Bipolar Disorder and Suicide -- Neurotransmitter.net

(Updated 1/12/04)

Muller-Oerlinghausen B, Berghofer A, Bauer M.
Bipolar disorder.
Lancet 2002 Jan 19;359(9302):241-7
"Bipolar, or manic-depressive, disorder is a frequent, severe, mostly recurrent mood disorder associated with great morbidity. The lifetime prevalence of bipolar disorder is 1.3 to 1.6%. The mortality rate of the disease is two to three times higher than that of the general population. About 10-20% of individuals with bipolar disorder take their own life, and nearly one third of patients admit to at least one suicide attempt. The clinical manifestations of the disease are exceptionally diverse. They range from mild hypomania or mild depression to severe forms of mania or depression accompanied by profound psychosis. Bipolar disorder is equally prevalent across sexes, with the exception of rapid cycling, a severe and difficult to treat variant of the disorder, which arises mostly in women. Because of the high risk of recurrence and suicide, long-term prophylactic pharmacological treatment is indicated." [Abstract]

Rihmer Z, Kiss K.
Bipolar disorders and suicidal behaviour.
Bipolar Disord. 2002;4 Suppl 1:21-5.
"Major depressive disorder is the leading cause of suicide, particularly in the absence of adequate treatment. The aim of this paper is to analyse the relationship between different forms of major mood disorders and suicidal behaviour. Population-based epidemiological surveys as well as clinical studies on the clinically explorable suicide risk factors in bipolar and unipolar depressive disorders are reviewed. The present literature shows that patients with bipolar disorders are at higher risk of attempted and completed suicide than that of patients with unipolar major depression. Contrasting only bipolar I and bipolar II patients, current findings indicate that the rate of prior suicide attempt is higher in bipolar II patients, and bipolar II disorder is overrepresented in depressed suicide victims. Among patients with different clinical manifestations of major mood disorders (unipolar major depression. bipolar I and bipolar II disorder), bipolar patients in general, and bipolar II subjects in particular carry the highest risk of suicide." [Abstract]

Rihmer Z, Pestality P.
Bipolar II disorder and suicidal behavior.
Psychiatr Clin North Am 1999 Sep;22(3):667-73, ix-x
"Despite the fact that the nosologic position of bipolar II disorder continues to be debated, several lines of research indicate that it is a distinct nosologic category that should be separated from both bipolar I and unipolar major depression. This review of the authors' and others' work demonstrates that the lifetime risk of suicide attempts is highest in bipolar II and lowest in unipolar patients, whereas risk is intermediate in bipolar I patients. Moreover, two reports show that bipolar II patients are over represented among suicide victims. Clinicians must take great care in not missing this diagnosis, which, when untreated, has ominous prognostic implications." [Abstract]

Oquendo MA, Mann JJ.
Identifying and managing suicide risk in bipolar patients.
J Clin Psychiatry 2001;62 Suppl 25:31-4
"Bipolar patients have been shown to be at high risk for suicidal behavior. Therefore, identifying potentially suicidal patients is necessary in the treatment of bipolar patients. A stress-diathesis model for suicidal behavior has been proposed to assist clinicians in determining which patients are at risk. In the model, suicidal behavior is the result of the interaction between an individual's threshold for suicidal acts and the stressors that can lead to suicidal behavior. Suicide risk factors can then be categorized as either diathesis-related or stress-related. In a study applying the model of suicidal behavior to bipolar disorder, bipolar patients who attempted suicide had higher levels of suicidal ideation, lifetime aggression, and substance abuse than the comparison group of nonattempters. Attempters had twice the number of major depressive episodes. Once high-risk patients are identified, their suicide risk can be managed through treatments such as prophylactic lithium treatment and other pharmacologic approaches." [Abstract]

Dalton EJ, Cate-Carter TD, Mundo E, Parikh SV, Kennedy JL.
Suicide risk in bipolar patients: the role of co-morbid substance use disorders.
Bipolar Disord. 2003 Feb;5(1):58-61.
"OBJECTIVE: Bipolar disorder is associated with a high frequency of both completed suicides and suicide attempts. The primary aim of this study was to identify clinical predictors of suicide attempts in subjects with bipolar disorder. METHODS: We studied 336 subjects with a diagnosis of bipolar I, bipolar II, or schizoaffective disorder (bipolar type). The Structured Clinical Interview for DSM-IV (SCID-I) was administered and subsequently two expert psychiatrists established a diagnosis. Predictors of suicide attempts were examined in attempters and non-attempters. RESULTS: The lifetime rate of suicide attempts for the entire sample was 25.6%. A lifetime co-morbid substance use disorder was a significant predictor of suicide attempts: bipolar subjects with co-morbid substance use disorders (SUD) had a 39.5% lifetime rate of attempted suicide, while those without had a 23.8% rate (odds ratio = 2.09, 95% CI = 1.03-4.21, chi2 = 4.33, df = 1, p = 0.037). CONCLUSIONS: Lifetime co-morbid SUD were associated with a higher rate of suicide attempts in patients with bipolar disorder. This relationship may have a genetic origin and/or be explained by severity of illness and trait impulsivity." [Abstract]

