Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review

Objectives:  To update and extend comparisons of rates of suicides and suicide attempts among patients with major affective disorders with versus without long-term lithium treatment.
Methods:  Broad searching yielded 45 studies providing rates of suicidal acts during lithium treatment, including 34 also providing rates without lithium treatment. We scored study quality, tested between-study variance, and examined suicidal rates on versus off lithium by meta-analytic methods to determine risk ratios (RRs) and 95% confidence intervals (CI).
Results:  In 31 studies suitable for meta-analysis, involving a total of 85,229 person-years of risk-exposure, the overall risk of suicides and attempts was five times less among lithium-treated subjects than among those not treated with lithium (RR = 4.91, 95% CI 3.82–6.31, p < 0.0001). Similar effects were found with other meta-analytic methods, as well as for completed versus attempted suicide, and for bipolar versus major mood disorder patients. Studies with higher quality ratings, including randomized, controlled trials, involved shorter exposures with somewhat lesser lithium superiority. Omitting one very large study or those involving lithium-discontinuation had little effect on the results. The incidence-ratio of attempts-to-suicides increased 2.5 times with lithium-treatment, indicating reduced lethality of suicidal acts. There was no indication of bias toward reporting positive findings, nor were outcomes significantly influenced by publication-year or study size.
Conclusions:  Risks of completed and attempted suicide were consistently lower, by approximately 80%, during treatment of bipolar and other major affective disorder patients with lithium for an average of 18 months. These benefits were sustained in randomized as well as open clinical trials.     

Suicidal risk in bipolar I disorder patients and adherence to long-term lithium treatment

Objectives:  Among the well-established treatments for bipolar disorder (BPD), lithium continues to offer an unusually broad spectrum of benefits that may include reduction of suicidal risk.
Methods:  We examined the association of suicidal acts with adherence to long-term lithium maintenance treatment and other potential risk factors in 72 BP I patients followed prospectively for up to 10 years at a Mood Disorders Research Center in Spain.
Results:  The observed rates of suicide were 0.143, and of attempts, 2.01%/year, with a 5.2-fold (95% CI: 1.5–18.6) greater risk among patients consistently rated poorly versus highly adherent to lithium prophylaxis (11.4/2.2 acts/100 person-years). Treatment non-adherence was associated with substance abuse, being unmarried, being male, and having more hypomanic–manic illness and hospitalizations. Suicidal risk was higher with prior attempts, more depression and hospitalization, familial mood disorders, and being single and younger, as well as treatment non-adherence, but with neither sex nor substance abuse. In multivariate analysis, suicidal risk was associated with previous suicidality > poor treatment adherence > more depressive episodes > younger age.
Conclusions:  The findings support growing evidence of lower risk of suicidal acts during closely monitored and highly adherent, long-term treatment with lithium and indicate that treatment adherence is a potentially modifiable factor contributing to antisuicidal benefits.     

Suicidal Behaviour in Mood Disorders—Who,When, and Why?

Objective:

About one-half to two-thirds of all suicides are by people who suffer from mood disorders; preventing suicides among those who suffer from them is thus central for suicide prevention. Understanding factors underlying suicide risk is necessary for rational preventive decisions.

Method:

The literature on risk factors for completed and attempted suicide among subjects with depressive and bipolar disorders (BDs) was reviewed.

Results:

Lifetime risk of completed suicide among psychiatric patients with mood disorders is likely between 5% and 6%, with BDs, and possibly somewhat higher risk than patients with major depressive disorder. Longitudinal and psychological autopsy studies indicate suicidal acts usually take place during major depressive episodes (MDEs) or mixed illness episodes. Incidence of suicide attempts is about 20- to 40-fold, compared with euthymia, during these episodes, and duration of these high-risk states is therefore an important determinant of overall risk. Substance use and cluster B personality disorders also markedly increase risk of suicidal acts during mood episodes. Other major risk factors include hopelessness and presence of impulsive–aggressive traits. Both childhood adversity and recent adverse life events are likely to increase risk of suicide attempts, and suicidal acts are predicted by poor perceived social support. Understanding suicidal thinking and decision making is necessary for advancing treatment and prevention.

Conclusion:

Among subjects with mood disorders, suicidal acts usually occur during MDEs or mixed episodes concurrent with comorbid disorders. Nevertheless, illness factors can only in part explain suicidal behaviour. Illness factors, difficulty controlling impulsive and aggressive responses, plus predisposing early exposures and life situations result in a process of suicidal thinking, planning, and acts.     

