Suicide in the elderly: approach to social determinants of health in the Dahlgren and Whitehead model

Carvalho, Mariana Lustosa de; Costa, Ana Paula Cardoso; Monteiro, Claudete Ferreira de Souza; Figueiredo, Maria do Livramento Fortes; Avelino, Fernanda Valéria Silva Dantas; Rocha, Silvana Santiago da

doi:10.1590/0034-7167-2020-0332

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Revista Brasileira de Enfermagem

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REVIEW • Rev. Bras. Enferm. 73 (suppl 3) • 2020 • https://doi.org/10.1590/0034-7167-2020-0332 copy

Suicide in the elderly: approach to social determinants of health in the Dahlgren and Whitehead model

Suicidio en ancianos: abordaje de los determinantes sociales de la salud en el modelo de Dahlgren y Whitehead

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

Identify in literature the social determinants of health related to suicide in the elderly, according to the model proposed by Dahlgren and Whitehead.

Method:

Integrative review of articles indexed in the databases BDENF, CINAHL, LILACS, and MEDLINE, with the following main descriptors: aged, suicide, social determinants of health, and risk factors. Primary studies were included which addressed social determinants of health and suicide in the elderly.

Results:

From the 19 articles analyzed, three categories emerged: proximal social determinants of health (male gender, mental disorders, physical illnesses, white race, 70-74 years old); intermediate social determinants of health (substance abuse, use of alcohol or psychotropic drugs, marital status, marital, social, and family problems, violence, previous suicide attempt, history of admission to psychiatric service); and distal social determinants of health (schooling, economic issues, sanitation, stressful events).

Conclusion:

Proximal determinants have more effects on suicide. Intermediate determinants are composed mainly of changeable factors. Distal determinants showed lesser associations.

Descriptors:
Suicide; Elderly; Social Determinants of Health; Risk Factors; Mental Health

Description	Components	Type	Descriptors
Participants (P)	Elderly People	DeCS	Elderly
		MeSH	Aged
		CINAHL titles	Aged
Phenomenon of interest (I)	Social determinants of health	DeCS	Suicide
		MeSH	Suicide
		CINAHL titles	Suicide
Context of the study Co	Suicide	DeCS	Social determinants of health Risk factors Socioeconomic factors Cultural characteristics Population groups
		MeSH	Social determinants of health Risk factors Socioeconomic factors Cultural characteristics Population group
		CINAHL titles	Social determinants of health Risk factors Socioeconomic factors Population characteristics

