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Social Disconnection and Late-Life Suicide: Mechanisms, Treatment Targets, and Interventions - Day One, Part One


Jovier: I’ll go ahead and just say, thank you all for coming. On behalf of the National Institute of Mental Health, I am Jovier Evans, Chief of the Geriatrics and Aging Processes Research Branch. I’d like to welcome you all here to our virtual workshop on Social Disconnection in Late Life Suicide. I’d also, on behalf of my colleague, Dr. Elizabeth Necka, who organized most of this meeting, thank you all for being here. Unfortunately, she was called away at the last minute so she may not make it to the morning sessions, but we hope to see her either later this afternoon or tomorrow. With that being said, again, we started planning this workshop a year ago. That was before all the other issues with regard to Covid and given this new reality and hopefully this will provide great evidence of the current state of this and how we can move forward. Alright, that said, I’m going to actually turn it over to Dr. Josh Gordon, the Director of the National Institute of Mental Health to welcome you all here, Doc?

Josh: Hi. Thanks, Jovier. I want to just make a few very brief remarks. You all know why we're here. We're here because of what can be called a crisis or an epidemic of suicide in the United States, that the leading edge of which is in older Americans, that they have the highest rates of suicide. Americans over 65 of any age group. The second reason why we're here has to do with the social disconnection that we recognize might be playing an important role in that rising rate of suicide.

Of course, our concerns about this, although they proceed the COVID pandemic, we recognize that social disconnection in the COVID era is likely on the rise, and we know it's on the rise for many older Americans who live on their own or in institutionalized settings, like nursing homes and assisted care facilities that have for very important reasons a reduced or even eliminated the ability for a family to visit in person.

The precise, though, a connection between social disconnection in late-life suicide deserves considerably more attention from a research perspective. We need to know what the extent of the issue in terms of that relationship, but even more important, we need to know the mechanisms by which that occurs, to be able to develop targets to prevent suicide in this group, and to lower the overall risk rate in that group. Let me be very explicit when I say mechanisms, and I think that will become obvious as you convene over the next two days.

Josh: No worries. Back to my thread, when I'm talking about mechanism, I don't want that to be misunderstood, mechanism is important across the entire spectrum of causes and effects in psychiatry. That means we're talking about brain mechanisms, yes, but not just brain mechanisms, we're talking about psychological mechanisms and social mechanisms, and how they impact the individual. Of course, when we're talking about social connectedness, we have to recognize that those mechanisms operate across the full spectrum of levels, affecting the brain, affecting behavior, and affecting social interaction. All of that is going to be on the table in the next two days. All of that is on the table in terms of trying to understand where are the best intervention points that can make a difference for older Americans, and indeed, older individuals worldwide.

Thank you, and with that, I just want to add my thanks to Jovier Evans and to Liz Neca. Liz Neca had a personal reason why she couldn't be joining us these two days, but I'm really pleased that Jovier is going to be guiding you through, and I look forward to hearing the results of this really wonderful two-day workshop. Thank you for allowing me to introduce, Jovier, I'll turn it back over to you.

Jovier: Thank you, Josh. Now I'm going to turn it over to our meeting chairs, Dr. Martha Bruce and Dr. Yeates Conwell. We'll go over the meeting charge for the day and the establishment of our terminology. Thanks.

Marty: I'll start. This is Marty Bruce. Thank you, Dr. Gordon, and it is a great pleasure to see so many of my old friends and to see so many faces of people I wanted to meet, so this is going to be a great two days. I want to remind you, and Dr. Gordon said it very quickly, but I'm going to remind you that what we're here about is to look at the current state of the science on social disconnection and suicide in late life. That includes looking at the mechanisms that we think might-- the mechanisms which social disconnected can affect the late-life suicide, look at potential treatment targets and opportunities, and potential barriers for time to effectively implement these interventions.

The format is going to include brief talks, moderated discussions among the presenters of those talks, some formal breakout sessions, and then a final moderated discussion. It's a lot packed into two days, and there isn't time for general questions, the questions that people have are going to be folded into those moderated talks. There will be opportunities, if you have a specific question or clarification check, you can use the chat function. There's going to be a lot of opportunities after these two days to continue to synthesize this information and to present questions and to process it. At this point, Liz and Jovier have set out a format that really will keep us moving along and try to provide opportunities as many as possible for the really wide range of expertise that we have here. We're really blessed that we have almost 400 people in the general audience from public career here, and right now, we're really asking all of you to observe and listen, and you're welcome to send comments after the two days. Welcome to everybody.

I want to thank you all, for taking the time to be here. I know we've been zooming and zooming and zooming for the last six months, but at the same time, it's a challenge to participate in something of this duration. Especially a cost in the pandemic, but an additional challenge is for those of you on the West Coast who had to wake up early, but perhaps there's [unintelligible 00:06:50], and direct even more so obviously, because of the fires. We're really concerned about the fires all over the United States, they're happening for you. Then, we're very concerned, of course, for the flooding and the hurricanes occurring in the South.

There's a lot going on and the fact that in addition of, many of you have children, either children at home, you're trying to-- I'm sure they're over there in the back corner, trying to go to school while you're trying to do this, or your children are at college and there's another set of worries, or your children are growing up and they're still-- they're always worries. I appreciate that during a pandemic we've got worries, we've got things to think about. We're also really blessed that we have the kind of lives and positions and work that allow us to be able to really gather together and to take our worlds and put them together so that we can help this whole problem that we're so concerned about.

I think that Yeates is going to go into talking about terms, but I do know that issues around suicide in late life and social disconnectedness are not new. The problem has been here forever, in a sense. Slowly over the last number of a couple of decades, people have encountered now the problem and more people slowly are dealing with it. I think the pandemic has only risen like a boiling water to people's attention, so this is all very timely. The group of people who will be speaking in the next two days come from different disciplines, different perspectives, and we're here.

This may be the first opportunity that we can really share our perspectives and our knowledge and put that together, so we can begin to identify areas that we could really potentially move the science forward by moving in that direction, identify opportunities, the challenges. Our job is not to formally synthesize the entire science, our job is not to find solutions, but our job is to help us all together think about or identify ways we could really make a difference going forward.

Our biggest job is to listen to each other and to enjoy talking with each other, and I know that it's going to be a great two days. Once again, thank you. Now, Yeates is going to set us all straight and tell me all the places they use the words wrong and get us going in the right direction. Yeates?

Yeates: That's great, Marty. Thank you. You've really framed the issues. It's such a pleasure to participate here, and as Marty said, see old friends and meet new ones. It's an extraordinary group that our friends and I managed to pull together here for this and a great privilege to be involved. Just thinking personally about these times, really, it's a difficult, complicated time. I think as Josh said, and Marty echoed, the COVID pandemic has really brought into relief for everybody around the world, really step back and think about it, the importance, the centrality of social connectedness for all of us in a way that I doubt would have happened otherwise.

It's a silver lining of a sort, it's a tough one but it offers us the opportunity to build on something where there is a real press socially and culturally around the world to understand these processes better and then to link them to suicide in older adults. I think there's another silver lining that I hope we don't lose sight of. I know we won't, as we dig down and we take off various layers of this complicated onion to realize that while older people are certainly vulnerable, for many reasons, to becoming socially isolated and socially disconnected and to experiencing then the many adverse consequences that can result from that.

I think they also have a lot to teach us about how to manage social disconnections, what that means, how with the process of aging, we see things differently and our values change. We actually can be pretty creative and talented drawing on our experience and how to mitigate some of those problems as well. We're looking for the mechanisms by which these associations happen. In that mechanistic understanding is both the pro and the con, so that we can take good advantage of knowing what works and why in the lives of older people to reduce suicide risk and make that available to others who don't necessarily have those resources available to them.

Part of the way we wanted to start, let me just share my screen if I may, here we go, to look at terminology and the point here is not to say that there are right terms for this, both with regard to social disconnection and suicide. There's been a lot of controversy over the years about how to use these terms. I still believe that we've nailed it, particularly with regard to older adults. That being said, I think it's useful to start where the leading edge is. Here's one set of definitions of some of the terms that we will deal with during the next two days, that's provided for us by the National Academy of Sciences, Engineering, and Medicine influential report last year on social isolation and loneliness.

They define social connections as structural-functional and quality aspects of how individuals connect to each other, social connections, social support, actual or perceived availability of resources of various kinds from others, typically in one social network, social isolation, the objective lack of or limited social contact with others and loneliness, the perception of social isolation or the subjective feeling of being lonely. I bet if we went around the room and obviously, we don't have time to do that, we would find a lot of different perspectives on how these terms work and how they don't work.

