September 2026

September is Suicide Prevention Month. AWD has tried to make this month’s difficult and complex topic accessible and resourceful by speaking with a variety of health care professionals. 

Dr. Anne Johnson is an outpatient geriatric psychiatrist at Duke. She completed medical school, general psychiatry residency training, and an additional year of fellowship training to specialize in caring for older adults and their mental health. She supports patients in managing different conditions like late life depression, anxiety, psychosis, and neurocognitive disorders. 

She spoke with AWD about her experience with older adults.

How are you?

I’m doing well. I’m actually at home today. Wednesday, I do all video visits at home. 

Oh, lovely.

I’ve been on video visits all morning, but I’m doing well overall.

Do I call you Dr. Johnson? 

You can call me Anne.

Okay. Thank you. Thank you, Anne.

Can you tell me about your work, specifically what it is you do and how you got there? 

I see patients in a clinic setting and develop a relationship over time and manage different conditions like late life depression, anxiety, psychosis, a lot of neurocognitive disorders. I often collaborate with other medical providers, being at Duke, and psychotherapists, and then sometimes in more challenging or severe illness with some of our interventional psychiatrists who do things like ECT or TMS (Electroconvulsive Therapy and Transcranial Magnetic Stimulation.) 

Wow. What was it about geriatric work that interested you? 

I went into medical school wanting to work with older adults and I didn’t exactly know what that would look like. I had some time between college and medical school actually working at a local senior center and got to see a lot of older adults and see relationships between spouses, relationships between caregivers and older adults and I just really enjoyed that.

Then I went to medical school thinking, “Okay, I want to work with older adults, but I don’t really know what I want to do with them.” I did a few different rotations and figured out that in psychiatry, I’m able to have a relationship with the person, with family members, and I just really love hearing stories and connecting with them over time. I think that’s what got me to geriatric psychiatry. 

It’s a really interesting field. I am obviously quite drawn to work involving older adults, too!

Yeah, that’s very cool.

Can you talk about how older adults are different from other people, younger people? 

Sure. Since we’re talking about risk factors and things for suicide, I would say much like the general adult population, a key risk factor for suicide in older adults is depression.

But in older adults, there’s a lot of other driving forces. Some of the things we think about that are more specific to older adults are: 

• Decline in physical health, 
• Chronic pain is a major risk factor, 
• Functional decline, 
• Loss of independence,
• Sensory, vision, hearing impairment, cognitive impairments,
• Social isolation. A lot of older adults are living alone or maybe grieving a spouse.

So strong social support can be really, really protective here. Looping back to depression, since we know that’s a major risk factor for suicide in the general adult population, as well as older adults.

I think that depression, especially in older adults is underdiagnosed and definitely inadequately treated. 

Why is that? Why does that go underdiagnosed? 

I think it’s really important for us to recognize that depression is not a normal thing that happens in aging.

And sometimes I think people just think

• This is what happens as we get older. We’re losing all these things. We’re losing the ability to be independent.
• We’re losing our vision. We’re losing our memory. Why wouldn’t you be depressed? But it’s not a normal consequence of aging.

And there’s many, many older adults who do not get depressed. Actually the rates of depression are lower in older adults. But I think we are missing a lot of people who are depressed.

I think prevention, being able to identify those folks, detecting when depression is happening and being able to manage it. Most mental health treatment for older adults is done in the primary care setting, long before they see me in the office. That’s where these people are usually getting their first antidepressant trial or their first engagement with therapy.

We diagnose depression the same way as we do in younger adults. There’s criteria that we have to diagnose depression. That’s a depressed mood, anhedonia–or the inability to feel joy and pleasure from activities you previously enjoyed.

You have to have one of those depressive symptoms or anhedonia. Then it’s a certain number of the following, like weight changes, sleep changes, energy, fatigue, feelings of worthlessness and suicidal ideation. Depression in older adults can look really different from depression in the general adult population.

So actually the low mood that a lot of people think about, like feeling low, feeling depressed, feeling blue – that’s often less prominent in older adults than in younger adults.  Actually, a lot of times it’s more anxiety and irritability.

Because there’s a lot of grieving and there’s a lot of change…

 Yeah. There’s a lot of what we would call somatic symptoms. 

Body stuff.

Yeah. And vegetative symptoms. So changes with sleep, a lot of early morning awakenings, a lot of changes with appetite; weight loss is a big thing we see in older adults, and fatigue. These are things that people go to primary care doctors for. Blood work.

