Download Is There a Window of Heightened Suicide Risk If Patients Gain

Professional Psychology: Research and Practice
2004, Vol. 35, No. 1, 84 – 89
Copyright 2004 by the American Psychological Association, Inc.
0735-7028/04/$12.00 DOI: 10.1037/0735-7028.35.1.84
Is There a Window of Heightened Suicide Risk If Patients Gain Energy in
the Context of Continued Depressive Symptoms?
Thomas E. Joiner Jr.
Jeremy W. Pettit
Florida State University
University of Houston
M. David Rudd
Baylor University
The authors’ purpose is to provide some empirical perspective on the important but understudied
possibility that when people become more energetic in the context of continued depressive symptoms,
suicide risk escalates. The authors studied 109 suicidal young adults; among those who initially reported
substantial depression, a subgroup was identified whose energy was increasing in context of continued
depressive symptoms. They were compared with others with regard to suicidality 1 month later. Results
suggested that those who have incomplete remissions (of any sort) may be more ill to begin with, and
this may account for higher suicide risk.
whose patient had died by suicide while the patient was out on pass
(pp. 278 –280).
A well-known piece of clinical lore cautions that there is a
window of heightened suicide risk when people become more
energetic in the context of continued depressive symptoms (i.e.,
problems with low energy subside, but other symptoms persist).
According to this view, individuals may acquire energy to act on
continued suicidality and/or may gain cognitive clarity to act on
their suicidal intentions.
There are anecdotal reports that appear to support this possibility. For example, Alvarez (1971) noted that Sylvia Plath experienced increased energy and artistic productivity during the period
before her suicide. This possibility was also noted—memorably— by Meehl (1973) in his famous paper “Why I Do Not Attend
Case Conferences.” Meehl described a conversation with a student
Meehl:
Why was he sent out on pass?
Student: Well, we felt that he had formed a good group relationship
and his depression was lifting considerably.
Meehl:
Did you say his depression was lifting?
Student: Yes, I mean he was less depressed than when he came
in—although he was still pretty depressed.
Meehl:
When does a patient with a psychotic depression1 have the
greatest risk of suicide?
Student: I don’t know.
THOMAS E. JOINER JR. received his PhD in clinical psychology from the
University of Texas at Austin. He is the Bright–Burton Professor of
Psychology at Florida State University. His research is on the psychology,
neurobiology, and treatment of suicidal behavior, mood disorders, and
related conditions.
JEREMY W. PETTIT received his PhD in clinical psychology from Florida
State University. He is an assistant professor of psychology at the University of Houston. He conducts research on the phenomenology and etiology
of mood disorders and suicidality.
M. DAVID RUDD received his PhD in psychology from the University of
Texas at Austin and completed postdoctoral training at the Beck Institute
in Philadelphia. He is a diplomate of the American Board of Professional
Psychology and is director of the doctoral program in clinical psychology
at Baylor University. His research interests include clinical suicidology,
cognitive therapy, treatment outcome, and ethics and regulatory process in
psychology.
PORTIONS OF THIS WORK were supported by a John Simon Guggenheim
Memorial Foundation Fellowship and by Grant MH48097 from the National Institute of Mental Health.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to
Thomas E. Joiner Jr., Department of Psychology, Florida State University,
Tallahassee, FL 32306-1270. E-mail: [email protected]
Meehl:
Well, what do the textbooks of psychiatry and abnormal
psychology say about the time of greatest suicide risk for a
patient with psychotic depression?
Student: I don’t know.
Meehl:
You mean you have never read, or heard in lecture, or been
told by your supervisors, that the time when a psychotically
depressed patient is most likely to kill himself is when his
depression is “lifting”?
Student: No, I never heard of that.
Meehl:
1
Well you have heard of it now. You better read a couple of
old books, and maybe next time you will be able to save
somebody’s life.
From Meehl’s description, there is no evidence that the patient was
psychotic per se, although the patient was described as mute on admission
to the hospital; the diagnosis in today’s parlance would be major depression with catatonic features.
84
WINDOW OF HEIGHTENED SUICIDE RISK?
