Death and Dying in the media

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Research Trends

A Systematic Review of Elderly Suicide Prevention Programs

Sylvie Lapierre1, Annette Erlangsen2, Margda Waern3, Diego De Leo4, Hirofumi Oyama5, Paolo Scocco6, Joseph Gallo7, Katalin Szanto8, Yeates Conwell9, Brian

Draper10, Paul Quinnett11, and the International Research Group for Suicide among the Elderly12

1Department of Psychology, Université du Québec à Trois-Rivières, Québec, Canada, 2Center for Register-Based Research, University of Aarhus, Denmark, 3Section of Psychiatry, Institute of Clinical

Neuroscience, Gothenburg University, Sahlgrenska University Hospital, Sweden, 4Australian Institute for Suicide Research and Prevention, Griffith University, Australia, 5Department of Social Welfare,

Aomori University of Health and Welfare, Japan, 6Department of Mental Health, Community Mental Health Centre, Padova, Italy, 7Department of Family Medicine & Community Health, University of

Pennsylvania School of Medicine, USA, 8Department of Psychiatry, University of Pittsburgh, USA, 9Center for the Study and Prevention of Suicide, Psychiatry, University of Rochester Medical Center,

New York, USA, 10Academic Department for Old Age Psychiatry, School of Psychiatry, University of New South Wales, Sydney, Australia, 11The QPR Institute, Inc., Spokane, WA, USA, 12An international network

of researchers working on suicide in older people (contact person, Annette Erlangsen, E-mail [email protected])

Abstract. Background: Suicide rates are highest among the elderly, yet research on suicide prevention in old age remains a much-ne- glected area. Aims: We carried out a systematic review to examine the results of interventions aimed at suicidal elderly persons and to identify successful strategies and areas needing further exploration. Methods: Searches through various electronic databases yielded 19 studies with an empirical evaluation of a suicide prevention or intervention program designed especially for adults aged 60 years and older. Results: Most studies were centered on the reduction of risk factors (depression screening and treatment, and decreasing isolation), but when gender was considered, programs were mostly efficient for women. The empirical evaluations of programs attending to the needs of high-risk older adults seemed positive; most studies showed a reduction in the level of suicidal ideation of patients or in the suicide rate of the participating communities. However, not all studies used measures of suicidality to evaluate the outcome of the intervention, and rarely did they aim at improving protective factors. Conclusions: Innovative strategies should improve resilience and positive aging, engage family and community gatekeepers, use telecommunications to reach vulnerable older adult, and evaluate the effects of means restriction and physicians education on elderly suicide.

Keywords: suicide, suicidal ideation, prevention, intervention, systematic review, elderly

Studies show that in many countries suicides rates among elderly persons are higher than or as high as young people (De Leo & Spathonis, 2004; Shah, 2007). Yet, suicide in old age is a much neglected area. In fact, there is a lack of basic knowledge and training about elderly suicide among clinicians (Heisel & Duberstein, 2005), as well as in suicide prevention centers (Adamek & Kaplan, 1996).

On a worldwide level, the suicide rates are found to be highest among the elderly. In 2000, the WHO estimated the rates of men and women, aged 75 and older, to be 50 and 16 per 100,000, respectively (World Health Organization,

2002). Detailed reviews have identified various predictors of suicide in old age (Conwell & Thompson, 2008; O’Con- nell, Chin, Cunningham, & Lawlor, 2004; Waern, Rubeno- witz, & Wilhelmson, 2003). Psychiatric disorders (in par- ticular depression) (Conwell et al., 1996; Waern, Runeson et al., 2002), physical illness (Waern, Rubenowitz et al., 2002), functional impairment (Conwell & Thompson, 2008), and stressful life events (such as loss of spouse) (Er- langsen, Jeune, Bille-Brahe, & Vaupel, 2004) increase the suicide risk in older adults.

Considering that the number of seniors and their propor-

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tion in the population will increase significantly all over the world in the coming decades (Christensen, Doblhammer, Rau, & Vaupel, 2009), the absolute number of suicides among older adults is expected to increase accordingly.

From a theoretical perspective, suicide is considered an outcome of both distal and proximal factors (Hawton & van Heeringen, 2009). It is often helpful to think of suicidality as a pathway where wishes to die and depression constitute the first steps into the process toward suicide (Caine & Conwell, 2001). Fortunately, the pathway does not inevita- bly lead to suicidal actions and might at any point be inter- rupted by internal or external factors. However, the process also fluctuates over time, which makes it difficult for health professionals to identify suicidal individuals (De Leo, Ce- rin, Spathonis, & Burgis, 2005).

