What Increases Suicide Risk Among Older Adults with Yeates Conwell, MD

#090- [CE Podcast]  Older white men have the highest rates of suicide, more than any other age group. Thus, it is essential that you have tools for addressing and preventing suicide among older adults.

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In this one hour continuing education podcast, you'll discover: 

• Statistics about older adults and suicide,  
• Cultural factors that may increase or mitigate risk for suicide, 
• The “5 D” framework for understanding suicide risk among older adults
•  How to help older adults who may be suicidal

Today's expert guest is Yeates Conwell, MD, Professor of Psychiatry at the University of Rochester School of Medicine and Dentistry, where he directs the Geriatric Psychiatry Program and the UR Medical Center’s Office for Aging Research and Health Services, and co-directs the UR Center for the Study and Prevention of Suicide. Dr. Conwell received his medical training at the University of Cincinnati and completed his Psychiatry Residency and a Fellowship in Geriatric Psychiatry at Yale University School of Medicine. In addition to teaching, clinical care, and service system development, Dr. Conwell directs an inter-disciplinary program of research in aging, mental health services, and suicide prevention.

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Transcript

Dr Regina Koepp

September is suicide prevention month. So I wanted to take some time in this podcast to focus on older adults and suicide risk, as well as suicide prevention. 

In this episode, I'll start by telling you a story. 

And then we'll have an interview with Dr. Yates Conwell. One of the leading experts in aging and suicide.

After the interview, I'll share a statistics on cultural factors that we need to be mindful of as we think about suicide risk and suicide prevention. Because we are talking about suicide. In today's podcast. I want to just give a disclaimer here. Please check in with yourself and decide is this the right time for me to be listening to a podcast about suicide risk and suicide prevention

and make a determination for yourself. Is this the right time for me at this time in my life? If it is, and you find that you are overwhelmed or triggered, please reach out for support with a mental health provider or friend. Wherever you get your support. Also, I'll say if you or somebody you love or somebody you're caring for is at risk for harming themselves or others, please call 9, 8, 8. 

For help. 

One of the things that I struggled with with this podcast is I want to give you clinical examples of my own, but to protect the privacy of people I work with, I can't share my own clinical examples in this public forum. So I want to share a story. That I read in the New York times in 2019. So this story came out in December of 2019. 

About the shavers. Mr and Mrs. Shaver, I think they were together since the fifties, they were high school sweethearts. They were incredibly devoted to one another, had three daughters and grandchildren. And over time, Mrs. Shaver developed Alzheimer's disease. And it became increasingly difficult for Mr. Shaver to care for her. 

And. One day, Mr. Shaver. Had. Given his wife per autopsy reports had given his wife. A high dose of oxymorphone and then had. Had her lay down to go to sleep. Shot her in the back of the neck and then put a towel over his head and shot himself in the mouth. And his daughter was concerned because they talked every day and he didn't answer his phone that day. And so police went over for a welfare check and found them. 

He didn't leave a note except for a little note to his granddaughter who was going to be married two weeks later. That said. May you both have many years of happiness? May life be good? 

This really is a, is a tragic situation. The daughters believe that he may have tried a sort of more peaceful route. To. Ending their lives. He never wanted his wife to move into a longterm care community. He didn't want himself to move into a longterm care community. He called it. 

The place. He himself in the autopsy. And review of his medical records was found to have had cancer. Himself and. 

And, and that's how he chose to end their lives. The daughters, they say. This wouldn't have been the ending that they would have chosen for But they don't hold it against him. 

So. In today's episode, you're going to learn about what's called the five D's of suicide prevention. 

So that's D like disease, disconnectedness, deadly means. Disability. And. Depression at the end of the episode, I'm going to share some strategies of starting a conversation with somebody that you're concerned, maybe suicidal. And. 

I hope that you use them. I hope that you use these strategies. All right. Let's jump into this interview with Dr. Yeates Conwell. 

Dr. Yeates Conwell is a Professor of Psychiatry at the University of Rochester School of Medicine and Dentistry, where he directs the geriatric psychiatry program, and the University of Rochester his medical centers office for aging research and health services. He co directs the University of Rochester Center for the Study and prevention of suicide. Dr. Conwell received his medical training at the University of Cincinnati and completed his psychiatry residency and a fellowship in geriatric Psychiatry at Yale University School of Medicine. In addition to teaching clinical care and service system development, Dr. Conwell directs an interdisciplinary program of research in aging, mental health services and suicide prevention. I cannot imagine a better guest and expert to talk about Mental Health and Aging, and particularly suicide and suicide prevention among older adults. In today's episode, we talk about the importance of listening, listening to older adults when they talk about what's causing their distress, and what might be contributing to some other reluctance to have these really difficult and important conversations. Speaking of conversations, let's jump into this one. 