Right.  I was wondering if there’s a distinction between fatigue and being tired. 

Yeah. I think those can be interchangeable in some ways. Fatigue, we talk about like a loss of energy. The person themself might not recognize this as depression or a symptom of depression.

So they go to primary care, they get worked up, right? They get all the blood work done, they get a physical exam, nothing’s really found. The next step might be to screen the person for depression symptoms at that point or consider that as the diagnosis that explains these symptoms. It’s kind of like depression, sometimes it’s just not diagnosed, right? Sometimes a person presents with these symptoms and it doesn’t really sound like a typical depression, so it doesn’t get diagnosed.

Then if it is diagnosed, the management can be more difficult because usually our older adults have more medical conditions that might complicate medications being used. They might be more sensitive to medications, they might have a kidney impairment. A lot of different reasons that we have to be really thoughtful about with the medications that are prescribed.

Right. Medications you can’t take with other medications, et cetera. 

Right. Like med interactions, or you might have to dose a medicine differently because of a kidney dysfunction and, or the person has cardiac disease. You have to be cautious about certain medications. Then of course, later in life, there’s brain changes that tend to happen.

Which are also not, not a given, right? 

Not a given, not a given. Right. It’s not a given that you’re going to develop a neurocognitive disorder or dementia later in life, but many people do.

What happens is the brain networks are disrupted, and then the ability to treat the depression can become more difficult. There are a lot of reasons why we might not be diagnosing these people, we might be missing people with the diagnosis.

Even if we do diagnose them, it can be challenging to treat them. 

Yes, they don’t always respond as well to medications.

Right, right.

There are a lot of reasons why it can be more challenging to identify and treat depression in older adults, as you say. One of the things that Aging Well Durham is particularly interested in is social participation. The Comprehensive Aging Plan recognizes that the impact of isolation is huge. Social support is a cross-cutting issue in the Plan.

Do you have anything you can tell us about community or social isolation? 

Yeah, definitely. I would say that loneliness is a big contributing factor for depression, for suicide. People are living alone, people have lost a spouse, people are isolated because of their physical impairments.

We know that strong social support, whatever that means for that person, whether it’s someone they live with, or friends they gather for lunch with, or a family member they talked to on the phone, whatever it is, that’s going to definitely be a protective factor. 

I wholeheartedly agree that social engagement is critical, not only for depression, but for just preserving brain health as we all get older and preventing dementia. Social engagement is just so key for that.

My mother had dementia, but before we acknowledged that was having cognitive challenges, she was depressed.  And then it morphed into something else. But one of the first symptoms for her that she had cognitive decline at all or whatever you want to call it was depression. 

Yeah, so depression is often one of the presenting symptoms for someone who has dementia. You try your best to treat the depression, and you might get that better.

But then you still recognize there are cognitive deficits. So that’s when you start talking about more of a diagnosis of dementia. 

So what do you do? Or can you recommend if a friend or family confides in me that perhaps somebody is feeling suicidal, what steps can I take? 

I would say the first thing is listen and continue to be present with that person, right? Continue to be their friend, their supportive family member with what they’re trusting you with. 

Then gently encourage them to get some help, supporting them during this process. Depending on how acute or serious it is, that might mean, “Why don’t we find a doctor and talk about this more?” Obviously, if it’s something that’s more alarming and acute, like they’re talking about not wanting to be alive, talking about wanting to die, wanting to kill themselves, you’re going to want to get them to an emergency room, you’re going to want to help them with that. 

It depends on where they are with that.

It is more of a passive suicidality. 

Can you talk about that? What does passive suicidality mean? 

Yeah, yeah. We usually think about suicidal ideation existing on a continuum.

People talk about passive suicidality. This is like the wish to be dead. Someone might say, “You know, things would be better off if I just wasn’t here.” “If I didn’t wake up tomorrow morning, it would be okay.” So that’s more of a passive suicidal wish. That is different from an active thought with a specific plan.

“I’m going to use my gun to kill myself.” would be an active suicidal thought. You’re going to need that person to get to urgent care, that person needs safety, right? Keep that person safe in that moment. 

The passive suicidality, obviously that’s very concerning to hear. But that is more where you want to stay by that person, support that person and get them to care. Right? 

Yeah. I’m a layman, but it seems to me if somebody is letting you know that they feel this way, then part of them wants help.

Oh, yes. Yeah. Yeah.

