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1Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Older Adult Suicide Prevention
Speakers:
• Kimberly Van Orden, University of Rochester School of
Medicine
• Rosalyn Blogier, Substance Abuse and Mental Health
Services Administration
• Christine Miara, Suicide Prevention Resource Center
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SUICIDE PREVENTION IN
LATER LIFE
National Council on Aging Webinar
September 17, 2015
Kim Van Orden, PhDAssistant Professor of Psychiatry
University of Rochester School of MedicineRochester, NY USA
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Disclosures Conflicts of interest - none
Collaborators
K23MH096936 NIMH
Kimberly Van Orden, PhD
• Yeates Conwell, MD
• Thomas Joiner, PhD and many more……
• Deborah King, PhD
• Alisa O’Riley, PhD
• Carol Podgorski, PhD
• Paul Duberstein, PhD
• Eric Caine, MD
• Phillip Smith, PhD
• Tracy Witte, PhD
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“My work is done. Why wait?”
George Eastman
March 14, 1932
Age 77
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Significance
Older adults are the most rapidly growing
segment of the population.
Older adults have higher rates of suicide
than other segments of the population.
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Worldwide Suicide Rates, WHO
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7
0
10
20
30
40
50
00-04
05-09
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+
Age Group in years
Rate
pe
r 1
00,0
00 p
op
ula
tio
n
Males
Females
Suicide rates among all persons by
age and sex--United States, 2010
Source: CDC vital statistics
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8
Suicide Rates 2010
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Significance
Older adults are the most rapidly growing
segment of the population.
Older adults have higher rates of suicide
than other segments of the population.
Suicidal behavior is more lethal in later life
than at other points in the life course.
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0
50
100
150
200
250
300
350
400
450
10-1
4
15-1
9
20-2
4
25-2
9
30-3
4
35-3
9
40-4
4
45-4
9
50-5
4
55-5
9
60-6
465
+
Age Group in years
Ra
te p
er
10
0,0
00
po
pu
lati
on
Males
Females
Self-inflicted injury among all persons by age and
sex – United States, 2007
Source: CDC WISQARS NEISS
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ATTEMPTED : COMPLETED SUICIDE
Deaths
Hospitalizations
Emergency
Dept visits
1
General
populationOlder adults
1
5
30
2
4
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LETHALITY OF LATE LIFE SUICIDE
• Older people are
– more frail (more likely to die)
– more isolated (less likely to be rescued)
– more planful and determined
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METHODS OF SUICIDE IN THE U.S.
57%
19%
12%
5%
2% 5%FIREARMS
Hanging, Strangulation,suffocation
Solid & liquid poisons
Gas Poisons
Jump from high place
All other methods
73%
11%
6%
3%
2%5%
Total Age > 65
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LETHALITY OF LATE LIFE SUICIDE
• Older people are
– more frail (more likely to die)
– more isolated (less likely to be rescued)
– more planful and determined
• Implying
– Interventions must be aggressive (indicated)
– More distal prevention is key (selective and
universal)
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As the largest and most rapidly growing segment of the population enters the
stage of life with highest risk for suicide, we should expect the total number (and
proportion) of late life suicides to increase dramatically in coming
decades.
WHAT CAN WE DO ABOUT IT?
