Cognitive Reappraisal Intervention for Suicide Prevention (CRISP) for Middle-Aged and Older Adults Hospitalized for Suicidality

Positive valence system function and anhedonia in middle-aged and older adults at high suicide risk

Positive valence systems are disrupted in late-life depression and in individuals at risk for suicide. The reward positivity (RewP) is an event-related potential measure of positive valence system function that relates to depression and anhedonia in children and young adults. However, it is unclear whether a reliable RewP signal can be elicited in middle-aged and older adults at high risk for suicide and, if so, whether this signal is similarly associated with clinical symptoms. In the current study, a RewP was elicited with a standard gambling task in middle-aged and older adults (N = 31) at discharge from a hospitalization for suicidal thought or behaviors. The resulting electrocortical response differed significantly for monetary wins compared to losses. Internal reliability of the RewP and the feedback negativity (FN) to monetary loss was good to excellent. Internal reliability of difference measures was lower but still largely acceptable, with residualized differences scores demonstrating stronger reliability than subtraction-based scores. A smaller residualized RewP, after accounting for the influence of the FN, was associated with greater severity of lassitude, an index of appetitive anhedonia. These findings set the groundwork for future studies of positive valence system function and depression in middle-aged and older adults at high risk for suicide.

A 50-state survey study of thoughts of suicide and social isolation among older adults in the United States

BACKGROUND

We aimed to characterize the prevalence of social disconnection and thoughts of suicide among older adults in the United States, and examine the association between them in a large naturalistic study.

METHODS

We analyzed data from 6 waves of a fifty-state non-probability survey among US adults conducted between February and December 2021. The internet-based survey collected the PHQ-9, as well as multiple measures of social connectedness. We applied multiple logistic regression to analyze the association between presence of thoughts of suicide and social disconnection. Exploratory analysis, using generalized random forests, examined heterogeneity of effects across sociodemographic groups.

RESULTS

Of 16,164 survey respondents age 65 and older, mean age was 70.9 (SD 5.0); the cohort was 61.4 % female and 29.6 % male; 2.0 % Asian, 6.7 % Black, 2.2 % Hispanic, and 86.8 % White. A total of 1144 (7.1 %) reported thoughts of suicide at least several days in the prior 2 week period. In models adjusted for sociodemographic features, households with 3 or more additional members (adjusted OR 1.73, 95 % CI 1.28-2.33) and lack of social supports, particularly emotional supports (adjusted OR 2.60, 95 % CI 2.09-3.23), were independently associated with greater likelihood of reporting such thoughts, as was greater reported loneliness (adjusted OR 1.75, 95 % CI 1.64-1.87). The effects of emotional support varied significantly across sociodemographic groups.

CONCLUSIONS

Thoughts of suicide are common among older adults in the US, and associated with lack of social support, but not with living alone.

TRIAL REGISTRATION

NA.

Relationship Between Emotion Regulation and Suicide Ideation and Attempt in Adults and Adolescents: A Systematic Review

INTRODUCTION

Suicide is one of the main causes of death in adults and adolescents, so research focused on identifying risk factors for suicidal behavior is needed. In recent years, emotion regulation, mainly the presence of difficulties regulating one's own negative emotions, has been associated with negative mental health outcomes.

OBJECTIVE

The purpose of this study was to systematically review the available evidence on the association between emotion regulation and suicide (ideation and attempt) in both adults and adolescents.

METHOD

A systematic search of scientific articles published in English and Spanish was carried out through the databases PsycINFO, MEDLINE, Scopus, and the Cochrane Library.

RESULTS

We identified 76 eligible studies, of which 70 reported that people with difficulties in emotion regulation reported higher levels of suicide ideation and more suicide attempts. The results were consistent in adolescents and adults, in clinical and general population samples, and when studies assessed both emotion regulation processes and strategies. However, few studies were longitudinal and most of them were with women.

CONCLUSIONS

We discuss the theoretical implications of the results, suggesting that actual psychological models might benefit from considering individual differences in ER in understanding why people engage in suicide behavior. Clinical implications are also discussed.HIGHLIGHTSDifficulties regulating one's emotions is associated with suicide behavior (SI and SA).Consistent results at all the ages and in the clinical and general population.Individual differences in ER could help researchers to understand suicide.

Towards Zero Suicide: need and opportunities to improve implementation of clinical elements for older adults

OBJECTIVE

The Zero Suicide (ZS) framework is increasingly used in Australia, but without published adaptations for older people, and limited access by older people when implemented. The aim of this paper is to inform Towards Zero Suicide (TZS) implementations to benefit older adults by considering the key differences in older adults at risk of suicide according to each clinical component of the ZS framework.

