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> Evidence-Based Practices\
> for Preventing Substance Abuse and Mental Health Problems in Older
> Adults

Excerpt: Prevention of Mental Health Problems: Suicide Prevention

Executive Summary

The prevention of substance abuse and mental health problems within the
aging population has been recognized as a national priority. The
Substance Abuse and Mental Health Services Administration's *Older
Americans Substance Abuse and Mental Health Technical Assistance Center*
(TAC) is committed to serving as a leading resource for the prevention
and early intervention of late-life substance use and mental health
problems. Despite the substantial prevalence and adverse consequences of
substance use and mental health problems in older persons and the
considerable knowledge related to preventing these problems,
evidence-based prevention and early intervention services are not widely
available nor promoted for this at-risk population. Given financial
restrictions facing many health care systems, guidance is needed to
direct limited available resources toward the provision of programs that
have proven effectiveness. To support this effort, the TAC has reviewed
the best available evidence supporting programs that target the
prevention and early intervention of substance abuse and mental health
problems in older adults.

The purpose of this review is to highlight prevention and early
intervention programs that have proven effectiveness. This report
identifies the demographic imperative for addressing late-life substance
use and mental health problems, describes the current terminology of
prevention programs and practices, provides a comprehensive review of
the published evidence base for the prevention and early intervention of
geriatric substance abuse and mental health problems based on the
empirical evidence, and describes dissemination and implementation
issues that align with state needs and priorities.

Five specific areas are addressed. These include the prevention and
early intervention of alcohol misuse, medication misuse, depression and
anxiety, suicide, and co-occurring substance abuse and mental health
problems among older adults. This review provides a comprehensive
examination of prevention programs in these areas that have been
published through September 2005.

#### Alcohol Misuse

-   Brief interventions can reduce alcohol misuse and hazardous drinking
    among older adults. Specifically, structured brief interventions and
    brief advice in health care settings have shown to be effective at
    reducing alcohol consumption in this population.

-   Little evidence is available regarding universal prevention programs
    targeted at the prevention or reduction of alcohol misuse among
    older adults. Some health education programs have demonstrated
    increased knowledge among older adults about hazardous alcohol use.

-   Recently developed screening and assessment instruments show promise
    as useful tools to improve identification of older at-risk drinkers
    and enhance clinician interactions to prevent or reduce alcohol
    misuse.

#### Medication Misuse

-   Computer-based health education tools designed for older adults have
    shown gains in knowledge and self-efficacy regarding potential drug
    interactions, as well as improvements in self-medication behaviors.

-   Clinical trials on early interventions with older adults who are at
    increased risk for medication misuse have had mixed results.
    Nonetheless, interventions with patients prior to hospital
    discharge, interventions targeted at changing provider prescription
    patterns, and home-based medication reviews show some promise to
    prevent medication misuse.

#### Depression and Anxiety

-   A moderate amount of evidence supports the effectiveness of problem
    solving therapy (PST) and exercise in preventing the onset or
    worsening of depression. In addition, targeted outreach is effective
    in engaging isolated and vulnerable older adults in mental health
    care.

-   More research is needed to determine whether other potentially
    effective strategies are effective in preventing depression,
    including: life review, reminiscence therapy, educational classes
    for older adults and providers, and mind-body wellness.

-   Minimal evidence supports prevention programs focused on late-life
    anxiety.

#### Suicide

-   Supportive interventions that include screening for depression,
    psychoeducation, and group-based activities have been associated
    with reduced rates of completed suicide among older adults.

-   Telephone-based supportive interventions have also been associated
    with a reduction in the rate of completed suicide.

-   Protocol-driven treatment of depression delivered by a care manager
    has been associated with reduced suicidal ideation.

#### Co-occurring Disorders

-   Concurrent treatment of substance abuse and depression may be
    effective in reducing alcohol use and improving depressive symptoms.

-   The evaluation and treatment of co-occurring substance use and
    mental health problems among older adults is an under-studied area.

This report highlights the evidence base for the prevention and early
intervention of substance use disorders and mental illness in older
adults. Of note, the field of prevention is far less developed than our
understanding of the diagnosis and treatment of substance abuse and
mental disorders in late-life. In particular, comparatively few
scientific efforts have focused on preventive measures, the early
identification of and intervention with high-risk individuals, and the
promotion of optimal health regarding substance abuse and mental health
concerns in late adulthood. However, this summary of the current
evidence base provides direction for both providers and consumers
regarding substance abuse and mental health prevention and early
intervention services. This information can be useful in planning and
implementing effective programs and practices, while also underscoring
future directions for research and evaluation.

