Persistence of suicidal ideation within acute phase treatment of major depressive disorder: analysis of clinical predictors

Abstract

Suicidal ideation (SI) is common in major depressive disorder (MDD), and it is a risk factor for suicidal behaviour. Antidepressants are effective in reducing SI, but in some subjects, SI may persist for weeks. This study aimed to disentangle the contribution of baseline clinical characteristics in SI nonremission at week 6. Research involved 198 outpatients with MDD and SI collected within the Combining Medications to Enhance Depression Outcomes trial and treated with different antidepressant combinations. Although SI decreased from baseline to week 6 (P < 0.0001), 78 patients (39%) failed to achieve SI remission. Insomnia [OR, 0.72; 95% confidence interval (CI), 0.52–0.99], reduced need for sleep (OR, 0.75; 95% CI, 0.58–0.99), self-confidence (OR, 0.52; 95% CI, 0.32–0.82), cheerfulness (OR, 0.57; 95% CI, 0.33–0.98), and comorbid panic disorder (OR, 0.93; 95% CI, 0.87–0.99) at baseline were associated with lack of SI remission after controlling for baseline depression and SI scores. The combination of baseline SI and insomnia was moderately effective in predicting the lack of SI remission, with a specificity of 80% (95% CI, 72–87%) and an NPV of 68% (95% CI, 63–72%). In individuals with MDD and SI, the presence of insomnia and bipolar features should prompt a search for more effective treatment solutions in order to favour SI remission and prevent suicidal behaviour.

In search of clinical targets for suicide prevention in major depressive disorder

“…In this context, one of the most popular approaches is to investigate and quantify suicide risk factors. Pompili (2022) has recently criticised this approach. In his opinion, the mere analysis of risk factors could be too simplistic and reductive as a preventive strategy for suicide.…”

“…Pompili (2022) provocatively argued against the common attitude of simply considering suicidal ideation a symptom of depression. This assumption would hinder a more comprehensive evaluation of patients with MDD experiencing suicidal ideation, including their past and recent traumatic experiences, stressful events, the presence of bipolar features, and current thoughts, emotions, and coping strategies that could contribute to suicidality (Olgiati et al, 2023, ICP – accepted for publication).…”

“…Prior reviews and meta-analyses reported associations of insomnia and nightmares with all suicide behaviours: suicidal ideation, attempted suicide, and suicide death (Pigeon et al, 2012;Bernert et al, 2015;Wang et al, 2019). Subsequent research has enriched this picture with more specific details: there seem to be correlations between insomnia symptom severity, lifetime suicidal behaviour, and mortality from suicide in psychiatric patients (Simmons et al, 2021); the association between insomnia and suicidal ideation is independent of depression (Simmons et al, 2020); the presence of insomnia has been associated with persistence of suicidal ideation during acute antidepressant treatment (Olgiati and Serretti, 2022) as well as in a long-time horizon (Kivela et al, 2019); to treat insomnia by means of pharmacological and psychotherapeutic interventions has been shown to reduce suicidal ideation (McCall et al, 2019;Jernelöv et al, 2021). To date, insomnia is considered one of the most robust predictors of suicidal behaviours (Wu et al, 2023).…”

The challenge of managing difficult to treat psychiatric conditions

“…At present, a few predictors were associated with suicide risk, but they do not have a relevant predictive power (Fanelli et al , 2022; Li et al , 2022). Another issue is that a proper antidepressant treatment is not always effective in reducing suicidal ideation (Olgiati and Serretti, 2022) and a valid doctor-patient relationship may be the most valuable tool to predict and manage suicidal behaviors (Pompili, 2022). Lithium is one of the very few medications that consistently showed an antisuicidal effect (Del Matto et al , 2020).…”

Persistent suicidal ideation in major depressive disorder patients: still in need of empathic understanding

“…The study by Olgiati and Seretti (2022) is relevant to this discussion as it consistently emphasized how suicide ideation may persist in major depressive disorder patients despite treatment. These authors found that although suicidal ideation decreased from baseline to week 6, about 40% of the patients failed to achieve suicidal ideation remission.…”