Older Americans comprise about 13 percent of the U.S. population, yet account for 18 percent of all suicide deaths, according to background information in the article. Depression is the strongest risk factor for late-life suicide and for suicide's precursor, suicidal ideation (thoughts of suicide). The majority of older adults who die by suicide have seen a primary care physician in preceding months. Recent national reports emphasize the public health need for intervention trials to reduce the risk for suicide in late life.
Martha L. Bruce, Ph.D., M.P.H., of Weill Medical College of Cornell University, White Plains, N.Y., and colleagues conducted a study to test the impact of a primary care-based intervention on reducing depression and major risk factors for suicide in older patients. The randomized trial, known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial), was conducted at 20 primary care practices in New York City, Philadelphia, and Pittsburgh regions, May 1999 through August 2001. The trial included a two-stage, age-stratified (60-74; 75 years and older) 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).
The intervention focused on two major components of care. First was physician knowledge, addressed by a clinical algorithm for treating geriatric depression in a primary care setting. The second was treatment management, put into practice by depression care managers. The intervention was compared with usual care after the physicians were educated about treatment guidelines and notified when a patient had a depression diagnosis.
The researchers found that in the intervention group, over two-thirds of patients expressing suicidal ideation were no longer suicidal at 4 months, an improvement rate resembling that observed among specialty mental health patients in an academic-based clinic.
"... the multisite PROSPECT demonstrated that an intervention consisting of guideline treatment managed by a master's-level clinician is both feasible and effective in significantly reducing [and resolving more quickly] suicidal ideation in geriatric patients suffering depression in primary care. The intervention was also effective in reducing depressive symptoms in patients with major depression and, when suicidal ideation was present, minor depression. Together, these findings indicate that efforts to improve the quality of depression treatment for geriatric primary care patients can focus on patients with suicidal ideation or major depression with the expectation that appropriate management will reduce depressive symptoms, suicidal ideation, and the risk of suicide in late life," the authors write. (JAMA. 2004;291:1081-1091. Available post-embargo at JAMA.com.)
Editor's Note: For information on the funding of the study and the financial disclosures of the author's, please see the JAMA article.