( More than depression?) Phili lipp ppe e Courtet tet - - PowerPoint PPT Presentation

Is sui uici cidal dal depressi epression

• n a spec

pecific ific phe henot notype ype ? (… More than depression?)

Phili lipp ppe e Courtet tet

Disclosure closure of conf nflict lict of inter terest

• Fonda

damental mental Foundation ndation

• Exelti

ltis

• Jans

nssen sen

• Servier

vier

• Otsuka

uka

Unmet et nee eeds

• In depression, the population attributable risk of mood

disorders for a first occurrence of SI or SA has been estimated at 51% - 44%

• Thus, reducing the duration of depressive episodes might

have a major impact on suicidal risk

• American Psychiatric Association practice guideline on

management of patients with suicidal behaviour: “Evidence for a lowering of suicide rates with antidepressant treatment is inconclusive”

• Total absence of treatments for acutely suicidal patients

Practice guide for the assessment and treatment of patients with suicidal behaviors. Available at https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/suicide.pdf. Accessed August 2018 Nock et al 2010 Sokero et al 2003

SSRI I (n = 5681) placebo bo (n = 2581) HDRS-SI≥3 : < 6%

Su Suic icidal idal depression pression

• 1. Two cohort

hort studies dies : Shor

• rt

t term rm follow low-up up

• 2. Clinical

nical sample ple of depre press ssed ed patients ients : 2 year ars follow llow-up up

Two wo co cohorts

• rts of unipola

ipolar r dep epress essed ed outp tpat atients, ents, 6 w 6 wee eeks follow

• w-up

up

Week 1-2

Inclusi sion

Week 2-4 Week 6

initia iati tion

• n of a

antid idepr pressa essant nt treatm tment nt

Self repor

• rts

ts : Suici icidal dal Ideation tion : MADRS S suicid cide item Depres essi sion

• n,

, anxie iety ty : Hospital spital Anxie iety ty and Depres essio sion n Scale Coho hort 1 Coho hort 2 Beck Hopel peles essness sness Scale Sleep (MADRS RS sleep item) Impu pulsivity sivity (Plu lutc tchik hik Impu pulsi lsivity vity Scale)

Total popul pulatio ion n HADS DS-D ≥ 11 (MADRS ≥ 20) Non n suicida dal depression

• n

(MADRS-SI SI < 2) Mode derately suic icida dal depression

• n

(MADRS-SI SI [2; 4[) Severely suic icida dal depression

• n

(MADRS-SI ≥ 4) N N % N % N % N % Coho hort 1

4845 4845 3969 3969 81,9 671 671 16,9 2292 2292 57,7 1006 1006 25,3

Coho hort 2

3566 3566 2537 2537 71,1 370 370 14,6 1408 1408 55,5 759 759 29,9

Bas asel eline ne soci ciodemographi demographic c ch char aract acteris eristics tics

Global p-value adjusted on depression severity for COHORT 1 and on depression severity and age for COHORT 2

Bas asel eline ne cl clinical cal ch char aracteri acteristics tics

Global p-value adjusted on depression severity for COHORT 1 and on depression severity and age for COHORT 2

Bas asel eline ne psych chopa

• patho

thology logy

Global p-value adjusted on depression severity for COHORT 1 and on depression severity and age for COHORT 2

Suicide de attempt pt during ring 6 we weeks follow low up

No SA durin ring g foll llow

• w-up

up SA durin ring foll llow

• w-up

up

OR [95% CI] p-valu lue OR [95% CI] Adju just sted p- va value (life fetim ime SA) COHORT 1 N= 3567 N= 68 No SI 601 (16.8) 2 (2.9)

• <0.001
• <0.001

Moderate SI 2063 (57.8) 24 (35.3) 3.50 [0.82; 14.83] 2.62 [0.61; 11.20] Severe SI 903 (25.3) 42 (61.8) 13.98 [3.37; 57.96] 8.08 [1.90; 34.26] COHORT 2 N= 2462 N= 15 No SI 359 (14.6) Moderate SI 1367 (55.8) 8 (53.3) Severe SI 726 (29.6) 7 (46.7)

Ev Evolution tion of sev ever erity ty of dep epress ession ion

Cohort 1 Cohort 2

• At each

h time e point nt: : higher her depressi ression

• n score

res s in Severe ere SI

• Improvement

rovement of depres ression sion in each h gr group up

• Non differ

fference ence in improveme rovement t

• f depressi

ression

• n between

ween groups ps

Unadjusted and Adjusted on age, study level, SA lifetime, MDE duration, treatment associated

