SAVING LIVES Understanding Depression And Suicide In The

SAVING LIVES: Understanding Depression And Suicide In The Elderly Sponsored by the Ohio Department of Mental Health , The Ohio Suicide Prevention Foundation, and your local Suicide Prevention Coalition Developed by Ellen Anderson, Ph. D. , PCC, 2003 -2008

“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 General’s Workshop Health Promotion and Aging, 1988 Elder. Care Gatekeeper Training 2

Goals For Suicide Prevention Ø Increase community awareness that suicide is a preventable public health problem Ø Increase awareness that depression is the primary cause of suicide Ø Change public perception about the stigma of mental illness, especially about depression and suicide Ø Increase the ability of the public to recognize and intervene when someone they know is suicidal Elder. Care Gatekeeper Training 3

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

The Feel of Depression Ø “What I had begun to discover is that…the 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 brain…comes 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. ” Elder. Care Gatekeeper Training 5

The Feel of Depression Ø “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. ” Elder. Care Gatekeeper Training 6

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 Ø For most of our history, depression and other mental disorders were viewed as demon possession Ø Afflicted people were “outside the gates”, unclean, causing people to fear of the mentally ill Ø Lack of understanding of illness in general led people to fear contamination, either real or ritual Elder. Care Gatekeeper Training 7 Ø

What Is Mental Illness? None of us are surprised that there are many ways for an organ of the body to malfunction Ø 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 Ø 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 Ø We confuse brain with mind Ø Elder. Care Gatekeeper Training 8

What Is Mental Illness? Ø We understand that something like Parkinson’s damages the brain and creates behavioral changes Ø Even diabetes is recognized as creating emotional changes as blood sugar rises and falls Ø 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 Elder. Care Gatekeeper Training 9

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” Ø Is it any wonder people avoid acknowledging mental illness? Ø Of all the diseases we have public awareness of, mental illness is the most misunderstood Ø Any 5 year-old knows the symptoms of the common cold, but few people know the symptoms of the most Elder. Care Gatekeeper Training 10 Ø

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

Suicide Is The Last Taboo – We Don’t 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 Ø Understanding suicide helps communities become proactive rather than reactive to a suicide once it occurs Ø Reducing stigma about suicide and its causes provides us with our best chance for saving lives Ø Ignoring suicide means we are helpless to stop it Elder. Care Gatekeeper Training 12 Ø

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

Why Should I Learn About Suicide Prevention? It is the 11 th largest killer of Americans, and the rate of suicide is highest among those over 75 Ø No one is safe from the risk of suicide – wealth, education, intact family, popularity cannot protect us from this risk Ø 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 Elder. Care Gatekeeper Training 14 Ø

Is Suicide Really a Problem? Ø 89 people complete suicide every day Ø 32, 467 people in 2005 in the US Ø Over 1, 000 suicides worldwide (reported) Ø 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 General’s Report on Suicide, 1999) Elder. Care Gatekeeper Training 15

Comparative Rates Of U. S. Suicides 2003 Ø Rates per 100, 000 population l l l l Ø National average 100, 000* White males Hispanic males African-American males Asians Caucasian females African American females Males over 85 - 11. 1 per - 18 - 10. 3 - 9. 1 ** - 5. 2 - 4. 8 - 1. 5 - 67. 6 Annual Attempts – 811, 000 (estimated) l 150 -1 completion for the young - 4 -1 for the elderly Elder. Care Gatekeeper Training 16 (*AAS website), **(Significant increases have occurred among African

The Unnoticed Death Ø For every 2 homicides, 3 people complete suicide yearly– data that has been constant for 100 years Ø During the Viet Nam War from 19641972, we lost 55, 000 troops, and 220, 000 people to suicide Elder. Care Gatekeeper Training 17

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

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

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 Elder. Care Gatekeeper Training 20 Depression is not a normal consequence of aging

Suicide Rate By Age Per 100, 000 Older people: 12. 7% of 1999 population, but 18. 8% of suicides. (Hovert, 1999; Bartels, 2003) Elder. Care Gatekeeper Training 21

What Factors Put Someone At Risk For Suicide? Biological, physical, social, psychological or spiritual factors may increase risk-for example: Ø A family history of suicide increases risk by 6 times Ø Access to firearms – people who use firearms in their suicide attempt are more likely to die Ø A significant loss by death, separation, divorce, moving, or breaking up with a boyfriend or girlfriend can be a trigger Ø (Goleman, 1997) Elder. Care Gatekeeper Training 22

Ø Social Isolation: elders become increasingly isolated as family and friends die or move away, and as they lose mobility and transportation Ø The 2 nd biggest risk factor - having an alcohol or drug problem l l 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 General’s call to Action, 1999) Elder. Care Gatekeeper Training 23

Ø 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 Ø At some point in this chronic illness, suicide seems like the only way out of the pain and suffering Ø Many Mental health diagnoses have a component of depression: anxiety, PTSD, Bi. Polar, etc Ø 90% of suicide completers have a depressive Elder. Care Gatekeeper Training 24 illness Ø

