Category: Aging and Older Adults
Keywords: Randomized Controlled Trial | Suicide | Aging / Older Adults
Presentation Type: Symposium
Older adults have higher rates of suicide than younger individuals in most countries in the world, and older white men have markedly elevated rates compared to other segments of the U.S. population. Given that the size of the older adult population will rise dramatically in the U.S. in coming decades, we can soon anticipate a very large rise in the number of older adults who die by suicide. A strong contributor to suicide risk in later life is social disconnectedness, which may be more malleable than other targets (e.g., functional impairment) and can be addressed with cognitive behavior therapy. However, there is scant data indicating approaches that reliably and effectively increase social connectedness. The purpose of the study that will be described in this talk is to evaluate the efficacy of a form of behavior therapy called Engage (Alexopoulos & Areán, 2014) in increasing social engagement and reducing both depressive symptoms and suicide ideation. Engage is designed to work primarily through “reward exposure,” which, in line with RDoC principles (e.g., Insel, 2014), targets the behavioral expression of positive valence systems’ dysfunction by having patients re-engage with pleasant, physical, or social activities they may have stopped doing because of depression. For this trial, subjects were focused solely on social activities because the hypothesis of the study is, in line with the Interpersonal Theory of Suicide (Van Orden et al., 2010), that targeting social engagement will increase positive connections and contributions to others, thus reducing two proximal risk factors for suicide—thwarted belonging and perceived burden, thereby reducing suicide risk. In Engage, subjects complete “action plans” each session that involve setting a social goal, brainstorming ways to achieve the goal, and setting specific steps to take. Engage is specifically tailored for older adults, including those with cognitive impairment, such as memory problems and executive functioning problems. Intentional repetition of steps in action planning is used. Further, Engage utilizes a stepped care format, in which additional strategies can be used for older adults who do not respond to action planning alone. Specifically, Engage focuses on characteristics of late-life depression that may act as barriers to success, including apathy and emotion dysregulation.
Methods: Older adults (age 60 or older) who were at elevated risk for suicide per the Interpersonal Theory of Suicide, by virtue of having reported feeling lonely or like a burden, were recruited from primary care clinics and an outpatient geriatric mental health clinic. Subjects were randomized to either 10 weekly sessions of Engage provided in their home, or care-as-usual with their PCP and/or mental health provider. Engage sessions were delivered by a clinical psychologist or a geriatric social worker; all therapists were certified as adherent to the Engage protocol before seeing study subjects. Ongoing fidelity monitoring by an outside Engage expert was conducted with approximately 15% of sessions. All sessions were rated as adherent. Assessment measures included the SCID for DSM V, depression severity (QIDS), suicide ideation and behavior (Columbia Suicide Severity Scale), severity of suicide ideation (Geriatric Suicide Ideation Scale), and both thwarted belonging and perceived burden (Interpersonal Needs Questionnaire). Subjects were assessed at baseline (in-person), 3 weeks following randomization (by phone), 6 weeks (phone), and 10 weeks (in-person).
Results: Recruitment is complete, with n=30 subjects randomized to Engage and n=32 randomized to care-as-usual. Results indicate that 96% of Engage subjects completed all sessions. Further, all subjects were willing and able to generate goals solely focused on social engagement each session. Regarding outcomes, a small pilot trial (n=3) was conducted at the start of the study. All three subjects were willing and able to generate social engagement goals each session; e.g., taking a walk to see a friend; going to get ice cream with her daughter; helping out by walking the neighbor’s dog, indicating the feasibility of focusing ENGAGE on social engagement exclusively. Regarding quantitative outcomes of the pilot, average depression severity decreased (mean scores 12.5 at base, 9.75 at 3 weeks, 7.33 at 6 weeks), suicide risk decreased (11.25 at base, 8.00 at 3 weeks, 8.67 at 6 weeks), and thwarted belongingness decreased slightly (6.25 at base, 6.25 at 3 weeks, 5.67 at 6 weeks). Qualitative outcomes indicate that subjects believed that increased social engagement lead to greater positive mood and well-being. One subject stated: “Socializing, it helps my mood to get out. Being around people does lift you up.” Another stated, “I have a reason to keep going, a direction, a family. I sent 83 Xmas cards! I have people in my life. Alone wraps itself around you like an ugly blanket and you lose track of the world you have available to you. My world is still out there. Action plans helped aim me—direction, got me back on track. [After the program] I will concentrate on expanding my outside contacts (like the senior center) and even if I’m here, I’ll do things to feel the outside connections, like getting on the phone.” Full outcomes analysis will be complete by June, 2017. Both quantitative and qualitative results will be presented.
Conclusions: Engage focused solely on social activites is a feasible and acceptable form of behavior therapy for older adults. If data indicate it also reduces depression and suicide ideation, research should examine procedures whereby it can be delivered in primary care, as most older adults do not seek specialty mental health treatment, but are seen in primary care.
University of Rochester School of Medicine
Friday, November 17
10:15 AM – 11:45 AM
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