Meehl was sure enough of this fact to be quite stern to the
student (at least as reported in the dialogue; Meehl [1973] stated
that this was an actual incident, although he does not claim that the
dialogue was quoted verbatim, and it seems likely that the stern
message was amplified for the benefit of making this point to his
readers). Others, too, have noted this view that lifting depression
may result in energy and/or cognitive clarity to act on continued
suicidality (e.g., Isaacson & Rich, 1997; Jameison, 1936). But to
our knowledge, there is no empirical evaluation of this issue
(perhaps because it is inherently difficult to study empirically).
Implicit within this perspective are several interesting assumptions. For example, it is assumed that surging energy in context of
sustained depression happens often enough to be of clinical concern. But how often does this actually occur? Moreover, the
perspective confers a special status on particular symptoms like
energy—when the energy symptom remits and other symptoms do
not, the window of vulnerability opens, according to this view. But
is this special status deserved? What happens regarding suicide
risk if, for example, the sadness symptom remits and other symptoms do not? Relatedly, it is clear that persistence of subclinical
depressive symptoms—any depressive symptoms, not just the
energy symptom— can be a negative prognostic sign (Judd, 1997).
Perhaps those who experience persistence of depressive symptoms
in the context of increased energy represent just one of many
patterns of incomplete remission, and perhaps it is incomplete
remission (an index of illness severity), and not increased energy,
that confers heightened suicide risk.
The purpose of the present study was to provide some empirical
evaluation of these questions among participants referred to treatment for suicidal behavior or severe suicidal ideation. It is, we
think, key to study patients who are suicidal to begin with, because
the claim of this piece of clinical lore is that pre-existing suicide
risk is acted on in context of lifting depression, not that suicidality
is newly instantiated by lifting depression in those who were
initially free of suicidality. In a sample of suicidal young adults,
we focused on those who, at intake, reported substantial depression; among these, we attempted to identify a subgroup whose
energy was increasing in the context of continued depressive
symptoms. We compared this subgroup to others with regard to
suicidality 1 month after intake.
Research Project on Suicidal Individuals
Participants for this study included 109 individuals (90 men; 19
women) who (a) were evaluated at intake prior to entry into a
larger study on treatment for suicidal young adults (Rudd et al.,
1996), (b) reported at least moderate depressive symptoms at
intake (as reflected by a score of at least 14 on the Beck Depression Inventory [BDI], described later; overall BDI mean at intake
was 27.12, SD ⫽ 8.88), (c) were evaluated again 1 month later, and
(d) reported at least a 1-point improvement on a BDI Energy
Symptom subscale (described later). Thus, all participants were
initially suicidal, all reported substantial depression at intake, and
all reported at least minimal improvement regarding the energy
symptom.
Of these 109 individuals, some experienced substantial improvement from intake to 1-month follow-up in overall depression
(defined as an improvement of 6 or more points on overall BDI
score), whereas others experienced little overall improvement
85
(even despite the fact that they were selected based on at least
minimal improvement regarding the energy symptom). It is this
latter group, which experienced improved energy in the context of
persistent depression, that we particularly wanted to characterize.
Participants were referred from two outpatient clinics, a 20-bed
inpatient facility, and an emergency room, all affiliated with a
major U.S. Army Medical Center. Mean age for the total sample
was 22.23 years (SD ⫽ 2.80 years, range ⫽ 18 –37). The gender
distribution (83% men) is common in military medical settings.
Most participants were Caucasian (n ⫽ 65, or 60%); 25% were
African American; 8% were Hispanic; 2% were Native American;
1% were Asian or Pacific Islander; the remainder were classified
as “other.” As might be expected, mood and anxiety disorders
were the most common diagnoses.
As is commonly the case in treatment studies, attrition from
baseline to 1-month follow-up was substantial because of patients
deciding not to pursue treatment, choosing to drop out of the study,
choosing to drop out of the military, or being reassigned by the
military. In the larger study (Rudd et al., 1996), attrition from
intake to 1-month follow-up was about 24%. For the current study,
the rate was similar; it is important to note that participants who
dropped out were not significantly different from participants who
completed 1-month follow-up on depressive or suicidal symptoms
at intake.
