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SAVING LIVES: Understanding Depression And Suicide In The Elderly

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Title: SAVING LIVES: Understanding Depression And Suicide In The Elderly


1
SAVING LIVESUnderstanding Depression And
Suicide In The Elderly
  • Sponsored by the Ohio Department of Mental Health
    in Partnership with the ADAMH Board of Franklin
    County and the Ohio Suicide Prevention Team
  • Developed by Ellen Anderson, Ph.D., PCC, 2003-2006

2
The capacity of an individual with mental or
behavioral problems to respond to mental health
interventions knows no end-point in the life
cycle. Even serious mental disorders in later
life can respond to clinical interventions and
rehabilitation strategies aimed at preventing
excess disability in affected individuals. C
Everett Koop, Surgeon Generals Workshop Health
Promotion and Aging, 1988
3
Goals For Suicide Prevention
  • Increase community awareness that suicide is a
    preventable public health problem
  • Increase awareness that depression is the primary
    cause of suicide
  • Change public perception about the stigma of
    mental illness, especially about depression and
    suicide
  • Increase the ability of the public to recognize
    and intervene when someone they know is suicidal

4
Training Objectives
  • Increase knowledge about the causes of suicide
    among the elderly
  • Learn the connection between depression and
    suicide
  • Dispel myths and misconceptions about suicide in
    the elderly
  • Learn risk factors and signs of suicidal behavior
    in the elderly
  • Learn to assess risk and find help for those at
    risk Asking the S question

5
The Feel of Depression
  • What I had begun to discover is thatthe grey
    drizzle of horror induced by depression takes on
    the quality of physical pain. But it is not an
    immediately identifiable pain, like that of a
    broken limb. It may be more accurate to say that
    despair, owing to some evil trick played upon the
    sick braincomes to resemble the diabolical
    discomfort of being imprisoned in a fiercely
    overheated room. And because no breeze stirs this
    caldron, because there is no escape from this
    smothering confinement, it is entirely natural
    that the victim begins to think ceaselessly of
    oblivion.
  • William Styron, 1990

6
The Feel of Depression
  • I am 6 feet tall. The way I have felt these past
    few months, it is as though I am in a very small
    room, and the room is filled with water, up to
    about 5 10, and my feet are glued to the floor,
    and its all I can do to breathe.

7
Mental Illness and Stigma
  • Historical beliefs about mental illness color the
    way we approach it even now, and offer us a way
    to understand why the stigma against mental
    illness is so powerful
  • For most of our history, depression and other
    mental disorders were viewed as demon possession
  • Afflicted people were outside the gates,
    unclean, causing people to fear of the mentally
    ill
  • Lack of understanding of illness in general led
    people to fear contamination, either real or
    ritual

8
What Is Mental Illness?
  • None of us are surprised that there are many ways
    for an organ of the body to malfunction
  • Stomachs can be affected by ulcers or excessive
    acid lungs can be damaged by environmental
    factors such as smoking, or by asthma the
    digestive tract is vulnerable to many possible
    illnesses
  • We have never understood that the brain is just
    like other organs of the body, and as such, is
    vulnerable to a variety of illnesses and
    disorders
  • We confuse brain with mind

9
What Is Mental Illness?
  • We understand that something like Parkinsons
    damages the brain and creates behavioral changes
  • Even diabetes is recognized as creating emotional
    changes as blood sugar rises and falls
  • Stigma about illnesses like depression,
    schizophrenia and Bi-Polar disorder seems to keep
    us from seeing them as brain disorders that
    create changes in mood, behavior and thinking

10
What Is Mental Illness?
  • We called it mental illness because we wanted to
    stop saying things like lunacy, madness,
    bats in her belfry, nuttier than a fruitcake,
    rowing with one oar in the water, insane, ga
    ga, wacko, fruit loop, sicko, crazy
  • Is it any wonder people avoid acknowledging
    mental illness?
  • Of all the diseases we have public awareness of,
    mental illness is the most misunderstood
  • Any 5 year-old knows the symptoms of the common
    cold, but few people know the symptoms of the
    most common mental illnesses such as depression
    and anxiety

11
Prevention Strategies
  • Crisis Centers and hotlines
  • Peer support programs
  • Restriction of access to lethal means
  • Intervention after a suicide
  • General suicide and depression awareness
    education
  • Depression Screening programs
  • Community Gatekeeper Trainings