Prevention of Mental Health Problems

One in five older adults has a significant mental disorder, including
more than 16 percent with a primary psychiatric illness and 3 percent
with dementia complicated by psychiatric symptoms.^1^ Depression and
anxiety disorders are among the most common mental health problems in
older persons and affect approximately 3-7 percent and 11 percent of the
general older adult population, respectively.^2^ The prevalence of other
mental health disorders such as schizophrenia and bipolar disorder is
much lower (less than 1%), although these disorders impart significant
functional impairments in older persons. As with substance abuse, the
prevalence of these disorders is heightened among persons receiving
health care in the primary care system, in outpatient mental health
settings, and in nursing homes.^3,4^

This review focuses on the universal, selective, and indicated
prevention of the most common mental health problems in older adults. We
specifically address the most prevalent conditions (mood and anxiety
disorders) and suicide. Similar to the mental health *treatment*
literature, most *prevention* programs target depressive symptoms and do
not address late-life anxiety or other mental health conditions.
Programs that target the reduction of depressive symptoms also heavily
inform our reviews of suicide prevention. We specifically excluded the
prevention of cognitive disorders, such as dementia, as this area
includes a relatively large, rapidly growing, and complex research
literature that is outside the scope of this review. The exclusion of
dementia is based on the premise that the prevention and treatment of
cognitive impairment disorders are most commonly addressed outside of
the mental health care system and are, thus, less pertinent to state and
local substance abuse and mental health care service providers and
administrators.

# Suicide Prevention

Suicide is the ninth leading cause of death among all persons in the
United States ^5^ and is disproportionately common among older adults.
Older adults (age 65+) represent 13 percent of the U.S. population,^6^
yet account for nearly one fifth of U.S. suicides.^5^ Men account for 82
percent of suicides among older adults and have a higher suicide rate
than women (38 vs. 5.7 per 100,000 persons).^5^ Lethal means are often
used in late-life suicide. The most frequent methods of suicide among
older adults include the use of firearms (men: 77%; women: 34%) and
poisoning (men: 12%; women: 29%).^5,7^

Despite the disproportionate rate of suicide among older adults, most
suicide prevention programs have focused on younger persons.^8^ However,
prevention of suicide in older adults is of special importance for
several reasons. Older adults are less likely to report suicidal
ideation compared to younger adults, and suicide attempts are more
likely to be deliberate and lethal.^9^ Compared to younger adults, older
adults make fewer attempts per completed suicide.^5^ In addition, more
than half (58%) of older adults (age 55+) contact their primary care
provider within 1 month of completing suicide. This rate is more than
twice as high as that for younger persons (23%; age \< 35). In contrast,
only 11 percent of older persons contact a mental health provider in the
month prior to suicide, a rate that is three times less frequent than
that of younger persons.^10^ It is noteworthy that older adults with
active suicidal ideation are more likely to engage in integrated mental
health and substance abuse services provided in a primary care setting,
as opposed to services provided through specialty mental health clinics
(83% vs. 54%).^11^

Early research has identified several risk factors for suicide.
Non-modifiable risk factors include older age, male sex, race, and
ethnicity.^9^ However, several risk factors are modifiable, including
the presence of suicidal thoughts and behavior, the presence of a
physical or mental illness, alcohol consumption, difficulty adjusting to
transitional life events, social support problems, personality
vulnerability factors, hopelessness, bereavement, and access to lethal
means.^9,12^ Significant risk factors for suicide also include
depression ^13-15^ and substance abuse.^16,17^ Of note, co-occurring
substance abuse and mental disorders are associated with an increased
risk for suicide among older adults.^15,18^ Moreover, benzodiazepines
have been linked with suicide among older adults who have poisoned
themselves.^19^

Several search strategies were used to identify programs addressing the
prevention of suicide among older adults. The PubMed, PsychInfo, CINAHL,
Ageline, Social Services Abstracts, and ERIC databases were used to
identify published literature using a combination of search terms:
suicide, suicidal ideation, prevention, and older adults. Bibliographic
searching helped identify additional references. Other search strategies
were also employed, including searches through Google, federal and
foundation grant databases, the Center for the Study of the Prevention
of Suicide (CSPS), the American Foundation for Suicide Prevention
(AFSP), and the online registry of the Evidence-based Practices in
Suicide Prevention Program.^8^ *(Of note, the online registry reviewed
14 suicide prevention programs through January 2005. Future reviews of
suicide prevention programs will be conducted through the SAMHSA NREPP
process. Among the 14 prevention programs, only one focused on older
persons (age 60+) and nine focused on school-aged children. Four
programs were identified as effective, eight were identified as
promising, and two did not receive a rating.)*

