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Archived Questions
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Suicide & The Elderly
We recently had a suicide of an elderly patient in our medical group practice. We are devastated and, as a result of our reflections, have resolved to do more effective screening. This has given rise to several questions: |
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Which elderly patients should a primary healthcare provider screen for suicidal ideas?
How often should this screening be done?
I would say that each elderly patient should be asked about suicide, at least at the initial intake appointment for medical care. Also, you should continue to inquire about suicide regularly thereafter-regardless of how repetitious it may seem-if you do not know the patient well, if the patient has signs or symptoms of depression, or if he/she has engaged in behaviors that betray anticipation of death, such as unusual focus on final arrangements, giving away cherished possessions or pets, or embarking on a starvation diet. I recommend inquiring about suicide at every visit if you see the patient infrequently.
Why is routine screening for suicidal ideas so important in the elderly?
Data from the Center for Disease Control show that suicide rates in the United States are highest among those 65 years of age and older and are continuing to rise in this group. Demographically, white males over 60 years of age who live alone are at the highest risk. Elderly persons are very serious about suicide and, contrary to the usual images presented of older people, they tend not to be timid once they have decided to end their lives; in fact they more frequently use violent methods such as firearms and jumping from high places than overdoses, and they have a higher proportion of completed suicides to attempts compared to younger individuals.
Yet recent studies show that physicians and other healthcare providers often miss even the most determined suicidal intention. One report indicates nearly 70% of elderly suicide victims had visited a primary health-care provider within a month before death; one can assume that the diagnosis of depression was missed or that screening for suicide was done inadequately, if at all. (So you are not alone!)
One possible reason for this astonishing finding is that depressed elderly patients sometimes do not appear obviously depressed. Elderly individuals who have many symptoms of depression may not experience sadness. They can still lack tearfulness or distinctly sad facial expression; also, they may complain of pain, headaches, anxiety, poor concentration, insomnia, and other symptoms but not actually endorse having sad mood. In this setting, many healthcare providers would not necessarily be prompted to ask about suicidal ideas. I believe that routine screening for suicidal ideas in a medical practice with elderly patients has the potential to be life-saving, and, at the least, communicates to the patient that you are interested in this critical aspect of his or her mental life.
How should this screening be done?
I believe that the question should be posed straightforwardly, in simple, unequivocal language. "Have you been thinking about killing yourself?" will suffice. I find it is less awkward to inquire about suicide in the context of a review of systems focusing on other depressive symptoms. For example, we have found in our own primary care practice that affirmative responses to a question about recent loss of interest or pleasure are correlated with acknowledgment of suicidal thoughts.
If the answer to the initial screen is affirmative or anything but a clear negative, the patient should be asked a series of follow-up questions to determine the frequency and intensity of suicidal thoughts. First, are suicidal thoughts frequently recurring and compelling in nature? Has the patient considered a plan of action? If there is a plan for suicide, are the proposed means readily accessible? Has it been rehearsed? Has a specific date or time been chosen? Is there a previous history of depressive disorder or suicide attempts? Together, these follow-up inquiries permit a rough assessment of the acuity of suicidal thoughts. People can and do lie or withhold information, but, in my experience, elderly patients are most often truthful. It is, of course, easier to judge the veracity and sincerity of answers when you know the patient well.
When should a patient who admits to suicidal ideas be hospitalized?
If there is any doubt about the patient's suicidal intentions, I would consider hospitalization. In extreme cases where the suicidal acuity is substantial and the patient is unwilling to accept hospitalization, psychiatric admission may have to be involuntary, via two-physician certificate in New York and similar mechanisms in other states. In practice, it is very difficult to involuntarily hospitalize a suicidal elderly patient without family support.
What should be noted in the medical chart?
Patients' responses to screening for suicide should be documented in the chart, along with your assessment of the degree of danger. If you are unable to convince a potentially suicidal patient to be psychiatrically admitted, I would also document your efforts to convince that individual and to call either family members or 911, depending on the circumstances.
What is a response to an elderly patient who argues that suicide is justified by real-life adverse circumstances?
If the patient points out, even justifiably, that his losses have been devastating or that his life circumstances are objectively adverse and that "anyone" would want to take his or her life in a similar situation, this argument should be countered by saying something to this effect: "You may or not be right about that, but please defer judgment on it until your depression is adequately treated. Your circumstances may not change, but your willingness to tolerate them and your ability to cope could both change significantly. The consequences are important enough to justify waiting."
Are "contracts for safety" of any use?
Some psychotherapists, including psychiatrists who treat depressed elderly outpatients, use a "contract for safety," in which the patient pledges on his honor not to act on suicidal impulses, and if the thoughts become overwhelmingly compelling, he promises to call the therapist or proceed to the closest emergency department. A contract may be useful in some clinical situations but, in my experience, only when there is a patient-doctor relationship of long duration and well-established mutual trust. It is not advisable to introduce a contract with a patient you do not know well, although it is reasonable to ask that he or she call under such circumstances.
How can primary care providers help each other when a patient commits suicide?
You note that you, your colleagues, and staff have been "devastated" by the event. I urge that you try to help each other through this experience. An informal "post-mortem" conference might be useful educationally. Emotionally, say to each other what you can to help relieve the painful feelings of guilt and anger that seem to me to be inevitable. Also, a conventional letter or gesture of condolence to the patient's family should still apply.
Do you have ideas for further reading on this topic?
Suggestions for further reading:
Alexopoulos GS: Interventions for depressed elderly primary care patients. International Journal of Geriatric Psychiatry 2001, 16:553-559.
Bruce ML, Pearson JL: Designing an intervention to prevent suicide: PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial). Dialogues in Clinical Neuroscience 1999, 1:100-112.
Pearson JL: Recent research on suicide in the elderly. Current Psychiatry Reports 2002, 4:59-63.
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