Suicidal behavior in bipolar manic-depressive patients and their families

There is a high risk of suicidal behavior in patients with primary affective disorder. An extensive investigation in patients with primary affective disorder reported attempted suicide in 26% of bipolar patients and 21% of unipolar patients, the highest rate occurring in female bipolar patients.¹ Woodruff et al.²⁰ found attempted suicide in 14% of unipolar patients as against 32% of bipolar patients with the highest rate in male bipolar patients. Winokur¹⁸ in a study of bipolar manic depressive patients found that 25% of patients had made at least one suicidal attempt and 70% had made threats of suicide at least some time in their lives. Venkabo Rao¹⁶ reported that suicidal ideas occurred in 75% of patients with recurrent affective disorder.Family studies have also reported a high incidence of suicide in the relatives of patients with affective disorder.⁸Mendlewicz et al.⁷ studying a matched group of bipolar probands with and without a family history of manic depressive illness, found high rates of suicide in first and second degree relatives but there was no significant difference in relation to sex or family history. The diagnosis of the relative that suicided was not stated. A study of relatives of patients with primary affective disorder¹⁰ reported that 79% of the suicides in first degree relatives were associated with a diagnosis of probable affective disorder and 10% by a diagnosis of probable alcoholism in the relative. Fathers in index cases were more likely to have committed suicide than mothers. A family history of suicide is considered a major risk factor in assessment of potentially suicidal patients,¹³ however, the relationship between attempted suicide in patients and suicide or attempted suicide in relatives has received little attention and the nature and predictability of this association is uncertain.The following report concerns an analysis of suicidal behavior in a population of bipolar manic-depressive patients and the relationship of this attempt to suicide or attempted suicide in their first and second degree relatives.     

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.     

Atypical antipsychotics and suicide in mood and anxiety disorders

Abstract:  Globally, a million people commit suicide every year, and 10–20 million attempt it. Mood disorders, especially major depressive disorder (MDD) and bipolar disorder, are the most common psychiatric conditions associated with suicide. Primary (psychiatric and physical illness), secondary (psychosocial), and tertiary (demographic) risk factors for suicide have been identified. Comorbid psychiatric illness, particularly anxiety symptoms or disorders, significantly increase the risk of suicidal behavior. Current standard risk assessments and precautions may be of limited value, while assessing the severity of anxiety and agitation may be more effective in identifying patients at risk. Lithium is the medication that has most consistently demonstrated an antisuicidal effect. The effects of antidepressants and conventional antipsychotics on suicide risk are uncertain, but atypical antipsychotics appear promising. Atypical antipsychotics have beneficial effects on depressed mood both in patients with MDD and in patients with bipolar disorder. In addition, data in patients with schizophrenia have demonstrated a significant improvement in the incidence of suicidal behavior with clozapine compared with olanzapine. Electroconvulsive therapy appears to have an acute benefit on suicidality.     

Bipolar depression and suicidal behavior

Suicide is a frequent and tragic consequence of bipolar depression. The prevention of suicidal behavior (SB) need an assessment of vulnerability traits related related to SB (personal suicide history, impulsive traits...), characteristics of depression (mixed depression, subtype of bipolar disorder...), psychiatric comorbidities and stressors psycho-social. Meanwhile, the characteristics of suicidal behavior (ie: severe or multiple attempts) suggest a diagnosis of bipolar disorder rather than major depressive disorder. In addition to a correct screening of bipolar disorders and assessment of suicidal behavior, the removal of lethal means, networking and treatment of depression reduces the risk of suicidal behavior. Finally, lithium may have a particular interest in subjects at high risk of suicide.     

Hopelessness and suicidal risk in bipolar disorder. A study in clinically nonsyndromal patients

Objective

Attempted suicide and death due to suicide are not uncommon among patients with bipolar disorder. Although some risk factors for suicidality in bipolar patients have been identified, little is known about hopelessness and other possible trait or diathesis-related factors. Consequently, the objective of this study was to investigate variables associated with suicidal risk in clinically nonsyndromal bipolar patients.

Methods

A sample of 102 outpatients with a diagnosis of bipolar disorder according to International Classification of Diseases, 10th Revision criteria during nonsyndromal stage were evaluated. On the basis of suicidal history, patients were divided into suicide attempt, suicidal ideation, and nonsuicidal groups. Sociodemographic, clinical, and psychopathological variables were assessed.

