STOCKHOLM – Interventions aimed at preventing suicide in older adults should target asymptomatic individuals and groups at risk for becoming depressed and suicidal to save the greatest number of lives, Dr. Yeates Conwell said at the 12th Congress of the International Psychogeriatric Association.
“There has been a tremendous amount of progress in recent years, largely from case-controlled, psychological autopsy studies, which have revealed an evidence base that I think provides a firm foundation for us to design preventive interventions,” said Dr. Conwell of the Center for the Study and Prevention of Suicide at the University of Rochester (N.Y.).
Preventive interventions could be created to match trajectories toward suicide that some individuals experience as they age. Strategies could be tailored to address the particular mix of personality strengths and weaknesses, social contexts, and cultural values of a person or group.
Early intervention could be appropriate in selected individuals who, as they age, begin to develop rigid responses to stress that trigger symptoms and then develop into syndromes of depression and hopelessness.
Preventive interventions could be indicated in the people who drop into a perisuicidal state, Dr. Conwell said.
Some of the risk factors for suicide that have been identified in older adults include psychiatric illness (especially depression), prior suicide attempts, comorbid medical conditions, social dependence and isolation, family discord, personal losses, inflexible coping skills, and access to a means to commit suicide.
About 1 in 30 suicide attempts made by people in the general population is completed. But among the elderly, this proportion increases to 1 in 4.
The rate of completion is greater among the elderly than among younger people because older adults are more frail and isolated, and they tend to be more deliberate and make plans about their self-destructive act. About 75% of older adults who attempt suicide do so with a firearm, compared with about 50% for all suicide attempters combined, Dr. Conwell noted.
These factors imply that “the interventions that we mount to prevent suicide in older adulthood have to be very aggressive but also suggest that we need to push preventive interventions” away from the suicidal crisis toward the realms of secondary and primary prevention, he said.
The primary care setting is an important place to intervene, given that many studies have shown that about 70%–75% of older people who have committed suicide saw a primary care provider in the month before the attempt; one-third to one-half of suicide completers had seen a primary care provider in the week before, he said. Mental health centers do not seem to be the place to intervene, since older adults are found at such centers in much lower proportions than younger adults.
Potential places to intervene outside of the medical setting include long-term care facilities, home health care agencies, and aging services providers. The highest number of lives may be saved by prioritizing intervention resources to four of nine possible ways of addressing suicide in older adults, Dr. Conwell said:
▸ In high-risk people who show no symptoms, depression could be screened for and treated by primary care providers in an office-based setting or by social services or home health care providers in the community. The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study used this design to detect and treat depression in primary care.
▸ To target high-risk but asymptomatic, groups of patients who may be socially isolated, in pain, or low functioning, geriatric physicians could assess and address problems to improve social and functional limitations. Good home health care and social outreach programs could maintain independence at home and reduce social isolation, he said.
▸ In order for preventive interventions to reach everyone, the entire population would have to be educated about normal aging and the fact that older age does not need to be “a negative time of life,” Dr. Conwell explained. Access to care and social services would need to be increased for all older adults through legislative means and social engineering, according to Dr. Conwell.
▸ Universal outreach to the entire population to help those who are depressed would entail reducing the stigma associated with receiving mental health care and restricting access to lethal means, such as firearms.