OTHER ARTICLES
Scientific Autobiography Yeates Conwell, M.D. o be asked to provide a scientific autobiography for the American Journal of Geriatric Psychiatry is a high honor indeed. The first question one asks when such an invitation arrives is, “What can I possibly say that would be of interest?” The second reaction might be, at least for those of us who equate older age with the experience, perspective, and wisdom that may warrant such an invitation, “There must be some mistake. I’m not nearly old enough!” The third is a recollection that to have achieved an age when one’s story may be of some use to others is the real honor and privilege. The predominant focus of my work over 30 years has been suicide and its prevention in older adults. I am fortunate to have discovered early on my “mission”—to advance the well-being of older adults through research, workforce development, and patient-centered clinical care. Through a series of developmental steps that I will relate here, I settled on late-life suicide prevention—a relatively unstudied topic at the time that was of substantial public health significance and enabled me to move ahead in a systematic fashion, generally following the prevent research cycle1 through three general phases of my research career (Figure 1). Each step forward, without exception, resulted from productive collaborations with others— mentors, mentees, and other colleagues who had vital perspectives to contribute and each of whom helped make the journey fun.
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DEFINING THE MISSION Some people discover the challenges and rewards of working with older adults later in their careers; too
many never realize them at all. I had the good fortune of realizing very early that it was an area in which I would concentrate my efforts. No doubt that tendency (I hesitate to call it a “decision” at its earliest stages) derived from the influence of grandparents and other role models of successful aging in childhood and adolescence. My interest crystalized as an intellectual and potential professional focus during my undergraduate years, when I worked as an aide in the Eugene duPont Memorial Convalescent Hospital in Wilmington, Delaware. There I learned how to transfer, toilet, bathe, and feed people, both old and young, who had been disabled by strokes or traumatic injuries. One person with whom I worked was a young man about my own age who suffered a cervical fracture in a motorcycle accident that left him quadriplegic. Somehow we managed the challenges of his slow and laborious rehabilitation together as partners in his care. He taught me humility (“There but for the grace of God go I”) and the power of “healing touch.” Many others for whom I provided care were older adults who struggled following strokes or falls to recapture their independence, or, where that was not possible, to find alternative capacities and meanings in their lives. The great majority did, working hard and drawing on deep wells of resilience. Inspired by them all, I came away wanting to understand where that strength came from, but also where it went in those sad instances in which the person lacked the resources or failed in their efforts to tap them. I came later to see suicide as emblematic of that failed struggle. This experience became the basis for meeting an undergraduate thesis requirement. I chose to learn and write about the emerging hospice movement, which was then in its infancy in the United States. A descriptive study enabled me to explore the philosophies,
Received July 25, 2017; accepted July 26, 2017. From the Office for Aging Research and Health Services, Center for the Study and Prevention of Suicide, Department of Psychiatry, University of Rochester Medical Center, Rochester, NY. Send correspondence and reprint requests to Yeates Conwell, University of Rochester Medical Center, 300 Crittenden Blvd., Rochester, NY 14642. e-mail:
[email protected] © 2017 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jagp.2017.07.015
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FIGURE 1.
The prevention research cycle applied.
