Engage coaching for caregivers: a pilot trial to reduce loneliness in dementia caregivers.

OBJECTIVES: There are no evidence-based interventions for reducing loneliness in family caregivers of people with dementia (ADRD caregivers), despite heightened risk. We examined feasibility, acceptability, and potential efficacy of a brief behavioral intervention, Engage Coaching for Caregivers, to reduce loneliness and increase social connection for older ADRD caregivers experiencing stress and loneliness. METHODS: A single-arm clinical trial of 8 individual sessions of Engage Coaching delivered remotely. Outcomes assessed 3-months post-intervention included loneliness and relationship satisfaction (co-primary) and perceived social isolation (secondary). RESULTS: Engage Coaching was feasible to deliver, with n = 25 of 30 enrolled completing at least 80% of sessions. 83% indicated the program met expectations and 100% reported the program was suitable and convenient. Improvements were observed in loneliness (standardized response mean [SRM] = 0.63), relationship satisfaction (SRM = 0.56), and perceived social isolation (SRM = 0.70). CONCLUSION: Engage Coaching is a promising behavioral intervention to enhance social connection for older ADRD caregivers.

Beyond maintaining safety: Examining the benefit of emotion-centered problem solving therapy added to safety planning for reducing late life suicide risk.

Few clinical trials have examined brief non-pharmacological treatments for reducing suicide risk in older Veterans, a high-risk group. Problem Solving Therapy (PST) is a promising psychosocial intervention for reducing late life suicide risk by increasing adaptive coping to problems through effective problem solving and related coping skills. The current randomized clinical trial will compare the efficacy of six telephone-delivered sessions of Safety Planning (enhanced usual care; EUC) only or an updated version of PST (emotion-centered PST [EC-PST]) + EUC to determine the added clinical benefit of EC-PST for reducing severity of suicidal ideation and for increasing reasons for living, a critical protective factor. Participants randomized to EC-PST + EUC or EUC only will be 150 Veterans (75 each) with active suicidal ideation who are aged 60 or older; have a current DSM-5 anxiety, depressive, and/or trauma-related disorder; and without significant cognitive impairment. Primary outcomes (Geriatric Suicide Ideation Scale and Reasons for Living-Older Adults scale) will be assessed at 11 timepoints: baseline, after each of 6 treatment sessions, posttreatment, and at follow-up at 1, 3, and 6 months posttreatment, and analyzed using mixed effects modeling. Additionally, moderators and mediators of primary outcomes will be examined-functional disability, executive dysfunction, and problem-solving ability. Qualitative feedback from participants will identify potential Veteran-centric changes to the EC-PST protocol and to EUC. Ultimately, the goal of this study is to inform the evidence-based clinical practice guidelines for treatments to reduce suicide risk in older Veterans and specifically to inform clinical decision-making regarding the merit of adding EC-PST to EUC.

Neurocognitive markers of passive suicidal ideation in late-life depression.

OBJECTIVES: (1) To delineate whether cognitive flexibility and inhibitory ability are neurocognitive markers of passive suicidal ideation (PSI), an early stage of suicide risk in depression and (2) to determine whether PSI is associated with volumetric differences in regions of the prefrontal cortex (PFC) in middle-aged and older adults with depression. DESIGN: Cross-sectional study. SETTING: University medical school. PARTICIPANTS: Forty community-dwelling middle-aged and older adults with depression from a larger study of depression and anxiety (NIMH R01 MH091342-05 PI: O'Hara). MEASUREMENTS: Psychiatric measures were assessed for the presence of a DSM-5 depressive disorder and PSI. A neurocognitive battery assessed cognitive flexibility, inhibitory ability, as well as other neurocognitive domains. RESULTS: The PSI group (n = 18) performed significantly worse on cognitive flexibility and inhibitory ability, but not on other neurocognitive tasks, compared to the group without PSI (n = 22). The group with PSI had larger left mid-frontal gyri (MFG) than the no-PSI group. There was no association between cognitive flexibility/inhibitory ability and left MFG volume. CONCLUSIONS: Findings implicate a neurocognitive signature of PSI: poorer cognitive flexibility and poor inhibitory ability not better accounted for by other domains of cognitive dysfunction and not associated with volumetric differences in the left MFG. This suggests that there are two specific but independent risk factors of PSI in middle- and older-aged adults.

The Geriatric Feelings of Burdensomeness Scale (GFBS).

