• Health Section • Recent stories by Abigail Trafford • Talk: Health news message boards • Health Talk Archive • Live Online Transcripts

Second Opinion: Elderly and Suicide
Hosted by Abigail Trafford
Washington Post columnist
Tuesday, Jan. 23, 2000; 2 p.m. EST

Welcome to Second Opinion, a weekly column and Live Online discussion with Post Health columnist Abigail Trafford.

The subject is depression in the elderly and the risk of suicide. Are you feeling nervous or "empty?" Very tired and slowed down? Irritable? These may be symptoms of depression. This medical illness often goes unrecognized and untreated in older Americans. The Surgeon General has launched an initiative to improve mental health care in the U.S. There is urgency in the government's message. Depression is a key predictor of suicide in the elderly and older people are more likely to kill themselves than younger adults. What can you do if you or someone you know may be suffering from depression?

The transcript follows.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

Abigail Trafford: Health Talk will be live momentarily. Sorry for the inconvenience.

Abigail Trafford: Hello everybody. We're here and ready to talk. This is a difficult subject. Depression is known as the common cold of mental illness. And now suicide is being seen as a major public health concern. More people kill themselves than are murdered every year by 3 to 2. We've got to talk about this. Send us your comments and questions.

Abigail Trafford: Hello, Dr. Reynolds and welcome to Health Talk. As you know I received a letter--unsiged--from a woman in Virginia who is planning to commit suicide. "I'm 65--female-- great-grandmother. At some point this year I will finally end my life. I've planned, read and worked to get to this point since I was 16. I've hated every day of my life as far back in life as I can go," she wrote. She has seven children. She has had some experience with mental health care and wrote that it is "babble." What's your response to this note?

Charles F. Reynolds, III: Abigail, what a sad letter. My hope is that the writer will seek and get help for what may very likely be clinical depression. Clinical depression is very common in older people with suicidal ideation. Depression is extremely treatable, in good hands, and suicidal ideation and hopelessness often improve with adequate treatment of depression. It would be a tragedy for the writer to leaver her family with the terrible legacy of suicide.

Abigail Trafford: Tell us about the suicide risk in older Americans. Why do they have more suicides than younger adults?

Charles F. Reynolds, III: Older Americans have the highest risk of commiting suicide, especially white males older than 75.

The risk is greatest in older patients who are clinically depressed, have feelings of hopelessness or of being trapped, are bereaved, have painful disabling medical illnesses, and are isolated.

If you know someone who is elderly and talks about commiting suicide or wishing they were dead, take it seriously-- dead seriously.

Abigail Trafford: Is it possible to prevent a person from committing suicide? What should you do?

Charles F. Reynolds, III: While it is not always possible to prevent suicide, especially in someone who is determined to kill themselves, it is possible to decrease the risk by taking talk of suicide seriously, especially in someone who is depressed and/or abusing drugs or alcohol. Under those circumstances, getting someone to professional help can reduce the risk of completed suicide.

Arlington, VA: How is it that so many Americans are misdiagnosed or even over medicated and yet, elderly patients are being overlooked when it comes to depression?

Charles F. Reynolds, III: You are right-- depression in elderly people is often overlooked, probably in as many as half of cases in primary care.

Often the symptoms of depression are mis-attributed by the elderly and by health care providers to common physical illnesses that afflict the elderly; or people mistakenly assume that depression is a natural and normal reaction to growing old. It is not. It is a treatable illness that causes much unnecessary suffering and leads to early death in the elderly, if not treated.

Depression kills the elderly-- but is it treatable.

Portland, Maine: It seems this person mentioned in the column has been through the "mental health BS" and found it to be that. My question then is: Is the desire to "save" someone from suicide more for those around the person than for the person in pain. Is it that society is so uncomfortable with death that we think a painful life must be better. In any case, I do think it is only fair for this woman to inform her 7 children of her decision, so at least they can try to understand their mother and why she wants this peace. Otherwise her suicide is a cop out and more painful for those left to pick up the pieces.

Charles F. Reynolds, III: Good question-- thanks.

For the most part, the wish to die and to commit suicide is born of tremendous pain, often a part of depression. It is usually not a rational choice. So, from that point of view, the wish to help someone with hopelessness and suicidal feelings really is appropriate, and for their benefit, because ususally something helpful can be done.

