INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2003; 18: 1082–1087.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/gps.1012

Gender in elderly suicide: analysis of coroners inquests

of 200 cases of elderly suicide in Cheshire 1989–2001
Emad Salib1,2* and Laura Green2
1
Liverpool University, Liverpool, UK
2
Hollins Park Hospital, Warrington, UK

SUMMARY
Objectives The aim of this study is to review gender differences in elderly suicide in relation to specific social aspects of
the suicidal process and health care contact before death. Such information may have practical value in identifying and
targeting vulnerable elderly in whom suicide may be potentially preventable.
Methods Data were extracted from the records of coroner’s inquests into all reported suicide of persons aged 60 and over,
in Cheshire over a period of 13 years 1989–2001. The Coroner’s office covers the whole county of Cheshire (population
1 000 000).
Results Men were less likely to have been known to psychiatric services (Odds Ratio [OR] 0.4 95% 0.2–0.6) and with less
frequently reported history of previous attempted suicide compared to women (OR 0.5 95% Confidence Intervals [CI] 0.2–
1). All deceased from ethnic minorities were men, none of whom had been known to psychiatric services. There was no
significant difference between women and men in relation to, physical or psychiatric morbidity, GP contact prior to suicide,
intimation of intent or living alone. Of suicide victims not known to services a surprisingly high proportion of 38% and 16%
were found to have psychiatric morbidity in men and women respectively.
Conclusion Suicide is an important problem in the elderly with gender playing an important part in their social behaviour
but a high proportion of the deceased were not known to local services. Primary Care professionals have an important role to
play in reducing elderly suicide as most contact with the health service in elderly suicide seem to be with GPs. Copyright #
2003 John Wiley & Sons, Ltd.

key words — elderly suicide; sex in elderly suicide; gender in elderly suicide; utilization of psychiatric service in elderly
suicide; primary care in elderly suicide

