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ElderCare Gatekeeper Training. 2.
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1. SAVING LIVES: Understanding Depression And Suicide In The Elderly Sponsored by the Ohio Department of Mental Health in Partnership with the ADAMH Board of Franklin County and the Ohio Suicide Prevention Team
Developed by Ellen Anderson, Ph.D., PCC, 2003-2006
2. ElderCare Gatekeeper Training 2 Introduce self and presentation. Explain about local Suicide Prevention Coalition efforts to reduce stigma, increase public awareness about depression and suicide.Introduce self and presentation. Explain about local Suicide Prevention Coalition efforts to reduce stigma, increase public awareness about depression and suicide.
3. ElderCare Gatekeeper Training 3 Goals For Suicide Prevention Increase community awareness that suicide is a preventable public health problem
Increase awareness that depression is the primary cause of suicide
Change public perception about the stigma of mental illness, especially about depression and suicide
Increase the ability of the public to recognize and intervene when someone they know is suicidal In creating this training, goals were established in order to provide structure for the program.
Goals for the training include:
Participants can more readily identify people-at-risk
They will be able to provide an appropriate initial response to people-at-risk
They will know how to get them help
And will consistently assist them in getting the appropriate help that they need
In creating this training, goals were established in order to provide structure for the program.
Goals for the training include:
Participants can more readily identify people-at-risk
They will be able to provide an appropriate initial response to people-at-risk
They will know how to get them help
And will consistently assist them in getting the appropriate help that they need
4. ElderCare Gatekeeper Training 4 Training Objectives Increase knowledge about the causes of suicide among the elderly
Learn the connection between depression and suicide
Dispel myths and misconceptions about suicide in the elderly
Learn risk factors and signs of suicidal behavior in the elderly
Learn to assess risk and find help for those at risk Asking the S question What we would like you to learn:
Gain knowledge about the causes of suicide among the elderly
Dispel myths and misconceptions about suicide
Learn risk factors/early warning signs of suicidal behavior as you work with elderly clients
Acquire knowledge regarding how to assess risk and get assistance for at-risk people learn how to ask the S questionWhat we would like you to learn:
Gain knowledge about the causes of suicide among the elderly
Dispel myths and misconceptions about suicide
Learn risk factors/early warning signs of suicidal behavior as you work with elderly clients
Acquire knowledge regarding how to assess risk and get assistance for at-risk people learn how to ask the S question
5. ElderCare Gatekeeper Training 5 The Feel of Depression What I had begun to discover is thatthe grey drizzle of horror induced by depression takes on the quality of physical pain. But it is not an immediately identifiable pain, like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played upon the sick braincomes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion.
William Styron, 1990
6. ElderCare Gatekeeper Training 6 The Feel of Depression I am 6 feet tall. The way I have felt these past few months, it is as though I am in a very small room, and the room is filled with water, up to about 5 10, and my feet are glued to the floor, and its all I can do to breathe.
7. ElderCare Gatekeeper Training 7 Mental Illness and Stigma Historical beliefs about mental illness color the way we approach it even now, and offer us a way to understand why the stigma against mental illness is so powerful
For most of our history, depression and other mental disorders were viewed as demon possession
Afflicted people were outside the gates, unclean, causing people to fear of the mentally ill
Lack of understanding of illness in general led people to fear contamination, either real or ritual
8. ElderCare Gatekeeper Training 8 What Is Mental Illness? None of us are surprised that there are many ways for an organ of the body to malfunction
Stomachs can be affected by ulcers or excessive acid; lungs can be damaged by environmental factors such as smoking, or by asthma; the digestive tract is vulnerable to many possible illnesses
We have never understood that the brain is just like other organs of the body, and as such, is vulnerable to a variety of illnesses and disorders
We confuse brain with mind
9. ElderCare Gatekeeper Training 9 What Is Mental Illness? We understand that something like Parkinsons damages the brain and creates behavioral changes
Even diabetes is recognized as creating emotional changes as blood sugar rises and falls
Stigma about illnesses like depression, schizophrenia and Bi-Polar disorder seems to keep us from seeing them as brain disorders that create changes in mood, behavior and thinking
10. ElderCare Gatekeeper Training 10 What Is Mental Illness? We called it mental illness because we wanted to stop saying things like lunacy, madness, bats in her belfry, nuttier than a fruitcake, rowing with one oar in the water, insane, ga ga, wacko, fruit loop, sicko, crazy
Is it any wonder people avoid acknowledging mental illness?
Of all the diseases we have public awareness of, mental illness is the most misunderstood
Any 5 year-old knows the symptoms of the common cold, but few people know the symptoms of the most common mental illnesses such as depression and anxiety
11. ElderCare Gatekeeper Training 11 Prevention Strategies General suicide and depression awareness education
Depression Screening programs
Community Gatekeeper Trainings
Crisis Centers and hotlines
Peer support programs
Restriction of access to lethal means
Intervention after a suicide
In researching suicide prevention, several strategies were recommended.
General Suicide Education: These programs provide people with facts about suicide, alert them to warning signs, and provide information about how to seek help for themselves or for others.
Screening Programs: Screening programs assist in identifying high-risk persons in order to provide more targeted treatment.
Community gatekeeper training: Like school gatekeeper training, this training provides information and resources to community members.
Crisis Centers and hotlines: These programs provide telephone support and counseling for suicidal people.
Peer Support Programs: These programs are designed to assist and support people and others at high-risk of suicide or suicidal behavior.
Restriction of access to lethal means: Activities designed to restrict access to handguns, drugs, and other common means of suicide.
Intervention after a suicide: Crisis response helps the community effectively cope with feelings of loss that come with the suicide of a friend or relative and prevent future suicides.
In researching suicide prevention, several strategies were recommended.
General Suicide Education: These programs provide people with facts about suicide, alert them to warning signs, and provide information about how to seek help for themselves or for others.
Screening Programs: Screening programs assist in identifying high-risk persons in order to provide more targeted treatment.
Community gatekeeper training: Like school gatekeeper training, this training provides information and resources to community members.
Crisis Centers and hotlines: These programs provide telephone support and counseling for suicidal people.
Peer Support Programs: These programs are designed to assist and support people and others at high-risk of suicide or suicidal behavior.
Restriction of access to lethal means: Activities designed to restrict access to handguns, drugs, and other common means of suicide.
Intervention after a suicide: Crisis response helps the community effectively cope with feelings of loss that come with the suicide of a friend or relative and prevent future suicides.
12. ElderCare Gatekeeper Training 12 Suicide Is The Last Taboo We Dont Want To Talk About It Suicide has become the Last Taboo we can talk about AIDS, sex, incest, and other topics that used to be unapproachable. We are still afraid of the S word
Understanding suicide helps communities become proactive rather than reactive to a suicide once it occurs
Reducing stigma about suicide and its causes provides us with our best chance for saving lives
Ignoring suicide means we are helpless to stop it
Talking about suicide is scary. Its hard to get people to come to trainings about suicide.
In fact, many people ask the question, Arent you opening a can of worms? By making people more aware of and less afraid of suicide, we hope to assist communities to be proactive in preventing suicide, rather than reactive to a suicide that has occurred.
Suicide is something that many think about at some point in life but no one wants to talk about.
Pretending it doesnt exist wont make it go away. Not learning about suicide means we are helpless to stop it.
