Clinical correlates of the worsening or emergence of suicidal ideation during SSRI treatment of depression: An examination of citalopram in the STAR*D study

Background: Untreated major depressive disorder (MDD) is a major risk factor for suicide, but some data suggest antidepressants may be associated with increased suicidal ideation (SI) in some depressed patients. The purpose of this study was to determine whether, and in whom, treatment of MDD is associated with increased or emergent SI. Methods: Patients were treated with Citalopram, 10-60 mg/day for 12-14 weeks. A score > 0 on Item 12 of the Quick Inventory of Depressive Symptomatology - Self-Report indicated the presence of SI. Worsening was defined by a ≥ 1 point increase. Emergent SI was defined by an increase from 0 at baseline to ≥ 1 during treatment. Results: Of the 1909 participants with baseline SI, 57% experienced improvement in SI by their first post-baseline visit and 5% worsened. By the final visit, 74% experienced improvement and 4% worsened. Of 1721 participants without baseline SI, 7% experienced emergence by the first postbaseline visit. Of these, 63% had no SI at their final visit. Major risk factors for treatment-emergent SI at the first treatment visit were drug abuse, severe depression and melancholic features. Limitations: Main limitations are lack of a comparison group to help pinpoint whether citalopram treatment added risk or protection, a placebo group to determine whether changes in SI were related to illness factors, medication effects or other factors, and more detailed and validated measures of SI. Conclusions: SI and behaviors, core features of MDD, wax and wane in intensity before, during, and perhaps after treatment. It is clinically important to understand risk factors, maintain careful surveillance and treat as vigorously as necessary to attain remission.