MEDICATIONS: SUICIDAL OLDER PATIENTS WITH DEPRESSION TAKE LONGER TO RESPOND TO TREATMENT

June 10, 2003 — Suicidal elderly patients with depression require special attention during therapy because they have a lower response rate and take longer to respond to treatment, according to an article in The Archives of General Psychiatry, one of the JAMA/Archives journals.

According to information in the article, people 65 years old and older have the highest rate of suicide, but little is known about the occurrence and course of thoughts about suicide (suicidal ideation) during the treatment of depression in elderly patients.

Benoit H. Mulsant, M.D., of Western Psychiatric Institute and Clinic, Pittsburgh, and colleagues investigated how suicidal ideation changes during short-term depression treatment and whether the response to treatment differed among three groups of patients depending on their level of suicidality at the beginning of the study.

Patients were divided into three groups as follows: 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); and those with no suicide attempt, suicidal ideation or thoughts of death (low-risk group, n=206). All participants were part of a previous study of patients with a major depressive episode treated with antidepressants paroxetine hydrochloride or nortryptyline hydrochloride, with or without psychotherapy.

The researchers found that suicidal ideation decreased rapidly early in treatment (weekly, 45-minute psychotherapy sessions), with more gradual changes afterwards. At the beginning of treatment, 77.5 percent of the patients reported suicidal ideation, thoughts of death or feelings that their life is empty. After 12 weeks of treatment, suicidal ideation had resolved in all treated patients, and 4.6 percent still reported thoughts of death.

Six-week and 12-week 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 longer time to respond to treatment than low-risk patients (average time to respond, 6 and 5 vs. 3 weeks).

"View of life markedly changes in a positive direction during successful treatment of late-life depression," write the authors. "Still, persistence is needed to prevent suicides in older patients with depression; high-risk patients experience a slower and less robust response, Thus, they remain at a greater risk for a longer period. Furthermore, as an earlier study has show, older suicidal patients are more likely to require augmentation pharmacotherapy and to relapse when treatment becomes less intensive. Therefore, treating depression in suicidal elderly persons may not be sufficient to prevent suicide."

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