Preventing late-life suicide: 6 steps to detect the warning signs

• have strong social support
• are not isolated
• have no access to firearms or other dangerous weapons.

Safety can be enhanced by having family members take responsibility for the senior’s well-being and by asking the patient to contract for safety. A safety contract may include:

• verbal confirmation—and ideally a written statement—that the patient will not commit suicide within a specified period
• a list of people the patient will contact when feeling suicidal
• steps being taken to monitor the patient’s welfare.

Finally, schedule follow-up appointments soon after discharge to certify patients are being closely monitored. To encourage outpatient medication adherence, build strong alliances with family members and ask patients to bring in their pill bottles during follow-up appointments.

CASE REPORT continued: Observation begins

The staff is clearly concerned about Mr. V’s suicide risk and requests that he voluntarily admit himself to the VA hospital. This decision is based on his level of isolation, the lethality of his suicide plan, access to a weapon, and the depression and hopelessness revealed by his screening tests. He reluctantly agrees and is admitted to the inpatient psychiatric unit for observation and treatment by a geriatric internist and a geriatric psychiatrist.

DRUG THERAPY FOR SUICIDALITY

For patients with mild depressive symptoms, psychotherapy may be sufficient to manage depression associated with suicidality. However, those with moderate-to-severe depression require both drug treatment and psychotherapy.

Drug selection depends upon the underlying psychiatric illness. If the older patient is experiencing a depressive disorder, a selective serotonin reuptake inhibitor (SSRI) or another antidepressant could serve as first-line treatment (Table 4). These medications are safe for suicidal patients because they are not fatal in overdose.

Administration. Because age-related changes in pharmacokinetics and spharmacodynamics can slow medication clearance, reduced dosages usually achieve a therapeutic effect and minimize the risk of side effects in geriatric patients.

Antidepressants commonly used for older patients are shown in Table 4. Excepting citalopram and escitalopram, these dosages are lower than usual. We start healthy older patients on one-half the usual dosage and those who are medically ill or have neurodegenerative disorders on one-third to one-fourth the usual dosage. We also titrate more slowly to reduce the risk of side effects.

Table 4

Antidepressants commonly used to treat geriatric depression

As in younger patients, the most common side effects of SSRIs in older patients include GI difficulties, overactivation, and sexual dysfunction. Paroxetine’s potential for anticholinergic effects may be a concern for some older patients.

Drug-drug interactions are of great concern when treating older patients, who take an average of six to nine medications per day.¹⁷ Compared with other SSRIs, fluoxetine and paroxetine, are more likely to inhibit cytochrome P-450 enzymes 2D6 and 3A4. They could thus increase blood levels of drugs taken concomitantly that are substrates of 2D6 or 3A4.

Antidepressant side effects can sometimes be used to advantage. For example, mirtazapine’s sedating property at lower dosages could help older patients with insomnia.

CASE REPORT concluded: Finding support

Mr. V is started on an SSRI antidepressant. He also receives supportive and milieu therapy and coping skills training. During his hospitalization, Mr. V contracts for safety and allows his sister to remove the handgun from his home.

Upon discharge, Mr. V is referred to a day treatment program that operates 3 to 5 days a week and offers case management, group therapy, and individual psychotherapy. The program helps him meet other older patients and allows him to discuss his life’s accomplishments and losses with others his age. His sister is an integral part of the program, and he maintains close contact with her.

Mr. V reports vague and occasional suicidal ideation, with no specific plan or intent. He and his sister note that his medical condition improved soon after his psychiatric condition stabilized.

Related resources

• Surgeon General’s Call to Action to Prevent Suicide. www.mental-health.org/suicideprevention/calltoaction.pdf
• Centers for Disease Control and Prevention. National Center for Injury Prevention and Control.

Drug brand names

• Bupropion • Wellbutrin
• Citalopram • Celexa
• Escitalopram • Lexapro
• Fluoxetine • Prozac
• Mirtazapine • Remeron
• Paroxetine • Paxil
• Sertraline • Zoloft
• Venlafaxine • Effexor

Disclosure

Drs. Montross reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Mohamed is a speaker and consultant to Forest Laboratories and Eli Lilly and Co.

Dr. Kasckow receives research support from, is a consultant to, and is a speaker for Forest Laboratories, Eli Lilly and Co., Pfizer Inc., and Janssen Pharmaceutica.