Men an Endangered Species? A Look at Suicide and Vascular
Depression
By Arline Kaplan © 2001 (All Rights Reserved)
In Los Angeles, prominent defense attorney Barry Levin, 54, reportedly upset
over a debilitating illness, dies from a self-inflicted gunshot wound to the
head. In Michigan, millionaire auto parts entrepreneur Heinz C. Prechter, 59,
reportedly suffering from depression, also dies from an apparent suicide.
These news stories in the Washington Post and the Los Angeles Times
provide clues to an often hidden epidemic—suicide in older men. Steven
P. Roose, M.D., professor of clinical psychiatry at Columbia University’s
College of Physicians and Surgeons and director of the Neuropsychiatry Research
Clinic at New York State Psychiatric Institute, recently pointed out that "the
suicide cohort in the U.S. is overwhelmingly white, male and old."
Speaking at an industry-sponsored symposium in New Orleans on "Men Over
50: An Endangered Species?" Roose discussed the scope of the suicide epidemic
and sought to raise physicians’ awareness about their role in preventing
suicides.
Suicide takes the lives of more than 30,000 Americans each year, making it the
eighth leading cause of death in the country. But Roose contends these numbers
reflect underreporting.
Only one out of every two of actual suicides is reported as a suicide, he said,
because of insurance, stigma and other issues. So really if there is an accurate
reporting of suicide, this number would probably double, with suicide becoming
the third leading cause of death in the United States.
Four out of five successful suicides occur among males.
"Women have many more attempts than men, but per attempt, a man is four
times more likely to die than a woman," he said.
The pattern of completed suicides also differs between men and women. In males,
he said, there is a rapid increase in the rate of suicide in late adolescence
and the early twenties. After that, the rate levels off until men reach their
mid-fifties. Then, for Caucasian men only, the rate of suicide starts to "astronomically
rise." For women, the suicide rate gradually increases during the teen
years and early adulthood and then stays level. There is no late age peak in
the suicide rate for women.
Although persons aged 65 years and older represent only 13% of the population,
they account for 20% of the reported suicides, Roose said. As age increases,
the suicide rate increases. So among those aged 85 years and older, "there
is an astoundingly high rate," he added.
According to the National Strategy for Suicide Prevention (2001), the rate of
suicide among adults aged 65 to 69 years was 13.1 per 100,000 population; 70
to 74, 15.2/100,000; 75 to 79, 17.6/100,000, 80 to 84, 22.9/100,000; and aged
85 years and older, 21/100,000.
Older adults who are divorced or widowed are at a higher risk for suicide than
those who are married. In 1998, the suicide rate among men aged 75 years and
older who were divorced was 3.4 times the rate for married men of the same age
group, and for men who were widowed, it was 2.6 times that for married men.
In the same age group, the suicide rate for divorced women was 2.8 times and
for widowed women was 1.9 times the rate of married women.
Firearms (71%), overdose (11%) and suffocation (11%) were the three most common
methods of suicide among older adults.
Looking at diverse populations, Roose said that 90% of all suicides in the United
States involve Caucasians.
Worldwide Problem
Being old and male are not only risk factors for suicide among Americans, but
also among people throughout the world.
"Whether it is in Europe, Asia or South America, and irrespective of what
the baseline suicide rate is for the entire population, in every place that
is reported, you have a significant increase in suicide once the population
goes past the age of 65. Older people have higher suicide rates around the globe.
What is also true internationally, is the difference in suicide rates between
men and women," Roose said.
He cited examples: The suicide rate in Italy for all ages is 8/100,000, but
it jumps to 21/100,000 in people aged 65 years and older. The suicide rate in
Hungary and other countries in Eastern Europe is 42/100,000 for all age groups,
climbing to double that rate for persons aged 65 and older. In China, the baseline
rate for all ages is 17/100,000, but it climbs to 52.5/100,000 among those aged
65 years and older.
