Dr. Gerardo Rivera, PsyD

1. Elderly depression and
Suicide Risk
Gerardo Rivera, Psy.D., M.P.H., HSPP
Behavioral Health Director

2. Objective
 Being able to identify elderly patients with depression and classify it’s
severity.
 Be able to identify special characteristics of depression in the elderly
population.
 Suicide Risk
 Identify level of care needed and treatment needed.
 Be able to choose basic treatment considering signs, symptoms and comorbid
conditions.

3. Depression

4. Depression and Public Health
 Leading cause of both injury and disease for people around the world.
 By 2020 second most common disability following heart disease.
 Estimated burden of $200 billion.
 Biggest challenge to depression is providing access to care.
 Depression affects an estimated one in 15 adults (6.7%) in any given year.

5. Depression worst outcome?

6. Suicide

7. Sociodemographic
Male Female Total
Year Frequency % Frequency %
2014 216 81.5 49 18.5 265
2015 220 88.0 30 12.0 250
2016 186 88.2 25 11.8 211
2017 223 85.8 37 14.2 260
2018 211 86.8 32 13.2 243
2019 74 87.1 11 12.9 85
http://www.salud.gov.pr/Estadisticas-Registros-y-Publicaciones/Estadisticas%20Suicidio/Mayo%202019.pdf

8. Elderly Suicide Statistics
2014 2015 2016 2017 2018 2019
65 + 61 23% 57 23% 49 23% 83 32% 61 25% 21 25%

9. Depressive Disorder
 Depressive Disorder Not Otherwise Specified
 Major Depressive Disorder
 Dysthymia
 Premenstrual Dysphoric Disorder
 Adjustment Disorder
 Depressive Disorder due to general medical condition
 Depressive Disorder due to substance
 Bipolar Disorder
 Schizoaffective Disorder

10. DSM V Criteria Major Depressive Disorder
 Symptoms must last at least two weeks for a diagnosis of depression.
 Feeling sad or having a depressed mood
 Loss of interest or pleasure in activities once enjoyed
 Changes in appetite — weight loss or gain unrelated to dieting
 Trouble sleeping or sleeping too much
 Loss of energy or increased fatigue
 Increase in purposeless physical activity (e.g., hand-wringing or pacing) or
slowed movements and speech (actions observable by others)
 Feeling worthless or guilty
 Difficulty thinking, concentrating or making decisions
 Thoughts of death or suicide

11. IMPORTANT
 Rule/Out Medical Causes Contributing or Causing Depressive Disorder!!!!

12. Severity
 Mild
 Feeling sad
 Changes in appetite
 Loss of energy
 Moderate
 Trouble sleeping
 Loss of interest or pleasure in activities once enjoyed
 Difficulty concentrating
 Severe
 Thought of death or suicide
 Feelings of worthlessness or guilty

13. Elderly population in P.R.: some facts..
 An aged society is considered when 10% or more of its
population is 65 years or older.
 2017 = 19.7% Puerto Ricans 65 or older (n= 658,755)
 56.8% women
 39.2% living alone
 48.8% with some disability

14. Elderly population in P.R.: some facts..
Top Five Death Causes (2017):
1. Cardiovascular disease
2. Cancer
3. Diabetes
4. Alzheimer related
5. Cerebrovascular disease

15. Late life depression prevalence
 Depression occurs in late life, but is not a normal part of
aging.
 On average, 1-3% of the 65+ population suffers from a
Major depressive Disorder (MDD).
 More common in women
 6-12 month course

16. Associated risk factors to late-life depression
 Chronic illness (CVA, DM, HTN,
CA, Alz)
 Cognitive impairment
 Functional impairment
 Hx of depression
 SUD (Alcohol, Rx)
 Altered sleep patterns
 Lack of social support
 Personality traits
 Stressful life events
 Bereavement
 Widowed / divorced
 Socioeconomic disadvantage
 Caregiver of disabled/ill

17. Assessment:
“Elderly depressed patients chief initial complaint is
usually of Physical nature”
 Fatigue
 Weight loss
 Headache
 Insomnia
 GI discomfort
 Pain
 Multiple unexplained Sxs
 Memory complaints
 Social withdrawal
 Diminished appetite
 Diminished meds intake
 Diminished self-care
 Increased use of
anxiolytic/tranquilizing meds
 Increased use of alcohol

