1. Suicide in geriatric depressed patients in Turkish Culture Işın Baral Kulaksızoğlu, M.D. Department of Psychiatry Istanbul Medical Faculty

2. -Population over 65 in Turkey %8.6 (U.S.A %26) -Life expectancy w=71.4, m=66.8 year (DPT 1999) After Japan and Mexico Turkey has the 3rd increasing the elderly population in the world according to WHO statistics.

3. Geriatric depression in Turkey In Black Sea Region; MDD over 60 is %29 »Bekaroglu et al (1991) In Mediterranean Region; MDD is %5,9, depressive symptoms are %11 »Ucku et al (1992)

4. Geriatric Depression Prevalance Study 1018 community dwelling elderly GDS and MMSE scores obtained Depressive(  14) Normal(<14) Total n=163 n =855 n=1018 %16,0 %84,0 %100 »Kulaksizoğlu IB et all. Int J Psychiatry 2005

5. Risks for geriatric depression in İstanbul Age:75-79 female gender no education 4 or more kids Only 7% were on AD

6. Similiar rates of geriatric depressive symptoms as other countries in the world Female gender- Universal truth Social factors are closely related with depression in a developing country; Türkiye –education, multiparity,child caring.. Elderly depression is unrecognised and untreated by medical staff

7. Suicide rates of eldely depressed patients ? Culture effects elderly suicide rates Higher in old age in USA, Hungary,Japan, China France, Spain, Italy, Austria….. Lower in old age;Norway, netherland Denmark Sweden, Poland, Australia…. İdeation or action? Factors associated with elderly suicide? Other ways: Passive suicide?

8. For Turkey WHO-EURO multicentre study; in a 4 year of period between 1998-2001, suicide attempts –46.89/100.000 for men –112.89/100.000 for women »Devrimci-özgüven Can J psychiatry 2003

9. Suicide Rates in Turkish population among age groups 15-24 (%) 25-35 (%) 65-74 (%) >75 (%) 199932.624.45.82.8 200034.521.15.32.5 Data obtained from the official Turkish State Statistics Institute

10. Between 2002 and 2004; only 3 elderly patients admitted to emergency department of İU.İstanbul Medical Faculty with a suicide attempt. Since last 5 years there is no admission of any elderly person to psychiatry department of the same hospital after a suicide attempt In the Government suicide statistics; 47 suicide in 1974 to 139 suicide in 1996 were reported over 65. İncreasing rates but still below the European average.

11. Questions then.. Are suicides under-reported? Are suicide ideations different in our elderly patients than young ones? Are there other ways of committing for old age suicide?

12. Are Suicides underreported? In Islam, suicide is strictly forbidden –Religious funeral or prayers are not allowed –They belive he/she will go directly to hell –It is a shame for the family to have a member who committed suicide –Medical staff or authorities are inclined to report suicides as accidents or intoxications to protect the families from the convicting attitude of the society, therefore statistic may not reflect the exact rates. But still low comparing other western and some eastern countries

13. Are suicide ideations different between young and old? 30 young and 30 elderly consecutive patients with major depression and admitted to Pscyhiatry and Geriatric Psychiatry were included in the study DSM-IV criteria were used for M.Depression The young group was between the ages of 14-40 and the elderly were above 60 years old. Sociodemografic data form, a questionnare for suicidal ideation( beliefs, plans, attempts…were asked) Hamilton Depression Scale, Geriatric Depression Scale, Beck anxiety scale and MMSE were given Elderly group was followed up for a 12 month period.

14. Mean age of the ED group was 71.1+ 7.6 years and YD group was 28.6 +6.8. Female gender was predominant in both patients group and percentages were as high as 83.3 % for YD and 80 % for ED. Income level, sex and education level were matched between the groups All were Caucasians and Muslims.

