Suicide Attempts In Bipolar Disorder Research Articles

Neurobiological aspects of suicide and suicide attempts in bipolar disorder

Suicide and bipolar disorder (BD) are challenging, complex, and intertwined areas of study in contemporary psychiatry. Indeed, BD is associated with the highest lifetime risk for suicide attempt and completion of all the psychiatric conditions. Given that several clinical risk factors for both suicide and BD have been well noted in the literature, exploring the neurobiological aspects of suicide in BD may provide insights into both preventive measures and future novel treatments. This review synthesizes findings regarding the neurobiological aspects of suicide and, when applicable, their link to BD. Neurochemical findings, genes/epigenetics, and potential molecular targets for current or future treatments are discussed. The role of endophenotypes and related proximal and distal risk factors underlying suicidal behavior are also explored. Lastly, we discuss the manner in which preclinical work on aggression and impulsivity may provide additional insights for the future development of novel treatments.

1776 – Clinical and cognitive correlates of suicide attempts in bipolar disorder

Introduction Bipolar disorder (BD) is strongly associated with suicidal behaviors. Suicidal behavior is based on a stress/vulnerability model. Several factors have been identified, including clinical features (such as impulsivity) and cognitive deficits (such as impaired decision making or problem solving). Identifying specific factors in BD patients is needed to better prevent suicidal behaviors. Objectives 1) To identify clinical and cognitive characteristics associated with suicidal behaviors in euthymic BD patients. 2) To determine a correlation between neuropsychological variables and the number and characteristics of suicidal attempts. Methods 214 euthymic BD patients from the national network of “Centres Experts Bipolaires” were included and divided into two groups based on the personal history of suicide attempts. Socio-demographic and clinical variables were collected and neuropsychological functions were assessed (attention, memory and executive functions). Results We found an association between suicidal behavior and gender, employment status. Suicidal attempters had significantly more mixed episodes and hospitalizations. There was no difference between the two groups concerning neuropsychological measures. The number of suicide attempts and verbal fluency scores were negatively correlated. Conclusions The lack of significant differences in neuropsychological scores may be due to a common vulnerability between suicidal behaviors and BD. Further studies, especially prospective ones, are needed in order to characterize high risk BD patients in order to develop effective specific preventive strategies.

Cerebrospinal fluid neuropeptide Y level associated with anxiety and suicide attempts in bipolar disorder

Cerebrospinal fluid neuropeptide Y level associated with anxiety and suicide attempts in bipolar disorder

Bipolar Disorder and a History of Suicide Attempts With a Duplication in 5HTR1A

Bipolar Disorder and a History of Suicide Attempts With a Duplication in 5HTR1A

A risk-scoring scheme for suicide attempts among patients with bipolar disorder in a Thai patient cohort

BackgroundIn Thailand, risk factors associated with suicide attempts in bipolar disorder (BD) are rarely investigated, nor has a specific risk-scoring scheme to assist in the identification of BD patients at risk for attempting suicide been proposed.ObjectiveTo develop a simple risk-scoring scheme to identify patients with BD who may be at risk for attempting suicide.MethodsMedical files of 489 patients diagnosed with BD at Suanprung Psychiatric Hospital between October 2006 and May 2009 were reviewed. Cases included BD patients hospitalized due to attempted suicide (n = 58), and seven controls were selected (per suicide case) among BD in- and out-patients who did not attempt suicide, with patients being visited the same day or within 1 week of case study (n = 431). Broad sociodemographic and clinical factors were gathered and analyzed using multivariate logistic regression, to obtain a set of risk factors. Scores for each indicator were weighted, assigned, and summed to create a total risk score, which was divided into low, moderate, and high-risk suicide attempt groups.ResultsSix statistically significant indicators associated with suicide attempts were included in the risk-scoring scheme: depression, psychotic symptom(s), number of previous suicide attempts, stressful life event(s), medication adherence, and BD treatment years. A total risk score (possible range −1.5 to 11.5) explained an 88.6% probability of suicide attempts based on the receiver operating characteristic (ROC) analysis. Likelihood ratios of suicide attempts with low risk scores (below 2.5), moderate risk scores (2.5–8.0), and high risk scores (above 8.0) were 0.11 (95% CI 0.04–0.32), 1.72 (95% CI 1.41–2.10), and 19.0 (95% CI 6.17–58.16), respectively.ConclusionThe proposed risk-scoring scheme is BD-specific, comprising six key indicators for simple, routine assessment and classification of patients to three risk groups. Further validation is required before adopting this scheme in other clinical settings.

