Suicide Prevention in the Older Adult Nina R. Ferrell, MA Geriatric Outreach Professional Relations Salt Lake Behavioral Health Hospital Presentation Content Credits 1. Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment, A Treatment Improvement protocol TIP 50 series, SAMHSA, U.S. Department of Heath and Human Services 2. Suicide Prevention for Older People, Early intervention, assessment referral option for staff working with older people who may be at risk of suicide, Training Manual, New South Wales Department of Health 3. Promoting Mental Health and Preventing Suicide: A Toolkit for Senior Living Communities, SAMHSA Presentation Content Credits 4. Get Connected! Linking Older Adults with Medication, Alcohol, and Mental Health Resources, SAMHSA 5. key Research Findings, Preventing Suicide, American Foundation Suicide Prevention 6.Promoting Emotional Health and Preventing Suicide, A Toolkit for Senior Centers, SAMHSA, 2015 1
Clinical Recommendations Be Direct Increase Your Knowledge About Suicidality Do What You Already Do Well- Empathy, Warmth and Supportive Trust Your Instincts Work Collaboratively with Suicidal Clients Realize Limits of Confidentiality and Share Limits Statistics The latest data from the Centers for Disease Control and Prevention from 2014 indicate 41, 149 persons died from suicide, making suicide the 10 th leading cause of death in United States. In 2013, a person died by suicide every 12.8 minutes. The suicide rate is approximately 12.6 per 100,000 persons The highest rate was 19.1 per 100,000 for those age 45 to 64 and second highest was those age 85 and over at 18.6 per 100,000. Statistics Suicide rate for males is 4 times higher than for females, in 2013, 78% were male and 22% female. Firearms are the most common method at 51%, followed by suffocation at 25% and poisoning at 16% Suicide rates in seniors maybe underreported by as much as 40%. Overdoses often reported by coroners as accidents if the person is elderly. 2
Ten Points to Keep You on Track 1. Almost all of your clients who are suicidal are ambivalent about living or not living. 2. Suicidal crisis can be overcome. 3. Although suicide cannot be predicted with certainty, suicide risk assessment is a valuable clinical tool. 4. Suicide prevention actions should be extend beyond the immediate crisis. Ten Points Continued 5. Suicide Contracts are not recommended and are never sufficient. 6. Some clients will be at risk of suicide, even after getting clean and sober. 7. Suicide attempts always must be taken seriously. 8. Suicidal individuals generally show warning signs 9. It is best to ask clients about suicide, and ask directly. Ten Points Continued 10. The outcome does not tell the whole story. 3
Maintain Positive Attitudes Before working with clients who are suicidal, counselors are advised to conduct their own suicidal attitude inventory. 1. What is my personal and family history of suicide? 2. What personal experiences do I have with suicide or suicide attempts, and how do they effect my work with suicidal clients? 3. What is my emotional reaction to clients who are suicidal? Maintain Positive Attitudes 4. How do I feel when talking to clients about their suicidal thoughts and behaviors? 5. What did I learn about suicide in my formative years? 6 Positive Behaviors 1. All Clients should be screened for suicidal thoughts and behaviors as a matter of routine. 2. People in substance abuse treatment settings often need additional services to ensure their safety. 3. All expressions of suicidality indicate significant distress and heightened vulnerability that require further questioning and action. 4. Warning signs for suicide can be indirect; you need to develop a heightened sensitivity to these cues. 4
Maintain Positive Attitudes 5. Talking about a client s past suicidal behavior can provide information about triggers for suicidal behavior. 6. You Should give clients who are at risk of suicide the telephone number of a suicide hotline. Types of Suicidal Thoughts and Behaviors Suicidal Ideation Lies on a continuum of severity from fleeting and vague thoughts of death to those that are persistent and highly specific. Serious suicidal ideation is frequent, intense, and perceived as uncontrollable. Types of Suicidal Thoughts and Behaviors Suicidal Plans Suicide planning lies on a continuum from vague and unrealistic plans to those that are highly specific and feasible. Serious suicide planning may also involve rehearsal or preparation for a suicide attempt. Suicide plans are more important because they signal more serious risk to carry out suicidal behavior than suicidal ideation that does not involve planning. 5
Suicidal Behaviors Suicide Attempt A deliberate act of self-harm that does not result in death but has some intent to die. Attempts have two major elements: 1. Subjective level of intent- how intensely did the client want to die and expect to die? 2. Objective lethality- how likely was it that the behavior would lead to death? Other Suicide Related Concepts Suicidal Intention or Intent Signals a high, acute risk for suicidal behavior, it means a client intends to make a suicidal attempt Suicidal Preparation Behaviors that suggest preparation signal high, acute risk for suicidal behavior. Risk Factors Prior history of suicide attempts (it should be noted that about half of all deaths by suicide are first-time attempts. Family history of suicide Severe substance use (e.g., dependence on multiple substances, early onset of dependence). Co-occurring mental disorders: Depression 6