The following section describes the evidence supporting approaches to
the prevention of suicide among older adults. Although national
strategies have been developed to address suicide ^20-22^ and many
sources have discussed the prevention of suicide among older
adults,^9,12,23-32^ only a handful of studies have evaluated the
effectiveness of interventions on reducing completed suicide or suicidal
ideation among older adults. The literature describing universal
prevention of suicide among older adults is largely based on Japanese
studies, with results from indicated and selective interventions derived
from American and Italian studies. Universal prevention programs are
described in Table 1 and consist of screening for depression,
psychoeducation, and group activities. Indicated and selected prevention
strategies are described in Table 2 and include treatment of depression
and the provision of telephone-based support. A review of these programs
is also provided within the text.

## Universal Prevention Strategies

The evidence base supporting the universal prevention of geriatric
suicide is minimal. Very few programs have attempted to reduce the rate
of suicide among older adults using a community-wide approach. However,
studies by Oyama and colleagues describe universal prevention programs
that provide screening for depression, psychoeducation, and group
activities. Please see Table 1 for further details regarding each study.

Oyama and colleagues^33^ evaluated the effectiveness of a universal
depression screening program, followed by mental health or psychiatric
care, and depression education in a rural, agricultural community in
Japan. Older residents (age 65+) completed the Japanese version of the
Zung Self-Rated Depression Scale. Those individuals who screened
positive were evaluated or provided treatment by a public health nurse
or a psychiatrist (if warranted). Educational health workshops were
offered to residents, including information regarding the signs,
symptoms, and potential treatments for depression, along with
information on using the mental health system, and developing
relationships with other community members and neighbors. The
intervention was associated with a reduction in suicide rates of 73
percent among older men and 76 percent among older women, compared to no
risk reduction in older men or women in the comparison regions. Suicide
completion in the pre-implementation to post-implementation phase
decreased from 11 to 4 for men and from 16 to 6 for older women. In
contrast to other suicide prevention programs, this program showed
effectiveness for both genders.^33^

Oyama and colleagues^34^ also evaluated the effectiveness of a
three-component universal prevention program targeting older members of
a rural agricultural community in Japan (age 65+). The first component
included local and regional mental health workshops at which a public
health nurse or psychiatrist provided group psychoeducation on
depression and risk for suicide. The second component included a group
activity program that provided opportunities for older adults to
participate in social, volunteer, recreational, and exercise activities
and was designed to promote and enhance the development of social
relationships. Finally, a self-report depression questionnaire was
distributed to older adults. Older adults were provided a description of
how to evaluate their responses and a referral to a psychiatrist or
public health nurse was provided to those who required a consultation.
Evaluation of this program showed that the incidence of suicide
decreased in older women during the 8-year period following program
implementation, as compared to the 8-year period prior to program
implementation. No reduction in suicide was seen among the control
group, nor was it seen among older men in the intervention region.^34^

#### *Assessment*

Few scales have been developed specifically for the assessment of
suicide risk or suicidal ideation among older adults. The Harmful
Behaviors Scale (HBS) is a 20-item scale that is scored based upon
observations of direct and indirect self-destructive behavior among
nursing home residents. While this instrument has internal consistency
and interrater reliability, it is limited in its reliance on observer
ratings.^35,36^ Two other instruments have been developed that have
potential merit in detecting and measuring suicidal ideation among older
adults; however, these instruments are longer and have yet to be fully
evaluated. They include the Reasons for Living Scale -- Older Adults
version (RLS-OA) and the Geriatric Suicide Ideation Scale (GSIS).^9^ The
development and testing of additional tools for evaluating suicide and
its prevention may be a useful addition to this field.^29^

## Selective and Indicated Prevention Strategies

The evidence base for indicated and selective prevention of suicide
among older adults is also small. Programs that target the reduction of
modifiable risk factors include depression treatment and telephone-based
social support. Please see Table 2 for further details.

