TUESDAY, March 2, 2004 (HealthDayNews) -- Educating doctors and using "care managers" when treating seniors for depression not only eased the depression but also reduced suicidal thoughts.
Although there are some questions about the real-world applicability of these findings, which appear in the March 3 issue of the Journal of the American Medical Association, the research does shed important light on a neglected field.
"The most striking aspect of suicide in the elderly, especially elderly males, is that it receives little to no attention," says Dr. Anand Kumar, a professor of psychiatry at the University of California, Los Angeles, and president of the American Association of Geriatric Psychiatry. "What's positive about this is that there's public health attention, albeit a small amount, being paid to a very important topic."
Nancy Osgood, a professor of gerontology at Virginia Commonwealth University Medical College of Virginia, says the finding offers hope. "It showed that something could be done to reduce the severity of depression and suicide ideation in older adults. We didn't know that before."
However, she cautions, "it might be possible to do in the real world, but it would be expensive."
While older Americans make up about 13 percent of the population, they account for 18 percent of suicide deaths. Depression is the greatest risk factor for suicide in this age group.
Despite these numbers, the illness is often improperly diagnosed and treated, especially in primary-care settings.
"Often depression is not identified in primary care," says study author Martha L. Bruce, a professor of sociology in psychiatry at Weill Medical College of Cornell University in White Plains, N.Y. "This is where you're going to find patients who have problems. This is an untapped population."
The current study looked at the impact of a specific intervention in a primary-care setting. The study authors enrolled seniors at 20 primary-care practices in New York City, Philadelphia and Pittsburgh. The practices were randomly selected to dispense either "usual care" or a special intervention designed for this study.
In the intervention group, physicians worked closely with "depression-care managers" who helped them recognize depression in patients and gave treatment recommendations. Depressed patients were first prescribed a selective serotonin reuptake inhibitor (SSRI). If the person did not want to take medication, the physician recommended psychotherapy with the care manager. The depression-care managers were master's level professionals such as social workers, nurses and psychologists. The study sponsors paid for treatment.
Depression severity and suicide ideation were measured at the beginning of the study and four months, eight months and one year later.
People who were treated by care managers lost their suicidal thoughts more quickly. At the end of four months, rates of "suicidal ideation" had dropped 12.9 percentage points, compared with 3 percentage points in the usual care group.
The intervention group also showed a response to treatment and a reduction in the severity of their symptoms. At eight months, about 70 percent of intervention patients who had had suicidal thoughts no longer had them, compared to about 44 percent of "usual care" patients. The effects were seen most dramatically in those participants with major depression.
The study did not have a sample size large enough to assess suicide attempts or suicide.
"This is only dealing with suicide ideation," says Dr. Herbert Hendin, medical director of the American Foundation for Suicide Prevention in New York City. "Suicide ideation depends on how serious it is and how preoccupied the person is. A lot of patients, it's not severe ideation. Transient ideation of suicide in people who are depressed is very common."
The real question is whether such a practice can be offered in the real world. Kumar acknowledges the seed of an idea has been planted and the intervention is "potentially realistic."
"It sort of draws attention to something that's lurking beneath the radar," he says. "It's the first study to demonstrate that standard psychiatric interventions are very helpful in a [primary-care] setting. This treatment is a pretty well established approach to depression, but in a setting where people don't get treated."
Bruce believes the model is feasible, but that its cost-effectiveness and other aspects need to be worked out. "The next step is looking at how do you take something like this and sustain it in a practice and disperse it to other practices," she says. "This is a big concern. How do you get this out there in real life?"
Others believe there may be ways to modify the practice to make it feasible.
"If we focused on severely depressed patients [which is where the study showed the most dramatic improvement], if physicians could be taught to easily and adequately identify severely depressed older people in their office, I think that would be a lot less expensive," Osgood says. Alternatively, she adds, perhaps people who are not quite as highly trained as the care managers in this study could be trained to coordinate care.
More information
For more on preventing suicide, visit the American Foundation for Suicide Prevention or the U.S. Surgeon General. The American Association of Geriatric Psychiatry has more on the mental health of the elderly, as does the American Psychiatric Association.
