Suicidal ideation and attempts in bipolar I and II disorders

OBJECTIVE: Few studies have investigated the prevalence of and risk factors for suicidal ideation and attempts among representative samples of psychiatric patients with bipolar I and II disorders. METHOD: In the Jorvi Bipolar Study (JoBS), psychiatric inpatients and outpatients were screened for bipolar disorders with the Mood Disorder Questionnaire from January 1, 2002, to February 28, 2003. According to Structured Clinical Interviews for DSM-IV Axis I and II Disorders, 191 patients were diagnosed with bipolar disorders (bipolar I, N = 90; bipolar II, N = 101). Suicidal ideation was measured using the Scale for Suicidal Ideation. Prevalence of and risk factors for ideation and attempts were investigated. RESULTS: During the current episode, 39 (20%) of the patients had attempted suicide and 116 (61%) had suicidal ideation; all attempters also reported ideation. During their lifetime, 80% of patients (N = 152) had had suicidal behavior and 51% (N = 98) had attempted suicide. In nominal regression models, severity of depressive episode and hopelessness were independent risk factors for suicidal ideation, and hopelessness, comorbid personality disorder, and previous suicide attempt were independent risk factors for suicide attempts. There were no differences in prevalence of suicidal behavior between bipolar I and II disorder; the risk factors were overlapping but not identical. CONCLUSION: Over their lifetime, the vast majority (80%) of psychiatric patients with bipolar disorders have either suicidal ideation or ideation plus suicide attempts. Depression and hopelessness, comorbidity, and preceding suicidal behavior are key indicators of risk. The prevalence of suicidal behavior in bipolar I and II disorders is similar, but the risk factors for it may differ somewhat between the two.     

Method of assessment determines prevalence of suicidal ideation among patients with depression

BackgroundHow different ways of assessing suicidal ideation influence its prevalence, correlates and predictive validity among patients with major depressive disorder (MDD) remains unclear.MethodsWithin the Vantaa Primary Care Depression Study (PC-VDS, 91 patients) and the Vantaa Depression Study (VDS, 153 psychiatric out-and 41 inpatients), suicidal ideation was assessed with the Scale for Suicidal Ideation (SSI), Hamilton Depression Scale (HAM-D) item 3 and Beck Depression Inventory (BDI) item 9, and by asking whether patients had seriously considered suicide during the episode. The positive and negative predictive values (PPV, NPV) for suicide attempts during a six-month follow-up were investigated.ResultsDepending on the setting, 56–88% of patients had suicidal ideation in some of the assessments, but only 8–44% in all of them. Agreement ranged from negligible to moderate (kappa 0.06–0.64), being lowest among primary care patients. The correlates of suicidal ideation overlapped. No assessment had optimal sensitivity, specificity, PPV and NPV. Nevertheless, PPVs ranged up to 43%.ConclusionsWhich MDD patient is classified as having suicidal ideation depends strongly on the method of assessment, with the greatest variation likely in primary care. Differences in assessments may cause inconsistency in risk factors. Predicting suicide attempts is difficult, but not futile.     

The Relationship Between Smoking and Suicidal Behavior in Psychiatric Patients with Major Depressive Disorder

Smoking is frequently associated with suicidal behavior, but also with confounding other risk factors. We investigated whether smoking independently predicts suicidal ideation, attempts (SAs), or modifies risk of SAs during major depressive episodes (MDEs). In the Vantaa Depression Study (VDS), a 5-year prospective study of psychiatric patients (N?=?269) with major depressive disorder (MDD), we investigated the association of suicidal ideation and smoking, and smoking as an independent risk factor for SAs in 2-level analyses of risk during MDEs. Smoking was not significantly associated with suicidal ideation, nor SAs after controlling for confounding factors, and no evidence of a significant effect during MDEs was found. Smoking was neither significantly associated with suicidal ideation, nor predicted suicide attempts.     