Define the problem
Establish risk & protective factors
Develop interventions
Phase 1
policies, and practices of end-of-life care in hospitalbased and community-based residential hospice care models and in general hospital “care as usual”. The experience helped me appreciate further that context, and in particular, how healthcare is delivered and how it interacts with personal characteristics and preferences, determine trajectories near the end of life. Entering medical school, I was sure that work with older adults and those nearing the end of life would be my focus, and less sure about whether geriatric medicine or psychiatry would be the route. Experiences through the next four years reinforced for me the choice of psychiatry. I began residency training at Yale with a full year of medical internship followed by three years of general psychiatry and a one-year fellowship. At the time, in the early 1980s, psycho-geriatrics was an established subspecialty in Europe but as yet had not taken official form in the United States. Added qualifications in geriatric psychiatry were sanctioned and the first exam given in 1991. I was pleased to be among the first cohort certified. Many people influenced my decision to enter academic psychiatry and, more specifically, to develop my skills in geriatric mental health research and practice. Craig Nelson, M.D., was an especially helpful mentor and role model for his systematic approach to patient care and the seemingly effortless and joyful manner in which he integrated research into clinical practice settings. Observing, questioning, learning, hypothesizing, and testing were all part of a good day’s work on our inpatient unit. Even at that time, the University of Rochester (UR) had a distinguished reputation in geriatrics, well ahead of the curve in development of subspecialty geriatric care. T. Franklin Williams, M.D., was responsible. As the second director of the National Institute on Aging and a founding father of the field of geriatric medicine in the United States, he changed the culture of care for older adults and created
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Implement interventions
Phase 2
Evaluate and take to scale Phase 3
important models that attracted many aspiring geriatricians to the university. Early efforts in geriatric psychiatry followed suit. I was pleased then to join the UR Department of Psychiatry with that explicit objective in 1985 and have remained on the faculty since that time.
DEFINING THE STRATEGY Shortly after my arrival at UR Eric D. Caine, M.D., emerged as my primary mentor, and we have continued to work closely together since that time. Another visionary thinker, Eric was quick to point out that, given my interest in late-life psychopathology, mood disorders, and end-of-life issues, suicide offered a potentially fertile area for investigation. Besides its public health significance and poignant meaning to affected older adults and their loved ones, late-life suicide had the advantage to a young investigator of being largely unexplored through research at the time. One could emerge after a day in the library having read all available research on the topic. Caring for suicidal patients as a hospitalist and learning about the processes by which they arrived at the decision to take their own lives were essential complements to my reading of the literature. With Eric’s guidance I reached out to the Medical Examiner for our region, Nicholas Forbes, M.D., who was generous and receptive to providing access to his office and their work. I spent many hours combing through files containing forensic reviews of suicides across the age spectrum, learning the stories behind hundreds of suicides and understanding the forensic process by which determinations of manner of death were made. Building on that foundation, I applied successfully for a Geriatric Mental Health Academic Award (K07) from the National Institute for Mental Health (NIMH) in 1988 with the objective of
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Conwell developing methods for the study of late-life suicide and implementing a program of research into its correlates from a multiaxial perspective.
PHASE 1: DESCRIPTIVE EPIDEMIOLOGY Suicide is a complex topic that requires the input of multiple disciplines for a thorough and meaningful understanding. Additionally, suicide studies serve as a window into larger and more general questions of importance to the health and well-being of older adults. Although important debate should be had about whether suicide can be a “rational act” (indeed, I have been involved in many such stimulating discussions), it is a reasonable generalization that suicide represents the ultimate adverse outcome in the lives of older adults impacted by the factors that place them at risk for taking their own lives. My goal, therefore, has been to elucidate those factors and, with that knowledge, propose interventions to mitigate them. These factors, some of which are fixed and others of which are causal and potentially modifiable,2 exist across multiple domains that map onto the multiaxial structure depicted in Figure 2. It is a model that I use frequently in teaching, the value of which lies not only in the distinct structure it provides for examining factors in each of the domains, but also in emphasizing areas of overlap—the notion of convergent risk as factors in each area accrue and protective factors diminish.
FIGURE 2.