CONCLUSION

TZS aspires to reduce deaths by suicide for people within healthcare by refocusing interventions on suicidality rather than diagnosis alone, emphasising evidence-based practices and cultural change. For TZS to be effective for older people, it is essential to ensure practices are based upon evidence relevant to older people and to ensure ageism is effectively counteracted. Older adults have distinct patterns of help seeking and service use, accompanied by differences in risk factors, presentations, and outcomes of suicidal behaviours. Ageism affects assessment, decision-making and actions to address self-harm and suicide for older people. Immediate and longer-term actions are essential to effectively implement TZS in this population.

An Emotion Regulation Tablet App for Middle-Aged and Older Adults at High Suicide Risk: Feasibility, Acceptability, and Two Case Studies

OBJECTIVE

The unique features of technological applications may improve the treatment of people at risk of suicide. In this article, we present feasibility and acceptability data as well as two case studies demonstrating the use of WellPATH, a tablet app that aims to help suicidal patients during emotionally-charged situations outside of therapy sessions. The WellPATH app was part of a 12-week psychotherapy intervention (CRISP - Cognitive Reappraisal Intervention for Suicide Prevention) for middle-aged and older adults after their discharge from a suicide-related hospitalization.

DESIGN

The use of WellPATH includes three stages: preparation and practice, incorporation, and actual use.

MEASUREMENTS

Feasibility was measured by the overall use of WellPATH during 12 weeks, and acceptability was measured with the three items of the Client Satisfaction Questionnaire.

RESULTS

Twelve study participants were administered WellPATH as part of CRISP. The results provide preliminary evidence of feasibility and acceptability of WellPATH. Study participants and therapists reported high satisfaction with WellPATH and provided feedback for future research and development. The patients in the case studies reported a reduction in negative emotions and an increase in emotion regulation (i.e., cognitive reappraisal ability) after using techniques on the WellPATH app.

CONCLUSION

Our preliminary findings suggest that use of technology applications such as the WellPATH app is feasible and accepted among middle-aged and older adults at high suicide risk. Further research with an adequately powered sample is needed to further evaluate WellPATH's feasibility and accessibility, and test its efficacy with this high-risk population.

The effect of social network strain on suicidal ideation among middle-aged adults with adverse childhood experiences in the US: A twelve-year nationwide study

Objective

Building on literature that measured the association between social network strain (SNS) and suicidal ideation using conventional regression analyses, we examined the effect of SNS, due to adverse childhood experiences (ACEs), on suicidal ideation using instrumental variables (IV) to eliminate the potential biases that may have occurred in earlier studies due to residual confounding.

Methods

This retrospective cohort study linked longitudinal data from the National Survey of Midlife Development in the United States (MIDUS) Refresher Biomarker Project (2012–2016), the MIDUS Refresher Project (2011–2014), the MIDUS 2 Biomarker Project (2004–2009), and the MIDUS 2 Project (2004–2006). Participants completed a phone interview, self-administered survey, and biomarker data collection. Exposure indicators included self-reported suicidal ideation, ACEs, and SNS from family, spouse, and friends. IV analysis was used to evaluate the continuous local average treatment effect of SNS on suicidal ideation when SNS only varied due to variation in ACEs.

Results

Our sample included 1703 middle-aged adults (52.9% females), which were followed up for 12 years. An IV probit model controlling for sociodemographic characteristics found a one-standard-deviation reduction in SNS reduced suicidal ideation by 22.6% (p < 0.01). A comprehensively controlled IV probit model found that a one-standard-deviation reduction in SNS is associated with a 21.4% (p = 0.05) decrease in suicidal ideation.

Conclusions

The causal pathway from SNS (due to ACEs) to suicidal ideation among middle-aged adults was established using IV analysis in this large-scale longitudinal study. The magnitude of this effect is sufficient to warrant the development of programs to improve social network relationships among family, friends, and spouses/partners. Suicide prevention programs addressing SNS may significantly reduce suicidal ideation among middle-aged Americans who have experienced ACEs.

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Social Network Strain (SNS) from family, spouse, and friends is common.

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SNS derives from demands, criticisms, disappointments, and irritations.

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SNS varies strongly with Adverse Childhood Experiences (ACEs).

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Reductions in SNS due to fewer ACEs decrease suicidal ideation.

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A one standard-deviation reduction in SNS lowers suicidal ideation by 20%.

Emotion Regulation and Depressive Symptoms Mediate the Association Between Schizotypal Personality Traits and Suicidality in Chinese College Students

OBJECTIVE

The psychological mechanisms underlying the relationship between schizotypal personality traits and suicidality are not understood. This study investigated the association of schizotypal personality traits with suicidality and explored the mediating role of cognitive appraisal and depression in the relationship between those two variables in a sample of Chinese college students.

METHOD

Participants (N = 2457) completed the Schizotypal Personality Questionnaire, the Emotional Regulation Questionnaire, the Zung Self-rating Depression Scale, and three questions related to suicidality.

