critical issues in elderly suicide prevention. Despite efforts in prevention at a national level, one American is lost to suicide every 16 min- utes

To the Editor: Dr. Warner’s letter highlights critical issues in elderly suicide prevention. Despite efforts in prevention at a national level, one American is lost to suicide every 16 min- utes. The toll is particularly high for men over the age of 75 years, who have a suicide rate 3.3 times higher than that of the general population, reaching 35.7 per 100,000 individuals (1). However, these numbers are underestimates because of underreporting.

Despite the alarming statistics, little is directly known about prevention interventions in later life. Dr. Warner points out several risk factors for suicide. However, there is limited direct evidence that addressing these factors (e.g., treating depression and pain, enriching the social network of persons at risk, removing firearms) reduces the incidence of suicide. The PROSPECT study focused on patients 60 years of age and older (75–84 years: N=155; ≥85: N=30) and used suicidal ide- ation and depressive symptoms as a proxy for suicide preven- tion. We selected this strategy for two reasons. First, depres- sion and suicidal ideation are risk factors for suicide. Second, there is face value in ameliorating depressive symptoms and thus reduction of suffering and family disruption and im- proved outcomes of several comorbid medical disorders. Showing that the PROSPECT intervention works in primary care patients is important because two-thirds of depressed older adults are exclusively treated in the primary care sec- tor. Nonetheless, the PROSPECT study provides no more than indirect evidence of the effectiveness of an intervention for suicide prevention.

Errors in the assessment and treatment planning of elderly suicidal patients can be fatal. Among elderly persons, there are only four suicide attempts for every completed suicide, but there are 100 to 200 attempts per completed suicide in individuals aged 15–24 years (1). Assessment difficulties arise, to a large measure, from the older patients’ reluctance to share thoughts on suicide and from poor acceptance of sui- cide risk by patients’ families. Much of the difficulty in treat- ment planning arises from the absence of direct knowledge of the effectiveness of clinical interventions specific to elderly suicide prevention. Another reason is the expectation by cli- nicians and families that suicide can be prevented in most, if not all, cases. This unrealistic expectation is in part generated by an emotional reaction caused by stigmatization of suicide and often leads to treatment measures that are either idiosyn- cratic, overly restrictive, or both.

We believe that direct studies of interventions for elderly suicide prevention and systematic efforts to destigmatize sui- cide are two initiatives likely to make a difference. Currently, our approach in the reduction of suicide risk must rely on in- direct findings of factors associated with high suicide rates. However, definitive guidance to clinicians can only come from effectiveness studies of specific interventions targeting reduction of suicide itself rather than reduction of suicide risk factors. Destigmatization of suicide and mental illness at the community level and during clinical interactions with

patients and families is critical. It can increase the accuracy and promptness of reporting suicide thoughts and related symptoms by patients and families, set appropriate outcome expectations, and allow clinicians to make informed and ra- tional treatment plans.

Reference

1. Centers for Disease Control and Prevention: Web-based Injury Statistics Query and Reporting System (WISQARS). Washington, DC, United States Department of Health and Human Services. www.cdc.gov/ncipc/wisqars

GEORGE S. ALEXOPOULOS, M.D.

White Plains, N.Y.

The author’s disclosures accompany the original article.

This letter (doi: 10.1176/appi.ajp.2009.09091254r) was accept- ed for publication in October 2009.

Limitations of the Hamilton Anxiety Rating Scale as a Primary Outcome Measure in Ran- domized, Controlled Trials of Treatments for Generalized Anxiety Disorder

To the Editor: In the August 2009 issue of the Journal, Falk Leichsenring, D.Sc., et al. (1) presented findings from a randomized, controlled trial comparing short-term psycho- dynamic psychotherapy and cognitive-behavioral therapy (CBT) in patients with generalized anxiety disorder. We are pleased to see a trial assessing the efficacy of short-term psy- chodynamic psychotherapy, a form of psychotherapy that has not been adequately studied in the treatment of anxiety disorders. However, despite the importance of the questions addressed in this study, there is a serious methodological con- cern that limits the conclusions that can be drawn.

The issue is the primary outcome measure. In random- ized, controlled trials, the primary outcome measure is the principal indicator by which the efficacy of an intervention is evaluated. It measures the outcome of greatest importance in a trial. The principal indicator of treatment efficacy in this study was the Hamilton Anxiety Rating Scale (HAM-A), a clinician-administered scale that assesses the severity of 14 broad categories of symptoms, presumed to be associated with anxiety. HAM-A has been used as an outcome measure in numerous generalized anxiety disorder treatment studies and has long been the standard primary outcome measure in pharmacological randomized, controlled trials.

At one time, when generalized anxiety disorder was a non- specific disorder characterized by diffuse anxiety symptoms, the use of HAM-A was appropriate. However, with the intro- duction of DSM-III-R in 1987, generalized anxiety disorder became a disorder of worry. The central symptom of DSM-IV- TR-defined generalized anxiety disorder is excessive and un- controllable worry. HAM-A does not adequately measure the central symptom of DSM-IV-TR generalized anxiety disorder (2). Furthermore, most of the symptoms assessed by HAM-A (e.g., cardiovascular, respiratory, and gastrointestinal symp- toms) are not among the DSM-IV-TR-associated symptoms of generalized anxiety disorder. HAM-A has been in existence for one-half century and remains a popular instrument for as- sessing anxiety despite these limitations. However, the scale is poor at discriminating between generalized anxiety disor-