Szanto and colleagues^37^ recently examined the course of suicidal
ideation among older adults (ages 59 -- 95) receiving short-term
treatment for depression. This secondary analysis evaluated 395 persons
with major depression receiving inpatient or outpatient treatment with
antidepressant medication alone or in combination with interpersonal
psychotherapy. Suicidal ideation rapidly decreased during the initial
stages of treatment and then declined more gradually. After 12 weeks of
treatment, only 18.4 percent of participants reported suicidal ideation,
thoughts of death, or feelings that life is empty, compared to 77.5
percent at the beginning of treatment. Moreover, after 12 weeks of
treatment, only 4.6 percent continued to report thoughts of death,
compared to 36.2 percent at the beginning of treatment. The decrease in
suicidal ideation was more gradual for those with a recent suicide
attempt or current suicidal ideation (median response time: 6 weeks) or
with recurrent thoughts of death (median response time: 5 weeks),
compared to those with no suicide attempt, suicidal ideation, or
thoughts of death (median response time: 3 weeks). This study suggests
that suicidal ideation can resolve among older adults receiving active
treatment for depression. However, it is noteworthy that individuals
with the most severe risk for suicide require treatment for an average
of 1½ months to see significant reductions in suicidal ideation.

Bruce and colleagues^38^ evaluated the effect of the Prevention of
Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) on
reducing suicidal ideation among older adults (age 60+) with depression.
PROSPECT combines depression treatment guidelines with depression care
management. Guidelines consist of a clinical algorithm for treating
geriatric depression in a primary care setting and are modified to
address the special circumstances associated with the treatment of
depression in older adults, including adverse events, medical
comorbidity, functional disability, cognitive functioning, and social
stigma. A "depression care manager" who works with the primary care
physician and a supervising psychiatrist conducts care management. Data
suggest that suicidal ideation resolves more quickly in patients
receiving care through a depression care management model employing
geriatric specific guidelines, compared to those receiving usual care.
PROSPECT participants had significant reductions in suicidal ideation by
4 and 8 months, compared to usual care. Of note, reductions were greater
among those diagnosed with major depression, compared to those with
minor depression. The intervention was also associated with reductions
in depression at 4, 8, and 12 months, compared to usual care. Specific
protective factors increased through the PROSPECT intervention included
the effective clinical care for mental, physical, and substance use
disorders as well as easy access to a variety of clinical interventions
and support for help-seeking. The intervention sought to decrease risk
factors, including barriers to accessing health care and the presence of
untreated mental illness. PROSPECT has been identified as an "effective"
selective and indicated prevention program by the registry of
evidence-based suicide prevention programs.^39^

DeLeo and colleagues^40^ evaluated the effectiveness of the
TeleHelp-TeleCheck service for suicide prevention among older persons in
Italy (age 65+). The program targeted older persons with a variety of
risk factors, including disability, social isolation, psychiatric
problems, poor compliance with hospital outpatient care instructions, or
individuals waiting for institutional admission. At-risk older persons
were referred by their health care physician or social worker to the
TeleHelp-TeleCheck service. Participants were provided with a remote
alarm device used to trigger a response network (TeleHelp). In addition,
TeleCheck included short, informal, twice-weekly telephone interviews by
trained staff. These checks were used to evaluate participant welfare
and to provide emotional support. Participants were also able to call
the TeleCheck line on a 24-hour basis. This service was evaluated over
an 11-year period among more than 18,000 older Italians. The
intervention was successful in reducing the number of observed suicides
among older women, though it did not significantly lower the rate of
completed suicides among older men. In addition, the TeleCheck component
of the intervention has been associated with fewer requests for
physician home visits, hospital admissions, and depression severity.^40^

In addition to the few studies that have specifically addressed the
reduction of suicide or suicidal ideation among older adults, several
other programs have concurrently targeted both younger and older adults
(not shown in tables). For example, a program in Gotland, Sweden
provided education to primary care physicians to improve treatment of
depression and lower rates of suicide. The rate of suicide decreased
following physician training; however, the rate of suicide increased 2
years after the completion of training. The small number of completed
suicides and the lack of focus on older adults makes it difficult to
draw conclusions from this study.^41,42^ In contrast, placing limits on
analgesic packaging has been defined as an "effective" universal
prevention program within the registry of evidence-based suicide
prevention programs.^43^ Due to high numbers of self-poisoning
associated with analgesics, the United Kingdom passed legislation in
1998 to limit pack sizes of analgesics to 32 tablets per sale at a
pharmacy and 16 tablets per sale at non-pharmacy locations. Printed
warnings regarding dangers of overdose were also provided. Rates of
self-poisoning in the United Kingdom among persons aged 12 and above
were evaluated over a 6-year period through a naturalistic design.
Packaging limitations, which restricted access to a lethal means of
suicide, were associated with a significant decrease (22%) in
self-poisoning with analgesics.^44,45^ The effectiveness of this
approach has not been evaluated in the United States, nor has it been
evaluated specifically among older adults.

