| BackgroundSuicide is a a significant public health issue around the world.Suicidal ideation refers to thoughts of killing oneself,ranging from a vague idea about dying to a specific suicide plan,and it is an essential predictor of suicidal behavior.Evidence shows that the suicide rate is much higher in older adults than that in young adults in most countries.As compared to community dwellers,nursing home residents exhibited more risk factors of suicidal ideation.Thus,suicide prevention for nursing homes faces severe challenges.Presently,most studies focused on the risk factors of late-life suicidal ideation;however,the protective factors and their potential mechanisms are rarely reported.Thus,mainstream suicide interventions are based on monitoring and eliminating the risk factors of suicide.Evidence shows that physical function limitations and depressive symptoms are two key risk factors for suicidal ideation among nursing home residents.According to the developmental psychopathology model of suicidal ideation as well as previous studies,physical function limitations can induce suicidal ideation through the mediation of depression.However,as an irreversible factor related to aging,physical dysfunction poses a challenge for suicide intervention which focuses on eliminating risk factors,making it necessary to explore the protective factors of suicidal ideation among nursing home residents and conduct suicide interventions from the perspective of protective factors.Resilience is a significant protective factor for suicidal ideation,which refers to an individual's process of adapting to adversities quickly or "bouncing back" from adversity,trauma,misfortune,threats,or significant stressors.The buffering model of resilience emphasizes that resilience plays a moderating role in the relationship between risk factors and adverse outcomes,which is the mechanism of resilience as a protective factor of suicide.Meanwhile,individuals' resilience can be improved through training interventions.Previous studies have found that resilience training has a good effect on suicide prevention.Different with the interventions of controlling risk factors,resilience training is a positive psychological intervention,which targets to stimulate individuals' internal strength and positive qualities,thus to reduce suicidal ideation and maintain mental health.However,the researches on the relationship between resilience and suicidal ideation,as well as the application of resilience intervention in suicide prevention,are mainly conducted among children,teenagers,college students and psychiatry patients.An intervention system suitable for Chinese nursing home residents has not yet been created.The resilience framework theory emphasizes that the development of resilience is comprehensively affected by three aspects-individual internal factors,external environmental factors,and the interaction between individuals and the environment Given the particularity of nursing home residents in individual characteristics and eternal environment,it is necessary to explore the protective effect of resilience on suicidal ideation among nursing home residents,to build a resilience-centered intervention program for them,and to verify the effect of resilience intervention on reducing suicidal ideation,thus to provide theoretical and practical guidance for suicide prevention in nursing homes.Objectives1.To explore the prevalence and associated factors of suicidal ideation among nursing home residents;2.To explore the relationship between resilience and suicidal ideation among nursing home residents and investigate whether resilience plays a moderating role in the relationship of key risk factors(limitations of physical function,depressive symptoms)and suicidal ideation based on the buffering model of resilience;3.To construct a resilience-centered intervention program for nursing home residents with suicidal ideation according to the resilience framework theory;4.To evaluate the effect of the resilience intervention program on reducing suicidal ideation and depressive symptoms,and improving resilience among nursing home residents;and to verify the target of the intervention program.MethodsThis study consists of three parts:The first part was a cross-sectional study that selected participants from 37 nursing homes in Jinan,Shandong Province,using two-stage cluster sampling from September 2018 to April 2019.The socio-demographic questionnaire,the questionnaire for the number of physical diseases,Mini-Mental State Examination(MMSE),Multidimensional Scale of Perceived Social Support(MSPSS),Beck Suicidal Ideation Inventory-Chinese Version(BSI-CV),Activities of Daily Living(ADL)Scale,Hospital Depression Scale(HDS),and the 10-item Conner-Davidson Resilience Scale(CD-RISC-10)were used to assess the participants,socio-demographic characteristics,numbers of physical diseases,cognitive function,perceived social support,suicidal ideation,physical function,depressive