Prevention can be implemented at different levels, aim- ing at different stages of suicidality depending on the tar- geted population. The Institute of Medicine (Mrazek & Haggerty, 1994) distinguishes between universal, selective, and indicated prevention. Universal prevention aims at re- ducing the incidence of new cases in entire populations, such as a nation or a local community, typically through information and skills enhancement. Selective prevention focuses on high-risk groups that generally display no ad- vance signs of suicidal thoughts or behavior, but are ex- posed to important losses and life transitions that can make them vulnerable to depression and suicide (e.g., the very old and highly disabled, the recently retired or bereaved, or those who suffer from painful chronic illnesses). This type of prevention is typically aimed at reducing risk predictors or improving resilience. Indicated prevention aims at indi- viduals who clearly exhibit suicide risk behaviors, such as those who have a psychiatric illness, who express wishes to die or suicidal ideations, or who are at imminent danger of attempting suicide.

Although psychiatric disorders are considered to be pre- sent in up to 90% of all elderly suicides (O’Connell et al., 2004), it is recommended that preventive efforts employ a multifaceted approach in order to obtain optimal effect (O’Connell et al., 2004). While interventions aimed at small high-risk groups are often implemented, these are thought to have only little impact on the suicide rate as a whole, which is why population-level strategies might be more effective (Lewis, Hawton, & Jones, 1997).

A comprehensive review of strategies for preventing suicides in all age groups identified the following policies: (1) awareness and education (including physician educa- tion and gatekeeper training), (2) screening, (3) treatment interventions, (4) means restriction, and (5) codes of con- duct for media coverage (Mann et al., 2005). Of these, phy- sician education, gatekeeper training, and means restriction were considered as more promising strategies (Mann et al., 2005). Yet, we do not know how this applies to the more specific context of elderly suicides. The current study pre- sents a systematic review of all programs that focus exclu- sively on older adults in order to appraise, synthesize, and report evidence of their outcomes. More precisely, the re-

view will try to answer the following questions: (1) What types of program are currently used to prevent elderly sui- cide? (2) Which type of intervention is the most efficient to reduce suicidal ideation or behavior or their associated risk factors in elderly persons?

The current study was carried out by the Task Force on Elderly Suicide for the International Association for Sui- cide Prevention.

Method

The guidelines from the Cochrane Collaboration served as an outline for the systematic review (Higgins & Green, 2008). Studies were considered eligible if published in peer-reviewed journals and when the participants consisted only of elderly persons, defined as persons 65 years of age or older. This limitation was later relaxed to include age 60 or older due to the low number of studies fulfilling the orig- inal age cutoff limit. Any intervention aiming at reducing suicidality (suicidal ideation, suicidal behavior, or death by suicide) and which included an empirical evaluation was considered. Priority was given to outcomes directly related to measures of suicidality; secondary priority was given to depression ratings.

Studies were identified through electronic searches of the Cochrane library, MEDLINE, ERIC, PsycINFO data- bases (1966–2009), cross-reference checks, and the collab- oration of the members of the International Research Group on Suicide among the Elderly. The search was carried out using index and free-text search terms for suicide, suicidal ideation, suicidal behavior, attempted suicide, prevention, intervention, mental health program, program evaluation, as well as elderly, older adults, and aged (65 years and old- er) in the age group. All languages and publication years were considered. The search was carried out in November 2009.

Similar interventions, i.e., primary care interventions or telephone counseling interventions, were presented togeth- er. Levels of evidence were reported based on the Oxford Centre for Evidence-Based Medicine (Oxford CEBM, 2009), where levels vary from 1 to 5, 1 being the highest level of evidence for a randomized control study. Articles summarizing findings from same data collection were con- sidered jointly and priority was given to outcomes from the longest follow-up period. Meta-analyses were preferred to single studies. For instance, five individual cohort studies (Oyama, Fujita, Goto, Shibuya, & Sakashita, 2006; Oyama, Goto, Fujita, Shibuya, & Sakashita, 2006; Oyama, Koida, Sakashita, & Kudo, 2004; Oyama, Ono et al., 2006; Taka- hashi et al., 1998) were excluded in favor of their meta- analysis (Oyama et al., 2008). This study pooled the data from the five cohort studies as they all applied the exact identical intervention, i.e., depression screening of entire rural communities.

