Occurrence and Course of Suicidality During Short-term Treatment of Late-Life Depression | Depressive Disorders | JAMA Psychiatry | JAMA Network
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Szanto  KGildengers  AGMulsant  BHBrown  GAlexopoulos  GReynolds  CF Identification of suicidal ideation and prevention of suicidal behavior in the elderly.  Drugs Aging. 2002;1911- 24Google ScholarCrossref
Frierson  RL Suicide attempts by the old and the very old.  Arch Intern Med. 1991;151141- 144Google ScholarCrossref
Conwell  YDuberstein  PRCox  CHerrmann  JHForbes  NTCaine  ED Relationships of age and Axis I diagnoses in victims of completed suicide: a psychological autopsy study.  Am J Psychiatry. 1996;1531001- 1008Google Scholar
Forsell  YJorm  AFWinblad  B Suicidal thoughts and associated factors in an elderly population.  Acta Psychiatr Scand. 1997;95108- 111Google ScholarCrossref
Skoog  IAevarsson  OBeskow  JLarsson  LPalsson  SWaern  MLandahl  SOstling  S Suicidal feelings in a population sample of nondemented 85-year-olds.  Am J Psychiatry. 1996;1531015- 1020Google Scholar
Shah  AHoxley  KMayadunne  V Suicidal ideation in acutely medically ill elderly inpatients: prevalence, correlates and longitudinal stability.  Int J Geriatr Psychiatry. 2000;15162- 169Google ScholarCrossref
Draper  BMacCuspie-Moore  CBrodaty  H Suicidal ideation and the "wish to die" in dementia patients: the role of depression.  Age Ageing. 1998;27503- 507Google ScholarCrossref
Alexopoulos  GSBruce  MLHull  JSirey  JAKakuma  T Clinical determinants of suicidal ideation and behavior in geriatric depression.  Arch Gen Psychiatry. 1999;561048- 1053Google ScholarCrossref
Mann  JJWaternaux  CHaas  GLMalone  KM Toward a clinical model of suicidal behavior in psychiatric patients.  Am J Psychiatry. 1999;156181- 189Google Scholar
Szanto  KReynolds  CFConwell  YBegley  AEHouck  PR High levels of hopelessness persist in geriatric patients with remitted depression and a history of suicide attempt.  J Am Geriatr Soc. 1998;461401- 1406Google Scholar
Szanto  KPrigerson  HGReynolds  CF Suicide in the elderly.  Clin Neurosci Res. 2001;1366- 376Google ScholarCrossref
Mann  JJBrent  DAArango  V The neurobiology and genetics of suicide and attempted suicide: a focus on the serotonergic system.  Neuropsychopharmacology. 2001;24467- 477Google ScholarCrossref
Fava  MRosenbaum  JF Anger attacks in patients with depression.  J Clin Psychiatry. 1999;60Suppl 1521- 24Google Scholar
Conwell  YLyness  JMDuberstein  PCox  CSeidlitz  LDiGiorgio  ACaine  ED Completed suicide among older patients in primary care practices: a controlled study.  J Am Geriatr Soc. 2000;4823- 29Google Scholar
Salib  ETadros  GCawley  S Elderly suicide and attempted suicide: one syndrome.  Med Sci Law. 2001;41250- 255Google Scholar
Szanto  KReynolds  CFFrank  EStack  JFasiczka  ALMiller  MDMulsant  BHMazumdar  SKupfer  DJ Suicide in elderly depressed patients: is "active" vs "passive" suicidal ideation a clinically valid distinction?  Am J Geriatr Psychiatry. 1996;4197- 207Google ScholarCrossref
Gildengers  AGHouck  PRMulsant  BHPollock  BGMazumdar  SMiller  MDDew  MAFrank  EKupfer  DJReynolds  CF Course and rate of antidepressant response in the very old.  J Affect Disord. 2002;69177- 184Google ScholarCrossref
Endicott  JSpitzer  RL A diagnostic interview: the Schedule for Affective Disorders and Schizophrenia.  Arch Gen Psychiatry. 1978;35837- 844Google ScholarCrossref
Mulsant  BHPollock  BGNebes  RMiller  MLittle  JTStack  JHouck  PRBensasi  SMazumdar  SReynolds  CF A double-blind randomized comparison of nortriptyline and paroxetine in the treatment of late-life depression: 6-week outcome.  J Clin Psychiatry. 1999;6016- 20Google Scholar