Our job is not to correct that. It's just to be aware that as we use these terms, we need to strive for reliability in using them and to recognize that there's plenty of room at the margins for refining our understanding of what they actually mean, particularly in a vulnerable older adult population. The same can be said for suicide where the terminology around suicidal ideation and behavior has for many, many years have been an area of controversy. I think personally still remains largely unresolved as a very careful set of definitions for older people.

We've got suicide, which is pretty clear, death caused by self-directed injurious behavior with any intent to die as a result of the behavior. Intent is the operational term there. Suicide attempts again, nonfatal self-directed potentially injurious behavior with any intent to die, again, intent, and it may or may not result in injury. Suicidal ideation, passive thoughts about wanting to be dead or active thoughts about killing oneself, not accompanied by preparatory behavior.

There's a separate nosology that will potentially come up in which preparatory behaviors important to acknowledge as a subset of suicidal behavior, a suicidal behavior, then being suicide attempts, and other behaviors and preparatory acts. Again, room here for skepticism about boundaries of some of these, the notion of what it means actually to have deaf ideation and its relationship to suicide in an older person under certain circumstances of loss or chronic illness and the like. Let me stop the sharing now and bring it back to the group with that kind of background and Marty before we move on to mechanisms, is there anything else that you think we need to cover?

Marty: Well, several people have asked for a copy of the slides. I don't know if that's generally, but I don't know if there's any way to make these definitions available to keep them throughout the next two days. I'm sure you can figure that out.

Yeates: Let's get a solution to that about how we can post these and other people's slides. I'm sure the same question will come up. I think it would be useful to be able to refer back periodically to some of these touchpoints.

Marty: Whether you agree or don't agree.

Jovier: We'll try to figure out the best way to do that, you guys. Yes, the slides will be available after the meeting, certainly, but we'll try to work out a way to find someplace to put them [crosstalk] Thanks.

Marty: Any other points Jovier, business, philosophical, or otherwise.

Jovier: I think the only thing I like to say is thank you all for being here. Welcome. It looks like we are a little ahead of schedule, We'll go ahead and get started, but I would remind everyone, please mute your audio if you're not actually speaking. Thank you. Well, I'm turning it over to you guys.

Marty: All right. I am introducing session number one and session number one is titled mechanisms by which social disconnection may be associated with late life suicide. For this session and all the sessions following we will let people introduce themselves. I will just say their name right now and who they are. The first two talks are on social connection in late-life and wellbeing. These are going to be presented by Dr. Julianne Holt-Lunstad and Dr. Laura Carlson. Julianne, I think you go first, thank you.

Julianne: Thank you. I will just go ahead and share my screen.

Marty: Just be sure to give a one-sentence about who you are and where you are. Thank you.

Julianne: Do you see one screen or two screens?

Kayla: Just one. It looks okay.

Yeates: Just one, yes.

Julianne: Well, thank you very much. My name is Julianne Holt-Lunstad and I'm joining you from Utah. I just want to start by thanking you for inviting me to participate in this workshop on this very important and timely topic. I'm certainly grateful to be here virtually with all of you today. Just by way of background and disclosures, I am a professor of psychology and neuroscience, and my area of expertise is focused on understanding the association between social connections and physical health. I do serve on a number of scientific advisory boards and consult with companies listed here.

I was also a member of the National Academy of Science Consensus Committee that recently issued a report on the medical and healthcare implications of social isolation and loneliness among older adults. Of course, this report provides a summary of the current evidence and is available to the public. It is certainly relevant to the topic here today. I'd like to start by sharing this quote by C.S Lewis. "Friendship is unnecessary, like philosophy, like art. It has no survival value. Rather, it is one of those things that gives value to survival." I share this because it is highly representative of the common belief that friends or being socially connected, may increase the quality of our lives but may have little to do with our survival, but of course, scientific evidence suggests that being socially connected is indeed vital to survival.

Given my research is focused on health and mortality, I was a bit humbled to be honest and felt a little under-qualified to present here today. However, I quickly realized that my entire line of research and much of the field could be tied back to a classic study on suicide published in 1897. The sociologist, Emile Durkheim, analyzed data on suicide rates across a variety of factors, he observed that suicide was more common among those who lacked social integration, and subsequently proposed that stable social ties and norms are important to behavioral regulation and ultimately protective.

Because being part of society gives meaning to life, lacking connection to society, is thought to be lacking connection to life. Thus according to Durkheim, being less socially connected with society gives rise to reduced worth on human existence and subsequently associated with higher suicide. In a landmark review, published in Science by House Landis and Umberson in 1988, summarize some of the first epidemiological evidence, and this review included data from five prospective studies and the evidence confirmed that lower levels of social integration significantly predicted age-adjusted mortality risk.

Since the original Durkheim study gave rise to more systematic research and conceptualization of social integration. This included the importance of social capital, social roles, social networks, attachment theory, social support, social thriving. In essence, these theoretical approaches emphasize the importance of social norms and shared values and society such as norms of goodwill and charity, or social units such as families, but also the importance of sense of meaning and purpose or mattering in life. That interconnection and influence between groups of individuals, the sense of safety and security that is gained by connections to others, a source of important resources to fulfill our needs, and flourishing regardless of adversity. These theoretical approaches suggests that social relationships may significantly influence our wellbeing in a variety of ways.

This growing interest is also reflected in the exponential growth in epidemiological research over the past few decades. For example, that review that I just mentioned in 1988, included only five studies. When my colleagues and I conducted a meta-analysis in 2010, at that time, the literature had grown to 148 independent studies, clearly growing. What this review or meta-analysis revealed is that averaging across those studies, which include a variety of measurement approaches, we find that greater social connection was associated with a 50% increase odds of survival.

We subsequently conducted another meta-analysis focused specifically on the risk associated with social deficits, and whether that was objective or subjective and whether that influenced the strength in terms of predicting risk. You can see the effects here. Despite the relative differences in effect sizes, they were not significantly different from each other. This does not mean that loneliness, social isolation, and living alone are measuring the same thing, but rather, both objective and subjective indicators of social deficits or social disconnection are equally important in predicting risk for earlier mortality. However, these indicators of social disconnection did have significantly smaller effects than other indicators of social connection.

There are now additional meta-analysis that confirm these findings and the data presented here are effect sizes by measurement type. Basically, this represents multiple conceptual and measurement approaches that have developed since the time of this classic Durkheim paper, and while the effects vary to some degree. The only indicator that was non-significant was received social support, and the strongest indicator, and significantly so, was complex measures of social integration, which was associated with a 91% increased odds of survival.

As we can see here from this chart, social factors depicted in the orange bars are comparable to risk factors, with other risk factors, factors, of course, that are taken quite seriously in public health. Of course, some variables were inversed, and some are protective while others are associated with risk so that each bar represents the strength of the effects on survival. Although they vary in their magnitude, even the least robust of this loneliness, was still found to exceed the risk associated with physical inactivity, obesity, and air pollution, suggesting that this should receive greater prioritization in public health.

Overall, what the evidence points to, is robust effects relative to other risk factors. These findings were consistent across gender, initial health status, cause of death, country of origin, both subjective and objective indicators predict risk and at least meta analytically suggest that this is a continuous rather than a dichotomous issue, it suggests multifactorial influence on risk and protection. Despite the strength of this evidence, there are certainly important gaps.

For instance, there are fewer prospective studies that assess multiple components of social disconnection, and even fewer that examine their synergistic effects. There are fewer that assess indicators of relationship quality, that examine cultural, ethnic, and economic differences, or distinguish between online versus in-person contact, which is critically important. The previously presented data, also supports the framework of a multifactorial construct, including structural-functional, and quality aspects of social connections.

In other words, the evidence suggests that the presence and absence of others matters, what others can provide, the resources that they can provide matters and the quality matters. Each component may contribute to risk and protection in different ways. However, this also points to additional gaps. There's no one single measurement approach that captures these multiple components that have been demonstrated to contribute to both risk and protection. If we only assess one dimension, we can potentially miss risk associated with other components. Further, the way in which we might intervene differs depending on the component that may be lacking.

Now, my program of research and the research of others has also focused on the psychological behavioral, and biological mechanisms. This is just a simplified model of possible direct and indirect pathways by which social connections may influence morbidity and mortality. I'm just going to highlight a few. Certainly, one of the most obvious pathways, at least obvious to the general public is behavioral pathways.

