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12/2/2013
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DEPRESSIVE DISORDERS:MAJOR DEPRESSION; GRIEF AND SUICIDE
DR. VERNA BENNER CARSON, PMHCNS-BC
&
KATHERINE J. VANDERHORST, BSN
2013C&V Senior Care Specialists,Inc
PURPOSE OF CAREGUIDE
STANDARDIZE CARE
PROVIDE CARE PLANNING
ASSESSMENT PROCESS
INTERVENTION
SUPPORTIVE THERAPIES'
TEACHING TOOLS
MEDICATIONS
TELEPHONE ASSESSMENT
CASE STUDY
LET’S REVIEW MAJOR DEPRESSION
2013C&V Senior Care Specialists,Inc
LEARNING OBJECTIVES:
AFTER CONTENT PRESENTATION, PARTICIPANTS WILL BE
ABLE TO:
• DEFINE MOOD, MOOD DISORDERS
• IDENTIFY SYMPTOMS OF DEPRESSION, RISK FACTORS
FOR DX, PHARM & NON-PHARM TREATMENT, NURSING
INTERVENTIONS FOR MAJOR DEPRESSION
• DISCUSS SUICIDE AS RISK WITH DEPRESSION
• DISTINQUISH DEPRESSION AND DEMENTIA
• UNDERSTAND AND RESPOND TO GRIEF
• ASSESS FOR DEPRESSION, DEMENTIA, GRIEF AND
SUICIDE RISK
• DISCUSS CASE STUDIES2013C&V Senior Care Specialists,Inc
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MOOD DISORDERS
• THE MENTAL DISORDERS THAT ARE
CHARACTERIZED BY A PROMINENT OR
PERSISTENT MOOD DISTURBANCE.
• MOST COMMON OF ALL PSYCHIATRIC
ILLNESSES.
2013C&V Senior Care Specialists,Inc
DEPRESSION
• ONE OF THE MOST COMMON HUMAN EMOTIONS
• A NORMAL HEALTHY REACTION THAT CAN MOTIVATE ONE TO DEAL WITH EVENTS AND EMOTIONS.
• EXISTS ON A CONTINUUM
• CRITICAL FOR CLINICIAN TO DETERMINE THE DIFFERENCE BETWEEN NORMAL AND PATHOLOGICAL LEVELS OF DEPRESSION.
2013C&V Senior Care Specialists,Inc
DEPRESSIVE DISORDER:MAJOR DEPRESSION
DEFINED: WHEN A PERSON IS SAD WITH DEPRESSED MOOD OR IRRITABLE MUCH OF EACH DAY FOR TWO WEEKS OR MORE. THERE IS A CLEAR CHANGE FROM PREVIOUS FUNCTIONING.
• THE SYMPTOMS CAUSE SIGNIFICANT IMPAIRMENT
OR DISTRESS IN SOCIAL, OCCUPATIONAL, SCHOOL,
RECREATIONAL, OR RELATIONAL FUNCTIONING.
• THE SYMPTOMS ARE NOT DUE TO MEDICAL
CONDITION (HYPOTHYROID), SUBSTANCE USE OR
MEDICATION.
2013C&V Senior Care Specialists,Inc
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SYMPTOMS OF MAJOR DEPRESSION
ANHEDONIA – ALMOST ALWAYS PRESENT
APPETITE CHANGES – USUALLY WEIGHT LOSS
SLEEP DISTURBANCES – INSOMNIA (MORE COMMON) OR HYPERSOMNIA
RESTLESSNESS OR PSYCHOMOTOR
RETARDATION
FATIGUE – DECREASED ENERGY
FEELING WORTHLESS, GUILTY,
HOPELESS OR HELPLESS
INABILITY TO THINK CLEARLY
OR MAINTAIN
CONCENTRATION
DIFFICULTY WITH MAKING
DECISIONS
THOUGHTS OF DEATH OR
SUICIDE: SUICIDE ATTEMPTS 2013C&V Senior Care Specialists,Inc
DEPRESSION DEPRESSION IS HIGHLY PREVALENT IN PRIMARY
HEALTH CARE SETTINGS AND FREQUENTLY GOES UNRECOGNIZED BY HEALTH CARE PRACTITIONERS
1 OUT OF 5 PATIENTS SEEING A PCP HAS SIGNIFICANT SYMPTOMS OF DEPRESSION
HEALTH CARE PROVIDERS FAIL TO RECOGNIZE DEPRESSION IN THEIR PATIENTS 50% OF THE TIME
DEPRESSION IS TREATABLE – PTS DO RETURN TO FULLY FUNCTIONAL LEVELS.
