Atypical depression is associated with suicide attempt in bipolar disorder

Objective: There is a dearth of research focusing on factors associated with suicide attempts. High rates of atypical depression have been reported in studies including unipolar and bipolar II patients. In this study, the association between suicide attempt and atypical depression, in addition to other major risk factors, was evaluated in 390 bipolar I and II out‐patients. Method: Variables were defined according to DSM‐IV criteria, and assessed with a Structured Interview for DSM‐IV (axis I and II). History of suicide attempt was obtained through interviews with patients and relatives. Attempters and non‐attempters were compared using univariate and multivariate analysis. Results: Attempters showed significantly higher rates of atypical depression, family history of completed suicide, depression at index episode and cluster B personality disorder. Conclusion: Our results highlight the relevance of atypical depression in bipolar disorder. A more accurate identification of potential attempters may contribute to the development of effective preventive treatment strategies.     

Borderline personality disorder and depression severity predict suicidal outcomes: A six-month prospective cohort study of depression,bipolar depression,and borderline personality disorder

Background

Suicide risk is high in patients with major depressive disorder (MDD), bipolar disorder (BD) and borderline personality disorder (BPD). Whether risk levels of and risk factors for suicidal ideation (SI) and suicide attempts (SA) are similar or different in these disorders remains unclear, as few directly comparative studies exist. The relationship of short-term changes in depression severity and SI is underinvestigated, and might differ across groups, for example, between BPD and non-BPD patients.

Methods

We followed, for 6 months, a cohort of treatment-seeking, major depressive episode (MDE) patients in psychiatric care (original n = 124), stratified into MDE/MDD, MDE/BD and MDE/BPD subcohorts. We examined risks of suicide-related outcomes and their risk factors prospectively. We examined the covariation of SI and depression over time with biweekly online modified Patient Health Questionnaire 9 surveys and analysed this relationship through multi-level modelling.

Results

Risk of SA in BPD (22.2%) was higher than non-BPD (4.23%) patients. In regression models, BPD severity was correlated with risk of SA and clinically significant SI. During follow-up, mean depression severity and changes in depression symptoms were associated with SI risk regardless of diagnosis.

Conclusions

Concurrent BPD in depression seems predictive for high risk of SA. Severity of BPD features is relevant for assessing risk of SA and SI in MDE. Changes in depressive symptoms indicate concurrent changes in risk of SI. BPD status at intake can index risk for future SA, whereas depressive symptoms appear a useful continuously monitored risk index.     

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.     

Sex differences in clinical predictors of suicidal acts after major depression: a prospective study

OBJECTIVE: Whether sex differences exist in clinical risk factors associated with suicidal behavior is unknown. The authors postulated that among men with a major depressive episode, aggression, hostility, and history of substance misuse increase risk for future suicidal behavior, while depressive symptoms, childhood history of abuse, fewer reasons for living, and borderline personality disorder do so in depressed women. METHOD: Patients with DSM-III-R major depression or bipolar disorder seeking treatment for a major depressive episode (N=314) were followed for 2 years. Putative predictors were tested with Cox proportional hazards regression analysis. RESULTS: During follow-up, 16.6% of the patients attempted or committed suicide. Family history of suicidal acts, past drug use, cigarette smoking, borderline personality disorder, and early parental separation each more than tripled the risk of future suicidal acts in men. For women, the risk for future suicidal acts was sixfold greater for prior suicide attempters; each past attempt increased future risk threefold. Suicidal ideation, lethality of past attempts, hostility, subjective depressive symptoms, fewer reasons for living, comorbid borderline personality disorder, and cigarette smoking also increased the risk of future suicidal acts for women. CONCLUSIONS: These findings suggest that the importance of risk factors for suicidal acts differs in depressed men and women. This knowledge may improve suicide risk evaluation and guide future research on suicide assessment and prevention.     

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.     