More disturbing than these statistics, Roose said, is the fact that in the United
States,
20% of older people who committed suicide saw a physician on the day that they
committed suicide, 41% had seen a physician within one week and 75% within one
month (National Strategy for Suicide Prevention, 2001).
Considering the effects of treatments for depression, Roose observed, "God
knows, the use of antidepressants has exploded in terms of use."
Still, despite all of our effective treatments for depression, the suicide rate
in the U.S. is not decreasing, he said.
"One of the critical issues is that we are not focusing on the patients
who are at greatest risk for suicide… the older patients. And that is backed
up by the fact that the amount of treatment studies in older Americans with
depressive illness is significantly restricted. If you get over the age of 75,
there are no large systematic data," he added.
Roose and colleagues just recently have completed the largest study of the treatment
in depression in patients over the age of 75. They randomized 178 patients to
citalopram (Celexa) versus placebo. The study included extensive magnetic resonance
imaging evaluations (MRI), along with cognitive functioning, platelet function
and neuropsychological evaluations.
The study "will give us data about the impact of treatment of depression
in the group that is at greatest risk for suicide," he said. Roose hopes
that eventually a psychobiology of the risk factors of suicide in this vulnerable
population will be developed.
"We want to call attention to this [need] and make this one of the research
agendas for the elderly," he said.
Vascular Depression
One of the acknowledged risk factors for suicide among older persons is the
higher prevalence of depression and more physical illnesses than in younger
adults.
Other speakers at the Endangered Species symposium discussed how erectile dysfunction,
cognitive decline, decreased testosterone and vascular disease are strongly
associated with reduced quality of life and depression. The speakers were K.
Ranga R. Krishnan, M.D., Duke University Medical Center; Raymond C. Rosen, Ph.D.,
UMDNJ-Robert Wood Johnson Medical School; Stuart N. Seidman, M.D., College of
Physicians and Surgeons of Columbia University; and Gary Small, M.D., UCLA School
of Medicine.
Krishnan, chairman of the department of psychiatry at Duke University, pointed
out that when psychiatrists examine patients who develop depression late in
life, they often find "subtle signs of vascular disease."
He defined vascular depression as a distinct subtype of late-life depression
usually characterized by the presence of major depression, specific characteristics
such as psychomotor retardation and apathy; older age of onset or change in
character of symptoms if early-onset, presence of non-central nervous system
vascular disease, and documentation of brain damage through neuroimaging findings
or by evaluating the patient neurologically.
"One of the first things that you will find when you do CT [computerized
tomography] scans or MRIs in elderly patients with depression is that many of
these patients often demonstrate strokes in the brain," Krishnan said.
"These strokes are present mostly in the frontal lobe or basal ganglia
regions of the brain. These are silent strokes or silent ischemic episodes.
You do not usually find motor signs or symptoms or sensory signs and symptoms.
What happens is that in these patients the stroke involves nonmotor and nonsensory
areas of the brain…primarily related to cognition and mood regulation."
There is a relationship between vascular disease and depression even in the
absence of full-blown depression, Krishnan said. He discussed evidence from
the Cardiovascular Health Study, a multicenter longitudinal study of risk factors
for coronary heart disease and stroke in 5,888 men and women aged 65 years and
older (Steffens et al., 1999). As part of their standardized clinical evaluation,
3,657 men and women have undergone brain MRI. Along with the MRIs, the researchers
conducted detailed interviews with the subjects and standardized assessments,
looking at cognitive function, the presence of depression as assessed by the
Center for Epidemiological Studies of Depression Scale (CES-D). On the MRI scans,
they graded the presence of silent strokes using a standardized system. They
found that there was a relationship between even mild depression as measured
by the CES-D and cerebrovascular disease, especially when lesions were in the
basal ganglia region.
"The next question is where in the brain are these lesions located which
you could specifically relate to depression," said Krishnan.
