Evaluation of Suicide Research in the Elderly

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A CRITICAL COMPARISON OF TWO RESEARCH APPROACHES TO SUICIDALITY IN THE ELDERLY: the qualitative and quantitative paradigms

Introduction:

Suicide may be considered a common and devastating emergency in the general practice of mental health. It is a phenomenon that is generally complex and inherently difficult to predict. Suicidality, which is the spectrum of psychological activities that culminates in the eventual death of the individual, may be especially complicated in the elderly. This is because people of that age group are known to traverse the continuum of suicidal behaviour with extraordinary secrecy, determination and lethality. Thus, there may be up to three new cases of elderly suicide for every one below the age of 25 years in many countries (Diego et al., 2004, Mello-Santos et al., 2005). Giving the intricate nature of the phenomenon in the elderly, understanding the immediate and remote factors that may be suggestive of imminent death by suicide may be an important step to setting up targeted interventions before it is too late.

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In the context of suicide research, immediate pointers to an impending suicide may, on the one hand, include a subjective ‘experience’ with suicidal ideas or the wish to die. This very personal experience may sometimes be expressed in signs and symptoms such as talking or writing about the end. A phenomenon sometimes referred to as suicidal warnings (Rudd et al., 2006). In this regards, immediate factors for imminent suicide may also extend to the ‘meanings’ attached to such notices by their recipients. The understanding of peoples experiences and meanings is strengthen by the qualitative research paradigm (Fossey et al., 2002). The more remote pointers to an imminent suicide may include correlates of suicidality within the larger population, as against the individual. The investigation of such independent risk factors within the population, or a systematically generated sample from it, is underpinned by the quantitative research model (Godwin et al., 2003). To provide a clear understanding of the qualitative and quantitative frameworks, this discourse aims to critically compare two studies using contrasting approaches in elucidating the factors related to suicide in the elderly.

The context and comparison

This first study, hereafter referred to as Kjiolseth and Ekeberg (Kjolseth and Ekeberg, 2012), was an investigation of the experiences and reactions of people to warnings they have received about the suicidal intention of their elderly wards. The authors relied on the technique of psychological autopsy (Beskow et al., 1990). Wherein, they re-created the circumstances of the suicide through interviews of 63 formal and informal carers of 23 individuals who had died in that manner aged 65 years or over. The second study, hereafter referred to as Ojagbemi et al (Ojagbemi et al., 2013), examined the predictive relationship between several health related variables and three behaviours occurring on a continuum leading to eventual death by suicide. The authors relied on a multi-stage probability sample of 2149 participants aged 65 years or over, and spread across a geographical area equivalent to a quarter of the national population.

The main research question explored by Kjiolseth and Ekeberg was; how did people perceive and react to suicidal warnings communicated to them by the elderly around them? Perception in this context may be broadly understood as the individual’s cognizance of the events external to them. Such perception may also feedback on how the individual will react. In the view of empiricists such as Locke (Baird et al., 2008) the awareness of externally occurring events may only be possible if they are mentally represented. In this regards, the reality is created in the mind of the recipient. Further, Bekerley (Atherton, 1987) contends that this reality is inherently modifiable according to previous experience. Therefore, since the previous experiences of different individuals may be inherently different, and dynamic, the proposition of a single or unitary reality may be less likely. In other words, the research question of Kjiolseth and Ekerberg may be best answered if the perception and reaction of a variety of carefully selected individuals who may have received the suicidal warnings are considered. Qualitative interviews may afford the opportunity for the researchers in this instance to generate more nuanced accounts from a wide selection of individuals who may be knowledgeable about the phenomenon of interest.

In contrast to Kjiolseth and Ekerberg, Ojagbemi et al wanted to find out if there are indices of health and wellbeing in the general population that may demonstrate predictive associations with suicidality among the elderly living in sub-Saharan African communities. This research question may suggest as follows; firstly, by indices, the authors appear interested in numerical or value indicators of health and wellbeing. Secondly, by predictive associations, they may also be interested in relationships. Thirdly, Ojagbemi et al appear interested in the general population, rather than individuals. The interest of the authors in the examination of predicted relationships between numerical and/ or non-numerical (i.e, categorical) indicators, with a focus on the general population may support a non-experimental quantitative approach (Martens, 1998).

In line with the quantitative framework, Ojagbemi et al specifically investigated the predictive relationship between a wide range of demographic and health related variables and three categories of behaviour occurring on a continuum leading to eventual suicide in people who have attained the age of 65 years or over at the start of the study. They additionally sort to investigate the transition between one behaviour and another. These categories of behaviour were namely; suicidal ideation, suicidal plans, and suicidal attempts. They hypothesized that several of the health and wellbeing indicators will predict the presence of these suicidal behaviours. The study was a community based cross-sectional survey of the elderly living in a geographical area equivalent to a quarter of the national population. Giving the research question of Ojagbemi et al about predictive associations, the exploration of several demographic and health related variables should allow the investigators to examine the independent effect of individual variables on the suicidal behaviours while holding the others constant. Furthermore, giving the interest of the authors on sub-Saharan African communities, the focus on communities spread over a wide geographical area, should allow for a wider generalisation of the findings to several sub-Saharan African communities. Conversely, the community based design may inherently exclude the elderly in care and nursing homes, as well as hospitals. Therefore, the findings may not be generalizable, after all, to the entire sub-Saharan African elderly population. Also, the cross-sectional design makes the picture of whether the elderly have had these behaviours long before they attained the age of 65 years unclear. As such it may be doubtful if the result represents the true depiction of affairs in the elderly population.

On the other hand, the study by Kjiolseth and Ekerberg studied people’s experiences and reactions to the ‘warnings’ they have received about the suicidal intentions or plans of the elderly around them. They have relied on psychological autopsy, based on several interviews with people the authors thought should have the knowledge and experience about the phenomenon they planned to investigate. Giving the research questions of the authors about how people perceived notices of suicide communicated to them, a re-enactment of the situation surrounding the eventual suicidal act, through information from key informants, may help shed light on people’s experiences and the processes involved in the reaction of individuals. The individual meaning is also referred to as phenomenology in the context of qualitative research (Thompson et al., 1989). However, with individual meanings it may be difficult to demonstrate ‘probabilistic’ generalisability to the wider group of formal or informal carers of the elderly who have died by suicide. On the other hand, it might be possible to generalise findings with strong ‘internal validity’ to similar contexts (Pawson and Tilley, 1997 ).

Furthermore, They were also interested in the general population of the elderly living a wide geographical area. In this regard, it is the ideal for the authors to access very elderly person living in the location of interest. However, it may be a near impossibility to attempt to interview every elderly person living in an area equivalent to a quarter of the country. As such, the authors resorted to a systematic method of taking a representative sample of the population of the elderly in the location of interest. In this way, they relied on a multi-stage area probability sample of the elderly living in households spread over the study location. They interviewed one elderly person per household, and eventually arrived at a sample size of 2149 participants

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