RESULTS

The cognitive reappraisal score was lower in the students with suicidality than the students without suicidality, whereas scores for depression and schizotypal personality traits were higher in the students with suicidality than the students without suicidality. Schizotypal personality traits and depression were risk factors for suicidality. Depression mediated the association between schizotypal personality traits and suicidality. Cognitive reappraisal negatively affected symptoms of depression and had a significant mediating effect on the association between schizotypal personality traits and suicidality.

CONCLUSIONS

Schizotypal personality traits and depression are risk factors for suicidality. Cognitive reappraisal and depression mediate the association between schizotypal personality traits and suicidality.

Screening for suicide risk among older adults: assessing preliminary psychometric properties of the Brief Geriatric Suicide Ideation Scale (BGSIS) and the GSIS-Screen

OBJECTIVES

To initially assess psychometric properties of two abbreviated versions of the Geriatric Suicide Ideation Scale (GSIS): a 10-item Brief Geriatric Suicide Ideation Scale (BGSIS), and a 5-item Geriatric Suicide Ideation Scale-Screen (GSIS-Screen).

METHODS

A series of psychometric analyses was conducted, assessing the internal consistency, test-retest reliability, construct and predictive validity of the abbreviated GSIS scales. This was done by selecting-out GSIS items from a combined dataset of studies on suicide ideation in older adults: 1) The GSIS scale development study (n = 107); 2) A clinical trial of Interpersonal Psychotherapy (IPT) modified for suicidal older adults(n = 25); 3) A longitudinal study of risk and resiliency to suicide ideation in community-residing older adults (n = 173).

RESULTS

Overall findings demonstrated strong internal consistency, test-retest reliability, concurrent and predictive validity for the BGSIS and GSIS-Screen with older adults across community, clinical, and residential settings.

CONCLUSION

Study findings support the use of the abbreviated GSIS scales when conducting research on suicide risk identification among older adults. Future research is recommended testing these scales prospectively in public health, residential, and clinical settings, in research and healthcare delivery contexts.

Modifiable predictors of suicidal ideation during psychotherapy for late-life major depression. A machine learning approach

This study aimed to identify subgroups of depressed older adults with distinct trajectories of suicidal ideation during brief psychotherapy and to detect modifiable predictors of membership to the trajectories of suicidal ideation. Latent growth mixed models were used to identify trajectories of the presence of suicidal ideation in participants to a randomized controlled trial comparing Problem Solving Therapy with "Engage" therapy in older adults with major depression over 9 weeks. Predictors of membership to trajectories of suicidal ideation were identified by the convergence of four machine learning models, i.e., least absolute shrinkage and selection operator logistic regression, random forest, gradient boosting machine, and classification tree. The course of suicidal ideation was best captured by two trajectories, a favorable and an unfavorable trajectory comprising 173 and 76 participants respectively. Members of the favorable trajectory had no suicidal ideation by week 8. In contrast, members of the unfavorable trajectory had a 60% probability of suicidal ideation by treatment end. Convergent findings of the four machine learning models identified hopelessness, neuroticism, and low general self-efficacy as the strongest predictors of membership to the unfavorable trajectory of suicidal ideation during psychotherapy. Assessment of suicide risk should include hopelessness, neuroticism, and general self-efficacy as they are predictors of an unfavorable course of suicidal ideation in depressed older adults receiving psychotherapy. Psychotherapeutic interventions exist for hopelessness, emotional reactivity related to neuroticism, and low self-efficacy, and if used during therapy, may improve the course of suicidal ideation.

Social Disconnection in Late Life Suicide: An NIMH Workshop on State of the Research in Identifying Mechanisms, Treatment Targets, and Interventions

Both social disconnection and suicide are significant public health concerns among older adults, and social disconnection is associated with greater risk for suicide-related thoughts and behaviors in late life. We present a synthesis of research discussed during a workshop hosted by the National Institute of Mental Health on social disconnection and late-life suicide. Social disconnection is related to suicide risk in late life via a variety of mechanisms, including biological, behavioral, and psychological correlates. Researchers in several scientific fields have begun to establish these connections and identify targets for interventions to reduce risk in late life. While research has demonstrated that social connection is amenable to change, there is little research to date on the most evidence-based interventions to mitigate social disconnection or the related risks. However, there are several promising biological, behavioral, and psychological interventions that may target various mechanisms, as well as social disconnection itself. With a relative paucity of research in this area, these lines of study are ripe for innovative investigation. In order to most effectively advance the field, we must establish more consistent definitions of social connection and disconnection; more accurately measure and assess older adults' social needs; examine the most effective approaches and modalities for assessment and intervention; take into account important contextual factors; and apply a translational, convergent scientific approach.

