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

Martha L Bruce, Thomas R Ten Have, Charles F Reynolds, Ira I Katz, Herbert C Schulberg, Benoit H Mulsant, Gregory K Brown, Gail J McAvay, Jane L Pearson, George S Alexopoulos
JAMA 2004 March 3, 291 (9): 1081-91

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, > 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).

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.

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