sign-based typology of depression. British Journal of Psychiatry 157:6571, 1990
114. Coryell
W, Lavoni
P, Endicott
J, et al:
Outcome in schizoaffective, psychotic, and nonpsychotic depression. Archives of General Psychiatry 41:787-791,
1984 115. Lee AS, outcome ishJournal
Murray
RM:
The
long-term
of Maudsley depressives. Bnitof Psychiatry 153:741-751,
1988 116.
Clowen CG: Recurrent psychotic unipolar depression. Journal of Clinical Psychiatry 44:216-218, 1983
Chronic Suicide
CarolJ.
C. Clark,
andafiercely independent flexible personality type.
Farran,
Ph.D. D.N.SC.,
and
in-
The
cases of risk fac-
illustrate the intricacy associated with suicide and alert other investigators and health care professionals to a possibk link between chronic dyspnea and suitors
R.N.
in a structured psychological autopsy study of suicide in older adults, 14 cases in which the subjects experienced chronic dyspnea in the months or weeks before death were examined. Thirteen of the subjects wet white men. Most had a diagnosable psychiatric disorder,
cide
H: Dimensions ence. American 140:466-469,
of delusional experiJournal of Psychiatry 1983
121. Kocsis jH, Croughan JL, Katz MM, et a!: Response to treatment with antidepressants of patients with severe or moderate nonpsychotic depression and of patients with psychotic depression. American Journal of Psychiatry 147: 621-624,
122. Lucki
1990
I: Behavioral
receptor
studies
agonists
drugs. Journal (Dec suppl):24-31,
as of Clinical
of serotonin
antidepressant
Psychiatry
52
1991
and Men
Dyspnea in Elderly
Sara L. Horton-Deutsch, M.S., R.N. David
117. Black DW, Winokur G, Nasrallah A: Effects of psychosis on suicide risk in 1,593 patients with unipolar and bipolaraffectivedisorders. AmenicanJournalof Psychiatry 145:849-852,1988 118. Mueser KT, Butler RW: Auditory hallucinations in combat-related chronic posttraumatic stress disorder. American journal of Psychiatry 144:299-302, 1987 119. StraussJS: Hallucinations and delusions as points on continua functions. Archives of General Psychiatry 21:581586, 1969 120. Kendlen KS, Glazer WM, Morgenstem
risk.
The effects ofphysical ailments on suicide in the elderly population are more difficult to quantify. Rates of suicide appear to be higher in patients with certain diagnoses such as malignant neoplasms and diseases of the central nervous system (for example, Huntington’s chorea and epilepsy). We also know that many chronic medical illnesses precipitate
Ms. Horton-Deutsch is a doctoral candidate at Rush University Graduate College of Nursing and a research nurse at the Center for Suicide Research and Prevention at Rush-Presbyterian-St. Luke’s Medical Center, 1725 West Harrison Street, Suite 955, Chicago Illinois 60612. Dr. Clark is director of the center. Dr. Farran is associate professor in the College of Nursing at Rush University.
Suicide among elderly persons is of serious concern to health care professionals and society. Elderly persons have the highest suicide rates of any age group in the U.S. Suicide attempts ofolder adults are more likely to be successful than those of younger persons (1). In addition, studies show that between 93 and 96 percent of suicide victims have a diagnosable psychiatric disorder at the time ofdeath (2,3). Although elderly persons who commit suicide are unlikely to have ever used mental health services, the majority visit their family physician within weeks or months before their death (4). Among this population, suicide rates vary with age, race, and gender, as well as with mental and physical ailments. The risk of suicide increases throughout the eighth decade of life. Elderly men commit suicide three times more often than elderly women, and elderly white men are at much greater risk than all other elderly men (5).
episodes of major depression, and as people live longer, more of us will suffer from chronic physical illness and depression. This diminished quality oflife has led some elderly persons to consider suicide as a choice or right. Therefore, it is necessary to study and discuss suicide among chronically ill elderly persons to evaluate appropriate interventions with these patients and their families. In this paper we present cases gathered from a community-based psychological autopsy study that focused on elderly persons who completed suicide. Fourteen men age 65 and over for whom chronic dyspnea was the chief complaint commited suicide during the course of our study. We present these cases to alert other investigators and health care professionals of a possible link between chronic dyspnea and suicide risk.
1198
December
Hospital
although none badprevious contact with a mental health professional. Other chronic
common characteristics or terminal heart disease, vey recent contact primary physician, prior ence of self or a significant
were or lung
suffering
disease,
a debilitating
with
a
experiother
1992
VoL 43
No.
12
and
Community
Psychiatry
Methods Cases. During
examiner’s office sent letters to next ofkin introducing the research team. A follow-up letter was then sent by the researchers, followed by a phone call to elicit consent. Two persons from each consenting family who had frequent contact with the subject, who had known the deceased for a number of years, and who had a personal relationship with the subject were chosen as informants. Typically, informants were spouses, children, and siblings. Most of the structured interviews were conducted in the informants’ homes. Three experienced clinical interviewers who were previously trained to a high degree of interrater reliability conducted all interviews. Interviews lasted approximately two hours. After the interviews were completed, next ofkin were asked to authorize release of medical and psychiatric records. Assessments. Informants supplied demographic data about subjects and information about subjects’ social activities, functioning, and life stress during the six months before death. Other information included lifetime medical history, circumstances of suicide, mental status in the week before death, lifetime history of psychiatric disorders, and personality characteristics. The Schedule for Affective Disorders and Schizophrenia was used to rate symptoms, and diagnoses were based on Research Diagnostic Criteria. Medical examiner’s reports, which included autopsy and toxicologic findings, were also collected. Weekly case conferences between the three interviewers and the senior investigator were held to review each case and determine psychiatric diagnoses consensually.
