Preventing late-life suicide: 6 steps to detect the warning signs

SCREENING INSTRUMENTS

Psychological assessments can often buttress the clinical interview findings. Several measurements are well-suited for detecting suicidal risk and concomitant depression (Table 3).

Beck SSI-C. The Beck Scale for Suicide Ideation – Current (SSI-C) assesses a patient’s preparation and motivation to commit suicide.⁹ This short (19-item) self-report measure asks patients to rate their wish to die, desire to attempt suicide, duration (and frequency) of suicidal thoughts, sense of control over suicide, and deterrents they face. The SSI-C helps to measure or monitor suicidality and is reliable and valid for psychiatric outpatients.⁹

BDI-II. The Beck Depression Inventory—recently revised in a second edition (BDI-II)¹⁰—can be useful because depression is one of the strongest risk factors for elder suicide. The 21-item BDI-II—a psychometrically sound, self-report instrument—asks about general symptoms of depression and gauges their severity. It can be applied to diverse patient populations and ages¹¹ and is appropriate for older patients who are also being treated medically.

Beck Hopelessness Scale. Hopelessness has been recognized as a possible harbinger of suicide.¹² One study showed that depression became a clinically meaningful suicide predictor only when accompanied by hopelessness.¹³

A score of 10 or more on the Beck Hopelessness Scale identified 91% of patients in one study who eventually committed suicide. The hopelessness patients expressed on this scale more strongly differentiated between those who did or did not commit suicide than did their scores on the BDI or SSI-C.¹⁴

Table 2

6-step clinical interview with an older suicidal patient

HRSD-R. The revised Hamilton Rating Scale for Depression (HRSD-R) documents patients’ levels of mood disturbance and suicidality. One item in this 21-item, clinician-administered instrument specifically asks about the patient’s level of suicidality in the past week. The scale has well-documented reliability and validity and is appropriate for psychiatric populations.¹⁵

CASE REPORT continued: Alarming findings

Along with the clinical interview, Mr. V. is screened with the Beck Hopelessness Scale and Beck Depression Inventory-II. These instruments are chosen because they are easy to administer, and patients can readily comprehend the questions—even when under duress. Mr. V’s results reveal moderate depression and severe hopelessness.

INPATIENT VS. OUTPATIENT CARE

Older patients are often referred to a psychiatrist because of vague suicidal ideation, but they may also present in an acute crisis—with immediate plans for suicide and readily accessible means. The first concern for their safety is to ensure they are not left alone.

Patient interview. First, listen empathetically and ask detailed questions, especially ones that remind patients of their daily connections and responsibilities. For instance, ask, “Do you have children who would be affected by your decision?” Address patients’ immediate needs, such as hunger, thirst, or pain.¹⁶ Work on building a therapeutic alliance before asking questions that may appear trivial to agitated patients (such as tasks assessing cognitive abilities).

Avoid arguing with patients, and refrain from offering advice or sermonizing. Allow them to describe their emotions, and communicate that you understand their concerns. Discuss how they can expect to receive treatment to ease their discomfort. Inform them that mental health specialists can treat them and monitor their progress.

Hospitalization. Begin discussing treatment options and broach the notion of hospital admission if necessary. One way to foster an alliance is to frame inpatient care as a way of helping them recover from their crisis in a safe environment.

To ensure patient safety, it is best to err on the side of admission. Admitting the suicidal patient not only guarantees strict supervision but also allows time for necessary psychological assessment. Hospitalization may also allow family members to remove any weapons or hazardous conditions from the patient’s home.

Including the family in problem-solving is especially important when managing older suicidal patients. For patients who are isolated from family or friends, recovery may depend on improving their support network.

Table 3

Comparing screening instruments for suicide risk

Outpatient care. Not all acutely suicidal older patients require hospital admission. They may be safely managed as outpatients if they: