Background

According to the World Health Organization (WHO), violence is "the intentional use of physical force or power, in fact or as a threat, against oneself, another person or a group or community, that causes or is highly likely to cause injury, death, psychological harm, mental health of development or deprivation" (^{Krug et al., 2002}). Therefore, voluntarily attacking oneself constitutes a form of violence and typifies conduct (suicidal behavior) understood as "the diversity of behaviors that includes thinking about suicide (or suicidal behavior), planning suicide, attempting suicide, and committing suicide itself" (^{World Health Organization, 2014}).

The WHO in 1976 defined suicide as "any act by which an individual causes him or herself injury, or harm, with a varying degree of intent to die, whatever the cause, degree of lethal intent or knowledge of true motive" (^{Montes de Oca y Rodríguez, 2019}). Currently, approximately 700,000 individuals take their own lives each year, but a greater number attempt it, and many more have suicidal thoughts, (^{WHO, 2023}), making it a public health problem (^OMS,2021b; ^{WHO, 2021a}) that could be prevented through joint public health actions (^{De Leo & Arnautovska, 2019}; ^{Nie et al., 2020}; ^{Zeppegno et al., 2019}).

In Colombia, the definition is a diversity of behaviors that include thinking about suicide (suicidal ideation), planning suicide, attempting suicide, and committing suicide itself (^{Harm et al. , 2024}; ^{Ministerio de Salud y Protección Social, 2018}; ^{Pan American Health Organization, 2006}; ^{Pérez, 1999}). A suicide attempt is a self-injurious behavior with a non-fatal outcome accompanied by implicit evidence that the person intends to die (^{Desalegn et al. , 2020}), which is self-inflicted, initiated and performed by an individual with the use of different methods, without the intervention of others, and a fatal outcome (^{Harm et al. , 2024}). The attempts are considered the main risk factor for completed suicide (^{Crosby et al., 2011}; ^{Rendón y Rodríguez, 2016}). The DSM-V recognizes suicidal behavior disorder in individuals who commit at least one suicide attempt in a period not exceeding 24 months and is not instrumentalized for any political or religious purpose (^{American Psychiatric Association, 2013}). Depressive disorders, use of psychoactive substances, loss of family and friends, and personality have been considered risk factors for committing an act. suicide in the general population (^{Velásquez, 2013}).

Although suicide affects all population groups mainly young people, an increase in suicidal behavior has recently been observed in the elderly population (60 years and over), establishing the need for decision-makers to explore personal, family, community, and social environments (^{Stone et al. , 2017}).

Regarding gender, rates are higher among older males than in any other demographic group (^{Cui & Fiske, 2020}). In the United States, the suicide rate for white men is 48.7 per 100,000 which is four times greater than the country's adjusted rate (^{Conejero et al., 2018}). Moreover, ^{Hu et al., (2020)} reported a meta-analysis involving ii,526 adults found a prevalence of suicidal behavior in elders living in rural areas between ii.5% and 21.5 in China, with those over 65 having the highest rate of completed suicide (44.3 per hundred thousand).

The most prevalent suicidal risk factors reported include age (major 45), impulsiveness, adverse life events, gender (males), widowed, separated, or divorced, living alone, unemployed, retired, family history, previous attempts, poor physical health, presence of firearms at home and mental illness (^{Minsalud, 2018}). After the COVID-19 pandemic, other risk factors increased such as social isolation, loss of job, relatives or social networks, as well as economic and productive downfall (^{Banerjee & Rai, 2020}).

Suicide is classified in different ways: completed (when the objective is achieved), frustrated (due to inexperience, rapid intervention by medical, family, or community services, or chance (^{Echeburúa, 2015}). In the elderly, suicide is not reported in more than 40% of cases and is considered "silent suicides" (due to overdose, starvation, or dehydration, as well as apparent accidents not reported (^{Gramaglia et al., 2019}; ^{Simon, 1989}). Suicide rates, especially in those older than 70, are the highest in almost the entire world (^{De Leo & Arnautovska, 2019}), and therefore said population is considered high-risk given their highly lethal methods, their few warning signs, and their state of vulnerability that leads them to perceive self-annihilation as the best solution to their problems (^{Alphs et al. , 2016}; ^{Stone & Crosby, 2014}).

In addition, other risk factors include family history of suicide (^{Montes de Oca y Rodríguez, 2019}; ^{Pérez, 2012}), recent widowhood or loss of a loved one (30), living alone, being single, social isolation (^{Calderón et al. , 2021}; ^{Montes de Oca y Rodríguez, 2019}; ^{Khurana & Raj, 2018}), recent house move, self-harm expressions and suicide threats, previous attempts, persistent insomnia, physical symptoms without organic cause, chronic illness, terminal illness with untreatable pain and alcoholism (^{Alphs et al., 2016}; ^{Conejero et al., 2018}).

