SAVING LIVES: Understanding Depression And Suicide In The Elderly Sponsored by the Ohio Department of Mental Health, The Ohio Suicide Prevention Foundation,

SAVING LIVES:Understanding Depression And Suicide In The Elderly

Sponsored by the Ohio Department of Sponsored by the Ohio Department of Mental Health , The Ohio Suicide Mental Health , The Ohio Suicide

Prevention Foundation, and your local Prevention Foundation, and your local Suicide Prevention CoalitionSuicide Prevention Coalition

Developed by Ellen Anderson, Ph.D., Developed by Ellen Anderson, Ph.D., PCC, 2003-2008PCC, 2003-2008

ElderCare Gatekeeper TrainingElderCare Gatekeeper Training 22

“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


Goals For Suicide Goals For Suicide PreventionPrevention

Increase community awareness that suicide Increase community awareness that suicide is a preventable public health problemis a preventable public health problem

Increase awareness that depression is the Increase awareness that depression is the primary cause of suicideprimary cause of suicide

Change public perception about the stigma Change public perception about the stigma of mental illness, especially about of mental illness, especially about depression and suicidedepression and suicide

Increase the ability of the public to Increase the ability of the public to recognize and intervene when someone recognize and intervene when someone they know is suicidalthey know is suicidal


Training ObjectivesTraining Objectives

Increase knowledge about the causes of Increase knowledge about the causes of suicide among the elderlysuicide among the elderly

Learn the connection between depression Learn the connection between depression and suicideand suicide

Dispel myths and misconceptions about Dispel myths and misconceptions about suicide in the elderlysuicide in the elderly

Learn risk factors and signs of suicidal Learn risk factors and signs of suicidal behavior in the elderlybehavior in the elderly

Learn to assess risk and find help for Learn to assess risk and find help for those at risk – Asking the “S” questionthose at risk – Asking the “S” question


The Feel of DepressionThe Feel of Depression ““What I had begun to discover is that…the grey What I had begun to discover is that…the grey

drizzle of horror induced by depression takes on the drizzle of horror induced by depression takes on the quality of physical pain. But it is not an immediately quality of physical pain. But it is not an immediately identifiable pain, like that of a broken limb. It may identifiable pain, like that of a broken limb. It may be more accurate to say that despair, owing to some be more accurate to say that despair, owing to some evil trick played upon the sick brain…comes to evil trick played upon the sick brain…comes to resemble the diabolical discomfort of being resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there because no breeze stirs this caldron, because there is no escape from this smothering confinement, it is is no escape from this smothering confinement, it is entirely natural that the victim begins to think entirely natural that the victim begins to think ceaselessly of oblivion.”ceaselessly of oblivion.”

William Styron, 1990William Styron, 1990


The Feel of DepressionThe Feel of Depression

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


Mental Illness and StigmaMental Illness and Stigma Historical beliefs about mental illness color the Historical beliefs about mental illness color the

way we approach it even now, and offer us a way way we approach it even now, and offer us a way to understand why the stigma against mental to understand why the stigma against mental illness is so powerfulillness is so powerful

For most of our history, depression and other For most of our history, depression and other mental disorders were viewed as demon mental disorders were viewed as demon possessionpossession

Afflicted people were “outside the gates”, Afflicted people were “outside the gates”, unclean, causing people to fear of the mentally illunclean, causing people to fear of the mentally ill

Lack of understanding of illness in general led Lack of understanding of illness in general led people to fear contamination, either real or ritualpeople to fear contamination, either real or ritual


What Is Mental Illness?What Is Mental Illness? None of us are surprised that there are many None of us are surprised that there are many

ways for an organ of the body to malfunctionways for an organ of the body to malfunction Stomachs can be affected by ulcers or Stomachs can be affected by ulcers or

excessive acid; lungs can be damaged by excessive acid; lungs can be damaged by environmental factors such as smoking, or by environmental factors such as smoking, or by asthma; the digestive tract is vulnerable to asthma; the digestive tract is vulnerable to many possible illnessesmany possible illnesses

We have never understood that the brain is We have never understood that the brain is just like other organs of the body, and as just like other organs of the body, and as such, is vulnerable to a variety of illnesses such, is vulnerable to a variety of illnesses and disordersand disorders

We confuse brain with mindWe confuse brain with mind


What Is Mental Illness?What Is Mental Illness?

We understand that something like We understand that something like Parkinson’s damages the brain and Parkinson’s damages the brain and creates behavioral changescreates behavioral changes

Even diabetes is recognized as creating Even diabetes is recognized as creating emotional changes as blood sugar rises emotional changes as blood sugar rises and fallsand falls

Stigma about illnesses like depression, Stigma about illnesses like depression, schizophrenia and Bi-Polar disorder schizophrenia and Bi-Polar disorder seems to keep us from seeing them as seems to keep us from seeing them as brain disorders that create changes in brain disorders that create changes in mood, behavior and thinkingmood, behavior and thinking


What Is Mental Illness?What Is Mental Illness? We called it mental illness because we wanted to stop We called it mental illness because we wanted to stop

saying things like “lunacy”, “madness”, “bats in her saying things like “lunacy”, “madness”, “bats in her belfry”, “nuttier than a fruitcake”, “rowing with one oar belfry”, “nuttier than a fruitcake”, “rowing with one oar in the water”, “insane”, “ga ga”, “wacko”, “fruit loop”, in the water”, “insane”, “ga ga”, “wacko”, “fruit loop”, “sicko”, “crazy”“sicko”, “crazy”

Is it any wonder people avoid acknowledging mental Is it any wonder people avoid acknowledging mental illness?illness?

