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October 8, 1997, Vol 278, No. 14 >
ARTICLE | October 8, 1997

Diagnosis and Treatment of Depression in Late Life: Title and subTitle BreakConsensus Statement Update FREE

Barry D. Lebowitz, PhD; Jane L. Pearson, PhD; Lon S. Schneider, MD; Charles F. Reynolds, III, MD; George S. Alexopoulos, MD; Martha Livingston Bruce, PhD; Yeates Conwell, MD; Ira R. Katz, MD, PhD; Barnett S. Meyers, MD; Mary F. Morrison, MD; Jana Mossey, PhD, MSN; George Niederehe, PhD; Patricia Parmelee, PhD
[+] Author Affiliations

This article is not an NIH Consensus Development Conference Panel statement. It is an update of information provided in the panel statement prepared as a result of the November 1991 NIH Consensus Development Conference on Diagnosis and Treatment of Depression in Late Life. The update was prepared by staff of the National Institute of Mental Health, the lead sponsor of the consensus conference, as well as other investigators in the field. This update is based on information not available at the time of the conference.

Corresponding author: Barry D. Lebowitz, PhD, National Institute of Mental Health, 5600 Fishers Ln, Room 18-101, Rockville, MD 20857 (e-mail: blebowit@nih.gov).


JAMA. 1997;278(14):1186-1190. doi:10.1001/jama.1997.03550140078045
Text Size: A A A
Published online
Article
References

Objective.  —To reexamine the conclusions of the 1991 National Institutes of Health Consensus Panel on Diagnosis and Treatment of Depression in Late Life in light of current scientific evidence.

Participants.  —Participants included National Institutes of Health staff and experts drawn from the Planning Committee and presenters of the 1991 Consensus Development Conference.

Evidence.  —Participants summarized relevant data from the world scientific literature on the original questions posed for the conference.

Process.  —Participants reviewed the original consensus statement and identified areas for update. The list of issues was circulated to all participants and amended to reflect group agreement. Selected participants prepared first drafts of the consensus update for each issue. All drafts were read by all participants and were amended and edited to reflect group consensus.

Conclusions.  —The review concluded that, although the initial consensus statement still holds, there is important new information in a number of areas. These areas include the onset and course of late-life depression; comorbidity and disability; sex and hormonal issues; newer medications, psychotherapies, and approaches to long-term treatment; impact of depression on health services and health care resource use; late-life depression as a risk factor for suicide; and the importance of the heterogeneous forms of depression. Depression in older people remains a significant public health problem. The burden of unrecognized or inadequately treated depression is substantial. Efficacious treatments are available. Aggressive approaches to recognition, diagnosis, and treatment are warranted to minimize suffering, improve overall functioning and quality of life, and limit inappropriate use of health care resources.