Heterogeneity of the risk of suicidal behavior in bipolar-spectrum disorders

OBJECTIVES: The risk of suicidal behavior is substantially elevated in major affective disorders (AD). In bipolar disorder (BD), as many as 15% of patients may commit suicide and family history of suicide is recognized as one of the most important risk factors. Lithium reduces the rates of suicidal behavior in BD, especially in patients who achieve full mood stabilization. Yet even patients who continue experiencing mood episodes do benefit from anti-suicidal properties of lithium. These observations raise questions about the nature of the relationship between the neurobiological mechanisms of BD and suicide, namely whether they are shared or independent. METHODS: We studied the distribution of suicides and suicide attempts in 539 subjects from 78 families of probands with major AD, all responders to lithium prophylaxis. A Cox proportional hazard regression model was used to assess the contribution of several independent variables to the risks of AD, BD, and suicidal behavior. RESULTS: The lifetime prevalence of BD was significantly greater among first-degree relatives of suicide than non-suicide probands (22% versus 11%) and the prevalence of BD in families was associated with an increased risk of developing mood disorder and subsequently committing or attempting suicide (p = 0.003). Families fell into 1 of 3 groups, corresponding to a low (<0.1%), intermediate (17.8%), and high (87.8%) risk for suicide in affectively ill subjects. CONCLUSIONS: Suicidal behavior is distributed unevenly in families of probands with BD, aggregating in a subset of families. Our results also suggest that partially overlapping sets of genetic factors may underlie BD and suicide.     

Risk of suicide in mood disorders

Suicide is commonly associated with mood disorders. Risk factors for suicide in mood disorders can be organized according to whether their effect is on the threshold or diathesis for suicidal acts or whether they serve mainly as triggers or precipitants of suicidal acts. Predisposition to suicidal behavior or diathesis is a key element that helps to differentiate patients who are at high risk versus those at lower risk. The objective severity of mood disorders does not identify depressed patients at high risk for suicide attempt. There is a lack of agreement over the suicide risk associated with characteristics of depression such as psychotic features, agitation, or anxiety, or mixed mood states as part of bipolar disorder. Risk factors affecting the diathesis for suicidal behavior include family history of suicide, low cerebrospinal fluid 5-hydroxyindolacetic acid, alcohol and/or substance abuse, cluster B personality disorder, high past impulsivity and aggression, chronic physical illness particularly involving the brain, marital isolation, parental loss before age 11, childhood history of physical and sexual abuse, hopelessness, and not living with a child under age 18. Most common precipitants of suicidal acts in mood disorders include interpersonal losses or conflicts, financial trouble, and job problems. Identification of high risk patients and effective treatment are required for suicide prevention to reduce morbidity and mortality in affective disorders.     

Does lithium exert an independent antisuicidal effect?

AIM OF STUDY: Recent investigations have indicated that adequate lithium treatment lowers the suicide mortality associated with affective illness. One important question is whether the mechanism by which lithium prophylaxis may be effective in prolonging survival can be explained exclusively in terms of successful protection against the recurrence of depressive episodes, or whether one should consider an independent anti-suicidal factor. METHODS: We investigated a group of high-risk patients with recurrent affective disorders (n = 167) who had committed one or more suicide attempts before the start of lithium prophylaxis within a collaborative project by the International Group for the Study of Lithium Treated Patients (IGSLI). According to their recurrence-related response to long-term lithium prophylaxis, patients were classified into three groups: excellent (n = 45), moderate (n = 81) and poor responders (n = 41). Only depressive episodes resulting into hospitalisation were considered. A marked reduction in the number of suicide attempts was observed in the excellent lithium responders. However, we also found that over 80% of moderate responders and nearly 50% of poor responders did not exhibit any further suicidal behaviour during lithium treatment. Furthermore, we could demonstrate a significant reduction of suicide attempts per year as compared to a corresponding pre-lithium period in all three groups (0.10 vs. 0.33, 0.06 vs. 0.27, 0.02 vs. 0.26). There were four suicides in this high-risk group, corresponding to a suicide-related standardised mortality ratio (SMR) of 13.7. This contrasts sharply with an expected suicide SMR of approx. 100 in this population. Suicide risk was not related to the recurrence-preventing effect. CONCLUSION: The reduction in suicide attempts, in both responders and non-responders, indicates that lithium possesses a specific anti-suicidal effect besides its mood-stabilising property.     

