Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm, Sweden.
Sence Research AB, Uppsala, Sweden.
JAMA Psychiatry. 2023 Dec 1;80(12):1218-1225. doi: 10.1001/jamapsychiatry.2023.2833.
Major depressive disorder (MDD) is an important risk factor of suicidal behavior, but the added burden of suicidal behavior and MDD on the patient and societal level, including all-cause mortality, is not well studied. Also, the contribution of various prognostic factors for suicidal behavior has not been quantified in larger samples.
To describe the clinical and societal outcomes, including all-cause mortality, of suicidal behavior in patients with MDD and to explore associated risk factors and clinical management to inform future research and guidelines.
DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study used health care data from the Stockholm MDD Cohort. Patients aged 18 years or older with episodes of MDD diagnosed between January 1, 2012, and December 31, 2017, in any health care setting were included. The dates of the data analysis were February 1 to November 1, 2022.
Patients with MDD with and without records of suicidal behavior.
The main outcome was all-cause mortality. Secondary outcomes were comorbid conditions, medications, health care resource utilization (HCRU), and work loss. Using Region Stockholm registry variables, a risk score for factors associated with suicidal behavior within 1 year after the start of an MDD episode was calculated.
A total of 158 169 unipolar MDD episodes were identified in 145 577 patients; 2240 (1.4%) of these episodes, in 2219 patients, included records of suicidal behavior (mean [SD] patient age, 40.9 [18.6] years; 1415 episodes [63.2%] in women and 825 [36.8%] in men). A total of 11 109 MDD episodes in 9574 matched patients with MDD without records of suicidal behavior were included as controls (mean [SD] patient age, 40.8 [18.5] years; 7046 episodes [63.4%] in women and 4063 [36.6%] in men). The all-cause mortality rate was 2.5 per 100 person-years at risk for the MDD-SB group and 1.0 per 100 person-years at risk for the MDD-non-SB group, based on 466 deaths. Suicidal behavior was associated with higher all-cause mortality (hazard ratio, 2.62 [95% CI, 2.15-3.20]), as well as with HCRU and work loss, compared with the matched controls. Patients with MDD and suicidal behavior were younger and more prone to have psychiatric comorbid conditions, such as personality disorders, substance use, and anxiety, at the start of their episode. The most important factors associated with suicidal behavior within 1 year after the start of an MDD episode were history of suicidal behavior and age, history of substance use and sleep disorders, and care setting in which MDD was diagnosed.
This cohort study's findings suggest that high mortality, morbidity, HCRU, and work loss associated with MDD may be substantially accentuated in patients with MDD and suicidal behavior. Use of medication aimed at decreasing the risk of all-cause mortality during MDD episodes should be systematically evaluated to improve long-term outcomes.
重度抑郁症（MDD）是自杀行为的重要危险因素，但自杀行为和 MDD 对患者和社会层面的额外负担，包括全因死亡率，尚未得到很好的研究。此外，各种预后因素对自杀行为的贡献在更大的样本中尚未得到量化。
描述 MDD 患者自杀行为的临床和社会结局，包括全因死亡率，并探讨相关的风险因素和临床管理，以为未来的研究和指南提供信息。
设计、设置和参与者：这项基于人群的队列研究使用了斯德哥尔摩 MDD 队列的医疗保健数据。纳入了 2012 年 1 月 1 日至 2017 年 12 月 31 日期间在任何医疗保健环境中被诊断患有 MDD 发作的年龄为 18 岁或以上的患者。数据分析日期为 2022 年 2 月 1 日至 11 月 1 日。
有和没有自杀行为记录的 MDD 患者。
主要结局是全因死亡率。次要结局是合并症、药物治疗、医疗保健资源利用（HCRU）和工作损失。使用斯德哥尔摩地区登记变量，计算了 MDD 发作后 1 年内与自杀行为相关的因素的风险评分。
共确定了 145577 例患者的 158169 例单相 MDD 发作，其中 2219 例（1.4%）发作记录了自杀行为，涉及 2219 例患者（患者平均年龄[标准差]为 40.9[18.6]岁；1415 例[63.2%]为女性，825 例[36.8%]为男性）。共纳入了 9574 例与无自杀行为记录的 MDD 相匹配的患者的 11109 例 MDD 发作作为对照（患者平均年龄[标准差]为 40.8[18.5]岁；7046 例[63.4%]为女性，4063 例[36.6%]为男性）。MDD-SB 组的全因死亡率为每 100 人年风险 2.5 例，MDD-non-SB 组为每 100 人年风险 1.0 例，基于 466 例死亡。与匹配的对照组相比，自杀行为与更高的全因死亡率（危险比，2.62[95%置信区间，2.15-3.20]）以及 HCRU 和工作损失相关。与 MDD 发作开始时相比，患有 MDD 且有自杀行为的患者更年轻，且更倾向于患有精神科合并症，如人格障碍、物质使用和焦虑。与 MDD 发作后 1 年内自杀行为相关的最重要因素是自杀行为史和年龄、物质使用和睡眠障碍史，以及 MDD 被诊断的医疗保健环境。
这项队列研究的结果表明，与 MDD 相关的高死亡率、发病率、HCRU 和工作损失可能在患有 MDD 和自杀行为的患者中大大加重。应系统评估针对降低 MDD 发作期间全因死亡率的药物治疗，以改善长期结局。
