The Deadly Triangle - UCLA Integrated Substance Abuse Programs

The Deadly Triangle: The Relationship Among
Depression, Substance Abuse, Suicide and
Older Adults
Patrick Arbore, Ed.D.
Director & Founder, The Center for Elderly Suicide
Prevention & Grief Related Services
Institute on Aging
San Francisco, CA 94118

Center for Elderly Suicide
Prevention
Accredited by the American Association of
Suicidology as an approved Crisis Intervention
Program
24-hour Friendship Line for the Elderly:
• Local Number in Bay Area – 415.752.3778
• Nationwide Toll Free Number – 800. 971.0016
• Contact: Patrick Arbore, (415) 750-4133 or
parbore@ioaging.org
2

Friendship Line Stats
• Receives approximately 2,000 in-coming
calls per month
• Makes approximately 3,000 out-going calls
per month (emotional support – Med
reminders
• Approximately 200 counseling visits per
month
3

Projected CA 60+ Population
Pop'n in
Millions
14
12
11.4
12.5
10
9
8
6
4
2
4.9
6.5
0
2000 2010 2020 2030 2040
Source: Ca Dept. of Aging Department of Finance, Population Projections, Report 03 P-3, May 2004
www.aging.ca.gov/stats/CensusTables/T113.pdf

THE DEADLY TRIANGLE
According to Nancy Osgood:
• The relationship between depression and
suicide, between alcoholism and depression and
between alcoholism and suicide is direct.
• Studies indicate that the risk of completed
suicides in alcoholics is 50 to 70 percent greater
than in those in the general population.
• Studies of individuals suffering from a major
affective disorder report a rate of suicide that is
more than 60% higher than the suicide rate in
the general population.
5

The Deadly Triangle Continued
• Studies of alcoholics reveal that between
30 and 60% suffer from depression.
• A significant proportion of alcoholics have
family members who suffer with
depression.
• Karl Menninger viewed both alcoholism
and suicide as expressions of a wish to
die.
6

Alcohol and
Suicide
• According to Conwell et al (1996) – At least one
third of persons who commit suicide have an
alcohol-use disorder
• Individuals with alcohol dependence are at
approx. 10x’s greater risk for completed suicide
compared with the general population
• Individuals with alcohol dependence are 6.5x’s
greater risk for attempted suicide compared with
individuals without alcohol dependence
• Suicide prevention efforts must include a focus
on alcoholism
7

Substance Abuse
According to Frederic Blow:
• Substance abuse among adults 60+ is one
of the fastest growing health problems in
the U.S.
• Substance abuse affects up to 17% of
older adults.
• Some older adults misuse OTC drugs.
• Elderly substance abuse is often
overlooked by health care providers
8

ACCORDING TO THE AMERICAN
MEDICAL ASSOCIATION
• Estimates that about 3 million older adults
have a drinking problem.
• Need to be aware that aging affects
alcohol tolerance.
• Some of the consequences of excessive
drinking include: nutritional deficiencies;
liver disease, cancer and cardiovascular
problems (including stroke).
9

ATTITUDES, BELIEFS AND
VALUES
• We all experience spoken and unspoken
messages as we grow up about old age,
death, and substance use through our
culture/race, families of origin, religious
institutions, community, etc.
• What were these messages?
• What messages do you still carry with
you?
10

PERSONAL BLOCKS
• Cognitive block
• Values bias
• “It’s not my problem”
• Feelings of the older problem drinker
• Feelings of the helper
• Inability to communicate with older problem drinkers
• Hostile communication
• Ageism
• Lack of understanding of psychological needs
• Power of grief and loss
11

AGEISM
• Has been called the ultimate prejudice, the
last discrimination, the cruelest rejection.
• Ageism is prejudice and discrimination
against older people.
• Everyone will become vulnerable to
ageism if they live long enough.
• Many people have never heard of ageism
much less its widespread and insidious
nature.
12

EFFECTS OF AGEISM
• Contributes to a sense of helplessness
and powerlessness among older adults.
• Oppresses older people.
• Results in an older person’s feelings of
shame and embarrassment by their own
aging.
• Contributes to depression.
13