Association of comorbid posttraumatic stress disorder and major depression with greater risk for suicidal behavior

OBJECTIVE: Posttraumatic stress disorder (PTSD) increases the risk of suicidal behavior; a major depressive episode also increases the risk for suicidal behavior. The authors' goal was to examine the effect of comorbid PTSD and major depressive episode on suicidal behavior. METHOD: Inpatients with a diagnosis of major depressive episode (N=156) were assessed for PTSD, suicidal behavior, and clinical risk factors for suicidal acts. RESULTS: Patients with comorbid major depressive episode and PTSD were more likely to have attempted suicide, and women with both disorders were more likely to have attempted suicide than men with both disorders. Cluster B personality disorder and PTSD were independently related to history of suicide attempts. CONCLUSIONS: The greater rate of suicide attempts among patients with comorbid PTSD and major depressive episode was not due to differences in substance use, childhood abuse, or cluster B personality disorders.     

Lithium and suicide prevention in bipolar disorder

IntroductionBipolar disorder (BD) is a severe and recurrent psychiatric disorder. The severity of prognosis in BD is mainly linked to the high rate of suicide in this population. Indeed, patients with BD commit suicide 20 to 30 times more frequently than the general population, and half of the BD population with an early age of onset have a history of suicide attempt. International therapeutic guidelines recommend lithium (Li) as the first-line treatment in BD for its prophylactic action on depressive or manic episodes. In addition, Li is the only mood stabilizer that has demonstrated efficacy in suicide prevention. This effect of Li is unfortunately often unknown to psychiatrists. Thus, this review aims to highlight evidence about the preventive action of Li on suicide in BD populations.MethodsWe conducted a literature search between April 1968 and August 2014 in PubMed database using the following terms: “lithium” AND “suicide” OR “suicidality” OR “suicide attempt”.ResultsAs confirmed by a recent meta-analysis, many studies show that Li has a significant effect on the reduction of suicide attempts and deaths by suicide in comparison to antidepressants or other mood-stabilisers in BD populations. Studies have demonstrated that long-term treatment with Li reduces suicide attempts by about 10% and deaths by suicide by about 20%. The combination of Li and an antidepressant could reduce suicidal behaviours by reducing suicidal ideation prior to depressive symptoms. It appears crucial for Li efficacy in suicide prevention to maintain the Li blood concentrations in the efficient therapeutic zone and to instate long-term Li treatment. The “impulsive-aggressive” endophenotype is associated with suicide in BD. The specific action of Li on the 5-HT serotoninergic system could explain the specific anti-suicidal effects of Li via the modulation of impulsiveness and aggressiveness. Furthermore, genetic variants of the glycogen synthase kinase 3α/β (GSK3α and β; proteins inhibited by Li) seem to be associated with more impulsiveness in BD populations.ConclusionThe anti-suicidal effect of Li has been very well demonstrated. By its specific action on the serotoninergic system, treatment with Li significantly reduces “impulsive-aggressive” behaviour which is a vulnerability factor common to suicide and BD. Long-term appropriately modulated treatment with Li seems to have considerable impact on the reduction of suicidal behaviours, suicidal ideation and death by suicide in the BD population.     

Features associated with the delayed initiation of mood stabilizers at illness onset in bipolar disorder

BACKGROUND: Whether delays in the initiation of appropriate pharmacotherapy for bipolar illness negatively affect course, outcome, or lifetime suicide risk remains at issue. METHOD: Lifetime affective syndromes and the initial emergence of affective symptoms were assessed by lifecharting in 56 DSM-IV bipolar patients. Lifetime treatment interventions were recorded by clinical interview with corroboration via record reviews. Lag times to the initiation of a mood stabilizer (after initial symptom onset and/or first lifetime affective episode) were assessed relative to functional outcome and lifetime suicide attempts. RESULTS: Mean +/- SD lag time from initial affective symptoms until first mood stabilizer treatment was 9.8 +/- 9.4 years. A greater number of years from symptom onset to first mood stabilizer was associated with poorer past year social functioning (r = -0.35, p =.008), more annual hospitalizations (r = 0.38, p =.004), and a greater likelihood for making a lifetime suicide attempt (odds ratio = 7.26, 95% confidence interval = 1.62 to 32.59; Wald chi2 = 6.69, df = 1, p =.010). Delayed mood stabilizer initiation was linked with poorer outcomes in these domains regardless of initial index episode polarities of mania versus depression. Prolonged delays to bipolar diagnoses and mood stabilizer initiation were associated with earlier ages at affective symptom onset (p <.03) and milder severity of initial symptoms (p =.003). Psychotherapy initiation often preceded mood stabilizer introduction by >/= 8 years. CONCLUSION: Delays in the initiation of mood stabilizer pharmacotherapy at illness onset, even for relatively mild symptoms at illness onset and regardless of index episode polarity, may confer an elevated risk for suicidal behavior, poorer social adjustment, and more hospitalizations in bipolar disorder. Greater surveillance screening for bipolar illness in patients who first present for psychotherapy may help to diminish these adverse outcomes.     