I agree with you that the writer would be leaving a terrible legacy for her children. Perhaps if she discussed her dilemma with them, they would be willing and able to help. Let's hope she tries.

Sterling, VA: What are the warning signs of depression? Especially in an elderly person with the beginning stages of Alzheimer's? Can the symptoms from one be mistaken for the other?

Abigail Trafford: According to the National Institute of Mental Health, the following are signs and symptoms of depression. As yourself if you feel: nervous or empty, guilty or worthless, very tired and slowed down; you don't enjoy things the way you used to; restless or irratable; like no one loves you; like life is not worth living. Also, ask yourself if you are: sleeping more or less than usual; eating more or less than usual; having persistent headaches, stomach aches or chronic pain. Dr. Reynolds: are there other symptoms of depression in people with early Alsheimer's? Do the signs overlap? Should both be treated?

Charles F. Reynolds, III: Yes, depression is very common in Alheimer's disease, especially in the early stages, when 20-30% of Alzheimer victims may become clinically depressed.

Depression in Alzheimer's disease responds to antidepressant treatment very well, as studies ongoing at Johns Hopkins are now showing.

And, let's not forget the caregiver of a family member with Zlzheimer's. Caregivers burn out, get depressed, and need help too.

Abigail Trafford: What is the legacy on family members and friends when a person commits suicide? How do people deal with the emotional trauma of having a loved one commit suicide?

Charles F. Reynolds, III: The legacy of suicide for family members is often a sad one-- in many cases depression, post-traumatic distress, proonged and complicated bereavement, and substance use follow in the wake of suicide. Suicide in one family member is also associated with an increased risk for sucide in other family members-- whether as a result of depression and or because of genetic risk to suicide is a subject of active scientific investigation.

Centreville,VA: Dr. Reynolds, why do you assume age has anything to do with this womens depression? She said herself she has felt this way since age 16, why now that she can be considered elderly, is it considered elderly depression?

Charles F. Reynolds, III: That's a good question, thanks.

It may be that the writer developed depression as a youth and then suffered from it chronically, into old age. That can and does happen.

In other cases, depression appears for the first time in old age. Many cases of elder suicide in fact have suffered depression onset only in old age.

Abigail Trafford: How can you tell the difference from "normal" sadness and clinical depression? Sorrow and loss are part of life. Feeling sad is universal.

Charles F. Reynolds, III: Always an important issue.

Clinical depression is characterized by feeling sad, blue, hopeless day in and day out, with little positive response to happy events, loss of pleasure and interest, and an inability to function.

Other important symptoms of depression include persistent sleep disturbance, loss of appetite, and diminished self esteem and guilt.

Chantilly, VA: My mother's depression went undetected for several years. In September she was put on an antidepressant (Celexa). She refused to be followed by mental health professionals. She was admitted to the hospital 2 weeks ago with severe dehydration. She no longer eats or drinks anything and is being tube fed. Her antidepressant was switched to Paxil but she was no longer a candidate for the psych unit because they cannot handle her medical needs. She was transferred to a nursing home yesterday. Can anything be done for her at this point in time regarding her depression?

Charles F. Reynolds, III: I'm glad you wrote-- thanks--this is all to common a story.

In many academic medical centers, your mother might well have been offered a trial of ECT, or electroconvulsive treatment-- which is highly safe and effective in medically frail and debilitated elderly with depression.

You might pursue this option even now. Medication like Paxil may still be quite appropriate medically, but the quickest way to get your mother out of the woods may well be ECT. Good luck to you and to her.

Abigail Trafford: But sometimes, is suicide "rational?" The woman who wrote me asks: "What is so wrong with deciding when to end your own life?" I think people do have a right to decide when and even how to end life, if circumstances permit this. We are talking about medical circumstances and end of life care and wanting to have a "good death." People have a right to forgo treatment that will end their life. Is this different from depression-related suicide?

Charles F. Reynolds, III: Yes, the desire to end suffering in the context of a painful terminal illness can be quite different from suicide in the context of clinical depression.