12
Suicide Is The Last Taboo We Dont Want To Talk
About It
  • Suicide has become the Last Taboo we can talk
    about AIDS, sex, incest, and other topics that
    used to be unapproachable. We are still afraid of
    the S word
  • Understanding suicide helps communities become
    proactive rather than reactive to a suicide once
    it occurs
  • Reducing stigma about suicide and its causes
    provides us with our best chance for saving lives
  • Ignoring suicide means we are helpless to stop it

13
What Makes Me A Gatekeeper?
  • Gatekeepers are not mental health
  • professionals or doctors
  • Gatekeepers are responsible adults who spend time
    with people who might be vulnerable to depression
    and suicidal thoughts teachers, coaches, police
    officers, EMTs, physicians, clergy, 4H leaders,
    and of course, whose who work with the elderly

14
Why Should I Learn About Suicide Prevention?
  • It is the 11th largest killer of Americans, and
    the rate of suicide is highest
  • among those over 75
  • No one is safe from the risk of suicide wealth,
    education, intact family, popularity cannot
    protect us from this risk
  • A suicide attempt is a desperate cry for help to
    end excruciating, unending, overwhelming pain. We
    must learn to answer that cry before it is too
    late

15
Is Suicide Really a Problem?
  • 89 people complete suicide every day
  • 32,439 people in 2004 in the US
  • Over 1,000,000 suicides worldwide (reported)
  • This data refers to completed suicides that are
    documented by medical examiners it is estimated
    that 2-3 times as many actually complete suicide
  • (Surgeon Generals Report on Suicide, 1999)

16
  • Comparative Rates Of U.S. Suicides-2003
  • Rates per 100,000 population
  • National average - 11.1 per
    100,000
  • White males - 18
  • Hispanic males - 10.3
  • African-American males - 9.1
  • Asians - 5.2
  • Caucasian females - 4.8
  • African American females - 1.5
  • Males over 85 - 67.6
  • Annual Attempts 811,000 (estimated)
  • 150-1 completion for the young - 4-1 for the
    elderly
  • (AAS website),(Significant increases have
    occurred among African Americans in the past 10
    years - Toussaint, 2002)

17
The Unnoticed Death
  • For every 2 homicides, 3 people complete suicide
    yearly data that has been constant for 100 years
  • During the Viet Nam War from 1964-1972, we lost
    55,000 troops, and 220,000 people to suicide

18
The Gender Issue
  • Women perceived as being at higher risk than men
  • Women do make attempts 4 x as often as men
  • But - Men complete suicide 4 x as often as women
  • Womens risk rises until midlife, then decreases
  • Mens risk, always higher than womens, continues
    to rise until end of life
  • Are women more likely to seek help? Talk about
    feelings? Have a safety network of friends?
  • Do men suffer from depression silently?

19
How Big Is The Problem For The Elderly?
  • Risk factors for suicide among older persons
    differ from those among the young
  • In addition to a higher prevalence of depression
  • older persons are more socially isolated
  • more frequently use highly lethal methods
  • have more chronic physical illnesses
  • Not surprisingly, suicide rates among the elderly
    are highest for those who are divorced or widowed
  • (NIMH website, 2003)

20
Suicide Rates Among The Elderly
  • The elderly have the highest suicide rate of any
    group
  • Depression in late life affects six million
    people, one out of six patients in a general
    medical practice
  • Only one in six patients is diagnosed/treated
    appropriately
  • 75 have seen a primary care physician within the
    last month of life
  • Evidence mounts that the majority of elderly
    suicide victims die in the midst of their first
    episode of major depression
  • Depression is not a normal consequence of aging
    and can alter the course of other medical
    conditions
  • (Empfield, 2003)

21
Suicide Rate By Age Per 100,000
Older people 12.7 of 1999 population, but 18.8
of suicides. (Hovert, 1999Bartels, 2003)
22
What Factors Put Someone At Risk For Suicide?
  • Biological, physical, social, psychological or
    spiritual factors may increase risk-for example
  • A family history of suicide increases risk by 6
    times
  • Access to firearms people who use firearms in
    their suicide attempt are more likely to die
  • A significant loss by death, separation, divorce,
    moving, or breaking up with a boyfriend or
    girlfriend can be a trigger
  • (Goleman, 1997)

