Update on Elderly Depression and Suicide

Dr. E CheungDr. E Cheung

Associate ConsultantAssociate Consultant

Psychogeriatric TeamPsychogeriatric Team

Castle Peak HospitalCastle Peak Hospital

Depression in the Elderly

Common Common TreatableTreatable Under-diagnosed & under-treatedUnder-diagnosed & under-treated > 60% treated inappropriately> 60% treated inappropriately Disease burdenDisease burden Morbidity & mortalityMorbidity & mortality

Prevalence of elderly depression in different care settings

Care settingCare setting Prevalence of Prevalence of depressive depressive symptomssymptoms

Prevalence of Prevalence of major major

depressive depressive disorderdisorder

CommunityCommunity 15%15% 1-3%1-3%

Primary carePrimary care 20%20% 10-12%10-12%

Acute hospitalAcute hospital 20-25%20-25% 10-15%10-15%

Long term careLong term care 30-40%30-40% 16%16%

Prevalence of Depression (2)

In Hong KongIn Hong Kong 1034 elderly aged 70 and above living in 1034 elderly aged 70 and above living in

Shatin (Chiu Shatin (Chiu et al, et al, 1998):Major depression 1.54%Major depression 1.54%Dysthymia 3.66%Dysthymia 3.66%Adjustment disorder with depressed Adjustment disorder with depressed

mood 1.54%mood 1.54%

Global burden of diseases (WHO)

19961996 20202020

Lower respiratory Lower respiratory diseasesdiseases

Ischaemic heart diseaseIschaemic heart disease

Diarrhoeal diseasesDiarrhoeal diseases Unipolar depressionUnipolar depression

Perinatal conditionsPerinatal conditions Road traffic accidentsRoad traffic accidents

Unipolar major Unipolar major depressiondepression

CVACVA

Ischaemic heart diseaseIschaemic heart disease COADCOAD

Depression is associated with increased mortality

AuthorAuthor NN FU (months)FU (months) Mortality Mortality (%)(%)

Murphy, Murphy, 19831983

124124 1212 1414

Rabins, Rabins, 19861986

100100 1212 88

Murphy, Murphy, 19881988

120120 4848 3434

Baldwin, Baldwin, 19861986

100100 4848 2626

Risk factors of elderly depression

1. 1. Female genderFemale gender2. Being widowed or divorced2. Being widowed or divorced3. Medical illness, e.g. stroke, neurological disorders3. Medical illness, e.g. stroke, neurological disorders4. Functional disability4. Functional disability5. Family and personal history of depression5. Family and personal history of depression6. Social isolation6. Social isolation7. Life events7. Life events8. Medications, e.g. antihypertensives, steroids and 8. Medications, e.g. antihypertensives, steroids and

antiparkinsonian drugsantiparkinsonian drugs9. Caregiving, e.g. carers of people with dementia9. Caregiving, e.g. carers of people with dementia

Aetiology (1)

SocialSocial: reduced social networks, loneliness, : reduced social networks, loneliness, bereavement, poverty, physical ill healthbereavement, poverty, physical ill health

PsychologicalPsychological: low self-esteem, lack of : low self-esteem, lack of capacity for intimacy, physical ill healthcapacity for intimacy, physical ill health

BiologicalBiological: neuronal loss/neurotransmitter : neuronal loss/neurotransmitter loss, genetic risk, physical ill healthloss, genetic risk, physical ill health

Aetiology (2)

Disease:Disease: Direct:Direct: CVA, Parkinson's disease, CVA, Parkinson's disease,

thyroid disease, Cushing's disease, thyroid disease, Cushing's disease, Hungtington's diseaseHungtington's disease

Indirect:Indirect: pain, disability, chronicity, pain, disability, chronicity, poor diet, decreased activitypoor diet, decreased activity

Aetiology (3)

DrugsDrugs:: Digoxin, L-dopa, steroidDigoxin, L-dopa, steroid Beta-blockers, methyldopaBeta-blockers, methyldopa Chronic benzodiazepine useChronic benzodiazepine use PhenobarbitonePhenobarbitone Neuroleptics in chronic useNeuroleptics in chronic use

Diagnosis

A syndromal diagnosis A syndromal diagnosis Based on eliciting a specific cluster of Based on eliciting a specific cluster of

symptoms through careful history taking symptoms through careful history taking and mental state examination, supplemented and mental state examination, supplemented by relevant physical examinationby relevant physical examination

No confirmatory laboratory testsNo confirmatory laboratory tests ICD-10 or DSM-IVICD-10 or DSM-IV

International Classification of Disease (ICD-10) Cardinal symptomsCardinal symptoms: depressed mood, loss of : depressed mood, loss of

interest (anhedonia), loss of energy (anergia)interest (anhedonia), loss of energy (anergia) Additional symptomsAdditional symptoms: reduced concentration, : reduced concentration,

reduced self esteem (present), guilty feelings reduced self esteem (present), guilty feelings (past), hopelessness and pessimism (future), self (past), hopelessness and pessimism (future), self harm or suicidal ideas, sleep disturbance, harm or suicidal ideas, sleep disturbance, decreased appetite, loss of libido, psychomotor decreased appetite, loss of libido, psychomotor changeschanges