Rem emission ion of dep epress ession

• n (H

(HAD-D ≤7) at 6 weeks

53.5% 50.1% 39.7% 53.5% 51.0% 42.6% Remission rates

Ev Evoluti tion

• n of MADR

DRS-SI SI in th the e 3 g 3 groups

• ups

Cohort 1 Cohort 2

• At each

h time e point nt: : higher her MADRS DRS-SI SI score res in Severe ere SI

• Improv

proveme ement nt of MADRS DRS-SI SI score res s in each h group up

• Better

ter Improvement rovement of MADRS DRS- SI in Severe ere SI

Unadj djus usted and Adju justed d on age, study level, SA lif ifetime ime, MDE E duratio ion, n, treatment associated & on Depr pression

• n at baselin

ine or at each h time or to the previou

• us evalu

luatio ion

Ev Evolution tion of prev evalenc alence of SI SI in th the e 3 g 3 group

• ups

54.9% 21.9% 7.4% 44.3% 16.7% 12.2%

* * * * * * * *

Unadj djus usted and Adju justed d on age, study level, SA lif ifetime ime, MDE E duratio ion, n, treatment associated & on Depr pression

• n at baselin

ine or at each h time or to the previou

• us evalu

luatio ion

Suici icidal dal Remissio issions (MADRS RS-SI= SI=0-1) 1) Our r resul ults : W4 30% Canuso uso: : W4 58% pcb (77% (77% esket) Severe SI (MADRS-SI≥4) Our results : W4 17% Canuso uso: : 10% pcb (7% (7% esket)

A persist rsisting ing severe ere suicidal cidal ideation ation is associat

• ciated

ed with th the risk sk of suicide cide attempt tempt during ring follow low up: : OR OR: 4.38 38 [2.0 .05; 5; 9.35] 35]

Pr Pred edictors ctors of per ersi sist stanc ance e of se seve vere SI SI

COHO HORT 1 COHO HORT 2 OR [95%CI] p-value OR [95%CI] p-value Variable Study dy level

• Cur

urren ent t MDE duration

• n (≥ 6 month

nths) s) 0.58 [0.06; 5.53]

• 1.69 [0.79; 3.61]
• Numb

mber er of MDE lifeti etime me 1.02 [0.94; 1.10]

• Age at first

st MDE (ye year ars) s) 1.02 [0.98; 1.06]

• MADRS-SI

SI Bas asel eline ne 6.72 [4.43; 10.18] <0.001 001 2.69 [2.08; 3.49] <0.001 001 Lack of Chan ange in HAD tota tal 1.52 [1.35; 1.70] <0.001 001 1.16 [1.10; 1.21] <0.001 001 Lack of Chan ange in Hopelessn sness 1.10 [0.91; 1.32]

• Lack of Chan

ange in impulsi sivity vity 1.01 [0.95; 1.08] Lack of Chan ange in MADRS RS-sl slee eep 1.38 [1.12; 1.69] 0.003 003 Lifet etime me SA 1.84 [0.68; 5.01]

• 1.28 [0.68; 2.41]
• Treatment change

3.00 [1.11; 8.09] 0.03 03 0.92 [0.50; 1.70]

Su Summ mmary ary

• In 2 large

ge independent ependent cohorts

• rts of depres

ressed sed unipolar polar outpatients atients, , suici icidal dal depressi ression

• n is :
• More

re severe ere at basel eline ine (risk k fact ctor

• rs,

, depres ressi sive e illness ness, , anxiety xiety, , depres ressi sion

• n,

, hopelessnes elessness, , impuls ulsivity, ity, sleep, eep, history

• ry of suici

icide de attempts mpts)

• During

ing the 6 week eks foll llow

• w up:

– Higher her risk sk of suicid cide e attempts mpts – Suicid cidal al ideati ation

• n still

ll more e severe vere (controll ntrolling ing for r depres ression) sion) – Less ss remiss mission ion of depress ression

• n

Percenta centage e symptom ptom reduct duction ion from

• m baseline

eline for r depressiv ssive e sy symptoms ptoms and d su suicidal cidal ideation tion

Su Suici cida dal l dep epres ression ion may ay be a su e a subtype type of MDD DD

• Dist

stinct inct psychiatri ychiatric c comorbi

• rbidi

ditie ties s and clinic inical al and sociodem ciodemogr grap aphic hic feat atures ures – Age ge at onset set of de depress pression

• n and

d child ldhood hood abu buse se – More re freq equent uent history tory of suicid cide e attempt mpt

• A propens

ensity ity to severe vere suici icida dal l ideati ation

• An actual

al risk sk of suic icid ide e attempt mpts s in short rt and d long g terms ms

• Resp

sponse

• nse to antid

idep epress ressant ant ±

Ackn knowl

• wledgeme

edgements nts

Dr E Olié ié Dr B Nobi bile le Mr A Alacreu reu