INTRODUCTION 1999; Harwood and Jacoby, 2000). Men are at higher

Risk factors that contribute to elderly suicide include:
age and male sex; physical illness; social isolation;
widowed status and psychiatric disorder (Barra-
clough, 1971; Lindesay, 1991; Cattell and Jolley,
1995; Baldwin, 1997; Harwood and Jacoby, 2000).
Gender differences in general suicidal behaviour have
been confirmed (Hawton, 2000; Qin et al., 2000).
Elderly males have higher suicide rates than elderly
females (Breed and Huffine, 1972; Cattell, 1988;
Conwell et al., 1991; Cattell and Jolly, 1995; Quan,
* Correspondence to: E. Salib, 18 Broughton Close, Appleton,
Warrington, Cheshire WA4 3DR, UK.
E-mail: katie.spencer@5boroughspartnership.nhs.uk
Copyright # 2003 John Wiley & Sons, Ltd.
risk of suicide following death of a spouse than
women (Bock and Webber, 1972; Cattell and Jolley,
1995; Li, 1995; Harwood and Jacob, 2000) and it
has been indicated that social isolation is a risk factor
for elderly men (Bock and Webber, 1972). However,
the problem of differentiating between social isola-
tion and living alone has proved difficult (Harwood
et al., 2000). Older women are more likely to be liv-
ing alone but less likely to be suicidal than older men
(Hess, 1990; Canetto, 1992). However, whether there
is actually an association between the two with
women living alone being at lower risk of suicide
remains unclear (Shah and De, 1998). A Japanese
study found many elderly people exhibiting subclini-
cal depressive states with recurring thoughts of
Received 24 March 2003
Accepted 27 August 2003
 gender in elderly suicide
suicide but very few who consulted family members,
professionals or others regarding this (Ono et al.,
2001). GP contact prior to death tends to be relatively
high prior to elderly suicide in relation to physical
complaints or recent ill health but with no overt
psychiatric difficulties evident in the consultation
(Barraclough, 1987). Conwell and Duberstein (2001)
found that another group of elders at high risk of sui-
cide are those with no active contact with primary
care at all. Contact with mental health services tends
to be low, in particular in elderly male suicide (Con-
well et al., 1996). It may be possible to assume that
elderly women may be at lower risk of suicide than
men due to their ability to access the appropriate treat-
ment for psychiatric problems (Canetto, 1992). Males
tend to use violent methods compared to women
(Barraclough, 1971; Lindesay, 1991; Cattell and Jolly,
1995; Harwood and Jacoby, 2000; Harwood et al.,
2001) and are more likely to succeed in their first
attempt (Salib et al., 2001b). It has also been demon-
strated that method chosen may be influenced by
familiarity and access to different methods (McIntosh
and Santos, 1986). The aim of this study is to review
gender differences in elderly suicide in relation to
specific social aspects of the suicidal process and
health care contact before death.
The findings are interpreted and compared to the
available literature on suicide in the elderly.
METHOD
Data were extracted from the records of coroner’s
inquests into all unexpected deaths of persons aged
60 and over, in Cheshire over a period of 13 years:
1989–2001.
The Coroner’s office of Cheshire is based at War-
rington and covers the whole county of Cheshire
(population 1,000,000).
As a proportion of open verdicts may be wrongly
included in suicide rate data (Salib et al., 2001a),
inclusion of all non-suicide verdicts, such as open ver-
dicts, or to selectively include some verdicts other
than suicide (Harwood et al., 2001) may result in
selection bias. In order to avoid this selection bias this
study included suicide verdicts only. Verdicts of acci-
dental death, misadventure and open verdicts were
excluded. A standard form was designed and used
to extract the data from the inquests’ files consistently
for the whole sample. Information recorded for all
cases included: demographic details; method of
death; circumstances leading to the death; previous
history of psychiatric and physical morbidity; social
isolation and evidence of intent. Two main categories
Copyright # 2003 John Wiley & Sons, Ltd.
1083
of suicide will be referred to in the text: (1) non-vio-
lent death which included: E950 ¼ Self-poisoning by
solid or liquid; E951 ¼ Gas in domestic use and
E952 ¼ Other gases and vapour and (2) violent death
which included all methods other than self poisoning:
E953 ¼ Hanging, strangulation and suffocation;
E954 ¼ Drowning: E955 ¼ Firearms and explosives;
E956 ¼ cutting or piercing instruments; E957 ¼
Jumping from high place; E958 ¼ Other methods.
SPSS was used in the statistical analysis and cross
tabulation to compute odds ratios (OR) and p-values.
RESULTS
The study included 200 suicide verdicts recorded by
the Cheshire coroner between 1989 and 2001 of per-
sons aged 60 and above within the County of Che-
shire. Mean age for the entire sample was 71 years
(SD ¼ 8, range 60–86); 117 (58.5%) of the sample
were men and 83 (41.5%) were women with mean
ages of 70 (SD ¼ 7) and 74 (SD ¼ 8) respectively.
The distribution of the main study variables by gender
are presented in Table 1. Statistically significant asso-
ciation with gender was found in marital status,
whether deceased were previously known to local
psychiatric services and history of DSH.
The low rate of widowed men at 30% compared to
54% widowed women may simply reflect the longer
survival of women and have no other specific signifi-
cance. Men were less likely to have been known to
psychiatric services (OR ¼ 0.4 95% 0.2–0.6
p < 0.05) and less likely to have attempted suicide
before compared to women (OR ¼ 0.5 95%
CI ¼ 0.2–1 p ¼ 0.06). All deceased from ethnic mino-
rities were men. There was no significant difference
between women and men in respect of; physical or
psychiatric morbidity, GP contact prior to suicide,
intimation of intent or living alone. The positive asso-
ciation between male sex and using violent means as
defined in the methods section is in keeping with
other studies. However, the unexpected higher rate
of violent suicide in women (48%) in this sample
may have resulted from the inclusion of suicide ver-
dicts only.
Table 2 deals with gender difference in deceased
elderly in respect of history of DSH. 80% of suicides
succeeded at the first attempt. Those succeeding at
second or subsequent attempts were more likely to
have suffered enduring physical illness prior to death
and this especially applied to men. In this study living
alone and being widowed prior to death at first
attempt especially applied to women. More men
saw their GP prior to death if they had attempted self
Int J Geriatr Psychiatry 2003; 18: 1082–1087.
1084 e. salib and l. green

