ANNOTATION (Kemuel Philbrick)

The Finding: Fifty-nine international quantitative studies were reviewed to ascertain which, if any, specific physical illnesses and/or functional disabilities are associated with suicidal behavior (subdivided into death wishes, suicidal ideation, nonfatal suicidal behavior, and/or completed suicide) in adults aged 65 and older.
Some studies examined broad populations with “physical illness” whereas others focused on particular categories, including subjective perceptions of poor health, vision and hearing loss, cardiovascular, pulmonary, gastrointestinal, renal, endocrine, genitourinary, musculoskeletal, neurological, and oncologic conditions, as well as chronic pain.
Some studies were population or register-based reviews, others were clinically-based reviews, and a handful were post-mortem studies.
Although there were contradictory findings in several areas, suicidal behavior was associated with functional disability and seven specific clinical categories: malignant diseases, neurological disorders, pain, COPD, liver disease, male genital disorders, and arthritis. It bears mention that studies focusing on cognitive impairment were not included in this review.
Six qualitative studies revealed recurring emphases on: frustration with illness, disability and loss of autonomy, physical discomfort and pain, diminished sense of usefulness, increased perception of being a burden, and diminished capacity to enjoy living.

Strengths and Weaknesses: This review was an ambitious undertaking to examine what is available in the world’s literature to clarify the association between common comorbidities of advancing age and the known heightened risk of suicide in the elderly; it represents a prodigious review of potentially informative studies resulting in close scrutiny of 61 different patient samples from four continents.
Unfortunately, this review encountered significant differences in methodology and definitions of suicidal behaviors. The severity of the various medical conditions and the time elapsed since initial diagnosis were rarely characterized. Furthermore, few studies offered sex-specific results. Lastly, the authors involved in post-mortem assessments acknowledged that they considered suicide appropriate in this age cohort, a perspective that may have shaped their findings.

Relevance: The risk for suicide conferred by physical illness and functional disability, while increased, remains modest compared to the risk associated with psychiatric comorbidity. The consultation psychiatrist often has the opportunity to assess both side-by-side. This opportunity will be strengthened by increased integration of psychiatric care into primary care and particularly geriatric and palliative care settings. When choices must be made about where to deploy integrated mental health professionals due to limited resources, it may be worth first choosing areas such as oncology, neurology, or pain clinics.