NUR 7633 Module 6 Late-Life Suicide Risk Case: PROSPECT Care Management and Safety Planning Example

A Sergeant's Handgun and a New Diagnosis: Weighing Late-Life Suicide Risk and Writing a Safety Plan With a 71-Year-Old Man

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7633: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Geriatric Population, Part A

Mentor Name

Month Day, Year

A Sergeant's Handgun and a New Diagnosis: Weighing Late-Life Suicide Risk and Writing a Safety Plan With a 71-Year-Old Man

What His Wife Noticed

Raymond, an invented patient, is 71 and served thirty years with the Camden police, retiring as a sergeant. Four months ago a neurologist diagnosed Parkinson disease after his hand began to shake and his walking slowed. Since then he has stopped going to the diner where retired officers meet, has given his fishing gear to his son-in-law and told his wife he does not want to "end up in a chair with someone wiping my chin." She found him sitting in the garage with the car off and the door closed one evening, and she called his primary care clinician the next morning.

He has hypertension and mild hearing loss. He drinks three or four whiskeys most evenings, up from one or two. His PHQ-9 is 19, with item 9 answered "more than half the days." He keeps his service handgun, loaded, in his nightstand. His older brother died by suicide twenty years ago.

Understanding Late-Life Risk

Conwell et al. (2011) reviewed what places older adults at risk for suicide and what protects them. Depression and other mood disorders are the strongest clinical factors, along with physical illness and functional decline, social disconnection and access to firearms, which account for most suicides among older men in the United States. Older adults make fewer attempts per death than younger people, use more lethal methods and often see a primary care clinician in the month before they die. The authors argue that prevention must work at several levels at once, from the individual to the community.

Raymond carries most of these factors: an older white man with severe depression, a new illness that threatens his independence, withdrawal from friends, rising alcohol use, a family history of suicide, a loaded handgun and the evening in the garage, which may have been a rehearsal. His protective factors are his marriage, his grandchildren and his Catholic faith.

The Assessment

He is interviewed alone and then with his wife. He admits that he sat in the garage thinking about starting the car and that he has thought about the gun. He has not set a date. He says he would not want his grandchildren to find him. His risk is judged high because of the recent preparatory behavior, the means at hand, his depression and his drinking. Hospital admission is discussed. He refuses, but he agrees to an intensive outpatient plan with daily contact for the first week, and the team judges that with the gun removed and his wife involved, outpatient care is reasonable while it is reviewed daily.

Removing the Means

Means counseling comes first. Raymond is asked, as one officer to another might be, to let his son-in-law, also a former officer, store the handgun at his home until his mood has improved. He agrees, and the son-in-law takes it that afternoon. The garage door opener is placed with his wife, and the car keys are kept by her at night for now. His alcohol is reduced with her help, and the whiskey leaves the house.

Care Management for Depression

Bruce et al. (2004) tested a care management model in 598 depressed adults aged 60 or older at 20 primary care practices in the New York, Philadelphia and Pittsburgh regions. Care managers worked with physicians to apply treatment guidelines for older adults, usually starting with an antidepressant and offering psychotherapy, and followed patients closely. Suicidal thinking fell from 29.4 percent to 16.5 percent in four months in the intervention group, compared with a fall from 20.1 percent to 17.1 percent in usual care, and among those with suicidal thoughts, the thoughts resolved faster, with the difference greatest at eight months.

Raymond's depression is treated in the same way. A care manager in his primary care office calls him daily for a week and then weekly, and the PHQ-9, including item 9, is repeated at each contact. Sertraline is started at a low dose, chosen because it does not worsen Parkinson symptoms the way some drugs can, and his neurologist is told. Interpersonal psychotherapy focuses on his role change from a strong, independent officer to a man facing a slow illness, and on what independence can still mean.

The Safety Plan and Follow-Up

Stanley et al. (2018) set a brief safety plan, followed by two or more check-in calls, against usual care in 1,640 adults seen for suicide-related concerns at Veterans Health Administration emergency departments. Over six months, 3.03 percent of those in the intervention group had suicidal behavior compared with 5.29 percent with usual care, about 45 percent fewer, and those in the intervention group were twice as likely to attend a mental health visit. The study compared sites rather than randomly assigning patients, which the paper notes, and most participants were younger men.

Raymond writes his own safety plan with the nurse practitioner. His warning signs are evenings alone and thinking about being a burden. His coping steps are walking the dog and calling his grandson. His people are his wife, his son-in-law and a retired partner who has offered to take him to the diner each Tuesday. The crisis line and the clinic's number are written on the card in his wallet. Calls come on days two, four and seven, then weekly.

Conclusion

Raymond is at high risk for suicide, with severe depression after a Parkinson diagnosis, rising alcohol use, a family history, a recent preparatory act and a loaded handgun. The review of late-life suicide explains why these factors weigh so heavily, and the gun, car and alcohol are dealt with the same day. Depression care follows the PROSPECT model with sertraline and interpersonal therapy, and a safety plan with scheduled calls supports him through the highest-risk weeks. His PHQ-9 and item 9 will be reviewed at every contact, and hospital admission will be raised again at once if his risk rises.

References

Bruce, M. L., Ten Have, T. R., Reynolds, C. F., Katz, I. I., Schulberg, H. C., Mulsant, B. H., Brown, G. K., McAvay, G. J., Pearson, J. L., & Alexopoulos, G. S. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: A randomized controlled trial. JAMA, 291(9), 1081-1091. https://doi.org/10.1001/jama.291.9.1081

Conwell, Y., Van Orden, K., & Caine, E. D. (2011). Suicide in older adults. Psychiatric Clinics of North America, 34(2), 451-468. https://doi.org/10.1016/j.psc.2011.02.002

Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894-900. https://doi.org/10.1001/jamapsychiatry.2018.1776