REFERENCES

1 +
 Diagnosis and treatment of depression in late life . NIH Consens Statement . 1991;;9( (3) ):Nov 4-6.
2 +
NIH Consensus Panel on Diagnosis and Treatment of Depression in Late Life.  Diagnosis and treatment of depression in late life . JAMA . 1992;;268:1018-1024.
3 +
Schneider LS, Reynolds CF, Lebowitz BD, Friedhoff AJ, eds. Diagnosis and Treatment of Depression in Late Life: Results of the NIH Consensus Development Conference . Washington, DC: American Psychiatric Press; 1994;.
4 +
Alexopoulos GS, Young RC, Shindeckler R.  Brain computed tomography in geriatric depression and primary degenerative dementia . Biol Psychiatry . 1992;;31:591-599.
5 +
Coffey CE, Wilkinson WE, Weiner RD, et al.  Quantitative cerebral anatomy in depression: a controlled magnetic resonance imaging study . Arch Gen Psychiatry . 1993;;50:7-16.
6 +
Krishnan KRR, Gadde KM.  The pathophysiologic basis for late-life depression: imaging studies of the aging brain . Am J Geriatr Psychiatry . 1996;;4( (suppl 1) ):S22-S33.
7 +
Alexopoulos GS, Meyers BS, Young RC, et al.  The course of geriatric depression with 'reversible dementia.' Am J Psychiatry . 1993;;150:1693-1699.
8 +
Alexopoulos GS, Meyers BS, Young RC, et al. The 'vascular depression' hypothesis. Arch Gen Psychiatry. In press.
9 +
Alexopoulos GS, Meyers BS, Young RC, et al.  The clinical presentation of 'vascular depression.' Am J Psychiatry . 1997;;154:562-565.
10 +
Leuchter AF, Dunkin JJ, Lufkin RB, et al.  Effect of white matter disease on functional connections in the aging brain . J Neurol Neurosurg Psychiatry . 1994;;57:1347-1354.
11 +
Leuchter AF, Simon SL, Daly KA, et al.  Quantitative EEG correlates of outcome in older psychiatric patients, II: two-year followup of patients with depression . Am J Geriatr Psychiatry . 1994;;2:290-299.
12 +
Katz IR.  On the inseparability of mental and physical health in aged persons: lessons from depression and medical comorbidity . Am J Geriatr Psychiatry . 1996;;4:1-16.
13 +
Rovner BW, Zisselman P, Shmuely Y.  Depression and disability in elderly persons with impaired vision: a followup study . J Am Geriatr Soc . 1996;;44:181-184.
14 +
Borson S, McDonald GJ, Gayle T, et al.  Improvement in mood, physical symptoms, and function with nortriptyline for depression in patients with chronic obstructive pulmonary disease . Psychosomatics . 1992;;33:190-201.
15 +
Bruce ML, Hoff RA.  Social and physical health risk factors for first onset major depressive disorder in a community sample . Soc Psychiatry Psychiatr Epidemiol . 1994;;29:165-171.
16 +
Bruce ML, Seeman TE, Merrill SS, et al.  The impact of depressive symptomatology on physical disability: MacArthur studies of successful aging . Am J Public Health . 1994;;84:1796-1799.
17 +
Johnson J, Weissman MM, Klerman GL.  Service utilization and social morbidity associated with depressive symptoms in the community . JAMA . 1992;;267:1478-1483.
18 +
Judd LL, Rapaport MH, Paulus MP, et al.  Subsyndromal symptomatic depression: a new mood disorder . J Clin Psychiatry . 1994;;55S:18-28.
19 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Press; 1994;.
20 +
Koenig HG, Blazer DG.  Minor depression in late life . Am J Geriatr Psychiatry . 1996;;4( (suppl 1) ):S14-S21.
21 +
Mossey JM, Knott KA, Craik R.  The effects of persistent depressive symptoms on hip fracture recovery . J Gerontol Med Sci . 1990;;45:M163-M168.
22 +
Mossey JM, Knott KA, Higgins M, et al.  Effectiveness of a psychosocial intervention, interpersonal counseling, for subdysthymic depression in medically ill elderly . J Gerontol Med Sci . 1996;;51A:M172-M178.
23 +
Stone A, Pearlstein T.  Evaluation and treatment of changes in mood, sleep, and sexual functioning associated with menopause . Obstet Gynecol Clin North Am . 1994;;21:391-403.
24 +
Schmidt P, Rubinow D.  Neuroregulatory role of gonadal steroids in humans . Psychopharm Bull . 1997;;33:219-220.
25 +
Truss M, Beato M.  Steroid hormone receptors: interaction with deoxyribonucleic acid and transcription factors . Endocr Rev . 1993;;14:459-479.
26 +
Salzman C, Schneider L, Alexopoulos G.  Pharmacological treatment of depression in late life . In: Bloom F, Kupfer D, eds. Psychopharmacology: Fourth Generation of Progress . New York, NY: Raven Press; 1995;:1471-1477.
27 +
Schneider LS.  Pharmacological considerations in the treatment of late life depression . Am J Geriatr Psychiatry . 1996;;4( (suppl 1) ):S51-S65.
28 +
Tollefson GD, Holman SL.  Analysis of the Hamilton Depression Rating Scale factors from a double-blind, placebo-controlled trial of fluoxetine in geriatric major depression . Int Clin Psychopharmacol . 1993;;8:253-259.
29 +
Roose SP, Glassman AH, Attia E, et al.  Comparative efficacy of selective serotonin reuptake inhibitors and tricyclics in the treatment of melancholia . Am J Psychiatry . 1994;;151:1735-1739.
30 +
Nemeroff CB, De Vane CL, Pollock BG.  Newer antidepressants and the cytochrome P450 system . Am J Psychiatry . 1996;;153:311-320.
31 +
Glassman AH, Roose SP.  Risks of antidepressants in the elderly: tricyclic antidepressants and arrhythmia-revising risks . Gerontology . 1994;;40 ( (suppl 1) ):15-20.
32 +
Niederehe G.  Psychosocial treatments with depressed older adults: a research update . Am J Geriatr Psychiatry . 1996;;4( (suppl 1) ):S66-S78.
33 +
Arean PA, Perri MG, Nezu AM, et al.  Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults . J Consult Clin Psychol . 1993;;61:1003-1010.
34 +
Reynolds CF, Frank E, Perel J, et al.  Maintenance therapies for late life recurrent major depression: research and review circa 1995 . Int Psychogeriatr . 1995;;7( (suppl) ):27-40.
35 +
Alexopoulos GS, Meyers BS, Young RC, et al.  Recovery in geriatric depression . Arch Gen Psychiatry . 1996;;53:305-312.
36 +
Reynolds CF, Frank E, Kupfer DJ, et al.  Treatment outcomes in recurrent major depression: a post hoc comparison of elderly ('young old') and midlife patients . Am J Psychiatry . 1996;;153:1288-1292.
37 +
Fries BE, Mehr DR, Schneider D, et al.  Mental dysfunction and resource use in nursing homes . Med Care . 1993;;31:898-920.
38 +
Simon GE, Von Korff M, Barlow W.  Health care costs of primary care patients with recognized depression . Arch Gen Psychiatry . 1995;;52:850-856.
39 +
Henk HJ, Karzelnick DJ, Kobak KA, et al.  Medical costs attributed to depression among patients with a history of high medical expenses in a health maintenance organization . Arch Gen Psychiatry . 1996;;53:899-904.
40 +
Von Korff M, Ormel H, Katon W, et al.  Disability and depression among high utilizers of health care . Arch Gen Psychiatry . 1992;;19:91-100.
41 +
Cooper-Patrick L, Crum RM, Ford DE.  Characteristics of patients with major depression who received care in general medical and specialty health settings . Med Care . 1994;;32:15-24.
42 +
Callahan CM, Hui SL, Nienaber NA, et al.  Longitudinal study of depression and health services use among elderly primary care patients . J Am Geriatr Soc . 1994;;42:833-838.
43 +
Williams-Russo P.  Barriers to diagnosis and treatment of depression in primary care settings . Am J Geriatr Psychiatry . 1996;;4( (suppl 1) ):S84-S90.
44 +
Williams-Russo P, Petersen J, Charlson ME, et al. Longitudinal course of depressive symptoms after bypass surgery. Presented at the National Institute of Mental Health Primary Care Conference, Rockville, Md, July 1996.
45 +
Callahan CM, Wolinsky FD.  Hospitalization for major depression among older Americans . J Gerontol Med Sci . 1995;;50A:M196-M202.
46 +
Olfson M, Pincus HA.  Outpatient mental health care in nonhospital settings: distribution of patients across provider groups . Am J Psychiatry . 1996;;153:1353-1356.
47 +
Ware JE, Bayliss MS, Rogers WH, et al.  Differences in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-forservice systems . JAMA . 1996;;276:1039-1047.
48 +
Newman AB, Enright PL, Manolio TA, et al.  Sleep disturbance, psychosocial correlates, and cardiovascular disease in 5201 older adults: the Cardiovascular Health Study . J Am Geriatr Soc . 1997;;45:1-7.
49 +
Callahan CM, Hendrie HC, Dittus RS, et al.  Improving treatment of late life depression in primary care: a randomized clinical trial . J Am Geriatr Soc . 1994;;42:839-846.
50 +
Henriksson MM, Marttunen MJ, Isometsä ET, et al.  Mental disorders in elderly suicide . Int Psychogeriatr . 1995;;7:275-286.
