‘Depression Care Managers’ Help Reduce Suicidal Thoughts

Adding a “depression care manager” to primary care offices is an effective method to identify and treat elderly patients with depression. Increasing recognition and elevating the quality of treatment of geriatric depression can significantly reduce suicidal thoughts in this high-risk population.

Data from National Center for Health Statistics show that older Americans make up about 13 percent of the U.S. population, yet account for more than 18 percent of all suicide deaths. Elderly white men appear to be most vulnerable to suicide. In an effort to confirm a previously identified link to geriatric depression as the single most common risk factor for elderly suicide and explore a primary care–based intervention aimed at reducing risk factors, the National Institute of Mental Health in 1999 began a 2.5-year multisite randomized controlled trial dubbed PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial).

A report of the initial outcomes of PROSPECT appeared in the March 3 issue of the Journal of the American Medical Association, and preliminary results were presented at the annual meeting of the American Association for Geriatric Psychiatry in Baltimore the week before.

The PROSPECT trial approached suicide risk reduction from the public health perspective, acknowledging that primary care practices were an important focus of study because the majority of older adults who die by suicide have seen their primary care physician within months of their death. The targeted intervention was aimed at factors that have been strongly related to suicide risk, were common in primary care practices, and could be changed.

Nearly 600 elderly patients participated in the study, which involved 20 primary care practices in the New York City, Philadelphia, and Pittsburgh metropolitan areas. Principal investigators Martha Bruce, Ph.D., M.P.H., a professor of psychiatry at the Weill Medical College of Cornell University, and Charles Reynolds III, M.D., a professor of psychiatry, neurology, and neuroscience at the University of Pittsburgh School of Medicine, along with a large group of collaborators, hypothesized that by educating primary care physicians and improving treatment to the level of guideline standards, a depression care manager could significantly improve clinical outcomes.

A depression care manager—who could be a social worker, nurse, or master’s-level psychologist—was randomly assigned to 10 primary care practices in the three metropolitan areas. The care managers provided psychotherapy, followed the progress of patients on medication, and were responsible for screening the patients.

The protocol’s guidelines recommended a first-line trial of the SSRI citalopram (Celexa), although clinicians were able to prescribe another drug if clinically warranted. Citalopram was chosen for the protocol due to its established efficacy, limited drug-interaction profile, low potential for central nervous system activation, and relative lack of any withdrawal syndrome. If a patient declined medication, the physician could prescribe interpersonal psychotherapy, done by the depression care manager. Each of the 10 practices using depression care managers was paired with a similar practice, which served as a control by providing its “usual care.”

Over the two-year period studied, the study sampled nearly 80 percent of all patients in each practice aged 60 or older (16,708). (Of the remaining 20 percent, some declined to participate, while others were excluded for various reasons, such as having dementia.) About 12 percent of the screened patients had depression, using the Centers for Epidemiological Studies-Depression Scale (CES-D).

The PROSPECT report in JAMA focuses on a subset of those who met DSM-IV criteria for major depression or clinically significant minor depression. A total of 568 patients were randomly assigned to either the active intervention (320) or usual care (278).

Patients assigned to the intervention group had a more favorable course of depression, both in the degree of symptoms and in the time to symptom reduction. The greatest difference between the groups was seen at four months. The effects of the intervention were not significant for those with minor depression, except those patients who also expressed suicidal ideation.

Rates of suicidal ideation overall declined faster in the intervention group, compared with those patients receiving usual care. At four months, raw rates of suicidal ideation in the intervention group declined by nearly 13 percent (29.4 percent to 16.5 percent), compared with only a 3 percent decline (20.1 percent to 17.1 percent) in the usual care group.

In spite of the lack of effect in patients with minor depression, the intervention was effective in reducing suicidal ideation, regardless of depression severity, the researchers said, reinforcing its role as a prevention strategy to reduce risk factors for suicide in elderly patients.

“Without such structured, formal screening and diagnostic procedures,” Reynolds said in a press release, “patients are less likely to volunteer information, accept a diagnosis of depression, or initiate treatment. Our findings in an elderly population adds to evidence from other studies that structured interventions can improve the quality of depression care in primary care.”

An abstract of “Reducing Suicidal Ideation and Depressive Symptoms in Depressed Primary Care Patients: A Randomized Controlled Trial” is posted online at http://jama.ama-assn.org/cgi/content/abstract/291/9/1081. ▪