Biomedical subjects

Katalin Szanto

Publications and source records attributed to Katalin Szanto.

10 recordsLinked to original sources

PubMed2006

Emergence, persistence, and resolution of suicidal ideation during treatment of depression in old age.

INTRODUCTION: To determine the rate and clinical correlates of emergent, persistent, and resolved suicidal ideation during treatment of major depression in the elderly. METHODS: Based on the course of suicidal ideation before and during 12 weeks of antidepressant treatment, we classified 437 elderly patients (234 treated with paroxetine; 203 with nortriptyline) as either non-suicidal or as having "emergent", "persistent", or "resolved" suicidality. We compared the four groups on pretreatment demographic and clinical measures and with respect to depression, anxiety, and akathisia during treatment. RESULTS: Rates of emergent, persistent, and resolved suicidality were 7.8%, 12.6%, and 15.6%, respectively. Patients with persistent suicidal ideation were more likely to have recurrent depression than non-suicidal patients or patients whose suicidality resolved with treatment. At the start of treatment, patients in all three suicidal groups had lower self-esteem than non-suicidal patients. During the course of treatment, emergent suicidality was not associated with akathisia, nor did rates of emergent suicidality differ between paroxetine- and nortriptyline-treated patients. While at baseline the levels of depression and anxiety and agitation were similar in the four groups, patients with resolved suicidality had a favorable treatment response, while patients with emergent and persistent suicidality were more likely to maintain higher depression scores and had higher levels of anxiety and agitation during treatment. DISCUSSION: Emergence of suicidal ideation is not common but is clinically significant during treatment of late-life depression and may signal more difficult-to-treat-depression.

Affect↗

PubMed2006

Maintenance treatment of major depression in old age.

BACKGROUND: Elderly patients with major depression, including those having a first episode, are at high risk for recurrence of depression, disability, and death. METHODS: We tested the efficacy of maintenance paroxetine and monthly interpersonal psychotherapy in patients 70 years of age or older who had depression (55 percent of whom were having a first episode) in a 2-by-2, randomized, double-blind, placebo-controlled trial. Among patients with a response to treatment with paroxetine and psychotherapy, 116 were randomly assigned to one of four maintenance-treatment programs (either paroxetine or placebo combined with either monthly psychotherapy or clinical-management sessions) for two years or until the recurrence of major depression. Clinical-management sessions, conducted by the same nurses, social workers, and psychologists who provided psychotherapy, involved discussion of symptoms. RESULTS: Major depression recurred within two years in 35 percent of the patients receiving paroxetine and psychotherapy, 37 percent of those receiving paroxetine and clinical-management sessions, 68 percent of those receiving placebo and psychotherapy, and 58 percent of those receiving placebo and clinical-management sessions (P=0.02). After adjustment for the effect of psychotherapy, the relative risk of recurrence among those receiving placebo was 2.4 times (95 percent confidence interval, 1.4 to 4.2) that among those receiving paroxetine. The number of patients needed to be treated with paroxetine to prevent one recurrence was 4 (95 percent confidence interval, 2.3 to 10.9). Patients with fewer and less severe coexisting medical conditions (such as hypertension or cardiac disease) received greater benefit from paroxetine (P=0.03 for the interaction between treatment with paroxetine and baseline severity of medical illness). CONCLUSIONS: Patients 70 years of age or older with major depression who had a response to initial treatment with paroxetine and psychotherapy were less likely to have recurrent depression if they received two years of maintenance therapy with paroxetine. Monthly maintenance psychotherapy did not prevent recurrent depression. (ClinicalTrials.gov number, NCT00178100.).

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PubMed2006

Social inequalities in response to antidepressant treatment in older adults.

CONTEXT: We examined the relationship between socioeconomic status and response to treatment for depression among older adults. METHODS: Secondary analysis of pooled data from the open-label phase of 2 National Institute of Mental Health-funded clinical trials of nortriptyline hydrochloride or paroxetine combined with interpersonal psychotherapy (N = 248). We used Cox proportional hazards regression analyses to examine the association between socioeconomic status, indexed by census tract median annual household income and the subject's educational attainment, and treatment response and remission according to the Hamilton Depression Rating Scale. The association between socioeconomic status and suicidality or depressed mood reported at each week of treatment was examined using repeated-measures generalized logit models. RESULTS: Subjects residing in middle-income census tracts were significantly more likely to respond to antidepressant treatment than subjects residing in low-income census tracts (adjusted hazard ratio, 1.80; 95% confidence interval [CI], 1.18-2.75]). Throughout the course of antidepressant treatment, subjects in the middle- and high-income census tracts were significantly less likely to report suicidal ideation (adjusted odds ratios, 0.48 [95% CI, 0.27-0.94] and 0.39 [95% CI, 0.16-0.94], respectively). No association was found between socioeconomic status and remission. CONCLUSION: Residence in a low-income census tract is associated with a less favorable course of depression among older adults receiving a combination of pharmacologic and psychosocial treatment.

Age Factors↗

PubMed2006

Speed of improvement in sleep disturbance and anxiety compared with core mood symptoms during acute treatment of depression in old age.

OBJECTIVES: The objective of this study was to examine the relative speed of improvement in sleep disturbance and anxiety symptoms compared with core mood symptoms in acute treatment of late-life major depression. METHOD: The authors conducted secondary analysis of acute treatment data in 470 older patients treated in three federally funded studies. The authors compared rates of improvement in three Hamilton Rating Scale for Depression symptom clusters after stratification by study. RESULTS: Anxiety symptoms improved more slowly with antidepressant monotherapy and with combined pharmacotherapy/psychotherapy, whereas sleep symptoms improved at a similar rate as core mood symptoms. CONCLUSIONS: Anxiety symptoms tend to persist in patients with late-life depression.