23
  • Social Isolation elders become increasingly
    isolated as family and friends die or move away,
    and as they lose mobility and transportation
  • The 2nd biggest risk factor - having an alcohol
    or drug problem
  • Many with alcohol and drug problems are
    clinically depressed, and are self-medicating for
    their pain
  • Many older people taking medication may be
    unaware of the risks for altered mental state
  • (Surgeon Generals call to Action, 1999)

24
  • The biggest risk factor for suicide completion?
  • Having a Depressive Illness
  • People with clinical depression often feel
    helpless to solve problems, leading to
    hopelessness a strong predictor of suicide risk
  • At some point in this chronic illness, suicide
    seems like the only way out of the pain and
    suffering
  • Many Mental health diagnoses have a component of
    depression anxiety, PTSD, Bi-Polar, etc
  • 90 of suicide completers have a depressive
    illness
  • (Lester, 1998, Surgeon General, 1999)

25
Depression Is An Illness
  • Suicide has been viewed for countless generations
    as
  • a moral failing, a spiritual weakness
  • an inability to cope with life
  • the cowards way out
  • A character flaw
  • Our cultural view of suicide is wrong -
    invalidated by our current understanding of brain
    chemistry and its interaction with stress,
    trauma and genetics on mood and behavior

26
  • The research evidence is overwhelming -
    depression is far more than a sad mood. It
    includes
  • Weight gain/loss
  • Sleep problems
  • Sense of tiredness, exhaustion
  • Sad or angry mood
  • Loss of interest in pleasurable things, lack of
    motivation
  • Irritability
  • Confusion, loss of concentration, poor memory
  • Negative thinking (Self, World, Future)
  • Withdrawal from friends and family
  • Sometimes, suicidal thoughts
  • (DSMIVR, 2002)

27
  • 20 years of brain research teaches that these
    symptoms are the behavioral result of
  • Internal changes in the physical structure of the
    brain
  • Damage to brain cells in the hippocampus,
    amygdala and limbic system
  • As Diabetes is the result of low insulin
    production by the pancreas, depressed people
    suffer from a physical illness what we might
    consider faulty wiring
  • (Braun, 2000 Surgeon Generals
    Call To Action, 1999, Stoff Mann, 1997, The
    Neurobiology of Suicide)

28
Faulty Wiring?
  • Literally, damage to certain nerve cells in our
    brains
  • The result of too many stress hormones
    cortisol, adrenaline and testosterone
  • Hormones activated by our Autonomic Nervous
    System to protect us in times of danger
  • Chronic stress causes changes in the functioning
    of the ANS, so that a high level of activation
    occurs with little stimulus
  • Causes changes in muscle tension, imbalances in
    blood flow patterns leading to illnesses such as
    asthma, IBS, back pain and depression
  • (Goleman, 1997, Braun, 1999)

29
Faulty Wiring?
  • Without a way to return to rest, hormones
    accumulate, doing damage to brain cells
  • Stress alone is not the problem, but how we
    interpret the event, thought or feeling
  • People with genetic predispositions, placed in a
    highly stressful environment will experience
    damage to brain cells from stress hormones
  • This leads to the cluster of thinking and
    emotional changes we call depression
  • (Goleman, 1997
    Braun, 1999)

30
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31
Where It Hits Us
32
One of Many Neurons
  • Neurons make up the brain and their action is
    what causes us to think, feel, and act
  • Neurons must connect to one another (through
    dendrites and axons)
  • Stress hormones damage dendrites and axons,
    causing them to shrink away from other
    connectors
  • As fewer and fewer connections are made, more and
    more symptoms of depression appear

33
  • As damage occurs, thinking changes in the
    predictable ways identified in our list of 10
    criteria
  • Thought constriction can lead to the idea that
    suicide is the only option
  • How do antidepressants affect this brain
    damage?
  • They may counter the effects of stress hormones
  • We know now that antidepressants stimulate genes
    within the neurons (turn on growth genes) which
    encourage the growth of new dendrites
  • (Braun, 1999)

34
  • Renewed dendrites
  • increase the number of neuronal connections
  • allow our nerve cells to begin connecting again
  • The more connections, the more information flow,
    the more flexibility and resilience the brain
    will have
  • Why does increasing the amount of serotonin, as
    many anti-depressants do, take so long to reduce
    the symptoms of depression?
  • It takes 4-6 weeks to re-grow dendrites axons
  • (Braun, 1999)

