What have we learned Kelly C Cukrowicz PhD Professor Department of Psychological Sciences Texas Tech University kellycukrowiczttuedu MEN WOMEN Women Prevalence of Suicide Across the Lifespan ID: 759546
Download Presentation The PPT/PDF document "SUICIDE IN OLDER ADULTS :" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
SUICIDE IN OLDER ADULTS: What have we learned?
Kelly C. Cukrowicz, Ph.D.
Professor
Department of Psychological Sciences
Texas Tech University
kelly.cukrowicz@ttu.edu
Slide2MEN
WOMEN
Women
Slide3Prevalence of Suicide Across the Lifespan
44,965 deaths by suicide in 2016 in the United States
10
th
ranking cause of death in the U.S.
3.4 male deaths by suicide for every female death by suicide
More specific information
White males: 31,032 – rate of 24.8 per 100,000 (10.9 for non-white males)
Firearms accounted for 51% of deaths
Slide44
Prevalence of Suicide in Older Adults
8,204
deaths by suicide in 2016 in the United States
among those 65+
Rate is 30.99 for men vs. 5.28 for women 65+ (16.66 overall rate per 100,000)
Rate of death by suicide increases steadily from age 65 to 85, with the highest rate of suicide deaths among older adults ages 85 and older (CDC, 2014).
4.6 male deaths by suicide for every female death by suicide
More specific information
White males more frequently die by suicide
(more than 2x other races)
Firearms accounted for
70
% of deaths
in this age group
Slide5Risk Factors vs. Warning Signs
Risk factors
Increase vulnerability for suicide ideation and suicidal behavior
Tend to be more stable (e.g., psychiatric disorder, history of suicidal behavior, gender)
Warning signs
Indicate risk is high right now
Tend to be more likely to change in the short term (e.g., agitation, mood changes, anger)
Slide6Empirically Demonstrated Risk Factors for Suicide
Psychiatric Disorders
Approximately
70-
95% of adults had a psychiatric disorder at the time of their suicide death
Affective Disorders
Major depression
– 44% to 87%
Other mood disorders
– 11% to 36%
Alcohol abuse/dependence
– 3% to 43%
Lesser role: psychotic disorder, personality disorders, anxiety disorders, dementia, eating disorders
Slide7Empirically Demonstrated Risk Factors for Suicide
History of suicidal behaviorPrevious suicidal behavior – especially concerning if multiple attempt history History of self-harmExpression of severe thoughts of suicidePlans/preparations for suicide
Access to means for suicide
51% of suicide decedents use guns and more than 50% of the US population own guns; 2/3 of gun deaths are suicide deaths
Presence of a gun in the home has been significantly associated with suicide deaths
Handguns
Risk greater for men
Slide8Affective experienceshopelessnessagitationsleep disruptionSocial isolationliving alonelow social interactionfamily discord
Empirically Demonstrated Risk Factors for Suicide
Negative life events
financial problems
physical illness
childhood abuse
combat exposure
Personality traits
impulsivity
rigid and independent style
Slide9Physical Health
Approximately 70% of suicide decedents had significant physical illness
HIV/AIDS, Huntington’s disease, multiple schlerosis, peptic ulcer, renal disease, spinal cord injury (Harris & Barraclough, 1994)
Physical illness burden, serious physical condition, functional impairment
Slide10Warning Signs
IS PATH WARM?IdeationSubstance abusePurposelessnessAnxietyTrappedHopelessnessWithdrawalAngerRecklessnessMood changes
Reported suicide or death ideation
Increased substance use
No reason for living or sense of purpose
Anxiety, agitation, unable to sleep
Feeling trapped, no way out
Hopelessness
Withdrawal from friends, family
Rage, uncontrolled anger
Acting reckless, risky behaviors
Dramatic mood changes
Slide11This is a lot of information…
How do we organize it and use it?
A good theory can be really helpful.
Slide12Interpersonal Theory of Suicide (Joiner, 2005)
Acquired Capability
I fear I’m a burden.
No one cares about me
.
I have attempted suicide.
I have experienced a lot of pain in my life.
Death by Suicide or
Near-Lethal Suicide Attempt
Perceived Burden + Thwarted Belonging
Slide13What is perceived burdensomeness?
