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Suicidal Events in the Treatment for Adolescents With Depression Study (TADS)Benedetto Vitiello, MD; Susan G. Silva, PhD; Paul Rohde, PhD; Christopher J. Kratochvil, MD; Betsy D. Kennard, PsyD; Mark A. Reinecke, PhD; Taryn L. Mayes, MS; Kelly Posner, PhD; Diane E. May, MSN; and John S. March, MD, MPHObjective: 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. Method: 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 ≥ 31) and depressive symptoms (Reynolds Adolescent Depression Scale score ≥ 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. Conclusion: 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.
(J Clin Psychiatry 2009;70(5):741-747. doi:10.4088/JCP.08m04607) Received August 8, 2008; accepted November 24, 2008. From the National Institute of Mental Health, Bethesda, Maryland (Dr Vitiello); Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina (Drs Silva and March); University of Oregon, Eugene (Dr Rohde); University of Nebraska, Omaha (Dr Kratochvil and Ms May); University of Texas Southwestern Medical Center, Dallas (Dr Kennard and Ms Mayes); Northwestern University, Chicago, Illinois (Dr Reinecke); and Columbia University, New York, New York (Dr Posner). The Treatment for Adolescents with Depression Study was supported by contract N01 MH80008 from the National Institute of Mental Health, Bethesda, MD, to Duke University Medical Center, Durham, NC. The opinions and assertions contained in this publication are the private views of the authors and are not to be construed as official or as reflecting the views of the National Institute of Mental Health, the National Institutes of Health, or the Department of Health and Human Services. Financial disclosure appears at the end of the article. Corresponding author and reprints: Benedetto Vitiello, MD, NIMH, Room 7147, 6001 Executive Blvd, Bethesda, MD 20892-9633 (e-mail: bvitiell@mail.nih.gov). |