Bruce ML, Ten Have TR, Reynolds III CF, Katz II, Schulberg HC, Mulsant BH, Brown GK, McAvay GJ, Pearson JL, Alexopoulos GS. Reducing Suicidal Ideation and Depressive Symptoms in Depressed Older Primary Care PatientsA Randomized Controlled Trial. JAMA. 2004;291(9):1081-1091. doi:10.1001/jama.291.9.1081
Author Affiliations: Department of Psychiatry, Weill Medical College of Cornell University, White Plains, NY (Drs Bruce, Schulberg, McAvay, and Alexopoulos); Center for Clinical Epidemiology and Biostatistics (Dr Ten Have) and Department of Psychiatry (Drs Katz and Brown), University of Pennsylvania, Philadelphia; Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pa (Drs Reynolds and Mulsant); Mental Illness Research Education and Clinical Center, Philadelphia VA Medical Center, Philadelphia, Pa (Dr Katz); Geriatric Research, Education and Clinical Center, VA Pittsburgh Health Care System, Pittsburgh, Pa (Dr Mulsant); and Division of Interventions and Services Research, National Institute of Mental Health, Bethesda, Md (Dr Pearson). Dr McAvay is now with Qualidigm, Middletown, Conn.
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, ≥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
Older Americans comprise about 13% of the US population, yet account
for 18% of all suicide deaths.1 Among adults
who attempt suicide, the elderly are most likely to die as a result.2 Recent national reports emphasize the public health
need for intervention trials to reduce the risk for suicide in late life.3,4
This article presents initial outcomes from the multisite, randomized
trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative
Trial). PROSPECT tested the impact of a primary care–based intervention
on reducing major risk factors for suicide in late life. Primary care practices
were important to study because the majority of older adults who die by suicide
have seen their physician within months of their death.5,6
PROSPECT approached suicide risk reduction from a public health perspective
by targeting factors that are strongly related to suicide risk, common in
primary care, and malleable.7 Depression is
the principal risk factor for suicide in late life and for suicide's clinical
precursor, suicidal ideation.2,8- 14 Although
not all older depressed patients are suicidal, the great majority of older
patients who report suicidal ideation or who die by suicide experience depression.
Late-life depression is common in primary care, with the prevalence of major
depression estimated at 6% to 9% of older patients in primary care settings.15- 17 Milder depressive
symptomatology affects an additional 17% to 37%.18 Similarly,
more than 7% of older primary care patients report some suicidal ideation,19,20 with the prevalence rising above
30% for patients with major depression.15,21
Despite the availability of efficacious pharmacological and psychosocial
treatments22,23 and a consensus
for primary care depression treatment guidelines,24,25 late-life
depression frequently remains improperly diagnosed and inadequately treated.22,26 Antidepressants are increasingly
prescribed, yet depression pharmacotherapy often remains inadequate because
of insufficient dosing and premature discontinuation by the physician as well
as poor patient adherence.27- 30
This disparity between knowledge and practice has stimulated interventions
to reduce this gap. Examples include training physicians in assessment and
treatment,31- 33 creating
professional roles to facilitate care,34 introducing
technologies to enhance clinical decision making,35 and
integrating depression management with care of other illnesses.36- 39
PROSPECT's intervention combined treatment guidelines tailored for the
elderly with care management. The study's relevance to routine practice included
(1) participation of community-based practices serving diverse populations
and (2) random sampling and screening techniques to increase the representativeness
of enrolled patients.
PROSPECT hypothesized that in a heterogeneous sample of older, depressed
primary care patients, patients recruited from practices randomized to receive
the intervention compared with usual care would demonstrate the following
over 4, 8, and 12 months: (1) greater reduction in suicidal ideation and (2)
greater reduction in depressive symptoms, increased response rates, and greater
remission rates in depressive symptoms.