a ten-month period (January 1 through October 31, 1990), a total of73 cases ofsuicide of persons age 65 and over were investigated by the medical examiner’s office in Cook County, Illinois. Of the 73 cases, 58 were men and 15 were women. The victims’ ages were evenly distributed between 65 and 84 years; eight were over 84. In 56 cases next ofkin consented to participate in a psychological autopsy study. Two knowledgeable informants per case were questioned in structured interviews, and all previous medical records were obtained. Police investigation reports and medical examiner’s reports were available for all cases. Fourteen men between the ages of 65 and 93 were selected for this study because oftheir expressed concerns about their inability to breathe in the months or weeks before death. All of the subjects had at least one of three physical illnesses associated with dyspnea: chronic obstructive pulmonary disease, congestive heart failure, and lung cancer. In addition, 12 ofl4 subjects had been prescribed oxygen, two during a hospitalization within one month ofdeath and ten for home use. Ofthe remaining two subjects, one had refused medical care for more than 20 years, and the other reportedly had difficulty affording the prescribed medications and treatments. In addition to these 14 cases, there were two cases in which next of kin refused to participate in the study and in which medical examiner’s reports identified complications of chronic obstructive pulmonary disease as the victims’ chief concern. Therefore, the 14 cases, which constituted one-fourth of the sample we studied, may not reflect the actual number of elderly persons experiencing chronic dyspnea in the months or weeks before death. Procedure. The Cook County medical examiner’s office provided the research team with information about newly adjudicated deaths by suicide in persons age 65 and over on a bimonthly basis during the tenmonth period. Approximately four weeks after the verdict, the medical
Results Ofthe 14 suicide victims, eight were married, four were widowed, and two were divorced. Ages ranged from 65 to 93 years. Death by a gunshot wound was the most common method of suicide (ten victims), followed by carbon monoxide intoxication (three), and falling from a high place (one). Table 1 presents characteristics of the 14 suicide victims. Three illustrative cases are presented below.
Hospital
December
and Community
Psychiatry
1992
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43
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Case 1. Mr. A was a 72-year-old white man who lived with his wife in a home that they owned. They had one son whom they saw weekly. Mr. A was said to be outgoing after his retirement seven years before; he enjoyed bowling and playing cards. He was said to be a proud, quiet, serious, and even-tempered man who rarely displayed emotion. Six years before his death, Mr. A was diagnosed as having angina and soon after underwent a triple-bypass operation. He continued to bowl and travel until 1989, when he became weak, short of breath, and easily fatigued; he was diagnosed as having heart failure. During the last two months oflife, he was hospitalized twice for atrial fibrillation, pulmonary edema, and renal insufficiency. During this time, he told his wife that all humans should die at age 65 and not suffer the way he was and the way his father had. Mr. A had cared for his father, who had dementia, for 14 years before his death. When Mr. A could no longer bowl, he also gave up playing cards, stating that if he could not do what he used to do, he would not do anything at all. He also lost his appetite and said that eating was too much work and made him short of breath. He became quieter, refused visitors, and no longer participated in weekly family dinners. In the past, Mr. A’s mood had fluctuated with the level of his air hunger; from this time forward, his mood remained sad. During his final hospitalization, Mr. A requested an early discharge and informed his nurse he did not believe that the quality of his life would improve. One week later he saw his doctor and asked if he would ever get any better. He was told that he would but that he would have to put off traveling. The next morning Mr. A killed himselfwith a gunshot wound to the head. A physical autopsy was not performed, and toxicologic analysis was negative. Mr. A’s symptoms were consistent with a single episode of major depression. Case 2. Mr. B was an 81-year-old widowed white man who lived alone since his wife’s death after a heart attack in 1983. He had been retired for
1199
Table 1 Characteristics
Age 75
72
71
of 14 elderly
male
suicide
victims
Psychiatric diagnosis
Medical condition
Major depression, unipolar
Lung cancer
Major
unipolar
Major
depression,
depression,
with
Homebound;
Hospitalized vious month; three months
three times in preoxygen prescribed before death
Emphysema
Oxygen prescribed before death; refused
for
First wife died ofleukemia; had history ofcolon cancer
colostomy
one month
Chronic obstructive pulmonary disease;
Forced early retirement; prescribed since 1980; bound
heart
fail-
retirement;
shortness before death
Homebound; slept prevent air hunger; cal treatment
hosof breath
oxygen home-
in recliner to medi-
Major depression, unipolar
Lung cancer; congestive heart failure
Homebound; live-in caretaker; oxygen prescribed one month before death
Major
Lung
Homebound; two months
cancer
alcohol-
66
Major unipolar,
78
oxygen
Oxy gen death
prescribed
one year before
depression, recurrent
Chronic obstructive pulmonary disease
Oxygen death
prescribed
six
Homebound;
Emphysema
ism
77
Major
depression,
unipolar,
Emphysema
died
of Alzheimer’s
Co-worker
oxygen
before
years
with
mitted
suicide
subject
went
death;
Oxygen
one week
prescribed
lung
cancer
corn-
in previous
year;
to emergency
of breath
Hospitalized
ten times
girlfriend many years
committed
room
24 hours
from
hos-
in last year; suicide
ago
Wife died of uterine cancer six months earlier; subject moved to apartment with daughter two months before death
prescribed
three years before alone with part-time
disease
On day ofdeath released pita! after hip replacement
lived
nurse
be-
Friend recently died oflung cancer with shortness of breath; subject complained ofstomach bloating, thought he had stomach cancer
fore death
delusional
subject
Wife died of cancer
Wife
prescribed
Emphysema
Major depression, unipolar; alcohol-
on
and a lung complication soon after she was placed in a nursing home
before death
depression,
unipolar
pacemaker
refused
for shortness before death Major
three stroke
Wife died of cancer; bed-bound mother-in-law was living in subject’s home when she died; relative died of throat cancer
ism
72
disease
early
Congestive ure
depression,
of lung
pitalized
fail-
Major depression, unipolar
unipolar;
died
Forced
heart
nephritis
68
Friend
state
months earlier; subject had three months before death
Chronic obstructive pulmonary disease;
ism
93
four months nursing care
Was told he needed day before death
Major depression, unipolar; alcohol-
74
Cared for father in vegetative for 14 years
Slept in recliner to prevent air hunger; shortness of breath from any activity; did not follow treatment plan
67
in
Brother died of lung cancer; neighbor died of cancer two months earlier
oxygen prescribed before death
Congestive heart failure; renal insufficiency
Congestive ure
abuse,
Stressor
day
Major depression, unipolar
remission
status
and delivered
80
Alcohol
dyspnea
Functional
unipolar
65
chronic
81 Major
depression,
Lung
Oxygen prescribed two months before death; told to stop driving at that time; lived alone but no longer able to care for self
cancer
unipolar
1200
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1992
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12
Wife
died
several
heart
years
attack; subject bypass heart surgery
Hospital
and Community
earlier
had
triple-
Psychiatry
of