Daskalopoulou EG, Dikeos DG, Papadimitriou GN, Souery D, Blairy S, Massat I, Mendlewicz J, Stefanis CN.
Self-esteem, social adjustment and suicidality in affective disorders.
Eur Psychiatry. 2002 Sep;17(5):265-71.
"Self-esteem (SE) and social adjustment (SA) are often impaired during the course of affective disorders; this impairment is associated with suicidal behaviour. The aim of the present study was to investigate SE and SA in unipolar or bipolar patients in relation to demographic and clinical characteristics, especially the presence of suicidality (ideation and/or attempt). Forty-four patients, 28 bipolar and 16 unipolar, in remission for at least 3 months, and 50 healthy individuals were examined through a structured clinical interview. SE and SA were assessed by the Rosenberg self-esteem scale and the social adjustment scale, respectively. The results have shown that bipolar patients did not differ from controls in terms of SE, while unipolar patients had lower SE than bipolars and controls. No significant differences in the mean SA scores were found between the three groups. Suicidality during depression was associated only in bipolar patients with lower SE at remission; similar but not as pronounced was the association of suicidality with SA. It is concluded that low SE lasting into remission seems to be related to the expression of suicidality during depressive episodes of bipolar patients, while no similar pattern is evident in unipolar patients." [Abstract]

Simpson SG, Jamison KR.
The risk of suicide in patients with bipolar disorders.
J Clin Psychiatry 1999;60 Suppl 2:53-6; discussion 75-6, 113-6
"Patients with bipolar disorder have a high risk of committing suicide, but determining the exact risk is complicated. For many years, the lifetime suicide risk in bipolar disorder was accepted as 15%, but recent researchers have suggested that the lifetime suicide risk may be lower. The group of bipolar patients at highest risk of suicide are young men who are in an early phase of the illness, especially those who have made a previous suicide attempt, those abusing alcohol, and those recently discharged from the hospital. The risk is also increased in patients who are in the depressed phase of bipolar illness, who have mixed states, or who have psychotic mania." [Abstract]

Vieta E, Colom F, Gasto C, Nieto E, Benabarre A, Otero A.
[Bipolar II disorder: course and suicidal behavior]
Actas Luso Esp Neurol Psiquiatr Cienc Afines 1997 May-Jun;25(3):147-51
"INTRODUCTION: Bipolar II disorder seems to be more than a mild form of classic manic-depressive illness. Differences with bipolar I concern genetic, biological, clinical and pharmacological aspects. Nevertheless, studies on suicidal behavior in both groups have resulted in inconsistent results PATIENTS AND METHOD: Twenty-two patients fulfilling Research Diagnostic Criteria for the diagnosis of bipolar II disorder and 38 bipolar I were evaluated with the Schedule for Affective Disorders and Schizophrenia by two independent interviewers, and compared. RESULTS: Bipolar II patients had significantly more previous episodes (p = 0.001), including both depressive (p = 0.003) and hypomanic switches (p = 0.006), but had been hospitalized (p = 0.001) and presented psychotic symptoms (p < 0.001) less frequently. CONCLUSIONS: There were no significant differences between both groups regarding suicidal behavior variables. These results suggest that bipolar II disorder is less severe than bipolar I regarding symptoms intensity, but more severe with respect to episodes frequency, and that suicide attempts rates are not useful to discriminate between both groups." [Abstract]

Leverich GS, Altshuler LL, Frye MA, Suppes T, Keck PE Jr, McElroy SL, Denicoff KD, Obrocea G, Nolen WA, Kupka R, Walden J, Grunze H, Perez S, Luckenbaugh DA, Post RM.
Factors associated with suicide attempts in 648 patients with bipolar disorder in the Stanley Foundation Bipolar Network.
J Clin Psychiatry. 2003 May;64(5):506-15.
"BACKGROUND: Clinical factors related to suicide and suicide attempts have been studied much more extensively in unipolar depression compared with bipolar disorder. We investigated demographic and course-of-illness variables to better understand the incidence and potential clinical correlates of serious suicide attempts in 648 outpatients with bipolar disorder. METHOD: Patients with bipolar I or II disorder (DSM-IV criteria) diagnosed with structured interviews were evaluated using self-rated and clinician-rated questionnaires to assess incidence and correlates of serious suicide attempts prior to study entry. Clinician prospective ratings of illness severity were compared for patients with and without a history of suicide attempt. RESULTS: The 34% of patients with a history of suicide attempts, compared with those without such a history, had a greater positive family history of drug abuse and suicide (or attempts); a greater personal history of early traumatic stressors and more stressors both at illness onset and for the most recent episode; more hospitalizations for depression; a course of increasing severity of mania; more Axis I, II, and III comorbidities; and more time ill on prospective follow-up. In a hierarchical logistic regression, a history of sexual abuse, lack of confidant prior to illness onset, more prior hospitalizations for depression, suicidal thoughts when depressed, and cluster B personality disorder remained significantly associated with a serious suicide attempt. CONCLUSION: Our retrospective findings, supplemented by prospective follow-up, indicate that a history of suicide attempts is associated with a more difficult course of bipolar disorder and the occurrence of more psychosocial stressors at many different time domains. Greater attention to recognizing those at highest risk for suicide attempts and therapeutic efforts aimed at some of the correlates identified here could have an impact on bipolar illness-related morbidity and mortality." [Abstract]

