Risk of suicide attempt and suicide death in patients treated for bipolar disorder

OBJECTIVES: To evaluate demographic and clinical predictors of suicide attempt and suicide death in a population-based sample of people treated for bipolar disorder (BD). METHODS: Computerized records were used to identify 32,360 individuals treated for BD at two large prepaid health plans. Suicide attempts were identified using computerized records of outpatient visit diagnoses and hospital discharge diagnoses. Suicide deaths were identified using state death certificate data. RESULTS: Overall event rates were 1.06 per 1,000 person-years for suicide death, 5.6 per 1,000 person-years for suicide attempt leading to hospitalization, and 13.9 per 1,000 person-years for suicide attempt not leading to hospitalization. Men had a significantly lower rate of suicide attempt [hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.56-0.83] but a higher rate of suicide death (HR 2.70, 95% CI 1.69-4.31). Suicide attempts were significantly more frequent among younger patients, but suicide deaths did not vary significantly by age. Substance use comorbidity was significantly related to risk of suicide attempt (HR 2.53, 95% CI 2.07-3.09) but not to risk of suicide death (HR 1.02, 95% CI 0.54-1.93). Comorbid anxiety disorder was associated with significantly higher risk of both suicide attempt (HR 1.40, 95% CI 1.14-1.72) and suicide death (HR 1.81, 95% CI 1.09-2.99). CONCLUSIONS: Among people treated for BD, risk of suicide death is significantly related to male sex and comorbid anxiety disorder. The predictors of suicide death differ markedly from predictors of suicide attempt.     

Correlates of suicide attempt history in bipolar disorder: a stress-diathesis perspective

Objectives:  Distinguishing clinical characteristics of bipolar patients who have made a suicide attempt may help to identify at-risk individuals. We sought to identify such factors and to consider them within a stress-diathesis model of suicidal behavior.
Methods:  Patients with bipolar disorder (N = 96) were compared with respect to the presence or absence at baseline evaluation of a history of suicide attempt. We used multiple logistic regression analysis to assess the unique associations of independent variables to history of a past suicide attempt.
Results:  The regression analysis showed that a history of suicide attempt in bipolar disorder was associated with greater recent suicidal ideation, more psychiatric hospitalizations, lifetime aggressive traits and an earlier age at onset of a first mood episode.
Conclusions:  Aggressive traits and early treatment of mood disorders, especially major depressive episodes, are potential targets for suicide prevention in bipolar disorder.     

Suicide attempts in bipolar I and bipolar II disorder: a review and meta-analysis of the evidence

Novick DM, Swartz HA, Frank E. Suicide attempts in bipolar I and bipolar II disorder: a review and meta‐analysis of the evidence. Bipolar Disord 2010: 12: 1–9. © 2010 The Authors.
Journal compilation © 2010 John Wiley & Sons A/S. Objective: The prevalence of suicide attempts (SA) in bipolar II disorder (BPII), particularly in comparison to the prevalence in bipolar I disorder (BPI), is an understudied and controversial issue with mixed results. To date, there has been no comprehensive review of the published prevalence data for attempted suicide in BPII. Methods: We conducted a literature review and meta‐analysis of published reports that specified the proportion of individuals with BPII in their presentation of SA data. Systematic searching yielded 24 reports providing rates of SA in BPII and 21 reports including rates of SA in both BPI and BPII. We estimated the prevalence of SA in BPII by combining data across reports of similar designs. To compare rates of SA in BPII and BPI, we calculated a pooled odds ratio (OR) and 95% confidence interval (CI) with random‐effect meta‐analytic techniques with retrospective data from 15 reports that detailed rates of SA in both BPI and BPII. Results: Among the 24 reports with any BPII data, 32.4% (356/1099) of individuals retrospectively reported a lifetime history of SA, 19.8% (93/469) prospectively reported attempted suicide, and 20.5% (55/268) of index attempters were diagnosed with BPII. In 15 retrospective studies suitable for meta‐analysis, the prevalence of attempted suicide in BPII and BPI was not significantly different: 32.4% and 36.3%, respectively (OR = 1.21, 95% CI: 0.98–1.48, p = 0.07). Conclusion: The contribution of BPII to suicidal behavior is considerable. Our findings suggest that there is no significant effect of bipolar subtype on rate of SA. Our findings are particularly alarming in concert with other evidence, including (i) the well‐documented predictive role of SA for completed suicide and (ii) the evidence suggesting that individuals with BPII use significantly more violent and lethal methods than do individuals with BPI. To reduce suicide‐related morbidity and mortality, routine clinical care for BPII must include ongoing risk assessment and interventions targeted at risk factors.     

