The seventh meeting under the theme of ‘Talking about the Human Rights of Older Persons’ took place online on June 6, 2022 with Prof. Diego De Leo. He is Emeritus Professor of Psychiatry at Griffith University in Brisbane, Australia and Director Emeritus of the World Health Organization (WHO) Collaborating Center for Research and Training in Suicide Prevention, and co-founder and past president of the International Academy for Suicide Research (IASP). Prof. De Leo was also the initiator of the World Day for the Prevention of Suicide. He has published extensively, with more than 500 peer-reviewed articles, 190 book chapters, 60 volumes and over 400 conference presentations. He also received numerous national and international awards, including the title of Doctor of Science by Griffith University for his research on suicide and psychogeriatrics in 2007 and the title of Officer of the Order of Australia by Queen Elizabeth in 2013. Prof. De Leo is presently Director of the Psychology Department at Primorska University, Slovenia and Director of the Slovene Center for Suicide Research. He is now Vice-President and is the incoming President of the Italian Association of Psychogeriatrics.
During the meeting, he shared his personal story on how he has become interested in the psychiatry of older adults, particularly in relation to suicide, the relations between demographic and cultural changes and psychogeriatrics, the key characteristics of suicide among older adults, and factors that contribute to variations in the rates of suicide in different countries.
1. Demographic and Cultural Changes, and Psychogeriatrics
Prof. De Leo has been interested in the psychiatry of older adults from his early career. While later life is arguably the most difficult part of life, it has not received sufficient attention or support yet. Due to rapid demographic change with an increase in the older population, special consideration for older adults is needed both from psychological and medical perspectives. Instead of being discouraged by the difficulty and complexity involved in treating older adults, he was intrigued by and attracted to the complex issues relating to the frailty and vulnerability of older adults and particularly the difficult challenges they bring to lone (if not lonely) persons in later life.
Prof. De Leo is especially interested in the psychology of male older people in relation to the changes in the gender dynamic associated with changing family structures. There have been dramatic changes in education, cultural values and how people relate to each other for the last several decades. Males of the older generations were brought up in an environment that was very different from today’s world, as a result of which they face greater difficulty in managing their daily life independently in the case of the loss of their spouses and feel alienated more strongly by digital technology. However, these aspects are not often and adequately understood by younger people including young professionals in psychology and psychiatry. In fact, this gap contributes to adding difficulties and complexities in dealing with and treating (male) older adults.
This is one of the reasons why Prof. De Leo is keen to initiate and provide a stimulus to promote a multi-disciplinary approach to older persons. He is going to be the next president of the Italian Association of Psychogeriatrics. This Association is multidisciplinary, consisting of psychiatrists, neurologists, geriatricians, psychologists and sociologists. He strongly believes that an open-minded view on the world of later life individuals is the best way to comprehend their complex daily lives as well as many difficulties they face not only at the physical and psychic level, but in relationships, communication and mobility (e.g. food shopping and sending mail). This means that one has to be attentive to those multiple issues in addressing the issues that older persons encounter. These multiple problems together with loneliness, which has become socially epidemic, create insurmountable difficulties and unbearable pain to some. At this point, suicide enters as a possibility to put an end to these sufferings and sometimes as a way to end their existence which some perceive as a burden to society. In other words, being alive while doing nothing, having no contact, having no liaisons with others, makes some feel that their life is meaningless. In this context, their connection to society is crucial but they are sometimes totally neglected and left to take the extreme step of ending their lives.
2. The Specificities of Elder Suicide/Suicidal Behavior
One of the key specificities of suicide and suicidal behavior among older people is that life becomes much more complicated in physical terms. Main risk factors for older age suicide are physical illnesses, physical frailty or a broad sense of frailty, which are more frequently entailed in older age than in other age groups. Besides physical frailty, isolation and loneliness, the loss of spouses and companions also constitute serious risk factors for older age suicide. Particularly, older male persons face even more challenges than older females. Today late life individuals grew up with different habits and attitudes compared to present day individuals. In many countries, males did not engage in cooking, cleaning and doing the laundry. To the extent that how to conduct these normal daily activities is not known to many older males, in the case of the loss of spouses, older males face serious problems in carrying out day-t0-day life. Under these situations, many older adults tend to lead a disappointed, unsatisfactory life, often with a wish to die before their spouses. This in turn leads to physical inactivity and weakening.
