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ObjectiveTo evaluate the association between changes in functional disability and suicide ideation among older adults following psychotherapy for depression.MethodsSixty-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.ResultsHierarchical 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).ConclusionsResults 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.

• What is the primary question addressed in this study? What are the risk and protective factors related to suicide outcomes among older veterans 65 years of age and older? • What is the main finding of this study? We found five domains of explanatory factors studied (i.e., neuropsychiatric, social determinants of health, aging stereotypes, residential and supportive housing settings, and multifactorial–neuropsychiatric/mental health and physical health) with more risk factors than protective factors reported. • What is the meaning of the finding? Our study suggests there are unique factors affecting risk of suicide for older veterans. Thus, more innovative targets to consider for intervention and more innovative methods to predict suicide in late-life are needed. Older veterans are vastly underrepresented in studies that shape national suicide prevention strategies. This is of great concern because factors that impact younger veterans may not be as robust in later life. Although younger veterans have higher rate of suicide, the highest counts of death by suicide are in older veterans. However, it remains unclear from the extant literature what factors may influence increased or decreased risk of late-life suicide in veterans. The objective of this systematic review was to identify risk and protective factors related to suicide outcomes (i.e., ideation, attempt, death, or suicide-related behavior [SRB]) among older veterans. Furthermore, it offers data regarding future study directions and hypothesis generation for late-life suicide research and for informing potential intervention and prevention efforts in this area. We searched 4 databases from inception up to May 5, 2022. We screened 2,388 abstracts for inclusion and 508 articles required full text review. The final sample included 19 studies published between 2006 and 2022. We found five domains of factors studied (i.e., neuropsychiatric, social determinants of health, aging stereotypes, residential and supportive housing settings, and multifactorial–neuropsychiatric/mental health and physical health) with more risk factors than protective factors reported. Across the three suicide outcomes only neuropsychiatric factors were consistently identified as risk factors. Neuropsychiatric factors also comprised the largest group of risk factors studied. More innovative targets to consider for intervention and more innovative methods to predict suicide in late-life are needed. There is also continued necessity to design suicide prevention interventions for older veterans given lethality trends. [ABSTRACT FROM AUTHOR]

Older people of color, those who are socially isolated, veterans, and incarcerated older adults experience disparities in mental healthcare and high levels of psychiatric and physical comorbidity, including increased risk of suicide. The identification of risk factors and understanding the culture and context that impact risk are major public health challenges. Effective approaches to address these challenges are likely to involve using national databases and applying advanced methodologies to address complex clinical questions in older adults. By leveraging extensive epidemiological datasets, we can effectively pinpoint risk factors and consequences associated with mental health disorders in later stages of life. Moreover, these datasets allow us to disaggregate heterogeneous groups which are often treated as homogeneous (e.g. people of color, veterans, etc.). This disaggregation may reveal significant within group differences and provide important contextual information regarding these groups which can be used to deliver precision mental healthcare in an efficient manner and reduce the burden of mental illness in late life. In this session, we will explore innovative methodologies of utilizing national datasets to discern the cultural and contextual elements that impact the mental health and well-being of four high-risk, older adult populations. Emphasis will be placed on identifying patterns in mental healthcare disparities and comprehending how factors such as race, ethnicity, sex, gender, and incarceration contribute to feelings of loneliness, suicide rates, and dementia. Furthermore, we will also discuss the potential application of this data in developing precise risk assessment tools and targeted prevention and treatment strategies. interventions for late-life mental health issues. [ABSTRACT FROM AUTHOR]

Late life veteran suicide is a public health concern, representing the highest number of suicide deaths of any age group, and a significantly higher death rate per attempt. Though a variety of clinical factors, including psychoactive medication use, has been associated with risk for attempt in this population, the timing and pattern of use relative to a fatal attempt has been less explored, particularly in a large national sample. 6,892 veterans aged ³65 years (M (SD) = 75.3(7.6)) who died by suicide between 2012-2019 were included. Medications that may be related to suicide risk (antidepressants, benzodiazepines, opioids, sedative-hypnotics, antipsychotics, and anticonvulsants) were identified as current use or past use, defined by a prescription filled within 6 months of attempt, or prescription filled prior to 6 months before an attempt. Other variables included psychiatric and medical diagnoses and sociodemographic variables. Lethal means were identified using the National Mortality Data Repository (MDR). Veterans who died by suicide were categorized in four ways based on psychoactive medication use in the time prior to their attempt; current use and past use (n = 1,676), current use and no past use (n = 188), no current use and past use (n = 1,744), and no current use and no past use (n = 3,284). Though the vast majority of attempts in all categories were made using firearms, the group with current use and past use was found to have a significantly higher rate of suicide death by overdose than those with all other use patterns (8% compared to 3-4%). This group was also found to be significantly younger than all other groups and have significantly higher rates of nearly all psychiatric disorders compared to the other groups (e.g., nearly 40% with a mood disorder compared to 15% in the no current or past use group). Overall, suicide deaths by overdose among veterans ³65 represented 4.4% of suicide deaths between 2012-2019, while deaths by firearm accounted for 82.7%. There were no indications of temporal patterns of psychoactive medication use and death by firearm. Temporal patterns of psychoactive medication use related to a suicide attempt with unique diagnostic and attempt-related characteristics are identifiable among older veterans who die by suicide. These findings may inform risk assessment among care providers and contribute to the understanding of the complex relationship of psychoactive prescription medications to late life veteran suicide. This work was supported by Award Number I01 CX001119 from the Clinical Science Research & Development Service of the U.S. Department of Veterans Affairs (VA) Office of Research and Development (PI: Dr. Byers). Dr. Byers is the recipient of a VA Research Career Scientist award (IK6 CX002386). Support for the Mortality Data Repository (MDR; previously known as the Suicide Data Repository or SDR) is provided by the VA Center of Excellence for Suicide Prevention. Support for VA/CMS data is provided by the Department of Veterans Affairs, VA Health Services Research and Development Service, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004). [ABSTRACT FROM AUTHOR]

Objective: Prior work suggests executive dysfunction (ED) on the Stroop Color and Word Test (SCWT) and the Mattis Dementia Rating Scale-2 Initiation/Perseveration subscale (DRS IP) predicts poor antidepressant response in late-life depression. This study examined if either patient perception of ED or the Trail Making Test Part B (TMT-B) could identify patients with impairment on the SCWT or DRS IP.Methods: Patients were 65 or older and had a diagnosis of major depression without dementia. Cognition was assessed with the TMT-B, the SCWT, and the DRS IP. A self-reported Perceived Deficits Questionnaire (PDQ) subscale assessed patients' perceptions of ED.Results: In 247 participants (mean age 71.3 years), the PDQ subscale was not associated with test performance. The sensitivity of the TMT-B in identifying impairment on the SCWT or DRS IP was low (35% and 23%, respectively).Conclusion: Neither the TMT-B nor self-reports are useful screening tools for ED on the SCWT or DRS IP. [ABSTRACT FROM AUTHOR]

