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AUTHOR McIntosh, John b.TITLE EIderty Suicide Data Bases: Levels, Availabilit ,

Omissioffis.PUB DATE 19 Nov 83NOTE 17ph; Paper presented at the Annual Scientific

kepti,of the Gerontological Society (36th, SanFrancis119co, CA, November 17-22, 1983).

PUB TYPE.) Viewpoints (120) -- Speeches/Conference Pagers (150)

EDRSRRICEDESCRTPTORS

ABSTRACT

MFOI/PCOI Plus Postage.Demography; Etiology; High Risk Persons; IndividualCharacteristics; *Information Needs; *Older Adults;Prevention; Research Needs; *Suicide

General data on suicide among the elderly areavailable but -the trendsiand_levels often -have been either ignoredMisrepresented; AvailabA4 data indicate -that despite .declines,suicide .rates in thp United States remaihhighest in ;old age.Impediments to understanding elderly suicide occur due te"bmissionsin available national -data bases. Inadequacies ofavailablee'.-H'_official; national and other.data,include thei'omisSion of:'maritalstatus and time .ilLthat'statui; race/ethnicity; socioeconomic statust'occupation (e.g., retired); liVing conditions' (e:g;-.; with whom)1. ALmental, physical, and chronic conditions; 'and. historical infOrmation(e.g.; pagt- attempts); This and other information about elderlysuicides would be useful to test etiological theories and determine'high risk subgroups for intervention; The unavailability:of Narious

::population data also produces problems, eo34, annual population datanecessary for rate/calculations are only available. in aggregate fromabove age 85. Data essential for:almore-grecise-comprehensioaeither not available or are .difficult_and/or_expensive to sec :.The,'quantity and quality of currently available data allow little ore_than a general impression -o elderly suicide. Better, more -de ailedinformation is recommended-.to improve the _understanding andprevention of suicide in .old :age..(Author/BL)

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Elderly Suicide Data_iBases:Levels, Availability, Omissions

by

John L. NcIntosh7Ph.D.Indiana University et.Aouth Ben

U.B. DEPARTMENT OF EDUCATIONNATIONAL INSTITUTE Of EDUCATION

EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC)

This, document has been reproduced asreceived from_ the person or. 'Organfzationoriginating it:Minor changes have been made to imple'reproduction quality

Points of view or opinions stated in document dp riot nefessarily represent otBCwl NIEpositio6 Or policy,

Address correspaAdence to:John L. McIntosh, Ph.D.

'Department of PsychologyIndiana University at South BendP.0.1Box 71/1

"PERMISSION TO REPRODUCE THISMATERIAL HAS BEEN ANTED BY

Aid 41

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TO THE EDUCATIONAL RESOURCESINFORMATION CENTER (ERIC)."

South Bend, IN 46634-,:Phone: (219) 237-4343

1..

Paper presented at the annual meeting of the Gerontological-Society of°America, San Francisco, CaIifornii, November 19, 963.

GSA, San Francisco, '83 'McIntosh, J.Li Ph.D. -

Elderly Suicide Data Eases.: Levels, Availability, Omissions

John L. McIntosh, Ph.D.*

Indiana University at South Rend

Department of Psychology

Abstract

General data on suicide among_the elderity.are available .but_the trendsand devels_haYe often_been_;either :ignored or srepresented. Data

highest in old _age._ Further impediments_ to U derStanding_ elder4y51Ppresented indicate that. despite declines, :U.S- uicide_rates, remain

suicide occur due to_ _omissions_ in _available- national data baseS.AVailable official national and other_ dAa;__ their strength ,

weaknesses,_ and inadequacies are_presented;_including the omission_p :

-.marital status_and_timb in that status, race/ethnicity; SES, occupalidri(e.g., retired), living conditions_ (e.g., with whom), mental, physical;7

and chronic conditions,_ and :historical_ information (e.g., _pastattempts). ._These and_other_information.about elderly_ suicides would beusefulto test etiological theories and determine)high_risk_subgroupsforkntervention. 'The unavailability of various population. data alsoproduces problems (e.g., annual, population_ data_ :necessary for ratecalculations are only available in aggregate form above agei85). Data'essential for a More precise Comprehension are either not_available_Orare difficult and/or .expensive to secure; The quantity and quality I,

currently available data -allow little more than a generarimpression ofelderly suicide and better; more detailed information is recommended toimprove our, ,understanding and prevention of suicide in olcYage;

*Address: Assistant ProfesS'or of EsyChology, IUSB, P. 0; Box 7111,South Bend, IN 46634;