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)• Depressed mood most of the dayDepressed mood most of the day• Marked diminished interest or pleasure in normal Marked diminished interest or pleasure in normal

activitiesactivities• Significant weight loss or weight gainSignificant weight loss or weight gain• Insomnia or hypersomniaInsomnia or hypersomnia• Psychomotor agitation or retardationPsychomotor agitation or retardation• Fatigue or loss of energyFatigue or loss of energy• Feelings of worthlessness or excessive guiltFeelings of worthlessness or excessive guilt• Recurrent suicidal thoughts or attemptsRecurrent suicidal thoughts or attempts• Reduced ability to concentrateReduced ability to concentrate

Diagnostic difficulties

Primary care physicians could identify no Primary care physicians could identify no more than 50% of patients with a more than 50% of patients with a diagnosable depressive syndrome (Mulsant diagnosable depressive syndrome (Mulsant & Ganguli, 1999)& Ganguli, 1999)

Presentation of depression in the elderly Presentation of depression in the elderly may be modified by factors associated with may be modified by factors associated with old ageold age

Clinical presentation of elderly depression Compared with young depressives, older people Compared with young depressives, older people

have (Weisman,1991):have (Weisman,1991): Less disturbed sleep (19% vs 25%)Less disturbed sleep (19% vs 25%) Less appetite disturbance (16% vs 27%)Less appetite disturbance (16% vs 27%) Less disturbed energy (11% vs 18%)Less disturbed energy (11% vs 18%) Less guilt (5% vs 13%)Less guilt (5% vs 13%) Less diminished concentration (8% vs 16%)Less diminished concentration (8% vs 16%) Fewer thought about death (22% vs 31%)Fewer thought about death (22% vs 31%)

Peculiar features of elderly depression Minimisation of sadness (Minimisation of sadness (GeorgotasGeorgotas, 1983), 1983) Somatisation or disproportionate complaints Somatisation or disproportionate complaints

associated with physical disorder (Sheehanassociated with physical disorder (Sheehan et alet al, , 2003)2003)

"Neurotic" symptoms of recent onset"Neurotic" symptoms of recent onset "Trivial" acts of deliberate self-harm"Trivial" acts of deliberate self-harm "Pseudodementia""Pseudodementia" Depression superimposed on dementiaDepression superimposed on dementia Accentuation of premorbid personality traits and Accentuation of premorbid personality traits and

recent change in behaviourrecent change in behaviour

Key questions to ask (1)

How is your mood?How is your mood? Have you lost interest in anything?Have you lost interest in anything? Do you get less pleasure from things you Do you get less pleasure from things you

usually enjoy?usually enjoy? How long have you had these symptoms?How long have you had these symptoms? Have you been diagnosed before with a Have you been diagnosed before with a

depressive disorder?depressive disorder?

Key questions to ask (2)

Any important health changes within the Any important health changes within the past year?past year?

Any major changes in your life in the Any major changes in your life in the preceding 3 months?preceding 3 months?

Any symptoms to suggest underlying Any symptoms to suggest underlying physical illness?physical illness?

Have you ever thought you would be better Have you ever thought you would be better off dead?off dead?

Assessment

HistoryHistory Mental state examinationMental state examination Use of standardised instruments, e.g. Use of standardised instruments, e.g.

Geriatric depression scale (GDS)Geriatric depression scale (GDS) Cognitive assessmentCognitive assessment Physical examinationPhysical examination InvestigationInvestigation

Geriatric Depression Scale (GDS) Validated standardised scales available Validated standardised scales available

locally for screening of depression: 15-item locally for screening of depression: 15-item Chinese Geriatric Depression Scale Short Chinese Geriatric Depression Scale Short Form (GDS) (Lee Form (GDS) (Lee et alet al, 1993), 1993)

Cut-off point of 8/15 Cut-off point of 8/15 Can be applied by trained non-medical Can be applied by trained non-medical

personnelpersonnel

老人憂鬱量表

以下列舉的問題是人們對一些事物的感受。在過去一星期內，你是否曾有以下的感受，如有的話，請圈『是』，若無的話，請圈『否』。

1. 你基本上對自己的生活感到滿意嗎？ 是 ／ 否2. 你是否已放棄了很多以往的活動和嗜好？ 是 ／ 否3. 你是否覺得生活空虛？ 是 ／ 否4. 你是否常常感到煩悶？ 是 ／ 否5. 你是否很多時感到心情愉快呢？ 是 ／ 否6. 你是否害怕將會有不好的事情發生在你身上呢？ 是 ／ 否7. 你是否大部份時間感到快樂呢？ 是 ／ 否8. 你是否常常感到無助? (即是沒有人能幫助自己) 是 ／ 否9. 你是否寧願晚上留在家裡，而不愛出外做些有新意的事情？ 是 ／ 否

