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. Author manuscript; available in PMC: 2022 Aug 1.
Published in final edited form as: Am J Geriatr Psychiatry. 2021 Apr 1;29(8):789–800. doi: 10.1016/j.jagp.2021.03.009

A Pilot Randomized Trial of Engage Psychotherapy to Increase Social Connection and Reduce Suicide Risk in Later Life

Kimberly A Van Orden 1, Patricia A Areán 2, Yeates Conwell 1
PMCID: PMC8286301  NIHMSID: NIHMS1690509  PMID: 33952416

Abstract

Background:

Targeting social connection to prevent suicide in later life shows promise but requires additional study to identify the most effective and acceptable interventions. This study examines acceptability, feasibility, and efficacy of Engage Psychotherapy to improve subjective disconnection (target mechanisms: low belonging and perceived burden), and improve clinical and functional outcomes (depression, suicide ideation, quality of life).

Methods:

Pilot randomized trial with adults age 60 and older who reported feeling lonely and/or like a burden. Participants were randomly assigned to 10 sessions of ‘Social Engage’ (S-ENG; n=32) or care-as-usual (CAU; n=30), with follow-up assessments at 3-weeks, 6-weeks, and 10-weeks.

Results:

S-ENG is feasible to deliver over 10 sessions and acceptable to older adults who report social disconnection—a population at risk for suicide. Participants were willing and able to focus each session on social engagement and demonstrated high levels of compliance. Social Engage did not show preliminary evidence of impact on belonging or perceived burden but was effective in reducing depressive symptoms and improving social-emotional quality of life.

Discussion:

S-ENG holds promise for improving social-emotional quality of life and depressive symptoms. Future research is needed to identify and measure target mechanisms that account for clinical and functional improvement.

Keywords: suicide, social connection, psychotherapy

Article Summary

We conducted a pilot RCT to examine acceptability, feasibility, and efficacy of Social Engage Psychotherapy (S-ENG) to improve social disconnection and reduce suicide risk. Results show that S-ENG is feasible and acceptable to socially-disconnected older adults. S-ENG did not impact belonging or perceived burden but was effective in reducing depressive symptoms and improving quality of life. S-ENG holds promise; research is needed to identify target mechanisms that account for clinical and functional improvement.

The size of the older adult population continues to increase in the U.S. and worldwide.1,2 Older adults have high rates of suicide and projections indicate subsequent cohorts will usher in even higher rates.3 A challenge to late-life suicide prevention is that older adults frequently die on a first attempt, in part due to selection of more immediately lethal means (e.g., firearms).4 Approaches that prevent development of suicidal thoughts—selective prevention—are needed to complement mental health treatment to reduce suicidal thoughts and prevent repeated attempts—indicated prevention.5

Social disconnection is associated with suicide risk factors—psychiatric and physical illness,6–9 functional impairment,10–12 and pain13—and suicide ideation,14,15 attempts,16 and deaths in later life.17,18 Social connection is a multifaceted construct,19 including three dimensions associated with suicide—social isolation (weak social ties/networks), social support (functions provided by relationships, e.g., emotional support), and subjective connection (feeling isolated/connected, e.g., loneliness, belonging).20 An additional dimension relevant to intervention development is ‘social engagement’ which refers to the behavior of engaging in social activities. The Interpersonal Theory of Suicide posits that low belonging and perceived burden on others (subjective disconnection) increase suicide risk.21 Low belonging is the perception of not belonging to valued relationships/groups and is associated with suicide ideation,15,22,23 attempts,16,24 and deaths17,25–27 in later life. Perceived burden is the perception of being a liability on others28 and is associated with emotional distress, loss of dignity and meaning,29–36 suicide ideation,37–39 attempts,40 and deaths in later life.41,42,43

While social disconnection is a significant contributor to late-life suicide, data demonstrating that increasing social connection is an effective strategy for preventing suicide are not available. Three interventions are associated with reductions in suicide rates among older adults, and all were multi-component interventions: telephone-based outreach, evaluation and support44,45; screening/referral for care, health education, and peer support46; and case management, supportive calls, psychoeducation, and psychiatric care.47 A common element is promotion of social connection with providers/peers; however, the studies were not designed to directly test this mechanism. Testing mechanisms could identify ‘key ingredients’ from multi-component interventions and more rapidly promote dissemination and implementation.