I think, again, staying with them, staying present, staying supportive, you know, we don’t want to abandon people in those moments when they’re trying to reach out for help. 

Absolutely not.

Can you talk about the distinction between masculine people and feminine people in terms of suicidality and older adults? 

We definitely know as a whole, in most, if not all countries that men die by suicide more than women. And that disparity actually widens with age. There is this concept of what’s called a gender paradox in suicide.

That essentially means that women have higher rates of suicidal thoughts and attempts, but men are dying more often. Men are succeeding more often with killing themselves. 

Is that a firearm related? 

Yeah, I think that’s a big part of it.

It’s definitely the means with which the person makes the attempt. I think we’ve seen that men have more access to lethal means, usually firearms, but even things like hanging or suffocation men are more likely to do. Women are more likely to overdose on medications, which may or may not succeed with killing themselves and often ends up with an ICU hospitalization as opposed to killing themselves.

It’s the access to more lethal means for men, I think that probably contributes. And then just this overall thought in mental health that men are more likely to have undiagnosed depression.

They’re generally not help-seeking. There might be depression that’s more likely to be undertreated in men.

 Is that cultural you think, or is it? 

That’s a good question. I don’t know exactly that. I think it’s more universal, but I’m not sure exactly. I know that’s definitely true here.

I would have to look into that a little bit more and see how universal that is. I think about women being able to be more social and have some of those protective factors that men just might not pursue.

Substance use is usually higher in men, which I know that substance use can lower the threshold for acting on some of the suicidal thoughts. Then there is this thought about cultural beliefs around suicide and that being a masculine thing to do, which is hard to even get around. But I think there is a little bit of that, that there’s some cultural beliefs there and we need to do a better job of telling men that seeking help and going to a doctor with their problems is more masculine.

We have a lot of work to do around gender in this country. I’ll just put that out there.

Oh yes. So yeah, I think kind of reframing what masculinity is in this topic too. 

So men can access healthcare. 

Yeah. So trying to figure out where is the comfortable place for a man to seek out support if he’s struggling. I think that’s another reason that primary care tends to be the place where people go because if they’re seeing any doctor at all, hopefully they’re seeing their primary care doctor.

And I can say men are going to be less likely to present to a mental health provider. 

Right. It makes me wonder about faith-based communities. That’s a place where men can express themselves and get help.  A place that they might feel like a safer place to be in. Sometimes they have men’s meetings and… 

Yeah. I think those are all really good ideas about how to get this more into the community and to solve the issue of people who have depression, who it’s going unnoticed, undiagnosed. 

Is there anything, is there a means of prevention that we haven’t mentioned beyond, identification, listening, getting help? Is your expertise based more on medical intervention? 

Yeah. As a psychiatrist, my specialty is going to be medication. I think that obviously the acute management, what we talked about before, just keeping someone safe, right? Their minimum, that would mean emergency room visits, psychiatric hospitalization, for example, stabilization.

But I think prevention really is going to stand with getting people evaluated for depression and getting it diagnosed and then getting it treated appropriately. Again, the primary care providers are the folks who are probably most capable of doing the most effective intervention. And that’s not necessarily the doctor in the primary care office, but the primary care office and what support that they can provide.

There’s a lot of evidence to say that these collaborative care models within primary care are the best supported intervention. So we have to make sure the primary care providers, or again, some staff in that office are in a good place to screen for depression and then be able to support the patients. After you get a positive screen, you have someone answer all these questions, you get a positive screen, what do you do after that? You have a thorough evaluation, right? We have to have the resources to do a more thorough evaluation and then kind of triage folks, what support are you going to be able to provide them at this point? 

And Duke is very good about that, in my experience.

Yeah. So I think hopefully you’re going to talk with some of the primary care folks who are just behavioral health embedded within primary care, because that is where, you know, I would love for you to hear more about the specific things that are being done in our primary care clinics. 

I would say by the time someone has gotten a referral to see me, I’m rarely screening for depression at that point, right? 

Right.

It’s more that I’m looking at medications and saying, you’ve had a trial of X, Y, and Z, what do we need to try next? Maybe their depression is treatment resistant in some way. It would be rare for me to see a patient– I have done that before, but it would be rare for me to be the first one to diagnose depression in a patient. A lot of times patients come to me where the primary care is saying, is this depression or dementia and help parse this out.

That’s something I do often, but the primary care office is where we can probably do the bulk of interventions. And then thinking about all of the places in the community where we can make people more comfortable with sharing how they’re feeling and getting help if needed. 

