Suicide Prevention for the Elderly

1. Suicide Prevention for the Elderly Family Service Agency, January 9, 2008 Jim Hawkins, MD Adjunct Clinical Associate Professor Department of Psychiatry and Behavioral Science Stanford University

2. Scope of the Problem • 6300 elderly commit suicide every year • 18 elderly commit suicide every day • Older adults have the highest suicide rate • Seldom occurs as a result of a single event • Helplessness, hopelessness are major factors • You can help prevent a suicide

3. Major risk factors • Death of a loved one • Chronic pain – physical or psychiatric • Social isolation • Loneliness • Substance abuse, especially alcohol • Changes in social roles • Intense humiliation / loss of face (more likely in Asian patients)

4. Clues / Risk factors • Changes in eating or sleeping habits • Unexplained fatigue or apathy • Trouble concentrating or being indecisive • Crying for no apparent reason • Inability to feel good about themselves or unable to express joy • Behavior changes or are just "not themselves"

5. More clues / risk factors • Withdrawal from family, friends or social activities • Talk about or seem preoccupied with death • Give away prized possessions • Take unnecessary risks • Have had a recent loss or expect one • Increase their use of alcohol, drugs or other medications

6. More clues / risk factors • Failure to take prescribed medicines or follow required diets • Acquire a weapon • Prolonged sad mood (more than just a few days) • Impulsive nature • Loss of interest in hobbies, work, etc. • Loss of interest in personal appearance • Male sex • Older male sex, alcoholic, alone in life, no friends

7. Somewhat lower risk factors • Transient sad mood • Female sex • No substance abuse • Family members and friends • Reactive mood • Can think of something that would help him/her feel better • Roman Catholic

8. Assessment • ASK! • You cannot prevent a suicide if you don’t ask the patient • You will not “suggest” suicide by asking the patient (a common ‘myth’)

9. How to ask: – some suggestions • Build rapport • Let the patient tell his/her own story • Can you tell me more about what has been happening to you? • Give empathy and sympathy • It sounds like life has really been difficult for you • I’m sorry things have not been going well. I hope I can help you

10. How to ask: more suggestions on what to say • People often ashamed to tell what they have been thinking • Create commonality • Other people, like you, who have been having a really rough time, have told me that they feel life is no longer worth living • Have you had such thoughts? • Can you tell me more about those thoughts?

11. How to ask: more suggestions on what to say • Have you had thoughts about ending your life? • How long have you been feeling this way? • If “yes,” consider asking the following: • Do you have a plan? • How would you do it? • Do you have the means to do it? • Pills, gun • Who would be upset if you died?

12. How to ask: more suggestions on what to say • Have you ever made a suicide attempt in the past? • Past history of suicide attempt is often thing of any true predictive value • How many times have you attempted to end your life? • When did you do this? • How did you try to end your life?

13. How to ask: more suggestions on what to say • How likely are you to do it (1 = unlikely, 10 = highly likely)? • Do you have any spiritual orientation? • What do you feel about the meaning of your life? • What could happen that would stop you from trying to end your life? • What could happen to help you feel better?

14. Further elements of a risk assessment • Current suicidal thoughts, intent, and plan • History of suicide attempts (eg. lethality of method, circumstances) • Family history of suicide • History of violence (eg. weapon use, circumstances) • Intensity of current depressive symptoms • Current treatment regimen and response • Recent life stressors (eg, marital separation, job loss) • Alcohol and drug use patterns

15. Further elements of a risk assessment • Psychotic symptoms • Current living situation (eg, social supports, availability of weapon) • Patients with altered perceptions of reality, such as those caused by intoxication or psychosis • Obtain a complete history of alcohol and drug use. • Note whether suicidal thoughts occur during intoxication or sobriety, or both. • The presence of psychotic symptoms in a depressed patient with suicidal ideation is an ominous sign.

16. Diagnostic / symptomatic categories for patients at high risk • Depression • Alcoholism • Chronic non-psychiatric medical illness (demoralization) • Chronic psychiatric medical illness • Mourning / grief • Personality disorders with impulsiveness

17. Diagnostic / symptomatic categories for patients at high risk • Three types of psychotic symptoms are particularly worrisome and could push a patient to commit suicide: • Auditory hallucinations commanding suicidal acts • Thoughts of external control (feeling that an outside force controls one's actions) • Religious preoccupation. • Patients may not readily report these symptoms; collateral interviews with family members can help confirm psychosis.

18. Differential features • Is the patient talking about being discouraged with life because of chronic illness? • Is the patient talking about end of life issues? • Is the patient talking about loss of meaning to life? • Does the patient have a reactive mood? • Is the patient attempting to upset someone with whom they are angry? • Does the patient have true major depression?

19. Sad Persons Scale • S ex (male) • A ge (elderly or adolescent) • D epression • P revious suicide attempts • E thanol abuse • R ational thinking loss (psychosis) • S ocial supports lacking • O rganized plan to commit suicide • N o spouse (divorced > widowed > single) • S ickness (physical illness)

20. Differential features • Has the patient lost the ability to control his/her life (physically or emotionally) • Has the patient lost a sense of meaning to his/her life?

21. Three Groups • It is useful to categorize depressed patients who are potentially suicidal into three groups: • Patients with ideation, plan, and intent • Patients with ideation and plan but without intent, and • Patients with ideation but no plan or intent.

22. Interventions / treatment issues • With all patients, one should employ: • Empathy / sympathy • ‘I care. I would be upset if you ended your life’ • Give 800 number: • National 1-800-273-TALK (8255) • Local (415) 752-3778 • Arrange for frequent visits • Arrange for people at patient’s living place to check the person more often

23. Interventions / treatment issues • Depressed patients with suicidal ideation, plan, and intent should be hospitalized, especially if they have current psychosocial stressors and access to lethal means. • When a patient's life is in imminent danger, the caregiver may breach confidentiality and contact a family member. • Depressed patients who refuse hospitalization may be involuntarilyhospitalized

24. Interventions / treatment issues • Caregivers can contact their local crisis center, or emergency department for assistance in arranging such commitments. • Depressed patients with suicidal ideation and a plan but without intent may be treated on an outpatient basis, especially when they have good social support and no access to lethal means. • However, some of these patients need hospitalization, especially if their environment does not offer adequate safety measures, such as responsible supervision. • Outpatient treatment may consist of antidepressant therapy (preferably with antidepressants that are safe in overdose), referral to a drug and alcohol treatment program, psychotherapy, or all of these.

25. Interventions / treatment issues • Depressed patients who express suicidal ideation but deny plan or intent should be evaluated carefully for psychosocial stressors. • Caregivers should encourage the patient or family members to remove weapons and other potentially lethal means from the patient's environment. • In general, patients in this category may be safely treated with antidepressant medication on an outpatient basis, but they should be seen by their physician often as long as suicidal thoughts persist.

26. Interventions / treatment issues • No suicide contract or “handshake:” • Although some caregivers use a written "no suicide" contract / no suicide handshake with patients • This is never a substitute for a thorough risk assessment. • Many patients who sign such a contract later commit suicide. • Therefore, the use of these contracts / handshake may give caregivers a false sense of security and provides no protection from legal liability

27. The case manager or therapist • How would you feel if a patient of yours ended their life? • Has it ever happened to you? • What things would you do to help yourself? • Seldom is the caregiver / therapist considered after a suicide

28. What are your thoughts? • What did I miss? • What are your comments? • What are some of your experiences? • What has worked for you?