Korean Journal of Biological Psychiatry

Address for correspondence: Seung Hee Ahn, MSW, JongnoGu Community Mental Health Center, 10 Sungkyunkwan-ro 15-gil, Jongno-gu, Seoul 03066, Korea
Tel: +82-2-745-0199, Fax: +82-2-745-3549, E-mail: mom9899@hanmail.net

Introduction

ㅔAlthough South Korea has shown a dramatic development in economy, there is inevitable dark side of the successful story. The high suicide rate in South Korea has risen as a main concern not only in the public health sector, but in the society as a whole due to its magnitude and destructiveness. Despite the recent effort to reduce the rate, Korean suicide rate is still the highest in the western pacific area rating 32 people per 100000 and ranks third among all nations reporting the suicide rate, following Sri Lanka and Lithuania, 35.3 and 32.7, respectively.1) The suicide rate for the elderly in Korea is even higher as it records 80.3 people per 100000, which is 3.8 times higher than the Organization for Economic Cooperation and Development (OECD) average of 20.9. It has been predicted that the rate will grow higher as the aging population increases.
ㅔMany researches have been carried out to explore the possible reasons for the higher suicide rates among the elderly people to date. Psychiatric illness including depression and alcoholism has been consistently reported to be related to suicides of the elderly through many studies.2)3) Other related factors are physical health and functioning and social factors such as stress and being solitary.4) Social connectedness in particular has caught interest in relation with suicide prevention, which has been well reflected in the strategy to tackle the suicide problem published by centers for disease control and prevention (CDC).5) Living alone has been considered as a factor that increased the possibility of suicide via depression-however, living alone doubled the risk of suicide directly, regardless of depression.6)7)
ㅔFrom the perspective of public health, it is suggested that selective prevention is more effective than universal prevention as the former targets the high-risk population based on the risk factors rather than the whole population.8) Consequently, in developing strategies to tackle the elderly suicide, the aged population living alone is considered to be central as the number exceeds 1.2 million, occupying 6.4% of all family types in Korea.9)
ㅔStudies investigating the risk factors causing suicidal idea among Korean elderly living alone reported controversial results. Rim and colleagues reported that suicidal ideation in this population is caused by family types, physical health and daily life functioning.10) Seo and Lee,11) however, recently suggested that social support is not directly associated with suicidal ideation, but indirectly via depression. Given the complexity in the mechanism resulting in complete suicide, studies targeting various populations are needed for broader understanding of the risk factors. This study aims to analyze the factors affecting the suicidal tendency of the elderly living alone on basic elderly-care services in Seoul to prevent repeated suicide attempts and make productive suggestions to the clinical implication for social welfare system.

Methods

Participants
ㅔWe collected participants from Jongno District, one of 25 districts in Seoul. We utilized the data of the elderly over 65 living alone in 2012, provided by the department of Elderly Welfare of Jongno District.
ㅔSubjects were 415 people out of 440 who gave the informed consent. Home-visit interviews were administered by trained interviewers. Among total subjects of 415 interviewees, responses of 408 people who gave answers were utilized in the final analysis. This study used the secondary data.