UNTREATED DEPRESSION CAN LEAD TO SUICIDE2013C&V Senior Care Specialists,Inc
RISK FACTORS FOR DEPRESSION
• PRIOR EPISODES OF DEPRESSION
• FAMILY HISTORY OF DEPRESSION
• PRIOR SUICIDE ATTEMPTS
• CHRONIC ILLNESSES
• UNRELENTING PAIN
• FEMALE GENDER
• AGE OF ONSET LESS THAN AGE 40
• POSTPARTUM PERIOD
2013C&V Senior Care Specialists,Inc
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2013C&V Senior Care Specialists,Inc
Nursing Interventions and Treatments in Major
Depressive Disorder
Maintain pt. safety
Empathy & compassion
Instill hope
Nutrition
Sleep
Hygiene
Social skills
2013C&V Senior Care Specialists,Inc
Nursing Interventions and Treatments in Major Depressive Disorders
Convey acceptance of patients
feeling and symptoms
• Health Teaching and
Psychoeducation
Offer hope – self limiting illness
• Challenge cognitive distortions (e.g.
negative thinking)
2013C&V Senior Care Specialists,Inc
Nursing Interventions and Treatments in Major
Depressive Disorders
Psychopharmacology - Antidepressants**MAOI’s – Inhibit enzymes that
metabolize serotonin and norepinephrine**TCA’s: Inhibit the reuptake of serotonin
and norepinephrine**SSRI’s: Inhibit the reuptake of
serotonin > Increases availability of serotonin-(Viibryd or vilazodone – released 2011),
**Other antidepressants Effexor – (SSNRI)PRISTIQ® (Desvenlafaxine) Extended-Release
Tablets (SSNRI)Wellbutrin – (NDRI)Cymbalta-(SSNRI)
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2013C&V Senior Care Specialists,Inc
Nursing Interventions and Treatments in
Major Depressive Disorder
Electroconvulsive Therapy (ECT)
- Used in those who are medication
resistant or have recurrent episodes.
2013C&V Senior Care Specialists,Inc
Nursing Interventions and Treatments in
Major Depressive Disorders
• Phototherapy – exposure to bright artificial light >
improves depressive sx’s
Used for tx in SAD – “Winter Blues”
2013C&V Senior Care Specialists,Inc
Nursing Interventions and Treatments in Major
Depressive Disorders
• Patient & Family Education
• Individual, couples, and family therapy
• Group Therapy
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2013C&V Senior Care Specialists,Inc
WHAT DO WE NEED TO BEGIN TO ASSESS IN HOME CARE?
(M1730) Depression Screening: Has patient been screened for depression, using a standardized depression screening tool? □ - 0 -No
□ - 1--Yes, patient was screened using the PHQ2© scale. (Instructions for this two-question too. Ask patient:”Over the last two weeks have you been bothered by the following problems”)
PHQ2
□ - 2 –Yes, with a different standardized assessment and the patient meets criteria for further evaluation for depression.□ - 3 – Yes, patient was screened with a different standardized assessment
and the patient does not meet criteria for further evaluation for depression.
DEPRESSION- (Continued)
A score of 3 on PHQ-2 or higher should trigger a complete Depression Assessment using a Standardized Tool such as PHQ-9 or Geriatric Depression Scale
(short version)
HOW COMFORTABLE ARE MOST NON-PSYCH HOME CARE CLINICIANS IN INTRODUCING
SUBJECT OF DEPRESSION? HOW ABOUT SUICIDALITY?