Dr. Regina Koepp  

How did you get interested in suicidality and suicide prevention and older adults?

Dr. Yeates Conwell   

I knew from the get go, that I was interested in mental health and older adults in particular, actually, I think it stemmed mainly from an experience I had as a college student working in a in a rehabilitation hospital, actually, where there were many older adults who were there for extended periods of time, recovering from falls, and broken hips and strokes and the like. And I was just so impressed with how hard they work and how determined they were and all the resources they were able to draw on to overcome those really major challenges to their independence and to their, their being. And so it really came from a kind of a strengths based approach, recognizing that there's a tremendous wealth of resources there. And I wanted to learn more about that. And then going into medical school and residency and being able to contrast that kind of strength on the one hand with the remarkable contrast when it goes off the rails on the other and then recognizing that the two come together, that people who have encountered challenges can either do very well with that, or on occasion, not the suicidal person, older person. Kind of is the worst outcome, then of that. So how do we help those people or prevent that by helping those people find connect with the resources that have made them older adults to begin with survivors? So

Dr. Regina Koepp  

yeah, we're all striving to get there. We're all striving to get into to older adulthood. None of us want to die young.

Dr. Yeates Conwell    

Right? We want to do it well.

Dr. Regina Koepp 

Yes. You mentioned the profound resilience and strengths that help older adults age well, and you also mentioned when, when there's suicidality or untreated depression that worsens and worsens and worsens that there. is a worst case outcome or there's a profound toll that that can take on older adults. And I think you were hitting on or alluding to suicide rates for older adults. Can you talk about that what the suicide rates are for older adults.

Dr. Yeates Conwell  

When you look around the world at all the countries that report such statistics to the World Health Organization, what you see is a is a trend with increasing rates of suicide across the life course for both men and women. Men tending to have higher rates than women. In the United States, it's a little different. We see increasing rates with age for men. And that's accounted for largely by the majority population, older white men. African American, Hispanic men tend to have a more varied kind of pattern over the course of the life with peak and younger adulthood and somewhat of a rise in later adulthood, but not as high. And then for women in the United States. Interestingly, suicide rates tend to keep quite low, but peak and midlife and then drop a little bit into older adulthood. So in later life, what one sees is a really very pronounced difference between suicide rates for men and women where it's about 12 times higher actually 10 or 12 times higher in old old adulthood for for men, for white men in particular.

Dr. Regina Koepp  

An old old starts when?

Dr. Yeates Conwell   

Oh, probably 75. And over.

Dr. Regina Koepp   

Yeah, I read a statistic that something like there are four attempts to one death by suicide among older adults, where younger adults is 25 to one, are you familiar with that? Or am I off?

Dr. Yeates Conwell   

No, you're quite, you're quite right. What I was talking about was suicide, death by suicide. And it's a remarkably different picture for attempted suicides were in those rates tend to be much higher in younger adulthood and very low, actually, in older adulthood. And in older adults, that ratio of suicides to attempted suicides is about two to one or four to one. Whereas in the over overall population, it's more like the 25 to 40 to one attempts to completed suicides that you see, and in younger adults. And later adolescence is actually many more attempted suicides to completed suicides, and they're much more likely to be counted for by women. So the pattern is shifted by age, and it's also shifted by gender.

Dr. Regina Koepp  

And some of the reasons for that, or what what do you suspect are reasons for the shift in that pattern?

Dr. Yeates Conwell   

Yeah, yeah, I think we're left to speculate a lot about that, but have good reason to think that, that at least with regard to the, the fatalities associated with suicidal behavior, they are much greater in older people, ie, the ratio of attempted to completed suicide is much lower than younger people, because older people, first of all, they're more frail, older people tend to have comorbid medical conditions. And so the reserve to survive a suicide attempt, if it's, if it's initiated is much lower. So they're more likely to die, fewer attempts more deaths by suicide. Interestingly, and importantly, older people who become suicidal, tend to then be more planful and determined to actually end their own lives, it's a less, I'm not a big fan of the construct of impulsive acts of suicide, but, but planful much more. So. In older adults, they're less likely to be discovered in the act or in the preparation for or in the aftermath of the suicides and more likely to die on that basis. And also, older people are more likely than younger and middle aged people to use immediately lethal means which in this country is firearms. Overall, about 50 to 55% of suicides are by a firearm. In older people that's more like 70 to 75%. So late life suicide is in large part a story of, of men using violent means to take their own lives

Dr. Regina Koepp  

And why Men in particular?