35
How Does Psychotherapy Help?
  • Medications may improve brain function, but do
    not change how we interpret stress
  • Psychotherapy, especially cognitive or
    interpersonal therapy, helps people change the
    (negative) patterns of thinking that lead to
    depressed and suicidal thoughts
  • Research shows that cognitive psychotherapy is as
    effective as medication in reducing depression
    and suicidal thinking
  • Changing our beliefs and thought patterns alters
    response to stress we are not as reactive or as
    affected by stress at the physical level
    (Lester, 2004)

36
What Therapy?
  • The standard of care is medication and
    psychotherapy combined
  • At this point, only cognitive behavioral and
    interpersonal psychotherapies are considered to
    be effective with clinical depression
    (evidence-based)
  • Patients should ask their doctor for a referral
    to a cognitive or interpersonal therapist

37
Possible Sources Of Depression
  • Genetic a predisposition to this problem may be
    present, and depressive diseases seem to run in
    families
  • Predisposing factors Childhood traumas, car
    accidents, brain injuries, abuse and domestic
    violence, poor parenting, growing up in an
    alcoholic home, chemotherapy
  • Immediate factors violent attack, illness,
    sudden loss or grief, loss of a relationship, any
    severe shock to the system
  • (Anderson, 1999, Berman Jobes, 1994, Lester,
    1998)

38
What Happens If We DontTreat Depression?
  • Significant risk of increased alcohol and drug
    use
  • Significant relationship problems
  • Withdrawal from daily activities, self-care
  • High risk for suicidal thoughts, attempts, and
    possibly death
  • (Surgeon Generals Call To Action, 1999)

39
PCPs And Diagnosis Of Depression
  • The elderly have often visited a health-care
    provider before completing suicide
  • 20 of elderly (over 65 years) who complete
    suicide visited a physician within 24 hours
  • 41 within a week
  • 75 within one month
  • Patients may not use the words depression or
    sadness
  • Because of the stigma that is still attached to
    this diagnosis, somatic symptoms may become the
    focus of complaint
  • There may be much denial and minimizing of
    affective symptoms
  • (Empfield, 2003)

40
Elders Have Additional Issues
  • The number of elders with mental illness will
    increase to 15 million in 2030
  • Mental illness has a significant impact on the
    health and functioning of older persons
  • Associated with increased utilization of services
    and higher costs
  • Our current mental health system is inadequate
  • Unprepared to address the anticipated growth in
    the number of elderly requiring treatment for
    late-life mental disorders
  • (Presidents New Freedom Commission on Mental
    Health, 2003
  • Jeste, et al., 1999 www.census.gov)

41
Barriers To MH Care
  • Fragmented service delivery system
  • Out of date Medicare policies
  • Stigma due to mental illness and advanced age
  • Mismatch between services that are covered and
    those preferred by older persons
  • Lack of adequate preventive interventions and
    programs that aid early identification of
    geriatric mental illness
  • (Bartels, 2003)

42
Medicare Expenditures For Mental Health Services
  • Total 1998 Medicare Health care Expenditures
  • 211.4 Billion
  • Total Mental Health Expenditures
  • 1.2 Billion (0.57)
  • Outpatient Mental Health Expenditures
  • 718 Million (0.34)
  • CMS, 2001

43
Expenditures On NIMH Newly Funded Grants
44
Falling Through The Cracks
  • Community Mental Health Services
  • Under-serve older persons
  • Lack staff trained to address medical needs
  • Often lack age-appropriate services
  • Principal Providers of Mental Health Care
  • Primary Care Physicians
  • Long-term Care Facilities
  • Medicare
  • Incomplete outpatient prescription drug coverage
  • Lack of mental health parity

45
Inadequate Workforce Of Trained Geriatric Mental
Health Providers
  • Current Workforce 2,425 Geriatric
    Psychiatrists
  • 200-700 Geriatric Psychologists
  • Estimated Current Need
  • 5,000 of each specialty
  • Severe Nursing and Allied Health Care Provider
    Shortage
  • (Bartels, 2003)