Results

As compared with the nonsuicidal group, female sex, combined psychopharmacologic treatment, and hopelessness were independently associated with suicide attempt. Hopelessness and insight into having a mental disorder were independently associated with history of suicidal ideation.

Conclusions

Patients with bipolar disorder and suicidal history are characterized by the presence of hopelessness, which probably confers greater vulnerability for suicidal behavior in the presence of stress factors. This identification of the risk profile for suicidal behavior in nonsyndromal bipolar patients adds complementary information to risk factors established for suicidality during acute phases of the disease, allows for differentiated preventive and treatment approaches of patients at risk, and suggests psychotherapy as an advisable intervention in this group of patients.     

Increased impulsivity associated with severity of suicide attempt history in patients with bipolar disorder

Background: Impulsivity is a prominent and measurable characteristic of bipolar disorder that can contribute to risk for suicidal behavior. The purpose of this study was to investigate the relationship between impulsivity and severity of past suicidal behavior, a potential predictor of eventual suicide, in patients with bipolar disorder. METHOD: In bipolar disorder subjects with either a definite history of attempted suicide or no such history, impulsivity was assessed with both a questionnaire (Barratt Impulsiveness Scale) and behavioral laboratory performance measures (immediate memory/delayed memory tasks). Diagnosis was determined with the Structured Clinical Interview for DSM-IV. Interviews of patients and review of records were used to determine the number of past suicide attempts and the medical severity of the most severe attempt. RESULTS: Subjects with a history of suicide attempts had more impulsive errors on the immediate memory task and had shorter response latencies, especially for impulsive responses. Impulsivity was highest in subjects with the most medically severe suicide attempts. Effects were not accounted for by presence of depression or mania at the time of testing. Barratt Impulsiveness Scale scores were numerically, but not significantly, higher in subjects with suicide attempts. A history of alcohol abuse was associated with greater probability of a suicide attempt. Multivariate analysis showed that ethanol abuse history and clinical state at the time of testing did not have a significant effect after impulsivity was taken into account. DISCUSSION: These results suggest that a history of severe suicidal behavior in patients with bipolar disorder is associated with impulsivity, manifested as a tendency toward rapid, unplanned responses.     

Suicide and attempted suicide in bipolar disorder: a systematic review of risk factors

OBJECTIVE: To determine the main risk factors for suicide and nonfatal suicidal behavior in patients with bipolar disorder through a systematic review of the international literature. DATA SOURCES: Studies were identified through electronic searches of MEDLINE (1966-December 2003), EMBASE (1980-December 2003), PsycINFO (1872-November 2003), and Biological Abstracts (1985-December 2003) using index and free-text search terms for bipolar disorder, bipolar depression, manic depression, mania, and affective disorders; combined with terms for self-harm, self-injury, suicide, attempted suicide, automutilation, self-mutilation, self-poisoning, and self-cutting; and combined with terms for risk, case control, cohort, comparative, longitudinal, and follow-up studies. No language restrictions were applied to the search. STUDY SELECTION: Included studies were cohort, case-control, and cross-sectional investigations of patients with bipolar disorder in which suicide (13 studies) or attempted suicide (23 studies) was reported as an outcome. The selected studies also used diagnostic tools including the DSM, International Classification of Diseases, and Research Diagnostic Criteria. DATA SYNTHESIS: Meta-analysis of factors reported in more than 1 study identified the main risk factors for suicide as a previous suicide attempt and hopelessness. The main risk factors for nonfatal suicidal behavior included family history of suicide, early onset of bipolar disorder, extent of depressive symptoms, increasing severity of affective episodes, the presence of mixed affective states, rapid cycling, comorbid Axis I disorders, and abuse of alcohol or drugs. CONCLUSIONS: Prevention of suicidal behavior in patients with bipolar disorder should include attention to these risk factors in assessment and treatment, including when deciding whether to initiate treatment aimed specifically at reducing suicide risk.     

