A prevalence study of suicide ideation among older adults in Hong Kong SAR

Transcription

1 INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY Int J Geriatr Psychiatry 2003; 18: Published online in Wiley InterScience ( DOI: /gps.1014 A prevalence study of suicide ideation among older adults in Hong Kong SAR Paul S. F. Yip 1 *, Iris Chi 2, Helen Chiu 3, Kwan Chi Wai 4, Yeates Conwell 5 and Eric Caine 5 1 The Hong Kong Jockey Club Centre for Suicide Research and Prevention, The University of Hong Kong, Hong Kong, China 2 Sau Po Centre on Ageing, The University of Hong Kong, Hong Kong, China 3 Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong, China 4 Clinical Trials Centre, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China 5 Department of Psychiatry, The University of Rochester, New York, USA SUMMARY Objective The objective of this paper is to ascertain estimates of the prevalence, and associated risk factors for, suicidal ideation among community-dwelling older adults in Hong Kong. Method The study was conducted as part of the General Household Survey (GHS), using face to face interviews of ethnic Chinese people aged 60 or above living in the community. Elders living in institutions or elderly homes were excluded from the study. Results Six percent of the sample was found to have ever had suicide ideation. The results showed that poor physical health, including poor vision, hearing problems, and a greater number of diseases; and poor mental health, especially in the form of depression, are predictors of suicidal ideation in the elderly population. Also, statistical analysis by linking individual factors to depression showed that financial and relationship problems are significant risk factors as well. Older adults who engaged in active coping, that is, those who actively seek to manage or control the negative events in their lives, fare better with lower levels of suicidal ideation than those who use passive coping styles. Conclusions The prevalence of suicidal ideation is similar among elders in Hong Kong and western countries. Factors that contribute to risk for suicidal ideation span physical and mental health, social, and psychological domains. Although the association of suicidal ideation to self-destructive acts remains to be determined, these findings indicate a variety of potential foci for late life suicide prevention efforts. Copyright # 2003 John Wiley & Sons, Ltd. key words depression; Hong Kong SAR; prevalence; suicidal ideation INTRODUCTION *Correspondence to: Dr Paul S. F. Yip, The Hong Kong Jockey Club Centre for Suicide Research and Prevention, Faculty of Social Sciences, The University of Hong Kong, Hong Kong, China. sfpyip@hku.hk Contract/grant sponsor: Working Group on Elderly Suicides of the Health and Welfare Bureau of the Hong Kong Government of the Special Administrative Region, Coroners, Census and Statistics Department. A recent World Health Organization report estimated suicide to be the cause of 1.8% of the world s 54 million deaths in 1998 (Jamison, 1999). The Organization also estimates a worldwide figure of one million suicide deaths in the year 2000 (World Health Organization, 2002). This translates into a global mortality rate of about 16 per or one death every 40 seconds. Worldwide, older adults are the highest risk group for suicide, exceeding the much-publicized rates of younger age groups. The ratio of attempted to completed suicides is considered much lower among seniors than young adults as older suicides demonstrate greater lethality and determination compared to younger groups (Kessler et al., 1999; Klinger, 1999; Conwell, 2001; Paykel et al., 1974). Apart from the people who die, there are many more who make non-fatal attempts on their own lives, or harbour destructive thoughts to that end. Our focus in this study is on suicidal ideation, defined as wishes to Received 20 May 2003 Copyright # 2003 John Wiley & Sons, Ltd. Accepted 26 August 2003