Dr. Yeates Conwell   

Yeah, right. And that racial difference in the gender differences are much even more speculative, having to do, potentially with issues of, of cultural factors, the nature of the social networks and people in which people circulate the ability to call on others for help, the willingness to do that the resources that can be drawn on in the, potentially in the African American community, and in the faith communities, the religious communities can be much more easily accessed, acceptable means. But it's fascinating and important to understand how these behaviors unfold in the face of the kinds of stressors that different segments of the population face. And there's a lot of concern currently about how these figures are going to be changing over time, where we're seeing now a relatively rapid increase, although still, overall lower levels in suicide rates, for example, among younger adult and an African American men. Yeah.

Dr. Regina Koepp  

Now, we were speculating on what what might drive? Or what might create greater risk for older white men in terms of access to resources? Can you actually talk about your mental health concerns with somebody? Is that culturally acceptable or not? I was also recently giving a presentation on ageism and mental health care. And one of the studies I came across was a 2017 study. So relatively recent, about adults of different ages presenting to the ER, and younger adults or people under 65, when they endorsed suicidal thoughts, or recent behaviors, were more likely to have a suicide risk assessment and be sent home with resources if they were discharged. And, and, and significantly fewer older adults who were endorsing suicide, and were sent home with resources. And if we know the rates are so high, you know, there's also a structural sort of ageism, the the point of that study was to talk about we can do better, you know that this is happening at many from many angles, there's a structural angle, where How well do providers understand, and professionals understand the mental health needs of older adults and resources available? How well do older adults? How much access to older adults have to talking about mental health concerns? Just one of the reasons I started this podcast was to make it more commonplace that we can have mental health conversations among older adults and adults of all ages. So what do you what do you make of that in terms of on one hand, there's the cultural piece, are men socialized to ask for help around mental health needs? No, no, not well, especially older generations? to how well are the systems supporting older adults, when older adults are seeking services for mental health concerns? It's another and three, you know, then there's the internalized sort of belief, like if I do get these services, can I even benefit? And so there's an there's something called the stereotype, embodiment threat, right, that we believe the stereotypes about ourselves as we age, which are inaccurate, but we believe them nonetheless. And that could be harmful in terms of our willingness to take medications like an antidepressant or to attend to psychotherapy, or what do you make of all of that?

Dr. Yeates Conwell 

Yeah, no, it's it's a complicated issue, isn't it? There are many different pieces to it. I guess the good news, there is that that might suggest different avenues for change, that might have an impact on older adult health and reduce suicide rates. And they're not mutually exclusive. One needs to address these in all sorts of different levels. The Institute of Medicine uses these terms of three different levels of preventive interventions. There's the indicated preventive intervention which targets that individual who is at risk in our discussion that risk for suicide. The next level is selective preventive interventions, which are targeting individuals and groups who share certain characteristics that place them at increased risk, and we can talk about those and then the third is universal preventive interventions which target the entire population. A lot of what what we were just talking about is attitudinal. At any one of those levels, and ageism, the stigma associated with aging, associated with mental illness associated with suicide as a particular kind of behavior or failure or weakness or something. So all of those things can be must be really addressed, I think, by attitudinal change, which is cultural, and it's a universal preventive intervention approach, eventually, hard to do. But, you know, Mothers Against Drunk Driving is, is, is a thing that's often cited as examples of how really powerful social movements can be built. And there's an awful lot of advantages I think we as a society could derive from, from somehow making aging and aging Well, a much more accepted expectation for all of us. I think one of the things that we can come back and talk about the selective and the indicated kind of Prevention's, as well, but I, I want not to leave the stigma and ageism issue yet, because I think it's so important that people don't appreciate the fact that older people tend to be satisfied with with their lives. More so actually, than middle aged and younger people. 

