Pilot randomized clinical trial of an SSRI vs bupropion: effects on suicidal behavior, ideation, and mood in major depression

Randomized controlled trials in depressed patients selected for elevated suicidal risk are rare. The resultant lack of data leaves uncertainty about treatment in this population. This study compared a serotonin reuptake inhibitor with a noradrenergic/dopaminergic antidepressant in major depression with elevated suicidal risk factors. We conducted a double-blind, randomized, clinical pilot trial of paroxetine (N=36) or bupropion (N=38) in DSM IV major depression with a suicide attempt history or current suicidal ideation. The effects during acute (8 weeks) and continuation treatment (up to 16 weeks) were measured. Main outcomes were suicidal behavior and ideation. The secondary outcome was modified 17-item Hamilton Depression Rating Scale score subtracting the suicide item (mHDRS-17). Treatment was not associated with time to a suicidal event and no treatment main effect or treatment × time interaction on suicidal ideation or mHDRS-17 was found. Exploratory model selection showed modest advantages for paroxetine on: (1) mHDRS-17 (p=0.02); and (2) in a separate model adjusted for baseline depression, for suicidal ideation measured with the Beck Scale for Suicidal Ideation (p=0.03), with benefit increasing with baseline severity. Depressed patients with greater baseline suicidal ideation treated with paroxetine compared with bupropion appeared to experience greater acute improvement in suicidal ideation, after adjusting for global depression. Given the lack of evidence-based pharmacotherapy guidelines for suicidal, depressed patients-an important public health population-this preliminary finding merits further study.     

Treatment-emergent suicidal ideation during 4 months of acute management of unipolar major depression with SSRI pharmacotherapy or interpersonal psychotherapy in a randomized clinical trial

Background: To date, few randomized controlled trials (RCTs) of major depression have examined suicidal ideation as an outcome measure. Our aim is to determine the incidence of treatment‐emergent suicidal ideation (ESI) and behaviors during the acute phase of treatment with an SSRI antidepressant or interpersonal psychotherapy (IPT) in patients with unipolar major depression. Methods: In a two‐site RCT, 291 adult outpatients with nonpsychotic major depression and a Hamilton Depression Rating Scale (HDRS) score ≥15 were randomly allocated to IPT or SSRI. Participants who did not remit with monotherapy received augmentation with the other treatment. ESI was defined as a postbaseline HDRS suicidality item score ≥2 or a postbaseline Quick Inventory of Depressive Symptomatology (QIDS) score ≥2 in patients with a baseline score ≤1. Results: Of the 231 participants who had no suicidal ideation at baseline, 32 (13.8%) subsequently exhibited ESI on at least one postbaseline visit. Time to suicidal ideation was significantly longer in patients allocated to SSRI compared to those allocated to IPT (HR = 2.21, 95% CI 1.04–4.66, P = .038), even after controlling for treatment augmentation, benzodiazepine use, and comorbidity with anxiety disorders. Worsening of suicidal ideation occurred in 7/60 patients who had suicidal ideation at baseline. In the large majority of cases, suicidal ideation was successfully managed with the study protocol. Conclusions: In the context of careful monitoring and frequent contact, selective serotonin reuptake inhibitor (SSRI) was associated with a lower risk of ESI than IPT and both SSRI and IPT appeared to be safe treatments for patients with past suicide attempts, none of whom exhibited ESI during the study. Depression and Anxiety, 2011.© 2011 Wiley‐Liss, Inc.     

Predictors of outcome following brief psychodynamic-interpersonal therapy for deliberate self-poisoning

BACKGROUND: We found that brief psychodynamic-interpersonal therapy was more helpful than usual care in deliberate self-poisoning patients, and resulted in reduced suicidal ideation and repetition of self-harm in the 6 months post-treatment. Here, we explore which baseline factors predicted outcome following treatment. METHOD: Patients presenting to an emergency department with deliberate self-poisoning were randomly assigned to brief psychodynamic-interpersonal therapy (PIT) or usual care. Severity of suicidal ideation 6 months post-treatment was used as the main outcome measure. Sociodemographic features and baseline psychological measures were used as predictor variables. Univariate and regression analyses were used to identify predictors of outcome for the whole group and for those who received psychotherapy. RESULTS: Principal predictors for the psychotherapy group were baseline severity of depression and a prior history of self-harm. For the group as a whole predictors were severity of suicidal ideation, anxiety and prior history of self-harm. CONCLUSIONS: Four session PIT for deliberate self-poisoning is effective in reducing suicidal ideation in patients with less severe depression, no prior history of self-harm, and who have not consumed alcohol with the overdose. Extended therapy may be indicated for those with more severe depression.     