Of all the diseases we have public awareness of, mental Of all the diseases we have public awareness of, mental illness is the most misunderstoodillness is the most misunderstood

Any 5 year-old knows the symptoms of the common cold, Any 5 year-old knows the symptoms of the common cold, but few people know the symptoms of the most common but few people know the symptoms of the most common mental illnesses such as depression and anxietymental illnesses such as depression and anxiety


Prevention StrategiesPrevention Strategies

General suicide and General suicide and depression depression awareness awareness education education

Depression Depression Screening Screening programsprograms

Community Community Gatekeeper Gatekeeper TrainingsTrainings

Crisis Centers and Crisis Centers and hotlineshotlines

Peer support Peer support programsprograms

Restriction of Restriction of access to lethal access to lethal meansmeans

Intervention after Intervention after a suicidea suicide


Suicide Is The Last Taboo – Suicide Is The Last Taboo – We Don’t Want To Talk We Don’t Want To Talk

About ItAbout It Suicide has become the Last Taboo – we can talk Suicide has become the Last Taboo – we can talk

about AIDS, sex, incest, and other topics that about AIDS, sex, incest, and other topics that used to be unapproachable. We are still afraid of used to be unapproachable. We are still afraid of the “S” word the “S” word

Understanding suicide helps communities Understanding suicide helps communities become proactive rather than reactive to a become proactive rather than reactive to a suicide once it occurssuicide once it occurs

Reducing stigma about suicide and its causes Reducing stigma about suicide and its causes provides us with our best chance for saving livesprovides us with our best chance for saving lives

Ignoring suicide means we are helpless to stop itIgnoring suicide means we are helpless to stop it


What Makes Me A What Makes Me A Gatekeeper?Gatekeeper?

Gatekeepers are not mental healthGatekeepers are not mental health

professionals or doctorsprofessionals or doctors Gatekeepers are responsible adults who Gatekeepers are responsible adults who

spend time with people who might be spend time with people who might be vulnerable to depression and suicidal vulnerable to depression and suicidal thoughts – teachers, coaches, police thoughts – teachers, coaches, police officers, EMT’s, physicians, clergy, 4H officers, EMT’s, physicians, clergy, 4H leaders, and of course, whose who work leaders, and of course, whose who work with the elderlywith the elderly


Why Should I Learn Why Should I Learn About Suicide About Suicide Prevention?Prevention?

It is the 11th largest killer of Americans, It is the 11th largest killer of Americans, and the rate of suicide is highest and the rate of suicide is highest

among those over 75among those over 75 No one is safe from the risk of suicide – No one is safe from the risk of suicide –

wealth, education, intact family, wealth, education, intact family, popularity cannot protect us from this riskpopularity cannot protect us from this risk

A suicide attempt is a desperate cry for A suicide attempt is a desperate cry for help to end excruciating, unending, help to end excruciating, unending, overwhelming pain. We must learn to overwhelming pain. We must learn to answer that cry before it is too lateanswer that cry before it is too late


8989 people complete suicide every day people complete suicide every day 32,46732,467 people in 2005 in the US people in 2005 in the US Over Over 1,000,0001,000,000 suicides worldwide suicides worldwide

(reported)(reported) This data refers to completed suicides This data refers to completed suicides

that are documented by medical that are documented by medical examiners – it is estimated that 2-3 examiners – it is estimated that 2-3 times as many actually complete suicidetimes as many actually complete suicide

(Surgeon General’s Report on Suicide, 1999)(Surgeon General’s Report on Suicide, 1999)

Is Suicide Really a Is Suicide Really a Problem?Problem?


Comparative Rates Of U.S. Comparative Rates Of U.S. Suicides-2003Suicides-2003

Rates per 100,000 populationRates per 100,000 population National averageNational average - 11.1 per 100,000* - 11.1 per 100,000* White malesWhite males - 18 - 18 Hispanic malesHispanic males - 10.3 - 10.3 African-American males African-American males - 9.1 ** - 9.1 ** Asians Asians - 5.2 - 5.2 Caucasian femalesCaucasian females - 4.8 - 4.8 African American females African American females - 1.5 - 1.5 Males over 85Males over 85 - - 67.667.6

Annual Attempts – 811,000 (estimated)Annual Attempts – 811,000 (estimated) 150-1 completion for the young - 4-1 for the 150-1 completion for the young - 4-1 for the

elderlyelderly (*AAS website),**(Significant increases have occurred among (*AAS website),**(Significant increases have occurred among

African Americans in the past 10 years - Toussaint, 2002)African Americans in the past 10 years - Toussaint, 2002)


The Unnoticed DeathThe Unnoticed Death

For every 2 homicides, 3 people For every 2 homicides, 3 people complete suicide yearly– data complete suicide yearly– data that has been constant for 100 that has been constant for 100 yearsyears

During the Viet Nam War from During the Viet Nam War from 1964-1972, we lost 55,000 1964-1972, we lost 55,000 troops, and 220,000 people to troops, and 220,000 people to suicidesuicide


The Gender IssueThe Gender Issue Women perceived as being at higher risk than menWomen perceived as being at higher risk than men Women do make attempts 4 x as often as menWomen do make attempts 4 x as often as men But - Men complete suicide 4 x as often as womenBut - Men complete suicide 4 x as often as women Women’s risk rises until midlife, then decreasesWomen’s risk rises until midlife, then decreases Men’s risk, always higher than women’s, continues Men’s risk, always higher than women’s, continues

to rise until end of lifeto rise until end of life Are women more likely to seek help? Talk about Are women more likely to seek help? Talk about

feelings? Have a safety network of friends?feelings? Have a safety network of friends? Do men suffer from depression silently? Do men suffer from depression silently?


How Big Is The Problem How Big Is The Problem For The Elderly?For The Elderly?

Risk factors for suicide among older persons Risk factors for suicide among older persons differ from those among the youngdiffer from those among the young

In addition to a higher prevalence of In addition to a higher prevalence of depressiondepression older persons are more socially isolatedolder persons are more socially isolated more frequently use highly lethal methodsmore frequently use highly lethal methods have more chronic physical illnesseshave more chronic physical illnesses

Not surprisingly, suicide rates among the Not surprisingly, suicide rates among the elderly are highest for those who are divorced elderly are highest for those who are divorced or widowedor widowed

(NIMH website, 2003)(NIMH website, 2003)


Suicide Rates Among The Suicide Rates Among The ElderlyElderly

• 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)


Suicide Rate By Age Per Suicide Rate By Age Per 100,000100,000

0%

5%

10%

15%

20%

25%

15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age

% S

uici

de p

er 1

00,0

00

Older people: 12.7% of 1999 population, but 18.8% of suicides. (Hovert, 1999;Bartels, 2003)


