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