Occurrence and course of suicidality during short-term treatment of late-life depression

BACKGROUND: Elderly persons (> or =65 years) have the highest rate of suicide; still, little is known about the occurrence, course, and responsivity of suicidal ideation during treatment of depression in late life and how suicidality affects treatment response. METHODS: This study was undertaken to determine (1) how suicidal ideation changes during short-term depression treatment and (2) whether treatment response differs among 3 groups of patients based on their levels of suicidality at baseline and during treatment (those with a recent suicide attempt or current suicidal ideation [high-risk group; n = 46], those with recurrent thoughts of death [moderate-risk group; n = 143], or those with no suicide attempt, suicidal ideation, or thoughts of death [low-risk group; n = 206]). This is a secondary analysis of pooled data from 3 treatment studies of late-life major depression. Participants were 395 elderly persons with a current major depressive episode, treated as inpatients or outpatients under protocolized conditions with paroxetine hydrochloride or nortriptyline hydrochloride, with or without interpersonal psychotherapy. Changes in suicidal ideation over time, rate of responses, and time to response in each group were compared. RESULTS: Suicidal ideation decreased rapidly early in the course of treatment, with more gradual change thereafter. At the beginning of treatment, 77.5% of the patients reported suicidal ideation, thoughts of death, or feelings that life is empty. After 12 weeks of treatment, suicidal ideation had resolved in all treated patients; 4.6% still reported thoughts of death. However, 6-week (P =.001) and 12-week (P =.02) rates of response were significantly lower in high-risk patients than in low- and moderate-risk patients. High- and moderate-risk patients needed a significantly (P<.001) longer time to respond than low-risk patients (median time to response, 6 and 5 vs 3 weeks). CONCLUSIONS: While suicidal ideation resolves rapidly, the resolution of thoughts about death is more gradual. Suicidal elderly persons with depression require special attention during depression treatment because they have a lower response rate and need a longer time to respond.     

Negative Emotions and the Course of Depression During Psychotherapy in Suicidal Older Adults With Depression and Cognitive Impairment

ObjectiveThe study examines the relationship of negative emotions with: 1) non-emotional symptoms (e.g., vegetative and physical symptoms) and 2) the course of depression in suicidal older adults with Major Depressive Disorder (MDD) and cognitive impairment treated with psychotherapy.DesignThe authors identified a subgroup of participants (N = 26) who expressed suicidal ideation at Baseline or Week 12 from a randomized controlled trial (RCT) of two psychosocial interventions, Problem Adaptation Therapy (PATH) and Supportive Therapy for Cognitively Impaired. The authors assessed negative emotions, non-emotional symptoms of depression, depression severity, and suicidal ideation at entry, week 4, week 8, and week 12.ParticipantsParticipants were 65 years and older and had a diagnosis of unipolar depression, varying degrees of cognitive impairment (up to moderate dementia) and suicidal ideation.SettingThe study was conducted in the Outpatient Department of New York Presbyterian/Weill Cornell Medicine in Westchester, NY.MeasurementsNegative emotions and non-emotional items were identified with the 24-item Hamilton Depression Rating Scale (Ham-D).ResultsAmong participants with suicidal ideation, the reduction in negative emotions from baseline to week 4, week 4 to week 8, and week 8 to week 12 was significantly associated with the reduction in non-emotional symptoms of depression at weeks 4, 8, and 12 (F_{(1, 35)} = 6.20, p = 0.02) and with the reduction in overall depression severity at weeks 4, 8, and 12 (F_{(1, 35)} = 26.63, p <0.0001) after controlling for depression severity at baseline (HAM-D total score) and time trends.ConclusionOur findings may guide the treatment of older patients with depression and suicidal ideation to help reduce depression and suicide risk.     