What Factors Put What Factors Put Someone At Risk For Someone At Risk For

Suicide?Suicide? Biological, physical, social, psychological or Biological, physical, social, psychological or

spiritual factors may increase risk-for spiritual factors may increase risk-for example:example:

A family history of suicide increases risk by 6 A family history of suicide increases risk by 6 timestimes

Access to firearms – people who use firearms Access to firearms – people who use firearms in their suicide attempt are more likely to diein their suicide attempt are more likely to die

A significant loss by death, separation, A significant loss by death, separation, divorce, moving, or breaking up with a divorce, moving, or breaking up with a boyfriend or girlfriend can be a triggerboyfriend or girlfriend can be a trigger

(Goleman, 1997)(Goleman, 1997)


Social IsolationSocial Isolation: elders become increasingly : elders become increasingly isolated as family and friends die or move away, isolated as family and friends die or move away, and as they lose mobility and transportationand as they lose mobility and transportation

The 2nd biggest risk factor - having an The 2nd biggest risk factor - having an alcohol or drug problemalcohol or drug problem Many with alcohol and drug problems are Many with alcohol and drug problems are

clinically depressed, and are self-medicating clinically depressed, and are self-medicating for their painfor their pain

Many older people taking medication may be Many older people taking medication may be unaware of the risks for altered mental stateunaware of the risks for altered mental state

(Surgeon General’s call to Action, 1999)(Surgeon General’s call to Action, 1999)


The biggest risk factor for suicide completion? The biggest risk factor for suicide completion?

Having a Depressive IllnessHaving a Depressive Illness People with clinical depression often feel People with clinical depression often feel

helpless to solve problems, leading to helpless to solve problems, leading to hopelessness – a strong predictor of suicide riskhopelessness – a strong predictor of suicide risk

At some point in this chronic illness, suicide At some point in this chronic illness, suicide seems like the only way out of the pain and seems like the only way out of the pain and sufferingsuffering

Many Mental health diagnoses have a Many Mental health diagnoses have a component of depression: anxiety, PTSD, Bi-component of depression: anxiety, PTSD, Bi-Polar, etcPolar, etc

90%90% of suicide completers have a depressive of suicide completers have a depressive illnessillness

(Lester, 1998, Surgeon General, 1999)(Lester, 1998, Surgeon General, 1999)


Depression Is An Depression Is An IllnessIllness Suicide has been viewed for countless Suicide has been viewed for countless

generations as:generations as: a moral failing, a spiritual weaknessa moral failing, a spiritual weakness an inability to cope with lifean inability to cope with life ““the coward’s way out”the coward’s way out” A character flawA character flaw

Our cultural view of suicide is wrong - Our cultural view of suicide is wrong - invalidated by our current invalidated by our current understanding of brain chemistry and understanding of brain chemistry and it’s interaction with it’s interaction with stress, trauma stress, trauma and geneticsand genetics on mood and behavior on mood and behavior


The research evidence is overwhelming - The research evidence is overwhelming - depression is far more than a sad mood. It depression is far more than a sad mood. It includes:includes:

1.1. Weight gain/lossWeight gain/loss

2.2. Sleep problemsSleep problems

3.3. Sense of tiredness, exhaustionSense of tiredness, exhaustion

4.4. Sad or angry moodSad or angry mood

5.5. Loss of interest in pleasurable things, lack of Loss of interest in pleasurable things, lack of motivationmotivation

6.6. IrritabilityIrritability

7.7. Confusion, loss of concentration, poor memoryConfusion, loss of concentration, poor memory

8.8. Negative thinking (Self, World, Future)Negative thinking (Self, World, Future)

9.9. Withdrawal from friends and familyWithdrawal from friends and family

10.10. Sometimes, suicidal thoughtsSometimes, suicidal thoughts(DSMIVR, 2002)(DSMIVR, 2002)


20 years of brain research teaches that 20 years of brain research teaches that these symptoms are the these symptoms are the behavioralbehavioral result ofresult of InternalInternal changes in the physical changes in the physical

structure of the brainstructure of the brain Damage to brain cells in the Damage to brain cells in the

hippocampus, amygdala and hippocampus, amygdala and limbic systemlimbic system

As Diabetes is the result of low insulin As Diabetes is the result of low insulin production by the pancreas, depressed production by the pancreas, depressed people suffer from a physical illness – people suffer from a physical illness – what we might consider “faulty wiring”what we might consider “faulty wiring” (Braun, 2000; Surgeon General’s Call To Action, 1999,(Braun, 2000; Surgeon General’s Call To Action, 1999,

Stoff & Mann, 1997, The Neurobiology of Suicide)Stoff & Mann, 1997, The Neurobiology of Suicide)


Faulty Wiring?Faulty Wiring? Literally, damage to certain nerve cells in our Literally, damage to certain nerve cells in our

brainsbrains The result of too many stress hormones – cortisol, The result of too many stress hormones – cortisol,

adrenaline and testosteroneadrenaline and testosterone Hormones activated by our Hormones activated by our AAutonomic utonomic NNervous ervous

SSystem to protect us in times of dangerystem to protect us in times of danger Chronic stress causes changes in the Chronic stress causes changes in the

functioning of the ANS, so that a high level of functioning of the ANS, so that a high level of activation occurs with little stimulusactivation occurs with little stimulus

Causes changes in muscle tension, imbalances Causes changes in muscle tension, imbalances in blood flow patterns leading to illnesses such in blood flow patterns leading to illnesses such as asthma, IBS, back pain and depressionas asthma, IBS, back pain and depression

(Goleman, 1997, Braun, 1999)(Goleman, 1997, Braun, 1999)


Faulty Wiring?Faulty Wiring? Without a way to return to rest, hormones Without a way to return to rest, hormones

accumulate, doing damage to brain cellsaccumulate, doing damage to brain cells Stress alone is not the problem, but how Stress alone is not the problem, but how

we interpret the event, thought or feelingwe interpret the event, thought or feeling People with People with genetic predispositionsgenetic predispositions, ,

placed in a highly placed in a highly stressful stressful environmentenvironment will experience damage to will experience damage to brain cells from stress hormonesbrain cells from stress hormones

This leads to the cluster of This leads to the cluster of thinking and thinking and emotional changesemotional changes we call depression we call depression

(Goleman, 1997; Braun, 1999)(Goleman, 1997; Braun, 1999)



Where It Hits UsWhere It Hits Us


One of Many NeuronsOne 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


As damage occurs, thinking changes in the As damage occurs, thinking changes in the predictable ways identified in our list of 10 predictable ways identified in our list of 10 criteriacriteria

““Thought constriction” can lead to the idea that Thought constriction” can lead to the idea that suicide is the only optionsuicide is the only option

How do antidepressants affect this “brain How do antidepressants affect this “brain damage”?damage”?

