Abstract

Introduction

The article analyzes 60 in-depth interviews conducted in 13 Brazilian municipalities with elderly individuals who have ideations or have attempted suicide. The study deals specifically with the physical, psychological and social circumstances associated with the events mentioned¹1. Minayo MCS, Cavalcante FG. Estudo sobre tentativas de suicídio em idosos sob a perspectiva da saúde pública [projeto de pesquisa]. Rio de Janeiro: Fiocruz; 2013.. This is the fruit of research supported by the National Council of Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq), which was preceded by an extensive review of the state of awareness of ideations and attempted suicides in the group in question.

This review²2. Minayo MCS, Cavalcante FG. Tentativa de suicídio entre idosos: revisão de literatura (2002-2013) Cien Saude Colet 2015; 20(6):1751-1762. analyzed 75 articles published between 2002 and 2013. It was noted that 94.7% of investigations are of an epidemiological nature and concentrate on secondary sources. The few qualitative studies reviewed showed a lack of theoretical and methodological consistency³3. Cavalcante FG, Minayo MCS, Meneghel SN, Silva RM, Gutierrez DDM, Conte M, Figueiredo AEB, Grubtis S, Cavalcante ACS, Mangas RMN, Vieira LJES, Moreira GAR. Autópsia psicológica e psicossocial sobre suicídio de idosos: abordagem metodológica. Cien Saude Colet 2012; 17(8):2039-2052.. In the related literature, depression is quoted as the most relevant factor to explain suicidal attempts by elderly people, associated with chronic physical suffering, functional, family and economic losses, abandonment, loneliness, violence undergone during the life cycle, mental disturbances and suffering and severe depression. There are differences of gender, ethnicity, age groups in old age, social questions and cultural traits⁴4. Conwell Y, Thompson C. Suicidal Behavior in Elders. Psychiatric Clinics of North America 2008; 31:333-356.–⁷7. Beeston D. Older People and Suicide. Staffordshire: Staffordshire University; 2006.. Although less common among the elderly, compared with adolescents and young people, attempted suicide is the presage of self-inflicted death⁷7. Beeston D. Older People and Suicide. Staffordshire: Staffordshire University; 2006..

Suicide is an intentional move to end one's own life. Non-fatal suicidal behavior appears in the form of ideation, where there are thoughts that encourage the desire to end one's existence, which become aggravated when they are accompanied by a suicide plan, in which a method for ending one's life is formulated. Attempted suicide involves conduct designed to cause death, which it may or may not result in⁵5. Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, Lee S. Suicide and Suicidal Behavior. Epidemiol Rev 2008; 30:133-154.. Literature has used the term suicidal behavior to express the conduct of a person who acts against themselves and threatens their own life, frequently leaving verbal or behavioral clues⁸8. Silverman MM, Berman AL, Sanddal ND, O'Carroll PW, Joiner TE. Rebuilding the Tower of Babel: A revised nomeclature for the study of suicide and Suicidal Behaviors. Suicide and Life-Threatening Behavior 2007; 37(3):248-263.,⁹9. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, organizadores. Relatório Mundial sobre Violência e Saúde. Geneva: OMS; 2002.. Self-neglect is a variation of such behavior, in which a person allows themselves to die. The border lines between the different definitions are tenuous, as an attempt may be interrupted and become fixed as an idea or intention, while a thought can evolve as a result of overwhelming anguish and anxieties and explode in the form of an act against life. However, not every thought about death or desire to die is a sign of risk. It is necessary to distinguish and differentiate ideas and behavior associated with risk of suicide and wishes to kill themselves that do not commit the person because they do not persist.

Sommers-Flanagan et al¹⁰10. Sommers-Flanagan J, Sommers-Flanagan R. Intake interviewing with suicidal patients: A systematic approach. Professional Psychology: Research and Practice, 1995; 26(1):41-47. put forward a proposition that guided this study³3. Cavalcante FG, Minayo MCS, Meneghel SN, Silva RM, Gutierrez DDM, Conte M, Figueiredo AEB, Grubtis S, Cavalcante ACS, Mangas RMN, Vieira LJES, Moreira GAR. Autópsia psicológica e psicossocial sobre suicídio de idosos: abordagem metodológica. Cien Saude Colet 2012; 17(8):2039-2052.. It should be stressed that in order to assess the risk of suicide it is necessary to take into account the seriousness of the attempt, the lethality of the method and its visibility. The evaluation of the suicidal intent may be considered: (a) non-existent, with no plan or idea of killing themselves; (b) minor, with no specific or concrete plan and few risk factors; (c) moderate, where a general plan exists, although self-control is intact and ‘reasons for living’ predominate; (d) severe, frequent and intense, with a specific and lethal plan, available means and questionable self-control; (e) extreme, with clear suicidal intent, frequent seeking for an opportunity and the presence of many risk factors. The more specific the plan, the graver the risk, which increases if the person has difficulty of verbal and physical self-control, and associates their behavior to the use of alcohol or other drugs and compulsive acts and thoughts. Three factors are taken into account in analyzing the attempted suicide¹⁰10. Sommers-Flanagan J, Sommers-Flanagan R. Intake interviewing with suicidal patients: A systematic approach. Professional Psychology: Research and Practice, 1995; 26(1):41-47.: an acute suicidal crisis, which may present for a short period, of hours or days, in which a release of emotion and a self-destructive attack are at work; the ambivalence shown in the degrees and ways in which people make the attempt; and the existence of a relational aspect that transforms the critical event into an act of communicative behavior. Sommers-Flanagan et al¹⁰10. Sommers-Flanagan J, Sommers-Flanagan R. Intake interviewing with suicidal patients: A systematic approach. Professional Psychology: Research and Practice, 1995; 26(1):41-47. recommend a medical diagnosis to measure the actual gravity of an attempt. In the absence of a diagnosis, presumed evaluations are made of the circumstances, acts and thoughts described in the stories of the elderly people.

