Suicide attempts among the elderly: a review of the literature (2002/2013)

Maria Cecília de Souza Minayo Fátima Gonçalves Cavalcante About the authors

Abstracts

Foi realizada revisão da literatura sobre as principais questões associadas às tentativas de suicídio em pessoas idosas. O estudo abrangeu o período de 2002 a 2013, a partir das bases Medline, Lilacs, PubMed, PsychInfo, SciELO, Biblioteca Virtual em Violência e Saúde da Bireme e Biblioteca Virtual de Saúde Pública (BVS/SP). Foram selecionadas 105 referências e analisadas 75. Os estudos se ampliaram na América do Norte, Europa e Ásia, são raros na América Latina e inexistem na África. Predominam investigações epidemiológicas. Os principais fatores predisponentes são doenças graves e degenerativas, dependência física, distúrbios e sofrimentos mentais e depressão severa. A depressão é o mais relevante fator explicativo associado a sofrimento físico crônico, perdas, abandonos, solidão e conflitos familiares. Diferenças de gênero, etnia, avanço da idade, questões sociais e traços culturais foram encontrados. O tema em pauta é da mais alta relevância para o Sistema Único de Saúde, mas não tem sido abordado no Brasil nem na teoria e nem na prática. Que esta revisão seja base para estudos empíricos que favoreçam o apoio à saúde do idoso e promova um envelhecer saudável.

Idoso; Tentativa de suicídio; Suicídio e ideação; Fatores de risco; Revisão


A literature review was carried out focusing on the main factors associated with suicide attempts among the elderly. The research was conducted between 2002 and 2013 in the MEDLINE, Lilacs, Pubmed, PsychINFO, SciELO, the Virtual Library in Violence and Health from BIREME and the Virtual Library of Public Health databases. 105 texts were selected and 75 were analyzed. Studies are on the increase in North America, Europe and Asia, rare in Latin America and do not exist in Africa. The major causal factors for attempted suicide are degenerative and chronic diseases, physical dependence, mental disturbances and suffering, as well as severe depression. Depression is the most relevant cause found, combined with chronic physical suffering, loss, abandonment, loneliness and family conflicts. Differences in gender, ethnicity, the ageing process, social issues and cultural backgrounds are also major contributing factors. The subject of suicide attempts among the elderly is a problem that is extremely relevant to the Unified Health System (SUS); however, this problem is not addressed in Brazil in theoretical or practical terms. We trust that this review can serve as a model for empirical studies to contribute to health support for the elderly and promote health in old age.

The elderly; Attempted suicide; Suicide and ideation; Risk factors; Review


Introduction

This study presents the current status of knowledge, the main issues discussed, the investigation methods applied and proposals for suicide prevention, which are found in studies into suicide attempts among elderly people.

A suicide attempt is understood to involve acts performed by individuals who intend to kill themselves, but which do not result in death11. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editores. Relatório Mundial sobre Violência e Saúde. Geneva: Organização Mundial da Saúde (OMS); 2002.. These actions are often related to the individuals’ emotional inability to identify feasible alternatives for solving their conflicts and sufferings, so that death appears to be the only way out. A series of factors are associated with suicide risks and include physically disabling diseases, mental illnesses, alcohol and substance abuse as well as family and socio-economic issues. With regards to elderly people, most studies show a strong incidence of depression and other psychiatric disorders, as well as degenerative diseases that cause dependence or unbearable physical suffering, dependence and social isolation.

A narrow relationship exists between ideation, attempted and consummated suicides among the elderly. The American Association of Suicidology22. American Association of Suicidology. Elder suicide fact sheet. [acessado 2014 maio 10]. http://www.sciencedaily.com.
http://www.sciencedaily.com...
estimates that among the general population there is one consummated death in every twenty-five suicide attempts; among youngsters, the ratio is of approximately one for every 100 to 200 attempts; and among the elderly, the ratio is 1:4. It is evident that it is important that society and the healthcare sector take action to reduce the risk of such acts.

There are several reason why interest has been shown in studying suicide attempts among elderly people in Brazil: (1) the number of people in the country over the age of sixty has increased; (2) international and national studies show that suicide attempts are a form of violence that demonstrate quality of life issues33. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am 2008; 31(2):333-356.66. Cavalcante FG, Minayo, MCS. Autópsias psicológicas e psicossociais de idosos que morreram por suicídio no Brasil. Cienc Saude Colet 2012; 17(8):1943-1954.; (3) the World Health Organization - WHO - have declared that, in the case of elderly persons, suicide attempts constitute a serious public health issue11. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editores. Relatório Mundial sobre Violência e Saúde. Geneva: Organização Mundial da Saúde (OMS); 2002.; (4) the fact that only the most severe cases reach the healthcare services and are statistically recorded. And last, but not least, (5) knowing the reasons why an elderly person has attempted to take his or her own life, is crucial in order to be able to create an effective suicide prevention program.

The current review deals mainly with articles about attempted suicide. Available literature shows that these suicide attempts are correlated to both ideation and consummated suicides, but also present characteristics of their own.

Method

The current research study covers the period from 2002 to 2013. It encompasses published articles which are indexed at the Public Health Virtual Library (BVS/SP) at the Pan-American Health Organization's Regional Library of Medicine (Bireme), at Medline, PubMed and at PsycINFO. The researched subjects include: “suicide attempts among the elderly”; “the risk of suicide attempts among the elderly”; and “the prevention of suicide attempts among the elderly.” This survey located a total of one hundred and five documents, thirty of which were not directly related to the subject reviewed because they dealt with self-neglect, ideation and consummated cases. Another series of articles excluded discussed cases of attempted suicide in long-stay institutions, such as nursing homes and retirement residences, and this issue does not form part of the present study. Of the remaining eighty texts, three did not refer to the period under review.

All the abstracts were read and thirty-five articles were analyzed in their full text versions. The review was carried out according to documental analysis criteria: by organizing the material in accordance with the aims of the current study; by analyzing the methodology adopted in the articles, the approach used to investigate their content and the emphasis given to their findings and conclusions.

The main analysis categories used in this study were (1) the viewpoint of the authors with regards to the reasons why elderly people attempt suicide and the risk factors involved in such cases; (2) the methods employed by the authors; (3) the regional diversity of the articles and their special characteristics; and (4) suicide prevention proposals.

Results

The views of the authors with regards to suicide attempts and the risk factors involved

The classificatory category called “views of the authors,”includes motivation, clinical and situational diagnosis and risk factors. The texts were read based on these three perspectives.

The most common diagnosis found in the majority of the articles on suicide attempts among the elderly, is the presence of chronic depression associated with other psychiatric problems77. De Leo D, Padoani W, Lonnqvist J, Kerkhof AJ, Bille-Brahe U, Michel K, Salander-Renberg E, Schmidtke A, Wasserman D, Caon F, Scocco P. Repetition of suicidal behaviour in elderly Europeans: a prospective longitudinal study. J Affect Disord 2002; 72(3):291-295.2323. Kato K, Akama F, Yamada K, Maehara M, Saito M, Kimoto K, Takahashi Y, Sato R, Ichimura A, Matsumoto H. Frequency and clinical features of suicide attempts in elderly patients in Japan. Psych Clin Neurosci 2013; 67(2):119-122.. Several authors claim that depression is the most relevant risk factor to make a person want to end their life2424. Szanto K, Mulsant BH, Houck P, Miller MD, Dew MA, Reynolds CF. Occurrence and course of suicidality during short-term treatment of late-life depression. Arch Gen Psychiatry 2003; 60(6):610-617.. Others underline the relevance of depression, claiming that this is the key to understanding the whole question of suicide99. Lykouras L, Gournellis R, Fortos A, Oulis, P, Christodoulou, GN. Psychotic (deulional) major depression in elderly and suicidal behaviour. J Affect Disord 2002; 19(1-3):225-229.,1212. Dabi E, Matusevich D, Finkelsztein C. Major depressive disorder in suicide attempts among over 60 years old patients. Vertex 2003; 14(52):124-127.,2020. Heisel MJ, Conwell Y, Pisani AR, Duberstein PR. Concordance of Self-and Proxy-reported Suicide Ideation in Depressed Adults 50 Years of Age or Older. Can J Psychiatry 2011; 56(4):219-226.,2525. Kirsi S, Erkki I, Lönnqvist J. Elderly suicide attempters with depression are often diagnosed only after the attempt. Int J of Geriatr Psychiatry 2004; 19(1)35-40.

26. Ziervogel A, Pfeiffer T, Hegerl U. How effective is advanced training concerning depression and suicidality among the elderly? Results of a pilot study. Arch Suicide Res 2005; 9(1):11-17.

27. Tan LL, Wong HB. Severity of depression and suicidal ideations among elder people in Singapore. Int Psychogeriatr 2008; 20(2):338-346.
-2828. McGirr A, Dombrovski AY, Butters MA, Clark L, Szanto K. Deterministic learning and attempted suicide among older depressed individuals: cognitive assessment using the Wisconsin Card Sorting Task. J Psychiatr Res 2012; 46(2):226-232..