2 suicide ideation among older adults in hong kong 1057 be dead or thoughts of killing oneself. Hong Kong, a Special Administrative Region (SAR) that was formerly a British Colony, has been under Chinese Sovereignty since Suicide risk in Hong Kong tends to increase across the life course for both men and women, with the highest suicide rates occurring among the oldest age groups (McIntosh and Santos, 1982; Lo and Leung, 1985; Hau, 1993; Ho, 1996; Yip, 1996). The suicide rate ratio of seniors to the general population is higher than in western countries (Yip, 1996, 1997; Yip et al., 1998). In 2000, 888 lives were lost through suicide, representing 2.5% of the total number of deaths in Hong Kong. In 2000, suicide rates for the age groups 5 14, 15 24, 25 59, and 75 or above were 0.5, 9.2, 12.2, 23, and 50 per respectively (Chan et al., 2002; Yip and Chi, 2002). The suicide rate for the general population was 12 per The ratio for male to female suicide rates were about 1.7 to 1 whereas the ratio for the younger age groups was about 1 which was also very different from that of western countries, for example, the male to female suicide ratio was about 4 to 1 in Australia (Yip, 1998b). Suicidal ideation is a risk factor for attempted and completed suicide (Schwab et al., 1972; Goldstein et al., 1991; Alexopoulos et al., 1999) and a commonly used sign to clinicians of the need for further risk assessment (Olfson et al., 1996). Estimates of the prevalence of suicidal ideation among older adults in western studies range from 0.7% in the prior week (Callahan et al., 1996) to 15.9% in the preceding month (Skoog et al., 1996). Seven percent of adults over age 80 years in UK endorsed a strong wish to die in the last two years (Rao et al., 1997), while in a Florida community survey six percent of respondents over age 60 endorsed ever having suicidal thoughts (Schwab et al., 1972). Rates were higher in women than men, and in subjects with histories of either mental or physical illnesses (Callahan et al., 1996; Skoog et al., 1996; Rao et al., 1997). Rates of late life suicide are higher in Asian than western countries (Yip, 1998b; Yip and Chi, 2002). However, suicidal ideation has not been well studied there. In this paper we examine the prevalence of suicide ideation among elderly in Hong Kong. We hypothesized that the suicide ideation is related to the following factors: (i) Health Status; (ii) Functioning ability; (iii) Financial Status; (iv) Utilization of Health Care; (v) Social Support; (vi) Life event Stressors; (vii) Coping Strategies and Styles; (viii) Depression. We suspect that poor health status, functional ability, financial status, inadequate social support and insufficient coping strategies and the presence of depression and life event stressor are expected to be related to the suicide ideation and/or attempts. To the best of authors knowledge the population-based sample is the first of this kind to be done in Asia or in an ethnic Chinese community. DATA AND METHOD Target population and sampling framework The target population was ethnic Chinese people living in Hong Kong, aged 60 and above, who were contactable by telephone and who lived in accessible areas. Collective households (e.g. homes for the aged or in the hospital), those with failed memory test, language barriers were also excluded from the sampling framework and it accounts for about 5%. With the assistance of the Census and Statistics Department (C&SD) of the Hong Kong SAR Government, the study was conducted as a supplement to the General Household Survey (GHS). A total of 2588 households were identified in the GHS as having at least one elderly person aged 60 or above. These households had been interviewed twice for a complete survey cycle of the GHS, once in October to November 1999 and a second time in a repeat interview carried out in January to February To elicit better response from the target respondents, those households confirmed as having at least one elderly person aged 60 or above on the GHS were asked in the repeat interview in January to February 2000 about their willingness to further participate in this prevalence study. Those who were unwilling to participate were excluded, leaving a total of 2297 eligible households as the sampling frame. Of this number, 1500 households were randomly selected for the prevalence study. When there was more than one person aged 60 or above in a household, one elderly person was randomly selected. Upon conclusion of the survey, a total of 917 elderly persons (out of 1500 selected) were successfully enumerated. The response rate was 72.5%. The interviewers who assist in collecting the information are graduates with social work training in the University of Hong Kong. Questionnaire (I) Dependent variable. Suicidality as considered in this paper refers to the actual wish to be dead (lower severity), suicidal ideation and intentions (including suicidal plans or gestures), and suicidal attempts (highest severity) (Linden and Barnow, 1997). The suicidal ideation measure was derived from six items