The electronic search yielded 490 references. Most of

S. Lapierre et al.: A Systematic Review of Elderly Suicide Prevention Programs 89

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90 S. Lapierre et al.: A Systematic Review of Elderly Suicide Prevention Programs

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these studies on suicide in old age only made recommen- dations about ways to prevent elderly suicide, few describe implemented interventions and even less evaluated them empirically. Of the 490 articles, only 19 met the inclusion criteria of an empirical evaluation of a suicide prevention or intervention program. In three cases, effects of their pro- gram were described in two subsequent publications, while five studies were combined in a meta-analysis, yielding a total of 11 different interventions. They are presented in Table 1 according to the Oxford CEBM (2009).

Results

Primary Care Interventions

The systematic review identified two primary care collab- orative treatment strategies: the IMPACT (Unützer et al., 2002, 2006) and PROSPECT studies (Alexopoulos et al., 2009; Bruce et al., 2004), both of which used a randomized controlled trial design (Level 1 on the Oxford classification of evidence) to examine the effect of their program on de- pressed elderly patients from primary care settings and to compare it to usual care. Participants in the intervention groups of both studies received support from depression care managers (nurses, psychologists or social workers) who offered education about treatment options, brief psy- chotherapy (interpersonal or behavioral) and provided close monitoring of depressive symptoms and medication side effects as well as follow-up of patients. Study protocol required that patients assigned to usual care could receive all depression treatments (counseling or medications), ex- cept access to the depression care manager’s services.

In Unützer et al.’s study (2006), depressed older adults were randomly assigned to the IMPACT program (Improv- ing Mood – Promoting Access to Collaborative Treatment for depression in primary care) or to usual care. After the 12-month intervention period, program participants had statistically significant lower rates of depression (Hunkeler et al., 2006; Unützer et al., 2002) and suicidal ideation (as- sessed with a single item) at 6, 12, 18, and 24 months (Unützer et al., 2006), compared to patients assigned to usual care. Patients in the intervention group also experi- enced greater quality of life and reported less functional impairment, suggesting that the effects of this intervention extended beyond reducing depressive symptoms (Unützer et al., 2002). Some key components of the IMPACT inter- vention could have facilitated the improvement: develop- ment of a therapeutic alliance, a personalized treatment plan that included patient preferences, as well as proactive follow-up (biweekly during acute phase and monthly dur- ing continuation phase) by the depression care manager. Tailored collaborative care and quality therapeutic relation- ship can actively engage older adults in treatment for depression and deliver long term benefits, such as self-

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efficacy and greater confidence in managing their depres- sion (Hunkeler et al., 2006; Unützer et al., 2002).

In the PROSPECT study (Prevention of Suicide in Pri- mary Care Elderly: Collaborative Trial), primary care prac- tices were randomly assigned to provide either the care management intervention or usual care (Alexopoulos et al., 2009). Results showed that, after 24 months, decline in sui- cidal ideation was 2.1 times greater [0.8–5.5] in the inter- vention group (16.9%; at baseline, 29.7%) than in usual- care group (17.4%; at baseline, 20.4%), though the differ- ence was not statistically significant (p = .11). The benefits were limited to patients with major depression who had a significant lower level of active suicidal desire at 4, 8, and 24 months, compared to the usual-care group. The differ- ences were not statistically significant among patients with minor depression. It should be noted that the study carried relatively high refusal and dropout rates. Furthermore, nei- ther of these randomized trials made gender specific dis- tinctions with regard to the impact of the intervention.

Community-Based Outreach

Various Japanese cohort studies have implemented com- munity-based outreach programs in rural areas of the coun- try, where the suicide rate was elevated (over 150/100,000) for both men and women aged 65 years and older (Chiu, Takahashi, & Suh, 2003; Oyama et al., 2004, 2005; Oyama, Fujita et al., 2006; Oyama, Goto et al., 2006; Oyama, Ono et al., 2006). These programs typically included mental- health workshops for the elderly, conducted by municipal public health nurses, to promote awareness of depression and suicide risk. The programs also included annual de- pression screenings of all residents aged 65 years and over. Positive results on the screening test were followed by a clinical interview with a psychiatrist (where available) or a general practitioner (GP) with follow-up meetings with mental health nurses. In another cohort study (Oyama et al., 2005), the program was different: group activities (so- cial, recreational, physical, volunteering) to reinforce so- cial support and no systematic depression screenings but a recommendation to participants to self-assess depression with a short questionnaire.