symptoms,and resilience,respectively.Descriptive analyses,univariate analyses and multiple logistic regression analyses were conducted by SPSS 22.0.A two-tailed p-value of<0.05 was defined as being statistically significant A moderated mediation model was constructed with suicidal ideation as the dependent variable,physical dysfunction as the independent variable,depressive symptoms as the mediating variable,and resilience as the moderating variable.Moderated mediating effect was analyzed using PROCESS macro through a 5000 re-samples bootstrapping within the 95%conditional interval(CI),and the 95%CI of interaction terms without 0 suggested the effect was significant.The second part was the intervention construction.First,using literature review and brainstorming methods to select appropriate intervention strategies and techniques and design specific intervention contents,forms,and doses.Then,the experts' consultation method was adopted to revise the draft intervention program and 11 experts were contacted via email.The questionnaire consisted of five parts-the introduction of the consultation content,experts'basic information,evaluation of the specific content of the intervention program,overall evaluation of the intervention progran,and experts' authority.Descriptive analyses by SPSS 22.0 were used to report the experts' characteristics and their opinions.The third part—the effect of resilience intervention on suicidal ideation in nursing home residents—was a randomized controlled trial(RCT).Among the 80 nursing home residents with suicidal ideation identified by the cross-sectional study,68 residents fulfilled the inclusion criteria and were willing to participate the intervention study.Participants were randomly assigned to the intervention(n=34)and control(n=34)groups.The intervention group received the resilience intervention program,while the control group received resilience-free health education with the same length and frequency as intervention group.Participants' suicidal ideation(primary outcome variable),depressive symptoms(secondary outcome variable),and resilience(target variable)were measured at baseline(T1),after the intervention(T2),and a month after the intervention(T3)using BSI-CV,HDS,and CD-RISC-10.Generalized Estimated Equation(GEE)of SPSS 22.0 software was used to examine the intervention program's effect on each variable.The intervention's target was then tested according to Baron and Kenny's sequential test analysis,i.e.to test whether the intervention effects on alleviating suicidal ideation and depressive symptoms were caused by resilience improvement All analyses used Intention-to-Treat Analysis(ITT),and statistical significance was defined as a two-tailed p-value of<0.05.ResultsThis study consists of three parts:1.The results of the first part:(1)A total of 538 residents living in 37 nursing homes were recruited;321(59.7%)were females and 217(40.3%)were males,with a mean age of 78.13±8.72 years(from 60-99 years).Among them,80 older adults(14.9%)had suicidal ideation in the past week.The mean score of the ADL Scale was 27.03±11.64.According to a cutoff point of 14,the older adults with physical dysfunction accounted for 82.0%,resulting in a mild disability rate of 23.6%,and a severe rate of 58.4%.The mean score of depressive symptoms was 5.21±4.31.According to a cutoff point of 7,the prevalence of depression was 24.5%.The mean score of resilience was 27.61±8.27.(2)The comparisons of characteristics between participants with and without suicidal ideation showed that female(?2=10.740,p=0.001),divorced,widowed or unmarried(?2=4.096,p=0.043),poor self-rated financial status(?2-18.815,p<0.001),and participants with an attempted suicide history(?2=21.097,p<0.001)or more physical diseases(t=2.817,p=0.006)were more likely to have suicidal ideation.The group with suicidal ideation had higher scores on the physical function limitations(t=10.294),and depressive symptoms(t=10.152),and lower scores in cognitive function(t=3.943),perceived social support(t=4.942)and resilience(t=11.081)when compared with the group without suicidal ideation(p<0.001).(3)The results of multiple logistic regression showed that limitations of physical function(OR=1.177,95%CI=[1.082,1.280])and depressive symptoms(OR=1.177,95%CI=[1.082,1.280])were risk factors for suicidal ideation,while resilience was a protective factor of suicidal ideation(OR=0.900,95%CI=[0.859,0.943]).The regression model accounted for 52.0%of the total variation in suicidal ideation(Nagelkerke R2=0.520).