Spanish Journal of Psychology (2014), 17, e14, 1–10.

© Universidad Complutense de Madrid and Colegio Oficial de Psicólogos de Madrid

doi:10.1017/sjp.2014.15

Suicidal Ideation, Depression and Quality of Life in the

Elderly: Study in a Gerontopsychiatric Consultation

Carla Ponte1, Vera Almeida1 and Lia Fernandes2

1 Instituto Superior de Ciências da Saúde-Norte (Portugal)
2 Universidade do Porto (Portugal)

Abstract.  The global increase in elderly population all over the world, especially in Portugal, justifies the importance of
mental health study in this age group. The aim of this study was to characterize the elderly patients in Gerontopsychiatry
Consultation of Centro Hospitalar São João in Porto, related to socio-demographic aspects, physical and global disabil-
ities, depression, suicidal ideation and quality of life, and to explore the association between suicidal ideation, depres-
sion, and quality of life and global and functional disability. In this cross-sectional study, 155 patients were recruited
consecutively, with a final sample of 75 subjects (59 women and 16 men) without cognitive deficits and a mean age of
72.8 (SD = 6.04). Concerning the depression level measured with the Geriatric Depression Scale (Barreto et al., 2008) it was
found that 66.7% presented severe depression and suicidal ideation (M = 41.96, SD = 36.38), a value considered with a
potential risk of suicide using the Suicidal Ideation Questionnaire (Ferreira & Castela, 1999). The elderly also perceived
their quality of life as low, revealing global disability assessed with the EasyCare- Elderly Assessment (Sousa & Figueiredo,
2000a). A significant positive correlation was also found between depression and suicidal ideation (rs =.71, p < .001),
as well as quality of life (rs = .50, p < .001), and suicidal ideation with quality of life (rs = .40, p < .001). The data obtained
in this study corroborate the results found in other studies.

Received 16 May 2012; Revised 6 November 2012; Accepted 21 February 2013

Keywords: elderly, depression, quality of life, suicidal ideation.

Over the last years, it has been an increasing interest progressive ageing. As a result, there is an increasing
in ageing issues, due to the exponential increase in need for research into the elderly population with a
the elderly population. The decrease in mortality that biopsychosocial approach that enhances life span,
occurs in all age groups, as a result of both medical quality of life and well-being, as well as successful
advances and improved living conditions, has fostered ageing.
an increase in life span and contributes to the absolute Theories of successful ageing, state that individuals
growth of the elderly population. According to a report are pro-active and able to regulate their quality of
released by the Institute for Family Policies (IFP, 2009), life by setting and pursuing goals, and by gathering
Portugal, followed by Spain, is the country in the resources that increase their adaptation to change.
European Union (EU) where the population is ageing Furthermore, these theories emphasize that individuals
the fastest. The proportion of people aged 65 or older are actively involved in preserving their well-being.
has doubled over the last 45 years, rising from 8% in Hence, successful ageing encompasses not only
1960 to 17% in 2005. According to recent data from well-being but also quality of life, which is worth
2011 Census, there are 2 023 000 old people (65 or more promoting from early developmental stages (Stevens,
years old) in Portugal, which is 19% of the population. 2001). According to Oliveira (2008), successful ageing
It is estimated that in 2030, 25% of the population will implies that individuals maintain their ability to func-
be elderly (Instituto Nacional de Estatística [INE], 2011). tion effectively, not only physically and psychologi-
Ageing as a social phenomenon, is a major challenge cally but also mentally. Fontaine (2000) highlights three
of the 21st Century and therefore requires depth studies factors that have a significant influence in successful
concerning livelihoods, quality of life, socio-economic ageing: to maintain health, to maintain high levels of
aspects, intergenerational solidarity, sustainability of cognitive and physical functioning, to strength social
social security and health systems and establishing a engagement and personal well-being or, to maintain
social model of support (INE, 2002a). Quality of life is social participation.
one of the major social problems associated with the According to Smith (2001), the concept of well-being
has changed from the mid-twentieth century onwards.
Correspondence concerning this article should be addressed to Vera
Until then, the concept simply denoted availability of
Almeida. Instituto Superior de Ciências da Saúde-Norte (Portugal). vital goods (basic needs). The current understanding
E-mail: vera.marg@gmail.com of the concept covers less tangible dimensions such as
2  C. Ponte et al.