Material and Method

The qualitative method was used, following a hermeneutic and dialectic approach, which seeks to understand the history and singularity of the other person, interpret their speech and contextualize the narratives and biographies in the historic scenario and living conditions. The raw material for this type of comprehensive investigation is the practical experience acquired, which organizes the person's learning process in the world; subjective experience which synthesizes their reflections on their experience; common sense, which translates opinions and values about practical and subjective experience into language and attitude; and social action, which consist of the common and at the same time contradictory exercise of individuals, groups and institutions in building their lives, histories and trajectories¹¹11. Minayo MCS. Análise qualitativa: teoria, passos e fidedignidade. Cien Saude Colet 2012; 17(3):621-626..

The study was based on the course proposed by Shneidman¹²12. Shneidman ES. Suicide thoughts and reflections, 1960-1980. Suicide Life Threat Behav 1981; 11(4):195-364., which establishes the various degrees of disturbance as a result of which a person becomes an enemy to their own self; on Bertaux¹³13. Bertaux D. Biography and Society. The Life History Approach in the Social Sciences. London: Sage Publications; 1981., who looks deeper into the relation between background and social life; on Durkheim¹⁴14. Durkheim E. O Suicídio: Um Estudo Sociológico. Rio de Janeiro: Zahar Editores; 1982., who defines suicide as an event in which the personal and psychological factors present themselves in specific social contexts; and on Lester and Thomas¹⁵15. Lester D, Thomas CC. Why people kill themselves: A 2000 Summary of Research on Suicide. Springfield: Charles C Thomas; 2000., who suggest a nexus between context, social aspects and subjectivity¹⁶16. Pinto LW, Assis SG, Pires TO. Mortalidade por suicídio em pessoas com 60 anos ou mais nos municípios bra-sileiros no período de 1996 a 2007. Cien Saude Colet 2012; 17(8):1963-1972.–¹⁸18. American Association of Suicidology. Elder suicide fact sheet. [acessado 2014 maio 10]. Disponível em: http://www.sciencedaily.com.
http://www.sciencedaily.com... .

The 13 Brazilian municipalities in which the study was conducted have suicide rates among elderly people of over 10/100,000. The choice of these locations took into account the proximity to universities and researchers with experience of this question and training in public health, mental health or social service. The following were selected: Manaus, in the north; Fortaleza, Recife, Teresina and Piripiri in the north-east; Campo Grande and Dourados in the midwest; Rio de Janeiro and Campos in the south-east; Porto Alegre, Santa Cruz do Sul, Venâncio Aires and Candelária in the south.

The research network was comprised of 53 collaborators, under the local coordination of 13 researchers. A field manual³3. Cavalcante FG, Minayo MCS, Meneghel SN, Silva RM, Gutierrez DDM, Conte M, Figueiredo AEB, Grubtis S, Cavalcante ACS, Mangas RMN, Vieira LJES, Moreira GAR. Autópsia psicológica e psicossocial sobre suicídio de idosos: abordagem metodológica. Cien Saude Colet 2012; 17(8):2039-2052. was drawn up collaboratively, with all the instructions to be followed, to serve as a guide for the investigators, who had hands-on training in the use of the material and in relation to technical and ethical behavior in the fields. The team's experience, the presence of two senior researchers in each location to take responsibility for the study, the words of the elderly people, and in some cases, of their family members and health professionals all contributed to enhancing the study.

Sixty elderly people at risk of suicide were interviewed, after selection with the help of health professionals involved with caring for these elderly individuals in hospitals, Psychosocial Care Centers, Integral Care Centers for the Elderly, Family Health Strategy Centers, Long-Term Institutions (ILPI) and Health Surveillance Centers. Families had great difficulty in agreeing to the elderly speaking about their suicidal behavior; however, once the first resistance was overcome, the approach became possible, following the ethical precepts. All those interviewed signed the consent form approved by the ethics committee of the Oswaldo Cruz Foundation.

