Behavioral Health 101: Suicide, Anxiety, Depression, and Substance Misuse/Abuse Among Older Adults

1. Behavioral Health 101: Suicide, Anxiety, Depression, and Substance Misuse/Abuse Among Older Adults

2. Presenters Stephen Bartels, MD, MSDirectorCenter for Health and AgingDartmouth CollegeFred Blow, PhDProfessor of PsychiatryUniversity of MichiganScientific Co-Directors for the SAMHSAOlder Americans Behavioral HealthTechnical Assistance Center

3. What We all Know Is Coming • 13 percent of U.S. population age 65+; expected to increase up to 20 percent by 2030 • 83 million ‘Baby Boomers’ (born from 1946-1964) in U.S. Census 2000 • Second wave ‘Baby Boomers’ (now aged 35-44) contains 45 million

4. What You May Not Know: Projected Prevalence of Major Psychiatric Disorders by Age Group Jeste, Alexopoulus, Bartels, et al., 1999

6. Worldwide Suicide Rates, WHO

7. LETHALITY OF LATE LIFE SUICIDE • Older people are • more frail (more likely to die) • more isolated (less likely to be rescued) • more planful and determined

8. ATTEMPTED : COMPLETED SUICIDE General population Older adults 1 2 4 Deaths Hospitalizations Emergency Dept visits 1 5 30

9. Self-inflicted injury among all persons by age and sex – United States, 2007 Source: CDC WISQARS NEISS

10. METHODS OF SUICIDE IN THE U.S. Total Age > 65

11. RISK FACTOR: Firearm Access *Model adjusts for education, living arrangements, and mental disorders that developed prior to the last year.(Conwell et al, AJGP 10:407-416, 2002 )

12. LETHALITY OF LATE LIFE SUICIDE • Older people are • more frail (more likely to die) • more isolated (less likely to be rescued) • more planful and determined • Implying • interventions must be aggressive • primary and secondary prevention are key

13. Comorbidity and Suicide Risk Juurlink et al., Arch Intern Med 2004;164:1179-1184

14. LAST PRIMARY CARE PROVIDER CONTACT IN SUICIDES

15. RISK FACTORS FOR SUICIDE AMONG OLDER ADULTS • Depression – major depression, other • Prior suicide attempts • Co-morbid general medical conditions • Often with pain and role function decline • Social dependency or isolation • Family discord, losses • Personality inflexibility, rigid coping • Access to lethal means

16. Assessment & PREVENTION FRAMEWORK HOW DO WE ASSESS RISK & PREVENT SUICIDE IN ELDERS? (Approaches to Prevention)

17. DOMAINS OF SUICIDE RISK IN LATER LIFE Psychiatric - depression - other Social - loss - isolation - dependency Psychological - personality - coping Medical - illness - treatment Biological - aging - environment Adapted from Blumenthal SJ, Kupfer DJ. Ann NY Acad Sci 487:327-340, 1986

18. DEVELOPMENTAL PROCESS OF LATE LIFE SUICIDE SUICIDE Peri-suicidal state Depression, hopelessness RISK  Symptoms,  Resiliency Role Changes, Medical Illnesses, Acute & Chronic Stressors Personality Factors, Social Ecology, Cultural Values & Perceptions TIME "Distal" RISK FACTORS "Proximal" Selective Indicated Universal Caine & Conwell, 2001

19. Institute of Medicine Terminology:“LEVELS”OF PREVENTIVE INTERVENTION “Indicated”– symptomatic and ‘marked’high risk individuals – interventions to prevent full-blown disorders or adverse outcomes. “Selective”– high-risk groups, though not all members bear risks – prevention through reducing risks. “Universal”– focused on the entire population as the target – prevention through reducing risk and enhancing health.