Although they highlight the crucial role played by chronic depression, most of the authors whose views stress that there is evidence that depression combined with physical and mental health morbidity and social issues are factors in cases of attempted suicide: symptoms of depression associated with chronic diseases, insomnia and the absence of family and friends with whom they can share their problems2929. Turvey CL, Conwell Y, Jones MP, Phillips C, Simonsick E, Pearson JL, Wallace R. Risk factors for late-life suicide: a prospective, community-based study. Am J Geriatr Psychiatry 2002; 10(4):398-406.; the loss of vision and hearing, other degenerative diseases and a fragile mental state1010. Yip PSF, Chi I, Chiu H, Wai KC, Conwell Y, Caine E. A prevalence study of suicide ideation among older adults in Hong Kong SAR. Int J Geriatr Psychiatry 2003; 18(11):1056-1062.; frequently undiagnosed personality disorders combined with chronic and degenerative diseases that lead to a loss of independence and acute suffering, loneliness and social isolation1111. Matusevich D, Finkelsztein C, Dabi E. Suicide attempts in elderly people. Vertex 2003; 14(52):119-123.,1212. Dabi E, Matusevich D, Finkelsztein C. Major depressive disorder in suicide attempts among over 60 years old patients. Vertex 2003; 14(52):124-127.; personality disorders associated with recent traumatic events1414. Tsoh J, Chiu HF, Duberstein PR, Chan SS, Chi I, Yip PS, Conwell Y. Attempted suicide in elderly Chinese persons: a multi-group, controlled study. Am J Geriatr Psychiatry 2005; 13(7):562-571.; lack of social support and physical inactivity combined with symptoms of depression and alcohol abuse1515. Awata S, Bech P, Koizumi Y, Seki T, Kuriyama S, Hozawa A, Ohmori K, Nakaya N, Matsuoka H, Tsuji I. Validity and utility of the Japanese version of the WHO-Five Well-Being Index in the context of detecting suicidal ideation in elderly community residents. Int Psychogeriatr 2007; 19(1):77-88.; the presence of cerebrovascular diseases3030. Chan SS, Lyness JM, Conwell Y. Cerebrovascular risk factors confer risk for suicide in later life? A case-control study. Am J Geriatr Psychiatry 2007; 15(6):541-544. and subclinical symptoms such as anxiety and hostile behavior patterns combined with insomnia and relational difficulties3131. Liu IC; Chiu CH. Case-control study of suicide attempts in the elderly. Int Psychogeriatr 2009; 21(5):896-902.; relationship with schizophrenia3232. Barak Y1, Knobler CY, Aizenberg D, Schizophr RES. Suicide attempts amongst elderly schizophrenia patients: a 10-year case-control study. Schizophr Res 2004; 71(1):77-81.; loneliness followed by financial and social survival difficulties associated with psychiatric issues combined with previous suicide attempts1818. Wiktorsson S, Runeson B, Skoog I, Ostling S, Waern M. Attempted suicide in the elderly: characteristics of suicide attempters 70 years and older and a general population comparison group. Am J Geriatr Psychiatry 2010; 18(1):57-67.; family conflicts, social privation, feelings of despair and a low level of self-esteem3333. Im MY, Kim YJ. A phenomenological study of suicide attempts in elders. J Korean Acad Nurs 2011; 41(1):61-71.,3434. Klonsky ED, Kotov R, Bakst S, Rabinowitz J, Bromet EJ. Hopelessness as a predictor of attempted suicide among first admission patients with psychosis: A 10 year cohort study. Suicide Life Threat Behav 2012; 42(1):1-10.; lack of social support associated with chronic depression2020. Heisel MJ, Conwell Y, Pisani AR, Duberstein PR. Concordance of Self-and Proxy-reported Suicide Ideation in Depressed Adults 50 Years of Age or Older. Can J Psychiatry 2011; 56(4):219-226.; loneliness, isolation, lack of social support, an environment where there are family conflicts, the loss of loved ones combined with mental disorders and substance abuse; the presence of degenerative diseases that cause acute suffering and the fact that they have made a previous suicide attempt1313. Serna PI. Prevención del suicidio en los ancianos, suicidio-homicidio, ampliado y asistido. Geriatrika 2004; 20(1):18-22.; panic syndrome associated with prescription drug abuse2222. Encrenaz G, Kovess-Masféty V, Gilbert F, Galéra C, Lagarde E, Mishara B, Messiah A. Lifetime risk of suicidal behaviors and communication to a health professional about suicidal ideation. Results from a large survey of the French adult population. Crisis 2012; 33(3):127-136.; personality disorders, anxiety disorders, a lifetime of substance abuse, problems related to a lack of maternal affection during their childhood development, and social maladjustments3535. May AM, Klonsky ED, Klein DN. Predicting future suicide attempts among depressed suicide ideators: A 10 year longitudinal study. J Psychiatr Res 2012; 46(7):946-952.,3636. Blüml V, Kapusta N, Doering S, Blahler E, Wagner B, Kersting A. Personality factors and suicide risk in a representative sample of German general population. Plos One 2013; 8(10):e76646.. In a multi-centric study carried out in Europe, De Leo et al.77. De Leo D, Padoani W, Lonnqvist J, Kerkhof AJ, Bille-Brahe U, Michel K, Salander-Renberg E, Schmidtke A, Wasserman D, Caon F, Scocco P. Repetition of suicidal behaviour in elderly Europeans: a prospective longitudinal study. J Affect Disord 2002; 72(3):291-295. found that the following factors predispose people to make repeated suicide attempts: losing a father in childhood which results in financial difficulties, relational problems, prevalence of affective psychoses, depression, alcohol abuse and disease.

Some authors highlight different gender patterns when discussing cases of attempted suicide among the elderly: risks tend to reduce with age in the case of women and to increase with men. Cook et al.88. Cook JM, Pearson JL, Thompson R, Black BS, Rabins PV. Suicidality in older African Americans: findings from the EPOCH study. Am J Geriatr Psychiatry 2002; 10(4):437-446. and Salib and Green3737. Salib E, Green L. Gender in elderly suicide: analysis of coroners inquests of 200 cases of elderly suicide in Cheshire 1989–2001. Int J Geriatr Psychiatry 2003; 18(12):1082-1087. again underline the role that chronic depression and psychiatric illnesses play in triggering the suicide process, both among men and women.

According to Lebret et al.1616. Lebret S, Perret-Vaille E, Mulliez A, Gerbaud L, Jalenques I. Elderly suicide attempters: characteristics and outcome. Int J Geriatr Psychiatry 2006; 21(11):1052-1059., the main reasons why elderly women attempt suicide are due to: physical dependence, degenerative diseases, memory disturbances and previous attempts to commit suicide; according to Inoue et al.3838. Inoue K, Tanii H, Abe S, Kaiya H, Okazaki Y, Nata M, Fukunaga T. Suicidal tendencies among the elderly in Mie Prefecture, Japan, between 1996 and 2002. Leg Med 2007; 9(3):134-138., this includes chronic physical diseases (cardiovascular, metabolic, orthopedic and digestive diseases), which make them dependent on others; as well as mental illnesses such as psychiatric disorders and stress. Lau et al.3939. Lau R, Morse CA, Macfarlane S. Psychological factors among elderly women with suicidal intentions or attempts to suicide: a controlled comparison. J Women Aging 2010; 22(1):3-14. underline low levels of resilience, distress, despair, social isolation and uncontrolled emotions. Blüml et al.3636. Blüml V, Kapusta N, Doering S, Blahler E, Wagner B, Kersting A. Personality factors and suicide risk in a representative sample of German general population. Plos One 2013; 8(10):e76646., show that there is a high risk of suicide attempts among women who have a neurotic personality when this is combined with moderate or severe symptoms of depression, difficulties in relationships and in adapting to the aging process. Cougle et al.4040. Cougle JR, Keough ME, Riccardi CJ, Sachs-Ericsson N. Anxiety disorders and suicidality in the National Comorbidity Survey-Replication. J Psychiatr Res 2009; 43(9):825-829. report that, in the case of elderly women, the four main forms of anxiety (social, post-traumatic, stress and panic syndrome) are predictive of suicide attempts. According to Cougle et al.4040. Cougle JR, Keough ME, Riccardi CJ, Sachs-Ericsson N. Anxiety disorders and suicidality in the National Comorbidity Survey-Replication. J Psychiatr Res 2009; 43(9):825-829., as already mentioned by Blüml et al.3636. Blüml V, Kapusta N, Doering S, Blahler E, Wagner B, Kersting A. Personality factors and suicide risk in a representative sample of German general population. Plos One 2013; 8(10):e76646., elderly women with neurotic personalities are much more likely to develop depression. This same author also states that the interaction between depression and anxiety disorders may explain why neurosis is a risk factor for women, but not for men.

