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

Social disconnection correlates of a "Wish to Die" among a large community-dwelling cohort of older adults

Introduction

Social disconnection and deaths by suicide among older adults are both important public health concerns, particularly in the context of ageing populations. The association between death ideation and behaviours, and social disconnection is well established and both functional and structural social relationships have been identified as predictive of suicide-related thoughts and behaviours. The "Wish to Die" (WTD) involves thoughts of or wishes for one's own death or that one would be better off dead is a commonly used indicator to capture death ideation. It has been shown to be as predictive as active ideation of future suicide attempt.

Methods

Data were from a large cohort of community-dwelling older adults aged 50+, The Irish Longitudinal Study on Ageing (TILDA). Cross-sectional analyses of the association between numerous markers of social disconnection (loneliness, social isolation, living alone, marital status, social participation, volunteering, and attending religious service) and WTD were conducted.

Results

Multiple markers of social disconnection were associated with a "wish to die". However, loneliness was the strongest risk factor while attendance of religious services was an important protective behaviour.

Discussion

There is a strong association between social disconnection and a WTD among older adults. There is also a strong association between depression and a WTD, while attending religious services or similarly prosocial settings may protect older adults from experiencing negative thoughts about dying.

Stress-related gene regulation: Do isolated and connected individuals differ?

BACKGROUND

Social isolation and loneliness (known as social disconnection, collectively) lead to serious downstream health effects, including shortening of lifespan and higher risk for cardiac disease. We must better understand how isolation and loneliness lead to these negative health outcomes. Previous literature has demonstrated that social motivation and social ability are contributors to the likelihood of social isolation and loneliness. We examined the effect of the above social factors on immune gene expression in socially-connected and -isolated individuals.

METHODS

Recruitment occurred via two online advertisements, one for socially isolated individuals and another for general research participants. Participants (n = 102) were separated into groups (isolated versus connected) based on which ad they responded to, and provided data on isolation, loneliness, social motivation, and social ability. The Conserved Transcriptional Response to Adversity (CTRA) stress gene regulation program was assessed with genome-wide transcriptional profiling.

RESULTS

CTRA gene expression patterns were reversed between connected and isolated groups across several variables. Social isolation was associated with higher CTRA levels in the connected group, but lower levels in the isolated group. Social approach was associated with lower CTRA levels in the connected group, but higher in the isolated group, and the converse was true for social avoidance. CTRA levels were minimally affected by social ability measures.

CONCLUSION

Prior work on social isolation and loneliness has focused on loneliness and has identified many negative downstream health effects. In this study we demonstrate that objective social isolation may not be associated with the same negative downstream health effects, and in fact, social interaction may be more stressful than social isolation for some socially-isolated individuals.

Social disconnection and suicide mortality among Japanese older adults: A seven-year follow-up study

BACKGROUND

Few prospective studies have examined the association between social disconnection and late-life suicide. Therefore, we conducted a large-scale prospective study of older adults in Japan to examine differences in suicide mortality according to specific aspects of social disconnectedness.

METHODS

We conducted a nationwide baseline survey of functionally independent older adults (age ≥65 years) from 12 municipalities in Japan from 2010 to 2011. We followed the participants (n = 46,144) for cause of death through December 2017 using vital statistics. Social disconnection was assessed based on the indicators of eating alone, a lack of instrumental/emotional support, no participation in community activities, and no contact with friends. We adopted Cox regression models with multiple imputation for missing values and calculated the population-attributable fraction (PAF).

RESULTS

A total of 55 suicide deaths were recorded during an average follow-up of 7 years. Older adults with social disconnection had a marginally increased risk of suicide. The hazard ratio for eating alone vs. eating together was 2.81 (95% confidence interval [CI]: 1.47-5.37). The direction of these associations and point estimations did not largely change after controlling for depressive symptoms, an evident risk factor for suicidal behavior. The PAF indicated that eating alone was attributable to around 1800 (29%) of the suicide deaths among older adults annually in Japan.

CONCLUSION

Avoidance of not only depressive symptoms, but also social disconnection including eating alone, is useful in suicide prevention among older adults.

