Muller-Oerlinghausen B, Berghofer A, Bauer M.
Lancet 2002 Jan 19;359(9302):241-7
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
Rihmer Z, Kiss K.
and suicidal behaviour.
Bipolar Disord. 2002;4 Suppl 1:21-5.
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."
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."
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]
EJ, Cate-Carter TD, Mundo E, Parikh SV, Kennedy JL.
in bipolar patients: the role of co-morbid substance use disorders.
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."
EG, Dikeos DG, Papadimitriou GN, Souery D, Blairy S, Massat I, Mendlewicz J, Stefanis
Self-esteem, social adjustment and suicidality in affective disorders.
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]
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
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."
E, Colom F, Gasto C, Nieto E, Benabarre A, Otero A.
disorder: course and suicidal behavior]
Actas Luso Esp
Neurol Psiquiatr Cienc Afines 1997 May-Jun;25(3):147-51
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]
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.
associated with suicide attempts in 648 patients with bipolar disorder in the
Stanley Foundation Bipolar Network.
J Clin Psychiatry. 2003
"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
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]
BH, Goldberg JF, Singer TM, Garno JL, Ernst CL, Davis GP.
of first suicide attempts in single versus multiple suicide attempters with bipolar
Compr Psychiatry. 2003 Jan-Feb;44(1):15-20.
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."
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]
SM, Otto MW.
Psychosocial approaches to suicide prevention: applications
to patients with bipolar disorder.
J Clin Psychiatry 2001;62
"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]
JB, Kane HS, Chiu YF, Simpson SG, MacKinnon DF, McInnis MG, McMahon FJ, DePaulo
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