There’s that component of medication, which can be so crucial. And it sounds like it’s also complicated by age and then helping that person get into the community if they’re not already. 

Yeah. And I guess one of the main things I probably left out there, which seems really basic, but like asking about suicidality, a lot of times we might overlook that, or it feels awkward to ask, but we need to be, we definitely need to be asking about it. And then on top of that, just reducing access to lethal means.

When someone discloses to you depression, these suicidal thoughts, we need to have a good idea. What do they have access to at home? I think there’s different ways that our primary care offices are doing that. We know that men use firearms: what does the family think about them having access to that? Or would it make sense for them to not have access to that? Again, a cultural barrier, unfortunately.

Yeah. Yeah. Yeah.

I will say in some difficult cases, I’ve got maybe a husband, and wife who is concerned about the husband. For instance, he might not listen to what the wife says. So I get the adult son to talk to him. You sometimes just have to navigate things like that.

Who does he respect? We have got to do anything, we have to do this to keep him safe. We have to put him in the hospital. 

Right.

So when you’re doing that type of safety planning or crisis planning, sometimes you have to get a little creative. I imagine moving game pieces around, family pieces.  

Right. Yeah. Yeah.

Well, it’s amazing the work you do. I really appreciate that you took time to talk with me today. 

Thank you.

Is there anything you’d like to say or anything else we should know about? 

I guess one thing I try to always kind of impart on the trainees that I work with. There are two questions that I always ask as part of a geriatric psychiatry about, there’s many questions, but two, which I really love to ask: 

• Who are the people that are important in your life? 
• Who are your supports? These are the people that they trust, they confide in.

These are the people who are going to be major protective factors for them. This goes back to that sense of loneliness that puts people at risk. So really trying to get a good sense of who the people in their life are that matter, is crucial. 

Suicide is an unfortunate part of many older adults’ experiences. There are many reasons for this, but central to most are feelings of isolation, depression, chronic pain, or a feeling that we are a burden on others. Older adults are at an increased risk for loneliness and social isolation because they are more likely to face factors such as living alone, the loss of family and friends, chronic illness, and hearing loss. Social isolation is associated with higher rates of depression, anxiety, and suicide. 

Additionally, older adults who are immigrants and/or who identify as LGBTQ+ experience social isolation more than other groups. Age-friendly communities are designed to mitigate social isolation and play an enormous role in the intervention of depression and suicide. Knowing resources for intervention is crucial. With that in mind, the following section provides some key information, supporting data, and helpful resources.

• While older adults comprise just 16.8% of the population, they make up approximately 22% of suicides.^{3, 2}
• In 2022, among the nearly 49,449 suicides that took place in the U.S., 10,433 were attributed to people age 65 and up.²
• Older adults tend to plan suicide more carefully. Men in particular are also more likely to use more lethal methods such as firearms, poisoning, or suffocation.^,5
• Among people who attempt suicide, one in four older adults will succeed, compared to 1 in 200 youths.⁶ Even if an older adults fails a suicide attempt, they are less likely to recover from the effects due to frailty or underlying health conditions. 
• (https://www.ncoa.org/article/suicide-and-older-adults-what-you-should-know/ )   “Suicide is more than a preventable tragedy—it’s a growing public health crisis. According to provisional statistics released by the Centers for Disease Control and Prevention (CDC), the U.S. suicide rate reached a historic high in 2022.¹ And, while nearly every age group experienced an increase, older Americans fared the worst. Compared to 2021, suicide deaths rose 8.1% among people age 65 and over.² “ 

Prevention

There are many complex reasons why a person would consider ending their life. Fortunately, there are many resources available to provide support, including some in Durham. The first step in prevention is recognizingthe signs that signify a desire for suicide. This following list of signs is provided from the National Council on Aging:

• Giving away beloved items or changing their will
• Sudden interest or disinterest in religion.
• Unexplained irritability or anger.
• Rapid change in mood from angry/irritable to content
• Avoiding social activities
• Neglecting self-care, medical regimens, and grooming
• Exhibiting a preoccupation with death
• Lacking concern for personal safety

Over 70% of older adults who die by suicide saw their primary care provider within 30 days of their death. Doctors can play a crucial role in suicide prevention by screening all patients for suicide risk. 

