Reducing Suicidal Ideation and Depressive Symptoms in Depressed Older Primary Care Patients: A Randomized Controlled Trial

• Published in: JAMA : the journal of the American Medical Association Vol. 291; no. 9; pp. 1081 - 1091
• Main Authors: Bruce, Martha L, Ten Have, Thomas R, Reynolds III, Charles F, Katz, Ira I, Schulberg, Herbert C, Mulsant, Benoit H, Brown, Gregory K, McAvay, Gail J, Pearson, Jane L, Alexopoulos, George S
• Format: Journal Article
• Language: English
• Published: Chicago, IL American Medical Association 03-03-2004
• Subjects: Adult and adolescent clinical studies; Aged; Aged, 80 and over; Algorithms; Antidepressive Agents - therapeutic use; Biological and medical sciences; Citalopram - therapeutic use; Combined Modality Therapy; Depression; Depression - drug therapy; Depression - therapy; Depressive Disorder - drug therapy; Depressive Disorder - psychology; Depressive Disorder - therapy; Female; Geriatrics; Health Services for the Aged; Humans; Male; Medical sciences; Mental depression; Middle Aged; Miscellaneous; Mood disorders; Older people; Patient Care Management - organization & administration; Patients; Practice Guidelines as Topic; Primary care; Primary Health Care; Psychology. Psychoanalysis. Psychiatry; Psychopathology. Psychiatry; Psychotherapy; Risk Factors; Serotonin Uptake Inhibitors - therapeutic use; Suicide - prevention & control; Suicides & suicide attempts; Human; Mood disorder; Medicine; Prevention; Primary health care; Clinical trial; Depression; Operation; Suicide ideation; Elderly; Public health
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.291.9.1081

CONTEXT Suicide rates are highest in late life; the majority of older adults
who die by suicide have seen a primary care physician in preceding months.
Depression is the strongest risk factor for late-life suicide and for suicide's
precursor, suicidal ideation. OBJECTIVE To determine the effect of a primary care intervention on suicidal ideation
and depression in older patients. DESIGN AND SETTING Randomized controlled trial known as PROSPECT (Prevention of Suicide
in Primary Care Elderly: Collaborative Trial) with patient recruitment from
20 primary care practices in New York City, Philadelphia, and Pittsburgh regions,
May 1999 through August 2001. PARTICIPANTS Two-stage, age-stratified (60-74, ≥75 years) depression screening
of randomly sampled patients; enrollment included patients who screened positive
and a random sample of screened negative patients. This analysis included
patients with a depression diagnosis (N = 598). INTERVENTION Treatment guidelines tailored for the elderly with care management compared
with usual care. MAIN OUTCOME MEASURES Assessment of suicidal ideation and depression severity at baseline,
4 months, 8 months, and 12 months. RESULTS Rates of suicidal ideation declined faster (P =
.01) in intervention patients compared with usual care patients; at 4 months,
in the intervention group, raw rates of suicidal ideation declined 12.9% points
(29.4% to 16.5%) compared with 3.0% points (20.1% to 17.1% in usual care [P = .01]). Among patients reporting suicidal ideation,
resolution of ideation was faster among intervention patients (P = .03); differences peaked at 8 months (70.7% vs 43.9% resolution; P = .005). Intervention patients had a more favorable course
of depression in both degree and speed of symptom reduction; group difference
peaked at 4 months. The effects on depression were not significant among patients
with minor depression unless suicidal ideation was present. CONCLUSIONS Evidence of the intervention's effectiveness in community-based primary
care with a heterogeneous sample of depressed patients introduces new challenges
related to its sustainability and dissemination. The intervention's effectiveness
in reducing suicidal ideation, regardless of depression severity, reinforces
its role as a prevention strategy to reduce risk factors for suicide in late
life.