15
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RISK FACTORS FOR SUICIDE AMONG OLDER ADULTS
Depression – major depression, other
Prior suicide attempts
Co-morbid general medical conditions
Often with pain and role function decline
Social dependency or isolation
Family discord, losses
Personality inflexibility, rigid coping
Access to lethal means
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What to look for: Risk factors
17
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RISK FACTOR: Psychiatric Dxin case/control studies of suicide in later life
Odds Ratio Harwood et al 2001
Beautrais 2002
Waern et al 2002
Conwell et al 2009
Chiu et al 2004
Any Axis I dx --
43.9 113.1 56.0 50.0
Any mood d/o Maj dep episode
4.0 --
184.6
63.1 28.6
56.0 14.0
59.2 36.3
Subst use d/o Anxiety disorder Schiz spectrum Dementia/del
ns -- ns 0.2
4.4 -- -- --
43.1 3.6
10.7 ns
3.0 3.0 ns ns
ns ns >1 ns
ns = not significant
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Personality Traits In Later Life Completed Suicides
• High Neuroticism– anxious– angry– sad – fearful– self-conscious
• Low Openness to Experience– follow routine– prefer familiar to the
novel– constricted range of
intellectual interests– blunted affective and
hedonic responses
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Suicide and Medical Illness
Cancer 1.73 (1.16-2.58)
Prostate disease (not CA) 1.70 (1.16-2.49)
COPD (for married) 1.86 (1.22-2.83)
CHF 1.36 (1.00 - 1.85)
COPD 1.30 (1.06 - 1.58)
Seizure disorder 2.41 (1.42 - 4.07)
Pain - moderate 1.24 (1.04 - 1.47)
- severe 4.07 (2.51 - 6.59)
Quan, et al., Soc Psychiatry Psychiart Epidemiol 2002; 37:190-197
Juurlink et al., Arch Intern Med 2004;164:1179-1184
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Comorbidity and Suicide RiskJuurlink et al., Arch Intern Med 2004;164:1179-1184
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CONNECTEDNESS AND SUICIDE IN OLDER ADULTS
Family discord and social isolation (Beautrais, 2002;
Rubenowitz et al, 2001; Duberstein et al, 2004; Harwood et al, 2006)
Having no confidantes (Miller, 1977; Turvey et al, 2002)
Living alone (Barraclough, 1971)
Not participating in community organizations or
having hobbies (Rubenowitz et al, 2001, Duberstein et al, 2004)
Functional impairment/disability (Conwell et al, 2000, 2010;
Duberstein et al, 2004, Waern et al, 2008)
Bereavement (Erlangsen et al, 2004; Conwell et al, 1990)22
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Axis I- psychopathology
Axis II- personality, coping style
Axis III
- physical health
Axis IV
- social context
Axis V- functioning
Area of highest convergent risk
Elderly widower with rigid, constricted coping,
macular degeneration, and depression, learns he can no longer drive.
Recently bereaved
older woman, disabled
and homebound by
arthritis, with no social
network on which to
call for support.
Elderly man with chronic
back pain and anxious,
neurotic personality
style.
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PREVENTION FRAMEWORK
HOW DO WE PREVENT
SUICIDE IN ELDERS?
(Approaches to Prevention)
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Institute of Medicine Terminology:“LEVELS” OF PREVENTIVE INTERVENTION
“Indicated” – symptomatic and ‘marked’ high risk
individuals – interventions to prevent full-blown
disorders or adverse outcomes.
“Selective” – high-risk groups, though not all members
bear risks – prevention through reducing risks.
“Universal” – focused on the entire population as the
target – prevention through reducing risk and
enhancing health.
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INDICATED PREVENTION
Because of the close association between depression
and suicide in older adults
o detection and effective treatment of depression are key
Routine screening for depression
o PHQ-9, GDS, CES-D
Depression treatment is effective
o Including at reducing suicidal ideation and maybe suicide
rates
Aging services’ coordination with primary care
and mental health care is essential
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Delivery system reform
Mental Health
Services
Primary Care
Service System
(PCMH)
Aging Services
Network
(ASN)
INTEGRATED
CARE
NETWORKS
Community
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Delivery system reform
Mental Health
Services
Primary Care
Service System
(PCMH)
Aging Services
Network
(ASN)
INTEGRATED
CARE
NETWORKS
Community
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HEALTHY IDEASIdentifying Depression, Empowering Activities for Seniors
An evidence-based program that integrates
depression detection & management into
existing care management services
o Depression screening
o Psychoeducation (incl caregivers)
o Linkage to primary care & mental health
o Behavioral activation
http://careforelders.org/default.aspx/MenuItemID/492/MenuGroup/.htm
29
Quijano, L. M., Stanley, M. A., Petersen, N. J., Casado, B. L., Steinberg, E. H., Cully, J. A., & Wilson, N. L. (2007). Healthy I.D.E.A.S: A depression intervention delivered by community-based case managers serving older adults. Journal of Applied Gerontology, 26 (2), 139-156.
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30
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“Open Door”
Brief, individualized
intervention to identify &
address barriers to
engagement in MH treatment
for older adults whose
depression was detected by
aging services.
oMajor Depression 51%
oSuicide ideation 29%31
Sirey et al., (2013). Improving engagement in mental health treatment for home meal recipients with depression. Clinical Interventions in Aging, 8, 1305-1312.