OBJECTIVES: The present article describes the development and psychometric evaluation of the Geriatric Feelings of Burdensomeness Scale using two samples of older adults collected through Amazon Mechanical Turk. The scale is a 25-item measure of general subjective feeling of being a burden on or problem for others. The goal of the measure is to capture a broad conceptualization of burdensomeness that is relevant to a variety of important psychological variables. METHOD: Two studies are described, including item development and selection, and the examination of reliability and validity evidence in a sample of 192 older adults. RESULTS: The estimates of reliability (coefficient alpha and average interitem correlations) were strong. Preliminary examination of convergent validity evidence found significant moderate correlations between the Geriatric Feelings of Burdensomeness Scale and measures of conceptually related constructs (hopelessness, suicidality, perceived burdensomeness, thwarted belongingness). Small, non-significant correlations were found between three indices of religiosity, providing preliminary discriminant validity evidence. CONCLUSIONS: Our results provide initial psychometric support for a more general and inclusive assessment tool for measuring older adults' feelings of burdensomeness. CLINICAL IMPLICATIONS: With further research on clinical significance of feelings of burdensomeness and predictive validity, this measure may be used to identify concerns and beliefs about burdensomeness among distressed older adults.

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.

URMC Universal Depression Screening Initiative: Patient Reported Outcome Assessments to Promote a Person-Centered Biopsychosocial Population Health Management Strategy.

Background: Patient-reported outcomes (PROs) can promote person-centered biopsychosocial health care by measuring outcomes that matter to patients, including functioning and well-being. Data support feasibility and acceptability of PRO administration as part of routine clinical care, but less is known about its effects on population health, including detection of unmet healthcare needs. Our objectives were to examine differences in rates of clinically significant depression across sociodemographic groups and clinical settings from universal depression screens in a large health system, estimate the number of patients with untreated depression detected by screenings, and examine associations between biopsychosocial PROs-physical, psychological, and social health. Methods: We analyzed data from over 200,000 adult patients who completed depression screens-either PROMIS (Patient Reported Outcomes Measurement Information System) or PHQ-2/9-as part of routine outpatient care. Results: Depression screens were positive in 14.2% of the sample, with more positive screens among younger vs. older adults, women vs. men, non-White vs. White, and Hispanics vs. non-Hispanics. These same sociodemographic indicators, as well as completing screening in primary care (vs. specialty care) were also associated with greater likelihood of detected depression in the medical record. Discussion: Universal screening for depression symptoms throughout a large health system appears acceptable and has the potential to detect depression in diverse patient populations outside of behavioral health. Expanded delivery of PROs to include physical and social health as well as depression should be explored to develop a clinically-relevant model for addressing patients' biopsychosocial needs in an integrated fashion across the health system.

Improvements in Functional Disability After Psychotherapy for Depression Are Associated With Reduced Suicide Ideation Among Older Adults.

OBJECTIVE: To evaluate the association between changes in functional disability and suicide ideation among older adults following psychotherapy for depression. METHODS: Sixty-five participants (65-91 years old, 72% White, and 66% female) with depression completed 12 sessions of problem solving therapy (PST) and completed measures of disability (WHO Disability Assessment Schedule 2.0) and suicide ideation (Geriatric Suicide Ideation Scale [GSIS]) at baseline and post-treatment. RESULTS: Hierarchical linear regressions found that reductions in functional disability were associated with overall reductions in suicide ideation on the GSIS (F[4,60] = 4.06, p < 0.01), particularly with the Loss of Worth GSIS subscale (F[4,60] = 7.86, p < 0.001, ΔR2 = 0.140). CONCLUSIONS: Results suggest decreased functional disability following depression treatment is associated with decreased suicide ideation, especially thoughts regarding loss of worth. These results highlight the potential for treatments that reduce functional disability (e.g., PST) to reduce risk of suicide among older adults.

Strategies to Promote Social Connections Among Older Adults During "Social Distancing" Restrictions.

Older age and medical comorbidity are factors associated with more severe illness and risk of death due to COVID-19 infection. Social distancing is an important public health strategy for controlling the spread of the virus and minimizing its impact on the older adult population. It comes at a cost, however. Loneliness is associated with myriad adverse health outcomes, one of which is impaired immune functioning, which adds even greater risk for coronavirus infection, complications and death. Older adults, therefore, are at compound risk, making effective management of loneliness and social isolation in our older patients a high priority target for preventive intervention. In this paper, the authors describe a cognitive-behavioral framework for social connectedness, including evidence-informed strategies clinicians can use to help patients develop a "Connections Plan" to stay connected and promote their social, mental, and physical health during "social distancing" restrictions. This set of strategies can be provided during brief (30 minute) telephone sessions and is analogous to creating a "Safety Plan" for suicide risk. The approach is illustrated with three case examples.

Sadness and Worry in Older Adults: Differentiating Psychiatric Illness from Normative Distress.