The main qualitative tool used in collecting the data was a format to guide the in-depth interviews, together with an identification form³3. Cavalcante FG, Minayo MCS, Meneghel SN, Silva RM, Gutierrez DDM, Conte M, Figueiredo AEB, Grubtis S, Cavalcante ACS, Mangas RMN, Vieira LJES, Moreira GAR. Autópsia psicológica e psicossocial sobre suicídio de idosos: abordagem metodológica. Cien Saude Colet 2012; 17(8):2039-2052.. The themes of this guide, in addition to a sociodemographic classification, were conversation with the elderly person about their social, community and family circumstances; their physical and mental health and functional capacity and the reasons given for the suicidal behavior.

This field information was first analysed by the local investigators and then cross-categorized by the two undersigned researchers, by means used in the attempts or expressions of ideation, severity of the events and reasons given by the elderly people: by sex, age, socioeconomic profile, risk factors and protection factors. The manual, to which all the investigators had access, contained theoretical guidance on the matter and methodology in relation to the fieldwork and organization, categorization and preliminary analysis of the cases. A contextualized and assumed analysis is presented of the severity and the multiple associations of the attempts and ideations interpreted by the researchers.

The study obviously has many limitations: the very fact of working with a subject that requires emotional equilibrium and control on the part of the researchers; of having had only one or two interviews with each elderly individual; and the difficulty of dealing with discrepancies of the reports. We aimed to minimize these limitations by means of dialogue shared in a communication network between the researchers, as proposed by Shneidman¹²12. Shneidman ES. Suicide thoughts and reflections, 1960-1980. Suicide Life Threat Behav 1981; 11(4):195-364..

Results

Sociodemographic profile and profile of the suicidal behavior of the group studied

In this study, the minor, moderate and severe categories of both the suicidal attempts and ideations of the elderly people interviewed proved significant¹⁰10. Sommers-Flanagan J, Sommers-Flanagan R. Intake interviewing with suicidal patients: A systematic approach. Professional Psychology: Research and Practice, 1995; 26(1):41-47.. A range from non-existent intentions to extreme risk of self-inflicted death and episodes of self-neglect was observed on an individual basis.

The demographic profile of the interviewees showed that the men (41%) fell into the 60 to 89 age group, split into 48% aged 60 to 69; 32% aged 70 to 79 and 20% aged 80 or more. The women (59%) ranged from 60 to 101 years of age, with 51.4% aged 60 to 69, 28.6% aged 70 to 79 and 20% aged 80 or more. Whereas half of the men are married or have remarried (48%) and the other half are divorced, separated, widowers or unmarried (52%), the majority of the women have no partner, are widows, divorced, separated or unmarried (77.2%).

More than half of the men attended and finished or did not complete elementary and middle school or technical school (52%), while others finished elementary school (32%) or are illiterate or semi-illiterate (8.0%). In contrast, more than half of the women attended and finished or did not complete elementary and middle school and some reached technical level (28.5%), while others had started elementary school (34.2%) or were illiterate or semi-illiterate (31.4 %). Only one elderly man and one elderly woman had higher education: one lives in the north and the other in the south. The majority of these individuals are Catholic (52% of men and 65.7% of the women). Some men (12%) said that they had no religion (Table 1).

The majority of the elderly women had been housewives, craftswomen (27.3%), farmers (18.2%) or worked in domestic service, pharmacies, stationery shops or restaurants (34.1%). A small percentage had been teachers, managers of their own businesses, trash pickers, civil servants or technicians (20.4%). The men worked mainly in farming (12.5%); as general service providers: facilitators/brokers, painters, bricklayers, metal workers, guards, scrap metal merchants, mechanics, barbers (35%); managers of their own businesses (20%): retailers, businessmen, rural producers, farmers; and technical activities (telephony, informatics, electrical, statistical) or public service (military, technicians and teachers) (12.5%).

The majority of those interviewed are retired or receive a spouse's pension (72%); some have an informal relationship, have no income or receive the continuous cash benefit (12%). Others (17%) still exercise professional, manual or artistic activities (17%). Half of the elderly women continue to work as domestic servants or take care of relations, with or without illnesses (48.9%).

The younger interviewees, aged 60 to 74, were largely located in the north, south and south-east (83.3% of cases in the north, 88.9% in the south and 66.7% in south-east). The north and midwest have a wider distribution of ages 60 to 101, with stories of older elderly people (50% in the midwest, including a man of 90 and a centenarian woman). (Table 2).

One hundred and two occurrences of self-neglect and of attempted suicide and ideations were described, and classified as minor, moderate or severe. Among the men, there were 25 mentions of attempts (58.1%) and 17 of ideations (39.6%). Among the women, 32 attempts (54.2%) and 22 ideations (37.3%).

Adding together the cases in the north-east (29) and the south (22), the suicidal attempts by men and women represent 89.4% of all the situations studied. In the north-east, statements about severe attempts predominate (38.6%), followed by moderate (10.5%) and minor (1.7%) attempts. In the south, the moderate (21.1%) and severe (17.5%) cases are evenly distributed.