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PubMed2006

Problems in psychotherapy with suicidal patients.

OBJECTIVE: The authors studied recurrent problems in psychotherapy with suicidal patients by examining the cases of patients who died by suicide while receiving open-ended psychotherapy and medication. METHOD: Therapists for 36 patients who died by suicide while in treatment filled out clinical, medication, and psychological questionnaires and wrote detailed case narratives. They then presented their cases at an all-day workshop, and critical problems were identified in the cases. RESULTS: Six recurrent problem areas were identified: poor communication with another therapist involved in the case, permitting patients or relatives to control the therapy, avoidance of issues related to sexuality, ineffective or coercive actions resulting from the therapist's anxieties about a patient's potential suicide, not recognizing the meaning of the patient's communications, and untreated or undertreated symptoms. CONCLUSIONS: These cases illuminate common problems therapists face in working with suicidal patients and highlight an unmet need for education of psychiatrists and other mental health professionals who work with this population.

Adult↗

PubMed2006

Indirect self-destructive behavior and overt suicidality in patients with complicated grief.

BACKGROUND: Complicated grief is associated with increased suicidal ideation in samples of bereaved individuals; however, suicidal behavior has not been assessed in these patients. Additionally, there are no reports of suicidality among help-seeking individuals with complicated grief. Therefore, we examined suicidal behavior and its correlates in 149 patients who signed informed consent statements to participate in a National Institute of Mental Health-funded treatment study of complicated grief. METHOD: All patients met criteria for complicated grief (Inventory of Complicated Grief score>or=25). Suicidality was assessed using a structured clinical interview administered prior to beginning treatment. Participants also completed self-report questionnaires and interview assessment measures rating the presence or absence of DSM-IV Axis I diagnosis and symptom severity. Data were gathered between April 2001 and April 2004. RESULTS: Thoughts of wanting to die following the death of a loved one were reported by 65% of participants. More than half of this group (38% of the study sample) engaged in self-destructive behavior, including 9% who made a suicide attempt and 29% who engaged in indirect suicidal behavior. In a multiple logistic regression model, only the severity of complicated grief symptoms (p<.0001) and history of a suicide attempt (p<.02) were significantly associated with postloss suicidal behavior. DISCUSSION: Consistent with reports of non-help-seeking bereaved people, a high rate of individuals seeking treatment for complicated grief endorsed a wish to die. Notably, 13% of this group made at least 1 suicide attempt, and 44% engaged in indirect self-destructive behavior. Given its frequency, this behavior should be included in assessment of bereaved people.

Attitude to Death↗

PubMed2004

Factors contributing to therapists' distress after the suicide of a patient.

OBJECTIVE: Factors contributing to therapists' severe distress after the suicide of a patient were investigated. METHOD: Therapists for 34 patients who died by suicide completed a semistructured questionnaire about their reactions, wrote case narratives, and participated in a workshop. RESULTS: Thirteen of the 34 therapists were severely distressed. Four factors were identified as sources of severe distress: failure to hospitalize an imminently suicidal patient who then died, a treatment decision the therapist felt contributed to the suicide, negative reactions from the therapist's institution, and fear of a lawsuit by the patient's relatives. Although one emotion was sometimes dominant in the therapist's response to the suicide, severely distressed therapists, compared to others, reported a significantly larger number of intense emotional states. CONCLUSIONS: Over one-third of therapists who experienced a patient's suicide were found to suffer severe distress, pointing to the need for further study of the long-term effects of patient suicide on professional practice.

Adult↗

PubMed2004

Desperation and other affective states in suicidal patients.

Data collected from 26 therapists who were treating patients when they died by suicide were used to identify intense affective states in such patients preceding the suicide. Eleven therapists provided comparable data on 26 patients they had treated who were seriously depressed but not suicidal. Although the two groups had similar numbers diagnosed with MDD, the suicide patients showed a significantly higher total number of intense affects in addition to depression. The acute affective state most associated with a suicide crisis was desperation. Hopelessness, rage, abandonment, self-hatred, and anxiety were also significantly more frequently evidenced in the suicide patients.

Acute Disease↗

PubMed2003

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.

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PubMed2002

Identification of suicidal ideation and prevention of suicidal behaviour in the elderly.

In almost all industrialised countries, men aged 75 years and older have the highest suicide rate among all age groups. Although in younger age groups suicide attempts are often impulsive and communicative acts, suicide attempts in older people (defined as aged 65 years and older) are often long planned and involve high-lethality methods. These characteristics, in addition to the fact that elderly are more fragile and frequently live alone, more often lead to fatal outcome. In later life, in both sexes, the most common diagnosis in those who attempt or complete suicide is major depression. In contrast to other age groups, comorbidity with substance abuse and personality disorders is less frequent. Physical illness plays an important role in the suicidal behaviour of the elderly: most frequently, depression and illness co-occur; less often, the physical illness or the treating medications are causally related to the depressive symptoms. However, only 2 to 4% of terminally ill elderly commit suicide. In addition to physical illness, complicated or traumatic grief, anxiety, unremitting hopelessness after recovery from a depressive episode and history of previous suicide attempts are risk factors for suicide attempts and completed suicide. During a depressive episode, elderly patients with suicidal ideation have higher levels of anxiety and, during treatment, anxiety decreases the probability of remission and recovery. As well as overt suicide attempts, indirect self-destructive behaviours, which often lead to premature death, are common, especially in residents of nursing homes, where more immediate means to commit suicide are restricted. Although we do not have randomised trials of treatment, studies suggest that antidepressant treatment may decrease suicide risk. Prevention and treatment trials are underway to detect the effectiveness of improved treatment of depression by primary care physicians as a means of reducing the prevalence of depressive symptoms, hopelessness and suicidal ideation.

Aged↗