(譬如：和家人到一新開張酒樓吃晚飯)10. 你是否覺得你比大多數人有多些記憶的問題？ 是 ／ 否11. 你認為現在活著是一件好事嗎？ 是 ／ 否12. 你是否覺得自己現在一無是處呢？ 是 ／ 否13. 你是否感到精力充沛？ 是 ／ 否14. 你是否覺得自己的處境無望？ 是 ／ 否15. 你覺得大部份人的境況比自己好嗎？ 是 ／ 否

總分 ________

Principles of management

1.1. Monitoring the risk of self-harmMonitoring the risk of self-harm 2.2. Educating the patient (and care givers) about depression Educating the patient (and care givers) about depression

and involving him or her in treatment decisionsand involving him or her in treatment decisions 3.3. Treating the whole person - coexisting physical disorder; Treating the whole person - coexisting physical disorder;

attention to sensory deficits and other handicaps; attention to sensory deficits and other handicaps; reviewing medication with a view to withdrawing those reviewing medication with a view to withdrawing those unnecessaryunnecessary

4.4. Treating depressive symptoms with the aim of complete Treating depressive symptoms with the aim of complete remission (as residual symptoms are a risk factor for remission (as residual symptoms are a risk factor for chronic depression)chronic depression)

5.5. Prompt referral of patients requiring specialist mental Prompt referral of patients requiring specialist mental health serviceshealth services

When to refer for specialist advice? (WPA, 1999) When the diagnosis is in doubt (e.g. is this dementia?)When the diagnosis is in doubt (e.g. is this dementia?) When depression is severe, as evidenced by: When depression is severe, as evidenced by:

Psychotic depressionPsychotic depression Severe risk to health because of failure to eat or drinkSevere risk to health because of failure to eat or drink Suicide riskSuicide risk

Complex therapy is indicated (e.g. in cases with medical Complex therapy is indicated (e.g. in cases with medical comorbidity)comorbidity)

When first-line therapy fails (although primary care When first-line therapy fails (although primary care physicians may wish to pursue a second course of an physicians may wish to pursue a second course of an antidepressant from a different class)antidepressant from a different class)

Treatment

Physical treatmentPhysical treatment Pharmacological treatmentPharmacological treatment Electroconvulsive therapyElectroconvulsive therapy

Psychosocial treatmentPsychosocial treatment

The Monoamine Hypothesis

The 3 monoamines: noradrenaline, The 3 monoamines: noradrenaline, serotonin and dopamineserotonin and dopamine

Depression believed to be the result of a Depression believed to be the result of a deficiencydeficiency of monoamine neurotransmitters of monoamine neurotransmitters

All known antidepressants act by increasing All known antidepressants act by increasing the activity of these neurotransmitters in the the activity of these neurotransmitters in the brain by various mechanismsbrain by various mechanisms

Special considerations in the elderly Pharmacokinetics (change in volume of Pharmacokinetics (change in volume of

distribution , metabolism, elimination)distribution , metabolism, elimination) Co-morbid physical illnessesCo-morbid physical illnesses Drug interactionsDrug interactions Dosing Dosing

Pharmacological treatment

Information for patients and carers:Information for patients and carers: Start low, go slowStart low, go slow Typical side effectTypical side effect Delay in onset of therapeutic actionDelay in onset of therapeutic action Lack of dependence potentialLack of dependence potential Need for continuation treatment Need for continuation treatment

following initial responsefollowing initial response

The Five “R”s of antidepressant treatment ResponseResponse RemissionRemission RecoveryRecovery RelapseRelapse RecurrenceRecurrence

Mood

Time

Acutetreatment

Continuationtreatment

Maintenancetreatment

Response

Remission

Relapse

Recovery

Recurrence

Principles of antidepressant treatment1.1. Ascertain diagnosisAscertain diagnosis2.2. The ultimate aim of treatment is The ultimate aim of treatment is remissionremission3. Treatment has to be adequate in dosage,

duration and compliance has to be ensured4. If there is no response after an adequate trial,

switch to another class of antidepressant5. If there is partial response, further increase

dosage and/or persist for a longer duration or augmentation

Principles of antidepressant treatment6.6. Address psychosocial issues and psychoeducationAddress psychosocial issues and psychoeducation7.7. Continuation treatmentContinuation treatment – at least 6 to 9 months – at least 6 to 9 months

after remission, longer for elderly (12 to 24 after remission, longer for elderly (12 to 24 months) at the months) at the same dosesame dose

8.8. Maintenance treatmentMaintenance treatment – prophylactic treatment – prophylactic treatment for patients with multiple past episodes, serious ill for patients with multiple past episodes, serious ill health, chronic social difficulties and very severe health, chronic social difficulties and very severe depressive symptoms. No consensus on length of depressive symptoms. No consensus on length of maintenance.maintenance.