抑郁障碍患者自杀未遂的危险因素分析

目的:分析抑郁障碍(MDD)患者自杀未遂的危险因素。方法:入组332例MDD患者,分为自杀未遂组(95例)和非自杀未遂组(237例);对入组者进行人口学与临床资料调查、汉密尔顿抑郁量表(HAMD-24)及汉密尔顿焦虑量表(HAMA-14)评估及血清甲状腺功能检测,并进行组间比较;分析自杀未遂的危险因素。结果:自杀未遂组年龄、首次发病年龄明显小于非自杀未遂组,病程、既往住院次数明显多于非自杀未遂组;单身、无业、受教育程度低、家族史阳性、伴有精神病性症状、共病焦虑障碍比率明显高于非自杀未遂组(P<0.05或P<0.01)。HAMD总分与焦虑躯体化、认知障碍、阻滞、绝望感、体质量、日夜变化因子分及HAMA评分明显高于非自杀未遂组(P<0.05或P<0.01)。血清游离三碘甲状腺原氨酸(FT3)水平明显高于非自杀未遂组(P<0.05)。多因素Logistic回归分析显示,伴有精神病性症状、既往住院次数、HAMD评分中认知障碍、绝望感因子是影响抑郁症患者自杀未遂的主要危险因素。结论:伴有精神病性症状、既往住院次数、HAMD评分中的认知障碍、绝望感因子可能为MDD患者...     

History of suicide attempts in pediatric bipolar disorder: factors associated with increased risk

BACKGROUND: Despite evidence indicating high morbidity associated with pediatric bipolar disorder (BP), little is known about the prevalence and clinical correlates of suicidal behavior among this population. OBJECTIVE: To investigate the prevalence of suicidal behavior among children and adolescents with BP, and to compare subjects with a history of suicide attempt to those without on demographic, clinical, and familial risk factors. METHODS: Subjects were 405 children and adolescents aged 7-17 years, who fulfilled DSM-IV criteria for BPI (n = 236) or BPII (n = 29), or operationalized criteria for BP not otherwise specified (BP NOS; n = 140) via the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. As part of a multi-site longitudinal study of pediatric BP (Course and Outcome of Bipolar Youth), demographic, clinical, and family history variables were measured at intake via clinical interview with the subject and a parent/guardian. RESULTS: Nearly one-third of BP patients had a lifetime history of suicide attempt. Attempters, compared with non-attempters, were older, and more likely to have a lifetime history of mixed episodes, psychotic features, and BPI. Attempters were more likely to have a lifetime history of comorbid substance use disorder, panic disorder, non-suicidal self-injurious behavior, family history of suicide attempt, history of hospitalization, and history of physical and/or sexual abuse. Multivariate analysis found that the following were the most robust set of predictors for suicide attempt: mixed episodes, psychosis, hospitalization, self-injurious behavior, panic disorder, and substance use disorder. CONCLUSIONS: These findings indicate that children and adolescents with BP exhibit high rates of suicidal behavior, with more severe features of BP illness and comorbidity increasing the risk for suicide attempt. Multiple clinical factors emerged distinguishing suicide attempters from non-attempters. These clinical factors should be considered in both assessment and treatment of pediatric BP.     