In the case of men, Bradvik et al.1717. Bradvick L, Berglung M. Repetition and severity of suicide attempts across the life clicle: a comparison by age group between suicide victims and controls with severe depression. BMC Psychiatry 2009; 9:62. invert the usual concept by saying that a suicide attempt is a predictor of depression. They list the main predetermining factors, which are: health problems, anxiety disorders and untreated psychiatric illnesses4141. Joe S, Ford BC, Taylor RJ, Chatters LM. Prevalence of suicide ideation and attempts among black Americans in late life. Transcult Psychiatry 2013; 51(2):190-208.; ongoing personal and sexual conflicts with their wife and disagreements with their children, divorce and low levels of self-esteem4242. Lindner R. Psychodynamic hypothesis about suicidality in elderly men. Psychother Psychosom Med Psychol 2010; 60(8):290-297.. Tan & Wong2727. Tan LL, Wong HB. Severity of depression and suicidal ideations among elder people in Singapore. Int Psychogeriatr 2008; 20(2):338-346. draw attention to the importance of chronic depression, degenerative physical diseases which cause suffering or sexual impotency and low levels of social support. Miret et al.4343. Miret M, Nuevo R, Morant C, Sainz-Cortón E, Jiménez-Arriero MA, López-Ibor JJ, Reneses B, Saiz-Ruiz J, Baca-García E, Ayuso-Mateos JL. The role of suicide risk in the decision for psychiatric hospitalization after a suicide attempt. Crisis 2011; 32(2):65-73. identify predetermining factors as: prior psychiatric hospitalization; use of more lethal methods in their previous suicide attempts. Capron et al.4444. Capron DW, Fitch K, Mendeley A, Blagg C, Mallott M, Joiner T. Role of anxiety sensitivity subfactor in suicidal ideation and suicide attempt history. Depress Anxiety 2012; 29(3):195-201. suggest additional factors: premeditated plans to kill him/herself, having persistent suicidal ideations, ironically verbalizing their previous suicide attempt, and suffering from anxiety disorders. When there are no apparent symptoms of depression, Kato et al.2323. Kato K, Akama F, Yamada K, Maehara M, Saito M, Kimoto K, Takahashi Y, Sato R, Ichimura A, Matsumoto H. Frequency and clinical features of suicide attempts in elderly patients in Japan. Psych Clin Neurosci 2013; 67(2):119-122. lend weight to humor disorders, lack of social support and physical inactivity as important risk factors. Awata et al.1515. Awata S, Bech P, Koizumi Y, Seki T, Kuriyama S, Hozawa A, Ohmori K, Nakaya N, Matsuoka H, Tsuji I. Validity and utility of the Japanese version of the WHO-Five Well-Being Index in the context of detecting suicidal ideation in elderly community residents. Int Psychogeriatr 2007; 19(1):77-88. underline alcohol abuse, symptoms of depression and other mental disturbances. Conwell et al.4545. Conwell Y, Duberstein PR, Connor K, Eberly S, Cox C, Caine ED. Access to firearms and risk for suicide in middle-aged and older adults. Am J Geriatr Psychiatry 2002 10(4):407-416. state that a precipitating factor is to keep a gun at home. Blüml et al.3636. Blüml V, Kapusta N, Doering S, Blahler E, Wagner B, Kersting A. Personality factors and suicide risk in a representative sample of German general population. Plos One 2013; 8(10):e76646. highlight as risk factors: inability to communicate, as well as high levels of anxiety. With regards to the last point, findings produced by Blüml et al.3636. Blüml V, Kapusta N, Doering S, Blahler E, Wagner B, Kersting A. Personality factors and suicide risk in a representative sample of German general population. Plos One 2013; 8(10):e76646. contradict those of Cougle et al.4040. Cougle JR, Keough ME, Riccardi CJ, Sachs-Ericsson N. Anxiety disorders and suicidality in the National Comorbidity Survey-Replication. J Psychiatr Res 2009; 43(9):825-829., who believe that anxiety is a predisposing factor in the case of elderly women but not in men. In a sample survey involving elderly homeless war veterans in the USA, Shinka et al.4646. Schinka JA, Schinka KC, Casey RJ, Kasprow W, Bossarte RM. Suicidal behavior in a national sample of older homeless veterans. Am J Public Health 2012; 102(Supl. 1):147-153. found that there was a strong connection between attempted suicide and those who had a background of psychiatric problems and substances abuse, fact that reinforces the findings of Miret et al.4343. Miret M, Nuevo R, Morant C, Sainz-Cortón E, Jiménez-Arriero MA, López-Ibor JJ, Reneses B, Saiz-Ruiz J, Baca-García E, Ayuso-Mateos JL. The role of suicide risk in the decision for psychiatric hospitalization after a suicide attempt. Crisis 2011; 32(2):65-73..

Covering the period between 2002 and 2013, it is important to point out that the greatest differences between the selected research topics are related to the regions of origin of the researchers themselves. Articles written by authors from Asia are mainly population and community-based and centered on hospital archive material1010. Yip PSF, Chi I, Chiu H, Wai KC, Conwell Y, Caine E. A prevalence study of suicide ideation among older adults in Hong Kong SAR. Int J Geriatr Psychiatry 2003; 18(11):1056-1062.,1414. Tsoh J, Chiu HF, Duberstein PR, Chan SS, Chi I, Yip PS, Conwell Y. Attempted suicide in elderly Chinese persons: a multi-group, controlled study. Am J Geriatr Psychiatry 2005; 13(7):562-571.,2121. Kwon JW, Kim JH. The impact of health-related quality of life on suicidal ideation and suicide attempts among Korean older adults. J Gerontol Nurs 2012; 38(11):48-59.,2727. Tan LL, Wong HB. Severity of depression and suicidal ideations among elder people in Singapore. Int Psychogeriatr 2008; 20(2):338-346.,3131. Liu IC; Chiu CH. Case-control study of suicide attempts in the elderly. Int Psychogeriatr 2009; 21(5):896-902.,3737. Salib E, Green L. Gender in elderly suicide: analysis of coroners inquests of 200 cases of elderly suicide in Cheshire 1989–2001. Int J Geriatr Psychiatry 2003; 18(12):1082-1087.,4646. Schinka JA, Schinka KC, Casey RJ, Kasprow W, Bossarte RM. Suicidal behavior in a national sample of older homeless veterans. Am J Public Health 2012; 102(Supl. 1):147-153.,4747. Chen WJ, Chen CC, Ho CK, Lee MB, Chung YT, Wang YC, Lin GG, Lu RY, Sun FC, Chou FH. The suitability of the BSRS-5 for assessing elderly who have attempted suicide and need to be referred for professional mental health consultation in a metropolitan city (Taiwan). Int J Geriatr Psychiatry 2009; 24(10):1151-1157., and most were co-authored by American and European researchers. Only a few researchers actually made profound studies on specific issues, as Kin et al.4848. Kim YR, Choi KH, Oh Y, Lee HK, Kweon YS, Lee CT, Lee KU. Elderly suicide attempters by self-poisoning in Korea. Int Psychogeriatr 2011; 1:1-7 and Kwon and Kim4949. Kwon JW, Kim JH. The impact of health-related quality of life on suicidal ideation and suicide attempts among Korean older adults. J Gerontol Nurs 2012; 38(11):48-59.. There are practically no studies on this subject in South America and the articles that exist only tend to cover local areas1111. Matusevich D, Finkelsztein C, Dabi E. Suicide attempts in elderly people. Vertex 2003; 14(52):119-123.,1212. Dabi E, Matusevich D, Finkelsztein C. Major depressive disorder in suicide attempts among over 60 years old patients. Vertex 2003; 14(52):124-127.,5050. Matusevich D; Finkelsztein C; Vairo MC. Dementia, suicide attempts and suicide. A case study. Vertex 2003; 14(52):128-133. which shows that there is a lack of theoretical investment in the subject.

