Older Adult Suicide Prevention - NCOA · 2019-02-04 · selor uses techniq ues drawn from motivational interviewing to help mobilize an individual¶s i ntrinsic motivati on to seek
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Quijano, L. M., Stanley, M. A., Petersen, N. J., Casado, B. L., Steinberg, E. H., Cully, J. A., & Wilson, N. L. (2007). Healthy I.D.E.A.S: A depression intervention delivered by community-based case managers serving older adults. Journal of Applied Gerontology, 26 (2), 139-156.
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“Open Door”
Brief, individualized
intervention to identify &
address barriers to
engagement in MH treatment
for older adults whose
depression was detected by
aging services.
oMajor Depression 51%
oSuicide ideation 29%31
Sirey et al., (2013). Improving engagement in mental health treatment for home meal recipients with depression. Clinical Interventions in Aging, 8, 1305-1312.
Open Door
5 steps in Open Door:
1. Recommend referral for MH treatment
2. Conduct barriers assessment
3. Define personal goal (that could be achieved
with MH care)
4. Provide education about depression treatment
options
5. Address barriers to accessing care.
32
Open Door
33
Clinical Interventions in Aging 2013:8submit your manuscript | www.dovepress.com
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Sirey et al
Engagement interventionThe Open Door intervention is a brief, individualized inter-
vention to identify and address barriers to engagement in
mental health treatment among older persons whose depres-
sion is detected in aging service settings. The premise of the
intervention is that by collaboratively engaging the older
adult in the process of seeking mental health treatment,
the intervention both creates an engagement plan that is
personalized and models the collaborative process of qual-
ity mental health treatment.42 A referral is the first step to
engagement, but often referrals are not accepted. The Open
Door intervention is conducted during three face-to-face,
30-minute intervention meetings in the client’s home with
one telephone follow-up. The Open Door intervention was
taught during a two-day training provided by the principal
study investigator (JAS) with weekly supervision provided
for the first 6 months followed by monthly supervision
thereafter.
There are five steps to the Open Door intervention: rec-
ommend referral, conduct a barriers assessment, define a
personal goal that could be achieved with care, provide educa-
tion about depression treatment options, and finally, address
the barriers to accessing care. The Open Door counselor
serves a similar function as the patient navigator whose role
in a hospital setting is to improve access to cancer screening
and treatment.43,44 The Open Door intervention is different
from other engagement interventions in two ways. First, the
barriers assessed as part of the intervention are empirically
defined from research identifying health beliefs and attitudes
that predict poor treatment participation outcomes, such as
not initiating care,45 dropping out,46 or not following a medi-
cation regimen.47 Second, the individualized assessment of
barriers goes beyond rational decision-making to elicit the
beliefs and concerns, including irrational ideas, that may be
underlying the reluctance to seek mental health treatment.
In some instances, the intervention allows the client to
articulate the fears that s/he may be self-conscious about
admitting, but have become the basis for not seeking mental
health treatment.
During the Open Door intervention meetings, the coun-
selor uses techniques drawn from motivational interviewing
to help mobilize an individual’s intrinsic motivation to
seek help.48 The client and counselor use problem-solving
techniques to brainstorm about solutions to barriers,
weigh the options, and create a specif ic plan to seek
mental health treatment. Sample intervention strategies
are shown in Table 1. The client’s treatment modality and
setting preferences are assessed using a scripted presenta-
tion of the available treatment options (eg, primary care
physician, mental health provider, research protocol). By
participating in this process, the Open Door intervention
addresses not only the referral, but also the first steps of
the treatment process.
Prior to the current study, a small feasibility pilot was
conducted with the Department of Senior Programs and
Services, which had documented a 22% (18/117) acceptance
rate of referrals to a mental health resource using their usual
referral procedures. In this feasibility pilot, home meal
program participants who screened positive for depression
on the Patient Health Questionnaire-9 were referred to a
mental health resource using the Open Door intervention.
Of the 29 participants referred, 20 (62%) accepted a referral
to mental health treatment and scheduled a first appointment
to be seen by a clinician. This feasibility study supported
Table 1 Examples of Open Door intervention
Psychologic barrier Open Door intervention activity Source of technique
(PST, MI, or PE)
Outcome
Personal stigma concern:
“My neighbor will not include
me if she thinks I’m crazy.”
Validate concern (stigma is real!)
Defin
e
di scl os ure opt ions
Emphasize personal choice
Review pros and cons of each option
MI – refle
c
t i ve listeni ng and emp athy
PST – brainstorming
MI – collaboration
PST – identify pros and cons and compare
Support
More hope
Less helplessness
Action plan
Treatment effic
a
cy concerns :
“What’s talking going to do?
Nothing can change.”
Identify hopeless as symptoms
of depression
Identify what she wishes to change
Link goal with treatment outcome
PE- – education about depression
PST – identify a goal
PE – review psychotherapy effic
a
cy data
and discuss the process of seeking care
Increase in knowledge
Increased motivation
Engagement
Attribution of depression symptoms:
“It’s the diabetes and my age
that cause my troubles”
Validate overlap of medical and
psychologic symptoms
Describe symptoms of depression
Review myths and potential for
misattribution
PE – depression symptom and medical
symptom overlap
PE – information on depression
PE – discuss myths and stereotypes
Increased knowledge
Increased perceived
need for treatment
Abbreviations: PE, psychoeducation; P ST, problem-solving therapy; MI, motivational interviewing.
