Psychosocial Suicide Prevention Interventions in the Elderly: A Mini-Review of the Literature

A systematic review of psychosocial protective factors against suicide and suicidality among older adults

BACKGROUND

Research on suicide rarely focuses on protective factors. The goal of this systematic review was to assess the evidence of the associations between protective factors and reduced suicidality among older adults.

METHOD

First, a scoping review was conducted to identify pertinent terms that refer to various protective factors against suicidality. A systematic review, following the PRISMA guidelines, was then conducted on a selection of 15 protective factors (e.g., perceived control, well-being and quality of life, life satisfaction, purpose-in-life, resilience, coping, religiosity, hope, self-regulation, sense of belonging, mattering, positive relationship, social support, social connectedness, and social participation), with separate searches performed on each factor in five databases. Empirical studies were eligible if participants were adults aged 60 years and over, and if the studies reported predictive statistical analysis.

RESULTS

A total of 70 studies were retained for the review. Suicidal ideation was the main outcome measure (91%). Significant associations were consistently observed between all protective factors and reduced suicidal ideations or behaviors, particularly for purpose-in-life, resilience, and positive relationships, indicating that these are solid components for suicide prevention. Using scales, instead of a single item, to measure protective factors (e.g. life satisfaction) was more efficient to capture the associations. On the other hand, results were similar whether studies used subjective (e.g., sense of belonging) or objective (e.g., social connectedness) measures.

CONCLUSION

Protective factors were inversely associated with suicidal ideation. Improving protective factors is essential for the development of late-life suicide prevention and interventions, instead of merely focusing on risk factors.

The Cost-Effectiveness of Psychosocial Interventions Following Self-Harm in Australia

Background: Psychosocial interventions following self-harm in adults, in particular cognitive behavioral therapy (CBT), can be effective in lowering the risk of repeated self-harm. Aims: To evaluate the cost-effectiveness of CBT for reducing repeated self-harm in the Australian context. Method: The current study adopted the accessing cost-effectiveness (ACE) approach using return-on-investment (ROI) analysis. Uncertainty and sensitivity analyses (Sas) tested the robustness of the model outputs to changes in three assumptions: general practitioner referral pathway (SA1), private setting intervention delivery (SA2), and training costs (SA3). Results: The intervention produced cost savings of A$ 46M (95% UI -223.7 to 73.3) and A$ 18.3M (95% UI -86.2 to 24.6), subject to the effect of intervention lasting 2- or 1-year follow-up. The ROI ratio reduced to 5.22 in SA1 (95% UI -10.1 to 27.9), 2.5 in SA2 (95% UI -4.8 to 13.3), and 5.1 in SA3 (95% UI -9.8 to 27.8). Limitations: We assumed that the effectiveness would reduce 50% within 5 years in the base case, and we used Australian data and a partial social perspective. Conclusions: The current study demonstrated cost-effectiveness of CBT for adults who have self-harmed with the return-on-investment ratio of A$ 2.3 to $6.0 for every A$ 1 invested.

Navigating the Shadows: A Comprehensive Review of Suicide in the Geriatric Population

This review critically examines the complex landscape of suicide within the geriatric population, defined as individuals aged 65 and older. By synthesizing existing research, we elucidate critical findings related to the prevalence, risk factors, and challenges associated with suicide in this demographic. Social isolation, mental health issues, and the intricate psychosocial dimensions of ageing emerge as pivotal factors contributing to the vulnerability of older individuals. The conclusion underscores a compelling call to action, urging collaborative efforts from healthcare professionals, policymakers, and communities to implement targeted prevention strategies. Our vision for the future involves building a supportive and resilient community for the geriatric population, emphasizing age-friendly policies, robust social support networks, and destigmatizing mental health discussions. Through this comprehensive exploration, we aim to contribute to a deeper understanding of suicide in the geriatric population and inspire effective interventions that prioritize the well-being and dignity of older individuals.