The appearance of suicidal behavior can be a product of stress and its relationship with the environment in which it operates. It also depends on other intrinsic personality factors that result in poor adaptation, loss of meaning in life, hopelessness, depression and psychological factors (^{Molina et al. , 2020}). Cogni-tively, the processing of information and the train of thought is also affected, a phenomenon described by Beck as the "cognitive triad" which implies a negative vision of oneself, the world and the future, generating alterations in the quality of life, well-being and satisfaction (^{Beck et al., 1979}).

Suicidal behavior is quite common and varies between 13.5% and 35% (^{Aslan et al. , 2019}); according to the Mexican Institute of Social Security, the main cause of suicide attempts in older adults is depression, triggered by a loss of vitality, changes in rhythm of life, decreased functions and capacities (added to unemployment or retirement), loss of significant figures (friends, partner, independence from children, distancing from family), the appearance of chronic-degenerative diseases and worsening economic situation, among others, added to poor health care (^{Martínez, 2007}) and age discrimination (^{Montes de Oca, 2013}), but more than 75% of consummated suicides had not disclosed prior suicidal intent (^{Schmutte & Wilkinson, 2020}).

Depression is one of the main risk factors (^{Molina et al. , 2020}), but cultural aspects change the hierarchy of importance of associated factors, such as gender, given that men seem to be more vulnerable than women (^{Echeburúa, 2015}; ^{Ramírez et al. , 2020}).

In Colombia, the prevalence of depression in the elderly is 49% (^{Minsalud, 2015}). Depressive symptoms are mainly characterized by a constant sad mood that becomes pathological, given its disproportionality, not limited to a specific stimulus, its profoundness and that it tends to persist over time (^{Cerquera, 2008}), loss of interest and enjoyment in activities and a loss of enthusiasm for life (motivational syndrome) (^{Cardona et al., 2018}). However, the stigmatization of mental health in old age in Colombia can lead to depressive symptoms being minimized or ignored, both by older adults themselves and by healthcare professionals. This creates a vicious cycle in which mental health problems in this population result in underreporting and a potential increase in the risk of suicidal behaviors.

This is compounded by the lack of longitudinal studies in Colombia that would allow for an understanding of how depressive symptoms evolve in older adults and their relationship with suicide risk, as depression in old age does not always manifest with the same signs as in other stages of life (^{Robledo - Marín et al., 2023}). Additionally, there is a significant gap in Colombian literature that would provide a better understanding of the relationship between depressive symptoms and suicidal behavior in old age, which could lead to clear prevention strategies for this population, especially in important public policies such as the National Mental Health Policy (^{Ministerio de Salud y Protección Social, 2019}) and the National Public Policy on Aging and Old Age 2022-2031 (^{Ministerio de Salud y Protección Social, 2022}).

The purpose of this article is to establish the relationship between depressive symptoms and suicidal behavior in older people residing in the urban areas of five Colombian cities.

Materials and methods

Analysis of data

A univariate analysis was performed to calculate absolute and relative frequencies and statistical measures; bivariate analysis was used to estimate the relationship between the dependent variable (suicidal behavior) and the independent variable (depressive symptomatology). Also, demographic, social and health variables were used to adjust the final model. In this analysis, hypothesis tests, p-values (p<0.05 statistical association), crude and adjusted prevalence ratios and their corresponding confidence intervals were calculated. Factors were estimated with logistical regression, given that a single point could be an early indicator of suicidal behavior and assumptions of the final model were verified.

Results

Discussion

People aged 60 and over show a higher incidence of suicidal ideation, considered a risk factor for completed suicide, in a relationship 8:1, and a third of those who fail to try again in the same year (^{Mann et al., 1999}). The risk of suicidal behavior reported in this study was 45.8%, with the highest risk in Pereira, followed by Medellín and Santa Marta and the lowest risk in Popayan. In this regard, a similar study carried out in Cuba in 2018 (^{Valiente et al., 2018}) reported that the presence of suicide threats or plans has a high relation with suicidal behavior, given that findings suggest that patients with previous suicide attempts present more severe clinical profiles than those who have made one attempt. Therefore, it is relevant to call special attention to all manifestations of suicidal behavior in the elderly population. Values like those found in this study were also reported by ^{Silva et al (2013)} in Chile, who reported a prevalence of suicidal thoughts of 35.3%, a desire to die of 20.2%, suicidal ideation of 14.3%, and attempted suicide of 7.7%. It is also important to note that in Colombia, the surveillance system emphasizes event reporting of "suicide attempts", however, it does not inquire about suicidal ideation or planning, which makes it difficult to monitor other manifestations of suicidal behavior, complicating its approach and early intervention. The findings of this study thus warrant the importance of considering the high lethality levels in the elderly population compared with other population groups (^{Andrade et al., 2016}; ^{O Connell et al., 2004}).