The empirical studies from Japan (Oyama et al., 2005, 2008) were carried out in localized areas, and the age-ad- justed incidence rate ratios of suicide (IRR: number of sui- cide cases divided by the population) were compared to baseline rates and to those in the comparison region. The results of the meta-analysis (Oyama et al., 2008) showed significant reductions in the rate ratio of suicide, compared to baseline, but mostly among women whose risk was re- duced by around 70%. The reduction in older men’s suicide rate ratios appeared to be associated with the presence of follow-up assessment by a clinical psychiatrist (IRR = 0.3 [0.1–0.7]), whereas no significant reduction was found for follow-up by GPs (IRR = 0.7 [0.4–1.2]). Oyama et al. (2005) had similar results. From the five studies included

in the meta-analysis, two showed a significant reduction in the suicide rate for the males (Oyama et al., 2004; Taka- hashi et al., 1998). Those particular interventions included educational activities, which emphasized that suicide is avoidable. During the years the programs were implement- ed, the suicide rate of the comparison areas remained high for both men and women, although the baseline suicide rates and socioeconomic characteristics were similar. Inter- vention centered on depression screening and group activ- ities seem very efficient for females, while there was no significant reduction for males in all but the two studies mentioned above.

Telephone Counseling

Four studies implemented telephone counseling outreach programs (De Leo, Carollo, & Dello Buono, 1995; De Leo, Dello Buono, & Dwyer, 2002; Fiske & Arbore, 2000; Mor- row-Howell, Becker-Kemppainen, & Judy, 1998). De Leo’s team evaluated the long-term impact on suicide rates of a telephone service that included (1) Tele-Help, a 24 h emergency service for elders to call for help, and (2) Tele- Check, a twice-weekly telephone support. After 11 years (priority was given to the publication presenting the longest follow-up period), the number of observed suicide (n = 6) of elderly service users living in the intervention area was statistically significantly lower (χ2 (1) = 10.6, p < .001) than the expected number (n = 20.86) calculated from the pre- vailing rate in the region (De Leo et al., 2002), with a stan- dardized mortality ratio indicating that only 28.8% of the expected suicide mortality occurred. This intervention also had a positive impact on clients’ psychosocial functioning (reductions in depression scores, hospital admission, and requests for home visit by GPs). Telephone outreach pro- grams seem to have had significant benefit for females on- ly: the difference between observed and expected number of suicides was significant (χ2 (1) = 8.4, p < .01). It should be noted that 84% of participants were women. Morrow- Howell et al. (1998) presented the evaluation of Link-Plus, a free telephone social work service with supportive ther- apy that was part of a crisis hot line dedicated to the pre- vention of suicide. After receiving standard crisis interven- tion, participants with low suicide risk were randomly as- signed to experimental (Link Plus) or waiting-list condition (control group). While there was no difference between groups at pretest on the Geriatric Depression Scale, clients of Link-Plus showed a reduction (p = .04) of depressive symptomatology after 4 months. Fiske and Arbore (2000) evaluated a community agency designed especially to pre- vent suicide among older adults. This agency had two pro- grams: The Friendship Line, which received 15 000 calls per year, provided emotional support, crisis intervention, information, and referral services for older adults; the Ge- riatric Outreach program provided counseling via tele- phone call appointments (17,000 per year) and home visits (1,500 per year) to elderly who may be at risk for suicide.

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A paired t-test revealed that there was a significant reduc- tion in hopelessness, but no significant changes in depres- sive symptoms. The last two studies did not include specif- ic measures of suicidality even if they were dedicated to elderly at risk of suicide.