51 +
Conwell Y, Duberstein PR, Cox C, et al.  Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study . Am J Psychiatry . 1996;;153:1001-1008.
52 +
Centers for Disease Control and Prevention.  Suicide among older persons—United States, 1980-1992 . MMWR Morb Mortal Wkly Rep . 1996;;45:3-6.
53 +
Conwell Y. Management of suicidal behavior in the elderly. Psychiatr Clin North Am. In press.
54 +
Clark DC.  Narcissistic crises of aging and suicidal despair . Suicide Life Threat Behav . 1993;;23:21-26.
55 +
Duberstein PR.  Openness to experience and completed suicide across the second half of life . Int Psychogeriatr . 1995;;7:183-198.
56 +
Henriksson MM, Isometsä ET, Hietanen PS, et al.  Mental disorders in cancer suicides . J Affect Disord . 1995;;36:11-20.
57 +
Isometsä E, Heikkinen M, Marttunen MJ, et al.  The last appointment before suicide: is suicide intent communicated? Am J Psychiatry . 1995;;152:919-922.
58 +
Gallo JJ, Anthony JC, Muthén BG.  Age differences in the symptoms of depression: a latent trait analysis . J Gerontol Psychol Sci . 1994;;49:P251-P264.
59 +
Allen-Burge R, Storandt M, Kinscherf DA, et al.  Sex differences in the sensitivity of two self-report depression scales in older depressed inpatients . Psychol Aging . 1994;;9:443-445.
60 +
Callahan CM, Hendrie HC, Nienaber NA, et al.  Suicidal ideation among older primary care patients . J Am Geriatr Soc . 1996;;44:1205-1209.
61 +
Rutz W, von Knorring L, Walinder J.  Frequency of suicide in Gotland after systemic postgraduate education of general practitioners . Acta Psychiatr Scand . 1989;;80:151-154.
62 +
Rihmer Z, Rutz W, Pihlgren H.  Depression and suicide in Gotland: an intensive study of all suicides before and after a depression-training programme for general practitioners . J Affective Disord . 1995;;35:147-152.
63 +
Rutz W, von Knorring L, Walinder J.  Long-term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression . Acta Psychiatr Scand . 1992;;85:83-88.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
 Diagnosis and treatment of depression in late life . NIH Consens Statement . 1991;;9( (3) ):Nov 4-6.
2 +
NIH Consensus Panel on Diagnosis and Treatment of Depression in Late Life.  Diagnosis and treatment of depression in late life . JAMA . 1992;;268:1018-1024.
3 +
Schneider LS, Reynolds CF, Lebowitz BD, Friedhoff AJ, eds. Diagnosis and Treatment of Depression in Late Life: Results of the NIH Consensus Development Conference . Washington, DC: American Psychiatric Press; 1994;.
4 +
Alexopoulos GS, Young RC, Shindeckler R.  Brain computed tomography in geriatric depression and primary degenerative dementia . Biol Psychiatry . 1992;;31:591-599.
5 +
Coffey CE, Wilkinson WE, Weiner RD, et al.  Quantitative cerebral anatomy in depression: a controlled magnetic resonance imaging study . Arch Gen Psychiatry . 1993;;50:7-16.
6 +
Krishnan KRR, Gadde KM.  The pathophysiologic basis for late-life depression: imaging studies of the aging brain . Am J Geriatr Psychiatry . 1996;;4( (suppl 1) ):S22-S33.
7 +
Alexopoulos GS, Meyers BS, Young RC, et al.  The course of geriatric depression with 'reversible dementia.' Am J Psychiatry . 1993;;150:1693-1699.
8 +
Alexopoulos GS, Meyers BS, Young RC, et al. The 'vascular depression' hypothesis. Arch Gen Psychiatry. In press.
9 +
Alexopoulos GS, Meyers BS, Young RC, et al.  The clinical presentation of 'vascular depression.' Am J Psychiatry . 1997;;154:562-565.
10 +
Leuchter AF, Dunkin JJ, Lufkin RB, et al.  Effect of white matter disease on functional connections in the aging brain . J Neurol Neurosurg Psychiatry . 1994;;57:1347-1354.
11 +
Leuchter AF, Simon SL, Daly KA, et al.  Quantitative EEG correlates of outcome in older psychiatric patients, II: two-year followup of patients with depression . Am J Geriatr Psychiatry . 1994;;2:290-299.
12 +
Katz IR.  On the inseparability of mental and physical health in aged persons: lessons from depression and medical comorbidity . Am J Geriatr Psychiatry . 1996;;4:1-16.
13 +
Rovner BW, Zisselman P, Shmuely Y.  Depression and disability in elderly persons with impaired vision: a followup study . J Am Geriatr Soc . 1996;;44:181-184.