## Conclusions

A review of the current evidence supporting the universal, selective,
and indicated prevention among older adults suggests that current
prevention programs can reduce the rate of suicide among older women,
but have shown more limited effectiveness among older men. Supportive
interventions appear to be effective for older women. There is a need,
however, for alternative interventions targeting suicide prevention
among older men. Of note, several of the prevention strategies have been
developed and evaluated in other countries (including Japan and Italy).
While these programs have shown effectiveness in their original setting,
it is possible that differences in health care systems and
characteristics of the older adult populations may limit their
generalizability to samples and settings in the United States.

Although there is little data to support the prevention of older adult
suicide, national strategies endorse science-based suicide prevention
initiatives. The following goals and objectives have been specifically
adapted from the National Suicide Prevention Strategy to meet the needs
of older adults:^22,29^

-   Promote awareness that suicide in older adults is a public health
    problem that is preventable;

-   Develop broad-based support for elder suicide prevention;

-   Develop and implement strategies to reduce the stigma associated
    with aging and with being a senior consumer of mental health,
    substance abuse, and suicide prevention services;

-   Develop and implement community-based suicide prevention programs
    for older adults;

-   Promote efforts to reduce access to lethal means and methods of self
    harm by older adults;

-   Implement training for recognition and assessment of at-risk
    behavior and delivery of effective treatment to older adults;

-   Develop and promote effective clinical and professional practices;

-   Improve access to and community linkages with mental health,
    substance abuse, and social services designed for the evaluation and
    treatment of older adults in primary and long-term care settings;

-   Improve reporting and portrayals of suicidal behavior, mental
    illness, and substance abuse among older adults in the entertainment
    and news media;

-   Promote and support research on late-life suicide and suicide
    prevention;

-   Improve and expand surveillance systems;

-   Implement interventions that improve social relations and decrease
    isolation in older adults; and

-   Increase access to geriatric specialty health care.

Future directions for the prevention of suicide among older adults may
include community-based educational initiatives that attempt to
de-stigmatize help-seeking, greater use of mental health screening and
treatment among older adults, education of stakeholders (including
gatekeepers who could serve an important role in identifying at-risk
older adults), and training of health care providers in suicide risk and
protective factors.^9^ Prevention of suicide should focus on
age-specific risk and protective factors that address differences
associated with race, ethnicity, and gender.^5^ While emphasis should be
placed on universal prevention strategies that stress educational
interventions, their combination with selective and indicated strategies
offers the most hope for effecting significant reductions in late-life
suicide rates.^29^ For instance, preventing or reducing problem drinking
and depressive symptoms, particularly in combination, is likely to
reduce risk for suicidal ideation and suicide. Finally, special
attention should be placed on the identification and treatment of older
adults with suicidal ideation in primary care.

Table 1. Universal prevention of late-life suicide

  ---------------------------------------------------------------------------------------------------------------------------------
  Reference   Study Design         Model/Conditions   Age   Sample           Followup        Outcome         Limitations/Comments
                                                                                             Measures and    
                                                                                             Results         
  ----------- -------------------- ------------------ ----- ---------------- --------------- --------------- ----------------------
  Oyama, et   Quasi-experimental   Screening for      65+   7,070 residents  5-year          Suicide         Non-randomized, time
  al., 2004                        depression,              of a rural       intensive       mortality in    series analysis could
  ^33^                             followup with            agricultural     period; 5-year  the             allow for a regression
                                   mental health care       region in Japan  maintenance     intervention    to the mean; program
                                   or psychiatric           covering         period,         area decreased  not utilized by all
                                   treatment, and           multiple         compared to     by 73% among    older members in the
                                   health education         municipalities   5-year          men and 76%     region.
                                   on depression.           (Joboji),        preparation     among women     
                                   Comparison group         compared to a    period and      over 10-year    
                                   did not receive          neighboring      5-year baseline study period    
                                   these services.          region (Iwate).  period.         compared to the 
                                                                             Approximately   10-year         
                                                                             30-60% of       baseline and    
                                                                             eligible older  preparation     
                                                                             adults          periods. No     
                                                                             participated in change was seen 
                                                                             program.        in rate of      
                                                                                             suicide among   
                                                                                             residents of    
                                                                                             the comparison  
                                                                                             region.         