ESCAPING AGEISM
• Involuntary isolation
• Alcoholism
• When one is drunk, one doesn’t have to
face – Prejudice and discrimination;
Ostracism; Loss of role; Loss of status
14

UNGRIEVED LOSSES
• Alcohol misuse can mask the pain of grief.
• If grief is un-grieved, “Acting out” will
occur.
• Acting out may look like – depression,
passive/aggressive behavior,
manipulation, violence/abuse,
hostility/rage.
• Losses of a lifetime need to be
experienced and expressed.
15

WHAT IS GRIEF?
• Refers to the process of experiencing the
psychological, behavioral, social and
physical reactions to the perception of
loss.
• Grief is not a static state and involves
many changes over time.
• Grief is a reaction to all types of loss, not
just death.
16

AGING, DRINKING AND
CONSEQUENCES
• Higher BAC from a given dose of alcohol.
• More impairment at a give BAC.
• Interactive effects of alcohol, chronic
illness and medication.
• Moderate levels of consumption can be
more risky.
• More consequences from maintaining
consumption.
17

PATTERNS OF DRINKING
• Late-onset cases (after about 60+)
comprise about 1/3 of older problem
drinkers.
• Early and intermediate onset cases
comprise about 2/3 of older problem
drinkers
18

ALCOHOL GUIDELINES FOR
OLDER ADULTS
• People age 65+ consume no more than
one standard drink per day or 7 standard
drinks per week.
• Older adults should consume no more
than two standard drinks on any one
occasion.
19

SIGNS & SYMPTOMS
• Anxiety and annoyance when asked about
alcohol use
• Hiding alcohol
• Drinking in spite of medical admonitions
against it
• Dehydration
• Malnutrition
• Sexual dysfunction
20

• Relationship problems
• Sleep problems
• Increased tolerance to alcohol
• Self-neglect; neglect of pets
• Depression
• Suicidal ideation or attempt
• Blackouts
21

• Morning drinking
• Morning shakes and tremors
• Confusion/memory problems
• Denial of drinking
22

GENDER
• Men – We know that male alcoholics and
drug takers outnumber females by well
over two to one.
• We know that a great many men have
dampened emotional experience.
• A connection between masculine
socialization, an inability to identify
feelings (alexithymia), covert depression,
and substance abuse seems obvious.
23

• Women – A report by the National Center
on Addiction and Substance Abuse
analyzed substance abuse and addiction
among 25.6 million mature women over
the age of 60.
• Issues – Shame and embarrassment;
denial and desperation; physicians fail to
recognize and treat the addiction.
24

DUAL DIAGNOSIS
• Alcohol problems are often found to exist
with and compound other mental
disorders.
• Alcoholism accelerates and mimics the
dementing process and can produce
confusion and memory loss and also
precipitates suicide.
25

DEPRESSION & SUBSTANCE
ABUSE
• Depression may be the cause of
substance abuse
• Depression may be the result of substance
abuse
• Depression may alter or exaggerate
substance abuse
• Depression and substance abuse may be
two symptoms of a single problem
26

“DON’T ASK; DON’T TELL”
• Inquiring about drinking may trigger strong
feelings on the part of the older person.
• Strong feelings include: shame and
denial
• Neither feeling may be experienced openly
by the older person.
• Expressions of rage, hostility, indignation
and contempt may take their place.
27

Addiction Definition
• Medical Model –
• AD = G + E + LB
• Addiction = Genetics + Environment +
Learned Behavior
28

Addiction
• Addiction is a brain disease
• Several studies of the brain back the idea that
there’s very little biological difference between
what goes on in the head of a gambling addict
and that of an alcoholic
• Many researchers believe that the same
processes lie behind all addictions, behavioral or
chemical – gambling, shopping, computer
gaming, love, work, exercise, pornography,
eating or sex
29

Center for Online Addiction
• This educational and treatment group estimates
that as much as 5 to 10% of the US population is
addicted to some kind of internet-based activity
– problem gambling is the most harmful of these
• Some researchers predict as many as 10% of
the US population will soon have a gambling
problem
• On-line gambling sites are now worth an
estimated $12 billion (NewScientist, Aug-Sept,
2006)
30

