Antidepressants, Psychotherapy and Emergent Suicidality

A while back, I cam across an interesting study published in the American Journal of Psychiatry. Bridge et. al. (2005) looked at the number of new cases of emergent suicidality during a clinical psychotherapy trial for depression in adolescents and what important predictors were at play. Emergent suicidality can be defined as an increase in the rate of suicide, suicidal attempts, preparation for suicide and suicidal thoughts during the early stages of treatment, although definitions sometimes varies across studies (Meyer et. al. 2010).

The general message of the Bridge et. al. study was that the rate of emergent suicidality in the drug-free psychotherapy trial was 12.5% (this was not attributable to the therapy itself). They also found that the strongest predictor of emergent suicidality was the level of self-reported suicidal thoughts at the baseline rather than what was recorded during the intake interview. So the more suicidal thoughts you have at the start of psychotherapy, the more likely you are to experience suicidality during the psychotherapy treatment.

In this clinical trial, which enrolled subjects similar to those enrolled in pharmacotherapy clinical trials, rates of emergent suicidality in patients receiving psychotherapy but no pharmacotherapy were comparable to rates observed in antidepressant trials. Self-reported suicidality in the week before intake predicted the onset of emergent suicidality to a much greater extent than did interview-rated suicidality, indicating that self-report may be a necessary component to the assessment of adolescent suicidal risk.

This is an important finding, because it casts a shadow of doubt over studies purporting to show an increase level of suicidality during treatment with antidepressants. Bridge et. al. concluded that this suicidality is roughly equal in both antidepressant trials and drug-free psychotherapy trials, which makes it unlikely that antidepressants themselves cause suicide. These studies did not control for baseline level of suicidal thoughts, which is an important confounder.

Emergent suicidality is a common occurrence in psychosocial treatment of adolescent depression, with rates similar to those reported recently in antidepressant trials. To evaluate accurately the role of treatment in emergent suicidality, it is important to assess self-reported suicidality at intake and to balance treatment groups on this key predictor of emergent suicidality.

These findings raise methodological issues for the design and interpretation of psychotherapy and pharmacotherapy treatment trials of depression in young patients. Notably, emergent suicidality, even in those patients who did not report suicidality during the intake interview, occurred fairly commonly.

So to sum up, the level of suicidality observed in drug-free psychotherapy and antidepressant trials are similar, the strongest predictor is base line level of self-reported suicidal thoughts and this was not controlled for in trials looking at suicidality under antidepressant treatments. Using self-reported level of suicidal thoughts is important.

References and Further Reading

Bridge, J. A., Barbe, R.P., Birmaher, B., Kolko, D. J. Brent, D.A. (2005). Emergent Suicidality in a Clinical Psychotherapy Trial for Adolescent Depression. Am J Psychiatry 162(11). 2173-2175.

Meyer RE, S. C., Youngstrom EA, Clayton PJ, Goodwin FK, Mann JJ, Alphs LD, Broich K, Goodman WK, Greden JF, Meltzer HY, Normand SL, Posner K, Shaffer D, Oquendo MA, Stanley B, Trivedi MH, Turecki G, Beasley CM Jr, Beautrais AL, Bridge JA, Brown GK, Revicki DA, Ryan ND, Sheehan DV. (2010). Suicidality and risk of suicide–definition, drug safety concerns, and a necessary target for drug development: a brief report. J Clin Psychiatry, 71(8), 1040-1046.

Cuffe, Steven P. (2007). Suicide and SSRI Medications in Children and Adolescents: An Update. DevelopMentor. Accessed: 2012-04-18.