Randomized study of school-based intensive interpersonal psychotherapy for depressed adolescents with suicidal risk and parasuicide behaviors

Aim:  The aim of the present study was to examine the intervention effects of intensive interpersonal psychotherapy for depressed adolescents with suicidal risk (IPT-A-IN) by comparison with treatment as usual (TAU) at schools.
Methods:  A total of 347 students from one-fifth of the classes of a high school in southern Taiwan completed the Beck Depression Inventory-II, the Beck Scale for Suicide Ideation, the Beck Anxiety Inventory and the Beck Hopelessness Scale for screening for suicidal risk. Of them, 73 depressed students who had suicidal risk on screening were randomly assigned to the IPT-A-IN or TAU group. Analysis of covariance (ANCOVA) was performed to examine the effect of IPT-A-IN on reducing the severity of depression, suicidal ideation, anxiety and hopelessness.
Results:  Using the pre-intervention scores as covariates, the IPT-A-IN group had lower post-intervention severity of depression, suicidal ideation, anxiety and hopelessness than the TAU group.
Conclusion:  Intensive school-based IPT-A-IN is effective in reducing the severity of depression, suicidal ideation, anxiety and hopelessness in depressed adolescents with suicidal risk.     

Lack of association between suicidal ideation and enhanced platelet 5-HT2A receptor-mediated calcium mobilization in cancer patients with depression.

BACKGROUND: Increased density of 5-HT2A receptors was observed in the platelets of depressive patients with suicidal ideation. Enhanced 5-HT2A receptor-mediated platelet calcium mobilization has been proposed as a biological marker for the pathophysiology of major depression in cancer patients as well as in physically healthy patients. To examine whether depressive cancer patients with suicidal ideation have enhanced 5-HT2A receptor-mediated platelet response compared with those without suicidal ideation, we compared 5-HT-induced platelet calcium mobilization in depressive cancer patients with and without suicidal ideation. METHODS: 5-HT-induced platelet calcium mobilization was examined in 24 cancer patients diagnosed as having major depression according to the DSM-IV criteria. Suicidal ideation was evaluated by the Hamilton Depression Rating Scale and Zung's Self Depression Scale, as well as by the DSM-IV criteria. RESULTS: There was no significant differences in 5-HT-induced platelet calcium response between the depressive cancer patients with (n = 8) and without suicidal ideation (n = 16). 5-HT-induced platelet calcium response was also not significantly associated with the severity of suicidal ideation or with the severity of depression assessed by Hamilton Depression Rating Scale and Zung's Self Depression Scale. CONCLUSIONS: These findings suggest that enhanced 5-HT2A receptor-mediated response was not associated with suicidal ideation in cancer patients with depression.     

Socioeconomic status and anxiety as predictors of antidepressant treatment response and suicidal ideation in older adults

BACKGROUND: Separate reports from the maintenance treatment for late-life depression (MTLD) trials have shown that low socioeconomic status (SES) and anxiety symptoms at the time of treatment initiation predict lower levels of response to antidepressant treatment and higher levels of suicidal ideation in older adults. AIM: To determine whether SES and anxiety independently contribute to worse treatment outcomes, as indicated by persistence of depressive symptoms during treatment and the persistence of suicidal ideation. Consistent with prior evidence that sociodemographic factors and clinical history are both prognostic of depression treatment efficacy, we hypothesized that SES and pre-existing anxiety symptoms will both predict lower levels of response to treatment and higher levels of suicidal ideation. METHOD: Secondary analyses of data from the MTLD trials. RESULTS: Regression analyses which controlled for comorbid anxiety indicated that residents of middle- and high-income census tracts were more likely to respond to treatment (HR, 1.63; 95%CI, 1.08-2.46) and less likely to report suicidal ideation during treatment (OR, 0.51; 95%CI, 0.28-0.90) than residents of low income census tracts. The same regression models indicated that pre-existing anxiety symptoms were independently related to lower treatment response (HR, 0.73; 95%CI, 0.60-0.89) and higher risk of suicidal ideation (OR, 1.45; 95%CI, 0.98-2.14). CONCLUSION: These findings demonstrate the importance of treating anxiety symptoms during the course of treatment for late-life depression and, at the same time, addressing barriers to treatment response related to low SES.     

