Screening may not reduce suicide in later life
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《英国医生杂志》
EDITOR—O'Connell et al are wise to warn against a reductionist approach to the complex topic of suicide in older people since an epidemiological perspective makes older people who commit suicide into objects of disease processes rather than subjects struggling to control their lives.1 They also prescribe vigorous screening and aggressive treatment despite the difficulties in reaching the highest risk group, reluctance to accept stigmatising labels, and the limited efficacy of available interventions.
Much seems to depend on the meaning of problems for individual people. Proud but rather rigid people who would rather not live if unable to do so with their normal vigour may opt for suicide, especially if depressed mood alters their judgment about their illness or disability. Older men living alone whose lives are changed for the worse by loss may be the highest risk group, but they may also be those least likely to engage with services.
We do not advocate therapeutic nihilism, but the limitations must be understood. Coping strategies built over a lifetime can collapse under the impact of successive adverse events, and professionals' ability to influence either coping strategies or adverse events is limited. A perceived failure to prevent suicide can have adverse effects on social and healthcare workers, so policies for identifying those at risk need to be realistic. Better management of disabilities, improved pain control, and greater financial security for vulnerable older people, with antidepressant and psychological treatments on offer to those with depression symptoms, may be more positive approaches than vigorous screening.
Steve Iliffe, reader in general practice
Department of Primary Care and Population Sciences, Royal Free and UCL Medical School, London NW3 2PF s.iliffe@pcps.ucl.ac.uk
Jill Manthorpe, professor of social work
Social Care Workforce Research Unit, King's College, London SE1 9NN Jill.Manthorpe@kcl.ac.uk
Competing interests: None declared.
References
O'Connell H, Chin A, Cunningham C, Lawlor B. Recent developments: suicide in older people. BMJ 2004;329: 895-9. (16 October.)
Much seems to depend on the meaning of problems for individual people. Proud but rather rigid people who would rather not live if unable to do so with their normal vigour may opt for suicide, especially if depressed mood alters their judgment about their illness or disability. Older men living alone whose lives are changed for the worse by loss may be the highest risk group, but they may also be those least likely to engage with services.
We do not advocate therapeutic nihilism, but the limitations must be understood. Coping strategies built over a lifetime can collapse under the impact of successive adverse events, and professionals' ability to influence either coping strategies or adverse events is limited. A perceived failure to prevent suicide can have adverse effects on social and healthcare workers, so policies for identifying those at risk need to be realistic. Better management of disabilities, improved pain control, and greater financial security for vulnerable older people, with antidepressant and psychological treatments on offer to those with depression symptoms, may be more positive approaches than vigorous screening.
Steve Iliffe, reader in general practice
Department of Primary Care and Population Sciences, Royal Free and UCL Medical School, London NW3 2PF s.iliffe@pcps.ucl.ac.uk
Jill Manthorpe, professor of social work
Social Care Workforce Research Unit, King's College, London SE1 9NN Jill.Manthorpe@kcl.ac.uk
Competing interests: None declared.
References
O'Connell H, Chin A, Cunningham C, Lawlor B. Recent developments: suicide in older people. BMJ 2004;329: 895-9. (16 October.)