20 years and appeared to have made a successful adjustment to retirement and widowhood. Four months before his death, Mr. B was told he had renal cancer with metastases to the lungs. His response to being told he had cancer was to want a “suicide machine.” Eight weeks later, at the insistence ofhis daughter, Mr. B accepted an appointment with an oncologist whom Mr. B said he liked. The doctor talked with Mr. B about the tough parts of having cancer-a shortened indefinite life span, need for assistance from others, and, in his case, the need to use oxygen and to stop driving his car. However, Mr. B continued to drive against medical advice. He also refused oxygen and refused a caretaker. During the last month ofhis life, Mr. B began refusing visitors. He was said to be extremely irritable and to have lost all interest in eating. He no longer read the newspaper, which he had done every day of his adult life; he talked daily about getting a suicide machine and was extremely restless, moving from bed to chair to find comfort from his dyspnea. During the last week ofhis life, he drove to the market against the doctor’s orders, and as a consequence his children decided to take the car away. On the day before his death Mr. B told his daughter to have his cat put to sleep because it was old and crippled. That evening Mr. B’s daughter said she would be back the next day with her brother to visit. The next morning, Mr. B died by carbon monoxide intoxication in his car a few hours before his children planned to take it from him. No autopsy was performed on Mr. B. His blood ethanol test was negative. The structured research interviews suggested that he had experienced a major depression, single episode. Case 3. Mr. C was a 66-year-old divorced white man with a ten-year history of chronic obstructive pulmonary disease. He had a history of addiction to alcohol and cigarettes. He was described by his friends as usually quite irritable. His response in 1980 to being told he had the disease was anger and resentment. At
that time he was forced to retire. He continued to live with his niece with whom he had stayed for the previous ten years. In 1981 while in his niece’s home, Mr. C made a suicide attempt by overdosing on diazepam and alcohol. According to his niece, he was diagnosed as having depression, but no follow-up psychiatric care was provided. During the last year ofhis life, Mr. C had more than ten hospitalizations
Hospital
December
and Community
Psychiatry
Chronic
obstructive
pulmonary
has
disease
frequently
associated increased
been with risk
depressive the
most
of
illness, prevalent
psychiatric diagnosis among elderly persons who die by suicide.
for dyspnea or oxygen intoxication. His niece reported that he did not want the paramedics called when he became short of breath; however, he would overuse oxygen until he became confused. He frequently stated that he might as well kill himself and displayed thoughts dominated by pessimism and feelings of resentment. His appetite was poor, he refused to leave his room, and he no longer wanted to be around people. Mr. C bad a strained relationship with his son, and this strain escalated during the last two weeks ofMr. C’s life when his son refused to provide care for him at home while his niece took a vacation. His son suggested he go into a nursing home. Everyone seemed to agree that he needed 24hour assistance, but Mr. C reacted angrily against being placed ternporarily in a nursing home or hiring a professional. After this episode Mr. C’s mood became mellow, and he began speaking of being a burden to everyone. His niece and son continued to argue over arrangements for Mr. C during the niece’s vacation. One week before the vacation, the arrangements had
1992
Vol. 43
No.
12
still not been made and Mr. C developed a severe dyspneic episode. He asked his niece to turn up his oxygen and turn on the fan in his bedroom. When he did not seem to catch his breath, the niece went to call the paramedics. While she was on the phone, she heard a loud noise from the bedroom and went back to find that Mr. C had shot himself in the mouth. Neither an autopsy nor a toxicologic examination was performed. Mr. C exhibited all the requisite symptoms of major depression, recurrent, and alcohol abuse in remission. Discussion Findings from this study must be weighed carefully, considering the small sample size and retrospective method ofdata collection by informant interview. Equally important, the study lacked a matched cornparison group, which would help us draw conclusions about whether rates of suicide were disproportionately high among these men with dyspnea and whether pulmonary compromise in medical patients is associated with an increased risk of death by suicide. Nevertheless, Hendin (6) and others have noted the value ofdetailed case studies to identify elderly persons at risk for suicide. Several record reviews of patients who died in general hospitals as a resuit ofsuicide have shown increased incidence ofsuicide in patients with respiratory disease (7-10). Retrospective accounts of suicide on medical-surgical hospital units identified dyspnea as a risk factor for suicide (1 1-i 3). Sawyer and associates (14) studied patients with chronic obstructive pulmonary disease who had enlisted in a nocturnal oxygen rehabilitation study. They reported one suicide and three attempted suicides among the 43 patients and hypothesized that when new treatments did not help, the patients became discouraged and felt hopeless, which led to depression and suicidal behavior. Findings from large general population surveys also have indicated that lung diseases are among the chronic diseases most strongly associated with depressive symptomatology (15). More specifically, chronic
1201
obstructive pulmonary disease has frequently been associated with increased risk ofdepressive illness (16), the most prevalent psychiatric diagnosis among elderly persons who die by suicide (3,4). All of the 14 dyspneic subjects in this study suffered from some type of depressive illness. Depression has been noted to complicate chronic lung disease in several ways. First, depression depletes motivation and energy, which often increases physical disability. Second studies have demonstrated that patients’ attitudes and beliefs about illness are related to a decrease in physical functioning (17,18). Finally, in a study of patients with chronic obstructive pulmonary disease, Dudley and associates (19) described a circular interaction between anxiety, depression, and dyspnea that increases functional disability. Several factors intrinsic to severely dyspneic states may increase suicide risk. First, patients who have chronic difficulty breathing may be more prone to major depressive illness and in this way more vulnerable to suicide. Second, severely dyspneic patients may be more prone to anxiety and panic states or disorders and thereby more vulnerable to suicide (20-23). Third, severely dyspneic patients generally live greatly restricted lives in terms of mobility, and this immobilizaton may turn their sense of restriction and helplessness i nto extreme hopelessness and suicidal despair. Fourth, severely dyspneic patients may suffer from reduced oxygenation and consequent organic mental status changes, contributing to the likelihood of suicide. Finally, it is possible-though not consistent with our observations in 14 casesthat severely dyspneic patients opt for death in a mentally competent frame of mind because the quality of their life has become so poor. Conwell and associates (24,2 5) observed that a confluence ofcircumstances, including premorbid character and coping style, previous experience with debilitating illness, and superimposed major depression, might predispose some elderly men ,
1202
and women who have frightening physical symptoms to commit suicide. In our study, 1 3 of 14 subjects had experienced loss of a loved one after a period of suffering; in four cases the loved one was said to have experienced shortness of breath in the months or weeks before death. Informants in our study frequently reported that subjects stated they were not willing to suffer for as long
It is crucial
to
carefully
whether
patients’
dyspnea
proportionate
judge is
consuming and difficult, it is crucial to judge carefully whether patients’ dyspnea is proportionate to their degree of physical impairment and to assess whether a depressive or anxiety disorder is present. Borson and McDonald (27) suggested several features that may be clues to the presence ofa depressive or anxiety disorder in patients with chronic lung disease, including increased dyspnea at rest, sudden fears ofdeath, heaviness of the chest, diurnal mood variation, frequent visits to emergency rooms, and changes in interpersonal behavior such as social avoidance, withdrawal, dependency, and helplessness.
