Suicidal ideation declines with improvement in the subjective symptoms of major depression

Suicidal ideation appears to be more strongly associated with subjective rather than neurovegetative symptoms of depression. Effective treatment, then, should produce reductions in suicidal ideation to the degree that these subjective symptoms are alleviated relative to treatment effects on other symptoms. In a randomized clinical trial comparing paroxetine and bupropion for treatment of depression in patients with either suicidal ideation or past attempt, depression severity and suicidal ideation were assessed weekly during the 8-week study. Depression rating scales - the 24-item Hamilton Depression Rating Scale [HDRS] and the Beck Depression Scale [BDI] - were decomposed into symptom clusters based on our published factor analyses, and their change over time compared to changes on the Beck Scale for Suicidal Ideation [SSI]. Improvement in factor scores associated with subjective symptoms of depression - HDRS Psychic Depression, BDI Subjective Depression, and BDI Self-Blame - were the best predictors of declining scores on the SSI regardless of type of drug treatment. BDI Subjective Depression was the best single predictor in the context of all other significant univariate predictors, accounting for 31.4% of the variance in the change in SSI. The three factors together accounted for 35.3%. This is a secondary analysis of clinical trial data, with fixed treatments. Effective treatments to reduce suicidal ideation are associated with the reduction of the subjective symptoms of depression, which may not always decline in synchrony with improvement in neurovegetative symptoms. This asynchrony may result in a period of elevated risk after the initiation of therapy. Data indicate that subjective depression symptoms should be a primary target in the treatment of depressed suicidal patients. •In a cross-sectional analysis, we had previously found that suicidal ideation is most closely associated with subjective, rather than neurovegetative symptoms of major depression.•In this clinical trial, in a separate sample of patients at elevated risk for suicidal behavior, treatment-related declines in these subjective symptoms were most closely associated with reductions in suicidal ideation, confirming and extending our earlier findings.•Subjective rather than neurovegetative symptoms of major depression, then, appear to be the most appropriate target for treatment of patients with elevated suicidal ideation.