Such studies in North America and Europe generally tend to refine research results, establishing associations and presenting relevant plans of action. This is the case of articles produced by Heisel et al.2020. Heisel MJ, Conwell Y, Pisani AR, Duberstein PR. Concordance of Self-and Proxy-reported Suicide Ideation in Depressed Adults 50 Years of Age or Older. Can J Psychiatry 2011; 56(4):219-226. Cook et al.88. Cook JM, Pearson JL, Thompson R, Black BS, Rabins PV. Suicidality in older African Americans: findings from the EPOCH study. Am J Geriatr Psychiatry 2002; 10(4):437-446. Baca-Garcia et al.5151. Baca-Garcia E, Perez-Rodriguez MM, Keyes KM, Oquendo MA, Hasin DS, Grant BF, Blanco C. Suicidal ideation and suicide attempts among Hispanic subgroups in the United States: 1991-1992 and 2001-2002. J Psychiatr Res 2011; 45(4):512-518. and so on. In addition, there are those contributions by Crandall et al.5252. Crandall M, Luchette F, Esposito TJ, West M, Shapiro M, Bulger E. Attempted suicide and the elderly trauma patient: risk factor and outcomes. J Trauma 2007; 62(4):1021-1027. and Stein et al.5353. Stein DJ, Chiu WT, Hwang I, Kessler RC, Sampson N, Alonso J, Borges G, Bromet E, Bruffaerts R, de Girolamo G, Florescu S, Gureje O, He Y, Kovess-Masfety V, Levinson D, Matschinger H, Mneimneh Z, Nakamura Y, Ormel J, Posada-Villa J, Sagar R, Scott KM, Tomov T, Viana MC, Williams DR, Nock MK. Cross-national analysis of the associations between traumatic events and suicidal behavior: findings from the WHO World Mental Health Surveys. Plos One 2010; 5(5):e10574., which are about the connections that exist between attempted suicide and trauma; the review by Fässberg et al.5454. Fässberg MM, van Orden KA, Duberstein P, Erlangsen A, Lapierre S, Bodner E, Canetto SS, De Leo D, Szanto K, Waern M. A systematic review of social factors and suicidal behavior in older adulthood. Int J Environ Res Public Health 2012; 9(3):772-745. on the social factors associated with attempted suicide; the study by Peisah et al.5555. Peisah C, Snowdon J, Gorrie C, Kril J, Rodriguez M. Clinicopathological findings of suicide in the eldely: three cases. Suicide Life Threat Behav 2007; 379(6):648-658. about establishing a possible relationship between attempted suicide and consummated suicides through clinical pathological analyses; the study by Wiktorsson et al.1818. Wiktorsson S, Runeson B, Skoog I, Ostling S, Waern M. Attempted suicide in the elderly: characteristics of suicide attempters 70 years and older and a general population comparison group. Am J Geriatr Psychiatry 2010; 18(1):57-67. about motivations for suicide attempts among the population in general, as well as among the elderly; follow-up studies made with a group of elderly people who had previously attempted suicide1919. Wiktorsson S, Marlow T, Runeson B, Skoog I, Waern M. Prospective cohort study of suicide attempters aged 70 and above: one-year outcomes. J Affect Disord 2011; 134(1-3):333-340.; the analyses carried out based on gender3838. Inoue K, Tanii H, Abe S, Kaiya H, Okazaki Y, Nata M, Fukunaga T. Suicidal tendencies among the elderly in Mie Prefecture, Japan, between 1996 and 2002. Leg Med 2007; 9(3):134-138.,4141. Joe S, Ford BC, Taylor RJ, Chatters LM. Prevalence of suicide ideation and attempts among black Americans in late life. Transcult Psychiatry 2013; 51(2):190-208.; studies about suicide risks during internment at psychiatric hospitals4242. Lindner R. Psychodynamic hypothesis about suicidality in elderly men. Psychother Psychosom Med Psychol 2010; 60(8):290-297.; those related to cognitive evaluations2828. McGirr A, Dombrovski AY, Butters MA, Clark L, Szanto K. Deterministic learning and attempted suicide among older depressed individuals: cognitive assessment using the Wisconsin Card Sorting Task. J Psychiatr Res 2012; 46(2):226-232.. Ziervogel et al.2626. Ziervogel A, Pfeiffer T, Hegerl U. How effective is advanced training concerning depression and suicidality among the elderly? Results of a pilot study. Arch Suicide Res 2005; 9(1):11-17. worked on the principle that it was necessary to train caregivers so that they could help prevent suicidal attempts, while Conwell & Thompson33. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am 2008; 31(2):333-356. has produced a vast series of studies on specific subjects and on suicide prevention.

A thematic and temporal summary of all the studies included in the present survey was organized and are presented in Table 1. The texts were listed by their year of publication and presented in quadrennial groups. An analysis was carried out on headings, topics and place of publication. The temporal evolution of the scientific research showed that, between 2002 and 2005, there were studies which linked cases of attempted suicide to consummated suicides, focusing on risk behavioral patterns, based on the theory that depression was the factor that causes the greatest concern, associated with chronic diseases and personality disorders.

Between 2006 and 2009, it was noted that the number of articles produced on this subject had greatly increased in all three continents, and that the focus of these studies was to outline the severity of depression, ideation, suicide attempts and the impact of risk factors. It was noted that, between 2010 and 2013, there was an enormous increase in the number of articles produced and the different types of approaches used in relation to this topic and suicide attempts, as well as to differences in gender, ethnicity, age groups, interpersonal difficulties, social support, anxiety, quality of life, the relationship between depression and perception, and between hope and psychosis; the type of support and treatment a person receives and their place in society.

During all these stages, there has been a consistent and growing concern to find ways to prevent depression and suicide attempts, as well as a realization that primary care and mental health professionals are needed to provide far greater support to the elderly.

Methods used in this research study

Of the 75 texts that were analyzed, only three used a qualitative approach method1212. Dabi E, Matusevich D, Finkelsztein C. Major depressive disorder in suicide attempts among over 60 years old patients. Vertex 2003; 14(52):124-127.,3333. Im MY, Kim YJ. A phenomenological study of suicide attempts in elders. J Korean Acad Nurs 2011; 41(1):61-71.,5050. Matusevich D; Finkelsztein C; Vairo MC. Dementia, suicide attempts and suicide. A case study. Vertex 2003; 14(52):128-133.. Even so, research studies carried out by Matusevich, for example, do not describe the methodological processes used. There are a total of six reviews5454. Fässberg MM, van Orden KA, Duberstein P, Erlangsen A, Lapierre S, Bodner E, Canetto SS, De Leo D, Szanto K, Waern M. A systematic review of social factors and suicidal behavior in older adulthood. Int J Environ Res Public Health 2012; 9(3):772-745.,5656. Nock MK, Borges G, Bromet EJ, Cha CC, Kessler RC, Lee S. Suicide and suicidal behavior. Epidemiol Rev 2008; 30:133-154.

57. Richard-Devantoy S, Jollant F, Deguigne F, Letourneau G. Neurocognitive markers of suicide vulnerability in the elderly: a review. Geriatr Psychol Neuropsychiatr Vieil 2013;11(4):367-378.

58. Mann JJ, Apter A, Bartolote J, Beautrais A, Currier D, Haas A, Hegerl U, Lonnqvist J, Malone K, Marusic A, Mehlum L, Patton G, Phillips M, Rutz W, Rihmer Z, Schmidtke A, Shaffer D, Silverman M, Takahashi Y, Varnik A, Wasserman D, Yip P, Hendin H. Suicide Prevention strategies: a systhematic review. JAMA 2005; 294(16):2064-2074.