46
Poor Quality Of Mental Health Care For Elders
  • gt 1 in 5 older persons given an inappropriate
    prescription (Zhan, 2001)
  • The elderly are less likely to be treated with
    psychotherapy (Bartels, et al., 1997)
  • Lower quality of general health care is
    associated with increased mortality in all
    settings (Druss, 2001)

47
Unmet Need For Mental Health Services In Nursing
Homes
  • Nursing Homes are the primary provider of Mental
    Health for elderly in institutions
  • Over one month 4.5 of mentally ill nursing
    home residents received mental health services
  • Over one year 19 in need of mental health
    services receive them
  • Least Likely to get help -Oldest, most physically
    impaired
  • Among the Most Common Disorders
  • Dementia
  • Depression
  • Anxiety Disorders and Psychotic Disorders
    (Burns et al., 1993 Burns Taube, 1990, 1991,
    Rovner et al., 1990Shea et al., Smyer et al.,
    1994)

48
Illness And Depression
  • Depression is common among older patients with
    certain medical disorders
  • Associated with worse health outcomes
  • Greater use and costs of medications
  • Greater use of health services
  • Medical illness greatly increases the risk for
    depression particularly in
  • Ischemic heart disease (e.g. MI, CABG)
    Stroke
  • Cancer Chronic lung disease
    Alzheimers disease Arthritis
    Parkinsons disease
  • In heart attack patients, depression is a
    significant predictor of death at 6 months
  • (Empfield, 2003)

49
Rates Of Depression Among Elders With Illness
  • Cognitively intact nursing home patients shown to
    have symptoms consistent with depressive
    disorders 60
  • Chronically ill outpatients in a primary care
    practice - 25
  • Hospitalized patients - 20
  • In nursing homes, regardless of physical health,
    major depression increases the likelihood of
    mortality by 59 in one year
  • (Empfield, 2003)

50
Depression Associated With Worse Health Outcomes
  • Worse outcomes
  • Hip fractures
  • Myocardial infarction
  • Increased mortality rates for Myocardial
    Infarction (Frasure-Smith 1993, 1995)
  • In Cancer, depression leads to
  • Increased Hospitalization
  • Poorer physical function
  • Poorer quality of life
  • Poorer pain control (Mossey 1990 Penninx et al.
    2001
  • (Katz 1989, Rovner 1991, Parmelee 1992
  • Ashby1991 Shah 1993, Samuels 1997)

51
Benefits Of Treatment For Depression In The
Elderly
  • Depression is one of the few medical conditions
    in which treatment can make a rapid and dramatic
    difference in an elderly persons level of
    function and quality of life
  • Treatment may help patients accept medical
    treatment that they otherwise might refuse
    because of feelings of hopelessness or futility
  • Treatment also helps enhance or recover coping
    skills needed to deal with the inevitable losses
    associated with chronic medical illness
  • (Empfield, 2003)

52
Efficacy Of Psychosocial Treatments For Geriatric
Depression
  • Substantial evidence exists that psychosocial
    treatment is effective for patients with
    depression
  • Problem solving or Cognitive-Behavioral therapy
    is superior for the management of geriatric
    depression
  • Treatment should be maintained at least six
    months after remission from a first episode of
    major depression and longer after a second or
    third episode
  • Many older patients have chronic depression which
    requires indefinite maintenance
  • (Empfield, 2003)

53
What We Need To Know
  • With all this data to concern us about elder
    Americans, what do we need to learn to help them,
    to reduce the number of people suffering from
    depression and suicidal thoughts?
  • What to look for
  • How to talk to a depressed/suicidal person
  • How to get help

54
Suicide Myths What Is True?
  • 1.Talking about suicide might cause a person to
    act
  • False it is helpful to show the person you take
    them seriously and you care. Most feel relieved
    at the chance to talk
  • 2. A person who threatens suicide wont really
    follow through
  • False many people who complete suicide talk
    about it often before they actually do it
  • (AFSP website, 2003)

55
  • Suicide Myths, continued
  • 3. Only crazy people kill themselves
  • False - Crazy is a cruel and meaningless word.
    Most people who kill themselves have not lost
    touch with reality they feel hopeless and in
    terrible pain
  • 4. No one I know would do that
  • False - suicide is an equal opportunity killer
    rich, poor, successful, unsuccessful, beautiful,
    ugly, young, old, popular and unpopular people
    all complete suicide
  • 5. Theyre just trying to get attention
  • False They are trying to get help. We should
    recognize that need and respond to it