GSA; San Francisco, Nov '83 AdvicIntOsht

\s

.Elderly Suicide Data Bases: Levels, Availability' 871ssiOns

,

Before' we can deal directly with the suicide data'for the elderlyiwe must consider the source of such available figures-officialstatistics. Official statistics on causes-43f-deathl including_forsuicidet are kept by:the U.S. and most developed 'countries in theworld.- Official data are derived from death:certificates and the cause

. listed thereon (see Brooke fi Atkinson, 1974, for a_desctiption_ofprocedures for ascertaining that a death was:suicide). ;It is importantto note that official mortality data are collected for medico-legal

.purposes and not, r search. porposies. The accuracyt_qualitY, and'usefulness ofthes officialffigures have been criticized by manyAwriters (among the Atkinson, 1978, Chapter '3; Douglas, 1967, Chapter12; Lester, 1972, Chapter 12; t Simpson* 1950). These authors argue ,that official stat stics'contaIrCsystematic biases (e.g., counted more

. .

accurately for som groups than for others)which make their usequestionable.

There is evid nee thAt the. classification'of deaths as suicide isaffected by several factors, including: the backgrounds and

i orientations of those who.determine the cause of death (coronerstmedical examiners .etc.,; see Lester' 1983,.Chapter. 6; for a recentreview); by sociAal taboos regarding_ suicide and negative sanctions(particularly ,.award the surviving:family memb rs)/ and particularcircumstances tif the death itself_ (e.g.t_metho employed, pre'sence orabsence of a note). _These and_other factors 1 ad to a lessened

.

likelihood of_a suicide unless i is obvious (see alsoShneidman,1963;_ llonkt_1975;VP. 193195; Gibbs, 1968; pp. 13-14)..Such classification'problems_undoubtedly lead to underreporting of-the'actual incidence_of suicide in &culture. There are other problems as

iwell_ Comparability of figures across time can be affecte by therevisions that-occur about every ten years in the internationalclassification of diseases and death. Available data on compara Ilty

.of these classification scheme revisions (see; e;cg;,i National Cen rfor Health.Statistia, 1982) suggest that this is a minor problem utone that should be noted.

-Other data problems important for the:present topic pertain tpopulation estimates._ Since suicide rates are based on both suicideinciaence and population figures (see Formula 1); inaccuracies ineither component will affect the resultant computed rates. I noted'above possible factors that affect (and generally lower) the suicidefigures, :but population figures are also suspect in some instances.Pqpulationiestimates are based on densus'data which are most inaccurateamong_the_young, the very old, and nonwhites (e.g., Native Americans:Passel, 197.6). A greatet problem is that population estimates that:areneeded to compute rates are often not available (Starsinict personalcommunication) for some age groups (e.g., breakdowns of the 85 and .

above population) or for specific racial groups.. .

No; of suicides in the populationFormula 1: Suicide rate = . X 100,000

No; of individuals in the population

Although the difficulties inht in the use of officialstatistics seem fdrkdable, some re have presented evidence

GSA, San Francisco, Nov '83 McIntosh, J.L.. Ph.D.

which suggests that the bias so often maintained is not as large as hasbeen claimed; For example, studies by Sainsbury and associates(Sainsburyi 1973; Sainsbury & Barraclough, 1968; Sainsbury & Jenkins,

,1982) have led to the conclusion that although suicide rates based onofficial statistics-are most likely- underestimates, little-systematicbias occurs; So long as the limitations are kept in mind and theconsistencies in the data are focused upon, the data should be avaluable part'of the information regarding the health of the groups

_--studied (Hopper & Guttmacher, 1979; Kleinman, 1982). Officialmortality statistics are the only consistently available nationwidesource of data (Glasser, 1981). As: such; they are the best (though-possibly low) estimates we have of the incidence of suicide in our.culture and its subgroups. Despite all theirlshortcomings, we can befairly confident that the official figures on suicide are the mostconservative estimates of the numbers which actually occur (Hatton, _

Valente; & Rink, I977). Reid (1160, p. 17) stated that.for suicide_the"death certificates form a fairly reliable guide to the frequency ofsuch events in any defined population."