Intervention. The PROSPECT intervention focused
on 2 major components of care. First is physician knowledge, addressed by
a clinical algorithm for treating geriatric depression in a primary care setting.40 Second is treatment management, operationalized by
depression care managers. Consistent with the predominant use of antidepressants
relative to psychotherapy in primary care, the algorithm recommended a first-line
trial of a selective serotonin reuptake inhibitor (SSRI). The protocol specified
citalopram because it is equally efficacious with other antidepressants, has
limited drug interactions, low potential for central nervous system activation,
and an insignificant withdrawal syndrome. Physicians could prescribe other
antidepressants if they had a clinical reason to do so. When a patient declined
medication therapy, the physician could recommend interpersonal psychotherapy41 from the care manager. The guidelines covered acute,
continuation, and maintenance phase treatment over the course of the study
year. Research funds covered the cost of interpersonal psychotherapy and citalopram,
which was dispensed by the care manager, but not other treatments. This decision
to structure treatment choices and to pay for the recommended ones limits
analyses of patient preferences or cost barriers. However, it does permit
testing outcomes achieved by specified treatments with known efficacy.
Practice-based, depression care managers collaborated with physicians
by helping them recognize depression, offering guideline-based treatment recommendations,
monitoring clinical status, and providing appropriate follow-up. The 15 depression
care managers included trained social workers, nurses, and psychologists.
They had psychiatric backup, weekly supervision by psychiatrist investigators,
and monthly interpersonal therapy cross-site supervision. Research associates
introduced the depression care manager to patients directly following the
baseline interview. The depression care manager interacted with patients in
person or by telephone at scheduled intervals, or when clinically necessary,
to monitor depressive symptoms, medication adverse effects, and treatment
Usual Care. The comparison condition was usual
care enhanced by initially educating physicians about the treatment guidelines
and notifying them when a patient met criteria for depression diagnosis. These
enhancements protected patients and focused the study on depression treatment
and management rather than recognition. The study did not pay for treatment
in usual care.
In both intervention and usual care, physicians were informed by letter
when patients reported suicidal ideation. PROSPECT had risk management guidelines
for patients identified at high suicide risk during research or clinical assessments.42 In these cases, physicians were notified immediately.
The research protocol received full review and approval from the institutional
review board of each of the 3 universities. Written informed consent was obtained
for all participants.
Population and Randomization. The study was
conducted in 20 primary care practices from greater New York City, Philadelphia,
and Pittsburgh. Practices varied in size (solo to medium sized), setting (rural,
suburban, and urban), population type (including 2 serving primarily African
American patients), and affiliation (16 community-based and 4 academic practices).
As the intervention located depression care managers on-site, the study
chose a practice-randomization design to reduce potential contamination bias.
Arguably, such "bias" is an intended effect of the intervention, which aims
to influence routine care. Practices were paired by region (urban vs suburban/rural),
affiliation, size, and population type. Within the 10 pairs, practices were
randomly assigned by flip of a coin to intervention or usual care.
Recruitment Procedures. Patients were recruited
using a 2-stage sampling design.43 The study
drew an age-stratified (60-74, ≥75 years), random sample of patients with
an upcoming appointment. Physicians notified sampled patients by mail allowing
patients to decline contact. Research associates telephoned the remaining
sample to confirm study eligibility: age 60 years or older, ability to give
informed consent, Mini-Mental State Examination (MMSE) score44 of
18 or higher, and ability to communicate in English. With oral consent, eligible
patients were screened for depression using the Centers for Epidemiologic
Studies Depression scale (CES-D).45
The study invited all patients with a CES-D score higher than 2046 as well as a 5% random sample of patients with lower
scores to enroll in the research protocol. The purpose of the 5% sample was
to assess for "false-negative" cases of screened depression. To increase the
screen's sensitivity, patients scoring 20 or lower and not selected randomly
were recruited if they responded positively to supplemental questions about
prior depressive episodes or treatment. Suicidal ideation was not included
in eligibility criteria. Eligible patients met at the practice with research
associates who, with signed consent, administered an in-person interview.47 These patients received telephone assessments at
4 and 8 months and an in-person interview at 12 months. All assessments were
conducted independent from the treating clinicians.