Clinical Treatment

In Szanto, Mulsant, Houck, Dew, and Reynolds’s research (2003), data from three intervention studies were pooled to evaluate a short-term (12-week) depression treatment using pharmacotherapy, with or without interpersonal psycho- therapy sessions (IPT). The goal of the analysis was to compare the impact of the intervention on suicidal ideation and depression according to the patients’ level of suicidal- ity: high, moderate, or low risk. After 12 weeks of treat- ment, suicidal ideation had resolved in all treated patients regardless of treatment assignment, and only 4.6% still re- ported thoughts of death. Patients with higher suicide risk needed longer time to respond to treatment (6 weeks) com- pared to low-suicide-risk elders (3 weeks). With a similar intervention, Szanto et al. (2001) also found high remission rates (defined by a score of 10 or lower on the Hamilton Depression Scale) in both suicidal (77%) and nonsuicidal (78%) depressed older adults; however, there was a higher relapse rates in ideators (26% vs. 13%) during maintenance treatment. The authors concluded that medical treatment, and potentially IPT, was able to reduce suicidal ideations in older persons. The studies did not report differential im- pact of treatment on elderly men and women.

Improving Resilience

All previously mentioned studies addressed risk factors (depression or isolation), basing their intervention ap- proach on the strong associations of mental illness or social factors with suicidal behavior. Instead, two intervention programs focused on strengthening protective factors to improve older adults’ resilience to suicidality. One program included an 11-week workshop, based on a cognitive-be- havioral approach, which was offered to small groups of early retirees who had problems adapting to retirement. It aimed at increasing meaning in life by helping participants set, plan, pursue, and realize meaningful, concrete personal goals (Lapierre, Dubé, Bouffard, & Alain, 2007). Levels of depression and psychological distress decreased signifi- cantly among participants in the program compared to those of the control group (participants of another study on adaptation to retirement) which remained high. Program participants also improved significantly on hope, goal re- alization, serenity, flexibility, and attitude toward retire- ment. The gains were maintained six months later. Eighty percent of the experimental group, but only 36% of the control group, reported absence of suicidal ideation at the 6-month follow-up. The group intervention format could

be adding some protection against suicide as well as the behavioral activation of the participants.

The other program provided a 16-week interpersonal psychotherapy, for adults over 60 years at elevated risk for suicide, to improve their social functioning and skills in order to enhance social support and satisfaction of interper- sonal needs (Heisel, Duberstein, Talbot, King, & Tu, 2009). Although the group was small, results indicated a signifi- cant reduction between pre- and posttreatment on the se- verity of depressive symptoms and on the score of the Ge- riatric Suicide Ideation Scale. The authors stressed the im- portance of a strong therapeutic alliance, round the clock access to the therapist, and the possibility for patients to talk openly about suicidal thoughts during sessions. The data concerning enhancement of social adjustment and per- ceived social support have yet to be published.

Discussion

This systematic review showed that 19 of the 490 publica- tions on elderly suicide presented an empirical evaluation of a prevention or intervention program focusing on older adults. Compared to the 83 studies on adult populations, identified by Mann et al. (2005) in their systematic review of suicide prevention strategies, our review showed a lack of evidence-based studies designed for the aged. There could be other studies that evaluated the effects of inter- vention programs on dimensions we consider as risk fac- tors, but if the authors did not conceive them as means for late life suicide prevention, they could not be retrieved in the review because they did not match the search terms. Moreover, although all 19 studies hoped to reduce suicid- ality by targeting known risk factors for older adults, some did not evaluate this outcome measure, but evaluated only the effects on depression or hopelessness.

The synthesis of the 19 studies yielded 11 different in- terventions presented here. Of these, three studies had sui- cide rate as the outcome measure, four studies looked at the impact on suicidal ideation, and four studies were limited to the assessment of depression levels. It would be interest- ing if future research would select similar outcome vari- ables in order to efficiently compare the effects of various types of interventions.

Impact of Interventions

Most programs (n = 9/11) addressed risk predictors. They were centered on depression screening and treatment, in- formation to older adults about symptoms, treatment op- tions, and use of medications, as well as reduction of social isolation. Our review showed that 6 of 9 interventions were associated with a reduction in the level of patients’ suicidal ideation or in the suicide rate of the participating commu- nities. Two of the three studies using depression measures

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found a significant reduction in this outcome variable. The empirical evaluations of programs attending to the needs of high-risk older adults seemed positive.