14 +
Borson S, McDonald GJ, Gayle T, et al.  Improvement in mood, physical symptoms, and function with nortriptyline for depression in patients with chronic obstructive pulmonary disease . Psychosomatics . 1992;;33:190-201.
15 +
Bruce ML, Hoff RA.  Social and physical health risk factors for first onset major depressive disorder in a community sample . Soc Psychiatry Psychiatr Epidemiol . 1994;;29:165-171.
16 +
Bruce ML, Seeman TE, Merrill SS, et al.  The impact of depressive symptomatology on physical disability: MacArthur studies of successful aging . Am J Public Health . 1994;;84:1796-1799.
17 +
Johnson J, Weissman MM, Klerman GL.  Service utilization and social morbidity associated with depressive symptoms in the community . JAMA . 1992;;267:1478-1483.
18 +
Judd LL, Rapaport MH, Paulus MP, et al.  Subsyndromal symptomatic depression: a new mood disorder . J Clin Psychiatry . 1994;;55S:18-28.
19 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition . Washington, DC: American Psychiatric Press; 1994;.
20 +
Koenig HG, Blazer DG.  Minor depression in late life . Am J Geriatr Psychiatry . 1996;;4( (suppl 1) ):S14-S21.
21 +
Mossey JM, Knott KA, Craik R.  The effects of persistent depressive symptoms on hip fracture recovery . J Gerontol Med Sci . 1990;;45:M163-M168.
22 +
Mossey JM, Knott KA, Higgins M, et al.  Effectiveness of a psychosocial intervention, interpersonal counseling, for subdysthymic depression in medically ill elderly . J Gerontol Med Sci . 1996;;51A:M172-M178.
23 +
Stone A, Pearlstein T.  Evaluation and treatment of changes in mood, sleep, and sexual functioning associated with menopause . Obstet Gynecol Clin North Am . 1994;;21:391-403.
24 +
Schmidt P, Rubinow D.  Neuroregulatory role of gonadal steroids in humans . Psychopharm Bull . 1997;;33:219-220.
25 +
Truss M, Beato M.  Steroid hormone receptors: interaction with deoxyribonucleic acid and transcription factors . Endocr Rev . 1993;;14:459-479.
26 +
Salzman C, Schneider L, Alexopoulos G.  Pharmacological treatment of depression in late life . In: Bloom F, Kupfer D, eds. Psychopharmacology: Fourth Generation of Progress . New York, NY: Raven Press; 1995;:1471-1477.
27 +
Schneider LS.  Pharmacological considerations in the treatment of late life depression . Am J Geriatr Psychiatry . 1996;;4( (suppl 1) ):S51-S65.
28 +
Tollefson GD, Holman SL.  Analysis of the Hamilton Depression Rating Scale factors from a double-blind, placebo-controlled trial of fluoxetine in geriatric major depression . Int Clin Psychopharmacol . 1993;;8:253-259.
29 +
Roose SP, Glassman AH, Attia E, et al.  Comparative efficacy of selective serotonin reuptake inhibitors and tricyclics in the treatment of melancholia . Am J Psychiatry . 1994;;151:1735-1739.
30 +
Nemeroff CB, De Vane CL, Pollock BG.  Newer antidepressants and the cytochrome P450 system . Am J Psychiatry . 1996;;153:311-320.
31 +
Glassman AH, Roose SP.  Risks of antidepressants in the elderly: tricyclic antidepressants and arrhythmia-revising risks . Gerontology . 1994;;40 ( (suppl 1) ):15-20.
32 +
Niederehe G.  Psychosocial treatments with depressed older adults: a research update . Am J Geriatr Psychiatry . 1996;;4( (suppl 1) ):S66-S78.
33 +
Arean PA, Perri MG, Nezu AM, et al.  Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults . J Consult Clin Psychol . 1993;;61:1003-1010.
34 +
Reynolds CF, Frank E, Perel J, et al.  Maintenance therapies for late life recurrent major depression: research and review circa 1995 . Int Psychogeriatr . 1995;;7( (suppl) ):27-40.
35 +
Alexopoulos GS, Meyers BS, Young RC, et al.  Recovery in geriatric depression . Arch Gen Psychiatry . 1996;;53:305-312.
36 +
Reynolds CF, Frank E, Kupfer DJ, et al.  Treatment outcomes in recurrent major depression: a post hoc comparison of elderly ('young old') and midlife patients . Am J Psychiatry . 1996;;153:1288-1292.
37 +
Fries BE, Mehr DR, Schneider D, et al.  Mental dysfunction and resource use in nursing homes . Med Care . 1993;;31:898-920.
38 +
Simon GE, Von Korff M, Barlow W.  Health care costs of primary care patients with recognized depression . Arch Gen Psychiatry . 1995;;52:850-856.