Time to emergence of severe suicidal ideation among psychiatric patients as a function of suicide attempt history

BACKGROUND: Little is known about the emergence of suicidal ideation among psychiatric inpatients with histories of no, single, or multiple suicide attempts. We investigated differences in time to reemergence of severe suicidal ideation among psychiatric patients as a function of their suicide attempt histories. METHOD: One hundred seventeen individuals meeting criteria for a major depressive disorder who were recently discharged from a psychiatric hospital and participating in a larger study of treatments for depression were included in the current study. Suicidal ideation, depressive symptoms, hopelessness, and depressogenic cognitions were assessed at baseline, and suicidal ideation was assessed at 3-, 6-, 12-, and 18-month follow-up, as well as inpatient readmission if applicable. Time to the reemergence of severe suicidal ideation was analyzed using survival analysis. RESULTS: Twenty-two percent of our sample reported the occurrence of severe suicidal ideation over an 18-month period. Severe suicidal ideation emerged earlier among patients who had a history of prior suicide attempts than those who did not, but single and multiple suicide attempters did not differ significantly in time to severe suicidal ideation. Suicide attempt history remained a significant predictor of time to severe suicidal ideation when statistically controlling for hopelessness, depressive symptoms, depressogenic cognitions, and suicidal ideation at admission and initial treatment group assignment, especially between single attempters and nonattempters. CONCLUSIONS: Although nearly a quarter of participants endorsed severe, clinically significant suicidal ideation within 18 months of discharge, those with suicide attempt histories reported the occurrence of severe suicidal ideation significantly earlier than those without suicide attempt histories.     

The relationship between childhood physical abuse and suicidality among depressed women: results from a community sample

OBJECTIVE: The aim of this study was to examine the distribution and determinants of suicidal ideation and suicide attempts in a community sample of women with major depressive disorder. Variables of interest included childhood physical abuse, individual and familial psychiatric history, and sociodemographic factors. METHOD: Women (age 15 to 64 years) from a community sample who met criteria for major depressive disorder (lifetime prevalence) (N=347) were assessed with a modified version of the Composite International Diagnostic Interview. Childhood physical abuse history was collected through a self-administered questionnaire. RESULTS: Approximately one-quarter (23.9%, N=83) of the women with major depressive disorder reported that they had made a suicide attempt, and more than half (55.6%, N=193) had experienced suicidal ideation. A history of suicide attempt was most strongly related to the number of comorbid psychiatric disorders (odds ratio=2.04, 95% confidence interval [CI]=1.21-3.43). Suicidal ideation was most strongly associated with a history of childhood physical abuse (odds ratio=2.77, 95% CI=1.26-6.12). CONCLUSIONS: Suicidal ideation and suicide attempts were reported frequently by women with a history of major depressive disorder. Correlates for suicide attempts showed some differences from those for ideation. This finding is of clinical importance, since it relates to the identification of individuals at risk for suicidal behavior.     

A proposed model of the development of suicidal ideations

BackgroundSuicidal ideations may precede suicide attempts. They are of particular concern in psychiatric populations because psychopathology is a major risk factor for suicide. The factors affecting the development of suicide ideations may differ among psychiatric patients with and without a previous suicide attempt and individuals without a psychiatric diagnosis.ObjectivesThe aim of this study is to develop a model of suicide ideation in psychiatric patients and the general population.MethodThe study included 196 participants: 92 psychiatric patients with a previous suicide attempt (“attempters”); 47 psychiatric patients who had never attempted suicide (“non-attempters”); and 57 healthy control subjects. Data were collected on socio-demographic parameters, clinical history, and details of the suicide attempts. Participants completed a battery of psychological instruments assessing aggression–impulsivity, mental pain (including depression and hopelessness) and communication difficulties, in addition to negative life events. Findings were correlated with suicidal ideation by group.ResultsThe correlations of the different variables with suicidal ideation differed between suicide attempters and non-attempters; therefore, the model was analyzed separately for each group. The study yielded three major findings: negative life events had a significant effect on both anger-in and impulsivity in non-attempters but not in attempters; hopelessness moderately contributed to suicidal ideations in attempters but not in non-attempters; loneliness contributed significantly to depression in non-attempters but was less distressing in attempters.ConclusionThe mechanism underlying suicidal ideation appears to differ between psychiatric patients who have previously attempted suicide and those who have not, supporting a dual model of suicidal ideation. Although this is only a preliminary study, these findings are important for furthering our understanding of the process of transition of suicidal thoughts to completion of suicide. These results need further replication with a larger cohort of subjects.     