They mayThey may counter the effects of stress hormonescounter the effects of stress hormones We know now that antidepressants stimulate We know now that antidepressants stimulate

genes within the neurons (turn on growth genes) genes within the neurons (turn on growth genes) which encourage the growth of new dendriteswhich encourage the growth of new dendrites

(Braun, 1999)(Braun, 1999)


Renewed dendrites:Renewed dendrites: increase the number of neuronal increase the number of neuronal

connectionsconnections allow our nerve cells to begin connecting allow our nerve cells to begin connecting

againagain The more connections, the more information The more connections, the more information

flow, the more flexibility and resilience the flow, the more flexibility and resilience the brain will havebrain will have

Why does increasing the amount of serotonin, Why does increasing the amount of serotonin, as many anti-depressants do, take so long to as many anti-depressants do, take so long to reduce the symptoms of depression? reduce the symptoms of depression?

It takes 4-6 weeks to re-grow dendrites & It takes 4-6 weeks to re-grow dendrites & axonsaxons

(Braun, 1999)(Braun, 1999)


How Does Psychotherapy How Does Psychotherapy Help?Help?

Medications may improve brain function, but do not Medications may improve brain function, but do not change how we change how we interpretinterpret stress stress

Psychotherapy, especially cognitive or interpersonal Psychotherapy, especially cognitive or interpersonal therapy, helps people change the (negative) patterns therapy, helps people change the (negative) patterns of thinking that lead to depressed and suicidal of thinking that lead to depressed and suicidal thoughtsthoughts

Research shows that cognitive psychotherapy is as Research shows that cognitive psychotherapy is as effective as medication in reducing depression and effective as medication in reducing depression and suicidal thinkingsuicidal thinking

Changing our beliefs and thought patterns alters Changing our beliefs and thought patterns alters response to stress – we are not as reactive or as response to stress – we are not as reactive or as affected by stress at the physical level affected by stress at the physical level (Lester, (Lester, 2004)2004)


What Therapy?What Therapy? The standard of care is medication and The standard of care is medication and

psychotherapy combinedpsychotherapy combined At this point, only cognitive behavioral At this point, only cognitive behavioral

and interpersonal psychotherapies are and interpersonal psychotherapies are considered to be effective with clinical considered to be effective with clinical depression (evidence-based)depression (evidence-based)

Patients should ask their doctor for a Patients should ask their doctor for a referral to a cognitive or interpersonal referral to a cognitive or interpersonal therapisttherapist


Possible Sources Possible Sources Of DepressionOf Depression

Genetic: a predisposition to this problem Genetic: a predisposition to this problem may be present, and depressive diseases may be present, and depressive diseases seem to run in familiesseem to run in families

Predisposing factors: Childhood traumas, Predisposing factors: Childhood traumas, car accidents, brain injuries, abuse and car accidents, brain injuries, abuse and domestic violence, poor parenting, growing domestic violence, poor parenting, growing up in an alcoholic home, chemotherapyup in an alcoholic home, chemotherapy

Immediate factors: violent attack, illness, Immediate factors: violent attack, illness, sudden loss or grief, loss of a relationship, sudden loss or grief, loss of a relationship, any severe shock to the systemany severe shock to the system

(Anderson, 1999, Berman & Jobes, 1994, Lester, 1998)(Anderson, 1999, Berman & Jobes, 1994, Lester, 1998)


What Happens If We Don’tWhat Happens If We Don’tTreat Depression?Treat Depression?

Significant risk of increased alcohol Significant risk of increased alcohol and drug useand drug use

Significant relationship problemsSignificant relationship problems Withdrawal from daily activities, Withdrawal from daily activities,

self-careself-care High risk for suicidal thoughts, High risk for suicidal thoughts,

attempts, and possibly deathattempts, and possibly death(Surgeon General’s Call To Action, 1999)(Surgeon General’s Call To Action, 1999)


PCP’s And Diagnosis Of PCP’s And Diagnosis Of DepressionDepression

• The elderly have often visited a health-care provider The elderly have often visited a health-care provider before completing suicidebefore completing suicide

• 20% of elderly (over 65 years) who complete suicide 20% of elderly (over 65 years) who complete suicide visited a physician within 24 hoursvisited a physician within 24 hours

• 41% within a week41% within a week• 75% within one month75% 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)


Elders Have Additional Elders Have Additional IssuesIssues

The number of elders with mental illness The number of elders with mental illness will increase to 15 million in 2030will increase to 15 million in 2030

Mental illness has a significant impact on Mental illness has a significant impact on the health and functioning of older personsthe health and functioning of older persons

Associated with increased utilization of Associated with increased utilization of services and higher costsservices and higher costs

Our current mental health system is Our current mental health system is inadequateinadequate

Unprepared to address the anticipated Unprepared to address the anticipated growth in the number of elderly requiring growth in the number of elderly requiring treatment for late-life mental disorderstreatment for late-life mental disorders

(President’s New Freedom Commission on Mental Health, 2003(President’s New Freedom Commission on Mental Health, 2003Jeste, et al., 1999; www.census.gov)Jeste, et al., 1999; www.census.gov)


Barriers To MH CareBarriers To MH Care Fragmented service delivery systemFragmented service delivery system

Out of date Medicare policiesOut of date Medicare policies

Stigma due to mental illness and advanced ageStigma due to mental illness and advanced age

Mismatch between services that are covered Mismatch between services that are covered and those preferred by older personsand those preferred by older persons

Lack of adequate preventive interventions and Lack of adequate preventive interventions and programs that aid early identification of programs that aid early identification of geriatric mental illness geriatric mental illness