39 +
Henk HJ, Karzelnick DJ, Kobak KA, et al.  Medical costs attributed to depression among patients with a history of high medical expenses in a health maintenance organization . Arch Gen Psychiatry . 1996;;53:899-904.
40 +
Von Korff M, Ormel H, Katon W, et al.  Disability and depression among high utilizers of health care . Arch Gen Psychiatry . 1992;;19:91-100.
41 +
Cooper-Patrick L, Crum RM, Ford DE.  Characteristics of patients with major depression who received care in general medical and specialty health settings . Med Care . 1994;;32:15-24.
42 +
Callahan CM, Hui SL, Nienaber NA, et al.  Longitudinal study of depression and health services use among elderly primary care patients . J Am Geriatr Soc . 1994;;42:833-838.
43 +
Williams-Russo P.  Barriers to diagnosis and treatment of depression in primary care settings . Am J Geriatr Psychiatry . 1996;;4( (suppl 1) ):S84-S90.
44 +
Williams-Russo P, Petersen J, Charlson ME, et al. Longitudinal course of depressive symptoms after bypass surgery. Presented at the National Institute of Mental Health Primary Care Conference, Rockville, Md, July 1996.
45 +
Callahan CM, Wolinsky FD.  Hospitalization for major depression among older Americans . J Gerontol Med Sci . 1995;;50A:M196-M202.
46 +
Olfson M, Pincus HA.  Outpatient mental health care in nonhospital settings: distribution of patients across provider groups . Am J Psychiatry . 1996;;153:1353-1356.
47 +
Ware JE, Bayliss MS, Rogers WH, et al.  Differences in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-forservice systems . JAMA . 1996;;276:1039-1047.
48 +
Newman AB, Enright PL, Manolio TA, et al.  Sleep disturbance, psychosocial correlates, and cardiovascular disease in 5201 older adults: the Cardiovascular Health Study . J Am Geriatr Soc . 1997;;45:1-7.
49 +
Callahan CM, Hendrie HC, Dittus RS, et al.  Improving treatment of late life depression in primary care: a randomized clinical trial . J Am Geriatr Soc . 1994;;42:839-846.
50 +
Henriksson MM, Marttunen MJ, Isometsä ET, et al.  Mental disorders in elderly suicide . Int Psychogeriatr . 1995;;7:275-286.
51 +
Conwell Y, Duberstein PR, Cox C, et al.  Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study . Am J Psychiatry . 1996;;153:1001-1008.
52 +
Centers for Disease Control and Prevention.  Suicide among older persons—United States, 1980-1992 . MMWR Morb Mortal Wkly Rep . 1996;;45:3-6.
53 +
Conwell Y. Management of suicidal behavior in the elderly. Psychiatr Clin North Am. In press.
54 +
Clark DC.  Narcissistic crises of aging and suicidal despair . Suicide Life Threat Behav . 1993;;23:21-26.
55 +
Duberstein PR.  Openness to experience and completed suicide across the second half of life . Int Psychogeriatr . 1995;;7:183-198.
56 +
Henriksson MM, Isometsä ET, Hietanen PS, et al.  Mental disorders in cancer suicides . J Affect Disord . 1995;;36:11-20.
57 +
Isometsä E, Heikkinen M, Marttunen MJ, et al.  The last appointment before suicide: is suicide intent communicated? Am J Psychiatry . 1995;;152:919-922.
58 +
Gallo JJ, Anthony JC, Muthén BG.  Age differences in the symptoms of depression: a latent trait analysis . J Gerontol Psychol Sci . 1994;;49:P251-P264.
59 +
Allen-Burge R, Storandt M, Kinscherf DA, et al.  Sex differences in the sensitivity of two self-report depression scales in older depressed inpatients . Psychol Aging . 1994;;9:443-445.
60 +
Callahan CM, Hendrie HC, Nienaber NA, et al.  Suicidal ideation among older primary care patients . J Am Geriatr Soc . 1996;;44:1205-1209.
61 +
Rutz W, von Knorring L, Walinder J.  Frequency of suicide in Gotland after systemic postgraduate education of general practitioners . Acta Psychiatr Scand . 1989;;80:151-154.
62 +
Rihmer Z, Rutz W, Pihlgren H.  Depression and suicide in Gotland: an intensive study of all suicides before and after a depression-training programme for general practitioners . J Affective Disord . 1995;;35:147-152.
63 +
Rutz W, von Knorring L, Walinder J.  Long-term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression . Acta Psychiatr Scand . 1992;;85:83-88.

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