Enrollment Statistics. Over approximately 2
years (May 1999-August 2001), the study sampled 78.9% (N = 16 708) of
patients 60 years or older with upcoming appointments (Figure 1). Of sampled patients, the study screened 9072 (54.3%);
10.5% could not be contacted, 7.8% were not eligible, and 27.4% refused. Patients
who completed the screen were more likely to be female (65.6% vs 63.9, P = .005) and older (74.9 vs 72.7 years, P<.001).
Of patients administered the CES-D, 1061 (11.7%) screened positive for
depression. An additional 827 patients screened negative but were chosen by
random (505 [5.6%]) or supplemental questioning (322 [3.5%]). Of the 1888
eligible patients, 1238 (65.6%) agreed to a baseline interview. Enrolled patients
did not differ from patients who refused by CES-D scores but were more likely
to be female (74.1% vs 70.1%, P = .09) and older
(74.1 vs 72.7 years, P = .01).
This report focuses on patients targeted by the intervention: those
with major depression48 or clinically significant
minor depression as defined by Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV) research criteria for minor depressive disorder48(pp721-721) modified by requiring 4 depressive symptoms, Hamilton Depression
Rating Scale (HDRS) score 10 or higher, and duration of at least 4 weeks.49 This depressed cohort included 598 patients (320
intervention; 278 usual care), including 47 recruited by random selection
and 109 from supplemental questions.
Depression diagnoses were determined by research associates (PhD, MA,
or experienced BA) trained in administering the Structured
Clinical Interview for Axis I DSM-IV Disorders50 and
by study psychiatrists who reviewed symptoms. The 24-item HDRS51 measured
depression severity. The Scale for Suicidal Ideation (SSI) measured presence
and intensity of suicidal ideation. As the SSI was highly skewed, it was dichotomized
at 0 vs greater than 0 to indicate any current suicidal ideation.52 The inter-rater reliability (intraclass correlation
coefficient under a random effects model [ICCRAND])53 of
assessors across the 3 study sites was 0.97 for the HDRS, 0.92 for major depression,
and 0.96 for the SSI score. Reliability was monitored regularly to prevent
Dropout over 12 months was 30.9% (99/320) and 31.3% (87/278) for the
intervention and usual care groups, respectively. Using a discrete time survival
model,54 dropout rates differed across all
3 follow-up visits (P = .04), with a significant
difference at 4 months (P = .04) but not at 8 (P = .10) or 12 months (P = .30).
We assessed the influence of group differences in dropout rates by comparing
results from our analysis (below) to results under the shared parameter model,
which explicitly adjusts for such differences.55 The
2 sets of models produced very similar results: treatment effects did not
differ by more than 5%, and P values were more significant.
The proportion of subjects with missed visits was very similar between groups;
differences did not exceed 2.5% points for any visit (P>.20).
The statistical analyses consisted of descriptive and intent-to-treat
(ITT) modeling procedures. Descriptive statistics included means and SDs for
continuous outcomes and percentages for binary outcomes. Tests and estimates
of ITT differences for both continuous and binary outcomes were based on longitudinal
models with random effects for clustering by patient, practice, or practice
pairs. For all longitudinal suicidal ideation and depression outcomes, clustering
by practice and pairs of practice was negligible and did not affect the analysis.
This corresponds to previous results by Wells et al.36 The
longitudinal random effects models included main effect and interaction terms
that represented ITT contrasts (ie, contrasts between randomized intervention
and usual care) at each of the 4-, 8-, and 12-month follow-up visits. Using
all data from all participants regardless of dropout or treatment adherence
status, such modeling allowed us to test ITT differences at each follow-up
visit (4, 8, and 12 months) separately and together with increased power and
accounting for group differences with respect to dropout and baseline ideation.
The "omnibus" test statistic, which tests for significant ITT contrasts at
any one of the follow-up visits, is a time by group interaction.56- 58 We
tested for significant ITT differences in linear trend for each outcome, but
the linear trend model did not fit any of the outcomes well. Hence, we rely
on separate ITT tests at each visit separately and jointly using interaction
tests. Interactions with site and baseline major depression status were also
tested. For continuous outcomes, analyses were based on SAS PROC MIXED (SAS
Institute Inc, Cary, NC). Both the PROC NLMIXED and the GLIMMIX macros in
SAS were used to employ 2- and 3-level random effects models, respectively,
for binary outcomes.59 Given the group difference
in baseline suicidal ideation, this variable was controlled for in all ITT
analyses. P = .01 was the level of significance.