Table 1. Sex in elderly suicide elderly suicide victims with a history of previous
Male n ¼ 117 Female n ¼ 83 attempts. However, those who were known were more
(58.5%) n (%) (41.5%) n (%) often women, especially those who succeeded on first
attempt, perhaps because they are more likely to seek
Intimation of intent help than men. Table 3 also shows that of those not
Yes 61 (52%) 40 (48%)
No 56 (48%) 43 (82%) known to the local service, 55% of men and 74% of
OR 1.2 95% CI 0.7–2 women were living alone. Considerably fewer
Marital status widowed elderly were known to local services prior
Widowed 35 (30%) 45 (54%) to suicide compared to the married group regardless
Other 82 (70%) 38 (46%)
OR 0.4 95% CI 0.2–0.6
of their gender. Nearly half of those not known to
Living alone the local service did not have GP contact during the
Yes 58 (50%) 48 (58%) 3 months prior to committing suicide. Of the elderly
No 59 (50%) 35 (42%) deceased who were not known to local services, 38%
OR 0.7 95% CI 0.7–1.3 of men and 16% of women were reported by family
Children
No 43 (37%) 27 (33%) members and friends to have displayed some evi-
Yes 74 (63%) 56 (67%) dence of psychiatric morbidity before suicide. Of
OR 1.2 95% CI 0.6–2.2 those known to the local service, significantly more
Known to services men saw their GPs prior to death and overall those
Yes 23 (20%) 34 (41%)
No 94 (80%) 49 (59%)
known to services were more likely to use a violent
OR 0.4 95% CI 0.2–0.7 method of death than those not known. A history of
Method of suicide DSH was more common in those known to services
Violent suicide 69 (59%) 40 (48%) overall but of those not known to services more
Non-violent suicide 48 (41%) 43 (52%) women had evidence of previous self harm. Table 4
OR 1.5 95% CI 0.9–2.7
Previous attempts reiterates that men known to services were more
Yes 18 (15%) 21 (25%) likely to see their GP, have previous psychiatric mor-
No 99 (85%) 62 (75%) bidity and evidence of DSH prior to death. Those not
OR 0.5 95% CI 0.2–1 known to services were more likely to live alone, be
History of recent ill
health & GP contact
widowed and show evidence of intent. Known women
Yes 56 (48%) 44 (53%) were more likely to use a violent method, have psy-
No 61 (52%) 39 (47%) chiatric morbidity and previous DSH than those not
OR 0.8 95% CI 0.8–1.4 known to services. Those not known were more likely
Ethnic origin to live alone, be widowed, have no children and show
White 111 (95%) 83 (100%)
Other 6 (5%) evidence of intent.
Psychiatric morbidity
Yes 57 (49%) 42 (51%)
No 60 (51%) 41 (49%) DISCUSSION
OR 1 95% CI 0.5–1.6
1. Interpretation of findings
In this study, the proportion of male suicides was
harm before than either women or men who suc- higher than the female suicides but only by approxi-
ceeded at first attempt. Men who succeeded on first mately 17%. This may be, at least partly, due to the
attempt were more likely to use violent means, in effect of excluding verdicts other than suicide in the
keeping with previous literature, compared with data collection. Henriksson et al. (1995) and Conwell
women succeeding at first attempt. Of those succeed- et al. (1996) have shown that suicide rates for elderly
ing on second or subsequent attempt, more women men are twice those for women. Harwood et al.
used violent methods, perhaps reflecting increased (2001) also demonstrated this marked male predomi-
levels of mental ill health. nance of two to one amongst older suicide victims.
Gender differences in relation to whether the However, other British studies by Cattell (1988) and
deceased were known or not to local psychiatric ser- Cattell and Jolley (1995) showed similar proportions
vices are presented in Table 3. Of those not known to for the two sexes. This may be partly explained by the
the local service 89% of men and 80% of women had changing rates of suicide in men and women, with a
no previous suicide attempt which may be indicative greater fall in rates of suicide in older women than
of the lethality of attempts hence the low number of older men during the last 15 years (Kelly and Bunting,

Copyright # 2003 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2003; 18: 1082–1087.
 gender in elderly suicide 1085

Table 2. History of DSH and Gender in elderly suicide in Cheshire 1989–2001

History of DSH 39 (20%) No history of DSH 161 (80%)
mean age 70 (SD 8) mean age 74 (SD 9)

