Dr. Ari D. Kalechstein, Ph.D., President and CEO
In September 2020, the mental healthcare community will focus on the troubling issue of suicide. The importance of this issue is underscored by a recent study published by the CDC. Specifically, in a sample of over 5,400 adults in the United States, approximately 25.5% of study participants aged 18-24 had “seriously considered” suicide in the month of June 2020. This spike was attributed in great part to the pandemic.
For adults aged 65 and older, the report showed:
- • 6.2% said that they were experiencing an anxiety disorder
- • 5.8% were experiencing a depressive disorder
- • 9.2% reported a trauma-based disorder
- • 2.0% had “seriously considered” suicide in the 30 days prior to the survey
Should we be more concerned about suicide among the elderly in skilled nursing facilities?
While “serious consideration” of suicide by 2% of those aged over 65 might seem low when compared to the 25.5% of young adults, the actual rate in adults older than 65 years may not reflect a real – and very troubling situation—for residents in skilled nursing facilities. Because the CDC survey did not differentiate between older adults who live independently versus those that live in a skilled/custodial setting, the community might be led to believe our elderly patients/residents are not necessarily at a high level of risk for suicide; however, that may not be the case.
This point is not meant to criticize the findings reported by the CDC. To the contrary, the survey serves to highlight the degree to which the pandemic is adversely affecting the mental state of the general population in the United States. Moreover, and for most any survey, no matter how comprehensive the inquiry and large the sample size, it can only be expected to address some important questions.
Nonetheless, as a team of professionals dedicated to the mental health of the elderly, it is important to note that the prevalence of clinical depression in a skilled setting is disproportionately high relative to the general population, i.e., 40 to 49% as reported by the CDC in 2012. Of course, that’s markedly greater than the prevalence rate of 5.8% for the general population of adults older than 65. And, based on inferential reasoning, if the prevalence rate of clinical depression is so much greater for SNF residents, then it is plausible the number of SNF residents who are seriously contemplating suicide at this time would be greater as well.
While having serious thoughts of suicide is not the same as actually having an intent or plan to commit suicide, it is something a trained mental healthcare provider should assess. So, what can be done to ensure we support the mental healthcare needs of elderly SNF residents, even as care providers are required to attend to other equally important issues, e.g., ensuring that patients/residents are not infected by COVID-19?
Four ways clinicians and facilities can partner together to support our seniors
First, it is imperative that we focus on who is making the diagnosis.For example, and according to data extracted from the Minimum Data Set (MDS), only 4.9% of nursing home residents have a diagnosis of depression; whereas, in academic studies, the prevalence rate of depression is 40 to 49%. The disparity in the prevalence rates of depression reported by the MDS and academic studies is partially, if not primarily, related to the training for those who assess depression and the time allotted to conduct assessments in a nursing home setting.
Typically, MDS coordinators or Social Services Directors, key staff who are already very busy, are asked to complete these full assessments on top of their daily responsibilities. These assessments can be uncomfortable or awkward to administer, and they can put those who are not specialized or adequately trained in a difficult position. In contrast to what you see as typical in the field, academic studies typically utilize nurses and/or clinicians who are specifically trained to identify mood symptoms and have more time to build rapport and conduct such assessments. To remediate this concern, Zimmet Healthcare Services Group chief innovation officer Steven Littlehale suggested nursing facilities provide in-house staff with additional education so that they can improve their capacity to detect depression, and contract experts in the area of mental health assessment.
Second, greater attention needs to be paid to the issue of adult suicide. According to JAMA, “Suicide in older adults is a major public health issue. Suicide rates increase during the life course and are highest among older white men in the United States. Specific health conditions and stress factors increase the complexity of the explanatory model for suicide in older adults. Psychiatric and neurocognitive disorders, social exclusion, bereavement, cognitive impairment, decision-making and cognitive inhibition, physical illnesses, and physical and psychological pain have all been noted as risk variables associated with suicide in older adults.” For example, in a survey of 129 nursing home residents, 11% of participants reportedly experienced active suicidal ideation in the year prior to the study. This finding was consistent with a review of 36 studies, which noted that the prevalence of suicidal ideation in nursing home patients ranged from 5-33% (Mezuk et al, 2014). Hence, the importance of creating strategies to detect and treat depression cannot be overstated.
Third, we need to consider an integrated approach to therapy. In terms of the treatment of depression, treatment outcome studies show that the most efficacious interventions include the prescription of psychotropic medication and behavioral therapy, particularly for those who are more severely depressed (Thompson et al., 2001). The use of a behavioral intervention in conjunction with medication can potentially allow facilities to engage in gradual dose reduction (GDR) when it is appropriate. Specifically, when it is determined that the combined effects of medication and behavioral therapy is reducing the onset of mental health symptoms, it may be feasible to change the dosing of psychotropic medications, e.g., reduce the dose size, reduce the number of psychotropic medications prescribed, taper off the medications.
Finally, SNF’s can tap into new revenue streams to support elderly mental health care. Since CMS has determined that remediation of mental health conditions is a critical component of effective care in a nursing home setting, CMS has created financial incentives to appropriately identify those residents that are experiencing depression. Specifically, and as a result of the patient driven payment model (PDPM), facilities see an increase in payment for the proper identification and treatment of patients with a depressive disorder.
In summary, the pandemic has created a series of crises of such magnitude that few of us have witnessed. For some, if not most, mental health providers, the pandemic has resulted in the need to reconsider important issues regarding the manner in which we and our colleagues assess and intervene on behalf of our patients, including, but not limited to, older adults. Over time, it is likely that more studies will examine and define the mental health needs of our elderly patients/residents in skilled nursing facilities. But, until then, we have to look beyond the data, and partner together to ensure residents get the care that they need.