Use of no-harm contracts
The no-suicide, or “no harm” verbal or written contract, in which patients agree that they would inform a relative, friend, or health care provider of their suicidal intent, and not act on it, is widely recommended. Note however that there is no firm evidence that these contracts are helpful. A no-suicide contract with a new patient with whom a therapeutic alliance has not yet been established is of little value. No-suicide contracts may alleviate the mental health professional’s anxiety without affecting the patient and may falsely relieve the practitioner’s concern and lower vigilance without having beneficial effect on the patient’s suicidal intent.
Treatment of Late-Life Depression
Antidepressants
The selective serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, Paxil, and Celexa, are safer and easier to administer than older antidepressants. Randomized studies of SSRIs have included more than 2000 depressed elderly patients. Even when SSRIs are not tolerated, their side effects typically consist of subjective discomfort rather than significant health risk to the patient. Their safety in routine use and overdose and their simplicity of administration allow these agents to be used by non-specialized physicians. Regardless of class, antidepressants lead to improvement of depressive symptomatology in approximately 60-70% of elderly patients. Even among responders, a significant number of elderly patients continue to have significant residual symptoms. Therefore, longer term monitoring of geriatric patients is important. Existing research data does not support firm conclusions about the benefits of medication in milder forms of depression. In mixed aged adults, maintenance drug treatment has proven more efficacious than placebo. In elderly patients with major depression, two studies have shown that nortriptyline and phenelzine alone or in combination with IPT constitute effective continuation treatment (4 to 6 months following remission in symptoms) and for maintenance treatment. The dosage of the drug that successfully treated the acute episode affords effective prophylaxis (protection against recurrence) while dosage reduction may compromise the stability of recovery.
Mood-Stabilizers
The role of agents other than antidepressants in reducing suicide risk has not been fully investigated except for lithium. In young and middle-age groups there is evidence supporting the prophylactic use of lithium in patients with major mood disorders at high risk of committing suicide. However, it is possible that protective effects of lithium vary as a function of age. The prophylactic effect of lithium on suicide in late-life has not been evaluated. The incidence of lithium side effects increases with age: lithium clearance decreases in association with diminished glomerular filtration rate; many types of medications (diurectics, non-steroidal anti-inflammatory agents, and angiotensin converting enzyme-inhibiting antihypertensive agents) affect serum lithium levels, as well as changes in hydration status. Lithium reduces the long-term risk of recurrent depression and mixed bipolar states even in blood concentration of 0.6-0.7 mEq/L. Moderate doses may be better tolerated in the elderly population, especially when medical conditions are present.
Electroshock Therapy
Electroshock therapy (ECT) is a safe and effective treatment for moderate or severe major depressive disorder, with controlled studies showing efficacy superior to placebo and antidepressant medication therapy. ECT is strongly indicated in patients with very high suicide risk who cannot wait for the three to six week interval needed for antidepressant agents to provide relief. In addition, ECT is often the treatment of choice in severely depressed elderly patients with comorbid medical conditions or poor tolerance of psychotropic medications. The safety and efficacy of ECT have been demonstrated for depressed patients with cardiovascular disease, stroke, or for physically ill elderly patients. Even the oldest patients with severe major depression appear to tolerate ECT and demonstrate similar or better acute response rates compared with younger patients, despite having a higher burden of physical illness and cognitive impairment. While ECT often exerts a profound short-term beneficial effect on suicidality, little evidence supports a long-term positive effect of ECT on suicide rates. A recent study showed the importance of continued antidepressant treatment after ECT. The study compared a group of depressed patients who committed suicide and a control group of depressed patients. While there was no difference in the frequency of ECT use and its efficacy, at the time of the last contact only 13 % of the patients in the lethal suicide group received continued antidepressant treatment compared to 46% of the patients who did not commit suicide.
Psychotherapy
The NIH Consensus Conference on Late-Life Depression concluded that psychotherapies, including Interpersonal Psychotherapy (IPT), cognitive-behavioral therapy (CBT), problem-solving therapy, and perhaps psychodynamic psychotherapies are as effective as antidepressant drugs in the acute treatment of depressed elderly outpatients with mild to moderate non-psychotic depression. IPT is a brief focused psychotherapy; it addresses four factors that often are part of the interpersonal context of older suicidal patients: grief, role transitions, role disputes, and interpersonal deficits. When combined with nortriptyline, IPT constitutes a highly effective acute, continuation, and maintenance treatment for geriatric major depression. Cognitive behavioral therapy combined with desipramine was found to be more effective than desipramine alone in the continuation and maintenance treatment of geriatric depression. Cognitive therapy has also been used successfully to treat suicidal persons including the elderly. CBT identifies the dysfunctional beliefs, which are typically helpless and hopeless in a depressed suicidal person, and the feelings associated with these beliefs, and then directs the patient to use problem-solving methods. By forming a more precise description of the problem, separating the problem from depressed mood, breaking down the problem into components, and considering possible solutions, suicide ceases to be the only option. These findings suggest that brief psychotherapies are effective in preventing relapse and recurrence of geriatric depression. Older suicide victims were found to have rigid character, low openness to experience. Especially for elderly men it is often unacceptable to express their dependency needs, and the loss of work, health, and mental capacity may trigger a narcissistic crisis, so it is conceivable that longer-term psychodynamic therapies that address these issues may also be helpful to treat suicidal elderly. Finally, suicidal crisis can hardly ever be resolved without the involvement of the patient’s support system.
Prevention of Suicidal Behavior
Although we do not have direct evidence from treatment trials that treatment of depression reduces suicide rate, indirect evidence suggests that the availability of trained professionals might influence suicide rates. In the U.S., Nevada and Montana have the highest suicide rates, and rank in the bottom with respect to the number of active psychiatrists, psychologists, social workers, and psychiatric nurses. Emergency telephone services may also reduce the suicide mortality in a given region. In the U.S., regions with higher density of suicide prevention centers showed smaller increases in suicide rates than other regions over a ten-year period. However, their effect on suicide prevention is limited because depressed and schizophrenic patients do not frequently contact these services. Currently two suicide prevention studies are underway to detect the effectiveness of improved treatment of depression by primary care physicians. The U.S. NIMH-sponsored multi-site “PROSPECT” study, (“Prevention of Suicide in Primary Care Elderly Collaborative Trial”) specifically targets a geriatric population. The goal of PROSPECT is to determine if, as hypothesized, placement of non-physician depression health specialists in primary care practices will have a favorable impact on rates of depression, hopelessness, and suicidal ideation in primary care patients with major depression, dysthymic disorder, or persistent minor depression. PROSPECT randomly assigns practices to either an intervention arm or to a treatment as usual arm. A total of 18 practices are participating, with a goal of recruiting six hundred depressed patients. Patients aged 75 and above are being over-sampled because of the highest suicide rate occurs in males in this age group. Three hundred patients (who are in the intervention practices) will receive acute, continuation, and maintenance treatment (medication, interpersonal psychotherapy) provided by depression health specialists. The primary outcome measures that are assessed every four months for two years are measures of depressive symptoms, hopelessness, and suicidal ideation/intent/ behavior.
Adapted from IDENTIFICATION OF SUICIDAL IDEATION AND PREVENTION OF SUICIDAL BEHAVIOR IN THE ELDERLY by Szanto K, Gildengers A, Mulsant BH, Brown G, Alexopoulos GS, Reynolds CF. Drugs and Aging. In press |
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