Antidepressant Use and Risk for Suicide Attempts in Bipolar Disorder

Article AbstractLetter to the EditorBecause this piece does not have an abstract, we have provided for your benefit the first 3 sentences of the full text.The use of antidepressants in bipolar disorder remains controversial with respect to whether, and when, they may destabilize mood and worsen clinical course. Despite previously identified links between suicide attempts and the proportion of time spent with depression in bipolar disorder, few longitudinal studies have examined the relationship between antidepressant use and suicidal behavior specifically in bipolar disorder. Retrospective studies have reported a greater risk for suicide attempts among bipolar patients taking antidepressants alone than among those taking concomitant mood stabilizers or mood stabilizers alone, while prospective studies have found either no link between suicidal acts and antidepressant use or fewer suicide attempts when antidepressants are combined with mood stabilizers than during mood stabilizer therapy alone.

Clinical and Cognitive Correlates of Suicide Attempts in Bipolar Disorder

We conducted a retrospective investigation of potential clinical, demographic, and neuropsychological risk factors for suicide attempts in patients diagnosed with bipolar disorder. Participants included 67 adult inpatients and outpatients aged 18-60 years meeting DSM-IV criteria for bipolar disorder (bipolar I and II disorders, bipolar disorder not otherwise specified). We assessed demographic factors, mood symptoms, psychosis, trauma history, trait impulsivity, trait aggression, and reasons for living. The primary outcome measures were the Barratt Impulsiveness Scale-version II, Aggression Questionnaire, and 10 cognitive outcome variables. The cognitive outcome variables assessed cognitive performance across several domains, including processing speed, attention, verbal learning, and executive function. Another aspect of cognitive function, decision making, was assessed using the Iowa Gambling Task. The study was conducted from July 2007-July 2009. We found that nonattempters reported significantly higher trait impulsivity scores on the Barratt Impulsiveness Scale compared to attempters (t(57) = 2.2, P = .03) and that, among attempters, lower trait impulsivity score was associated with higher scores of lethality of prior attempts (r(25) = -0.53, P = .01). Analyses revealed no other group differences on demographic, clinical, or neurocognitive variables when comparing attempters versus nonattempters. Regression models failed to identify any significant predictors of past suicide attempt. The largely negative results of our study are particularly important in highlighting the clinical dilemma faced by many clinicians when trying to predict which patients will make serious suicide attempts and which patients are at a lower risk for acting on suicidal thoughts. A limitation of our work is that we examined stable trait measures of impulsivity among a euthymic sample rather than mood state or the impact of mood state on traits. Overall, we conclude that suicidal behavior is extremely difficult to predict, even when comprehensive clinical and neurocognitive information is available.

Genome-Wide Association Study of Suicide Attempts in Mood Disorder Patients

Family and twin studies suggest that liability for suicide attempts is heritable and distinct from mood disorder susceptibility. The authors therefore examined the association between common genomewide variation and lifetime suicide attempts. The authors analyzed data on lifetime suicide attempts from genomewide association studies of bipolar I and II disorder as well as major depressive disorder. Bipolar disorder subjects were drawn from the Systematic Treatment Enhancement Program for Bipolar Disorder cohort, the Wellcome Trust Case Control Consortium bipolar cohort, and the University College London cohort. Replication was pursued in the NIMH Genetic Association Information Network bipolar disorder project and a German clinical cohort. Depression subjects were drawn from the Sequential Treatment Alternatives to Relieve Depression cohort, with replication in the Netherlands Study of Depression and Anxiety/Netherlands Twin Register depression cohort. Strongest evidence of association for suicide attempt in bipolar disorder was observed in a region without identified genes (rs1466846); five loci also showed suggestive evidence of association. In major depression, strongest evidence of association was observed for a single nucleotide polymorphism in ABI3BP, with six loci also showing suggestive association. Replication cohorts did not provide further support for these loci. However, meta-analysis incorporating approximately 8,700 mood disorder subjects identified four additional regions that met the threshold for suggestive association, including the locus containing the gene coding for protein kinase C-epsilon, previously implicated in models of mood and anxiety. The results suggest that inherited risk for suicide among mood disorder patients is unlikely to be the result of individual common variants of large effect. They nonetheless provide suggestive evidence for multiple loci, which merit further investigation.