PROTOCOL: Non-pharmacological interventions for older people with a diagnosis of depression: An evidence and gap map

This is the protocol for an evidence and gap map. The objectives are as follows: To map available randomized control trials, economic evaluations, and systematic reviews that assess the effectiveness and cost-effectiveness of non-pharmacological interventions for older people with a diagnosis of depression and identify any existing gaps in the evidence that can inform future research.

Digital interventions to reduce social isolation and loneliness in older adults: An evidence and gap map

Background

Social isolation and loneliness are more common in older adults and are associated with a serious impact on their well-being, mental health, physical health, and longevity. They are a public health concern highlighted by the COVID-19 pandemic restrictions, hence the need for digital technology tools to enable remotely delivered interventions to alleviate the impact of social isolation and loneliness during the COVID-19 restrictions.

Objectives

To map available evidence on the effects of digital interventions to mitigate social isolation and/or loneliness in older adults in all settings except hospital settings.

Search Methods

We searched the following databases from inception to May 16, 2021, with no language restrictions. Ovid MEDLINE, Embase, APA PsycInfo via Ovid, CINAHL via EBSCO, Web of Science via Clarivate, ProQuest (all databases), International Bibliography of the Social Sciences (IBSS) via ProQuest, EBSCO (all databases except CINAHL), Global Index Medicus, and Epistemonikos.

Selection Criteria

Titles and abstracts and full text of potentially eligible articles were independently screened in duplicate following the eligibility criteria.

Data Collection and Analysis

We developed and pilot tested a data extraction code set in Eppi-Reviewer and data were individually extracted and coded based on an intervention-outcome framework which was also used to define the dimensions of the evidence and gap map.

Main Results

We included 200 articles (103 primary studies and 97 systematic reviews) that assessed the effects of digital interventions to reduce social isolation and/or loneliness in older adults. Most of the systematic reviews (72%) were classified as critically low quality, only 2% as high quality and 25% were published since the COVID-19 pandemic. The evidence is unevenly distributed with clusters predominantly in high-income countries and none in low-income countries. The most common interventions identified are digital interventions to enhance social interactions with family and friends and the community via videoconferencing and telephone calls. Digital interventions to enhance social support, particularly socially assistive robots, and virtual pets were also common. Most interventions focused on reducing loneliness and depression and improving quality of life of older adults. Major gaps were identified in community level outcomes and process indicators. No included studies or reviews assessed affordability or digital divide although the value of accessibility and barriers caused by digital divide were discussed in three primary studies and three reviews. Adverse effects were reported in only two studies and six reviews. No study or review included participants from the LGBTQIA2S+ community and only one study restricted participants to 80 years and older. Very few described how at-risk populations were recruited or conducted any equity analysis to assess differences in effects for populations experiencing inequities across PROGRESS-Plus categories.

Authors' Conclusions

The restrictions placed on people during the pandemic have shone a spotlight onto social isolation and loneliness, particularly for older adults. This evidence and gap map shows available evidence on the effectiveness of digital interventions for reducing social isolation or loneliness in older adults. Although the evidence is relatively large and recent, it is unevenly distributed and there is need for more high-quality research. This map can guide researchers and funders to consider areas of major gaps as priorities for further research.

The effect of suicide severity and patient's age on mental health professionals' willingness to treat: The moderating effect of ageism

Understanding mental health professionals' (MHPs) willingness to treat suicidal older adults is critical in preventative psychotherapy. We examined the effect of a hypothetical patient's age and suicide severity on MHPs' willingness to treat or refer them to another therapist. Vignettes of hypothetical patients were presented to 368 MHPs aged 24-72 years. The vignettes had two age conditions (young/old) and three suicidality severity conditions. MHPs completed measures of their levels of willingness to treat/likeliness to refer and their levels of ageism. As suicide severity intensified, MHPs were less willing to treat and more likely to refer. Willingness to treat was the lowest for the old/suicide attempt condition. Ageism moderated the relationships between patient age and willingness to treat: MHPs with higher ageism were less willing to treat older than younger patients, regardless of suicidality severity. Findings indicate that MHPs with higher ageism levels are more reluctant to treat older suicidal patients and highlight the need for training MHPs to reduce ageism and enhance competence in suicide interventions.