59. Van der Wurff FB, Stek ML, Hougendijk WL, Beekman TA. Electroconvulsive therapy for the depressed elderly. Cochrane Database Syst Rev 2003; (2):CD003593.
-6060. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002; 159(6):909-916.. All the remaining articles resulted from epidemiological approaches. In the latter case, these include: frequency studies with multi-variant analyses88. Cook JM, Pearson JL, Thompson R, Black BS, Rabins PV. Suicidality in older African Americans: findings from the EPOCH study. Am J Geriatr Psychiatry 2002; 10(4):437-446.,1616. Lebret S, Perret-Vaille E, Mulliez A, Gerbaud L, Jalenques I. Elderly suicide attempters: characteristics and outcome. Int J Geriatr Psychiatry 2006; 21(11):1052-1059.,1818. Wiktorsson S, Runeson B, Skoog I, Ostling S, Waern M. Attempted suicide in the elderly: characteristics of suicide attempters 70 years and older and a general population comparison group. Am J Geriatr Psychiatry 2010; 18(1):57-67.,2222. Encrenaz G, Kovess-Masféty V, Gilbert F, Galéra C, Lagarde E, Mishara B, Messiah A. Lifetime risk of suicidal behaviors and communication to a health professional about suicidal ideation. Results from a large survey of the French adult population. Crisis 2012; 33(3):127-136.,2323. Kato K, Akama F, Yamada K, Maehara M, Saito M, Kimoto K, Takahashi Y, Sato R, Ichimura A, Matsumoto H. Frequency and clinical features of suicide attempts in elderly patients in Japan. Psych Clin Neurosci 2013; 67(2):119-122.,3636. Blüml V, Kapusta N, Doering S, Blahler E, Wagner B, Kersting A. Personality factors and suicide risk in a representative sample of German general population. Plos One 2013; 8(10):e76646.,3737. Salib E, Green L. Gender in elderly suicide: analysis of coroners inquests of 200 cases of elderly suicide in Cheshire 1989–2001. Int J Geriatr Psychiatry 2003; 18(12):1082-1087.; prevalence studies based on population numbers1010. Yip PSF, Chi I, Chiu H, Wai KC, Conwell Y, Caine E. A prevalence study of suicide ideation among older adults in Hong Kong SAR. Int J Geriatr Psychiatry 2003; 18(11):1056-1062.,2727. Tan LL, Wong HB. Severity of depression and suicidal ideations among elder people in Singapore. Int Psychogeriatr 2008; 20(2):338-346.,4141. Joe S, Ford BC, Taylor RJ, Chatters LM. Prevalence of suicide ideation and attempts among black Americans in late life. Transcult Psychiatry 2013; 51(2):190-208.,4747. Chen WJ, Chen CC, Ho CK, Lee MB, Chung YT, Wang YC, Lin GG, Lu RY, Sun FC, Chou FH. The suitability of the BSRS-5 for assessing elderly who have attempted suicide and need to be referred for professional mental health consultation in a metropolitan city (Taiwan). Int J Geriatr Psychiatry 2009; 24(10):1151-1157.,6161. Shah A. Attempted suicide in the elderly in England: age-associated rates, time trends and methods. Int Psychogeriatr 2009; 21(5):889-895.,6262. Kapusta SD, Etzersdorfer E, Sonneck G. Trends in suicide rates of the elderly in Austria, 1970-2004: an analysis of changes in terms of age groups, suicide methods and gender. Int J Geriatric Psychiatry 2007; 22(5):438-444.; retrospective analyses based on archives from hospitals and hospital emergency care units77. De Leo D, Padoani W, Lonnqvist J, Kerkhof AJ, Bille-Brahe U, Michel K, Salander-Renberg E, Schmidtke A, Wasserman D, Caon F, Scocco P. Repetition of suicidal behaviour in elderly Europeans: a prospective longitudinal study. J Affect Disord 2002; 72(3):291-295.,1818. Wiktorsson S, Runeson B, Skoog I, Ostling S, Waern M. Attempted suicide in the elderly: characteristics of suicide attempters 70 years and older and a general population comparison group. Am J Geriatr Psychiatry 2010; 18(1):57-67.,1919. Wiktorsson S, Marlow T, Runeson B, Skoog I, Waern M. Prospective cohort study of suicide attempters aged 70 and above: one-year outcomes. J Affect Disord 2011; 134(1-3):333-340.,2929. Turvey CL, Conwell Y, Jones MP, Phillips C, Simonsick E, Pearson JL, Wallace R. Risk factors for late-life suicide: a prospective, community-based study. Am J Geriatr Psychiatry 2002; 10(4):398-406.,3131. Liu IC; Chiu CH. Case-control study of suicide attempts in the elderly. Int Psychogeriatr 2009; 21(5):896-902.,3737. Salib E, Green L. Gender in elderly suicide: analysis of coroners inquests of 200 cases of elderly suicide in Cheshire 1989–2001. Int J Geriatr Psychiatry 2003; 18(12):1082-1087.,5050. Matusevich D; Finkelsztein C; Vairo MC. Dementia, suicide attempts and suicide. A case study. Vertex 2003; 14(52):128-133. and psychiatric hospitals1616. Lebret S, Perret-Vaille E, Mulliez A, Gerbaud L, Jalenques I. Elderly suicide attempters: characteristics and outcome. Int J Geriatr Psychiatry 2006; 21(11):1052-1059.,2323. Kato K, Akama F, Yamada K, Maehara M, Saito M, Kimoto K, Takahashi Y, Sato R, Ichimura A, Matsumoto H. Frequency and clinical features of suicide attempts in elderly patients in Japan. Psych Clin Neurosci 2013; 67(2):119-122.; longitudinal studies77. De Leo D, Padoani W, Lonnqvist J, Kerkhof AJ, Bille-Brahe U, Michel K, Salander-Renberg E, Schmidtke A, Wasserman D, Caon F, Scocco P. Repetition of suicidal behaviour in elderly Europeans: a prospective longitudinal study. J Affect Disord 2002; 72(3):291-295.,3535. May AM, Klonsky ED, Klein DN. Predicting future suicide attempts among depressed suicide ideators: A 10 year longitudinal study. J Psychiatr Res 2012; 46(7):946-952.; evidence-seeking review studies5454. Fässberg MM, van Orden KA, Duberstein P, Erlangsen A, Lapierre S, Bodner E, Canetto SS, De Leo D, Szanto K, Waern M. A systematic review of social factors and suicidal behavior in older adulthood. Int J Environ Res Public Health 2012; 9(3):772-745.,5656. Nock MK, Borges G, Bromet EJ, Cha CC, Kessler RC, Lee S. Suicide and suicidal behavior. Epidemiol Rev 2008; 30:133-154.,5757. Richard-Devantoy S, Jollant F, Deguigne F, Letourneau G. Neurocognitive markers of suicide vulnerability in the elderly: a review. Geriatr Psychol Neuropsychiatr Vieil 2013;11(4):367-378.,5959. Van der Wurff FB, Stek ML, Hougendijk WL, Beekman TA. Electroconvulsive therapy for the depressed elderly. Cochrane Database Syst Rev 2003; (2):CD003593.,6060. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002; 159(6):909-916.,6363. Milner A, De Leo D. Who seeks treatment where? Suicidal behaviours and health care: Evidence from a community survey. J Nerv Ment Dis 2010; 198(6):412-419.,6464. Cox GR, Owens C, Robinson J, Nicholas A, Lockley A, Williamson M, Cheung YTD, Pirkis J. Interventions to reduce suicides at suicide hotspots: a systematic review. BMC Public Health 2013; 13:214.; studies using controlled cases from a sampling of psychiatric patients1414. Tsoh J, Chiu HF, Duberstein PR, Chan SS, Chi I, Yip PS, Conwell Y. Attempted suicide in elderly Chinese persons: a multi-group, controlled study. Am J Geriatr Psychiatry 2005; 13(7):562-571.,1717. Bradvick L, Berglung M. Repetition and severity of suicide attempts across the life clicle: a comparison by age group between suicide victims and controls with severe depression. BMC Psychiatry 2009; 9:62.,3030. Chan SS, Lyness JM, Conwell Y. Cerebrovascular risk factors confer risk for suicide in later life? A case-control study. Am J Geriatr Psychiatry 2007; 15(6):541-544.

31. Liu IC; Chiu CH. Case-control study of suicide attempts in the elderly. Int Psychogeriatr 2009; 21(5):896-902.
-3232. Barak Y1, Knobler CY, Aizenberg D, Schizophr RES. Suicide attempts amongst elderly schizophrenia patients: a 10-year case-control study. Schizophr Res 2004; 71(1):77-81.; community-based controlled case studies3939. Lau R, Morse CA, Macfarlane S. Psychological factors among elderly women with suicidal intentions or attempts to suicide: a controlled comparison. J Women Aging 2010; 22(1):3-14.,6565. Beautrais AL. A case control study of suicide and attempt suicide in older adults. Suicide Life Threat Behav 2011; 32(1):1-9.

66. Bruce ML, Alexopoulos GS, Schulberg HC, Ten Have T, Kaatz IRR, Reinolds CF. Interventions for treatment of depression in primary care. JAMA 2004; 291(9):1081-1091.
-6767. Wyder M, De Leo D. Behind impulsive suicide attempts: Indications from a community study. J Affect Disord 2007; 104(1-3):167-173.; population-based studies using scales such as: the Geriatric Suicide Ideation Scale (GSIS-C)1616. Lebret S, Perret-Vaille E, Mulliez A, Gerbaud L, Jalenques I. Elderly suicide attempters: characteristics and outcome. Int J Geriatr Psychiatry 2006; 21(11):1052-1059.,4646. Schinka JA, Schinka KC, Casey RJ, Kasprow W, Bossarte RM. Suicidal behavior in a national sample of older homeless veterans. Am J Public Health 2012; 102(Supl. 1):147-153.,6363. Milner A, De Leo D. Who seeks treatment where? Suicidal behaviours and health care: Evidence from a community survey. J Nerv Ment Dis 2010; 198(6):412-419.; the Beck Hopelessness Scale3333. Im MY, Kim YJ. A phenomenological study of suicide attempts in elders. J Korean Acad Nurs 2011; 41(1):61-71.; the Mini Mental State Examination scale (MMSE)99. Lykouras L, Gournellis R, Fortos A, Oulis, P, Christodoulou, GN. Psychotic (deulional) major depression in elderly and suicidal behaviour. J Affect Disord 2002; 19(1-3):225-229.,3131. Liu IC; Chiu CH. Case-control study of suicide attempts in the elderly. Int Psychogeriatr 2009; 21(5):896-902. and tests such as the Anxiety Sensitivity Index (ASI)4343. Miret M, Nuevo R, Morant C, Sainz-Cortón E, Jiménez-Arriero MA, López-Ibor JJ, Reneses B, Saiz-Ruiz J, Baca-García E, Ayuso-Mateos JL. The role of suicide risk in the decision for psychiatric hospitalization after a suicide attempt. Crisis 2011; 32(2):65-73.; clinical-pathological studies5454. Fässberg MM, van Orden KA, Duberstein P, Erlangsen A, Lapierre S, Bodner E, Canetto SS, De Leo D, Szanto K, Waern M. A systematic review of social factors and suicidal behavior in older adulthood. Int J Environ Res Public Health 2012; 9(3):772-745. and neuropsychiatric studies5757. Richard-Devantoy S, Jollant F, Deguigne F, Letourneau G. Neurocognitive markers of suicide vulnerability in the elderly: a review. Geriatr Psychol Neuropsychiatr Vieil 2013;11(4):367-378.; prospective group studies77. De Leo D, Padoani W, Lonnqvist J, Kerkhof AJ, Bille-Brahe U, Michel K, Salander-Renberg E, Schmidtke A, Wasserman D, Caon F, Scocco P. Repetition of suicidal behaviour in elderly Europeans: a prospective longitudinal study. J Affect Disord 2002; 72(3):291-295.,1919. Wiktorsson S, Marlow T, Runeson B, Skoog I, Waern M. Prospective cohort study of suicide attempters aged 70 and above: one-year outcomes. J Affect Disord 2011; 134(1-3):333-340.,2929. Turvey CL, Conwell Y, Jones MP, Phillips C, Simonsick E, Pearson JL, Wallace R. Risk factors for late-life suicide: a prospective, community-based study. Am J Geriatr Psychiatry 2002; 10(4):398-406.,3333. Im MY, Kim YJ. A phenomenological study of suicide attempts in elders. J Korean Acad Nurs 2011; 41(1):61-71.,3434. Klonsky ED, Kotov R, Bakst S, Rabinowitz J, Bromet EJ. Hopelessness as a predictor of attempted suicide among first admission patients with psychosis: A 10 year cohort study. Suicide Life Threat Behav 2012; 42(1):1-10.,5151. Baca-Garcia E, Perez-Rodriguez MM, Keyes KM, Oquendo MA, Hasin DS, Grant BF, Blanco C. Suicidal ideation and suicide attempts among Hispanic subgroups in the United States: 1991-1992 and 2001-2002. J Psychiatr Res 2011; 45(4):512-518.; random population based transversal studies3535. May AM, Klonsky ED, Klein DN. Predicting future suicide attempts among depressed suicide ideators: A 10 year longitudinal study. J Psychiatr Res 2012; 46(7):946-952.,5353. Stein DJ, Chiu WT, Hwang I, Kessler RC, Sampson N, Alonso J, Borges G, Bromet E, Bruffaerts R, de Girolamo G, Florescu S, Gureje O, He Y, Kovess-Masfety V, Levinson D, Matschinger H, Mneimneh Z, Nakamura Y, Ormel J, Posada-Villa J, Sagar R, Scott KM, Tomov T, Viana MC, Williams DR, Nock MK. Cross-national analysis of the associations between traumatic events and suicidal behavior: findings from the WHO World Mental Health Surveys. Plos One 2010; 5(5):e10574.,6868. Demirçin S, Akkoyun M, Yilmaz R, Gökdoğan MR; Suicide of elderly persons: towards a framework for prevention. Geriatr Gerontol Int 2011; 11(1):107-113.; random multi-centric sample studies5353. Stein DJ, Chiu WT, Hwang I, Kessler RC, Sampson N, Alonso J, Borges G, Bromet E, Bruffaerts R, de Girolamo G, Florescu S, Gureje O, He Y, Kovess-Masfety V, Levinson D, Matschinger H, Mneimneh Z, Nakamura Y, Ormel J, Posada-Villa J, Sagar R, Scott KM, Tomov T, Viana MC, Williams DR, Nock MK. Cross-national analysis of the associations between traumatic events and suicidal behavior: findings from the WHO World Mental Health Surveys. Plos One 2010; 5(5):e10574.,5454. Fässberg MM, van Orden KA, Duberstein P, Erlangsen A, Lapierre S, Bodner E, Canetto SS, De Leo D, Szanto K, Waern M. A systematic review of social factors and suicidal behavior in older adulthood. Int J Environ Res Public Health 2012; 9(3):772-745.,5656. Nock MK, Borges G, Bromet EJ, Cha CC, Kessler RC, Lee S. Suicide and suicidal behavior. Epidemiol Rev 2008; 30:133-154.,6666. Bruce ML, Alexopoulos GS, Schulberg HC, Ten Have T, Kaatz IRR, Reinolds CF. Interventions for treatment of depression in primary care. JAMA 2004; 291(9):1081-1091., case studies5555. Peisah C, Snowdon J, Gorrie C, Kril J, Rodriguez M. Clinicopathological findings of suicide in the eldely: three cases. Suicide Life Threat Behav 2007; 379(6):648-658. and trend analyses3838. Inoue K, Tanii H, Abe S, Kaiya H, Okazaki Y, Nata M, Fukunaga T. Suicidal tendencies among the elderly in Mie Prefecture, Japan, between 1996 and 2002. Leg Med 2007; 9(3):134-138.,6161. Shah A. Attempted suicide in the elderly in England: age-associated rates, time trends and methods. Int Psychogeriatr 2009; 21(5):889-895.,6262. Kapusta SD, Etzersdorfer E, Sonneck G. Trends in suicide rates of the elderly in Austria, 1970-2004: an analysis of changes in terms of age groups, suicide methods and gender. Int J Geriatric Psychiatry 2007; 22(5):438-444.,6969. Erlangsen A, Canudas-Romo V, Conwell Y. Increased use of antidepressants and decreasing suicide rates: a population-based study using Danish register data. J Epidemiol Community Health 2008; 62(5):448-454..

