Review Article

Yonago Acta medica 2002; 45:69–73

Depression and Suicidal Behavior in the Elderly: A Literature Review
Ikuko Miyabayashi
Department of Nursing Care Environment and Mental Health, School of Health Science,
Tottori University, Yonago 683-8503 Japan
Depression and suicide are significant health problems in the United States and Japan,
and suicide is still considered primarily a phenomenon of adolescence to middle age.
However, it is also a significant problem in the elderly (65 years old and above). The
purpose of this report was to review the literature relative to the depression and suicidein the elderly in the United States and Japan. Several important factors involved withelderly suicide were different between the 2 countries. While Americans suffer frompsychological problems, Japanese more likely suffer from physiological problems.
Cultural and religious backgrounds play an important role in the decision to commit
suicide.
Key words: cultural differences; depression; elderly; suicideii) There is a high correlation between suicide
behavior and depression (Nordstrom et al.,
1995; Fawcett et al., 1990; Malone et al.,
1995; Isometsa et al., 1994; Pokorny, 1993;
Roy, 1999);

Depression and suicide are significant
health problems in the United States and Japan.
There are more than 30,000 suicides a year in
the United States – the 8th leading cause ofdeath in 1998 (Mann et al., 1999). In Japan,
there were 31,413 suicides in 1999. This was
the 6th leading cause of death (Health and Welfare Statistics Association, 2001). Nevertheless,suicide is still considered primarily a phenomenon of adolescence to middle age, and most research has focused on this age group. The reality is that suicide is also just as a significant
problem in later life (Osgood, 1992; Takahashi,
1995; Stack, 1996).
Takahashi (1997a, 1997b) compared andcontrasted attitudes toward suicide between
Japanese and Americans, suggesting that mostJapanese think that suicide is not always an abnormal behavior. In contrast, Americans are
more likely to think that suicide usually resultsfrom psychiatric problems that can be prevented.
The reasons why suicide is a significant
problem in the elderly rather than in other age
groups are as follows:iii) Despite a high prevalence among the elderly, depression is rarely recognized or treatedproperly in this group. This suggests thatthe elderly group has a high risk in this aspect more than any other age groups.
The purpose of this report was to review theliterature relative to depression and suicide in
the elderly in Japan and the United States, focusing on the cultural differences between theJapanese and Americans.
Depression and the elderly
Depression, one type of mental disorder, is asignificant risk factor of suicide (Nordstrom etal., 1995; Fawcett et al., 1990; Malone et al.,
1995; Isometsa et al., 1994; Pokorny, 1993;
Roy, 1999).
Although depression is considered a major
factor for suicide in the elderly, there is a lack ofreliable data because of difficulty in diagnosis.

i) The elderly have the highest successful suicide rate;69

I. Miyabayashi

Blazer (1989) reported that diagnosed cases ofmajor depression were not differentiated from
cognitive impairment, anxiety and disruptions.
The most frequently used approach in epidemiological studies was not based on confirmed
diagnoses but symptoms. Several researchers
shared the concern that diagnoses were difficult
to confirm, especially in a certain population orcommunity. The term “depression” in the following research was not well defined comparedto the current concept. However, the results of
the research are worthwhile mentioning. Blazer
and Williams (1980) surveyed 997 people withsymptoms of depression who were over the ageof 65 in a community in North Carolina andfound 14.7% had significant dysphoric symptoms. Murrell and his coworkers (Murrell et al.,
1983; Murrell and Noris, 1984) interviewed
2,517 people (over 55 years old) with depressive symptoms (diagnosed based on these
symptoms) and found that 16% had significant
depressive symptoms, especially in the oldest
age group (75 years and above) and in females.
Berkman et al. (1986) surveyed 2,806 people (ageand sex, not determined) in New Haven andfound 16% with significant depressive symptoms in females and older people. Kennedy etal. (1989) investigated 2,137 people (age andsex, not determined) in the Bronx in New Yorkand found 16.9% with significant depressive
symptoms in females and the oldest. Most researchers used the Center for Epidemiologic
Studies Depression Scale for screening, while
Blazer and Williams (1980) used the Older
American Resources and Services Depression
Scale. The results of these reports were similarin prevalence (approximately 15%) and demographic trends (more in females and the mostelderly).
As seen in the community population,
studies on an inpatient population had similar
results. Rifai et al. (1994) studied the symptomof hopelessness in 63 depressed patients with anaverage age of 67.2 years and found that patients with high hopelessness scores had a history of suicidal attempts and were also more
likely to drop out of treatment. Shah et al.
(1997) screened for depression among acutely
ill geriatric patients in a hospital with a shortgeriatric depression scale. Depression wascommon among those geriatric inpatients.
There are few diagnosis-based epidemiological studies on relationships between the elderly and depression in the United States. In
Japan, there was a close relationship between
the elderly and depression (Koizumi et al.,
1990; Takahashi, 1992, 1993; Chow, 1996;
Takahashi, 1998). In the Japanese elderly, oneof the characteristics of depression was a denialof being depressed. Their depressive symptoms
manifested as somatic or hypochondriac complaints that their family members often ignored
and were unable to be accurately diagnosed bytheir primary physicians (Takahashi, 1995).
Interestingly, in other countries, for example inEngland, the opposed was found. Dewey et al.
(1993) surveyed the 3-year mortality of 1,063
people who were 65 years old or above in acommunity in Liverpool and found that effects
of depressive symptoms were not confirmed asa strong factor for mortality.
Suicide and the elderly
Although the suicide rate has increased mostdramatically among the young during the past
20 years, the elderly white male remained having the highest suicide rate in the United States(Devons, 1996). There are 2 high-risk groups:
the young and the elderly. This phenomenon is
also seen in Japan. Depression was suspected
to be a major factor in suicide of the elderly.
However, there is a lack of reliable data,
because it is difficult to identify specific cases.
Several researchers (Jobes et al., 1987; Hlady
and Middaugh, 1988; McIntosh, 1989; Fischer
et al., 1993; Phillips and Ruth, 1993) stated that
suicide was underreported due to a reluctance tocertify the death as suicide, the non-uniformityof certification procedures, and the variability
in the background and training of those responsible for certifying the cause of death. In termsof accuracy, the thoroughness of a postmortem
examination could reveal the cause of death.
However, autopsies were performed on about
50% of suicide cases and accidental deaths. In
suicide, the 10 most common causes of death
were firearms, hanging, tranquilizers, barbitu70