Abstract Results Of The ADNI-Depression Study. Overview: Late life depression (LLD) is one of the most common mental health disorders with which older patients are afflicted. LLD is complicated by the common co-occurrence of cognitive impairment (CI). Estimates suggest as many as 50-60% of older depressed patients may have mild cognitive deficits however the mechanisms contributing to CI are unclear. The ADNI-Depression (ADNI-D) Study is a 5-year two-site (University of California San Francisco and the University of Pittsburgh) NIMH sponsored study of late life depression. The study aims to characterize cognitive functioning patients with LLD and clarify neurobiological mechanisms contributing to cognitive impairment and accelerated cognitive decline in this patient population. The ADNI -D study partners with the Alzheimer's Disease Network Initiative (ADNI) and utilizes its core labs for data management, brain imaging, and biomarker assessments. The ADNI D study has been designed to focus on evaluating the impact of reduced cerebral blood flow, cortical atrophy, white matter disease, and amyloid deposition on cognitive impairment in LLD. The study is longitudinal; after an initial assessment subject are followed for 2 ½ years. ADNI-D is committed to rapid data sharing of the ADNI-D data. This session will present initial data from the ADNI-Depression Study baseline evaluation and will be organized into 4 topic areas. ADNI-D Methodology and Sample Characteristics (Nelson) The ADNI D sample is a well characterized sample of older adults with depression. The ADNI D methodology facilitates comparisons of this cohort of LLD participants with the larger ADNI study of non-depressed older adults with normal cognition, Mild Cognitive Impairment (MCI), and dementia in order to clarify neurobiological mechanisms contributing to cognitive impairment and accelerated cognitive decline. This session will be focused on describing the ADNI-D methodology for participant enrollment and data collection and to report ADNI D sample (n=121) characteristics for depression severity, lifetime history of depression and depression treatment, and functional impairment. Specifically, participant enrollment criteria and methods for the assessment of depression severity and lifetime history of depression and depression treatments will be summarized. Additionally, standardized methodology for collection of neuroimaging data, biomarkers, and data management will be presented. Cognitive Functioning in the ADNI Depression cohort (Morin). The clarification of types and severity of cognitive dysfunction in LLD remains a significant area of research. This session will focus on identifying the cognitive impairment rates of participants with LLD in the ADNI-D study at baseline, highlighting methodological considerations for matching subjects to ADNI participants on basis of cognitive functioning for biomarker analyses, and to assess the relationship of subjective cognitive complaints and ApoE status with objective measures cognitive performance. Association of Cortical Atrophy, White Matter Lesions, and Amyloid Accumulation with Cognition in Late Life Depression (Mackin) Cognitive impairment (CI) in LLD is often characterized by deficits of executive functioning (EF), memory, and language and LLD has been strongly linked to accelerated rates of cognitive decline in older adults. However, the causes of CI in LLD are not clear, in part due to limitations of previous work which have lacked comparisons to well characterized non-depressed older adults with CI caused by neurodegenerative diseases that are often concurrent with LLD, such as the early stages of Alzheimer's disease (AD) and cerebrovascular disease (CVD). The ADNI-D study will facilitate clarification of neurobiological mechanisms contributing to CI in LLD. This session will be focused on evaluating the impact of reduced cerebral blood flow (hypoperfusion), cortical atrophy, and amyloid deposition on CI in LLD in the context of previously documented relationships between CI and subcortical white matter abnormalities and genetic risk factors. Functional Network Level Pathophysiologic Abnormalities Associated with Late Life Depression (Tosun) Cognitive impairment, particularly in the domains of information processing speed, executive functioning, and memory, in LLD is consistent with neurobiological conceptualizations of LLD as being heavily mediated by extended neural networks comprised of the orbitofrontal, medial prefrontal, and cingulate cortices, and anatomical connections with the temporal and parietal lobes, and basal ganglia. By disturbing the normal function and dynamics of different brain networks, the pathophysiological mechanisms of LLD may generate different specific clinical symptoms. Therefore we examine the extent to which multimodal neuroimaging techniques can identify biomarkers reflecting key pathophysiologic processes in LLD and whether such biomarkers may act as predictors, moderators, and mediators of depressive symptoms. This might facilitate development of personalized treatments based on a better understanding of the pathophysiological mechanisms of late life depression. [ABSTRACT FROM AUTHOR]