Added to this, older males tend to find today’s world unfamiliar or even hostile, where direct contacts with other people are becoming increasingly scarce. It is very common that they tend to be nostalgic about the past, the ‘good old times’ where the world was more direct and people had direct contacts with each other. Even if they own digital devices, or are offered a digital company they either do not use or dislike it. This then creates a distance between them and the present world. At the same time, young doctors and psychologists tend to impose on older persons the use of these instruments. This however adds even more distance between older adults and carers. It is important to understand that older adults are not satisfied with surrogated types of vicinity or companionship: they want to have physical relationships. This underlines a great contradiction in our society as it is difficult for this need of older persons to be met under the current health systems that are often under-resourced and under-staffed. This problem gets even worse when older adults are the last ones in the list of socio-economic priorities.
The European Congress of Psychiatry was held on 4-7 June. One fact noticeable at the Congress was that only very few psychiatrists are interested in older people psychiatry. This illustrates how problematic it can be for society in the near future to deal with and find better solutions for older age-related issues. People in general today are attracted to youth and young people. This suggests that it is extremely difficult and complex to do something useful for older adults, and that we need to fundamentally change our culture and launch campaigns to stimulate attention and attraction towards older adults. Otherwise, we will meet ever more difficulties in finding people with professional competence for older adults. However, we should not be discouraged by this. Rather, with an acute understanding of the nature of the issue, we should search more actively for more interesting and novel avenues, solutions and attitudes.
3. Factors Affecting Suicide Rates
Suicide is a global phenomenon. Three quarters of all suicides happen in mid- and low-income countries: only one quarter of the global number of suicides occur in high-income countries. WHO data on suicide are based on statistical data as well as on a much larger quota of estimates: not all countries provide (complete) data sets. The most recent report by WHO on suicide was based on the Global Burden of Disease Study, which is grand in scale and hugely important in providing the basis for estimates concerning suicide rates.
While suicide is found everywhere, its level is different across different countries and many factors can play a part. An important factor that accounts for different suicide rates is the quality of life and access to health services. For instance, Lithuania was known to be a country with very high rates of suicide for the last century, but the rates of suicide, among older adults, have halved over the last two decades. While there have been no longitudinal observations able to determine the causality, the WHO concludes that there had been significant improvements in the quality of life, especially improved access to health facilities among older people. It is important to note that older people still continue to have the highest suicide rates virtually all over the globe. They represent the most vulnerable segment of population to suicide demographically. While it is probably true that improved quality of life and better access to health services have contributed to reducing suicide rates, it is also important to recognize that anti-suicide strategies for later life have not been widely implemented and - most probably - suicide prevention strategies have not had significant impact on reducing suicide rates in late life. Although there have been some positive signs of a reduction in suicide globally, more work is needed.
Socio-cultural factors such as people’s attitudes can also affect suicide rates. Italy and Latin countries traditionally show low levels of suicide. Traditional and historical motives embedded in these cultures can explain this. Catholicism as a religion and its moral laws tend to bind people and create solidarity among them, and particularly their close family ties help them to have a sense of protection that is more important than the one provided by government’ institutions. In some other countries where there are higher rates of suicide, these can often be explained by the habits associated with masculinity. Masculinity often here refers to attitudes kept and practiced among men such as the tendency not to express pain, weaknesses, sorrow and despair, while only sharing with others their successes but not failures. In many Anglo-Saxon countries, these attitudes are still prevalent and form the basis of the behavior of men. In these cultures, it is often the case that males have their spouses or partners as the sole source of the ventilation of their powerful feelings in the lack of connection with a wider circle of friends and family members. The break-down of a relationship can easily lead to the collapse of the world for these men. In this context, suicide often enters as a solution.
This suggests that a historical and sociological lens is needed to fully grasp the causes of suicide. Suicide has too long been considered as the subject of psychiatry while its psychosocial, environmental and political factors have too often been ignored. Suicide is a complex phenomenon and has no simple solutions. We should not be naïve about finding solutions to suicide but should at the same time maintain a multidisciplinary spirit and prepare to act at many levels for anti-suicide strategies to be effective.
4. The Future
We live in an increasingly individualistic society. While some people are understandably nostalgic about the past, there is no way to return to the past. To implement correctives, we need to settle with and make a more reasoned use of smart phones and social media in a way that permits real relationships and the real development of life. Above all, we need to counteract the massification of people which deprives them of individual identities.
While the future is difficult to predict, Prof. De Leo remains optimistic that there will be processes, adjustments and adaptations in policies and education with regard to the use of internet materials, as people will resist being watched and controlled by external powers. People will sooner or later realize that they would need spirituality beyond materiality, which will lead them to take on actions and engage at different levels to fight ‘the massification’, whose outcomes however remain to be seen.
manji74@asemgac.org