Autors	Country / Year of publication	Study outline / Number of participants	Objectives	Social determinants of health (SDH)	NE
Cavalcante FG, Minayo MCS⁽¹¹11 Cavalcante FG, Minayo MCS. Autópsias psicológicas e psicossociais de idosos que morreram por suicídio no Brasil. Ciênc Saúde Colet. 2012;17(8):1943-54. doi:10.1590/S1413-81232012000800002 https://doi.org/0.1590/S1413-81232012000... ⁾	Brazil / 2012	Descriptive study with a qualitative approach N = 51	Performing at least 50 psychosocial autopsies with relatives of elderly who had died by suicide. That in ten municipalities with high rates of these events, spread through all five Brazilian regions.	Proximal SDHs: Male sex, physical illnesses, and mental disorders Intermediate SDHs: Marital status, social problems, previous suicide attempt Distal SDHs: Schooling, economic issues	III 3
Minayo MCS, Cavalcante FG⁽¹²12 Minayo MCS, Cavalcante FG. Estudo compreensivo sobre suicídio de mulheres idosas de sete cidades brasileiras. Cad Saude Publica. 2013;29(12):2405-15. doi: 10.1590/0102-311X00048013 https://doi.org/10.1590/0102-311X0004801... ⁾	Brazil / 2013	Descriptive study with a qualitative approach N = 11	Empirically understanding the cases and multiple causes of 11 women who died by suicide and the fragments of personal stories that led to self-inflicted death, told by their families.	Proximal SDHs: Physical illnesses Intermediate SDHs: Violence and family problems	III 3
Zurbarán GTG, Rojo IG, Acosta VAJ, Jáuriga BL⁽¹³13 Zurbarán GTT, Rojo IG, Acosta VAJ, Jáuriga BL. Suicidio en la tercera edad: un problema de salud comunitario. Rev Cubana Hig Epidemiol [Internet]. 2001 [cited 2019 Jul 08];39(2):147-51. Avaliable from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1561-30032001000200012&lng=es http://scielo.sld.cu/scielo.php?script=s... ⁾	Cuba / 2001	Descriptive and retrospective study N = 40	Observing epidemiological and sociocultural variables in suicidal cases, as well as suicidal behavior in the third age and suicide methods found in patients with depressive disorder and disabling chronic disease.	Proximal SDHs: Male sex, mental disorder Intermediate SDHs: Marital Status Distal SDHs: Economic issues	IV
Shah A⁽¹⁴14 Shah A. A replication of the relationship between adversity earlier in life and elderly suicide rates using five years cross-national data. J Inj Violence Res. 2012;4(1):7-9. doi: 10.5249/jivr.v4i1.65 https://doi.org/10.5249/jivr.v4i1.65... ⁾	England / 2012	Cross-sectional, correlational study N = 305	Examining the relationship between the suicide rates of the elderly and indirect measures of adversity in early life.	Distal SDHs: Sanitation	III 3
Seyfried LS, Kales HC, Ignacio RV, Conwell Y, Valenstein M⁽¹⁵15 Seyfried LS, Kales HC, Ignacio RV, Conwell Y, Valenstein M. Predictors of suicide in patients with dementia. Alzheimers Dement. 2011;7(6):567-73. doi: 10.1016/j.jalz.2011.01.006 https://doi.org/10.1016/j.jalz.2011.01.0... ⁾	United States / 2011	Retrospective cohort study N = 294,952	Examining potential predictors of suicide in the elderly, veteran patients diagnosed with dementia.	Proximal SDHs: White race and mental disorders Intermediate SDHs: Substance abuse and use of psychotropic drugs	III 2
Torresani S, Toffol E, Scocco P, Fanolla A⁽¹⁶16 Torresani S, Toffol E, Scocco P, Fanolla A. Suicide in elderly South Tyroleans in various residential settings at the time of death: a psychological autopsy study. Psychogeriatrics. 2014;14(2):101-9. doi: 10.1111/psyg.12046 https://doi.org/10.1111/psyg.12046... ⁾	Italy / 2014	Cross-sectional and retrospective study N = 525	Describing the characteristics of a sample of elderly suicide victims in south Tyrol ⁽autonomous region in northern Italy⁾ and investigating whether the characteristics and risk factors for suicide of the elderly differ according to different life settings at the time of death.	Proximal SDHs: Male sex and mental disorders Intermediate SDHs: Marital Status Distal SDHs: Schooling, economic issues, stressful life event ⁽hospitalization⁾	III 3