Dr. Yeates Conwell   

You're speaking of theory, we've also got socio emotional selectivity theory and Laura Carson's work and others, which shows that, but we don't recognize that in older people, I think, because of the ages on which you were referring, we project our own fears, concerns, culturally embedded ones onto the aging process. And then as we age, we become older people, and we carry those attitudes along with us. But nonetheless, older people still important not forget, are, by and large, on average, very happy and satisfied with their lives, it's not normal to be depressed, it's not normal to be suicidal, it's not normal to think that your life isn't worth living. So those are really important attitudinal issues to address and find ways around them. You know, it's not moving back to the selective preventive intervention idea, if an older person carries those attitudes, and they need help. And they're less likely to get it, because they're, they have innovations against talking about their emotions, and so on. Then we need to design systems in a way that make it okay to do that. So older people aren't going to go to mental health clinics, or psychologists and psychiatrists in their private offices, they're going to go to their primary care doctors. Yeah, that's where the action is in large part for older people, because they're going there. Because they've got all these comorbid medical conditions, on average, you know, once a month, or there abouts. And if that isn't a setting in which it is more comfortable and acceptable for that older person, to talk about their feelings and issues related to depression, or even suicidal thoughts, they will build at that capacity. They've thought about this stuff, off and on, probably all their lives. So this isn't this isn't new to them, and given the opportunity to talk and find ways that are acceptable to them. They'll they'll draw on that.

Dr. Regina Koepp   

Yeah, you're making me think of the importance of primary care mental health integration. So for years, I worked in a geriatric primary care clinic, where I was the mental health provider as part of the primary care team. And, and that's how I think that's how most even outpatient mental health providers get their older adult clients or patients is that they come from other medical providers. Yeah, neurologist or an internist or primary care provider.

Dr. Yeates Conwell   

Right. So you were in an office down the hall and the primaries, right. Walk his or her patient in and introduce Yeah,

Dr. Regina Koepp  

Yeah. And so some of the typical scenarios would be around grief and loss. A new medical diagnosis, like Answer another terminal condition or a neurological illness like ALS or something another would be stopping driving. So I worked with older, typically older men at a VA. So older veterans who, you know, if you want to talk about barriers to talking about emotions, try talking to older veterans. And, but, of course, we all have the capacity to do it. And so as soon as we would just kind of build rapport and scratch the surface, older veterans would tell me older male veterans would tell me, I never knew this would be available. I never knew it would be like this, I always had these ideas about mental health, that, you know, I would be laying on a couch, I didn't know it would be this, you know, it was the Friday and view. And so, but yeah, so if, you know, a primary care provider would would instruct the older adult, you know, unfortunately, you can't drive safely. Now you'll and and the response would be, well, I'm just going to kill myself, if I can drive, you know, I live in a rural area, what am I going to do? How can I go to the bank? And, and so then the primary care provider would walk the older family to my office, or, you know, as a veteran, so we would often work with post traumatic stress disorder, if that was coming up, what do you see are some of the risk factors for older adults in suicidality or suicidal thinking?

Dr. Yeates Conwell  

We need to understand what's driving that person's distress, I find it useful to have a framework and the framework that I think is about as simple as it can get. And something that's complicated isn't, is what I call the five D's in addition to demography, right? So older male, white is Depression, that mental illness is a powerful driver of suicide risk, and we need to understand the underlying condition that somebody has. And for older adults, it's far more often depression, clinical depression, than is the case. For other diagnoses. If they're there, they constitute increased risk, definitely. But depression is that much more common in its association with suicide in older people than is the case in middle age and younger. So depression. 

Dr. Yeates Conwell   

Second is a disease or physical illness that, that older people face a lot of that, of course, the, the predictive value of a depression diagnosis is quite high. With regard to suicide outcomes, the predictive value of an older person, an older person of physical illness is, of course, very low, because it's so the base rate of physical illness is so high. But nonetheless, there are studies that show that certain physical illnesses are additional risk factors above and beyond depression. And those things tend to be neurological conditions, central nervous system kinds of things. So it might be strokes, or Parkinson's disease or dementia, epilepsy. 

And then the third D associated with that is disability or functioning and older people, that's just a big deal. Of course, being able to maintain independent functioning is critical for older people to be able to optimize that. And to help the older person kind of redefine what they regard is acceptable independence. And that's a transition that we all need to go through as our functioning is impaired. But some people can become an increasingly suicidal or at greater risk facing that functional impairment. So that's the third D. Good. 

Fourth, disconnectedness. We know that social connections, both the objective measurement of the depth primarily of one's social network, the ability to call on individuals to feel close to people to feel as if you belong, is critically important to health. So it's both objective and subjective in that, and there are lots of important studies now that show that the lack of that social connectedness is associated with suicide risk, as well as with mortality from hypertension and diabetes, the likelihood of developing cognitive impairment and on from there, so that is a big Big modifiable risk factor, I would add an important concept. 