In some churches, suicide is viewed as a failure of faith, a lack of trust in God, even a sin, not caring for the body and the life God has given us.
Talking about suicide, its causes and associated feelings provides us with our best opportunity for prevention.
Talking about suicide is scary. Its hard to get people to come to trainings about suicide.
In fact, many people ask the question, Arent you opening a can of worms? By making people more aware of and less afraid of suicide, we hope to assist communities to be proactive in preventing suicide, rather than reactive to a suicide that has occurred.
Suicide is something that many think about at some point in life but no one wants to talk about.
Pretending it doesnt exist wont make it go away. Not learning about suicide means we are helpless to stop it.
In some churches, suicide is viewed as a failure of faith, a lack of trust in God, even a sin, not caring for the body and the life God has given us.
Talking about suicide, its causes and associated feelings provides us with our best opportunity for prevention.
13. ElderCare Gatekeeper Training 13 What Makes Me A Gatekeeper? Gatekeepers are not mental health
professionals or doctors
Gatekeepers are responsible adults who spend time with people who might be vulnerable to depression and suicidal thoughts teachers, coaches, police officers, EMTs, physicians, clergy, 4H leaders, and of course, whose who work with the elderly If you spend time with people who might be in a high risk group for suicidal behavior, you are a gatekeeper. Other gatekeepers include correctional facility staff, police officers, medical staff, Scout masters, youth group workers, crisis intervention personnel, and emergency care workers. In reality, if you live in the world, you are a gatekeeper for friends, coworkers and family members as well.
If you spend time with people who might be in a high risk group for suicidal behavior, you are a gatekeeper. Other gatekeepers include correctional facility staff, police officers, medical staff, Scout masters, youth group workers, crisis intervention personnel, and emergency care workers. In reality, if you live in the world, you are a gatekeeper for friends, coworkers and family members as well.
14. ElderCare Gatekeeper Training 14 Why Should I Learn About Suicide Prevention? It is the 11th largest killer of Americans, and the rate of suicide is highest
among those over 75
No one is safe from the risk of suicide wealth, education, intact family, popularity cannot protect us from this risk
A suicide attempt is a desperate cry for help to end excruciating, unending, overwhelming pain. We must learn to answer that cry before it is too late People kill themselves for a lot of reasons, but the biggest one is the terrible, unending, unendurable pain sometimes called psychache. We tend to think that people are just seeking attention, but the reality is they may be suffering terrible emotional pain. You see elderly people every day, and may be more likely than any one else to hear and understand the kind of pain they are in. Elders tend not to want to talk about their feelings, or acknowledge a need for emotional assistance. People are more likely to seek help from people they know and trust, regardless of how uncomfortable they might be with help-seeking.People kill themselves for a lot of reasons, but the biggest one is the terrible, unending, unendurable pain sometimes called psychache. We tend to think that people are just seeking attention, but the reality is they may be suffering terrible emotional pain. You see elderly people every day, and may be more likely than any one else to hear and understand the kind of pain they are in. Elders tend not to want to talk about their feelings, or acknowledge a need for emotional assistance. People are more likely to seek help from people they know and trust, regardless of how uncomfortable they might be with help-seeking.
15. ElderCare Gatekeeper Training 15 89 people complete suicide every day
32,439 people in 2004 in the US
Over 1,000,000 suicides worldwide (reported)
This data refers to completed suicides that are documented by medical examiners it is estimated that 2-3 times as many actually complete suicide
(Surgeon Generals Report on Suicide, 1999) Many people do not think of suicide as a significant health issue in this country, but as you can see, we are losing many people to a completely treatable illness. If you think it is not important, consider that we lose 3 people to suicide for every 2 we lose to homicide, a statistic that has been stable for the past 100 years.
Many people do not think of suicide as a significant health issue in this country, but as you can see, we are losing many people to a completely treatable illness. If you think it is not important, consider that we lose 3 people to suicide for every 2 we lose to homicide, a statistic that has been stable for the past 100 years.
16. ElderCare Gatekeeper Training 16 Comparative Rates Of U.S. Suicides-2003
Rates per 100,000 population
National average - 11.1 per 100,000*
White males - 18
Hispanic males - 10.3
African-American males - 9.1 **
Asians - 5.2
Caucasian females - 4.8
African American females - 1.5
Males over 85 - 67.6
Annual Attempts 811,000 (estimated)
150-1 completion for the young - 4-1 for the elderly
(*AAS website),**(Significant increases have occurred among African Americans in the past 10 years - Toussaint, 2002)
These figures, unfortunately, are merely an estimate. Some experts fear the numbers are at least 2-3 higher, since many suicides are not identified as such. Because the stigma is so high, and because there are real financial consequences to a suicidal death as well as social, deaths that cannot be definitively called suicide are usually called an accident. Cars driven into trees on a clear night with no alcohol involvement, for example. We want to protect other family members. People wonder if life insurance must pay on suicide, because in the past it did not. In most states, if the death occurs more than 2 years after the policy is in effect.
Just an aside - suicide is no longer a crime, which is why we talk about completed rather than committed suicide. These figures, unfortunately, are merely an estimate. Some experts fear the numbers are at least 2-3 higher, since many suicides are not identified as such. Because the stigma is so high, and because there are real financial consequences to a suicidal death as well as social, deaths that cannot be definitively called suicide are usually called an accident. Cars driven into trees on a clear night with no alcohol involvement, for example. We want to protect other family members. People wonder if life insurance must pay on suicide, because in the past it did not. In most states, if the death occurs more than 2 years after the policy is in effect.
Just an aside - suicide is no longer a crime, which is why we talk about completed rather than committed suicide.
17. ElderCare Gatekeeper Training 17 The Unnoticed Death For every 2 homicides, 3 people complete suicide yearly data that has been constant for 100 years
During the Viet Nam War from 1964-1972, we lost 55,000 troops, and 220,000 people to suicide
18. ElderCare Gatekeeper Training 18 The Gender Issue Women perceived as being at higher risk than men
Women do make attempts 4 x as often as men
But - Men complete suicide 4 x as often as women
Womens risk rises until midlife, then decreases
Mens risk, always higher than womens, continues to rise until end of life
Are women more likely to seek help? Talk about feelings? Have a safety network of friends?
Do men suffer from depression silently?
19. ElderCare Gatekeeper Training 19 How Big Is The Problem For The Elderly? Risk factors for suicide among older persons differ from those among the young
In addition to a higher prevalence of depression
older persons are more socially isolated
more frequently use highly lethal methods
have more chronic physical illnesses
Not surprisingly, suicide rates among the elderly are highest for those who are divorced or widowed
(NIMH website, 2003) The next slide will show you just how much is at stake.The next slide will show you just how much is at stake.
20. ElderCare Gatekeeper Training 20 Suicide Rates Among The Elderly 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) Clearly this is a serious health risk for the elderly. The most important fact on this slide is that depression is not normal at any stage of life.Clearly this is a serious health risk for the elderly. The most important fact on this slide is that depression is not normal at any stage of life.
21. ElderCare Gatekeeper Training 21 Suicide Rate By Age Per 100,000 Note the rate at which suicide impacts people over 75.Note the rate at which suicide impacts people over 75.