3 1058 p. s. f. yip ET AL. of the Geriatric Mental State Examination-Version A (GMS-A), a semi structured interview designed for elderly subjects (Copeland and Dewey, 1991). The items, each rated dichotomously (yes/no) were: (1) Has ever felt suicidal or wished to be dead; (2) has felt suicidal or wished to be dead sometime in the last year; (3) has felt suicidal or wished to be dead sometime in the last month; (4) has felt a wish to be dead for at least two weeks in the last month; (5) rejected suicide but has actually wished to be dead because life is a burden; (6) has done something or planned to do something about killing self. The percentages of individual items were not shown due to sparseness of the data and some possible missing values among the six items from the respondents. Our interest is on the prevalence on suicide ideation and/or attempts. In the current study, a case is considered as having suicidal ideation when any one or more of the six items is endorsed. (II) Independent variables i. Health Status Separate ratings of the presence or absence of 13 diseases were obtained by asking respondents whether a doctor had ever told them that they had hypertension, heart disease, stroke, Parkinson s Disease, diabetes, respiratory problems (including chronic bronchitis and emphysema and asthma), chronic live diseases, kidney diseases, malfunction of thyroid gland, arthritis, cancer, bone fracture, or dementia. Respondents were also asking whether they had chronic pain (more than six months), incontinence, long-term constipation, or problems chewing. Moreover, two items on vision and hearing problems were also collected, each on a four-point scale from 1 ( ¼ very good) to 4 ( ¼ almost or totally blind/deaf). ii. Functioning Functional capability was assessed by basic activities of daily living (ADL), measured by the Physical Self Maintenance Scale (PSMS) and instrumental activities of daily (IADL) (Lawton and Brody, 1969). ADL limitations refer to help needed to accomplish six basic activities including toileting, feeding, and dressing, grooming, bathing, and transferring. Each activity was rated on a five-point scale (0 to 4). IADLs include difficulties in using the telephone, shopping, cooking, and laundry, using public transportation, medication, and financial management, each rated on a 4 point scale ranging from 0 to 3. In both ADL and IADL measures, responses for the items were summed with higher scores indicating higher functional disability. iii. Financial Status Respondents were asked whether they received government welfare called Comprehensive Social Security Assistance Scheme (CSSA Scheme). A measure of financial status was based on one item that inquired of subjects what they felt about their financial situation. Responses were rated on a five-point scale: 1 ¼ very sufficient; 2 ¼ sufficient; 3 ¼ fine; 4 ¼ insufficient; 5 ¼ very insufficient. iv. Utilization of Health Care Frequency of receiving medical services and hospitalization for mental health problem from family doctor or psychiatrist was recorded. v. Social Support Social support from family members and friends was measured by Lubben Social Network Scale (LSNS) (Lubben, 1988). The LSNS is a ten-item measure of five aspects of social networks family, friends, helping others, confidant relationships, and living arrangements rated on a six-point scale ranging from 0 to 5. The Chinese version of the LSNS has been widely in previous studies among Chinese older adults (Chi and Chou, 2001; Chou and Chi, 2001). Responses for these ten items were summed with higher scores indicating higher level of social support. vi. Life Events Stressors Stressful life events were assessed using a series of questions about the occurrence of particular events in the preceding three years. All respondents were asked if they had experienced each of six different life events: moving house, death or serious illness of a family member, relationship