Age at onset in 3014 Sardinian bipolar and major depressive disorder patients

Tondo L, Lepri B, Cruz N, Baldessarini RJ. Age at onset in 3014 Sardinian bipolar and major depressive disorder patients. Objective: To test if onset age in major affective illnesses is younger in bipolar disorder (BPD) than unipolar‐major depressive disorder (UP‐MDD), and is a useful measure. Method: We evaluated onset‐age for DSM‐IV‐TR major illnesses in 3014 adults (18.5% BP‐I, 12.5% BP‐II, 69.0% UP‐MDD; 64% women) at a mood‐disorders center. Results: Median and interquartile range (IQR) onset‐age ranked: BP‐I = 24 (19–32) < BP‐II = 29 (20–40) < UP‐MDD = 32 (23–47) years (P < 0.0001), and has remained stable since the 1970s. In BP‐I patients, onset was latest for hypomania, and depression presented earlier than in BP‐II or UP‐MDD cases. Factors associated with younger onset included: i) being unmarried, ii) more education, iii) BPD‐diagnosis, iv) family‐history, v) being employed, vi) ever‐suicidal, vii) substance‐abuse and viii) ever‐hospitalized. Onset‐age distinguished BP‐I from UP‐MDD depressive onsets with weak sensitivity and specificity. Conclusion: Onset age was younger among BPD than MDD patients, and very early onset may distinguish BPD vs. UP‐MDD with depressive‐onset.     

Interactions between bipolar disorder and antisocial personality disorder in trait impulsivity and severity of illness

Swann AC, Lijffijt M, Lane SD, Steinberg JL, Moeller FG. Interactions between bipolar disorder and antisocial personality disorder in trait impulsivity and severity of illness. Objective: We investigated trait impulsivity in bipolar disorder and antisocial personality disorder (ASPD) with respect to severity and course of illness. Method: Subjects included 78 controls, 34 ASPD, 61 bipolar disorder without Axis II disorder, and 24 bipolar disorder with ASPD, by Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV) (SCID‐I and ‐II). Data were analyzed using general linear model and probit analysis. Results: Barratt Impulsiveness Scale (BIS‐11) scores were higher in ASPD (effect sizes 0.5–0.8) or bipolar disorder (effect size 1.45) than in controls. Subjects with both had more suicide attempts and previous episodes than bipolar disorder alone, and more substance‐use disorders and suicide attempts than ASPD alone. BIS‐11 scores were not related to severity of crimes. Conclusion: Impulsivity was higher in bipolar disorder with or without ASPD than in ASPD alone, and higher in ASPD than in controls. Adverse effects of bipolar disorder in ASPD, but not of ASPD in bipolar disorder, were accounted for by increased impulsivity.     

Prospective predictors of suicide and suicide attempts in 1,556 patients with bipolar disorders followed for up to 2 years

Objectives:  Bipolar disorders are associated with high rates of suicide attempts (SAs) and completions. Several factors have been reported to be associated with suicide in persons with bipolar disorder, but most studies to date have been retrospective and have not utilized multivariate statistics to account for the redundant prediction among variables submitted for analysis.
Methods:  This study examined the association between baseline clinical and demographic variables and subsequent SAs and completions through 2 years of follow-up of participants in the Systematic Treatment Enhancement Program for Bipolar Disorder using a pattern-mixture model.
Results:  Of the sample with complete data (n = 1,556), 57 patients (3.66%) experienced an SA or completion (CS). Several variables predicted suicidality (SA + CS) in this data set when considered alone, but after controlling for redundant prediction from other baseline characteristics, only history of suicide [odds ratio (OR) = 4.52, p < 0.0001] and percent days depressed in the past year (OR = 1.16, p = 0.036) were significantly associated with SAs and completions. A secondary analysis included a greater number of variables but a smaller sample size (n = 1,014). In the secondary analyses, only prior SAs predicted prospective suicidality (OR = 3.87, p = 0.0029).
Conclusions:  These results indicate that patients with bipolar disorder who present with a history of SAs are over four times as likely to have a subsequent SA or completion. Further studies are needed to evaluate and prevent future attempts in this high-risk cohort.     

Increased trait-like impulsivity and course of illness in bipolar disorder

Background:  Impulsivity as a trait characteristic is increased in bipolar disorder and may be a core factor of the illness. We have investigated relationships between trait-like impulsivity, measured by the Barratt Impulsiveness Scale (BIS-11), and demographic and illness-course characteristics of bipolar disorder.
Methods:  We studied 114 subjects with bipolar disorder and 71 healthy comparison subjects. Diagnoses were based on the Structured Clinical Interview for DSM-IV. In addition to impulsivity, we examined age, education, gender, psychiatric symptoms, and characteristics related to course of illness. We used general linear mixed model analysis to evaluate the manner in which the variables contributed to BIS-11 scores.
Results:  All BIS-11 subscale scores were higher in bipolar disorder than in comparison subjects. There were less consistent independent effects of education and age. Elevated BIS-11 scores were associated with early onset, more frequent episodes of illness, and a history of suicide attempts. These relationships persisted when age, gender, and education were taken into account.
Discussion:  These results show that, after accounting for common confounding factors, trait-like impulsivity was substantially higher in subjects with bipolar disorder than in nonbipolar comparison subjects, regardless of symptoms. Within subjects with bipolar disorder, high trait impulsivity was associated with a more severe course of illness.     