22. ElderCare Gatekeeper Training 22 What Factors Put Someone At Risk For Suicide? Biological, physical, social, psychological or spiritual factors may increase risk-for example:
A family history of suicide increases risk by 6 times
Access to firearms people who use firearms in their suicide attempt are more likely to die
A significant loss by death, separation, divorce, moving, or breaking up with a boyfriend or girlfriend can be a trigger
(Goleman, 1997) These are only a few of the factors, but are probably the most significant.These are only a few of the factors, but are probably the most significant.
23. ElderCare Gatekeeper Training 23 Social Isolation: elders become increasingly isolated as family and friends die or move away, and as they lose mobility and transportation
The 2nd biggest risk factor - having an alcohol or drug problem
Many with alcohol and drug problems are clinically depressed, and are self-medicating for their pain
Many older people taking medication may be unaware of the risks for altered mental state
(Surgeon Generals call to Action, 1999) People who are socially isolated tend to be very lonely. We know from other types of studies among primates, for example, that loneliness, literally, can kill you. We are a social animal, and we need contact with others. When we dont get it, we become even more inappropriate in our behavior, more depressed, and less likely to see a reason for living. In some tribes, shunning, or ostracism, can lead to the death of the person who is shunned. They simply sit down, give up, and die.People who are socially isolated tend to be very lonely. We know from other types of studies among primates, for example, that loneliness, literally, can kill you. We are a social animal, and we need contact with others. When we dont get it, we become even more inappropriate in our behavior, more depressed, and less likely to see a reason for living. In some tribes, shunning, or ostracism, can lead to the death of the person who is shunned. They simply sit down, give up, and die.
24. ElderCare Gatekeeper Training 24 The biggest risk factor for suicide completion?
Having a Depressive Illness
People with clinical depression often feel helpless to solve problems, leading to hopelessness a strong predictor of suicide risk
At some point in this chronic illness, suicide seems like the only way out of the pain and suffering
Many Mental health diagnoses have a component of depression: anxiety, PTSD, Bi-Polar, etc
90% of suicide completers have a depressive illness
(Lester, 1998, Surgeon General, 1999) We really need to understand depression better, since it is the single biggest factor in suicide. We really need to understand depression better, since it is the single biggest factor in suicide.
25. ElderCare Gatekeeper Training 25 Depression Is An Illness Suicide has been viewed for countless generations as:
a moral failing, a spiritual weakness
an inability to cope with life
the cowards way out
A character flaw
Our cultural view of suicide is wrong - invalidated by our current understanding of brain chemistry and its interaction with stress, trauma and genetics on mood and behavior Suicides direct link with depression is important to understand. What we have learned in the last 20 years is that depression is a physical illness, one that can be cured with treatment. Now that we have ways of scanning brains for cellular activity, ways of mapping size and electrical activity, we can see the changes that bring about depression.Suicides direct link with depression is important to understand. What we have learned in the last 20 years is that depression is a physical illness, one that can be cured with treatment. Now that we have ways of scanning brains for cellular activity, ways of mapping size and electrical activity, we can see the changes that bring about depression.
26. ElderCare Gatekeeper Training 26 The research evidence is overwhelming - depression is far more than a sad mood. It includes:
Weight gain/loss
Sleep problems
Sense of tiredness, exhaustion
Sad or angry mood
Loss of interest in pleasurable things, lack of motivation
Irritability
Confusion, loss of concentration, poor memory
Negative thinking (Self, World, Future)
Withdrawal from friends and family
Sometimes, suicidal thoughts
(DSMIVR, 2002) The DSMIV, the diagnostic and statistical manual of mental health disorders, is quite clear on the group of symptoms that can be diagnosed as a depressive disorder. Although we do not have blood tests for this problem, the listed criteria can be easily determined, as long as the patient is telling the truth about their symptoms. Many come in with vague somatic complaints because, for many, the body literally aches. The surgeon generals report says that an assessment of depressive symptoms is as accurate and reliable as many blood tests currently the standard for assessment.The DSMIV, the diagnostic and statistical manual of mental health disorders, is quite clear on the group of symptoms that can be diagnosed as a depressive disorder. Although we do not have blood tests for this problem, the listed criteria can be easily determined, as long as the patient is telling the truth about their symptoms. Many come in with vague somatic complaints because, for many, the body literally aches. The surgeon generals report says that an assessment of depressive symptoms is as accurate and reliable as many blood tests currently the standard for assessment.
27. ElderCare Gatekeeper Training 27 20 years of brain research teaches that these symptoms are the behavioral result of
Internal changes in the physical structure of the brain
Damage to brain cells in the hippocampus, amygdala and limbic system
As Diabetes is the result of low insulin production by the pancreas, depressed people suffer from a physical illness what we might consider faulty wiring
(Braun, 2000; Surgeon Generals Call To Action, 1999, Stoff & Mann, 1997, The Neurobiology of Suicide)
28. ElderCare Gatekeeper Training 28 Faulty Wiring? Literally, damage to certain nerve cells in our brains
The result of too many stress hormones cortisol, adrenaline and testosterone
Hormones activated by our Autonomic Nervous System to protect us in times of danger
Chronic stress causes changes in the functioning of the ANS, so that a high level of activation occurs with little stimulus
Causes changes in muscle tension, imbalances in blood flow patterns leading to illnesses such as asthma, IBS, back pain and depression
(Goleman, 1997, Braun, 1999) As our brain cells become less able to connect with one another, our thinking changes in predictable ways. We find problem-solving more difficult, and get stuck on the idea that suicide is the only option. Most people tend to think of depression as affecting only the emotions, but it also hurts our thinking processes.
For some time now we have wondered why increasing the amount of the neurotransmitter, serotonin, as most of the newer anti-depressants do, has slowly reduced the symptoms of depression. It seems clear now that increased serotonin blocks or reduces the effect of the stress hormones, allowing our nerve cells to begin functioning again.As our brain cells become less able to connect with one another, our thinking changes in predictable ways. We find problem-solving more difficult, and get stuck on the idea that suicide is the only option. Most people tend to think of depression as affecting only the emotions, but it also hurts our thinking processes.
For some time now we have wondered why increasing the amount of the neurotransmitter, serotonin, as most of the newer anti-depressants do, has slowly reduced the symptoms of depression. It seems clear now that increased serotonin blocks or reduces the effect of the stress hormones, allowing our nerve cells to begin functioning again.
29. ElderCare Gatekeeper Training 29 Faulty Wiring? Without a way to return to rest, hormones accumulate, doing damage to brain cells
Stress alone is not the problem, but how we interpret the event, thought or feeling
People with genetic predispositions, placed in a highly stressful environment will experience damage to brain cells from stress hormones
This leads to the cluster of thinking and emotional changes we call depression
(Goleman, 1997; Braun, 1999) As our brain cells become less able to connect with one another, our thinking changes in predictable ways. We find problem-solving more difficult, and get stuck on the idea that suicide is the only option. Most people tend to think of depression as affecting only the emotions, but it also hurts our thinking processes.
For some time now we have wondered why increasing the amount of the neurotransmitter, serotonin, as most of the newer anti-depressants do, has slowly reduced the symptoms of depression. It seems clear now that increased serotonin blocks or reduces the effect of the stress hormones, allowing our nerve cells to begin functioning again.As our brain cells become less able to connect with one another, our thinking changes in predictable ways. We find problem-solving more difficult, and get stuck on the idea that suicide is the only option. Most people tend to think of depression as affecting only the emotions, but it also hurts our thinking processes.
