SAVING LIVES: Understanding Depression And Suicide In The Elderly

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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

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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
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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

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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• 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)

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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

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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?

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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)

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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)

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Suicide Rate By Age Per 100,000
Older people 12.7 of 1999 population, but 18.8
of suicides. (Hovert, 1999Bartels, 2003)
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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)

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• 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)

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• 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)

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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

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• 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)

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• 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)

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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)

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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)

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Where It Hits Us
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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

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• 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)

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• 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)

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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)

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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

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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)

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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)

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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)

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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)

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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)

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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

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Expenditures On NIMH Newly Funded Grants
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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

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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

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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)

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• 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

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• 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)

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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

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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

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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"

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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

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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?

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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

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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)

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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

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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?

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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

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

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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

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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

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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

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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)

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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)

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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)

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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.