Overall level of depressive symptoms was assessed by the Beck
Depression Inventory (BDI; Beck, Rush, Shaw, & Emery, 1979),
a 21-item self-report inventory. Each item was rated on a scale
ranging from 0 to 3. Thus, possible overall inventory scores ranged
from 0 to 63. The BDI is not indicative of the full clinical
syndrome of depression but, rather, is intended as an index of
severity of depressive symptomatology. Beck, Steer, and Garbin
(1988) provided a review of the BDI’s properties—including high
internal consistency coefficient in clinical populations—and its
expected web of associations with various clinical indicators (e.g.,
consistently high associations with clinician-rated depressive
symptoms). All participants in this sample had a BDI score of at
least 14 at intake (M ⫽ 27.12, SD ⫽ 8.88); at 1-month follow-up,
BDI mean was 8.61 (SD ⫽ 8.45). This decrease was presumably
due to the passing of suicidal crises and initiation of treatment.2
A BDI subscale reflecting the energy symptom was composed
of BDI Item 15 (one possible answer to which is “I have to push
myself very hard to do anything”) and BDI Item 17 (one possible
answer to which is “I get tired from doing anything”). The alpha
coefficient of this composite was .71 at intake and .76 at 1-month
follow-up. Moreover, the validity of measuring energy with the
BDI has been supported in past work (e.g., Joiner, Gencoz, Gencoz, Metalsky, & Rudd, 2001). Further still, we re-analyzed data
presented by Metalsky and Joiner (1997) on the Hopelessness
Depression Symptom Questionnaire (HDSQ), which has several
formally developed subscales corresponding to various depressive
symptoms (e.g., insomnia, suicidality, anhedonia, and so forth),
including energy problems. The data set also included the BDI. We
calculated the correlations between the BDI Energy subscale used
2
All patients received either treatment-as-usual (a combination of inpatient stay, usually with outpatient medicine checks and/or psychotherapy of
various types) or an intensive problem-solving psychotherapy. All patients
started treatment in the interval between intake and 1-month follow-up.
JOINER, PETTIT, AND RUDD
86
here and the 9 HDSQ subscales, expecting that the BDI Energy
subscale would correlate highest with the HDSQ Energy subscale.
In fact, it did. The correlation between the BDI Energy subscale
and the HDSQ Energy subscale was .70 ( p ⬍ .001, N ⫽ 258),
whereas the average correlation of the BDI Energy subscale with
the other 8 HDSQ subscales was .43. These results provide both
convergent (i.e., the substantial correlation between the BDI Energy subscale and the HDSQ Energy subscale) and divergent (i.e.,
the lower correlations between the BDI Energy subscale and the
other HDSQ subscales) validity data for the BDI Energy index
used in the present study.
For purposes of comparison to the BDI Energy subscale, we
formed two other BDI subscales. Specifically, a BDI subscale
reflecting sadness/demoralization was formed, composed of BDI
Item 1 (one possible answer to which is “I am so sad or blue that
it is quite painful”), BDI Item 2 (one possible answer to which is
“I feel that the future is hopeless and that things cannot improve”),
BDI Item 3 (one possible answer to which is “As I look back on
my life all that I can see is a lot of failure”), and BDI Item 4 (one
possible answer to which is “I don’t get satisfaction out of anything any more”). Alpha coefficients for this subscale were .76 at
intake and .70 at 1-month follow-up. A BDI subscale reflecting
low self-esteem/guilt was also formed, composed of BDI Item 5
(one possible answer to which is “I feel as though I am very bad
or worthless”), BDI Item 7 (one possible answer to which is “I am
disgusted with myself”), and BDI Item 8 (one possible answer to
which is “I blame myself for everything bad that happens”). Alpha
coefficients for this subscale were .80 at intake and .81 at 1-month
follow-up.
Suicidality was measured at intake and 1-month follow-up with
the Modified Scale for Suicidal Ideation (MSSI; Miller, Norman,
Bishop, & Dow 1986), an 18-item scale that is a modified version
of Beck, Kovacs, and Weissman’s (1979) Scale for Suicidal Ideation. It is a semi-structured interview, to be administered either by
professionals or paraprofessionals. Items cover such topics as wish
to die; intensity, frequency, and duration of suicidal ideation;
suicide plans; and writing about suicide. Each MSSI item is rated
on a 0 to 3 scale; overall scale scores thus may range from 0 to 54,
with higher scores indicating more severe symptoms. Miller et al.