For some time now we have wondered why increasing the amount of the neurotransmitter, serotonin, as most of the newer anti-depressants do, has slowly reduced the symptoms of depression. It seems clear now that increased serotonin blocks or reduces the effect of the stress hormones, allowing our nerve cells to begin functioning again.
30. ElderCare Gatekeeper Training 30
31. ElderCare Gatekeeper Training 31 Where It Hits Us
32. ElderCare Gatekeeper Training 32 One of Many Neurons As dendritic branches die back, the result of onslaught by stress hormones, fewer and fewer connections can be made in these brain areasAs dendritic branches die back, the result of onslaught by stress hormones, fewer and fewer connections can be made in these brain areas
33. ElderCare Gatekeeper Training 33 As damage occurs, thinking changes in the predictable ways identified in our list of 10 criteria
Thought constriction can lead to the idea that suicide is the only option
How do antidepressants affect this brain damage?
They may counter the effects of stress hormones
We know now that antidepressants stimulate genes within the neurons (turn on growth genes) which encourage the growth of new dendrites
(Braun, 1999)
34. ElderCare Gatekeeper Training 34 Renewed dendrites:
increase the number of neuronal connections
allow our nerve cells to begin connecting again
The more connections, the more information flow, the more flexibility and resilience the brain will have
Why does increasing the amount of serotonin, as many anti-depressants do, take so long to reduce the symptoms of depression?
It takes 4-6 weeks to re-grow dendrites & axons
(Braun, 1999)
35. ElderCare Gatekeeper Training 35 How Does Psychotherapy Help? Medications may improve brain function, but do not change how we interpret stress
Psychotherapy, especially cognitive or interpersonal therapy, helps people change the (negative) patterns of thinking that lead to depressed and suicidal thoughts
Research shows that cognitive psychotherapy is as effective as medication in reducing depression and suicidal thinking
Changing our beliefs and thought patterns alters response to stress we are not as reactive or as affected by stress at the physical level (Lester, 2004)
36. ElderCare Gatekeeper Training 36 What Therapy? The standard of care is medication and psychotherapy combined
At this point, only cognitive behavioral and interpersonal psychotherapies are considered to be effective with clinical depression (evidence-based)
Patients should ask their doctor for a referral to a cognitive or interpersonal therapist
37. ElderCare Gatekeeper Training 37 Possible Sources Of Depression Genetic: a predisposition to this problem may be present, and depressive diseases seem to run in families
Predisposing factors: Childhood traumas, car accidents, brain injuries, abuse and domestic violence, poor parenting, growing up in an alcoholic home, chemotherapy
Immediate factors: violent attack, illness, sudden loss or grief, loss of a relationship, any severe shock to the system
(Anderson, 1999, Berman & Jobes, 1994, Lester, 1998) We do not yet know how genetic factors predispose people to depressive illnesses, but research suggests that heredity is definitely a factor
Predisposing factors are varied, but most seem to be the result of extreme stress, either acute, as in an illness, or chronic, as in domestic violence, sexual abuse of children, or poor parenting. Stress seems to have a powerful impact on the amygdala, the place in our brain where we respond to stress or danger. It also increases the agitation of the limbic system, and seems to damage cells in the hippocampus.
Severe shocks to the system may or may not lead to depression, but predisposing factors and heredity, teamed with a severe shock, will almost certainly lead to depressionWe do not yet know how genetic factors predispose people to depressive illnesses, but research suggests that heredity is definitely a factor
Predisposing factors are varied, but most seem to be the result of extreme stress, either acute, as in an illness, or chronic, as in domestic violence, sexual abuse of children, or poor parenting. Stress seems to have a powerful impact on the amygdala, the place in our brain where we respond to stress or danger. It also increases the agitation of the limbic system, and seems to damage cells in the hippocampus.
Severe shocks to the system may or may not lead to depression, but predisposing factors and heredity, teamed with a severe shock, will almost certainly lead to depression
38. ElderCare Gatekeeper Training 38 What Happens If We Dont Treat Depression? Significant risk of increased alcohol and drug use
Significant relationship problems
Withdrawal from daily activities, self-care
High risk for suicidal thoughts, attempts, and possibly death
(Surgeon Generals Call To Action, 1999) Considering what we have learned, it seems criminal to ignore the need for treatment of depression in our society. Its as if we had chosen to ignore lung cancerConsidering what we have learned, it seems criminal to ignore the need for treatment of depression in our society. Its as if we had chosen to ignore lung cancer
39. ElderCare Gatekeeper Training 39 PCPs And Diagnosis Of Depression The elderly have often visited a health-care provider before completing suicide
20% of elderly (over 65 years) who complete suicide visited a physician within 24 hours
41% within a week
75% 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) Primary Care physicians are those most likely to be treating depressed elderly patients. They may need additional training in how to look at their older patients.Primary Care physicians are those most likely to be treating depressed elderly patients. They may need additional training in how to look at their older patients.
40. ElderCare Gatekeeper Training 40 Elders Have Additional Issues The number of elders with mental illness will increase to 15 million in 2030
Mental illness has a significant impact on the health and functioning of older persons
Associated with increased utilization of services and higher costs
Our current mental health system is inadequate
Unprepared to address the anticipated growth in the number of elderly requiring treatment for late-life mental disorders
(Presidents New Freedom Commission on Mental Health, 2003
Jeste, et al., 1999; www.census.gov)
41. ElderCare Gatekeeper Training 41 Barriers To MH Care Fragmented service delivery system
Out of date Medicare policies
Stigma due to mental illness and advanced age
Mismatch between services that are covered and those preferred by older persons
Lack of adequate preventive interventions and programs that aid early identification of geriatric mental illness
(Bartels, 2003) The Presidents New Freedom Commission on Mental Health has suggested the importance of revising policy and reimbursement to improve access and continuity of services by supporting comprehensive outreach mental health services in home and community-based settings where older persons seek services and reside. This includes redesigning the mental health system to respond to the preferences and needs of older persons and the mismatch between covered and preferred services. This means Medicare changes.
Finally, they identified the pressing need to develop a workforce with specialized training in gerontology and geriatric mental health.
The Presidents New Freedom Commission on Mental Health has suggested the importance of revising policy and reimbursement to improve access and continuity of services by supporting comprehensive outreach mental health services in home and community-based settings where older persons seek services and reside. This includes redesigning the mental health system to respond to the preferences and needs of older persons and the mismatch between covered and preferred services. This means Medicare changes.
Finally, they identified the pressing need to develop a workforce with specialized training in gerontology and geriatric mental health.
42. ElderCare Gatekeeper Training 42 Medicare Expenditures For Mental Health Services Total 1998 Medicare Health care Expenditures:
211.4 Billion
Total Mental Health Expenditures:
1.2 Billion (0.57%)
Outpatient Mental Health Expenditures:
718 Million (0.34%)
CMS, 2001 Unfortunately, no one is paying attention to these needs. AS you can see, Medicare makes mental health an extremely low priority. Less than 1% of the total budget went to MH expenses. Less than half of 1% went for therapy.Unfortunately, no one is paying attention to these needs. AS you can see, Medicare makes mental health an extremely low priority. Less than 1% of the total budget went to MH expenses. Less than half of 1% went for therapy.
