Reducing suicidal ideation and depressive symptoms in depressed older primary care patients - A randomized controlled trial

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, greater than or equal to75 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.