And then the the fifth is deadly means back to that notion that older adults who die by suicide do so with a firearm. Something like 96% of firearm deaths among older people in the US each year are suicides. So that link between firearms and suicide is especially tight for older people. And it's another of those five DS, I think we need to fold into our diagnostic process just simply by understanding as is the recommendation for primary care practitioners and others that you need to know if an older person has a firearm in the home and develop strategies for managing that risk if they become depressed or suicidal. So I hope that's a useful framework. One of the really important concepts here, though, when one thinks about those five, right, is they're not just a list, right? Think of it as a Venn diagram. So each of these domains is overlapping. They're all there.

And, and people move in and out of each of these domains, you become ill get treatment, you get better, you can't become ill. But it causes functional impairment loss. You're an older person, and you lose your hearing, very common, but it affects the so then there's a functional impairment, but that functional impairment and that physical underlying condition affects your ability to connect with others socially. I tell the end and on from there that that then those are predisposing factors to depression. And if you happen to have a firearm in your bedside table, a handgun, then that combination as one moves through those different overlapping domains to the center in which all five of those are present. That's that's the scary situation. It's complicated there, all these different moving parts. The good news about that is that it is a dynamic process. And that because there are all these different contributors, it actually isn't that hard, because you can change any one of those five, and you're changing the risk, right? You've got a highly suicidal older person, don't want to overstate it, that person, you might, you know, get right to the emergency room and have treatment initiated. But if there's a depressed, functionally impaired, hopeless, older person, and they've got a firearm in the home, and you can develop some kind of agreement to have that firearm removed by a family member to a safe place for the time being, then that immediately changes that level of risk, right? Yes, he's gonna say the same thing about any one of those five of somebody is feeling disconnected, then we begin to think about how to help that individual feel more connected, even as all of these other domains are still pertinent, or disease, of course, the diagnosis and the treatment of the illness, the optimization of functioning by instituting some kind of supportive intervention, environmental intervention, or depression, diagnosis and treatment for which as you know, we have a lot of really effective treatments for depression and older people. So that the good news is that you don't need to take it all on you need to understand that it's all there and then begin picking things off that are of priority to that older person, generate that relationship, begin instituting the interventions increase the level of of hope that they can experience.

Dr. Regina Koepp   

Yes. Now say families are concerned about a loved one in that situation. What would you recommend that families do?

Dr. Yeates Conwell  

If you're worried about an older person in your family, then do two things First of all, step back and ask yourself what am I worried about? I need to check my own biases and attitudes at the door. Because it's so often is the case that we project our anxiety He's about aging onto that older person. And it may be our own discomfort that we're picking up on. But recognize that, but then go into the room and just tell him that you're worried. Ask him what's up. So often, in our society, I think in particular, again, it's that complicated, ageist thing. As younger people and middle aged folks were reluctant to talk to our seniors about how they're feeling. It's not the way we were raised. It's not the way they were raised to be asked those questions. There's the caregiver care receiver kind of relationship where the parent takes care of the child. And then at some point, in normal aging, that relationship reverses. And that's a tough developmental milestone for families often. So people need to work on that and get comfortable with the idea of having these conversations and taking the responsibility of just asking Mom or Dad, what's up How you feeling? I'm worried about you. And I think people will be not always but more often than not surprised that the older person's capable of talking, beginning to to share something of what they're going through. And that in and of itself is enormously helpful. And then beyond that going, and if you remain concerned helping that older person recognize that there may be help available and looking for it, probably in the primary care doctor's office to begin with.

Dr. Regina Koepp  

You know, that simple act of a conversation and expressing concern to adults talking together? It attends to that d of disconnectedness, which is the simple act of having a conversation requires connection.

Dr. Yeates Conwell   

Yeah, yeah. I don't know, if you, you were of the AFSP is, what do they call it? Share the awkward or something like that. So they have a really very interesting, very effective campaign. public service announcements for adolescence. One asks, the other the, you know, they're sitting there looking awkward, the way you agers would kind of think about these things together, and then one finally turns the other and says something like, what's up?

