Suicidality and risk of suicide--definition, drug safety concerns, and a necessary target for drug development: a consensus statement.
OBJECTIVE
To address issues concerning potential treatment-emergent "suicidality," a consensus conference was convened March 23-24, 2009.


METHODS
This gathering of participants from academia, government, and industry brought together experts in suicide prevention, clinical trial design, psychometrics, pharmacoepidemiology, and genetics, as well as research psychiatrists involved in studies of major depression, bipolar disorder, schizophrenia, substance abuse/dependence, and other psychiatric disorders associated with elevated suicide risk across the life cycle. The process involved reviews of the relevant literature, and a series of 6 breakout sessions focused on specific questions of interest.


METHODS
Each of the participants at the meeting received references relevant to the formal presentations (as well as the slides for the presentations) for their review prior to the meeting. In addition, the assessment instruments of suicidal ideation/behavior were reviewed in relationship to standard measures of validity, reliability, and clinical utility, and these findings were discussed at length in relevant breakout groups, in the final plenary session, and in the preparation of the article. Consensus and dissenting views were noted.


METHODS
Discussion and questions followed each formal presentation during the plenary sessions. Approximately 6 questions per breakout group were prepared in advance by members of the Steering Committee and each breakout group chair. Consensus in the breakout groups was achieved by nominal group process. Consensus recommendations and any dissent were reviewed for each breakout group at the final plenary session. All plenary sessions were recorded and transcribed by a court stenographer. Following the transcript, with input by each of the authors, the final paper went through 14 drafts. The output of the meeting was organized into this scholarly article, which has been developed by the authors with feedback from all participants at the meeting and represents a consensus view. Any areas of disagreement have been noted.


CONCLUSIONS
The term suicidality is not as clinically useful as more specific terminology (ideation, behavior, attempts, and suicide). Most participants applauded the FDA's effort to promote standard definitions and definable expectations for investigators and industry sponsors by endorsing the terminology in the Columbia Classification Algorithm of Suicide Assessment (C-CASA). Further research of available assessment instruments is needed to verify their utility, reliability, and validity in identifying suicide-associated treatment-emergent adverse effects and/or a signal of efficacy in suicide prevention trials. The FDA needs to build upon its new authority to systematically monitor postmarketing events by encouraging the development of a validated instrument for postmarketing surveillance of suicidal ideation, behavior, and risk within informative large health care-related databases in the United States and abroad. Over time, the FDA, industry, and clinical researchers should evaluate the impact of the current Agency requirement that all CNS clinical drug trials must include a C-CASA-compatible screening instrument for assessing and documenting the occurrence of treatment-emergent suicidal ideation and behavior. Finally, patients at high risk for suicide can safely be included in clinical trials, if proper precautions are followed, and they need to be included to enable premarket assessments of the risks and benefits of medications related to suicidal ideation, suicidal behavior, and suicide in such patients.
Meyer
Roger E
RE
Best Practice Project Management, Inc, PO Box 30219, Bethesda, MD 20824, USA. rmeyer@best-practice.net
Salzman
Carl
C
Youngstrom
Eric A
EA
Clayton
Paula J
PJ
Goodwin
Frederick K
FK
Mann
J John
JJ
Alphs
Larry D
LD
Broich
Karl
K
Goodman
Wayne K
WK
Greden
John F
JF
Meltzer
Herbert Y
HY
Normand
Sharon-Lise T
SL
Posner
Kelly
K
Shaffer
David
D
Oquendo
Maria A
MA
Stanley
Barbara
B
Trivedi
Madhukar H
MH
Turecki
Gustavo
G
Beasley
Charles M
CM
Beautrais
Annette L
AL
Bridge
Jeffrey A
JA
Brown
Gregory K
GK
Revicki
Dennis A
DA
Ryan
Neal D
ND
Sheehan
David V
DV
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000928:Antidepressive Agents / Q000009:adverse effects* / Q000627:therapeutic use; D002648:Child; D002986:Clinical Trials as Topic / Q000941:ethics / Q000592:standards*; D003245:Consensus Statements as Topic; D003865:Major Depressive Disorder / Q000188:drug therapy / Q000523:psychology; D055808:Drug Discovery; D064420:Drug-Related Side Effects and Adverse Reactions; D006801:Humans; D001523:Mental Disorders / Q000188:drug therapy* / Q000523:psychology; D015201:Meta-Analysis as Topic; D011594:Psychometrics; D016032:Randomized Controlled Trials as Topic / Q000941:ethics / Q000706:statistics & numerical data; D015203:Reproducibility of Results; D018570:Risk Assessment; D013405:Suicide / Q000145:classification / Q000523:psychology* / Q000706:statistics & numerical data*; D013406:Suicide, Attempted / Q000145:classification / Q000523:psychology / Q000706:statistics & numerical data; D009626:Terminology as Topic; D014481:United States; D014486:United States Food and Drug Administration
D000928:Antidepressive Agents