problem, and financial problem, victimization in a theft or robbery, and involvement in legal battles. These items were selected based upon previous study indicating their strong psychological impact on Hong Kong elderly (Boey and Chiu, 1998). vii. Coping Strategies and Styles Style or method of coping was measured by the Simplified Coping Style Questionnaire (Xie, 1998). This is a 20-item scale, each item ranging in value from 0 to 4, a self-report measure designed for the Chinese population. The scale measures active coping styles versus passive coping styles. In general, coping serves two functions, dealing with the problem that is causing the emotional distress (problem-focused or active coping) and dealing with the distressing emotions caused by the problem (emotion-focused or passive coping) (Kraaij et al., 2002). Questions 1 to 12 reflect active coping strategies, while questions 13 to 20 reflect passive coping strategies. Xie (1998) found high correlation among all 12 items of

4 suicide ideation among older adults in hong kong 1059 active coping styles (Cronbach Alpha ¼ 0.89) and all 8 items of passive coping styles (Cronbach Alpha ¼ 0.78). viii. Depression The 15-item Geriatric Depression Scale Short Form (GDS) was used to measure depressive symptoms. Yesavage and Brink (1983) discuss in detail the properties of the scale and its appropriateness for use with community-dwelling adults. The participants were asked about 15 depressive symptoms that they might have experienced in the two weeks preceding the interview. The 15 items were scored on a dichotomous scale from 0 to 1 (0 ¼ no, 1 ¼ yes), and the scale was the unweighted sum of the 15 component items, with a potential range of 0 to 15. The Chinese version of the GDS had been validated in earlier studies (Lee et al., 1994; Boey and Chiu, 1998). A cut-off score of 5 was used for the original version whereas a cut-off 8 was adopted for the translated Chinese version used here (Boey and Chiu, 1998; Chou et al., 1999). Both univariate and multiple logistic regressions with stepwise selection method were employed to test for individual and multiple effects. Since some of the variables are highly correlated, results for the univariate and multiple regressions were both reported. The significance level for all results was set at p < RESULTS Socio-economic profile The cases were made up of 48.5% men and 51.5% women. The ages of the interviewees ranged from 60 to 98 years and the mean age was 71 years. Forty-eight percent of the total interviewed were aged 60 to 69 years, 37.1% aged 70 to 79 years and 14.9% aged 80 and above. Their length of stay in Hong Kong ranged from 1 to 86 years and the mean length was 48.3 years. Prevalence of suicide ideation About 5.5% (n ¼ 50) of the elderly population have endorsed at least one of the six items. Of those, ten of them have carried out a suicide attempt within a year. Among elderly people who were depressed (n ¼ 116), 25.9% had suicidal ideation, in contrast to only 2.5% of non-depressed elderly subjects. Since the independent variables are correlated, univariate and multivariate analysis were both reported. Results from a logistic regression relating individual factors to suicidal ideation are presented in Table 1. Table 1. Results of a Logistic regression to examine the individual risk factors to suicidal ideation Odds 95% Confidence p-value ratio interval Sex Female 1.00 Male Age Years in HK Marital status Married, with spouse 1.00 Married, not with spouse Single > Separated > Divorced Widowed Living arrangement Alone 1.00 Spouse only Spouse and children Children only Relatives/friends Not related Employed Educational level No religion Financial status CSSA Self-rated financially insufficient Self-rated health as unhealthy Health and functioning Memory (cognition) Number of diseases Chronic pain Incontinence < Long-term constipation Eating problem Vision problem Hearing problem IADL PSMS Utilization of health care Frequency of seeing doctor Social support life event stressors LSNS Life event Change of living (negative) Member died or ill Relationship Financial problems Robbed Court case Passive coping Active coping < Depression < Note: If the ratio is larger than one, it implies a higher risk of having suicide ideation; if it is smaller than one, then the risk is smaller.