On the assumption that available suicide data are not perfect butare at least a useful index' to the -levels which occur among apopulation, let us consider what is available regarding thecharacteristics, levels and trends of elderly suicide data before wefocus on what is not available: I will present thb_general findings_ofmuch of -the available data for which population estimates exist-(withwhich to calculate rates). The annually available characteristicscoded in the data are: age (5- and.10-year age groups generally), -sex,race 1white, all nonwhites;_ black, nonwhites excluding blacks, NativeAmericans (American Indians], Chinese,,Japanese, Filipino,_ and "allother," in recent years), geographic information (state, Standard -

Metropolitan Statistical Areas ISMSAs],_etc.), whether an autopsy wasperformed, _date of death, and_the suicide method employed (see e.g.,McIntosh &' Santos, in press, for suicide methods by age). These datacharacteristics do not generally.. provide sufficient- information to testtheories about the etiology of elderly suicide and_the'cOntribution of-these factors to the suicidal acts of_the aged. They provide usessentially with 4 general idea regarding -the extent and trends ofelderly suicide but alone are an insufficient base withwhich toundeistand aged suicide. For example, important age-related trends insuicide rates have occurred in our_country. I_am certain Dr. SeidenWili_discuss the point in greater detail,-but_the two trends are 1)suicide rates have increased_ for the young and- 2) decreasectfor theJelderly (see Figure 1 & the_bottom_of Figure 2). The available suicidddata are_ ineufficient to_telia us why elderIy rates have declined: Ithas not_ been_the increasing number_of suicide prevention centers in theU.S._ The old rarely_utilize.them (McIntosh, Hubbard,.& Santos, 1981);Combined with other, kinds of data and; using correlational methods wehave begun to find_hinti that_the economic changes for the-old are a__-factor_iMarshallo 1978) and_that the increasing proportion of women (alow suicide risk population) in old age (McIntosh, Hubbard,.& Sant6s,1980) but not the general increase in the elderly population as:a whole(Holinger & Offer, 19821_may be important factors. We are still asunsure as was Busse (1974) when he stated

How much eif the decrease might be the'result of the use of

GSA; San Francisco; Nov '83, 3 McIntosh, J.L., Ph.D.

anti-depressant drugs is not known; or of increased therapeuticefforts on,the part of suicide prevention centers and communitymental health programs; or the increased economic security-andhealth care resulting from the implementations)/ social securityand Medicare legislation; All are possible factors. (p. 221)

We remain far from an adequate expIana,tion_for this important trend.Traditional characterizations of(suicide rates by age have stated .

that rates increase with age; peaking in old age. While_this remains---generally true, the two trends already noted_have altered the curve to

a more bimodal one isee.Figure.3). Despite increases for theyoung anddecreases for' tie old; however; it is: important to:note_that suicidepeaks in old age today just as it always has in the United States; Theold have been: and continue to be the highest risk group for suicide; :

Insert Figures 1-3 about here.

Although the oft-cited statement_that_the aged comprise 10% of thepopulation but commit 25% of,the suicides (e.g., BoCk; 1972; Butler;1975; Resnik & Cantor.; 19701 ekaggerates the case (the 65+ populationhas .never committed a-full 25% of the suicides; see the-top of Figure2); the essential relationship remains accurate. That isi suicide isoverrepresented among the_elderly._ For example those 65 years of ageand above made up_11.3% of_the_1980 population, but they committedp169% of the suicides (4537/2.6869; NCHS, 1983; U.S. Bureau of theCensus; 1982).

t The old age peak in- suicide rates is especially so for males andwhites (see Figures 4 & 5). As can be_seeny suicide rates are mostdivergent for the sexes and races_in old age because rates for therespective groups (males vas_feMales_t_whites;vs;,nonWhites) are movingin opposite directions.in old age. That is; rates for women peak inMiddle age,and decline_in_old-age whereas those for men continue to',rise throughout the elderly years._ Similarly; rates for nonwhites as awhole peak in young adulthood and decline to low levels in old agewhereas rates_for whites rise with -age and peak in old age; ThehigheSt_riSk individuals for suicide from a demographic/epidemiologicalstandpoint; therefore, are elderly white males (there are also specificracial differences by age, see McIntosh, 1980, and McIOtosh'& Santos;1981) . ,

.Insert Figures 4 75 about here;

fore turning completely_to elderly suicide data Iimitations.andneedS; one of these issues denters.bn the4daia that I have thus fai -

presen ed. Much. of_ the elderly suicide data 4 have discussed has been. based: pian "Old" being defined as 65 and above. There is good evidence

that is aggregrate groupingkdisguises important differences. Arecent compilation of official data (McIntosh; 1983) has stibown thatsuicide rates_ both the,young-old (55-74 or 65-74)and oldold_

;475+) subpopulations have declined over.time; but that the dedlibe has

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_GSA, San Francisco, Nov ' 83

been somewhat greater among the young-old and hasfor young-old males (see Figure 0. Consideringsincpc homogenous group does noeseem wa ntedthan in many other behaviors and circumstances (

.L974).=

Insert Figure 6 about here.

J.L., Ph.D.

