SUICIDE IN OLDER ADULTS: WHAT HAVE WE LEARNED?

Transcription

1 SUICIDE IN OLDER ADULTS: WHAT HAVE WE LEARNED? Kelly C. Cukrowicz, Ph.D. Professor Department of Psychological Sciences Texas Tech University

2 MEN WOMEN Women

3 Prevalence of Suicide Across the Lifespan 44,965 deaths by suicide in 2016 in the United States 10 th ranking cause of death in the U.S. 3.4 male deaths by suicide for every female death by suicide More specific information White males: 31,032 rate of 24.8 per 100,000 (10.9 for non-white males) Firearms accounted for 51% of deaths

4 4 Prevalence of Suicide in Older Adults 8,204 deaths by suicide in 2016 in the United States among those 65+ Rate is for men vs for women 65+ (16.66 overall rate per 100,000) Rate of death by suicide increases steadily from age 65 to 85, with the highest rate of suicide deaths among older adults ages 85 and older (CDC, 2014). 4.6 male deaths by suicide for every female death by suicide More specific information White males more frequently die by suicide (more than 2x other races) Firearms accounted for 70% of deaths in this age group

5 Risk Factors vs. Warning Signs Risk factors Increase vulnerability for suicide ideation and suicidal behavior Tend to be more stable (e.g., psychiatric disorder, history of suicidal behavior, gender) Warning signs Indicate risk is high right now Tend to be more likely to change in the short term (e.g., agitation, mood changes, anger)

6 Empirically Demonstrated Risk Factors for Suicide Psychiatric Disorders Approximately 70-95% of adults had a psychiatric disorder at the time of their suicide death Affective Disorders Major depression 44% to 87% Other mood disorders 11% to 36% Alcohol abuse/dependence 3% to 43% Lesser role: psychotic disorder, personality disorders, anxiety disorders, dementia, eating disorders

7 Empirically Demonstrated Risk Factors for Suicide History of suicidal behavior Previous suicidal behavior especially concerning if multiple attempt history History of self-harm Expression of severe thoughts of suicide Plans/preparations for suicide Access to means for suicide 51% of suicide decedents use guns and more than 50% of the US population own guns; 2/3 of gun deaths are suicide deaths Presence of a gun in the home has been significantly associated with suicide deaths Handguns Risk greater for men

8 Empirically Demonstrated Risk Factors for Suicide Affective experiences hopelessness agitation sleep disruption Social isolation living alone low social interaction family discord Negative life events financial problems physical illness childhood abuse combat exposure Personality traits impulsivity rigid and independent style

9 Physical Health Approximately 70% of suicide decedents had significant physical illness HIV/AIDS, Huntington s disease, multiple schlerosis, peptic ulcer, renal disease, spinal cord injury (Harris & Barraclough, 1994) Physical illness burden, serious physical condition, functional impairment

10 Warning Signs IS PATH WARM? Ideation Substance abuse Purposelessness Anxiety Trapped Hopelessness Withdrawal Anger Recklessness Mood changes Reported suicide or death ideation Increased substance use No reason for living or sense of purpose Anxiety, agitation, unable to sleep Feeling trapped, no way out Hopelessness Withdrawal from friends, family Rage, uncontrolled anger Acting reckless, risky behaviors Dramatic mood changes

11 This is a lot of information How do we organize it and use it? A good theory can be really helpful.

12 Interpersonal Theory of Suicide (Joiner, 2005) Perceived Burden + Thwarted Belonging Acquired Capability I fear I m a burden. No one cares about me. I have attempted suicide. I have experienced a lot of pain in my life. Death by Suicide or Near-Lethal Suicide Attempt

13 What is perceived burdensomeness? The sense that one does not contribute to others in their life Others would be better off without him or her These perceptions lead to emotionally painful thoughts of self-hatred Van Orden, K. A., Witte, T. K., Cukrowicz, K. C. et al. (2010). The interpersonal theory of suicide. Psychological Review, 117,

14 What is thwarted belongingness? A sense of feeling disconnected from others Feeling alone, even in the presence of others Feeling that he/she doesn t care about people and they don t care about/support him/her Van Orden, K. A., Witte, T. K., Cukrowicz, K. C. et al. (2010). The interpersonal theory of suicide. Psychological Review, 117,

15 What is acquired capability? The loss of the fear of suicidal behaviors Acquired over time through exposure to physically painful and/or fear inducing experiences Over time, these experiences result in lowered fear of death and greater pain tolerance Van Orden, K. A., Witte, T. K., Cukrowicz, K. C. et al. (2010). The interpersonal theory of suicide. Psychological Review, 117,

16 The Interpersonal Theory of Suicide Loneliness Death Ideation Thwarted Belongingness Nonreciprocal Care Self Resentment Hopelessness Desire for Suicide Suicidal Intent Lethal or Near Lethal Suicide Attempt Liability Perceived Burdensomeness Lowered Fear of Death Increased Pain Tolerance Death Ideation Acquired Capability Van Orden, K. A., Witte, T. K., Cukrowicz, K. C. et al. (2010). The interpersonal theory of suicide. Psychological Review, 117,

17 Importance of Suicide Ideation We can think of suicide ideation as a critical flag for those who might die by suicide BUT we must keep in mind some important things: Many people at risk for suicide do not disclose thoughts of suicide. Lots of people who think about suicide do not ever harm themselves. Suicide ideation can be chronic.