(4)Results of the moderated mediating model(with suicidal ideation as the dependent variable,physical dysfunction as the independent variable,depressive symptoms as the mediating variable,and resilience as the moderating variable)indicated that:1)The direct effect of physical function limitations on suicidal ideation was significant(B=0.190,95%CI=[0.113,0.268]),the effect of physical function limitations on depressive symptoms was significant(B=0.158,95%CI=[0.080,0.235]),the effect of depressive symptoms on suicidal ideation was significant(B=0.199,95%CI=[0.109,0.289]),i.e.the path of"limitations on physical function—depressive symptoms—suicidal ideation" was significant.2)Resilience was negatively related to suicidal idearion(B=-0,158,95%CI=[-0.246,-0.069]),and depressive symptoms(B=-0.383,95%CI=[-0.466-0.301]).3)Resilience alleviated the development from physical function limitations to depressive symptoms,then to suicidal ideation,through significant moderating effect:Firstly,resilience significantly moderated the direct path from physical function limitations to suicidal ideation(B=-0.140,95%CI=[-0.211,-0.068]).Secondly,resilience significantly moderated the path from the physical function limitations to depressive symptoms(B=-0.120,95%CI=[-0.185,-0.054]).Thirdly,resilience significantly moderated the path from depressive symptoms to suicidal ideation(B=-0.089,95%CI=[-0.152,-0.027]).2.The results of the second part:The resilience intervention strategies of "I have,I am,I can," consistent with the resilience framework theory's connotation,were selected through literature review to construct the resilience-centered intervention program.For program revision,11 experts were invited.The response rate was 100%,the judgment coefficient was 0.94(0.8-1.0),the familiarity was 0.81(0.5-1.0),and the authority coefficient was 0.87(0.75-1.0).The resilience intervention program was recognized by experts through two rounds of written consultation.This eight-week program consisted of a one-on-one,face-to-face,60-90 minutes intervention session once a week.The five stages of this program were-First,a one-week confidence-building phase;second,resilience core training through the "I have" strategy,which contained two themes named "2.1 Finding what I have" and "2.2 Gratitude for what I have";third,resilience training using the "I am" strategy;with two themes,namely "3.1 Exploring Advantages" and "3.2 Using Advantages";fourth,using the "I can" strategy to implement resilience core training,including two themes of "4.1 Acceptance of Stress" and"4.2 Relieving Stress" Each theme had a duration of one week,with the second,third,and fourth stages completed in six weeks in total.The fifth stage was the summary stage,lasting for one week.3.The results of the third part:(1)Of 68 randomized participants who completed the assessment at baseline(T1),64 completed it at T2,with a loss rate of 5.88%.Eventually,a total of 61 older adults finished the investigation in the follow-up at T3.There was no statistical difference in basic characteristics and the scores of suicidal ideation,depressive symptoms and resilience between the lost and completed samples(p>0.05).In all,68 participants were randomly assigned to the intervention group(n=34)and control group(n=34).There were no statistical differences between the groups in basic characteristics and the scores of suicidal ideation,depressive symptoms and resilience(p>0.05).(2)GEE analysis was used to examine the effect of the intervention on suicidal ideation.The results showed that the main effect of time was statistically significant(p<0.001),indicating the suicidal ideation scores in both groups changed over time.The interaction effect of group× time was statistically significant(p=0.002),indicating the differences in the variation trend in suicidal ideation scores between the intervention and control groups at three time points.The parameter estimation results showed that the time effects and the interaction effects of group × time at T2 and T3 were statistically significant(p<0.05).A paired comparison of the estimated marginal mean results showed that,in the intervention group,the suicidal ideation scores at T2 and T3 were both lower than that at T1(T2:Mean difference=-7.238,Cohen's d=0.80;and T3:Mean difference=-6.598,Cohen's d=0.75),but the suicidal ideation score at T3 was higher than that at T2(Mean difference=0.640,Cohen's d=0.06).As for the control group,the suicidal ideation scores at T2 and T3 were both lower than that at T1(T2:Mean difference=-2.851,Cohen's d=0.35;and T3:Mean difference=-2.015,Cohen's d=0.20),whereas the scores of T3 were higher than that of T2(Mean difference=0.836,Cohen's d=0.16).(3)The effect of the intervention on depressive symptoms was tested by GEE analysis.The results showed that the main effect of time was statistically significant(p<0.001),indicating the scores of depressive symptoms in the two groups changed over time.The interaction effect of group × time was statistically significant(p=0.009),indicating the differences in the variation trend in depressive symptoms scores between the intervention and control groups at three time points.The parameter estimation results showed that the time effects at T2 and T3 and interaction effects of group × time at T2 were statistically significant(p<0.05),while the interaction effects of group × time at T3 were not significant(p=0.074).A paired comparison of the estimated marginal mean results showed that,in the intervention group,the depressive symptoms scores at T2 and T3 were both lower than that at T1(T2:Mean difference=-3.522,Cohen's d=0.71;and T3:Mean difference=-2.472,Cohen's d=0.54).As for the control group,the scores of depressive symptoms at T2 and T3 were both lower than that at T1(T2:Mean difference=-1.519,Cohen's d=0.44;and T3:Mean difference=-1.168,Cohen's d=0.36).Inter-group comparison results showed that the depressive symptoms scores of the intervention group were lower than the control group at T2(Mean difference=-2.768,Cohen's d=0.55).