2013C&V Senior Care Specialists,Inc
2013C&V Senior Care Specialists,Inc
DEPRESSION- (Continued)
DEPRESSION PROTOCOL
1. Administers MINI-COG, PHQ-9 or GDS & OASIS
2. Provides pt./family education/self management support
3. Provides proactive follow-up, tracks pt. clinical responses via GDS or PHQ9
.
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2013C&V Senior Care Specialists,Inc
DEPRESSION- INTERVENTIONS4. Evaluates outcomes of counseling and med mgmt.5. Facilitates adherence to antidepressant meds via med teaching, supervision and med mgmt. 6. Monitors response to psych meds7. Assesses and follows up for changes in meds or other TX if pt not responding.
.
2013C&V Senior Care Specialists,Inc
.
DEPRESSION- (Continued)
8. Obtains order from PCP for psychiatric evaluation and refers to
our psychiatrist if patient not responding to TX
9. Provides relapse prevention techniques and education
*Important-Critical to track scores across all episodes of care.
DEMENTIA AND DEPRESSION
2013C&V Senior Care Specialists,Inc
Patients with Alzheimer’s
become depressed;
Important to pay attention to
sad face, change in appetite,
change in weight, change in
sleep, slow movements,
expressions of despair,
suicidal talk.
Untreated depression adds to
patient’s confusion.
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2013C&V Senior Care
Specialists,Inc
C&V SENIOR CARE SPECIALISTS,INC All
Rights Reserved 2013
Patient with Symptoms of Depression and
Dementia. Referred for Depression
Assess with GDS and Mini-Cog
If non-verbal, use Faces
Reassess at 6-8 weeks
with Mini-Cog GDS
GDS Improved
Mini-Cog (Still Positive from Initial
Assessment)
Probably Depression
Refer to MD for the Dementia Assessment
Do FAST as well
GDS Improved
Mini-Cog Improved
Probably Depression
All Rights Reserved
C&V Senior
Care Specialists Inc. 2013
2013C&V Senior Care Specialists,Inc
Grief
2013C&V Senior Care Specialists,Inc
Typical Symptoms Characteristic of Grief
Reaction• Disbelief, shock, numbness
• Anger
• Feeling of guilt
• Sadness, tearfulness
• Preoccupation with the deceased
• Disturbed sleep and appetite
• Seeing or hearing the voice of the deceased.
• With time –symptoms abate –usually clears within 6 months. Can last for 12 months
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2013C&V Senior Care Specialists,Inc
Pathological Grief Reactions
• Delayed Grief
▫ Persistent absence of any emotion
• Distorted Grief
▫ Abnormal mourning at the time of the loss
to include:
SXS of major depression: prolonged
functional impairment, suicidality,
preoccupation with feelings of
worthlessness, & marked psychomotor
retardation.
Psychotic symptoms
Substance abuse
2013C&V Senior Care Specialists,Inc
Goal of Evaluation & Tx
• FACILITATE NORMAL GRIEVING PROCESS AND TO
IDENTIFY AND TREAT PATHOLOGICAL PROCESS
2013C&V Senior Care Specialists,Inc
Dysthymic Disorder: Chronic Depression
Characterized by the following:
- Chronic less severe form of depression
- Low, gloomy, or sad mood every day for
2 years
- Not easily distinguishable from persons
“usual” functioning – “I have always
been this way”
- Prevents full enjoyment of life
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2013C&V Senior Care Specialists,Inc
Dysthymic Disorder:
Chronic Depression
- Thoughts of death or suicide
absent
- As common as Major Depression
- Occurs twice as often in females
when compared to males
- Dx typically missed in primary care
settings
ASSESSMENTS FOR DEPRESSION
• DEPRESSION
▫ PHQ9
▫ GDS (SHORT VERSION)
▫ SAD PERSONS
2013C&V Senior Care Specialists,Inc
TREATMENT GOALS FOR DEPRESSION
• PSYCHOEDUCATION
• MEDICATION
▫ UNDERSTANDING & ADHERENCE
• CHARTING – MOOD, SLEEP, APPETITE,
EXERCISE, ETC
• RECOGNIZE EARLY WARNING SIGNS
• RELAPSE PREVENTION
• IMPROVED FUNCTIONING2013C&V Senior Care Specialists,Inc
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2013C&V Senior Care Specialists,Inc
Suicide: Epidemiology
Suicide was the seventh leading cause of death for males and the fifteenth leading cause of death for females in 2007.1
Almost four times as many males as females die by suicide.1
Firearms, suffocation, and poison are by far the most common methods of suicide, overall. However, men and women differ in the
method used, as shown below
2013C&V Senior Care Specialists,Inc
Suicide Epidemiology cont…
Question???