Suicide risk factors in children and adolescents with bipolar disorder

Suicidal behavior in children and adolescents with bipolar disorder is a major public health problem that remains understudied. Most research on suicidal behavior in bipolar disorder has been conducted in older adolescents and adults and is limited by retrospective design. Although preliminary research suggests that the early onset of bipolar disorder is associated with increased suicide risk, few studies have prospectively examined the effects of prior suicidal behavior, clinical course, comorbid psychiatric disorders, familial suicidality, and psychosocial factors on suicidal behavior in bipolar youths. More systematic research is needed to better understand suicidal behavior in bipolar children and adolescents. Increased knowledge of the risk factors that contribute to suicidal behavior should lead to better prevention and treatment.     

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.     

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.     

Serum lipids,metabolic syndrome and lifetime suicide attempts in patients with bipolar disorder

Objective

Bipolar disorder is associated with a high risk of suicide. Many clinical characteristics and, recently, biomarkers have been studied with the aim to find useful predictors of suicidality. The role of serum lipids has also been explored albeit with conflicting results; however, few studies have been focused on patients with bipolar disorder.Aim of our study is to investigate whether serum cholesterol, triglycerides, HDL-c and metabolic syndrome are associated with lifetime suicide attempts in a large naturalistic sample of patients with bipolar disorder.

Methods

220 patients with bipolar disorder were included. History of lifetime suicide attempts was systematically and retrospectively assessed for each patient. Blood exams testing total cholesterol, triglycerides, and HDL-c levels were performed, and metabolic syndrome was diagnosed according to NCEP ATP-III modified criteria. Serum lipid levels and metabolic syndrome were compared in patients with or without history of suicide attempt. According to a theory that links impulsivity and violence with low cholesterol, the association between lipid levels and violent suicidal behavior was also assessed.

Results

Lifetime suicide attempts rate was 32.3%. There were no statistically significant differences between patients with and without lifetime suicide attempts in cholesterol, triglycerides, HDL-c levels, and the prevalence of metabolic syndrome. No differences in the same variables were found in violent suicide attempters compared with nonviolent ones. Clinical characteristics such as gender, low education, higher number of manic and depressive episodes, and taking more medications for bipolar disorder were associated with lifetime suicide attempts.

Conclusions

Our results do not support the hypothesis of a strong association between serum lipid levels and suicide in patients with bipolar disorder.     

Perspectives on lithium treatment of bipolar disorder: action, efficacy, effect on suicidal behavior

Objective: To review studies of (A) whether lithium has a prophylactic action in bipolar disorder, (B) the efficacy of prophylactic lithium treatment in comparison with the efficacy of treatment with anticonvulsant drugs, and (C) the effect of lithium treatment on suicidal behavior.
Methods: Analysis of all relevant publications.
Results: (A) The claim that a prophylactic action of lithium has never been satisfactorily demonstrated is based on wrong assumptions, biased selection of references, and unjustified generalizations. (B) In typical bipolar disorder lithium is significantly more efficacious than carbamazepine; in atypical bipolar disorder there is a non-significant trend for carbamazepine to be better than lithium. Valproate has not been proven prophylactically efficacious in typical bipolar disorder; in atypical bipolar disorder it may have an effect, but it has not been compared with that of lithium. (C) A significant association has been found between prophylactic lithium treatment, on the one hand, and reduced mortality and suicidal behavior, on the other. No such association has been reported for prophylactic treatment with other mood stabilizers.
Conclusion: In bipolar disorder the choice of prophylactic drug must be based on a weighing of efficacy against tolerability, interactions, ease of management, use during pregnancy and lactation, and expense. Lithium should be the preferred prophylactic drug in patients with typical bipolar disorder and in patients who are at high risk of committing suicide, that is, patients with severe depressions or depressions combined with persistent suicidal ideas or with suicide attempts in the past.     

Family-focused treatment of the suicidal bipolar patient

Objectives:  Bipolar patients are at high risk for suicidal ideation and attempts. Suicidal behavior is correlated with poor family communication and/or high levels of intrafamilial conflict, particularly among adolescent bipolar patients. This article describes the application of family-focused therapy (FFT) as an adjunct to pharmacotherapy in the management of suicidal ideation and behavior among bipolar patients.
Methods:  We describe the empirical basis of FFT in studies of adult and adolescent patients. We then describe the manner by which the three modules of FFT – psychoeducation, communication skills training and problem solving – are adapted to address the clinical issues presented by suicidal bipolar adults or adolescents and their families.
Results:  Key objectives of the treatment are to help the family recognize that suicidal behavior is a part of the pathophysiology of bipolar disorder but that it is also to some extent under environmental control. Thus, the family is in a unique position to develop and help assure the success of a suicide prevention contract. A case study of an adolescent with suicidal behavior is presented.
Conclusions:  Future research should include a focus on: (i) cross-cultural issues in suicide and bipolar disorder; and (ii) the adaptation of interventions shown to be effective in reducing suicidal behaviors in non-bipolar populations.     

