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SAVING LIVES: Understanding Depression And Suicide In The Elderly

This training program aims to increase awareness about the connection between depression and suicide in the elderly population. It also aims to dispel myths and misconceptions surrounding suicide in the elderly, as well as provide knowledge on risk factors and signs of suicidal behavior. Developed by Ellen Anderson, Ph.D., PCC, Sponsored by the Ohio Department of Mental Health, the Ohio Suicide Prevention Foundation, and local Suicide Prevention Coalitions.

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SAVING LIVES: Understanding Depression And Suicide In The Elderly

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  1. 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

  2. “The capacity of an individual with mental or behavioral problems to respond to mental health interventions knows no end-point in the life cycle. Even serious mental disorders in later life can respond to clinical interventions and rehabilitation strategies aimed at preventing excess disability in affected individuals.” C Everett Koop, Surgeon General’s Workshop Health Promotion and Aging, 1988 ElderCare Gatekeeper Training

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

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

  5. 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 ElderCare Gatekeeper Training

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

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

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

  9. 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 ElderCare Gatekeeper Training

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

  11. 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 Prevention Strategies ElderCare Gatekeeper Training

  12. 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 ElderCare Gatekeeper Training

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

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

  15. 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) ElderCare Gatekeeper Training

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

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

  18. The Gender Issue • Women perceived as being at higher risk than men • Women do make attempts 4 x as often as men • But - Men complete suicide 4 x as often as women • 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? ElderCare Gatekeeper Training

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

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

  21. Suicide Rate By Age Per 100,000 Older people: 12.7% of 1999 population, but 18.8% of suicides.(Hovert, 1999;Bartels, 2003) ElderCare Gatekeeper Training

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

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

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

  25. Depression Is An Illness • Suicide has been viewed for countless generations as: • a moral failing, a spiritual weakness • an inability to cope with life • “the 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 ElderCare Gatekeeper Training

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

  27. 20 years of brain research teaches that these symptoms are the behavioral result of • Internalchanges 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) ElderCare Gatekeeper Training

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

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

  30. ElderCare Gatekeeper Training

  31. Where It Hits Us ElderCare Gatekeeper Training

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

  33. As damage occurs, thinking changes in the predictable ways identified in our list of 10 criteria • “Thought constriction” can lead to the idea that suicide is the only option • How do antidepressants affect this “brain damage”? • They maycounter 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) ElderCare Gatekeeper Training

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

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

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

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

  38. What Happens If We Don’tTreat 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) ElderCare Gatekeeper Training

  39. 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 (Empfield, 2003) ElderCare Gatekeeper Training

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

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

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

  43. Expenditures On NIMH Newly Funded Grants ElderCare Gatekeeper Training

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

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

  46. 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) ElderCare Gatekeeper Training

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

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

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

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

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