Factors Necessary for the
Development of Addiction
• A biological vulnerability to become an
addict
• The addictive potential of the drug
• Long enough time of exposure to a drug
for addiction to develop
• Psychological stress, depression,
loneliness
• The burden of caregiving
• Loss of a spouse or other social losses
31

THE PRESENCE OF ALCOHOL
MISUSE AND DEPRESSION
• The presence of co-existing major
depressive disorder and alcohol misuse
may markedly increase the likelihood of
suicidal ideation, suicide attempts and
completed suicide.
32

Depression and Suicide
• Depression is the most common diagnosis
in older adults who have attempted suicide
• Depression frequently accompanies a
chronic illness, particularly when the
disease impairs function
• Physical health status is the most
consistently reported risk factor for the
onset and persistence of depression in
late life
33

Alcohol Related Aggression
• Acute alcohol consumption facilitates aggressive
behavior
• Correlational studies indicate that approximately
50% of violent crimes reported to the police in
North America involved the use of alcohol by the
perpetrator at the time of the offense
• Survey data from the marital violence literature
reveal that a history of heavy drinking is
associated with, and even predicts, the future
perpetration of spousal violence
34

Most Common Psychiatric Co-
Morbidities in Older Alcoholics
• Depression (20-30%)
• Cognitive Loss (10-40%)
• Anxiety Disorders (10-20%)
35

Depression
According to the World Health Organization:
• The single largest public health problem
after heart disease is depression
• Depression will affect between 25 and
45% of the adult population
36

Quote by Dr. Janet Taylor
Depression is at an epidemic rate in this
country. Pain and sadness don’t keep you
from functioning. Depression does.
37

Lifetime Prevalence for Depression
• Depression is the most prevalent mental health
disorder for people of all ages in the US
• The lifetime risk for depression is 6 to 25%
• According to the NIMH, 9.5% or 18.8 million
American adults suffer from a depressive
disorder in any given year
• According to the World Health Organization, less
than 25% of individuals with depression receive
adequate treatment
38

Late Life Depression (LLD)
• Major depression affects nearly 2 to 3
million individuals in North America 65+
• When milder levels of depression are
included, as many as 6 million older adults
in the US might be affected
• Frequently manifests as physical
symptoms and is often under-recognized,
misdiagnosed, and under-treated
39

Depression & Loneliness
• Loneliness is one of our most serious
problems in our society
• The lack of relationships creates
loneliness
• Occurs when a person has fewer
interpersonal relationships than desired
• Research has shown that loneliness leads
to depression
40

Loneliness – The Feeling
• Is a feeling of longing and emptiness that
is caused by the lack of emotional
attachment and/or social ties
• More than ¼ of married people, majority
are female, suffer from loneliness
• Being lonely is not the same as being
alone
41

Loneliness & Complications
• Loneliness makes a person vulnerable to
many different situations – can include
more depression, alcohol use, and higher
blood pressure
• Loneliness is associated with higher risks
for heart disease, lessened longevity, and
increased risk for recurrent illness
42

Prevention of Loneliness
• Emotional support, love and intimacy, are
essential to prevent loneliness
• Satisfying two relationship needs will help
people overcome feelings of loneliness:
(1) The need for emotional attachments;
and (2) the need for social ties
43

Depression & Anxiety
• Depression can also be attributed to
anxiety in older adults
• The relationship between anxiety and
depressive symptoms in later life are
relatively common among older adults
44

Suicide Death in the U.S. 2010 Official Final
Data – American Association of Suicidology
• Suicide rate for the nation – 12.4 per
100,000 population
• Suicide rate for young persons – 10.5 per
100,000 population (15-24)
• Suicide rate for older adults – 14.9 per
100,000 (65+)
• Average of 1 older adult (65+) dies by
suicide every 88 minutes
45

SUICIDE DEFINITION BY
SHNEIDMAN
• Currently in the Western World, suicide is
a conscious act of self-induced
annihilation, best understood as a
multidimensional malaise in a needful
individual who defines an issue for which
the suicide is perceived as the best
solution.
46