  Oyama, et   Quasi-experimental   Group activities,  65+   6,817 residents  8-year period   A 76% reduction Non-randomized, time
  al., 2005                        psychoeducation,         of a rural       prior to        in suicide was  series analysis could
  ^34^                             and                      agricultural     intervention,   seen among      allow for a regression
                                   self-assessment of       region in Japan  compared to     females         to the mean,
                                   depression               covering         8-year period   (age-adjusted   intervention only
                                   available to all         multiple         after beginning incident rate   effective for females,
                                   older members of a       municipalities   of              reduction of    program not utilized
                                   region. Comparison       (Yuri town),     intervention.   0.24;           by all older members
                                   group did not            compared to a                    confidence      in the region.
                                   receive these            neighboring                      interval (0.10  
                                   services.                region (Chokai                   -- 0.58). No    
                                                            town).                           change seen in  
                                                                                             rate of suicide 
                                                                                             among men or in 
                                                                                             the comparison  
                                                                                             region.         
  ---------------------------------------------------------------------------------------------------------------------------------

Table 2. Selective and indicated prevention of late-life suicide

+-----+-----+--------+----+----------+-------+------------+----------+
| Ref | St  | Mode   | A  | Sample   | Fol   | Outcome    | Limi     |
| ere | udy | l/Cond | ge |          | lowup | Measures   | tations/ |
| nce | Des | itions |    |          |       | and        | Comments |
|     | ign |        |    |          |       | Results    |          |
+=====+=====+========+====+==========+=======+============+==========+
| De  | Qua | TeleHe | 6  | 18,641   | 11    | Observed   | Non-ran  |
| L   | si- | lp-Tel | 5+ | older    | -year | suicides   | domized, |
| eo, | exp | eCheck |    | adults   | pe    | were       | inte     |
| et  | eri | se     | M  | in the   | riod. | sig        | rvention |
| a   | men | rvice: | ea | Veneto   | 13%   | nificantly | only     |
| l., | tal | Twice  | n: | region   | of    | lower than | e        |
| 2   |     | weekly | 80 | of       | the   | expected   | ffective |
| 002 |     | tel    | .0 | Italy.   | pa    | (o         | for      |
| ^   |     | ephone | [+ | Most     | rtici | bserved=6; | females. |
| 40^ |     | s      | ]{ | part     | pants | exp        | A        |
|     |     | upport | .u | icipants | st    | ected=21). | previous |
|     |     | and    | nd | were     | opped | Resulted   | exa      |
|     |     | eme    | er | widowed  | using | in         | mination |
|     |     | rgency | li | (68%),   | the   | sig        | of this  |
|     |     | re     | ne | females  | se    | nificantly | program  |
|     |     | sponse | }6 | (84%),   | rvice | fewer      | resulted |
|     |     | for up | .8 | lived    | d     | suicides   | in       |
|     |     | to     | y  | alone    | uring | among      | re       |
|     |     | 20,000 | ea | (73%),   | the   | women      | ductions |
|     |     | p      | rs | and were | fol   | (n=2) than | in       |
|     |     | ersons |    | p        | lowup | expected,  | requests |
|     |     | re     |    | artially | (45%  | but no     | for home |
|     |     | ferred |    | self-su  | due   | difference | visits   |
|     |     | by     |    | fficient | to    | in         | by       |
|     |     | g      |    | (63%).   | d     | suicides   | general  |
|     |     | eneral |    |          | eath, | among men  | practi   |
|     |     | p      |    |          | 21%   | (n=4),     | tioners, |
|     |     | ractit |    |          | due   | compared   | hospital |
|     |     | ioners |    |          | to    | to         | adm      |
|     |     | or     |    |          | i     | expected   | issions, |
|     |     | social |    |          | nstit | number     | and      |
|     |     | wo     |    |          | ution | (n=9).     | de       |
|     |     | rkers. |    |          | aliza |            | pression |
|     |     |        |    |          | tion, |            | scores.  |
|     |     |        |    |          | and   |            |          |
|     |     |        |    |          | other |            |          |
|     |     |        |    |          | due   |            |          |
|     |     |        |    |          | to a  |            |          |
|     |     |        |    |          | move  |            |          |
|     |     |        |    |          | out   |            |          |
|     |     |        |    |          | of    |            |          |
|     |     |        |    |          | the   |            |          |
|     |     |        |    |          | a     |            |          |
|     |     |        |    |          | rea). |            |          |
+-----+-----+--------+----+----------+-------+------------+----------+
| S   | Sec | Active | 5  | 395      | 12    | Reports of | R        |
| zan | ond | tre    | 9+ | in       | w     | suicidal   | eduction |
| to, | ary | atment |    | patients | eeks. | ideation,  | in       |
| et  | an  | for    | Ra | and      |       | thoughts   | suicidal |
| a   | aly | depr   | ng | out      |       | of death,  | ideation |
| l., | sis | ession | e: | patients |       | or         | took an  |
| 2   | of  | with   |    | with     |       | feelings   | average  |
| 003 | th  | an     | 5  | major    |       | that life  | of 1.5   |