Suicidal ideation and behaviour in patients with persecutory delusions: Prevalence,symptom associations,and psychological correlates

BackgroundTo determine the prevalence of suicidal ideation and behaviour - and their correlates - in patients with persecutory delusions.Methods110 patients with persecutory delusions in the context of non-affective psychosis were assessed for suicidal thoughts and behaviours over the past month. Symptom and psychological assessments were also completed.ResultsThe severity of suicidal ideation was: no suicidal ideation (n = 26, 23.6%); wish to be dead (n = 21, 19.1%); nonspecific active suicidal thoughts (n = 14, 12.7%); suicidal thoughts with methods but no intent (n = 29, 26.4%); suicidal thoughts with intent but no specific plan (n = 13, 11.8%); and suicidal intent with plan (n = 7, 6.4%). In the past month, five patients (4.5%) had made an actual, interrupted, or aborted suicide attempt. The severity of suicidal ideation was associated with higher levels of depression, paranoia, hallucinations, anger, insomnia, negative beliefs about the self and others, pessimism, worry, and delusion safety-seeking behaviours and lower levels of psychological well-being and reward responsiveness. Severity of ideation was not associated with cannabis or alcohol use, working memory, pain, or meaningful activity levels.ConclusionsPatients with persecutory delusions are typically in a severe state of psychological stress, and at risk of suicide, as indicated by very high levels of suicidal ideation. This exploratory study also identifies correlates of suicidal ideation that could be investigated in causal research designs.     

Treatment outcome in suicidal vs. non-suicidal elderly patients.

The authors investigated treatment outcome in elderly suicidal and non-suicidal patients with recurrent major depression. Patients without suicidal ideation in the current episode (Non-Ideators; n=150) were compared with 30 patients who expressed suicidal ideation (Ideators). Patients received combined pharmacotherapy and psychotherapy during acute and continuation treatment. Ideators had higher numbers of lifetime suicide attempts and reported significantly higher levels of depression, anxiety, and hopelessness before starting treatment. Ideators and Non-Ideators had almost identical remission rates (77% vs. 78%), but Ideators had higher relapse rates during continuation treatment (26% vs. 13%) and were more likely to receive augmentation pharmacotherapy. Anxiety and use of adjunctive medication, but not suicidal ideation, were negatively related to both remission and relapse. Our data suggest that elderly suicidal patients have an overall favorable treatment outcome. However, treatment response may be more brittle and may require the continuing use of adjunctive medications to prevent early relapse.     

Suicidal ideation among elderly homecare patients

OBJECTIVES: To identify the prevalence, correlates, and one-year naturalistic course of suicidal ideation in a representative sample of elderly adults newly admitted to visiting nurse homecare. METHOD: Five hundred and thirty-nine participants (aged > or =65), newly initiating homecare for skilled nursing services, were interviewed with the Structured Clinical Interview for DSM-IV (SCID-IV) and measures of depression severity, medical comorbidity, functional status, and social support. Participants were classified as having no suicidal ideation in the past month, passive ideation, active ideation, or active ideation with poor impulse control or suicide plan. RESULTS: Fifty-seven participants (10.6%) reported passive and six (1.2%) reported active suicidal ideation. Higher depression severity, greater medical comorbidity, and lower subjective social support were independently associated with the presence of any level of suicidal ideation. At one year, suicidal ideation persisted for 36.7% of those with ideation at baseline, and the incidence of suicide ideation was 5.4% CONCLUSIONS: The high prevalence, persistence, and incidence of suicidal ideation in medically ill home healthcare patients underscore the relevance of this population for suicide prevention efforts. The clinical and psychosocial factors associated with suicidal ideation in this underserved, high-risk population are potentially modifiable, and thus useful targets for suicide prevention interventions.     

Suicidal status during antidepressant treatment in 789 Sardinian patients with major affective disorder

Objective: Relationships between antidepressant treatment and suicidality remain uncertain in major depressive disorder (MDD), and rarely evaluated in bipolar disorder (BPD). Method: We evaluated changes in suicidality ratings (Hamilton Depression Rating Scale item‐3) at the start and after 3.59 ± 2.57 months of sustained antidepressant treatment in a systematically assessed clinical sample (n = 789) of 605 patients with MDD, 103 patients with BPD‐II and 81 patients with BPD‐I (based on DSM‐IV; 68.1% women; aged 44.3 ± 16.1 years), comparing suicidal vs. non‐suicidal and recovered vs. unrecovered initially suicidal patients. Results: Suicidal patients (103/789, 16.5%; BPD/MDD risk: 2.2) were more depressed and were ill longer. During treatment, 81.5% of suicidal patients became non‐suicidal; 0.46% of 656 initially non‐suicidal patients reported new suicidal thoughts, with no new attempts. Becoming non‐suicidal was associated with greater depression severity and greater improvement. Conclusion: Suicidal ideation was prevalent in patients with depressed major affective disorder, but most of the initially suicidal patients became non‐suicidal with antidepressant treatment, independent of diagnosis, treatment type or dose.     