Of course, having strong social connections has been linked to encouraging healthier behaviors and less risk-taking, while lacking social connection or being socially disconnected has been linked to substance use, poor sleep and poor eating habits. Of course, there are important biological pathways that I'd like to focus on also, given that humans are social species, it's argued that loneliness is like a biological drive, just like hunger signals us to eat and thirst signals us to drink water loneliness is thought to be a biological drive that motivates us to reconnect. Do we literally crave human contact? A recent study out of MIT found that 10 hours of isolation had a similar neural signature as 10 hours without food, suggesting acute social isolation causes social craving similar to hunger. Neuroscience also supports the biological manifestation of motivational cues to maintain social ties. For example, social pain shares similar neural mechanisms as physical pain.

According to Social Baseline Theory, social proximity is the neural default. When we lack proximity to others, our brain, and peripheral systems are in a heightened state of alert, which if prolonged, could cause wear and tear on the brain and body. For example, chronic levels of loneliness have been linked to chronic inflammation. Conversely, meta-analytic data has shown that social support and social integration were significantly related to lower levels of inflammation.

Given chronic inflammation has been implicated in a number of chronic health conditions as well as cognitive and mental health outcomes, inflammation may be a common mechanism that it may explain the association with these diverse outcomes. Another potential mechanism is neuropeptide oxytocin. Although typically associated with pregnancy and lactation, there is a large animal literature and growing human literature, implicating oxytocin as a key biological mechanism in social bonding, stress regulation, and pain sensation, or sensitivity.

Importantly, research suggests that oxytocin may signal sensitivity to social cues and is being explored in its role in various disorders including depression, and that have been characterized by social disruptions. Further, endogenous release of oxytocin can occur through close social contacts, such as holding hands, hugging, and other forms of physical affection, which may be particularly relevant in our current state, where we may be lacking close physical contact with others.

Lastly, I just want to highlight the gut-brain relationship as a potential critical mechanism but a much less understood pathway. Microbiomes play an important role in the programming of the hypothalamic-pituitary-adrenal axis, the APA axis early in life, and stress reactivity over the lifespan. Indeed, research suggests that microbiome might be highly relevant for understanding psychiatric disorders. However, less is known for its role in social isolation, loneliness, and other forms of social disconnection.

Nonetheless, several behaviors known to influence the microbiome, such as diet are prone to social influence. Furthermore, animal research suggests that diverse social networks are associated with more diverse and healthier microbiome, suggesting this is a potential avenue for further research. Overall, a better understanding of mechanisms provides crucial insight needed to intervene to reduce risk. During this pandemic, the challenge to reduce risk is exponentially compounded.

If loneliness is a biological cue, similar to thirst, we cannot access what we crave most. It's as if we are all incredibly thirsty but being told that the water is not safe to drink. Thus we're faced with this challenge of how to satisfy this biological need without close proximity to others. One comforting sentiment has been the idea that we're all in the same boat, a sense of solidarity that we're in this together, and the comfort that you aren't alone in the struggle.

However, this analogy might be flawed. Perhaps a better analogy is that we're all facing the same storm. Some of us may be in a yacht, others in rowboats and some may be going solo and kayaks. We are not all equally equipped to weather the storm. This pandemic has highlighted a number of inequalities, many of which may be magnified in this crisis. This pandemic provides an opportunity for us to better understand these inequalities. I'd like to just simply conclude by highlighting several key challenges.

First, loneliness is regularly conflated with other concepts of social disconnection. Thus aggregating, evaluating, and disseminating evidence may lead to reduce precision. Second, greater attention is needed to, sorry, greater attention is given to deficit versus protective factors. Given the large effect sizes associated with indicators of social connection, greater attention should be paid to protective factors and preventative efforts.

Third, despite robust and convincing evidence, sorry, converging evidence, there is significant variability in terminology, measures, and outcomes, and standardization and consensus are certainly needed. Fourth, there's limited research on low income underserved and vulnerable populations or at-risk populations. This is clearly needed in order to better serve those most in need. Fifth, despite strong evidence of the effects of social connection and isolation, the evidence focused on modifying risk is mixed and lower quality.

Finally, the bulk of the evidence is based on research related to in-person connections. Less is known about remote or online connecting socially and so caution should be taken when widely scaling such interventions. Importantly, the recent National Academy of Science consensus report provides important recommendations on how we can potentially address some of these challenges. Thank you for this opportunity to present here today. Here are some additional resources relevant to this. Thank you.

Marty: Thank you, Julianne, much appreciated. Yeates is a psychiatrist, and I know he appreciated all your biological references. I am a trained sociologist so it did my heart good that you would start with Durkheim. Thank you. All right. Next, Laura Cartensen is going to talk. Laura, you want to get your slides up and introduce yourself. Thank you.

Laura: Thank you. Thanks for having me today. It's really terrific to be part of this group. That yes, as you were just saying Martha coming from such different perspectives around a shared interest in suicide and late life, my name is Laura Carstensen. I'm a professor of psychology at Stanford University, and I also direct the Stanford Center on longevity. I have spent my career studying emotion and aging, as it relates to motivation, and then how motivational changes may also influence emotional experience and cognitive processing.

I began my career being trained as a clinical psychologist and with an interest in isolation and depression and anxiety. This was like 30 years ago when I began my career. At that time, it was literally textbook knowledge that old age itself was associated with a time of sadness, fear, depression, and despair. One prominent theory at the time was called Disengagement Theory. This was a theory that suggested that as people grow older, they come to withdraw from the social world in preparation for death and that society comes to withdraw from the individual to help prepare for the loss of its citizens.

There wasn't a lot of data on emotion and aging at the time, but these were strong presumptions that we had about old age. The NIMH epidemiological catchment area studies in the late 1980s was really the beginning of a turn into thinking about wellbeing and mental health and old age is they found lower rates of depression, anxiety, virtually all psychiatric disorders, with the exception of the dementias in older people compared to younger people, and it really set off a line of research on aging and emotion. We continue to see that when we find that older people are doing well. It seems to surprise people within the science and outside of the science and deep, it makes headlines virtually any time we come up with a study with findings that suggest that older people are actually doing well. What I'm going to suggest this morning is that age itself may be a protective factor, for emotional well-being, but it's protective in a way in which emotionally meaningful contact becomes more important than ever before.

For people who have contact the access to that kind of contact, they do increasingly well. If people don't have access to that contact, we could at least hypothesize that it would be especially distressing at a time in life where meaningful contact is so important. Let me give you a flavor of the kind of research findings that suggest that emotion may be protected by age. Economists often study satisfaction as opposed to happiness or emotion, and large-scale studies across multiple countries they find this U-shaped curve of life satisfaction with younger people and older people reporting the highest levels of satisfaction with life and less in the middle of life.

Older people, notably, showing reporting the greatest levels, highest levels I should say of life satisfaction. We often associate loneliness with old age and loneliness in old age is a major problem. For many reasons that Juliane just laid out. Probably interacts with biological susceptibilities that occur with age as well, but notably rates of loneliness are higher in younger people than they are in older people. These are findings from a study that was done in the UK.

Cigna reported recently the same findings in the United States, based on a sample of 20,000 Americans. Here are some findings from a Gallup Poll data, that Stone and his colleagues have reported over the years. Where we sent you simply ask people, I believe this is in the last two days, how much stress did you experience and what we see here a cross-sectional findings from 18 to 85. You see lower levels of stress reported as people are at older ages.

Less worry, less anger. When we look at these reports, we're seeing a relatively positive profile of emotional well-being. My group was also as skeptical as many of you may be that when you have a people really reporting their experience where they changing this in hindsight through memory and reconstruction and putting a more positive face on their experience. My group began a study in the late 1990s, which we continued in 2010 ultimately. Where we conducted an experienced sampling study with people aged 18 to 94, initially.

We asked people to carry electronic pagers for a week, and we page them at random times during the day and ask them to tell us the intensity with which they were experiencing each of 19 different emotions. Some positive and some negative, but you see here are the cross-sectional findings, and we see a steep decline in the reports of negative emotions. Which I'm showing you here are the cross-sectional findings, and we also questioned this and thought these really could be cohort effects that perhaps the oldest generation is and always was the greatest generation. We may not see these kinds of effects if we were to follow people over time.

We did follow them over time, and we found the same pattern within individuals. Where people were reporting fewer negative emotions than daily life, as they reached older ages. It has been postulated that part of the reason older people may do better than younger people in daily emotional experience is because they're better able to avoid stress, better able to avoid difficult situations. Social situations that may generate concern or worry and discomfort. By the way, if you see that yellow line on the slide here, I have no idea where that comes from. [laughs] That's just a Zoom thing. I'm not trying to make a point here at all. I've never seen that before. We'll see how it appears on all my slides.