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Open Door
5 steps in Open Door:
1. Recommend referral for MH treatment
2. Conduct barriers assessment
3. Define personal goal (that could be achieved
with MH care)
4. Provide education about depression treatment
options
5. Address barriers to accessing care.
32
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Open Door
33
Clinical Interventions in Aging 2013:8submit your manuscript | www.dovepress.com
Dovepress
Dovepress
1308
Sirey et al
Engagement interventionThe Open Door intervention is a brief, individualized inter-
vention to identify and address barriers to engagement in
mental health treatment among older persons whose depres-
sion is detected in aging service settings. The premise of the
intervention is that by collaboratively engaging the older
adult in the process of seeking mental health treatment,
the intervention both creates an engagement plan that is
personalized and models the collaborative process of qual-
ity mental health treatment.42 A referral is the first step to
engagement, but often referrals are not accepted. The Open
Door intervention is conducted during three face-to-face,
30-minute intervention meetings in the client’s home with
one telephone follow-up. The Open Door intervention was
taught during a two-day training provided by the principal
study investigator (JAS) with weekly supervision provided
for the first 6 months followed by monthly supervision
thereafter.
There are five steps to the Open Door intervention: rec-
ommend referral, conduct a barriers assessment, define a
personal goal that could be achieved with care, provide educa-
tion about depression treatment options, and finally, address
the barriers to accessing care. The Open Door counselor
serves a similar function as the patient navigator whose role
in a hospital setting is to improve access to cancer screening
and treatment.43,44 The Open Door intervention is different
from other engagement interventions in two ways. First, the
barriers assessed as part of the intervention are empirically
defined from research identifying health beliefs and attitudes
that predict poor treatment participation outcomes, such as
not initiating care,45 dropping out,46 or not following a medi-
cation regimen.47 Second, the individualized assessment of
barriers goes beyond rational decision-making to elicit the
beliefs and concerns, including irrational ideas, that may be
underlying the reluctance to seek mental health treatment.
In some instances, the intervention allows the client to
articulate the fears that s/he may be self-conscious about
admitting, but have become the basis for not seeking mental
health treatment.
During the Open Door intervention meetings, the coun-
selor uses techniques drawn from motivational interviewing
to help mobilize an individual’s intrinsic motivation to
seek help.48 The client and counselor use problem-solving
techniques to brainstorm about solutions to barriers,
weigh the options, and create a specif ic plan to seek
mental health treatment. Sample intervention strategies
are shown in Table 1. The client’s treatment modality and
setting preferences are assessed using a scripted presenta-
tion of the available treatment options (eg, primary care
physician, mental health provider, research protocol). By
participating in this process, the Open Door intervention
addresses not only the referral, but also the first steps of
the treatment process.
Prior to the current study, a small feasibility pilot was
conducted with the Department of Senior Programs and
Services, which had documented a 22% (18/117) acceptance
rate of referrals to a mental health resource using their usual
referral procedures. In this feasibility pilot, home meal
program participants who screened positive for depression
on the Patient Health Questionnaire-9 were referred to a
mental health resource using the Open Door intervention.
Of the 29 participants referred, 20 (62%) accepted a referral
to mental health treatment and scheduled a first appointment
to be seen by a clinician. This feasibility study supported
Table 1 Examples of Open Door intervention
Psychologic barrier Open Door intervention activity Source of technique
(PST, MI, or PE)
Outcome
Personal stigma concern:
“My neighbor will not include
me if she thinks I’m crazy.”
Validate concern (stigma is real!)
Defin
e
di scl os ure opt ions
Emphasize personal choice
Review pros and cons of each option
MI – refle
c
t i ve listeni ng and emp athy
PST – brainstorming
MI – collaboration
PST – identify pros and cons and compare
Support
More hope
Less helplessness
Action plan
Treatment effic
a
cy concerns :
“What’s talking going to do?
Nothing can change.”
Identify hopeless as symptoms
of depression
Identify what she wishes to change
Link goal with treatment outcome
PE- – education about depression
PST – identify a goal
PE – review psychotherapy effic
a
cy data
and discuss the process of seeking care
Increase in knowledge
Increased motivation
Engagement
Attribution of depression symptoms:
“It’s the diabetes and my age
that cause my troubles”
Validate overlap of medical and
psychologic symptoms
Describe symptoms of depression
Review myths and potential for
misattribution
PE – depression symptom and medical
symptom overlap
PE – information on depression
PE – discuss myths and stereotypes
Increased knowledge
Increased perceived
need for treatment
Abbreviations: PE, psychoeducation; P ST, problem-solving therapy; MI, motivational interviewing.
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PEARLSThe Program to Encourage Active & Rewarding
Lives for Seniors
PEARLS is an evidence-based program
designed to improve the detection and
treatment of late-life depression within aging
services.
oProblem Solving Therapy, Activity Scheduling, plus
collaborative depression care management by a
multidisciplinary team
http://www.pearlsprogram.org34
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PEARLS% with at least a 50% reduction in
depression severity score at 6 month f/u8
92
Yes
No
35
54
46 Yes
No
Usual Care, n=66 PEARLS, n= 72
Ciechanowski et al., (2004). Community-Integrated Home-Based Depression Treatment in Older Adults. A Randomized Controlled Trial. JAMA, 291, 1569-1577.
