Patients' severe functional limitations, disability, increasing dependence on others, and the fear of becoming a burden are significant risk factors for elder suicide. Physicians must make efforts to ascertain their older patients' mental status and potential suicide ideation.
Specific Goals of suicide prevention
There are three specific goals of suicide prevention:
1) Interrupting individuals' specific plans to take their lives,
2) Rreducing the risks that affect particular individuals, and
3) Rreducing the overall number of suicides.
Physicians can help by implementing the following strategies:
Addressing suicide risks in the direct care of patients,
Modifying the practice of their medical groups,
Joining public health efforts to reduce suicides,and
Advocating for changes in public policy.
Psychiatric illness—most commonly major depression; but bipolar disorder and PTSD are also high risk;
Substance abuse including prescription medications as well as alcohol and/or illegal drugs;
Access to Weapons;
Chronic physical illness, especially illnesses that are permanent, disabling, and/or terminal;
Chronic severe pain;
Recent onset of dementia;
Being a victim of ongoing violence;
Lack of engaging, satisfying, and/or meaningful activities;
Experience of discrimination, especially for LGBT individuals;
Prior suicide attempts (although 60% of suicide decedents have never previously attempted suicide);
Family or spousal history of suicide; and
History of childhood trauma or being bullied.
Demoralizing Health Conditions: A major contribution physicians can make to suicide prevention is effective treatment of health conditions that result in demoralization. Particularly important are conditions that cause severe functional limitations and/or are terminal. Disability and growing dependency frequently breed hopelessness and fear of becoming a useless burden, which are significant risk factors for suicide. Providing effective treatment for such physical health conditions is a preventive intervention. However, many older patients fear death less than disability. It may be more important to address disability than acute disease.
Treating pain: Effective pain management is critical for many at-risk patients. But drugs for pain, particularly opiates and benzodiazepines, carry significant risks of addiction, accidental overdoses, and falls—the major cause of premature disability and death in old age. And they can be used for suicide.
When possible, physicians should use alternatives to depressant and addictive drugs, including nonpharmacological interventions such as biofeedback, physical therapy, routine exercise, and pain-focused cognitive behavioral therapy, as well as relatively safe medications such as Cymbalta, Lyrica, or prescription NSAIDs.
Screening: Identifying major depression or substance abuse is exceedingly difficult. Even primary care physicians who pay attention to their patients' moods and look for signs of substance abuse will probably miss people at risk
Useful screens include the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder-7 (GAD-7) among others, which can be completed by patients, their aides, or relatives prior to seeing the primary care provider.
Behavioral treatment: Treatment for depression, substance abuse, or other behavioral disorders can be effective and reduce related suicide risks. Sometimes primary care physicians can provide effective treatment themselves, but often it is preferable to refer patients to mental health professionals.
Upstream factors: In addition to treatment, it can be useful for physicians to talk with their patients about "upstream" contributors to suicide risk including social isolation, family estrangement, inactivity and boredom, bereavement, and/or lack of a sense of self-worth, meaning, or purpose.