PC urr especiallyhe elderly as asuicideany me

ee.g., Neugart ni

As measured titv suicide rates, old age is the time ok highest risk;The data on which these rates, are computed, however, have severallimitations which lessen their potential usefulness for aiding in theunderstanding of elderly suicide (for a further general discussion ofthese limitations, see Boldt, 1981). In addition to the underreportingproblem, official national suicide data are also incomplete, i.e.,important information about the individuals who committed suicide arenot ayailable. In some cases the information was available on 'stateand local levels, (i.e., the.actual death certificates) but it was notretained or coded for national data. due us ally to the'lackof funds orinterest (Greenberg, personal communication). Examples'of possiblyimportant data fpm the standpoint of understanding suicidal behaviorinclude socioeconomic status and incomei'occupation and employmentsituation (or "retired" and time since retirement), living conditionsand circumstances (including with whom one lives), the existence ofphysical or mental illness, alcoholism and/or drug abuse and/or chronicconditionsi as well as historical information (such as pastexperiences, past suicide attempts,, hospitalizations, recent loss,religion and religiosity, etc.). One factar-,:which usually is availableon the'death certificates is the individual's marital status. Thesuicide literature contains many statements that the widowed anddivorced are high risk for suicide (e.g., Frederick, 1978). The lastnational data avoidable in the U.S., however, was for'the. time period1959-61 (see 'Kramer, Pollack, Redick, & Locke, 1972) [Marital statuswas -returned to the information available opi the detailed moct itytapesin1979 for the nation..]. Even here though, other import tinformation is lacking,-e.g., the time in that status (widoited,'morried,_divorced, separated, number,of marriagesi.circumstancessurrounding_the status, etc.).

An additional data problem iq the unaVailabili of figures thatare potentially available on the dOded data but are untabulated. Ode-such example is the)lack of data by age for specific U.S. racial/ethnieMinorities (see e.g., McIntosh'& Santos, 1981). These data Are onlyavailable to those who are able to obtain costly annual computer tapeswhich contain.death records_and who then extract the_information on ageand ethnicity. The_availabie coded racial groups alto includeomissions, most noticeably any data for Hispanick(Hispapic da.ta arecoded by'some states [McIntosh & Santos' unpublished data), butgenerally _they are included in aggregrate form with the reett of thewhife populatlop_and are not Even if-many'of these-44ata -were availablOrhowever4._population figures with which to caIculdtefates are_available for few of them. __A particularly pertinent, examplelere is'that suicidefigures are available:in- and 10-year age groupstei 100 +, but populationrestimates are available only for the aggregate

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GSA, Sari Francisco, Nov -'83 S McIntosh, J.L., Ph.D.'

1_ 5..4 /8+-population as a whole. These extremelyAldgxoups have been,_suggested to be at lower risk for suicide than-their.immediatelY"younger" groups_(e.g., Bromley', 1974, p; 146), but-population'data.necessary to test such statements are not available;

_One_of the most glaring final problems with suicide-data (evengreater than in many ways than the desired in-depth' and historicalinformation) -is that its-must be collected from secondary- sources; fromthe family, friends, and others. 'Our greatest source erification,and of valid and reliable data, the suicide irictim, is of available toprovide that information.

In sum, the official mortality data.provide-informa ion on -.thecharacteristics of elderly suicides as a group:but provid little in ("'.

the understanding and prediction of the specific elderly individual whocommits suicide._these characteristics are not necessarily related tothe reasons for the elderly person's.suicide. For example; a personmay have been a widow at the time of their death but thatcharacteristic may be a minor or unimportan%one iqq.their suicide: Ithas been suggested that elderly suicides are most commonly multiplycaused, with the_suiciole_more 'a response to an entire life situationthan to any single aspect or event (Barter, 1969). To be sure, therei&:a need for in- depth individual data collection that may be more.sensitive tothe.multielicity.of circumstances and their historicalplate in producing a suicidal act; \:

To improve suicide data for the elderly and\provide figures thatare useful in hypothesis and theory testing as well as for prevention,systematic, consistent, accurate, detailed, and_historicai infOrmatiOn1is needed on the elderly suicide population. Stich a detailed andIT:etfievable data base would certainly be costly and timeconsu ing tecollect, maintain, and update; The problems are great the ataare mees;led if the complex questions generated by theory are toadequately tested and our knOwledge, understanding; and preventefforts are to improveamongthis high risk population.

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Ai San Francisco, Nov 'pa P6

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org4nization'of sudden death. -Pittsburgh:- Uniyersity of PittsburghPre s. .