Oquendo MA, Waternaux C, Brodsky B, Parsons B, Haas GL, Malone KM, Mann JJ.
Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters.
J Affect Disord 2000 Aug;59(2):107-17
"OBJECTIVE: Bipolar Disorder is associated with a higher frequency of attempted suicide than most other psychiatric disorders. The reasons are unknown. This study compared bipolar subjects with a history of a suicide attempt to those without such a history, assessing suicidal behavior qualitatively and quantitatively, and examining possible demographic, psychopathologic and familial risk factors. METHODS: Patients (ages 18 to 75) with a DSM III-R Bipolar Disorder (n = 44) diagnosis determined by a structured interview for Axis I disorders were enrolled. Acute psychopathology, hopelessness, protective factors, and traits of aggression and impulsivity were measured. The number, method and degree of medical damage was assessed for suicide attempts, life-time. RESULTS: Bipolar suicide attempters had more life-time episodes of major depression, and twice as many were in a current depressive or mixed episode, compared to bipolar nonattempters. Attempters reported more suicidal ideation immediately prior to admission, and fewer reasons for living even when the most recent suicide attempt preceded the index hospitalization by more than six months. Attempters had more lifetime aggression and were more likely to be male. However, attempters did not differ from nonattempters on lifetime impulsivity. LIMITATIONS: The generalizability of the results is limited because this is a study of inpatients with a history of suicide attempts. Patients with Bipolar I and NOS Disorders were pooled and a larger sample is needed to look at differences. We could not assess psychopathology immediately prior to the suicide attempt because, only half of the suicide attempters had made attempts in the six months prior to admission. Patients with current comorbid substance abuse were excluded. No suicide completers were studied. CONCLUSIONS: Bipolar subjects with a history of suicide attempt experience more episodes of depression, and react to them by having severe suicidal ideation. Their diathesis for acting on feelings of anger or suicidal ideation is suggested by a higher level of lifetime aggression and a pattern of repeated suicide attempts." [Abstract]
Michaelis BH, Goldberg JF, Singer TM, Garno JL, Ernst CL, Davis GP.
Characteristics of first suicide attempts in single versus multiple suicide attempters with bipolar disorder.
Compr Psychiatry. 2003 Jan-Feb;44(1):15-20.
"Although suicidality remains highly prevalent among patients with bipolar disorder, little research exists examining the characteristics of successive attempts among individuals who make and survive a first suicide attempt. We compared bipolar subjects with a history of one suicide attempt to those with multiple attempts and assessed demographic characteristics, family histories, psychopathology, and clinical dimensions of suicidal behavior. Fifty-two DSM-IV bipolar patients (age 21 to 74 years) with a history of at least one suicide attempt were consecutively evaluated in the Bipolar Disorders Research Clinic of the New York Presbyterian Hospital. Circumstances surrounding each lifetime suicide attempt were assessed by direct interviews, questionnaires, and chart reviews along with family psychiatric histories, substance abuse histories, current psychopathology, and features of impulsivity and aggression. Multiple suicide attempts occurred in approximately two thirds of the study group. Single attempters were significantly more likely than multiple attempters to show high seriousness of intent at their first attempt (OR = 0.65, 95% CI = 0.43 to 0.99), and tended to be less likely than multiple attempters to exhibit mixed states at their first attempt (OR = 0.54, 95% CI = 0.28 to 1.01). Seriousness of intent was consistent across the first and second attempts (r =.48, P <.01) and second and third attempts (r =.74, P <.05). Single and multiple attempters differed in no other clinical or demographic characteristics studied. We conclude that multiple suicide attempts are common among bipolar patients. Those who survive an initial suicide attempt involving high seriousness of intent appear less likely than those with low intent to make subsequent attempts. Consequently, single attempters may represent a group more closely resembling those who complete suicide on a first attempt, in terms of the risk for death associated with their first attempt. However, multiple suicide attempts among bipolar patients are not necessarily associated with a higher risk for lethality in first suicide attempt survivors." [Abstract]

Shyovitz M.
A family member's legal experience with an insurer's refusal to recertify inpatient mental health treatment.
J Clin Psychiatry 2001;62 Suppl 25:44-50
"My son Nathaniel has bipolar disorder and was hospitalized for 6 months, during which time our insurance company was prepared to refuse certification more than once despite a policy that included 365 days of inpatient mental health treatment. A break in coverage by the insurance company would have meant that Nathaniel, still suicidal, would not receive the life-saving care he needed. Fortunately, I am a lawyer, which enabled me to act as a legal advocate for my son when our insurer threatened not to recertify. Because my son's experience with the insurance company is not unusual--many patients with mental illness struggle with insurance companies who refuse to certify treatment--I believe that the family or support people of seriously ill psychiatric patients should be prepared to act in circumstances similar to mine. Psychiatric inpatient units should, as a matter of course, provide information on legal remedies that can be obtained before irreparable harm occurs." [Abstract]
Gray SM, Otto MW.
Psychosocial approaches to suicide prevention: applications to patients with bipolar disorder.
J Clin Psychiatry 2001;62 Suppl 25:56-64
"Hopelessness, dysfunctional attitudes, and poor problem-solving abilities are psychosocial risk factors that have been identified as predictors of suicide. These psychosocial risk factors may help clinicians apply specific therapies and treatments to patients with bipolar disorder at risk for suicide. A search of the literature on suicide prevention revealed 17 randomized, controlled studies, which the authors reviewed to determine the efficacy of strategies aimed at eliminating psychosocial risk factors for suicide. Three strategies emerged as efficacious: (1) applying interventions to elicit emergency care by patients at times of distress; (2) training in problem-solving strategies; and (3) combining comprehensive interventions that include problem solving with intensive rehearsal of cognitive, social, emotional-labeling, and distress-tolerance skills. On the basis of their review of the literature, the authors make recommendations for suicide prevention for patients with bipolar disorder." [Abstract]
Potash JB, Kane HS, Chiu YF, Simpson SG, MacKinnon DF, McInnis MG, McMahon FJ, DePaulo JR Jr.
Attempted suicide and alcoholism in bipolar disorder: clinical and familial relationships.
Am J Psychiatry 2000 Dec;157(12):2048-50
"OBJECTIVE: This study examined the clinical and familial relationships between comorbid alcoholism and attempted suicide in affectively ill relatives of probands with bipolar I disorder. METHOD: In 71 families ascertained for a genetic linkage study, 337 subjects with major affective disorder were assessed by using the Schedule for Affective Disorders and Schizophrenia-Lifetime Version. RESULTS: Subjects with bipolar disorder and alcoholism had a 38.4% lifetime rate of attempted suicide, whereas those without alcoholism had a 21.7% rate. Attempted suicide among subjects with bipolar disorder and alcoholism clustered in a subset of seven families. Families with alcoholic and suicidal probands had a 40.7% rate of attempted suicide in first-degree relatives with bipolar disorder, whereas other families had a 19.0% rate. CONCLUSIONS: Comorbid alcoholism was associated with a higher rate of attempted suicide among family members with bipolar disorder. Attempted suicide and alcoholism clustered in a subset of families. These relationships may have a genetic origin and may be mediated by intoxication, mixed states, and/or temperamental instability." [Abstract]