Dr. Regina Koepp  

I know when I for 10 years, I was teaching psychology interns and postdoctoral fellows and medical residents in geriatric mental health. Sometimes, you know, the way mental health providers are in some, in some graduate programs are being trained now is to sort of apply a model to an illness, right? And sometimes, that wouldn't work. So well, working with older adults, in my opinion, doesn't work. So well working with anybody, but in the student would come back to me and say, you know, I'm trying to do the kind of behavioral therapy with this structure with this older adults. And I would say, Well, what what about if you just have a conversation, just make it a conversation, don't make it an application. And the student would try it, and it would be night and day, you know, and just the importance of connection and the, the bridging that awkward, that, you know, I think we all want to be seen and understood and valued and heard, especially when we're going through transitions that are, we've never experienced before with illness, and changes in our ability and our functioning and requiring assistance from others. And just all of these, you know, what our life is like, doesn't match how we see ourselves. And that can be, you know, there's a difference between our real need versus our self concept like how we perceive ourselves, and that and that conflict is so complicated internally for people. But just being seen and heard and valued. Is, is a remarkable intervention in and of itself, not that it would be the only intervention for for this, but just how valuable these family conversations are, how valuable bridging that awkward space with curiosity and understanding and connection. I thank you for sharing that that's so important.

Dr. Yeates Conwell   

Actually, just just to get it right. The program that AFSP has as funded is called seize the awkward. I recommend it to you but it The point being, that, don't we need that for our conversations with older people too, we need something that kind of demystifies it and says older people sit down and talk with us and be connected. And that gets us a long way. And maybe it is oftentimes not sufficient, because of the underlying problems that need to be addressed, but necessary in order to get the older person engaged in the process of diagnosis and treatment. Yeah.

Dr. Regina Koepp 

That was very helpful. These five D's, the importance of a conversation, just the need for with, with relentless concern, the need for professional care, and then professionals to have, you know, understanding of these five DS as well, especially in primary care, you know, I worry in primary care, we hear of just shorter, shorter and shorter times with patients, you know, I hear so many families, especially around dementia disorders, who say, you know, we don't get any information from primary care. And I worry, you know, I don't want to vilify primary care, because I think they are kind of left to do a lot of work with a tiny amount of time, which is insufficient to treat all these needs, what are what's your take on that?

Dr. Yeates Conwell  

Well, you know, I did did a bunch of studies with so called psychological autopsy methods where a somebody died by suicide, and you go back, and you try to reconstruct, really what what may have happened by talking with family members, and, and also providers and looking at all sorts of records and that kind of thing. And I had the opportunity to talk with a lot of primary care doctors who had lost a patient to suicide, and it was profoundly difficult for them. They're in the business of primary care to help people and it feels like a failure, sometimes. But I think it's really important. My theory actually, is that primary care, doctors come back to that concept in a minute, are preventing suicide all the time. back up a little bit. And you know, it is this selective preventive interventions, it's the treating pain effectively, it's helping people through rehab and optimizing their independent functioning and recognizing and treating their depression and facilitating referrals to folks like you. And when it gets more complex, these are all things that happen in routine primary care practice. I think that's happening all the time, and I think they do a great job. But times are changing. And, you know, I, there's reason to be concerned, I think about how time available by a primary care doctor to sit with and diagnose and effectively treat this complex mix of contributing factors may not may not be enough. 

Dr. Yeates Conwell   

On the other hand, primary care is changing and health systems are changing both in terms of the delivery of care as well as the financing of care. I think we've got to move as thoughtfully and systematically aggressively as possible to that notion of integrated care, where it's not about actually the primary care doctor, seeing the patient for eight minutes. It's the whole episode of care, it starts with the patient's ability to get in to see the doctor quickly by calling up and, and having access they feel comfortable with, it's the smile of the receptionist when they get there. It's the time with the doctor, it's the ability then to trust that within that treatment context, they're going to get the different services that they need that are important to them. So it's it's their own priorities that then drive the nature of the care. And then with regard to financing, you know, we're struggling as, as a nation to figure out how to pay for health care. And there are terms that people may not be familiar with, but things like value based purchasing and so on where the reimbursement for the services that are provided, actually can hinge on the quality of those services and the ability actually to get the end result which might be by having somebody see Or having a social work console or being written a prescription for the air conditioner that they need to make their lives comfortable at home? All of these things are ways to approach the promise and the limitations of primary care practice.

Dr. Regina Koepp  

Now Dr. Conwell, what would you say for families who are hearing from their loved ones, some either flippant statements about suicide or clear statements about suicide? What would you recommend to families in that instance?