Suicidal ideation among patients during the rehabilitation period after life-threatening physical illness

A total of 496 patients were examined for suicidal ideation during the acute hospital period and at 3, 6, 12, and 24 months' follow-up after suffering either stroke, traumatic brain injury, myocardial infarction, or spinal cord injury. A total of 7.3% of patients had suicidal ideation during the in-hospital evaluation (acute-onset suicidal ideation), and 11.3% developed it during the chronic 3 to 24 month rehabilitation period (delayed-onset suicidal ideation). Compared with delayed-onset suicidal patients, acute-onset suicidal patients had more predisposing risk factors (i.e., personal psychiatric history and alcohol abuse/dependence) and less social support (i.e., lower frequency of being married). Both acute and delayed-onset suicidal ideation, however, were strongly associated with the existence of major depression and impaired social functioning. These findings suggest that the detection and appropriate treatment of depressive disorders and social isolation may be the most important factor in preventing suicide both during the acute and chronic period following life-threatening physical illnesses.     

Suicidal ideation in Huntington disease: the role of comorbidity

Huntington disease (HD) is a neurodegenerative condition characterized by cognitive impairments, motor abnormalities, and psychiatric disturbance. An increased risk for suicide has been documented. The majority of HD research has focused on cognitive and motor features of HD; the implications of psychiatric manifestations have received less consideration. Recent studies have sought to identify the stages of HD in which patients are at increased risk to experience suicidal ideation, though no study has examined possible risk factors for suicidality. The current study examines the presence of psychiatric comorbidity and its involvement in suicidal ideation. Suicidal ideation was examined in 1941 HD patients enrolled in the Huntington Study Group. Of those, 19% (N=369) endorsed current suicidal ideation. Logistic regression analyses indicated that depression/anxiety and aggression/irritability are significant predictors of suicidal ideation. In a subsample with the greatest suicidal ideation, alcohol and drug abuse were also predictive. It is recommended that all individuals with HD (specifically those with features of depression, aggression, substance abuse) have routine suicide assessment; further research is needed to understand the high rate of suicide in HD.     

Adequacy of, attitudes toward, and adherence to treatments by suicidal and nonsuicidal depressed patients

We examined differences in treatments received, and attitudes and adherence to them between suicidal and nonsuicidal patients with major depressive disorder (MDD). Psychiatric MDD patients with no suicidal behavior (N = 92), suicidal ideation (N = 92), or attempts (N = 34) were compared during 6 months of follow-up in the Vantaa Depression Study (VDS). Patients with suicidal behavior received antidepressants or adequate antidepressant treatment significantly more often, had more frequent appointments with psychiatrists, more psychotherapeutic support, and more favorable attitudes toward antidepressant treatment than nonsuicidal patients. However, after adjusting for the confounding severity of depression, the significance of these differences was lost. Adherence to treatment was similar in the patient groups. Overall, among psychiatric patients with MDD, those known to be suicidal have higher suicide risk and should receive more intensive treatment. However, suicidal behavior per se does not seem to markedly influence treatments provided nor should it be associated with negative attitudes or poor adherence to treatments.     

Suicide Ideation and Behaviour in People with Pathological Gambling Attending a Treatment Service

