Older Americans comprise 13 percent of the population but account for 18 percent of all suicides. The major risk factor for suicide in late life is major depression.
"Since most older Americans who kill themselves have seen their doctor within a month of the event, effectively treating depression in primary care is a preventive intervention that can save lives," noted NIMH Director Thomas Insel, M.D.
Reynolds and colleagues set out to demonstrate that by educating physicians and improving treatment up to guideline standards, a social worker, nurse or masters-level psychologist assigned to assist in depression management can significantly improve clinical outcomes. The "depression care managers" were assigned to 10 randomly selected primary care practices in greater Philadelphia, Pittsburgh and New York City. Each practice was paired with a similar practice, which served as a control by providing its "usual care" in the study, called PROSPECT (Prevention of Suicide in Primary care Elderly: Collaborative Trial).
In initial screenings over two years, about 12 percent of the primary care patients tested positive for depression. From these, 598, mostly females and two-thirds with major depression, were recruited into the study.
The care managers applied structured treatment guidelines: First, they offered patients the serotonin selective reuptake inhibitor (SSRI) or another antidepressant if clinically warranted. If a patient didn't want medication treatment, the doctor could recommend Interpersonal Psychotherapy (IPT) from the care manager, who was supervised weekly by a psychiatrist investigator. Occasionally, patients received combination treatment. The care managers actively followed up the patients, monitoring their symptoms, drug side effects and treatment adherence.
Suicidal thinking resolved more quickly in patients who received the intervention. Also, intervention patients had a more favorable course of depression, as measured by severity of symptoms, rate of treatment response and remissions. For example, at eight months, about 70 percent of intervention patients initially plagued by suicidal thoughts were free of them, compared to about 44 percent of "usual care" patients. Although the intervention didn't lift depression symptoms in patients with minor depression any more than usual care, it did significantly decrease suicidal thoughts in those who had them. Suicide itself occurs too infrequently in primary care for the study to have measured any impact on actual suicide rates, note the researchers.
"Without such structured, formal screening and diagnostic procedures, patients are less likely to volunteer information, accept a diagnosis of depression or initiate treatment," explained Reynolds. "Our finding in an elderly population adds to evidence from other studies that structured interventions can improve the quality of depression care in primary care."
The results of PROSPECT indicate that quality treatment of depression in primary care can be a prevention strategy to reduce the risk for suicide in late life.
Other researchers participating in the PROSPECT study are: Herbert Schulberg, Ph.D., Gail McAvay, Ph.D., George Alexopoulos, M.D., Cornell University; Thomas Have, Ph.D., Ira Katz, M.D., Ph.D., Gregory Brown, Ph.D., University of Pennsylvania; Benoit Mulsant, M.D., University of Pittsburgh; Jane Pearson, Ph.D., NIMH.
NIMH is part of the National Institutes of Health (NIH), the Federal Government's primary agency for biomedical and behavioral research. NIH is a component of the U.S. Department of Health and Human Services.
Journal
JAMA