Suicide & Older Adults Julie E. Malphurs, PhD

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1 Suicide & Older Adults Julie E. Malphurs, PhD Lead Program Analyst, Mental Health Service Miami VA Healthcare System & Asst. Professor of Research Department of Psychiatry and Behavioral Science Center on Aging Miller School of Medicine, University of Miami

2 Disclosures Employee at the Miami VAHS No financial relationships with any commercial interests to report

4 Major Depression 16.2% of US population report at least one lifetime episode 17 million U.S. adults each year More than half of patients have first episode by age 40 Duration: 6 months 2 years if left untreated About 2/3 will respond to first treatment choice 50% of those will achieve full remission Depression Guideline Panel. Depression in Primary Care: Vol 1. Detection and Diagnosis. Clinical Practice Guideline No. 5. Rockville, MD: US Dept of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research; no ; Kessler RC et al. J Affect Disord. 1993;29: Kessler et al., JAMA 2003

adults each year More than half of patients have first episode by age 40 Duration: 6 months 2 years if left untreated About 2/3 will respond to first treatment

6 Late-Life Depression Incidence of major depression declines with age, but minor depression is much more common Depressive symptoms occur in 15% 25% of older adults (>65 years) that fail to meet criteria but cause distress and interfere with functioning Fewer than half of depressed seniors are recognized as being depressed and of those who are identified fewer than half receive treatment U.S. Dept of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, NIH, NIMH, 1999; JAGS December 2007

of those who are identified fewer than half receive treatment U.S. Dept of Health and Human Services. Mental Health: A Report of the Surgeon General.

7 Secondary Depression Depression increases with other comorbidities: 11.5% of Elderly Hospital Patients 13.5% of those who require home healthcare Depression is associated with increased risk of CAD and DM II among other diseases

5% of those who require home healthcare Depression is

9 Unexplained Physical Symptoms Major Depression Dizziness Joint Pains Fatigue Back Pain Muscle Pain Weakness Abdominal Pain Chest Pain Physical Illness

11 Major Depression Is Associated with Chronic Medical Illness % 25% Prevalence of Major Depression (%) % 10% 6% 14% 5 2% 4% 0 Community Primary Care Clinic Medical Inpatient Setting Nursing Home Katon W, Schulberg H. Gen Hosp Psychiatry. 1992;14: Rosen J, Mulsant BH, Pollock BG. Nursing Home Med. 1997;5:

Clinic Medical Inpatient Setting Nursing Home Katon W, Schulberg H.

13 Impact of Untreated Depression: Morbidity & Mortality Patient morbidity Poorer health outcomes Suicide attempts Accidents Lost jobs Alcohol Use & Abuse Marital Problems Mortality Older white men have highest suicide rates Fatal accidents Death due to related medical complications Societal costs Caregiver burden Higher medical costs Increased healthcare utilization Preskorn SH. Outpatient Management of Depression: A Guide for the Primary Care Practitioner. 2nd ed. Caddo, OK: Professional Communications, Inc.; 1999: Chapter 2.

medical complications Societal costs Caregiver burden Higher medical costs Increased healthcare utilization Preskorn SH.

14 Ethnic Minority Elderly and Depression HISPANIC >65 will increase by more than 450% by 2050 Depressive disorder prevalence in primary care increased from 4.5% to 8.6% between Higher prevalence of depressive symptoms (11-40%) Higher depressionassociated mortality from both suicide and medical disorders AFRICAN-AMERICAN >65 will increase by 131% by 2030 Lower rates of depression recognition and treatment Poorer medical outcomes associated with comorbid depression (EX: diabetes and stroke/hyperglycemia/renal failure/hypertriglyceridemia)

6% between 1992-97 Higher prevalence of depressive symptoms (11-40%) Higher depressionassociated mortality from both suicide and medical

15 Fewer than half of depressed persons are recognized as being depressed and of those who are identified fewer than half receive treatment.

16 In 2010, the number of deaths by suicide (worldwide) outnumbered all deaths from war, murder, and forces of nature combined

17 Suicide The elderly make up 12.9% of the population and account for 15.9% of the suicides In 2009 the suicide rate was 14.8 per 100,000 for those 65 and older General population suicide rate : 11 per 100,000 That equates to 1 suicide every 90 minutes, 16 a day, 5858 in a year

18 Suicide and Lifetime Axis I Diagnosis By Age Affective syndromes Other (primary psychosis, ETOH, substance, etc) No diagnosis Conwell, Am J Psychiatry, 1994

20 The suicide rates for men increases with age, most significantly after age 65. The rate of suicide in men 85+ is four times the national average : 48.8 per 100,000 The suicide rates for women peaks between the ages of years old, and again after age 75. Statistics from Centers for Disease Control (2009) via American Foundation for Suicide Prevention (2012)

8 per 100,000 The suicide rates for women peaks between the ages of 45-54 years old, and