Factors Affecting Emergency Medical Utilization After Self-harm and Effectiveness of Community-Based Suicide Prevention Provisions in Preventing Self-harm: A Nationwide Registry-Based Study in Korea

In order to formulate and implement a community-based suicide prevention program, as well as evaluate the effectiveness of these programs, it is necessary to understand the epidemiological characteristics of self-harm. Clinical data were collected from the National Emergency Department Information System (NEDIS) data panel in Korea for patients seen after self-harm episodes. Socioeconomic factors were collected from Statistics Korea. Variables representing SP provisions (SPPs) were collected from the Korea Foundation for Suicide Prevention. Increasing the number of mental health providers resulted in lower annual emergency department visit rate after self-harm (VRSH) in the entire population, as well as in both the young and elderly populations. An increase in the mental health budget led to a significant reduction in VRSHs. However, the number of suicide prevention centers did not have any significant association with the VRSH. This study also provides substantial evidence that community-based SPPs are effective in preventing self-harm.

A systematic review of evidence-based aftercare for older adults following self-harm

OBJECTIVE

Self-harm is closely associated with suicide in older adults and may provide opportunity to intervene to prevent suicide. This study aimed to systematically review recent evidence for three components of aftercare for older adults: (1) referral pathways, (2) assessment tools and safety planning approaches and (3) engagement and intervention strategies.

METHODS

Databases PubMed, Medline, PsychINFO, Embase and CINAHL were searched from January 2010 to 10 July 2021 by two reviewers. Empirical studies reporting aftercare interventions for older adults (aged 60+) following self-harm (including with suicidal intent) were included. Full text of articles with abstracts meeting inclusion criteria were obtained and independently reviewed by three authors to determine final studies for review. Two reviewers extracted data and assessed level of evidence (Oxford) and quality ratings (Alberta Heritage Foundation for Medical Research Standard Quality Assessment Criteria for quantitative and Attree and Milton checklist for qualitative studies), working independently.

RESULTS

Twenty studies were reviewed (15 quantitative; 5 qualitative). Levels of evidence were low (3, 4), and quality ratings of quantitative studies variable, although qualitative studies rated highly. Most studies of referral pathways were observational and demonstrated marked variation with no clear guidelines or imperatives for community psychiatric follow-up. Of four screening tools evaluated, three were suicide-specific and one screened for depression. An evidence-informed approach to safety planning was described using cases. Strategies for aftercare engagement and intervention included two multifaceted approaches, psychotherapy and qualitative insights from older people who self-harmed, carers and clinicians. The qualitative studies identified targets for improved aftercare engagement, focused on individual context, experiences and needs.

CONCLUSION

Dedicated older-adult aftercare interventions with a multifaceted, assertive follow-up approach accompanied by systemic change show promise but require further evaluation. Research is needed to explore the utility of needs assessment compared to screening and evaluate efficacy of safety planning and psychotherapeutic approaches.

Pandemics and Suicide Risk: Lessons From COVID and Its Predecessors

ABSTRACT

In its mortality and global reach, COVID-19 is among the worst pandemics to hit the globe since the 1918 influenza. During a pandemic, it is not uncommon for deaths from suicide to be downplayed as communities respond to the immediate mortality of the disease. In this analysis, we review pandemic history to uncover its impact on suicide rates, a frequent proxy for community mental health, and whether public health responses were effective. We incorporate lessons from more than 100 years of epidemics to assess whether the current public health response can benefit from the lessons of history.

Strategies to Prevent Elderly Suicide: A Delphi Consensus Study

OBJECTIVES

In the next decades, many countries will become 'ageing societies'. This combined with the current high rates of suicide in later life suggests that many older adults may die by suicide before clinical trials can be conducted to demonstrate the best approaches to prevent late-life suicide.