(Bartels, 2003)(Bartels, 2003)


Medicare Expenditures For Medicare Expenditures For Mental Health Services Mental Health Services

Total 1998 Medicare Health care Total 1998 Medicare Health care Expenditures: Expenditures:

211.4211.4 Billion Billion

Total Mental Health Expenditures:Total Mental Health Expenditures:

1.21.2 Billion (0.57%) Billion (0.57%)

Outpatient Mental Health Expenditures:Outpatient Mental Health Expenditures:

718 Million718 Million (0.34%) (0.34%) CMS, 2001CMS, 2001


Expenditures On NIMH Newly Funded Grants

0

50

100

150

200

250

1995 1996 1997 1998 1999 2000Fiscal Year

Mill

ions

of D

olla

rs

Total NIMHGrants

AgingGrants


Falling Through The Falling Through The CracksCracks

Community Mental Health ServicesCommunity Mental Health Services Under-serve older personsUnder-serve older persons Lack staff trained to address medical needsLack staff trained to address medical needs Often lack age-appropriate servicesOften lack age-appropriate services

Principal Providers of Mental Health Care: Principal Providers of Mental Health Care: Primary Care PhysiciansPrimary Care Physicians Long-term Care FacilitiesLong-term Care Facilities

Medicare Medicare Incomplete outpatient prescription drug coverage Incomplete outpatient prescription drug coverage Lack of mental health parityLack of mental health parity


Inadequate Workforce Of Inadequate Workforce Of Trained Geriatric Mental Trained Geriatric Mental

Health ProvidersHealth Providers Current Workforce:Current Workforce:

2,425 Geriatric Psychiatrists2,425 Geriatric Psychiatrists200-700 Geriatric Psychologists200-700 Geriatric Psychologists

Estimated Current Need:Estimated Current Need: 5,000 + of each specialty5,000 + of each specialty

Severe Nursing and Allied Health Severe Nursing and Allied Health Care Provider ShortageCare Provider Shortage

(Bartels, 2003)(Bartels, 2003)


Poor Quality Of Mental Poor Quality Of Mental Health Care For EldersHealth Care For Elders

> 1 in 5 older persons given an > 1 in 5 older persons given an inappropriate prescription inappropriate prescription (Zhan, 2001)(Zhan, 2001)

The elderly are less likely to be The elderly are less likely to be treated with psychotherapy treated with psychotherapy (Bartels, et al., (Bartels, et al., 1997)1997)

Lower quality of general health care Lower quality of general health care is associated with increased is associated with increased mortality in all settings mortality in all settings (Druss, 2001)(Druss, 2001)


Unmet Need For Mental Unmet Need For Mental Health Services In Nursing Health Services In Nursing

HomesHomes Nursing Homes are the primary provider of Nursing Homes are the primary provider of

Mental Health for elderly in institutionsMental Health for elderly in institutions Over one month: Over one month: 4.5%4.5% of mentally ill nursing of mentally ill nursing

home residents received mental health serviceshome residents received mental health services Over one year: Over one year: 19%19% in need of mental health in need of mental health

services receive themservices receive them Least Likely to get help -Oldest, most physically impairedLeast Likely to get help -Oldest, most physically impaired

Among the Most Common DisordersAmong the Most Common Disorders DementiaDementia DepressionDepression Anxiety Disorders and Psychotic DisordersAnxiety Disorders and Psychotic Disorders

(Burns et al., 1993 Burns & Taube, 1990, 1991, Rovner et al., 1990Shea et al., Smyer et al.,

1994)


Illness And DepressionIllness And Depression Depression is common among older Depression is common among older

patients with certain medical disorders patients with certain medical disorders Associated with worse health outcomesAssociated with worse health outcomes

Greater use and costs of medicationsGreater use and costs of medications Greater use of health servicesGreater use of health services

Medical illness greatly increases the risk for Medical illness greatly increases the risk for depression particularly in:depression particularly in: Ischemic heart disease (e.g. MI, CABG) Stroke Ischemic heart disease (e.g. MI, CABG) Stroke

Cancer Cancer Chronic lung disease Chronic lung disease

Alzheimer’s disease Alzheimer’s disease Arthritis Parkinson’s Arthritis Parkinson’s diseasedisease

In heart attack patients, depression is a In heart attack patients, depression is a significant predictor of death at 6 monthssignificant predictor of death at 6 months

(Empfield, 2003)


Rates Of Depression Rates Of Depression Among Elders With IllnessAmong Elders With Illness

Cognitively intact nursing home patients Cognitively intact nursing home patients shown to have symptoms consistent with shown to have symptoms consistent with depressive disorders – depressive disorders – 60%60%

Chronically ill outpatients in a primary Chronically ill outpatients in a primary care practice - care practice - 25%25%

Hospitalized patients - Hospitalized patients - 20%20% In nursing homes, regardless of physical

health, major depression increases the likelihood of mortality by 59% in one year

(Empfield, 2003)


Depression Associated With Depression Associated With Worse Health OutcomesWorse Health Outcomes

Worse outcomesWorse outcomes Hip fracturesHip fractures Myocardial infarctionMyocardial infarction

• Increased mortality rates for Myocardial InfarctionIncreased mortality rates for Myocardial Infarction (Frasure-Smith 1993, 1995)(Frasure-Smith 1993, 1995)

In Cancer, depression leads toIn Cancer, depression leads to Increased HospitalizationIncreased Hospitalization Poorer physical function Poorer physical function Poorer quality of lifePoorer quality of life Poorer pain controlPoorer pain control (Mossey 1990; Penninx et al. 2001;

(Katz 1989, Rovner 1991, Parmelee 1992; (Katz 1989, Rovner 1991, Parmelee 1992; Ashby1991; Shah 1993, Samuels 1997)Ashby1991; Shah 1993, Samuels 1997)


Benefits Of Treatment For Benefits Of Treatment For Depression In The ElderlyDepression 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

(Empfield, 2003)


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

(Empfield, 2003)


What We Need To KnowWhat We Need To Know

With all this data to concern us about With all this data to concern us about elder Americans, what do we need to elder Americans, what do we need to learn to help them, to reduce the learn to help them, to reduce the number of people suffering from number of people suffering from depression and suicidal thoughts?depression and suicidal thoughts?

