Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial.
BACKGROUND
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.


METHODS
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.


METHODS
Two-stage, age-stratified (60-74, > or =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).


METHODS
Treatment guidelines tailored for the elderly with care management compared with usual care.


METHODS
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.
Department of Psychiatry, Weill Medical College of Cornell University, White Plains, NY, USA.
Martha L
ML
Bruce
Thomas R
TR
Ten Have
Charles F
CF
Reynolds
Ira I
II
Katz
Herbert C
HC
Schulberg
Benoit H
BH
Mulsant
Gregory K
GK
Brown
Gail J
GJ
McAvay
Jane L
JL
Pearson
George S
GS
Alexopoulos
D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000928:Antidepressive Agents / Q000627:therapeutic use; D015283:Citalopram / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D003863:Depression / Q000188:drug therapy / Q000628:therapy; D003866:Depressive Disorder / Q000188:drug therapy / Q000523:psychology / Q000628:therapy*; D005260:Female; D006299:Health Services for the Aged; D006801:Humans; D008297:Male; D008875:Middle Aged; D010346:Patient Care Management / Q000458:organization & administration; D017410:Practice Guidelines as Topic; D011320:Primary Health Care; D011613:Psychotherapy; D012307:Risk Factors; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use*; D000092864:Suicide Prevention
D000928:Antidepressive Agents; D015283:Citalopram; D017367:Selective Serotonin Reuptake Inhibitors