Clinical depression is not a normal part of aging, however doctors often miss symptoms in their older patients, making it all the more important to recognize the signs. The 988 Suicide & Crisis Lifeline offers these actions to help intervene in suicidality:

ASK: Be direct with your questions, like, “Are you thinking about suicide?” and “Can you tell me what’s going on?” Deep listening and unbiased responses are valuable. Without judgement, let the person know the reasons they should stay.

BE THERE: If possible, being there in person is best. Work with them to find other friends who will be supportive. Don’t make any promises you can’t keep. 

KEEP THEM SAFE: Has the person done this before? Do they have a plan? Do they have access to a method of self-harm? Learning where they’re at can be helpful; the more thought-out the plan, the higher the risk.

HELP THEM CONNECT: If you or someone in your life is thinking about suicide, help them connect to resources. Support systems are essential: they need to know who’s on their team, and who to call, email, or get information from. Below are some great ways to help someone connect. 

988 HELPLINE: Just dial 988, or text, or chat online at 988helpline.org  

AskMeNC.org: for veterans old and new.

NC PEER WARMLINE: Talk with trained peers who have lived experience.

Phone: 1 855-733-7762 available 24/7

Substance Abuse and Mental Health Services Administration (SAMHSA) offers a searchable, confidential directory of mental health providers across the U.S. 

The Partnership for a Healthy Durham‘s Mental Health Committee has English and Spanish versions of a Mental Health guide – https://healthydurham.org/committees/substance-abuse-and-mental-health-committee.

Durham County offers Mental Health First Aid Courses. The Mental Health First Aid (MHFA) course for adults teaches people how to:

• Recognize signs of mental health and substance use challenges in adults
• Provide initial help and guide people toward appropriate care
• Understand the impact of mental health problems and common treatments
• Build mental health literacy and feel more comfortable managing a crisis
• Decrease stigmatizing attitudes

For further information, there is a website (below) with a contact number: Call 919-560-7771 for more information.

https://dconc.gov/Public-Health/Community-Programming/For-Organizations-and-Faith-Communities/Mental-Health-First-Aid

Links supporting the article:

• https://pmc.ncbi.nlm.nih.gov/articles/PMC9910279/
• https://www.ncoa.org/article/suicide-and-older-adults-what-you-should-know/
• https://www.cdc.gov/suicide/facts/data.html?CDC_AAref_Val=https://www.cdc.gov/suicide/suicide-data-statistics.html 

Beth Soule, MSN, RN, CCM and Angela Burnett, LCMHCS, spoke with Aging Well Durham about their experiences at Duke Primary Care in Knightdale, finding ways to intervene, interact, and prevent their clients from suicide or ideation. 

Beth sees Medicare patients, who are generally 65 and older, for annual wellness visits, chronic care management, as well as advanced care planning. During a wellness visit, she routinely does a PHQ-9, which is a screener for depression, and a GAD-7, a screener for anxiety.

Angela is a Behavioral Health therapist and a licensed clinical mental health counselor. After Beth screens clients, she may refer them to Angela for further treatment. 

Hello! Let’s jump in. How does this work, this relationship between the nurse, counselor, and client?

Angela: I get patients from Beth, but then I also get them from their primary care providers if they come in and we do screenings. They’ll do the GAD and the PHQ-9. Whenever a patient comes in for their sick visit, wellness visit, depending upon their score, their discussion that they have with their PCP, they’ll put in a referral for me or someone among our team.

BETH: I ask those screening questions just to be in front of any mood problems that there might be. I also screen for gun safety and storage. You got me (to interview) because I was the one that wrote the screener and steps and regular documentation, as well as the information we share out in terms of with the patients. 

We also give out gun locks.

Yes, I have one!

Duke gives these free. 

I got it free from a Duke Health table at a conference. I don’t even have a gun. 

BETH: Give it away – have somebody use it. We’ve partnered with the Duke Firearm Injury Prevention Partnership and with Durham County and Public Health. We give these out free as we assess and make sure that people are medically able to own a gun. Usually they say they own one gun, but, you know, if the guy has five guns and none of them are locked away, he gets five. Five locks.

Wow. That’s great. (Visit the main office, Durham County Department of Public Health, 414 E. Main St., Monday through Friday between 8:00 AM and 5:00 PM or contact them by phone at 919 560-7765 to get a lock or lock box as well.)

That’s what we do, try to be in front of things. In a nutshell, that’s what I do for Wellness. It’s all about prevention.