What to look forWhat to look for How to talk to a depressed/suicidal How to talk to a depressed/suicidal

personperson How to get help How to get help


Suicide Myths – What Is Suicide Myths – What Is True?True?1.Talking about suicide might cause a 1.Talking about suicide might cause a

person to actperson to act

False – it is helpful to show the person you take them False – it is helpful to show the person you take them seriously and you care. Most feel relieved at the chance seriously and you care. Most feel relieved at the chance to talkto talk

2. 2. A person who threatens suicide won’t really A person who threatens suicide won’t really follow throughfollow through

False – many people who complete suicide talk about it False – many people who complete suicide talk about it often before they actually do itoften before they actually do it

(AFSP website, 2003)(AFSP website, 2003)


Suicide Myths, continuedSuicide Myths, continued::

3. 3. Only “crazy” people kill themselvesOnly “crazy” people kill themselves False - Crazy is a cruel and meaningless word. Most False - Crazy is a cruel and meaningless word. Most

people who kill themselves have not lost touch with people who kill themselves have not lost touch with reality – they feel hopeless and in terrible painreality – they feel hopeless and in terrible pain

4. No one I know would do that4. No one I know would do thatFalse - suicide is an equal opportunity killer – rich, False - suicide is an equal opportunity killer – rich,

poor, successful, unsuccessful, beautiful, ugly, poor, successful, unsuccessful, beautiful, ugly, young, old, popular and unpopular people all young, old, popular and unpopular people all complete suicidecomplete suicide

5. They’re just trying to get attention5. They’re just trying to get attention False – They are trying to get help. We should False – They are trying to get help. We should

recognize that need and respond to itrecognize that need and respond to it


Suicide myths, continued:Suicide myths, continued:

6.6. Suicide is a city problem, not in the Suicide is a city problem, not in the

country or a small towncountry or a small town False – rural areas have higher suicide rates than urban False – rural areas have higher suicide rates than urban

areasareas

7.7. Once a person decides to die nothing can Once a person decides to die nothing can stop themstop them - - They really want to dieThey really want to die

NO - most people want to be stopped – if we don’t try to NO - most people want to be stopped – if we don’t try to stop them they will certainly die - people want to stop them they will certainly die - people want to end their pain, not their lives, but they have no hope end their pain, not their lives, but they have no hope that anyone will listen, that they can be helpedthat anyone will listen, that they can be helped

(AFSP website, 2003(AFSP website, 2003))


How Do I Know If How Do I Know If Someone Is Suicidal?Someone Is Suicidal?

Now we understand the connection Now we understand the connection between depression and suicidebetween depression and suicide

We have reviewed what a depressed We have reviewed what a depressed person looks likeperson looks like

Not all depressed people are suicidal – Not all depressed people are suicidal – how can we tell?how can we tell?

Suicides don’t happen withoutSuicides don’t happen without warning - verbal and behavioralwarning - verbal and behavioral clues are present, but we may not clues are present, but we may not notice themnotice them


Verbal ExpressionsVerbal Expressions Common statementsCommon statements

I shouldn't be hereI shouldn't be here I'm going to run awayI'm going to run away I wish I were deadI wish I were dead I'm going to kill myselfI'm going to kill myself I wish I could disappear foreverI wish I could disappear forever If a person did this or that…., would If a person did this or that…., would

he/she diehe/she die Maybe if I died, people would love me Maybe if I died, people would love me

moremore I want to see what it feels like to dieI want to see what it feels like to die


Some Behavioral Warning Some Behavioral Warning SignsSigns

Common signsCommon signs Previous suicidal thoughts or attemptsPrevious suicidal thoughts or attempts Expressing feelings of hopelessness or guiltExpressing feelings of hopelessness or guilt (Increased) substance abuse (Increased) substance abuse Becoming less responsible and motivatedBecoming less responsible and motivated Talking or joking about suicideTalking or joking about suicide Giving away possessionsGiving away possessions Having several accidents resulting in injury; Having several accidents resulting in injury;

"close calls" or "brushes with death""close calls" or "brushes with death"


What On Earth Can What On Earth Can II Do? Do? We are reluctant to ask questions of We are reluctant to ask questions of

depressed people because we feel it is “none depressed people because we feel it is “none of my business”, or fear the responsibilityof my business”, or fear the responsibility

Depression is an illness, like heart disease, Depression is an illness, like heart disease, and and suicidal thoughts are a crisis, like a suicidal thoughts are a crisis, like a heart attackheart attack

You would not leave a heart attack victim You would not leave a heart attack victim lying on the sidewalk. You would make lying on the sidewalk. You would make somesome attempt to administer CPRattempt to administer CPR

Anyone can learn to ask the right questions Anyone can learn to ask the right questions to help a depressed and suicidal personto help a depressed and suicidal person


What Stops Us?What Stops Us? Most of us still believe suicide and Most of us still believe suicide and

depression are “none of our business”depression are “none of our business” Most are fearful of getting a yes answerMost are fearful of getting a yes answer What if: we knew how to respond to What if: we knew how to respond to

“yes”?“yes”? We could recognize depression symptoms like We could recognize depression symptoms like

we recognize symptoms of a heart attack?we recognize symptoms of a heart attack? We were no longer afraid to ask for help for We were no longer afraid to ask for help for

ourselves, our parents, our children?ourselves, our parents, our children? We no longer felt ashamed of our feelings of We no longer felt ashamed of our feelings of

despair and hopelessness, but recognized despair and hopelessness, but recognized them as symptoms of a brain disorder?them as symptoms of a brain disorder?