Suicide and the Elderly
• White men over the age of 85 were at the
greatest risk of all age-gender-race groups
• In 2006, the suicide rate for these men
was 48.4/100,000 – This was 2.5 times the
current rate for men of all ages
(17.8/100,000)
• 84.6% of elderly suicides were male – the
rate of male suicides in late life was 7.7
times greater than female suicides
47

Elderly Suicide Risk Factors
• Death of a loved one
• Physical illness, uncontrollable pain
• Perceived poor health
• Social isolation/loneliness
• Major changes in social roles
48

ACCORDING TO DAVID CLARK
• Only 15% of the elderly who die by suicide
have ever made any form of suicide
attempt before in their lives.
• For approximately 60% of all cases of
suicide and 83% of elderly suicides –
major depression plays a pivotal role in
facilitating suicide.
49

Reasons for Suicide in Older Adults
• An inability to adjust to changing
circumstances
• Rejection-aggression – a rejection leads to
pain and self-directed aggression
• Poor interpersonal relations
• Combination of a trauma such as poor
health (stroke, eg.) or rejection from a
family member
50

Reasons Continued
• Visual impairment, neurological disorders,
malignant diseases, cardiovascular
disease
51

SUICIDE METHOD REGARDLESS
OF AGE
• Firearms are the most common method of
suicide in the U.S.
• Hanging is the 2 nd most prevalent method
of suicide.
• 71% of suicides committed by older adults
involved a firearm.
• Most gun deaths are suicides, not
homicides.
52

SUICIDE ATTEMPTERS
1. Rational people – facing an insoluble
problem, generally a fatal or debilitating
illness.
2. Impulsive people – young, truly but
temporarily miserable.
3. Irrational people – Alcoholic,
schizophrenic, depressed.
4. Desperate people – a cry for help.
53

CULTURE & SUICIDE
• The prevalence of suicide in elderly immigrants
is largely determined by their country of origin.
• Regardless of culture, elderly individuals are
more likely to complain of somatic symptoms
than of psychological distress.
• Many Asian nations have observed greater rates
of suicide among older rather than younger age
groups.
• Suicide in old age is more prevalent in Latin
countries.
54

Acute and Chronic Suicide in the
Elderly
• Acute suicide that leads to death may be
attributed to natural causes or accidental
causes thus leading to an underestimate
of the frequency of suicide
• More difficult for clinicians is chronic
suicide – failure to eat; sustained drug and
alcohol abuse; refusal to use lifesustaining
meds; self-neglect

IMPLICATIONS
• Complete consideration should be paid to
both the personal characteristics and
circumstances and the socio-cultural
milieu of an elderly person.
56

LGBT SUICIDE RISK FACTORS
• Low self-esteem
• Loneliness
• Depression
• Substance abuse
• Prior suicide attempts
57

SELF-DESTRUCTION
• Agitation & Lethality are the bad parents of
self-destruction.
• Agitation is the motivation for suicide.
• Lethality is the suicide trigger.
58

ASSESSMENT ISSUES
• Asking directly about suicidal thoughts or plans
is an essential part of history taking.
• Is the person experiencing severe anxiety or
agitation?
• Is the person depressed?
• Does the person have a drinking problem?
• Is there current alcohol use?
• Is there access to lethal means, especially
firearms?
• Are there recent causes of stress?
59

• Is there a family history of suicidal or
violent behavior?
• Is there lack of access to good treatment?
• Is the individual socially isolated?
• Does the individual experience chronic
pain?
• Has there been a recent hospitalization;
surgery; diagnosis of cancer, dementia,
HIV/AIDS, stroke, etc?
60

INTERVENTIONS
• Continuous monitoring of the person’s lethality
rating.
• Active outreach – befriending and caring.
• Knowledge and use of community resources.
• Hospitalization if needed.
• Transfusion of hope – be active.
• Involve significant others.
• Consultation as needed for the helper.
61

WORKING WITH AMBIVALENCE
• Ambivalence means the simultaneous and contradictory
attitudes or feelings toward an object, person or idea.
• A common myth is that talking about suicide “plants” the
idea.
• Approximately 75% of persons-at-risk give indications
about suicide before they attempt the act.
• “There is a part of you that wants to live and part of you
that wants to die.”
• A helper can represent support, hope and a connection
to life.
62

