What are the risk factors for suicide in bipolar disorder? Jl Aff Dis:Dec:2012

06.12.12

Suicidal behaviour is a major public health problem worldwide, with one million people  committing  suicide every year. 90% of attempters and completers suffer from at least one mental disorder. These are mostly unrecognized, untreated, or in adequately treated. Most frequently they suffer from major depressive episode (56–87%), substance use disorder (26– 55%) or schizophrenia (6–13%) at the time of their act.

Literature generally suggest that in bipolar disorders the annual risk of attempts is 400–1400/100 000 (0.9%). This is 30 to 60-fold  the general population rate. Without treatment about 1000/100 000 bipolar patients commit suicide every year (Gibbons et al., 2009). About one third to one half of bipolar patients attempt suicide at least once in their lifetime and approximately 15–20% of bipolar patients die due to suicide. Attempt success rate is high in bipolar disorder.

Identifying the risk factors associated with suicidal behaviour in bipolar disorder is essential to formulate individual and service level  interventions.This review by Xenia Gonda   et al   provides detailed analysis of the factors associated with suicidal behaviour in this group.

Gender: Though the gender pattern of suicidal behavior seen in the general population ( more males complete suicide) is replicated generally, the  difference was less marked. Among bipolar attempters, women report more sexual abuse in childhood and men more substance use.

Prior suicide attempt:

Prior suicide attempt is reported in case of 40% of treated bipolar patients (Leverich et al., 2003).Lifetime  suicide attempts are higher than  unipolar patients (28% vs 13%) (Rihmer and Angst, 2005). Community studies showed that the lifetime rate of prior suicide attempts was 1.5 to 2.5 higher in bipolar than in unipolar patients (Kessler et al., 1999; Szadoczky et al., 2000).

Suicidal ideation: Prevalence of suicidal ideation varies between 14–59%. Higher levels of suicide ideation are correlated with greater risk of future suicide attempts in bipolar patients

Family history of suicide: Bipolar patients are over represented among patients with a family history of suicide this may be due to a higher heritability of bipolar disorder compared to unipolar depression. Attempted and completed suicide in the family can  increase risk of suicide attempts.

Suicide in different mood episodes of bipolar disorder:  Suicides or attempts occur mostly during severe, pure or mixed depressive episodes (78–89%) and less frequently during mixed affective episodes or dysphoric mania (11–20%), but very rarely during states of euphoric mania or euthymia (0–7%). Mixed episode is an important risk factor. They are three times as frequent in bipolar II disorder compared to unipolar depression, which may in part contribute to the increased suicide risk observable in bipolar II disorder compared to unipolar depression.

Rapid cycling course:

Prevalence of current rapid cycling in bipolar disorder is 13– 56% (Gao et al 2009).It increases the risk of suicide attempts. These attempts  are characterized by a higher intent and lethality compared to non-rapid cyclers (Coryell et  al 2003).

Illness characteristics:  Attempts are common at the onset of  illness ( during the first depressive episode) and early in the illness course.longer duration of untreated illness, number of previous episodes,  more prior hospitalizations due to depression, atypical depression,  history of psychosis during depression are factors that increase risk.

Age of onset: earlier the age of onset , higher suicide attempt risk.It may be due to the fact that early onset illness may be linked with other factors increasing suicide risk. ( ie severity of illness, rapid cycling, more Axis I and II comorbidities or increased childhood physical and sexual abuse)

Life events related to suicide in BD:  Early traumatic experiences, past interpersonal losses, and  greater mean number of negative life events prior to the most recent affective episode are associated with increased suicidal acts. Physically abused group report increased suicidal ideation in manic phase and the sexually abused group reporting increased suicidal ideation in depressed phase.

Comorbidity: 65% of bipolar patients have at least one psychiatric comorbidity, 42% two or more, and 24% three or more comorbid conditions besides their bipolar illness. Strongest association with suicide attempts was found in case of anxiety disorders, eating disorder, and alcohol and drug abuse disorders.

Substance use:  Association is not  clear, with contradictory results from studies .

Personality features and affective temperaments:  impulsivity,aggressive traits, cyclothymia and cyclothymic temperament increase suicidal risk.

Conclusion:

Most factors are similar to established risk factors for suicide/attempts in individuals with mental disorders.

Clinical Practice: Authors provide a table of factors that are clinically relevant and worth exploring during patient assessment. Risk assessments for suicidal behaviour in this group of patients should cover these areas.

Summary of the article:

Suicidal behavior in bipolar disorder: Epidemiology, characteristics and major risk factors.

Gonda X, Pompili M, Serafini G, Montebovi F, Campi S, Dome P, Duleba T, Girardi P, Rihmer Z.J Affect Disord. 2012 Dec 20;143(1-3):16-26.