Mulsant  BHPollock  BGNebes  RMiller  MDSweet  RAStack  JHouck  PRBensasi  SMazumdar  SReynolds  CF A twelve-week double-blind randomized comparison of nortriptyline and paroxetine in older depressed in patients and outpatients.  Am J Geriatr Psychiatry. 2001;9406- 414Google ScholarCrossref
Miller  MDCornes  CFrank  EEhrenpreis  LSilberman  RSchlernitzauer  MATracey  BRichards  VWolfson  LZaltman  JBensasi  SReynolds  CF Interpersonal psychotherapy for late-life depression: past, present and future.  J Psychother Pract Res. 2001;10231- 238Google Scholar
Hamilton  M Development of a rating scale for primary depressive illness.  Br J Soc Clin Psychol. 1967;6278- 296Google ScholarCrossref
Folstein  MFFolstein  SWMcHugh  PR "Mini-Mental State": a practical method for grading the cognitive state of patients for the clinician.  J Psychiatr Res. 1975;12189- 198Google ScholarCrossref
Miller  MDParadis  CFHouck  PRMazumdar  SStack  JARifai  AHMulsant  BReynolds  CF Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale.  Psychiatry Res. 1992;41237- 248Google ScholarCrossref
Beck  ATKovacs  MWeissman  A Assessment of suicidal intention: the Scale for Suicide Ideation.  J Consult Clin Psychol. 1979;47343- 352Google ScholarCrossref
Cheng  ATChen  THChen  CCJenkins  R Psychosocial and psychiatric risk factors for suicide: case-control psychological autopsy study.  Br J Psychiatry. 2000;177360- 365Google ScholarCrossref
Mann  JJKapur  S The emergence of suicidal ideation and behavior during antidepressant pharmacotherapy.  Arch Gen Psychiatry. 1991;481027- 1033Google ScholarCrossref
Reynolds  CFDew  MAFrank  EBegley  AEMiller  MDCornes  CMazumdar  SPerel  JMKupfer  DJ Effects of age at onset of first lifetime episode of recurrent major depression on treatment response and illness course in elderly patients.  Am J Psychiatry. 1998;155795- 799Google Scholar
Zweig  RAHinrichsen  GA Factors associated with suicide attempts by depressed older adults: a prospective study.  Am J Psychiatry. 1993;1501687- 1692Google Scholar
Szanto  KMulsant  BHHouck  PRMiller  MDMazumdar  SReynolds  CF Treatment outcome in suicidal versus non-suicidal elderly.  Am J Geriatr Psychiatry. 2001;9261- 268Google ScholarCrossref
Detre  TPJarecki  HG Modern Psychiatric Treatment.  Philadelphia, Pa JB Lippincott1971;
Worthington  JFava  MDavidson  KAlpert  JNierenberg  AARosenbaum  JF Patterns of improvement in depressive symptoms with fluoxetine treatment.  Psychopharmacol Bull. 1995;31223- 226Google Scholar
Haskell  DSDiMascio  APrusoff  B Rapidity of symptom reduction in depressions treated with amitriptyline.  J Nerv Ment Dis. 1975;16024- 33Google ScholarCrossref
Waern  MBeskow  JRuneson  BSkoog  I Suicidal feelings in the last year of life in elderly people who commit suicide.  Lancet. 1999;354917- 918Google ScholarCrossref
Original Article
June 2003

Occurrence and Course of Suicidality During Short-term Treatment of Late-Life Depression

Author Affiliations

From the Department of Psychiatry, the Intervention Research Center for the Study of Late-Life Mood Disorders (Drs Szanto, Mulsant, Dew, and Reynolds and Ms Houck), and the Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System (Dr Mulsant), Pittsburgh, Pa. Dr Mulsant is now with the Western Psychiatric Institute and Clinic, Pittsburgh. Drs Mulsant and Reynolds have received honoraria and/or grant support from antidepressant manufacturers, including Bristol-Myers Squibb, Wallingford, Conn; Eli Lilly & Co, Indianapolis, Ind; Forest Pharmaceuticals Inc, St Louis, Mo; GlaxoSmithKline, Brentford, Middlesex, England; Pharmacia & Upjohn, Inc, Kalamazoo, Mich; Pfizer Inc, New York, NY; and Solvay Pharmaceuticals, Marietta, Ga.

Arch Gen Psychiatry. 2003;60(6):610-617. doi:10.1001/archpsyc.60.6.610

Background  Elderly persons (≥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 in patients 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.