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Bruce ML, Ten Have TR, Reynolds III CF, et al. Reducing Suicidal Ideation and Depressive Symptoms in Depressed Older Primary Care Patients: A 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
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