Suicide-related cognitions and emotional bias performance in a community sample

BACKGROUND

Suicide is theorized to be connected to social interactions and feelings of belongingness. Those with suicide-related cognitions (SRCs) demonstrate attentional bias toward negative or suicide-related words, which can lead to increased feelings of rejection or alienation. As social interactions employ both verbal and nonverbal cues, there exists a gap in understanding how perception of emotional expressions can contribute to the development or exacerbation of suicidal ideation.

METHODS

The current sample (N = 114, 60.5 % female, 74.6 % white) completed the Suicide Cognitions Scale-Revised (SCS-R) and Patient Health Questionnaire (PHQ-9) to assess SRCs and depression severity. The Emotional Bias Task (EBT) was used to assess emotional response latency.

RESULTS

Multiple regression analyses on EBT results showed that endorsement of SRCs and depression severity were not associated with any particular emotional response bias. However, presence of SRCs showed an association with longer latencies to identify ambiguous emotional expressions, even when controlling for depressive symptoms and age LIMITATIONS: Measures were self-completed online. Relative homogeneity of the sample and cross-sectional design limits interpretation of the results.

CONCLUSIONS

Those with more severe SRCs take longer to recognize positive, nonverbal cues. Irregular processing of positive emotional stimuli combined with bias toward negative verbal cues could worsen feelings of rejection or alienation in social interactions, therefore increasing risk of developing SI. This suggests that interventions focusing on allocation of attentional resources to process positive social cues may be beneficial for those with SRCs to reduce severity and risk of suicide.

Depressive Symptoms Associated With Social Participation in Older Adults Living With Mild Cognitive Impairment

Mild Cognitive Impairment (MCI) affects 15% of adults 50 years old and over. Individuals living with MCI have shown decreased social participation, a critical activity as it may delay cognitive decline. Depression may be a key factor in limiting participation. This study is a secondary data analysis of 30 older adults living with MCI, looking for associations with participation. Participation was examined using the Patient Reported Outcomes Measurement Information System (PROMIS®) Satisfaction with Participation in Social Roles Computer Adaptive Test (CAT) form. Depressive symptoms were reported using the PROMIS Quality of Life in Neurological Disorders Depression CAT form and the Patient Health Questionnaire (PhQ-9) form. Results showed that demographics (age, sex) were not significantly associated with participation, but depressive symptoms were significantly associated. This suggests that adults living with MCI who have higher levels of depressive symptoms may be a uniquely vulnerable population who benefit from interventions that support participation.

Improving social reward responsivity and social connectedness in psychotherapies for late-life depression: Engage & Connect as an example

Psychotherapies are effective in reducing late-life depression. Yet, about half of patients remain depressed at treatment end. Advances in neuroscience can inform simplified interventions that target key brain networks impacted by depression. Behavioral activation therapies that increase social connectedness may improve social reward responsivity and alter abnormalities of the Positive Valence System (PVS). Engage & Connect is an example for a scalable and simple neuroscience-informed psychotherapy, aimed to improve PVS functions and social reward responsivity by increasing engagement in rewarding social activities. Interventions that improve social reward responsivity can be promising first-line treatments for late-life depression in the community.

Characteristics and Correlates of Ten-Year Trajectories of Posttraumatic Stress Symptoms in Older U.S. Military Veterans

OBJECTIVES

To examine the nature and correlates of 10-year trajectories of posttraumatic stress disorder (PTSD) symptoms in older U.S. military Veterans.

DESIGN AND SETTING

A nationally representative web-based survey of older U.S. Veterans who participated in the National Health and Resilience in Veterans Study over 5 waves between 2011 and 2021.

PARTICIPANTS

A total of 1,843 U.S. Veterans aged 50 and older (mean age = 67).

MEASUREMENTS

PTSD symptoms were assessed using the PTSD Checklist. Self-report measures at baseline assessed sociodemographic characteristics; trauma exposures; psychiatric and substance use disorders; mental, cognitive, and physical functioning; and psychosocial factors including expectations of aging. Latent growth mixture modeling identified the nature and correlates of 10-year PTSD symptom trajectories.