to their Conclusions
degree of physical impairment and
as the loved one had. Thus the debilitating effects of chronic illness were well known to our subjects and were dreaded. Finally, the 14 chronic dyspneic men who killed themselves shared common personality traits. Informants described them as individuals who had difficulty accepting help from others and as proud, rigid mdividuals who would rather not perform activities if it meant doing so with diminished vigor. Twelve of the 14 subjects had this personality type, which was also the prominent personality type found by Conwell and associates (26) in a study of suicide and cancer and by Clark in an unpublished study of 56 consecutive suicides (Clark DC, 1990). Although none of the subjects were being treated by mental health professionals, all but one were under the care ofa physician during the penod immediately before death. Five subjects had seen their physician within 24 hours of death, four within one week of death, and four within one month of death, and one had refused medical care for more than 20 years. Although treating patients with dyspnea and depression may be time
We realize that a complex set of circumstances is part of any suicide. Factors other than mental and physical illness, such as personal attitudes, values, and coping styles, also must be considered. A recent survey by Mellick and associates (28) found that somatic complaints, including imaginary symptoms, often masked depression. In our study, the presence ofa depressive illness may have affected the subject’s view of his illness. Conversely, the presence of an irreversible illness may have led to a depressive illness and eventually to suicide. To adequately assess and treat elderly patients, mental health professionals must consider all possible hypotheses carefully and rigorously. Health care professionals who work with elderly persons must be educated about identifying those at risk. Gift (29) noted that dyspnea is the second most common reason for seeing a health care professional. Dyspnea is also the most distressing and disabling symptom that occurs in chronic obstructive pulmonary disease (30). Therefore, in addition to assessing physiological determinants of dyspnea, clinicians must evaluate patients for their perceptions and psychological responses to dyspnea. Only after health care professionals are able to identify those at risk can appropriate referral and treatment be instituted. We must continue to study and discuss these relationships in order to develop appropriate interventions
December
Hospital
assess
whether
depressive
disorder
to a
or
anxiety
is present.
1992
VoL 43
No.
12
and Community
Psychiatry
with perhaps these their other
patients and their families and to discover a way to enable chronically ill people to express fear and suffering in some way than suicide.
1 5. Murrell S, Himmelfarb S, Wright K: Prevalence of depression and its comelates in older adults. Amenicanjoumnal of Epidemiology 117:173-185, 1983 16.
Kukull W, Koespell T, Inue T, et a!: Depression and physical illness among elderly general medical clinic patients. journal
Acknowledgment
162,
The
study
was supported by a grant to Dr. Clark from the Andrus Foundation of the American Association of Retired
17.
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References 1 . Sunsbury P: Social and epidemiological aspects of suicide with special references to theaged, in ProcessesofAging. Edited by Williams R, Yibbitts C, Donahue W.
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New York, Atherton, 1963 2. Dorpat U, Ripley HS: A study of suicide in the Seattle area. Comprehensive Psychiatry 1:349-359, 1960
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RobinsE,MurphyGE,
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Successful suicides in ageneral hospital over a 15-year period. General Hospital Psychiatry 2:1 18-126, 1980 12. Farberow N, McKelligottj, Cohen 5, et al: Suicide among patients with cardiorespiratorydisease. JAMA 195:128134, 1966 13. SalmonJ, Hajek P, RachutE,etal:Mortality conference: suicide of an appropriately depressed medical patient. General Hospital Psychiatry 2:307-313, 1982 14. SawyerJ,Adam K, Conway W, etal: Suicide in cases of chronic obstructive pulmonary disease. journal of Psychiatric Treatment and Evaluation 5:281-283, 1983
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Fawcett j, Scheftner WA, Clark DC, et al: Clinical predictors of suicide in patients with major affective disorders: a
H&CP
Life Threatening Behavior 1:184-202, 1971 8. Glickman L: Psychiatric Consultation in theGeneral Hospital. New York, Marcel Dekker, 1980 9. PollackS:Suicide in thegeneral hospital, in Clues man E,
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A: Dyspnea: a clinical perspective. Scholarly Inquiry for Nursing Practice 1:73-85, 1987 Moody L, McCormick K, Williams A: Psychophysiologic correlates of quality of life in chronic bronchitis and emphysema. Western journal of Nursing Research 13:336-352, 1991
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Effect ofattitudes and beliefs on exercise tolerance in chronic bronchitis. British Medicaljournal 286:171-173, 1983
Persons.
3.
of Affective
controlled Journal
Community
Psychiatry
to Begin
Using
Structured
Beginning next month, Hospital and Community Psychiatry will publish structured abstracts with all literature reviews and full-length research reports. Authors now submitting literature reviews or full-length research papers should include structured abstracts a maximum of 250 words long. Abstracts for research reports must include the following headings and information: Objective, the study purpose or research question; Methods, including study design, setting, subjects, intervention(s) ifany, and main outcome measure(s); Results, the main results of the study; and Conclusions directly supported by the data. Abstracts for literature reviews must include the following headings and information: Objective, the primary purpose of the review; Methods, data sources searched, how studies were selected or excluded, and (if applicable) how data were abstracted; and Results and Condusions, the main
December
1992
Vol. 43
No.
12
Abstracts
findings
or conclusions from the reand their clinical or other applicability. For other types of full-length papers, authors should include standard factual abstracts a maximum of 1 50 words long. Brief reports do not require abstracts. Research reports and other regular articles should not exceed 3,000 words excluding references and tables. Literature reviews and special articles, generally solicited by the editor, can be 4,000 to 7,000 words plus no more than 100 references; please consult the editor before submitting such material. Maximum length for brief reports is 1,200 words, plus no more than ten references and one table or figure. Types of articles published in H&CP are described in more detail in the Information for Contributors; see the November issue, pages 10771078, or contact H&CP at 1400 K Street, N.W., Washington, D.C. 20005 (telephone, 202-682-6070). view
1203
114. Coryell
W, Lavoni
P, Endicott
J, et al:
Outcome in schizoaffective, psychotic, and nonpsychotic depression. Archives of General Psychiatry 41:787-791,
1984 115. Lee AS, outcome ishJournal
Murray
RM:
The
long-term
of Maudsley depressives. Bnitof Psychiatry 153:741-751,
1988 116.
