Advances in Psychiatry

Suicide is among the leading causes of death in adults aged 50 years and older in the United States and rates for middle-aged and older adults have increased from 13.9 per 100,000 in 2000 to 18.30 per 100,000 in 2019. “Suicide in this age group is alarmingly high and the group with the highest suicide rate based on age and sex in men 75 years and older. And we know that the risk for people who have been hospitalized for suicidality increases in the first few weeks after discharge,” says Dimitris N. Kiosses, PhD, Professor of Psychology in Psychiatry at Weill Cornell Medicine.

Dr. Dimitris Kiosses

Despite these sobering statistics, there are few clinical trials on psychosocial interventions for middle-aged and older adults who are hospitalized for suicidality. To address this gap, Dr. Kiosses and colleagues in the Department of Psychiatry at NewYork-Presbyterian/Weill Cornell Medical Center and the Weill Cornell Institute of Geriatric Psychiatry, developed the Cognitive Reappraisal Intervention for Suicide Prevention (CRISP) to reduce suicide risk among middle-aged and older adults in the first three months after hospital discharge. Funded in part by the National Institute of Mental Health, CRISP is a 12-week psychosocial intervention created on the theory that hospitalization for suicidality is preceded by an emotional crisis – “a perfect storm.” This emotional crisis is related to patient- and situation-specific triggers and that: a) identifying these personalized triggers and associated negative emotions and b) providing strategies for an adaptive response will reduce suicidal ideation and improve suicide prevention.

“The theory is that these individuals may go through an emotional storm that they may not be able to deal with,” says Dr. Kiosses. “We believe if we can identify the triggers and the negative emotions that contribute to suicidal ideation and behavior and develop specific techniques to diminish these negative emotions, we may help people reduce their suicide risk.”

Taking the WellPATH

Key to the psychotherapy intervention, the CRISP therapist incorporates environmental aids to help patients outside of the office improve cognitive reappraisal and regulate their emotions during emotionally charged situations. With this in mind, Dr. Kiosses and Dr. David Putrino of the Icahn School of Medicine at Mount Sinai developed the WellPATH tablet application that focuses on cognitive reappraisal strategies to reduce negative emotions.

The WellPATH program is divided into three stages:

Preparation and Practice

Meeting with the patient during their hospitalization, the therapist and patient identify situations, problems, or concerns that prompt the powerful negative emotions and suicidal ideation. They then develop a plan that includes a list of cognitive reappraisal strategies, a video of the therapist highlighting these strategies, and telephone numbers to call if the patient has active suicidal ideation.

Incorporation

The therapist inputs these triggers, negative emotions, and techniques into the app.

Actual Use

The patient takes the tablet home with them to use in emotionally charged situations.

“Even though older adults may have dealt with a lot of stressors in their lives, when specific new stressors occur, they may not be able to cope with them and we don't know why,” says Dr. Kiosses. “If we can identify negative emotions associated with these emotional storms and then develop specific cognitive reappraisal techniques, we can change the perspective of how the person views things in order to reduce negative emotions.”

As one example, a patient may identify “spouse criticism” as the trigger, and “worthlessness” as the negative emotion associated with the trigger. The therapist and the patient then develop specific text or video strategies to help the patient reduce the feeling of worthlessness and incorporate these strategies into WellPATH. When the patient is faced with this specific negative emotion, and during scheduled reminders, he or she uses the app to access and utilize the pre-planned strategies.

“We identify the emotional storms that the patients faced before hospitalization and we explore potential storms that they may face after their discharge,” says Dr. Kiosses. “When they are back home after their discharge and they experience these negative emotions, they go to the tablet, find the negative emotion that they’re experiencing, find the trigger for this negative emotion, and then start reading or watching the techniques. We then measure the intensity of negative emotions before and after the use of techniques.”

Dr. Kiosses and the Weill Cornell Medicine researchers tested the feasibility and acceptability of the WellPATH app as part of the CRISP intervention in a small study of 12 patients after a suicide-related hospitalization. The patients were significantly depressed at admission and still depressed at discharge. The study findings published in the May 2022 issue of the American Journal of Geriatric Psychiatry showed that all the patients used WellPATH and remained in the study throughout the 12 weeks without any suicide attempt or rehospitalization. Study participants and therapists reported high satisfaction with WellPATH and provided feedback for future research and development. The article includes two case studies in which the patients also described a reduction in negative emotions and an increase in emotion regulation. Based on these results, Dr. Kiosses has received funding for another NIH study to evaluate WellPATH app as a stand-alone intervention and test its engagement with cognitive reappraisal in 40 middle-aged and older adults (50-90 years old) after a suicide-related hospitalization.

Dr. Kiosses believes that patients can benefit from the WellPATH app techniques by using them regularly rather than just when they are facing an emotional crisis. “Even though they aren’t going through the emotional storm, they may be better prepared to deal with it when it comes, if they have practiced the techniques during scheduled practice sessions,” he says. “If we find that this mobile, psychosocial intervention is effective, we may be able to transfer it to other populations, such as adolescents who may be more technology savvy, or to populations with milder forms of suicidal ideation.”

“We have seen many people dying from suicide. It’s devastating for families and for the community,” adds Dr. Kiosses. “We know that some people in the beginning of the day may not even know that they will try to kill themselves in the evening. So, we will continue to try to understand what triggers a suicide attempt, and to arm patients with the tools to prevent them from taking that step.”