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& Atkinson, M._A$14); 400brtaihmeht. deaths -fromsuicide. n E. . Brooke' 4 .),_Suicide and dttempt 0 suicidea=pp. 15-70). Geneva: World Health Organization, Public HealthPapers No. 58. :

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Hatt , C. L., Valente, S. 14;, & Rink, A.-(137). VariabIesoin suicides ti tics: In C.L.; Hatton, S.._14. Valente, & A. R nk (Eds:).,Su'cid: A_sessment and intervention (pp. 133-138). New York:Appleton- Century- Crofts.

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(1g/9). Rehinking suicide: 'Notes towardrvicesr7I I

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Kleinman, J. C. (1982); 'The continued vitality of vital statistics;American-Journalfaf-Public-Health. 12. 125-0127.

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McIntosh,. J. L. (1983, April); Suicide among the youn -old andoId-older _Components of the decline in elderly Sul.° de.- Paperpresented at the annual meeting of the American Association OfSuicidologY, Dallas, TX.

McIntosh, J. Hubbard, R. Wir-4, Santos, J. F. (19.80,November):Suicide _am g_nonwhite elderly: 1960-1977. Paper presented at theannual mee ng 'of the GerodtoIogical Society of America, San Diego,CA. - 04.

McIntosh, J. L., Hubbard, R. W., & Santos,-J.. F. (1981). Suicide amongthe elderly:. A review of :issues With case studies. Odurnal.ogGerontological Social Work, 4, 63-74.

mcIntOsh, J. L., & Santos, 3..F. (1981). Suicide among minorityelderly' A prelimipary investigation. Suicide and Life- ThreateningBehvavior, Ale 1,51-166.-

McIntosh; J. L., & Santos, J. P.'(in press). Methods of'suicide byage: Sex and race differences among;the young-and old.International'Journal of Aging and.Human Development.

monk, M. -(1975) . °Epidemiology. InqS.' Perlin .(Ed:), A Aandbook for tistudy .of suicide (pp. 185a211). New York: OxfOrd University Press.

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Neugarteh, 0._L. (1974,' September)._ Age groups in Ameritan society andthe rise of the young-old. Annals of the Americ an-Acadev of,Political and Social Science, pp. 187-198;

Passel, J. S. (1976). Provisional evaluatiOn of the 1970 census countof American Indians. DemographYi 3, 397-409.

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ik, H. L. P., & Cantor, J. M. (1970). Suicide and aging. _Journalf the American Geriatrics-Sqclety, IS, 152 -158. T'

Sainsbury,,P., (1973). Suicide: Opinions and facts. ofthe Royal Societyof'Medicine; -664 579-587.

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Sainsbury, P., & Jenkins,- J. S. (.1982). The accuracy of officiallyreported suicide statistics for'. purposes of epidemiologicalresearch: Journa . s-o e*, de 011fldd o:; the 36, 43-4C.

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aetiology.of suicide. American_Sociologicat_Review, 15, 658461.

Starsinic, D. W. (1978, April 18). Chief, State and National EstimatesBranch, U.S. Bureau Of the Cens personal communication.

United States Bpreau of the Census. 1982). preliminary estimates ofthe population. of the -United Statesi'byage, sex,. and.race:1970 -1981. CurrentLPopiIation_Reports, Series P-250 No. 917.

GSA, San Franciscb, Nov '83

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McIntosh; J.L;, Ph:D..

Figure I_Suicide among the- Young; 1933-1978

19 0 1940' 19 0 19 0 1.90 19.0YEARS

11

r

r

r

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1

GSA; San Francisco; Nov '83 10 McIntosh;

Figure 2Elderly. Suicide/Population Contribution:.

Percentages and RateS; 1909=1979

. PhD

V

0 11

lb

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cr

19b0 1910 1910 1990 1940 ma 19e0 1910' 19t0

YEARS

GSA,.SanFrancisco, Nov '83 II McIntosh, J;L, PhJ3;

Figure 3United States Suicide by Age, 1969, 1974, 1979

113

#

9

15=

24

25-

34

3544

A GE

45-

54

55-

54

6574

75-

84

14

1469

1974

1979

tL

GSA, San Francisco, Nov '83. 12 McIntosh;

Figure 4.-

United States Suicide-by Age and Sex; 1978

;19 29 39 59 69 79

FIQ-Ect'

15

GSA, San Francisco, :Nov 183 13

Figtire 5United States Suicide by Age and Race, 197.8

McIntosh, J.L., Ph.D.

a

9 19 29 39 49 59 69 79

RGE,

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GSA, San Francisco, Nov '83 14 MCItitogh.T.L: h.13;

Figure 6Old-Old (75 +) & Young-Old (55=74 & 65 -74) Suicide by Sex, 1933-79

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z55-74

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