Assessment of Suicidality in Depression Research

A recent meta-analysis (i.e., statistical analysis of multiple studies) found that suicidal thoughts and behaviors are rarely reported in trials of psychological interventions for depression. 

Using Metapsy’s public meta-analytic database, researchers identified randomized controlled trials of psychological treatments for depression. They then examined whether suicidal thoughts and behaviors were included in the eligibility criteria, outcomes, or adverse events for these trials.

The study included randomized controlled trials from January 1, 1966 to May 1, 2023, in which a psychological intervention for depression was compared to a control condition (e.g., treatment as usual) or another active intervention (e.g., medication) in adults with symptoms or a diagnosis of depression. Studies were only included if they used previously validated psychometric scales to assess suicide outcomes. 

The results showed that suicidal thoughts and behaviors were rarely reported in trials of psychological interventions for depression. In more than half of the studies, people at high risk of suicide were excluded from participation.

In the 12 studies where suicide was assessed as an outcome, psychological interventions had a small beneficial effect on suicidal thoughts and risk immediately after the intervention but not at follow-up. This finding appeared to be related to two studies that recruited participants with past or current suicidal thoughts and included a treatment component focused on suicide.

Among the 25 trials in which suicide was assessed as an adverse event, the prevalence of suicide-related adverse events did not differ between the intervention and control groups. However, in 14 of these trials, suicide risk was criteria for exclusion from the study. 

The researchers noted the possibility that a small percentage of participants experienced worsening of depression symptoms during the trials. A previous study using data from the same database observed a worsening of depression symptoms from baseline to post-intervention follow-up in 2-5% of participants in the intervention group and 7-13% of controls.¹ The researchers also noted that suicide-related adverse events could have been unnoticed or not reported, and individuals receiving inpatient treatment who may have received more intensive monitoring and follow-up were not included in the studies reviewed. 

The results of this study highlight the importance of including validated measurements of suicidal thoughts and behaviors in clinical trials of depression. It also suggests there should be mandated reporting of suicide-related adverse events in journal articles, even if none were observed, to increase understanding of the efficacy of psychological interventions for suicide prevention.

Miguel, C., Cecconi, J., Harrer, M., Ballegooijen, W. V., Bhattacharya, S., Karyotoki, E., Cuijpers, P., Gentili, C., & Cristea, I. A. (2024). Assessment of suicidality in trials of psychological interventions for depression:  A meta-analysis. Lancet Psychiatry, 11(4), 252–261.

1. Cuijpers, P., Karyotaki, E., Ciharova, M., Miguel, C., Noma, H., & Furukawa, T. A. (2021). The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta-analysis. Acta Psychiatrica Scandinavica, 144(3), 288–299.