Programs aiming at improving protective factors are still rare, even if some authors have emphasized social interac- tion and communication through activation programs (Hei- sel et al., 2009; Oyama et al., 2005; Oyama, Ono et al., 2006; Unützer et al., 2006) or the realization of meaningful personal goals (Lapierre et al., 2007). Strategies that en- hance positive aging and quality of life by increasing em- powerment, coping and adaptive behavior (Heisel & Du- berstein, 2005), flexibility (Brandtstädter & Rothermund, 2002), social skills (Hinrichsen & Hernandez, 1993), self- esteem (Chatterton, Hall, & Tarrier, 2007), sense of belong- ing (McLaren, Gomez, Bailey, & Van Der Horst, 2007), reasons for living (Malone et al., 2000), hope (Snyder & Rand, 2004), meaning in life (Edwards & Holden, 2001; Heisel & Flett, 2004), religion or spirituality (Dervic et al., 2004), and even humor (Richman, 1993) could be innova- tive and promising ways to prevent suicide in older adults.

Gender Differences

Gender-specific distinctions regarding the impact of the in- terventions were seldom considered. However, when gen- der was considered, most programs appeared to have ben- efited women more than men. Women are more likely than men to use social resources and mental health services (Drapeau, Boyer, & Lesage, 2009), so workshops, tele- phone counseling, and group meetings are more likely to appeal to them. Older men, on the other hand, are particu- larly less inclined to seek medical advice (Drapeau et al., 2009) and could prefer intervention programs that focus on action and problem solving rather than the expression of emotions or creating new relationships.

Moreover, researchers from the IMPACT trial, described above, found that older men were significantly less likely than women to be referred to the collaborative-care treat- ment program (Hinton, Zweifach, Oishi, Tang, & Unützer, 2006). They observed significant gender differences in the presentation of depressive symptoms. Qualitative inter- views, with 30 clinicians involved in the IMPACT trial, indicated that older men expressed their depression atypi- cally, making it more difficult to recognize and complicat- ing the referral process (Hinton et al., 2006). It seemed that men endorsed core symptoms, like feeling down and lack of interest, less often than older women. On the other hand, they were also more likely to express their distress through somatic symptoms or interpersonal stress. Informants add- ed that older men could have difficulty assessing and rec- ognizing their emotions and could try to conceal their de- pression to avoid mental illness, stigma, and feelings of shame often associated with their negative perception of the disorder (Hinton et al., 2006). The authors suggested that future avenues for intervention should address attitu- dinal barriers to help-seeking and treatment in older men

by deemphasizing labeling of depression and accentuating the focus on symptoms and stressors (Hinton et al., 2006). Future research should also seek new ways of reaching sui- cidal older men, for example by training community gate- keepers (Matthieu, Cross, Batres, Flora, & Knox, 2008). Risk assessment could be improved by addressing a wider than usual range of issues (Lapierre et al., 2011), such as those frequently faced by suicidal older men, such as in- voluntary retirement, pain, dependency, daily hassles, sleep problems, loss of driver’s license, bereavement, and, in par- ticular, alcohol abuse. None of the suicide prevention pro- grams addressed substance use in elderly males, even though a retrospective case-control study showed that al- cohol dependence or misuse was observed in 35% of the elderly men who died by suicide, and that alcohol use dis- order remained an independent predictor of suicide risk (Waern, 2003). Oyama et al. (2008) added that intervention programs should also address older men’s impulsivity, which makes them more at risk for suicidal behavior (Neu- feld & O’Rourke, 2009). Studies evaluating suicide pre- vention programs should have sufficient power to test the differential impact on men and women; more research is still needed to determine the type of intervention that might have a positive influence on older men. We should add that no studies looked at the differential impact of their pro- grams on young- and old- elderly persons to see if each group presents different challenges.

Future Interventions

Improvement in the detection, treatment, and management of mood disorders should still be the primary focus of sui- cide prevention. In addition, new programs should involve relatives, because they are an important part of the lives of many elderly individuals (Richman, 1993). Moreover, fam- ily members, but also friends, formal and informal caregiv- ers, who are in regular contact with distressed older adults, may have valuable information regarding life context and suicidal risk that health professionals are lacking or un- aware of (Waern, Beskow, Runeson, & Skoog, 1999). It seems necessary to involve them in the treatment process. All opportunities (home visits, case management, nursing care, follow-up, contacts with caregivers) must be used to increase chances for suicide prevention. According to Jones (2002), telephone counseling outreach programs (such as TeleHelp-TeleCheck services) seem to give the essential elements to the prevention of suicide, that is, a regular, confiding relationship with a helping person, and a method of increasing the person’s sense of mastery, in spite of the physical distance with the health care staff. One of the important findings of the telecommunication studies is that face-to-face contact may not be required for success- ful mental health care interventions (De Leo et al., 2002; Fiske & Arbore, 2000; Morrow-Howell et al., 1998). Many elderly patients find medical centers intimidating and their services difficult to negotiate or inconvenient. Jones (2002)

94 S. Lapierre et al.: A Systematic Review of Elderly Suicide Prevention Programs

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considers that using telecommunications to expand educa- tion and support as well as detection and treatment of men- tal illness should be a key component of health service planning. Round the clock access to the therapist could also be helpful, creating a lifeline that could increase feelings of security (Heisel et al., 2009).