Table 1
The way the issues researched in these articles evolved during the period between 2002 and 2013.

Suicide Prevention Proposals

The health sector works with three traditional levels of suicide prevention: the first, is to ensure that the problem does not occur; the second, if the problem occurs, to propose that the person receives the necessary care on a clinical, family and community level; and the third, involves treatment that can help a person to overcome or minimize the type of acute suffering that leads to attempted suicide.

Most of the authors referred to in this paper did not develop suicide prevention proposals. Those who do share many concerns: reviews that list suicide prevention actions5858. Mann JJ, Apter A, Bartolote J, Beautrais A, Currier D, Haas A, Hegerl U, Lonnqvist J, Malone K, Marusic A, Mehlum L, Patton G, Phillips M, Rutz W, Rihmer Z, Schmidtke A, Shaffer D, Silverman M, Takahashi Y, Varnik A, Wasserman D, Yip P, Hendin H. Suicide Prevention strategies: a systhematic review. JAMA 2005; 294(16):2064-2074.

59. Van der Wurff FB, Stek ML, Hougendijk WL, Beekman TA. Electroconvulsive therapy for the depressed elderly. Cochrane Database Syst Rev 2003; (2):CD003593.
-6060. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002; 159(6):909-916.,6363. Milner A, De Leo D. Who seeks treatment where? Suicidal behaviours and health care: Evidence from a community survey. J Nerv Ment Dis 2010; 198(6):412-419.,6464. Cox GR, Owens C, Robinson J, Nicholas A, Lockley A, Williamson M, Cheung YTD, Pirkis J. Interventions to reduce suicides at suicide hotspots: a systematic review. BMC Public Health 2013; 13:214.; evaluation studies about the effectiveness of interventions6060. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002; 159(6):909-916.,6666. Bruce ML, Alexopoulos GS, Schulberg HC, Ten Have T, Kaatz IRR, Reinolds CF. Interventions for treatment of depression in primary care. JAMA 2004; 291(9):1081-1091.,6767. Wyder M, De Leo D. Behind impulsive suicide attempts: Indications from a community study. J Affect Disord 2007; 104(1-3):167-173.,7070. Szanto K, Kalmar S, Hendin H. A suicide prevention program in a region with a very high suicide rate. Arch Gen Psychiatry 2007; 64(8):914-920.

71. Brown GK, Ten Have T, Henriques GR, XIE SX, Hollander JE, Beck AT. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA 2005; 294(5):563-570.

72. Mcleavey BC, Daly RJ, Ludgate JW, Murray CM. Interpersonal problems solving skills training in the treatment of self-poisoning patients. Suicide Life Threat Behav 2004; 24(4):282-394.

73. Bergin L, Walsh S. The role of hope in psychotherapy with older adults. Aging Ment Health 2005; 9(1):7-15.
-7474. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF Identification of suicidal ideation and prevention of suicidal behavior in the elderly. Drugs Aging 2002; 19(1):11-24.; and reinforcing conclusive proposals based on epidemiological analyses6868. Demirçin S, Akkoyun M, Yilmaz R, Gökdoğan MR; Suicide of elderly persons: towards a framework for prevention. Geriatr Gerontol Int 2011; 11(1):107-113.,7272. Mcleavey BC, Daly RJ, Ludgate JW, Murray CM. Interpersonal problems solving skills training in the treatment of self-poisoning patients. Suicide Life Threat Behav 2004; 24(4):282-394.,7474. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF Identification of suicidal ideation and prevention of suicidal behavior in the elderly. Drugs Aging 2002; 19(1):11-24.

75. Heisel MJ. Suicide and its prevention among older adults. Can J Psychiatry 2006; 51(3):143-154.

76. Juurlink DN, Herrmann N, Szalai JP, Koop A, Redelmeier DA. Medical illness and risk of suicide in the elderly. Arch Intern Med 2004; 164(11):1179-1184.

77. Verheul R, Van Den Bosch, LMC, Maarten WJK, Koeter J, Ridder AJ, Stijnen T, Brink WVD. Personality disorder: 12-month, randomized clinical trial in The Netherlands. BJP 2003; 182:135-140.

78. May AM, Klonsky ED. Assessing Motivations for Suicide Attempts: Development and Psychometric Properties of the Inventory of Motivations for Suicide Attempts. Suicide Life Threat Behav 2013; 43(5):532-546.
-7979. Conwell Y. Suicide prevention in later life: a glass half full, or half empty? Am J Psychiatry 2009; 166(8):845-848.. Many authors emphasize the need for primary care, which requires the integrated efforts of family members, society, as well as professional health workers. The theory that supports investing in a basic level of health is based on the idea that suicide results from a complex group of stressful factors which a person experiences through life and which manifest themselves in old age6666. Bruce ML, Alexopoulos GS, Schulberg HC, Ten Have T, Kaatz IRR, Reinolds CF. Interventions for treatment of depression in primary care. JAMA 2004; 291(9):1081-1091.

67. Wyder M, De Leo D. Behind impulsive suicide attempts: Indications from a community study. J Affect Disord 2007; 104(1-3):167-173.
-6868. Demirçin S, Akkoyun M, Yilmaz R, Gökdoğan MR; Suicide of elderly persons: towards a framework for prevention. Geriatr Gerontol Int 2011; 11(1):107-113.,7575. Heisel MJ. Suicide and its prevention among older adults. Can J Psychiatry 2006; 51(3):143-154.. In this sense, a risk evaluation, even though there are many different scales available nowadays to help in such evaluations, does not exclude the need for the skills of a health professionals to establish an empathic relationships with an elderly person, and who can also pay special attention to a person's particular circumstances, future expectations, quality of life and history of illnesses and suffering.