security, personal dignity, opportunities to achieve autonomous and socially integrated. To be aware of
personal goals, life satisfaction, joy, and self-esteem. functional preservation is crucial because it allows the
Focusing on the elderly, Zimerman (2000) suggests elderly to lead an active and independent life (Faria &
that the concept of well-being requires different dimen- Marinho, 2003).
sions: physical (gymnastics and sports), psychic (per- Mental disorders are common among the elderly.
ception, reasoning, memory, attention, affection) and Although, in Portugal, the incidence and prevalence
social (communication, socialization, sense of belonging). of most mental disorders remains undetermined, the
Warr, Butcher, and Robertson (2004), concluded that available data reveals the impact of various determi-
certain activities carried out within the family, the nants possibly associated with psychological distress
communities or the church significantly contribute to (Ministério da Saúde, 2008). Portugal has the highest
the well-being of the elderly. Nevertheless, the defini- rates of mental disorders (22.9%) in Europe, which is
tion of well-being is difficult as it belongs to a field of near the USA rates (the country with the highest prev-
study that includes other major concepts and research alence in the world – 26.3%). In the same study, 7.9%
domains, such as quality of life. The concept of quality of of Portuguese suffered from depression. Research has
life is related to self-esteem and to personal well-being. identified several factors associated with an increased
Besides that, it also includes a broad range of life areas risk for depression in individuals aged over 65 years.
such as functional ability, socioeconomic level, emo- Marques and Firmino (2003) argue that there is no
tional state, social interaction, cognitive activity, family evidence that genetic factors significantly contribute to
support, health, cultural, ethical and religious standards, the etiology of geriatric depression. When sociodemo-
lifestyle, job satisfaction and/ or satisfaction with daily graphic variables such as gender and marital status
activities and finally, the context in which one lives are taken into account, it is possible to conclude that
(Vecchia, Ruiz, Bocchi, & Corrente, 2005). throughout life cycle depression is consistently more
The term “quality of life” has a subjective meaning common in women than in men, and that depressive
because it refers to the individual’s perception of life episodes are more frequent among divorced or wid-
and bears upon socio-cultural level, age, expectations, owed elderly. More than that, several diseases are also
and interests. The World Health Organization Quality associated with depression, generally those that are
of Life (WHOQOL) Group defined quality of life as an chronic, painful and involve disability. Among the
“individual’s perception of their position in life in the elderly, functional disability is a feature that induces
context of the culture and value systems in which they depression by itself, and can have a greater impact than
live and in relation to their goals, expectations, stan- the disease or the pain associated with it (Marques &
dards and concerns” (Fleck et al., 2000). It is a multidi- Firmino, 2003).
mensional concept that includes not only objective and Depression is the most common psychiatric disorder
measurable criteria, such as physiological functioning or among the elderly (Conwell, Duberstein, & Caire, 2002;
maintenance of daily living activities (Fonseca, Martin, & Marques & Ramalheira, 2006) and it seems to be respon-
Amado, 2005), but also subjective component that sible for loss of autonomy, strong impairment and
reveal the balance between expectations and achieve- worsening of preexisting pathological conditions
ments (Gonçalves, Martín, Guedes, Cabral-Pinto, & (Gusmão, Xavier, Hector, Benedict, & Caldas de
Fonseca, 2006). Applied to the elderly, the concept is Almeida, 2005). Depressive states in their paroxystic
often associated with dependency-autonomy (Sousa, form can lead to suicide, and the frequency of these
Galante, & Figueiredo, 2003). Dependencies identified events is higher for individuals aged over 65 years
in the elderly are not only the result of biological mod- (Cohen, Llorente, & Eisdorfer, 1998; Costa, 2005; Fontaine,
ifications but also of modifications in social demands, 2000; Marques & Ramalheira, 2006; Saraiva, 2006).
and often these seem to determine those dependencies Ferreira and Castela (1999) stress that suicidal ideation
(Sousa et al., 2003). Three types of dependency are is a key indicator for suicidal behavior. This ideation
described: (1) structured, where the participation in refers specifically to thoughts and cognitions of self-
productive processes is determinant to the human destruction, i.e. of ending one’s life. The appraisal of
being; (2) physical, when there is functional inability to the severity of suicidal ideation fosters a viable and
perform daily activities; (3) behavioral, which is often proactive approach to the identification of individuals
preceded by physical dependence. This last type is at risk. In fact, ideation can be seen as a preliminary
socially induced since, regardless of the elderly’s level stage that precedes more serious suicidal behaviors.
of competence, others expect them to have disabilities. Moreover, although suicidal ideation is an essential
Elderly quality of life becomes critical when one recog- feature of suicidal behavior, it is not sufficient to deter-
nizes that the ageing process has an impact on different mine it. Furthermore, suicidal ideation is also an
levels. In this way, it is crucial to create conditions that important risk factor for suicide attempts (Taylor, Dal
allow the elderly to have a healthier life, more dignified, Grande, Gill, Fisher, & Goldney, 2007). Consequently,
 Suicidal Ideation and Depression in the Elderly  3