This study aimed to describe the 12-month period prevalence and risk factors for suicidal ideation and behaviour in a cohort of patients with pathological gambling attending a treatment service. Seventy-nine people with a diagnosis of pathological gambling received a mail out survey that included questions on postulated risk factors for suicidal ideation and behaviour, the modified Suicide Ideation Scale (SIS), the South Oaks Gambling Screen (SOGS), the Beck Depression Inventory (BDI) and the CAGE. A total of 54.4% of the surveys were returned completed. There were 81.4% who showed some suicidal ideation and 30.2% reported one or more suicide attempts in the preceding 12 months. Suicidal ideation and behaviours were positively correlated with the gambling severity (SOGS scores), the presence of debt attributed to gambling, alcohol dependence and depression (BDI). Suicidal ideation/behaviour was not significantly associated with gender and living arrangements, nor a history of receiving treatment for depression during the preceding 12 months. People with pathological gambling attending a treatment service had higher levels of suicidal ideation and behaviour than previous studies. Pathological gambling should be seen as a chronic condition with a similar risk for suicidal ideation and behaviour as other mental illnesses. Counselling services, general practitioners and mental health services should screen for gambling problems when assessing risk after suicide attempts and for suicide risk in patients presenting with gambling problems and co-morbid depression, alcohol abuse and a previous suicide attempt.The authors have no conflict of interest to declare.The intensive treatment service at Flinders Medical Centre is funded by a grant from the South Australian Department of Human Services.     

The clinical picture of major depression in children and adolescents

Symptom frequency and severity were compared in two sequential clinically referred samples of 95 children and 92 adolescents, aged 6 to 18 years, all medically healthy, assessed with the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present Episode, who met unmodified Research Diagnostic Criteria for major depressive disorder (MDD). There were no significant differences between the two groups in the majority of depressive symptoms. However, prepubertal children had greater depressed appearance, somatic complaints, psychomotor agitation, separation anxiety, phobias, and hallucinations, whereas adolescents had greater anhedonia, hopelessness, hypersomnia, weight change, use of alcohol and illicit drugs, and lethality of suicide attempt, but not severity of suicidal ideation or intent. Adolescents with a duration of the depressive episode of two years or greater had significantly higher rates of suicidal ideation and intent, lethality, and number of suicide attempts than youngsters with depressive episodes of shorter duration. A principal components factor analysis of psychiatric symptoms was carried out in all 296 youngsters evaluated during the same period who met DSM-III criteria for any Axis I diagnosis. The majority had an affective disorder. Factors were quite similar for both adolescents and children and included an "endogenous" and an "anxious" factor, as in many studies of adult depression. In addition, three other factors were found: negative cognitions, appetite and weight changes, and a conduct factor. Suicidal ideation was a component of both the negative cognitions factor and the conduct factor.(ABSTRACT TRUNCATED AT 250 WORDS)     

Characteristics of out-patient adolescents with suicidal tendencies

Suicidal adolescent out-patients were compared with non-suicidal subjects with respect to background factors, psychopathology and treatment received. Data for suicidal ideation, suicide attempts, psychiatric diagnoses (DSM-III-R) and other patient-related factors were collected prospectively during treatment of 122 male and 138 female out-patients aged 12–22 years. In total, 42% of subjects displayed suicidal tendencies, and 18% had attempted suicide. According to polychotomous regression, mood disorder, previous psychiatric treatment arid low level of psychosocial functioning at treatment entry were associated with suicide attempts and with suicidal ideation for both sexes. Suicidal patients were more often receiving psychotropic medication and had more total appointments (mean number 15 vs. 9) than non-suicidal patients. Suicidal and non-suicidal patients kept their scheduled appointments to the same extent (66% vs. 65%). Treatments which meet the needs of disordered suicidal adolescents need to be developed.     

A longitudinal view of triggers and thresholds of suicidal behavior in depression

BACKGROUND: Recurrent brief depressive disorder (RBD) and major depressive disorder (MDD) share the same diagnostic picture of full-blown depression and are both associated with increased suicide attempt rates. However, longitudinal diagnostic shifts from RBD to MDD or vice versa, called "combined depression" (CD), have demonstrated a substantially higher risk of suicide attempts in epidemiologic and clinical studies. Following the stress-diathesis model of suicidal behavior, we compared possible triggers and thresholds for suicidal behavior among patients with RBD, MDD, and CD. RBD and MDD diagnoses were based on DSM-IV criteria. Furthermore, the goal of this study was to determine if impulsivity as an underlying factor could explain high suicide attempt rates in CD. METHOD: A structured clinical interview evaluating comorbid Axis I and II disorders and RBD and a battery of instruments assessing suicidal behavior were administered to 101 patients with RBD (N = 27), MDD (N = 33), or CD (N = 41). RESULTS: Patients with CD showed significantly higher (p < .05) scores on measures of suicidal behavior in comparison with RBD and MDD patients. Together with comorbid substance abuse and marital status, CD was among the highest-ranking risk factors for suicide attempts. Impulsivity was identified as a major underlying factor, predicting 80.7% of suicide attempts. CONCLUSION: CD seems to be an important clinical risk factor for the prediction of suicide attempts, similar to risk factors such as substance use disorders and borderline personality disorder. All of these factors share the same diathesis for increased impulsivity and suicidal ideation, which could explain comorbidity and suicidal behavior. The coexistence of a greater propensity for suicidal ideation and impulsivity in RBD might also explain why such patients are more prone to attempt suicide, even if they do not, in the case of RBD, meet the duration criteria for MDD.     