Depression Is An Illness n Suicide has been viewed for countless generations as: a moral failing, a spiritual weakness n an inability to cope with life n “the coward’s way out” n A character flaw n n Our cultural view of suicide is wrong - invalidated by our current understanding of brain chemistry and it’s interaction with stress, trauma and genetics on mood and behavior Elder. Care Gatekeeper Training 25

n The research evidence is overwhelming - depression is far more than a sad mood. It includes: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 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) Elder. Care Gatekeeper Training 26

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 General’s Call To Action, 1999, Stoff & Mann, 1997, The Neurobiology of Suicide) Elder. Care Gatekeeper Training 27

Faulty Wiring? n Literally, damage to certain nerve cells in our brains n n 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) Elder. Care Gatekeeper Training 28

Faulty Wiring? n n 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 29 Elder. Care Gatekeeper Training

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Where It Hits Us Elder. Care Gatekeeper Training 31

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 Elder. Care Gatekeeper Training 32

n n n 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 that antidepressants stimulate genes within the neurons (turn on growth Elder. Care Gatekeeper Training 33 genes) which encourage the growth of new

n n n Renewed dendrites: n increase the number of neuronal connections n 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? Elder. Care Gatekeeper Training 34

How Does Psychotherapy Help? n n 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 Elder. Care Gatekeeper Training 35 affected by stress at the physical level

What Therapy? n n n 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 Elder. Care Gatekeeper Training 36

Possible Sources Of Depression Ø Genetic: a predisposition to this problem may be present, and depressive diseases seem to run in families Ø Predisposing factors: Childhood traumas, car accidents, brain injuries, abuse and domestic violence, poor parenting, growing up in an alcoholic home, chemotherapy Ø 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) Elder. Care Gatekeeper Training 37

What Happens If We Don’t Treat Depression? Ø Significant risk of increased alcohol and drug use Ø Significant relationship problems Ø Withdrawal from daily activities, self-care Ø High risk for suicidal thoughts, attempts, and possibly death (Surgeon General’s Call To Action, 1999) Elder. Care Gatekeeper Training 38

PCP’s 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 Ø Because of the stigma that is still attached to this diagnosis, somatic symptoms may become the focus of complaint Ø There may be much denial and minimizing of affective symptoms Ø Elder. Care Gatekeeper Training (Empfield, 2003) 39

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

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

Medicare Expenditures For Mental Health Services Ø Total 1998 Medicare Health care Expenditures: 211. 4 Billion Ø Total Mental Health Expenditures: 1. 2 Billion (0. 57%) Ø Outpatient Mental Health Expenditures: 718 Million (0. 34%) CMS, 2001 Elder. Care Gatekeeper Training 42

Expenditures On NIMH Newly Funded Grants Elder. Care Gatekeeper Training 43

Falling Through The Cracks Ø Community Mental Health Services l l l Ø Principal Providers of Mental Health Care: l l Ø Under-serve older persons Lack staff trained to address medical needs Often lack age-appropriate services Primary Care Physicians Long-term Care Facilities Medicare l l Incomplete outpatient prescription drug coverage Lack of mental health parity Elder. Care Gatekeeper Training 44

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

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

Unmet Need For Mental Health Services In Nursing Homes Ø Ø Ø 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 l Ø Least Likely to get help -Oldest, most physically impaired Among the Most Common Disorders l l l Dementia Depression Anxiety Disorders and Psychotic Disorders (Burns et al. , 1993 Burns & Taube, 1990, 1991, Rovner et al. , 1990 Shea et al. , Smyer et al. , 1994) Elder. Care Gatekeeper Training 47

Illness And Depression is common among older patients with certain medical disorders Ø Associated with worse health outcomes Ø l l Ø 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 Alzheimer’s disease Arthritis Parkinson’s disease l Ø In heart attack patients, depression is a significant predictor of death at 6 months (Empfield, 2003) Elder. Care Gatekeeper Training 48

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

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

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 person’s level of function and quality of life Ø Treatment may help patients accept medical treatment that they otherwise might refuse because of feelings of hopelessness or futility Ø Treatment also helps enhance or recover coping skills needed to deal with the inevitable losses associated with chronic medical illness Ø Elder. Care Gatekeeper Training (Empfield, 2003) 51

Efficacy Of Psychosocial Treatments For Geriatric Depression Substantial evidence exists that psychosocial treatment is effective for patients with depression Ø Problem solving or Cognitive-Behavioral therapy is superior for the management of geriatric depression Ø 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 Ø Many older patients have chronic depression which requires indefinite maintenance Ø Elder. Care Gatekeeper Training (Empfield, 2003) 52

What We Need To Know Ø 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? Ø What to look for Ø How to talk to a depressed/suicidal person Ø How to get help Elder. Care Gatekeeper Training 53

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 won’t really follow through False – many people who complete suicide talk about it often before they actually do it Elder. Care Gatekeeper Training (AFSP website, 2003) 54

