by Michael D. Anestis, M.S.
Although suicide can impact individuals of all ages, older adults are at particularly high risk (Heisel & Duberstein, 2005), with Caucasian males over the age of 65 consistently exhibiting the highest rate of death by suicide. Given the increased risk of suicide in this demographic, it is vital that we develop treatments specifically aimed to address the problem rather than relying purely on models that have only been tested on younger samples. That being said, today I would like to discuss a study published in Professional Psychology: Research and Practice by Marnin Heisel, Paul Duberstein, Nancy Talbot, Deborah King, and Xin Tu (2009).
In this study, the authors examined the utility of an adapted form of interpersonal psychotherapy (IPT) in the treatment of older adults at elevated risk for suicide. As we have mentioned before, IPT is an empirically supported treatment for depression, although much of the research on this point has focused on younger samples. Several studies have found that IPT is efficacious in the treatment of depression in older adults (Reynolds et al., 1996, 1999), but these findings have not been universally consistent (e.g., Reynolds et al., 2006). Although some studies have found that IPT is effective in reducing suicidal ideation in older adults (Bruce et al., 2004; Szanto, Mulsant, Houck, Dew, & Reynolds, 2003), Heisel and colleagues (2009) pointed out that, in several of these studies, while ideation was reduced, participants remained actively suicidal. As a result, the authors were interested in adapting IPT to more directly address suicidality in older adults in an effort to see if treatment could be made more effective.
Before getting into details regarding the sample and results, I want to take a moment to point out why a study like this is useful. The authors carefully reviewed prior findings on a particular topic, identified a weakness, hypothesized a way to improve the situation, and directly tested their beliefs empirically. In other words, rather than dismissing IPT for older adults at elevated suicide risk because it is imperfect or adopting another approach (or adaptation of IPT) without any empirical support, the authors held themselves accountable and accumulated evidence capable of measuring whether or not their beliefs are accurate. Additionally, consistent with a developmental model, the authors were careful to recruit from a particular population rather than assuming that results from one sample generalize to other demographics. In the absence of data for a particular group, the best approach is to use data from other samples; however, accumulating data specifically on older adults, particularly given the differential findings for older versus younger adults, was an excellent way to more directly test their hypotheses and ensure that their findings truly reflect their demographic of interest.
Okay, back to the study itself. All participants were at least 60 years of age and had demonstrated suicidal ideation and/or death ideation and/or self-injurious behavior within the past two years. Participants were excluded if they demonstrated cognitive impairment (e.g., dementia), if they had a lifetime history of schizophrenia, or if they had a current substance use diagnosis, as IPT has not been shown to be effective in treating these conditions. The study itself was preliminary in nature, so the sample size was extremely small, with a total of 11 participants completing treatment. In this case, the small sample size makes sense, as they did not want to conduct a large study on an adapted treatment for actively suicidal individuals that did not yet have any empirical evidence supporting its potential utility. Participants received 16 weekly sessions of IPT, with each session lasting 50 to 60 minutes. Each participant was assessed on measures of suicidal ideation, death ideation, and depressive symptoms at pretreatment, mid-treatment (after session 8), posttreatment (after session 16), and at a 3-month follow-up appointment. Much like other empirically supported treatments, this adapted form of IPT was valuable in that it was time-limited, offering an opportunity for individuals to receive treatment over a shorter period of time that is seen in many forms of therapy not supported by scientific evidence (e.g., psychoanalysis).
Heisel and colleagues (2009) presented readers with a summary of the theory of IPT, which centers on the belief that depression and interpersonal relationships impact one another bi-directionally. In other words, bad interpersonal interactions increase depression, which further damages interpersonal interactions, and so on. In this study, IPT was adapted from its standard manualized form such that the therapist more directly focused on suicide risk as it relates to interpersonal interactions (see the actual article for a more in depth description of the alterations to standard protocol). As an example, the authors described a hypothetical therapy session for a client who had self-injured during the previous week. In this scenario, the therapist and client would discuss interpersonal and environmental factors that may have contributed to the self-injury episode, the impact that the behavior had on the participant's family and peers, how this topic was discussed with others, and what happened as a result of those conversations. The therapist and client then would spend time discussing ways in which interpersonal interactions could be enhanced.
Even with the small sample size, the authors reported some interesting and very promising preliminary findings. Suicidal ideation scores began improving immediately after eligibility for the study had been established and before treatment had even begun. Additionally, suicidal ideation and a measure of personal and social worth both significantly improved between eligibility and posttreatment. Death ideation and the measure of loss of personal and social worth both improved between pretreatment and posttreatment, meaning that, during the course of therapy itself, participants improved in these variables. Surprisingly, suicidal ideation scores did not improve during the course of treatment, meaning that while overall improvement was found, all of this improvement occurred prior to the actual onset of therapy. Depression scores improved significantly during the course of treatment, although in the end, scores were still elevated relative to the general population. Given that the reduction in depression symptoms was statistically significant - a difficult feat given the small sample size - the elevated posttreatment symptoms likely reflect the extreme severity of participants' depression at the onset of therapy. At the same time, because there was no control group in this study, we can not rule out the possibility that improvements were actually due to the passage of time rather than the therapy itself.
The authors were very careful to point out that these findings are preliminary. A small sample size tends to lead to what are known as type 2 errors (false negatives), which make it difficult to detect significant effects. The goal of the study was thus to establish that the treatment is promising enough to warrant investigation with a larger sample capable of providing more meaningful results. If participants had shown no improvement or their symptoms had become more severe, the authors would have concluded that it was not a safe option and should not be pursued further.
So what can we take from this study? The best conclusion to draw is that there is reason to believe this adapted form of IPT could be useful in treating older adults with elevated suicide risk. We would need to see stronger results in a larger sample before we could confidently consider it empirically supported, but this was a strong first step. In this sense, the authors performed an extremely valuable service by investigating a potential new approach to helping a demographic at particularly high risk for death by suicide. I look forward to seeing future findings on this matter.
If you would like to learn more about suicide, depression, or interpersonal psychotherapy, we recommend the following resources, all of which are available through our online store:
- Cognitive Therapy of Depression by Aaron Beck, John Rush, Brian Shaw, & Gary Emery
- The Interpersonal Solution to Depression: A Workbook for Changing How You Feel by Changing How You Relate by Jeremy Pettit & Thomas Joiner
- Why People Die by Suicide by Thomas Joiner
- The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients
by Thomas Joiner, Kim Van Orden, Tracy Witte, & David Rudd
- Clinician's Quick Guide to Interpersonal Psychotherapy by Myrna Weissman
- Comprehensive Guide To Interpersonal Psychotherapy by Myrna Weissman