56
  • Suicide myths, continued
  • Suicide is a city problem, not in the
  • country or a small town
  • False rural areas have higher suicide rates
    than urban areas
  • Once a person decides to die nothing can stop
    them - They really want to die
  • NO - most people want to be stopped if we
    dont try to stop them they will certainly die -
    people want to end their pain, not their lives,
    but they have no hope that anyone will listen,
    that they can be helped
  • (AFSP website, 2003)

57
How Do I Know If Someone Is Suicidal?
  • Now we understand the connection between
    depression and suicide
  • We have reviewed what a depressed person looks
    like
  • Not all depressed people are suicidal how can
    we tell?
  • Suicides dont happen without
  • warning - verbal and behavioral
  • clues are present, but we may not
  • notice them

58
Verbal Expressions
  • Common statements
  • I shouldn't be here
  • I'm going to run away
  • I wish I were dead
  • I'm going to kill myself
  • I wish I could disappear forever
  • If a person did this or that?., would he/she die
  • Maybe if I died, people would love me more
  • I want to see what it feels like to die

59
Some Behavioral Warning Signs
  • Common signs
  • Previous suicidal thoughts or attempts
  • Expressing feelings of hopelessness or guilt
  • (Increased) substance abuse
  • Becoming less responsible and motivated
  • Talking or joking about suicide
  • Giving away possessions
  • Having several accidents resulting in injury
    "close calls" or "brushes with death"

60
What On Earth Can I Do?
  • We are reluctant to ask questions of depressed
    people because we feel it is none of my
    business, or fear the responsibility
  • Depression is an illness, like heart disease, and
    suicidal thoughts are a crisis, like a heart
    attack
  • You would not leave a heart attack victim lying
    on the sidewalk. You would make some attempt to
    administer CPR
  • Anyone can learn to ask the right questions to
    help a depressed and suicidal person

61
What Stops Us?
  • Most of us still believe suicide and depression
    are none of our business
  • Most are fearful of getting a yes answer
  • What if we knew how to respond to yes?
  • We could recognize depression symptoms like we
    recognize symptoms of a heart attack?
  • We were no longer afraid to ask for help for
    ourselves, our parents, our children?
  • We no longer felt ashamed of our feelings of
    despair and hopelessness, but recognized them as
    symptoms of a brain disorder?

62
Reduce Stigma
  • Stigma about having mental health problems keeps
    people from seeking help or even acknowledging
    their problem
  • Reducing the fear and shame we carry about having
    such shameful problems is critical
  • People must learn that depression is truly a
    disorder that can be treated not something to
    be ashamed of, not a weakness
  • Learning about suicide makes it possible for us
    to overcome our fears about asking the S
    question

63
Learning QPR Or, How To Ask The S Question
  • It is essential, if we are to reduce the number
    of suicide deaths in our country, that community
    members/gatekeepers learn QPR
  • First identified by Dr. Paul Quinnett as an
    analogue to CPR, QPR consists of
  • Question asking the S question
  • Persuade Getting the person to talk, and to
    seek help
  • Refer Getting the person to professional help
  • (Quinnett, 2000)

64
Ask Questions!
  • You seem pretty down
  • Do things seem hopeless to you
  • Have you ever thought it would be easier to be
    dead?
  • Have you considered suicide?
  • Remember, you cannot make someone suicidal by
    asking
  • If they are already thinking of it they will
    probably be relieved that the secret is out
  • If you get a yes answer, dont panic. Ask a few
    more questions

65
How Much Risk Is There?
  • Assess lethality
  • You are not a doctor, but you need to know how
    imminent the danger is
  • Has he or she made any previous suicide attempts?
  • Does he or she have a plan?
  • How specific is the plan?
  • Do they have access to means?