Male 18 Female 21 Male 99 Female 62

mean age 68 mean age 73
2 p-value mean age 73 mean age 75
2 p-value

Living alone
Yes 8 (44%) 9 (43%) 0.01 0.92 50 (50%) 39 (63%) 2.14 0.14
Marital status
Widowed 5 (28%) 9 (43%) 0.96 0.34 30 (30%) 36 (58%) 12.14 <0.001
Children
No children 6 (33%) 2 (10%) 2.33 0.13 37 (37%) 25 (40%) 0.14 0.71
GP contact
Yes 14 (78%) 12 (57%) 1.86 0.17 42 (42%) 32 (52%) 1.30 0.23
Method
Violent 10 (56%) 13 (62%) 0.16 0.67 59 (60%) 27 (43%) 3.95 0.05
Evidence of intent
Yes 8 (44%) 8 (38%) 0.16 0.67 53 (53%) 32 (52%) 0.01 0.91
Psychiatric morbidity
Yes 13 (72%) 16 (76%) 0.05 0.83 62 (63%) 36 (58%) 0.33 0.56
Physical morbidity of
Yes 14 (78%) 13 (62%) 1.15 0.28 43 (43%) 29 (46%) 0.17 0.68
Known to services
Yes 8 (44%) 11 (52%) 0.24 0.62 15 (15%) 23 (37%) 10.18 0.001

Table 3. Gender differences in elderly suicide who were known and unknown to local psychiatric services in Cheshire 1989–2001
Known to services 57 (28.5%) Not known to services 143 (71.5%)
mean age 69 (SD 7) mean age 74 (SD 9)

Male Female Male Female

23 (40%) 34 (60%) 94 (66%) 49 (34%)
mean age 68 mean age 70
2 p-value mean age 72 mean age 78
2 p-value

Living alone
Yes 6 (26%) 12 (35%) 0.54 0.46 52 (55%) 36 (74%) 4.48 0.03
Marital status
Widowed 2 (9%) 33 (35%) 5.24 0.02 11 (12%) 34 (69%) 18.29 <0.001
Children
No children 10 (44%) 5 (15%) 5.86 0.02 33 (35%) 22 (45%) 1.30 0.25
GP contact
Yes 18 (78%) 19 (56%) 3.02 0.08 38 (40%) 25 (51%) 1.47 0.23
Method
Violent 15 (65%) 22 (65%) — — 54 (57%) 18 (37%) 5.53 0.02
Evidence of intent
Yes 6 (26%) 12 (35%) 0.54 0.46 55 (58%) 28 (57%) 0.02 0.88
Psychiatric morbidity
Yes 21 (91%) 34 (100%) — — 36 (38%) 8 (16%) 7.30 0.001
History of DSH
Yes 8 (35%) 11 (32%) 0.04 0.85 10 (11%) 10 (20%) 2.56 0.11

1998). Women have a greater ability to cope with
changes ageing may bring and their increased flexibil-
ity to cope is due to experience of changing circum-
stances during life, e.g. the changes experienced
during child bearing and the different stages of child
development. In contrast (Breed and Huffine, 1979),
men are thought to gain less experience of change
with their development though adult life following a
more stable course. As a result, they may be less able
to cope with the age-related mental, physical and
social changes and thus are at higher risk of suicide
(Breed and Huffine, 1979). The study found that a

Copyright # 2003 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2003; 18: 1082–1087.
1086 e. salib and l. green

Table 4. Gender differences in elderly suicide in relation to local services

Males Females

Known Not known Known Not known

23 94
2 p-value 34 94
2 p-value

Living alone
Yes 6 (26%) 52 (55%) 6.32 0.01 12 (35%) 36 (74%) 12.0 <0.001
Marital status
Widowed 2 (9%) 11 (12%) 5.01 <0.05 12 (35%) 34 (69%) 9.44 <0.001
Children
No children 10 (44%) 33 (35%) 0.56 0.05 5 (15%) 22 (45%) 8.34 <0.01
GP contact
Yes 18 (78%) 38 (40%) 10.6 <0.01 15 (56%) 25 (51%) 0.19 0.66
Method
Violent 15 (65%) 54 (57%) 0.46 0.48 22 (65%) 18 (37%) 6.29 0.01
Evidence of intent
Yes 6 (26%) 55 (58%) 7.78 <0.01 12 (35%) 28 (57%) 3.84 0.05
Psychiatric morbidity
Yes 21 (91%) 36 (38%) 20.78 <0.001 34 (100%) 8 (16%) 56.22 <0.001
History of DSH
Yes 8 (35%) 10 (11%) 7.08 <0.001 11 (32%) 10 (20%) 1.52 0.22