According to Motohashi, Kaneko, and Sasaki (2004), the content of suicide prevention programs must be multi- faceted to answer the needs of suicidal persons. In addition to the early detection (with the help of family and commu- nity gatekeepers) and treatment of high-risk elderly indi- viduals, physician education and increased outreach to old- er adults are key strategies for suicide prevention. Suo- minen, Isometsä, and Lönnqvist (2004) have indicated that the majority (93%) of elders who have attempted suicide have seen a health professional in the last 12 months. How- ever, only 38% had received a diagnosis indicating a mood disorder. Although patients seem to have difficulties in communicating their wish to die to their doctor (Fekete, Osvath, & Michel, 2004; Wittink, Barg, & Gallo, 2006; Wittink, Dahlberg, Biruk, & Barg, 2008), contacts with health professionals are probably a form of help-seeking and could constitute a special opportunity for prevention. Therefore, in primary care settings, valuable strategies should include seeing patients frequently and regularly to monitor adherence to the prescribed regimen and response to treatment, and offer support to address sources of distress (Grek, 2007). Furthermore, many studies found that painful chronic diseases or sleep disorders were associated with suicidal ideation (Lapierre et al., 2011). Since older adults might report more easily sleep problems or physical pain than depression to their family doctors (Pan, Lee, Chiang, & Liao, 2009), attention should be directed to the evalua- tion of these difficulties as part of the investigation of pos- sible suicide risk. However, since doctors alone cannot ded- icate the time needed by high-risk patients, collaborative care models, such as IMPACT and PROSPECT, can im- prove outcomes by offering access to the services of de- pression care managers (nurses, psychologist, or social workers). Our review did not identify any published studies that evaluated the impact of physicians’ education on el- derly suicide, although it is often strongly recommended for recognition of persons at risk of suicide (Gilbody, Whit- ty, Grimshaw, & Thomas, 2003). Considering previous suc- cessful experience with educational programs on depres- sive disorders for general practitioners (Rutz, von Knorr- ing, & Wålinder, 1992), this might be an area to explore further in future primary care intervention. Already, PROS- PECT and IMPACT studies have included algorithm-based recommendations for physicians.

To our knowledge, there are no programs centered on means restriction that focus exclusively on the elderly, even if two studies from the United States did indicate that fire- arm accessibility, especially handguns, was associated with a higher risk of suicide in older adult men (Birckmayer & Hemenway, 2001; Conwell et al., 2002). Furthermore, in a study on firearm homicide and suicide in the general pop-

ulation, Ludwig and Cook (2000) demonstrated that the Brady Handgun Violence Prevention Act (waiting period and background check) was associated with a significant reduction in firearm suicide among persons 55 years or old- er in the American states where the act was implemented.

Research on suicide prevention and intervention in nurs- ing homes patients is also a neglected area of study (Scoc- co, de Girolamo, & Pavan, 2006), even if recent data call attention to the high rates of all types of suicidal behaviors in older adults living in long-term care facilities (Mezuk et al., 2008; Scocco, Rapattoni et al., 2006; Scocco, Fantoni, Rapattoni, de Girolamo, & Pavan, 2009). Finally, there were also no media reporting guidelines or internet pro- grams especially designed to prevent elderly suicide. Inno- vative strategies could include eHealth applications, de- fined as health promotion, information, or intervention us- ing or being delivered over the internet (Kreps & Neuhauser, 2010). Web-based depression management in- terventions have been created and their effects seemed pos- itive even though enrollment and follow-up completion rate were relatively low (Clarke et al., 2005). Emotional support was also offered online to distressed suicidal users of a confidential and anonymous site, though it was not empirically evaluated (Barak, 2007). Moreover, none fo- cused exclusively on depressed or suicidal elderly persons.