18 Example: Reporting Concerns with Suicide Risk in Older Adults Research suggests that older adults may not report suicide ideation even when they experience suicide ideation Contradiction 1 Rate of deaths by suicide increases in late life Rate of self-reported suicide ideation decreases with increasing age Contradiction 2 Older males more likely to die by suicide Suicide ideation has not been shown to be greater in older males than in females

19 So What Do We Do When Things Don t Add Up? Person who denies thoughts of suicide, but their actions suggest otherwise They have some of the risk factors or warning signs mentioned above

20 Example Distribution for Illustration

21 Study of Suicide Ideation in Older Adults We wanted to know whether the variables that are part of the interpersonal theory (thwarted belonging, perceived burden, hopelessless) are more painful when experienced together Do people who feel thwarted belonging and perceived burdensomeness report the greatest suicide ideation if they also feel hopeless? Would elevated scores on these three variables allow us to identify those who deny thoughts of suicide, but report other experiences that are highly associated with suicide ideation (i.e., depressive symptoms, isolation).

22 Novel Statistical Approach: Zero-Inflated Modeling Allows for estimation of both the zero and positive responses to questionnaires assessing suicide ideation. Some zeros arise from participants who deny suicide ideation and have little or no psychological distress (non-ideators) Additional zeros may arises from participants who deny suicide ideation while reporting other empirically-based risk factors (e.g., depression, hopelessness) for suicide ideation (potential ideators)

23 What Our Distributions Look Like Death ideation = 66 occurrences of zero Suicide ideation = 104 occurrences of zero

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25 Figure 2. Probability of Non-ideator Status (Excess Zero) as a Function of Perceived Burdensomeness and Hopelessness Along the Continuum of Scores for Thwarted Belonging. TB = Thwarted Belonging, BHS = Beck Hopelessness Scale.

26 What The Data Tells Us Increasing scores on thwarted belonging, perceived burdensomeness, and hopelessness are associated with: Greater probability that an individual may be experiencing thoughts of suicide, whether or not they are reported. The presence or absence of suicide ideation, but less important to determining the severity of thoughts of suicide.

27 Implications Perceived burden, thwarted belonging, and hopelessness should be key targets in the determination of whether someone might be experiencing thoughts of suicide Regardless of whether the person is reporting such thoughts Questions assessing perceived burden and thwarted belonging may be less threatening to endorse than thoughts of suicide Mental health practitioners should target perceptions of being a burden, a sense of thwarted belonging, and hopelessness to reduce the risk of developing suicide ideation

28 Suicide in Rural Communities Suicide is also prevalent among rural-dwelling adults in the U.S. and in countries around the world (Hirsch, 2006) Rural communities have had significantly higher rates of death by suicide than those in urban areas throughout the past two decades (Hirsch, 2006) Rural older adults are 30% 50% more likely to die by suicide when compared to older adults residing in urban locations (Baume & Clinton, 1997)

29 Extending this Research to Middle-Aged and Older Adults in Rural Communities Primary goals: To determine a preliminary estimate of the prevalence of suicide ideation, self-injury, and history of suicide attempts in rural communities. To examine risk factors that may be unique to rural locations.

30 What We ve Learned 25% 30% 20% 25% 15% 20% 10% 15% 10% 5% 5% 0% Lifetime history of ideation and attempts Suicide ideation in past year Previous attempt Suicidal communications 0% Lifetime history of ideation and attempts Rural Texas Previous attempt Cross-National

31 Thwarted Belonging Rural Identity Anxiety Suicide Ideation History of Suicide Attempts Economic Distress Depressive Symptoms Perceived Burden Moderators: Life Satisfaction Hope Lower Conformity to Masc. Norms Reasons for Living

32 Assessment of Suicide Risk 32

33 Eliciting Information on Suicide Risk Include questions about perceived burdensomeness, thwarted belonging, and hopeless! Normalize thoughts of suicide It sounds like you ve been experiencing a lot of emotional pain recently, others in your situation might think about suicide. Have you had any thoughts about suicide recently? Begin assessment with the past and work forward Ensure a complete picture of current experiences Frequency How often do you think about suicide? Intensity When you think about suicide, are intense are your thoughts (scale 1 to 10)? How does this compare to how intense they usually are? Duration How long have you had these thoughts? 33

34 COLUMBIA-SUICIDE SEVERITY RATING SCALE Screen Version - Recent cssrs.columbia.edu Screening versions and extended versions Pediatric & adult Lifetime and recent Versions for ED, law enforcement, family/friends, corrections, outpatient For inquiries and training information contact: Kelly Posner, Ph.D. New York State Psychiatric Institute, 1051 Riverside Drive, New York, New York, 10032; posnerk@nyspi.columbia.edu 2008 The Research Foundation for Mental Hygiene, Inc.