Assessment
ㅔSuicidal tendency was measured by the Korean version of mini international neuropsychiatric interview (K-MINI). The MINI is an abbreviated interview developed for Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) and International Classification of Diseases and Related Health Problems 10th edition (ICD-10) psychiatric disorders. We employed the K-MINI which Yoo et al.12) translated into Korean. The Suicidal module was composed of 6 questions. Points less than 5 was marked as low, 6-9 as middle and over 10 as high. For the measurement of depression, depression module of K-MINI was employed. Health-related quality of life was measured with a brief version of World Health Organization Quality-of-life Scale (WHOQOL-BREF). The WHOQOL was developed in the project initiated by the World Health Organization (WHO) to evaluate quality of life cross-culturally.13) The WHOQOL-BREF, an abbreviated version of the WHOQOL for the convenience in research, is comprised of 26 items covering 4 domains, namely physical health, psychological health, social relationships, and environment. We utilized the Korean version of the instrument translated and validated by Min and colleagues.14) In this study, the result score was converted into the 100-point scale.
ㅔAlcohol problem was assessed by the Korean version of the alcohol use disorders identification test (AUDIT-K). The original version was developed by Babor and Grant15) for the WHO in 1989 and Lee et al.16) translated the tool into Korean and standardized it in 2000. The AUDIT-K consists of 10 questions, with 5-point scale for each. Tests that scored over 12 were considered to have alcohol problems, over 15 to be sufficiently diagnosed with an alcohol use disorder, and over 26 to have alcohol dependence. The frequency of interaction with family, friends and neighbors was questioned to measure the degree of social support that the participants had. The participants were asked to choose one of the three level of the interaction. No interaction was marked as 0, occasional interaction as 1, and frequent interaction as 2. Information on sex, education level, age, and income was also gathered as controlled variables. The Korean version of mini-mental state examination (MMSE-KC) was used to assess the cognitive decline.

Data analysis
ㅔChi-square and Fisher's exact test was used to examine the association of suicidal tendency with variables such as demographical characteristics, social activity and mental health problems. Multiple logistic regression was used to identify variables associated with suicidal tendency. Level of significance was p = 0.05 (two-sided). We performed all exploratory and formal statistical analyses with SPSS version 18.0 (SPSS Inc., Chicago, IL, USA) for Windows.

Results

Characteristics of the study population
ㅔDemographic information of all participants is presented in Table 1. Women were predominant than men (71.1% vs. 28.9%). Average age was relatively high marking 76.5, with 67.9% (277 out of 408) of the group over 80 and 32.1% of the group less than 80. Bereavements mostly accounted for the reason for living alone, as suspected by the high average age, followed by separation/divorce and unmarried state. An absolute majority of participants (98.5%, 402 out of 408) reported any form of health insurance while 1.5% (6 people) had no insurance at all. 16.2% (66 out of 408) had high school education or higher, and average years of education was 5.48 years. Most of the participants reported the relatively stable residence state as 90% (367 out of 408) did not move over 5 years. Economic state was relatively poor as most participants (92.2%) had a living with under 500000 won of monthly income. The state of unemployment outweighed employment, with 86.5% (353 out of 408) to 13.5% (55 people).
ㅔPeople in complete isolation accounted for 13%(53 out of 408), while the others had some degree of relationship (87%, 345 people). 94.9% (387 out of 408) did not participate in social activities, while 5.1% (21 people) participated in any form of social activities.

The Suicidal tendency by sex
ㅔTable 2 shows that suicidal tendency covering suicidal ideation, suicidal plan and the history of suicidal attempt was higher in men than women. Separately, there was a significant difference between male and female on suicide ideation and suicidal plan, with male higher in both (p = 0.02, p = 0.03, respectively), while experience of suicidal attempt showed no statistical difference.

Distribution of suicide risk by demographical variables
ㅔA univariate analysis was conducted to identify suicide-risk distribution by demographical variables, health, and the quality of life. Table 3 shows that the younger age group under 79 (p = 0.024), depressive disorder (p < 0.000), low quality of life (p = 0.002), and alcohol problems (p = 0.022) were likely to predict the higher previous suicidal attempt, while cognitive dysfunction did not make any significant differences.

Factors influencing the suicidal tendency in the elderly living alone
ㅔAn analysis of logistic regression was conducted to identify the influence of factors on the entire suicide risk including suicidal ideation, suicidal plan, and suicide attempt (Table 4). The result showed that the suicide risk was high in persons isolated from social support [odds ratio (OR) = 4.49, 95% confidence interval (CI) = 1.23-16.33, p = 0.02], having depression (OR = 14.85, 95% CI = 5.88-37.52, p < 0.001), and having low quality of life (OR = 4.39, 95% CI = 0.97-19.78, p = 0.05).