early identification of potential self-defeating cogni- deficits1, (d) without cognitive deficits2 (e) without
tions might assist both individuals and caregivers neurodegenerative and / or cerebral-vascular condi-
(Chamberlain, Goldney, Delfabbro, Gill, & Dal Grande, tions3. The decision to include the elderly in this study
2009). Like mental illnesses, suicide causes intense was based on Gerontopsychiatry consultation records.
suffering not only to individuals but also to their
families and communities (European Union, 2008; Procedure
World Health Organization [WHO], 2009). Every
After approval from the hospital’s Health Ethics
year, nearly one million people worldwide commit
Committee, data collection started in April 2009 and
suicide and this represents approximately 1.5% of
ended in October 2009. Then, the respective authors
all causes of death, making suicide the 10th leading
were contacted in order to obtain permission to use the
cause of death (WHO, 2009). In most industrialized
scales. For the included patients (reaching inclusion
countries, the suicide rate among the elderly is
and exclusion criteria), informed consent was obtained
higher than in other age groups (Rubenowitz, Waern,
(including the study objectives, risks and benefits as
Wilhelrnson, & Allebek, 2001), and in individuals
well as a guarantee of confidentiality). For participants
aged 75 and older, this rate can be three times higher
with some type of deficit, informed consent was obtained
than in younger individuals.
from their caregiver or family member.
When other features such as gender, age, marital
status, economic status and work situation are consid-
Materials
ered, it is possible to identify the characteristics of an
individual at greater risk of suicide. The risk of com- Selection of participants required the use of specific
mitting suicide is greater for males aged over 65 years, instruments for screening cognitive impairment: the
widowed, inactive, socially isolated, lacking religious Mini-Mental State Examination (Folstein, Folstein, &
practices, depressed and suffering from various emo- McHugh, 1975, adapted by Guerreiro et al., 1994), the
tional or economic, as with physical or mental health Clock Drawing Test (Shulman, Shedletsky, & Silver,
problems (Campos & Leite, 2002; Saraiva, 2006; WHO, 1986; standards by Cacho, García-García, Arcaya,
2000). Some research studies show that ageing and Lantada, & Vincent, 1999); and two sub-tests of the
mood disturbances (depression) are associated with Battery of Lisbon for the Assessment of Dementia
suicide risk (Cohen, Llorente, & Eisdorfer, 1998; Conwell, (Guerreiro, 1998) —Stories and the Token Test. After
Duberstein, & Caine, 2002). that, the elderly patients selected were assessed with
The objectives of this research study are: the instruments: a Sociodemographic and Clinical Data
To characterize elderly patients aged 65 years or Questionnaire; the EasyCare —Elderly Assessment
older for the first time at the Gerontopsychiatry System (Portuguese version by Sousa & Figueiredo,
Consultation of CHSJ, related to socio-demographic 2000); the Geriatric Depression Scale (Yesavage et al.,
aspects, physical and global disabilities (including 1983; adapted by Barreto, Leuschner, Santos, & Sobral,
activities of daily living), organic pathologies as well 2008) and the Suicidal Ideation Questionnaire (Reynolds,
as psychological variables (perceived quality of life, 1988, adapted by Ferreira & Castela, 1999).
depression, and suicidal ideation).
Assessing the relationship between suicidal ideation, Sociodemographic and Clinical Data Questionnaire
depression and quality of life and global and functional
A semi-structured questionnaire was designed in
disability.
order to obtain sociodemographic and clinical data.
This questionnaire includes the variables: age, gender,
Method
marital status, education, cohabitation, and occupation/
Participants leisure, as well as questions related to health prob-
lems (physical and psychiatric). The questionnaire also
In this cross-sectional study, 155 patients aged 65 or
contains questions concerning bereavement issues,
older were recruited consecutively in a convenience
suicide attempts, alcohol, tobacco and drug use.
sample. Participants were recruited from those
attending for the first time the Gerontopsychiatry
Consultation of CHSJ. This hospital is a Central 1Information documented in the patient’ clinical record, retrieved