Dr. Yeates Conwell   

Yeah, yeah, really important. We've talked about a little of this, that the first thing is to hear them to take seriously what they're saying and not let one's own anxiety, get in the way of actually being available to and asking that question of How are you doing, and I'm concerned about you, and let's find some help. And then to help that older person find that help. And very likely that might be with suggesting that they see their primary care doctor going along with them, helping provide the information that that doctor can then use to make that diagnosis and draw the resources in that are necessary. But there may be others as well. It may be that if one is very concerned that one thinks about asking if they could take the firearms for a while to keep them safe, to be more present, perhaps, to find to help with the connectedness issue, while they get the care that they need. So ask the question, and then help that older person realize that there are probably really easily accessible answers. And let's get together and try to find them.

Dr. Regina Koepp    

Yes, and I'll just put a plug that treatment for depression, like psychotherapy is equally effective for older adults as it is for adults at younger ages. And so I know there's a lot of misconception about that. And primary care is a great place to start. Like you're saying, I'll also link to the National Suicide Prevention hotline for families who are very concerned and need immediate attention. And I want to thank you Dr. Conwell for being here and sharing so much the five DS are great rubric for helping families just to conceptualize what's happening and you know, sometimes we get in tunnel vision, it's hard to see the the sort of full nature of what can be causing distress for for folks and especially older adults. That's very helpful conceptualization tool, the five DS and and the importance of connection and conversation. So thank you so much for being here.

Dr. Yeates Conwell   

I've enjoyed our conversation. Thanks for having me.

Dr. Regina Koepp   

I really like in this interview, how Dr. Conwell was encouraging us to lean in and have that awkward conversation. So let's talk for a minute about how to help an older adult who may be suicidal. The first thing that you want to do is talk with them about what you've been noticing in a compassionate and concerned way. 

So you might say something like. I've been noticing that you haven't been yourself lately. You are staying in bed a lot more, and you're kind of more blue than you usually are. I'm really concerned about We're another thing you could try is I've been worried about you. Can we talk about what you're going through? 

If not, who are you willing to talk to about what you're going through? Or third option might be. It seems like you're going through a really difficult time. How can I help you find someone to talk to? How can I help you find help? 

So you want to start that conversation? You'll also want to encourage them to see their primary care provider to rule out any medical concerns that could be causing a suicidal ideation. You might encourage a family member to accompany the older adult to their medical appointments or mental health appointments and share their concerns about. 

Increasing depressive symptoms or suicidal ideation. 

You might encourage family members to email or fax their own concerns and what they're observing. To the older adults, medical providers. If you are working with an older adult, you might get a release of information to talk with the medical providers as well. 

You as a mental health provider might follow up on your concerns about suicide with questions like. Do you feel as though life is no longer an option for Have you had more thoughts about death and dying? Are you having thoughts about harming yourself? Are you planning to harm yourself or take your life? 

Is there a gun in the house or a collection of pills 

How often are you alone? 

And of course. As providers. You need to do your part by encouraging removal of pills and weapons or other means. You know, making sure that your clients and colleagues. Are recommending use of 9, 8, 8, the mental health hotline. Oh, 9, 8, 8. And yes, it's for older adults You as a mental health provider, senior care provider, if you have a release could also call their primary care provider or a mental health provider that's working with the older adult. 

As mental health providers, we need to take any talk of suicide. Seriously. Even among older adults. And so this is where we really have to do our work on making sure that we are practicing with an 

anti-ageist lens so you need to. Check in with yourself about any biases you might have about growing older and the value of an older life or the value of a life. Of somebody living with a disability or an illness. And who is also experiencing depression. And, and to make sure that your own ageist or abelist perspectives are not influencing the quality of care that you're providing someone. 

So it's really important that you take actions to help. So it's important that you encourage the older adult to see their primary care provider as we've already. Discussed. To encourage optimal health with medical conditions and other mental health conditions. You might encourage the older adult, 

To spend more time with friends and family. And encourage friends and family. To potentially be involved in medical and mental health appointments. It's really important to provide education about what's typical with aging and what's not typical with aging. I hear a lot of people. Make statements that they believe that depression is normal with aging. 

Or dementia is normal with aging. And we know that those conditions are not normal with aging and benefit from mental health care. So depression is highly, highly treatable among older adults at the same rates as other age groups. So please encourage older adults to get connected to mental health care. If they're experiencing depression. 

There's a lot that can be done and is highly, highly effective. And by doing this, you're providing hope about treatment. And if you're a mental health provider, you can provide that treatment. It's also important to brainstorm any barriers to getting involved with treatment like transportation. Or perhaps. 