| ^   | ree | tidepr | 9- | de       |       | was empty  | months.  |
| 37^ | R   | essant | 95 | pression |       | decreased  | S        |
|     | CTs | medi   |    | and      |       | from 77.5% | econdary |
|     |     | cation | M  | active   |       | to 18.4%.  | analysis |
|     |     | or     | ea | t        |       | Decrease   | of       |
|     |     | i      | n: | reatment |       | in         | outcome  |
|     |     | nterpe | 72 | with     |       | suicidal   | data     |
|     |     | rsonal | .0 | antide   |       | ideation   | from a   |
|     |     | ps     | [+ | pressant |       | took more  | com      |
|     |     | ychoth | ]{ | me       |       | time for   | bination |
|     |     | erapy. | .u | dication |       | those with | of       |
|     |     |        | nd | alone or |       | a recent   | studies. |
|     |     |        | er | in       |       | suicidal   |          |
|     |     |        | li | com      |       | attempt or |          |
|     |     |        | ne | bination |       | current    |          |
|     |     |        | }7 | with     |       | ideation.  |          |
|     |     |        | .4 | inter    |       |            |          |
|     |     |        |    | personal |       |            |          |
|     |     |        |    | therapy. |       |            |          |
+-----+-----+--------+----+----------+-------+------------+----------+
| Bru | Mul | PR     | 6  | Urban    | 4-,   | Rates of   | The      |
| ce, | tis | OSPECT | 0+ | primary  | 8-,   | suicidal   | inte     |
| et  | ite | trial  |    | care     | and   | ideation   | rvention |
| a   | RCT | (Prev  | Ra | patients | 12-   | differed   | group    |
| l., |     | ention | ng | with     | month | at         | had      |
| 2   |     | of     | e: | major or | foll  | baseline,  | greater  |
| 004 |     | S      |    | minor    | owup. | but were   | suicidal |
| ^   |     | uicide | 6  | dep      | After | similar by | ideation |
| 38^ |     | in     | 0- | ression. | 12    | 4-, 8-,    | at       |
|     |     | P      | 94 | 72%      | mo    | and        | baseline |
|     |     | rimary |    | female.  | nths, | 12-month   | and thus |
|     |     | Care   |    | 28%      | 31%   | i          | greater  |
|     |     | El     |    | min      | of    | nterviews. | imp      |
|     |     | derly: |    | orities. | the   | Raw rates  | rovement |
|     |     | C      |    | Part     | in    | of         | in the   |
|     |     | ollabo |    | icipants | terve | suicidal   | inte     |
|     |     | rative |    | ra       | ntion | ideation   | rvention |
|     |     | T      |    | ndomized | and   | declined   | group    |
|     |     | rial). |    | to       | 31%   | 12.9% in   | may      |
|     |     | Depr   |    | PROSPECT | of    | the        | r        |
|     |     | ession |    | or usual | the   | in         | epresent |
|     |     | tre    |    | care by  | usual | tervention | re       |
|     |     | atment |    | site.    | care  | and 3.0%   | gression |
|     |     | guid   |    |          | group | in usual   | to the   |
|     |     | elines |    | Inter    | had   | care.      | mean.    |
|     |     | for    |    | vention: | dr    | Among only | De       |
|     |     | older  |    | n=320    | opped | those      | pression |
|     |     | adults |    |          | out.  | patients   | scores   |
|     |     | c      |    | UC:      |       | with       | also     |
|     |     | oupled |    | n=278    |       | suicidal   | improved |
|     |     | with   |    |          |       | ideation   | more in  |
|     |     | care   |    |          |       | at         | the      |
|     |     | manag  |    |          |       | baseline,  | inte     |
|     |     | ement, |    |          |       | there was  | rvention |
|     |     | co     |    |          |       | sig        | group.   |
|     |     | mpared |    |          |       | nificantly | Effects  |
|     |     | to     |    |          |       | greater    | on       |
|     |     | usual  |    |          |       | reduction  | suicidal |
|     |     | care   |    |          |       | in         | ideation |
|     |     | (UC).  |    |          |       | suicidal   | were     |
|     |     |        |    |          |       | ideation   | more     |
|     |     |        |    |          |       | at 8       | pr       |
|     |     |        |    |          |       | months in  | onounced |
|     |     |        |    |          |       | the        | in those |
|     |     |        |    |          |       | in         | with     |
|     |     |        |    |          |       | tervention | major    |
|     |     |        |    |          |       | group      | de       |
|     |     |        |    |          |       | compared   | pression |
|     |     |        |    |          |       | to the     | compared |
|     |     |        |    |          |       | usual care | to those |
|     |     |        |    |          |       | group.     | with     |
|     |     |        |    |          |       | D          | minor    |
|     |     |        |    |          |       | ifferences | dep      |
|     |     |        |    |          |       | in         | ression. |
|     |     |        |    |          |       | suicidal   | It is    |
|     |     |        |    |          |       | ideation   | not      |
|     |     |        |    |          |       | among this | known    |
|     |     |        |    |          |       | subgroup   | how      |
|     |     |        |    |          |       | did not    | suicidal |
|     |     |        |    |          |       | differ at  | ideation |
|     |     |        |    |          |       | 4 or 12    | is       |
|     |     |        |    |          |       | months.    | r        |
|     |     |        |    |          |       |            | eflected |
|     |     |        |    |          |       |            | in       |
|     |     |        |    |          |       |            | suicidal |
|     |     |        |    |          |       |            | b        |
|     |     |        |    |          |       |            | ehavior. |
+-----+-----+--------+----+----------+-------+------------+----------+