METHODS

A New Zealand (NZ) 'expert panel' has reviewed key considerations for suicide prevention interventions in older adults based on existing evidence, where available, and expert opinion. The key considerations were extracted from the current literature. The Delphi survey method was used to reach consensus for identifying interventions to be recommended as part of a national strategy for older adults' suicide prevention.

RESULTS

A set of 20 key recommended considerations are presented. The major addition to existing recommendations is the need for 'A suicide prevention strategy for the elderly…' to enhance the national all-ages suicide prevention strategy.

CONCLUSION

The recommended statements are offered for consideration by stakeholder groups preparing new interventions, large-scale public healthcare planning and governmental policy.

Development of a Suicide Prediction Model for the Elderly Using Health Screening Data

Suicide poses a serious problem globally, especially among the elderly population. To tackle the issue, this study aimed to develop a model for predicting suicide by using machine learning based on the elderly population. To obtain a large sample, the study used the big data health screening cohort provided by the National Health Insurance Sharing Service. By applying a machine learning technique, a predictive model that comprehensively utilized various factors was developed to select the elderly aged > 65 years at risk of suicide. A total of 48,047 subjects were included in the analysis. Individuals who died by suicide were older, and the number of men was significantly greater. The suicide group had a more prominent history of depression, with the use of medicaments significantly higher. Specifically, the prescription of benzodiazepines alone was associated with a high suicide risk. Furthermore, body mass index, waist circumference, total cholesterol, and low-density lipoprotein level were lower in the suicide group. We developed a model for predicting suicide by using machine learning based on the elderly population. This suicide prediction model can satisfy the performance to some extent by employing only the medical service usage behavior without subjective reports.

Self-inflicted injury and the older trauma patient: a 20 year review of suicide attempts and outcomes

PURPOSE

Older patients (Older) have complex health management needs often requiring additional resources. Mental health disorders are common among trauma patients, yet minimal information on older suicidal related injury and outcomes exists. A review of trauma patients with intentional self-inflicted injury at one trauma center was done to describe and identify unique elements of this cohort of patients.

METHODS

Trauma registry data from 2000 to 2019 were reviewed for intentional injury and data abstracted included demographics, injury severity, diagnoses, comorbidities and outcomes. Cohorts by age were compared: Older (65 +) vs Younger (< 65). Values considered significant at p ≤ 0.05.

RESULTS

557 suicide attempts were identified with 9% among Older patients. Most patients were male with median age of 75 years for Older and 35 years for Younger cohort, with similar length of stay (LOS) and injury severity scores (ISS). Penetrating injury was more common among Older patients with firearm used most often, 34% vs 14% for Younger. Differences were evident between male and female Older patients with ISS 16.7 vs 5, p < 0.01 and mortality, p = 0.03. The outcome of discharge to home was significantly different between Older and Younger, 6% vs 20% (p < 0.05). A difference in mortality was evident, Older 38% vs Younger 18% (p < 0.05).

CONCLUSION

With the growing aging population, it is important to acknowledge the resultant increase in concomitant mental health issues and suicidality among older patients, where depression may be undiagnosed and untreated. Providing care within this cohort may reduce future attempts and lessen the burden on the health care system.

Understanding Vulnerability to Late-Life Suicide

PURPOSE OF REVIEW

We review recent evidence on suicide among older adults, examine risk factors contributing to vulnerability to late-life suicide, and summarize possible interventions.

RECENT FINDINGS

We found a steadily increasing rate of late-life suicide in the USA in the past decade. Evidence supporting the integration of depression care managers into primary care for risk reduction is among the strongest to date. Pharmacologic and neuromodulation studies should be considered in geriatric depression complicated by suicidality. Broad societal campaigns about suicide education, as well as active outreach to psychiatric patients after discharge or a suicidal crisis, prevent suicidal behavior. Growing research supports an integrative multidisciplinary approach. Suicide is a complex and multifaceted behavior with numerous casual points for intervention. Access to deadly means, presence of depression, disease, disability, and social disconnection are factors that increase vulnerability. Quality geriatric care, regular screening in primary and emergency care settings, and a multidisciplinary approach are necessary to mitigate risk factors. The COVID-19 pandemic amplifies need for a more aggressive approach.