20. Points of Access Health Care Primary Specialty Long-term Home Community Religion Churches Temples • Vet Centers • VSO • Banks • Utility companies • Pharmacists • Mail carriers Social Services Senior centers Nutrition Transportation Peer support Outreach Mental Health Services

21. OPTIMAL SUICIDE PREVENTION = Indicated + Selective + Universal “MULTI-LAYERED SUICIDE PREVENTION”

22. Example of a Multi-Facetted Approach • All residents age ≥ 65 in Yasuzuka, Japan • Intervention – 7 yrs • Mental health education workshops • Annual, voluntary screening of depression • 2-stage screening and referral to general practitioner for treatment with psychiatric consultation available • 64% ↓ in suicide risk for women • Nonsignificant for men • No change for men or women in comparison region OYAMA ET AL., Gerontologist

23. Summary • Future directions and models of suicide prevention in older will move beyond a focus on the highest risk group and setting to incorporate a “population health” multi-level approach addressing: Multiple: • life domains • points of access • levels of prevention: Indicated, Selective, and Universal

24. Resources: Suicide Prevention Resource Centerhttp://www.sprc.org/

25. Helpful review articles

26. Overview of Alcohol and Psychoactive Medication Misuse in Older Adults

27. Substance Abuse and Older Adults #1 Most common addiction: Nicotine (~18-22%) #2 Alcohol (~2-18%) #3 Psychoactive Prescription Drugs (~2-4%) #4 Other Illegal Drugs (marijuana, cocaine, narcotics) (<1%)

28. WHO Drinking Definitions • Harmful drinking: Use of alcohol that causes complications (includes abuse and dependence) • Hazardous drinking: Use of alcohol that increases risk for complications • Non-hazardous drinking: Use of alcohol without clear risk of complications (includes beneficial use)

29. Prevalence of Use and Misuse of Psychoactive Medications • At least one in four older adults use psychoactive medications with abuse potential (Simoni-Wastila, Yang, 2006)  • 11% of women > 60 years old misuse prescription medication (Simoni-Wastila, Yang, 2006) • 18-41% of older adults are affected by medication misuse (Office of Applied Studies, SAMHSA, 2004)

30. Growing Problem • By 2020, non-medical use of psychoactive prescription drugs among adults aged >=50 years will increase from 1.2% (911,000) to 2.4% (2.7 million) (Colliver et al, 2006) • In 2004, there were an estimated 115,803 emergency department (ED) visits involving medication misuse and abuse by adults aged 50 or older • In 2008, there were 256,097 such visits, representing an increase of 121.1 percent (SAMHSA, DAWN Report, 2010)

31. Who is at greatest risk for medication misuse/abuse? • Factors associated with prescription drug misuse/abuse in older adults • Female gender • Social isolation • History of a substance abuse • History of or mental health disorder – older adults with prescription drug dependence are more likely than younger adults to have a dual diagnosis • Medical exposure to prescription meds with abuse potential (Source: Simoni-Wastila, Yang, 2006)

32. Prescription Drug Abuse in Older Adults • Reduced ability to absorb & metabolize meds with age • Increased chance of toxicity or adverse effects • Med-related delirium or dementia wrongly labeled as Alzheimer’s disease

33. Medications to Target in Substance Abuse Interventions • Central Nervous System (CNS) Depressants – Antianxiety medications, tranquilizers, sedatives and hynotics • Benzodiazepines • Barbiturates • Opioids and Morphine Derivatives— Narcotic analgesics/pain relievers • Codeine, hydrocodone, oxycodone, morphine, fentanyl, meperidine

34. Prescribing and Use Patterns for Benzodiazepines • Older primary care patients (aged >/= 60) who received new benzodiazepine prescriptions from primary care physicians for insomnia (42%) and anxiety (36%) • After 2 months, 30% used benzodiazepines at least daily • Both those continuing and those not continuing daily use reported significant improvements in sleep quality and depression, with no difference between groups in rates of improvement • A significant minority developed a pattern of long-term use (Source: Simon & Ludman, 2006)

35. Alcohol and Medication Misuse An estimated one in fiveolder adults may be affected by combined difficulties with alcohol and medication misuse. Alcohol-medication interactions may be a factor in at least 25% of ED admissions (NIAAA, 1995).