The sociodemographic characteristics of intervention and usual care
patients did not differ statistically (Table 1). Patient age ranged from 60 to 94 years, the majority were
female, and 28.4% were minorities. Although the overall percentage of minority
patients did not vary between groups (P = .69), 22.8%
of the intervention's minority patients were Hispanic compared with 6.3% in
usual care (P = .06). The groups did not differ by
depression diagnosis or severity; 66.2% had major depression. The mean (SD)
HDRS score (18.1 [6.0]) indicated moderate severity. A larger proportion of
intervention patients reported suicidal ideation than in usual care (29.4%
vs 20.1%; P = .01).
Treatments received by both groups are described in Table 2. Intervention patients were significantly more likely than
usual care patients to report depression treatment at each follow-up period.
At 4 months, for example, 89.2% of intervention patients compared with 52.5%
of usual care patients reported depression treatment (P<.001). Intervention patients had higher rates of medication-only
(P<.001) and psychotherapy-only (P<.001) treatment. The small proportions of patients receiving combination
treatment did not differ between groups (P = .23).
Similar patterns were observed at 8 months and 12 months.
The first hypothesis concerned the impact of the intervention on the
prevalence of suicidal ideation over time (Table 3). These comparisons were conducted among all depressed patients
and then stratified by depression diagnosis.
As noted, patients in the intervention group were more likely to report
suicidal ideation at baseline than patients in the usual care group (29.4%
vs 20.1%, P = .01). By 4 months and at each subsequent
interview, rates of suicidal ideation no longer differed between groups reflecting
a significantly greater decline in suicidal ideation in the intervention group
after adjusting for the baseline difference. 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). Adjusting for the baseline difference, the omnibus trend testing ITT
differences in change over time was significant among all depressed patients
(P = .01) and among patients with major depression
(P = .006). The differences were not significant
among patients with minor depression (P = .98). The
interaction between the intervention and depression diagnosis on reduced suicidal
ideation was not statistically significant (P = .64).
The second hypothesis was tested by comparing the clinical course of
intervention and usual care patients using 3 sets of depression indexes. These
comparisons were conducted among all depressed patients and then stratified
by depression diagnosis.
The first analyses examined changes in depression severity, measured
by the HDRS score (Table 4). Baseline
depression severity did not differ between the groups. The decrease in HDRS
score from baseline was greater in the intervention group than the usual care
group at 4 months (7.4 vs 3.9, P<.001), 8 months
(8.2 vs 6.2, P<.001), and 12 months (8.8 vs 7.2, P = .006) yielding an overall significant omnibus test
(P<.001). Among patients with major depression,
the effects of the intervention remained significant at each time period (P<.03) and overall (P<.001).
Among patients with minor depression, the effect was less pronounced and not
significant at any follow-up period. The overall omnibus trend for minor depression
only was not significant (P = .39). The interaction
between group and depression diagnosis on change in depression severity was
statistically significant (P = .008).
The second outcome was response to depression treatment as measured
by a 50% or more decrease in HDRS score from baseline (Table 5). These results mirrored those for depression severity.
A larger proportion of intervention patients had depression responses compared
with usual care patients at 4 months (42.7% vs 29.1%, P = .001), 8 months (46.2% vs 35.5%, P = .02),
and 12 months (52.1% vs 42.0%, P = .02); the overall
omnibus trend was significant (P = .003). Again,
the impact of the intervention was significant in patients with major depression
but not minor depression, although the interaction between group and diagnosis
was not statistically significant (P = .30).