Loneliness (one form of subjective disconnection) does appear in one recent meta-analysis to be responsive to behavioral intervention.48 However, included studies did not focus exclusively on older adults, none have been replicated, and many had design limitations. Two RCTs of interventions to increase connection in older adults demonstrated efficacy in reducing loneliness49 and depressive symptoms and perceptions of burden.50 Targeting social connection to prevent suicide shows promise, but requires additional study to identify the most effective and acceptable interventions given numerous causes of social disconnection and limited evidence-base to support one intervention over another.

The objective of this study is to examine the application of Engage Psychotherapy51–54 to improve social connection as a means of selective suicide prevention. Engage is an easily implemented, modularized intervention. We used an experimental therapeutics paradigm to examine mechanisms whereby Engage affects clinical and functional outcomes. The selection of target mechanisms was guided by the Interpersonal Theory of Suicide21 and prior research on Engage.55 Engage Psychotherapy for depression targets modifiable mechanisms involved in late-life depression, including reward functioning, by helping patients increase reward-seeking and addressing barriers that interfere with both reward-seeking (e.g., addressing apathy) and reward processing (e.g., addressing negativity bias and affect regulation). Research into mechanisms of Engage indicates that socially-rewarding activities may be especially potent activators of neural reward systems involved in late-life depression.55 The study’s conceptual model (Figure 1) posits that our intervention—Social Engage—increases social engagement through a process of identifying valued social activities and creating individualized plans for achieving social goals, thereby impacting subjective disconnection (target mechanisms: belonging, perceived burden), reducing depressive symptoms and suicide ideation (clinical outcomes), and improving quality of life (functional outcome).

Figure 1.

Figure 1.

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Conceptual model for Social Engage as selective suicide prevention within an Experimental Therapeutics Framework

We adapted Engage for social disconnection by focusing on social engagement. We conducted a pilot randomized trial with adults age 60 and older who reported subjective disconnection (feeling lonely and/or like a burden). Participants were randomly assigned to 10 sessions of ‘Social Engage’ (S-ENG) or care-as-usual (CAU), with follow-up assessments at 3-weeks, 6-weeks, and 10-weeks. Our first objective was to examine feasibility and acceptability of S-ENG by examining the number of sessions completed and participant feedback. Our second objective was to test target engagement by examining the proportion of sessions focused on social engagement (versus general pleasant or physical activities) and the effect of S-ENG on subjective disconnection (belonging, perceived burden). Our third objective was to assess clinical and functional impact of S-ENG by examining indicators of suicide risk—depression severity, suicide ideation severity, and quality of life.

Methods

Participants

Participants were 62 adults age 60 years or older recruited from primary care and an outpatient geriatric psychiatry clinic who endorsed loneliness (“I feel lonely”) and/or feeling like a burden on others (“I feel like a burden on others”) in the prior two weeks (“somewhat” or “very true for me”); these items were used in a prior trial to identify a population suitable for selective suicide prevention due to perceived social disconnection.50,56 Exclusion criteria were: residing in residential care facilities (due to different socialization opportunities); hearing loss precluding communication with interventionists; cognitive impairment that could preclude engagement in S-ENG (Montreal Cognitive Assessment<20);57 psychosis (past month); and problematic drinking (past year; AUDIT >5).58 Level of depressive symptoms and ongoing psychiatric treatment were not inclusion/exclusion criteria, though imminent suicide risk would have been cause for exclusion (this did not occur). No participants were lost to follow-up, but 5 participants withdrew (see CONSORT diagram, Figure 2).

Figure 2.

Figure 2.

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CONSORT Diagram

Procedures

Interested individuals completed in-home baseline interviews. Given that participants were selected for suicide risk factors, all were assessed for suicide risk, developed coping cards (similar to safety plans), completed firearm safety education, and were given emergency numbers for suicide prevention. Participants’ primary care or mental health providers were notified of enrollment and given information on patients’ depressive and anxiety symptoms, suicide ideation/behavior, alcohol misuse, and cognition. Providers were given brief recommendations, including suggestions for ongoing monitoring. As the study intervention addressed social engagement and was not focused on treatment for depression or other mental disorders, participants were not required to stop psychiatric treatments, including psychotherapy; this was done to increase acceptability and reflect real-world conditions in which S-ENG might be offered as a community program. This study was approved by the Institutional Review Board of the University of Rochester and participants provided written informed consent. The study was listed on clinicaltrials.gov (NCT02188485).