66
Do . . .
  • Use warning signs to get help early
  • Talk openly - reassure them that they can be
    helped - Try to instill hope
  • Encourage expression of feelings
  • Listen without passing judgment
  • Make empathic statements
  • Stay calm, relaxed, rational

67
  • But when someone is suicidal, a true friend
    learns how to listen

68
Dont
  • Make moral judgments
  • Argue lecture, or encourage guilt
  • Promise total confidentiality/offer reassurances
    that may not be true
  • Offer empty reassurances youll get over this
  • Minimize the problem -All you need is a good
    nights sleep
  • Dare the suicidal person- You wont really do
    it
  • Use reverse psychology - Go ahead and kill
    yourself
  • Leave the person alone
  • Never Go It Alone

69
Getting Help
  • Refer for professional help
  • When people exhibit 5 or more symptoms of
    depression
  • When risk is present (e.g. specific plan,
    available means)
  • Know your community resources
  • Keep a folder, a list of helpers
  • Maintain collaboration with treating agency to
    provide behavioral information to therapists

70
Local Professional Resources
  • Your Hospital Emergency Room
  • Your Local Mental Health Agencies
  • Your Local Mental Health Board
  • School Guidance Counselors
  • Local Crisis Hotlines
  • National Crisis Hotlines
  • Your family physician
  • School nurses
  • 911
  • Local Police/Sheriff
  • Local Clergy

71
Mourning Vs. Depression
  • In this age group, it is also important to
    distinguish between mourning and depression
  • Mourning often creates some problems in
    functioning for up to 2 months. It may come off
    and on
  • When duration of deep mourning lasts longer than
    2 months, or there is marked guilt unconnected to
    the loved ones death, and there are other
    symptoms, depression should be assessed
  • Bereavement can become "complicated- In
    addition to major depression, the bereaved
    elderly may suffer from what might be termed a
    minor depression not all the typical symptoms
    but enough to require treatment as any other
    depression
  • (Empfield, 2003)

72
Bereavement After A Suicide Loss
  • Compared with homicide, accidental death or
    natural death, suicide death is very difficult
    for family members to resolve
  • Family members experience
  • Greater pain
  • More difficulty finding meaning in the death
  • More difficulty accepting the death
  • Less support and understanding
  • More need for mental health care
  • Staff members may experience the same emotions
    after a suicidal death
  • (Smith, Range Ulner, 1991)

73
Impact Of Depression On Religious Beliefs
  • Many older people have strong religious faith, or
    have been involved in their religion all their
    lives
  • Most find more comfort than strain associated
    with religion
  • But depression is associated with feelings of
    alienation from God
  • Suicidality can be associated with religious fear
    and guilt, particularly with belief in having
    committed an unforgivable sin for simply thinking
    of suicide
  • This religious strain is associated with greater
    depression and suicidality, regardless of
    religiosity levels or the degree of comfort found
    in religion
  • (Sanderson, 2000)

74
Final Suggestions For Better Care
  • Mental health outreach services
  • Integrated service delivery in primary care
  • Mental health consultation and treatment teams in
    long-term care
  • Family/caregiver support interventions
  • Psychological and pharmacological treatments
  • (Draper, 2000 Unützer, et al., 2001 Schulberg,
    et al., 2001
  • Bartels et al., 2002, 2003 Sorenson, et al.,
    2002)

75
Outreach Programs
  • Gatekeeper Model
  • Trains community members to identify and refer
    community-dwelling older adults who may need
    mental health services
  • Effective at identifying isolated elderly, who
    received no formal mental health services
  • Florio Raschko, 1998

76
Caregiver Support Interventions
  • Delays placement in nursing homes for persons
    with dementia from 166 days to 19.9 months
  • ( Mittleman et al., 1995 Moniz-Cook et al., 1998
    Riordan Bennett, 1998 Roberts et al.,
    1999)
  • Improved Caregiver Mental Health -Decreased
    incidence and severity of depression -Improved
    health (e.g., lowered blood pressure)-Improved
    stress management (Sorensen, Pinquart,
    Duberstein, 2002)

77
Peer Support
  • Peer support groups for older persons with losses
    improve mental health outcomes (Lieberman
    Videka-Sherman 1986)
  • Peer support groups may be more acceptable to
    older persons and allow participants to be
    recipients and providers of assistance
    (Schneider Kropf, 1992)

78
Websites For Additional Information
  • Ohio Department of Mental Health
  • www.mh.state.oh.us
  • NAMI
  • www.nami.org
  • National Institute of Mental Health
  • www.nih.nimh.gov
  • American Association of Suicidology
  • www.suicidology.org
  • Suicide Awareness/Voice of Education
  • www.save.org
  • American Foundation for Suicide Prevention
  • www.afsp.org
  • Suicide Prevention Advocacy Network
  • www.spanusa.org
  • Suicide Prevention Resource Center
  • www.sprc.org