Domains of suicide risk. Adapted with permission from Conwell.3
PSYCHOPATHOLOGY
PERSONALITY, COPING STYLE
SOCIAL CONTEXT
Area of highest convergent risk
FUNCTIONING
PHYSICAL HEALTH
ACCESS TO LETHAL MEANS
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My strategy in this early phase was to address research questions in each domain and, where possible, their interactions. I did so in close collaboration with a growing cadre of colleagues and mentees who have interests and expertise in areas complementary to my own. In addition to Eric Caine (public health and preventive psychiatry), they included Paul Duberstein, Ph.D. (personality psychology), Kenneth Conner, Psy.D., M.P.H. (substance use disorders and aggressive behaviors), Jeffrey Lyness, M.D. (late-life mood disorders and functional status), and many others. Together we developed and refined a psychological autopsy protocol for the systematic retrospective study of the circumstances, observable symptoms and behaviors of people who were determined by the Medical Examiner to have taken their own lives. We implemented the protocol and published preliminary findings sufficient to support two subsequent NIMH-funded R01s. One focused on factors associated with attempted suicide in adults aged 50 years and over admitted for inpatient care following suicide attempts, and the second examined these same variables and constructs among people over age 50 years who were determined to have died by suicide in Monroe and Onondaga counties (Syracuse, NY, region). We learned a great deal from those studies. They established, for example, the central importance of late-life mood disorders—both major affective illness and subsyndromal depressive states—to suicide in later life.4,5 These illnesses were relatively straightforward but frequently undiagnosed or inadequately treated, highlighting the importance, and potential benefits in lives saved, of good care for older adults with common mental disorders. Paul Duberstein’s work helped establish the role of personality traits— in particular, neuroticism and low openness to experience—to suicide in this age group.6,7 We found that comorbid medical illness and functional disability were ubiquitous in older people who took their own lives, underscoring the relevance of primary care as a setting for preventive interventions.5,8 Social disintegration emerged repeatedly in our analyses as a key feature of the older suicidal person, manifest in the risk associated with unmarried conjugal status, living alone, and lacking connections to family, friends, and community—so, too, did other acute and chronic stressors commonly seen in this time of life, such as bereavement, threats to independence, family conflicts, and financial concerns.9–12 We also showed the
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PHASE 2: INTERVENTIONS RESEARCH Many of the findings from our studies resonated with or were reinforced by those of other investigators in the United States, the UK, New Zealand, and Australia. Collectively, we knew much about the factors contributing to suicide in older adulthood, and so the logical next step was to apply that knowledge to the development and testing of preventive interventions. Although other distinguished groups were examining potential neurobiological mechanisms driving suicide risk in adult samples, we elected to focus efforts in this next phase of research on the development and testing of clinical, psychosocial, and community-based preventive interventions. In particular, we took a public health and populations orientation to prevention, of which Eric Caine has been a major champion.14 We reasoned that because suicidal states are highly lethal in later life, our work should emphasize more “upstream” approaches.3 The great majority of suicides in later life are among men; 75% of older adult men who take their own lives do so with a firearm; and, unlike in younger adulthood, when there may be as many as 200 suicide attempts per completed suicide, there may be only 1 to 4 attempts for each suicide death in later life. Older adults are more socially isolated, have greater medical comorbidity with lower physical resilience, and undertake their suicidal acts with greater lethality of implementation using more immediately lethal methods. Rates of suicidal ideation (or at least its detection) are lower among older people and older adults are less likely to reveal depressive symptoms than their younger counterparts. In sum, the relative likelihood of detecting and intervening to prevent the death of an acutely suicidal older adult is small. Our efforts therefore, should emphasize interventions that prevent the suicidal state from developing in a vulnerable older person. Based on these considerations, we took two approaches to prevention—the mitigation of social disconnectedness in later life and