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SPECTRUM OF ASN DEPRESSION CARE
None Mild Mod Severe
ASN
CAU
Augmented
ASNCAU
(E.g., PEARLS)
Collaborative
Care
Management(ASN + MH + PC)
Illness complexity (severity; med comorbidity)
Menta
l H
ealth
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SELECTIVE PREVENTION
High-risk groups, though not all members
bear risks – prevention through reducing
risks.
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Tele-Help/Tele-Check Service for the Elderly
18,641 service users in Padua, Italy
January 1, 1988 thru December 31, 1998
Mean age = 80.0 years
84% women, 73% lived alone
Suicides observed = 6
expected = 20.9
Among women
DeLeo et al., Br J Psychiatry 181:226-229, 2002
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Massachusetts Telehelp - TelecheckElder Community Care can provide:
oComprehensive mental health/substance abuse
assessment
oIn-home counseling
oTelephone call befriending service (TeleConnect)
oIn-home personal monitoring system (TeleHelp)
oAccess to 24 hour emergency response
oMedication management by a psychiatric nurse
practitioner.
oReferral to community resources and services39http://www.eldercommunitycare.org/
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http://www.ioaging.org/services/all-inclusive-
health-care/friendship-line/
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OBJECTIVE: To examine whether linking
socially disconnected seniors with peer supports
is effective in reducing risk for suicide.
DESIGN
o Sample: Primary care patients ≥60 yrs who self-
identify as lonely or a burden on others
o RCT comparing
• CAU (n=200)
• TSC (n=200) – peer companion
THE SENIOR CONNECTION (TSC)
U01 CE001942-01
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TSC Intervention – Anticipated Outcomes
Reduced…
o Loneliness, burdensomeness
(psychological disconnectedness)
o Depression, SI, worthlessness
Improved …
o Structural connectedness
o Physical health
oWell-being
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UNIVERSAL PREVENTION
Focused on the entire population as the
target – prevention through reducing risk
and enhancing health.
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QPRQuestion, Persuade, Refer
Considered a “best practice” intervention
oby SAMHSA & Suicide Prevention Resource Center
Target of intervention is gatekeepers
1 to 2 hour education program
othink CPR but for suicide prevention.
Empirically shown to increase:
oknowledge and self-efficacy about helping identify and
refer suicidal individuals, including older adults
44Wyman et al., (2008); Matthieu et al. (2008); Cross et al. (2011)
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QPR
1) Teaches the warning signs of a suicidal
crisis.
2) Teaches how to respond:
Question the individual’s desire or intent
regarding suicide
Persuade the person to seek and accept help
Refer the person to appropriate services
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QPR
Developer is Paul Quinnett, PhD
www.qprinstitute.com
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Warning Signs of Acute Risk
Threatening to hurt or kill him or herself, or
talking of wanting to hurt or kill him/herself;
and or,
Looking for ways to kill him/herself by
seeking access to firearms, available pills, or
other means; and/or,
Talking or writing about death, dying or
suicide, when these actions are out of the
ordinary.47
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Warning SignsAmerican Association of Suicidology
IdeationSubstance Abuse
PurposelessAgitationTrapped
Hopelessness
WithdrawalAnger
RestlessnessMood changes
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1-800-273-TALK
National Suicide Prevention Lifeline
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OPTIMAL SUICIDE PREVENTION =
Indicated
+
Selective
+
Universal
“MULTI-LAYERED SUICIDE
PREVENTION”
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OPTIMAL SUICIDE PREVENTION =
Indicated – detect and treat depression
+
Selective – optimize independent
functioning, increase social connectedness
+
Universal – education to reduce ageism,
gatekeeper programs
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52
Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities.
HHS Publication No. SMA 4515, CMHS-NSPL-0197. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.
http://store.samhsa.gov/product/Promoting-Emotional-Health-and-Preventing-Suicide/SMA10-4515
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Developmental Trajectories: Risk & Resilience
Suicide in late-life is not an expected or “normal” response to the stresses of aging
• Resiliency• Positive emotions
• Emotion regulation
• Closeness in
relationshipsCharles & Carstensen (2010) ;
Gatz et al. 1996
• Risk• psychiatric illness
• social
disconnectedness
• functional impairment
• physical illness
• pain
Conwell, Y., Van Orden, K., & Caine, E. (2011). Suicide in Older Adults. Psychiatric Clinics of North America; Van Orden & Conwell (2011). Suicides in Late Life. Current Psychiatry Reports.
