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A Randomized Controlled Trial

Martha L. Bruce, PhD, MPH; Thomas R. Ten Have, PhD; Charles F. Reynolds III, MD; Ira I. Katz, MD, PhD; Herbert C. Schulberg, PhD; Benoit H. Mulsant, MD; Gregory K. Brown, PhD; Gail J. McAvay, PhD; Jane L. Pearson, PhD; George S. Alexopoulos, MD

JAMA. 2004;291:1081-1091.

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 life.

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.

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