It is important to remember that if pain is adequately treated and depression and grief are appropriately addressed, then requests for euthanasia in terminal illness may be suspended. People can and do change their minds under these circumstances.

VA: My grandfather tried to commit suicide two years ago. This was no cry for help - he would have succeeded but for a fluke. His reason was fear that he was going senile (he had a high fever that caused delusions that terrified him). He also suffered from bad seasonal depression, so he moved to Florida and is near my aunt and uncle. He seemed much better but he recently had a heart attack. My aunt and uncle have NO sympathy for him. He can be a pain in the butt, but my god, he's 90 years old! They view suicide as a taboo topic and all they do is complain about him and say he is faking/milking his illness. I'm at my wit's end and scared he will get depressed and try to kill himself again. My parents are so worried they are moving down there to be closer. What can I do to get my relatives to see that he needs understanding, not ridicule? Most of my family is old-fashioned and have the mind-set of the "old country".

Charles F. Reynolds, III: A tough dilemma for you and your family.

Often a family's attitudes about depression can get in the way of effective help.

It's important to remember that difficult behavior in an older person-- such as irritability or increased dependency-- actually goes away when depression is adequaately treated.

Part of good treatment is also educating the family about the nature of depression in old age and the reasons for treatment.

There are many good geriatric psychiatrists in Florida; you can locate them throught the membership roster of the American Association for Geriatric Psychiatry.

I encourage you to do so.

Abigail Trafford: Is there a difference between suicide in the elderly and suicide in young people, particularly teenagers?

Charles F. Reynolds, III: The highest rate of suicide in young people is between the ages of 15 and 24. Substance abuse and alcohol abuse are more likely to be implicated in the suicides of youth than in the elderly.

Abigail Trafford: suicide in older people is often linked or triggered by another illness such as heart disease of cancer. Sometimes big-time surgery such as coronary bypass surgery leads to depression. Is there a biological connection between illnesses? Or is the depression strictly a psychological response to the other disorder?

Charles F. Reynolds, III: Depression is often a psychological reaction to medical illensss like heart disease or cancer-- perhaps understandable as a kind of grief over the loss of good health and the threat of mortality.

At the same time, there is likely also a biological connection. Cardiovascular and cerebrovascular disease risk factors seem to set the stage for late onset depression; and certain types of cancer, such as breast cancer or cancer of the pancrease, are strongly associated with depression.

Depression is now also regarded as a risf factor for hear disease; and depression in the post heart attack patient is a risk factor for early mortality.

This is truly a two way street!

Mechanicsville, MD: Dr. Reynolds/Ms. Trafford, this woman has made it seem that she has been down the road of mental health treatment and feels it was all BS. She also seems confident that she has done all that is necessary in her life and the time to end it is near. However, she is obviously calling out for help by sending this letter. I understand the depression making her want to kill herself, but what about her antimental health attitude and the cry for help, is this too a part of the depression?

Abigail Trafford: I, too, think that her letter is a reaching out, a desire for understanding and cry for help. Her anti-mental health attitude is not uncommon. Sometimes it comes from having a bad experience in the nonsystem of mental health care in this country. (The parity laws of treating mental diseases like physical diseases have only just gone into effect.) Once bitten, twice shy. Dr. Livingston--what do you think? Is her anti-mental health attitude a feature of depression--or a separate problem. How do you over come anti-mental health attitudes?

Charles F. Reynolds, III: Yes, often the refusal to accept treatment and negative beliefs about the likely outcomes of treatment are themselves the products of depression.

Alexandria, VA: Is there any positive research outlook for long-term refractory depression--drugs don't work, therapy doesn't work. Continual ECT doesn't sound like a very attractive option.

Charles F. Reynolds, III: Yes, a recent study in the New England Journal of Medicine by Keller and colleagues showed the value of combined cognitive behavioral therapy and antidepressant medication (nefazodone) for chronic depression.

Often, what may be regarded as refractory depression simply has been adequately treated.

Abigail Trafford: Some elderly people who are depressed would be horrified if someone told them they were depressed and ought to take medication to feel better. They wouldn't hear of it. How can you get help for such a person? Should doctors say, here take this pill, it will help you sleep better--and not mention it's an anti-depressant?

