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Katalin Szanto, MD; Benoit H. Mulsant, MD; Patricia Houck, MSH; Mary Amanda Dew, PhD; Charles F. Reynolds III, MD

Arch Gen Psychiatry. 2003;60:610-617.

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 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.

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.

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