Which demographic group of U. S. has the
highest suicide rate?
2013C&V Senior Care Specialists,Inc
ANSWER
Older Americans are disproportionately likely to die by suicide.Of every 100,000 people ages 65 and older, 14.3 died by suicide in 2007. This figure is higher than the national average of 11.3 suicides per 100,000 people in the general population. 1
Non-Hispanic white men age 85 or older had an even higher rate, with 47 suicide deaths per 100,000
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2013C&V Senior Care Specialists,Inc
More Suicide Facts
• In the U.S., teen suicide is nearly five (5) times as common among boysas among girls.
• Women attempt suicide twice oftenas men.
• Suicide is more common among whites than blacks of all ages.
• The use of guns in suicide is increasing rapidly.
2013C&V Senior Care Specialists,Inc
Assessment of Risk for Self-Harm• Behaviors:
Observe and identify Non-
Compliance with healthcare
recommendations/treatment plan.
▫ Clinical Examples:
Non-compliant diabetic patient
Non-compliant depressed patient
2013C&V Senior Care Specialists,Inc
Self-Injury
• Defined: An act of deliberate harm to one’s
own body. This injury is done to oneself
without the aid of another person and the
injury is severe enough to cause tissue
damage.
• What are some forms of self-injury?
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2013C&V Senior Care Specialists,Inc
Self-Injury
• Self-Injury and Suicide attempts are two separate phenomena!!!
• Persons who self-injure typically want relief from tension, not to kill themselves.
▫ Self injury is a contained event that occurs in a short time span with an awareness of the consequences of the act.
▫ Lethality is usually low.
2013C&V Senior Care Specialists,Inc
Self-Injury
Categorized by the type of patient and the clinical context in which it occurs:
• Individuals with mental retardation
• Psychotic patients
• Prison populations
• Character disordered individuals, particularly personality disorders such as borderline personality disorder
2013C&V Senior Care Specialists,Inc
Assessment of Risk for Self-Harm
Suicidal behavior: • Divided into categories
▫ Suicidal ideation
▫ Suicidal threats
▫ Suicidal attempts
▫ Completed suicides
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2013C&V Senior Care Specialists,Inc
Suicidal Ideation
Defined: The thought of
self-inflicted death
Vary in seriousness
Passive: thoughts with no intent to act
Active: plans or thoughts of causing one’s own death
All suicidal behavior is serious, whatever the intent, and thus suicidal ideations deserves the nurses highest priority care
2013C&V Senior Care Specialists,Inc
Suicidal Threat
• Defined: A warning, direct or
indirect, verbal or non-verbal,
that a person is planning to
take one’s own life.
• Usually occurs prior to suicidal
activity.
• A threat is often an indicator
of ambivalence.
2013C&V Senior Care Specialists,Inc
Suicide Attempt
• Defined: Any self-destructive action taken by a person that will lead to death if not stopped.
• When assessing a suicide attempt, the lethality of the attempt is considered.
• All suicide threats must be taken seriously.
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2013C&V Senior Care Specialists,Inc
Lethality of Method
• High: gunshot, hanging,
jumping
• Medium: overdose of
pills/alcohol because allows
time for discovery
• Low: superficial scratching,
head banging, pillow over face,
biting, holding breath.
2013C&V Senior Care Specialists,Inc
Suicide Assessment
• Nursing assessment Includes the
following questions: Does the person have a plan?
