Unmet need in major depressive disorder and acute suicidal ideation or behavior: findings from a longitudinal electronic health record data analysis

Figures & data

Figure 1. Study design. (a) MDSI cohort. (b) Non-MDSI cohort. Abbreviations: MDSI, major depressive disorder and acute suicidal ideation or behavior; MDD, major depressive disorder; Dx, diagnosis. ^a≥1 diagnosis for MDD or other depressive disorder within the 12 months prior to or on the index date. ^b≥12 months of health care activity prior to the index period. ^cThe date of the first occurrence of suicidal ideation is defined as the index date and could occur any time within the index period. ^d≥1 diagnosis code for acute suicidal ideation or behavior during 31 October 2016 to 30 September 2019. ^e≥1 diagnosis for a depressive disorder during the study period.

Table 1. Baseline characteristics in the MDSI cohort, matched non-MDSI cohort, and standard differences in propensity score–matched cohorts.

Parameter	MDSI cohort (n = 71,161)		Non-MDSI cohort (n = 71,161)		|Std diff^a|
	n	%	n	%	%
Age group, years
18–29	27,393	38.5	27,422	38.5	0.1
30–39	13,278	18.7	13,211	18.6	0.2
40–49	11,077	15.6	11,017	15.5	0.2
50–59	10,659	15.0	10,674	15.0	0.1
60–69	5,837	8.2	5,846	8.2	0.0
70–79	2,092	2.9	2,159	3.0	0.6
≥80	825	1.2	832	1.2	0.1
Female	39,144	55.0	39,164	55.0	0.1
Race
African American	8,893	12.5	9,006	12.7	0.5
Asian	625	0.9	660	0.9	0.5
Caucasian	56,009	78.7	55,780	78.4	0.8
Other/unknown	5,634	7.9	5,715	8.0	0.4
Ethnicity
Hispanic	4,670	6.6	4,697	6.6	0.2
Not Hispanic	61,981	87.1	61,793	86.8	0.8
Unknown	4,510	6.3	4,671	6.6	0.9
Region
Midwest	40,550	57.0	40,506	56.9	0.1
South	11,102	15.6	10,987	15.4	0.4
West	5,960	8.4	5,998	8.4	0.2
Northeast	8,378	11.8	8,446	11.9	0.3
Other/unknown	5,171	7.3	5,224	7.3	0.3
Insurance
Commercial	23,841	33.5	23,760	33.4	0.2
Medicaid	14,343	20.2	14,358	20.2	0.1
Medicare	4,916	6.9	4,956	7.0	0.2
Multiple	4,722	6.6	4,745	6.7	0.1
Other payer type	2,592	3.6	2,575	3.6	0.1
Uninsured	4,530	6.4	4,524	6.4	0.0
Unknown	11,804	16.6	11,819	16.6	0.1
Missing	4,413	6.2	4,424	6.2	0.1

Abbreviations: MDSI, major depressive disorder and acute suicidal ideation or behavior; Std diff, standard difference.

^a|Std diff| ≥10% was considered as significant.

Table 2. Depression and other mental health–related treatments recorded for patients with MDSI.

Parameter^a	Pre-period of MDSI event (n = 71,161)		Index MDSI event (n = 71,161)		1-month post-period of MDSI event (n = 57,058)		6-month post-period of MDSI event (n = 40,261)
	n	%	n	%	n	%	n	%
Pharmacologic therapy
Antidepressants	22,303	31.3	29,292	41.2	16,581	29.1	17,469	43.4
SSRI	15,101	21.2	17,106	24.0	10,391	18.2	11,316	28.1
SNRI	5,979	8.4	6,303	8.9	3,936	6.9	4,718	11.7
Serotonin modulators	5,479	7.7	13,244	18.6	5,684	10.0	6,178	15.3
Norepinephrine-serotonin modulator	1,710	2.4	3,393	4.8	1,973	3.5	2,137	5.3
Tricyclic and tetracyclic antidepressants	1,981	2.8	1,225	1.7	737	1.3	1,077	2.7
Bupropion, maprotiline	3,631	5.1	3,365	4.7	2,043	3.6	2,784	6.9
Monoamine oxidase inhibitors	17	<0.1	16	<0.1	6	<0.1	11	<0.1
Agents used to augment antidepressant treatment	9,952	14.0	14,316	20.1	6,934	12.2	8,245	20.5
Lithium	146	0.2	288	0.4	141	0.2	198	0.5
Second-generation antipsychotics^b	3,681	5.2	10,031	14.1	3,855	6.8	4,364	10.8
Anticonvulsant	1,549	2.2	1,728	2.4	962	1.7	1,251	3.1
Thyroid hormone	2,652	3.7	2,113	3.0	1,243	2.2	1,679	4.2
Psychostimulants	2,032	2.9	865	1.2	826	1.4	1,115	2.8
Buspirone	2,152	3.0	1,918	2.7	1,191	2.1	1,759	4.4
Other psychotherapeutic drugs	20,531	28.9	30,035	42.2	9,601	16.8	11,760	29.2
Other second-generation antipsychotics	830	1.2	2,405	3.4	838	1.5	992	2.5
Nonstimulant ADHD treatments^c	2,440	3.4	3,651	5.1	1,232	2.2	1,488	3.7
Benzodiazepines	19,030	26.7	27,741	39.0	8,287	14.5	10,463	26.0
Sleep aids^d	3,277	4.6	4,150	5.8	1,437	2.5	1,961	4.9
Nonpharmacologic therapy
Psychotherapy	6,760	9.5	13,320	18.7	8,203	14.4	8,260	20.5
Transcranial magnetic stimulation	14	<0.1	5	<0.1	10	<0.1	22	0.1
Electroconvulsive therapy	92	0.1	221	0.3	223	0.4	226	0.6
Vagus nerve stimulation	26	<0.1	0	0.0	2	<0.1	7	<0.1