In the other regions, there is a higher proportion of severe attempts. By sex, 60% of the men and 62.5% of the women made severe suicidal attempts, which converges with findings in the related literature²2. Minayo MCS, Cavalcante FG. Tentativa de suicídio entre idosos: revisão de literatura (2002-2013) Cien Saude Colet 2015; 20(6):1751-1762.,⁴4. Conwell Y, Thompson C. Suicidal Behavior in Elders. Psychiatric Clinics of North America 2008; 31:333-356.,⁶6. Mitty E, Flores S. Suicide in Late Life. Geriatric Nursing 2008; 29(3):160-165.,⁷7. Beeston D. Older People and Suicide. Staffordshire: Staffordshire University; 2006..

With regard to ideations, 14 cases were reported by elderly people living in the north-east, nine in the south-east, seven in the north and seven in the south, which together represent 95% of the total. The higher percentage of severe ideations (23.1%) in the north-east is notable, followed by the cases in the south-east and south (18%). In the north, the stories show only cases of mild ideations (10.2%). In the sample taken as a whole, the men report more severe ideations (53% of the cases) than the women (36.4%). The conclusion is that their situation tends to slide from moderate to severe; and that of the women, from mild to moderate and severe, which confirms data in the related literature that men are at greater risk of suicide²2. Minayo MCS, Cavalcante FG. Tentativa de suicídio entre idosos: revisão de literatura (2002-2013) Cien Saude Colet 2015; 20(6):1751-1762.,⁴4. Conwell Y, Thompson C. Suicidal Behavior in Elders. Psychiatric Clinics of North America 2008; 31:333-356.,⁶6. Mitty E, Flores S. Suicide in Late Life. Geriatric Nursing 2008; 29(3):160-165.,⁷7. Beeston D. Older People and Suicide. Staffordshire: Staffordshire University; 2006.. Although the figures and percentages of cases of attempts and ideations are presented separately, in the majority of situations, these events are interlinked, particularly when the suicidal attempt is serious²2. Minayo MCS, Cavalcante FG. Tentativa de suicídio entre idosos: revisão de literatura (2002-2013) Cien Saude Colet 2015; 20(6):1751-1762.,⁴4. Conwell Y, Thompson C. Suicidal Behavior in Elders. Psychiatric Clinics of North America 2008; 31:333-356.,⁷7. Beeston D. Older People and Suicide. Staffordshire: Staffordshire University; 2006. (table 3).

With regard to the means, the majority of attempts were made by hanging (24% of men and 31.3% of women), followed in this order by drug overdose (16% of men and 25% of women), poisoning (20% of men and 21% of women), and other means (firearms, bladed weapons, falling from a height, drowning), as related in the literature¹⁶16. Pinto LW, Assis SG, Pires TO. Mortalidade por suicídio em pessoas com 60 anos ou mais nos municípios bra-sileiros no período de 1996 a 2007. Cien Saude Colet 2012; 17(8):1963-1972.–²⁰20. May AM, Klonsky ED, Klein DN. Predicting future suicide attempts among depressed suicide ideators: A 10 year longitudinal study. J Psychiatr Res 2012; 46(7):946-952.. Attention is drawn to the high percentage of attempts to die by causing oneself to be hit by a vehicle (14% of the men and women) and of self-mutilation by men, information that is not to be found in the bibliography studied¹⁷17. Cavalcante FG, Minayo MCS. Autópsias psicológicas e psicossociais de idosos que morreram por suicídio no Brasil. Cien Saude Colet 2012; 17(8):2039-2052.,¹⁸18. American Association of Suicidology. Elder suicide fact sheet. [acessado 2014 maio 10]. Disponível em: http://www.sciencedaily.com.
http://www.sciencedaily.com... ,²⁰20. May AM, Klonsky ED, Klein DN. Predicting future suicide attempts among depressed suicide ideators: A 10 year longitudinal study. J Psychiatr Res 2012; 46(7):946-952.. Differences of gender are noted. Women tend to opt for hanging, drug overdose, poisoning and being hit by a vehicle. The men plan hanging, death by bladed weapon, by firearm or by falling from a height²⁰20. May AM, Klonsky ED, Klein DN. Predicting future suicide attempts among depressed suicide ideators: A 10 year longitudinal study. J Psychiatr Res 2012; 46(7):946-952..

Histories, motivation and reasons for the suicidal behavior from the viewpoint of the elderly person

The aim is to provide examples of suicidogenic crises, the role of ambivalence between wanting to live and wishing to die, the relational aspects of suicidal behavior and normal thoughts about death. Pseudonyms – names of flowers – are used instead of people's names, to respect anonymity and distinguish the narratives. The cases analysed show a multiplicity of combined precipitating and associated factors. This is the order of the reasons given by the elderly people and according to their logic: (1) depression as an illness or associated with losses; (2) suffering as a result of chronic or painful diseases and functional incapacities; (3) abuse of alcohol and other drugs; (4) personal experience of violence and abandonment during the life cycle.

Depression associated with physical, family and financial losses and to abandonment - In twenty cases, seven involving men and 13 involving women, depression was the most serious risk factor associated with the ideation and to suicidal acts, in a pluricausal context of suffering in the course of life. We describe some, starting with the men.

