Clinical trials of psychological interventions for depression rarely include assessments of suicidality, according to findings from a systematic review and meta-analysis published in The Lancet Psychiatry.
It has been widely established that depression is associated with an elevated risk for suicidal thoughts and behaviors. Although clinical trials of pharmacotherapy for depression routinely assess suicidal ideation as an outcome of interest, relatively little is known about how psychological interventions for depression affect suicidality.
To this aim, investigators at Vrije Universiteit Amsterdam in the Netherlands searched publication databases through May 2023 for randomized controlled trials of psychological interventions for adults with depression to evaluate the role of suicidality as potential eligibility criteria, outcomes of interest, and/or adverse events across trials. For the meta-analysis, the investigators only included trials in which suicide outcomes were assessed using clinical scales with established psychometric properties.
Of the 469 placebo-controlled trials for depression interventions, 425 did not assess suicide and the investigators noted that 80 and 171 studies had any or high suicidal risk as exclusion criteria, respectively. Of the 44 trials that included suicide outcomes, 33 only reported on suicide as an adverse event. The remaining 11 trials were included in this analysis. The pooled study population comprised 3930 individuals who were mostly women (71%).
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Monitoring and reporting of suicidal thoughts and behaviours according to detailed prespecified safety protocols needs to improve across psychotherapy trials, even when people deemed at risk of suicide are excluded.
The psychological interventions were cognitive behavioral therapy approaches and the control treatments were usual care or enhanced usual care. The suicide outcomes of interest included suicidal ideation (k=9) and suicide risk (k=3).
In the aggregated analysis, the investigators found that suicidal ideation and suicide risk were decreased immediately after the intervention (standardized mean difference [SMD], -0.31; 95% CI, -0.60 to -0.03; I2, 68%).
The investigators also found that psychological interventions significantly reduced suicidal ideation and suicide risk immediately after the intervention in studies with active control groups (k=10; SMD, -0.34; 95% CI, -0.66 to -0.02; I2, 72%), studies with treatment as usual as the control (k=9; SMD, -0.40; 95% CI, -0.74 to -0.05; I2, 71%), and for the outcome of suicidal ideation alone (k=8; SMD, -0.36; 95% CI, -0.70 to -0.02; I2, 70%). However, the investigators did not observe significant effects in studies without a direct intervention, studies without single-item measures, and studies with continuous outcomes.
At follow-up, no significant effects were observed on suicidal ideation or suicide risk (k=6; SMD, -0.49; 95% CI, -1.31 to 0.32; I2, 79%).
The investigators noted, “[O]ur study shows that assessment of suicide was rarely reported in trials of psychological interventions targeting depression.” Study authors concluded, “Monitoring and reporting of suicidal thoughts and behaviours according to detailed prespecified safety protocols needs to improve across psychotherapy trials, even when people deemed at risk of suicide are excluded.”
The limitations of this study included the small sample size, the use of single-item suicide outcomes in the trials, and the combination of trials that used different suicide outcomes.
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