Chronic care management is across the continuum, and advanced care planning is just to make sure that people have their P’s and Q’s in order on their wishes. Part of the deal with that is to make sure that in their final days, we’re delivering care at the level that they’re wanting, that they’re not intubated in the ICU with nobody being able to visit. 

End of life planning is one of the goals in the Community Support and Health Services domain.  I have a lot of questions for you, but thank you, Beth. Angela?

So I am fortunate enough to work with Beth as often as possible. I am a behavioral health therapist. I’m a licensed clinical mental health counselor.

I get patients from Beth, but then I also get them from their primary care providers (PCP) if they come in and we do screenings. They’ll do the GAD-7 and the PHQ-9 that Beth referenced. Whenever a patient comes in for their sick visit, wellness visit, depending upon their score, their discussion that they have with their PCP, they’ll put in a referral for me or someone among our team.

We provide services in-person as well as virtually.

I see a lot of patients that have anxiety and depression. Typically, whenever someone comes in, we do the PHQ-9, and there is a number 9 that’s a reference to if they’re having suicidal thoughts. Then we would escalate to what we call an ASQ (a suicide screener). They ask “how severe are those thoughts?” Then we escalate that further.

We make sure the person is safe. We both work under the umbrella of Population Health at Duke Primary Care, not under psychiatry, not under DukeWell, which is also a place that you might find population health nurses as well at Duke.

So we work directly in primary care with the primary care population, not as an ancillary, if that makes sense.

Yes, that makes sense. Do you have a lot of older adult patients? 

ANGELA: Yes, yes. It’s been kind of fascinating being in this role. Getting to work with individuals that are 65 and older because that population may have never worked with a therapist or the stigma around mental health was different when they were in their 20s or teenage years growing up.

So a lot of things may have somewhat snowballed by the time they get to their 60s, 70s, 80s.

They’re processing things from years ago that have been tucked away in other spaces and they’re dealing with new issues, whether that be medical illnesses, caregiver stress – whatever the case may be. There’s older issues as well as newer issues. 

I didn’t think of the backlog. That there might also be early issues, trauma. 

I’ve been thinking about aging, as you mentioned, and the things that come along with aging, like losing abilities or losing people, that may make some tend towards depression. 

ANGELA: I do hear the word burden a lot. It’s always interesting, some of the words are similar in different sessions. They don’t want to be a burden to their children or other family members, or they’re isolated, so they don’t want to be a burden. That’s always a little red flag for me whenever I hear that word. 

BETH: Yes, that’s a small word but huge in the topic that you’re actually wanting to talk about because of perceived and real burden.

Yes. When you hear that, you’re like, ding, ding, ding, red flag!

Even if they don’t reach the thresholds with the screening tools, I say, “Do you feel like you would benefit from being able to talk to somebody?”

So regardless of the value, it’s the perceived burden or the perceived need that I will act on. I actually encourage folks to call me. I only get to see them once a year, but if they need to get in to see someone, let me do that, get out those questionnaires. Regardless of the value, I will put in an order and we’ll get you to talk to somebody.

Oh, that’s good. That’s great to hear. So you’re dealing with an older population. They come in and they have a lot of general issues. What are other red flag issues?

BETH: One of the things that I do see a lot is depression over losses, bereavement, peers that are going away, family members that were taken suddenly or untimely, and they’re really having a very difficult time with that. That’s one of the things that I refer to Angela for is the processing of that grief. We also give resources for free grief counseling in the community.  Some people feel like one-to-one, some people feel like a group. 

So community bereavement services. 

What we do is try to be in front of things. 

When my mom died, my father and I took advantage of the Duke Bereavement Services. It was really helpful for both of us. 

BOTH: Oh, wonderful! Great.

So you’re prevention, you’re upfront.

BETH: So I am prevention, absolutely. Angela’s treatment. 

What can you say about that, Angela?

Well, it depends on the severity. In counseling there’s just a mode— what’s really more of an acronym, it’s called SLAP. 

• How Specific is a plan?
• How Lethal is it?
• How much Access, like a gun or medication? 
• If there is a Plan.

Once you’re screening someone–and a lot of this is just conversation, it’s not like I’m ticking off boxes. I’m just trying to get a natural, organic conversation going, 

“Have you ever really thought about suicide? 

What does that look like for you? 

Do you have access to that? 

Is there a plan?” 

It depends on the tier that they go through. “No, it’s just, it’s just something I think about because I don’t want to be a burden.”