Suicide prevention by lithium SUPLI--challenges of a multi-center prospective study.

Several studies have shown that there is a significantly increased risk of suicide related mortality in patients with a positive history of suicide attempts. The SUPLI-Study is the first prospective, randomized, double blind, placebo controlled multi-center trial focusing on the proposed suicide preventive effects of lithium in patients with suicidal behavior but not suffering from bipolar disorder or recurrent major depressive disorder. Patients with a recent history of a suicide attempt are treated with lithium versus placebo during a 12 month period. The hypothesis is that lithium treatment will lead to a 50% reduction of suicidal behavior. The protocol of the study and preliminary results are presented.     

The association of comorbid anxiety disorders with suicide attempts and suicidal ideation in outpatients with bipolar disorder

Individuals with bipolar disorder are at increased risk for suicide attempts and completion. Although anxiety may be a modifiable suicide risk factor among bipolar patients, anxiety disorder comorbidity has not been highlighted as critical in identification of high-risk individuals nor has its treatment been integrated into suicide prevention strategies. In this study, ancillary to the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), 120 outpatients with bipolar disorder completed detailed assessment of suicidal ideation and behaviors. We examined the association of current and lifetime comorbid anxiety disorders with suicidal ideation and behaviors univariately and with adjustment for potential confounders in regression models. Lifetime anxiety disorders were associated with a more than doubling of the odds of a past suicide attempt, and current anxiety comorbidity was associated with a more than doubling of the odds of current suicidal ideation. Individuals with current anxiety disorders had more severe suicidal ideation, a greater belief suicide would provide relief, and a higher expectancy of future suicidal behaviors. However, some of these associations appeared to be better accounted for by measures of bipolar severity including an earlier age at bipolar onset and a lack of current bipolar recovery. Comorbid anxiety disorders may play a role in characteristics of bipolar disorder that then elevate risk for suicidal ideation and attempts. While further research is needed to establish the precise nature of these associations, our data support that the presence of comorbid anxiety disorders in individuals with bipolar disorder should trigger careful clinical assessment of suicide risk.     

Clinical predictors of suicidal acts after major depression in bipolar disorder: a prospective study

Objective:  This study determined the clinical predictors of suicidal behavior during a 2-year follow-up of patients with bipolar disorder presenting with a major depressive episode (MDE).
Method:  Sixty four patients with DSM-III-R bipolar disorder were assessed at presentation for treatment of an MDE. Correlates of past suicidal behavior were determined by comparing patients with and without a history of suicide attempts using a t -test, Wilcoxon test or chi-squared test of independence on individual explanatory variables. Putative predictors of attempts during the follow-up period were tested separately using Cox proportional hazards regression analysis.
Results:  Twelve of 64 patients had at least one suicide attempt in the follow-up period, five of them attempted in the first 2 months and seven around or shortly after the 1-year follow-up visit. All attempters had a history of past suicide attempts. Most predictors of future suicidal behavior were correlates of past suicidal behavior. Family history of suicide acts and comorbid borderline personality disorder predicted early attempts, while younger age, high hostility scores, number of past attempts, subjective pessimism as reflected in depression and suicidal ideation, and few reported reasons for living predicted suicidal acts during the whole period.
Conclusion:  In this data set of bipolar patients we noted an intriguing picture of two clusters of suicide attempts. Hostility was the strongest risk factor. These findings may have implications in both the identification of at-risk patients and the timing of clinical interventions including aggressive pharmacotherapeutic prophylaxis to prevent relapse or recurrence of depressive symptomatology.     

Comorbid anxiety in bipolar disorder: does it have an independent effect on suicidality?