Suicidal ideation in gender and sexual minority students in the largest Brazilian University

OBJECTIVE

Identifying the presence of suicidal ideation and associated factors among university students from a public university in Brazil.

METHODS

A cross-sectional study was performed with 72 university students between 18 and 29 years old. Were used a sociodemographic data questionnaire and the Beck's Suicidal Ideation Scale.

RESULTS

The suicidal ideation was significantly in the participants, as well as the association of gender, gender identity, sexual orientation and housing with it.

CONCLUSIONS

The suicidal ideation in this population is important, and there is a need to explore the factors related, such as gender, sexual orientation, gender identity and housing.

Suicidal behaviors and ideation during emerging viral disease outbreaks before the COVID-19 pandemic: A systematic rapid review

The current COVID-19 pandemic is the most severe pandemic of the 21st century, on track to having a rising death toll. Beyond causing respiratory distress, COVID-19 may also cause mortality by way of suicide. The pathways by which emerging viral disease outbreaks (EVDOs) and suicide are related are complex and not entirely understood. We aimed to systematically review the evidence on the association between EVDOs and suicidal behaviors and/or ideation. An electronic search was conducted using five databases: Medline, Embase, Web of Science, PsycINFO and Scopus in April 2020. A rapid systematic review was carried out, which involved separately and independently extracting quantitative data of selected articles. The electronic search yielded 2480 articles, of which 9 met the inclusion criteria. Most of the data were collected in Hong Kong (n = 3) and the USA (n = 3). Four studies reported a slight but significant increase in deaths by suicide during EVDOs. The increase in deaths by suicide was mainly reported during the peak epidemic and in older adults. Psychosocial factors such as the fear of being infected by the virus or social isolation related to quarantine measures were the most prominent factors associated with deaths by suicide during EVDOs. Overall, we found scarce and weak evidence for an increased risk of deaths by suicide during EVDOs. Our results inform the need to orient public health policies toward suicide prevention strategies targeting the psychosocial effects of EVDOs. High-quality research on suicide risk and prevention are warranted during the current pandemic.

Optimal doses of antidepressants in dependence on age: Combined covariate actions in Bayesian network meta-analysis

Background: The meta-analysis by Furukawa et al. (The Lancet Psychiatry 2019, 6(7)) reported optimal doses for antidepressants in adult major depressive disorder (MDD). The present reanalysis aimed to adjust optimal doses in dependence on age. Methods: Analysis was based on the same dataset by Cipriani et al. (The Lancet 2018, 391(10128)) comparing 21 antidepressants in MDD. Random-effects Bayesian network meta-analysis was implemented to estimate the combined covariate action using restricted cubic splines (RCS). Balanced treatment recommendations were derived for the outcomes efficacy (response), acceptability (dropouts for any reason), and tolerability (dropouts due to adverse events). Findings: The combined covariate action of dose and age suggested agomelatine and escitalopram as the best-balanced antidepressants in terms of efficacy and tolerability that may be escalated until 40 and 60 mg/day fluoxetine equivalents (mg/day FE ), respectively, for ages 30-65 years. Desvenlafaxine, duloxetine, fluoxetine, milnacipran, and vortioxetine may be escalated until 20-40 mg/day FE , whereas bupropion, citalopram, mirtazapine, paroxetine, and venlafaxine may not be given in doses  > 20 mg/day FE . Amitriptyline, clomipramine, fluvoxamine, levomilnacipran, reboxetine, sertraline, and trazodone revealed no relevant balanced benefits and may therefore not be recommended for antidepressant treatment. None of the antidepressants was observed to provide balanced benefits in patients >70 years because of adverse events exceeding efficacy. Interpretation: Findings suggest that the combined covariate action of dose and age provides a better basis for judging antidepressant clinical benefits than considering dose or age separately, and may thus inform decision makers to accurately guide antidepressant dosing recommendations in MDD. Funding: No funding.