The sense that one does not contribute to others in their life Others would be better off without him or herThese perceptions lead to emotionally painful thoughts of self-hatred
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C.
et al. (2010). The interpersonal theory of
suicide.
Psychological Review
,
117
, 575-600.
Slide14What is thwarted belongingness?
A sense of feeling disconnected from others Feeling alone, even in the presence of others Feeling that he/she doesn’t care about people and they don’t care about/support him/her
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C. et al. (2010). The interpersonal theory of suicide. Psychological Review, 117, 575-600.
Slide15What is acquired capability?
The loss of the fear of suicidal behaviors
Acquired over time through exposure to physically painful and/or fear inducing experiences Over time, these experiences result in lowered fear of death and greater pain tolerance
Van
Orden
, K. A., Witte, T. K.,
Cukrowicz
, K. C.
et al. (2010). The interpersonal theory of
suicide.
Psychological Review
,
117
, 575-600.
Slide16The Interpersonal Theory of Suicide
Death Ideation
Loneliness
Nonreciprocal
Care
Self Resentment
Liability
Thwarted Belongingness
Perceived Burdensomeness
Death Ideation
Hopelessness
Desire for Suicide
Suicidal Intent
Lethal or Near Lethal Suicide Attempt
Lowered Fear of Death
Increased Pain Tolerance
Acquired Capability
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C.
et al. (2010). The interpersonal theory of
suicide.
Psychological Review
,
117
, 575-600.
Slide17Importance of Suicide Ideation
We can think of suicide ideation as a critical flag for those who might die by suicide
BUT – we must keep in mind some important things:
Many people at risk for suicide do not disclose thoughts of suicide.
Lots of people who think about suicide do not ever harm themselves.
Suicide ideation can be chronic.
Slide18Example: Reporting Concerns with Suicide Risk in Older Adults
Research suggests that older adults may not report suicide ideation even when they experience suicide ideation
Contradiction 1
Rate of deaths by suicide increases in late life
Rate of self-reported suicide ideation decreases with increasing age
Contradiction 2
Older males more likely to die by suicide
Suicide ideation has not been shown to be greater in older males than in females
Slide19So What Do We Do When Things Don’t Add Up?
Person who denies thoughts of suicide, but their actions suggest otherwise
They have some of the risk factors or warning signs mentioned above
Slide20Example Distribution for Illustration
Slide21Study of Suicide Ideation in Older Adults
We wanted to know whether the variables that are part of the interpersonal theory (thwarted belonging, perceived burden, hopelessless) are more painful when experienced together
Do people who feel thwarted belonging and perceived burdensomeness report the greatest suicide ideation if they also feel hopeless?
Would elevated scores on these three variables allow us to identify those who deny thoughts of suicide, but report other experiences that are highly associated with suicide ideation (i.e., depressive symptoms, isolation).
Slide22Novel Statistical Approach: Zero-Inflated Modeling
Allows for estimation of both the zero and positive responses to questionnaires assessing suicide ideation. Some zeros arise from participants who deny suicide ideation and have little or no psychological distress (non-ideators)Additional zeros may arises from participants who deny suicide ideation while reporting other empirically-based risk factors (e.g., depression, hopelessness) for suicide ideation (potential ideators)
Slide23What Our Distributions Look Like
Death ideation = 66 occurrences of zero
Suicide ideation = 104 occurrences of zero
Slide24Slide25Figure 2
. Probability of Non-
ideator
Status (Excess Zero) as a Function of Perceived Burdensomeness and Hopelessness Along the Continuum of Scores for Thwarted Belonging.
TB = Thwarted Belonging, BHS = Beck Hopelessness Scale.
Slide26What The Data Tells Us
Increasing scores on thwarted belonging, perceived burdensomeness, and hopelessness are associated with:
Greater probability that an individual may be experiencing thoughts of suicide,
whether or not
they are reported.
The presence or absence of suicide ideation, but less important to determining the severity of thoughts of suicide.