Discussion

ㅔThe aim of this study is to investigate the risk factors affecting suicidal tendency in the elderly living alone on basic care services and to find a approach for future interventions. Our finding confirmed that depression, social support and health-related quality of life are risk factors for suicidal attempts in the elderly living alone on basic care services. Depression showed the strongest association with suicidal tendency in both univariate and multivariate analyses, which is consistent with many previous studies.4)5)6)7)8)9)10)11)12)13)14)15)16)17) While the prevalence of depression was reported relatively low in this study (22%, 90 out of 406) considering the known higher prevalence in this population, the proportion of people with depression among suicidal attempters (58.8%, 20 out of 34) approximated to other studies.18)19) While males were more likely to show suicidal ideation and planning, we were unable to find the difference in the experience of suicidal attempts by sex in the univariate analysis. Although suicidal idea and plan as symptoms of depression are generally known to be more prevalent in women across the life span, living alone affects more men than women in the elderly.20)21) A Korean study investigating gender difference in mental health among elderly Koreans reported that men living alone were approximately three times more likely to have depressive symptoms and five times to have suicidal ideation while women were not affected by the factor of living alone.22)
ㅔAs for the discrepancy between experience of suicidal attempt and plan, many studies investigated the gap between simple ideation and suicidal attempts.23)24) For example, Lewitzka et al.23) compared a group of people with only suicidal ideation to the group with history of suicidal attempts. It showed that while the proportion of female was higher in both groups, female were significantly more likely to have suicidal ideation without attempts. This seemingly different report of suicidal ideation by sex may be down to the difference in the study population as the previous reserch was conducted with the patients with an affective disorder, whereas our study was conducted with people living within a community. It should be noted, however, that male complete suicides outnumbered female in most studies.25)26)
ㅔThose who have younger age, depression, low health-related quality of life and an alcohol problem were significantly more likely to report the experience of suicidal attempts, as shown in the univariate analysis. The weaker social support showed the moderate association with history of suicidal attempts. Depression is a predominant risk factor reported consistently for suicidality regardless of the population. Although health condition affects the mental health factors and vice versa, and both interplay in forming suicidality, one study suggested that physical health solely had an independent influence on the suicidal ideation.27) Some authors argued that physical illness is more associated with men than women in terms of suicidality, which could be a hint for developing interventions specific to this population. Alcohol problem showed the significant association not with suicidal tendency, but suicidal attempts. Consistent with the previous study conducted with the elderly living alone in Seoul, our study strongly suggested that the alcohol problem played an important role in pushing the ideation into action.28) Interestingly, our study showed less suicidality in age over 80, which is counter-intuitive given the fact that the group over 80 shows the highest suicidal rate among all age groups in Korea.29) This may imply the distinctive mechanism between suicidal ideation and suicidal attempt.
ㅔThe recent understanding of suicide highlighted the internal psychological process of "build-up to the final action", called an "ideation-to-action" framework.30) This framework has shed light on contributors and protective factors by emphasizing a three-step process from suicidal ideation to attempt. This theory hypothesizes that suicidal ideation develops in combination with pain and hopelessness and lack of social connectedness, and varied contributors play a role in facilitating the progression from ideation to attempts.
ㅔSeveral limitations need to be addressed. First, although the sample size is relatively large compared with previous studies on the elderly living alone conducted in Korea, the larger sample may be needed to investigate possible risk factors comprehensively. Second, as our study was conducted in a specific context of Jongno district, we should be cautious with the generalization of the result.
ㅔIn conclusion, suicidality is a complex phenomenon caused by internal and external contributors. We found that social support, depression and health-related quality of life are associated with suicidal tendency in the elderly living alone on basic services. Our evidence will contribute to establishing suicidal prevention policy for the elderly living alone on care services.