After the analysis of data and adjustment of variables of this study was completed, it was concluded that males had an increased risk of presenting suicidal behavior 4 times greater than females; these findings differ from those reported by ^{Silva et al in Chile (Silva et al., 2013}) who found that women had twice the risk of men of suicidal ideation and thrice of a suicide attempt as well as from those reported by ^{Bethancourt Santana et al in Cuba (2015)} who found greater suicidal intent in older women compared to men by ^{González et al (2018)} and by ^{Fachola in Uruguay (2015)} who emphasized female predominance in suicidal behavior phenomena. On the contrary, another study by ^{Molina et al (2020)} revealed that suicidal behavior was similar for both sexes. These differences reported between studies, could most likely be explained by the cultural, social and economic characteristics and context of each country.

Regarding age, a higher risk of suicidal behavior, although not significant, was observed in individuals between 60 and 69 years, while in Cuba a higher risk was reported in the population older than 80 (^{Bethancourt, 2015}).

According to the Mental Health Bulletin published by the Ministry of Health and Social Protection in 2018, more than 90% of those who present suicidal behavior also suffer some type of depressive disorder or substance abuse, suggesting that depression could increase the risk of suicidal behavior by up to 20 times; this is consistent with the findings of this study which indicate that depressive symptoms can increase risk of suicidal behavior up to 10 times. ^{Silva et al (2013)} also found that mood disorders and substance abuse were associated with a higher frequency of suicidal behavior and reported a decreased relation between anxiety disorders and other mental disorders with suicidal behavior, suggesting new possibilities of inquiry for future research. Similarly, Bethancourt et al reported that depression was the factor most associated with suicidal behavior risk (^{Bethancourt, 2015}). In this regard, it should be taken into account that factors such as loneliness, social isolation, the empty nest syndrome, widowhood, death of close friends, dependency in carrying out daily activities, disability, pain and chronic disease, are factors that increase emotional decline and consequently the risk of depression in the elder population that could later be associated with a greater presence of suicidal behavior (^{Andrade et al., 2016}; ^{Cardona et al., 2015}; ^{Fernández et al. , 2022}). From a biological standpoint, suicidal behavior in elders presents specific neuronal characteristics such as decreased serotonin and increased norepinephrine, which are directly linked to depression, due to increased hopelessness, demotivation, impulsiveness and reactivity that can lead to suicidal behavior and increased lethality when performing self-injurious acts (^{Andrade et al., 2016}; ^{Carballo et al., 2008}; ^{Mann, 1999}; ^{van Heeringen, 2003}).

The results of this study also indicate that physical inactivity increases the probability of suicidal behavior by 115%, which agrees with findings reported by ^{Ramírez Arango et al (2020)} in a study carried out in three Colombian cities which found that disability increased the risk of suicidal ideation. Although disability was not significantly associated with suicidal behavior, other reports have highlighted that reduced mobility increases the risk of suicidal behavior by 2.14 times, which could be related to difficulties in carrying out basic activities of daily living.

Moreover, Andrade-Salazar et al reported that the impact on quality of life and the perception of deterioration in health behaved as predictors of suicidal behavior in a Colombian population of elders (^{Andrade et al., 2016}) coinciding with the results of this study which showed that perception of low quality of life increased the risk of suicidal behavior by approximately 150%. Similarly, a systematic review by ^{Calderón-Cholbi et al. (2021)} reported that the perception of health status and quality of life are relevant as predictors of suicidal behavior in the elderly population.

Conclusions

The primary purpose of this study was to establish the relationship between depressive symptoms and suicidal behavior in older people residing in the urban areas of five Colombian cities. The results confirm that most older adults in the five cities analyzed are women. In general, they have low educational levels, high coverage of the social security system, and are between the ages of 60 and 69. Suicidal behavior is strongly influenced by factors such as sex, depressive symptoms, quality of life, and physical activity. Men are four times more at risk than women, while a low quality of life and physical inactivity significantly increase this risk. Additionally, depressive symptoms increase the likelihood of suicidal behaviors by nearly ten times, highlighting the need for specific interventions focused on these factors to improve mental health and prevent suicide.

It can be concluded that suicidal behavior in older people is a multifactorial phenomenon and that it is preventable, which is why it requires early detection of depressive symptoms in the first place, followed by promoting physical activity and the subjective perception of the quality of life.