Suicidal Behavior Tied to All-Cause Mortality in Major Depressive Disorder

Major depressive disorder (MDD) episodes with suicidal behavior are associated with a higher risk for all-cause mortality.

Patients with major depressive disorder (MDD) who exhibit suicidal behavior face increased mortality, health care resource utilization (HCRU), and work loss, according study findings published in JAMA Psychiatry. These findings emphasize the importance of comprehensive treatment evaluation in reducing the risk for all-cause mortality during MDD episodes.

To investigate the overall risk for death in patients with MDD and suicidal behavior, researchers conducted a population-based cohort study analyzing data from the Stockholm MDD Cohort.

The researchers collected data from patients aged 18 and older who were diagnosed with episodes of MDD between January 1 2012 to December 31, 2017 in the region of Stockholm. Patients were divided into 2 groups — either the major depressive disorder-suicidal behavior (MDD-SB) group or the MDD-non-SB group — based on at least 1 record of suicidal behavior during their MDD episode(s). Suicidal behavior was defined according to International Classification of Diseases, Tenth Revision (ICD-10)codes for intentional self-harm (X60-X84).

The 2 groups were matched based on age, sex, year of MDD diagnosis, and sociodemographic status. The primary endpoint was all-cause mortality. Secondary endpoints included comorbid conditions, medications, HCRU, and work loss.

These findings show an association between suicidal behavior and all-cause mortality in patients with MDD and warrant additional interventional studies in health care practice.

Of the 145,577 patients included in the study, a total of 158,169 unipolar MDD episodes were identified. The MDD-SB group of patients (n=2219) had a mean age of 40.9 (SD 18.6), with 1415 episodes (63.2%) reported by women and 825 episodes (36.8%) reported by men. The MDD-non-SB control group had 11,109 recorded MDD episodes across 9574 patients. Their average age was 40.8 (SD 18.5), with 7046 episodes (63.4%) reported by women and 4063 episodes (36.6%) reported by men.

The all-cause mortality rate was 2.5 per 100 person-years in the MDD-SB group and 1.0 per 100 person-years in the MDD-non-SB group, with a hazard ratio (HR) of 2.62 (95% CI, 2.15-3.20).

There was also a higher proportion of add-on treatments for those in the MDD-SB group (medication, 17.8%; electroconvulsive therapy [ECT], 3.3%) compared with the MDD-non-SB group (medication, 4.9%; ECT, 0.4%). This trend persisted at both index and 12 months after.

The 2 factors most strongly associated with a risk for suicidal behavior were a previous history of suicidal behavior and age, with patients age 20 and younger or 70 and older having the highest risks.

Furthermore, there were notable differences in average work loss days (87.1 vs 53.0), outpatient physician visits (11.4 vs 7.7), and inpatient bed days (11.1 vs 2.1) between the MDD-SB group and MDD-non-SB group, respectively.

The researchers concluded, “These findings show an association between suicidal behavior and all-cause mortality in patients with MDD and warrant additional interventional studies in health care practice.”

The results of this study may have been limited by the criteria used to attribute individual episodes of suicidal behavior, potentially resulting in an overestimation of episode prevalence.

Disclosure: Multiple study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

This article originally appeared on Psychiatry Advisor


Lundberg J, Cars T, Lampa E, et al. Determinants and outcomes of suicidal behavior among patients with major depressive disorder. JAMA Psychiatry. Published online August 16, 2023. doi:10.1001/jamapsychiatry.2023.2833