Some authors mention initiatives that are outside the medical sphere. For example, Nock et al.5656. Nock MK, Borges G, Bromet EJ, Cha CC, Kessler RC, Lee S. Suicide and suicidal behavior. Epidemiol Rev 2008; 30:133-154., underline the important role that spirituality, religious beliefs and practices have in this respect, bearing in mind the powerful moral objections that these show towards suicidal behavior; these authors also highlight the positive effects of social support, the presence of children at home and the integration of elderly people with their communities1313. Serna PI. Prevención del suicidio en los ancianos, suicidio-homicidio, ampliado y asistido. Geriatrika 2004; 20(1):18-22.. Cultivating friendships and relationships is seen as an important factor to help the elderly ward off feelings of depression as well to avoid thinking about suicide, or to attempt and consummate a self-inflicted death, as highlighted by Beeston44. Beeston D. Older People and Suicide. Centre for Ageing and Mental Health. UK: Stanfordshire University; 2006. and Conwel and Thompson33. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am 2008; 31(2):333-356.. Other studies such as those by Mann et al.5858. Mann JJ, Apter A, Bartolote J, Beautrais A, Currier D, Haas A, Hegerl U, Lonnqvist J, Malone K, Marusic A, Mehlum L, Patton G, Phillips M, Rutz W, Rihmer Z, Schmidtke A, Shaffer D, Silverman M, Takahashi Y, Varnik A, Wasserman D, Yip P, Hendin H. Suicide Prevention strategies: a systhematic review. JAMA 2005; 294(16):2064-2074., Kapusta et al.6262. Kapusta SD, Etzersdorfer E, Sonneck G. Trends in suicide rates of the elderly in Austria, 1970-2004: an analysis of changes in terms of age groups, suicide methods and gender. Int J Geriatric Psychiatry 2007; 22(5):438-444., Conwell & Thompson33. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am 2008; 31(2):333-356., Shah6161. Shah A. Attempted suicide in the elderly in England: age-associated rates, time trends and methods. Int Psychogeriatr 2009; 21(5):889-895. underline that restricting access to potentially lethal agents, as well as providing treatment for depression, have produced significant results in preventing suicide.

According to Cox et al.6464. Cox GR, Owens C, Robinson J, Nicholas A, Lockley A, Williamson M, Cheung YTD, Pirkis J. Interventions to reduce suicides at suicide hotspots: a systematic review. BMC Public Health 2013; 13:214., four basic actions are required to prevent suicide attempts: restrict access to agents used in such attempts by creating physical barriers to their use; make it possible for elderly people to seek help by installing emergency health alarms and hotlines in their homes; increase the probability of a third-person intervention, by asking lay persons or trained health professionals to keep an eye on the elderly; and alert and encourage the media to produce responsible reporting on the subject, with guidelines to help health professionals know what to do and what not to do in such cases.

Several researchers emphasized the importance of providing adequate training for health professionals who work in primary and mental healthcare services, so that they will know how to carry out suicide prevention proposals and mitigate the risk of suicide attempts1313. Serna PI. Prevención del suicidio en los ancianos, suicidio-homicidio, ampliado y asistido. Geriatrika 2004; 20(1):18-22.,3636. Blüml V, Kapusta N, Doering S, Blahler E, Wagner B, Kersting A. Personality factors and suicide risk in a representative sample of German general population. Plos One 2013; 8(10):e76646.,6868. Demirçin S, Akkoyun M, Yilmaz R, Gökdoğan MR; Suicide of elderly persons: towards a framework for prevention. Geriatr Gerontol Int 2011; 11(1):107-113.. Serna1313. Serna PI. Prevención del suicidio en los ancianos, suicidio-homicidio, ampliado y asistido. Geriatrika 2004; 20(1):18-22. states that there is evidence that most elderly people who have attempted or consummated a suicide, did not receive the proper care or even basic treatment5959. Van der Wurff FB, Stek ML, Hougendijk WL, Beekman TA. Electroconvulsive therapy for the depressed elderly. Cochrane Database Syst Rev 2003; (2):CD003593.,6060. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002; 159(6):909-916.,7676. Juurlink DN, Herrmann N, Szalai JP, Koop A, Redelmeier DA. Medical illness and risk of suicide in the elderly. Arch Intern Med 2004; 164(11):1179-1184.. If the risks had only been recognized during their medical consultations, then a greater number of vulnerable elderly people would certainly have had a greater chance of being dissuaded from the idea of committing suicide. In the case of primary health care, if the Brief Symptom Rating Scale (BSRS-5) is used in combination with a personal interview to find out whether an elderly person has a cognitive behavioral pattern, then this will help professionals to act before a problem occurs3131. Liu IC; Chiu CH. Case-control study of suicide attempts in the elderly. Int Psychogeriatr 2009; 21(5):896-902.. Other authors are concerned about forming an integrated primary healthcare service, which also includes emergency and other services related to mental healthcare, so as to provide effective follow-up care to elderly people who have already attempted suicide33. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am 2008; 31(2):333-356.,6262. Kapusta SD, Etzersdorfer E, Sonneck G. Trends in suicide rates of the elderly in Austria, 1970-2004: an analysis of changes in terms of age groups, suicide methods and gender. Int J Geriatric Psychiatry 2007; 22(5):438-444..

Even if depression has always been an important factor associated with a person's efforts to kill him/herself, the studies analyzed emphasize the importance of primary healthcare and the need to improve the diagnostic process, so that the proper referrals may be made. In treatments involving the most severe cases, and in order to prevent suicide attempts, it is proposed to use anti-depressant medication combined with various types of psychotherapy: cognitive therapy7070. Szanto K, Kalmar S, Hendin H. A suicide prevention program in a region with a very high suicide rate. Arch Gen Psychiatry 2007; 64(8):914-920., dialectical behavior therapy7171. Brown GK, Ten Have T, Henriques GR, XIE SX, Hollander JE, Beck AT. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA 2005; 294(5):563-570.; problem-solving therapy7777. Verheul R, Van Den Bosch, LMC, Maarten WJK, Koeter J, Ridder AJ, Stijnen T, Brink WVD. Personality disorder: 12-month, randomized clinical trial in The Netherlands. BJP 2003; 182:135-140.; and adaptive therapy7272. Mcleavey BC, Daly RJ, Ludgate JW, Murray CM. Interpersonal problems solving skills training in the treatment of self-poisoning patients. Suicide Life Threat Behav 2004; 24(4):282-394.. However, there is still no general consensus on the subject. For example, Erlangsen et al.6969. Erlangsen A, Canudas-Romo V, Conwell Y. Increased use of antidepressants and decreasing suicide rates: a population-based study using Danish register data. J Epidemiol Community Health 2008; 62(5):448-454., from a community-based research, show that treatment with anti-depressants does not necessarily reduce the number of suicide attempts. And Heisel7575. Heisel MJ. Suicide and its prevention among older adults. Can J Psychiatry 2006; 51(3):143-154., underlines the fact that studies do not yet exist that prove the effectiveness of combining medication with different methods of psychotherapy. This is because many types of psychotherapy that seem to be effective with another age group are difficult for older people to accept. However, Bruce et al.6666. Bruce ML, Alexopoulos GS, Schulberg HC, Ten Have T, Kaatz IRR, Reinolds CF. Interventions for treatment of depression in primary care. JAMA 2004; 291(9):1081-1091. and Szanto et al.7474. Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF Identification of suicidal ideation and prevention of suicidal behavior in the elderly. Drugs Aging 2002; 19(1):11-24. found that the combination of antidepressants and interpersonal therapies produced positive effects, although, as they say themselves, it is still impossible to say whether one form of intervention is more important than any other. There are also other proposals, such as electroconvulsive therapy, which is used to treat elderly people suffering from depression and, in particularly, to treat those who have already attempted suicide. However, as Van der Wurff et al.5959. Van der Wurff FB, Stek ML, Hougendijk WL, Beekman TA. Electroconvulsive therapy for the depressed elderly. Cochrane Database Syst Rev 2003; (2):CD003593. point out, studies do not yet exist which prove the effectiveness of such procedures.

Discussion

The wide range and number of reasons and factors given by the group of authors, whose work has been reviewed in this paper, on the one hand, that it is never a single cause that leads a person to commit suicide attempts. On the other hand, there is no general consensus about the multi-causality of this phenomenon.

Most of the authors tend to enhance the role that depression plays when they explain the reasons for attempted suicide. However, there is still a certain amount of controversy on the subject. For example, Richard-Devantoy et al.5757. Richard-Devantoy S, Jollant F, Deguigne F, Letourneau G. Neurocognitive markers of suicide vulnerability in the elderly: a review. Geriatr Psychol Neuropsychiatr Vieil 2013;11(4):367-378., indicate that suicidal behavioral patterns result from the complex interaction that exists between stress factors and vulnerability factors, including cognitive deficiencies, with a special emphasis on depression and a person's history of previous attempts. Also, in their recently concluded research paper, May & Klonsky7878. May AM, Klonsky ED. Assessing Motivations for Suicide Attempts: Development and Psychometric Properties of the Inventory of Motivations for Suicide Attempts. Suicide Life Threat Behav 2013; 43(5):532-546. state that, from all the most commonly described motives for attempted suicide and suicidal ideation, the only ones that can be considered to be truly universal are despair and unbearable emotional suffering.