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Recent Bipolar Disorder & Suicide Research
1) Balda�ara L, Nery-Fernandes F, Rocha M, Quarantini LC, Rocha GG, Guimar�es JL, Ara�jo C, Oliveira I, Miranda-Scippa A, Jackowski A
Is cerebellar volume related to bipolar disorder?
J Affect Disord. 2011 Jul 21;
BACKGROUND: Recent data suggest that cerebellum influences emotion modulation in humans. The findings of cerebellar abnormalities in bipolar disorder (BD) are especially intriguing given the link between the cerebellum emotional and behavioral regulation. The purpose of this study was to evaluate cerebellar volume in patients with euthymic BD type I compared to controls. Moreover, we investigated the possible relationship between cerebellar volume and suicidal behavior. METHODS: Forty-patients with euthymic BD type I, 20 with and 20 without history of suicide attempt, and 22 healthy controls underwent an MRI scan. The participants were interviewed using the Structured Clinical Interview with the DSM-IV axis I (SCID-I), the Hamilton Depression Rating Scale (HDRS), the Young Mania Rating Scale (YMRS) and the Barratt Impulsiveness Scale (BIS-11). RESULTS: Groups were age, gender and years of schooling-matched. The left cerebellum (p=0.02), right cerebellum (p=0.02) and vermis (p<0.01) were significantly smaller in the BD group; however, there were no volumetric differences between the BD subjects with and without suicidal attempt. There was no correlation between cerebellar measurements and clinical variables. LIMITATIONS: The main strength is that our sample consisted of patients with euthymic BD type I without any comorbidities, however, these results cannot establish causality as the cross-sectional nature of the study. CONCLUSIONS: Our findings suggest that the reduction in cerebellar volumes observed in BD type I might be a trait-related characteristic of this disorder. Additional studies with larger samples and subtypes of this heterogeneous disorder are warranted to determine the possible specificity of this cerebellar finding. [PubMed Citation] [Order full text from Infotrieve]

2) Parker GB
Bipolar II disorder - diagnostic and management lessons for health practitioners from a coronial inquest.
Med J Aust. 2011 Jul 18;195(2):81-3.
A coronial inquest into the suicide of television newsreader Charmaine Dragun identified that a likely contributory factor to her death was the failure of many health practitioners to diagnose a bipolar II disorder and to provide more specific treatment for her condition. Lack of awareness about bipolar II disorder among practitioners and the public, as well as screening and detection problems, may have contributed to the failure to diagnose this disorder over the course of a decade. Detection and management of bipolar II disorder generally differs from that for a unipolar disorder, in that mood stabilisers rather than antidepressants are more often a priority. The diagnosis therefore has distinctive implications for management and course of the illness. The Coroner recommended "increased awareness by health professionals of the need to exclude a bipolar disorder in all patients presenting with signs and symptoms of depression" and highlighted the need for "readily available" screening tools. [PubMed Citation] [Order full text from Infotrieve]

3) Capuano A, Ruggiero S, Vestini F, Ianniello B, Rafaniello C, Rossi F, Mucci A
Survival from coma induced by an intentional 36-g overdose of extended-release quetiapine.
Drug Chem Toxicol. 2011 Jul 19;
Quetiapine is a second-generation antipsychotic drug approved for the treatment of bipolar disorders and schizophrenia. Acute quetiapine overdose is rare, and quetiapine has long been thought to be safer than other antipsychotics. Nevertheless, as reported in the literature, the severity of the effect of quetiapine overdose has not been associated with a high serum concentration of the drug or with the reported ingested dose. In this article, we report a case of survival from coma induced by a massive extended-release (XR) quetiapine ingestion at a dose greater than reported in some previous fatal cases. A 34-year-old woman with chronic schizophrenia ingested 36?g of quetiapine fumarate XR for attempted suicide. She was initially lethargic, but her clinical conditions rapidly deteriorated and she collapsed unconscious. The woman was taken to the nearest hospital, where the medical emergency team found her in deep coma with response only to deep painful stimuli (Glasgow Coma Scale 9). An endotracheal tube was inserted for airway protection, and the patient was transferred to a critical care area for ventilatory support and maintenance of hydration status and electrolytic balance. Spontaneous breathing was restored in approximately 36 hours, and a few days later, she was discharged without reporting clinical complications. This is the first case of coma induced by an intentional 36-g overdose of quetiapine XR. Given the widespread use of quetiapine and the lack of information about its toxicity in overdose, this case report reinforces the importance of closely monitoring patients taking quetiapine and helps to better define the safety of this drug. [PubMed Citation] [Order full text from Infotrieve]

