Spiritual considerations in suicide and depression among the elderly.

Suicide in the elderly is a tragedy and, sadly, is not a rare event. In 2003, 31,484 Americans committed suicide, making it the 11th leading cause of death in the US, and the 18th leading cause of death in the elderly. (1) Rates of completed suicide are highest among older men, for whom we see a steady increase in suicide with increasing age. The suicide rate in the 65 to 69 age group is about 21 per 100,000 and increases to about 32 per 100,000 in men aged 75 to 79. In the oldest group, men 85 and older, the rate skyrockets to nearly 48 per 100,000, more than double the rate for men age 18 to 65 years of age. Firearms play the largest role in completed suicide in this age group; in 2003, over 73% of older adults who killed themselves used firearms. Use of firearms as a means of suicide overshadowed suffocation and poisoning (each at about 10%) and other causes.

Depression is a major risk factor for suicide in the elderly, and the two major trials in suicide prevention in older adults have focused on detecting and treating major depression and dysthymia. (2,3) Major depression and dysthymic disorder affect between 5% and 10% of older adults seen in the primary care setting. (4) Given this important link between suicide and depression in the elderly, this article will focus on older depressed patients.

Clinicians caring for older depressed adults need to be aware of the higher suicide risk in this group, as well as the factors that may increase that risk. It is a truism that a key challenge for older adults is dealing with the losses that are expected for this age group. Certainly, spousal bereavement and the resultant social isolation and sense of loneliness can lead to depression and thoughts of suicide. Loss of friends and companions can also increase depression risk. In addition, now that older adults are living longer, we are seeing them experience loss of their middle-aged children as well.

Beyond these bereavement-related challenges are the losses associated with physical illness, caregiving, and work transition. Dealing with loss of physical function (eg, from stroke, myocardial infarction, chronic obstructive pulmonary disease, vision and hearing deficit, chronic pain) can over-whelm one's ability to manage everyday activities and can engender feelings of frustration and misery. Likewise, physical impairment in one's spouse or significant other can force one to take on a new role as caregiver. Those providing care for loved ones have among the highest rates of depression. Another role transition comes at full retirement, when either both spouses retire or one spouse retires. Adjustment to one's "new life" can be challenging. Decreased income, more time together, and less structured time generally strain a marital relationship. Each of these role transitions--as a widow/widower, chronically ill patient, as a caregiver, as a rudderless retiree--can lead an older person to despair as she or he contrasts a more youthful, naive vision of one's older years with the realities that one must deal with. Certainly, death is one reality that older people face--death of significant others, as well as one's own demise.

How one deals with these challenges depends both on how one has dealt with prior challenges and on one's life perspective. For many older adults, this perspective takes on a substantial spiritual and religious dimension as they use their faith to cope with adversity. Certainly, research has shown that the relationship between religious coping and health is strongest in older adults. (5) Understanding the patient's faith background will help the clinician manage a variety of medical problems, particularly if the problem list includes chronic and/or psychiatric conditions. This is especially true in geriatric depression.

Asking about faith and religious involvement should be part of initial assessment of older depressed patients. If the subject has not come up during the history, then clinicians can insert questions into the social history about religious background, current church attendance, and whether patients use their faith to cope with problems. Red flags in this area would include ceasing to attend church or a report that he or she cannot rely on their faith anymore to get through life. Follow-up questions such as "Do you feel that God has abandoned you?" or "Are you angry at God for the way things have turned out for you?" may provide a good measure of changes in the patient's spirituality. Recent stoppage of church attendance removes not only an important source of social support, but also the reinforcing effects that being in a faith community has on spiritual coping. Depressed patients who have "lost their faith" may be at higher risk for poor depression outcomes and development of suicidal thoughts. In one study, our group found that religious participation and religious coping were related to depression outcome among currently treated older depressed patients. (6)

Clinicians are often conflicted about how much to "push" religious and spiritual issues with depressed patients. Unfortunately, the default often becomes ignoring these issues altogether. A good clinical rule of thumb in this area is that if faith has been one of the areas impacted by illness, then the patient should be encouraged to reconnect with religious and spiritual activity. This discussion may prompt some patients to ask clinicians about their faith background. While some clinicians may be reluctant to disclose information about their religious background, or lack thereof, defensiveness or evasion on the part of clinicians will not foster a therapeutic relationship. For those clinicians unwilling to discuss these issues, a simple, "I'd rather not focus on my background, but I want to hear more about what your faith has meant to you" will usually suffice. For clinicians with an active spiritual life, particularly if there is a shared religious background with the patient, disclosing one's own religious orientation can have a powerful and therapeutic effect on the older depressed patient.

The subject of praying with patients often arises as an issue when caring for religious older adults. At times, patients or their families may request intercessory prayer to address physical and emotions problems the patient may be experiencing. There are no clear guidelines about praying with depressed patients in a clinical setting. Religious clinicians should never engage in a practice that is intensely personal if either patient or clinician is uncomfortable doing so. Clinicians who are comfortable and sincerely believe that prayer will be a comfort to the patient may then ask the patient if he or she would like to lead the prayer. Occasionally patients will ask clinicians to take the lead. Again, if clinicians feel comfortable and if they believe it will provide comfort to the patient, then asking for God's presence, guidance and healing may be a simple yet powerful act that will provide at least short-term comfort, foster a closer therapeutic relationship, and open the door to future discussion about the role of faith and religious practice in improving the patient's depression.

In sum, depression is common in the elderly, and older depressed adults have the highest rates of completed suicide in the United States. Older adults are generally among the most religious demographic groups. Clinicians must have a comfort level in inquiring about spiritual issues, including faith and participation in religious activities. Those caring for older depressed adults may choose to share aspects of their own spirituality to achieve a positive therapeutic end.

References

1. Centers for Disease Control. Web-based Injury Statistics Query and Reporting System. Available at: http://www.cdc.gov/ncipc/wisqars/default.htm. Accessed September 12, 2006.

2. Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002;288:2836-2845.

3. Bruce ML, Ten Have TR, Reynolds CF 3rd, et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA 2004;291:1081-1091.

4. Lyness JM, Caine ED, King DA, et al. Psychiatric disorders in older primary care patients. J Gen Intern Med 1999;14:249-254.

5. Reed P. Spirituality and well-being in terminally ill hospitalized adults. Res Nurs Health 1987;10:335-344

6. Bosworth HB, Park KS, McQuoid DR, et al. The impact of religious practice and religious coping on geriatric depression. Int J Geriatr Psychiatry 2003;18:905-914.

How ambitious does a person have to be?
--Lisa Kudrow

David C. Steffens, MD, MHS 

From the Division of Geriatric Psychiatry, Duke University Medical Center, Durham, NC.

Reprint requests to David C. Steffens, MD, MHS, Professor of Psychiatry and Medicine, Head, Division of Geriatric Psychiatry, Duke University Medical Center, Box 3903, Durham, NC 27710. Email: [e-mail]