Risk factors for recurrence (WHO, 1989)1.1. ComorbidityComorbidity

2.2. Chronic medical conditionsChronic medical conditions

3.3. Chronic affective symptomsChronic affective symptoms

4.4. Older age of onset of first episodeOlder age of onset of first episode

5.5. Severe functional impairment during depressionSevere functional impairment during depression

6.6. Psychotic depressionPsychotic depression

7.7. Previous suicide attemptPrevious suicide attempt

8.8. Family history of suicide and bipolar disorderFamily history of suicide and bipolar disorder

Tricyclic antidepressants (TCA)

Nortriptyline (Nortrilen), dothiepine Nortriptyline (Nortrilen), dothiepine (Prothiaden), amitriptyline(Prothiaden), amitriptyline

Anticholinergic S/EAnticholinergic S/E Anti-histaminergic S/EAnti-histaminergic S/E Anti-adrenergic S/EAnti-adrenergic S/E CardiotoxicityCardiotoxicity

Stephen M. Stahl: Essential Psychopharmacology 1996

Mechanism of action of TCAs

Shown here is an icon of a tricyclic antidepressant (TCA). These drugs are actually five drugs in one: (1) a serotonin reuptake inhibitor (SRI); (2) a noradrenaline reuptake inhibitor (NRI); (3) an anticholinergic/antimuscarinic drug (M1); (4) an alpha adrenergic antagonist (alpha); and (5) an antihistamine (H1).

Stephen M. Stahl, Essential Psychopharmacology, 1996

Therapeutic actions of TCAs

The serotonin reuptake inhibitor (SRI) portion of the TCA is inserted into the serotonin reuptake pump, blocking it and causing an antidepressant effect

Stephen M. Stahl, Essential Psychopharmacology, 1996

Therapeutic actions of TCAs

The noradrenergic portion of the TCA is inserted into the noradrenaline reuptake pump , blocking and causing an antidepressant effect

Stephen M. Stahl, Essential Psychopharmacology, 1996

Side effects of TCAs

Side effects of the tricyclic antidepressants- part 1. In this diagram, the icon of the TCA is shown with its H1 (antihistamine) portion inserted into histamine receptors, causing the side effects of weight gain and drowsiness.

Stephen M. stahl, Essential Psychopharmacology, 1996

Side effects of TCAs

Side effects of the tricyclic antidepressants - part 2. In this diagram, the icon of the TCA is shown with its M1 (anticholinergic/antimuscarinic) portion inserted into acetylcholine receptors, causing the side effects of constipation, blurred

vision, dry mouth and drowsiness.

Stephen M. Stahl, Essential Psychopharmacology, 1996

Side effects of TCAs

Side effects of the tricyclic antidepressants - part 3. In this diagram, the icon of the TCA is shown with its alpha (alpha adrenergic antagonist) portion inserted into alpha adrenergic receptors, causing the side effects of dizziness, decreased blood pressure and drowsiness.

Dose titration of TCA

Most commonly used TCA: dothiepine Most commonly used TCA: dothiepine (Prothiaden)(Prothiaden) Starting dose: 50mg nocteStarting dose: 50mg nocte Then increase in increments of 25 to Then increase in increments of 25 to

50mg depending on side effects every 50mg depending on side effects every few days aiming at an initial target dose few days aiming at an initial target dose of 150mgof 150mg

Maximum dose of 225mg nocteMaximum dose of 225mg nocte

Selective Serotonin Reuptake Inhibitors (SSRIs) Citalopram (Cipram), sertraline (Zoloft), Citalopram (Cipram), sertraline (Zoloft),

paroxetine (Seroxat), fluoxetine (Prozac), paroxetine (Seroxat), fluoxetine (Prozac), escitalopram (Lexapro)escitalopram (Lexapro)

GI upsetGI upset AnorexiaAnorexia HeadacheHeadache Insomnia, anxiety, tremourInsomnia, anxiety, tremour Sexual dysfunctionSexual dysfunction SIADHSIADH

Stephen M. Stahl, Essential Psychopharmacology,1996

Selective Serotonin Reuptake Inhibitor (SSRI)

Shown here is the icon of a selective serotonin reuptake inhibitor (SSRI). In this case, 4 out of the 5 pharmacological properties of the TCAs (tricyclic antidepressants; Figure 6-13) are removed. Only the serotonin reuptake inhibitor (SRI) portion remains; thus the SRI action is selective, which is why these agents are called selective SRIs.

Includes fluoxetine, fluvoxamine, citalopram, paroxetine, sertraline and escitalopram

Stephen M. Stahl, Essential Psychopharmacology, 1996

Mechanism of Action of SSRIs

In this diagram, the SRI (serotonin reuptake inhibitor) portion of the SSRI molecule is shown inserted in the serotonin reuptake pump, blocking it and causing an antidepressant effect. This is analogous to one of the dimensions of the TCAs.