Obesity is associated with previous suicide attempts in bipolar disorder.

Gomes FA, Kauer-Sant'Anna M, Magalhães PV, Jacka FN, Dodd S, Gama CS, Cunha Â, Berk M, Kapczinski F. Obesity is associated with previous suicide attempts in bipolar disorder. There is a paucity of data about risk factors for suicide attempts in bipolar disorder. The aim of this study is to examine the association between suicide attempts and obesity in people with bipolar disorder. Two hundred fifty-five DSM-IV out-patients with bipolar disorder were consecutively recruited from the Bipolar Disorder Program at Hospital das Clínicas de Porto Alegre and the University Hospital at the Universidade Federal de Santa Maria, Brazil. Diagnosis and clinical variables were assessed with Structured Clinical Interview for DSM-IV-axis I (SCID I) and Program structured protocol. History of suicide attempts was obtained from multiple information sources including patients, relatives and review of medical records. Patients with body mass index (BMI) ≥ 30 were classified as obese. Over 30% of the sample was obese and over 50% had a history of suicide attempt. In the multivariate model, obese patients were nearly twice (OR = 1.97, 95% CI: 1.06-3.69, p = 0.03) as likely to have a history of suicide attempt(s). Our results emphasise the relevance of obesity as an associated factor of suicide attempts in bipolar disorder. Obesity may be seen as correlate of severity and as such, must be considered in the comprehensive management of bipolar patients.

Atypical depression is associated with suicide attempt in bipolar disorder

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. 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. Attempters showed significantly higher rates of atypical depression, family history of completed suicide, depression at index episode and cluster B personality disorder. 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.

Functional impairment and previous suicide attempts in bipolar disorder.

The aim of the present study was to assess the association between previous suicide attempts and functional impairment among euthymic patients with bipolar disorder (BD). Seventy-one Diagnostic Statistical Manual IV (DSM-IV) patients with BD and 61 healthy volunteers were recruited from the Bipolar Disorder Program at the Clinic Hospital of Barcelona. Patients with (n = 36, 50.7%) and without (n = 35, 49.3%) previous suicide attempts were assessed using the Structured Clinical Interview for DSM-IV-TR (SCID-P). Previous suicide attempts were carefully investigated by means of patient and caregiver interview and by a standard structured interview from the protocol of our BD Program. The Functioning Assessment Short Test (FAST) was employed to assess functional impairment. Euthymic patients with previous suicide attempts showed functional impairment, particularly in occupational (F = 30.39; p = 0.001) and cognitive functioning (F = 18.43; p = 0.001). In addition, family history of psychiatric illness (χ2: 6.49; degrees of freedom (df) = 2;132; p = 0.010), family history of affective disorders (χ2 = 5.57; p = 0.017), psychotic symptoms (χ2 = 5.88; p = 0.014) and axis II comorbidity were associated with previous suicide attempts (χ2 = 5.16; p = 0.021). Bipolar patients with previous suicide attempts had lower overall functioning than patients who did not attempt suicide. Previous suicide attempts were particularly associated with the occupational and cognitive domains of functioning.

Risk factors associated with lifetime suicide attempts in bipolar I patients: findings from a French National Cohort

Risk factors that may be associated with suicide attempts in bipolar disorder are still a matter of debate. We compared demographic, illness course, clinical, and temperamental features of suicide attempters vs those of nonattempters in a large sample of bipolar I patients admitted for an index manic episode. One thousand ninety patients (attempters = 382, nonattempters = 708) were included in the study. Multivariate analysis evidenced 8 risk factors associated with lifetime suicide attempts as follows: multiple hospitalizations, depressive or mixed polarity of first episode, presence of stressful life events before illness onset, younger age at onset, no free intervals between episodes, female sex, higher number of previous episodes, and cyclothymic temperament. These characteristics may help identify subjects at risk for suicide attempt throughout the course of bipolar disorder. We finally propose to integrate such characteristics into a stress-diathesis model of suicidal behavior, adapted to bipolar patients.