Older adults experience greater emotional well-being in late life. However, older adults may be vulnerable to certain physiologic risk factors, including less physiologic resilience to prolonged stress. Depression and anxiety can be difficult to diagnose in late life owing to differences in self-reported symptoms from younger adults and unclear distinctions between normative and non-normative emotional experiences. We discuss age differences in the presentations of depression and anxiety, and normative and non-normative late life developmental trajectories around bereavement and grief, social isolation and loneliness, and thoughts of death and suicide. We provide recommendations for clinicians for assessing and diagnosing older adults.

A Case Report of Problem Solving Therapy for Reducing Suicide Risk in Older Adults with Anxiety Disorders.

Objectives: Suicide is a global public health problem among older adults. Problem-solving therapy (PST) has demonstrated promise in reducing late-life suicide risk, chiefly in secondary analyses of studies on late-life depression. PST mitigates negative beliefs about one's problem-solving abilities and maladaptive problem-solving styles, which suicidal older adults report. The effects of PST on suicide risk in older adults with primary anxiety disorder diagnoses have not been examined. Anxiety is a risk factor for suicide, but it is less studied in research on suicide compared to depression. This paper describes two cases of older individuals with anxiety disorders and suicidal ideation who completed six sessions of PST. Methods: Assessments of suicide risk, anxiety, depressive symptoms, and problem-solving ability were administered. Results: Both cases exhibited a clinically significant reduction in suicide risk, along with reductions in anxiety, worry, and depressive symptoms by posttreatment. Conclusions & Clinical Implications: Findings highlight the potential for PST as a psychotherapeutic intervention for reducing suicide risk in older adults with anxiety disorders.

A Shortened Version of the Reasons for Living-Older Adults Scale for Clinical and Research Utility.

BACKGROUND AND OBJECTIVES: Older adults have elevated suicide rates, and identification of protective factors, such as reasons for living, is important in preventing suicide. The Reasons for Living-Older Adults scale (RFL-OA) is a 69-item measure of these protective factors in late life, which yields good psychometric properties. However, its length limits its utility in some clinical and research contexts where a shorter measure is ideal. The objective of this study was to create a shortened version of the RFL-OA. RESEARCH DESIGN AND METHODS: First, data collected previously during validation of the original RFL-OA (n = 199, age 65 and older, 65% female) were used to select 30 items, spanning all content areas, that were highly endorsed. Second, new data were collected (n = 219, age 60 and older, 52% female) with the 30-item RFL-OA and measures of depression, hopelessness, suicidal ideation, religiosity, health, and social desirability to examine the measure's internal consistency and convergent and discriminant validity. RESULTS: Scores on the 30-item RFL-OA exhibited strong internal consistency. The short RFL-OA demonstrated good convergent validity via significant, moderate correlations with suicidal ideation, hopelessness, depression, and religiosity. It demonstrated adequate discriminant validity via only small correlations with disability, subjective health, and social desirability. DISCUSSION AND IMPLICATIONS: The shorter RFL-OA has good psychometric properties among community-dwelling older adults. It may have greater utility, compared to the original 69-item measure, for clinicians and researchers with limited time but who want to assess protective factors against suicidal behavior in late life.

Difficulties in emotion regulation and chronic pain-related disability and opioid misuse.

Risk for opioid misuse is a crucial consideration for patients with chronic pain, given the recent high rates of opioid-related deaths in the U.S. Emotion regulation difficulties may be associated with chronic pain outcomes such as opioid misuse, but may also be amenable to intervention. The aim of this study was to examine associations between difficulties with emotion regulation and disability and risk for opioid misuse among Appalachian chronic pain patients. The Difficulties in Emotion Regulation scale (DERS-18), Pain Disability Index (PDI), Screener and Opioid Assessment for Patients with Pain - Revised (SOAPP-R), and Current Opioid Misuse Measure (COMM) were collected from 149 patients (age 25-80, 59% female) presenting to a behavioral medicine department for evaluation. The extent to which DERS-18 scores predict risk for opioid misuse and disability was examined via hierarchical regression, logistic regression, and receiver operating characteristic (ROC) curve analyses. DERS-18 scores account for 45% of variance in SOAPP-R, 36% in COMM scores, and 11% in PDI scores. A one-point increase in DERS-18 score is associated with 19% greater odds of being at risk for misuse as measured by the SOAPP-R, and 16% greater odds on the COMM. In ROC analyses, the DERS-18 is a good predictor of risk on the SOAPP-R (AUC = .85) and COMM (.83), with cut-off scores in the mid-30s exhibiting good sensitivity and specificity. Difficulties in emotion regulation are associated with poorer functioning and with greater risk of opioid misuse in this population, but may be amenable to intervention.

Functional disability and suicidal behavior in middle-aged and older adults: A systematic critical review.