Intervention

S-ENG involved up to 10 in-home individual sessions over approximately 10 weeks. The manual was adapted from Engage for late-life depression by the lead author, with input from an Engage developer (co-author PA). Engage, as originally developed, coaches patients to re-engage with pleasant, physical, or social activities they may have stopped doing in the context of depression. Subjects create ‘action plans’ that involve setting a goal, brainstorming ways to achieve the goal, and selecting specific actions to take before their next session. Therapists follow-up at subsequent sessions for each action plan, including whether it was completed (i.e., participants engaged in planned activities). Engage is a stepped, modular intervention that addresses barriers to action plan implementation and challenges in processing positive outcomes when exposed to rewarding activities. Barriers addressed are negativity bias, affect regulation and apathy. When barriers are identified, simple behavioral interventions to address barriers are added to action plans. Modifications for this study were minimal and involved adapting psychoeducational materials to address the importance of social connection, adding a values clarification exercise on aspects of connection most important to participants, and instructions to therapists to focus action plans on social engagement. Barrier strategies for negativity bias, apathy, and affect dysregulation were unchanged, though therapists addressed additional barriers relevant to social connection in a few participants—social skills (n=2) and concerns about burdening others (n=3). Therapists were clinical psychologists (n=2) and master’s level social workers (n=2). All sessions rated for fidelity (random sample of 15% of sessions) were rated as adherent by an external Engage expert. The lead author (KVO) provided weekly supervision. CAU participants did not participate in study interventions other than safety actions at assessments (described above).

Measures

Target mechanisms were subscales for (low) belonging and perceived burden from the Interpersonal Needs Questionnaire (INQ)28,59 and S-ENG session notes on the content of action plans and frequency of completion of action plans; clinical outcomes were the 16-Item Quick Inventory of Depressive Symptomatology (QIDS-C)60 clinician interview and the Geriatric Suicide Ideation Scale—Screening version,61 which provides a continuous score of severity of suicide ideation. The functional outcome was social-emotional quality of life, assessed by a composite score including both social and emotional domains from the World Health Organization Quality of Life Scale (WHOQOL-Bref);62 the WHOQOL scoring manual recommends five domain scores, but given our focus on social-emotional quality of life, we combined these items, supported by high internal consistency (Cronbach’s Alpha=0.85).

Measures to characterize the sample are: World Health Organization Disability Assessment Schedule63 (WHODAS) for functional impairment; Montreal Cognitive Assessment57 (MoCA); Ten Item Personality Inventory64 for the Big Five dimensions; Columbia Suicide Severity Rating Scale65 for suicide ideation and attempt (lifetime and past month); Modified Cornell Services Inventory66 assessed medical services in the prior three months; AUDIT-C58 assessed alcohol use; GAD-767 assessed anxiety; number of medical conditions was self-reported by a checklist derived from the Minimum Data Set Version 2.0.68

Participants provided feedback on acceptability in final S-ENG sessions by responding to open-ended prompts: Things I learned about myself in Engage; skills that helped me in Engage; steps I will take to stay engaged.

Data Analytic Strategy

To examine the mechanism of missing data, participants who withdrew from the study (n=5) were compared on several baseline variables, with no differences on age, sex, living alone, MoCA, depression severity, belonging, nor suicide attempt history, indicating that it is appropriate to assume data were missing at random and suitable for maximum likelihood models.69 Missing data for individual items on self-report questionnaires were minimal and managed by replacing missing values with the mean of the respondents’ non-missing items.

Randomization was stratified by antidepressant prescription based on the urn randomization model.26 Neither assessors nor subjects were masked to group assignment.

An a priori power analysis for an anticipated sample size of n=50 in each arm indicated the minimum detectable effect size for comparing the conditions was 0.51 (Cohen’s d, power=0.8, two-sided alpha =0.05, 10% attrition). Due to initially slow recruitment, funding for the study ended before reaching the target sample size. Given that a prior study of Engage demonstrated effects with 39 participants53 and several studies on social isolation in older adults demonstrated preliminary efficacy with comparable sample sizes,70 we decided to analyze our data with a smaller sample size than was planned.