Recently with COVID, we thought this would be a time to reassess age differences and emotional experience. We have a global pandemic, no one can escape it. It is a sustained and ubiquitous, this kind of stress. It's also resulting and social isolation for individuals across the ages, but especially in older adults. We put a survey into the field, we included the same 19 emotions that we have included in this experience, sampling study and looked at differences in age and their reports. This is over the last week of negative emotions and positive emotions. What we see as a similar pattern, is what we've seen with experienced sampling and what others have found in research with normal healthy aging populations, and that as we see this reduction and reports of negative emotions and a slight increase in positive.

Let me just know that for this increase in positive, some studies find an increase in positive emotions, some don't, so that's less reliable, but the decrease in negative emotions is a highly reliable finding the latest stage. As this research program unfolded over the years that I've been studying emotion, we developed a theory really aimed at trying to account for these age differences. For a long time in the field, these findings were referred to as the paradox of aging. How could it be? There is such clear loss that occurs with age. How could it be that older people were doing better emotionally? We developed a theory called socioemotional selectivity theory. In a nutshell, I'll describe it to you.

This is the theory that maintains that humans are uniquely able to monitor time, I mean lifetime mortality, not clock time and calendar time, which many species can monitor, of course, but humans take into account how much time we have left in our lives. We do so acutely, at times when we lose a loved one or may get a diagnosis, but also tacitly and day-to-day life. When we think things like, "How many RO1s do I need to submit in my career?" We start to see this clock ticking and see the time left as being increasingly limited. Because chronological age is associated with time left in life, we see goals change as well. Goals are always set in temporal context we can't set them outside of a temporal context. Specifically, this theory suggests that in youth or when people perceive their time horizons as fast and nebulous as going on indefinitely, that people are in exploratory modes of goal seeking. They're expanding horizons, meeting new people, taking risks and exploring the world, but when people see their future as being limited, they tend to change goals.

They tend to focus on the present, on what matters most, and they're able to see what matters most more clearly than ever when time is running out. What happens later in life we see is that people care more about meaningful relationships than never before in life. Less tolerant of wasting time, less interested in relationships that may be interesting, but unpleasant, and to instead really focus on those relationships that matter most. Those goals that matter most. For most people, those goals would involve emotionally close social relationships.

One of the other things we looked at over time related to this theory, was social networks. We know that social networks get smaller with age. We know that older people interact with others less. What we were interested in, was the type of people

included in social networks and in our initial study, this was what the first study. We looked at this in an elderly sample from a German study called BASE where the participants ranged from 69 to 104. We looked at their social networks and saw as many had observed before that networks were smaller, but they were selectively smaller. We had these broken down into those members of the network who were very emotionally close, defined as so close I can't imagine life without, and then people who were less close than that, and increasingly less closeout to more acquaintance type relationships.

What we've found is that the decline and that work size is related to these more peripheral social partners. While emotionally close social partners are retained in a more recent study or analysis, I should say. This is based on the same longitudinal study that I presented motion findings from a few minutes ago, we found the same kind of pattern. Now this age range is 18 to 94. We see the total network size over time getting smaller, but what you see in the green line is the inner circle. Those most emotionally close. That inner circle is well maintained. This pattern in old age predicts wellbeing.

Pruning a network, having a disproportionately large number of emotionally close people compared to more peripheral people appears to be good for wellbeing. We've also looked at the influence of goals on cognitive processing and found something called now in the field. The positivity effect, older people are more likely to direct attention to positive information and away from negative information than younger people are. If we show people eye apps, images like these with some positive and some negative, and later ask people to just recall the images that they saw, older people disproportionately remember positive images and forget negative images and neutral ones.

This was the first study that really identified the positivity effect. Since this time it's been replicated more than a hundred times using autobiographical memory. We see this in neuroimaging where people are shown positive and negative images. We see deeper processing of positive images over negative images and better retention. We see this very positive profile of age and emotional wellbeing. As you might imagine, very often people say, well, what about suicide? How could this be? If suicide rates aren't going up and indeed, as you all know here today, we do see relatively high rates of suicide and older people.

But if we look more closely at this profile of age and suicide, what we see is that it's actually going down in females, but it's going up strikingly in males. If you take a closer look at these age patterns and include ethnicity, it looks like it's white men who are at risk for suicide, and we're seeing decreases and other ethnicities of males and all groups of females. This pattern is actually consistent with the idea that overall we're seeing better emotional wellbeing and a reduction in suicide, but there is a particular group, these white men Angus Deaton, and Anne Case have written about these deaths of despair.

It appears that there is this group of white men who've also been associated by the way, of course, with substance abuse that is at greater risk. If we put all this together as I've been thinking about this conference today and the issues more generally, it may well be that age is protective. Generally speaking, people focus on what matters most to them in life as they get older. For most people, that's a very good thing for mental health, but if a similar kind of a shift occurs motivationally and you're interested in more than ever, in what matters most, what's most meaningful, and it is not available to you, then that puts you at greater risk than ever.

It may be that this pattern, which has often been viewed as disconnected in the literature is actually something worth pursuing that could help to identify some mechanisms of considerable importance. Thank you.

Yeates: That's terrific. Thank you both. Maybe you want to unshare your screen?

Laura: There we go.

Yeates: Great. Come back to the group. There's so much richness in this discussion. We're really going to be looking forward to opportunities to process it all. Since Marty and I have the opportunity to speak a little bit more often, and she mentioned I was a psychiatrist, I'll mention a little bit more about that when my colleagues and I in the center for the study and prevention of suicide here at the University of Rochester have had opportunities to try to understand these phenomena. In a larger cultural context, we took several terrific opportunities to collaborate with colleagues in China.

One of the really remarkable things I think about the epidemiology of it is that while in China, there are values about-- Through Confucianism and filial piety and those kinds of notions about aging and the centrality of the older person in the nuclear family network and so on. Even under those circumstances, suicide rates among older people tended to be very very high. What is it about meaning that people derive from the culture around them? In addition to the family, in which they're living in the interpersonal relationships they have with others, we have so much to learn from.

We're going to be taking a break now. We built this break into the morning in order for us to kind of get settled, to get into a rhythm but also to be able to make sure that we've got everything under control here.


Yeates: While we reconvene, people will come on back and be prepared to listen and learn and contribute. While we're doing that, in order to keep on time, I was just thinking about a talk I heard many years ago at a meeting by Norman Sartorius, who was the head of psychiatry for the WHO at the time. It was right at the time, not too long after the dissolution of the Soviet Union. His observation was that there were many countries in the Soviet block that experienced rather dramatic increases in suicide rates during that time and one can understand that in terms of Durkheim's notion of anomie, back to Durkheim, the father of the field, really of suicide studies.

He also observed that that did not appear to be the case in general for older adults. He opined that that was because, under the crisis circumstances, older adults carried talents, roles, knowledge, and experience with them that became very useful in those early transition days. Things like knowing how to render soap from animals or stand in a bread line while others went to work. That was a really interesting observation, that I'm sure it says something about the importance of how to keep older people engaged under certain social circumstances.

With that background, why don't we get going again in the next session, which has the header of interpersonal and environmental factors in late-life suicide disconnection, social disconnection, and suicide? Our first speaker, Robert Taylor. Robert, are you available and ready to go?

Robert Taylor: I am here and ready.

Yeates: Thank you take it away.

Robert: I'm assuming that everybody can see my screen now.

Yeates: Yes.

Robert: Okay, I will go ahead and start. This presentation is on social support, social isolation among older African Americans. Let me just first introduce myself again, I'm Robert Joseph Taylor from the University of Michigan, I'm the Harold Johnson Endowed Professor of Social Work, Director of the Program for Research on Black Americans at the Institute for Social Research. The populations that I do my research with are adult and older African Americans and Black-Caribbean. My research areas are in form of social support networks, religious participation, and the impact of support and religion on mental health more generally. That's a basic outline of what I'm going to cover today. You all have it back there to take a quick look at that.

First, I want to talk about the bulk of the research I'm going to share is all on this data set is the National Survey of American life James Jackson is the API of that data set. Many of you know he recently passed in the last two weeks. There were 6000 adult interviews, including African Americans, Black-Caribbeans, and non-Hispanic whites. One thing that we know is that the African American population is diverse, but the Black-Caribbean population is extremely diverse, having different cuisine, different languages, coming from different islands, and different South American countries.

This is a map showing the distribution of Black-Caribbean immigrants in the United States. If you notice it's mostly the northeast corridor, with a little bit in Florida, and then spread out between Houston, Atlanta, Chicago. Oh, what's not shown here is New Orleans and Los Angeles. These are the country's most represented in terms of black immigrants in the National Survey of American life. This is the sampling area for the National Survey of American life. These are the cities that the survey was in, the stars are an approximation is not exactly correct.