4) Oquendo MA, Galfalvy HC, Currier D, Grunebaum MF, Sher L, Sullivan GM, Burke AK, Harkavy-Friedman J, Sublette ME, Parsey RV, Mann JJ
Treatment of Suicide Attempters With Bipolar Disorder: A Randomized Clinical Trial Comparing Lithium and Valproate in the Prevention of Suicidal Behavior.
Am J Psychiatry. 2011 Jul 18;
Objective: Bipolar disorder is associated with high risk for suicidal acts. Observational studies suggest a protective effect of lithium against suicidal behavior. However, testing this effect in randomized clinical trials is logistically and ethically challenging. The authors tested the hypothesis that lithium offers bipolar patients with a history of suicide attempt greater protection against suicidal behavior compared to valproate. Method: Patients with bipolar disorder and past suicide attempts (N=98) were randomly assigned to treatment with lithium or valproate, plus adjunctive medications as indicated, in a double-blind 2.5-year trial. An intent-to-treat analysis was performed using the log-rank test for survival data. Two models were fitted: time to suicide attempt and time to suicide event (attempt or hospitalization or change in medication in response to suicide plans). Results: There were 45 suicide events in 35 participants, including 18 suicide attempts made by 14 participants, six from the lithium group and eight from the valproate group. There were no suicides. Intent-to-treat analysis using the log-rank test showed no differences between treatment groups in time to suicide attempt or to suicide event. Post hoc power calculations revealed that the modest sample size, reflective of challenges in recruitment, only permits detection of a relative risk of 5 or greater. Conclusions: Despite the high frequency of suicide events during the study, this randomized controlled trial detected no difference between lithium and valproate in time to suicide attempt or suicide event in a sample of suicide attempters with bipolar disorder. However, smaller clinically significant differences between the two drugs were not ruled out. [PubMed Citation] [Order full text from Infotrieve]

5) Lett TA, Zai CC, Tiwari AK, Shaikh SA, Likhodi O, Kennedy JL, M�ller DJ
ANK3, CACNA1C and ZNF804A gene variants in bipolar disorders and psychosis subphenotype.
World J Biol Psychiatry. 2011 Aug;12(5):392-7.
Abstract Objectives. The ANK3, CACNA1C and ZNF804A genes have been implicated in both bipolar disorders (BPD) and schizophrenia (SCZ). It has been suggested that BPD with psychosis may be a clinical manifestation of genes overlapping between BPD and SCZ. We therefore tested the association of these genes with BPD in a large family-based sample, and then dissected the phenotype into psychosis present or absent subgroups. Methods. We genotyped four high interest single nucleotide polymorphisms from ANK3 (rs10994336, rs9804190), CACNA1C (rs1006737), and ZNF804A (rs1344706). Family based association testing (FBAT) was performed on 312 families, and within psychotic (N = 158) and non-psychotic BPD (N = 119) subgroups. Results. In the whole sample, we found a nominal association in ZNF804A (rs1344706, P = 0.046), and a trend in CACNA1C (rs1006737, P = 0.077). In the psychotic BPD subgroup, as hypothesized, stronger signals were observed in ZNF804A (P = 0.019) and CACNA1C (P = 0.017). We found no association in the ANK3 markers, but the rs10994336 variant was nominally associated with non-psychotic BPD (P = 0.046). Exploratory analysis revealed the rs1344706 variant was also implicated in suicide-attempt behaviour (P = 0.038). Conclusions. These tentative results are consistent with the hypothesis that the subphenotype of BPD with psychosis may represent a clinical manifestation of shared genetic liability between BPD and SCZ. [PubMed Citation] [Order full text from Infotrieve]

6) Dumlu K, Orhon Z, Ozerdem A, Tural U, Ulaş H, Tunca Z
Treatment-induced manic switch in the course of unipolar depression can predict bipolarity: Cluster analysis based evidence.
J Affect Disord. 2011 Jul 8;
BACKGROUND: Antidepressants are known to induce manic switch in patients with depression. Treatment-induced mania is not considered as bipolar disorder in DSM IV. The aim of this study was to assess whether clinical characteristics of patients with unipolar depression with a history of treatment-induced mania were similar to those of patients with bipolar disorder. METHOD: The study included 217 consecutive patients with DSM-IV mood disorders, diagnosed as: bipolar disorder type I (BP-I, n=58) or type II (BP-II, n=18) whose first episodes were depression, recurrent (unipolar) major depressive disorder with a history of antidepressant treatment-induced mania (switchers=sUD; n=61) and without such an event (rUD; n=80). First, the groups were compared with regard to clinical features and course specifiers using variance and chi-square analysis. Variables that differed significantly between the four groups were included in two-step cluster analysis to explore naturally occurring subgroups in all diagnoses. Subsequently, the relationship between the naturally occurring clusters and pre-defined DSM-IV diagnoses were investigated. RESULTS: Two-step cluster analysis revealed two different naturally occurring groups. Higher severity of depressive episodes, with higher rate of melancholic features, higher number of hospitalization and suicide attempts were represented in one cluster where switchers (77%), bipolar I (94.8%) and II (83.3%) patients clustered together. CONCLUSION: The findings of this study confirm that treatment-induced mania is a clinical phenomenon that belongs within the bipolar spectrum rather than a coincidental treatment complication, and that it should be placed under "bipolar disorders" in future classification systems. LIMITATIONS: The study includes the limitations of any naturalistic retrospective study. [PubMed Citation] [Order full text from Infotrieve]

