Pilot randomized clinical trial of an SSRI vs bupropion: effects on suicidal behavior, ideation, and mood in major depression

Abstract

Randomized controlled trials in depressed patients selected for elevated suicidal risk are rare. The resultant lack of data leaves uncertainty about treatment in this population. This study compared a serotonin reuptake inhibitor with a noradrenergic/dopaminergic antidepressant in major depression with elevated suicidal risk factors. We conducted a double-blind, randomized, clinical pilot trial of paroxetine (N=36) or bupropion (N=38) in DSM IV major depression with a suicide attempt history or current suicidal ideation. The effects during acute (8 weeks) and continuation treatment (up to 16 weeks) were measured. Main outcomes were suicidal behavior and ideation. The secondary outcome was modified 17-item Hamilton Depression Rating Scale score subtracting the suicide item (mHDRS-17). Treatment was not associated with time to a suicidal event and no treatment main effect or treatment × time interaction on suicidal ideation or mHDRS-17 was found. Exploratory model selection showed modest advantages for paroxetine on: (1) mHDRS-17 (p=0.02); and (2) in a separate model adjusted for baseline depression, for suicidal ideation measured with the Beck Scale for Suicidal Ideation (p=0.03), with benefit increasing with baseline severity. Depressed patients with greater baseline suicidal ideation treated with paroxetine compared with bupropion appeared to experience greater acute improvement in suicidal ideation, after adjusting for global depression. Given the lack of evidence-based pharmacotherapy guidelines for suicidal, depressed patients-an important public health population-this preliminary finding merits further study.

Figure 1

Flow diagram of progress through phases of the parallel randomized trial of two groups (enrollment, intervention allocation, follow-up, and data analysis) (Schulz et al, 2010).

Figure 2

Scatter-plot of Scale for Suicidal Ideation (SSI) (Beck et al, 1979) score vs time, by treatment, in patients with baseline SSI ⩽8. Locally weighted polynomial regression lines for scatter-plot smoothing (Cleveland, 1979) use 80% of points to fit and Epanechnikov kernel. Data points may represent more than one patient.

Figure 3

Scatter-plot of Scale for Suicidal Ideation (SSI) (Beck et al, 1979) score vs time, by treatment, in patients with baseline SSI ⩾9. Locally weighted polynomial regression lines for scatter-plot smoothing (Cleveland, 1979) use 80% of points to fit and Epanechnikov kernel. Data points may represent more than one patient.