Does the person have the means available to
carry out the plan?
How lethal is the plan?
2013C&V Senior Care Specialists,Inc
Suicidal behaviors
• There are many different clinical
presentations
• Mood disturbances often present
• Somatic complaints often present
• Feelings of hopelessness/
helplessness present
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2013C&V Senior Care Specialists,Inc
FACTS45% of people who completed suicide
had visited their primary care provider
within one month of their attempt
20% had contact with their mental
health provider within one month of
their attempt
Among the Elderly:
> 80% give clues of their intent
75% are known to have visited their
PCP in the month before they took
their life
2013C&V Senior Care Specialists,Inc
Predisposing Factors:Psychiatric Diagnosis
> 90% of adults who end their lives by
suicide have associated psychiatric
illness
Mood disorders
Substance abuse
Schizophrenia
Anxiety disorders
2013C&V Senior Care Specialists,IncMood disorders & Suicidal Behavior
• Suicide is the most serious complication of a mood disorder, 15% of those with this illness, end their lives by suicide.
• Suicide is particularly common in the depressed elderly men
• Patients with bipolar disorder and psychotic depression are at greatest risk.
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2013C&V Senior Care Specialists,Inc
Alcohol Use and Suicidal Behavior:
• Alcohol use is associated
with 25-50% of suicides.
• Among patients who are
alcohol dependent, suicide
often occurs late in the
disease often related to
interpersonal loss or onset
of medical complications
2013C&V Senior Care Specialists,Inc
Predisposing factors cont…Personality
Traits
• Four aspects of personality that are most
closely associated with suicidal behaviors
are:
hostility
impulsivity
depression
hopelessness
• These traits cross diagnostic groups
• Loss or lack of social support
• Negative life events
• Chronic medical illness
2013C&V Senior Care Specialists,Inc
Predisposing Factors cont…
Family History
• A family history of suicide is a
significant risk factor for self-
destructive behavior.
• Offspring of those who attempt
suicide are at markedly greater
risk of suicide themselves.
▫ Identification and imitation of
family member
▫ Family stress related to
suicide
▫ Transmission of genetic
factors
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2013C&V Senior Care Specialists,Inc
Presenting symptoms for self-destructive
behavior
HopelessnessWeight lossSocial withdrawalSlowed speech, fatigueSuicidal thoughts/plansAgitation/restlessnessPersistent insomniaHelplessnessSelf-reproachFeelings of failureUnworthinessDepressed mood
2013C&V Senior Care Specialists,Inc
Nursing Interventions
• Take a detailed medical and psychiatric history
• Take a family history
• Mental status examination
• Psychosocial history
• Evaluate for recent losses, stressors, substance abuse
• Ask direct questions about suicidal thoughts, plans, & intent.
• SAD PERSONS
SUICIDALITY
M1730 a Score of 3 on PHQ2 should trigger additional depression assessment tool – PHQ9 or GDS which would ask about suicide risk
HISTORY – SUICIDAL ATTEMPT?? CURRENT PLAN? METHOD TO CARRY OUT PLAN?
These items MUST be explored – Remember that YOU WILL NOT MAKE SOMEONE COMMIT SUICIDE IF YOU ASK
THEM ABOUT IT – TO THE CONTRARY – TALKING ABOUT IT DECREASES THE DESIRE TO FOLLOW THROUGH WITH IT-
COMPLETE “SAD PERSONS” Suicide Assessment Tool –
IMPLEMENT PSYCHIATRIC EMERGENCY POLICY IF NECESSARY
2013C&V Senior Care Specialists,Inc
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SUICIDALITY
Suicide Thinking; Suicidal Gestures or Attempts may be Associated with any of the Psychiatric Disorders –Depression, Bipolar, Schizophrenia or Anxiety. The Risk is Especially High When Patients Engage in Alcohol and/or Substance Abuse and/or Experience
Command Hallucinations.