Anxiety disorders and risk for suicidal ideation and suicide attempts: a population-based longitudinal study of adults

CONTEXT: Controversy exists whether anxiety disorders are independently associated (ie, after adjusting for comorbid mental disorders) with suicidal ideation and suicide attempts. OBJECTIVE: To examine whether anxiety disorders are risk factors for suicidal ideation and suicide attempts in a large population-based longitudinal study. METHODS: Data come from the Netherlands Mental Health Survey and Incidence Study, a prospective population-based survey with a baseline and 2 follow-up assessments over a 3-year period. The Composite International Diagnostic Interview was used to assess DSM-III-R mental disorders. Lifetime diagnoses of anxiety disorders (social phobia, simple phobia, generalized anxiety disorder, panic disorder, agoraphobia, obsessive-compulsive disorder) were assessed at baseline. Multiple logistic regression analyses were used to examine whether anxiety disorders were associated with suicidal ideation and attempts at baseline (n = 7076) and whether anxiety disorders were risk factors for subsequent onset of suicidal ideation and attempts (n = 4796). RESULTS: After adjusting for sociodemographic factors and all other mental disorders assessed in the survey, baseline presence of any anxiety disorder was significantly associated with suicidal ideation and suicide attempts in both the cross-sectional analysis (adjusted odds ratio for suicidal ideation, 2.29; 95% confidence interval, 1.85-2.82; adjusted odds ratio for suicidal attempts, 2.48; 95% confidence interval, 1.70-3.62) and longitudinal analysis (adjusted odds ratio for suicidal ideation, 2.32; 95% confidence interval, 1.31-4.11; adjusted odds ratio for suicide attempts, 3.64; 95% confidence interval, 1.70-7.83). Further analyses demonstrated that the presence of any anxiety disorder in combination with a mood disorder was associated with a higher likelihood of suicide attempts in comparison with a mood disorder alone. CONCLUSIONS: This is the first study to demonstrate that a preexisting anxiety disorder is an independent risk factor for subsequent onset of suicidal ideation and attempts. Moreover, the data clearly demonstrate that comorbid anxiety disorders amplify the risk of suicide attempts in persons with mood disorders. Clinicians and policymakers need to be aware of these findings, and further research is required to delineate whether treatment of anxiety disorders reduces the risk of subsequent suicidal behavior.     

Adjunctive lithium treatment in the prevention of suicidal behaviour in depressive disorders: a randomised, placebo-controlled, 1-year trial

Objective: Evidence based on controlled studies is still limited for treatment strategies that prevent recurrence of suicide attempts. Findings from observational as well as meta‐analytic studies strongly suggest that lithium may have suicide‐protective properties. Method: Patients with a recent suicide attempt in the context of an affective spectrum disorder (n = 167) were treated with either lithium or placebo during a 12‐month period. Results: Survival analysis showed no significant difference of suicidal acts between lithium and placebo‐treated individuals (adjusted hazard ratio 0.517; 95% CI 0.18–1.43). However, post hoc analysis revealed that all completed suicides had occurred in the placebo group accounting for a significant difference in incidence rates (P = 0.049). Conclusion: Results indicate that lithium treatment might be effective in reducing the risk of completed suicide in adult patients with affective disorders. Our findings contribute to the growing body of evidence suggesting a specific antisuicidal effect of lithium.     