Delfim (aged 69), from Piauí, and Cravo (71), from Porto Alegre, suffered the tragic loss of children. Delfim has been blind for five years. Now a widower and without his son, he lives in a shelter and feels abandoned. He tried to hang himself: I lost my taste for life. At 71, depressed, he slashed his wrists and describes his crisis: I feel great pain and don't think about what I'm doing. I just want to end the pain. Cravo lives with his wife and endures reduced mobility, after an operation for prostate cancer. Full of sorrow, he says: I died a little after the surgery. He attempted self-mutilation.

Antúrio (aged 80), from Piauí, today feels uprooted. He lives in a shelter and, although he has functional capability, even in a wheelchair, he complains of abandonment. He describes how he planned his suicide: I thought about getting a rope and hanging myself. I hung the rope up and got down on my knees, but the boy came and took me out. I wanted them to find me dead, hanging. He summarizes his loneliness: I feel sad living like this, alone, thrown to the wolves.

Gravata (67) and Goivo (63), from Candelária, are survivors²¹21. Shneidman ES. A Commonsense book of death. Refections at Ninety of a Lifelong Thanatologist. Oxford: University Press; 2008., as they had family members who had committed suicide. All of them were farmers. In Gravata's case, the depression started after surgery for thrombosis, in which he lost his independence and began to suffer intense pain: I couldn't stand it any longer, I used to lie down, grab my head with both hands and squeeze it, it felt as if it would explode. Goivo's depression started when one of his sons-in-law killed themselves, leaving him with a huge debt to pay off: all this mess gets into your head and you wind up in a blind alley. They tried to poison themselves. Jacinto (76), from Manaus, went into a depression when a debt incurred by one of his children caused him problems in the neighborhood. He came close to self-mutilation: I thought about going round the back of the house in the depths of night and slashing my wrists, letting myself bleed out.

At 74 years of age, Ranunculo, from Fortaleza, feels bad, rootless and depressed. He lives in an old people's home: my parents used to say that that I was the only one of their children who could turn out to be an assassin, a bandit, violent. Ever since I was little I have had as it were a perverse instinct, an evil that accompanies me. He says that some time ago he faced a serious case of torture. He attempted suicide by drug overdose, being hit by a car or train, by poisoning, falling from a height and bladed weapon. When I hear talk about something dangerous, I don't plan it, I act immediately. This is how he describes one of his suicidogenic crises: The first time I threw myself under a train. He acts impulsively, feeling anesthetized before the act and is not motivated by a desire to die, but to challenge life.

Among the women there are also various cases of depression linked to losses and other problems, and those experienced by Estrelicia, Iris, Cravínia, Astromélia, Margarida, Gardênia, Palma, Tulipa and Amarilis are described here. In the case of Estrelícia (aged 60), from Piauí, alcohol abuse is combined with loneliness and depression. She tried to kill herself by drug overdose and by firearm. She was once a nightclub proprietor, but lost everything and now lives in a shelter. I feel all alone and tossed out into the world. I once had so much, so many people and now I'm abandoned. Iris (64), from Manaus, lost a baby when she was young, which exhausted her strength and brought on depression: I felt terrible, it made me very depressed! I used to hear voices, as if I was surrounded by people. Years later, she was affected by a serious family financial crisis, with impacts on what she held most precious, family ties. Iris planned to hang herself, but didn't do it because a granddaughter was about to be born.

Cravina (63), from Piauí, now a widow, suffered postpartum depression, involving thoughts of suicide and of killing the baby. Now her oldest son has turned into a drug user and has become the source of her suffering. Her depression is severe. She has already made two attempts by poisoning and by hanging: I took rat poison and ammonia and lay down, expecting to die. I was thrashing about, I vomited blood and asked to be taken to hospital. Astromélia (71), from Recife has been a widow for 14 years. Her depression dates back to the successive loss of three children in the same year: it's a pain that is just indescribable. Her ideations express themselves by self-neglect: I thought that by not eating, not sleeping, not taking my medicines, my life would end, finish peacefully, without bothering anyone.

Margarida (73), from Piripiri, mother of ten children, lost her husband in an accident when the children were little. She now lives with a son who is a compulsive drinker, feeling fear and despair, and suffers from severe depression: The distress of living alone, just us two together, is very sad. She tried to hang herself. Gardenia (83), from Piripiri, a widow, mother of ten children, suffered postpartum depression and physical abuse by her husband. A daughter lives in what was her house and she sleeps in her grandson's room: I lost my place, I feel put out by that. She is in a deep depression and has made four attempts by drug overdose: it's an empty life! Dissatisfied with life. It was the illness [depression] and having all those children! Her depression has been pathological since the birth of the children and today, at an advanced age, she is at severe risk of suicide.