(1986) have reported reliability coefficients (e.g., coefficient alpha ⫽ .94) and construct validity data (see also Clum & Yang,
1995; Joiner, Rudd, & Rajab, 1997).
Testing and diagnostic interviews at intake and at follow-up
were conducted by clinical staff (two licensed doctoral-level psy-
chologists, three licensed master’s-level professionals, and one
advanced-level doctoral student) prior to entry into the treatment
study. All staff were thoroughly trained and carefully monitored
(see Rudd et al., 1996, for more information on procedures).
Means, standard deviations, and correlations among the measures discussed above are presented in Table 1. Baseline means for
MSSI suicidality and BDI depressive symptoms were in the clinical range, as would be expected. MSSI and BDI means were
considerably lower at 1-month follow-up, again as would be expected, given that all participants had started treatment. Neither
gender nor age was correlated with any of the variables listed in
Table 1.
Is increased energy in the context of persistent depression a
common pattern? Of 109 individuals (all of whom experienced
at least some increase in energy from intake to follow-up), most (n
⫽ 101, or 93%) experienced substantial improvement from intake
to 1-month follow-up in overall depression (defined as a 6 or more
point improvement on overall BDI score), whereas 8 others (7%)
experienced little overall improvement (even despite the fact that
they were selected based on at least minimal improvement regarding the energy symptom). When the energy subscale was removed
from the overall index, 2 of these 8 individuals obtained a higher
score by 2 points on the BDI at follow-up than at intake; 1 of the
8 individuals obtained a higher score by 1 point at follow-up than
at intake; 1 individual obtained the same score at intake as at
follow-up; 1 individual’s score decreased 1 point; 1 individual’s
score decreased 2 points; 1 individual’s score decreased 3 points;
and 1 individual’s score decreased 4 points. We thus estimated that
approximately 7% of initially suicidal, depressed patients will
experience improved energy in the context of persistent depressive
symptoms.
Does improved energy in the context of persistent depressive
symptoms relate to persistent suicidality? To test this possibility,
we conducted a repeated measures analysis of variance (ANOVA),
with MSSI-intake and MSSI-1 month as repeated measures and
group status (substantial decrease in depression vs. not, as defined
above) as a between-subjects factor. If those individuals who
experienced energy gains in the context of continued depression
were at higher risk for suicide than those who experienced energy
gains in the context of remitted depression, we would expect a
significant effect for the Time ⫻ Group interaction term, indicating that suicidality decreased from intake to 1-month follow-up in
different ways for the two groups. Moreover, a particular form for
the interaction would be expected, such that suicide risk would be
Table 1
Means and Standard Deviations of, and Intercorrelations Between, All Variables
Variable
1.
2.
3.
4.
5.
6.
7.
8.
BDI total: intake
BDI total: 1 month
MSSI: intake
MSSI: 1 month
BDI Energy: intake
BDI Energy: 1 month
BDI Sadness: intake
BDI Sadness: 1 month
M
SD
1
2
3
4
5
6
7
8
27.12
8.61
26.24
6.72
2.83
0.74
5.81
1.43
8.88
8.45
9.16
10.45
1.19
1.00
2.62
1.82
—
.38*
.37*
.16
.68*
.32*
.82*
.34*
—
.27*
.46*
.45*
.77*
.20*
.88*
—
.28*
.26*
.15
.33*
.21*
—
.27*
.30*
.13
.43*
—
.49*
.45*
.38*
—
.16
.69*
—
.21*
—
Note. N ⫽ 109. BDI ⫽ Beck Depression Inventory; MSSI ⫽ Modified Scale for Suicidal Ideation.
* p ⬍ .05.
WINDOW OF HEIGHTENED SUICIDE RISK?
higher in individuals who experienced energy gains in the context
of continued depression, as compared with other patients.