Case-Control Analyses of the Impact of Pharmacotherapy on Prospectively Observed Suicide Attempts and Completed Suicides in Bipolar Disorder

Given high rates of suicide and suicide attempts in bipolar disorder and the data suggesting a suicide-protective effect of lithium, we evaluated the impact of pharmacotherapy on prospectively observed suicides and suicide attempts in subjects in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). The STEP-BD study enrolled 4360 participants with DSM-IV bipolar disorder diagnoses from September 1998 through November 2004. There were 270 suicide events in STEP-BD (8 completed suicides, 262 attempts). These occurred in 182 of STEP-BD participants (cases). Inclusion criteria required cases to be white or Caucasian, have at least 1 postbaseline visit, and have prescription information within 30 days of the suicide event. This reduced the available cohort to 106 cases. Matching included age, gender, history of previous suicide attempt, and a propensity score that considered bipolar subtype, marital status, age at onset, and history of psychosis, resulting in 93 matched pairs. A secondary analysis added mood state status within 30 days of the suicide event to the propensity score (N = 54 pairs). The association of drug prescriptions with suicide attempts/completions was assessed using a conditional logistic regression model. The results do not indicate a relationship between lithium use and suicide attempts or completions (p = .41). Similar findings were found for exposure to valproate, carbamazepine, lamotrigine, and the atypical antipsychotic medications. An association between selective serotonin reuptake inhibitor (SSRI) prescription and suicide events was observed (p < .0001). Findings were similar in a secondary analysis that controlled for mood state. Our data are not consistent with a suicide-protective effect of lithium. The association between suicide events and SSRI prescriptions requires cautious interpretation due to complex relationships between treatment, severity, and suicidality. clinicaltrials.gov Identifier: NCT00012558.

Social phobia is associated with suicide attempt history in bipolar inpatients

In an attempt to reduce the phenotypical heterogeneity in an ongoing genetic study of suicidal behavior, we investigated the impact of comorbid anxiety disorders on suicidal behavior in bipolar disorder (BD) patients. Anxiety disorders were compared in 406 BD I and BD II patients with or without lifetime history of suicide attempt. Among anxiety disorders, only social phobia (SP) was significantly associated with history of suicide attempt in BD [p<0.001, odds ratio 4.26 (2.284-7.946)]. Moreover, onset of SP was found to precede onset of BD. This result suggests that SP is an important risk factor for suicidal behavior in BD. Further studies are required to determine whether comorbid SP may help to identify a more homogeneous BD sub-group, especially when studies of suicidal behavior are conducted. A second question is whether SP identifies a sub-group of subjects with BD who have a more severe illness course and whether treatment of SP with selective serotonin reuptake inhibitor (SSRI) antidepressants is associated with improvement or worsening of the course of BD.

Does first episode polarity predict risk for suicide attempt in bipolar disorder?

Background Defining bipolar disorder (BD) subtypes with increased risk of suicidal behavior may help clinical management. We tested the hypothesis that the polarity of a patient's first mood episode would be a marker for BD subtypes with differential risk for suicidality. Methods One hundred thirteen subjects with DSM-IV defined BD were classified based on whether their first reported episode was manic/hypomanic (FM) or depressed (FD). They were compared on demographic and clinical variables. Logistic regression adjusting for potential confounds tested the association between first episode polarity and history of suicide attempt. Results Multiple logistic regression analysis showed that FD group membership was associated with eightfold odds of a past suicide attempt, adjusting for years ill and total number of lifetime major depressive episodes. Limitations Sample size, retrospective design, recall bias, assessment during a mood episode, and imprecise recall of hypomania. Conclusions Polarity of patients' first reported mood episode suggested a depression-prone subtype with a greater probability of past suicide attempt. The FM group had more alcoholism and psychosis, but less likelihood of past suicide attempt. Validation of these putative subtypes requires prospective study.