There are two OASIS items relevant to Suicide Risk –
These are M1730 and M1740
2013C&V Senior Care Specialists,Inc
SUICIDALITY
M1740:#2-Impaired Decision-making
#4- Physical Aggression
# 6-Delusional, hallucinatory, or paranoid
HISTORY – SUICIDAL ATTEMPT??
USE COMMENT SECTION – COMPLETE “SAD PERSONS” Suicide Assessment Tool or Assessing Suicide Risk as a Spectrum
IMPLEMENT PSYCHIATRIC EMERGENCY POLICY IF NECESSARY
2013C&V Senior Care Specialists,Inc
IF SUICIDAL
CALLING 911 IS THE
BEST RESPONSE IF A
PATIENT IS
THREATENING
SUICIDE AND/OR
HOMICIDE – NO
OTHER RESPONSE
WILL DO!
2013C&V Senior Care Specialists,Inc
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• WE ASK THE PATIENT OR THE CALLER(IF ON-CALL)
THE FOLLOWING QUESTIONS:
• ARE YOU PLANNING TO HARM YOURSELF?
• HOW WILL YOU DO THIS? WHAT ARE YOUR PLANS?
• DO YOU HAVE THE MEANS AVAILABLE (I.E. GUN, MEDS
FOR OVERDOSE, CAPACITY TO JUMP FROM A BRIDGE
OR HIGH BUILDING, ETC.) TO HARM YOURSELF OR
OTHERS?
• IS THERE ANYONE ELSE WITH YOU THAT I CAN TALK
TO?’
• I WANT TO HELP YOU – WHAT CAN I DO TO KEEP YOU
SAFE?
• REASSURE PATIENT THAT YOU ARE CONCERNED AND
WILL HELP.
DETERMINING RISK
IF ANYONE ELSE IS WITH YOU –GET THE ATTENTION OF THAT PERSON – HAVE HER/HIM CALL 911 WITH PATIENT’S ADDRESS/TELEPHONE
NUMBER.
2013C&V Senior Care Specialists,Inc
ON-GOING ACTIONS..
• DEVELOP A STRATEGY WITH
SUPPORT PERSON THAT INVOLVES:
CONTINUED VERBAL SUPPORT
REINFORCE COMMITMENT NOT TO
HARM SELF.
COMMITMENT OF SUPPORT
PERSON TO REMAIN WITH PATIENT
A STRATEGY TO TRANSPORT
PATIENT TO AN EMERGENCY ROOM
IF SITUATION WORSENS
• CONTINUE TO REASSURE
PATIENT.
• REPEATEDLY SAY THAT YOU ARE
CONCERNED AND WANT TO
HELP.
• ASK IF ANYONE ELSE IS WITH
PATIENT AND ASK IF YOU CAN
TALK TO THAT PERSON.
• OBTAIN VERBAL COMMITMENT
FROM PATIENT THAT HE/SHE
WILL NOT HARM SELF.
IF PATIENT IS ALONE AND SITUATION IS UNSAFE –FIND OUT PATIENT’S LOCATION AND TELEPHONE NUMBER AND TELL PATIENT EMERGENCY
HELP WILL BE OBTAINED IMMEDIATELY – CALL 911 TO REPORT PSYCHIATRIC EMERGENCY
2013C&V Senior Care Specialists,Inc
2013C&V Senior Care Specialists,Inc
Exploring Predisposing/Precipitating Factors:
• Help patients understand high-risk times
and situations that lead to suicidal/self-
destructive thoughts and behaviors.
• Help the patient identify the triggers for
their self-destructive thought, feelings,
behaviors.
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2013C&V Senior Care Specialists,Inc
Factors that Protect Against Suicide
• Effective treatment for psychiatric, medical illness and substance abuse
• Support system (family, community, healthcare providers)
• Access to treatment• Restricted access to high lethal methods of suicide• Learned skills in problem solving, conflict
resolution, non-violent handling of disputes• Cultural and Religious beliefs that discourage
suicide and support self-preservation
CASE STUDIES
2013C&V Senior Care Specialists,Inc
ANY QUESTIONS???
2013C&V Senior Care Specialists,Inc