However, the effect for this interaction term was not significant,
F(1, 107) ⫽ 0.05, p ⫽ .83, suggesting comparable changes in
suicidality from intake to follow-up for the two groups. Examination of the cell means for intake and 1-month MSSI scores for the
two groups, displayed in Table 2, indicates that both groups
experienced an approximately 20-point drop in MSSI from intake
to follow-up. An important finding is that the means in Table 2
tentatively suggest that those who will go on to experience continued depression have somewhat higher suicidality scores to
begin with, ANOVA F(1, 107) ⫽ 2.12, p ⫽ .075, one-tailed. It
should be emphasized that this is a tentative finding, but it is not
very compatible with the view that subsequent increased energy is
playing a role. Instead, it may be that those who experience
persistence of depressive symptoms in the context of increased
energy represent just one of many patterns of incomplete remission, and perhaps it is incomplete remission (an index of illness
severity), and not increased energy, that confers heightened suicide
risk. If so, we would expect a similar pattern of results as reported
above and in Table 2 for patients who experience continued
depression in context of improvement on any symptom, not just
the energy symptom.
Do improved mood/morale and improved low self-esteem/guilt
in the context of persistent depressive symptoms relate to persistent suicidality? To test this possibility, we conducted the study
again as described above except that we selected individuals who,
instead of experiencing at least a 1-point improvement on the BDI
Energy Symptom subscale, experienced at least a 1-point improvement on the BDI Sadness/Demoralization Symptom subscale and,
separately, on the BDI Low Self-Esteem/Guilt subscale. We then
reran the repeated measures ANOVA, with MSSI-intake and
MSSI-1 month as the repeated measure and group status (substantial decrease in depression vs. not, as defined above) as a betweensubjects factor (separate analyses for sadness/demoralization and
for low self-esteem/guilt). Results were highly similar to those
reported above and in Table 2. This pattern of results is not very
compatible with a special role for the energy symptom and suggests instead a different possibility—incomplete remissions, even
if some symptoms improve and regardless of which symptoms
improve, are a marker of illness severity, and illness severity, in
turn, may account for heightened risk for suicidality.
Table 2
MSSI Suicidality Indexes at Intake and 1-Month Follow-Up for
Those With Increased Energy and Persistent Depression Versus
Those With Increased Energy and Decreased Depression
Participants
Those with increased energy and
persistent depression
Those with increased energy and
decreased depression
MSSI score:
intake
MSSI score:
1-month
follow-up
8
30.75
10.38
101
25.88
6.44
n
Note. For comparison, overall MSSI mean at intake was 26.24 (SD ⫽
9.16); at follow-up, 6.72 (SD ⫽ 10.45). MSSI ⫽ Modified Scale for
Suicidal Ideation.
87
Collectively, these results suggest an alternative view to the
well-known clinical lore that there is a window of heightened
suicide risk when people become more energetic in the context of
continued depressive symptoms. Specifically, incomplete remissions— of any sort—may explain the effect. On average, those
who experience incomplete remissions are more ill to begin with
(Judd, 1997), and this may account for heightened suicidality over
time. According to this view, those who experience increased
energy in the context of persistent depression represent but one of
many instances of incomplete remissions. Our data were roughly
consistent with this view: Those who experienced increased energy or improvements in sadness/demoralization or improvements
in low self-esteem/guilt but whose overall depression persisted,
had somewhat higher suicidality scores than others to begin with.
There are some potential limitations to this study that must be
considered. As we pointed out in the introduction, it is likely that
this topic has received limited empirical attention because it is
inherently difficult to study empirically. This difficulty affected
our study, too—it is a challenge indeed to form a large enough
sample that is suicidal and depressed to begin with, is available one
month later, and who experienced at least some increased energy
over the one-month interval. Our overall sample was reasonably
large, but our subgroup of individuals who experienced increased
energy in the context of continued depression was small. We
submit, however, that this, in itself, is useful information—the
pattern of increased energy against the backdrop of persistent
depression is relatively rare. On the other hand, the relatively small
size of this subgroup may have undermined statistical power to
detect significant effects—a point to which we will return.