RESULTS

Most of the sample had no/low PTSD symptoms (88.7%), while 6.0% had consistently subthreshold symptoms, 2.7% consistently high symptoms, and 2.6% increasing symptoms. Relative to the no/low symptom group, the subthreshold and high symptom groups reported more medical conditions and cognitive difficulties, with younger age and more lifetime traumatic events additionally linked to the high symptom trajectory. Relative to the no/low symptom group, Veterans with increasing symptoms were more likely to report functional disability and lifetime nicotine use disorder, cognitive difficulties, negative expectations regarding physical and emotional aging, and traumatic events over the study period.

CONCLUSIONS

Despite high rates of trauma exposure, most older Veterans do not evidence symptomatic PTSD trajectories; however, about 11% do. Results underscore the importance of assessing PTSD symptoms in this population and considering longitudinal trajectories as well as associated risk and protective factors.

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.

Depressive symptoms anticipate behavioral and emotional factors among older adults: A prospective cross-lagged panel design

This study examined the temporal relationship among depression, anxiety, insomnia, perceived stress, and physical activity in adults aged 60+ years with a history of major depressive disorder. We conducted a longitudinal study with 12 weeks of follow-up. Assessments consisted of phone or video interviews and included questionnaires evaluating depression, anxiety, insomnia, perceived stress, and physical activity. Our analytic approach consisted of a depression-focused cross-lagged panel model (CLPM) to examine week-to-week correlations among the five measures. The depression-focused CLPM identified statistically significant week-to-week self-predictive effects for each of the five measures. Higher depressive symptom burden was a strong predictor of increased stress, greater insomnia, and less physical activity the following week. No other cross-measure predictions were statistically significant. Our analytical approach clarifies the directional relationship among variables that typically co-occur with depression showing that higher depression symptom burden predisposes older adults to poor sleep, a reduced level of daytime activity, and a greater sense of stress. These findings support the need for longitudinal assessments and targeted interventions for reducing symptoms of depression in older adults.

Factors related to suicidal ideation among bereaved family members of patients with cancer: Results from a nationwide bereavement survey in Japan

BACKGROUND

Bereaved family members are known to have a higher risk of suicide, although relevant research is lacking. We aimed to clarify the percentage of bereaved family members of patients with cancer who experience suicidal ideation and the associated factors.

METHODS

We conducted a secondary analysis of two cross-sectional nationwide bereavement surveys in Japan, analyzing data from a total of 17,237 bereaved family members of patients with cancer. The Patient Health Questionnaire 8 (PHQ-8) and Item 9 of the PHQ-9 were used to assess depression (PHQ-8 score ≥10) and suicidal ideation, respectively. We assessed items such as socio-demographic data, complicated grief (CG), preparedness for bereavement, and perceived social support. Logistic regression analysis was used to reveal factors related to suicidal ideation.

RESULTS

Overall, 11 % of subjects reported some amount of suicidal ideation in the previous two weeks, with a suicidal ideation rate as high as 42 % among those with a higher risk of depression. Significant associations (all p < 0.0001) were found between suicidal ideation and the family member's depressive state (OR: 10.01), poor physical health status during caregiving (OR: 1.24), poor psychological health status during caregiving (OR: 1.38) pre-existing mental illness (OR: 1.38), insufficient preparedness for bereavement (OR: 0.59), and poor perceived social support (OR: 1.42).

LIMITATIONS

The respondents were limited to family members of patients with cancer in Japan, and the study involved cross-sectional self-reported data.

CONCLUSIONS

Clinicians should identify bereaved family members at a high risk of suicide by carefully assessing these risk factors identified in the present study.

Risk Prediction Models for Depression in Community-Dwelling Older Adults

OBJECTIVE

To develop streamlined Risk Prediction Models (Manto RPMs) for late-life depression.

DESIGN

Prospective study.

SETTING

The Survey of Health, Ageing and Retirement in Europe (SHARE) study.

PARTICIPANTS

Participants were community residing adults aged 55 years or older.

MEASUREMENTS

The outcome was presence of depression at a 2-year follow up evaluation. Risk factors were identified after a literature review of longitudinal studies. Separate RPMs were developed in the 29,116 participants who were not depressed at baseline and in the combined sample of 39,439 of non-depressed and depressed subjects. Models derived from the combined sample were used to develop a web-based risk calculator.