15. MeanMedianSDMinMaxUZp HDS Genç24.725.04.31532young vs. old391.00.8750.382 Yaşlı26.327.06.21640 GDS score Yaşlı20.0 4.11330 BECK score Genç29.028.512.5959 young vs. old 224.03.3470.001 Yaşlı18.815.512.2647 CGI Genç4.95.00.736 young vs. old 421.50.4430.658 Yaşlı4.85.01.237 MMSE Genç28.229.02.61730 young vs. old depressives 268.02.7360.006 Yaşlı26.627.02.62130 Old dep vs.old controls270.52.6990.007 Yaşlı28.329.01.42430 Yaşlı21.118.56.31744

16. "Hayat boş, yaşamaya değmez" diye düşündüğünüz oluyor mu? Do you have thoughts such as ‘Life is not worth living’? yes%TotalChi Sq.SDp Young2376.730 X2X2 0.34110.559 Old2170.030Yates0.08510.770 Ölürsem yakınlarım rahat eder" diye düşünüyor musunuz? Do you ever think that your family will be better off if you die ? Yes%TotalChi Sq.SDp Young723.330 X2X2 0.34110.559 old930.030Yates0.08510.770

17. ("Keşke ölmüş olsaydım" diye düşündüğünüz oluyor mu?) Do you wish to die? yes%TotalChi SqSDp young 1550.030X2X2 0.26810.605 old 1756.730Yates0.06710.796 ("Ölüm tek çare" diye düşündüğünüz oluyor mu?) Death is the only solution yes%TotalChi SqSDp young723.330X2X2 3.59010.058 old1446.730Yates2.63710.104

18. (İntihar etmeyi düşündüğünüz oluyor mu?) Do you ever think of the idea of suicide YES%TotalCHİ sq.SDp Young1136.730 X2X2 0.69310.405 old826.730Yates0.30810.579 (İntihar etmek için bir tasarı ya da planınız var mı?) Do you have plans for committing suicide? Yes%TotalChi Sq.SDp Young620.729 X2X2 0.15010.698 Old725.028Yates0.00510.943

19. Results Ideation and pre-occupation with suicide were not statisticly different between young and elderly groups After one year of follow-up 25% of the elderly group had suicidal thoughts nevertheless none of them had an actual attempt Intra-familial conflicts and chronic disabling medical diseases were the main causes of suicidal ideation Hanging and jumping are the most common choices of suicide. Elderly prefers more lethal methods Religious and cultural diaproval were major barriers to do the act in the elderly depressed group.

20. Discussion Affective illnesses, particularly unipolar and bipolar depression, are the major risk factors that predispose to suicide across all age groups Islamic disapproval may be discouraging factor for lower rates of elderly suicide in Turkey. –In Ethiopia similar results were obtaioned among Muslims Alem A et all Acta Psych Scan 1999 Self killing is not an option for adults who had strong religious education. Eskin M Soc.Psych.epidemiol. 2004 Religiously unaffiliated subjects had significantly more lifetime suicide attempts and more first-degree relatives who committed suicide than subjects who endorsed a religious affiliation. Dervic K Am J Psychiatr 2004

21. Other factors may be related to low suicide rates ; ‘Self-anger’ and agressive behaviors may decline by age Those who prone to violence died early in life Turkish culture may provide more of a role for the elderly and elderly may have more prestige in the community. They stay in the familiy, There is a stigma of nursing home… Turkish elderly may experience less stressors in their daily life. Substance and alcohol abuse is a not a common problem in Turkish elderly

22. Are there other ways of committing suicide? Passive and Chronic suicidal behavior –Stoping medications –Malnutrition Stop eating or drinking water Fasting to die –Disobeying the medical advises; diet etc –Refusing any help for caring Osgood et all 1991 first mentioned ‘indirectly self- destructive behavior’ of elderly ‘Those over 75 are more likely to use passive forms of self-destructive behavior’ ‘Elderly who acts in chronic a suicidal manner are less likely to be brought to the attention of authorities’

23. Conclusion Suicide is an important risk for elderly depressed patients despite both the İslam and Turkish culture Clinicians must be careful for passive suicidal attempts Psychosocial prevention programs are needed Governmental Support and new politics for Socio- medical programs for elderly care are needed Collaboration and multicentre studies are essential for understanding the effect of Muslim on elderly people for their attitudes for death and dying

24. Thank you for your attention