significantly higher proportion of widowed men were
not previously known to the services. The risk of sui-
cide has been reported to be high in widowed men
(Bock and Webber, 1972; Cattell and Jolly, 1995; Li,
1995; Harwood and Jacob, 2000) but also as an equal
factor risk for men and women (Meehan et al., 1991;
Karipo et al., 1987; Kreitman, 1988). It may be of
interest, in light of this study, that widowhood in
elderly suicide as a risk factor is revisited in relation
to whether they were known to psychiatric services
and not just as a social risk factor. The study found
no significant gender difference in childlessness in
elderly suicide victims which may imply that the pro-
tective effect of having children appears to diminish in
old age. The lack of evidence for the protective effect
of child bearing for elderly women in terms of suicide
risk (Appleby, 1996; Catalan, 2000; Quin, 2000) is not
surprising and could be explained by loss of maternal
role due to children growing up and moving away
from home. Of those not known to service, nearly half
of men and women did not have GP contact in the 3
months prior to committing suicide. A large propor-
tion of suicide victims having no contact with any
health services prior to the event. Consequently it will
be impossible to reduce suicide rates without active
identification and targeting of these people. It is evi-
dent that men in particular are an important target
group with half not being seen by the health services
prior to suicide. Of suicide victims not known to ser-
vices, a surprisingly high proportion of 38% and 16%
in men and women respectively were found to have
psychiatric morbidity as reported by family members
and friends during coroner’s inquest. This is an unex-
pectedly high percentage considering the fact that
depression is one of risk factors of suicide in the
elderly (Cattell and Jolley, 1995; Conwell et al.,
1996; Shah and De, 1998). The only effective way to
reduce suicide rates is to actively take the health ser-
vice to those people, e.g. by using of outreach pro-
grammes. Reaching vulnerable elderly people who
do not use local services and are at risk of suicidal
behaviour must be given high priority, as it appears
they are likely to succeed at a first suicide attempt.
GPs have an important role to play in reducing elderly
suicide as most contact with the health service by the
elderly is with GPs (Vassilas and Morgan, 1994). Spe-
cific postgraduate teaching designed to help detection
and treatment of depression has been shown to reduce
elderly suicide (Rutz et al., 1992) and may be of use in
elderly suicide prevention.
LIMITATIONS OF THE STUDY
The main limitations of this study include the small
sample size and limited duration of data collection,
which may reduce its statistical impact. It was also
difficult to collect information about the circum-
stances surrounding elderly suicide and to obtain
GP psychiatric records.
The collected suicide data came from one county,
Cheshire, which may not be representative of the
whole elderly population of the UK. The study did
not also exclude the interaction between age, cohort
and period effect.

Copyright # 2003 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2003; 18: 1082–1087.
 gender in elderly suicide
KEY POINTS
* Suicide is an important problem in the
elderly with gender playing an important part
in their social behaviour but a high proportion
of the deceased were not known to local
services.
* Men were less likely to have been known to
psychiatric services and with less frequently
reported history of previous attempted suicide
compared to women.
* All deceased from ethnic minorities were men,
none of whom were known to psychiatric
services.
* Of suicide victims not known to psychiatric
services a surprisingly high proportion of 38%
and 16% in men and women respectively were
found to have psychiatric morbidity.
* Primary Care professionals have an important
role to play in reducing elderly suicide as most
contact with the health service in elderly suicide
seem to be with General Practitioners.
ACKNOWLEDGEMENT
The authors are grateful to Miss Katie Spencer and
Mrs Emma Jones at Beckett Day Unit, Hollins Park
Hospital for their help in preparing the manuscript.
Thanks also to Sheila Cawley and Bernadett Hayes,
Hollins Park for their support.
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