Mobility is an issue. Maybe they have a medical condition that doesn't allow them to be as fluid in their mobility. And so they don't drive or they don't They don't trust their body to leave their house. So can you provide zoom, can a family member help them set up their telehealth appointments and equipment, et 

I'll also say there was some research done on, even when older adults present to the ER, there was a study in 2017 that showed that when. That looked at a sort of chart reviews in the ed. The emergency department. And found that older adults, even older adults who were endorsing suicidal ideation were less likely to be evaluated for mental health concerns. 

And less likely to be. Referred with mental health support into the community, even after statements about suicide. And so we need. To be providing older adults with mental health care for depression, for dementia, for suicidal ideation. And so on and yes, depression can be treated in the context of dementia, especially in the early stages. 

So let's all do our part to shift the narrative about mental health and aging. Alright. I hope those tips are helpful and I hope you use them. 

Let's talk for a moment about resilience factors. Studies show that older African-American men and women have some of the lowest rates of suicide. So it really begs us to discover why. What's going on. What's protecting older African-American folks from risk for suicide. And so a group of researchers got together and interviewed 33 African-American women to S to dig into this and to learn more about resilience among. 

Black women. And they found that. There was a repertoire of resilience that black women share. Including shared experiences of struggle. Centuries of strength building. And what they call the counter evaluation of privilege. And so what that means is that that the experience of having a minority stress and racism based stress and trauma. Has been the reason they have had to cultivate the resilience. And and that resilience protects them. The article is the repertoire of resilience, black women, social resistance to suicide. By Kamisha spates and Brittany Slaton. So let me find. 

What. 

The woman said. 

Okay. So let's look at what the research said. 45% of the women researched in this study, evaluate privilege or lack thereof very differently from the dominant society. They did not place or inordinate value on societies, privileged groups. In fact, they perceived white men. And better situated minorities as weaker and less capable of handling struggle because of their privilege. 

Kelly, age 34 said as far as white men, I don't think they've been through enough and they don't know how to take pressure. They don't know how to take any oppression because they've been given so much and they haven't been taught how to handle life when things don't work out. 

The women agreed that as a privilege group, white men are given opportunities and advantages because they so rarely experienced difficult times. They do not learn how to contend with life stressors and are unable to cope. And contrast, they viewed their own lack of privilege as a source of strength, experience and capability. 

For contending with adverse times and pressure filled situations. A woman named Tasha in this study said white men in general have a lot of things that are working for them just by virtue of the fact that they are white and they are males. They have more advantages and an easier road to hoe as my grandmother would say, and so maybe when they get to a Rocky part in the road, they do not know how to handle it. They do not know where to turn because they haven't built that strength. 

Black women have had centuries to build strength. The participants defined themselves as more capable than white men and other minority groups. They perceive their marginalized, social status and lack of privilege, not as a social deficit, but as a means by which they have developed their capacity for contending with adverse situations. 

Justine, who was a woman who was also interviewed eloquently, stated that unlike other social groups, black women quote know what struggle is and what to do when we struggle. 

What stood out to me in, in learning about this research. Is. The community. The shared experiences of struggle. Centuries of strength building. So this is like an ancestral Influence, right. Like we know our ancestors struggled and survived because I am here. Right. The centuries of strength building and calling into the room. That the centuries of strength building it's in my bones. It's in my cells. It's in my blood. And then this idea of the counter evaluation of privilege. That Justine said. We know what struggle is and what to do when we struggle. 

I want to end this program by talking about psychotherapy. That has been studied for reducing the risk of suicide. And there's a program that's called social engage. And it's, I believe a 10 session program for older adults who report social disconnection. And, and that therefore increases their risk for suicide as part of those five D's of suicide risk 

In this treatment participants focus each session on social engagement. And And the studies have showed that it reduces depressive symptoms and improve social, emotional quality of life. 

Other interventions to reduce loneliness are also proving to be helpful in that, and that sort of addresses that disconnection. One study looked at. Using tailored social connectedness intervention. So people with small to moderate networks may benefit from. Interventions designed to build friendships. 

Individuals that have many close confidants may benefit the most from psychotherapy. And individuals reporting moderately frequent contact with. Medium-sized social networks may benefit from. Interventions designed to build friendships as well as psychotherapy. So there's some interesting research around loneliness and disconnection. 

So there are interventions that are working and are helpful. And like I said before, depression is not a normal part of aging. It needs to be worked up. It can be treated and treatment is incredibly. Effective for older adults. All right. That's all for today. Don't forget to head on over to the website to get your continuing education. 

Bye for now.