In addition, we note that results were obtained within the context
of a large-scale suicide treatment project in a military environment—not necessarily representative of the usual mental health
setting (e.g., gender ratio was 4.6 men to 1 woman). Also, attrition
was considerable, and although patients who stayed and those who
dropped out were similar on study variables, this issue should be
considered in interpreting our findings. Caution should be exercised in generalizing to other clinical settings and populations. By
the same token, the study is fairly representative of the naturalistic
situation, in which a suicidal person in crisis elicits some form of
professional intervention (if only temporarily). The structure of the
research project, although perhaps not completely representative of
the usual situation, nonetheless provided at least preliminary empirical insight regarding the possibility that increased energy in the
context of persistent depression exacerbates suicide risk.
Implications and Applications
Our goal was to address such questions as the following: How
common is the pattern of increased energy in the context of
continued depression? Is there something special about increased
energy in the context of persistent depression regarding suicide
risk? We have provided some answers: The pattern is relatively
rare; there may not be anything special about increased energy and
continued depression, but, rather, those who have incomplete
remissions (regardless of symptom pattern) may be more ill to
begin with, and this may be the reason for higher suicide risk.
Still, we have not definitively characterized the phenomenon of
possible increased suicide risk in the initial stages of recovery from
depression. In what follows, we discuss various alternative expla-
88
JOINER, PETTIT, AND RUDD
nations of this phenomenon, we relate our data to these explanations, and then we close with recommendations to clinicians, one
of which we believe covers most if not all of the various views on
this phenomenon.
One view on increased suicidality in the initial stages of recovery from depression is that the decision to die by suicide may be
energizing, because the decision resolves ambivalence and points
to a means of relief. Notably, this perspective implies a time course
in which suicidality produces increased energy (via relief), with no
diminution in suicidality. Our participants, however, experienced
marked decreases in suicidality, even though some of them remained depressed and experienced increased energy (see means in
the top row of Table 2). We thus do not feel that this view
constitutes a full explanation of the current empirical findings.
Another view is that as a patient begins to show signs of
improvement, support systems pull back, and the patient faces the
possibility that he or she will face the same obstacles and problems
as were present before the depression began (and which may have
contributed to the depression in the first place). The lifting of
depression may illuminate these problems and thus demoralize the
individual, heightening suicide risk. There was no evidence of this
in the 1-month time frame of our study, but it is possible that this
process cannot be detected over short time frames. An interesting
avenue for future research would be to repeat our design with a
longer follow-up period and with measurement of receding support
systems and of individuals’ perception of problems and obstacles
over time.
A third possibility is that psychomotor agitation, a symptom of
depression, masquerades as an increase in energy. Many patients
who experience psychomotor agitation report that it is the most
distressing and uncomfortable symptom of all the depressive
symptoms. For those who previously displayed psychomotor retardation, the onset of agitation may resemble an increase in
energy simply because the patient is out of bed and activated.
Nevertheless, such patients may continue to experience severe
depressive symptoms and may even report an increase in general
distress level as a result of the agitation. If suicides occur in this
context, they may be attributable to (a) continued intense depressive symptoms, and/or (b) a temporary worsening of general
distress due to the introduction of psychomotor agitation. It is
important to note that this possibility is quite consistent with our
general conclusion that incomplete remissions of any sort may be
implicated in suicidality in context of lifting depression.3
A fourth view is that as depressive symptoms lift, even if they
lift incompletely, suicide risk decreases relative to when no symptoms have improved. Our data (see Table 2) are consistent with
this view, as is the broaden-and-build model of positive emotion
(Fredrickson, 1998) and our application of it to suicidality (Joiner,
Pettit, et al., 2001). Briefly, the broaden-and-build model proposes
that positive emotions—including energy— have the momentary
effect of broadening cognition and behavior, so that exploration,
experimentation, and play are more likely. Furthermore, because
positive emotions subserve exploration and experimentation, they
have the long-term effect of resource building. Through exploration and experimentation, new ideas and actions are discovered,
building up an individual’s repertoire of physical, intellectual, and
social resources. Using the model as context, Joiner, Pettit, et al.