That’s passive ideation. We’re going to keep a temperature on that. Typically I see patients at least twice a month or once a month depending on where they land on our initial assessments and depending on the needs of the patient. If they’re feeling like this is working for them, like if they need that space to talk. If it progresses, then we’re definitely going to escalate that to a little bit more of an inpatient setting.

If they come in, they’re having ideation, when they leave, I’ll typically give them access to the 988 number or make sure they have a resource to call if it’s 3 in the morning and things are just not going well for them. If not, then I will escalate that to psychiatry for a mental health examination or psychiatric examination because it could be something that’s off, like a chemical imbalance. Our bodies change as we get older. We want to see what else is going on.

It’s not just contained in that one room.

Glad to hear that because I know, you know, as we get older, our medications may increase and that can create symptoms that look like dementia, for instance. 

Exactly. Yeah.

BETH: And they do masquerade as each other. Speaking of red flags, one of the things I look for is if someone comes in with their service cap on: Marines, Navy, Army, the jackets, military symbols. That can be a flag. These folks know guns, they know how to use them, and they know what they’re used for.

The national statistics on gun safety and suicide finds that guns are the number one mechanism of suicide in the 65 and older population. 

85-year-old men, apparently. 

Yes, and peaking at 85. It’s men more than women, whites over Black, etc. 

With every patient that I screen, I also say, everybody always thinks about guns. Even if they don’t have a gun or they do have a gun, I say our concern is the safety of the people in the house. Are any guns locked and loaded, or locked away, keys separate, ammunition stored separately?

We follow the SAFE guidelines. The SAFE-T (Suicide Assessment Five-Step Evaluation and Triage) tool helps health workers check if a person might try to hurt themselves. The five steps are:

• Identify risk factors, 
• Identify protective factors, 
• Conduct a suicide inquiry, 
• Determine risk level and interventions, 
• Document the plan. 

There are some adults who shouldn’t be around guns, like friends or family with memory problems, PTSD, substance use, thoughts of suicide.

Even if they say, “I don’t have a gun,” I say “Are there children in your home, are there friends or family?” I go through it to make sure that we’ve heightened awareness. That’s really where I try to elevate, is the heightened awareness (that there is a potential for danger to others).

That’s really important. What happens next? I guess you’ve told me the next steps, which would be to get a psychiatrist and then possibly go off to treatment or ICU.

BETH:  I cannot IVC someone, which is involuntary commitment.

ANGELA: I will emphasize, if someone is having suicide ideation and they’re ticking all the boxes, we don’t leave them alone. You don’t let them leave because they have to stay in your presence and you want them to, because clearly they’re going through something. They need support. They need support.

BETH: We will make sure that that person— it’s a handoff. It’s not, go up here, go home and call this person. Right. We’re taking you to this person.

IVC might look like a transport to the emergency department where they’re evaluated by our colleagues who are much better equipped: a physician, number one, because they may be seeing me without a physician to visit. They may be coming in to see Angela as a standalone visit.

Our colleagues in the community might be supporting us to the next step, which looks like mental health evaluation at that point, and then paperwork for involuntary commitment if they endorse the fact that the patient is of harm to themselves and/or others. And there’s a 72-hour hold with that.

Right. What would you like people to know about suicide and suicide ideation?  

ANGELA: Normalize talking about it. Support community. Some people will say, “Talking about it causes it.” I’ve heard that before, but it doesn’t.

It really normalizes, “Wow, other people have felt this way or think this way and it’s okay to ask for help, that it’s safe to ask for help.” It’s preferred that you ask for help so that we can lower the temperature on it, so that we check in about their community support, making sure people are not isolating, calling a friend, just checking in. 

Beth mentioned grief.

BETH: Grief is a big thing because when patients get to this stage, it’s not just that their partner passed. It could be that their siblings have passed, their aunts and uncles have passed. I’ve heard many patients say, “Well, everybody’s gone and I don’t have anyone.”

Part of the wellness visit with that structure of once a year visit with me, is: they hear it. I  always say, “Talk about it.” I don’t care whether you share it up, share it out, just tell  it because we cannot help you if we don’t know about it.

ANGELA:  I usually highlight the fact that if your mood is keeping you from doing important things that you want to do, that’s when we move. If you hear someone say, “I used to like to do these things and I don’t anymore,” and I’ll ask, “Well, what changed? What’s changed for you? And then “How do we change it back?”

What do we need to put in place for you that you don’t have now, that you did once have?