7) Altamura AC, Buoli M, Dell'osso B, Albano A, Serati M, Colombo F, Pozzoli S, Angst J
The impact of brief depressive episodes on the outcome of bipolar disorder and major depressive disorder: A 1-year prospective study.
J Affect Disord. 2011 Jul 5;
BACKGROUND: Brief depressive episodes (BDEs) cause psychosocial impairment and increased risk of suicide, worsening the outcome and long-term course of affective disorders. The aim of this naturalistic observational study was to assess the frequency of BDEs and very brief depressive episodes (VBDEs) and their impact on clinical outcome in a sample of patients with major depressive disorder (MDD) and bipolar disorder (BD). METHOD: Seventy patients with a diagnosis of MDD or BD were followed up and monthly visited for a period of 12months, assessing the eventual occurrence of BDEs and/or VBDEs. Clinical and demographic variables of the total sample and of the groups divided according to the presence of BDEs or VBDEs were collected and compared by one-way ANOVAs. Hamilton Depression Rating Scale 21 items (HDRS), Young Mania Rating Scale (YMRS), Clinical Global Impression (severity of illness) (CGIs) and the Short Form Health Survey (SF-36-item 1) were administered at baseline and logistic regression was performed to evaluate whether baseline scores were predictive of the onset of BDEs or VBDEs. RESULTS: BDEs (88.6% of the total sample), VBDEs (44.3% of the total sample) and BDEs+VBDEs (40.0% of the total sample) were found to occur frequently across the sample. BDE patients showed more death thoughts during major depressive episodes (?(2)=4.14, df=1, p=0.04, Phi=0.24) compared to patients without BDEs. Indeed VBDE patients showed a higher rate of hospitalization (?(2)=5.71, df=1, p=0.031, phi=0.29), a more frequent prescription of a combined treatment (?(2)=13.07, df=7, p=0.03, phi=0.43) and higher scores at SF-36 item 1 (F=6.65, p=0.01) compared to patients without VBDEs. Finally, higher SF-36 item 1 scores were found to be predictive of VBDEs (odds ratio=2.81, p=0.03). DISCUSSION: Major depressives, either unipolar or bipolar, with BDEs or VBDEs showed a worse outcome, represented by a more severe psychopathology and higher rates of hospitalization. VBDEs were predicted by a negative subjective general health perception. Studies with larger samples and longer follow-up are warranted to confirm the results of the present study. [PubMed Citation] [Order full text from Infotrieve]

8) Br�ne M, Sch�bel A, Karau R, Faustmann PM, Dermietzel R, Juckel G, Petrasch-Parwez E
Neuroanatomical correlates of suicide in psychosis: the possible role of von economo neurons.
PLoS One. 2011;6(6):e20936.
Suicide is the most important incident in psychiatric disorders. Psychological pain and empathy to pain involves a neural network that involves the anterior cingulate cortex (ACC) and the anterior insula (AI). At the neuronal level, little is known about how complex emotions such as shame, guilt, self-derogation and social isolation, all of which feature suicidal behavior, are represented in the brain. Based on the observation that the ACC and the AI contain a large spindle-shaped cell type, referred to as von Economo neuron (VEN), which has dramatically increased in density during human evolution, and on growing evidence that VENs play a role in the pathophysiology of various neuropsychiatric disorders, including autism, psychosis and dementia, we examined the density of VENs in the ACC of suicide victims. The density of VENs was determined using cresyl violet-stained sections of the ACC of 39 individuals with psychosis (20 cases with schizophrenia, 19 with bipolar disorder). Nine subjects had died from suicide. Twenty specimen were available from the right, 19 from the left ACC. The density of VENs was significantly greater in the ACC of suicide victims with psychotic disorders compared with psychotic individuals who died from other causes. This effect was restricted to the right ACC. VEN density in the ACC seems to be increased in suicide victims with psychosis. This finding may support the assumption that VEN have a special role in emotion processing and self-evaluation, including negative self-appraisal. [PubMed Citation] [Order full text from Infotrieve]

9) Ishitobi M, Shukunami K, Murata T, Wada Y
Hypomanic switching during influenza infection without intracranial infection in an adolescent patient with bipolar disorder.
Pediatr Emerg Care. 2011 Jul;27(7):652-3.
Manic switching, which is mood changing from depression to mania, induced by intracranial viral infections have been previously reported. However, manic switching induced by influenza infection without intracranial viral infection in a patient with bipolar disorder (BD), has not been previously reported.We report a patient with adolescent BD who showed a first episode of hypomanic switching during influenza B infection without intracranial viral infection. In addition to neurological monitoring, careful psychiatric interventions for hypomanic state is very important to prevent inappropriate treatment of BD and reduce the risk of suicide attempts in cases presenting with hypomanic symptoms during influenza infection. [PubMed Citation] [Order full text from Infotrieve]

10) Ekinci O, Albayrak Y, Ekinci AE, Caykoylu A
Relationship of trait impulsivity with clinical presentation in euthymic bipolar disorder patients.
Psychiatry Res. 2011 Jul 1;
The purpose of this study was to examine trait impulsivity in patients with bipolar disorder and explore the possible connections between impulsivity and clinical presentation of the illness. Diagnoses were based on the Structured Clinical Interview for DSM-IV. The sociodemographic and clinical properties of 71 patients with bipolar disorder, who were euthymic according to Young Mania Rating Scale and Hamilton Depression Scale scores, were recorded. Their trait impulsivity was evaluated by using the Barratt Impulsiveness Scale (BIS) and impulsivity subscale of the Temperament and Character Inventory, and the results were compared with 50 age- and sex-matched healthy controls and among patients with different clinical properties. All BIS-11 subscale scores were higher in bipolar than in comparison subjects. There were no effects of education and age. Elevated BIS-11 scores were associated with predominant depressive polarity, longer duration of illness and a history of psychotic mood episodes and suicide attempts. These relationships persisted when age, gender, and education were taken into account. 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 and may vary according to different clinical presentations. [PubMed Citation] [Order full text from Infotrieve]