43. ElderCare Gatekeeper Training 43 Expenditures On NIMH Newly Funded Grants Despite the growing need for geriatric mental health training for professionals and for information on the impact of medications and treatments on elders, grants are not going in the direction of care for the aging.Despite the growing need for geriatric mental health training for professionals and for information on the impact of medications and treatments on elders, grants are not going in the direction of care for the aging.
44. ElderCare Gatekeeper Training 44 Falling Through The Cracks Community Mental Health Services
Under-serve older persons
Lack staff trained to address medical needs
Often lack age-appropriate services
Principal Providers of Mental Health Care:
Primary Care Physicians
Long-term Care Facilities
Medicare
Incomplete outpatient prescription drug coverage
Lack of mental health parity
45. ElderCare Gatekeeper Training 45 Inadequate Workforce Of Trained Geriatric Mental Health Providers Current Workforce: 2,425 Geriatric Psychiatrists
200-700 Geriatric Psychologists
Estimated Current Need:
5,000 + of each specialty
Severe Nursing and Allied Health Care Provider Shortage
(Bartels, 2003)
46. ElderCare Gatekeeper Training 46 Poor Quality Of Mental Health Care For Elders > 1 in 5 older persons given an inappropriate prescription (Zhan, 2001)
The elderly are less likely to be treated with psychotherapy (Bartels, et al., 1997)
Lower quality of general health care is associated with increased mortality in all settings (Druss, 2001)
Here are some examples of barriers to MH care. In general, elders with mental disorders are not getting good treatment.Here are some examples of barriers to MH care. In general, elders with mental disorders are not getting good treatment.
47. ElderCare Gatekeeper Training 47 Unmet Need For Mental Health Services In Nursing Homes Nursing Homes are the primary provider of Mental Health for elderly in institutions
Over one month: 4.5% of mentally ill nursing home residents received mental health services
Over one year: 19% in need of mental health services receive them
Least Likely to get help -Oldest, most physically impaired
Among the Most Common Disorders
Dementia
Depression
Anxiety Disorders and Psychotic Disorders (Burns et al., 1993 Burns & Taube, 1990, 1991, Rovner et al., 1990Shea et al., Smyer et al., 1994)
48. ElderCare Gatekeeper Training 48 Illness And Depression Depression is common among older patients with certain medical disorders
Associated with worse health outcomes
Greater use and costs of medications
Greater use of health services
Medical illness greatly increases the risk for depression particularly in:
Ischemic heart disease (e.g. MI, CABG) Stroke
Cancer Chronic lung disease Alzheimers disease Arthritis Parkinsons disease
In heart attack patients, depression is a significant predictor of death at 6 months
(Empfield, 2003)
49. ElderCare Gatekeeper Training 49 Rates Of Depression Among Elders With Illness Cognitively intact nursing home patients shown to have symptoms consistent with depressive disorders 60%
Chronically ill outpatients in a primary care practice - 25%
Hospitalized patients - 20%
In nursing homes, regardless of physical health, major depression increases the likelihood of mortality by 59% in one year
(Empfield, 2003)
50. ElderCare Gatekeeper Training 50 Depression Associated With Worse Health Outcomes Worse outcomes
Hip fractures
Myocardial infarction
Increased mortality rates for Myocardial Infarction (Frasure-Smith 1993, 1995)
In Cancer, depression leads to
Increased Hospitalization
Poorer physical function
Poorer quality of life
Poorer pain control (Mossey 1990; Penninx et al. 2001;
(Katz 1989, Rovner 1991, Parmelee 1992;
Ashby1991; Shah 1993, Samuels 1997)
51. ElderCare Gatekeeper Training 51 Benefits Of Treatment For Depression In The Elderly Depression is one of the few medical conditions in which treatment can make a rapid and dramatic difference in an elderly persons 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)
52. ElderCare Gatekeeper Training 52 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) Referral for therapy is not common for geriatric patients, but should become the standard of treatment. Elders often object to the idea of therapy, but will listen to medical personnel who suggest and encourage therapy.Referral for therapy is not common for geriatric patients, but should become the standard of treatment. Elders often object to the idea of therapy, but will listen to medical personnel who suggest and encourage therapy.
53. ElderCare Gatekeeper Training 53 What We Need To Know With all this data to concern us about elder Americans, what do we need to learn to help them, to reduce the number of people suffering from depression and suicidal thoughts?
What to look for
How to talk to a depressed/suicidal person
How to get help
54. ElderCare Gatekeeper Training 54 Suicide Myths What Is True? 1.Talking about suicide might cause a person to act
False it is helpful to show the person you take them seriously and you care. Most feel relieved at the chance to talk
2. A person who threatens suicide wont really follow through
False many people who complete suicide talk about it often before they actually do it
(AFSP website, 2003) 1. If you ask a person about suicide and they are not thinking about it, they will tell you so and go on if they are already thinking of it, you now have a chance to talk with them and reduce their sense of hopelessness, reducing the likelihood that they will attempt it. If you will not talk with them, what will intervene in their despair? If no one notices, no one talks to them, will they not believe things really are hopeless?
Because depression tends to be a chronic illness, people may fight suicidal thoughts for years, and may talk about it often before attempting.
2. The word crazy should be dropped from our vocabulary. It has become so demeaning and cruel, especially when people are suffering from an illness, and only serves to stigmatize and reduce the chance that people will take the illness seriously. If someone is crazy, we dont have to have compassion for them, dont have to seek a cure, dont have to treat them as human.
1. If you ask a person about suicide and they are not thinking about it, they will tell you so and go on if they are already thinking of it, you now have a chance to talk with them and reduce their sense of hopelessness, reducing the likelihood that they will attempt it. If you will not talk with them, what will intervene in their despair? If no one notices, no one talks to them, will they not believe things really are hopeless?
Because depression tends to be a chronic illness, people may fight suicidal thoughts for years, and may talk about it often before attempting.
2. The word crazy should be dropped from our vocabulary. It has become so demeaning and cruel, especially when people are suffering from an illness, and only serves to stigmatize and reduce the chance that people will take the illness seriously. If someone is crazy, we dont have to have compassion for them, dont have to seek a cure, dont have to treat them as human.
55. ElderCare Gatekeeper Training 55 Suicide Myths, continued:
3. Only crazy people kill themselves
False - Crazy is a cruel and meaningless word. Most people who kill themselves have not lost touch with reality they feel hopeless and in terrible pain
4. No one I know would do that
False - suicide is an equal opportunity killer rich, poor, successful, unsuccessful, beautiful, ugly, young, old, popular and unpopular people all complete suicide
5. Theyre just trying to get attention
False They are trying to get help. We should recognize that need and respond to it
1.Depression knows no boundaries and can affect anyone, even people who seem to have everything
2.We often struggle with parents who tell us their kid is just seeking attention. If someone were struggling with a physical ailment and kept asking for help for the pain, we would react appropriately and help them relieve the pain. When the pain is emotional, we need to react in the same way.
3. This is true throughout Ohio. Wyandot county with a population of 35,000, has one of the highest suicide rates in the state.
1.Depression knows no boundaries and can affect anyone, even people who seem to have everything
2.We often struggle with parents who tell us their kid is just seeking attention. If someone were struggling with a physical ailment and kept asking for help for the pain, we would react appropriately and help them relieve the pain. When the pain is emotional, we need to react in the same way.
3. This is true throughout Ohio. Wyandot county with a population of 35,000, has one of the highest suicide rates in the state.