The third outcome tested was remission from depression, defined as HDRS
score less than 10 (Table 6).60,61 Among all patients, 4-month remission
rates were significantly higher in the intervention practices compared with
usual care (48.2% vs 34.2%, P<.001). The difference
between the 2 groups narrowed and was not significant at 8 months (49.6% vs
43.5%, P = .08) or 12 months (54.8% vs 52.7%, P = .26). This pattern over time yielded a statistically
significant overall omnibus trend (P<.001). Similar
results were observed among patients with major depression but not minor depression.
When remission was redefined as HDRS score less than 7, the pattern of results
was similar. The statistical interaction between the intervention and depression
diagnosis was not significant using HDRS score less than 10 (P = .23) or HDRS score less than 7 (P = .08).
Two sets of post-hoc analyses examined the effect of the PROSPECT intervention
stratified by both depression diagnosis and suicidality. Among patients who
reported suicidal ideation at baseline, suicidal ideation had resolved by
4 months in 66.7% of 75 intervention patients compared with 58.7% of 46 patients
receiving usual care (P = .34). The difference between
groups was more pronounced and statistically significant at 8 months (70.7%
vs 43.9%, P = .005). By 12 months, more than two
thirds of both groups no longer expressed suicidal ideation (68.7% vs 65.8%, P = .89). Consistent with the group difference peaking
at 8 months, the omnibus test for change across time was significant (P = .03). The pattern was similar within the major depression
and minor depression subgroups, although the omnibus test did not reach statistical
significance in either group (major depression, P =
.09; minor depression, P = .09).
Intervention patients had significantly greater decreases in HDRS scores
compared with patients receiving usual care whether at baseline they reported
suicidal ideation (all depressed, n = 150, P<.001;
major depression, n = 127, P<.001) or no suicidal
ideation (all depressed, n = 448, P<.001; major
depression, n = 269, P<.001). The majority (87%
[179/202]) of patients with minor depression did not report suicidal ideation,
and the impact of the intervention on their depressive symptoms was not significant
overall (P = .72). In contrast, for patients with
minor depression but also suicidal ideation (n = 23), the intervention was
associated with a significantly greater overall decrease in depressive severity
relative to usual care (P = .03).
The principal finding of this multisite, randomized primary care trial
is that suicidal ideation resolved more quickly in patients from practices
randomly assigned to receive the intervention compared with patients receiving
usual care. Additionally, intervention patients had a more favorable course
of depression as measured by severity of depressive symptoms, response to
depression treatment, and depression remission. The impact of the intervention
on depressive symptoms was greater among patients with major depression than
for patients with mild depression unless suicidal ideation was also present.
Rates of suicide are highest among the very old, especially old white
men. Although individual primary care clinicians infrequently experience suicides
among their patients,62,63 the
devastating nature of these events underscores the importance of developing
effective approaches to minimize suicide risk. While suicide itself occurs
too infrequently in primary care to measure the intervention's impact on completed
suicides (and the PROSPECT study was not designed to do so), the intervention
did achieve a faster reduction in rates of suicidal ideation than observed
in usual care. One patient in the intervention group died by suicide; the
follow-up methodology did not permit us to know reliably the causes of death
for patients in the usual care group. Two patients, 1 in the intervention
group and 1 in the usual care group, made suicide attempts. While it is reasonable
to hope from our findings that the rate of completed suicides in a large group
of treated patients would be favorably affected, no study has explicitly demonstrated
Suicidal ideation ranges from mild, passive ideation to severe and active.
In primary care, the low prevalence of active ideation reduces the feasibility
of comparing outcomes by severity of ideation or conducting trials only for
active ideation. In contrast, evidence suggests that mild ideation is more
persistent and more difficult to treat.64 These
findings underscore the challenges in reducing overall suicide risk in primary
care and the importance of designing primary care interventions that address
the range in severity of suicidal ideation.
A potential limitation to these study results is the higher baseline
prevalence of suicidal ideation reported in intervention practices compared
with usual care. We have not been able to explain this difference. It may
have resulted from failure of the practice-level randomization (despite no
group differences in depression), rater bias (although ongoing monitoring
suggested none), another methodological factor, or chance. Model-based regression
adjustments chosen to compensate for this baseline difference still demonstrated
an effect of the intervention on both suicidal ideation and depression. We
note that depression at baseline did not differ between groups. Another potential
limitation to the study's generalizability is the fact that depression treatment
was provided at no cost to participants.
