Need Help Stat

CONSIDER: DEPRESSION

Suicide

"Suicide is not chosen; it happens when pain exceeds resources for coping with pain"1

Warning Signs of Suicide
Suicide Warning Signs 2,3

  • Talking about suicide or intent to die
  • Preoccupation with death
  • A cogent plan is present and lethal means available (e.g. prescription drugs)
  • Preoccupied with thoughts of impending death or suicide
  • Statements of hopelessness, helplessness, or worthlessness
  • Suddenly happy and calmer after depression symptoms
  • Expresses despair, hopelessness, pessimism about future
  • Making arrangements or getting affairs in order
  • Giving things away

 

Questions to Ask:

Direct questioning is the best method for determining if someone is going to commit suicide. Questions you might ask:4

  • Are you thinking about suicide?
  • Are you thinking about hurting yourself?
  • Are you having recurring thoughts about dying?
  • Have you thought about how you might do it?
  • Do you know when you would do it?
  • Do you have something to do it with? (e.g. prescription medications)

 

You will not push a person who is considering suicide to do it. In fact, you may decrease the risk of suicide by giving the person the chance to express their feelings.

If a person is at imminent risk for suicide call "911" or get them to the emergency room as soon as possible. For further information on suicide view the following links:

Resources
Contemplating Suicide call 1-800-273-TALK or 1-800-273-8255

SAVE (Suicide Awareness Voices of Prevention). Someone you know is suicidal: http://www.save.org/prevention/someone_you_know.html
Misconceptions about suicide: http://www.save.org/prevention/misconceptions.html.
For survivors. A resource for those left behind.
http://www.save.org/coping/when_worst.html

Mayo Clinic Staff. (2005). What to do if someone you know is suicidal. Mayo Foundation for Medical Education and Research. http://www.mayoclinic.com/invoke.cfm?id=MH00058

American Psychiatric Association. www.psych.org

U.S. Department of Health and Human Services. (1999). The Surgeon General's Call to Action to Prevent Suicide. Access @ www.surgeongeneral.gov/library/calltoaction

Suicide

The rate of suicide among older adults is higher than that for any other age group---and the suicide rate for persons 85 years and older is the highest of all, twice the overall national rate. Women are twice as likely to be depressed, but men are less likely to report it and more likely to be successful at suicide.

Several studies have found that many older adults who commit suicide have visited a primary care physician very close to the time of the suicide - 20 percent on the same day and 40 percent within 1 week of the suicide. This fact demonstrates the need for primary care providers, nurses and other caregivers to be alert to the signs and symptoms of depression.

References

1. U.S. Department of Health and Human Services, CDC, Substance Abuse and Mental Health Organization. (2004). National Strategy for Suicide Prevention. Contemplating Suicide? Accessed 1/19/2005 at www.metanoia.org

2. Suicide Awareness Voices Education. (2004). Suicide & Depression Basics: Symptoms and Danger Signs. Access 1/14/2005 at www.save.org

3. Hall, R. Hall, RC, Chapman, M. (2003). Identifying Geriatric Patients at Risk for Suicide and Depression. Clinical Geriatrics; 11(10), pp. 36-44.

Mayo Clinic Staff. (2005). What to do if someone you know is suicidal. Mayo Foundation for Medical Education and Research. Accessed 1/14/2005 at: www.mayoclinic.com/invoke.cfm?id=MH00058

For more information on secondary prevention of suicide in the elderly please see: Holkup P. Evidence-based protocol. Elderly suicide: secondary prevention. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core; 2002 Jun. 56 p. Click here.

Definitions Depression: In the broadest sense, depression is defined as a syndrome comprised of a constellation of affective, cognitive, and somatic or physiological manifestations (NIH Consensus Development Panel, 1992).

 

DSM-IV criteria for the diagnosis of major depressive disorder are frequently used as the standard by which older patients' depressive symptoms are assessed in clinical settings (American Psychiatric Association, 2000). Five criteria from a list of nine must be present nearly every day during the same 2-week period and must represent a change from previous functioning: (1) depressed, sad, or irritable mood, (2) anhedonia or diminished pleasure in usually pleasurable people or activities, (3) feelings of worthlessness, self-reproach, or excessive guilt, (4) difficulty with thinking or diminished concentration, (5) suicidal thinking or attempts, (6) fatigue and loss of energy, (7) changes in appetite and weight, (8) disturbed sleep, and (9) psychomotor agitation or retardation. For this diagnosis, at least one of the five symptoms must include either depressed mood, by the patient's subjective account or observation of others, or markedly diminished pleasure in almost all people or activities.