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the detection and management of depression in primary care settings. Social Connectedness This line of interventions research emerged from my collaboration with Kimberly Van Orden, Ph.D., who joined our team in 2009. With collaborators at Florida State University, Kim has made major contributions to development and operationalization of the Interpersonal Theory of Suicide. The theory stresses the central role of loneliness (“thwarted belonging”), feeling that one is a burden on others (“perceived burdensomeness”), and the capacity to take one’s own life.15 Kim and I have worked closely together to apply this theory to older adulthood. Loneliness and feeling like a burden on others are common, distressing feelings in later life that may be modifiable and mitigation of which will reduce suicide risk and improve overall health and well-being.16 A series of studies has unfolded with support from the Centers for Disease Control and Prevention, NIMH, and now the National Institute on Aging in which we tested aspects of the theory. One recently completed randomized controlled trial (RCT) examined the effects of a peer companion intervention called The Senior Connection relative to care as usual among older adult primary care patients who endorse feeling lonely or like a burden on others.17 Initial indications are of promising effects on depression, anxiety, and feelings of burdensomeness in the isolated older person. With Kim’s leadership we are now extending that work in a second RCT to test the beneficial effects of older adults’ volunteering their time to support others on factors known to place them at risk for suicide. Kim is also now developing interventions to help older adults improve their skills in relating to others, increasing their social connectedness, and reducing risk for suicide and other adverse outcomes. Primary Care Early detection and aggressive treatment of mood disorders is an important strategy for prevention given the close association between late-life suicide and these conditions. Our findings, consistent with those of others, indicated that a half to three-quarters of older people who took their own lives had visited a primary care doctor in the month before death; the
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Conwell majority of these patients had depressive disorders. These observations underscored the importance of integrated depression care management interventions to suicide prevention. Other groups of investigators were busy establishing a robust evidence base for the effectiveness of this approach for depressed older adults in the developed world.18,19 My opportunity to contribute to this body of work came as a result of longstanding relationships with investigators in China, where I have been engaged in a series of initiatives since 2000. These included my consultation to Chinese investigators on studies of suicide in rural Liaoning, Hunan, and Shandong provinces,20 and a sequence of NIH Fogarty International Center (FIC)-funded training grants for Chinese scholars in suicide prevention for which Eric Caine was the director. Out of these projects has grown a wide net of research collaborations in global mental health. One of the training program’s visiting scholars to Rochester was Shulin Chen, M.D., Ph.D., who is now Professor of Psychology at Zhejiang University. During his postdoctoral training in Rochester, Shulin and I developed an adaptation of collaborative depression care management (DCM) for use in Chinese primary care clinics. With funding for a RCT from the FIC we compared the DCM model with enhanced care as usual for older adults with major depression in urban Hanzhou.21 Results were striking for the strength of the intervention’s effect, supporting its potential for more widespread use in China. Based on these findings, we then obtained funding from the NIMH Office for Research on Disparities and Global Mental Health to adapt and test the DCM model in rural settings. The Chinese Older Adult Collaborations in Health (COACH) study, which is currently underway, targets depressed older adults with comorbid hypertension in rural primary care clinics in Zhejiang province. Important to our suicide prevention agenda, COACH combines depression and social connectedness elements by incorporating a community health worker into the treatment team whose focus is support of the older person’s adherence to care and engagement in their community.
NEXT STEPS: PHASE 3: IMPLEMENTATION AND DISSEMINATION RESEARCH If COACH is successful in reducing depression and related risk factors for suicide in older adult Chinese primary care patients, research must then address how best to implement and disseminate the model most effectively. Anticipating this next step, we have engaged community-level health and human services providers and provincial-level government officials in exploring our options. With supplemental NIMH support we conducted mixed-methods assessments of the model with its stakeholders to understand potential barriers and opportunities for its dissemination. How, we hope to learn, can we take this apparently effective intervention to scale, delivering care to tens or hundreds of thousands of Chinese older adults with depressive illness?
CONCLUSION At every point in this journey my work has been both enabled and enriched by mentors, mentees, and collaborators. In order to accomplish the mission that has guided my work, it as essential to populate the field with skilled, well-informed, and diverse investigators who are familiar with the issues of suicide and its prevention and share a passion for addressing this public health problem. It is humbling to think that over the same time period as the work described here, the overall suicide rate in the United States has risen rather than decreased. The overall U.S. suicide rate of 13.8 per 100,000 in 2015 is at a 30-year high. Although the suicide rate for older adults has declined during that time, rates between 1999 and 2014 rose by almost 50% among middle-aged adults, the cohort that we in geriatric mental health will be caring for in a few short years. The commitment I feel for the work is no less than when I was a junior investigator, but the urgency is even greater.