Clowen CG: Recurrent psychotic unipolar depression. Journal of Clinical Psychiatry 44:216-218, 1983
Chronic Suicide
CarolJ.
C. Clark,
andafiercely independent flexible personality type.
Farran,
Ph.D. D.N.SC.,
and
in-
The
cases of risk fac-
illustrate the intricacy associated with suicide and alert other investigators and health care professionals to a possibk link between chronic dyspnea and suitors
R.N.
in a structured psychological autopsy study of suicide in older adults, 14 cases in which the subjects experienced chronic dyspnea in the months or weeks before death were examined. Thirteen of the subjects wet white men. Most had a diagnosable psychiatric disorder,
cide
H: Dimensions ence. American 140:466-469,
of delusional experiJournal of Psychiatry 1983
121. Kocsis jH, Croughan JL, Katz MM, et a!: Response to treatment with antidepressants of patients with severe or moderate nonpsychotic depression and of patients with psychotic depression. American Journal of Psychiatry 147: 621-624,
122. Lucki
1990
I: Behavioral
receptor
studies
agonists
drugs. Journal (Dec suppl):24-31,
as of Clinical
of serotonin
antidepressant
Psychiatry
52
1991
and Men
Dyspnea in Elderly
Sara L. Horton-Deutsch, M.S., R.N. David
117. Black DW, Winokur G, Nasrallah A: Effects of psychosis on suicide risk in 1,593 patients with unipolar and bipolaraffectivedisorders. AmenicanJournalof Psychiatry 145:849-852,1988 118. Mueser KT, Butler RW: Auditory hallucinations in combat-related chronic posttraumatic stress disorder. American journal of Psychiatry 144:299-302, 1987 119. StraussJS: Hallucinations and delusions as points on continua functions. Archives of General Psychiatry 21:581586, 1969 120. Kendlen KS, Glazer WM, Morgenstem
risk.
The effects ofphysical ailments on suicide in the elderly population are more difficult to quantify. Rates of suicide appear to be higher in patients with certain diagnoses such as malignant neoplasms and diseases of the central nervous system (for example, Huntington’s chorea and epilepsy). We also know that many chronic medical illnesses precipitate
Ms. Horton-Deutsch is a doctoral candidate at Rush University Graduate College of Nursing and a research nurse at the Center for Suicide Research and Prevention at Rush-Presbyterian-St. Luke’s Medical Center, 1725 West Harrison Street, Suite 955, Chicago Illinois 60612. Dr. Clark is director of the center. Dr. Farran is associate professor in the College of Nursing at Rush University.
Suicide among elderly persons is of serious concern to health care professionals and society. Elderly persons have the highest suicide rates of any age group in the U.S. Suicide attempts ofolder adults are more likely to be successful than those of younger persons (1). In addition, studies show that between 93 and 96 percent of suicide victims have a diagnosable psychiatric disorder at the time ofdeath (2,3). Although elderly persons who commit suicide are unlikely to have ever used mental health services, the majority visit their family physician within weeks or months before their death (4). Among this population, suicide rates vary with age, race, and gender, as well as with mental and physical ailments. The risk of suicide increases throughout the eighth decade of life. Elderly men commit suicide three times more often than elderly women, and elderly white men are at much greater risk than all other elderly men (5).
episodes of major depression, and as people live longer, more of us will suffer from chronic physical illness and depression. This diminished quality oflife has led some elderly persons to consider suicide as a choice or right. Therefore, it is necessary to study and discuss suicide among chronically ill elderly persons to evaluate appropriate interventions with these patients and their families. In this paper we present cases gathered from a community-based psychological autopsy study that focused on elderly persons who completed suicide. Fourteen men age 65 and over for whom chronic dyspnea was the chief complaint commited suicide during the course of our study. We present these cases to alert other investigators and health care professionals of a possible link between chronic dyspnea and suicide risk.
1198
December
Hospital
although none badprevious contact with a mental health professional. Other chronic
common characteristics or terminal heart disease, vey recent contact primary physician, prior ence of self or a significant
were or lung
suffering
disease,
a debilitating
with
a
experiother
1992
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and
Community
Psychiatry
Methods Cases. During
examiner’s office sent letters to next ofkin introducing the research team. A follow-up letter was then sent by the researchers, followed by a phone call to elicit consent. Two persons from each consenting family who had frequent contact with the subject, who had known the deceased for a number of years, and who had a personal relationship with the subject were chosen as informants. Typically, informants were spouses, children, and siblings. Most of the structured interviews were conducted in the informants’ homes. Three experienced clinical interviewers who were previously trained to a high degree of interrater reliability conducted all interviews. Interviews lasted approximately two hours. After the interviews were completed, next ofkin were asked to authorize release of medical and psychiatric records. Assessments. Informants supplied demographic data about subjects and information about subjects’ social activities, functioning, and life stress during the six months before death. Other information included lifetime medical history, circumstances of suicide, mental status in the week before death, lifetime history of psychiatric disorders, and personality characteristics. The Schedule for Affective Disorders and Schizophrenia was used to rate symptoms, and diagnoses were based on Research Diagnostic Criteria. Medical examiner’s reports, which included autopsy and toxicologic findings, were also collected. Weekly case conferences between the three interviewers and the senior investigator were held to review each case and determine psychiatric diagnoses consensually.