If you notice a few things, number one is highly in the northeast, the based in the Black-Caribbean population, and highly in the south, based on the distribution of African Americans. Now I'm going to switch gears a little bit and start to talk about our research but first, I want to talk about why our research is a little bit more unique. Then when we talk about source of support, we're talking about three networks that we concentrate on family, friends, and congregation networks. What do I mean by the congregation? A church networks in particular.

First, the family networks, tabs are permanent and there are clearly explicit norms and expectations for affection and assistance. People feel that they may not ever know their mother, but they still feel a tie to that parent that they may have never known. That's the permanence of those relationships. While friendship networks, the ties are voluntary, and again, motivation emerges from a history of reciprocal assistance. People's friends come and go outside of a person's network. Congregation networks are similar to friends, but different in that, again, they're voluntary, they're not permanent.

Their motivation to provide support emerges from a history of assistance, reinforced by several things that are common within churches and congregations. One is the fellowship of spiritual helping. Second is the sharing of life events through things like marriages, funerals, baptisms, things like that. Third, is again shared experiences at services, and meetings of exhilarating groups. Different churches vary in terms of the amount of time that people may stay at a service or the amount of time that they stay at a church during a particular week. For some religions, a service might be an hour, an hour and a half but other their services could last all day.

Here's some research by Neil Kraus. Again, this is not using a national survey of American life. His work is on older adults. What he finds is this, is that church support is associated with positive self-right to help, life satisfaction, more healthcare use, and lower mortality rates. Here's one example from his work and that is older African Americans who receive higher levels of emotional support you have from church members are more likely to state that religion was important in dealing with racial discrimination. One thing that we see when we talk about social support is there's a lot of emphasis on the positive aspects with very little emphasis or acknowledgment of the negative aspects.

We know like anything, it has both positives and negatives, and some of the negative aspects, what we call negative interactions, but people use different terms they use problematic relationships, use negative support, there's a lot of different terms for this. We prefer the term, negative interactions. They're defined by things like criticisms, disputes, and arguments, gossip, things like that. What we know is negative interactions are strongly related to well-being. Negative information about others is weighted more heavily than positive information. A

s one example, 10 people may say, I gave a really good talk today, but one person may say, "I thought your talk was average, mediocre, or bad." What I'm going to thinking about is the one person that said that my talk is average or bad, way more than the 10 people who liked the presentation. Again, with our research and our research team, we do work both on the correlates of these networks, as well as the impact of the networks. I'm going to share-- This is just one paper on the correlates of the networks. There's another paper on, again, the correlates of the networks.

This is a paper on family support, negative interaction, and lifetime DSM-IV disorders. Again, this is among older African Americans. What this research finds is emotional support was not associated with, again, lifetime mood disorders, anxiety disorders, or the number, whereas negative interaction was positively associated with all three. Again, what you want to look at are the ones that are highlighted. You want to look at right here, right here and right here. There's a paper on suicide, again, negative interactions and emotional support from families, again, among African Americans, but not older African Americans across the lifespan.

What we find is emotional support, again, looking at the highlighted numbers, emotional support is protective of suicidal attempts, and suicidal ideation whereas negative interaction was a risk factor for attempts and for ideation. Here's another paper on social support, but looking at church support, and suicidal behaviors. This is what we found. First, I like to look at ideation.

Again, if you just look at the highlighted, you'll see what's significant. What we say is that subjective closeness to church members is protective of suicidal ideation whereas contact with church members has a positive relationship with suicidal attempts. Some people have looked at this and misinterpreted our results, even though we're pretty clear in the paper what this means. This does not mean that contact with church members is a risk factor, as a matter of fact, it means the opposite. What happens is that, again, we're looking at cross-sectional data. When people had an attempt, what they're more likely to do is to make that network more of a church-based network and hang out more with church members.

What I mean by that is that they're more likely to interact with church members as a preventive strategy. Why would people do that? Because church members, congregation members are less likely to engage in substance abuse, marital infidelity, criminal behavior, other risky behaviors, that may be risk factors for subsequent suicidal attempts. One thing that we see also is that most of the research on church support and there's not a lot of research in this area, it's very little. Most of the research on church support all looked at church support and doesn't control for family support. Here's a paper on church and families support and depressive symptoms. This is what defines is that when you-- Essentially, we have two regression models. The first model only looks at church support.

Again, what it says is that the emotional support from church members is protective of depressive symptoms and negative interaction with church members is a risk factor. However, once we control for family support, what we see is that emotional support from church members is still significant. The family variables are also significant. Only negative interaction with church members is left out or is no longer significant. What this means, essentially, is that church support is not simply a proxy for family support. It's important in its own right. Now, I want to move to research on social isolation. This is work that we have been doing more recently.

When we looked at social isolation, the way we look at it, one of the ways we look at it is looking at objective isolation, which is frequency of contact, and subjective isolation, which is subjective closeness. That's measured by how close are you to your family members. Only looking at the people who say they're not subjectively close. We make this for a part a variable. Both of our research is based on this. Isolated from both family and friends, isolated from family only, from friends only, and now isolated from either group. Again, if you take a quick look at this data, it's too much to really go through.

I just wanted to show you the two main points. What it is, in terms of objective isolation, only 4% of both black Caribbeans and African Americans say that they are objectively isolated from both their families and friends which means that they don't regularly see either their family or their friends. It's lower for subjective isolation. Only roughly 2% say that they are subjectively isolated from both families and friends. As of recent paper using that variable, again, looking at mental health, I will show some of the results from this paper. This is among African Americans.

This is actually pretty clear, in that, number one, objective isolation is positively associated with depressive symptoms. Both objective and subjective are positively associated with depressive symptoms. You get the same pattern with serious psychological distress. Depressive symptoms are measured by the CESD. I say psychological distress is measured by the Kessler-6 and is a combination of both depressive symptoms and symptoms of anxiety. Another recent paper, but this time, we get used to the same pattern variable, but this time look at the psychiatric disorders.

Again, here, I want to share not all the results, but one of the tables. In this table what we see is objective socio-isolation is not associated with any 12-month DSM-IV disorder. Whereas objective is significantly associated. From both family and friends, from family only, and from friends only. This is a paper on socio-isolation, and depression, and psyche distress in older adults. It has similar findings, but I'm not going to cover it here today. For people who are interested in this area here's a lit review that covers all of our research. It was published within the last month.

It really goes through research on suicide psychiatric disorders, again among older African Americans and black Caribbeans. Looking at both racial differences, but with a real focus on within-group differences. Here are some conclusions and future directions. Number one, all three of these groups are important sources of support. Negative interactions of family and other network members that is toxic for mental health. Most people aren't isolated from family and friends. However, people that are isolated, they have more symptoms of depression, more symptoms of anxiety, and more DSM-IV-- more likely have a DSM-IV disorder.

Subjective isolation tends to be a more consistent correlate of poor mental health than objective and this is reiterate, what's been said earlier, there's unbelievably little research on self-side isolation loneliness among African Americans. There are hundreds of papers on loneliness maybe a handful at best if that on loneliness among African Americans. The other issue is that there, again, hundreds of national probability studies on the total population very few, literally two or three on African Americans black Caribbeans, more work in this area is needed. This is my last slide. This is our Twitter handle, our web page and I can be reached through email here. I'm going to stop sharing my screen now.

Yeates: Very good. Thank you so much, Robert. We'll move directly on to the next talk, which is Dr. Amy Fisk. Amy, are you teed up?

Amy: I'm ready. Can you hear me?

Yeates: Sure can.

Amy: Okay, great. First of all, I'm just so delighted to be here. It is really a pleasure to be meeting with a group of people with likeminded individuals with interest in this area. Also takes me back to my roots first, let me introduce myself, Amy Fisk. I'm an associate professor at West Virginia University in the department of psychology. When I talk about my roots, I actually began to be interested in psychology. I volunteered at San Francisco suicide prevention ages ago and started working in their geriatric program. One of the things I did while we were there was to participate in an evaluation of our services, which were entirely designed to reduce disconnection for older adults who might be at risk of suicide.

What we found is after a year of getting services from our program levels of hopelessness were lower significantly in the group of people who are our clients compared to a comparison group. This hooked me on the idea that there is something to be done and that social connections really make a difference. Let me pull up my slide. What I'm going to do is just dive a little bit into some research that I've done that specifically on functional impairment and suicide risk and late-life and talk about the role that social disconnection might have in that.