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. They’re just trying to get attention False – They are trying to get help. We should recognize that need and respond to it Elder. Care Gatekeeper Training 55

Suicide myths, continued: 6. Suicide is a city problem, not in the country or a small town False – rural areas have higher suicide rates than urban areas 7. Once a person decides to die nothing can stop them - They really want to die NO - most people want to be stopped – if we don’t 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 Elder. Care Gatekeeper Training )56 (AFSP website, 2003

How Do I Know If Someone Is Suicidal? Now we understand the connection between depression and suicide Ø We have reviewed what a depressed person looks like Ø Not all depressed people are suicidal – how can we tell? Ø Suicides don’t happen without warning - verbal and behavioral clues are present, but we may notice them Ø Elder. Care Gatekeeper Training 57

Verbal Expressions Ø Common statements l l l l 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 Elder. Care Gatekeeper Training 58

Some Behavioral Warning Signs Ø Common signs l l l l 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" Elder. Care Gatekeeper Training 59

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 Ø Depression is an illness, like heart disease, and suicidal thoughts are a crisis, like a heart attack Ø You would not leave a heart attack victim lying on the sidewalk. You would make some attempt to administer CPR Ø Anyone can learn to ask the right questions to help a depressed and suicidal person Ø Elder. Care Gatekeeper Training 60

What Stops Us? Most of us still believe suicide and depression are “none of our business” Ø Most are fearful of getting a yes answer Ø What if: we knew how to respond to “yes”? Ø l l l 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? Elder. Care Gatekeeper Training 61

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

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

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

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

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

Ø But when someone is suicidal, a true friend learns how to listen Elder. Care Gatekeeper Training 67

Don’t… Make moral judgments Ø Argue lecture, or encourage guilt Ø Promise total confidentiality/offer reassurances that may not be true Ø Offer empty reassurances – “you’ll get over this” Ø Minimize the problem -“All you need is a good night’s sleep” Ø Dare the suicidal person- “You won’t really do it” Ø Use reverse psychology - “Go ahead and kill yourself” Ø Leave the person alone Ø Ø Never Go It Alone Elder. Care Gatekeeper Training 68

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

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 Elder. Care Gatekeeper Training 70

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 one’s 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 • Elder. Care Gatekeeper Training (Empfield, 2003) 71

Bereavement After A Suicide Loss Compared with homicide, accidental death or natural death, suicide death is very difficult for family members to resolve Ø Family members experience: Ø l l l Ø 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) Elder. Care Gatekeeper Training 72

Impact Of Depression On Religious Beliefs Ø Ø Ø 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) Elder. Care Gatekeeper Training 73

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

Outreach Programs Ø “Gatekeeper” Model l l 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 Elder. Care Gatekeeper Training 75

Caregiver Support Interventions Ø 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) Ø Improved Caregiver Mental Health -Decreased incidence and severity of depression -Improved health (e. g. , lowered blood pressure) -Improved stress management (Sorensen, Pinquart, Duberstein, 2002) Elder. Care Gatekeeper Training 76

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

Websites For Additional Information Ø Ø 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 Ø Ø 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 Elder. Care Gatekeeper Training 78

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 Ø You would try CPR if you saw a heart attack victim Ø Don’t be afraid to “interfere” when someone is dying more slowly of depression Ø Depression is a treatable disorder Ø Suicide is a preventable death Ø Elder. Care Gatekeeper Training 79

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 Elder. Care Gatekeeper Training 80

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. ” Administration on Aging, 2000 Elder. Care Gatekeeper Training 81

Ø 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. Elder. Care Gatekeeper Training 82

A Brief Bibliography Ø Ø 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 Elder. Care Gatekeeper Training 83

Ø 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. Ø Jamison, K. R. , (1999). Night Falls Fast: Understanding Suicide. Alfred Knopf. Ø Lester, D. (1998). Making Sense of Suicide: An In -Depth Look at Why People Kill Themselves. American Psychiatric Press. Ø Elder. Care Gatekeeper Training 84

Ø Mc. Leod, D. “Elderly suicides: the religious divide”, Guasrdian unlimited, 2001, Feb 5. Ø 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. Ø Quinnett, P. G. (2000). Counseling Suicidal People. QPR Institute, Spokane, WA. Ø President’s New Freedom Council on Mental Health, 2003. Ø Rando, T. (1988). Grieving. Lexington, MA: Lexington Books. Elder. Care Gatekeeper Training 85

Ø 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. Ø Styron, W. (1992). Darkness Visible. Vintage Books. Ø Surgeon General’s Call to Action (1999). Department of Health and Human Services, U. S. Public Health Service. Ø Ø Tang, T. Z. & De Rubeis, R. J. ((1999). “Sudden Gains and critical sessions in cognitive-behavioral therapy for depression”. Journal of Consulting and Clinical Psychology 67: 894 -904. Elder. Care Gatekeeper Training 86