Hospital located in the city of Porto. Since this hos- from the Geriatric Psychiatry Consultation Archives
2Information documented in the patient’ clinical record, retrieved
pital is part of the Faculdade de Medicina of the
from the Geriatric Psychiatry Consultation Archives and/ or verified
Universidade do Porto, it is also a University Hospital
at the moment of data collection through the administration of the
designed for undergraduate and post-graduate studies. instruments.
The inclusion criteria were: (a) age 65 years or older, 3Information documented in the patient’ clinical record, retrieved

(b) voluntary and informed consent, (c) without auditory from the Geriatric Psychiatry Consultation Archives
4  C. Ponte et al.

Mini-Mental State Examination - MMSE (Folstein, 10 points, with a cutoff value of 6 points (Cacho et al.,
Folstein, & McHugh, 1975, adapted by Guerreiro 1999).
et al., 1994)

The MMSE is the most widely used standardized Sub-tests of the Battery of Lisbon for the Assessment of
instrument to assess cognitive impairment (Folstein Dementia - BLAD (Guerreiro, 1998)
et al., 1975). It is composed by 30 items, divided into six
Two sub-tests of BLAD (Guerreiro, 1998) were used.
groups, covering dimensions related to the subject’s
This battery is the only tool aimed at a “comprehensive
cognitive deterioration: (a) orientation —temporal and
neuropsychological study” of adults adapted to the
spatial, (b) retention (of words), (c) attention and calcu-
Portuguese population. Formally, it is a battery of tests,
lation, (d) recall (of words), (e) language and (f) con-
that is, a coherent association of evidence (“A’s” cut
structive skills. The score ranges from 0 to 30 points
off tasks, repeating digits, naming, repetition, reading,
and has the following cut-off points for the Portuguese
writing; verbal initiative; stories; verbal memory with
population: ≤ 15 for illiterates; ≤ 22 for those with 1 to
interference; associative learning of words; visual
11 years of education and ≤ 27 for those with more than
memory; token test; graph motor initiative; arithmetic,
11 years of education (as adapted by Guerreiro et al.,
among others) that allows an exploratory evaluation
1994). Participants who scored below the cut-off point
of the various brain regions and their more eloquent
were considered to have a cognitive impairment. Used
functions. Many of these tests were adapted from
as a single screening tool, MMSE has limitations and,
classic instruments, such as the Wechsler Memory Scale,
therefore, it was decided to combine this instrument
the Luria Battery and the Raven’s Progressive Matrices
with the Clock Drawing Test (Cacho et al., 1999) and
(Santana, 2005).
two sub-tests of the Battery of Lisboa for the Assessment
This battery has been adapted (Guerreiro, 1998)
of Dementia (Guerreiro, 1998) in order to fill this gap
and contains normative values for several age
and to detect false negatives.
groups (35–49, 50–64, 65–79) and educational levels
(illiterate; literacy at or below the fourth grade; lit-
Clock Drawing Test (Cacho et al., 1999)
eracy higher than the fourth grade). In order to eval-