Abbreviations: MDSI, major depressive disorder and acute suicidal ideation or behavior; SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin norepinephrine reuptake inhibitor; ADHD, attention-deficit/hyperactivity disorder; MDD, major depressive disorder.

^aPatients may receive more than one therapy or type of therapy per period. Percentages were calculated out of the total number of patients receiving a therapy within each period.

^bSecond-generation antipsychotics with US Food and Drug Administration approval for MDD: aripiprazole, brexpiprazole, olanzapine in combination with fluoxetine (specifically treatment-resistant MDD), and quetiapine XR.

^cClonidine, guanfacine, and atomoxetine.

^dEszopiclone, zaleplon, and zolpidem.

Table 3. PHQ-9 scores for the MDSI cohort^a.

Parameter	Pre-period of MDSI event (n = 71,161)		Index MDSI event (n = 71,161)		6-month post-period of MDSI event (n = 40,261)
	n/Mean	%/SD	n/Mean	%/SD	n/Mean	%/SD
Patients with PHQ-9 score	3,141	4.4	941	1.3	3,062	7.6
PHQ-9 total score	13.0	7.5	17.0	7.2	12.1	7.5
PHQ-9–derived depression severity^b
None/minimal	523	16.7	70	7.4	593	19.4
Mild	543	17.3	113	12.0	641	20.9
Moderate	697	22.2	118	12.5	648	21.2
Moderately severe	661	21.0	231	24.5	571	18.6
Severe	717	22.8	409	43.5	609	19.9

Abbreviations: PHQ-9, 9-item Patient Health Questionnaire; MDSI, major depressive disorder and acute suicidal ideation or behavior; SD, standard deviation.

^aPHQ-9 total score reported as mean and SD; all other parameters reported as n and %.

^bDepression severity categories were defined as follows: none/minimal, score 0–4; mild, 5–9; moderate, 10–14; moderately severe, 15–19; and severe, 20–27. The mean (SD) PHQ-9 scores during these periods were 13.0 (7.5), 17.0 (7.2), and 12.1 (7.5), respectively. Among those with a PHQ-9 score available during the index period, approximately 80% had scores indicating moderate-to-severe depression.

Table 4. Shifts in PHQ-9 score categories for patients with MDSI with scores during pre- and 6-month post-periods (n = 1,139)^a.

Parameter	Depression severity during the 6-month post-period
	None/minimal		Mild		Moderate		Moderately severe		Severe
	n	%	n	%	n	%	n	%	n	%
Pre-period depression severity
None/minimal (n = 161, 14.1%)	76	47.2	30	18.6	23	14.3	20	12.4	12	7.5
Mild (n = 217, 19.1%)	44	20.3	83	38.2	49	22.6	26	12.0	15	6.9
Moderate (n = 259, 22.7%)	25	9.7	71	27.4	94	36.3	37	14.3	32	12.4
Moderately severe (n = 240, 21.1%)	24	10.0	40	16.7	53	22.1	82	34.2	41	17.1
Severe (n = 262, 23.0%)	25	9.5	35	13.4	54	20.6	46	17.6	102	38.9

Abbreviations: PHQ-9, 9-item Patient Health Questionnaire; MDSI, major depressive disorder and acute suicidal ideation or behavior.

^aDepression severity categories were defined as follows: none/minimal, score 0–4; mild, 5–9; moderate, 10–14; moderately severe, 15–19; and severe, 20–27.

Figure 2. Post-period HRU in the MDSI cohort. (a) Proportion of patients with all-cause HRU. (b) Proportion of patients with MDD-related HRU. Abbreviations: HRU, health care resource utilization; MDSI, major depressive disorder and acute suicidal ideation or behavior; ED, emergency department; MDD, major depressive disorder. ^aHRU reported for the 57,058 patients in the MDSI cohort with ≥1 month of data in the post-period. ^bHRU reported for the 40,261 patients in the MDSI cohort with ≥6 months of data in the post-period.

Figure 3. All-cause HRU: MDSI versus non-MDSI cohorts. (a) During the 1-month post-period. (b) During the 6-month post-period. Abbreviations: HRU, health care resource utilization; MDSI, major depressive disorder and acute suicidal ideation or behavior; OR, odds ratio; CI, confidence interval; ED, emergency department.

Data sharing statement

The data that support the findings of this study are not publicly available due to privacy or ethical restrictions.