Antidepressants and suicidal behavior in bipolar disorder

Patients with bipolar disorder are at very high risk for suicidal ideation, non-fatal suicidal behaviors and suicide and are frequently treated with antidepressants. However, no prospective, randomized, controlled study specifically evaluating an antidepressant on suicidality in bipolar disorder has yet been completed. Indeed, antidepressants have not yet been shown to reduce suicide attempts or suicide in depressive disorders and may increase suicidal behavior in pediatric, and possibly adult, major depressive disorder. Available data on the effects of antidepressants on suicidality in bipolar disorder are mixed. Considerable research indicates that mixed states are associated with suicidality and that antidepressants, especially when administered as monotherapy, are associated with both suicidality and manic conversion. In contrast, growing research suggests that antidepressants administered in combination with mood stabilizers may reduce depressive symptoms in patients with bipolar depression. Further, the only prospective, long-term study evaluating antidepressant treatment and mortality in bipolar disorder, although open-label, found antidepressants and/or antipsychotics in combination with lithium, but not lithium alone, reduced suicide in bipolar and unipolar patients (Angst F, et al. J Affect Disord 2002: 68: 167–181). We conclude that antidepressants may induce suicidality in a subset of persons with depressive (and probably anxious) presentations; that this induction may represent a form of manic conversion, and hence a bipolar phenotype, and that lithium's therapeutic properties may include the ability to prevent antidepressant-induced suicidality.     

The effect of pharmacotherapy on suicide rates in bipolar patients

Suicide is a complex and multicausal human behavior and also a great challenge for psychiatry. We review the evidence available concerning pharmacological prevention of suicide in bipolar disorder patients. Several clinical trials provide evidence that effective acute and long-term treatment of bipolar depression provides a strong protection against suicide, suicide attempts, and probably against other complications of this disorder. Current major mood disorder is the most important risk factor of suicide, and bipolar II patients carry the highest risk. In bipolar patients suicidal behavior is most likely to occur during pure or mixed depressive episodes. Since bipolar disorder is a highly recurrent illness, adequate long-term pharmacotherapy is needed to prevent suicidal behavior.     

The prospectively observed course of illness among depressed patients who commit suicide

OBJECTIVE: These analyses were conducted to describe the course of illness among patients with major affective disorders who commit suicide. METHOD: Twenty-nine patients who entered a long-term, high-intensity follow-up study of major affective disorders and who later committed suicide within 1 year of their last follow-up interview were individually matched to other patients by age, sex, the presence or absence of lifetime drug or alcohol abuse, time to last interview and polarity. Those who suicided were compared with their controls by depressive and substance abuse morbidity during follow-up, treatment resistance, treatment compliance, suicidal behavior and psychosocial adjustment. RESULTS: Among the various measures used to characterize the course of illness during a mean follow-up of 4.3 years, only those pertaining to suicidal behavior robustly separated the suicide group from their controls. Suicidal behavior in the remote past seemed as predictively important as suicidal behavior during follow-up. CONCLUSION: Of the various features monitored over time in patients with major affective disorder, suicidal behavior itself was the clearest correlate of risk for completed suicide.     

Suicide risk in mood disorders

PURPOSE OF REVIEW: The aim of this review is to highlight the traditional and newly recognized suicide risk factors in patients with mood disorders. RECENT FINDINGS: Current research findings clearly suggest that suicidal behaviour in patients with mood disorder is a 'state-dependent' phenomenon. Recently, there is, however, a growing body of evidence that besides the well accepted clinically explorable suicide risk factors in mood disorders (e.g., severe depression, prior suicide attempt, comorbid anxiety, substance use, personality disorders and so on), mixed state of depression could also be an important precursor of suicidal behaviour. This might be particularly true in unrecognized cases of bipolar depressives, when antidepressant monotherapy (unprotected by mood stabilizers or atypical antipsychotics) can worsen the clinical picture and rarely induce an aggressive or self-destructive behaviour. SUMMARY: In the majority of patients with mood disorders, suicidal behaviour is predictable and preventable, with a good chance. A careful and systematic exploration of suicide risk factors in patients with mood disorder helps clinicians to identify patients at high suicide risk. A successful, acute and long-term treatment of these patients substantially reduces the suicidal behaviour even in this high-risk population.     

Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study

OBJECTIVE: Suicidal behavior is highly prevalent in borderline personality disorder and major depressive episode, although the characteristics of suicide attempts in the two disorders are believed to differ. Comorbidity of borderline personality disorder and major depressive episode may obscure characteristics of suicide attempts that are uniquely related to the psychopathology of each disorder. We compared suicidal behavior in patients with borderline personality disorder, major depressive episode, and borderline personality disorder plus major depressive episode to determine whether characteristics of suicide attempts differed between groups and if aspects of core psychopathology predicted specific attempt characteristics. METHOD: Eighty-one inpatients with borderline personality disorder, including 49 patients with borderline personality disorder plus major depressive episode, were compared to 77 inpatients with major depressive episode alone on measures of depressed mood, hopelessness, impulsive aggression, and suicidal behavior, including lifetime number of attempts, degree of lethal intent, objective planning, medical damage, and degree of violence of suicide methods. RESULTS: No significant differences were found in the characteristics of suicide attempts between patients with borderline personality disorder and those with major depressive episode. However, patients with both disorders had the greatest number of suicide attempts and the highest level of objective planning. An increase in either impulsive aggression or hopelessness or a diagnosis of borderline personality disorder predicted a greater number of attempts. Hopelessness predicted lethal intent in all three groups and predicted objective planning in the group with both disorders. Medical damage resulting from the most serious lifetime suicide attempt was predicted by number of attempts. CONCLUSIONS: Comorbidity of borderline personality disorder with major depressive episode increases the number and seriousness of suicide attempts. Hopelessness and impulsive aggression independently increase the risk of suicidal behavior in patients with borderline personality disorder and in patients with major depressive episode.     

Late onset first manic episode: role of lithium]

This case reports on a first manic episode occurring to a 68 year old patient. Until now this male patient had been diagnosed with a recurrent depressive disorder. This depressive illness started 29 years ago and was punctuated by several depressive episodes. During one of these episodes associated to psychotic features, following the lithium discontinuation, the patient committed a homicide-suicide. He was found not to be responsible for his crime and treatment was subsequently restarted. For the next fifteen years the patient was stabilized using the association of antidepressant plus lithium, then lithium alone. Until the current manic episode subsequent to a further lithium discontinuation, the patient thanks to the mood stabilizer, could enjoy a good quality of life with a very satisfying social and professional adjustment. Following the case report, an analysis of published data on epidemiological parameters and risk factors associated was conducted. Findings show that perpetrators of murder suicides are mainly males (> 85%) suffering from depression (40% to 75%). Cases of homicide-suicide more frequently involve individuals committing a violent suicide shortly after (minutes or hours) committing one or more homicides. These cases often occur within a disturbed family context with drugs or alcohol abuse, social or cultural stresses such as poor social level or unemployment being other risk factors. Fire-arms are the most frequently used in suicides. Reported annual incidence is similar every year, ranging from 0.2 to 0.3 per 100,000 in the United States and other countries. Due to suicide but also to other disorders, mortality and morbidity rates are higher with patients suffering from mood disorders. A long term treatment with lithium results in a decrease of morbidity rate and suicidal risk in the general population.     

Suicide in mood disordered children and adolescents

This article reviews the risk factors for fatal and nonfatal suicidal behavior in children and adolescents. Numerous empirical studies suggest that mood disorders are among the most important risk factors for youth suicidal behavior. In addition, other psychosocial factors increase risk for youth suicidal behavior independent of mood disorders. Prevention strategies for suicidal behavior should incorporate methods to identify children and adolescents who suffer from major depressive, dysthymic, and bipolar disorders. Such strategies should identify children and adolescents who have a history of suicidal ideation and/or suicide attempts.     

Suicidality in bipolar compared to unipolar depressed inpatients

The aim of the present analyses was to evaluate differences in suicidality (past suicide attempts, suicidal thoughts at time of admission and completed suicides during the hospital stay) between bipolar and unipolar depressed inpatients. Apart from a higher frequency of past suicide attempts in bipolar depressed patients (26.6% in bipolar vs. 17.8% in unipolar patients), findings do not indicate any further differences in suicidality (suicidal thoughts (about 40% in both groups) and completed suicides during the hospital stay (0.8% in both groups)) between bipolar and unipolar patients. Factors with a predictive value for suicidal thoughts at the time of admission were a positive family history for affective disorders, past suicide attempts, and the depressive and paranoid hallucinatory syndrome (all associated with an increased risk). Female gender, an older age at hospitalisation and a longer duration of the illness were found to be associated with a lower probability for having suicidal tendencies at the time of admission. The risk for committing suicide during the hospital stay was increased if the patients had a history of past suicide attempts and suicidal thoughts at the time of admission. A more pronounced depressive syndrome at time of admission was slightly associated with a lower risk of committing suicide. Received: 25 April 2000 / Accepted: 28 June 2000