A Southeast Asian expert consensus on the management of major depressive disorder with suicidal behavior in adults under 65 years of age

Abstract

Background The high prevalence of suicidal behavior among individuals with major depressive disorder (MDD) in Southeast Asia (SEA) underscores the need for optimized management to address depressive symptoms, reduce suicide risk and prevent suicide in these individuals. Given the lack of clear guideline recommendations for assessing and managing these patients, regional consensus-based recommendations which take into account diverse local contexts across SEA may provide useful guidance for clinical practice. Methods A narrative literature review and pre-meeting survey were conducted prior to the consensus meeting of an SEA expert panel comprising 13 psychiatrists with clinical experience in managing patients with MDD with suicidal behavior. Utilizing the RAND/UCLA Appropriateness Method, the expert panel developed consensus-based recommendations on the assessment and treatment of adult patients with MDD with suicidal behavior under 65 years. Results Screening of adult patients under 65 years with MDD for suicide risk using both a validated assessment tool and clinical interview is recommended. An improved suicide risk stratification – incorporating both severity and temporality, or using a prevention-focused risk formulation – should be considered. For a patient with an MDD episode with low risk of suicide, use of antidepressant monotherapy, and psychotherapy in combination with pharmacological treatment are both recommended approaches. For a patient with an MDD episode with high risk of suicide, or imminent risk of suicide requiring rapid clinical response, or for a patient who had received adequate AD but still reported suicidal behavior, recommended treatment strategies include antidepressant augmentation, combination use of psychotherapy or electroconvulsive therapy with pharmacological treatment, and inpatient care. Suicide-specific psychosocial interventions are important for suicide prevention and should also be part of the management of patients with MDD with suicidal behavior. Conclusions There are still unmet needs in the assessment of suicide risk and availability of treatment options that can deliver rapid response in patients with MDD with suicidal behavior. These consensus recommendations on the management of adult patients with MDD with suicidal behavior under 65 years may serve as a useful guidance in diverse clinical practices across the SEA region. Clinical judgment based on careful consideration of individual circumstances of each patient remains key to determining the most appropriate treatment option.

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“…In Indonesia, depression is ranked as one of the leading causes of disability-adjusted life years (ref). Currently, there are still unmet needs in the assessment and treatment of individuals with depression and SI 7. Moreover, studies identified specific cultural and social risk factors for suicide in Southeast Asia, such as the level of religious involvement and severity of interpersonal problems 8.…”

“…Currently, there are still unmet needs in the assessment and treatment of individuals with depression and SI. 7 Moreover, studies identified specific cultural and social risk factors for suicide in Southeast Asia, such as the level of religious involvement and severity of interpersonal problems. 8 Also, compared with high-income countries (HICs), the male-to-female ratio for suicide is closer to 1, 2 and the overall reported prevalence of mental health conditions is lower in Southeast Asia.…”

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“…In China, the estimated prevalence of SA in patients with MDD is 23.7% [3], highlighting the strong need for early detection and intervention of SA among these patients. Numerous studies have identi ed some risk factors for SA in patients with MDD, such as gender [4], genetic factors [5,6], substance use [7,8], stressful life events [9,10], and anxiety [11,12].…”