Estimates of the prevalence of major depression among elderly Americans seen in primary care range from 6% to 9%; 7% percent report having suicidal thoughts. And the fact that the majority of elderly patients who die by suicide have been seen by their primary care physicians in the months prior points to a need to improve depression treatment in primary care.
"Depression care managers" (nurses, social workers, and psychologists with special training in managing depression) were randomly assigned to primary care practices in a multi-state clinical trial to see whether they could help reduce the number of suicides among older adults. Treatment of these patients (n = 598) entailed prescription of citalopram (Celexa) or "interpersonal psychotherapy" (short-term, structured counseling that focuses on interpersonal relations), or both. The psychotherapy was handled by the care managers, but it was supervised by psychiatrists. Patients in practices randomized to the control group received usual care enhanced by education on depression. Patients were reevaluated at four, eight, and 12 months.
FIGURE
At the baseline assessment, patients in the intervention group were significantly more likely to report having suicidal ideation than the patients in the usual-care group, but at the first follow-up and thereafter, there was no difference in the reported incidence of suicidal ideation. And while the severity of depression was similar at baseline in both groups, the intervention group had significantly better treatment outcomes, as measured by severity of symptoms and response to treatment at all follow-up points. While this significance did not hold for minor depression, the results point to the effectiveness of early interviews in the primary care setting for reducing suicidal ideation in elderly patients.
Bruce ML, et al. JAMA 2004;291(9):1081-91.