I'll just clue you in what I'm going to try and convince you is that lack of social connection might increase risk for suicide among older adults in part by interfering with people's ability to meet the challenges of aging. Let me see if I can convince you that. If you look at some of the risk factors for suicide and late life, some of them stand out as being things that are particularly relevant in late life and very common late life. Those are, for example, physical illness and disability and that's where much of my research has been focused. I think in order to understand the relationship between these things and suicide, it's helpful to have a lifespan perspective.

I found the lifespan theory of motivation by Heckhausen and Richard Schultz to be pretty helpful in conceptualizing this. I want to chat about that a little bit. What this theory basically suggests it posits that we all like to meet our own goals by our own effort, working independently. You can see the line across the top that says primary control, striving, people strive to meet their own goals through their own efforts throughout the lifespan. That's a universal, they would say, and also stable. What does vary across the lifespan, however, is the extent to which we're able to meet our own goals using our own efforts.

You'll see the dashed line that says primary control capacity. Of course, that starts pretty low in childhood increases though with adulthood, but in latter part of life, that declines as our independence is abridged by, for example, physical health problems or cognitive problems. In essence, what this theory says is people use different strategies for meeting their own goals, and how viable those strategies are depend on how much opportunity they actually have to meet their own goals. I'll talk about that a little bit more where we talk about what those strategies are. I won't go through these in a lot of detail but what you can see is one of the main strategies that people use is to select goals, invest effort in it, and persist in getting them done.

Those folks categorize that as selective primary control and I'll refer to it here probably as persistence. Another strategy people sometimes use is a compensatory primary control. In other words, this would be if you're faced with loss or failure, what strategy do you use to meet your goals? These strategies include asking other people for help or advice or finding an entirely different way to meet your goal. Then there are other strategies as well, including giving up on the goal and engaging with a different goal or doing things to bolster your motivation.

What's important here and what I was really attracted to was the whole idea about seeking help or finding different ways of meeting your goal. What I'm going to refer to in this presentation is compensatory strategies. What's helpful here is to think about the fact that persistence is of course, what we all prefer to do, wants to meet your goals independently, but there are times when you can no longer do so. If that's true for you, then the most adaptive thing to do would be to compensate using those compensatory strategies. An example of that is if you are not able to get a driver's license renewed, for example, because you can't see then persisting and trying to get your driver's license renewed is likely not going to be successful.

Whereas, asking your friends driving where you need to go could actually be successful and then of helping you meet your goals. I also want to point out before we leave this slide that if you think about these compensatory strategies, a key part of that relies on social connection, doesn't it? You have to have people in your network to be able to ask for help if you're going to be asking for help or advice. I will also mention by the way that research does definitely back up is part of the theory that suggests that most people do start out by using the primary control strategies, including persistence, and just keep trying to meet their own goals when functional limitations get bad enough and some of these research that most people do migrate to compensatory strategies or at least incorporate them as well in their repertoires, however, some people don't.

When they do, it's generally only when they need to, most people don't like asking for help before they absolutely need to. I wanted to apply this to suicidal risk, and it occurred to me that of course with aging people often are no longer able to meet their own goals due to some of these impediments. As some people are going to choose these compensatory strategies, and those are going to be the people who are going to age successfully there a variety of reasons that people might not choose those compensatory strategies best probably a smaller group of people.

My thought is those are going to be people who will be unlikely to meet their goals and therefore will be more at risk for depression, hopelessness, and suicidal thinking. In my lab, we conducted a cross-sectional study and we went into a primary care setting and try to determine if there was a relationship between the use of these control strategies, especially the compensatory control strategies, and suicidal ideation. We picked a sample of people who had some limitations due to their health and are older adults who are 55 or older, I think.

What we found is a little bit of a busy slide, but we found that each of these control strategies was related a little differently but this one that says SPC, this is Selective Primary Control that is persisting and meeting your goals was related to less suicidal ideation. That makes sense, especially if that's among people who can still meet some of their goals through their own direct effort. What's not shown here is we also just look at compensatory strategies together. Those were also related to the less suicidal ideation. In this slide, I had broken it down by the help-seeking versus modifying the goal.

Although they were not significant when I broke them down to that level and you can see that the one that had perhaps the higher effect size was help-seeking. I thought that was important. It was also true that we had an interaction between persisting and help-seeking. I wanted to show you that as well. Essentially, although this is a little bit hard to interpret. If you look at it, the highest levels of suicidal ideation were among those who had low help-seeking and low level of persistence. In other words, either one of those strategies could be helpful in reducing suicide risk but if you have neither, then that's a problem.

That had given us some cross-sectional evidence that there is an association between shifting to these compensatory strategies and lower levels of suicidal ideation, but we wanted to do something to find out whether this was prospective instead of just cross-sectional. We collected some pilot data from people who had either recently had a heart attack or recently had a diagnosis or an exacerbation of congestive heart failure. The reason we picked those probably obviously is because we thought we might have higher levels of functional impairment in that sample. We collected data baseline six weeks, three months, six months, nine months a year so we got a lot of data on these people over time.

One of the surprises, by the way, probably shouldn't have been surprised is I was expecting that as people had more functional impairments, that suicide risk and depression were going to grow across the year, what actually ended up happening is they declined largely over the year, which is really a good thing, but what we found in our prospective analyses if you look at these highlighted effect sizes, that there were a small to moderate effect sizes showing that compensatory control strategies that there is help-seeking and modifying your goals measured at baseline predicted how much drop there was in depressive symptoms on that first line and how much drop there was in suicidal ideation.

These were not significant in this tiny sample of 10 people, but it did give us a signal that we're really up to something here that it does look like control strategies may be related to suicidal ideation and particularly we focused on the compensatory control strategies. In fact, in these prospective analysis, we didn't really find the same thing for persistence, which suggests that compensatory strategies do become really important. The next thing we wanted to figure out was is it true then what I originally surmised that you'd have to have some social support in order to ask somebody for help. Is that really necessary?

What you find here, the highest correlation between strategy use and social support was in the compensatory strategies. It's probably true that it's especially helpful to have a social network in order for you to learn how to use those compensatory strategies. What is also, I think of interest though, is each of these strategies seem to be related to level of social support. That means that for example, it might be possible that people are encouraging people to persist more, coaching their loved ones or friends to be motivated to do things, to meet their own goals. I think it'd be interesting to know what might've contributed to those.

I think that altogether, this does suggest that having social support is helpful or could be helpful in terms of allowing people to adapt as they have functional impairments that might get in the way of, they're meeting their goals. I just want to touch briefly on two other areas that I think could be useful to look at as well where social connections might be important. One is giving support to other people because we all know that doing nice things for other people does make a person feel better and that's certainly true for older adults as well and what we found is that we did a sample of people who had vision impairments and vision diagnoses.

We found that those who reported that they gave informal support to others, the more informal support they gave to others, the less likely they were endorsed suicidal ideation. Again got a signal there that that was something that was relevant. I think this is especially interesting in light of the things Dr. Carstensen was talking about that older adults have lots of experience and wisdom and knowledge and they have a lot to give to other people. Having somebody else in the network that you can actually provide something to can be playing on strengths and really be helpful. Another possibility is just a very basic possibility that having people around will give you opportunities for pleasant events.

One of the things we know is that engaging in pleasant events generally is a way to reduce depressive symptoms in people and what we did is we looked at whether a physical disability was associated with some aspect of outcomes and what role pleasant events played in that. It actually confirmed that pleasant events did mediate the association between disability and these aspect of outcomes, including depressive symptoms, positive affect, and meaning in life. This suggests that just having social contacts, I think can be really useful in that way as well.

Going back to this little flowchart, I think I would argue that social disconnection should have been put into my chart in the first place, and I'm certainly going to be focusing on it now as a way of potentially facilitating people, being able to adapt the challenges of late life. These are various ways in which potentially social disconnection can be important in terms of suicide risk in late life and it's also possible that other risk factors might interact with the social connection just as functional impairment and disability does as well.

I just wanted to mention that when I've looked through the literature, it seems to me we're pretty good at demonstrating that for older adults, social isolation is extremely important and various other aspects of social connection are extremely important when it comes to suicide risk in older adults but I think what I'm seeing our main effects and I'm not seeing a lot of looking at whether social support or social connection, in general, might moderate the effects of other risk factors on suicide. I would argue that we could look for example, at pleasant event- at a stressful life events that we know are associated with depression and also suicidality. Is it possible that social connection can moderate that relationship as well? Then of course there are other research questions that I'd be interested in pursuing, coming out of the research that I was just doing.