Differential response to combined treatment in patients with psychotic versus nonpsychotic major depression

Research has demonstrated that depressed patients with psychotic features show poorer outcomes when treated with pharmacotherapy alone compared with those without psychotic features. However, research has not investigated whether this differential response also applies to combined treatment that includes pharmacotherapy and psychotherapy. In the current study, data were pooled from two clinical trials in which patients diagnosed with major depressive disorder with or without psychotic features were treated with combined treatment. Although similar in severity at pretreatment, results indicated that patients with psychotic depression showed a poorer response in terms of depression severity at postoutpatient treatment and at 6-month follow-up compared with those with nonpsychotic depression. Following treatment, patients with psychotic depression were over four times as likely to exhibit high levels of depression and suicidal ideation. Current state-of-the-art combined treatments have poorer efficacy in depressed patients with psychotic symptoms, and adapted treatment approaches are needed.     

Suicidal ideation in the Finnish general population. A 12-month follow-up study

Background The epidemiology of suicidal ideation has remained a relatively unstudied area. The aim of this study was to investigate the incidence, prevalence and persistence of and recovery from suicidal ideation in a sample of the Finnish general population. Methods Postal questionnaires including the Beck Depression Inventory (BDI) were mailed to the study subjects (n = 1,593) at baseline and on follow-up after 12 months. The suicidality item of BDI was used to screen suicidal ideation. Results The 12-month incidence (4.6 %) and prevalence of suicidal ideation (14.7 %) were higher in men than in women (3.1 % and 9.2 %, respectively). Sixty-nine per cent of those men and 59 % of those women who had suicidal ideation at baseline continued to have suicidal thoughts on follow-up. Suicidal ideation and the severity of depression associated strongly. Over half of the men and women who had persistent suicidal ideation had not visited any health services for help with psychological distress during the 12-month follow-up period. Daily smoking associated with a decreased probability of recovery from suicidal ideation. Conclusions Suicidal ideation is common and persistent at the population level. Seeking professional help for depression with suicidal tendencies is disproportionately low in relation to the high prevalence of suicidal ideation. Accepted: 19 September 2001     

Effects of Health-Related Quality of Life on Suicidal Ideation and Depression among Older Korean Adults: A Cross-Sectional Study

Objective The aim of this study was to investigate the prevalence of depression and suicidal ideation among older Korean adults and the predictors of suicidal ideation. Methods We analyzed data from 5,604 Koreans aged 65 or older collected by the Korea National Health and Nutrition Examination Survey in 2012–2016, an annual national, cross-sectional, epidemiologic study of the Korean population. A chi-square test was used to assess differences in socio-demographic characteristics by suicidal ideation. Psychological variables, self-rated physical health, and the five dimensions of the Korean version of the EQ-5D (EuroQoL) were compared between four subgroups categorized according to the presence/absence of suicidal ideation and depression. Multiple logistic regression was used to estimate the predictive power of health-related quality of life variables, as well as physical and psychological factors regarding suicidal ideation. Results Overall, 11.5% of the sample reported suicidal ideation, and 20.0% of the suicidal ideation group were diagnosed with depression. Respondents with suicidal ideation had significantly lower levels of health-related quality of life than those without suicidal ideation. EQ-5D self-control (OR=1.42), anxiety/depression (OR=2.32), depression (OR=2.07), and self-rated physical health (OR=1.36) were found to significantly predict suicidal ideation. Conclusion Suicidal ideation without depression was prevalent among older Koreans. Self-control, anxiety/depression of EQ-5D, selfrated physical health, and depression predicted suicidal ideation. Interventions to screen older Koreans for early detection of suicide risk and prevention strategies should consider evaluating each EQ-5D dimension.     

Adequacy of, attitudes toward, and adherence to treatments by suicidal and nonsuicidal depressed patients

We examined differences in treatments received, and attitudes and adherence to them between suicidal and nonsuicidal patients with major depressive disorder (MDD). Psychiatric MDD patients with no suicidal behavior (N = 92), suicidal ideation (N = 92), or attempts (N = 34) were compared during 6 months of follow-up in the Vantaa Depression Study (VDS). Patients with suicidal behavior received antidepressants or adequate antidepressant treatment significantly more often, had more frequent appointments with psychiatrists, more psychotherapeutic support, and more favorable attitudes toward antidepressant treatment than nonsuicidal patients. However, after adjusting for the confounding severity of depression, the significance of these differences was lost. Adherence to treatment was similar in the patient groups. Overall, among psychiatric patients with MDD, those known to be suicidal have higher suicide risk and should receive more intensive treatment. However, suicidal behavior per se does not seem to markedly influence treatments provided nor should it be associated with negative attitudes or poor adherence to treatments.     