18. Assessment: Suggested guidelines
 Administer screening
tools: PHQ-9 and GDS
(Geriatric Depression
Scale)
 Review DSM V diagnosis
criteria
 Physical examination
 Determine severity
 Assess suicide risk always
 ID comorbid
psychiatric/medical
conditions
 Review current
medications
 Assess current life
stressors
 Assess ADLs / disability /
cognitive status (MoCA)
 Evaluate social support

19. Screening Tools: PHQ-9 and GDS

20. Suicidal Ideation Present: What to
Assess?
 Identify the nature of current suicidal ideation ( previous attempts, illness,
pain, loss, etc..)
 Explore planning: Have you had thoughts on how you might hurt yourself?
 Probability: How sure you are on acting or following those thoughts of hurting
yourself?
 Preventive factors: Is there anything that can be done to prevent you from
doing or thinking of doing harm to yourself?

21. Management
 Mild
 Referral to collocated
 Moderate
 Referral to collocated
 Consider using psychotherapy and or psychopharmacology
 Partial Hospitalization referral
 Severe
 Inpatient hospitalization and/or Partial Hospitalization

22. Partial Hospitalization (Day Hospital)
 No suicidal or homicidal plans
 Moderate depressive symptoms
 Significant dysfunction in social, occupational or academic
settings
 Mental status recently affected by a crisis (i.e loss of a
loved one, unemployment, loss of housing)

23. Partial Hospitalization (Day Hospital)
 Usual treatment is between 3-5 days although extension can be requested
 Usual schedule 8am-2pm or 5pm-9pm
 Maximum of 7 days
 Patient receives around 5-7 therapy sessions
 Group or individual therapies
 At least 2 psychiatric evaluations
 Can be started in pharmacotherapy and/or optimize current medications regimen
 Family interventions
 Patient have the opportunity to practice techniques learned in the Day
Hospital and returned next day for feedback

24. Psychopharmacology
What to do before prescribing a psychiatric
medication?

25. Psychotropic Medication
Medical
Conditions
&
Medications
Side effects
Sign &
Symptoms

26. Establish reasonable expectation!!!!

27. Antidepressants
 SSRI
 Escitalopram
 Fluoxetine
 Paroxetine
 Sertraline

28. Antidepressants
 SNRI
 Venlafaxine
 Duloxetine

29. Antidepressants
 Atypical
 Mirtazapine
 Bupropion

30. Psychotherapy
 Brief CBT
 Interpersonal Psychotherapy
 Problem focused therapy

31. Post Test
Juan acude a su médico primario con quejas de no poder dormir, sentirse triste y
ansioso por situación familiar. Estos síntomas llevan 1 semana de evolución. Juan
niega ideas suicidas y homicidas. A su vez niega síntomas psicóticos. Cuál es la
intervención más adecuada para con Juan?
 A. Iniciarlo en antidepresivo
 B. Referirlo a una hospitalización total
 C. Referirlo a una hospitalización parcial
 D. Referirlo al colocado para evaluación y sesión corta de terapia
Respuesta:
D. Referirlo al colocado para evaluación y sesión corta de terapia

32. Myrna es una paciente con asma la cual acude al su médico primario con quejas
de depresión con tristeza, minusvalía, desesperanza, problemas de sueño y ha
contemplado que sería de su familia si ella no estuviese viva. Cuál es la mejor
intervención con Myrna?
 A. Referirla a hospitalización total
 B. Iniciar tratamiento farmacológico
 C. Referirla a hospitalización parcial
 D. Referirla al colocado
Post Test
Respuesta:
C. Referirla a hospitalización parcial

33. Reference
 http://www.salud.gov.pr/Estadisticas-Registros-y-
Publicaciones/Estadisticas%20Suicidio/Febrero%202019.pdf
 https://www.psychiatry.org/
 https://www.uptodate.com/contents/search?search=depression
 DSM V
 Blackburn, P., Wiese, B., Wilkins, M. Depression in Older Adults: Diagnosis and
Management. British Columbia Medical Journal 2017; 59(3): 171-177
 KoK, R.M., Reynolds, C.F. Management of Depression in Older Adults: A review.
JAMA; 2017;317(20): 2114-2122
 Knight, B.G & Qualls, S.H. Psychotherapy for Depression in Older Adults. Wiley
(2006)
 SAMHSA: Older Americans Behavioral Health. Issue Brief 4: Preventing Suicide in
Older Adults

34. Preguntas