Serotonergic-Noradrenergic Reuptake Inhibitor (SNRI) Venlafaxine (Efexor/Efexor XR)Venlafaxine (Efexor/Efexor XR) Side effects similar to SSRISide effects similar to SSRI May cause hypertension at high dosesMay cause hypertension at high doses

Stephen M. Stahl, Essential Psychopharmacology, 1996

Serotonergic-noradrenergic Reuptake Inhibitors (SNRI)

Shown here is the icon of a dual reuptake inhibitor which combines the actions of both a serotonin reuptake inhibitor (SRI) and a noradrenaline reuptake inhibitor (NRI). In this case, 3 out of the 5 pharmacological properties of the TCAs (tricyclic antidepressants) were removed. Both the SRI portion and the NRI portion of the TCA remain; however the alpha, antihistamine and anticholinergic portions are removed. These serotonin/noradrenaline reuptake inhibitors are called SNRIs or dual inhibitors. A small amount of dopamine reuptake inhibition (DRI) is also present in some of these agents, especially at high doses.

e.g. Venlafaxine

Reversible inhibitors of monoamine oxidase A (RIMA) Moclobemide (Aurorix)Moclobemide (Aurorix) NauseaNausea HeadacheHeadache InsomniaInsomnia RestlessnessRestlessness AgitationAgitation

Other antidepressants

SARI – SARI – nefazodone (Serzone)nefazodone (Serzone) Sedation, lack of 5HT2 stimulation S/ESedation, lack of 5HT2 stimulation S/E

NaSSA – NaSSA – mirtazapine (Remeron)mirtazapine (Remeron) Sedation, dry mouth, increased appetite, Sedation, dry mouth, increased appetite,

weight gainweight gain NDRI – NDRI – bupropion (Wellbutrin)bupropion (Wellbutrin)

Headache, dry mouth, agitation, nausea, Headache, dry mouth, agitation, nausea, insomniainsomnia

Stephen M. Stahl, Essential Psychopharmacology, 1996

Serotonin-2 Antagonist/reuptake Inhibitors (SARI)

Shown here are icons for two of the serotonin 2 antagonist/reuptake inhibitors (SARIs). These agents also have a dual action, but the two mechanisms are different from the dual actions of the SNRIs (serotonin noradrenaline reuptake inhibitors). The SARIs act by potent blockade both of serotonin 2 (5HT2) receptors, combined with SRI (serotonin reuptake inhibitor) actions. Nefazodone also has weak NRI (noradrenaline reuptake inhibition) as well as weak alpha adrenergic blocking properties. Trazodone also contains antihistamine properties and alpha antagonist properties, but lacks NRI properties.

Stephen M. Stahl, Essential Psychopharmacology, 1996

Noradrenergic and Specific Serotonergic Antidepressant (NaSSA)

e.g. Mirtazapine

Other antidepressants

Mianserin (Tolvon)Mianserin (Tolvon):: Sedation, aplastic anaemia, Sedation, aplastic anaemia,

agranulocytosisagranulocytosis TrazodoneTrazodone::

Sedation, orthostatic hypotension, Sedation, orthostatic hypotension, priapismpriapism

Commonly used antidepressant drugs

Drug group

Member commonly used

in the elderly

Starting dose Therapeutic dose

Common side effects

SSRI Sertraline 50 mg OM 50 mg BD Nausea, headache, weight loss

  Citalopram 10 -20 mg OM 40 mg OM

TCA Nortriptyline 10 -25 mg nocte

75 - 100 mg nocte

Dizziness, sedation, dry mouth, urinary retention,

postural hypotension, cardiotoxicity

SNRI Venlafaxine XR 75 mg daily 150 - 225 mg daily

Hypertension

NaSSA Mirtazapine 15 mg nocte 30 - 45 mg nocte

Weight gain, sedation, dizziness

RIMA Moclobemide 150 mg BD 300 mg BD

Agitation, insomnia and headache

Other pharmacological treatment

Others:Others: AntipsychoticsAntipsychotics Lithium augmentationLithium augmentation Tri-iodothyronine (T3) augmentationTri-iodothyronine (T3) augmentation Antidepressant combinationAntidepressant combination Anticonvulsant augmentationAnticonvulsant augmentation Buspirone augmentationBuspirone augmentation Pindolol augmentationPindolol augmentation

Electroconvulsive therapy (ECT)

Safe and effectiveSafe and effective Indication in food refusal, suicidal risk, Indication in food refusal, suicidal risk,

severe retardation and poor response to severe retardation and poor response to drug treatmentdrug treatment