Late life is often associated with declining health, with an estimated 11-32% of community-dwelling older adults living with frailty. Frailty, a durable phenotype associated with depression, is often measured as an accumulation of physical and mental deficits. This underlying distress may be associated with suicidal thoughts. Frailty has never been assessed as a risk factor for suicide on a national level but may be useful as a prognostic marker. Our primary objective was to determine the relationship of frailty to subsequent risk of suicide attempt and death by suicide across age groups in a large national cohort of veterans aged 50+. With >70% of the veteran population aged 50+ and ∼70% of veteran suicides occurring in older veterans, this study has potential to be highly impactful. We performed a longitudinal cohort study on a national sample of mid to late-life veterans: All veterans aged 50+ who used VA healthcare services during study baseline of fiscal years 2012-2013 (N=5,059,526) with ongoing follow-up through the end of calendar year 2017. We linked four national databases: (1) National Patient Care Database (NPCD), for VA inpatient and outpatient services; (2) Centers for Medicare & Medicaid Services (CMS), for non-VA inpatient and outpatient services; (3) Suicide Prevention Applications Network (SPAN), for information on non-fatal suicide attempts; and (4) Mortality Data Repository (MDR), for cause-specific death information and dates. Demographic information for age, gender, and race/ethnicity was obtained from NPCD and/or CMS records. To study the role of frailty and its connection to late-life suicide-related behaviors, we used a cumulative deficit method and frailty index (FI) developed by Orkaby et al. (2019). This index integrates 31 variables (deficits) from ICD-9/10 diagnoses and procedure codes and HCPCS (Healthcare Common Procedure Coding System) codes from NPCD and CMS data. Variables relate to morbidity (e.g., diabetes), functional status (e.g., use of durable medical equipment), cognition and mood (e.g., depression), sensory loss (e.g., blindness), and other geriatric conditions (e.g., weight loss in the past year). FI scores were calculated at baseline index date of study entry and within two years prior, summing the number of accrued deficits then dividing by 31 (total number of possible deficits), producing scores from 0 to 1. We defined Non-frail as FI≤0.1, Pre-frail as 0.10.4. Suicide attempt and death outcomes were derived from SPAN and MDR databases through 2017. Non-fatal suicide attempts were derived from SPAN, based on standardized clinician reports uploaded to the national database. Fatal suicide attempts were derived from MDR with ICD-10 codes X60-X84 and Y87.0. Cumulative incidence of any suicide attempt was plotted by patient age in years across frailty categories. We used Cox proportional hazards regression to examine time to suicide attempt at follow up, with age as the time scale and censoring at end of study. We examined multivariable models adjusted in steps: Model 1, unadjusted; Model 2, adjusted for demographics (race, gender, region); Model 3, Model 2 + adjusted for substance use disorder and PTSD; Model 4, Model 3 + adjusted for Charlson Comorbidity Index (CCI). We did not adjust for depression as it was included in the FI. We adjusted for CCI to examine the FI's robustness as a marker for suicide risk in the context of another global index. Our sample's average age was 68 (SD 11), 94% male, 77% white, and 14% black. Fifty-one percent of veterans aged 50+ were non-frail, while 26% were pre-frail, 12% mildly frail, 6% moderately frail, and 4% severely frail. The average FI score was 0.10. There were 29,679 suicide attempts at follow up, with 9,659 fatal attempts. Cumulative incidence rates of suicide attempt were significantly higher for more frail than less frail individuals (Figure 1). Our fully adjusted model (Table 1, Model 4) showed a strong dose-response relationship between frailty severity and risk of suicide attempt (fatal and non-fatal), with hazard ratios (HR) increasing from 1.55 for Pre-frail to 2.50 for Severely frail individuals. An attenuated HR effect was seen for fatal attempts: ranging from 1.29 for Pre-frail to 1.56 for Severely frail individuals. Furthermore, we found a significant interaction of FI by age groups 50-64 and 65+ (p-interaction<0.001) with higher HRs and a more salient dose-effect in ages 50-64. Our findings suggest a cumulative deficit FI may be a strong prognostic marker associated with risk of suicide attempt in young-old to oldest-old beyond other factors such as substance use disorder, PTSD, and CCI. This study provides clinicians with a better understanding of potential frailty-related suicide risk in patients aged 50+. I01 CX001119-05 (PI: Byers) Veterans Administration Clinical Science Research & Development [ABSTRACT FROM AUTHOR]

Older veterans have the highest number of lives lost to suicide, make up majority of the veteran population, and are highly likely to experience conditions (e.g., chronic pain, sleep disorders, musculoskeletal) associated with commonly prescribed medications that are potential markers for suicide risk (hereafter referred to as "high-risk" drug categories), including benzodiazepines, sedative-hypnotics, opioids, antidepressants, antipsychotics, and antiepileptics. The research presented in this session will highlight important patterns in high-risk drug prescribing and use and related outcomes in late life. The presentations will highlight various groups of older veterans that may be important to consider and, yet, neglected in the polysubstance and polypharmacy and suicide prevention conversation, including those who recently attempted suicide, veterans with late-life posttraumatic stress disorder (PTSD), and older veterans transitioning from prison to community. Drs. Maust and Morin will present findings on polypharmacy prescribing and use of high-risk medications in late life. First, drawing from the literature and his own research studies, Dr. Maust will provide a big picture overview of trends in polypharmacy among older adults in the U.S., including older veterans. Next, Dr. Morin will describe high-risk profiles of use in the 90 days prior to a first documented suicide attempt among veterans >=65 years who attempted suicide between 2012 and 2014, using Veterans Health Administration (VHA) medical record data. In addition, she will examine associations of these profiles with diagnostic, lethality, and utilization factors. Drs. Byers and Barry will speak about more specific subgroups of older veterans, with recommendations for possible intervention to reduce suicide, unintended death by overdose, and substance use disorder (SUD)-related emergency department (ED) visits and hospitalizations, emphasizing importance of care transition models for prevention. Dr. Byers will present a cohort study of veterans >=50 years seen in VHA. Findings provide evidence that late-life PTSD increases risk of suicide attempts and suicide by overdose (and accidental and undetermined death), independent of comorbid disorders. Furthermore, findings will be presented about the relationship of late-life PTSD to cause-specific high-risk drugs. Finally, Dr. Barry will provide an example of increased risk for SUD-related ED visits and hospitalizations (found in the literature to be strongly associated with suicide attempts) among older veterans transitioning from prison to community. Findings show that those re-entering society following prison sentence are at significantly higher risk for SUD-related ED visit or hospitalization compared to matched controls. These results highlight urgent need for assistance during this vulnerable period of transition. [ABSTRACT FROM AUTHOR]