The impact of child sexual abuse on the course of bipolar disorder: a systematic review

Maniglio R. The impact of child sexual abuse on the course of bipolar disorder: a systematic review.
Bipolar Disord 2013: 15: 341–358. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. Objectives: The aim of this review was to elucidate the impact of child sexual abuse on all clinical phenomena that occur after the onset of bipolar disorder, including associated clinical features that are not part of the diagnostic criteria for the disorder. Methods: Five databases were searched and supplemented with a hand search of reference lists from retrieved papers. Study quality was assessed using a validated quality assessment tool. Blind assessments of study eligibility and quality were conducted by two independent researchers to reduce bias, minimize errors, and enhance the reliability of findings. Disagreements were resolved by consensus. Results: Eighteen studies that included a total of 2996 adults and youths with bipolar disorder and met the minimum quality criteria necessary to ensure objectivity and not invalidate results were analyzed. Across studies, child sexual abuse was strongly (and perhaps directly) associated with posttraumatic stress disorder; whereas it was less strongly (and perhaps indirectly) related to suicide attempts, alcohol and/or drug abuse or dependence, psychotic symptoms, and an early age of illness onset. In regard to the association between child sexual abuse and other clinical variables concerning the course of bipolar disorder, evidence was scant or conflicting. Conclusions: Child sexual abuse is associated (either directly or indirectly) with some clinical phenomena that represent a more severe form of bipolar disorder. Although such a traumatic experience may directly affect the development of posttraumatic stress disorder, the effects of early sexual abuse on later suicidal behavior, substance abuse, and psychotic symptoms may operate through the mediating influences of certain psychopathological or neurobiological variables.     

A comparison of the medical lethality of suicide attempts in bipolar and major depressive disorders

Objectives:  Among mood disorders, bipolar disorder (BPD) is often noted to involve the highest rates of suicide attempts and possibly of completion. This study sought to determine whether suicide attempters with BPD exhibit suicide attempts with higher lethality than attempters with major depressive disorder (MDD) and to explore differences in clinical features associated with suicidal acts.
Methods:  Mood disordered suicide attempters were interviewed about Axis I and II diagnoses, lifetime history of suicide attempts, suicidal intent, suicidal ideation, the medical lethality of their most severe suicide attempt, severity of depression, hopelessness, lifetime aggression, and impulsivity.
Results:  The maximum lethality of suicidal acts tended to be higher among BPD attempters compared with those with MDD. However, there were no differences in the number of suicide attempts, intent to die or suicidal ideation. Suicide attempters with BPD reported higher levels of aggression and impulsivity but less hopelessness compared with MDD attempters. These differences could not be explained by Cluster B personality disorder comorbidity. Of note, within the BPD group, but not the MDD group, males reported suicidal acts with higher lethality. Multivariate analyses suggested that risk for more lethal suicide attempts is associated with BPD and male sex and that bipolar males appear to be especially vulnerable to these behaviors.
Conclusions:  Males with BPD make more lethal suicide attempts than females with BPD, an effect not observed among the MDD sample. Our findings suggest that higher rates of suicidal behavior in BPD may be due to a specific effect of BPD on males, leading to more dangerous suicidal behaviors. This effect, together with the larger proportion of males in the BPD group compared with the MDD group may lead to higher rates of reported attempted and completed suicide.     