Research Needs and Future Directions

Attention to the prevention and appropriate treatment of substance abuse
and mental health problems was identified as a major priority for older
adults by the President's New Freedom Commission on Mental Health.^46^
As identified in this review, there is a need for organizing,
disseminating, and understanding evidence-based prevention and early
intervention programs for late-life substance abuse and mental illness.
While progress has been made in understanding the effectiveness of these
programs and practices for older adults, there are challenges to
matching these models to different service settings and different
subgroups of older adults.

The growth in the aging population will have a significant impact on the
substance abuse and mental health service delivery systems.^1,47,6^ In
anticipation of this growing problem, it is essential that substance
abuse and mental health services meet the specific needs of older
adults. For instance, cohorts of the young-old (e.g., baby boomers) and
the old-old have different patterns of service utilization and different
perceptions of stigma associated with receiving care for substance use
or mental health disorders. Moreover, the prevalence of substance abuse,
mental health disorders, and suicidal ideation vary across ethnic
groups.^15,48-53^ Mental health services are infrequently utilized by
older minority populations ^54^ and lower utilization rates may be
associated with limited access, stigma, distrust of mental health
providers, and limited availability of culturally-competent
services.^55,56^ The lack of information on specific ethnic differences
and culturally-appropriate service provision represents a limitation of
the current evidence base. A greater understanding of cultural and
ethnic differences is needed to enhance the ability to provide
appropriate prevention and early intervention to older minorities with
substance use and mental health disorders. For instance, social
marketing associated with universal prevention interventions should be
specifically tailored to cultural and language differences of ethnic
groups. In addition, cultural competence should be enhanced across the
full spectrum of prevention interventions.

This report provides a comprehensive review of the evidence for
prevention and early intervention of alcohol abuse, medication misuse,
depression and anxiety, suicide, and co-occurring disorders in older
adults. As indicated by our findings, the development of preventive
interventions associated with substance abuse surpasses that associated
with mental health problems. However, the development and rigorous
evaluation of programs that target both of these areas are sorely
needed. In addition, there is a need to identify methods to
appropriately translate information from clinical trials and research
settings into the health care arenas where older adults most frequently
receive care, and into social services settings where they receive other
needed services. Likewise, population-based programs that target broad
audiences of older adults may also offer hope for the universal
prevention of substance use and mental health problems. In summary,
substance use and mental health problems pose significant risks for the
functioning and well-being of older adults. Although several prevention
and early intervention programs have been developed, there is a
considerable need for dissemination and implementation of effective
programs, as well as for further research aimed at the development and
testing of novel programs.

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