Virtual Workshop: Social Disconnection and Late-Life Suicide: Mechanisms, Treatment Targets, and Interventions

Sponsor(s): NIMH Division of Translational Research

Thursday, September 17, 2020, 10:00 a.m.-4:00 p.m. ET
Friday, September 18, 2020, 10:00 a.m.-3:00 p.m. ET

About the Workshop:

On September 17 and 18, 2020, the NIMH Division of Translational Research conducted a two-day virtual workshop, “Social Disconnection and Late Life Suicide,” which brought together clinician scientists, behavioral scientists, neuroscientists, geriatric psychiatrists, epidemiologists, and implementation scientists to discuss the current state of the science on social disconnection and suicide.

Background:

Suicide is the tenth leading cause of death in the United States. In late adulthood, suicide rates are higher than in any other age group and have risen more than 40% in the past 10 years.  Social disconnection – a term which refers to either objective social isolation, perceived social isolation (otherwise known as loneliness), or the co-presence of both – is one of the primary risk factors for a suicidal attempt.  It is at its highest levels in late adulthood and is one of the primary motivators of self-harm in older adults. As the American population rapidly ages – over 20% of the population will be over the age of 65 by 2030 – there is an urgent need to advance mechanistic understanding of the link between social disconnection and suicide risk, to identify treatment targets for promising interventions to address social disconnection and suicide in late-life, and to elucidate barriers to and achievements in implementing interventions and providing services to socially disconnected older adults contemplating suicide. 

Presentations explored several research topics and covered a wide range of novel findings and ideas around several major themes, including: 

1) The mechanisms by which social disconnection confers risk for suicide in older adulthood;

2) Potential treatment targets for future intervention development;

3) Opportunities for and obstacles to effective implementation of interventions to address and prevent late-life suicide.

Summary

The need for consistency in terminology

For the workshop, participants adopted the following definitions used by the National Academies of Science: 

• Social connections were defined as structural-functional and quality aspects of how individuals connect; 
• Social support was defined as actual or perceived availability of resources of various kinds from others, typically in one social network; 
• Social isolation was defined as the objective lack of or limited social contact with others; and 
• Loneliness was defined as the perception of social isolation or the subjective feeling of being lonely.

Inconsistency in how social disconnection is measured and defined is a challenge that reduces precision when aggregating, evaluating, and disseminating research evidence. Similarly, researchers need to be specific and conceptually identify whether the construct of interest is isolation or loneliness. 

There is no clinical “gold standard” for screening for loneliness or isolation, though tools like the newly developed Extreme Social Isolation Risk (ESIR) screener are undergoing validation studies. This is a barrier for encouraging health providers to screen for loneliness or isolation among their aging patients. Without a screening tool, studying social isolation and loneliness using administrative health care data is also a challenge.

A focus on mechanisms

Workshop participants discussed psychological, biological, and social mechanisms linking disconnection to suicide risk and the interplay among them. 

Psychological Mechanisms: Strong social connections may encourage proper diet and exercise, whereas deficient connections may enable more risk taking, poorer diets, substance use, and sleep deficiencies. Disconnected older adults may be less able to develop compensatory strategies, such as asking people for help or advice, as they age. 

Biological Mechanisms: Loneliness was likened to a biological drive that motivates people to reconnect. Chronic levels of loneliness have been linked with chronic inflammation and neuropeptide oxytocin. The microbiome may also be an important biological mechanism linking social disconnection and suicide risk. Candidate neurobiological mechanisms include the effects of social isolation effects on serotonin, the HPA axis, and acute sleep loss. 

Biological changes brought about by disease may influence one’s social functioning, leading to social isolation that could mediate or moderate the relationship between disconnection and suicide risk. For example, individuals with depression and borderline personality disorder who are vulnerable to suicidal behavior exhibit disruptive corticosteroidal egocentric learning signals that can exacerbate interpersonal crises. Neurodegenerative disorders (i.e., Alzheimer's disease, frontotemporal dementia, Parkinson's disease, and Lewy body dementia) may impair social processes like interpreting information from faces, recognizing the thoughts and feelings of others, or behaving within social norms, ultimately resulting in changes in one’s social connections.