11) Perroud N, Baud P, Mouthon D, Courtet P, Malafosse A
Impulsivity, aggression and suicidal behavior in unipolar and bipolar disorders.
J Affect Disord. 2011 Jun 30;
BACKGROUND: Predictors of suicidal behaviors (SB) in bipolar (BD) and major depressive disorder (MDD) patients are poorly understood. It has been recognized that behavioral dysregulation characterizes SB with traits of impulsivity and aggression being particularly salient. However, little is known about how these traits are segregated among mood disorder patients with and without a history of suicide attempt (SA). METHODS: This article aims to compare impulsivity and aggression between 143 controls, 138 BD and 186 MDD subjects with or without a history of SA. RESULTS: BD and MDD patients showed higher impulsivity scores (BIS-10=57.9 vs. 44.7, p<0.0001) and more severe lifetime aggression than controls (Lifetime History of Aggression=7.3 vs. 3.9, p<0.0001). Whereas impulsivity helped to distinguish MDD subjects without a history of SA from those with such a history, this was not the case in BD subjects where no difference in impulsive traits was observed between BD without and with history of SA (57.2 vs. 63.2 for BIS-10; p=0.259). Impulsive and aggressive traits were strongly correlated in suicide attempters (independently of the diagnosis) but not in non-suicide attempters. LIMITATIONS: Dimensional traits were not characterized at different stages of illness. CONCLUSIONS: Impulsivity, as a single trait, may be a reliable suicide risk marker in MDD but not in BD patients, and its strong correlation with aggressive traits seems specifically related to SB. Our study therefore suggests that the specific dimension of impulsive aggression should be systematically assessed in mood disorder patients to address properly their suicidal risk. [PubMed Citation] [Order full text from Infotrieve]

12) Saunders K, Brain S, Ebmeier KP
Diagnosing and managing psychosis in primary care.
Practitioner. 2011 May;255(1740):17-20, 2-3.
Psychosis is broadly defined as the presence of delusions and hallucinations. It can be organic or functional. The former is secondary to an underlying medical condition, such as delirium or dementia, the latter to a psychiatric disorder, such as schizophrenia or bipolar disorder. The identification and treatment of psychosis is vital as it is associated with a 10% lifetime risk of suicide and significant social exclusion. Psychosis can be recognised by taking a thorough history, examining the patient's mental state and obtaining a collateral history. The history usually enables a distinction to be made between bipolar disorder, schizophrenia and other causes. Early symptoms often include low mood, declining educational or occupational functioning, poor motivation, changes in sleep, perceptual changes, suspiciousness and mistrust. The patient's appearance, e.g. unkempt or inappropriately attired, may reflect their predominant mental state. There may be signs of agitation, hostility or distractibility. Speech may be disorganised and difficult to follow or there may be evidence of decreased speech. Mood may be depressed or elated or change rapidly. Patients may describe abnormal thoughts and enquiry into thoughts of suicide should be routine. Disturbances of thought such as insertion or withdrawal may be present along with perceptual abnormalities i.e. illusions, hallucinations. Insight varies during the course of a psychotic illness but should be explored as it has implications for management. All patients presenting with first episode psychosis for which no organic cause can be found should be referred to the local early intervention service. In patients with a known diagnosis consider referral if there is: poor response or nonadherence to treatment; intolerable side effects; comorbid substance misuse; risk to self or others. [PubMed Citation] [Order full text from Infotrieve]

13) Karakus G, Tamam L
Impulse control disorder comorbidity among patients with bipolar I disorder.
Compr Psychiatry. 2011 Jul-Aug;52(4):378-85.
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14) Kopeĭko GI
[Bipolar and monopolar affective disorders of juvenile age].
Vestn Ross Akad Med Nauk. 2011;(4):26-30.
Results of clinico-psychopathological and clinico-catamnestic studies are presented based on the examination of 174 patients with affective disorders that manifested themselves at the age of 15-25 years. The main psychopathological features of juvenile phase-affective conditions are described (subtle vital manifestations of the thymic component, polymodality of the affect with simultaneous presentation of two varieties of affective disorders, instability of the affect changing within a single phase, high occurrence of overvalued ideas reflecting specific emotions of the juvenile age with concomitant manifestations of pubertal psychological crisis underlain by common pathogenetic mechanisms). High frequency of mixed affective conditions and the predominance of the bipolar type of the disease are emphasized, clinical features of mono- and bipolar pathology are described. It is concluded that a special algorithm of psychopharmacological and psychotherapeutic therapy adapted to the juvenile age is needed for the treatment of the above disorders. [PubMed Citation] [Order full text from Infotrieve]

15) Van Meter AR, Moreira AL, Youngstrom EA
Meta-analysis of epidemiologic studies of pediatric bipolar disorder.
J Clin Psychiatry. 2011 May 31;
OBJECTIVE: Meta-analyze all published epidemiologic studies reporting pediatric mania or bipolar disorder to investigate whether pediatric bipolar disorder is becoming more prevalent and whether rates vary significantly by country. DATA SOURCES: Searches of PubMed and PsycInfo were conducted through the spring of 2010 using the following search terms: child, pediatric, young, adolescent, epidemiology, prevalence, bipolar, mania, suicide, and psychiatric. We also manually reviewed references in recent reviews of epidemiology of bipolar disorder. STUDY SELECTION: All studies reporting rates for mania or hypomania in community epidemiologic samples with participants up to 21 years of age. DATA EXTRACTION: All articles were coded to extract relevant variables. Prevalence rates were calculated from reported number of cases with bipolar disorders, then logit transformed. Twelve studies were included, enrolling 16,222 youths between the ages of 7 and 21 years during a period from 1985 to 2007. Six samples were from the United States; 6 were from other countries (the Netherlands, the United Kingdom, Spain, Mexico, Ireland, and New Zealand). RESULTS: The overall rate of bipolar disorder was 1.8% (95% CI, 1.1%-3.0%). There was no significant difference in the mean rates between US and non-US studies, but the US studies had a wider range of rates. The highest estimates came from studies that used broad definitions and included bipolar disorder not otherwise specified. Year of enrollment was negatively correlated with prevalence (r = -0.04) and remained nonsignificant when controlling for study methodological differences. CONCLUSIONS: Mean rates of bipolar disorder were higher than commonly acknowledged and not significantly different in US compared to non-US samples, nor was there evidence of an increase in rates of bipolar disorder in the community over time. Differences in diagnostic criteria were a main driver of different rates across studies. [PubMed Citation] [Order full text from Infotrieve]