Slide27Implications
Perceived burden, thwarted belonging, and hopelessness should be key targets in the determination of whether someone might be experiencing thoughts of suicide
Regardless
of whether the person is reporting such thoughts
Questions assessing perceived burden and thwarted belonging may be less threatening to endorse than thoughts of suicide
Mental health practitioners should target perceptions of being a burden, a sense of thwarted belonging, and hopelessness to reduce the risk of developing suicide ideation
Slide28Suicide in Rural Communities
Suicide is also prevalent among rural-dwelling adults in the U.S. and in countries around the world (Hirsch, 2006)
Rural communities have had significantly higher rates of death by suicide than those in urban areas throughout the past two decades (Hirsch, 2006)
Rural older adults are 30% – 50% more likely to die by suicide when compared to older adults residing in urban locations (Baume & Clinton, 1997)
Slide29Extending this Research to Middle-Aged and Older Adults in Rural Communities
Primary goals:
To determine a preliminary estimate of the prevalence of suicide ideation, self-injury, and history of suicide attempts in rural communities.
To examine risk factors that may be unique to rural locations.
Slide30What We’ve Learned…
Slide31Economic Distress
Rural Identity
Depressive Symptoms
Thwarted Belonging
Perceived Burden
Suicide Ideation
Anxiety
History of Suicide Attempts
Moderators:
Life Satisfaction
Hope
Lower Conformity to Masc. Norms
Reasons for Living
Slide32Assessment of Suicide Risk
32
Slide3333
Include questions about perceived burdensomeness, thwarted belonging, and hopeless!Normalize thoughts of suicide“It sounds like you’ve been experiencing a lot of emotional pain recently, others in your situation might think about suicide. Have you had any thoughts about suicide recently?”Begin assessment with the past and work forward Ensure a complete picture of current experiencesFrequency – “How often do you think about suicide?”Intensity – “When you think about suicide, are intense are your thoughts (scale 1 to 10)?” “How does this compare to how intense they usually are?”Duration – “How long have you had these thoughts?”
Eliciting Information on Suicide Risk
Slide34COLUMBIA-SUICIDE SEVERITY RATING SCALE Screen Version - Recent
For inquiries and training information contact: Kelly Posner, Ph.D.
New York State Psychiatric Institute, 1051 Riverside Drive, New York, New York, 10032; posnerk@nyspi.columbia.edu© 2008 The Research Foundation for Mental Hygiene, Inc.
cssrs.columbia.edu
Screening versions and extended versions
Pediatric & adult
Lifetime and recent
Versions for ED, law enforcement, family/friends, corrections, outpatient
Slide35Interpersonal Needs QuestionnaireThe following questions ask you to think about yourself and other people. Please respond to each question by using your own current beliefs and experiences, NOT what you think is true in general, or what might be true for other people. Please base your responses on how you’ve been feeling recently. Use the rating scale to find the number that best matches how you feel and circle that number. There are no right or wrong answers: we are interested in what you think and feel.
These days the people in my life would be better off if I were goneThese days the people in my life would be happier without meThese days I think I am a burden on societyThese days I think my death would be a relief to the people in my lifeThese days I think the people in my life wish they could be rid of meThese days I think I make things worse for the people in my lifeThese days, other people care about meThese days, I feel like I belongThese days, I rarely interact with people who care about meThese days, I am fortunate to have many caring and supportive friendsThese days, I feel disconnected from other peopleThese days, I often feel like an outsider in social gatheringsThese days, I feel that there are people I can turn to in times of needThese days, I am close to other peopleThese days, I have at least one satisfying interaction every dayNote. Items 7, 8, 10, 13, 14, and 15 are reverse coded.
1123457Not at all true for meSomewhat true for meVery true for me
How Do I Assess Perceived Burden
and Thwarted Belonging?
Slide36How to assess acquired capability?
Questions about fearlessness about suicide
Duration of thoughts of suicide and details of imagery
Plans for suicide; preparations made to carry out that plan
Previous experiences with self-harm, suicidal behavior
Exposure to violence
Slide37C
AMS SUICIDE STATUS FORM–4 (SSF-4) INITIAL SESSIONPatient: Clinician: Date: Time: Section A (Patient):
Please list your reasons for wanting to live and your reasons for wanting to die. Then rank in order of importance 1 to 5.
