August 06, 2019
By Julie Gould
Briana Mezuk, PhD, University of Michigan School of Public Health, shares insights on what LTC staff can do to lower the risk of suicide among residents.
Tell us a little about yourself and your research interests.
I've always been interested in mental health and the nature of human experience, for lack of a better term. I majored in Neuroscience and History & Philosophy of Science at the University of Pittsburgh and got my PhD in Mental Health from Johns Hopkins School of Public Health. Most of my research examines how social, psychological, and behavioral factors intersect to influence mental and physical health. Mental and physical health are often siloed, both in research and in clinical care, but my goal is to examine the linkages between them to hopefully arrive at a more comprehensive understanding of health. To that end, I've conducted studies examining the relationship between depression and type 2 diabetes, loneliness and inflammation, and depression and late-life frailty. It is this latter research that got my thinking about suicide in long-term care: I started wondering "What are the types of settings that would be appropriate for prevention and intervention of these overlapping syndromes (depression and frailty)?" Residential long-term care is a prime place.
Can you highlight what was known regarding suicide/risk of suicide in LTC facilities prior to your study?
We knew there wasn't much known about the topic. We and a few other folks overseas had done some work looking at the issue, but most research on mental health in LTC had only addressed depressive symptoms. While depression is definitely a risk factor for suicide, it certainly isn't the whole story. In 2011 SAMHSA produced a toolkit on "Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Facilities", and in it they noted, "There are few reliable statistics on suicide in senior living communities. However, we do know that residents of these communities have many of the risk factors associated with suicide, such as depression, social isolation, lack of a sense of purpose in life, illness and pain, and family losses." (page v). That is, we knew that there were factors in play that increase risk of suicide, but we didn't know whether suicide was occurring in these settings.
So, until our study, there really hadn't been a comprehensive assessment of quantifying suicide in these types of settings, or among people transitioning into/out of these settings.
What can long-term care staff take away from your findings?
Two main things are things: (1) suicide does occur in LTC even though these are supervised settings where people should have more limited access to lethal means (the most common cause of death in LTC were firearm and poisoning in our study); and (2) the transition period (either anticipating entering into long-term care, or when people return home from being in LTC (either temporarily or on a more permanent basis)) are periods when suicide occurs.
How can long-term care staff/facilities improve and lower the risk of suicide among older adults housed in their facilities?
In my opinion, every staff member of a LTC facility needs to be trained - with periodic refresher trainings on the SAMHSA toolkit "Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Facilities". Even though it is a few years old, it still is—in my opinion—the most accessible and complete toolkit for training staff on suicide awareness and prevention - including on how to respond if there is a suicide in a facility.
As articulated in this toolkit, "preventing suicide" isn't the ultimate goal - the ultimate goal is to "promote emotional health" - doing that, within the entire residential community, is the goal. Doing that well will reduce risk of suicide. Suicides are just too rare and event to have as the ONLY target for intervention - the target needs to be emotional health and wellbeing at the community level.
This is directly from the toolkit, with parentheticals added by me:
- Whole Population Approach: Activities and programs that benefit the emotional well-being of all residents (providing meaningful experiences, connections, and social roles among residents, such as having residents organize food drives, volunteer at local schools, hosting lunch-and-learns led by residents, engage with groups outside the facility - churches, community advisory boards, etc))
- At-Risk Approach: Strategies ensuring that staff properly identify and effectively treat residents at risk of suicide (training staff that depression is not "normal" in later life, training on how to identify symptoms of depression, providing comprehensive depression care that includes both pharmacologic and psychotherapeutic elements)
- Crisis Response Approach: Procedures for appropriate responses to suicide deaths and attempts (having transparent discussions with residents and family members in the aftermath of a suicide death, evaluating procedures for reducing access to lethal means)
What challenges do long-term care facility staff members face when addressing suicide/mental health among older adults living/transitioning into the facilities?
The only thing the SAMHSA toolkit doesn't fully address - and where I think more work is needed - is what is the role of facilities during the transition period, when and older adults is considering moving into residential LTC. Every nursing home resident needs to go through Pre-Admission Screening Resident Review (PASRR), and assisted living facilities have application procedures.
As we state in our paper: "These types of transitions involve not just the resident but also his or her family and friends. Indeed, the decision making as to whether, when, and where one will move into residential LTC is almost always undertaken through input of the person and his or her family and clinicians." How are facilities involved in those discussions, particularly in terms of addressing fears and concerns that potential residents have?
Alternatively, what types of policies and/or technologies do we need to be engaged in to allow more people to "age in place", which is what nearly 90% of older adults want to do? This transition period is the most challenging element we need to understand.
What knowledge gaps still exist between suicide risk in long-term care facilities?
Our study, while it was the most comprehensive of its kind, still didn't include every state in the US—California and Florida, two states known for their large retirement communities, are not yet included in the CDC's National Violent Death Reporting System data, which is what we used for the study. They will be in the data soon, but it will still be a little bit of time before we have sufficient years of data to analyze to see if our results apply to those states as well.
Is there anything else you would like to add?
Promoting emotional health is something that we should value at every age, for every person. As others have said before me, there is no health without mental health.
Mezuk B, Ko TM, Kalesnikava VA, et al. Suicide Among Older Adults Living in or Transitioning to Residential Long-term Care, 2003 to 2015 [published online June 14, 2019]. JAMA Netw Open. 2019;2(6):e195627. doi:10.1001/jamanetworkopen.2019.5627