Psychoactive medication use and risk of suicide in long‐term care facility residents

Article in review: Hedna, K., Fastbom, J., Jonson, M., Wilhelmson, K. & Waern, M. (2022) Psychoactive medication use and risk of suicide in long‐term care facility residents, International Journal of Geriatric Psychiatry, DOI: 10.1002/gps.5684

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Summary

There is a need to better understand the relationship between the use of psychoactive medications and suicide risk among residents of Long Term Care Facilities (LTCFs). This retrospective cohort study from Sweden, spanning eight years and published in 2022, has honed in on this topic. The study also investigates the role of psychiatric and medical conditions in the occurrence of suicide by residents of LTCFs.

The study found that less than half of the LTCFs who died by suicide we are taking anti-depressants at the time of death. As such, anti-depressants have been identified as a positive protective factor for care residents. Suicide risk was found to be increased for those taking hypnotic drugs.

Mental illness among older people living in care

As our population ages, so too does the number of older people living in long-term care facilities (LTCFs). In Sweden, the location of this study, it is estimated that one in every ten adults over the age of 75 is currently living in an LTCF. The authors have previously identified that for older people living in LTCFs, depression is common and there is a fourfold increase in reports of active/ passive suicide ideation. Thoughts of suicide are common among LTCF residents, associated with the changes resulting from a move to care; loss of health, physical disabilities and bereavements.

Some neuropsychiatric conditions that impact older people may increase behavioural symptoms such as agitation or aggression. Depression may be misdiagnosed when there are co-concerns of cognitive impairment, physical disorders or psychotic illness. Antidepressants and other psychoactive medicines are commonly used by residents in LTCFs, to treat several symptoms that can be associated with increased suicide risk. Anti-hypotonic drugs are thought to worsen depression, impair judgment and increase confusion, as well as provide access to medication for overdose attempts.

The scant previous research on the rates of suicide in LTCFs has identified

• one small study in which eight of twelve people who died by suicide had been diagnosed with depression but were not receiving treatment at the time of death
• a study that demonstrated an elevated risk of suicide ideation among care residents who were taking psychoactive mediations

Method and study

Data collected from a baseline population of 288,305 older people living in LTCFs in Sweden were included in the study. The study group had the following characteristics:
• Mean age of 86.5 years
• 67.1% female
• 55% widowed
• 91.4% were born in Sweden

Prescribed medications

• 42% were prescribed antidepressants
• 38.6% were prescribed hypnotic drugs
• 14.7% were prescribed anti-dementia drugs

Specialised care rates for psychiatric and somatic conditions

• 24% were receiving specialised care for depression
• 7.3% were receiving specialised care for anxiety disorders
• Less than 10% were receiving care for each of the following- schizophrenia, substance/ drug disorders, bipolar disorder and sleeping disorders

• 21.8 were receiving specialised care for cardiovascular disease
• 13.6% were receiving specialised care for cerebrovascular disease
• 8.2% were receiving specialised care for cancer

Incidence of suicide and self-harm

• Over the study period, suicide was the cause of death for 110 people from the cohort- 64 men and 46 women
• 1% of the study group had previous episodes of self-harm (2942 people)
• One-third of these suicides occurred within the first six months of residence at the LTCF and about a half occurred within getting the first year
• 54% of the people who died by suicide were on anti-hypnotics during their final three months of life
• 45.5% of the people who died by suicide were prescribed antidepressants

In this study, antidepressants were associated with a lower risk of suicide risk for people living in LTCFs. However, this is not congruent with data reported for the general Swedish population aged over 75 years, for whom an increased risk of suicide has been associated with the use of antidepressants. Suicide risk was more than doubled for people requiring specialised care for depression.

The higher risk for people who are taking hypnotics has a greater correspondence with the finding that there is an increased risk of suicide for those prescribed this category of medication. An anticipated link between specialised care and somatic conditions and increased suicide risk was not identified.

This data asserts the clear need for more information about the impact of antidepressants and hypnotics on suicide risk and that suicide risks may vary amongst various sub-populations of older adults.