Reduce StigmaReduce Stigma Stigma about having mental health problems Stigma about having mental health problems

keeps people from seeking help or even keeps people from seeking help or even acknowledging their problemacknowledging their problem

Reducing the fear and shame we carry about Reducing the fear and shame we carry about having such “shameful” problems is criticalhaving such “shameful” problems is critical

People must learn that depression is truly a People must learn that depression is truly a disorder that can be treated – not something disorder that can be treated – not something to be ashamed of, not a weaknessto be ashamed of, not a weakness

Learning about suicide makes it possible for Learning about suicide makes it possible for us to overcome our fears about asking the us to overcome our fears about asking the “S” question“S” question


Learning “Learning “QPRQPR” – Or, How To ” – Or, How To Ask The “S” QuestionAsk The “S” Question

It is essential, if we are to reduce the It is essential, if we are to reduce the number of suicide deaths in our number of suicide deaths in our country, that community country, that community members/gatekeepers learn “members/gatekeepers learn “QPRQPR””

First identified by Dr. Paul Quinnett as First identified by Dr. Paul Quinnett as an analogue to CPR, “an analogue to CPR, “QPRQPR” consists of” consists of QQuestion – asking the “S” questionuestion – asking the “S” question PPersuade – Getting the person to talk, and to ersuade – Getting the person to talk, and to

seek helpseek help RRefer – Getting the person to professional helpefer – Getting the person to professional help

(Quinnett, 2000)(Quinnett, 2000)


Ask Questions!Ask Questions! You seem pretty downYou seem pretty down Do things seem hopeless to youDo things seem hopeless to you Have you ever thought it would be easier Have you ever thought it would be easier

to be dead?to be dead? Have you considered suicide?Have you considered suicide? Remember, you cannot make someone Remember, you cannot make someone

suicidal by asking suicidal by asking If they are already thinking of it they will If they are already thinking of it they will

probably be relieved that the secret is probably be relieved that the secret is outout

If you get a yes answer, don’t panic. Ask If you get a yes answer, don’t panic. Ask a few more questionsa few more questions


How Much Risk Is There?How Much Risk Is There? Assess lethalityAssess lethality

You are not a doctor, but you need You are not a doctor, but you need to know how imminent the danger to know how imminent the danger isis

Has he or she made any previous Has he or she made any previous suicide attempts? suicide attempts?

Does he or she have a plan?Does he or she have a plan? How specific is the plan? How specific is the plan? Do they have access to means?Do they have access to means?


Do . . .Do . . . Use warning signs to get help early Use warning signs to get help early Talk openly - reassure them that they Talk openly - reassure them that they

can be helped - Try to instill hope can be helped - Try to instill hope Encourage expression of feelingsEncourage expression of feelings Listen without passing judgmentListen without passing judgment Make empathic statementsMake empathic statements Stay calm, relaxed, rationalStay calm, relaxed, rational


But when But when someone is someone is suicidal, a suicidal, a true friend true friend learns how learns how to listento listen


Don’t…Don’t… Make moral judgmentsMake moral judgments Argue lecture, or encourage guiltArgue lecture, or encourage guilt Promise total confidentiality/offer reassurances Promise total confidentiality/offer reassurances

that may not be truethat may not be true Offer empty reassurances – “you’ll get over this”Offer empty reassurances – “you’ll get over this” Minimize the problem -“All you need is a good Minimize the problem -“All you need is a good

night’s sleep”night’s sleep” Dare the suicidal person- “You won’t really do it”Dare the suicidal person- “You won’t really do it” Use reverse psychology - “Go ahead and kill Use reverse psychology - “Go ahead and kill

yourself”yourself” Leave the person aloneLeave the person alone Never Go It AloneNever Go It Alone


Getting HelpGetting Help

Refer for professional helpRefer for professional help When people exhibit 5 or more symptoms When people exhibit 5 or more symptoms

of depressionof depression When risk is present (e.g. specific plan, When risk is present (e.g. specific plan,

available means)available means) Know your community resourcesKnow your community resources

Keep a folder, a list of helpersKeep a folder, a list of helpers Maintain collaboration with treating Maintain collaboration with treating

agency to provide behavioral information agency to provide behavioral information to therapiststo therapists


Local Professional Local Professional ResourcesResources

Your Hospital Your Hospital Emergency RoomEmergency Room

Your Local Mental Your Local Mental Health AgenciesHealth Agencies

Your Local Mental Your Local Mental Health BoardHealth Board

School Guidance School Guidance CounselorsCounselors

Local Crisis HotlinesLocal Crisis Hotlines

National Crisis National Crisis HotlinesHotlines

Your family Your family physicianphysician

School nursesSchool nurses

911911

Local Police/SheriffLocal Police/Sheriff

Local ClergyLocal Clergy


Mourning Vs. DepressionMourning 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)


Bereavement After Bereavement After A Suicide LossA Suicide Loss

Compared with homicide, accidental death Compared with homicide, accidental death or natural death, suicide death is very or natural death, suicide death is very difficult for family members to resolvedifficult for family members to resolve

Family members experience:Family members experience: Greater painGreater pain More difficulty finding meaning in the deathMore difficulty finding meaning in the death More difficulty accepting the deathMore difficulty accepting the death Less support and understandingLess support and understanding More need for mental health careMore need for mental health care

Staff members may experience the same Staff members may experience the same emotions after a suicidal deathemotions after a suicidal death

(Smith, Range & Ulner, 1991)(Smith, Range & Ulner, 1991)


Impact Of Depression On Impact Of Depression On Religious BeliefsReligious Beliefs

Many older people have strong religious faith, or have been Many older people have strong religious faith, or have been involved in their religion all their livesinvolved in their religion all their lives

Most find more comfort than strain associated with religionMost find more comfort than strain associated with religion But depression is associated with feelings of alienation from But depression is associated with feelings of alienation from

GodGod Suicidality can be associated with religious fear and guilt, Suicidality can be associated with religious fear and guilt,

particularly with belief in having committed an unforgivable particularly with belief in having committed an unforgivable sin for simply thinking of suicidesin for simply thinking of suicide

This religious strain is associated with greater depression This religious strain is associated with greater depression and suicidality, regardless of religiosity levels or the degree and suicidality, regardless of religiosity levels or the degree of comfort found in religionof comfort found in religion

(Sanderson, 2000)(Sanderson, 2000)


Final Suggestions For Final Suggestions For Better CareBetter Care

Mental health outreach servicesMental health outreach services Integrated service delivery in primary Integrated service delivery in primary

carecare Mental health consultation and Mental health consultation and

treatment teams in long-term caretreatment teams in long-term care Family/caregiver support interventionFamily/caregiver support interventionss Psychological and pharmacological Psychological and pharmacological

treatmentstreatments(Draper, 2000; (Draper, 2000; Unützer, et al., 2001; Schulberg, et al., 2001; Unützer, et al., 2001; Schulberg, et al., 2001;

