Reducing Suicidal Ideation and Depressive Symptoms in Depressed Older Primary Care Patients

TLDR

Suicide rates are highest in late life, and most older adults who die by suicide have seen a primary care physician recently; depression is the strongest risk factor for late‑life suicide and its precursor, suicidal ideation. The study aimed to determine the effect of a primary care intervention on suicidal ideation and depression in older patients. The PROSPECT randomized controlled trial recruited 598 depressed older adults from 20 primary care practices, used age‑stratified screening, and compared tailored care‑management guidelines with usual care, assessing suicidal ideation and depression severity at baseline and at 4, 8, and 12 months. The intervention reduced suicidal ideation faster than usual care, with a 12.9‑point decline at 4 months versus 3.0 points (P=.01) and faster resolution of ideation (70.7% vs 43.9% at 8 months, P=.005); depression symptoms improved more rapidly and to a greater degree in the intervention group, peaking at 4 months, though effects were not significant in minor depression without ideation, demonstrating the intervention’s effectiveness in reducing suicidal ideation regardless of depression severity.

Abstract

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.To determine the effect of a primary care intervention on suicidal ideation and depression in older patients.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.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).Treatment guidelines tailored for the elderly with care management compared with usual care.Assessment of suicidal ideation and depression severity at baseline, 4 months, 8 months, and 12 months.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.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.