Abstract This session will highlight the particular challenges of addressing suicide among older veterans in VHA care using epidemiological and novel statistical approaches, and offer a promising way forward for early identification and prevention of late-life suicide. The research presented here will highlight various unique factors in older veterans that may be missing from the suicide prevention conversation, including the saliency of physical health, pain, high-risk subpopulations, and psychosocial interventions. Drs. Byers and Morin will present findings on late life suicide in VHA using medical record data for novel investigations of administrative data. First, using her database of over 5 million veterans receiving VHA care, Dr. Byers will provide a big picture overview of nationally based estimates of the occurrence of suicide-related outcomes, including non-fatal attempts and death by suicide, in veterans over age 50. Additionally, she will discuss factors that influence risk of a first attempt in later life, as well as factors that further influence, among survivors, who goes on to repeat an attempt and who does not. Next, Dr. Morin will describe physical and mental health comorbidity profiles of 2,131 veterans over 65 who attempted suicide between 2012 and 2014, and last saw a primary care provider prior to their attempt. The relatively minimal depression prevalence as well as high incidence of chronic pain in more than half of these attempters, as well as higher rates of fatality using firearms among these individuals compared to those with multiple mental health comorbidities will be discussed. These findings raise awareness about possible points of intervention in a group that may otherwise not be considered to be as high-risk as a population with significant comorbid mental health concerns. Drs. Barry and Van Orden will speak about more specific subgroups of older veterans, with recommendations for possible intervention to reduce unintended death and suicide, emphasizing the importance of transition of care models for prevention of late-life suicide. Dr. Barry will provide an example of increased risk for suicide and unintended death among older veterans transitioning from prison to the community. Findings show that those re-entering society following a prison sentence are at significantly higher risk for suicide attempt by multiple means, with higher rates of fatality compared to matched controls. These results highlight the urgent need for assistance during this vulnerable period of transition. Finally, Dr. Van Orden will discuss transition of care models more specifically and their importance in combating loneliness, a major risk factor for late-life suicide. She will share compelling findings related to a novel intervention currently being studied on the benefits of volunteer-provided peer companionship for older veterans transitioning from community living center (CLC) stays back into the community. This intervention is targeted to support upstream suicide prevention. [ABSTRACT FROM AUTHOR]

Introduction Depression has been strongly linked to suicide ideation in older adults. However, the role of other factors is less clear. Perceived stress is a factor that is emerging as a potential contributing factor in suicide ideation in older adults. We hypothesized higher levels of perceived stress would be associated with increased self-reported suicidal ideation independent of depressive symptom severity in older adults with LLD. Methods This study used data from community-dwelling older adults aged 65 with current diagnosis of major depression. Eligible participants completed measures of depression symptom severity (Hamilton Depression Rating Scale-17 item), current suicidal ideation (Geriatric Suicide Ideation Scale; GSIS), and perceived stress (Perceived Stress Scale; PSS). Statistical analyses were conducted using SPSS version 20. Descriptive statistics, including demographic and clinical characteristics of the participants were obtained. A linear regression analysis was then conducted, assessing the relationship of perceived stress to suicidal ideation, controlling for the effects of age, education, gender, and depression symptom severity. R2 were then calculated based on standardized beta values in the final model. Results Participants were 225 older adults with a mean age of 71.4 (SD = 5.6), who were 64.9% female. Sixteen percent of the variance in suicidality (GSIS total score) was accounted for by the variables assessed. In particular, lower education (B = −.13, p =.04), male gender (B = −.13, p =.04), greater depression severity (B =.15, p =.02) and higher current perceived stress (B =.32, p <.001) were all significantly associated with higher suicidality ratings. In this model; perceived stress accounted for 10.1% of the variance in suicide ideation ratings, over half of the variance explained by the total model. Conclusions Our findings suggest that increased perceived stress might be a particularly important factor of those more likely to think about suicide. Perceive stress may thus be a useful factor that could improve early identification and intervention of suicide ideation among late life depression patients at a high risk for suicidal behaviors. Mechanisms and coping strategies to reduce perceived stress could be directly implemented in depressed patients with suicidal ideation. Further research is warranted on perceived stress in relation to suicidal ideation. This research was funded by This work was supported by R01 MH0977669: (PI:Mackin), R01 MH101472 (PI:Mackin); UCSF Epstein Endowment Fund [ABSTRACT FROM AUTHOR]