Bartels et al., 2002, 2003; Sorenson, et al., 2002;) Bartels et al., 2002, 2003; Sorenson, et al., 2002;)


Outreach ProgramsOutreach Programs

““Gatekeeper” ModelGatekeeper” Model Trains community members to Trains community members to

identify and refer community-identify and refer community-dwelling older adults who may need dwelling older adults who may need mental health servicesmental health services

Effective at identifying isolated Effective at identifying isolated elderly, who received no formal elderly, who received no formal mental health servicesmental health services

Florio & Raschko, 1998Florio & Raschko, 1998


Caregiver Support Caregiver Support InterventionsInterventions

Delays placement in nursing homes for Delays placement in nursing homes for persons with dementia from 166 days to persons with dementia from 166 days to 19.9 months19.9 months

( Mittleman et al., 1995; Moniz-Cook et al., 1998 ( Mittleman et al., 1995; Moniz-Cook et al., 1998 Riordan & Bennett, 1998; Roberts et al., 1999)Riordan & Bennett, 1998; Roberts et al., 1999)

Improved Caregiver Mental HealthImproved Caregiver Mental Health --Decreased incidence and severity of Decreased incidence and severity of depression -Improved health (e.g., depression -Improved health (e.g., lowered blood pressure)lowered blood pressure)-Improved stress management-Improved stress management

(Sorensen, Pinquart, Duberstein, (Sorensen, Pinquart, Duberstein, 2002)2002)


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)


Websites For Additional Websites For Additional InformationInformation

Ohio Department of Ohio Department of Mental HealthMental Health

www.mh.state.oh.uswww.mh.state.oh.us NAMINAMI

www.nami.orgwww.nami.org National Institute of National Institute of

Mental HealthMental Healthwww.nih.nimh.govwww.nih.nimh.gov

American Association American Association of Suicidologyof Suicidologywww.suicidology.orgwww.suicidology.org

Suicide Suicide Awareness/Voice of Awareness/Voice of EducationEducationwww.save.orgwww.save.org

American Foundation American Foundation for Suicide Preventionfor Suicide Preventionwww.afsp.orgwww.afsp.org

Suicide Prevention Suicide Prevention Advocacy NetworkAdvocacy Networkwww.spanusa.org

Suicide Prevention Suicide Prevention Resource CenterResource Center

www.sprc.orgwww.sprc.org


Permanent Solution-Permanent Solution- Temporary Problem Temporary Problem

Remember a depressed person is Remember a depressed person is physically ill, and physically ill, and cannotcannot think clearly think clearly about the morality of suicide, about the morality of suicide, cannot cannot think think logically about their value to friends and logically about their value to friends and familyfamily

You would try CPR if you saw a heart You would try CPR if you saw a heart attack victimattack victim

Don’t be afraid to “interfere” when Don’t be afraid to “interfere” when someone is dying more slowly of someone is dying more slowly of depressiondepression

Depression is a treatable disorderDepression is a treatable disorder Suicide is a preventable deathSuicide is a preventable death


The Ohio Suicide Prevention The Ohio Suicide Prevention FoundationFoundation

The Ohio State University, Center on The Ohio State University, Center on Education and Training for Education and Training for

EmploymentEmployment

1900 Kenny Road, Room 20721900 Kenny Road, Room 2072

Columbus, OH 43210Columbus, OH 43210

614-292-8585614-292-8585


“ 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

The Calling and the Opportunity


Stephen J. Bartels, M.D., M.S. Stephen J. Bartels, M.D., M.S. Director, Aging Services Research NH-Director, Aging Services Research NH-Dartmouth Psychiatric Research Center Dartmouth Psychiatric Research Center is the author of a presentation on mental is the author of a presentation on mental health in the elderly, which is available health in the elderly, which is available on the web. His information provided on the web. His information provided much valuable background for this much valuable background for this presentation, and some of his slides, presentation, and some of his slides, which are available for public use, are which are available for public use, are also a part of this presentation.also a part of this presentation.


A Brief BibliographyA Brief Bibliography Anderson, E. “The Personal and Professional Anderson, E. “The Personal and Professional

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Blumenthal, S.J. & Kupfer, D.J. (Eds) (1990). Blumenthal, S.J. & Kupfer, D.J. (Eds) (1990). Suicide Over the Life Cycle: Risk Factors, Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients.Assessment, and Treatment of Suicidal Patients. American Psychiatric Press.American Psychiatric Press.

Dein, S. and Littlewood, R. “Apocalyptic Suicide”. Dein, S. and Littlewood, R. “Apocalyptic Suicide”. Mental Health, Religion, & CultureMental Health, Religion, & Culture, 2000 (3)2, , 2000 (3)2, 109-114. 109-114.

Doka, K.J. (1989). Disenfranchised Grief: Recognizing hidden sorrow. Lexington, MA: Lexington Books


Empfield, Maureen MD( 2002) PSYCHIATRY Empfield, Maureen MD( 2002) PSYCHIATRY FOR THE PRIMARY CARE PHYSICIANFOR THE PRIMARY CARE PHYSICIAN – – Section 2. URL.Section 2. URL.

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McLeod, D. “Elderly suicides: the religious McLeod, D. “Elderly suicides: the religious divide”, Guasrdian unlimited, 2001, Feb 5.divide”, Guasrdian unlimited, 2001, Feb 5.

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Tang, T.Z. & De Rubeis, R.J. ((1999). “Sudden Tang, T.Z. & De Rubeis, R.J. ((1999). “Sudden Gains and critical sessions in cognitive-behavioral Gains and critical sessions in cognitive-behavioral therapy for depression”. therapy for depression”. Journal of Consulting and Journal of Consulting and Clinical Psychology 67: 894-904.Clinical Psychology 67: 894-904.

SAVING LIVES: Understanding Depression And Suicide In The Elderly Sponsored by the Ohio Department of Mental Health, The Ohio Suicide Prevention Foundation,

Documents

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