Objective:  Comorbid anxiety disorder is reported to increase suicidality in bipolar disorder. However, studies of the impact of anxiety disorders on suicidal behavior in mood disorders have shown mixed results. The presence of personality disorders, often comorbid with anxiety and bipolar disorders, may explain these inconsistencies. This study examined the impact of comorbid Cluster B personality disorder and anxiety disorder on suicidality in bipolar disorder.
Methods:  A total of 116 depressed bipolar patients with and without lifetime anxiety disorder were compared. Multiple regression analysis tested the association of comorbid anxiety disorder with past suicide attempts and severity of suicidal ideation, adjusting for the effect of Cluster B personality disorder. The specific effect of panic disorder was also explored.
Results:  Bipolar patients with and without anxiety disorders did not differ in the rate of past suicide attempt. Suicidal ideation was less severe in those with anxiety disorders. In multiple regression analysis, anxiety disorder was not associated with past suicide attempts or with the severity of suicidal ideation, whereas Cluster B personality disorder was associated with both. The results were comparable when comorbid panic disorder was examined.
Conclusions:  Comorbid Cluster B personality disorder appears to exert a stronger influence on suicidality than comorbid anxiety disorder in persons with bipolar disorder. Assessment of suicide risk in patients with bipolar disorder should include evaluation and treatment of Cluster B psychopathology.     

Suicide attempts and ideation in patients with bipolar I disorder

BACKGROUND: Suicidal thinking and behavior are common in individuals with bipolar disorder. METHOD: Suicidal ideation and suicide attempts were examined in 175 patients with bipolar I disorder (diagnosis confirmed with the Schedule for Affective Disorders and Schizophrenia or the Structured Clinical Interview for DSM-IV) participating in the Pittsburgh Study of Maintenance Therapies in Bipolar Disorder. Patients who attempted suicide before entering the study were compared with those who did not attempt suicide with respect to clinical and demographic characteristics. RESULTS: Twenty-nine percent of the patients had attempted suicide prior to entering the study. Suicide attempts happened at a relatively young age and in the first period of the illness. Greater severity of bipolar disorder, as indicated by a greater number of previous depressive episodes (p =.0009) and higher HAM-D-25 scores (p =.04), and higher body mass index (p =.03) were significantly correlated with a history of suicide attempts. None of the patients with a history of suicide attempt attempted suicide again. However, 5 patients without a history of suicide attempt did attempt suicide. Four of these patients did not display severe suicidal ideation at the assessment that preceded the suicide attempt. No subject completed suicide during the 11 years of the study. CONCLUSION: Greater severity of bipolar disorder and higher body mass index are significantly correlated with a history of suicide attempts. However, a treatment program in a maximally supportive clinical environment can reduce suicidal behavior in high-risk patients. In some cases, suicide risk is transient and may be preceded by a period of severe suicidal ideation that lasts only a few minutes or hours. In such cases, mental health professionals are unable to predict suicide attempts.     

Suicidal Behavior in Mood Disorders: Response to Pharmacological Treatment

Suicidal behavior is strongly associated with depression, especially if accompanied by behavioral activation, dysphoria, or agitation. It may respond to some treatments, but the design of scientifically sound, ethical trials to test for therapeutic effects on suicidal behavior is highly challenging. In bipolar disorder, and possibly also unipolar major depression, an underprescribed medical intervention with substantial evidence of preventive effects on suicidal behavior is long-term treatment with lithium. It is unclear whether this effect is specifically antisuicidal or reflects beneficial effects of lithium on depression, mood instability, and perhaps aggression and impulsivity. Antisuicidal effects of anticonvulsant mood stabilizers (carbamazepine, lamotrigine, valproate) appear to be less than with lithium. Further evaluation is needed for potential antisuicidal effects of atypical antipsychotics with growing evidence of efficacy in depression, particularly acute bipolar depression, while generally lacking risk of inducing agitation, mania, or mood instability. Short-term and long-term value and safety of antidepressants are relatively secure for unipolar depression but uncertain and poorly tested for bipolar depression; their effects on suicidal risk in unipolar depression may be age-dependent. Sedative anxiolytics are virtually unstudied as regards suicidal risks. Adequate management of suicidal risks in mood disorder patients requires comprehensive, clinically skillful monitoring and timely interventions.