Palma (65), from Porto Alegre, was married to an alcoholic, jealous and aggressive husband: I lived that life for 33 years, suffering. Her first depressive crisis came about two years after the marital separation and when her children left home: I cried a lot, I didn't want to do anything any more. I lost the will to live. She tried to kill herself by taking medicine and self-mutilation and has severe ideations. I want to disappear, walking with no destination or be torn to pieces by a fierce dog. Tulipa (74), from Venâncio Aires, survived the death by suicide of a young son. The other son no longer talks to her, only her daughters give her any attention. Her trajectory was also affected by the violence of the husband from whom she separated and by the loss of her job, as she was retired for disability at the age of 40, and the loss of her home. She attempted suicide by hanging, six months after her son's death. She is in deep depression.

Amaralis's case is closely related to separations and losses. She made five attempts by drug overdose: In the attempts, I felt that I was the worst mother, the worst wife and that I should have stayed with him [her husband who abused her]. That's when the depression started. She explained that the first attempt was due to the overload of responsibilities for caring and providing for her children, after the separation. She attributes the second to the fact that the children had left home: Separation from the children was a blow for me. The third was due to the distress over the breakdown of her daughter's marriage and the fear that her return to the maternal home would overload her. I felt so angry that I wanted to kill my daughter and the grand daughters. The fourth followed her son's divorce. The fifth, contradictorily, came after good news, when she unexpectedly received a significant indemnity for length of service. Off-balance, she cried: No, this isn't mine, I don't think I deserve it.

The burden of chronic illnesses, disabilities and comorbidities - There are nineteen cases, nine among men and ten among women, in which chronic illnesses and disabilities were the main factors associated with the suicidal behavior. Two are commented on per sex.

Crisântemo (71), from Fortaleza, married and retired from the military, lives in an old people's home, although he has six children. He has suffered an infarct, a cerebrovascular accident, has had three coronary by-passes and even went blind for six months as a result of diabetes. He is hospitalized against his wishes and does not accept the progressive limitations of old age and his illnesses: I don't accept being labeled an old person. I shall go on living only for as long as I can take care of myself, and when I can no longer manage, I'll blow out the candle. He has already had many ideations about killing himself by drug overdose and bladed weapon. Alecrim (84), from Recife, a retired retailer, started to suffer a lot after a thrombosis in his leg: he complains of pain 24 hours a day: The pain is just too bad. I feel my life is useless and want to die. I don't like living the life I have today. He has attempted suicide by poisoning more than once and explains: I did it because I became desperate, because nobody believes in my pain.

Angélica (60), from Rio de Janeiro, suffered sexual abuse in her infancy and severe physical abuse by her husband for nine years She became pregnant five times and lost all the babies. Separated, she returned to my mother's house, living among a load of people caught up in altercations and shortages. A stroke restricted her mobility. Today she is in a shelter. She has attempted suicide by poisoning a few times and planned to get herself run over: I waited for an hour and a half, but no big car came along to kill me. She lists the reasons for wanting to die: sadness about the family, seeing myself rejected.

Acácia (82), from Recife, worked on a farm, and in the city, as a trash picker. She has lived through many losses: four years ago, God took my old man. I also lost a son in an accident and two brothers, one due to cachaça [cane alcohol] and the other from cancer. She developed diabetes, Alzheimer's disease and labyrinthitis, as well as nerve disease. She has made three attempts to kill herself, each more severe than the previous one: two by drug overdose and another by throwing herself in front of a car. She continues to have intense ideations: desire to disappear. I think about dying every day.

Association with the abusive use of alcohol and other drugs – There are eight cases, six of men and two of women, in which the abuse of alcohol and other drugs is associated with suicidal behavior. The situations of the four men and two women who best represent this group are presented

Lisianto (60), from Rio de Janeiro, a musician, became a marijuana and cocaine addict and his life went off the rails: he lost his job in an information technology store and became demoralized. He lost his wife and son and went to live in the streets. He met people in a Spiritualist Centre who helped him to reduce his drug consumption. In this process, he had severe ideations: throwing himself off a high place or under a train. Tango (69), from Rio de Janeiro, used to drink a lot, separated from his wife and wound up in the streets. This started his career of institutionalization. He survived a shelter in which many elderly people died. He was transferred to a psychiatric hospital and has been living in a shelter for five years, where he plays music and tries to live better. He is treated for hypertension, diabetes and depression and frequents the Pinel Hospital: I managed to stop drinking and I like myself better. He has minor suicidal ideations, as follows: I'm going to die and end all this once and for all. Monsenhor (74), from Rio de Janeiro, worked as a civil servant and driver. He was a compulsive drinker. He has already been placed in three old people's homes. He has cirrhosis, hypertension, glaucoma and cataracts and says that he deserves to be punished for the life he led. He has frequent suicidal thoughts: caustic soda, which is quick and easy. This is a private matter. Of course my life is over. There's no such thing as Sunday, Monday, Christmas any more, it's all the same for me.