21 Suicide Attempts 12.8% repeat self-harm within 12 months 1.5 % die by suicide within 12 months Risk Factors History of self-harm Previous psychiatric treatment Age Murphy E, Kapur N, Webb R, Purandare N, Hawton K, Bergen H, Waters K, Cooper J. Risk factors for repetition and suicide following self-harm in older adults: multicentre cohort study. Br J Psychiatry Dec 8

22 Suicide Rates* Among Persons Ages 65 Years and Older, by Race/Ethnicity and Sex, United States, During , the highest suicide rates for males ages 65 and older were among the Non-Hispanic Whites with suicides per 100,000 and the highest rates for females ages 65 and older were among the Asian/Pacific Islanders with 6.43 suicides per 100,000. Statistics from Centers for Disease Control (2009)

23 Statistics from Centers for Disease Control (2009) via American Foundation for Suicide Prevention (2012)

25 Percentage of Suicides Among Persons Ages 65 Years and Older, by Race/Ethnicity and Mechanism, United States, During , the greatest percentage of suicides occurred by firearm among all race/ethnicity groups for persons ages 65 years and older (Non-Hispanic Whites: 74.3%, Non- Hispanic Blacks: 75.5%, Hispanics: 50.4%, American Indian/Alaskan Natives: 69.2%) except for Asian/Pacific Islanders. Statistics from Centers for Disease Control (2009)

26 Percentage of Suicides, by Age Group, Sex and Mechanism, United States, During , the greatest percentage of suicides among males in each age group, years, years, and 65 years and older occurred by firearms (51.9%, 53.3%, and 79.2%, respectively). The greatest percentage of suicides among females ages years occurred by suffocation (43.0%). The greatest percentage of suicides among females ages years occurred by poisoning (42.5%) and firearms (35.2%) among females 65 years and older. Statistics from Centers for Disease Control (2009)

27 Suicide & Older Veterans PTSD Vietnam veterans Homelessness Substance Abuse/Mental Health Disorders Schinka JA, Schinka KC, Casey RJ, Kasprow W, Bossarte RM. Suicidal behavior in a national sample of older homeless veterans. American Journal of Public Health 2012; 102: Suppl 1, S147-S153. Mrnak-Meyer J, Tate SR, Tripp JC, Worley MJ, Jajodia A, McQuaid JR. Predictors of suicide-related hospitalization among US veterans receiving treatment for co-morbid depression and substance dependence: who is the riskiest of the risky? Suicide & Life Threatening Behavior 2011; 41: Kaplan MS, McFarland BH, Huguet N, Valenstein M. Suicide risk and precipitating circumstances among young, middle-aged, and older male veterans. American Journal of Public Health 2012; 102: S131-S137.

28 Murder-Suicide in Older Adults Malphurs JE, Cohen D. A state-wide case-control study of spousal homicide-suicide in older persons. American Journal of Geriatric Psychiatry, 2005; 13: Malphurs JE & Cohen D. Newspapers as a source of surveillance data for homicide-suicides. American Journal of Forensic Medicine and Pathology, 2002; 23: Malphurs JE, Cohen D & Eisdorfer C. Antecedents of homicide-suicide and suicide among older married men. American Journal of Geriatric Psychiatry, 2001; 9:49-57.

30 Tale of Love and Illness Ends in Deaths Charles D. Snelling and his wife, Adrienne Willie Jefferson, and his wife Mary

31 National Strategy for Suicide Prevention Guidelines set by the NIH and Surgeon General for implementation by 2005, including: Increase proportion of primary care clinicians and other health care providers who routinely assess the presence of lethal means in the home (5.1) Incorporate screening for depression, substance abuse and suicide risk as a minimum standard of care for assessment in primary care settings, hospice, and skilled nursing facilities for all federally-supported healthcare programs (7.9)

32 Risk Factors Recent death of a loved one Physical illness Uncontrolled pain or fear of prolonged illness Perceived poor health Social isolation or loneliness Caregiving Major changes in life (e.g. retirement)

33 Assessment of Risk Columbia-Suicide Severity Rating Scale (C-SSRS) Assesses suicidal ideation and behavior ALSO identifies risk factors and those at risk Alcohol and other substance abuse do NOT play a diminishing role late in life Firearms are used in 72.5% of all suicide attempts in the elderly. Men use them more For all ages, there is 1 completion for every attempts; for the elderly, the completion is 1 in 4 attempts.

35 Responding to Suicide Risk Assure the patient s immediate safety and determine most appropriate treatment setting Refer for MH treatment and assure that follow-up is made Inform and involve someone close to the patient Limit access to means of suicide Increase frequency of contact and make a commitment to work with patient through current crisis

37 National Suicide Hotline Resource TALK (8255)

38 Questions?

Bipolar Disorder and Substance Abuse Joseph Goldberg, MD

Bipolar Disorder and Substance Abuse Joseph Goldberg, MD Diabetes and Depression in Older Adults: A Telehealth Intervention Julie E. Malphurs, PhD Asst. Professor of Psychiatry and Behavioral Science Miller School of Medicine, University of Miami Research Coordinator,