71-88% with good outcome71-88% with good outcome Post ECT confusion 18-52%Post ECT confusion 18-52% Twice or three times weekly for 6 to 12 Twice or three times weekly for 6 to 12

sessionssessions

Psychosocial interventions

Basic psychotherapeutic processes:Basic psychotherapeutic processes: Listening and talkingListening and talking Release of emotionRelease of emotion Giving informationGiving information Providing a rationaleProviding a rationale Restoration of moraleRestoration of morale SuggestionSuggestion Guidance and adviceGuidance and advice The therapeutic relationshipThe therapeutic relationship

Psychoeducation

Nature and pathogenesis of depressionNature and pathogenesis of depression Use of a “Stress-diathesis” modelUse of a “Stress-diathesis” model Proposed treatment, expected side effects, Proposed treatment, expected side effects,

delay in onset of therapeutic responsedelay in onset of therapeutic response Expected duration of continuation and Expected duration of continuation and

maintenance treatmentmaintenance treatment

Evidence-based psychosocial treatments Interpersonal therapyInterpersonal therapy Cognitive behavioural therapyCognitive behavioural therapy For moderate to severe depression, the For moderate to severe depression, the

combination of pharmacotherapy and combination of pharmacotherapy and psychological treatment has been found to psychological treatment has been found to be superior to either treatment given alonebe superior to either treatment given alone (Reynolds (Reynolds et alet al, 1999), 1999)

Elderly suicide

Elderly suicide in Hong Kong Extent of the problem High rate of elderly suicide:High rate of elderly suicide:

Two to three times higher in the elderly (25–35 per Two to three times higher in the elderly (25–35 per 100,000) than the general population (10-13 per 100,000) than the general population (10-13 per 100,000)100,000)

30% of all suicide deaths were aged 60 or above30% of all suicide deaths were aged 60 or above High rate of successHigh rate of success Ageing populationAgeing population

Population aged 65 or above increased from 0.63 Population aged 65 or above increased from 0.63 million in 1996 to 0.76 million in 2000 (21% million in 1996 to 0.76 million in 2000 (21% increase)increase)

Suicide rates by age group in Hong Kong

CountryCountry Number ofNumber of

suicidessuicides

Rate perRate per

100 000100 000

Ranking byRanking by

suicide ratesuicide rate

ChinaChina 195 000195 000 16.116.1 2424

India India 87 00087 000 9.79.7 4545

Russia Russia 52 50052 500 41.541.5 33

USAUSA 31 00031 000 11.911.9 3838

Japan Japan 20 00020 000 16.816.8 2323

Germany Germany 12 50012 500 15.815.8 2525

WHO, 1999 Ranking by number of suicides

CountryCountry Number ofNumber of

suicidessuicides

Rate perRate per

100 000100 000

Ranking by Ranking by

number of number of

suicidessuicides

LithuaniaLithuania 16001600 41.941.9 2222

EstoniaEstonia 600600 40.140.1 2525

RussiaRussia 52 50052 500 37.637.6 33

Latvia Latvia 850850 33.933.9 2323

HungaryHungary 30003000 32.932.9 1616

Sri LankaSri Lanka 54005400 31.031.0 99

WHO, 1999 Ranking by rates of suicide

What do we know about elderly suicide in Hong Kong?

Characteristics of elderly suicide completers Low attempt to completion ratio – 4:1Low attempt to completion ratio – 4:1 Greater determination as evidenced by:Greater determination as evidenced by:

Lethal methods: 52% by jumping from Lethal methods: 52% by jumping from height, 36% by hanging (Chi & Yu, 1997)height, 36% by hanging (Chi & Yu, 1997)

Fewer warning signsFewer warning signs Greater planning and resolveGreater planning and resolve

Prevention after onset of a suicidal crisis Prevention after onset of a suicidal crisis may be less successful for the elderlymay be less successful for the elderly

Characteristics of elderly suicide completers Evidence from psychological autopsy studies:Evidence from psychological autopsy studies:

71-95% of suicide victims aged 65 or above 71-95% of suicide victims aged 65 or above had a major psychiatric disorder (Conwell had a major psychiatric disorder (Conwell et alet al, , 2002)2002)

86% of HK Chinese elderly suicide victims had 86% of HK Chinese elderly suicide victims had a diagnosable psychiatric disorder compared a diagnosable psychiatric disorder compared with 9% in controls, with depression being the with 9% in controls, with depression being the most common diagnosis (Chiu most common diagnosis (Chiu et alet al, 2004), 2004)

Characteristics of elderly suicide completers Elderly suicide completion is also associated with:Elderly suicide completion is also associated with:

Past history of suicide attemptPast history of suicide attempt Physical illness and functional impairmentPhysical illness and functional impairment Social isolationSocial isolation Recent life eventRecent life event Rigid, anxious and obsessional personality styleRigid, anxious and obsessional personality style

Risk factors

GeneticsFamily Hx

Psychiatric disorder

PersonalitySocial milieu

Service utilisation of elderly suicide completers Locally, 77% of suicide completers had consulted a Locally, 77% of suicide completers had consulted a

doctor one month before death, compared to 39% in doctor one month before death, compared to 39% in controls (Chiu controls (Chiu et alet al, 2004), 2004)