Depression and suicidal behavior

rates, car exhaust, other sources of carbon
monoxide, jumping from man-made structures,drowning and cutting-piercing instrument. If
all deaths due to these causes (excluding
drowning) were considered suicides, the number of suicide cases would exceed about 50%
among all deaths. In some metropolitan areas, ahigh rate of suicide may reflect a high rate of
autopsy examinations performed. McIntosh(1992) predicted that in the future, the elderly
suicide rate will be extremely high based on thelarge “baby boomer” population.
Why do the elderly commit suicide? Jorm etal. (1995) studied factors associated with attempted suicides in the elderly and suggested several factors in addition to depression: a status ofbeing unmarried, poor health (self rated), disability, pain, hearing impairment, visual impairment, and living in a nursing home or ahotel. Johnston and Walker (1996) stressed theimportance of assessing the elderly with atypical symptoms of depression who might not express their distress and stated that 3 factors must
be considered in assessing suicidal tendencies
in the elderly: i) impaired ability to communicate, ii) intractable tinnitus and iii) a feeling of
helplessness.
Even in contemporary Japanese society,there are a strong stigma against suicide as amental disorder and an intense prejudice toward
related mental disorders. Because of this, Japanese individuals were reluctant to seek help
from mental health professionals and fearedthat they might be ostracized if they were diagnosed as a psychiatric illness (Takahashi, 1997a,
1997b).
Lester and Yang (1992) studied the correlation among the suicide rate, the divorce rate, theimpact of the gross national product per capita,
the unemployment rate and the percentage ofthe population that was Roman Catholic. Economic prosperity had a beneficial impact on theelderly. The unemployment rate had an impact
on only those aged 54 years or younger. When
Roman Catholic membership increased, the suicide rate in the elderly population lowered. The
suicide rate was high, when the divorce rate washigh. In contrast in Japan, the divorce rate wascomparably low. However, the suicide rateincreased in the elderly. The divorce rate after
retirement age has increased, since some wives
demanded divorce after long years of tolerating
unacceptable conditions. As a result, male suicide attempts increased (Takahashi, 1997a,
1997b).
In North America, Canetto (1992) studied
gender and suicide in the elderly and found thatthe older women were less likely to attempt
suicide than older men. Several other researchers reported a similar result (Osgood, 1985;
McIntosh, 1992; Conwell and Brent, 1995). In
Japan, the number of male suicides was statistically greater than those of females (Health andWelfare Statistic Association, 2001).
Schnid et al. (1994) pointed out a differencein risk factors between ideation and attempts,
and the significant predictors included religion,
examination of mental status, living arrangements and medication history. The establishedrisk factors did not appear significant in the distinction of ideation from attempters.
The Japanese elderly were mostly Buddhists, and religious doctrine includes developing the ability to accept death with complete
equanimity. Death is one of the choices to escape from anguish and suffering, characteristicfeatures of human existence. It is consideredpurification in Buddhism. Japanese society
also accepts the act of suicide as a form of artistry. In contrast, in countries with a high number of Christians including the United States,
the act of suicide is severely condemned. Society also condemns the act. In the United States,
the causes of suicide include biological problems such as diseases, psychological problems
including death of a spouse or friend, an unforeseen future after retirement, economical
problems, a reduced role in society, and sociocultural problems. In contrast, in Japan, difficulties due to physical handicap, disease, senility and physical inferiority, together with psychological and biological factors are the causesof suicide. Furthermore, the Japanese elderly
may hide any psychological problems, sincehaving such problems might be seen as weakness that the elderly do not accept. Thus, early71