Social Mechanisms: In addition to an older person’s family and friendship networks, congregational or religious networks were considered as possibly protective – particularly for older African American and Black Caribbean individuals. Providing support to others as one ages may also be protective. However, negative social interactions within one’s networks can increase the risk for depression, anxiety, and other mental health disorders. 

Interventions to reduce social disconnection and prevent suicide

There is a need for primary prevention strategies to prevent feelings of loneliness or isolation, which requires identifying those people who are at risk for disconnection and may include people of lower socioeconomic status, women, lesbian, gay, bisexual, transgender, and queer (LGBTQ) older adults, and people with recent losses. Also important is the need for interventions for people who are already lonely, isolated, or socially disconnected, and mitigating the effects of disconnection on suicide and other health outcomes. 

There is collective evidence that behavioral interventions can reduce loneliness. However, because of the heterogeneity of approaches and populations, and sometimes lack of a theory guiding the intervention, there is no clarity on what comprises an ‘evidence-based’ intervention for reducing loneliness. 

Interventions that have been shown to reduce depression or suicide risk (e.g., caring contacts, pharmacological treatments for depression, esketamine, and safer versions of electroconvulsive therapy) likely promote connectedness. Still, researchers have rarely investigated this mechanism specifically. Emotional regulation interventions for individuals hospitalized with serious ideation or a recent suicide attempt can target increasing social connection or reducing the negative emotions that are associated with being socially disconnected.

Technological interventions may hold promise for addressing social isolation and suicide risk in older adults. For example, one may identify a person who is lonely or at risk of suicide by mining their internet search history data. Ongoing work is adapting existing suicide prevention techniques, like caring contacts or hope boxes, to new technological platforms. New technological interventions, including telemedicine, mobile applications, online communities, video games, digital assistance, and avatars, are also being tested. However, caution was raised about technological interventions. Many older, low-income adults do not use technology, do not have access to technology, or do not have the appropriate technological platforms to avail themselves of these newer products. There are also issues with accessing applications on devices that are difficult for older people to use: for example, small icons or ‘swiping’ on screens are physiologically difficult for older individuals due to hearing or vision impairment, limited (and normal) amounts of executive dysfunction or excess moisture on one’s fingers.

There is also a need to encourage suicide prevention within the systems that provide care for the aging population. This includes embedding effective treatments for suicide in healthcare systems, using patient-reported outcomes in their delivery of care, and aligning with the age-friendly health system movement that emphasizes a focus on the four M's (Mobility, Mentation, Medications, and what Matters). Evidence-based interventions are critical for encouraging insurers to pay for interventions addressing social disconnection in older adults.

The heterogeneous elderly population

One of the greatest challenges with interventions for persons already disconnected is encouraging them to address it. Research is similarly challenging, and many trials have not actually enrolled lonely participants. There is a need for focused or targeted interventions for the heterogeneous aging population, including aging, white men who comprise most elderly suicides in the United States, victims of elder abuse, and persons formerly incarcerated who reenter civil society in late life.

Addressing Scientific Gaps

Some avenues for future research that were identified include: 

• Prospective studies that examine multiple components of social disconnection and synergies between the emotional, functional, and structural aspects of isolation; 
• Studies in minority populations, including those in the minority racial, cultural, ethnic, and economic groups; 
• Psychotherapy trials that enroll more men; 
• Studies that test for differences between online versus in-person contact; 
• Theoretical models that place social support or social connection as moderators of suicide risk among other established risk factors; 
• Studies on the importance of social connection for individuals with cognitive deficits or reduced cognitive functioning; and
• Studies in older adults with more severe forms of suicidal ideation.

The importance of collaboration

Addressing social isolation and suicide risk in older adults will require collaborations. This includes collaborating with community-based organizations that serve elderly patients, including those that serve individuals with home health services and home-delivered meals. Collaborating with primary care providers will likely be critical for preventing suicide among older men who are not connected to any other services. Finally, interdisciplinary collaborations between researchers will be necessary, especially considering the many mechanisms by which social disconnection may increase suicide risk among older adults. 

Recording:

Watch the recording.