The Clock Drawing Test is an instrument designed to uate two of the several partial domains relating to
assess cognitive functioning (Garcia-Portilla et al., 2009) the cognitive logical functioning —logical memory
whose importance, as a screening tool for cognitive defi- and verbal comprehension —two sub-tests were
cits associated with neurological and/ or psychiatric selected: Stories / Logical Memory and the Token Test.
conditions, has been increasing in recent years (Silva, There are several tools for assessing memory in its
Mendonça, & Guerreiro, 2009). The test allows the assess- different domains, and among these one of the most
ment of an extensive set of cognitive domains, including used is the Logical Memory sub-test of the Wechsler
visuospatial ability, constructional praxis, abstract Memory Scale (Johnson, Storandt, & Balota, 2003).
thinking (Ismail & Shulman, 2006; Marques-Teixeira, In this study, a version adapted by Guerreiro (1998)
2005; Silva et al., 2009), perception, executive functioning, which is designated as a Stories sub-test was used.
attention and comprehension (Garcia-Portilla et al., 2009). According to Storandt and Hill (1989), considering
The Clock Drawing Test is quite simple to adminis- that difficulties in recent memory are common among
ter, it can be completed in about two minutes and only older adults, this sub-test is a good tool to differen-
requires a blank sheet of paper and a pencil. The sub- tiate healthy elderly from those who apparently
ject is asked to draw a round clock face and to put in might be at an early stage of dementia (mild cogni-
the numbers. The test is completed once the subject tive impairment).
draws the clock’s hands to show any given time (the The Stories sub-test is designed to assess immediate
most common being eleven hours and ten minutes) verbal memory through immediate recall of stories. The
(Ismail & Shulman, 2006). This test has the disadvan- test consists of reading aloud two short stories to the
tage that it cannot be used with illiterate subjects that participant, who afterwards should recall each of the
lack numeracy skills and therefore cannot tell the time. stories spontaneously. The number of ideas precisely
For this reason, the Clock Drawing Test was not used memorized is counted; allowing the amount of informa-
among the illiterate participants (N = 31). The value of tion absorbed and accurately understood to be deter-
the test as a single screening instrument has limitations mined. The aim is to understand if the individual can
in term of sensitivity to cognitive deficits. The scoring recall a story after storing its verbal content in the short-
system consists of assigning points according to the term memory (Guerreiro, 1998).
presence and accuracy of the clock features. The final The Token Test was originally developed by De Renzi
score is the result of the sum of the scores obtained on and Vignolo (1962), and it is designed to assess verbal
the three quotation criteria, and varies between 0 and comprehension in children and adults. The version
 Suicidal Ideation and Depression in the Elderly  5