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Helpful review articlesHelpful Review ArticlesConwell, Y., Van Orden, K., & Caine, E. D. (2011). Suicide in older adults. The Psychiatric Clinics of
North America, 34(2), 451-468. doi: 10.1016/j.psc.2011.02.002. NIHMSID # 278215
Lapierre, S., Erlangsen, A., Waern, M., De Leo, D., Oyama, H., Scocco, P., . . . Quinnett, P. (2011). A
systematic review of elderly suicide prevention programs. Crisis: The Journal of Crisis Intervention
and Suicide Prevention, 32(2), 88-98.
Rudd, M. D., Berman, A. L., Joiner, T. E., Jr., Nock, M. K., Silverman, M. M., Mandrusiak, M., Van Orden,
K. A., & Witte, T. (2006). Warning signs for suicide: theory, research, and clinical applications.
[Review]. Suicide & Life-Threatening Behavior, 36(3), 255-262. doi: 10.1521/suli.2006.36.3.255
Van Orden, K. A., Mellqvist Fässberg, M., Duberstein, P., Erlangsen, A., Lapierre, S., Bodner, E.,
Canetto, S. S., De Leo, D., Szanto, K., & Waern, M. (in press). A systematic review of social factors
and suicidal behavior in older adulthood. International Journal of Environmental Research and
Public Health. PMC in process
Erlangsen A, Nordentoft M, Conwell Y, Waern M, De Leo D, Lindner R, Oyama H, Sakashita T,
Andersen-Ranberg K, Quinnett P, Draper B, Lapierre S; International Research Group on Suicide
Among the Elderly. (2011). Key considerations for preventing suicide in older adults: consensus
opinions of an expert panel. Crisis, 32(2):106-9.
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Thank you
Contact information:
Kim Van Orden, PhD
University of Rochester Medical Center
300 Crittenden Boulevard
Rochester, NY 14642 USA
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Promoting Emotional Health and Preventing Suicide:
Toolkits for Providers of Services for Older Adults
September 17, 2015Rosalyn Blogier, LCSW-C, Public Health Advisor,
Substance Abuse and Mental Health Services Administration
Chris Miara, M.S., Senior Project Director,
Suicide Prevention Resource Center
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Creating the Toolkits
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Asbury SummitIt Takes a Community: A Summit on Opportunities for
Mental Health Promotion and Suicide Prevention in
Senior Living Communities
October 15-16, 2008
“It Takes a Community”
Report on the Summit on Opportunities for Mental Health Promotion and
Suicide Prevention in Senior Living Communities
http://www.sprc.org/library/It_Takes_A_Community.pdf
Background58
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Why Are Such Toolkits Important?
Statistics are Alarming Depression is not a normal part of aging
Normal thoughts about death are different from suicidal thoughts
It is important to reduce stigma associated with mental health disorders
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There is Hope and Help
Protective Factors Appropriate assessment and care for physical
and behavioral health issues
Social connectedness
Sense of purpose or meaning
Resilience around change
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Framework for the Toolkits
• Whole Population- Promote the emotional
health of all older adults
• At Risk-Recognize and respond to individuals at
risk
• Crisis Response-Respond to a suicide attempt
or death
(Langford, L. 2008. A Framework for Mental Health Promotion and Suicide Prevention in Senior Living Communities)
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Audience for the Toolkit
• Senior Center staff and volunteers
• Community service providers for older adults (e.g., meals on wheels, transportation, home care)
• Behavioral health professionals
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The Role of Senior Centers & Their Partners in Addressing Suicide
1. Provide activities that increase the emotional well-being of all participants
2. Identify and get help for those individuals at risk of suicide
3. Respond to a suicide death or attempt
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Activities that increase the emotional well-being of all their participants
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Identifying and getting help for individuals at risk of suicide
Train staff and volunteers
Refer to mental health providers
Conduct screening
Provide counseling
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Providing Support after a Suicide
Postvention protocols
Community support meetings
Mental health counseling
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Resources in Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Centers
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For more information
• Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Centers: http://store.samhsa.gov/product/Promoting-Emotional-Health-and-Preventing-Suicide/SMA15-4416
• Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities: http://store.samhsa.gov/product/SMA10-4515
• Suicide Prevention Resource Center
www.sprc.org
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70Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Q&A
www.ncoa.org