Gerânio (73), from Santa Cruz do Sul, a farmer and tobacco industry worker, lives with his wife. He has reduced mobility as a result of a serious traffic excellent caused by drunken driving. He says he is aware that he is addicted and currently takes care of himself for his little granddaughter's sake: I picked my little granddaughter up and fell down with her, out front there. It did something to my head when I saw her bleeding. That's when I told myself that I'm nobody anymore! I had some poison there, I picked it up and took it. Lírio (65), from Santa Cruz do Sul, was left a widow with three children. Her husband died as a result of an electric shock. She sold land and sorted herself out with the help of her maternal family. She had a second marriage to a man who was a compulsive drinker and violent. The response to her suffering was an attempt to hang herself. The neighbors saved her in time, but it weakened her. She separated and says: Now I take care of my mother and my house, sometimes of my grandchildren and I still plant all kinds of things.

Iris (74), from Recife, worked on a farm, and in the capital, as a domestic servant. Married to a retailer, her happiness came from having put seven children through further education. However, her husband was an alcoholic, abused her and cheated on her: the children grew up, married and abandoned me, they don't phone, no one ever comes to take me out. What upsets me most is not having my own space, my house. I let my children sell my little houses and lost my home. Her first attempted suicide coincided with her children leaving home: I didn't plan it much, one day I woke up and thought: ‘I don't want to live’. I went and bought rat poison and took it. It was during the week, everyone had left the house to go to work. That was already 10 years ago. Today, she's the one who drinks: I drink a little every day to forget my problems and life's sorrows. My daughter already tried to take me to AA and to the Psychosocial Alcohol and Drugs Care Center - (Centro de Atenção Psicossocial Álcool e Drogas - CAPS Ad), but I didn't like it. I think you have to have a reason in order to stop drinking, and I don't have one.

Cycle of violence and suicidal behavior – Eight cases were considered, two of men and two of women, in which the impact of violence between generations was the main evidence associated with suicidal ideations and acts. One male and three females who best represent this group are presented here.

Narciso (66), from Manaus, married, three children, was a teacher, taxi driver and businessman. Today he works as a driver and facilitator. He comes from a poor family, prospered and achieved power. However relationships at home were always marked by rivalry, aggression, physical and verbal violence, reproducing what he had experienced in his own family. One of his children killed themselves with a firearm. He first phoned his father and told him: ‘I'm not killing myself, you're killing me. Narciso recounts: when I got there my son was lying on the ground with a gun under his head. After his death, the whole family lost control, it was destroyed. Now it is Narciso who is at risk of suicide: I'm going to do something stupid one day, I've already told them [his family].

Amarilis (65), whose story has already been mentioned, had her whole life marked by her father, husband and son in law's alcoholism and by physical and psychological violence in infancy. Retaliation by her ex-husband after the separation caused her to change States, to hide, to protect the children. She has already tried to kill herself five times by drug overdose. The cases of Camélia (66), from Candelária, Hortênsia (74), from Manaus and Beladona (75), from Campo Grande confirm that the repetition of conjugal violence and violence in the life-cycle are associated with suicidal behavior.

It is important to stress that in some cases studied, the desire for death appears sporadically in the face of difficulties and being tired of life. This is the case for Jardim, aged 74, from Dourados, a widower for 10 years. He has been diagnosed with Alzheimer's and is cared for by one of his daughters. These days I'm sad, silent, I'm already old and I have to die, I'm no use for anything any more. I'm tired of life and I'm waiting to die. Equally, Dona Rosa, from Dourados, who's 101, lost heart after she lost her daughter from cancer: I feel sadness, or the daughter who died, I'm already old, I should have gone before her. I'm very sad and I pray.

Discussion

More than being a question of death, above all, suicide speaks of life: it takes it to the limit, charges it for what has been done or not done and causes reflection on consequences and responsibilities. For these reasons it is a highly complex subject which is seen to be transversal to through those of accidents, violence, sickness, the abuse of alcohol and other drugs and mental disturbances. In old age, it evokes affective and social problems and rifts that ran through the subject in childhood, adolescence, youth and adult life. Paradoxically, at the end of life, the attempt to kill oneself can become a controller of anguish, revealing the personal limitation in processing the suffering experienced. Much suicidal behavior becomes aggravated as it is repeated and causes deaths and after-effects When they intensify, the ideations qualitatively increase the risk of suicide and, in old age, as has been noted in this study, they can also emerge in the form of self-neglect.

Suicidal attempts and ideations among elderly people are a phenomenon that is difficult to enumerate in its empirical manifestation, but that can be quantified from the viewpoint of the diversity of means and manifestations throughout the life cycle. This approach enables a qualitative and critical insight into the cases, within a hierarchy of variables by causal nexus contextualized in the biography and life in society, according to explanations by the elderly individuals themselves.

The study shows how the various factors that provoke suicidal behavior fit together. All the reasons recounted here by the elderly people, whether for either trying to kill themselves or for wishing for death or allowing themselves to die, have been encountered in the literature²2. Minayo MCS, Cavalcante FG. Tentativa de suicídio entre idosos: revisão de literatura (2002-2013) Cien Saude Colet 2015; 20(6):1751-1762.–¹⁰10. Sommers-Flanagan J, Sommers-Flanagan R. Intake interviewing with suicidal patients: A systematic approach. Professional Psychology: Research and Practice, 1995; 26(1):41-47.;¹⁷17. Cavalcante FG, Minayo MCS. Autópsias psicológicas e psicossociais de idosos que morreram por suicídio no Brasil. Cien Saude Colet 2012; 17(8):2039-2052.–²⁰20. May AM, Klonsky ED, Klein DN. Predicting future suicide attempts among depressed suicide ideators: A 10 year longitudinal study. J Psychiatr Res 2012; 46(7):946-952.. What most set the cases apart was the question of gender, in terms of severity, the means used and the associated factors. Apart from the fact that the most serious occurrences of attempts and ideations were encountered in the north east and the south, the reasons given by the elderly individuals for attempting to take their life were similar in the thirteen locations studied.