Executive functioning in depressed patients with suicidal ideation

OBJECTIVE: Suicidal thinking has been associated with cognitive rigidity, however, not all depressed patients contemplate suicide. Therefore, we hypothesized that compared with depressed subjects without suicidal ideation, depressed individuals with suicidal ideation would display poorer performance on measures of executive functioning that involve mental flexibility. METHOD: In-patients with a current major depressive episode who had no current suicidal ideation (n=28) were compared with those who had current suicidal ideation (n=5) on measures of executive functioning and two neurocognitive tests that predominantly assess non-frontal regions. RESULTS: Compared with non-suicidal depressed patients, depressed suicidal patients performed significantly worse on several measures of executive functioning after controlling for age, IQ, severity of depression and prior suicide attempts. The two groups performed similarly on tests that predominantly assess non-frontal regions. CONCLUSION: Depressed individuals contemplating suicide have cognitive rigidity, which does not appear to be a global brain dysfunction. Suicidal mental states may result from dysfunctional executive decision-making that is associated with the frontal lobe.     

Predicting future suicide attempts among depressed suicide ideators: a 10-year longitudinal study

Suicidal ideation and attempts are a major public health problem. Research has identified many risk factors for suicidality; however, most fail to identify which suicide ideators are at greatest risk of progressing to a suicide attempt. Thus, the present study identified predictors of future suicide attempts in a sample of psychiatric patients reporting suicidal ideation. The sample comprised 49 individuals who met full DSM-IV criteria for major depressive disorder and/or dysthymic disorder and reported suicidal ideation at baseline. Participants were followed for 10 years. Demographic, psychological, personality, and psychosocial risk factors were assessed using validated questionnaires and structured interviews. Phi coefficients and point-biserial correlations were used to identify prospective predictors of attempts, and logistic regressions were used to identify which variables predicted future attempts over and above past suicide attempts. Six significant predictors of future suicide attempts were identified - cluster A personality disorder, cluster B personality disorder, lifetime substance abuse, baseline anxiety disorder, poor maternal relationship, and poor social adjustment. Finally, exploratory logistic regressions were used to examine the unique contribution of each significant predictor controlling for the others. Comorbid cluster B personality disorder emerged as the only robust, unique predictor of future suicide attempts among depressed suicide ideators. Future research should continue to identify variables that predict transition from suicidal thoughts to suicide attempts, as such work will enhance clinical assessment of suicide risk as well as theoretical models of suicide.     

Real-time predictors of suicidal ideation: mobile assessment of hospitalized depressed patients

Suicidal ideation is a risk factor for suicide attempt and completion. Cross-sectional or retrospective studies cannot capture the dynamic course and possible predictors of suicidal ideation as it occurs in daily life. This study utilizes an experience sampling paradigm to identify real-time predictors of suicidal ideation in inpatients with major depressive disorder. Thirty-one depressed patients admitted to a psychiatric unit were signaled by a mobile device to record suicidal ideation, affect, and other symptoms, multiple times a day over 1 week. Participants completed a total of 1350 questionnaires. Seventy-four percent of the sample reported suicidal ideation during the week. Time-lagged analyses revealed that momentary ratings of Sadness, Tension, and Boredom (as well as suicidal ideation itself) predicted subsequent suicidal thoughts in the following hours. Baseline severity of depression and past suicide attempts were both correlated with mean ideation severity during the week. A number of predictors identified in prior research (e.g. hopelessness) were unrelated to subsequent suicidal ideation in the current study. Momentary interventions that guide individuals through activities designed to reduce levels of Sadness, Tension, and Boredom in real-time (e.g., thought challenging, relaxation, behavioral activation) may be especially warranted.     

