How to Monitor Suicidal Ideation After Esketamine and Adjunctive CBT
Which measures should clinicians use to follow suicidal ideation and related worsening after esketamine with or without CBT in major depression?
Follow-up after acute esketamine in major depression with suicidal ideation requires repeated assessment, but not all suicidality scales performed similarly in this trial. The study provides a practical monitoring framework by showing which measures were more sensitive to change and by defining an event-based worsening signal used during follow-up.
-
Assess both suicidal ideation and overall depressive severity
Do not rely on a single suicidality item alone. The trial followed patients using the Beck Scale for Suicidal Ideation, the Columbia-Suicide Severity Rating Scale, clinician global impression ratings for suicide severity and improvement, and the Montgomery-Asberg Depression Rating Scale including a composite depression score.
-
Use BSSI as a key repeated ideation measure
Include the self-report BSSI when tracking suicidal ideation over time because it showed sensitivity to between-group differences in this study. By week 18, least squares mean change was -6.01 with CBT versus -4.10 with treatment as usual, a mean difference of -1.91 with P = .025.
-
Pair ideation tracking with clinician global suicide ratings
Add clinician-rated suicide severity and improvement measures because these also detected differences favoring adjunctive CBT. At week 18, CGI improvement differed by -0.37 and CGI severity by -0.33 between groups, both statistically significant.
-
Track broader depression burden with composite MADRS
Monitor overall depressive symptoms alongside suicidality rather than focusing only on the suicidal ideation item. In this trial, the composite MADRS score was more informative than the MADRS suicidal ideation subitem, with a week-18 between-group difference of -3.77 favoring CBT while the SI item did not reach significance.
-
Do not depend on the C-SSRS ideation subscale alone for change detection
The authors noted that the C-SSRS is suitable for assessing suicide risk and may be especially useful for suicide-related behaviors, but in this trial it was the least sensitive ideation measure for detecting group differences. The C-SSRS ideation-only score showed no difference between groups at week 18, with a group difference of 0.13 and P = .623.
-
Define clinically important worsening with an event-based threshold
When monitoring for deterioration, the trial counted an event as suicide death, attempted suicide, psychiatric hospitalization, or a 75% or greater increase from baseline in BSSI for 2 consecutive ratings. This offers a concrete event-oriented framework for identifying worsening during follow-up.
Clinical Considerations
- These assessment findings come from a randomized trial designed primarily for feasibility, not from a definitive validation study comparing suicide rating scales.
- The study found no difference between groups in event-based survival analysis, so the monitoring approach should not be interpreted as proving event reduction.
- The C-SSRS may still be useful for assessing suicide-related behaviors even though its ideation subscale was less sensitive than other measures in this trial.
Bottom Line
After esketamine for major depression with suicidal ideation, monitor with BSSI plus clinician global suicide ratings and overall depression severity, and do not rely on the C-SSRS ideation subscale alone to detect clinical change.
