Suicidal events in the Treatment for Adolescents With Depression Study (TADS).
OBJECTIVE
The Treatment for Adolescents with Depression Study (TADS) database was analyzed to determine whether suicidal events (attempts and ideation) occurred early in treatment, could be predicted by severity of depression or other clinical characteristics, and were preceded by clinical deterioration or symptoms of increased irritability, akathisia, sleep disruption, or mania.


METHODS
TADS was a 36-week randomized, controlled clinical trial of pharmacologic and psychotherapeutic treatments involving 439 youths with major depressive disorder (DSM-IV criteria). Suicidal events were defined according to the Columbia Classification Algorithm of Suicidal Assessment. Patients were randomly assigned into the study between spring 2000 and summer 2003.


RESULTS
Forty-four patients (10.0%) had at least 1 suicidal event (no suicide occurred). Events occurred 0.4 to 31.1 weeks (mean +/- SD = 11.9 +/- 8.2) after starting TADS treatment, with no difference in event timing for patients receiving medication versus those not receiving medication. Severity of self-rated pretreatment suicidal ideation (Suicidal Ideation Questionnaire adapted for adolescents score > or = 31) and depressive symptoms (Reynolds Adolescent Depression Scale score > or = 91) predicted occurrence of suicidal events during treatment (P < .05). Patients with suicidal events were on average still moderately ill prior to the event (mean +/- SD Clinical Global Impressions-Severity of Illness scale score = 4.0 +/- 1.3) and only minimally improved (mean +/- SD Clinical Global Impressions-Improvement scale score = 3.2 +/- 1.1). Events were not preceded by increased irritability, akathisia, sleep disturbance, or manic signs. Specific interpersonal stressors were identified in 73% of cases (N = 44). Of the events, 55% (N = 24) resulted in overnight hospitalization.


CONCLUSIONS
Most suicidal events occurred in the context of persistent depression and insufficient improvement without evidence of medication-induced behavioral activation as a precursor. Severity of self-rated suicidal ideation and depressive symptoms predicted emergence of suicidality during treatment. Risk for suicidal events did not decrease after the first month of treatment, suggesting the need for careful clinical monitoring for several months after starting treatment.
Vitiello
Benedetto
B
NIMH, NIH, Bethesda, MD 20892-9633, USA. bvitiell@mail.nih.gov
Silva
Susan G
SG
Rohde
Paul
P
Kratochvil
Christopher J
CJ
Kennard
Betsy D
BD
Reinecke
Mark A
MA
Mayes
Taryn L
TL
Posner
Kelly
K
May
Diane E
DE
March
John S
JS
D000293:Adolescent; D002648:Child; D015928:Cognitive Behavioral Therapy / Q000379:methods; D003865:Major Depressive Disorder / Q000453:epidemiology* / Q000523:psychology* / Q000628:therapy; D039721:Diagnostic and Statistical Manual of Mental Disorders; D005260:Female; D005473:Fluoxetine / Q000627:therapeutic use*; D006801:Humans; D007508:Irritable Mood; D008297:Male; D011595:Psychomotor Agitation / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use*; D012893:Sleep Wake Disorders / Q000175:diagnosis / Q000453:epidemiology; D013405:Suicide / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires
D005473:Fluoxetine; D017367:Selective Serotonin Reuptake Inhibitors