RESULTS

The authors identified 129 predictors of late-life depression after reviewing 227 studies. In non-depressed participants at baseline, the RPMs based on regression and Least Absolute Shrinkage and Selection Operator (LASSO) penalty (34 and 58 predictors, respectively) and the RPM based on Artificial Neural Networks (124 predictors) had a similar performance (AUC: 0.730-0.743). In the combined depressed and non-depressed participants at baseline, the RPM based on neural networks (35 predictors; AUC: 0.807; 95% CI: 0.80-0.82) and the model based on linear regression and LASSO penalty (32 predictors; AUC: 0.81; 95% CI: 0.79-0.82) had satisfactory accuracy.

CONCLUSIONS

The Manto RPMs can identify community-dwelling older individuals at risk for developing depression over 2 years. A web-based calculator based on the streamlined Manto model is freely available at https://manto.unife.it/ for use by individuals, clinicians, and policy makers and may be used to target prevention interventions at the individual and the population levels.

Suicide Prevention Interventions and Their Linkages in Multilayered Approaches for Older Adults: A Review and Comparison

Multilayered approaches to suicide prevention combine universal, selective, and indicated prevention interventions. These approaches may be more successful in reducing suicide rates among older adults if they link these layers more systematically: that is, if the programs are designed so that interventions at a lower level facilitate involvement at a higher level when appropriate. This study aimed to examine the effect on suicide rates of the structure of multilayered approaches, and in particular the types of interventions and the connections or linkages between them. We also wished to consider any different effects by sex. A literature search used PubMed and PsycINFO to identify systematic reviews of interventions in this age group. From the reference lists of these articles, we identified controlled studies assessing the impact of a multilayered program on suicide incidence among older adults. We were particularly interested in initiatives linking different kinds of prevention interventions. We found three relevant systematic reviews, and from these, we identified nine eligible studies. These included seven non-randomized controlled studies from rural areas in Japan (average eligible population: 3,087, 59% women, average duration: 8 years). We also found two cohort studies. The first was from a semi-urban area in Padua, Italy (18,600 service users, 84% women, duration: 11 years). The second was from urban Hong Kong, with 351 participants (57% women) over a 2-year follow-up period. We used a narrative synthesis of these studies to identify five different multilayered programs with different forms of connections or linkages between layers. Two studies/programs (Italy and Hong Kong) involved selective and indicated prevention interventions. One study/program (Yuri, Japan) included universal and selective prevention interventions, and the final six studies (two programs in northern Japan) involved linkages between all three layers. We also found that these linkages could be either formal or informal. Formal linkages were professional referrals between levels. Informal linkages included advice from professionals and self-referrals. Several of the studies noted that during the program, the service users developed relationships with services or providers, which may have facilitated movements between levels. All five programs were associated with reduced suicide incidence among women in the target groups or communities. Two programs were also associated with a reduction among men. The study authors speculated that women were more likely to accept services than men, and that the care provided in some studies did less to address issues that are more likely to affect men, such as suicidal impulsivity. We therefore suggest that it is important to build relationships between levels, especially between selective and indicated prevention interventions, but that these can be both formal and informal. Additionally, to reach older men, it may be important to create systematic methods to involve mental health professionals in the indicated prevention intervention. Universal interventions, especially in conjunction with systematically linked indicated and selective interventions, can help to disseminate the benefits across the community.

Promoting Social Connection in Dementia Caregivers: A Call for Empirical Development of Targeted Interventions

Social connection is an understudied target of intervention for the health of individuals providing care for a family member with Alzheimer's disease and related dementias (ADRD). To guide future research, we discuss considerations for interventions to promote social connection, with a particular focus on reducing loneliness: (a) include caregiver perspectives in designing and delivering interventions; (b) adapt to stages of dementia; (c) consider caregiving demands, including the use of brief interventions; (d) specify and measure mechanisms of action and principles of interventions; (e) consider dissemination and implementation at all stages of research. With support from the National Institute on Aging for a Roybal Center for Translational Research in the Behavioral and Social Sciences of Aging, we are developing a portfolio of mechanism-informed and principle-driven behavioral interventions to promote social connection in ADRD caregivers that can be flexibly applied to meet a diverse set of needs while maximizing resources and reducing demands on caregivers.

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.