Wanta BT, Schlotthauer AE, Guse CE, Hargarten SW⁽¹⁷17 Wanta BT, Schlotthauer AE, Guse CE, Hargarten SW. The burden of suicide in Wisconsin’s older adult population. WMJ [Internet]. 2009 [cited 2019 July 05];108(2):87-93. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19437934 https://www.ncbi.nlm.nih.gov/pubmed/1943... ⁾	United States / 2009	Cross-sectional study N = 534	Characterizing risk factors for suicide in Wisconsin’s elderly.	Proximal SDHs: Male sex and mental illnesses Intermediate SDHs: Marital status and alcohol consumption Distal SDHs: Schooling	III 3
Grabbe L, Demi A, Camann MA, Potter L⁽¹⁸18 Grabbe L, Demi A, Camann MA, Potter L. The health status of elderly persons in the last year of life: a comparison of deaths by suicide, injury, and natural causes. Am J Public Health. 1997;87(3):434-7. doi: 10.2105/ajph.87.3.434 https://doi.org/10.2105/ajph.87.3.434... ⁾	United States / 1997	Cross-sectional and retrospective study N = 9,181	Identifying health variables related to suicide in 65-year-old people and older and comparing suicide with other causes of death and health variables, sociodemographic variables, daily life activities, and the use of health services during the later year of life.	Proximal SDHs: Male, white race, and mental disorders Intermediate SDHs: Alcohol consumption ⁽three or more doses per day⁾, previous suicide attempt Distal SDHs: Economic issues	III 3
Almeida OP, McCaul K, Hankey GJ, Yeap BB, Golledge J, Flicker L⁽¹⁹19 Almeida OP, McCaul K, Hankey GJ, Yeap BB, Golledge J, Flicker L. Suicide in older men: the health in men cohort study (HIMS). Prev Med. 2016;93:33-8. doi: 10.1016/j.ypmed.2016.09.022 https://doi.org/10.1016/j.ypmed.2016.09.... ⁾	Australia / 2016	Cohort study N = 38,170	Investigating the prevalence and incidence of suicide attempt among Australian elderly and clarify how the morbidity burden contributed to suicidal behavior.	Proximal SDHs: Mental disorders and physical illnesses	III 2
Altınöz AE, Yenilmez C, Öner SK, Yıldız P⁽²⁰20 Altınöz AE, Yenilmez Ç, Öner SK, Yıldız P. Completed suicide rates of older adults in 5-year age bands in Turkey between 2002 and 2013: a retrospective study. Geriatr Gerontol Int. 2019;19(1):66-9. doi: 10.1111/ggi.13569 https://doi.org/10.1111/ggi.13569... ⁾	Turkey / 2019	Cross-sectional and retrospective study N = 3,450	Comparing the causes and methods of suicides among the elderly aged 65 to 69, 70 to 74 and ≥ 75, for full rates of gross suicide and sex between 2002 and 2013.	Proximal SDHs: Male, aged 70 to 74 Intermediate SDHs: Marital problems Distal SDHs: Economic issues	III 3
Cheung G, Merry S, Sundram F⁽²¹21 Cheung G, Merry S, Sundram F. Do suicide characteristics differ by age in older people? Int Psychogeriatr. 2018;30(3):323-30. doi: 10.1017/S1041610217001223 https://doi.org/10.1017/S104161021700122... ⁾	New Zealand / 2018	Cross-sectional and retrospective study N = 225	Reporting the characteristics of the elderly who died by suicide and investigate whether these characteristics differ in three age groups: 65-74, 75-84, and 85 or more.	Intermediate SDHs: Marital status, no history of admission to psychiatric service	III 2
Cheung G, Douwes G, Sundram F⁽²²22 Cheung G, Douwes G, Sundram F. Late-Life suicide in terminal cancer: a rational act or underdiagnosed depression? J Pain Symptom Manage. 2017;54(6):835-42. doi: 10.1016/j.jpainsymman.2017.05.004 https://doi.org/10.1016/j.jpainsymman.20... ⁾	New Zealand / 2017	Cross-sectional and retrospective study N = 214	Comparing the sociodemographic and clinical characteristics of elderly with and without terminal cancer who died by suicide and analyze the suicide reasons of those with terminal cancer to determine whether they represent rational suicide.	Proximal SDHs: Male sex and mental disorder Intermediate SDHs: Previous suicide attempt	III 2
