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 suicide in the elderly in the United States and Japan. Several important factors involved with elderly suicide were different between the 2 countries. While Americans suffer from psychological problems, Japanese more likely suffer from physiological problems. Cultural and religious backgrounds play an important role in the decision to commit suicide

Miyabayashi, Ikuko

Yonago Acta Medica

Orientador: Prof. Dr. Gustavo Manoel Schier DóriaDissertação (mestrado) - Universidade Federal do Paraná, Setor de Ciências da Saúde, Programa de Pós-Graduação em Saúde da Criança e do Adolescente. Defesa : Curitiba, 09/12/2016Inclui referências: p. 176-181Área de concentração: Psiquiatria InfantilResumo: O uso de substâncias lícitas e ilícitas é presente na sociedade há vários séculos e a adolescência é um período de vulnerabilidade para uso e desenvolvimento do transtorno por uso de substâncias (TUS). Por isso, o interesse em políticas públicas e pesquisas em relação aos métodos mais efetivos na prevenção e tratamento do TUS nesta faixa etária vem aumentando. O presente estudo visou comparar o nível de prontidão dos adolescentes para mudança de comportamento antes e após a aplicação da entrevista motivacional (EM) e seus desfechos após a alta. O diagnóstico de TUS foi avaliado através da Entrevista Diagnóstica Kiddie-Sads (K-SADS-PL), a Versão Brasileira da Schedule for Affective Disorders and Schizophrenia for School Aged-Children para crianças e adolescentes de 6 a 18 anos - seção abuso de substâncias e dependência química, a motivação foi mensurada pela escala URICA (Rhode Island Change Assessment Questionnaire) e a Entrevista Motivacional foi baseada nos estudos de Miller e Rollnick e no projeto CYT (Cannabis Youth Treatment) em 6 sessões. A amostra total foi constituída de 30 adolescentes que estavam no primeiro internamento psiquiátrico integral para tratamento do TUS, sexo masculino, brancos, afrodescendentes e pardos, com idades entre 12 e 17 anos e 11 meses. O estudo constituiu-se em ensaio clínico randomizado sem cegamento, e os adolescentes foram divididos nos grupos de intervenção e de controle. A média de idade dos adolescentes foi de 15,8 anos (IC 95%=DP 15,0 - 16,6) para o grupo EM e 16,5 anos (IC 95%=DP 15,7 - 17,4) para o grupo controle e a maioria pertencia às classes sociais C e D (80%). Observou-se baixa escolaridade: 83,3% não haviam terminado o ensino fundamental, 80% repetiram pelo menos um ano e 83,3% haviam interrompido seus estudos. Os jovens desta amostra residiam com famílias monoparentais (63,3%) e 73,3% deles apresentaram parentes com problemas por uso de substâncias. Os principais diagnósticos obtidos nesta amostra de adolescentes com TUS foram de dependência química de maconha (50%), uso de tabaco (83,3%) e abuso de álcool (20,0%) e prevalência importante de comorbidades psiquiátricas (80%); os principais transtornos associados foram o Transtorno de Conduta (50%) e o Transtorno de Déficit de Atenção e Hiperatividade (43,3%). Os resultados da aplicação da EM mostraram que os dois grupos avançaram da escala de pré-contemplação para a de contemplação após o internamento. No grupo EM houve diferença significativa no nível de prontidão nas subescalas