Transcript Understanding Depression and Suicide In The Elderly

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, 20032008
“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
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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
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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 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.”
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 Parkinson’s
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
General suicide and
depression awareness
education
 Depression Screening
programs

 Community
Gatekeeper
Trainings
Crisis Centers and
hotlines
 Peer support programs
 Restriction of access to
lethal means
 Intervention after a
suicide

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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
 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, EMT’s, 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
 32,467 people in 2005 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 General’s Report on Suicide, 1999)
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Comparative Rates Of U.S. Suicides-2003
 Rates
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per 100,000 population
National average
White males
Hispanic males
African-American males
Asians
Caucasian females
African American females
Males over 85
- 11.1 per 100,000*
- 18
- 10.3
- 9.1 **
- 5.2
- 4.8
- 1.5
- 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 19641972, we lost 55,000 troops, and 220,000
people to suicide
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The Gender Issue
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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
Women’s risk rises until midlife, then decreases
Men’s risk, always higher than women’s, 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
% Suicide per 100,000
25%
20%
15%
10%
5%
0%
15-24
25-34
35-44
45-54 55-64
Age
65-74
75-84
85+
Older people: 12.7% of 1999 population, but 18.8% of suicides.
(Hovert, 1999;Bartels, 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
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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)
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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
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Suicide has been viewed for countless generations
as:
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a moral failing, a spiritual weakness
an inability to cope with life
“the coward’s way out”
A character flaw
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
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
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)
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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 General’s Call To Action, 1999, Stoff & Mann, 1997, The
Neurobiology of Suicide)
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Faulty Wiring?
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Literally, damage to certain nerve cells in our brains
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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?
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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
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(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?
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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?
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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 (evidencebased)
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 Don’t
Treat 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 General’s Call To Action, 1999)
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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
 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
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(Empfield, 2003)
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Elders Have Additional Issues
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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
(President’s New Freedom Commission on Mental Health, 2003
Jeste, et al., 1999; www.census.gov)
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Barriers To MH Care
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Fragmented service delivery system
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Out of date Medicare policies
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Stigma due to mental illness and advanced age
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Mismatch between services that are covered and those
preferred by older persons
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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
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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
250
Millions of Dollars
200
Total NIMH
Grants
150
Aging
Grants
100
50
0
1995
1996
1997
1998
Fiscal Year
1999
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Falling Through The Cracks
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Community Mental Health Services
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Principal Providers of Mental Health Care:
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Under-serve older persons
Lack staff trained to address medical needs
Often lack age-appropriate services
Primary Care Physicians
Long-term Care Facilities
Medicare
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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
> 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
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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
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Least Likely to get help -Oldest, most physically impaired
Among the Most Common Disorders
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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
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Medical illness greatly increases the risk for depression
particularly in:
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Greater use and costs of medications
Greater use of health services
Ischemic heart disease (e.g. MI, CABG)
Stroke
Cancer
Chronic lung disease Alzheimer’s
disease Arthritis
Parkinson’s disease
In heart attack patients, depression is a significant
predictor of death at 6 months
(Empfield,
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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%
patients - 20%
 In nursing homes, regardless of physical health,
major depression increases the likelihood of
mortality by 59% in one year
 Hospitalized
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(Empfield,49
2003)
Depression Associated With Worse
Health Outcomes
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Worse outcomes
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Hip fractures
Myocardial infarction
• Increased mortality rates for Myocardial Infarction (Frasure-Smith 1993, 1995)
 In
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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 person’s 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
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(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
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(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 won’t 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. They’re 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:
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
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(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 don’t happen without
warning - verbal and behavioral
clues are present, but we may not
notice them
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Verbal Expressions
 Common
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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
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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”?
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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, don’t 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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Don’t…








Make moral judgments
Argue lecture, or encourage guilt
Promise total confidentiality/offer reassurances that may
not be true
Offer empty reassurances – “you’ll get over this”
Minimize the problem -“All you need is a good night’s
sleep”
Dare the suicidal person- “You won’t 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 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
(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;)
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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
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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)
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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)
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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

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Permanent SolutionTemporary 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
Don’t be afraid to “interfere” when someone is dying
more slowly of depression
Depression is a treatable disorder
Suicide is a preventable death
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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
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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
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 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.
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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
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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. JosseyBass.
 Jamison, K.R., (1999). Night Falls Fast: Understanding
Suicide. Alfred Knopf .
 Lester, D. (1998). Making Sense of Suicide: An InDepth Look at Why People Kill Themselves. American
Psychiatric Press.

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McLeod, D. “Elderly suicides: the religious divide”,
Guasrdian unlimited, 2001, Feb 5.
 Martin, W. Religiosity and US suicide rates, 19721978. 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.
President’s New Freedom Council on Mental Health,
2003.
 Rando, T. (1988). Grieving. Lexington, MA:
Lexington Books.

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
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 General’s 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-behavioral therapy for depression”. Journal of
Consulting and Clinical Psychology 67: 894-904.
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