Outcomes were analyzed using an intent-to-treat approach by fitting mixed-effects regression models using the ‘mixed’ package from Stata 14.71 All models included random intercepts for participants and the 3- 6- and 10-week assessments were treated as the dependent variable, with a ‘time’ factor to examine change in the outcomes over the assessment period, a ‘condition’ binary variable, and the time-by-condition interaction to examine the effect of S-ENG on outcomes. All tests of significance were two-tailed (alpha 0.05). We did not adjust reported p values because we conducted a small number of a priori statistical tests in the context of a pilot trial, warranting balanced consideration of Type II error. We calculated standardized effect sizes appropriate for random-effects models (dGMA-raw) that can be interpreted similarly to Cohen’s d.72 We conducted sensitivity analyses to examine potential confounders of ongoing mental health treatment and personality (neuroticism and conscientiousness) by including these as covariates.

Results

Table 1 characterizes the sample, including that characteristics were balanced across conditions at baseline. The average age was 72 (std 9.07); most were female, identified as white, and lived alone. The average MoCA score was consistent with normal cognitive function, with a range including scores consistent with mild impairment (22–30). The average depression score was in the mild range (7.90, std 4.79). Almost half reported current antidepressant prescriptions and 37% reported outpatient psychotherapy in the past three months. These elevated proportions are due, in part, to recruitment from primary care clinics and an outpatient geriatric psychiatry clinic. Anxiety symptoms were in the mild range. AUDIT scores were consistent with occasional drinking. Participants reported an average of four-to-five medical conditions and an average WHODAS score corresponding to the 83rd percentile (normed for community-dwelling adults) indicating significant impairment. Fifteen percent reported prior suicide attempts, 19% reported suicide ideation in the past month, and the average score for suicide ideation (GSIS) is comparable to a sample of community-dwelling older men screened for a study using a similar design—providing a psychosocial intervention as selective suicide prevention.61 These characteristics are consistent with our objective of enrolling a sample representative of a population of older adults appropriate for selective suicide preventive intervention due to subjective disconnection.

Table 1:

Participant characteristics at baseline

Total Sample S-ENG CAU Difference
Demographics
Age 72 (9.07) 72.78 (9.27) 71.46 (8.96) F(1,60)=0.32, p=0.571
Female1 42 (68%) 22 (69%) 20 (67%) χ2=0.03, p=.861
Race (White)2 57 (92%) 31 (97%) 26 (87%) χ2=2.18, p=.140
Lives alone 43 (69.0) 21 (66%) 22 (73%) χ2=0.43, p=.511
Married 12 (19%) 6 (19%) 6 (20%) χ2=0.02, p=.901
Psychiatric & Functional Characteristics
MoCA 25.91 (2.52) 26.52 (2.90) 25.27(1.90) F(1,60)=3.93, p=.052
Prior suicide attempt 9 (15%) 4 (13%) 5 (17%) χ2=0.22, p=.642
Suicide ideation past month3 12(19%) 3(16%) 3 (23%) χ2=0.59, p=.443
Disability (WHODAS)4 21.56 (12.51) 20.65 (13.43) 22.53 (11.60) F(1,60)=0.35, p=556
Number of medical conditions 4.64 (2.58) 5.00 (2.72) 4.24 (2.39) F(1,59)=1.33, p=.254
Psychotherapy5 20 (37%) 11 (37.9%) 9 (36%) χ2=0.07, p=.81
Current antidepressant 27 (43.60%) 14 (43.75%) 13(43.33%) χ2=0.00, p=.97
Alcohol (AUDIT) 1.42 (1.37) 1.28 (1.37) 1.57 (1.38) F(1,60)=0.66, p=.418
Anxiety (GAD-7) 7.24 (5.30) 7.72 (5.66) 6.73 (4.93) F(l,60)=0.53, p=.469
Target Mechanisms
(thwarted) Belonging 6.23 (3.87) 6.47 (3.69) 5.97 (4.11) F(1,61)=0.26, p=0.614
Perceived burden 1.25 (1.98) 1.25 (1.98) 1.23 (1.98) F(1,61)=0. 0.00, p=0.974
Clinical & Functional Outcomes
Depressive symptoms (QIDS)6 7.90 (4.79) 8.41 (4.32)4 7.37 (5.26)2 F(1,61)=0.73, p=0.398
Geriatric Suicide Ideation Scale 7.79 (3.18) 7.81 (3.27)4 7.77 (3.14) F(1,61)=0.00, p=0.955
Social-Emotional Quality of Life7 55.81 (15.36) 54.69 (15.99)4 57.01 (20.83) F(1,61)=0.35, p=0.556
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Notes:

1

df for all χ2 tests are 1, n=62 unless otherwise noted.