5 1060 p. s. f. yip ET AL. Women had a higher risk of having suicide ideation than men. Marital status is not significant in itself, but being widowed seems to be marginally so ( p ¼ 0.04). Other factors that are significant predictors of suicidal ideation include a self-rated poor financial state, selfrated poor physical health, the number of chronic diseases, vision problems, hearing problems, having problems with ADLs and IADLs, the lack of social support, and the frequency of seeing a doctor. Life events that increase the risk of having suicidal thoughts are relationship problems, being robbed, and involvement in court cases. The single most significant health factor appears to be incontinence, and the single most significant psychological factor appears to be depression. Coping skills are significantly related to the risk. Specifically, those who used fewer active coping skills and those who are depressed are at higher risk for suicidal ideation. A forward selection method was employed to determine the significant risk factors affecting suicidal ideation in the presence of the other risk factors. Table 2 shows that when attempting to determine the risk for an elderly person of suicidal ideation, attention should be paid to factors such as the number of diseases they suffer from, their visual and hearing functionality, whether the elderly person was involved in a court case, and how depressed the elderly person appears to be. Usually, court cases refer to those involved in the court proceeding and pending for a trial. There are no significant difference in profile between the ideators and attempts (Results are not shown here). The number of suicide attempts is very small (n ¼ 10). DISCUSSIONS Estimates of the prevalence of suicidal ideation in older adults vary widely. The 5.5% of elderly people surveyed in the prevalence study expressed a wish to commit suicide in Hong Kong is similar to the 7.3% found in Lish et al. (1996) and 6% in a Florida Community survey endorsed ever having had suicidal Table 2. Results from a Logistic regression using forward selection for suicide ideation Odds 95% Confidence p-value ratio interval Number of diseases Vision problem Hearing problem Court case Depressed thoughts (Schwab et al., 1972). These suicidal thoughts are highly correlated with both depression and physical illness (Conwell et al., 2002). The depression among the elderly was very much neglected and untreated in the community. Over 30% of the elderly had indicated among their wishes to die to their family members among the suicide samples. However, the family members fail to respond to the need and have not taken the warning sign serious enough to obtain support from professionals. Findings of the current study also suggest that indicators of physical health status, including chronic pain, in continence and vision impairment are significantly related to depression among Hong Kong older adults. It might be related to the inadequacy of the medical and health service to elderly. On the other hand, about 75% of the elderly victims in a separate psychological autopsy study had consulted a medical practitioner within one month of his or her suicide and more than 90% within three months (Yip et al., 2001). Similar observations have been made in studies from other countries (Pirkis and Burgess, 1998; Appleby et al., 1999; Isometsä, 2000; Conwell, 2001). It suggests that primary care physicians or general practitioners can be a valuable partner to work as a gate keeper in community-based prevention of suicide older adults by detecting older adults at risk. Marriage has been shown to be a protective factor against suicide (Smith et al., 1988; Yip, 1998a), and being widowed increases suicide risk (Duberstein et al., 1998). Our findings showed that being widowed has a higher risk than other marital status groups. Due to the difference in life expectancy between men and women worldwide, for example, 78 and 82 years for males and females in Hong Kong respectively, about 30% of older adults are widowed (Census and Statistics Department, 2002). They represent a special group to target in suicide prevention efforts. The reduction of suicide rate in UK for the past few years is attributed to the decrease in suicide rate among the older widowed group (Yip et al., 2000). A good family relationship has been shown to be a protective factor which is especially applicable to Chinese family. It is less common for older adults to live with their children in western countries than in Hong Kong. Recent years, however, have seen a change in which the prevalence of extended families has reduced substantially while the nuclear family has become the norm. The mean household size has decreased from 5.0 to 3.1 in the past two decades (Yip and Lee, 2002). Yip reports that both single and widowed elders are at high risk for suicide in Hong Kong (Yip, 1997) may be explained in part by

6 suicide ideation among older adults in hong kong 1061 the older adults unhappiness with losing close contact with their adult children or their grandchildren. As well, seniors may function less well when staying alone by themselves than when with family, increasing risk, especially for those who lack an active coping response. The financial status of the seniors has been shown to be significant to suicide ideation. The poverty level among the older adults is high. Family members are the major source of income for about 45% of older adults in Hong Kong, and 15% received welfare from the Government. Many feel the support from the Government is insufficient (Census and Statistics Department, 2002). Also, the majority of the recipients do suffer from more problems, for example, physical illness, disabilities, and lack of family support, further contributing to suicide risk. Furthermore, such factors as vision and hearing problems, difficulty in carrying out daily living activities and the lack of a social support network are significant factors relating to their wish to commit suicide. Suicide among elders is not solely a medical problem, but a public health approach is needed for the prevention. It must involve all sectors of our community (Yip et al., 2001). The 5.5% suicide ideation is not particularly high in the international standard. However, it is important for a rapidly ageing city such as Hong Kong to reduce the suicide rate and ideation to a low level. Otherwise, the situation is likely to worsen. Limitation of the study It is a cross sectional study which might not be able to establish the cause effect relationship with the suicide ideation. Also, it is based on self-reported measures with no disentanglable information about suicide attempts and lack of structured psychiatric diagnosis. 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