Effect of next-step antidepressant treatment on suicidal ideation: findings from the VAST-D trial

Area of Science:

• Psychiatry
• Clinical Psychology
• Pharmacology

Background:

• Major depressive disorder (MDD) is a significant risk factor for suicide.
• Effective MDD treatment is crucial for suicide prevention.
• Many patients require subsequent 'next-step' treatments after initial medication failure, but their impact on suicidal thoughts is understudied.

Purpose of the Study:

• To investigate factors associated with suicidal ideation (SI) and attempts (SA) at baseline.
• To explore predictors of current SI during next-step treatments for MDD.
• To analyze the efficacy of different next-step treatments on suicidal behaviors.

Main Methods:

• Secondary analysis of the VA Augmentation and Switching Treatments for Depression trial.
• Randomized 1522 participants to three next-step treatments: Switching to Bupropion (S-BUP), Combining with Bupropion (C-BUP), or Augmenting with Aripiprazole (A-ARI).
• Examined baseline features of lifetime SI/SA and current SI during the 12-week treatment.

Main Results:

• Patients with lifetime SI + SA had distinct demographic and clinical profiles, including higher childhood adversity and more severe depression, but were more likely to respond to next-step treatment.
• Overall prevalence of SI decreased from 46.5% at baseline to 21.1% at end-of-treatment.
• Current SI during treatment was linked to baseline SI, poorer mental health, greater MDD severity/duration, and specific treatment arms (S-BUP or C-BUP vs. A-ARI).

Conclusions:

• Next-step medication treatments generally reduce SI in MDD patients.
• Approximately 20% of patients may experience emergent or worsening SI, necessitating continuous monitoring.
• Treatment choice may influence the risk of SI during acute treatment for MDD.