79
Permanent Solution- Temporary Problem
  • Remember a depressed person is physically ill,
    and cannot think clearly about the morality of
    suicide, cannot think logically about their value
    to friends and family
  • You would try CPR if you saw a heart attack
    victim
  • Dont be afraid to interfere when someone is
    dying more slowly of depression
  • Depression is a treatable disorder
  • Suicide is a preventable death

80
  • The Ohio Suicide Prevention Foundation
  • The Ohio State University, Center on Education
    and Training for Employment
  • 1900 Kenny Road, Room 2072
  • Columbus, OH 43210
  • 614-292-8585

81
The Calling and the Opportunity
The opportunity to address these critical
challenges is before us. If we hesitate, our
service delivery systems will be strained even
further by the influx of aging baby boomers and
by the needs of underserved older Americans.
Above all, now is the time to alleviate the
suffering of older people with mental disorders
and to prepare for the growing numbers of elders
who may need mental health services. Administ
ration on Aging, 2000
82
  • Stephen J. Bartels, M.D., M.S. Director, Aging
    Services Research NH-Dartmouth Psychiatric
    Research Center is the author of a presentation
    on mental health in the elderly, which is
    available on the web. His information provided
    much valuable background for this presentation,
    and some of his slides, which are available for
    public use, are also a part of this presentation.

83
A Brief Bibliography
  • Anderson, E. The Personal and Professional
    Impact of Client Suicide on Mental Health
    Professionals. Unpublished Doctoral dissertation,
    U. of Toledo, 1999.
  • Blumenthal, S.J. Kupfer, D.J. (Eds) (1990).
    Suicide Over the Life Cycle Risk Factors,
    Assessment, and Treatment of Suicidal Patients.
    American Psychiatric Press.
  • Dein, S. and Littlewood, R. Apocalyptic
    Suicide. Mental Health, Religion, Culture,
    2000 (3)2, 109-114.
  • Doka, K.J. (1989). Disenfranchised Grief
    Recognizing hidden sorrow. Lexington, MA
    Lexington Books

84
  • Empfield, Maureen MD( 2002) PSYCHIATRY FOR THE
    PRIMARY CARE PHYSICIAN Section 2. URL.
  • Jacobs, D., Ed. (1999). The Harvard Medical
    School Guide to Suicide Assessment and
    Interventions. Jossey-Bass.
  • Jamison, K.R., (1999). Night Falls Fast
    Understanding Suicide. Alfred Knopf .
  • Lester, D. (1998). Making Sense of Suicide An
    In-Depth Look at Why People Kill Themselves.
    American Psychiatric Press.

85
  • McLeod, D. Elderly suicides the religious
    divide, Guasrdian unlimited, 2001, Feb 5.
  • Martin, W. Religiosity and US suicide rates,
    1972-1978. Journal of clinical psychology, vol.
    40(1984) pp. 1166-1169 Smith, Range Ulner.
    Belief in Afterlife as a buffer in suicide and
    other bereavement. Omega Journal of Death and
    Dying, 1991-92, (24)3 217-225.
  • Quinnett, P.G. (2000). Counseling Suicidal
    People. QPR Institute, Spokane, WA.
  • Presidents New Freedom Council on Mental Health,
    2003.
  • Rando, T. (1988). Grieving. Lexington, MA
    Lexington Books.

86
  • Rosenblatt, P. (1996). Grief that does not end.
    In D. Klass, P. Silverman, S. Nickman (Eds.),
    Continuing Bonds New Understandings of grief (pp
    45-58). Schneidman, E.S. (1996). The Suicidal
    Mind. Oxford University Press.
  • Stoff, D.M. Mann, J.J. (Eds.), (1997). The
    Neurobiology of Suicide. American Academy of
    Science.
  • Styron, W. (1992). Darkness Visible. Vintage
    Books.
  •  Surgeon Generals Call to Action (1999).
    Department of Health and Human Services, U.S.
    Public Health Service.
  • Tang, T.Z. De Rubeis, R.J. ((1999). Sudden
    Gains and critical sessions in cognitive-behaviora
    l therapy for depression. Journal of Consulting
    and Clinical Psychology 67 894-904.
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