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.64 The depression response rate of intervention
patients was also similar to rates observed in randomized efficacy trials
of SSRIs.65,66 These findings
are important given study methodology chosen to increase the relevance of
PROSPECT's findings to real world practice. First, the study was conducted
in a variety of practices, most of which were nonacademic, relatively small,
and serving heterogeneous populations. Second, although refusals reduced the
sample's strict representativeness, the sampling and screening procedures
resulted in more heterogeneity than generally achieved in randomized trials.
Further, the protocol included patients regardless of factors that are typically
excluded in most randomized controlled trials, such as mild cognitive impairment,
medical comorbidity, concurrent medical treatments, or, perhaps most important,
suicidality. We argue that this heterogeneity increases the relevance of the
findings to actual practice.
This study's application of formal depression screening and diagnostic
procedures differs from traditional clinical practice67 where
identification of depression is unstructured and often dependent on patients
volunteering pertinent information. Consequently, many patients may have been
reluctant to accept a depression diagnosis or initiate treatment. In this
context, the intervention's positive impact on patient outcomes using ITT
analyses is encouraging and consistent with recent clinical guidelines that
suggest that routine depression screening in primary care has the potential
to improve patient outcomes if followed with appropriate treatment and care
PROSPECT was designed to evaluate the total impact of its intervention,
which contains 2 major elements. First is the implementation of treatment
guidelines modified to address the nuances of treating depression in older
patients where "uptake of antidepressants," vulnerability to adverse effects,
competing medical morbidity, functional disability, cognitive impairments,
and social stigma can complicate prescribing, treatment initiation, and treatment
adherence.68- 73 Second
is the addition of a depression care manager, a role consistent with recent
trends in using master's-level clinicians to manage a range of chronic medical
conditions.74,75 Future analyses
will attempt both to determine which components of PROSPECT's intervention
were important to its therapeutic effects and to determine the extent to which
patient clinical or psychosocial characteristics modify the intervention's
These findings are consistent with evidence that interventions can improve
the quality of depression care in primary care. Most of these studies have
been conducted in younger or mixed-aged samples.36,76,77 By
targeting the elderly, PROSPECT is similar to the Improving Mood-Promoting
Access to Collaborative Treatment (IMPACT) trial in demonstrating the positive
effect of a multicomponent primary care intervention.37 Despite
differences in key design features (eg, unit of randomization, sample selection,
clinical measures), both studies reported comparable short-term (3-4 months)
effects on response rates (ie, 50% decline in depression severity) in each
study's intervention group vs usual care (PROSPECT, 41.0% vs 23.8%; IMPACT,
31.8% vs 14.8%). These findings underscore the potential value of such primary
care interventions for resolving depression, improving quality of life and,
as in PROSPECT, reducing risk factors for suicide in late life. They also
underscore the importance of building on these successful trials by developing
effective strategies to sustain these interventions in routine practice, to
increase their efficacy further (allowing more patients to achieve response
and remission), and to disseminate them more broadly.
The intervention's impact in reducing suicidal ideation argues that
care management should be added as an empirically demonstrated effective intervention
in suicidal behavior practice guidelines.26 Importantly,
much of the intervention's impact was on the speed of patient improvement,
which is relevant for reducing both the risk for suicidal behavior and ongoing
suffering among patients and families. Thus, intervention patients experienced
not only more "depression free days,"78 but
also days free from suicidal ideation.
The finding that the intervention's effect differed by depression severity
suggests the clinical utility of focusing on patients with major depression.
This point has several caveats, however. First, patients with minor depression
who reported suicidal ideation benefited from the intervention, albeit this
subgroup was small. Second, the demarcation between major and minor depression
is more conventional than absolute so that the findings offer a guide rather
than a prescription to clinical decision making. Third, not every patient
with minor depression remitted over time, suggesting that "watchful waiting"
may be useful for identifying symptoms that persist or exacerbate.
In summary, 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 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.