a ten-month period (January 1 through October 31, 1990), a total of73 cases ofsuicide of persons age 65 and over were investigated by the medical examiner’s office in Cook County, Illinois. Of the 73 cases, 58 were men and 15 were women. The victims’ ages were evenly distributed between 65 and 84 years; eight were over 84. In 56 cases next ofkin consented to participate in a psychological autopsy study. Two knowledgeable informants per case were questioned in structured interviews, and all previous medical records were obtained. Police investigation reports and medical examiner’s reports were available for all cases. Fourteen men between the ages of 65 and 93 were selected for this study because oftheir expressed concerns about their inability to breathe in the months or weeks before death. All of the subjects had at least one of three physical illnesses associated with dyspnea: chronic obstructive pulmonary disease, congestive heart failure, and lung cancer. In addition, 12 ofl4 subjects had been prescribed oxygen, two during a hospitalization within one month ofdeath and ten for home use. Ofthe remaining two subjects, one had refused medical care for more than 20 years, and the other reportedly had difficulty affording the prescribed medications and treatments. In addition to these 14 cases, there were two cases in which next of kin refused to participate in the study and in which medical examiner’s reports identified complications of chronic obstructive pulmonary disease as the victims’ chief concern. Therefore, the 14 cases, which constituted one-fourth of the sample we studied, may not reflect the actual number of elderly persons experiencing chronic dyspnea in the months or weeks before death. Procedure. The Cook County medical examiner’s office provided the research team with information about newly adjudicated deaths by suicide in persons age 65 and over on a bimonthly basis during the tenmonth period. Approximately four weeks after the verdict, the medical
Results Ofthe 14 suicide victims, eight were married, four were widowed, and two were divorced. Ages ranged from 65 to 93 years. Death by a gunshot wound was the most common method of suicide (ten victims), followed by carbon monoxide intoxication (three), and falling from a high place (one). Table 1 presents characteristics of the 14 suicide victims. Three illustrative cases are presented below.
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and Community
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Case 1. Mr. A was a 72-year-old white man who lived with his wife in a home that they owned. They had one son whom they saw weekly. Mr. A was said to be outgoing after his retirement seven years before; he enjoyed bowling and playing cards. He was said to be a proud, quiet, serious, and even-tempered man who rarely displayed emotion. Six years before his death, Mr. A was diagnosed as having angina and soon after underwent a triple-bypass operation. He continued to bowl and travel until 1989, when he became weak, short of breath, and easily fatigued; he was diagnosed as having heart failure. During the last two months oflife, he was hospitalized twice for atrial fibrillation, pulmonary edema, and renal insufficiency. During this time, he told his wife that all humans should die at age 65 and not suffer the way he was and the way his father had. Mr. A had cared for his father, who had dementia, for 14 years before his death. When Mr. A could no longer bowl, he also gave up playing cards, stating that if he could not do what he used to do, he would not do anything at all. He also lost his appetite and said that eating was too much work and made him short of breath. He became quieter, refused visitors, and no longer participated in weekly family dinners. In the past, Mr. A’s mood had fluctuated with the level of his air hunger; from this time forward, his mood remained sad. During his final hospitalization, Mr. A requested an early discharge and informed his nurse he did not believe that the quality of his life would improve. One week later he saw his doctor and asked if he would ever get any better. He was told that he would but that he would have to put off traveling. The next morning Mr. A killed himselfwith a gunshot wound to the head. A physical autopsy was not performed, and toxicologic analysis was negative. Mr. A’s symptoms were consistent with a single episode of major depression. Case 2. Mr. B was an 81-year-old widowed white man who lived alone since his wife’s death after a heart attack in 1983. He had been retired for
1199
Table 1 Characteristics
Age 75
72
71
of 14 elderly
male
suicide
victims
Psychiatric diagnosis
Medical condition
Major depression, unipolar
Lung cancer
Major
unipolar
Major
depression,
depression,
with
Homebound;
Hospitalized vious month; three months
three times in preoxygen prescribed before death
Emphysema
Oxygen prescribed before death; refused
for
First wife died ofleukemia; had history ofcolon cancer
colostomy
one month
Chronic obstructive pulmonary disease;
Forced early retirement; prescribed since 1980; bound
heart
fail-
retirement;
shortness before death
Homebound; slept prevent air hunger; cal treatment
hosof breath
oxygen home-
in recliner to medi-
Major depression, unipolar
Lung cancer; congestive heart failure
Homebound; live-in caretaker; oxygen prescribed one month before death
Major
Lung
Homebound; two months
cancer
alcohol-
66
Major unipolar,
78
oxygen
Oxy gen death
prescribed
one year before
depression, recurrent
Chronic obstructive pulmonary disease
Oxygen death
prescribed
six
Homebound;
Emphysema
ism
77
Major
depression,
unipolar,
Emphysema
died
of Alzheimer’s
Co-worker
oxygen
before
years
with
mitted
suicide
subject
went
death;
Oxygen
one week
prescribed
lung
cancer
corn-
in previous
year;
to emergency
of breath
Hospitalized
ten times
girlfriend many years
committed
room
24 hours
from
hos-
in last year; suicide
ago
Wife died of uterine cancer six months earlier; subject moved to apartment with daughter two months before death
prescribed
three years before alone with part-time
disease
On day ofdeath released pita! after hip replacement
lived
nurse
be-
Friend recently died oflung cancer with shortness of breath; subject complained ofstomach bloating, thought he had stomach cancer
fore death
delusional
subject
Wife died of cancer
Wife
prescribed
Emphysema
Major depression, unipolar; alcohol-
on
and a lung complication soon after she was placed in a nursing home
before death
depression,
unipolar
pacemaker
refused
for shortness before death Major
three stroke
Wife died of cancer; bed-bound mother-in-law was living in subject’s home when she died; relative died of throat cancer
ism
72
disease
early
Congestive ure
depression,
of lung
pitalized
fail-
Major depression, unipolar
unipolar;
died
Forced
heart
nephritis
68
Friend
state
months earlier; subject had three months before death
Chronic obstructive pulmonary disease;
ism
93
four months nursing care
Was told he needed day before death
Major depression, unipolar; alcohol-
74
Cared for father in vegetative for 14 years
Slept in recliner to prevent air hunger; shortness of breath from any activity; did not follow treatment plan
67
in
Brother died of lung cancer; neighbor died of cancer two months earlier
oxygen prescribed before death
Congestive heart failure; renal insufficiency
Congestive ure
abuse,
Stressor
day
Major depression, unipolar
remission
status
and delivered
80
Alcohol
dyspnea
Functional
unipolar
65
chronic
81 Major
depression,
Lung
Oxygen prescribed two months before death; told to stop driving at that time; lived alone but no longer able to care for self
cancer
unipolar
1200
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Wife
died
several
heart
years
attack; subject bypass heart surgery
Hospital
and Community
earlier
had
triple-
Psychiatry
of