As far back as 2002, Conwell et al.4545. Conwell Y, Duberstein PR, Connor K, Eberly S, Cox C, Caine ED. Access to firearms and risk for suicide in middle-aged and older adults. Am J Geriatr Psychiatry 2002 10(4):407-416. were already drawing attention to the fact that prospective cohort and retrospective control case studies indicated that affective disorders were potent risk factors that might induce an elderly person to commit suicide, and therefore have important implications with regards to suicide prevention methods. In the second place of importance, the authors noted that the absence or loss of family ties an unbending personality and other mental issues play an important part in explaining why elderly people try to commit suicide. However, even at that time, these diligent researchers commented that it was still necessary to define more clearly the interaction that exists between the emotional, physical and social issues that determine the risk of a suicide attempt and consummated suicides, as Conwell7979. Conwell Y. Suicide prevention in later life: a glass half full, or half empty? Am J Psychiatry 2009; 166(8):845-848. have also stated in more recent years.

An important point noted in existing literature, is that suicide attempts are usually treated from studies of consummated cases of suicide. It is possible that this can be explained by the fact that information about an attempted suicide often comes from psychological autopsies33. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am 2008; 31(2):333-356.

4. Beeston D. Older People and Suicide. Centre for Ageing and Mental Health. UK: Stanfordshire University; 2006.

5. Meneghel SN, Gutierrez DMD, Silva, RM, Grubits S, Hesler LZ, Ceccon RF. Suicídio de idosos sob a perspectiva de gênero. Cienc Saude Colet 2012; 17(8):1983-1992.
-66. Cavalcante FG, Minayo, MCS. Autópsias psicológicas e psicossociais de idosos que morreram por suicídio no Brasil. Cienc Saude Colet 2012; 17(8):1943-1954.,5656. Nock MK, Borges G, Bromet EJ, Cha CC, Kessler RC, Lee S. Suicide and suicidal behavior. Epidemiol Rev 2008; 30:133-154.. It is through such studies, that a series of predetermining motives have become more widely known: social isolation, death and the loss of people who were reference points in their lives, depression, previous suicide attempts, intense feelings of despair, illnesses that limit a person's physical and mental independence; losing one's sense of social relevance and the meaning of one's existence; permanent and frequent physical pain; loss of independence, which is often also regarded as a loss of personal dignity and a source of humiliation33. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am 2008; 31(2):333-356.

4. Beeston D. Older People and Suicide. Centre for Ageing and Mental Health. UK: Stanfordshire University; 2006.

5. Meneghel SN, Gutierrez DMD, Silva, RM, Grubits S, Hesler LZ, Ceccon RF. Suicídio de idosos sob a perspectiva de gênero. Cienc Saude Colet 2012; 17(8):1983-1992.
-66. Cavalcante FG, Minayo, MCS. Autópsias psicológicas e psicossociais de idosos que morreram por suicídio no Brasil. Cienc Saude Colet 2012; 17(8):1943-1954.,6161. Shah A. Attempted suicide in the elderly in England: age-associated rates, time trends and methods. Int Psychogeriatr 2009; 21(5):889-895.,6868. Demirçin S, Akkoyun M, Yilmaz R, Gökdoğan MR; Suicide of elderly persons: towards a framework for prevention. Geriatr Gerontol Int 2011; 11(1):107-113..

A point of great relevance concerns the methodological approaches used in this research. Most of the articles (94.7%) have been studied by using epidemiological tools. Most function with secondary data or by using an empirical approach, which in the case of the latter almost always involve the use of a system of scales. The three studies (4%) which use a qualitative approach investigated individual and collective cases by using in-depth interviews, or through the use of other tools, including psychodrama. With regards to the almost total absence of a qualitative approach in research works about attempted suicide, the first question that the methodological framework underlines is: why is it that an elderly person who has tried to committed suicide is almost never listened to by researchers when they are doing their in-depth interviews? After all, he/she is still alive and, in most cases, still has the physical and mental abilities to define his/her situation. Surely they themselves are the most important people who should talk about their reasons to commit suicide, their ability to overcome such a situation. A rather timid approach of this kind appeared in an article written by Chen et al.4747. Chen WJ, Chen CC, Ho CK, Lee MB, Chung YT, Wang YC, Lin GG, Lu RY, Sun FC, Chou FH. The suitability of the BSRS-5 for assessing elderly who have attempted suicide and need to be referred for professional mental health consultation in a metropolitan city (Taiwan). Int J Geriatr Psychiatry 2009; 24(10):1151-1157. after they had described a study they had carried out related to the prevalence of suicide attempts, using five items of the BSRS-5: “when the BSRS-5 is used to assess elderly patients who have attempted suicide, it is desirable that a mental healthcare professional conducts the interview so as to verify if the elderly person still has suicidal thoughts”. The authors suggest that the person who has tried to commit suicide has something to say about what is happening to him/her, regardless of the questions that a professional may ask them, which are based on their own technical points of reference. When one acknowledges that attempted suicide are related to life experiences involving relationships, disease, loss and other significant circumstances, it is worth considering that there is no one more capable of describing these events than the elderly person involved.

Another point worth mentioning is that, since most of the authors quoted in this study are associated with the fields of psychology and psychiatry, they generally pay little attention to matters related to social and micro-social experiences or to matters of context. Such experiences and contexts are usually only mentioned as a variable, which influences the end results. To immerse themselves only in the inner psychic conditions that lead to suicide attempts, would be the antithesis of the proposal put forward by Durkheim8080. Durkheim E. O suicídio. São Paulo: Editora Abril; 1980. Coleção Os Pensadores., for whom all social problems can only be understood through sociological analyses. This Durkheimian theory is long out-ofdate, but there is still a risk of encountering its extreme opposite, which occurs when what happens only to an individual is greatly overvalued. This observation is not an intent to criticize epidemiological studies based on psychological and psychiatric matrixes. We merely wish to register an alert about the need to combine different research methods.

Final Considerations

Firstly, some of the limitations related to the current study are: the fact that the bibliography material that was studied is limited to the databases mentioned in the reviewing method; it was impossible to access all the cited articles in their entirety; and, the difficulties experienced by the present authors as regards their familiarity and understanding of the content and analyses related to a subject matter they have only recently began to research in depth. Even so, some conclusions and questions from the current study should be highlighted:

  1. The complex nature of the “suicide attempt” phenomenon among the elderly. Most of the articles emphasize how physical, neurobiological, medical, psychological and social issues are contributing factors in such cases. Most of these show that predetermining elements include: severe and degenerative diseases, physical dependence on others, mental disorders and suffering and, above all, chronic depression.

  2. There is no consensus of the relevance that each factor has in relation to the outcome of an attempted suicide. Most authors emphasize the role of depression, though there is still a good deal of controversy in many of their arguments. This disease is seen in its own symptomatology, or is associated with chronic physical suffering and the ending of life, or even social and cultural issues. According to May & Klonsky7878. May AM, Klonsky ED. Assessing Motivations for Suicide Attempts: Development and Psychometric Properties of the Inventory of Motivations for Suicide Attempts. Suicide Life Threat Behav 2013; 43(5):532-546., the only motivations that can be considered as being universal are despair and unbearable emotional suffering.

  3. Gender differences should be considered when considering self-inflicted attempts to kill oneself. In accordance with all available universal knowledge, elderly women show a greater tendency towards suicidal ideation and make more attempts against their own lives; men tend to be more successful in concluding this final act. There are, of course, exceptions to this as shown by studies carried out among the populations in China, Japan and Singapore, where suicide attempts and consummated cases of suicide are high among both men and women. In a gradation of different age groups involving elderly people, in the case of those aged over eighty, the rate of suicide attempts went down among the women but increased among the men.

  4. From the point of view of the role played by the public healthcare sector, several questions need to be considered. (1) There is a close relationship among the elderly between suicidal ideation, suicidal attempts and consummated acts of suicide. (2) Available literature shows that it is possible to prevent suicide by taking action relative to issues associated with suicide, which include providing social and psychological support, as well as medical assistance.

From a social viewpoint, it is important to ensure that an elderly person is not isolated or abandoned, so that they can spend their lives as part of their community and live with dignity until the end of their days. From a medical standpoint, it is crucial to give elderly people access to treatment that can reduce degenerative conditions, suffering and dependence on others. From at psychological point of view, proposals are urgently required to provide psychotherapeutic assistance, which focuses on an elderly person's strengths and possibilities, and which can be combined with psychiatric treatment. With regards to treatment involving medication, much still needs to be done to fully establish the effects of certain substances, as well as the effects of electroconvulsive therapies and to discover how these combine with one another and with certain psychotherapy practices. In order to do this, it would be well worthwhile investing more in training health professionals who can understand and diagnose the causes of suicide attempts and what can be done to help the elderly overcome their feelings of despair.

As highlighted at the beginning of this study, no article by a Brazilian author has yet been registered in the different international databases related to suicide attempts by elderly people. So, this study will be of great value to the Brazilian Unified Health System – SUS since it concerns an existing problem that is still not properly dealt with in the country. It is hoped that the current review may serve as a basis for empirical studies that can benefit from the information herein contained.

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Publication Dates

  • Publication in this collection
    June 2015

History

  • Received
    14 Sept 2014
  • Reviewed
    20 Oct 2014
  • Accepted
    31 Oct 2014
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