Most were because of non-psychiatric problemsMost were because of non-psychiatric problems Only 37% of the suicide completers had a life time Only 37% of the suicide completers had a life time

history of consulting a psychiatrist although 86% of history of consulting a psychiatrist although 86% of them suffered from a psychiatric problem (Chiu them suffered from a psychiatric problem (Chiu et alet al, , 2004) 2004)

The rate of consulting a psychiatrist is 65% in a The rate of consulting a psychiatrist is 65% in a Swedish psychological autopsy study (Waern Swedish psychological autopsy study (Waern et alet al, , 2002)2002)

Studies on suicidal ideations

Among 516 elderly aged 70 or above in Among 516 elderly aged 70 or above in Berlin (Linden & Barnow, 1997):Berlin (Linden & Barnow, 1997): 14.7% 14.7% said that life is not worth living said that life is not worth living

(77.5% had depression)(77.5% had depression) 5.4% 5.4% wished to be dead or thought about wished to be dead or thought about

suicide (95.7% had depression)suicide (95.7% had depression) 1.0% 1.0% showed suicidal ideas or gestures showed suicidal ideas or gestures

(100% had depression)(100% had depression)

Completer- 30/100,000

Attempter – 100/100,000

Suicidal Intentions – 1-5%

Life not worth living – 15-19%

Normal – 80%

NormalSlightlydepressed

LifeNotWorthLiving

Suicidal Intentions

Attempters Completers

TIME-LINE

Evidence-based means and tools

Gotland study (Rihmer Gotland study (Rihmer et alet al, 1995):, 1995): depression-related suicide rates decreased withdepression-related suicide rates decreased with

training programme for training programme for general practitioners on general practitioners on the diagnosis and treatment of depressionthe diagnosis and treatment of depression

TeleHelp-TeleCheck service (De Leo TeleHelp-TeleCheck service (De Leo et alet al, 2002):, 2002): reduction in elderly suicide rates after reduction in elderly suicide rates after

introductintroductionion of tele-help service of tele-help service

What do we know about elderly suicide?1.1. Elderly suicides are characterised by a higher rate than the Elderly suicides are characterised by a higher rate than the

general population, higher lethality, greater determination general population, higher lethality, greater determination and fewer warning signs and fewer warning signs

2.2. They are consistently associated with a number of risk They are consistently associated with a number of risk factors, e.g. past history of suicide, physical illness, factors, e.g. past history of suicide, physical illness, psychiatric illness and certain personality traits (Conwell psychiatric illness and certain personality traits (Conwell et et alal, 2002), 2002)

3.3. Some of these factors are modifiable, e.g. depressive illnessSome of these factors are modifiable, e.g. depressive illness4.4. The majority of elderly who eventually commit suicide The majority of elderly who eventually commit suicide

would make contact with a primary care physician one would make contact with a primary care physician one month before their suicide (but not necessarily for a mood month before their suicide (but not necessarily for a mood problem) and most remain undetected (Chiu problem) and most remain undetected (Chiu et alet al, 2004), 2004)

What do we know about elderly suicide?5.5. Low utilisation rate of psychiatric service among elderly suicide Low utilisation rate of psychiatric service among elderly suicide

completers may reflect lack of awareness and stigmatisation in the completers may reflect lack of awareness and stigmatisation in the community (Chiu community (Chiu et alet al, 2004), 2004)

6.6. Suicidal ideations and intentions are highly correlated with Suicidal ideations and intentions are highly correlated with depressive disorder and are useful key markers for identification of depressive disorder and are useful key markers for identification of at-risk individuals (Linden & Barnow, 1997)at-risk individuals (Linden & Barnow, 1997)

7.7. Programme aimed at educating primary care physicians about Programme aimed at educating primary care physicians about depression has been shown to reduce suicide rate, e.g. Gotland depression has been shown to reduce suicide rate, e.g. Gotland study (Rihmer study (Rihmer et alet al, 1995), 1995)

8.8. Telecheck shown to be a useful tool in providing care for elderly at Telecheck shown to be a useful tool in providing care for elderly at risk of suicide and reduce suicide rate (De Leo risk of suicide and reduce suicide rate (De Leo et alet al, 2002), 2002)

9.9. Relevant and locally validated instruments are available, e.g. GDSRelevant and locally validated instruments are available, e.g. GDS

Strategies in suicide prevention

Universal preventionUniversal prevention Selective preventionSelective prevention Indicated/targeted preventionIndicated/targeted prevention

Elderly Suicide Prevention Programme (ESPP) A early detection and targeted intervention A early detection and targeted intervention

programme programme Two-tiered model: Two-tiered model:

First tier comprises primary health care First tier comprises primary health care practitioners, various listed NGOs and hotlines practitioners, various listed NGOs and hotlines coordinated by a regional committeecoordinated by a regional committee