20 years and appeared to have made a successful adjustment to retirement and widowhood. Four months before his death, Mr. B was told he had renal cancer with metastases to the lungs. His response to being told he had cancer was to want a “suicide machine.” Eight weeks later, at the insistence ofhis daughter, Mr. B accepted an appointment with an oncologist whom Mr. B said he liked. The doctor talked with Mr. B about the tough parts of having cancer-a shortened indefinite life span, need for assistance from others, and, in his case, the need to use oxygen and to stop driving his car. However, Mr. B continued to drive against medical advice. He also refused oxygen and refused a caretaker. During the last month ofhis life, Mr. B began refusing visitors. He was said to be extremely irritable and to have lost all interest in eating. He no longer read the newspaper, which he had done every day of his adult life; he talked daily about getting a suicide machine and was extremely restless, moving from bed to chair to find comfort from his dyspnea. During the last week ofhis life, he drove to the market against the doctor’s orders, and as a consequence his children decided to take the car away. On the day before his death Mr. B told his daughter to have his cat put to sleep because it was old and crippled. That evening Mr. B’s daughter said she would be back the next day with her brother to visit. The next morning, Mr. B died by carbon monoxide intoxication in his car a few hours before his children planned to take it from him. No autopsy was performed on Mr. B. His blood ethanol test was negative. The structured research interviews suggested that he had experienced a major depression, single episode. Case 3. Mr. C was a 66-year-old divorced white man with a ten-year history of chronic obstructive pulmonary disease. He had a history of addiction to alcohol and cigarettes. He was described by his friends as usually quite irritable. His response in 1980 to being told he had the disease was anger and resentment. At
that time he was forced to retire. He continued to live with his niece with whom he had stayed for the previous ten years. In 1981 while in his niece’s home, Mr. C made a suicide attempt by overdosing on diazepam and alcohol. According to his niece, he was diagnosed as having depression, but no follow-up psychiatric care was provided. During the last year ofhis life, Mr. C had more than ten hospitalizations
Hospital
December
and Community
Psychiatry
Chronic
obstructive
pulmonary
has
disease
frequently
associated increased
been with risk
depressive the
most
of
illness, prevalent
psychiatric diagnosis among elderly persons who die by suicide.
for dyspnea or oxygen intoxication. His niece reported that he did not want the paramedics called when he became short of breath; however, he would overuse oxygen until he became confused. He frequently stated that he might as well kill himself and displayed thoughts dominated by pessimism and feelings of resentment. His appetite was poor, he refused to leave his room, and he no longer wanted to be around people. Mr. C bad a strained relationship with his son, and this strain escalated during the last two weeks ofMr. C’s life when his son refused to provide care for him at home while his niece took a vacation. His son suggested he go into a nursing home. Everyone seemed to agree that he needed 24hour assistance, but Mr. C reacted angrily against being placed ternporarily in a nursing home or hiring a professional. After this episode Mr. C’s mood became mellow, and he began speaking of being a burden to everyone. His niece and son continued to argue over arrangements for Mr. C during the niece’s vacation. One week before the vacation, the arrangements had
1992
Vol. 43
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still not been made and Mr. C developed a severe dyspneic episode. He asked his niece to turn up his oxygen and turn on the fan in his bedroom. When he did not seem to catch his breath, the niece went to call the paramedics. While she was on the phone, she heard a loud noise from the bedroom and went back to find that Mr. C had shot himself in the mouth. Neither an autopsy nor a toxicologic examination was performed. Mr. C exhibited all the requisite symptoms of major depression, recurrent, and alcohol abuse in remission. Discussion Findings from this study must be weighed carefully, considering the small sample size and retrospective method ofdata collection by informant interview. Equally important, the study lacked a matched cornparison group, which would help us draw conclusions about whether rates of suicide were disproportionately high among these men with dyspnea and whether pulmonary compromise in medical patients is associated with an increased risk of death by suicide. Nevertheless, Hendin (6) and others have noted the value ofdetailed case studies to identify elderly persons at risk for suicide. Several record reviews of patients who died in general hospitals as a resuit ofsuicide have shown increased incidence ofsuicide in patients with respiratory disease (7-10). Retrospective accounts of suicide on medical-surgical hospital units identified dyspnea as a risk factor for suicide (1 1-i 3). Sawyer and associates (14) studied patients with chronic obstructive pulmonary disease who had enlisted in a nocturnal oxygen rehabilitation study. They reported one suicide and three attempted suicides among the 43 patients and hypothesized that when new treatments did not help, the patients became discouraged and felt hopeless, which led to depression and suicidal behavior. Findings from large general population surveys also have indicated that lung diseases are among the chronic diseases most strongly associated with depressive symptomatology (15). More specifically, chronic
1201
obstructive pulmonary disease has frequently been associated with increased risk ofdepressive illness (16), the most prevalent psychiatric diagnosis among elderly persons who die by suicide (3,4). All of the 14 dyspneic subjects in this study suffered from some type of depressive illness. Depression has been noted to complicate chronic lung disease in several ways. First, depression depletes motivation and energy, which often increases physical disability. Second studies have demonstrated that patients’ attitudes and beliefs about illness are related to a decrease in physical functioning (17,18). Finally, in a study of patients with chronic obstructive pulmonary disease, Dudley and associates (19) described a circular interaction between anxiety, depression, and dyspnea that increases functional disability. Several factors intrinsic to severely dyspneic states may increase suicide risk. First, patients who have chronic difficulty breathing may be more prone to major depressive illness and in this way more vulnerable to suicide. Second, severely dyspneic patients may be more prone to anxiety and panic states or disorders and thereby more vulnerable to suicide (20-23). Third, severely dyspneic patients generally live greatly restricted lives in terms of mobility, and this immobilizaton may turn their sense of restriction and helplessness i nto extreme hopelessness and suicidal despair. Fourth, severely dyspneic patients may suffer from reduced oxygenation and consequent organic mental status changes, contributing to the likelihood of suicide. Finally, it is possible-though not consistent with our observations in 14 casesthat severely dyspneic patients opt for death in a mentally competent frame of mind because the quality of their life has become so poor. Conwell and associates (24,2 5) observed that a confluence ofcircumstances, including premorbid character and coping style, previous experience with debilitating illness, and superimposed major depression, might predispose some elderly men ,
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and women who have frightening physical symptoms to commit suicide. In our study, 1 3 of 14 subjects had experienced loss of a loved one after a period of suffering; in four cases the loved one was said to have experienced shortness of breath in the months or weeks before death. Informants in our study frequently reported that subjects stated they were not willing to suffer for as long
It is crucial
to
carefully
whether
patients’
dyspnea
proportionate
judge is
consuming and difficult, it is crucial to judge carefully whether patients’ dyspnea is proportionate to their degree of physical impairment and to assess whether a depressive or anxiety disorder is present. Borson and McDonald (27) suggested several features that may be clues to the presence ofa depressive or anxiety disorder in patients with chronic lung disease, including increased dyspnea at rest, sudden fears ofdeath, heaviness of the chest, diurnal mood variation, frequent visits to emergency rooms, and changes in interpersonal behavior such as social avoidance, withdrawal, dependency, and helplessness.