used in this study was adapted by Guerreiro (1998) personal appearance, to dress and feed themselves.
and consists of a set of 20 different pieces resulting The total score may range from 0 to 22. f) Sphincter
from the combination of two geometric shapes (circles control —urinary and fecal incontinence. The score can
and squares) with two sizes (small and large) and five reach a maximum of 17 points (Sousa & Figueiredo,
different colors (white, black, yellow, red and green). 2000).
The test requires subjects to manipulate the tokens in EasyCare takes about 10 minutes to complete (Sousa &
response to a sequence of oral commands, expressed Figueiredo, 2000a). Regarding test results, the maximum
in different degrees of complexity, to assess language score for disability is 100. This result can be calcu-
comprehension. lated by gradually adding, first, the scores obtained
in the items concerning the instrumental / functional
area and then the scores concerning sphincter control.
EasyCare - Elderly Assessment System (Portuguese
It is important to be aware that higher scores indicate
version by Sousa & Figueiredo, 2000a)
greater disability. However, the possibility of establish-
EasyCare (Sousa & Figueiredo, 2000a) assesses physical ing a value that indicates that the subject has no prob-
well-being, mental and social health of the elderly. lems is excluded (only extreme values enable one with
It assesses also the elderly’s perception of their own clear indications). In fact, the score is a simple orienta-
abilities without considering their skills, allowing the tion, as such, when median values were obtained the
identification of the overall disability. It is a multidi- clinical judgment plays a prevalent role in terms of
mensional instrument designed to assess the social and interpretation (Sousa & Figueiredo, 2000a).
health needs of the elderly.
EasyCare contains a personal information form with Geriatric Depression Scale - GDS (Yesavage et al., 1983;
the purpose of gathering personal data and the possi- adapted by Barreto et al., 2008)
bility of registering information concerning residence
GDS (Barreto et al., 2008) is the only scale specifically
status, granted benefits (e.g., social support), the final
designed to assess depression among the elderly. This
degree of education, as well as information concerning
scale is commonly used to screen the potential exis-
the age of retirement (Sousa & Figueiredo, 2000a). This
tence of depressive disorders in older adults, concern-
instrument addresses the following areas: a) Physical
ing the subject’s state of mind over the previous week
Disabilities —visual and auditory accuracy, mastica-
(Garcia-Portilla et al., 2009). GDS consists in 30 items,
tion and speech, these questions are intended to collect
formulated as easily understandable questions with
information about potential problems associated with
Yes and No answers. This scale provides a single score,
the use of certain devices (glasses, hearing aids, and
obtained with the sum of each item scoring (1 or 0).
dental prosthesis). The score ranges from 0 to 12 points;
The total score ranges from 0 to 30. The cut-off points
higher scores indicate higher impairment. b) Subjects’
are as follows: 1–10 —no depression, 11–20 —mild
perceived quality of life —refers to the quality of life as
depression and 21–30 —severe depression (Barreto
perceived by the subject, considering health, loneliness,
et al., 2008).
and accommodation. This index can vary between
0 and 15 points, where a higher value means a lower
Suicidal Ideation Questionnaire - SIQ (Reynolds, 1988,
perceived quality of life. The following areas, deter-
Portuguese version, adapted by Ferreira & Castela, 1999)
mine the patient´s Global Disability, and these corre-
spond to: c) Instrumental / functional area —capacity to The SIQ (Ferreira & Castela, 1999) aims to assess the
carry out household, preparing meals, shopping, han- severity of suicidal thoughts and cognitions. It includes
dling money, using the phone and taking medicines. items that cover the hierarchy of thoughts about sui-
The scores range from 0, which indicates overall func- cide, ranging from mild to very serious thoughts. It
tional/ instrumental capacity, to 23 points. In the view consists in 30 items and comprises seven possible
of the patient´s difficulty or inability to perform a choices, organized in the categories: I never had this
task, the evaluator has the opportunity to record infor- thought (0); I have had this thought before but not in
mation concerning the caregiver (spouse or partner, the past month (1); almost once a month (2); a couple of
family member, friend or neighbor, private or public times a month (3); about once a week (4); a couple of
support services as well as other types of support, or times a week (5); almost every day (6). For scoring pur-
even, the lack of assistance). d) Mobility —the ability to poses, items are scored from 0 to 6, with a high score
leave the house and walk outdoors, move around inside indicating cognitions occurring with significant regu-
the house, walk up and down stairs, move from the bed larity. The scores in SIQ can range from 0 to 180. The
to a chair, use the toilet, use the bath or the shower. The SIQ is applicable not only as a measure of suicidal ide-
maximum score for this index is 41 points. e) Personal ation, but also as part of a battery to assess psycho-
care activities – patient´s ability to take care of their pathological issues (Ferreira & Castela, 1999).
6  C. Ponte et al.