I. Miyabayashi

Nippon Iji Shinpo 1996;3789:37–40 (in Japanese).
6 Conwell Y, Brent D. Suicide and aging. 1. Patterns of psychiatric diagnosis. Internat Psychogeriatr 1995;7:149–164.
7 Devons CA. Suicide in the elderly: how to identify and treat patients at risk. Geriatrics 1996;51:
67–72.
8 Dewey ME, Davidson AI, Copeland JRM. Expressed wish to die and mortality in older people:
community replication. Age Ageing 1993;22:
109–113.
9 Fawcett J, Scheftner WA, Fogg L, Clark DC,
Young MA, Hedeker D, et al. Time-related predictors of suicide in major affective disorder. Am
J Psychiatry 1990;147:1189–1194.
10 Fischer EP, Comstock GW, Monk MA, Sencer
DJ. Characteristics of completed suicides: implications of differences among methods. Suicide Life Threat Behav 1993;23:91–100.
11 Health and Welfare Statistics Association. [Mortality statistics.] Kosei No Shihyo 2001;48:408–
409 (in Japanese) (Table 3-1).
12 Hlady WG, Middaugh JP. The underrecording ofsuicides in state and national records, Alaska,
1983–1984. Suicide Life Threat Behav 1988;18:
237–245.
13 Isometsa ET, Henrikson MM, Aro HM, Heikkinen
ME, Kuoppasalmi KI, Lonnqvist JK. Suicide in
major depression. J Psychiatry 1994;151:530–
536.
14 Jobes DA, Berman AL, Josselson AR. Improving the validity and reliability of medical-legal
certifications of suicide. Suicide Life Threat
Behav 1987;17:310–325.
15 Johnston M, Walker M. Suicide in the elderly.
Gen Hosp Psychiatry 1996;18:257–260.
16 Jorm AF, Henderson AS, Scott R, Korten AE,
Christensen H, MacKinnon AJ. Factors associated with the wish to die in elderly people. Age
Ageing 1995;24:389–392.
17 K e n n e d y G J , K e l m a n H R , T h o m a s C ,Wisniewski W, Metz H. Hierarchy of characteristics associated with depressive symptoms in an
urban elderly sample. Am J Psychiatry 1989;146:
220–225.
18 Koizumi T, Isono H, Yamakawa K, Takanami A,
Fujisawa N, Kushiya A. Mental health activitiy
in later life: epidemiological survey on senile
depression and suicide prevention activity in therural area with high suicide frequency of theaged. Jpn Clin Psychol 1990;19:53–61 (in Japanese).
19 Lester D, Yang B. Social and economic correlates of the elderly suicide rate. Suicide Life
Threat Behav 1992;22:36–47.
20 Malone KM, Haas GL, Sweeney JA, Mann JJ.
Major depression and the risk of attempted suicide. J Affect Disord 1995;34:173–185.

diagnosis opportunities are lost. As a healthcare provider, consideration of psychologicalproblems must be impeccable, even thoughphysical conditions seem normal.
Conclusion
In the 21st century, the United States and Japanare both facing aging society. Although depression is a significant predictor of suicide in theelderly, increasing numbers and rates of suicide
have not been focused on as major health problems. More than half of elderly people did notknow much about depression as being a healthproblem, and they believed that it was normal.
In Japan, the number of suicides significantly
lowered after suicide prevention was implemented in remote areas where suicide rates had
been high. Thus, it is important to educate andencourage not only the elderly and their families but also primary health professions to implement prevention strategies.
Several important findings concerned withelderly suicides include:i) “The elderly” is a high-risk group;ii) Depression seems to be a major cause ofsuicide;iii) Causes of depression are different between
the United States and Japan – Japanese are
more likely to suffer from physiologicalproblems, while Americans suffer frompsychological problems;iv) Cultural and religious backgrounds play animportant role in the decision to commit
suicide.

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Received August 9, 2002; Accepted September 4, 2002
Corresponding author: Ikuko Miyabayashi

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