From the various policies identified by Mann et al. (2005) in their comprehensive review of preventive strate- gies, only depression screening and treatment intervention were applied and empirically evaluated to the more specific context of elderly suicides. Physician education, gatekeep- er training, means restriction, and codes of conduct for me- dia coverage are strategies that still need to be explored.

Conclusion

In sum, many of the reviewed interventions applied a mul- tifaceted approach at individual, group, or population lev- els. Five studies implemented “indicated” prevention pro- grams which targeted individuals who exhibit suicide risk behaviors or clinical depression, while four studies applied the “selective” type of prevention by targeting groups that face difficult situations (disability, isolation) that can make them vulnerable to suicide. Only the Japanese community- based outreach programs were targeting entire population and combined “universal,” “selective,” and “indicated” levels of prevention. However, their positive influence was seldom significant for both genders. All types of preventive interventions were useful for the population they reached. However, none stood out from the others with regard to their effect on the various outcome variables. Interventions attending to depressed elderly individuals seemed to suc- ceed through their personalized treatment plan and im- proved follow-up; telecommunications were an interesting tool for vulnerable groups, while population screening and awareness programs were associated with reduced rates of elderly suicide in local communities. Nonetheless, the pre-

S. Lapierre et al.: A Systematic Review of Elderly Suicide Prevention Programs 95

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vention of suicide among elderly citizens still faces chal- lenging tasks. For now, priority should be given to reaching out to those who fail to seek medical or psychological help. In particular, we need trials that demonstrate successful in- terventions aimed at older men. Development of positive aging, strengths, coping, and resilience still represent un- explored potentials for elderly suicide prevention and in- tervention.

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Received March 15, 2010 Revision received August 14, 2010 Accepted October 20, 2010 Published online May 23, 2011

About the authors

Sylvie Lapierre, PhD, is Professor of Psychology and Director of the Research Laboratory of Gerontology at the Université du Québec à Trois-Rivières in Canada. She is also the co-chair of the IASP Task Force on Elderly Suicide Prevention.

Annette Erlangsen, PhD, is a Senior Researcher at the National Cen- ter for Register-Based Research, University of Aarhus in Denmark.

Margda Waern, MD PhD, is Associate Professor of Psychiatry with a special focus on suicidology at the Section of Psychiatry, Sahl- grenska Academy at the University of Gothenburg in Sweden.

Diego De Leo, MD PhD DSc FRANZCP, is Professor of Psychiatry and Director of the Australian Institute for Suicide Research and Prevention at Griffith University in Australia.

Hirofumi Oyama, MD PhD, is Professor of Psychiatry at the Depart- ment of Social Welfare, Aomori University of Health and Welfare, Japan.

Paolo Scocco is a Consultant Psychiatrist of Psychiatric Clinic, De- partment of Neuroscience, University of Padua, and Department of Mental Health, Local Health Directorate ULSS 16, Padova, Italy.

Joseph J. Gallo, MD MPH, is Professor at the Department of Family Medicine and Community Health, University of Pennsylvania School of Medicine, USA.

Katalin Szanto, MD, is Associate Professor of Psychiatry at the Uni- versity of Pittsburgh, Western Psychiatric Institute and Clinic, USA.

Yeates Conwell, MD, is Professor of Psychiatry and Co-director of the Center for the Study and Prevention of Suicide in the Department of Psychiatry at University of Rochester Medical Center, New York, USA.

Brian Draper, MBBS MD FRANZCP, is Professor of Psychiatry at the Academic Department for Old Age Psychiatry, School of Psy- chiatry, University of New South Wales in Sydney, Australia.

Paul Quinnett is President and CEO of the QPR Institute, Clinical Assistant Professor, University of Washington School of Medicine, and former Director of Spokane Mental Health’s Elder Services Pro- gram, USA.

Sylvie Lapierre

Université du Québec à Trois-Rivières Department of Psychology 3351 des Forges Trois-Rivières, Québec Canada G9C1L1 Tel. +1 819 376-5011 ext. 3531 Fax +1 819 376-5195 E-mail [email protected]

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sy ch

ol og

ic al

A ss

oc ia

tio n

or o

ne o

f i ts

a lli

ed p

ub lis

he rs

. T

hi s

ar tic

le is

in te

nd ed

s ol

el y

fo r t

he p

er so

na l u

se o

f t he

in di

vi du

al u

se r a

nd is

n ot

to b

e di

ss em

in at

ed b

ro ad

ly .