TREATMENT ISSUES
• Ideal focus should be primary prevention.
• Should be based on an understanding of risk
factors.
• Knowledge of the management of suicidal
persons.
• An understanding of ageism in our society.
• Treatment of the associated psychiatric
disorders (if present).
• Combinations of treatment: 12-step; grief
counseling; adult day care; etc.
63

Implications for Helpers --
Substance Abuse and Suicide
• Suicidal behavior can be manifested
directly or indirectly (accidental overdoses)
• The presence of coexisting major
depressive disorder increases the
likelihood of suicidal ideation, suicide
attempts, and completed suicide
• Antisocial personality disorder, especially
with impulsiveness and violence,
increases suicide risk
64

Implications continued
• Hopelessness
• Interpersonal loss in the recent past
• Look for meaningful connections among risk factors to
help determine risk lethality
• The treatment of coexisting psychiatric conditions can
improve substance abuse and decrease risk of suicide
• Given the importance of interpersonal loss in
precipitating suicide among substance abusers,
psychosocial interventions should include reconnecting
these person to their social support system
65

Reading List
• Blazer, D. (1998). Emotional problems in
later life. New York: Springer Publishing
Co.
• Dayton, T. (2000). Trauma and addiction.
Deerfield Beach, FL: Health Comm. Inc.
• Didion, J. (2005). The year of magical
thinking. New York: Alfred a. Knopf.
• Ebersole, P. & Hess, P. (1998). Toward
healthy aging. New York: Mosby.
66

Reading List Continued
• Greenspan, M. (2003). Healing through the dark
emotions. Boston: Shambhala Publications, Inc.
• Jacobs, D. (ed.). (1999). Guide to suicide assessment
and intervention. San Francisco: Josey Bass Publishers.
• Khantzian, E.J. & Mack, J.E. (1994). How AA works and
why it’s important for clinicians to understand. Journal of
substance abuse treatment, 11(2).
• Paolo, S., Giovanni, D.G., Luigi, P. (2006). Suicide
phenomena in nursing homes: A neglected issue in
geriatric research and clinical management? J Am
Geriatr Soc. (54)8, 1299-1300.
67

Reading List Continued
• Rando, T.A. (1993). Treatment of
complicated mourning. Champaign, IL:
Research Press.
• Real, T. (1997). I don’t want to talk about
it. New York: Scribner.
• Schacter-Shalomi, Z. (1995). From aging
to sageing. New York: Warner books.
• Schwartz, M. (1996). Morrie: In his own
words. New York: A Delta Book.
68

Reading List Continued
• Solomon, A. (2001). The noonday demon.
New York: A Touchstone Book.
• Styron, W. (1992). Darkness visible. New
York: Vintage Books.
• Leader, D. (2008). The new black:
Mourning, melacholia and depression.
Minneapolis: Graywolf Press.6969
69

References Continued
Gardner, P.J. & Poole, J.M. (2009). One
story at a time: Narrative therapy, older
adults and addictions. Jnl of Applied
Gerontology, 600-630.
Kingston, M.H. (2011). I love a broad margin
to my life. New York: Alfred A. Knopf.
Okun, B. & Nowinski, J. (2011). Saying
goodbye: How families can find renewal
through loss. New York: Berkley Books.
70

References Continued
• Sexton, L.G. (2011). Half in love: Surviving
the legacy of suicide – A memoir.
Berkeley: Counterpoint.
• Bonanno, G.A. (2009). The other side of
sadness. New York: Basic Books.
• Rieff, D. (2008). Swimming in a sea of
death. New York: Simon and Schuster.
71

References Continued
• Gardner, P.J. (2009). One story at a time:
Narrative therapy, older adults, and addictions.
Journal of Applied Gerontology, 28, 600-620.
• Gillick, M.R. (2006). The denial of aging.
Cambridge: Harvard University Press.
• Lustbader, W. (2011). Life gets better: The
unexpected pleasures of growing older. New
York: Jeremy P. Tarcher/Penguin.
• Yalom, I. (2008). Staring at the sun: Overcoming
the horror of death.