Another thing that I think is of interest is for older adults who have cognitive impairment is social connection more or less important. We know that when someone, for example, is diagnosed with dementia, often, I think others shy away from the person, don't know how to interact with the person. We don't know what the effect is for somebody who's got cognitive impairment, could it be that actually, it's a greater need for social connection? I think a lot of work has to be done in that area as well. I just wanted to thank the people who've been involved and helped me do my research and thank you all for listening.

Marty: Okay, Thank you, Amy. This is very interesting, and I appreciate your thoughts and your time. We're now going to pull together our four different speakers through this overarching session on mechanisms and it's Julianne, Laura, Robert, and Amy who are going to discuss their different, both their data and their thoughts. Moderated by George [unintelligible 01:38:20] of Cornell. Welcome, all.

George: Thank you very much. Georgio, and Liz, I'm grateful for including me in this conference. I'm learning a great deal already. I would like with the chair's permission to take the opportunity to show very few slides on social isolation effect on depression and on suicide ideation in healthcare workers is, do I have your permission?

Marty: Yes. All good.

Yeates: Yes, go terrific.

George: One of the things I do when I wake up every morning over the last few months is to look at the death rate in the United States due to COVID. Today's number is 199,746 deaths. By this time that I'm speaking, they probably have crossed 200,000 people. The numbers without the point of reference mean, very little. I just wanted to point out to you that during the Second World War 405,399, people died from the United States. Now, where 49.27%, the death rate of the Second World War and the COVID-19 war is still going on

just to give that perspective. The Department of Psychiatry of Cornell wanted to develop a tracking instrument of symptoms-- made it available to healthcare personnel throughout the New York Presbyterian system. People, anonymously, could rate their symptoms. The goal was not to do research, the goal was to make them aware of the need for access and services. The symptom tracker was developed by a Cornell listeners group and has been made available and still operates right now. What I'm going to show to you is the responses of 1858 healthcare workers working during the COVID pandemic. The data are a few weeks old. Again, they were not intended for research. What you see here is the PHQ-9 distribution at the various age groups. They're below 45 and 64, and 65 and above.

What it shows is that in the group of up to age 45, 45% of people rated PHQ-9 scores in the moderate to severe depression level. This is a staggering percentage. The good news is that the older health care personnel had a lower rate. 27% of them scored at the moderate to severe level. If you look at their association with social isolation, but before you do that, look at the left side of this slide. Notice that there was no relationship between the depression scores of the PHQ-9 and fear of recent exposure to COVID or finances. Most of the people who responded were healthcare workers who work at the front lines. However, the social isolation item, which was a four-item-- It had the range of four points, not at all, somewhat affected, very much affected, and extremely affected.

There was an association overall with depression. There was a stronger association in the age 65 and over. While older people were less likely to have high scores of depression, they were more likely to have an association between the perception of social isolation and depression. Well, these are not patients, these are healthcare workers. We analyzed the PHQ item nine, which is the suicide item, and 85% of them gave low scores. You can see this is a skewed distribution. Again, these are not patients.

What I'm going to show you is how that relates to ages first. It turned out that the highest score on the suicide side item were by the young people, people 18 to 25 years old, and old people age 75 plus. There was an age effect there. There was again, no association between the suicide item and fear of recent exposure to COVID, or finances affected by COVID. There was an association, weak nonetheless, between socializer isolation and the overall group suicide ideation.

That association was stronger in the over 65 years old. The story to summarize it is that old healthcare workers were less likely to develop depression. Their depression was associated with suicide, I'm sorry, with social isolation. The same associations with social isolation were in the suicide item on the PHQ-9. My last slide has to do with patients. These were people who were treated with Problem Solving therapy or supportive therapy, and they had major depression, the executive dysfunction. We looked to see at this trajectory of the suicide ideation score of the Hamilton overtime where they were receiving treatment. We use latent growth mixture models and identified a stable trajectory on changing during treatment and the declining trajectory, the good trajectory.

Here, social support, at the entry to the study was by far the strongest predictor, identified through a random forest machine learning and outscored all other items, followed by apathy neuroticism, and perception of therapists. In a more recent study that Batarian and I are doing, that emphasizes reward exposure as the main mechanism of action. In that particular study, we have analyzed what type of reward exposure is most valuable in inducing behavioral activation and reducing depression.

It turned out that activities doing together with another person had the highest association with behavioral activation, and reduction of depression. With that, this is where they had to say. I'll take my slides away and start the discussion. I would suggest that I think the format of this is to get comments and questions from the participants using the chat function? Am I correct, Marty?

Marty: This is really a conversation among the four presenters, Julianne, Laura, Robert, and Amy. It's an opportunity for them to comment or ask questions of each other. You engage me as well. Yeates, I've got that right, yes?

Yeates: Yes. I think this is a golden opportunity. I think a start synthesizer, lots to take in here.

George: Comments? Julianne, Robert, Amy, any additional remarks?

Robert: I think I have one or two things to say. I appreciated the synergy in the presentations. I can see a lot of overlap between what, at least for me, the first two presenters and the third presenter. My work is a bit more sociological, a little bit less psychological. That being said, I try to make my work as more multidisciplinary as possible. I could definitely see ties between-- I can't remember the name of the first presenter but with Laura Carstensen.

I can definitely see how they relate to each other. The big issue, though, obviously, that I want to push that I feel I said already, it's just a lack of research, in terms of minority groups in this area, and the lack of quality data. That is a big issue. I've always been amazed, I started looking at research on loneliness. Oh, I'm trying to remember. I must say, maybe 1998, 22 years ago, and was shocked that there was just nothing on loneliness in African Americans and started a paper that I never finished. Then to see now, there's almost no research on this topic, still, over this 23-year period and before.

Julianne: I was nodding my head because I am in complete agreement with Robert. Having just recently completed the National Academy of Science consensus report, where we reviewed this evidence. That was the conclusion that the committee also included in that report. That there is absolutely a great need for that. Thank you for really making that point.

George: Julianne, if I may ask, you mentioned that complex marriage of social integration has the highest association with mortality? Can you give an example to the group of what these measures are?

Julianne: Yes. I would probably need to go back to the data to look at the names of specific measures. They were classified as complex if they were measures that included, say, for instance, both structural and functional. It might have looked at both size of the social network, as well as engagement and feelings of connection to that network. Those types of measures encompassed more than one, but the majority did not include any indicator of quality. That would be a component that might be missing in some of them.

Those complex measures were greater predictors. Keep in mind, that was all-cause mortality, so it wasn't specific to suicide. It was a significantly stronger predictor of risk than the overall average or any of the other specific measurement approaches.

Amy: I just wanted to say, Dr. Holt-Lunstad, that I felt like your overview was so compelling. I've been listening to the research that you sent me. It would be hard to imagine denying the importance of social connection in terms of some of these outcomes that we're looking at. I really appreciate that. Especially some of the potential biological indicators or markers of problems with social connection. Very compelling.

Julianne: Thank you. One point I probably ought to make clear is that some of those biological mechanisms may have considerable overlap between different outcomes, whether it be physical, mental, cognitive, health, and even suicide. The evidence is growing around mechanisms, some of the interconnections between mechanisms. For instance, even behavioral components with biological and even within biological, there's a lot certainly to be learned that and, of course, then the extent to which then those biological changes might influence behavior. Certainly can better inform not only understanding risk, but potential opportunities for intervention to reduce risk.

Yeates: Kim Van Orden mentioned in a chat, the work of Susan Charles, a theory on strengths and vulnerabilities. I think, Dr. Carstensen, you mentioned that and it's something Amy Fisk, I know you've worked with as well. Could somebody maybe add a little bit of background if you think that's relevant to our discussion?

George: Sorry, are you asking Laura Carstensen to comment?

Yeates: Sure, Laura, or Amy.

George: Laura is not here. Laura was not able to stay for that session.

Yeates: All right, thank you. I don't think that Dr. Charles is part of the group today, either. Amy can you comment on that?

Amy: I can talk a little bit about it, although I might not be the best person to summarize the theory. Actually, probably I'm not the best person but the thing that I know about the strength and vulnerability theory is that it also suggests that, with late-life, particularly in the very late-life, people do have strengths associated with aging, and well-being does tend to get better with aging. One thing that I think was striking is that at the very tail end, things do tend to get more challenging again. I think that's one of the hallmarks I think of the savvy theory. Again, I'm sorry that I'm not able to really articulate that, there might be someone else who might be able to do it better than I.

Yeates: Thank you.

George: Perhaps, Amy, you can comment on-- Can you give us a clinical sense of what are the compensatory strategies that you refer to in your talk?