2

Non-white race: 3 black, 1 Native American, 1 refuse to answer.

3

Wish to be dead or thoughts of killing oneself on the Columbia Suicide Severity Rating Scale.

4

WHODAS summary scores range from 0 to 100, with a score of 18 corresponding to the 80th percentile for community-dwelling adults.

5

Psychotherapy in the past 3 months per Cornell Services Index; some participants reported only on current mental health treatment and did not specify psychotherapy or medications, thus there was some missing data on this variable, with df=1, n=53.

6

QIDS symptom severity ranges for total sample: 23 (37%) scored in the no symptoms range (scores 0–5), 21 (34%) mild symptoms (scores 6–10),14 (23%) moderate (scores 11–15), 4 (6%) severe (scores 16+).

7

WHOQOL composite score of social and emotional domains, normed scoring with a population mean of 50.

Results support feasibility and acceptability of S-ENG: all participants completed at least one session; over half (66%) completed 10; most completed at least 6 (88%). Review of therapist notes indicated that all action plans addressed social engagement; the majority of participants (96%) successfully completed at least one planned social activity, consistent with increases in social engagement. Therapists coached participants to transform goals focused on pleasant/physical activities to ‘make them social’ (e.g., attend an exercise class or walk with a friend). The majority (90%) focused at least one action plan on non-family connections and 25% focused at least one on family relationships. Table 2 presents feedback on S-ENG: 1) increased insight into the importance of social connection; 2) value of using action plans to be proactive and intentional with social engagement (e.g., reaching out, joining groups, utilizing supports such as transportation assistance); 3) utility of ‘barrier strategies’ to overcome negative self-talk, low self-esteem, and anxiety. Several (30%) noted the utility of accountability for social engagement and reported plans to start psychotherapy or support groups. Participants appreciated information on local opportunities for social engagement.

Table 2:

Feedback on Benefits of Social Engage

Importance of connection Being proactive Addressing barriers
“I learned that staying involved in social activities will stave away depression.”
“I was dealing with inertia because of grief… it helped kick me in the ass a little bit.”
“Asking “how can I fit here” instead of thinking I don’t.”
“I learned that reaching out to people helps me feel useful.”
“Once you start doing it, it becomes habit - reaching out and being with people and engaging in activities.”
“I’m worthy of interacting with other people.”
“I learned that doing things with family makes me feel less lonely.”
“Action plans helped with accountability.”
“I learned I can get out and be accepted by others.”
“I learned I’m not as much of a loner as I thought; I’m more influenced by people around me than I realized.”
“I can become more proactive/active in seeking connections within the community and beyond.”
“Instead of collapsing into myself, I’m opening up. I used to withdraw; now I don’t. I’m more aware of myself than I ever have been in my life. I’m more accepting of things; I talk to myself when I feel depressed or unworthy.”
“I learned I really do want and need communication with people.”
“I learned how I valued my sons’ and husband’s relationships.”
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Results of intention to treat analyses appear in Table 3. For target mechanisms of subjective disconnection, our hypotheses were not supported: S-ENG was not associated with improvements in belonging or perceived burden; including personality dimensions as covariates did not affect results. For clinical outcomes, our hypotheses were partially supported: S-ENG was associated with statistically-significant improvements in depression severity at all timepoints with a moderate effect size (adjusted mean difference at 10-weeks= −2.47, SE .85, dGMA-raw= .52), but was not associated with decreases in suicide ideation. Adjusting for ongoing mental health treatment did not affect results; in fact, those not in mental health treatment evidenced a greater decline in depressive symptoms (3.47 points) versus those in treatment (2.42 points). For functional outcomes, our hypothesis were supported: S-ENG was associated with statistically-significant improvement in social-emotional quality of life with a small-to-moderate effect size (adjusted mean difference at 10-weeks= 5.78, SE 2.39, dGMA-raw= .38). While normative data on the WHOQOL with older adults is under-investigated, two studies with older adults suggest a cut-score below 60 (out of 100) as a clinically meaningful indicator of poor quality of life,73,74 suggesting that the magnitude of change in social-emotional quality of life associated with S-ENG represents clinically-meaningful improvement.