Life events and onset of a new phase in bipolar affective disorder

Background: There is an increasing focus on the impact of psychosocial factors and stressors on the course of bipolar affective disorder. The life event research has revealed many biases and the results are conflicting. In a prospective study we examined the relationship between life events and affective phases in a group of bipolar patients with a long duration of the disease. Methods: A group of patients with at least three admissions to hospital for bipolar disorder was followed every 3 months for up to 3 years. At each examination an evaluation of affective phase was made according to the Hamilton Depression Scale, the Newcastle Depression Rating Scale and the Bech‐Rafaelsen Mania Rating Scale. Moreover, the patients were rated according to the Paykel Life Events Scale. Their current medical treatment was noted. Results: Fifty‐six patients (19 men and 37 women) were included in the study. Women experienced a significantly higher number of life events than men. In 21% of the 353 examinations of women, a new phase was preceded by life events whereas this was the case only in 8% of the 152 examinations of men. In 13% of the male examinations the patients were in a manic phase and in 5% in a depressive phase. In 5% of the female examinations the patients were in a manic phase and in 15% in a depressive phase. Half of the women's depressive phases were preceded by life events, but none of the depressive phases of men. The categories of life events preceding the depressive phases presented a significant overweight of somatic ill health and conflicts in the family. Conclusion: We found a gender difference in the course of bipolar affective disorder, as women had a significantly higher number of depressive episodes than men and men had a higher number of manic episodes than women. In bipolar patients with long duration of disease a significant number of depressive episodes in women were preceded by negative life events. Somatic health problems and conflicts in the family were significant factors preceding new depressive phases.     

Joint effect of ADARB1 gene,HTR2C gene and stressful life events on suicide attempt risk in patients with major psychiatric disorders

Objectives. Adenosine to inosine RNA editing, serotonin 2C receptor (HTR2C), and stressful life events (SLEs) have all been implicated in suicidal behaviour. We examined the main and moderating effects of RNA editing (ADAR, ADARB1) and HTR2C genes, childhood trauma (CT), recent SLEs and psychiatric disorders as contributors to suicide attempt (SA) vulnerability. Methods. Study included 165 suicide attempters and 188 suicide non-attempters, all diagnosed with one of major psychiatric disorders. CT and recent SLEs were assessed using Early Trauma Inventory–Self Report and List of Threatening Experiences Questionnaire, respectively. Selected ADAR and ADARB1 tag-variants, and HTR2C rs6318 were pre-screened for association with SA, while generalized linear models and backward selection were applied to identify individual and interacting SA risk factors. Results. ADARB1 rs9983925 and rs4819035 and HTR2C rs6318 were associated with SA. The best minimal model found emotional abuse, recent SLEs, rs9983925 and rs6318 as independent SA risk factors, and general traumas as a factor moderating the effect of psychiatric disorders and emotional abuse. Conclusions. SA vulnerability in psychiatric patients is related to the joint effect of ADARB1 and HTR2C variants, the existing mood disorder and the cumulative exposures to a various childhood and recent stressful experiences.     

Quality of life in bipolar disorder patients: a comparison with a general population sample

Objectives: To compare the Quality of Life (QoL) of bipolar disorder (BD) patients with that of the general population; and, within the BD patients, to find the demographic and clinical variables associated with low QoL, controlling for the effects of potential confounders. Methods: Based on the 25th percentile of the physical (PCS) and the mental (MCS) component scores (PCS <53 and MCS < 50, respectively) of the Medical Outcomes Survey 36-item Short-Form Health-Survey (SF-36) of a general population representative sample (n = 1,210), we compared by logistic regression the QoL of 48 euthymic and 60 non-euthymic BD outpatients and the general population. Within BD patients, we analyzed the clinical and course-of-illness variables associated with low physical and mental QoL, including manic and depressive symptoms and consumption of addictive substances; in addition, we calculated the partial correlation of the different variables with the dimensional PCS and MCS through multiple linear regression. Results: Low physical QoL was significantly more frequent among both euthymic [odds ratio (OR) = 3.5; 95% confidence interval (CI): 1.9–6.5] and non-euthymic (OR = 4.0; 95% CI: 2.3–7.0) BD patients than in the general population; the respective values for low mental QoL were OR = 2.2; 95% CI: 1.2–4.0 and OR = 8.5; 95% CI: 4.6–15.7. Low mental QoL was more frequent among non-euthymic than euthymic BD patients (OR = 3.9; 95% CI: 1.6–9.1). Within BD patients, low mental QoL was associated with the length of illness (or early onset), the presence of depressive symptoms, nicotine dependence and the lack of social support. Conclusions: Among the BD patients, who experience lower physical and mental QoL even in a euthymic period, the optimal control of depressive symptoms as well as the availability of social support may enhance their well-being.