilhelmson

(2003). Predictors of suicide in the old elderly. Gerontology, 49(5), 328–334. https://doi.org/10.1159/000071715

45.

Wiktorsson

Runeson

Skoog

Östling

Waern

(2010). Attempted suicide in the elderly: Characteristics of suicide attempters 70 years and older and a general population comparison group. American Journal of Geriatric Psychiatry, 18(1), 57–67. https://doi.org/10.1097/JGP.0b013e3181bd1c13

46.

Yip

P. S. F.

Zheng

Wong

(2022). Demographic and epidemiological decomposition analysis of global changes in suicide rates and numbers over the period 1990–2019. Injury Prevention, 28(2), 117–124. https://doi.org/10.1136/injuryprev-2021-044263