Statistical Analysis Table 1. Sociodemographic characteristics of the sample

Statistical analyses were performed using Statistical

Age N %
Program for Social Sciences (SPSS, version 17.0). For
characterization of the sample descriptive analyses
65–74 years 49 65.3
were used and to assess the association between sui- 75–84 years 22 29.3
cidal ideation, depression and other variables (socio- ≥ 85 years 4 5.3
demographics, physical and global disability, medical Education level
and psychological variables), a correlation analysis Illiterate 13 17.3
was performed. Additionally, the study of patients’ Incomplete elementary education 6 8
perceived quality of life, depression and suicidal ide- Complete elementary education 36 48
ation, was investigated using Spearman’s rank corre- 2° Cycle 4 5.3
lation test (rs). The significance level of 95% and 99% 3° Cycle 10 13.3
High school 6 8
was used.
Marital status
Single 3 4.0
Results Married/Cohabitation 47 62.7
Divorced/Separated 3 4.0
Descriptive Analysis Widowed 22 29.3
Residential area
From an initial sample of 155 elderly patients, 80 were
Urban 44 58.7
excluded because they did not fulfill the inclusion
Suburban 23 30.7
criteria (Table 1). The final sample comprised 75 elderly
Rural 8 10.6
with a predominance of female (78.7%). The age ranged Living situation
from 65 to 88 years, with a mean age of 72.8 years Alone 15 20
(SD = 6.04). In most of the cases, educational level With family 58 77.3
was low, with an average of 4.68 years (SD = 3.51). Institutionalized 2 2.7
Regarding marital status, the majority of participants Total 75 100
were married (62.7%), followed by widowed (29.3%).
Regarding place of birth, all the participants were from
The mean was 41.96 (SD = 36.38). These results reveal
the north of Portugal and most of them lived in urban
an important variation within the final scores.
areas (58.7%). The majority of participants (77.3%)
Considering the value of 41 (from which there is a
lived with family (the majority with their spouse or
potential risk of suicide), 40% of the patients were
other relatives).
above the cut-off point.
Concerning the level of physical disability (Table 2)
In relation to information about the history of sui-
the answers ranged from 0 to 4, with an average of
cidal behaviors within the family and community, 16%
1.41 (SD = 1.2), which means that these patients had
(N = 12) of the patients reported knowledge of suicidal
no disabling physical conditions. The index of global
behavior in their family and 17.3% (N = 13) cases of
disability (including instrumental / functional area,
suicide in the community. In this sample, 37.3% men-
mobility; personal care activities and sphincter control),
tioned already having attempted to commit suicide
ranged from 0 to 61, with a mean of 11.87 (SD = 13.56).
and 14.7% had made their attempt less than two years
None of the subjects in the sample presented a severe
ago (the most common method used (18.7%) was drug
level of disability (score higher than 62).
poisoning).
In the final sample the majority of patients (N = 75)
had some type of chronic health complaints not related
Correlational Analysis
to psychiatric diseases. These data were completed with
medical records and osteoarticular diseases were found A significant correlation between depression and sui-
to be the most common condition (65.3%), followed by cidal ideation was found (rs = .71, p < .001), indicating
gastrointestinal and cardiovascular diseases. that increases in depression scores were associated
Relating to perceived quality of life, scores ranged with increases in suicidal ideation. When examining
from 8 to 14, with an average of 10.47 (SD = 1.49), indi- the association between depression and perceived
cating a low level. The majority (71.3%) reported feel- quality of life, a highly significant correlation was
ings of loneliness. found (rs = .50, p < .001). This result indicates that
Concerning depression, 93.4% were depressed, with increases in depression scores were associated with
66.7% of the participants being severely depressed. increases in the quality of life scores, denoting poor
In terms of suicidal ideation (Table 3 and 4), answers quality of life. Concerning the Easy care index, a signif-
varied between a minimum of 0 and a maximum of 129. icant positive correlation between depression and the
 Suicidal Ideation and Depression in the Elderly  7

Table 2. EASYcare scores

Dimensions M (SD) Obtained range (min-max) Possible range (min-max)

Functional/Instrumental 4.80 (5.53) 0–19 0–23

Mobility 4.28 (6.10) 0–28 0–41
Personal care activities .85 (2.74) 0–13 0–19
Sphincter control 1.84 (3.01) 0–12 0–17
Global disability 11.87 (13.56) 0–61 0–100