Table 3:

Condition (S-ENG vs CAU) by time interaction in intent to treat analyses

Outcome Mean Differences (SE)a Time by condition interaction
3-weeks 6-weeks 10 weeks
(low) Belonging (INQ) .82 (.75) z = 1.09, p=.276 −.49 (.75) z = −0.65, p=.514 −.79 (.72) z = −1.09, p=.278 chi2(3) = 4.91, p=0.178b
Perceived burden (INQ) −.10 (.39) z = −.27, p=.790 −.16 (.39) z = −.40, p=.689 −.20 (.38) z = −.54, p=.591 chi2(3) = 0.32, p=0.957
Depression (QIDS) −3.16 (.89) z = −3.57, p=.000 −2.21 (.88) z = −2.51, p=.012 −2.47 (.85) z = −2.89, p=.014 chi2(3)= 15.05, p=0.002
Suicide ideation (GSIS) −.60 (.53) z = −1.13, p=.257 −.27 (.52) z = −.51, p=.609 −.34 (.52) z = −.51,p=511 chi2(3)= 1.31, p=0.726b
Social-emotional quality of life (WHOQOL)3 -- -- 5.78 (2.39) z = 2.42, p=.015 chi2(1) = 5.86, p=0.015
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Abbreviations:S-ENG, The Social Engage psychotherapy intervention; CAU, care as usual; SE, standard error; INQ, Interpersonal Needs Questionnaire; QIDS, Quick Inventory of Depressive Symptoms; GSIS, Geriatric Suicide Ideation Scale—Screening Form; WHOQOL (World Health Organization Quality of Life Scale).

Notes:All significance tests are two-sided. Models are mixed effects maximum likelihood regressions, with random intercepts at the subject level and fixed effects for time, condition, and condition by time interaction (depicted above). Models with sex and age were run and results were unchanged, thus, more parsimonious models without those covariates are presented.

a

Mean differences are represented by ENG=1, CAU=0, such that negative means indicate lower scores for ENG.

b

Significant effect of time, with scores decreasing for both groups.

3

WHOQOL was only administered at baseline and 10-week follow-up.

Discussion

Results indicate that S-ENG —a behavioral psychotherapy for social engagement—is feasible to deliver over 10 sessions and acceptable to older adults who report social disconnection—a population at risk for suicide. Participants were willing and able to focus each session on social engagement and demonstrated high levels of compliance. S-ENG was effective in increasing social engagement (via review of session notes and qualitative feedback provided to therapists) but did not impact forms of subjective disconnection hypothesized as target mechanisms —belonging or perceived burden. S-ENG was effective in reducing depressive symptoms and improving social-emotional quality of life. Null effects on belonging and perceived burden should be interpreted with caution given that the trial ended before reaching the target sample size.

Results suggest future directions. First, measuring changes in perceptions of belonging and burden in real-time (via ecological momentary assessment; EMA) may enhance sensitivity by removing difficulties with recall. Assessing social behaviors (as well as perceptions) via objective measures of social engagement in real-time via smartphone technology (e.g., recording conversations and time outside the home) may be a more appropriate and sensitive way to operationalize target engagement for a social engagement intervention. Second, feedback from participants suggests that improvements may unfold over time indicating a longer duration of intervention and follow-up may be needed to document improvement in subjective connection: participants reported increased insight and awareness of the importance of social connection, increased social engagement, and acquisition of skills to manage barriers to social engagement; however, it may take more time (and practice) to build/improve social connections that impact perceptions about social connection (i.e., to feel less lonely and like one belongs). A follow-up trial with booster sessions provided over 6 months and EMA to assess target engagement may provide more precise measurement of targets and a more effective dose of S-ENG. Alternatively, S-ENG may need to be modified given that results from session notes and therapist feedback could be due to social desirability; modifications could involve adding daily self-monitoring of social engagement, such as were employed in a recent trial of behavioral activation to reduce loneliness,75 given that self-monitoring is an effective tool for behavior change. S-ENG may have reduced depressive symptoms and improved social-emotional quality of life through mechanisms other than social connection; thus, alternative mechanisms (e.g., general activation) should be explored. While trials in younger adults demonstrate belonging and perceived burden are sensitive to intervention,76 these characteristics could be less malleable in some populations of older adults, such as those with enduring patterns of maladaptive interpersonal interaction;77 personality dimensions and personality disorders could be investigated as potential moderators of the effect of S-ENG.