PEARLSThe Program to Encourage Active & Rewarding
Lives for Seniors
PEARLS is an evidence-based program
designed to improve the detection and
treatment of late-life depression within aging
services.
oProblem Solving Therapy, Activity Scheduling, plus
collaborative depression care management by a
multidisciplinary team
http://www.pearlsprogram.org34
PEARLS% with at least a 50% reduction in
depression severity score at 6 month f/u8
92
Yes
No
35
54
46 Yes
No
Usual Care, n=66 PEARLS, n= 72
Ciechanowski et al., (2004). Community-Integrated Home-Based Depression Treatment in Older Adults. A Randomized Controlled Trial. JAMA, 291, 1569-1577.
SPECTRUM OF ASN DEPRESSION CARE
None Mild Mod Severe
ASN
CAU
Augmented
ASNCAU
(E.g., PEARLS)
Collaborative
Care
Management(ASN + MH + PC)
Illness complexity (severity; med comorbidity)
Menta
l H
ealth
SELECTIVE PREVENTION
High-risk groups, though not all members
bear risks – prevention through reducing
risks.
Tele-Help/Tele-Check Service for the Elderly
18,641 service users in Padua, Italy
January 1, 1988 thru December 31, 1998
Mean age = 80.0 years
84% women, 73% lived alone
Suicides observed = 6
expected = 20.9
Among women
DeLeo et al., Br J Psychiatry 181:226-229, 2002
Massachusetts Telehelp - TelecheckElder Community Care can provide:
oComprehensive mental health/substance abuse
assessment
oIn-home counseling
oTelephone call befriending service (TeleConnect)
oIn-home personal monitoring system (TeleHelp)
oAccess to 24 hour emergency response
oMedication management by a psychiatric nurse
practitioner.
oReferral to community resources and services39http://www.eldercommunitycare.org/
40
http://www.ioaging.org/services/all-inclusive-
health-care/friendship-line/
OBJECTIVE: To examine whether linking
socially disconnected seniors with peer supports
is effective in reducing risk for suicide.
DESIGN
o Sample: Primary care patients ≥60 yrs who self-
identify as lonely or a burden on others
o RCT comparing
• CAU (n=200)
• TSC (n=200) – peer companion
THE SENIOR CONNECTION (TSC)
U01 CE001942-01
TSC Intervention – Anticipated Outcomes
Reduced…
o Loneliness, burdensomeness
(psychological disconnectedness)
o Depression, SI, worthlessness
Improved …
o Structural connectedness
o Physical health
oWell-being
UNIVERSAL PREVENTION
Focused on the entire population as the
target – prevention through reducing risk
and enhancing health.
QPRQuestion, Persuade, Refer
Considered a “best practice” intervention
oby SAMHSA & Suicide Prevention Resource Center
Target of intervention is gatekeepers
1 to 2 hour education program
othink CPR but for suicide prevention.
Empirically shown to increase:
oknowledge and self-efficacy about helping identify and
refer suicidal individuals, including older adults
44Wyman et al., (2008); Matthieu et al. (2008); Cross et al. (2011)
Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities.
HHS Publication No. SMA 4515, CMHS-NSPL-0197. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.
Suicide in late-life is not an expected or “normal” response to the stresses of aging
• Resiliency• Positive emotions
• Emotion regulation
• Closeness in
relationshipsCharles & Carstensen (2010) ;
Gatz et al. 1996
• Risk• psychiatric illness
• social
disconnectedness
• functional impairment
• physical illness
• pain
Conwell, Y., Van Orden, K., & Caine, E. (2011). Suicide in Older Adults. Psychiatric Clinics of North America; Van Orden & Conwell (2011). Suicides in Late Life. Current Psychiatry Reports.
Helpful review articlesHelpful Review ArticlesConwell, Y., Van Orden, K., & Caine, E. D. (2011). Suicide in older adults. The Psychiatric Clinics of
North America, 34(2), 451-468. doi: 10.1016/j.psc.2011.02.002. NIHMSID # 278215
Lapierre, S., Erlangsen, A., Waern, M., De Leo, D., Oyama, H., Scocco, P., . . . Quinnett, P. (2011). A
systematic review of elderly suicide prevention programs. Crisis: The Journal of Crisis Intervention
and Suicide Prevention, 32(2), 88-98.
Rudd, M. D., Berman, A. L., Joiner, T. E., Jr., Nock, M. K., Silverman, M. M., Mandrusiak, M., Van Orden,
K. A., & Witte, T. (2006). Warning signs for suicide: theory, research, and clinical applications.
Statistics are Alarming Depression is not a normal part of aging
Normal thoughts about death are different from suicidal thoughts
It is important to reduce stigma associated with mental health disorders
There is Hope and Help
Protective Factors Appropriate assessment and care for physical
and behavioral health issues
Social connectedness
Sense of purpose or meaning
Resilience around change
Framework for the Toolkits
• Whole Population- Promote the emotional
health of all older adults
• At Risk-Recognize and respond to individuals at
risk
• Crisis Response-Respond to a suicide attempt
or death
(Langford, L. 2008. A Framework for Mental Health Promotion and Suicide Prevention in Senior Living Communities)
62
Audience for the Toolkit
• Senior Center staff and volunteers
• Community service providers for older adults (e.g., meals on wheels, transportation, home care)
• Behavioral health professionals
63
The Role of Senior Centers & Their Partners in Addressing Suicide
1. Provide activities that increase the emotional well-being of all participants
2. Identify and get help for those individuals at risk of suicide
3. Respond to a suicide death or attempt
64
Activities that increase the emotional well-being of all their participants
65
Identifying and getting help for individuals at risk of suicide
Train staff and volunteers
Refer to mental health providers
Conduct screening
Provide counseling
66
Providing Support after a Suicide
Postvention protocols
Community support meetings
Mental health counseling
67
Resources in Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Centers
68
For more information
• Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Centers: http://store.samhsa.gov/product/Promoting-Emotional-Health-and-Preventing-Suicide/SMA15-4416
• Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities: http://store.samhsa.gov/product/SMA10-4515