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QuickScan Reviews in Psychiatry, December 30 2011
Antidepressants Reduce Suicidal Ideation in MDD
Effect of Antidepressant Medication Treatment on Suicidal Ideation and Behavior in a Randomized Trial:
An Exploratory Report From the Combining Medications to Enhance Depression Outcomes Study.
J Clin Psychiatry; 2011; 72 (October): 1322-1332
Serotoninergic and noradrenergic antidepressants, both in combination and
as monotherapy, effectively treat suicidal ideation in MDD, and none are likely to be associated with
emergent suicidal ideation.
The Combining Medications to Enhance Depression Outcomes (CO-MED) study tested
the effects of monotherapy versus combination therapy using 2 different medications as initial
treatment for depression. These 2 approaches were compared for remission rates, speed of remission,
tolerability, and long-term benefits.Objective:
To perform a subanalysis of the CO-MED data in order to evaluate the association
between suicide risk and a broad range of clinical characteristics and to assess differential outcomes
for 3 different treatment groups.Methods:
The CO-MED study used a cohort of 665 outpatients with nonpsychotic major depressive
disorder (MDD) to compare the efficacy of escitalopram to 2 antidepressant combinations: venlafaxine
extended release (venlafaxine-XR) plus mirtazapine; and escitalopram plus bupropion sustained release
(bupropion-SR). Based on responses to specific questions on the Concise Health Risk Tracking Self-
Report (CHRT-SR) scale, the presence of suicidal ideation was assessed.Results:
110 participants had pretreatment suicidal ideation, and all 3 treatments were associated
with decreases in suicidal ideation. Patients receiving bupropion-SR plus escitalopram had significantly
greater improvements in suicidal ideation than did patients receiving other medications. For the 555
participants without pretreatment suicidal ideation, emergent ideation was a rare event. Only 1% of
participants taking escitalopram or bupropion-SR plus escitalopram had emergent ideation at week 12.
Approximately 2% of participants taking venlafaxine-XR plus mirtazapine had emergent ideation at
week 12, and about 3% of this group had emergent ideation at week 28. Differences were not
statistically significant between treatment groups on any suicidal measure. More participants receiving
venlafaxine-XR plus mirtazapine attempted suicide (4 of 173 patients) than did participants receiving
the other treatments (escitalopram plus placebo, 0 of 180 patients; bupropion-SR plus escitalopram 0
of 144 patients), and these findings were statistically significant.Conclusions:
In terms of depressive symptoms and function, a positive antidepressant treatment
response is as likely for patients with MDD and suicidal ideation as it is for those without suicidal
ideation. In this study, all 3 treatments resulted in improvements in suicidal ideation, and none were
likely to be associated with emergent suicidal ideation.Reviewer's Comments:
The findings of this study confirm what multiple other studies have
demonstrated: antidepressants appear to be effective in reducing suicidal ideation. Therefore, this
symptom should continue to be an indication to prescribe antidepressants. Of course, the Food and
Drug Administration's warnings should only be interpreted as their recommendation for closer
monitoring of suicidal symptoms in prescribing antidepressants and not as a relative contraindication
in any way. However, as with many other studies, this study was not powered to conclusively find
differences in emergent suicidal ideation. (Reviewer-John G. Koutras, MD).
() Refer to original journal article.
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