References 1. Institute of Medicine, Mrazek PJ, Haggerty RJ: Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: National Academy Press, 1994 2. Kraemer HC, Kazdin AE, Offord DR, et al: Coming to terms with the terms of risk. Arch Gen Psychiatry 1997; 54:337–343
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3. Conwell Y: Suicide later in life: challenges and priorities for prevention. Am J Prev Med 2014; 47:S244–S250 4. Conwell Y, Duberstein PR, Cox C, et al: Age differences in behaviors leading to completed suicide. Am J Geriatr Psychiatry 1998; 6:122–126
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Editorial 5. Conwell Y, Lyness JM, Duberstein P, et al: Completed suicide among older patients in primary care practices: a controlled study. J Am Geriatr Soc 2000; 48:23–29 6. Duberstein PR, Conwell Y, Caine ED: Age differences in the personality characteristics of suicide completers: preliminary findings from a psychological autopsy study. Psychiatry 1994; 57:213– 224 7. Duberstein PR, Conwell Y, Seidlitz L, et al: Personality traits and suicidal behavior and ideation in depressed inpatients 50 years of age and older. J Gerontol B Psychol Sci Soc Sci 2000; 55:18– 26 8. Conwell Y, Duberstein PR, Hirsch JK, et al: Health status and suicide in the second half of life. Int J Geriatr Psychiatry 2010; 25:371– 379 9. Duberstein PR, Conwell Y, Caine ED: Interpersonal stressors, substance abuse, and suicide [see comments]. J Nerv Ment Dis 1993; 181:80–85 10. Duberstein PR, Conwell Y, Conner KR, et al: Suicide at 50 years of age and older: perceived physical illness, family discord and financial strain. Psychol Med 2004; 34:137–146 11. Duberstein PR, Conwell Y, Conner KR, et al: Poor social integration and suicide: fact or artifact? A case-control study. Psychol Med 2004; 34:1331–1337 12. Duberstein PR, Conwell Y, Cox C: Suicide in widowed persons. A psychological autopsy comparison of recently and remotely bereaved older subjects. Am J Geriatr Psychiatry 1998; 6:328–334
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13. Conwell Y, Duberstein PR, Connor K, et al: Access to firearms and risk for suicide in middle-aged and older adults. Am J Geriatr Psychiatry 2002; 10:407–416 14. Caine ED: Forging an agenda for suicide prevention in the United States. Am J Public Health 2013; 103:822–829 15. Van Orden KA, Witte TK, Cukrowicz KC, et al: The interpersonal theory of suicide. Psychol Rev 2010; 117:575–600 16. Holt-Lunstad J, Smith TB, Layton JB: Social relationships and mortality risk: a meta–analytic review. PLoS Med 2010; 7:e1000316 17. Van Orden KA, Stone DM, Rowe J, et al: The Senior Connection: design and rationale of a randomized trial of peer companionship to reduce suicide risk in later life. Contemp Clin Trials 2013; 35:117–126 18. Bruce ML, ten Have TR, Reynolds CF 3rd, et al: Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA 2004; 291:1081– 1091 19. Unutzer J, Katon W, Callahan CM, et al: Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002; 288:2836–2845 20. Zhang J, Wieczorek W, Conwell Y, et al: Characteristics of young rural Chinese suicides: a psychological autopsy study. Psychol Med 2010; 40:581–589 21. Chen S, Conwell Y, He J, et al: Depression care management for adults older than 60 years in primary care clinics in urban China: a cluster-randomised trial. Lancet Psychiatry 2015; 2:332–339
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