Charles F. Reynolds, III: Instead of using the term depression, use more experiential words like not ejoying life, worrying alot, or having trouble sleeping. These words lack the stigma of depression and may mke it easier for an elderly person, who would never admit to being depressed, to accept treatment

Virginia: Dr. Reynolds, I have been struggling with undiagnosed depression for a while now. I recently went to my family doctor for a cold and mentioned it to him. After about a handful of questions he gave me a starter pack of Paxil and told me he thought I was a prime candidate for this antidepressant. I questioned whether or not I needed to see a therapist before and or during taking this medication and he said if I wanted to but it was not necessary. It has been almost a month and I have yet to start this medication or see a therapist. I have less of a problem seeing a therapist then I do taking mind altering drugs. I have heard all sorts of things on antidepressants especially SSRIs and I am torn between being hurt by the drug and continuing be hurt period.

Charles F. Reynolds, III: Pay attention to your own preferences in this reqard. Many Americans prefer psychotherapy or counseling to taking an antidepressant medication. Seek out a psychotherapist if that's your preference and then discuss further with a mental health professional whether medication is truly appropriate or not.

Washington, DC: Dr. Reynolds,

I am a demographer specializing in research related to aging populations. What demographic research would you like to see related to depression and suicide among older americans? Do you find that specific research questions are going unexamined? Thanks for your perspective ; with the aging of the Baby Boomers, these 'elderly' issues are increasingly important to our country's health.

Charles F. Reynolds, III: We need more research on the demographic and health antecedents of depression in old age, so that we can begin to design preventive intervention trials.

Great question.

Abigail Trafford: In distinguishing clinical depression from "normal" sorrow, is the lenght of time a person feels down an important facts. Is it all right to feel really blue for three days? Or two weeks? Especially if you are facing a tremendous loss such as the loss of a job, the death or disability of a loved one. When do you say, enough is enough?

Charles F. Reynolds, III: The AMerican Psychiatric
Association stipulates two weeks of feeling down and blue as its criterion of clinical depression.

Burlington, NC: Dr. Reynolds, what about insecurity in everyday life things such as relationships and jobs when there is no reason to feel insecure? And what about sadness and worring over things such as potentially bad choices and fear of making a mistake so bad to the point where things that are fine become problematic because of these feelings? Would you say these to are signs of depression?

Charles F. Reynolds, III: They may actually me signs of an anxiety disorder, such as generalized anxiety disorder.

Often anxiety disorders precede or co-exist with depression.

Both anxiety disorders and depression respond to good treatment.

Abigail Trafford: Is there a difference between suicide in the elderly and suicide in young people, particularly teenagers?

Charles F. Reynolds, III: Elder suicide is often associated with clinical depression, bereavement, and hopelessness.

In youth, we see sucide more commonly associated with substance abuse.

Abigail Trafford: Who should you go to if you think you might have depression or anxiety? What kind of doctor? Are family doctors good at detecting these disorders? Who should treat them?

Charles F. Reynolds, III: Family doctors can be helpful to persons with milder forms of depression and usually prescribe antidepressant medications.

If someone has a more sever depression, then consulting with a mental health specialist (psychologist or psychiatrist) would ususally be more likely to lead to good treatment and recovery.

In the case of a person who is a child, youth, or elderly, then seeing a mental health specialist who specializes in child or geriatric psychology or psychiatry is very appropriate.

WAshington DC: Doctor, my mother is nearly 76 years old, and has been suffering from what I think is severe depression for the past 3 years. She is very anti-mental health assistance, something that she is particularly anti because I went through a suicidely depressed period when I was a teen and college student. I have learned just not to tell her that I am under continuing medical and psychological management.

She is also a retired doctor, so (forgive me) she thinks she knows it all. What kind of strategy would you suggest that I pursue to try to help my mother?

Charles F. Reynolds, III: Tough situation-- you have my sympathy.

It may be more acceptable to your mother to work with your general medical physician to be treated. If so, you could ask the MD to get a second opinion fro a geriatric psychiatrist about treatment options, which the general physician would then try to carry out. Good luck.

Abigail Trafford: Our time is up. Thank you all very very much. This is important to talk about. Join me same time next week for another Health Talk

   |       |