percent) when treated with combined pharmacotherapy and interpersonal psychotherapy, but that the relapse rate was higher among suicidal elderly (26% versus 13%, Szanto et al., 2001). These data suggest that elderly suicidal depressed patients have an overall favorable treatment outcome, but that treatment response may be more brittle and may require the continuing use of adjunctive medication to prevent early relapse.

A recent “indicated” preventive intervention in the elderly looks promising. An NIMH-supported study on Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT; Bruce and Pearson, 1999) is testing the effectiveness of placing depression care managers in primary care practices in preventing and reducing suicidal ideation and behavior, hopelessness, and depressive symptomatology. The study is obtaining a sample representative of practice populations and is over-sampling patients with depression and the very old, i.e., those aged 75 and above. The essential tasks of the depression care manager are to convey clinical information to the primary care physician, to monitor the patient’s treatment compliance with treatment that is informed by Agency for Health Care Policy and Research guidelines, to assess the patient’s clinical status, to provide psychotherapy when requested, and to arrange specialist referrals. Preliminary data suggest that PROSPECT’s intervention is more effective than treatment as usual. Although both patient populations had similar base rates, after 12 months, 10 percent of the patients in the intervention group had suicidal ideation compared to 17 percent of those in usual care; and only 5 percent expressed hopelessness compared to 17 percent in usual care (Reynolds et al., 2001). These data suggest that a depression care manager can be an effective intervention.

INTEGRATED APPROACHES TO PREVENTION

The World Health Organization (WHO) began espousing national responses to the problem of suicide by 1989, and in 1996 the United Nations formulated official guidelines for national suicide prevention strategies that urged governments to adopt comprehensive approaches to reducing suicidality and increasing personal resilience and community connectedness (United Nations, 1996). Currently, Asian countries generally experience significant lack of basic mental health services, and often only have either the volunteer “Befrienders” services (see hotlines section) for those contemplating suicide or a few crisis centers staffed by volunteers. Furthermore, some countries still consider suicide a crime, thus limiting health care services available to attempters (for review, see Murthy, 2000).

A number of European national and United States state governments,



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