Table 3. Suicidal Ideation Questionnaire

Dimensions Mean (sd) Obtained range (min-max) Possible range (min-max)

Suicidal ideation 41.96 (36.38) 0–129 0–180

Table 4. SIQ means concerning frequent thoughts

Item Questions M SD

6 I thought about death. 3.03 1.73

5 I thought of people dying. 2.75 1.65
12 I wish I was dead. 2.41 1.85
22 I thought it wasn’t worth it. 2.39 1.81
1 I thought it would be better if I weren’t alive. 2.35 1.83
23 I thought that my life was too miserable to go on. 1.92 1.81
17 I wished I had never been born. 1.81 1.83

functional/instrumental area was found (rs = .23, Concerning perceived quality of life and state of
p = .043). High values in depression were associated with health, home and loneliness, patient perceived their
greater inability to perform activities of daily living. quality of life as low. This result is supported both by
No correlation was found with global disability. national and international studies (Fernandes et al.,
In addition, a significant positive correlation between 2009). According to Sousa, Galante, and Figueiredo
suicidal ideation and the patients´ perceived quality of (2003), dependency-autonomy has been associated with
life was found (rs = .40, p < .001), indicating that high the quality of life in the elderly population. Although
scores for suicidal ideation were associated with a poor this is a multidimensional and subjective concept, it
perception of quality of life (Table 5). seems to be clear that mobility and autonomy contribute
to a better perception of quality of life as well as to a
Discussion positive mental state.
In this study, with a sample of 75 patients, 78.7% were As in previous studies in this age group, the majority
female. Similar results have been found in most of the had severe depression. In fact, depression has great
national studies (INE, 2002; Carrilho & Patrício, 2009). importance among elderly, as a major cause of psycho-
Regarding to physical disability, these patients did not logical distress, appearing as the most common psychiat-
reveal significant limitations in terms of vision, audi- ric disorder in this population (Conwell, Duberstein, &
tion, mastication, or speech that could interfere with Caire, 2002; Marques & Firmino, 2003; Marques &
their day-to-day living. Similar results were obtained Ramalheira, 2006). Moreover, it is often associated
in the global disability index, revealing that patients with loss of autonomy as a result of disability, and
had sufficient autonomy and ability to perform their increased of pre-existing illnesses (Gusmão, Xavier,
daily living activities. Concerning diseases, most of Heitor, Bento, & Caldas de Almeida, 2005). Depressive
patients reported chronic conditions with osteoarticular states are very common in old age and can lead to
diseases being the most common complaint. In turn, suicide, which is often higher in people aged over 65
this particular condition involved pain, discomfort and years (Cohen, Llorente, & Eisdorfer, 1998; Costa, 2005;
disability as well as loss of mobility and independence. Fontaine, 2000; Marques & Ramalheira, 2006).
8  C. Ponte et al.

Table 5. Correlational analyses common treatable diseases among the elderly who use
the National Health Service. Hence, many deaths by
Rs suicide could be avoided if the health system developed
efficient preventive measures.
Suicidal Ideation / .71** The consolidation of the relationship between these
  Depression (QIS/GDS) variables, particularly between the associated depres-
Suicidal Ideation /Perceived quality .40** sive condition and / or suicidal ideation, may prove to
  of life (QIS/EASYcare)
be important, not only in a broad preventive perspec-
Suicidal Ideation/Global ns
tive, but also in improving the delivery of mental
  Disability (QIS/EASYcare)
Depression/Perceived Quality .50**
health care. As described in previous studies (Cohen,
  of Life (GDS/EASYcare) Llorente, & Eisdorfer, 1998; Costa, 2005; Fontaine, 2000;
Depression/Functional .23* Marques & Ramalheira, 2006), depressive states are
  Disability (GDS/EASYcare) very common in old age and can lead to suicide (above
all over 65 years). Therefore, considering the progressive
rs Spearman‘s correlation coefficient *p < .05; **p < .01. ageing of the Portuguese population, it becomes crucial
to recognize and analyze its consequences in order to
A positive association was found between depres- find appropriate solutions to this problem.
sion and the patients´ perceived quality of life, being
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