Polypharmacy and suicide attempts in bipolar disorder

OBJECTIVE: The aim of this study was to assess the association between suicide attempts and the use of multiple drugs in patients with bipolar disorder. METHOD: One hundred sixty-nine bipolar disorder outpatients diagnosed using the DSM-IV Structured Clinical Interview were included. Demographic and socioeconomic data, number of medications currently in use, history of suicide attempts, number of years undiagnosed, age of onset and current psychiatric co-morbidities were assessed using a structured questionnaire and DSM-IV criteria. The main outcome measure was the number of psychotropic drugs currently in use. RESULTS: Approximately half of all patients (48.5%) presented a history of suicide attempt; 84% were using more than one medication, and 19% were using more than three drugs. The most frequent combinations of drugs used by these patients were: lithium + valproate (17%); lithium + antipsychotics (10%); lithium + valproate + antipsychotics (9%); and antidepressants + any drug (6%). The number of suicide attempts was associated with the use of multiple drugs. CONCLUSIONS: Our findings support the notion that the use of combination therapy in bipolar disorder may be related to severity of the BD, such as number of suicide attempts.

Polypharmacy and suicide attempts in bipolar disorder

The aim of this study was to assess the association between suicide attempts and the use of multiple drugs in patients with bipolar disorder. One hundred sixty-nine bipolar disorder outpatients diagnosed using the DSM-IV Structured Clinical Interview were included. Demographic and socioeconomic data, number of medications currently in use, history of suicide attempts, number of years undiagnosed, age of onset and current psychiatric co-morbidities were assessed using a structured questionnaire and DSM-IV criteria. The main outcome measure was the number of psychotropic drugs currently in use. Approximately half of all patients (48.5%) presented a history of suicide attempt; 84% were using more than one medication, and 19% were using more than three drugs. The most frequent combinations of drugs used by these patients were: lithium + valproate (17%); lithium + antipsychotics (10%); lithium + valproate + antipsychotics (9%); and antidepressants + any drug (6%). The number of suicide attempts was associated with the use of multiple drugs. Our findings support the notion that the use of combination therapy in bipolar disorder may be related to severity of the BD, such as number of suicide attempts.

Correlates of suicide attempt history in bipolar disorder: a stress‐diathesis perspective

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. 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. 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. Aggressive traits and early treatment of mood disorders, especially major depressive episodes, are potential targets for suicide prevention in bipolar disorder.

Characteristics and psychosocial problems of patients with bipolar disorder at high risk for suicide attempt

Background: Bipolar disorder with a history of substance abuse or suicide attempt is a strong predictor of suicide. A high comorbidity of substance use disorders may obscure the specificity of findings about suicide behaviors in Western patients with bipolar disorder. Methods: The clinical data of Chinese bipolar patients (DSM-III-R) in Taiwan who had been naturalistically followed up for at least 15 years were obtained by a combination of chart reviews and interviews with patients and family members. The national identity numbers were used to search for deceased subjects. Results: There were 158 patients originally included for chart review; 4 of them died from suicide. A 9.9% lifetime prevalence of alcohol use disorders was found in 101 final subjects who accepting interview. Multiple logistic regression showed that subjects with a history of suicide attempt ( n=53, 52.5%) were more likely to have interpersonal problems with spouse or romantic partner (adjusted odds ratio=2.85, 95% C.I.=0.69–11.51), occupational problems mainly maladjustment and frequently changing job (adjusted odds ratio=3.08, 95% C.I.=1.12–10.49), and an earlier age (≤22 years) of onset (adjusted odds ratio=0.96, 95% C.I.=0.90–1.02). Limitation: To use an interview schedule for assessing the psychosocial problems of clinical population limits the interpretation and generalisability of the data. Conclusion: Despite low comorbidity of alcohol/drug use disorders in Chinese bipolar patients, a consistently high rate of suicide attempts reinforces that bipolar disorder is a high-risk group of suicide. An earlier age of onset, interpersonal problems with spouse or romantic partner, and occupational maladjustment rather than demographic characteristics may collectively identify those at high risk of suicide attempt in bipolar disorder.