title: The association between suicidality and treatment with selective serotonin reuptake inhibitors in older people with major depression: a systematic review.
abstract: BACKGROUND
  Suicide among the elderly is an emerging public health issue. In Australia, suicide is a leading cause of death, most notably amongst elderly men over the age of 75. Depression is one of the main causes of suicide in older people. Selective serotonin reuptake inhibitors are considered to be a safe pharmacological therapy in the management of depression in adults. The risk of suicidality/suicide associated with the use of antidepressants in older people is unclear.
  
  
  OBJECTIVE
  The objective of this review was to determine the association between treatment with selective serotonin reuptake inhibitors and suicidality/suicide in older people who suffer from major depression.
  
  
  METHODS
  
  
  
  METHODS
  Consideration was given to studies that included older people aged 60 years and over, regardless of gender or ethnic background, with Diagnostic and Statistical Manual of Mental Disorders Fourth Edition or equivalent diagnostic criteria for Major Depressive Disorder without psychotic features.  Types of intervention(s)/phenomena of interest:  The review considered treatments using any selective serotonin reuptake inhibitors medication. Comparators included placebo or a different class of antidepressants including monoamine oxidase inhibitors or tricyclic antidepressants.  Types of studies:  This review considered both experimental and observational study designs including randomized controlled trials, non-randomized controlled trials, prospective and retrospective cohort studies and case control studies.  Types of outcomes:  The primary outcome measures of interest in this systematic review were worsening or emergent suicidal ideation, attempted suicide and completed suicide. For this systematic review, the term 'suicide attempt' referred to potentially self-injurious behavior with a non-fatal outcome.
  
  
  METHODS
  A three-step search strategy was employed that aimed to locate both published and unpublished studies in the English language. An initial search in PubMed was followed by a second search using all identified keywords and index terms across multiple databases and grey literature sites. Finally, the reference list of all identified reports and articles were searched for additional studies. METHODOLOGICAL QUALITYÂ : Critical appraisal was undertaken by two independent reviewers using the standard critical appraisal instrument from the Joanna Briggs Institute Mata-Analysis of Statistical Assessment and Review Instrument. The McMaster Quality Assessment Scale for Harms was used to analyse reporting quality on suicide related harm.
  
  
  METHODS
  The primary data on the number of emergent or worsening of suicidal ideation, attempted suicide and completed suicides, in both arms of randomized controlled trials and observational studies was extracted using the standardized data extraction tool from the Joanna Briggs Institute Mata-Analysis of Statistical Assessment and Review Instrument. Baseline demographic data on each study was collected for presentation in tabular format.
  
  
  RESULTS
  The data from randomized controlled trials and observational studies was pooled separately in statistical meta-analysis using RevMan V 5.1 software (The Cochrane Collaboration). Population demographic and other study characteristics were presented in tables and as a narrative summary.
  
  
  RESULTS
  Following critical appraisal, eight randomized controlled trials and five observational studies (i.e. population cohort and retrospective case control studies) with data on suicide-related events were included in the systematic review. Based on the data on TRUNCATED AT 500 WORDS.
authors.affiliation: 1.The Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, South Australia .|2. Noarlunga Mental Health Service, South Australia.
authors.forename: Edward
authors.initials: E
authors.lastname: KoKoAung
authors.affiliation: 1.Noarlunga Mental Health Service, South Australia.|2.Professional Prosthetic and Orthotic Services, Repatriation General Hospital, South Australia.
authors.forename: Sally
authors.initials: S
authors.lastname: Cavenett
authors.affiliation: The Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, South Australia.
authors.forename: Alexa
authors.initials: A
authors.lastname: McArthur
authors.affiliation: The Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, South Australia.
authors.forename: Edoardo
authors.initials: E
authors.lastname: Aromataris
mesh_terms: D000368:Aged; D000929:Antidepressive Agents, Tricyclic / Q000009:adverse effects / Q000627:therapeutic use; D001315:Australia; D003865:Major Depressive Disorder / Q000188:drug therapy* / Q000523:psychology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017367:Selective Serotonin Reuptake Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D059020:Suicidal Ideation; D013406:Suicide, Attempted / Q000517:prevention & control* / Q000523:psychology; D000092864:Suicide Prevention
chemical_list: D000929:Antidepressive Agents, Tricyclic; D017367:Selective Serotonin Reuptake Inhibitors
keywords: Older people; SSRI; antidepressant; major depression; suicidality; suicide attempt