He discussed a study he and colleagues conducted involving 88 elderly patients
who were depressed and 47 controls.
"We identified the lesions and then mapped them, using a technique called
Statistical Parametric Mapping [SPM]. The SPM analysis basically identified
regions in the brain where there was an increased lesion density in the depressed
group compared to controls—the medial-orbital prefrontal white matter,"
he said. He added that severity of depression among depressed patients was correlated
with lesions in the medial-orbital region.
When considering the consequences of depression in patients with these types
of vascular changes, Krishnan said studies shows that these patients do not
respond as well to medications and that they may be more prone to cognitive
decline and dementia. There is also an increased risk of stroke and an increased
risk of mortality probably related to the concomitant vascular disease.
With regard to suicide attempts, he cited a study by colleagues Eileen Ahearn,
M.D., Ph.D., and David Steffens, M.D., at Duke. The investigators looked at
19 patients with suicide attempt history and age-and gender-matched them to
19 patients without such a history. Individuals with lesions seemed to have
a slightly higher rate of suicide attempts.
Treatment Considerations
Treatment options for vascular depression include behavioral intervention, stress
management, exercise training and pharmacological approaches, according to Krishnan.
"Pharmacological treatment involves a number of medications—the two
major classes being tricyclics and serotonin reuptake inhibitors," he said.
"There are a couple of things to keep in mind when treating this group
of patients, the first is to protect them from drug/drug interactions. Remember
that the elderly often receive between seven and 11 prescriptions per year,
and they are usually taking between four and seven drugs. So you need to be
aware of protein binding and enzyme effects through the cytochrome P450 system,
such as CYP 2D6, CYP 3A4 and 2C9 and C19 interactions.
"One should also remember that many patients with cardiac disease may have
other medical conditions that could affect the use of drugs, such as liver disease
and renal failure," he said.
Because of tricyclics’ well-known cardiac side effects (e.g., orthostatic
hypotension, Type 1 antiarrhythmic properties, conduction disturbance and increased
heart rate), Krishnan said he tends to favor the use of selective serotonin
reuptake inhibitors (SSRIs) in this population (Krishnan et al., 2001).
"SSRIs are generally much safer," he said.
He explained there is no evidence of orthostatic hypotension or pro/antiarrhythmic
properties with SSRIs. Additionally, they are associated with a modest decrease
in heart rate and they usually do not affect blood pressure, pulse rate, electrocardiogram
QRS waves, or QT intervals (Glassman, 1998).
Another interesting aspect of SSRIs, according to Krishnan, is that many SSRIs
also affect platelet function by reducing platelet aggregation.
"So one way in which these drugs may be useful in this population could
be…that they are also working directly on platelet aggregation and thereby
affecting the vascular process itself."
References
Glassman
AH(1998), Cardiovascular effects of antidepressant drugs: updated J Clin Psychiatry
59(suppl 15):13-18.
Krishnan KR (2001), Vascular disease and depression. Presented at the 154th
annual‘ meeting of the American Psychiatric Association. New Orleans, May
6.
Krishnan KR, Doraiswamy PM, Clary CM (2001), Clinical and treatment response
characteristics of late-life depression associated with vascular disease: a
pooled analysis of two multicenter trials with sertraline. Prog Neuropsychopharmacol
Biol Psychiatry 25(2):347-361.
National Strategy for Suicide Prevention (2001), At a glance – suicide
among the elderly. Available at: www.mentalhealth.org/suicide prevention/elderly.
Accessed on July 25, 2001.
Roose SP (2001), Suicide in men over 50: an epidemic. Presented at the 154th
annual‘ meeting of the American Psychiatric Association. New Orleans, May
6.
Steffens DC, Helms MJ, Krishnan KR, Burke GL (1999), Cerebrovascular disease
and depression symptoms in the Cardiovascular Health Study. Stroke 30(10):2159-2166.
(GT/Web
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