de pré-contemplação e ação (p<0,01), bem como mudanças em relação à manutenção do tratamento, da abstinência e o retorno escolar em maior porcentagem no grupo da intervenção. Este estudo concluiu que houve mudanças significativas após a intervenção, indicando a importância de avaliação e de tratamento que levem em conta as características desta população, também considerando intervenções de baixo custo. Palavras-chave: Adolescente hospitalizado. Transtornos Relacionados ao Uso de Substâncias. Entrevista Motivacional.Abstract: The use of licit and illicit substances is present in our society for centuries and adolescence is a period of vulnerability to the use and development of substance use disorder (SUD). Therefore, the interest in public policies and researches regarding the most effective methods in the prevention and treatment of SUD in this age group has been increasing. This study aimed comparing the readiness to change of teenagers before and after the application of motivational interviewing (MI) and their outcomes after discharge. The SUD diagnosis was assessed by the Schedule for Affective Disorders and Schizophrenia for School Aged-Children - section abuse and dependence of substances, the motivation to change was measured by the URICA scale (Rhode Island Change Assessment Questionnaire) and Motivation Interviewing was based on studies of Miller and Rollnick and CYT Project (Cannabis Youth Treatment) in 6 sessions. The total sample consisted of 30 adolescents, who were in their first psychiatric hospitalization for treatment of SUD, males, white, African Americans and mixed race, aged 12 and 17 years and 11 months. The study consisted in an open randomized clinical trial, and adolescents were divided into intervention and control groups. The average age of the sample was 15,8 years (IC 95%=DP 15,0 - 16,6) in MI group and 16,5 years (IC 95%=DP 15,7 - 17,4) in control group and the majority belonged to social classes C and D (80%). Low educational level was observed: 83,3% had not finished elementary school, 80% have repeated at least one year and 83,3% had discontinued their studies. The sample of this study lived with single-parent families (63,3%) and 73,3% of them had relatives with substance use problems. The main diagnosis of adolescents with SUD were marijuana dependence (50%), tobacco use (83,3%) and alcohol abuse (20,0%); high prevalence of comorbid mental disorders was found (80,0%), the most associated were the conduct disorder (50%) and hyperactivity and attention deficit disorder (43,3%). The results of MI application showed that both groups proceeded from precontemplation subscale to contemplation subscale after treatment. MI group showed significant changes in pre-contemplation and action subscales (p<0,01), as well as changes regarding motivation to maintain treatment after discharge, abstinence and school frequency in greater percentage than in control group. This study concluded that there were considerable changes after the intervention, indicating the importance of assessment and treatment that considers the characteristics of this population and considering effective low-cost interventions. Keyword: Adolescent, hospitalized. Substance-Related Disorders. Motivational Interviewing

