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The Relationship Between Suicide Ideation and Late-Life Depression

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Objective

To describe the course of suicide ideation (SI) in primary-care based late-life depression treatment, identify predictors of SI, characterize the dynamic relationship between depression and SI, and test the hypothesis that collaborative care decreases the likelihood of reporting SI by decreasing the severity of depressive symptoms.

Methods

This was a secondary analysis of a randomized controlled trial comparing collaborative care to usual care for late-life depression. Participants were 1,801 adults age 60 and older from eight diverse primary-care systems. Depression was measured using the Hopkins Symptoms Checklist (HSCL-20). SI was operationalized using one item from the HSCL-20. Predictors of incident SI were identified by a series of univariate analyses followed by multiple logistic regression. A mediator analysis was conducted to test the hypothesis that the effect of collaborative care on SI can be ascribed to the intervention's effect on depressive symptoms.

Results

The prevalence of SI was 14% (N = 253); the cumulative incidence over 24 months was 21% (385). The likelihood that SI emerged after baseline was highly dependent on change in depression (odds ratio: 5.38, 95% confidence interval: 3.93–7.36, df = 81, t = 10.66, p <0.0001). As hypothesized, the effect of collaborative care on SI was mediated by the treatment's effect on depression.

Conclusion

SI is not uncommon in depressed older adults being treated in primary care. The likelihood that depressed older adults will report SI is strongly determined by the course of their depression symptoms. Providers should monitor SI throughout the course of depression treatment.

Section snippets

METHODS

The IMPACT trial was conducted in 18 primary care clinics affiliated with eight diverse health care organizations in five states. The IMPACT intervention entailed promotion of collaborative care by utilizing a depression care manager (DCM), usually a nurse or social worker, who disseminated patient education, performed systematic monitoring of treatment response, delivered problem-solving treatment if desired by the patient, assured that the primary care physician was aware of the patient's

RESULTS

Detailed characteristics of the sample have been reported previously.18 The mean age was 71.2 (SD: 7.5) years and 65% were women. Approximately 23% were from ethnic minority groups. Comorbid major depression and dysthymic disorder was present in 52.9%, and 70.7% reported having two or more prior depressive episodes. The mean HSCL-20 depression score was 1.7 (0.6), indicating moderate to severe depression. More than one third (35.4%) screened positive for cognitive impairment and 29.0% screened

DISCUSSION

SI is not uncommon in older adults presenting for depression treatment in primary care settings. The likelihood that participants will report SI after the initiation of treatment is strongly determined by the course of their depression symptoms. Only a very small number of participants have SI without reporting clinically significant depression symptoms.

Among those participants whose depression remits, few report SI. Interestingly, 21% of depressed participants who enter treatment denying SI

CONCLUSION

The management of suicide risk in primary care is a formidable challenge37., 38. but effective depression treatment appears to be a powerful tool for reducing SI in older primary care patients and should be considered a high priority for the clinical management of suicide risk.

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    This work was supported, in part, by funding from the John A. Hartford Foundation, and the National Institute of Mental Health under grants T32MH73553 and K24MH07271.

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    Copyright © 2007 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.