16) Marchand WR, Lee JN, Garn C, Thatcher J, Gale P, Kreitschitz S, Johnson S, Wood N
Aberrant emotional processing in posterior cortical midline structures in bipolar II depression.
Prog Neuropsychopharmacol Biol Psychiatry. 2011 May 30;
Bipolar II depression is a serious and disabling illness associated with significant impairment and high rates of suicide attempts. However, mechanisms underlying emotional dysregulation in this condition are poorly characterized. The goal of this work was to investigate one component of emotional processing in this disorder, brain activation associated with exposure to emotional faces. Functional MRI was used to study 16 unmedicated male subjects with bipolar II depression and 19 healthy male controls. The activation paradigm exposed subjects to happy, fearful and neutral faces. The two key findings of this study were as follows. First, bipolar subjects demonstrated significantly decreased activation in response to happy facial expression in the left posterior cortical midline structures (CMS) and frontal cortex. Second, depression severity was positively correlated with activation of the posterior CMS and other regions. Our results suggest that mechanisms involving CMS dysfunction may play a role in the neurobiology of bipolar II depression as has been demonstrated for unipolar illness. Further investigations of CMS function in bipolar spectrum disorders are warranted. [PubMed Citation] [Order full text from Infotrieve]

17) Pompili M, Venturini P, Innamorati M, Serafini G, Telesforo L, Lester D, Tatarelli R, Girardi P
The role of asenapine in the treatment of manic or mixed states associated with bipolar I disorder.
Neuropsychiatr Dis Treat. 2011;7:259-65.
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18) Chiu JF, Chokka PR
Prevalence of Bipolar Disorder symptoms in Primary Care (ProBiD-PC): A Canadian study.
Can Fam Physician. 2011 Feb;57(2):e58-67.
Objective To describe the prevalence of patients who screen positive for symptoms of bipolar disorder in primary care practice using the validated Mood Disorders Questionnaire (MDQ). Design Prevalence survey. Setting Fifty-four primary care practices across Canada. Participants Adult patients presenting to their primary care practitioners for any cause and reporting, during the course of their visits, current or previous symptoms of depression, anxiety, substance use disorders, or attention deficit hyperactivity disorder. Main outcome measures Subjects were screened for symptoms suggestive of bipolar disorder using the MDQ. Health-related quality of life, functional impairment, and work productivity were evaluated using the 12-Item Short-Form Health Survey and Sheehan Disability Scale. Results A total of 1416 patients were approached to participate in this study, and 1304 completed the survey. Of these, 27.9% screened positive for symptoms of bipolar disorder. All 13 items of the MDQ were significantly associated with screening positive for bipolar disorder (P < .05). Patients screening positive were significantly more likely to report depression, anxiety, substance use, attention deficit hyperactivity disorder, family history of bipolar disorder, or suicide attempts than patients screening negative were (P < .001). Health-related quality of life, work or school productivity, and social and family functioning were all significantly worse in patients who screened positive (P < .001). Conclusion This prevalence survey suggests that more than a quarter of patients presenting to primary care with past or current psychiatric indices are at risk of bipolar disorder. Patients exhibiting a cluster of these symptoms should be further questioned on family history of bipolar disorder and suicide attempts, and selectively screened for symptoms suggestive of bipolar disorder using the quick and high-yielding MDQ. [PubMed Citation] [Order full text from Infotrieve]

19) Pompili M, Rihmer Z, Akiskal H, Amore M, Gonda X, Innamorati M, Lester D, Perugi G, Serafini G, Telesforo L, Tatarelli R, Girardi P
Temperaments mediate suicide risk and psychopathology among patients with bipolar disorders.
Compr Psychiatry. 2011 Jun 3;
BACKGROUND: Several studies have demonstrated that bipolar II (BD-II) disorder represents a quite common, distinct form of major mood disorders that should be separated from bipolar I (BD-I) disorder. The aims of this cross-sectional study were to assess temperament and clinical differences between patients with BD-I and BD-II disorders and to assess whether temperament traits are good predictors of hopelessness in patients with bipolar disorder, a variable highly associated with suicidal behavior and ideation. METHOD: Participants were 216 consecutive inpatients (97 men and 119 women) with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), BD who were admitted to the Sant'Andrea Hospital's psychiatric ward in Rome (Italy). Patients completed the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire, the Beck Hopelessness Scale (BHS), the Mini International Neuropsychiatric Interview (MINI), and the Gotland Scale of Male Depression. RESULTS: Patients with BD-II had higher scores on the BHS (9.78 � 5.37 vs 6.87 � 4.69; t(143.59) = -3.94; P < .001) than patients with BD-I. Hopelessness was associated with the individual pattern of temperament traits (ie, the relative balance of hyperthymic vs cyclothymic-irritable-anxious-dysthmic). Furthermore, patients with higher hopelessness (compared with those with lower levels of hopelessness) reported more frequently moderate to severe depression (87.1% vs 38.9%; P < .001) and higher MINI suicidal risk. CONCLUSION: Temperaments are important predictors both of suicide risk and psychopathology and may be used in clinical practice for better delivery of appropriate care to patients with bipolar disorders. [PubMed Citation] [Order full text from Infotrieve]

20) Prince A, Nelson K
Educational needs of practice nurses in mental health.
J Prim Health Care. 2011;3(2):142-9.
[PubMed Citation] [Order full text from Infotrieve]