Rate and fill out each item according to how you feel right now. Then rank in order of importance 1 to 5 (1 = most important to 5 = least important)
Rank
How much is being suicidal related to thoughts and feelings about yourself? Not at all: 1How much is being suicidal related to thoughts and feeling about others? Not at all: 1
2 3 4 5 : completely2 3 4 5 : completely
1) RATE PSYCHOLOGICAL PAIN (hurt, anguish, or misery in your mind, not stress, not physical pain):Low pain: 1 2 3 4 5 :High painWhat I find most painful is: 2) RATE STRESS (your general feeling of being pressured or overwhelmed):Low stress: 1 2 3 4 5 :High stressWhat I find most stressful is: 3) RATE AGITATION (emotional urgency; feeling that you need to take action; not irritation; not annoyance):Low agitation: 1 2 3 4 5 :High agitationI most need to take action when: 4) RATE HOPELESSNESS (your expectation that things will not get better no matter what you do):Low hopelessness: 1 2 3 4 5 :High hopelessnessI am most hopeless about: 5) RATE SELF-HATE (your general feeling of disliking yourself; having no self-esteem; having no self-respect):Low self-hate: 1 2 3 4 5 :High self-hateWhat I hate most about myself is: N/A6) RATE OVERALL RISK Extremely low risk: 1 2 3 4 5 :Extremely high riskOF SUICIDE: (will not kill self) (will kill self)
Rank
REASONS
FOR
LIVING
Rank
REASONS
FOR
D
YING
Slide38Se
c
tion
B
(Clinician):
Y N Suicide ideationFrequencyDurationY N Suicide plan
Describe:
per day seconds
per week minutes
per month hours
When: Where: How: Access to means Y N How: Access to means Y NDescribe: Describe:
Y N Suicide preparation Y N Suicide rehearsal Y N
History of suicidal behaviors
Single attemptMultiple attemptsY N ImpulsivityY N Substance abuse Y N Significant lossY N Relationship problems Y N Burden to othersY N Health/pain problems Y N Sleep problemsY N Legal/financial issues Y N Shame
Describe: Describe: Describe: Describe: Describe: Describe: Describe: Describe: Describe: Describe: Describe:
Se
c
tion
C
(Clinician):
TREATMENT PLAN
Problem
#
Problem
Desc
r
iption
Goals
and
Obje
c
ti
v
es
In
t
e
r
v
entions
Du
r
ation
1
S
elf-H
a
r
m
P
o
t
ential
Sa
f
e
t
y
and
S
t
abili
t
y
S
t
abilization
Plan
Comple
t
ed
D
2
3
Slide3939
Management of Suicide Risk
Slide40Treatment recommendations
Treatment for suicide or
another problem (e.g., depression)
?
For chronic suicide risk or longer duration ideation – suicide specific treatment
Collaborative Assessment and Management of Suicide Risk (
Jobes
, 2017)
Suicide-specific assessment and treatment-planning
Tracking of on-going risk
Clinical outcomes and dispositions
Flexible in approach to addressing drivers of suicide risk
Only suicidal in context of depressive episode – treatment targeting
the specific area of concern
Slide41Between Session Care
Individuals thinking about suicide may need help with:Reminders of signals of crisisAssistance with managing strong emotions tied to suicide riskIdeas for distraction (people, activities)People to call for helpWhere to go for helpHow to make the environment safeCrisis Response Plans address these concerns
41
Slide42Crisis Response Plan
42
Slide43AcknowledgementsAmerican Foundation for Suicide Prevention
Former graduate students:Erin F. Schlegel, Ph.D.Danielle R. Jahn, Ph.D.Erin Poindexter, Ph.D.Ryan Graham, Ph.D.Project FRONTER staff:Billy Philips, Ph.D.Theresa HuckabeeCathy Hudson
Collaborators:Jennifer S. Cheavens, Ph.D.Kimberly A. Van Orden, Ph.D.Ryan B. Williams, Ph.D.Friona Prabhu, M.D.Michael Ragain, M.D.Ron Cook, D.O.Kitten Litton, M. D.
Thank you for your attention!
kelly.cukrowicz@ttu.edu