Elderly patients with depression who are suicidal require special attention because they have a lower response rate and take longer to respond to treatment than depressed peers who are not at risk for suicide, according to an article in the June issue of the Archives of General Psychiatry.

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

A total of 395 elderly participants with depression were divided into three groups based on baseline level of risk for suicide: those with a recent suicide attempt or current suicidal ideation (high-risk group, 46 patients), those with recurrent thoughts of death (moderate-risk group, 143 patients), and those with no suicide attempt, suicidal ideation or thoughts of death (low-risk group, 206 patients).

All participants were part of a previous study of patients with a major depressive episode who had been treated with the antidepressant paroxetine or nortryptyline, with or without psychotherapy.

K. Szanto, M.D., and his American colleagues found that suicidal ideation decreased rapidly early in treatment (weekly 45-minute psychotherapy sessions), with more gradual changes afterward. At the beginning of treatment, 77.5 percent of patients reported suicidal ideation, such as thoughts of death or feelings that their life is empty. After 12 weeks of treatment, suicidal ideation had resolved in all treated patients, although 4.6 percent still reported thoughts of death.

Rates of response at 6 weeks and 12 weeks were significantly lower in high-risk patients than in low- and moderate-risk patients. For the high- and moderate-risk patients who did respond to treatment, time until response was significantly longer than in the low-risk patients (average time to respond, 6 weeks, 5 weeks, 3 weeks, respectively).

"View of life markedly changes in a positive direction during successful treatment of late-life depression," wrote 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 shown, 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."