BACKGROUND: Middle-aged and older adults have elevated rates of suicide around the globe, but there is a paucity of knowledge about risk factors for suicide in these age groups. One possible risk factor may be functional disability, which is more common at later ages. METHODS: The current systematic critical review examined findings regarding the associations between functional disability and suicidal behavior (suicidal ideation, suicide attempts, and death by suicide) in middle-aged and older adults (i.e. age 50 and older). RESULTS: Forty-five studies were found that examined these associations. The majority of studies supported a significant association between functional disability and suicidal ideation. In addition, findings to date strongly suggest that depression serves as a mediator of the association between functional disability and suicidal ideation, though most studies did not directly test for mediation. LIMITATIONS: Firm conclusions regarding suicide attempts and death by suicide, as well as mediation, cannot be drawn due to a relative lack of research in these areas. CONCLUSIONS: The association between functional disability and suicidal behavior suggests an important area for prevention and intervention among middle-aged and older adults, but additional research is necessary to clarify the specifics of these associations and examine appropriate intervention strategies. Important future directions for research in this area include the direct comparison of associations of risk factors with different types of suicidal behavior, greater use of longitudinal data with multiple time points, and further examination of potential mediators and moderators of the association between functional disability and suicidal behavior.

Predicting Risk for Opioid Misuse in Chronic Pain with a Single-Item Measure of Catastrophic Thinking.

BACKGROUND: Chronic pain patients are frequently treated with opioid medications in primary care, where brief measures of risk for opioid misuse have great utility. Catastrophic thinking is a clinically relevant and potentially modifiable factor associated with several chronic pain outcomes, including risk for opioid misuse. This study examined the utility of a single-item measure of pain-related catastrophizing in predicting risk of opioid misuse. METHOD: 119 chronic pain patients completed the Coping Strategies Questionnaire catastrophizing item, Pain Catastrophizing Scale (PCS), and Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). Area under the receiver operator curve (AUC) and linear regression were used to examine predictive utility of the catastrophizing item. RESULTS: The catastrophizing item demonstrated a fair ability to discriminate those with high risk for opioid misuse on the SOAPP-R (AUC = 0.74), whereas the PCS demonstrated good discrimination (AUC = 0.85). The single item alone accounted for 30% of variance in SOAPP-R scores. CONCLUSION: A single question assessing pain catastrophizing has utility for predicting risk for opioid misuse. In addition, it provides the primary care provider with information on a potentially modifiable risk factor that can be addressed within the context of a brief clinical visit.

Perceived Burdensomeness in Older and Younger Adults: Evaluation of the Psychometric Properties of the Interpersonal Needs Questionnaire.

OBJECTIVES: We evaluated measurement invariance of the Interpersonal Needs Questionnaire (INQ-15) Perceived Burdensomeness subscale across younger and older adult age groups as well as the construct validity of the Perceived Burdensomeness subscale by comparing nomological networks across age groups. METHOD: We used nested multigroup confirmatory factor analyses to address measurement invariance and Fisher's r-to-z transformations to compare correlations between perceived burdensomeness and other constructs in younger and older samples. RESULTS: Results generally supported measurement invariance, but signals of differences in fit in older adults were present. The INQ-15 Perceived Burdensomeness subscale exhibited a significantly lower correlation with depressive symptoms in older adults compared to younger adults. Correlations between perceived burdensomeness and all other constructs were similar across age groups. CONCLUSION: This study provides marginal support for measurement invariance of the INQ-15 Perceived Burdensomeness subscale across younger and older adults, but results also suggest age differences in the perceived burdensomeness construct.

Health Conditions and Passive Suicidal Ideation in the Survey of Health, Ageing, and Retirement in Europe.

OBJECTIVES: To examine the associations between health conditions and passive suicidal ideation in middle-aged and older adults. METHOD: Multivariate logistic regression analyses were conducted on data from 35,664 middle-aged and older adults from the Survey of Health, Ageing, and Retirement in Europe. Mediation analyses were also conducted to test the roles of disability and depression in risk of ideation. RESULTS: After including demographic variables, disability, depression, and other health conditions as covariates, heart attack, diabetes/high blood sugar, chronic lung disease, arthritis, ulcer, and hip/femoral fractures were associated with increased odds of passive suicidal ideation. When grouped by organ systems, conditions affecting the endocrine, respiratory, and musculoskeletal systems were associated with increased odds of passive suicidal ideation, as was the total number of conditions. Individuals with greater numbers of health conditions exhibited greater levels of disability and depression, which partially explained the increased risk of passive suicidal ideation among those with more health conditions. DISCUSSION: Certain specific health conditions, as well as total number of conditions, are associated with passive suicidal ideation in middle age and older adulthood. Health is a critical risk factor for suicidal ideation in late life and should be further studied in this particularly at-risk population.