Carneiro, Maria Cecília Beltrame

Universidade Federal do Paraná

Impacto da entrevista motivacional no tratamento de adolescentes hospitalizados por transtorno por uso de substâncias

Repositório Digital Institucional da UFPR

Tottori University Research Result Repository

69Depression and Suicidal Behavior in the Elderly:  A Literature ReviewIkuko MiyabayashiDepartment of Nursing Care Environment and Mental Health, School of Health Science,Tottori University, Yonago 683-8503 JapanDepression 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).  Thepurpose 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 commitsuicide.Key words:  cultural differences; depression; elderly; suicideDepression and suicide are significanthealth problems in the United States and Japan.There are more than 30,000 suicides a year inthe United States – the 8th leading cause ofdeath in 1998 (Mann et al., 1999).  In Japan,there were 31,413 suicides in 1999.  This wasthe 6th leading cause of death (Health and Wel-fare Statistics Association, 2001).  Nevertheless,suicide is still considered primarily a phenome-non of adolescence to middle age, and most re-search has focused on this age group.  The reali-ty is that suicide is also just as a significantproblem in later life (Osgood, 1992; Takahashi,1995; Stack, 1996).Takahashi (1997a, 1997b) compared andcontrasted attitudes toward suicide betweenJapanese and Americans, suggesting that mostJapanese think that suicide is not always an ab-normal behavior.  In contrast, Americans aremore likely to think that suicide usually resultsfrom psychiatric problems that can be prevent-ed.The reasons why suicide is a significantproblem in the elderly rather than in other agegroups are as follows:  i) The elderly have the highest successful sui-cide rate; ii) There is a high correlation between suicidebehavior and depression (Nordstrom et al.,1995; Fawcett et al., 1990; Malone et al.,1995; Isometsa et al., 1994; Pokorny, 1993;Roy, 1999);iii) Despite a high prevalence among the elder-ly, depression is rarely recognized or treatedproperly in this group.  This suggests thatthe elderly group has a high risk in this as-pect more than any other age groups.The purpose of this report was to review theliterature relative to depression and suicide inthe elderly in Japan and the United States, fo-cusing on the cultural differences between theJapanese and Americans.Depression and the elderlyDepression, 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 majorfactor for suicide in the elderly, there is a lack ofreliable data because of difficulty in diagnosis.Yonago Acta medica 2002; 45:69–73Review ArticleI. Miyabayashi70Blazer (1989) reported that diagnosed cases ofmajor depression were not differentiated fromcognitive impairment, anxiety and disruptions.The most frequently used approach in epidemi-ological studies was not based on confirmeddiagnoses but symptoms.  Several researchersshared the concern that diagnoses were difficultto confirm, especially in a certain population orcommunity.  The term “depression” in the fol-lowing research was not well defined comparedto the current concept.  However, the results ofthe research are worthwhile mentioning.  Blazerand 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 symp-toms.  Murrell and his coworkers (Murrell et al.,1983; Murrell and Noris, 1984) interviewed2,517 people (over 55 years old) with depres-sive symptoms (diagnosed based on thesesymptoms) and found that 16% had significantdepressive symptoms, especially in the oldestage 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 symp-toms 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 depressivesymptoms in females and the oldest.  Most re-searchers used the Center for EpidemiologicStudies Depression Scale for screening, whileBlazer and Williams (1980) used the OlderAmerican Resources and Services DepressionScale.  The results of these reports were similarin prevalence (approximately 15%) and demo-graphic trends (more in females and the mostelderly).As seen in the community population,studies on an inpatient population had similarresults.  Rifai et al. (1994) studied the symptomof hopelessness in 63 depressed patients with anaverage age of 67.2 years and found that pa-tients with high hopelessness scores had a his-tory of suicidal attempts and were also morelikely to drop out of treatment.  Shah et al.(1997) screened for depression among acutelyill geriatric patients in a hospital with a shortgeriatric depression scale.  Depression wascommon among those geriatric inpatients.There are few diagnosis-based epidemiol-ogical studies on relationships between the el-derly and depression in the United States.  InJapan, there was a close relationship betweenthe 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 symptomsmanifested as somatic or hypochondriac com-plaints that their family members often ignoredand 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 1,063people who were 65 years old or above in acommunity in Liverpool and found that effectsof depressive symptoms were not confirmed asa strong factor for mortality.Suicide and the elderlyAlthough the suicide rate has increased mostdramatically among the young during the past20 years, the elderly white male remained hav-ing the highest suicide rate in the United States(Devons, 1996).  There are 2 high-risk groups:the young and the elderly.  This phenomenon isalso seen in Japan.  Depression was suspectedto 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; Hladyand Middaugh, 1988; McIntosh, 1989; Fischeret al., 1993; Phillips and Ruth, 1993) stated thatsuicide was underreported due to a reluctance tocertify the death as suicide, the non-uniformityof certification procedures, and the variabilityin the background and training of those respon-sible for certifying the cause of death.  