Concurrent medical conditions are frequently present in older patients and should not preclude a diagnosis of depression; indeed, there is a high incidence of medical co-morbidity. When depression occurs in late life, it may be a relapse of an earlier depression. If it is a first time occurrence, it may be triggered by another illness, hospitalization, or placement in a nursing home. Unlike the onset of depression in non-elderly populations, depression in the elderly is thought to be a psychological disorder triggered by specific stressors, such as medical illness. Another causal factor is grief following the death of a loved one.

Assessment/Screening Tools

 

Atypical Presentation Symptoms of depression in the elderly may not follow the classic DSM-IV criteria. Instead, clinical depression is characterized by symptoms that interfere with the ability to function normally for a prolonged period of time (Table 1).

Table 1. Assessment and Intervention for Depression
Symptoms Nursing Assessment and Interventions
  • Persistent sadness lasting two or more weeks
  • Difficulty sleeping or concentrating
  • Feeling slowed down Withdrawing from regular social activities
  • Excessive worries about finances and health problems Pacing and fidgeting
  • Feeling worthless or helpless
  • Weight/appearance changes or frequent tearfulness
  • Thoughts of suicide or death
  • Multiple psychosomatic complaints
    • Pain
    • Headaches
    • Fatigue
    • Insomnia
    • GI symptoms
    • Arthritis pain
    • Multiple diffuse symptoms
    • Unexplained weight loss
    		•
  • Assess for underlying treatable cause:
    • Pre-existing medical condition
    • Lab tests include: thyroid stimulating hormone, chemistry panel, complete blood count, and medication levels (if needed); urinalysis, electrocardiogram, serum B12 and serum folate.
    • Correct/treat metabolic/systemic disturbances.
    Medications
    • Steroids, narcotics, sedative/hypnotics, benzodiazepines, antihypertensives, H2 antagonists, beta-blockers, antipsychotics, immunosuppressive and cytotoxic agents.
    • Remove, taper, or change etiologic agents.
    Other
  • Differentiate from delirium and dementia
  • Subsequent questioning of the family or caregiver about the elder's verbal and nonverbal expressions of depression
  • Recommend treatment for depression. It is highly successful and is not a normal part of growing older. 60-80% response rate.
  • If the evaluation determines that the person is depressed, ask for a referral to a geriatric psychiatrist---geriatric psychiatrists are the specialists best suited to effectively and efficiently treat mental illness in older adults.
  • Institute safety precautions for suicide risk as per institutional policy. (See Suicide Resource)
  • Monitor and document responses to medication and other therapies; readminister depression screening tool.
  • Preventive screening:
  • Assess all patients for depression using GDS, particularly high risk. See Try this tool.
  • Monitor patients after a loss for depression beyond normal grief.
    		•

    Treatment Options Depression is one of the most successfully treated illnesses. When properly diagnosed and treated, more than 80 percent of those suffering from depression recover and return to their normal lives. Untreated depression is likely to persist causing distress, disability, wasted health care dollars, substance abuse, and medical complications, or suicide and death.

    Common treatments for depression include psychotherapy, antidepressant medications, and electroconvulsive therapy (ECT).

    Psychotherapy can play an important role in the treatment of depression with or without medication. This type of treatment is utilized in cases of mild to moderate depression and is usually for a defined period of time (10-20 weeks).

    Antidepressant medications work by increasing the level of neurotransmitters in the brain. Many feelings such as pain and pleasure are a result of the functioning of the neurotransmitters and when the supply of neurotransmitters is imbalanced, depression may result. It is critical that patients take prescribed medication as directed. Missing doses or taking more than the prescribed amount of the medication compromises the effect of the antidepressant. Medication is typically prescribed for 6 months to 1 year and results from the medication may not be evident until at least 4-6 weeks after the initial dosage. For common medications used in depression click here.

    Electroconvulsive therapy (ECT) is a treatment that is safe and effective for severe depression. This treatment is used for life threatening depression that does not respond to antidepressants.

    References NIH Consensus Development Panel (1992). Diagnosis and treatment of depression in late life. JAMA, 268, 1018-1024. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders. 4th ed. - TR. Washington, DC: American Psychiatric Association.

     

    Last updated - March 2005