Ho RCM, Ho ECL, Tai BC, Ng WY, Chia BH⁽²³23 Ho RCM, Ho ECL, Tai BC, Ng WI, Chia BH. Elderly suicide with and without a history of suicidal behavior: implications for suicide prevention and management. Arch Suicide Res. 2014;18(4):363-75. doi: 10.1080/13811118.2013.826153 https://doi.org/10.1080/13811118.2013.82... ⁾	Singapore / 2014	Cross-sectional study N = 409	Identifying clinical predictor factors of suicide in the elderly, especially those without a history of suicidal behavior.	Proximal SDHs: Mental disorder Intermediate SDHs: Social problems, alcohol consumption, use of psychotropic drugs	III 2
Carney SS, Rich CL, Burke PA, Fowler RC⁽²⁴24 Carney SS, Rich CL, Burke PA, Fowler RC. Suicide over 60: the San Diego study. J Am Geriatr Soc. 1994;42(2):174-80. doi: 10.1111/j.1532-5415.1994.tb04948.x https://doi.org/10.1111/j.1532-5415.1994... ⁾	United States / 1994	Cross-sectional study N = 204	Verifying whether selected clinical factors that characterize suicides after 60 years old differ from factors in younger suicidal people and determine characteristics of male and female suicide in the elderly.	Intermediate SDHs: Marital status and previous suicide attempt Distal SDHs: Economic issues	III 3
Préville M, Hébert R, Boyer R, Bravo G, Seguin M⁽²⁵25 Préville M, Hébert R, Boyer R, Bravo G, Seguin M. Physical health and mental disorder in elderly suicide: a case-control study. Aging Ment Health. 2005;9(6):576-84. doi: 10.1080/13607860500192973 https://doi.org/10.1080/1360786050019297... ⁾		Cross-sectional study N = 95	Assessing the risk of suicide associated with physical illness compared to elderly people who died of natural causes.	Proximal SDHs: Mental disorders	III 3
Zhou L, Wang G, Jia C, Ma Z⁽²⁶26 Zhou L, Wang G, Jia C, Ma Z. Being left-behind, mental disorder, and elderly suicide in rural China: a case-control psychological autopsy study. Psychol Med. 2018;49(3):458-64. doi: 10.1017/S003329171800106X https://doi.org/10.1017/S003329171800106... ⁾	China / 2018	Case-control study N = 242	Examining the relationship of demographic characteristics, including abandonment, mental disorder, depressive symptoms, stressful life events, social support and suicide.	Proximal SDHs: Mental disorders Intermediate SDHs: Marital problems, alcohol consumption and social problems Distal SDH: Stressful life events ⁽unemployment, hospitalization, and grief⁾	III 2
Koo YW, Kõlves K, Leo DD⁽²⁷27 Koo YW, Kõlves K, Leo DD. Suicide in older adults: differences between the young-old, middle-old, and oldest old. Int Psychogeriatr . 2017;29(8):1297-306. doi: 10.1017/S1041610217000618 https://doi.org/10.1017/S104161021700061... ⁾	Australia / 2017	Cross-sectional study N = 978	Analyzing the differences in suicides among the elderly ⁽65 years old and over⁾ compared to middle-aged adults ⁽35-64 years old⁾ in Queensland, Australia, during the years 2000 to 2012.	Proximal SDHs: physical illnesses Distal SDHs: Stressful life event ⁽grief⁾
Sun WJ, Xu L, Chan WM, Lam TH, Schooling CM⁽²⁸28 Sun WJ, Xu L, Chan WM, Lam TH, Schooling CM. Depressive symptoms and suicide in 56,000 older Chinese: a Hong Kong cohort study. Soc Psychiatry Psychiatr Epidemiol. 2012;47(4):505-14. doi: 10.1007/s00127-011-0362-z https://doi.org/10.1007/s00127-011-0362-... ⁾	China / 2012	Cohort study N = 55,946	Examining associations between depressive symptoms and suicide and modifiable factors such as sex, age and health status in elderly Chinese	Proximal SDHs: Mental disorders	III 2
Voshaar RCO, Kapur N, Bickley H, Williams A, Purandare N⁽²⁹29 Voshaar RC, Kapur N, Bickley H, Williams A, Purandare N. Suicide in later life: a comparison between cases with early-onset and late-onset depression. J Affect Disord. 2011;132(1-2):185-91. doi:10.1016/j.jad.2011.02.008 https://doi.org/10.1016/j.jad.2011.02.00... ⁾	England and Wales	Cross-sectional and retrospective study N = 839	Comparing behavioral, clinical, and care characteristics of elderly people with early or late depression at the time of suicide.	Proximal SDHs: Male sex and mental disorders Intermediate SDHs: Marital status, alcohol consumption and use of psychotropic drugs	III 3

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[1] Corresponding author: Mariana Lustosa de Carvalho. E-mail: marianalustosacarvalho@gmail.com