Risk Factors Cont. Anxiety Disorders (especially PTSD) Severe mental illness (schizophrenia, bipolar disorder). Personality disorder (best researched are borderline and antisocial personality disorders). Anorexia History of Childhood Abuse (especially sexual abuse). Risk Factors Cont. Stressful life circumstances: Unemployment and low level of education, job loss, especially when nearing retirement. Divorce or separation Legal Difficulties Major and sudden financial losses Social Isolation, low social support Risk Factors Conflicted Relationships Multiple medical diagnosis and limitations Personality Traits- Proneness to negative affect (sadness, anxiety, anger). Aggression and/or impulsive traits. Inflexible/rigid personality characteristics 7
Risk Factors Cont. Firearm ownership or access to a firearm Sexual Orientation Protective Factors Protective factors are buffers that lower the long-term risk of suicide. Reasons for living Being clean and sober and maintaining sobriety support system Religious attendance and /or internalized spiritual teachings against suicide Presence of a child in the home and/or childrearing responsibilities Intact marriage Trusting relationship with a counselor physician, or other service provider. Employment Trait optimism (a tendency to look at the positive side of life). Risk of Suicide: Age, Gender and Race or Ethnicity Age Adolescents and young adults are more likely to make nonfatal suicide attempts than older adults. However, older individuals are more likely to die by suicide. High suicide intent More deadly methods Greater physical fragility Live alone so less likely to be rescued 8
Risk of Suicide: Age, Gender and Race or Ethnicity Gender Women attempt more often Men are more likely to die in attempt Men have higher intent to die and use more lethal means, usually firearms Risk of Suicide: Age, Gender and Race or Ethnicity Race and Ethnicity Whites and Native Americans have higher rates than African Americans Males are at highest risk Highest rate of suicide among white males is during older adulthood, age 70 and older. Highest rate among Native Americans and African Americans is during late adolescents and young adulthood. Risk of Suicide: Age, Gender and Race or Ethnicity Hispanics/Latinos have fairly similar rates of suicidal thoughts and behaviors as with white, non Hispanic individuals with the exception of youth and adults who become acculturated to mainstream American culture, particularly among females. 9
Reasons for Suicidal Behavior Desire to die Hopelessness Extreme or prolonged sadness Perceived failure or self-hate following relapse Loneliness, feeling like a burden to others Escape from a painful emotional state Disinhibition while intoxicated Escape from an entrapping situation Get attention Reasons for Suicidal Behavior Impulsive reaction to an acute stressful life event(e.g., break-up) Hurt another individual (e.g., make another individual feel guilty) Paranoia or other psychosis (e.g., command hallucination to take one s own life) Escape a progressive deteriorating health situation (e.g., terminal disease). SAFE-T Suicide Assessment Five-Step Evaluation and Triage 1. Identify Risk Factors Note those that can be modified to reduce risk 2. Identify Protective Factors Note those that can be enhanced 3. Conduct Suicide Inquiry Suicidal thoughts, plans, behavior, and intent 10
SAFE-T 4. Determine Risk Level/Intervention Determine risk, choose appropriate intervention to address and reduce risk 5. Document Assessment of risk, rationale, intervention and follow-up. Postvention After Suicide or Attempt Feelings: Disbelief Denial Grief Guilt Anger Shame Suicide Assessment tools Columbia Suicide Severity Rating Scale Patient Health Questionnaire The Suicide Behaviors Questionnaire- revised Geriatric Depression Scale 11
Postvention After Suicide or Attempt Coping Strategies to help yourself Give yourself time to heal with the loss and accept whatever emotions you feel. Remember that everyone grieves differently. The suicide of a family member, friend or client can affect your emotional health. Get help if you feel emotionally vulnerable yourself. Talk about the person who died with someone you trusta family member, friend, member of the clergy or staff Postvention After Suicide or Attempt Express your feelings with a counselor or a support group with others who are likely to understand what you are going through. Stay with your daily routine and take care of your basic needs- eat, sleep, and attend your regular activities. Be prepared for holidays and anniversaries, since they can be difficult emotionally, consider dong something special in memory of he the person who died. How to Help Others How you feel about suicide will affect how you respond to others. Take the time to get clear about your feelings before you try and help someone else. What to say: Express empathy, and acknowledge their pain and sadness. I am so sorry for your loss. I can see that you are hurting. 12
How to Help Others Ask if they want to talk about the person, and just listen. Do you want to talk about? Let them know you care about their well-being. I am here to support you in any way. What to do Be kind and reach out- send a card, have lunch, watch a show, etc. Call and visit regularly Listen when they talk about their feelings and don t try and make them feel better. Offer to help with their responsibilities, but don t take over unless they ask. Resources to Help Cope With Suicide The National Suicide Prevention Lifeline 10 800 273-8255 SOS: A Handbook for Survivors of Suicide by Jeffrey Jackson (2003) can be downloaded from www.sprc.org/library/sos_handbook.pdf How to Help Others What to do Be kind and reach out- send a card, have lunch, watch a show, etc. Call and visit regularly Listen when they talk about their feelings and don t try and make them feel better. Offer to help with their responsibilities, but don t take over unless they ask. 13