36. Medications with significant alcohol interactions Benzodiazepines Other sedatives Opiate/Opioid Analgesics Some anticonvulsants Some psychotropics Some antidepressants Some barbiturates Medication and Alcohol Interactions (Source: Bucholz et al., 1995; NIAAA, 1998)

37. Alcohol-Medication Interactions • Short term use - Increases the availability of medications causing an increase in harmful side effects • Chronic use – Decreases the availability of medications causing a decease in effectiveness • Enzymes activated by alcohol can transform medications into toxic metabolites and damage the liver, e.g., acetaminophen (Tylenol) • Magnify the central nervous system effects of psychoactive medications

38. Screening Approaches

39. Barriers to Identification • Ageist assumptions • Failure to recognize symptoms • Lack of knowledge about screening • Attempts at self-diagnosis or description of symptoms attributed to aging process or disease • Many do not self-refer or seek treatment • Although most older adults (87 percent) see physicians regularly, an estimated 40 percent of those who are at risk do not self-identify or seek services for substance abuse (Raschko, 1990)

40. Screening Instruments and Assessment Tools • Alcohol Consumption • Quantity, Frequency, Binge Drinking • AUDIT-C • Alcohol Consequences • CAGE, AUDIT, MAST, SMAST • Elder-Specific: MAST-Geriatric Version, SMAST-G • Health Screening Survey • includes other health behaviors • nutrition, exercise, smoking, depression

41. Screening and Assessment Recommendations for Older Adults • Every person over 60 should be screened for alcohol and prescription drug abuse as part of regular physical examination • “Brown Bag Approach” • Screen or re-screen if certain physical symptoms are present or if the older person is undergoing major life transitions

42. Screening and Assessment Recommendations for Older Adults • Ask direct questions about concerns • Preface question with link to medical conditions of health concerns • Do not use stigmatizing terms (i.e. alcoholic)

43. Motivational Brief Prevention and Intervention Methods

44. A Not Drinking B Light-Moderate Drinking C Heavy Drinking D Alcohol Problems E Mild Dependence F Chronic/Severe Dependence The Spectrum of Interventions for Older Adults Prevention/ Education Brief Advice Brief Interventions Pre-Treatment Intervention Formal Specialized Treatments

45. Relationship between Alcohol Use and Alcohol Problems None Alcohol Use Light Moderate Heavy Problem Low Risk At Risk Dependent Severe Moderate Small Alcohol Problems None

46. Early Empirical Support for Brief Interventions with Older Adults Physician advice for older adult at-risk drinkers led to reduced consumption at 12 months (University of Wisconsin; N=156; 35-40% change) : Elder-specific motivational enhancement session conducted in-home reduced at-risk drinking at 12 months (University of Michigan; N=454) Project GOAL (Guiding Older Adult Lifestyles) Health Profile Project

47. Current Knowledge • Brief Interventions (BI) can reduce alcohol use for at least 12 months among older adults • Motivational enhancement effective • Approach is acceptable to older adults and can be conducted in health clinics and in-home • BI appears to reduce alcohol-related harm • BI appears to reduce health care utilization

48. SBIRT MODEL • Screening • Brief Intervention • Referral to Treatment

49. Evidence for SBIRT Screening, Brief Interventions and Referral to Treatment (SBIRT) Large body of research on screening and brief interventions for at-risk and problem alcohol use in: Primary Care:Bien et al. 1993; Burke et al. 2003; Dunn et al. 2001; Whitlock et al. 2004 Emergency Care:Havard, et al, 2008 Psychiatric Emergency Care: Barry, et al, 2006; Milner, et al, 2008

50. CSAT SBIRT Initiative • Designed for implementation in medical settings • Major focus on “nondependent” substance use • Emphasize simple screening followed by one session of brief advice/brief intervention, educational, motivational interviewing • Refer to Treatment for “deep end’ services and other care, as needed • Competitive 5 year grants awarded to states (Governor) – Cohorts in 2003, 2006, 2008