(4)The effect of the intervention on resilience was tested by GEE analysis.The results showed that the main effect of time was statistically significant(p<0.001),indicating the scores of resilience in the two groups changed over time.The interaction effect of group × time was statistically significant(p<0.001),indicating the differences in the variation trend in resilience scores between the intervention and control groups at three time points.The parameter estimation results showed that the time effects and the interaction effects of group × time at T2 and T3 were both statistically significant(p<0.01).A paired comparison of the estimated marginal mean results showed that,in the intervention group,the resilience scores at T2 and T3 were both higher than that at T1(T2:Mean difference=7.635,Cohen's d=0.79;and T3:Mean difference=6.499,Cohen's d=0.70),whereas the scores of T3 were lower than those of T2(Mean difference=-1.136,p=0.025).As for the control group,the resilience scores at T2 and T3 were both higher than that at T1(T2:Mean difference=1.594,Cohen's d=0.23;and T3:Mean difference=1.100,Cohen's d=0.13).Inter-group comparison results showed that the resilience scores of the intervention group were higher than the control group at T2(Mean difference=6.217,Cohen's d=0.63)and T3(Mean difference=5.575,Cohen's d=0.62).(5)The target of the intervention program was was tested by GEE analysis.(1)For the suicidal ideation as the outcome variable,concerning of the groups,time,group × time,and resilience simultaneously,the effect of resilience on suicidal ideation was significant(B=-0.347,SE=0.099,95%CI:[-0.540,-0.154],p<0.001),while the effect of group × time(i.e.,the direct effect of the intervention on suicidal ideation)was no longer significant(p=0.099),revealing the intervention effect on suicidal ideation was caused by the change of resilience.(2)For the depressive symptoms as the outcome variable,concerning the groups,time,group ×time,and resilience on depressive symptoms simultaneously,resilience was found to have a significant effect on depressive symptoms(B=-0.292,SE=0.051,95%CI=[-0.393,-0.192],p<0.001),while the effect of group × time(i.e.,the direct effect of the intervention on depressive symptoms)was no longer significant(p=0.691),revealing the intervention effect on depressive symptoms was caused by resilience improvement.Conclusion1.Suicidal ideation is especially severe in nursing home residents.2.Resilience is an essential protective factor of suicidal ideation among nursing home residents.On one hand,the direct effect of resilience on suicidal ideation is significant On the other hand,resilience protects nursing home residents from suicidal ideation through the buffering effect,which alleviates the effect of physical function limitations and depressive symptoms on suicidal ideation.3.Based on the resilience framework theory and the intervention strategy of "I have,I am,I can",a resilience intervention program was constructed for nursing home residents with suicidal ideation.The intervention program was revised by the experts' consultation method,and the formal version of intervention program was recognized by experts.4.The resilience-centered intervention program had a significant effect on alleviating nursing home residents' suicidal ideation and depressive symptoms and improving their resilience.Furthermore,the effects on alleviating suicidal ideation and depressive symptoms were caused by resilience improvement.Significance1.This study explored the protective effect and mechanism of resilience on suicidal ideation among nursing home residents,which provides theoretical basis for nursing home suicide prevention through the perspective of resilience,and is of great theoretical value.2.This study changed the focus of suicide prevention from controlling risk factors to stimulating protective factors and explored how to mobilize older adults' internal strength to counteract suicidal ideation,which expands the connotation of the crisis intervention in older adults.3.This study constructed a resilience-centered intervention program for nursing home residents with suicidal ideation,and tested the effects of the intervention through randomized control trials,which provided essential theoretical and practical guidance for suicide prevention among nursing home residents. |
PDF Full Text Request