Amy: Yes, thanks for asking. Really, there are only two categories within that, in terms of the way this theory identifies them. One is asking other people for help or advice and the other is finding a different way to meet the goals, so designing another strategy for getting there. If for example, you're not able to walk as well as you used to walk, maybe you'll buy a walker, and use that to go out on walks during the day. You're still hitting your goal, you are just doing it differently.

If you can't drive, maybe you'll learn how to take the bus. It also leaves open and I think is really intriguing, the possibility of technology. We're working with some folks in our engineering department to see if there might be different things that could, and I think it'd be interesting to ask, do robotic pets, for example, or do pets in general, or robotic companions. Do those actually reduce social isolation?

I think that those kinds of things could be potentially creative ways of meeting your goals, and maybe fall into that category as well. Asking for help or advice, I think it's pretty obvious. I think that's when I'm really focused because it just strikes me that a lot of people really are so fiercely independent. I've often thought that control is such an important part of suicide, right? It just seems to me that it fits. Basically, those people who would prefer to work independently, even when they're beating their head against the wall, because they're not really able to meet their goals without help. That's why I'm thinking that's a relevant thing. It's normally those two.

The other thing that could be classified or is classified as a compensatory strategy is disengaging from the goal and picking a new goal. That's also been shown to be adaptive. As you might have noticed, in the research we did, that was not adaptive, a month ago, folks in primary care, it actually was associated with greater depressive symptoms or greater suicidal ideation. That's why I'm focusing on help-seeking and modifying the way of getting to your goal.

I think what is sad is that most people who do research in developmental psychology on this theory, skip the part about asking other people for help and they designed measures that miss out on that part, which I think for our purposes, may be the most important element.

George: Thank you.

Robert: I've received a question that I'd like to answer. One is to simply discuss the low rates of suicides among older African Americans. What we see is, historically, we have seen relatively low rates among the black population in general. There's a book by Robert Hill in 1976, called The strength of black families. One of the strengths was the low rates of suicide. However, what we're also seeing more recently is a really big jump in adolescent suicide among African Americans.

Again, I don't do adolescent research so it's not as if I've read that work. I'm familiar with people talking about it. It's been a pretty drastic jump. Michael Lindsay at NYU is probably the number one expert in that area, at least that I know of. In addition, I want to speak one other quick thing, which is when people-- Especially with COVID-19, with African Americans, because we have higher mortality rates, among people who are survivors, we also have higher levels of what we call carelessness, which just mean, no surviving siblings, as an example. What you see is that is one way that contributes to loneliness because people-- Even if you've set somebody up with technology or ways to communicate, most of the network is past. When you look at friendships among older African Americans, it really goes down as people get older. Again, my feeling is because of carelessness.

Marty: So George, this is Marty, I am listening to the conversations and I'm really impressed that we have really been addressing the biological and the psychological. You'd call it the environmental or the structural. Everything from, do you go to or are there churches that you can go to? Do you have a church group to where the biological mechanisms? Do you have the capacity to ask for help? Can you even be in such a situation where you could ask for help? I want to bring us back to thinking about mechanisms.

Where in that mishmash, or those things that everything is interrelated. Does it make sense to better understand the mechanisms of late-life suicide. Julianne, you started with this beautiful overview that included biology, so maybe you could reflect on where biology fits with the psychology and the social-environmental culture.

Julianne: Yes. As I was listening to the other presenters, I was really reminded of-- Some of the presenters talked about the importance of perceived support in suicide. Much of my early research was focused on perceived support, and how it influenced our physiology. Some of this early work, we bring people into a lab and hook them up to monitors and measure their physiological responses under various challenging situations to see how their physiology responded and compared. What we found was that people were much more reactive, among those who had low perceptions of support, relative to those that had higher perceptions of support.

Part of this has really gotten me thinking, particularly in light of the pandemic, where we may not have our source of support in our home, and the proximity to them may not be very close, and how our perceptions of support may have a large play, a large role in how people are coping under the circumstances. The extent to which we can feel that we can count on our network, during this may play a very large role. Then similarly, what efforts can be done to help strengthen those perceptions of support.

As I presented, even in the mortality data, the perceptions of support were associated with a 35% increase of the survival. That perception of support, I think, not only is really important but also influences our physiology, which can in turn have implications for other outcomes. I'd really be curious to hear from the other speakers as well, in terms of their thoughts on perceived support, particularly in this context.

George: There is one question here? Do we have time? Doctors Bruce and Conwell?

Yeates: Yes, George. Why don't we extend this discussion for another 5 to 10 minutes and have a hard stop let's say at 12:45? We'll start the session again, following lunch at 1:30. Yes, let's proceed for a few more minutes.

George: There is a question about-- I'm reading it, "What makes white old men so vulnerable to late-life suicide, whether they're moderating variables? What is their relationship to such a disconnection?" Who wants to take that up?

Robert: I’ll sort of start. Again, I'm going to be serious now. That is really not my area of research. However, it is pretty clear that when you see that they're really high levels of suicide in states like North and South Dakota, Montana. Not attempts, but completed suicides among white men, in particular, part of it social isolation, and part of it is access to firearms. That combination with other things is pretty toxic.

Amy: I also wanted to chat about this as well. I got a question about autonomy and older white men. In my lab, we actually have looked at a measure of the value a person places on autonomy. We have found that in fact, it is associated with suicidal ideation. We found it more so in older adults than in younger adults, and also more so in men. Actually, not significantly women, but it was significant in men. This idea of perhaps being socialized to be fiercely independent, and not necessarily feel you need to rely on social support could potentially be a risk factor. I think it's important to pursue.

Robert: I have also received a question about discrimination and suicidal behaviors. I'm a co-author on a paper, by a very, very bright young scholar, named Janelle Goodwill. In this paper, we found that everyday racial discrimination is positively associated with both depressive symptoms and suicidal ideation among African American men. There's a clear impact, again, even controlling for depressive symptoms.

George: There is another question by Nancy Donovan, "What is the connection if any, of suicide in older white men to unmarried status and spousal loss?" Well, we know that losing a spouse, spouse loss, is associated with higher mortality in men. Does anybody want to address this question? Yeates, you probably have data on that.

Yeates: Yes, that's generally true. Others might have more precise epidemiologic data to cite but in general, across a life course, unmarried status of any sort is an increased risk factor. I think when one looks specifically at older adults, there gets to be, I think, some pretty interesting gender differences. I don't know anything about race and ethnicity as a factor, coloring those relationships.

Among older women, it appears that the relationship between widowhood, for example, and suicide is less tight than it is among older men who are widowed, suggesting something which I think makes sense to us in terms of the level of dependency perhaps, or the challenge that those vulnerable men have when they lose support of a particular kind. That may be a little different among women. A fascinating area about which we don't know of. Amy, you were nodding your head on that you have any other--

Amy: No, I agree exactly with that.

Marty: A related question, I think, because it has to do with how people have been cultivated or their roles in life over time. This question came in about, does help-seeking behavior or maybe just affects suicide risk among aging veterans, especially those who've been somehow indoctrinated or trained or chose to live a life where they have so much self-sufficiency. Amy, I move that question to what extent that opportunity or ability to ask for help really may depend upon what you've done up to that point in your life.

Amy: I think it's probably usually associated with how you've been socialized. It's also true for people that they're involved in military are also socialized to ask for help, but among their co-worker team members. I could see that would make a lot of sense. I think there's just a lot we don't really know. There's not I think a huge amount of research on help-seeking. When people talk about help-seeking, in the literature what people are really usually saying is, "Do you go to a doctor for this?" That's what we mean by help-seeking. You see very little research just on DUI on your social network or assistance with emotional or instrumental problems, but I think that's an area for research.

George: I think we are approaching the end of our time, and [crosstalk]--

Yeates: Thank you, George, and thank you everybody for your contributions this morning. It's really been stimulating and fabulous. We're going to take a break and Marty you can help me in trying to remember all of the logistical reminders here. One is, please do stay on through lunch. Don't log off of Zoom because when you log back on, it will become a little bit more complicated tracking you and your names and linking you.

The other is that we will start again at 1:30, so we're slightly curtailing your lunch. I hope that's not a problem. We look forward to seeing everybody join us again for the afternoon, which will start with a very brief recap and then delve into two more sections of this kind of a presentation. Anything, Marty?

Marty: No, that's great. Thank you. [crosstalk]

Jovier: You covered everything Yeates. Thank you very, very much, and thank you all for being so accommodating and open. This morning I have been taking notes. Thank you very much and we will see you all again at 1:30.