Reducing Suicidal Ideation and Depression in Older Primary Care Patients: 24-Month Outcomes of the PROSPECT Study

Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
American Journal of Psychiatry (Impact Factor: 12.3). 07/2009; 166(8):882-90. DOI: 10.1176/appi.ajp.2009.08121779
Source: PubMed

ABSTRACT The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) evaluated the impact of a care management intervention on suicidal ideation and depression in older primary care patients. This is the first report of outcomes over a 2-year period.
Study participants were patients 60 years of age or older (N=599) with major or minor depression selected after screening 9,072 randomly identified patients of 20 primary care practices randomly assigned to provide either the PROSPECT intervention or usual care. The intervention consisted of services of 15 trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 24 months.
Compared with patients receiving usual care, those receiving the intervention had a higher likelihood of receiving antidepressants and/or psychotherapy (84.9%-89% versus 49%-62%) and had a 2.2 times greater decline in suicidal ideation over 24 months. Treatment response occurred earlier on average in the intervention group and increased from months 18 to 24, while no appreciable increase in treatment response occurred in the usual care group during the same period. Among patients with major depression, a greater number achieved remission in the intervention group than in the usual-care group at 4 months (26.6% versus 15.2%), 8 months (36% versus 22.5%), and 24 months (45.4% versus 31.5%). Patients with minor depression had favorable outcomes regardless of treatment assignment.
Sustained collaborative care maintains high utilization of depression treatment, reduces suicidal ideation, and improves the outcomes of major depression over 2 years.

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    • "Promising findings notwithstanding ( Alexopoulos et al . , 2009 ; Gallo et al . , 2013 ; Un€ utzer et al . , 2006 ) , concerns have been raised about collaborative care ' s cost and sus - tainability ( Almeida et al . , 2012 ) and potential for disrupt - ing workflow and undermining continuity of care ( Wittink , Duberstein , & Lyness , 2013 ) ."
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    ABSTRACT: Objectives: To conduct a systematic review of studies that examined associations between physical illness/functional disability and suicidal behaviour (including ideation, nonfatal and fatal suicidal behaviour) among individuals aged 65 and older. Method: Articles published through November 2014 were identified through electronic searches using the ERIC, Google Scholar, PsycINFO, PubMed, and Scopus databases. Search terms used were suicid* or death wishes or deliberate self-harm. Studies about suicidal behaviour in individuals aged 65 and older with physical illness/functional disabilities were included in the review. Results: Sixty-five articles (across 61 independent samples) met inclusion criteria. Results from 59 quantitative studies conducted in four continents suggest that suicidal behaviour is associated with functional disability and numerous specific conditions including malignant diseases, neurological disorders, pain, COPD, liver disease, male genital disorders, and arthritis/arthrosis. Six qualitative studies from three continents contextualized these findings, providing insights into the subjective experiences of suicidal individuals. Implications for interventions and future research are discussed. Conclusion: Functional disability, as well as a number of specific physical illnesses, was shown to be associated with suicidal behaviour in older adults. We need to learn more about what at-risk, physically ill patients want, and need, to inform prevention efforts for older adults.
    Aging and Mental Health 09/2015; DOI:10.1080/13607863.2015.1083945 · 1.75 Impact Factor
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    • "In keeping with this view, it has to be noted that patients with late-onset depression (i.e., > 60 years old) tend to exhibit more prominent deficits in verbal memory, processing speed, and executive function, notably inhibitory control. Notably, executive dysfunction in elderly populations has been associated with more residual depressive symptoms, greater risk of recurrence, as well as with poorer response to antidepressant treatment [124] [125]. The most important limitation when interpreting the findings regarding the relationship between the use of antidepressants and cognitive impairment derives from the over-representation of samples composed by subjects aged >65 years, which limits generalizability of the data to younger populations. "
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    ABSTRACT: Major depressive disorder (MDD) is a prevalent and recurring mental disorder often associated with high rates of non-recovery and substantial consequences on psychosocial outcome. Cognitive impairment is one of the most frequent residual symptoms of MDD. The persistence of cognitive impairment even in remitted phases of the disorder, notably in the domains of executive function and attention, suggests that it may serve as a mediational nexus between MDD and poor functional outcome, accounting for occupational and relational difficulties regardless of clinical improvement on depressive symptoms. The critical impact of cognitive deficits on psychosocial dysfunction invites clinicians to regularly screen and assess cognition across multiple domains, taking into account also clinical correlates of cognitive dysfunction in MDD. Despite the availability of several instruments for the screening and assessment of cognitive dysfunction, the lack of consensus guiding the choice of appropriate instruments increases the likelihood to underestimate cognitive dysfunction in MDD in clinical settings. On the other hand, the unsatisfactory effect of most antidepressant treatments on cognitive deficits for many individuals with MDD calls for the development of genuinely novel therapeutic agents with potential to target cognitive dysfunction. Notwithstanding the necessity of further investigations, this review indicates that neuropsychological deficits (e.g., impaired executive functions) are stable markers of MDD and underscores the need for the development of integrative and multi-modal strategies for the prevention and treatment of neuropsychological impairments in MDD.
    CNS & Neurological Disorders - Drug Targets (Formerly Current Drug Targets - CNS & Neurological Disorders) 11/2014; 13(10). DOI:10.2174/1871527313666141130203823 · 2.63 Impact Factor
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    • "Thus far, most suicidal prevention studies for older people have been conducted in primary care settings [18]. For example, suicide ideation was reduced for up to 2 years among older US adults using collaborative care models in which depression treatment was augmented in primary care with expert mental health consultation and medication recommendations, psychoeducation, and the option of brief psychotherapy [19,20]. However, reducing the frequency or severity of thoughts about suicide does not necessarily indicate reduced suicide risk [17]. "
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    ABSTRACT: Suicide is common among the elderly worldwide. However, no literature could be found on the beliefs/expectations that protect young-old people from attempting suicide. The purpose of this study was to explore young-old outpatients' reasons for not killing themselves in Taiwan. Data for this qualitative descriptive study were extracted from a large research series. From the 83 elderly outpatients in the original sample, 31 were chosen for this study because they were young-old (65-74 years old) and from two randomly selected medical centers in northern Taiwan. Data on participants' reasons for not killing themselves in unhappy situations were collected in individual interviews using a semi-structured guide and analyzed by content analysis. Analysis of interview data identified six major themes: satisfied with one's life, suicide cannot resolve problems, fear of humiliating one's children, religious beliefs, never thought about suicide, and living in harmony with nature. These identified protective factors (reasons for living) could be added to suicide-prevention programs for the elderly. Our findings may also serve as a reference for geriatric researchers in western countries with increasing numbers of elderly ethnic minority immigrants.
    BMC Public Health 04/2014; 14(1):372. DOI:10.1186/1471-2458-14-372 · 2.26 Impact Factor
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