56. ElderCare Gatekeeper Training 56 Suicide myths, continued:
Suicide is a city problem, not in the
country or a small town
False rural areas have higher suicide rates than urban areas
Once a person decides to die nothing can stop them - They really want to die
NO - most people want to be stopped if we dont try to stop them they will certainly die - people want to end their pain, not their lives, but they have no hope that anyone will listen, that they can be helped
(AFSP website, 2003) .
.
57. ElderCare Gatekeeper Training 57 How Do I Know If Someone Is Suicidal? Now we understand the connection between depression and suicide
We have reviewed what a depressed person looks like
Not all depressed people are suicidal how can we tell?
Suicides dont happen without
warning - verbal and behavioral
clues are present, but we may not
notice them This first should seem obvious, and is the most highly correlated to actual completion, but many dismiss it as attention seeking behavior.
Yet most who complete suicide have made one or more attempts in their past. We need to think of this as a first step that may lead to more attempts.
Some disagree that suicides dont happen without warning, and maybe there are a few but if we look at the symptom list, and the behaviors we have seen before the suicide, it may become apparent that we did not know what we were seeing.
This first should seem obvious, and is the most highly correlated to actual completion, but many dismiss it as attention seeking behavior.
Yet most who complete suicide have made one or more attempts in their past. We need to think of this as a first step that may lead to more attempts.
Some disagree that suicides dont happen without warning, and maybe there are a few but if we look at the symptom list, and the behaviors we have seen before the suicide, it may become apparent that we did not know what we were seeing.
58. ElderCare Gatekeeper Training 58 Verbal Expressions Common statements
I shouldn't be here
I'm going to run away
I wish I were dead
I'm going to kill myself
I wish I could disappear forever
If a person did this or that?., would he/she die
Maybe if I died, people would love me more
I want to see what it feels like to die Sometimes red flags come in the form of what people say. It is not always the words, sometimes it is the tone of voice flat, dead, muted speaking. Sometimes statements are direct and to the point, such as:
I wish I were dead.
I am going to kill myself.
Im going to end it all.
I dont want to live anymore.
Indirect statements can be more subtle. These may include such things as:
No one cares if I live or die.
Does it hurt to die?
Youd be better off without me.
Theyll be sorry when I am gone.
These comments should not be ignored, or considered attention seeking. These are clear indicators that someone no longer believes life is worth living. This is not a temporary funk, but a serious medical condition which may lead to death. People who talk about killing themselves are preparing themselves, and everyone else, for the actual act.Sometimes red flags come in the form of what people say. It is not always the words, sometimes it is the tone of voice flat, dead, muted speaking. Sometimes statements are direct and to the point, such as:
I wish I were dead.
I am going to kill myself.
Im going to end it all.
I dont want to live anymore.
Indirect statements can be more subtle. These may include such things as:
No one cares if I live or die.
Does it hurt to die?
Youd be better off without me.
Theyll be sorry when I am gone.
These comments should not be ignored, or considered attention seeking. These are clear indicators that someone no longer believes life is worth living. This is not a temporary funk, but a serious medical condition which may lead to death. People who talk about killing themselves are preparing themselves, and everyone else, for the actual act.
59. ElderCare Gatekeeper Training 59 Some Behavioral Warning Signs Common signs
Previous suicidal thoughts or attempts
Expressing feelings of hopelessness or guilt
(Increased) substance abuse
Becoming less responsible and motivated
Talking or joking about suicide
Giving away possessions
Having several accidents resulting in injury; "close calls" or "brushes with death"
60. ElderCare Gatekeeper Training 60 What On Earth Can I Do? We are reluctant to ask questions of depressed people because we feel it is none of my business, or fear the responsibility
Depression is an illness, like heart disease, and suicidal thoughts are a crisis, like a heart attack
You would not leave a heart attack victim lying on the sidewalk. You would make some attempt to administer CPR
Anyone can learn to ask the right questions to help a depressed and suicidal person Very few professionals or members of the public find this an easy question to ask. This is a question that many licensed clinicians have trouble asking, because to get a yes answer gives us a tremendous responsibility. We dont have to ask a heart attack victim if they are dying we can see it, yet we would not take the blame if, having tried CPR, a heart attack victim died anyway. We are fearful of the awesome responsibility of keeping a suicidal, depressed person alive. If not us, who? Yes, we are our brother/sisters keeper.
And, for those who are concerned about their faith, losing it, or fearing the consequences of their wish for death, we have the opportunity to help them understand that depression and suicidal thoughts are an illness, not a problem with ones relationship with God. If we could take that stigma away from the religious depressed, it would be one less burden they have to bear.
We learned to do CPR by the millions, and we can learn to ask the S questions, too.Very few professionals or members of the public find this an easy question to ask. This is a question that many licensed clinicians have trouble asking, because to get a yes answer gives us a tremendous responsibility. We dont have to ask a heart attack victim if they are dying we can see it, yet we would not take the blame if, having tried CPR, a heart attack victim died anyway. We are fearful of the awesome responsibility of keeping a suicidal, depressed person alive. If not us, who? Yes, we are our brother/sisters keeper.
And, for those who are concerned about their faith, losing it, or fearing the consequences of their wish for death, we have the opportunity to help them understand that depression and suicidal thoughts are an illness, not a problem with ones relationship with God. If we could take that stigma away from the religious depressed, it would be one less burden they have to bear.
We learned to do CPR by the millions, and we can learn to ask the S questions, too.
61. ElderCare Gatekeeper Training 61 What Stops Us? Most of us still believe suicide and depression are none of our business
Most are fearful of getting a yes answer
What if: we knew how to respond to yes?
We could recognize depression symptoms like we recognize symptoms of a heart attack?
We were no longer afraid to ask for help for ourselves, our parents, our children?
We no longer felt ashamed of our feelings of despair and hopelessness, but recognized them as symptoms of a brain disorder?
62. ElderCare Gatekeeper Training 62 Reduce Stigma Stigma about having mental health problems keeps people from seeking help or even acknowledging their problem
Reducing the fear and shame we carry about having such shameful problems is critical
People must learn that depression is truly a disorder that can be treated not something to be ashamed of, not a weakness
Learning about suicide makes it possible for us to overcome our fears about asking the S question
63. ElderCare Gatekeeper Training 63 Learning QPR Or, How To Ask The S Question It is essential, if we are to reduce the number of suicide deaths in our country, that community members/gatekeepers learn QPR
First identified by Dr. Paul Quinnett as an analogue to CPR, QPR consists of
Question asking the S question
Persuade Getting the person to talk, and to seek help
Refer Getting the person to professional help
(Quinnett, 2000) 40 years ago someone thought it would be a good idea if the average American could learn some basics that would keep a person who was having a heart attack alive until the ambulance arrived. Millions of us have learned CPR, and many have been saved who might otherwise have died. Now we need to learn how to do it again, all of us, to stop the unnecessary deaths caused by depression and mental illness. Both on and off the job, if we all learned QPR, we could save a lot of lives.40 years ago someone thought it would be a good idea if the average American could learn some basics that would keep a person who was having a heart attack alive until the ambulance arrived. Millions of us have learned CPR, and many have been saved who might otherwise have died. Now we need to learn how to do it again, all of us, to stop the unnecessary deaths caused by depression and mental illness. Both on and off the job, if we all learned QPR, we could save a lot of lives.