(2001) found that suicidal patients prone to positive moods, as
compared with those less prone to such moods, displayed more
positive problem-solving attitudes following treatment for suicidal
symptoms and, partly as a function thereof, displayed enhanced
treatment response. These findings suggest that clinicians may
improve their chances of achieving successful treatment outcomes
if they present skill-building treatments during windows of positive mood for the client, rather than in times of crisis.
A fifth possibility is that low statistical power impeded our
ability to detect the role in escalating suicide risk of increased
energy combined with persistent overall depression. Statistical
power was challenged given the relatively low number of patients
in the group who experienced persistent depression despite increased energy. It would therefore be premature to fully reject the
role of surging energy with sustained depression in suicidality, and
we urge continued research on this topic.
Indeed, we do not recommend that the role of increased energy
with sustained depression in suicidality be rejected. On the contrary, we recommend that it be subsumed within a more general
view that extends to other clinical profiles, not just improved
energy within sustained depression. Specifically, our data, combined with work on incomplete remission (e.g., Judd, 1997), suggest that clinicians should be attentive to any situation in which a
substantially depressed person’s symptoms (any of them) continue
after sufficient treatment. Continued depressive symptoms can
serve as a risk factor for re-instantiated full-syndrome depression
and can serve as a marker for illness severity. Recurrent depression
and severity of depression, in turn, are associated with serious
suicidality. Clinicians who are attentive to incomplete symptom
responses will detect those who have improved energy but little
improvement in other symptoms and will also detect those with
other incomplete recovery profiles who might also be at substantial
risk.
What to do for patients in this situation? Evidence indicates that
augmented treatment should be considered for those who partially
respond to initial treatment (Pettit, Voelz, & Joiner, 2001). For
patients who partially respond to antidepressant medications, augmentation strategies would include increased dose, lithium augmentation, and addition of scientifically supported psychotherapy
(e.g., McCullough, 2000; Rudd, Joiner, & Rajab, 2000). For patients who partially respond to scientifically supported psychotherapies, augmentation strategies would include increased frequency
of sessions and addition of antidepressant medicines.
Of course, detection of incomplete treatment response requires
ongoing and objective assessment of symptoms. Regular use of
3
It is also worth noting that psychomotor agitation is a possible side
effect of certain antidepressant medications (e.g., fluoxetine; Rickels &
Schweizer, 1990). It is thus possible that an incomplete remission in
response to antidepressant medicine is further complicated by this side
effect. Here again, though, we view this as consistent with our general
conclusion that incomplete remission is an important and parsimonious
explanation of suicidality in the context of remitting depression. Also, we
are not suggesting that antidepressants such as selective serotonin reuptake
inhibitors (SSRIs) cause suicidal ideation or behavior, as some have
speculated. To the contrary, empirical evidence suggests that the use of
SSRIs is associated with decreased suicidality among depressed patients
(Leon et al., 1999; Warshaw & Keller, 1996), and that comparable rates of
suicidal ideation are found across the different classes of antidepressants
(Beasley, Sayler, Bosomworth, & Wernicke, 1991; Fava & Rosenbaum,
1991; see also Leon et al., 1999; Warshaw & Keller, 1996).
WINDOW OF HEIGHTENED SUICIDE RISK?
scales like the BDI is helpful in this regard. Suicide risk level
should also be regularly monitored (an example of an effective
approach is described in Joiner, Walker, Rudd, & Jobes, 1999);
risk level and attendant clinical decisions and actions should be
regularly justified and documented in progress notes.
In summary, we sought to provide some empirical perspective
on the important piece of clinical lore that depressed patients who
experience increased energy but otherwise sustained depression
are at high suicide risk. Results indicated that this pattern occurred
in approximately 7% of patients, and that a special relation between this pattern and suicidality may not be supportable. Rather,
we suggested that this pattern is one of many examples of incomplete remission, and that incomplete remission may be the more
comprehensive and useful pattern on which to focus. There is
parsimony to this view in that clinicians who are aware of it may
be better positioned to assess, prevent, and treat suicidality in
depressed patients, even if there are multiple ways in which lifting
depression relates to suicidality.
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Received April 28, 2003
Revision received July 15, 2003
Accepted October 7, 2003 䡲