Hopelessness and suicidal ideation in outpatients with treatment-resistant depression: prevalence and impact on treatment outcome

Depression and hopelessness are risk factors for suicide. The purpose of this study was to examine the extent of suicidal ideation and hopelessness in outpatients with treatment-resistant depression (TRD) and to study the impact of suicidal ideation and hopelessness on treatment with nortriptyline (NT). The degree of suicidal ideation and hopelessness was assessed during the screen visit with the use of items #3 and #30 of the Hamilton Depression Rating Scale (HAM-D) in 89 patients with TRD who entered a 6-week open trial of NT. Forty of these patients also completed the Beck Hopelessness Index (BHI) during the screen visit. In separate logistic regressions, the scores from the BHI and the two HAM-D items were then tested as predictors of clinical response to the 6-week trial with NT, controlling for the severity of depression. More than half of patients reported thoughts or wishes of death to self and significant hopelessness. A greater degree of hopelessness before treatment in completers, reflected by the score on the HAM-D item #30, predicted response to NT. More than half of patients with prominent hopelessness who completed the trial responded. Patients with TRD are more likely than not to report prominent suicidal ideation and hopelessness. Furthermore, a full 6-week trial of NT, a relatively noradrenergic tricyclic antidepressant, may be particularly useful in patients who have failed to respond to several antidepressants and also report significant hopelessness.     

Depression, desperation, and suicidal ideation in college students: results from the American Foundation for Suicide Prevention College Screening Project at Emory University

The objective of this investigation was to examine suicidal ideation and depression in undergraduate college students who participated in the American Foundation for Suicide Prevention-sponsored College Screening Project at Emory University. The principal measure of depressive symptoms was the nine-item depression module from the Patient Health Questionnaire (PHQ-9). Additional questions were focused on current suicidal ideation, past suicide attempts, and episodes of deliberate self-harm and on symptoms of anxiety and distress. Seven hundred and twenty-nine students participated over a 3-school-year interval (2002-2005). Most notably, 11.1% of the students endorsed current (past 4 weeks) suicidal ideation and 16.5% had a lifetime suicide attempt or self-injurious episode. Students with current suicidal ideation had significantly higher depression symptom severity than those without suicidal ideation (t = -9.34, df = 706, P<.0001, d = 1.9), and 28.5% of the students with PHQ-9 scores of 15 or higher reported suicidal ideation compared to 5.7% of those with lower scores (chi(2) = 56.29, df = 1, P<.0001, two-tailed). Suicidal ideation was prominently associated with symptoms of desperation (odds ratio 2.6, 95% CI 1.5-4.6, P<.001). The vast majority of students with moderately severe to severe depression (85%) or current suicidal ideation (84%) were not receiving any psychiatric treatment at the time of assessment. These results suggest that there is a strong relationship between severity of depressive symptoms and suicidal ideation in college students, and that suicidal feelings and actions are relatively common in this group. This underscores the need to provide effective mental health outreach and treatment services to this vulnerable population. As this analysis was based on data collected at a single institution, the results may not be representative of all college students or young adults.     

Treating late-life depression with interpersonal psychotherapy in the primary care sector

BACKGROUND: Interpersonal psychotherapy (IPT) is an empirically-validated intervention for treating late-life depression. OBJECTIVE: To determine the manner in which IPT is utilized by primary care physicians in relation to antidepressant medications. METHODS: The authors reviewed treatment logs prepared by care managers during the first 12 months of a patient's participation in the PROSPECT clinical trial to determine initial and longitudinal treatment patterns utilized by physicians, and clinical outcomes associated with initial treatment assignment. RESULTS: Primary care physicians in practices randomized to PROSPECT's intervention arm initially prescribed an antidepressant medication for 58% of eligible patients and referred only 11% of them to IPT. Over time, however, 27% of patients participated in IPT as monotherapy or augmentation therapy. Initial treatment assignment was not associated with depressive status at 4 and 12 months nor with suicidal ideation at 4, 8, and 12 months. CONCLUSION: IPT is an effective treatment for late-life depression whose greater use by primary care physicians should be encouraged.