64. ElderCare Gatekeeper Training 64 Ask Questions! You seem pretty down
Do things seem hopeless to you
Have you ever thought it would be easier to be dead?
Have you considered suicide?
Remember, you cannot make someone suicidal by asking
If they are already thinking of it they will probably be relieved that the secret is out
If you get a yes answer, dont panic. Ask a few more questions Whether you are involved with a person in a home, at your church/temple/mosque, at a nursing home or another setting, learn to ask questions when you see signs of depression and suicidal thinking, as discussed before. If they are not thinking about it, they will simply tell you so.Whether you are involved with a person in a home, at your church/temple/mosque, at a nursing home or another setting, learn to ask questions when you see signs of depression and suicidal thinking, as discussed before. If they are not thinking about it, they will simply tell you so.
65. ElderCare Gatekeeper Training 65 How Much Risk Is There? Assess lethality
You are not a doctor, but you need to know how imminent the danger is
Has he or she made any previous suicide attempts?
Does he or she have a plan?
How specific is the plan?
Do they have access to means? This can be done by asking a series of questions:
One sign is seldom enough to predict suicidal thoughts. Look for many of the previously mentioned signs giving things away, sadness, etc.
Has the person made previous attempts? This is one of the biggest risk factors
Does the individual have a plan? If there is a plan, there is an increased risk of suicidal behavior
Does the individual have access to means that would assist in carrying out the plan? Having the means to carry out the plan further increases risk, and signifies that action should be taken immediately to ensure the safety of the individual.
This can be done by asking a series of questions:
One sign is seldom enough to predict suicidal thoughts. Look for many of the previously mentioned signs giving things away, sadness, etc.
Has the person made previous attempts? This is one of the biggest risk factors
Does the individual have a plan? If there is a plan, there is an increased risk of suicidal behavior
Does the individual have access to means that would assist in carrying out the plan? Having the means to carry out the plan further increases risk, and signifies that action should be taken immediately to ensure the safety of the individual.
66. ElderCare Gatekeeper Training 66 Do . . . Use warning signs to get help early
Talk openly - reassure them that they can be helped - Try to instill hope
Encourage expression of feelings
Listen without passing judgment
Make empathic statements
Stay calm, relaxed, rational
The best way to get them to open up to you is to ask specific questions and to listen without passing judgment. People are already ashamed of their suicidal thoughts, and if they experience judgment from you, they are likely to stop talking. If you cant think of anything to say, simply invite more information by saying, Tell me more about that.
Empathic statements can be as simple as I can see how you might feel that way, it must have been hard for you NOT I know how you feel you cant know.
Your calmness is crucial. Suicidal people are in a crisis, and see no hope. If you get upset and anxious, this will confirm their fears. If you can stay calm and rational, they will de-escalate also, and begin to see there might be help if they tell someone what they are feeling.
The best way to get them to open up to you is to ask specific questions and to listen without passing judgment. People are already ashamed of their suicidal thoughts, and if they experience judgment from you, they are likely to stop talking. If you cant think of anything to say, simply invite more information by saying, Tell me more about that.
Empathic statements can be as simple as I can see how you might feel that way, it must have been hard for you NOT I know how you feel you cant know.
Your calmness is crucial. Suicidal people are in a crisis, and see no hope. If you get upset and anxious, this will confirm their fears. If you can stay calm and rational, they will de-escalate also, and begin to see there might be help if they tell someone what they are feeling.
67. ElderCare Gatekeeper Training 67 But when someone is suicidal, a true friend learns how to listen
68. ElderCare Gatekeeper Training 68 Dont Make moral judgments
Argue lecture, or encourage guilt
Promise total confidentiality/offer reassurances that may not be true
Offer empty reassurances youll get over this
Minimize the problem -All you need is a good nights sleep
Dare the suicidal person- You wont really do it
Use reverse psychology - Go ahead and kill yourself
Leave the person alone
Never Go It Alone Make moral judgments no arguing or lecturing
Act shocked rather, handle the situation calmly, they will be encouraged to talk if you are calm
Encourage guilt (e.g. your children will be sad, and you dont want them to have to grieve over your death) This is also not helpful, and not what the individual needs.
Promise total confidentiality/offer reassurances that may not be true For most professionals confidentiality is required to be broken when individuals state their intentions to harm themselves or others. Even if you do not have this requirement as part of your profession, suicide should never be kept a secret.
Offer empty reassurance a person in terrible pain cannot hear that others are worse off this may actually may make them feel more guilty (I cant even do this right!)
Minimize the problem/offer simplistic solutions If they believed a simple solution would work they would not be suicidal. This assumes they havent really thought about things, which is seldom true. Most helpful is validating the problem with empathetic listening (I.e. do your best to understand the problem from their perspective, and show them you understand.
Dare the person (e.g.You wont really do it.) This may expedite suicidal behavior and/or be the deciding factor for those individuals who are teetering.
Use reverse psychology (e.g. Go ahead and kill yourself.) This sometimes works with different situations, but is not worth the risk when the consequences are life and death.
Leave the person alone This is critical, especially if your risk assessment has lead to a high probability of completion.
Make moral judgments no arguing or lecturing
Act shocked rather, handle the situation calmly, they will be encouraged to talk if you are calm
Encourage guilt (e.g. your children will be sad, and you dont want them to have to grieve over your death) This is also not helpful, and not what the individual needs.
Promise total confidentiality/offer reassurances that may not be true For most professionals confidentiality is required to be broken when individuals state their intentions to harm themselves or others. Even if you do not have this requirement as part of your profession, suicide should never be kept a secret.
Offer empty reassurance a person in terrible pain cannot hear that others are worse off this may actually may make them feel more guilty (I cant even do this right!)
Minimize the problem/offer simplistic solutions If they believed a simple solution would work they would not be suicidal. This assumes they havent really thought about things, which is seldom true. Most helpful is validating the problem with empathetic listening (I.e. do your best to understand the problem from their perspective, and show them you understand.
Dare the person (e.g.You wont really do it.) This may expedite suicidal behavior and/or be the deciding factor for those individuals who are teetering.
Use reverse psychology (e.g. Go ahead and kill yourself.) This sometimes works with different situations, but is not worth the risk when the consequences are life and death.
Leave the person alone This is critical, especially if your risk assessment has lead to a high probability of completion.
69. ElderCare Gatekeeper Training 69 Getting Help Refer for professional help
When people exhibit 5 or more symptoms of depression
When risk is present (e.g. specific plan, available means)
Know your community resources
Keep a folder, a list of helpers
Maintain collaboration with treating agency to provide behavioral information to therapists At what point should you make a referral for professional help?
Signs of depression may indicate the person is at risk for suicidal ideation. Depression is a very treatable illness, and no one should have to suffer with untreated depression.
When risk is present (e.g. specific plan, available means) Err on the side of over-referral, remember the consequences here are high stakes!
Know your community resources Educate yourself on these, or at a minimum be aware of someone who does have these resources
Maintain collaboration with treating agency: You may have behavioral information that will assist the therapist
At what point should you make a referral for professional help?
Signs of depression may indicate the person is at risk for suicidal ideation. Depression is a very treatable illness, and no one should have to suffer with untreated depression.
When risk is present (e.g. specific plan, available means) Err on the side of over-referral, remember the consequences here are high stakes!