The emotion-elicited late positive potential is stable across five testing sessions

Many studies have examined associations between neural and behavioral markers of attention to emotion and individual differences in affective functioning. However, the majority of these studies are cross-sectional, and examine associations between brain, behavior, and individual differences at one or two time-points, limiting our understanding of the extent to which these neural responses reflect trait-like patterns of attention. The present study used the Emotional Interrupt paradigm, and examined the stability and trajectory of behavioral (i.e., reaction time to targets following task-irrelevant appetitive, neutral, and aversive images), and neural responses to images (i.e., the late positive potential or LPP), across five sessions separated by one week in 86 individuals. Additionally, we examined the extent to which the LPP and behavioral measures were sensitive to naturally occurring daily fluctuations in positive and negative affect. Results indicate that, though the magnitude of the conditional LPP waveforms decreased over time, the degree of emotional modulation (i.e., differentiation of emotional from neutral) did not; in fact, differentiation of appetitive from neutral increased over time. Behavioral responses were similarly stable across sessions. Additionally, we largely did not observe significant effects of state positive and negative affect on the LPP or behavior over time. Finally, the LPP elicited by appetitive images significantly predicted reaction time to targets following these images. These data suggest that neural and behavioral markers of attention to motivationally salient cues may be trait-like in nature, and may be helpful in future studies seeking to identify markers of vulnerability for diverse forms of psychopathology.

Empirically Evaluated Suicide Prevention Program Approaches for Older Adults: A Review of the Literature from 2009-2021

Mental health in later life and suicide risk among older adults are important topics for social work. There is evidence-based research to support the use selective and indicated strategies for suicide prevention, yet, universal prevention approaches are also needed. However, the extent to which the broader contexts of suicide have been examined remains largely absent from the literature. This article presents findings from a systematic review of articles published between 2009 and 2021, focusing what types of empirically evaluated suicide prevention programs effectively prevent and reduce suicidality in older adults. Using the PICO and PRISMA guidelines, a final sample of 8 articles were reviewed in this systematic review. The articles were categorized into three types of programs: 1) primary and home health care, 2) community-based outreach, and 3) counseling. The articles also examined the involvement of social workers in these programs. Following a description of the articles, the authors assess each study using the GRADE rating system. Lastly, the authors discuss the role of the social worker in mental health promotion and prevention strategies.

Towards an Explanatory Model of Suicidal Ideation: The Effects of Cognitive Emotional Regulation Strategies, Affectivity and Hopelessness

Suicide constitutes a public health problem that has a significant economic, social and psychological impact on a global scale. Recently, the American Psychological Association has indicated that suicide prevention should be a public health priority. Suicidal ideation appears as a key variable in suicide prevention. The objective of this research was to verify the adjustment of an explanatory model for suicidal ideation, which considers the effects of cognitive emotion regulation strategies, affectivity and hopelessness. An open mode on-line sample of 2,166 Argentine participants was used and a path analysis was carried out. The results make it possible to conclude that the model presents an optimal fit (χ2 = .10, p = .75, CFI = .99, RMSEA = .01) and predicts 42% of suicidal thoughts. The model proves to be invariant based on age and gender. In conclusion, there is an importance of reducing the use of automatic strategies, such as repetitive negative thoughts of ruminative type, and increasing the use of more controlled strategies, such as reinterpretation or planning.

Direct and indirect associations between perception of childhood trauma and suicidal ideation through emotion dysregulation in males who use heroin

Emotion dysregulation is considered as one of the factors related to suicide in individuals with childhood trauma (CT). However, no research has been performed on the role of emotion dysregulation in the relationship between perception of CT and suicidal ideation in individuals who use heroin. This study aimed to evaluate direct and indirect relationships between perception of CT and suicidal ideation through emotion regulation difficulties (ERD) and cognitive emotion regulation strategies (CERSs) in males with a DSM diagnosis of heroin dependence. In a cross-sectional design, 310 males with a DSM diagnosis of heroin dependence completed the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Difficulties in Emotion Regulation Scale (DERS), the Cognitive Emotion Regulation Questionnaire-Short version (CERQ-Short), the Obsessive-Compulsive Drug Use Scale-Form Heroin (OCDUS-Form Heroin), and the Depression Anxiety Stress Scales (DASS). The results revealed that perception of CT had no direct relation to suicidal ideation. Perception of CT was indirectly associated with suicidal ideation through some ERD dimensions [e.g., non-acceptance of emotional responses (Non-acceptance), limited access to emotion regulation strategies (Strategies), lack of emotional awareness (Awareness)] and the CERS of positive reappraisal. The findings suggest that high suicidal ideation may stem from a perception of CT and subsequently emotion dysregulation in individuals who use heroin. Also, the findings of this research may have implications for the prevention and treatment of suicidal ideation in individuals using heroin with a perception of CT. The results of the present study require further examination through longitudinal studies.