The primary limitation was the sample size that was underpowered to detect small changes in target mechanisms and suicide ideation. A larger sample size with both Type I and II error fully addressed is needed. The size of the effect for depression was medium while the effect for social-emotional quality of life was small-to-medium, though future research is needed to confirm a magnitude of change in quality of life perceived by older adults as meaningful in the context of social disconnection. A lack of assessment of social engagement in both groups limited our ability to fully examine this potential target mechanism. Aspects of the study design that increase generalizability to the population of interest—older adults at risk for suicide—also created a heterogenous sample with regards to functioning and contributors to disconnection that may reduce precision for detecting effects. A more homogenous sample with regards to contributors to disconnection (e.g., assisted living, those recently giving up driving, personality characteristics) or severity of suicide risk (i.e., suicide ideation at entry) could be considered to determine whether sub-populations demonstrate clear benefit. Allowing participants to continue mental health treatment increased generalizability but leaves open the possibility that benefit of S-ENG could be due, in part, to adjunctive treatment received by some participants; however, our data suggest that effects were greater when S-ENG was delivered alone, making this possibility unlikely. A future study specifically examining potential benefits of S-ENG as adjunctive care could be useful.

Strengths include focus on a behavioral intervention specifically targeting social disconnection as a means of late-life suicide prevention—an under-studied strategy with the potential to affect numerous domains of health in later life. Our study was designed in an experimental therapeutics approach and grounded in a psychological theory of suicide. Engage has been shown to be easy to learn and provide with fidelity, even by those without mental health degrees,54 making S-ENG suitable for a range of service delivery settings where older adults at risk for suicide present, including primary care clinics and community agencies.

Social connection is essential for health and quality of life at all ages and may be an especially useful intervention target for promoting mental health in later life. While declines in physical, sensory, and cognitive function are common with advancing age—and associated with suicide risk—social functioning remains malleable throughout life. Lifespan developmental theories of socioemotional development suggest that social connections become an even greater priority in later life.78 For those who do not demonstrate aging-related increases in social function, intervening on social connection with S-ENG represents an opportunity to shift developmental trajectories towards improved health, functioning, and well-being. Another application could be to mitigate the effect of other suicide risk factors that may be less malleable: some older adults with declines in physical health and functioning could benefit from S-ENG to assist them in maximally capitalizing on social connection to buffer effects of stressors such as chronic pain, dementia, and loss of independence that increase suicide risk in later life. Identifying the most malleable and potent mechanisms in the relationship between social connection and well-being in later life may lead to refinement of interventions to optimize efficacy and allow tailoring to the needs and preferences of older adults experiencing social disconnection.

Highlights.

  • Primary question addressed: Does Social Engage Psychotherapy reduce social disconnection (target mechanism) and suicide risk factors in later life (depression, suicide ideation, quality of life)?

  • Main Finding: Social Engage did not impact belonging or perceived burden but was effective in reducing depressive symptoms and improving social-emotional quality of life.

  • Meaning of findings: Social Engage holds promise for improving social-emotional quality of life and depressive symptoms. Future research is needed to identify and measure target mechanisms that account for clinical and functional improvement.

Acknowledgements:

The authors want to acknowledge the input of Drs. Tom Campbell, Mark Mapstone, Kevin McCormick, and Chip Reynolds; research staff and Engage therapists, Sybil Prince, Laurel Prothero, Caroline Silva, and Lisa Wholley; Dr. Rebecca Crabb for providing fidelity ratings of Engage sessions; Natalie Mai-Dixon and Holly Murphy for administrative support; Dr. EJ Santos and Laurel Seifert at the UR Medicine Older Adults Clinic and Karen Vitale and the providers of the Greater Rochester Practice-Based Research Network (GR-PBRN) for guidance and support in recruitment.

Funding:

This study was supported by NIMH (K23MH096936, Van Orden, PI) with support from the University of Rochester Clinical and Translational Science Institute (Grant # UL1 TR002001 from the National Institutes of Health).

Footnotes

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Disclosures

The authors have no conflicts of interest to report.

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