Characterization of suicidal depression: A 1 year prospective study

BackgroundSuicidal ideation (SI) is an important risk factor of death by suicide. Recent data suggest that suicidal depression (i.e., moderate to severe depression with SI) could be a specific depression subtype with worse clinical outcomes than nonsuicidal depression (i.e., without SI).MethodsAmong 898 French adult inpatients (67% women, mean age: 41.23 [SD: 14.33]) with unipolar depression, 71.94% had moderate to severe depression (defined using the cut-offs of validated scales: beck depression inventory, clinician-rated 30-item inventory depression symptomatology, and quick inventory of depressive symptomatology) and among them, 63.6% had SI according to the suicidal item (score ≥ 2) of the depression scale they filled in. Clinical features (anxiety, psychological pain, and hopelessness) were assessed at baseline. The occurrence of a suicide attempt (SA) or a suicide event (SE) (i.e., actual, aborted or interrupted SA, or hospitalization for SI) was recorded during the 1-year follow-up. The risk of actual SA and SE was compared between groups with adjusted Cox regression models.ResultsThe risk of actual SA and SE during the follow-up was 2- and 1.8-fold higher, respectively, in patients with suicidal depression, independently of potential cofounders such as history of lifetime SA, age, sex, and baseline depression severity.ConclusionsSuicidal depression is associated with poorer prognosis in terms of actual SA/SE, despite optimal care (i.e., care in a hospital department specialized in the management of suicidal crisis). Specific therapeutic strategies might be needed for these patients.     

Lithium and suicidal behavior in major affective disorder: a case-control study

OBJECTIVE: A number of studies have suggested that lithium may be particularly effective in reducing suicide risks among patients with major affective disorders. The design of many of these studies left them open to biases associated with treatment compliance, however. METHOD: Subjects were drawn from a naturalistic, long-term follow-up of patients with major affective disorders. Fifteen who committed suicide while receiving somatotherapy where matched to non-suicidal patients who were similarly receiving somatotherapy at the same point in follow-up. The same procedure was followed for 41 patients who made a serious suicide attempt during follow-up. RESULTS: Six (40.0%) of the patients who committed suicide, and eight (53.3%) of their controls, were thought to have been taking lithium in the preceding week. Among attempters and their controls, nine (22.0%) and eight (19.5%), respectively, were taking lithium. CONCLUSION: These results do not support previous suggestions that lithium has uniquely antisuicidal properties. Other existing datasets should be explored with this design to establish whether lithium does, or does not, offer special protection against suicide.     

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.     

Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder

OBJECTIVE: The authors investigated the predictive potential of a stress-diathesis model for suicidal behavior based on correlates of past suicidal acts. In this model, suicidal acts are precipitated by stressors such as life events or a major depressive episode in the setting of a propensity for acting on suicidal urges. This diathesis is expressed as the tendency to develop more pessimism in response to a stressor and/or the presence of aggressive/impulsive traits. The predictive potential of the diathesis was tested by determining whether clinical correlates of past suicidal behavior predict suicidal acts during a 2-year follow-up of patients with a major depressive episode. METHOD: Patients with DSM-III-R major depressive disorder or bipolar disorder (N=308) were assessed at presentation for treatment of a major depressive episode. Potential predictors of suicidal acts in the 2 years after study enrollment were identified on the basis of an association with previous suicidal behavior and were tested by using Cox proportional hazards regression analysis. In addition, pessimism and aggression/impulsivity factors were generated, and their predictive ability was tested by using Cox proportional hazards regression analysis. RESULTS: The three most powerful predictors of future suicidal acts were a history of suicide attempt, subjective rating of the severity of depression, and cigarette smoking, each of which had an additive effect on future risk. The pessimism and aggression/impulsivity factors both predicted suicidal acts, and each factor showed an additive effect. CONCLUSIONS: In addition to obtaining a history of suicidal behavior, clinicians may find it useful to assess patients' current level of pessimism, aggressive/impulsive traits, and comorbidity with substance use disorders, including nicotine-related disorders, to help identify patients at risk for suicidal behavior after major depression. Interventions such as aggressive pharmacotherapeutic prophylaxis to prevent relapse or recurrence of depressive symptoms may protect such at-risk individuals from future suicidal behavior.     

Association of 5-HT(2A) receptor gene polymorphism with major affective disorders: the case of a subgroup of bipolar disorder with low suicide risk.

BACKGROUND: The implication of serotonin in suicide and affective disease explains why the 5-HT(2A) receptor gene has been proposed as a candidate gene in these disorders, although with conflicting results. METHODS: We analysed the distribution of the 5-HT(2A)-1438A/G genetic polymorphism in 192 patients with major affective disorder (127 bipolar disorders and 65 unipolar disorders) compared to 142 healthy control subjects. RESULTS: We found a higher frequency of the A allele in affected patients than in control subjects (p =.034), this difference being particularly striking for the subgroup of patients with type I bipolar disorder (p =.015). Patients with no personal and/or familial history of suicide attempts mainly accounted for the excess of the A allele in affected patients. CONCLUSIONS: The association detected in this study suggests that the 5-HT(2A) receptor gene may play a role in the genetic susceptibility to bipolar disorder, through a specific subgroup of bipolar type I patients with lower risk of suicidal behavior.