Know your community resources Educate yourself on these, or at a minimum be aware of someone who does have these resources
Maintain collaboration with treating agency: You may have behavioral information that will assist the therapist
70. ElderCare Gatekeeper Training 70 Local Professional Resources Your Hospital Emergency Room
Your Local Mental Health Agencies
Your Local Mental Health Board
School Guidance Counselors
Local Crisis Hotlines
National Crisis Hotlines
Your family physician
School nurses
911
Local Police/Sheriff
Local Clergy There are many resources available to assist people, their families and those working closely with them. Learn the ones in your community.
There are many resources available to assist people, their families and those working closely with them. Learn the ones in your community.
71. ElderCare Gatekeeper Training 71 Mourning 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 ones 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) Loss of a long-term partner, or even an adult child, can cause mourning that looks like, and may be, depression. It is important to observe carefully, and to treat for depression if the mourning seems to remain at early deep levels.Loss of a long-term partner, or even an adult child, can cause mourning that looks like, and may be, depression. It is important to observe carefully, and to treat for depression if the mourning seems to remain at early deep levels.
72. ElderCare Gatekeeper Training 72 Bereavement After A Suicide Loss Compared with homicide, accidental death or natural death, suicide death is very difficult for family members to resolve
Family members experience:
Greater pain
More difficulty finding meaning in the death
More difficulty accepting the death
Less support and understanding
More need for mental health care
Staff members may experience the same emotions after a suicidal death
(Smith, Range & Ulner, 1991) Much research has been done on the impact of suicide on family and close friends. It is difficult to overestimate how painful such a death is, and how much risk it sets up for family members regarding their own suicidal thinking. Much research has been done on the impact of suicide on family and close friends. It is difficult to overestimate how painful such a death is, and how much risk it sets up for family members regarding their own suicidal thinking.
73. ElderCare Gatekeeper Training 73 Impact Of Depression On Religious Beliefs Many older people have strong religious faith, or have been involved in their religion all their lives
Most find more comfort than strain associated with religion
But depression is associated with feelings of alienation from God
Suicidality can be associated with religious fear and guilt, particularly with belief in having committed an unforgivable sin for simply thinking of suicide
This religious strain is associated with greater depression and suicidality, regardless of religiosity levels or the degree of comfort found in religion
(Sanderson, 2000) People who believe that their faith makes them immune from things like depression become very upset when they lose interest in their faith (a common symptom of depression), and may be told by friends that they are not praying enough, or do not have enough faith. If they see the depression as a loss of faith or loss of Gods love, rather than as a physical illness, they may experience more anguish than a non-believer. Teaching people about the physical nature of depression is crucial in our churches and communities.
People who believe that their faith makes them immune from things like depression become very upset when they lose interest in their faith (a common symptom of depression), and may be told by friends that they are not praying enough, or do not have enough faith. If they see the depression as a loss of faith or loss of Gods love, rather than as a physical illness, they may experience more anguish than a non-believer. Teaching people about the physical nature of depression is crucial in our churches and communities.
74. ElderCare Gatekeeper Training 74 Final Suggestions For Better Care Mental health outreach services
Integrated service delivery in primary care
Mental health consultation and treatment teams in long-term care
Family/caregiver support interventions
Psychological and pharmacological treatments
(Draper, 2000; Untzer, et al., 2001; Schulberg, et al., 2001;
Bartels et al., 2002, 2003; Sorenson, et al., 2002;) Collaborate with community mental health to develop outreach services for homebound elders and those in nursing homes
Work with physicians to increase screening of elders for depression in their practices and to coordinate with MH care.
Nursing homes should have MH consultation and access to therapy/pharmacological treatment
Caregivers often develop depression over time from the loss of freedom, stress of caring for a sick loved one, and should have respite and MH care available. Support groups are often the best way to approach this.
We need to find better access for elders for both treatments.Collaborate with community mental health to develop outreach services for homebound elders and those in nursing homes
Work with physicians to increase screening of elders for depression in their practices and to coordinate with MH care.
Nursing homes should have MH consultation and access to therapy/pharmacological treatment
Caregivers often develop depression over time from the loss of freedom, stress of caring for a sick loved one, and should have respite and MH care available. Support groups are often the best way to approach this.
We need to find better access for elders for both treatments.
75. ElderCare Gatekeeper Training 75 Outreach Programs Gatekeeper Model
Trains community members to identify and refer community-dwelling older adults who may need mental health services
Effective at identifying isolated elderly, who received no formal mental health services
Florio & Raschko, 1998
76. ElderCare Gatekeeper Training 76 Caregiver Support Interventions Delays placement in nursing homes for persons with dementia from 166 days to 19.9 months
( Mittleman et al., 1995; Moniz-Cook et al., 1998 Riordan & Bennett, 1998; Roberts et al., 1999)
Improved Caregiver Mental Health -Decreased incidence and severity of depression -Improved health (e.g., lowered blood pressure) -Improved stress management (Sorensen, Pinquart, Duberstein, 2002)
77. ElderCare Gatekeeper Training 77
78. ElderCare Gatekeeper Training 78 Websites For Additional Information Ohio Department of Mental Health
www.mh.state.oh.us
NAMI
www.nami.org
National Institute of Mental Health
www.nih.nimh.gov
American Association of Suicidology
www.suicidology.org
Suicide Awareness/Voice of Education
www.save.org
American Foundation for Suicide Prevention
www.afsp.org
Suicide Prevention Advocacy Network
www.spanusa.org
Suicide Prevention Resource Center
www.sprc.org
79. ElderCare Gatekeeper Training 79 Permanent Solution- Temporary Problem Remember a depressed person is physically ill, and cannot think clearly about the morality of suicide, cannot think logically about their value to friends and family
You would try CPR if you saw a heart attack victim
Dont be afraid to interfere when someone is dying more slowly of depression
Depression is a treatable disorder
Suicide is a preventable death This well-known quote, from Dr. Edwin Schneidman, the founder of suicidology, is a key idea that helps us stay focused on our goal. WE need to help people understand there are other solutions available, no matter how difficult the problem may be.This well-known quote, from Dr. Edwin Schneidman, the founder of suicidology, is a key idea that helps us stay focused on our goal. WE need to help people understand there are other solutions available, no matter how difficult the problem may be.
80. ElderCare Gatekeeper Training 80 The Ohio Suicide Prevention Foundation
The Ohio State University, Center on Education and Training for Employment
1900 Kenny Road, Room 2072
Columbus, OH 43210
614-292-8585
81. ElderCare Gatekeeper Training 81 Leave up on the board as you thank the audience and offer other trainingsLeave up on the board as you thank the audience and offer other trainings
82. ElderCare Gatekeeper Training 82 Stephen J. Bartels, M.D., M.S. Director, Aging Services Research NH-Dartmouth Psychiatric Research Center is the author of a presentation on mental health in the elderly, which is available on the web. His information provided much valuable background for this presentation, and some of his slides, which are available for public use, are also a part of this presentation.
83. ElderCare Gatekeeper Training 83 A Brief Bibliography Anderson, E. The Personal and Professional Impact of Client Suicide on Mental Health Professionals. Unpublished Doctoral dissertation, U. of Toledo, 1999.
Blumenthal, S.J. & Kupfer, D.J. (Eds) (1990). Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. American Psychiatric Press.
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