Depression as primary or secondary causality or as an effect of abandonment, family, personal and financial losses, incapacitating and painful illnesses, psychiatric suffering, and violence, is the most expressive factor in a significant number of cases, due to the emptiness, discomfort and feeling of uselessness that it causes. However, in effect, it is present as pain and sadness in almost all the stories studied and associated with the multiple causalities already mentioned.

In the cases of violence, current repercussions were encountered of physical, psychological and sexual ill-treatment and neglect that had occurred throughout life. These problems are exacerbated in old age, above all in cases of depending on others and in the form of abandonment, loneliness, neglect and economic-financial abuses.

Traffic accidents appear in an association with suicide - in an unusual and little-known fashion - as they were intentionally provoked as a suicidal act Even though in the cases studied they did not result in the death of the elderly person, there were aggravations and after-effects for them and the death of others. This way of seeking death throws the blame onto others and depletes the elderly individual's responsibility. Traffic accidents (frequently associated with alcohol) also appear as a result of post-traumatic stress in the case of the survivors²¹21. Shneidman ES. A Commonsense book of death. Refections at Ninety of a Lifelong Thanatologist. Oxford: University Press; 2008. when, feeling great desperation at the loss of a relation, they became at risk of suicide and got involved in accidents. In the majority of cases, elderly individuals who caused traffic accidents resulting in death and harm to others were not treated and developed various types of after-effects which put them today at progressive risk of suicide. Accordingly, both accidents and their effects may turn into suicide risks, as they may themselves be a suicidal act, as reported in this study.

It was important to hear the elderly people¹¹11. Minayo MCS. Análise qualitativa: teoria, passos e fidedignidade. Cien Saude Colet 2012; 17(3):621-626., subjects of the reasons for speeding up the end.

The relevance of their words confirms what a number of studies worldwide have been showing: suicidal behavior manifests itself in the existential dynamics and in the suffering they see as unbearable. On one side, a feeling of the lack of a significant place, either in their families or in social life, draws our attention. On another, the lack of acceptance by many of them of the progressive restrictions, of the sensory reduction or reduced mobility that this implies. In turn, chronic physical and mental illnesses and disabilities may result from inadequate health care – which in general aggravates them - or the impact of loss and violence, crossed through by comorbidities²²22. Osgood NJ. Suicide in the elderly: a practitioners guide to diagnosis and mental health intervention. Rockville: Aspen Systems Corporation; 1985.,²³23. Canetto SS. Women and suicidal behavior: a cultural analysis. Am J Orthopsychiatry 2008; 78(2):259-266.. For many people, such situations become suicide risks. Finally, it must be remembered that, based on evidence, the World Health Organization has produced a number of primary and secondary prevention manuals, which are at the disposal of professionals and family members, and these include SUPRE-MISS²⁴24. Organização Mundial de Saúde. Manual de Prevenção Primária do Suicídio. [acessado 2015 abr 15]. Disponí-vel em: http://whqlibdoc.who.int/publications/2000/WHO_MNH_MBD_00.4_por.pdf
http://whqlibdoc.who.int/publications/20... .

Final considerations

Although in this article it has not been possible to look in depth at questions of prevention, the conversations with the elderly people themselves, their family members and health professionals who participate in the care provided to them, show that certain initiatives work as protective factors. Highlights among these are (1) prolonging to the maximum the elderly people's activities and relationships with the family, the community and their social nucleus. They need to feel alive and useful and this is the best preventive treatment. (2) Instructing family members and informal and professional carers about the aging questions that result in suicidal behavior, to assist them in preventing them. (3) Arranging for psychological treatment and, if necessary, medications for those who have persistent ideations or have already tried to end their own life. (4) As the number of elderly people tends to increase exponentially in Brazil, it is important to pay particular attention to the oldest and most dependent of the elderly, considered today, throughout the world as those most vulnerable to suicide. (5) The health and care networks, in general, are prepared to medicate an attempted suicide, but not to identify and treat the signs and risks and prevent the act.

From the stories told by the elderly people, it was noted that the most successful care has been that which has their compliance and that of the family, community and religious network and the support of health professionals and services. The more diversified the network that supports them, the better the support and the rebuilding of lives at risk. However, more than medicating them – and this has to be done where necessary – it is essential to ensure that they can lead this last stage of their lives calmly and lightly.

Acknowledgments

We thank CNPq and FAPERJ/CEPE for their support.

References

Publication Dates

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