In termsof accuracy, the thoroughness of a postmortemexamination could reveal the cause of death.However, autopsies were performed on about50% of suicide cases and accidental deaths.  Insuicide, the 10 most common causes of deathwere firearms, hanging, tranquilizers, barbitu-Depression and suicidal behavior71rates, car exhaust, other sources of carbonmonoxide, jumping from man-made structures,drowning and cutting-piercing instrument.  Ifall deaths due to these causes (excludingdrowning) were considered suicides, the num-ber of suicide cases would exceed about 50%among all deaths.  In some metropolitan areas, ahigh rate of suicide may reflect a high rate ofautopsy examinations performed.  McIntosh(1992) predicted that in the future, the elderlysuicide rate will be extremely high based on thelarge “baby boomer” population.Why do the elderly commit suicide?  Jorm etal. (1995) studied factors associated with attem-pted suicides in the elderly and suggested sev-eral factors in addition to depression:  a status ofbeing unmarried, poor health (self rated), dis-ability, pain, hearing impairment, visual im-pairment, and living in a nursing home or ahotel.  Johnston and Walker (1996) stressed theimportance of assessing the elderly with atypi-cal symptoms of depression who might not ex-press their distress and stated that 3 factors mustbe considered in assessing suicidal tendenciesin the elderly:  i) impaired ability to communi-cate, ii) intractable tinnitus and iii) a feeling ofhelplessness.Even in contemporary Japanese society,there are a strong stigma against suicide as amental disorder and an intense prejudice towardrelated mental disorders.  Because of this, Japa-nese individuals were reluctant to seek helpfrom mental health professionals and fearedthat they might be ostracized if they were diag-nosed as a psychiatric illness (Takahashi, 1997a,1997b).Lester and Yang (1992) studied the correla-tion 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.  Eco-nomic prosperity had a beneficial impact on theelderly.  The unemployment rate had an impacton only those aged 54 years or younger.  WhenRoman Catholic membership increased, the sui-cide rate in the elderly population lowered.  Thesuicide 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 afterretirement age has increased, since some wivesdemanded divorce after long years of toleratingunacceptable conditions.  As a result, male sui-cide attempts increased (Takahashi, 1997a,1997b).In North America, Canetto (1992) studiedgender and suicide in the elderly and found thatthe older women were less likely to attemptsuicide than older men.  Several other research-ers reported a similar result (Osgood, 1985;McIntosh, 1992; Conwell and Brent, 1995).  InJapan, the number of male suicides was statis-tically 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 arrange-ments and medication history.  The establishedrisk factors did not appear significant in the dis-tinction of ideation from attempters.The Japanese elderly were mostly Bud-dhists, and religious doctrine includes develop-ing the ability to accept death with completeequanimity.  Death is one of the choices to es-cape from anguish and suffering, characteristicfeatures of human existence.  It is consideredpurification in Buddhism.  Japanese societyalso accepts the act of suicide as a form of art-istry.  In contrast, in countries with a high num-ber of Christians including the United States,the act of suicide is severely condemned.  Soci-ety also condemns the act.  In the United States,the causes of suicide include biological prob-lems such as diseases, psychological problemsincluding death of a spouse or friend, an un-foreseen future after retirement, economicalproblems, a reduced role in society, and socio-cultural problems.  In contrast, in Japan, diffi-culties due to physical handicap, disease, senili-ty and physical inferiority, together with psy-chological and biological factors are the causesof suicide.  Furthermore, the Japanese elderlymay hide any psychological problems, sincehaving such problems might be seen as weak-ness that the elderly do not accept.  Thus, earlyI. Miyabayashi72diagnosis opportunities are lost.  As a healthcare provider, consideration of psychologicalproblems must be impeccable, even thoughphysical conditions seem normal.ConclusionIn the 21st century, the United States and Japanare both facing aging society.  Although depres-sion is a significant predictor of suicide in theelderly, increasing numbers and rates of suicidehave not been focused on as major health prob-lems.  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 significantlylowered after suicide prevention was imple-mented in remote areas where suicide rates hadbeen high.  Thus, it is important to educate andencourage not only the elderly and their fami-lies but also primary health professions to im-plement 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 betweenthe United States and Japan – Japanese aremore likely to suffer from physiologicalproblems, while Americans suffer frompsychological problems; iv) Cultural and religious backgrounds play animportant role in the decision to commitsuicide.References 1 Berkman LF, Berkman CS, Kasl S.  Depressivesymptoms in relation to physical health and func-tioning in the elderly.  Am J Epidemiol 1986;124:372–388. 2 Blazer DG.  Depression in the elderly.  N Engl JMed 1989;50:117–126. 3 Blazer DG, Williams CD.  Epidemiology of dys-phoria and depression in an elderly population.Am J Psychiatry 1980;137:439–444. 4 Canetto CS.   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