Suicidal Behavior and Insight into Illness Among Patients with Schizophrenia Spectrum Disorders

The purpose of the present study was to explore the relationship between suicidal behavior and socio-demographic and clinical factors, including insight into illness, in patients with schizophrenia spectrum disorders. We evaluated 104 inpatients using the Self-Appraisal of Illness Questionnaire (SAIQ) for insight assessment, several Beck-related symptoms rating scales, and the Positive and Negative Syndrome Scale (PANSS) for psychopathology. These patients were also evaluated for suicidal behavior and risk using the critical items of the Scale for Suicide Ideation (SSI) and lifetime suicide attempts. Patients with suicidal behavior generally had greater insight into illness than those who were non-suicidal. After controlling for depressive symptoms, the association of insight into illness with current suicidal ideation remained significant, whereas the association between insight and lifetime suicide attempts was no longer significant. As predicted, the regression analyses revealed that those with greater suicide risk had significantly higher levels of depressive symptoms and hopelessness and more lifetime suicide attempts. Moreover, greater insight into illness appeared to have a close, independent connection to suicidal behavior. Our findings suggest that depression, hopelessness, and greater insight into illness are major risk factors for suicide in patients with schizophrenia. It is plausible that depression mediates the relationship between greater insight into illness and suicidal behavior. Aggressive improvement of insight without the risk of deteriorating depressive symptoms may be warranted to reduce the risk of suicide.     

Depressive characteristics of adult psychiatric inpatients with a history of multiple versus one or no suicide attempts

Background: A growing body of research suggests that individuals with a history of multiple suicide attempts exhibit more severe psychopathology than individuals with only one or no previous suicide attempts. Given the strong link between diagnoses of major depression and suicide risk, our primary goal was to determine which specific depressive characteristics differentiate multiple attempters from patients with one or no previous attempts. Methods: Participants were 121 depressed adult psychiatric inpatients. Participants were administered diagnostic interviews to assess the course and characteristics of their depression history as well as measures of suicidal ideation, suicide attempts, depressive symptoms, hopelessness, and dysfunctional attitudes. Results: Patients with a history of multiple suicide attempts exhibited higher levels of suicidal ideation and depressive symptoms, but not hopelessness or dysfunctional attitudes, than the other two groups. In addition, multiple attempters reported an earlier age of major depression onset. Conclusions: The current results add to a growing body of research suggesting that multiple attempters may represent a distinct patient population. Depression and Anxiety, 2009. Published 2008 Wiley‐Liss, Inc.     

Prospective prediction of first lifetime suicide attempts in a multi-site study of substance users

Although considerable empirical work has been devoted to identifying risk factors for suicide attempts, most longitudinal research has studied recurrent attempts rather than first lifetime attempts. The present study sought to examine prospective predictors of first lifetime suicide attempts among adults receiving treatment for substance use. Data were drawn from the National Treatment Improvement Evaluation Study, a study of addiction treatment programs. Data were collected at treatment intake, treatment exit, and one year post-treatment. Patients (n = 3518) with no lifetime history of suicide attempts at treatment intake were followed at treatment exit and one year post-treatment, when they reported on the occurrence of suicide attempts since the prior assessment. Prospective suicidal behavior was assessed using logistic regression in relation to sociodemographic variables, health-related work impairment, history of psychiatric treatment utilization, history of suicidal ideation, history of depressive symptoms, substance use, and childhood abuse, assessed at intake. Health-related work impairment, history of suicidal ideation, and childhood physical abuse significantly predicted first lifetime attempts in a multivariate analysis. Suicidal ideation, health-related functional impairments, and childhood physical abuse may be particularly important in assessing risk for first lifetime suicide attempts. Findings suggest that future clinical work and research would benefit from considering these factors when identifying individuals at heightened risk of making a first suicide attempt.     

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.