to their Conclusions
degree of physical impairment and
as the loved one had. Thus the debilitating effects of chronic illness were well known to our subjects and were dreaded. Finally, the 14 chronic dyspneic men who killed themselves shared common personality traits. Informants described them as individuals who had difficulty accepting help from others and as proud, rigid mdividuals who would rather not perform activities if it meant doing so with diminished vigor. Twelve of the 14 subjects had this personality type, which was also the prominent personality type found by Conwell and associates (26) in a study of suicide and cancer and by Clark in an unpublished study of 56 consecutive suicides (Clark DC, 1990). Although none of the subjects were being treated by mental health professionals, all but one were under the care ofa physician during the penod immediately before death. Five subjects had seen their physician within 24 hours of death, four within one week of death, and four within one month of death, and one had refused medical care for more than 20 years. Although treating patients with dyspnea and depression may be time
We realize that a complex set of circumstances is part of any suicide. Factors other than mental and physical illness, such as personal attitudes, values, and coping styles, also must be considered. A recent survey by Mellick and associates (28) found that somatic complaints, including imaginary symptoms, often masked depression. In our study, the presence ofa depressive illness may have affected the subject’s view of his illness. Conversely, the presence of an irreversible illness may have led to a depressive illness and eventually to suicide. To adequately assess and treat elderly patients, mental health professionals must consider all possible hypotheses carefully and rigorously. Health care professionals who work with elderly persons must be educated about identifying those at risk. Gift (29) noted that dyspnea is the second most common reason for seeing a health care professional. Dyspnea is also the most distressing and disabling symptom that occurs in chronic obstructive pulmonary disease (30). Therefore, in addition to assessing physiological determinants of dyspnea, clinicians must evaluate patients for their perceptions and psychological responses to dyspnea. Only after health care professionals are able to identify those at risk can appropriate referral and treatment be instituted. We must continue to study and discuss these relationships in order to develop appropriate interventions
December
Hospital
assess
whether
depressive
disorder
to a
or
anxiety
is present.
1992
VoL 43
No.
12
and Community
Psychiatry
with perhaps these their other
patients and their families and to discover a way to enable chronically ill people to express fear and suffering in some way than suicide.
1 5. Murrell S, Himmelfarb S, Wright K: Prevalence of depression and its comelates in older adults. Amenicanjoumnal of Epidemiology 117:173-185, 1983 16.
Kukull W, Koespell T, Inue T, et a!: Depression and physical illness among elderly general medical clinic patients. journal
Acknowledgment
162,
The
study
was supported by a grant to Dr. Clark from the Andrus Foundation of the American Association of Retired
17.
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References 1 . Sunsbury P: Social and epidemiological aspects of suicide with special references to theaged, in ProcessesofAging. Edited by Williams R, Yibbitts C, Donahue W.
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New York, Atherton, 1963 2. Dorpat U, Ripley HS: A study of suicide in the Seattle area. Comprehensive Psychiatry 1:349-359, 1960
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RobinsE,MurphyGE,
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Successful suicides in ageneral hospital over a 15-year period. General Hospital Psychiatry 2:1 18-126, 1980 12. Farberow N, McKelligottj, Cohen 5, et al: Suicide among patients with cardiorespiratorydisease. JAMA 195:128134, 1966 13. SalmonJ, Hajek P, RachutE,etal:Mortality conference: suicide of an appropriately depressed medical patient. General Hospital Psychiatry 2:307-313, 1982 14. SawyerJ,Adam K, Conway W, etal: Suicide in cases of chronic obstructive pulmonary disease. journal of Psychiatric Treatment and Evaluation 5:281-283, 1983
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H&CP
Life Threatening Behavior 1:184-202, 1971 8. Glickman L: Psychiatric Consultation in theGeneral Hospital. New York, Marcel Dekker, 1980 9. PollackS:Suicide in thegeneral hospital, in Clues man E,
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A: Dyspnea: a clinical perspective. Scholarly Inquiry for Nursing Practice 1:73-85, 1987 Moody L, McCormick K, Williams A: Psychophysiologic correlates of quality of life in chronic bronchitis and emphysema. Western journal of Nursing Research 13:336-352, 1991
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Effect ofattitudes and beliefs on exercise tolerance in chronic bronchitis. British Medicaljournal 286:171-173, 1983
Persons.
3.
of Affective
controlled Journal
Community
Psychiatry
to Begin
Using
Structured
Beginning next month, Hospital and Community Psychiatry will publish structured abstracts with all literature reviews and full-length research reports. Authors now submitting literature reviews or full-length research papers should include structured abstracts a maximum of 250 words long. Abstracts for research reports must include the following headings and information: Objective, the study purpose or research question; Methods, including study design, setting, subjects, intervention(s) ifany, and main outcome measure(s); Results, the main results of the study; and Conclusions directly supported by the data. Abstracts for literature reviews must include the following headings and information: Objective, the primary purpose of the review; Methods, data sources searched, how studies were selected or excluded, and (if applicable) how data were abstracted; and Results and Condusions, the main
December
1992
Vol. 43
No.
12
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findings
or conclusions from the reand their clinical or other applicability. For other types of full-length papers, authors should include standard factual abstracts a maximum of 1 50 words long. Brief reports do not require abstracts. Research reports and other regular articles should not exceed 3,000 words excluding references and tables. Literature reviews and special articles, generally solicited by the editor, can be 4,000 to 7,000 words plus no more than 100 references; please consult the editor before submitting such material. Maximum length for brief reports is 1,200 words, plus no more than ten references and one table or figure. Types of articles published in H&CP are described in more detail in the Information for Contributors; see the November issue, pages 10771078, or contact H&CP at 1400 K Street, N.W., Washington, D.C. 20005 (telephone, 202-682-6070). view
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