That’s great. One of the things that I’ve been hearing— I just spoke with a psychiatrist. She was talking about the fact that men are reluctant to seek help and the disparity between genders.

BETH: That is a real issue.

And social isolation, of course, is a huge issue. Social Participation is actually a domain in the Durham Comprehensive Aging Plan, which we are the backbone agency for.

BETH: Yes, I would agree with that too.

ANGELA: Absolutely. Absolutely.

BETH: I normalize trying to talk about their mood. I really do.

I have to ask those questions if they’ve not already answered them. We do provide self-reporting, but if they don’t fill out through the iPad or the opportunity before their visit to share that information, I do ask those. I did have a gentleman who was in the military who had a gun in every room in his house. He even said, “When it’s my time to go, you won’t know about it. I’ll step out in the backyard and take care of it.”  

That’s the stoic white male. Ultimately, he did find out for various reasons that he could no longer have firearms in his home because of a caregiver concern. And they were removed, all of them.

In order to keep his caregiver, he elected to give those up. But that’s what the conversation, opening the door, talking about it can do, right? 

Yes, I was just talking with someone who was collecting data for the city with these really neutral, benign health surveys, and she said it was so hard to get the men to fill out the surveys. They wouldn’t even do a survey to win a smartwatch or whatever.

BETH: In terms of firearms safety Duke is one of the leaders in North Carolina. We are lucky to have a legal school, statisticians who have a branch of nothing but firearm litigation. 

Whoa.

So Duke Legal has a whole thing on nothing but firearms.

We have the School of Statistics, we’ve got the School of Medicine, we’ve got Public Health, we’ve got School of Nursing, who are all interested in participating in a hub or a center, if you will, in order to organize research on gun safety, violence prevention, injury.

We’re rolling in all of the hospitals as well. As we’re starting to do the assessments, people are becoming a little bit less afraid to ask. Not only do you have people that are afraid to tell you, you’ve got providers that don’t want to ask the hard questions.

Oh dear. 

Yeah. When we start to talk about gun safety assessment, they’ll say, “I’d rather talk about not driving than guns.”

Wow. To Angela’s point, we need to normalize the conversation.

BETH: The Center for Firearm Safety that we’re looking into building currently, whether it’s a brick-and-mortar building or just a group or virtual space that we meet in; we are trying to pull in the students like the School of Medicine and the School of Nursing to have those conversations, to go ahead and get it out there. 

I’m trying to be proactive as a population health nurse and talking about those uncomfortable things like memory, like gun safety, like driving.

It seems like with all these stigmas, there’s hardly anything to talk about. Do you know what I mean? It’s hard to have a real conversation.

I think people want to talk about them. 

Yes. 

You have to ask. They’re not going to bring it to the conversation, right? You have to ask those questions because they probably don’t want to think about it.

“I don’t know what to do with that.” But if I ask, now they have to think about it, right?

Social isolation, as we mentioned earlier, is of primary interest to AWD. Would you talk about options, please.

ANGELA: You know, the senior center might be a great idea, but if they don’t drive and they’re homebound, How do they get there? 

That’s right.

You’re isolating. How do we find other means for you to connect? If they are tech savvy, can they do online groups? Are there organizations in the community that will come to their house?

AWD is hard at work helping to get people connected to the community. Is there anything you’d care to leave with us that we haven’t covered?

BETH: The thing that I focus on is, it’s okay not to be okay. We can help. 

Okay. Again, if you can’t tell us or report it, we can’t help. So it is okay to not be okay, right?

Yes, I agree with that 100%. Yes. People think they’re unique, that the pain and anguish they suffer won’t be understood. I think sometimes it’s helpful to let people know that it’s not uncommon, right?

ANGELA: Exactly. And, you know, the mood is passing, the thoughts are passing, so we don’t want to make permanent decisions on passing thoughts. Permanent solutions to temporary problems, right? Isn’t this something we always throw out there? 

Yeah, absolutely. I love that saying.

BETH: Yeah, “Suicide is a permanent solution to a temporary problem.”  And also, “Sharing it halves the problem.” In other words, it’s not all mine anymore. I’ve shared it.

And then when— with the sharing, we can then go to the next step if needed.

ANGELA: Sometimes watchful waiting. Maybe no intervention is necessary.  

BETH: Maybe small changes in medications or the starting of a medication  if you don’t feel like talking to Angela, right? Over time, as we soften you up as we’re able, I’ve had people that wanted to go talk to Miss Angela. 

I’m always advocating to normalize the conversation.