35 How Do I Assess Perceived Burden and Thwarted Belonging? Interpersonal Needs Questionnaire The following questions ask you to think about yourself and other people. Please respond to each question by using your own current beliefs and experiences, NOT what you think is true in general, or what might be true for other people. Please base your responses on how you ve been feeling recently. Use the rating scale to find the number that best matches how you feeland circle that number. There are no right or wrong answers: we are interested in what you think and feel Not at all true for me Somewhat true for me Very true for me 1.These days the people in my life would be better off if I were gone 2.These days the people in my life would be happier without me 3.These days I think I am a burden on society 4.These days I think my death would be a relief to the people in my life 5.These days I think the people in my life wish they could be rid of me 6.These days I think I make things worse for the people in my life 7.These days, other people care about me 8.These days, I feel like I belong 9.These days, I rarely interact with people who care about me 10.These days, I am fortunate to have many caring and supportive friends 11.These days, I feel disconnected from other people 12.These days, I often feel like an outsider in social gatherings 13.These days, I feel that there are people I can turn to in times of need 14.These days, I am close to other people 15.These days, I have at least one satisfying interaction every day Note. Items 7, 8, 10, 13, 14, and 15 are reverse coded.

36 How to assess acquired capability? Questions about fearlessness about suicide Duration of thoughts of suicide and details of imagery Plans for suicide; preparations made to carry out that plan Previous experiences with self-harm, suicidal behavior Exposure to violence

37 CAMS SUICIDE STATUS FORM 4 (SSF-4) INITIAL SESSION Patient: Clinician: Date: Time: Section A (Patient): Rank Rate and fill out each item according to how you feel right now. Then rank in order of importance 1 to 5 (1 = most important to 5 = least important) 1) RATE PSYCHOLOGICAL PAIN (hurt, anguish, or misery in your mind, not stress, not physical pain): What I find most painful is: 2) RATE STRESS (your general feeling of being pressured or overwhelmed): Low pain: :High pain Low stress: :High stress What I find most stressful is: 3) RATE AGITATION (emotional urgency; feeling that you need to take action; not irritation; not annoyance): I most need to take action when: 4) RATE HOPELESSNESS (your expectation that things will not get better no matter what you do): Low agitation: :High agitation Low hopelessness: :High hopelessness I am most hopeless about: 5) RATE SELF-HATE (your general feeling of disliking yourself; having no self-esteem; having no self-respect): Low self-hate: :High self-hate What I hate most about myself is: N/A 6) RATE OVERALL RISK Extremely low risk: :Extremely high risk OF SUICIDE: (will not kill self) (will kill self) 1)How much is being suicidal related to thoughts and feelings about yourself? Not at all: : completely 2)How much is being suicidal related to thoughts and feeling about others? Not at all: : completely Please list your reasons for wanting to live and your reasons for wanting to die. Then rank in order of importance 1 to 5. Rank REASONS FOR LIVING Rank REASONS FOR DYING

38 Section B (Clinician): Y N Suicide ideation Frequency Duration Y N Suicide plan Y N Suicide preparation Y N Suicide rehearsal Y N Describe: per day seconds When: Where: How: How: Describe: Describe: History of suicidal behaviors Single attempt Describe: Multiple attempts Describe: Y N Impulsivity Y N Substance abuse Y N Significant loss Y N Relationship problems Y N Burden to others Y N Health/pain problems Y N Sleep problems Y N Legal/financial issues Y N Shame Describe: Describe: Describe: Describe: Describe: Describe: Describe: Describe: Describe: per week minutes per month hours Access to means Y N Access to means Y N Section C (Clinician): TREATMENT PLAN Problem # Problem Description Goals and Objectives Interventions Duration 1 Self-Harm Potential Safety and Stability Stabilization Plan Completed 2 3

39 Management of Suicide Risk 39

40 Treatment recommendations Treatment for suicide or another problem (e.g., depression)? For chronic suicide risk or longer duration ideation suicide specific treatment Collaborative Assessment and Management of Suicide Risk (Jobes, 2017) Suicide-specific assessment and treatment-planning Tracking of on-going risk Clinical outcomes and dispositions Flexible in approach to addressing drivers of suicide risk Only suicidal in context of depressive episode treatment targeting the specific area of concern

41 41 Between Session Care Individuals thinking about suicide may need help with: Reminders of signals of crisis Assistance with managing strong emotions tied to suicide risk Ideas for distraction (people, activities) People to call for help Where to go for help How to make the environment safe Crisis Response Plans address these concerns

42 Crisis Response Plan 42

43 Thank you for your attention! Acknowledgements American Foundation for Suicide Prevention Former graduate students: Erin F. Schlegel, Ph.D. Danielle R. Jahn, Ph.D. Erin Poindexter, Ph.D. Ryan Graham, Ph.D. Project FRONTER staff: - Billy Philips, Ph.D. - Theresa Huckabee - Cathy Hudson Collaborators: Jennifer S. Cheavens, Ph.D. Kimberly A. Van Orden, Ph.D. Ryan B. Williams, Ph.D. Friona Prabhu, M.D. Michael Ragain, M.D. Ron Cook, D.O. Kitten Litton, M. D.