Watch for suicide risk factors in elderly patients: depression, social isolation - Clinical Rounds - Michele G. Suvillan

CHICAGO -- Primary care physicians may be the only ones to see the red flags associated with suicide in elderly patients, because most elderly suicide victims never come to the attention of psychiatrists.

Primary care physicians should be highly alert to signs of depression and increasing social isolation among their elderly patients, particularly those who live alone, Dr. George El-Nimr said in a poster session at a meeting of the International Psychogeriatric Association.

"Previous studies have shown that attempted suicide and deliberate self-harm are associated with social isolation, which was also round to be associated with the onset of suicidal ideation," said Dr. El-Nimr of Hollins Park Hospital in Warrington, England. Yet data suggest that more than 80% of" elderly who commit suicide never see a psychiatrist before their death and that only about 15% are under psychiatric care when they commit suicide.

Dr. El-Nimr conducted a retrospective study of 200 suicides of people aged 60 years and older that occurred in Cheshire from 1989 to 2001.

Women, whether living alone or with someone else, were more likely than men to have contacted their primary care physician and to have been known to psychiatric services before suicide.

"Women seem to have a higher tendency to utilize services and ask for help," Dr. El-Nimr said. "They also appear to present their problems in a way that attracts the attention of relevant psychiatric services."

And, he added, children who urge an elderly parent to get help are more likely to have an impact on mothers than on fathers. But since most suicide victims never get a psychiatric referral, their primary care physicians must be alert for any danger sign: depression, which can present as physical ailments; alcoholism; social isolation; and living alone.

It's also important to note the presence or absence of close family members, whether spouses or children, he said. 'According to our study, childless women and widowed men, as well as the socially isolated, are at a particular risk."

If danger signs emerge, an integrated care approach is likely to be most successful.

Michele G. Suvillan
OB/GYN News, Dec 1, 2003

Treating minor depression and dysthymia in the elderly - By Caroline Wellbery

It is well known that elderly persons are subject to major depression, albeit at a lower rate than younger persons. Elderly persons also may have minor depression or dysthymia, which might be amenable to treatment with medication or behavioral intervention. Ciechanowski and colleagues examined whether an intervention focused on problem solving would be more effective than usual care in the treatment of dysthymia and depression in elderly patients.

Persons 60 years and older who received senior services or lived in senior housing projects were screened for depression, as were self-referred persons. They were randomized to usual care or a program used to treat dysthymia and minor depression, the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS), adapted to a home-based problem-solving treatment. The program involved eight 50-minute in-home sessions given over 19 weeks, with evaluation at baseline, six months, and 12 months. In patients with insufficient improvement, the primary care physician was contacted to evaluate the patient for antidepressant use and previously unidentified risk factors for depression. Outcomes included rates of depression (as assessed by a validated scale); health-related quality of life, including physical, emotional, and social function; health care utilization; and antidepressant use.

Most patients were low-income women. Intervention patients received a mean of 6.6 visits. There were no differences in antidepressant use between the groups at any time during the study. Significant differences favoring the intervention group were noted in depression scores, improvement of more than 50 percent, and remission. The scores in all of these categories dropped, but not significantly, between six and 12 months.

The PEARLS intervention resulted in greater remission of depression at 12 months in study subjects compared with the usual-care group (36 versus 12 percent). Depression severity also was decreased in patients who received the intervention. Functional and emotional well-being improved in the intervention group at 12 months. The lack of improvement in social and physical well-being may have been a result of physical and practical barriers in the target population. In addressing the nonsignificant decline in improvement in depression between six and 12 months in the intervention group, the authors speculate that better overall improvement may have been obtained with ongoing intervention sessions. In spite of the modest gains, this study demonstrates a successful, community-based, nonpharmacologic intervention for depression.

CAROLINE WELLBERY, M.D.
American Family Physician, Jan 15, 2005