Second tier comprises specialist psychogeriatric Second tier comprises specialist psychogeriatric service in the form of a Fast Track Clinic and service in the form of a Fast Track Clinic and multidisciplinary treatment teammultidisciplinary treatment team

Important features of the two-tiered model Improved access: one-stop service for the Improved access: one-stop service for the

clientclient Increased capacity for detection through the Increased capacity for detection through the

use of standardised instruments and training use of standardised instruments and training of non-medical personnelof non-medical personnel

Free-flow of patients between the two tiers Free-flow of patients between the two tiers according to needs assessmentaccording to needs assessment

Aims of ESPP

1.1. Early detection of elderly at risk of suicideEarly detection of elderly at risk of suicide

2.2. Effective and adequate managementEffective and adequate management

Early detection

1.1. Raising the awareness of target referrers and Raising the awareness of target referrers and general public:general public:

a.a. Promotional and bibliographic materialPromotional and bibliographic materialb.b. Liaison with target medical referrersLiaison with target medical referrersc.c. Liaison with non-medical target referrersLiaison with non-medical target referrersd.d. Organise training sessions, lectures, publicity Organise training sessions, lectures, publicity

activitiesactivitiese.e. Setting up of regional committee with local Setting up of regional committee with local

NGOsNGOs

Early detection

2.2. Improving access to serviceImproving access to servicea.a. Setting-up of Fast Track Clinic (FTC) with an Setting-up of Fast Track Clinic (FTC) with an

aim of providing medical assessment in a aim of providing medical assessment in a timely mannertimely manner

b.b. Early intervention service by CPNs within 7 Early intervention service by CPNs within 7 days of referral with medical outreach in days of referral with medical outreach in exceptional casesexceptional cases

c.c. Non-medical referral accepted, including Non-medical referral accepted, including screening using the GDS and referrals from screening using the GDS and referrals from listed NGOslisted NGOs

Effective and adequate management1.1. Individual biopsychosocial assessment with early Individual biopsychosocial assessment with early

intervention serviceintervention service2.2. Multidisciplinary approach including involvement of Multidisciplinary approach including involvement of

referrerreferrer3.3. Regular case conferenceRegular case conference4.4. Adequate biological and psychosocial treatmentAdequate biological and psychosocial treatment5.5. Coordination of psychosocial support and mobilising Coordination of psychosocial support and mobilising

resources from the communityresources from the community6.6. Intensive follow-up by home visits and/or telecheckIntensive follow-up by home visits and/or telecheck7.7. In-patient facility In-patient facility

Service boundary

1.1. Age 65 or aboveAge 65 or above

2.2. Residing in the relevant catchment areasResiding in the relevant catchment areas

3.3. Inclusion criteriaInclusion criteria

a.a. Suicidal ideation/thoughts/talk/planSuicidal ideation/thoughts/talk/plan

b.b. Previous attempt of suicidePrevious attempt of suicide

c.c. Suspected moderate to severe depression Suspected moderate to severe depression (either by medical assessment or by screening (either by medical assessment or by screening using the GDS)using the GDS)

NGO/hotlines(Screening)

GP/DH/GOPD TMH/POHA&E, in-patient

FTCEarlyIntervention

(CPN)

In-patient serviceHome visits/telecheck

Multidisciplinaryteam

Suicide attempt

Mood problem

Suicidal idea Consultation

Workflow of ESPP

Clinical assessment and management Full psychiatric assessmentFull psychiatric assessment Clear documentationClear documentation Indicate rationale for decisionsIndicate rationale for decisions

Assessment of suicidal risk

Asking about suicidal inclinations does not Asking about suicidal inclinations does not make suicidal behaviour more likelymake suicidal behaviour more likely

Willingness to make tactful but direct enquiries about a patient’s intention

Be alert to factors that signify an increased risk of suicide

Assessment of suicidal risk

Consider known risk factorsConsider known risk factors Assess current suicidal riskAssess current suicidal risk Assess suicidal intent – planning, Assess suicidal intent – planning,

preparation, precaution against discovery, preparation, precaution against discovery, final rite, verbal cues, suicide notefinal rite, verbal cues, suicide note

Collateral informationCollateral information

Suggested questioning sequence

Whether the patient:Whether the patient: hopes things turn out wellhopes things turn out well gets pleasure out of lifegets pleasure out of life feels hopeful from day to dayfeels hopeful from day to day feels able to face each dayfeels able to face each day ever despairs about thingsever despairs about things feels life to be a burdenfeels life to be a burden wishes it would all endwishes it would all end

Suggested questioning sequence

Whether the patient:Whether the patient: knows why he/she feels this wayknows why he/she feels this way has thought of ending lifehas thought of ending life has thought about the possible methodshas thought about the possible methods has ever acted on any suicidal thoughts or has ever acted on any suicidal thoughts or

intentionsintentions feels able to resist any suicidal thoughtsfeels able to resist any suicidal thoughts

The End