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Suicide in Bipolar Disorder: Risks and Management

Published online by Cambridge University Press:  07 November 2014

Ross J. Baldessarini ,
Maurizio Pompili  and
Leonardo Tondo
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Abstract

Bipolar disorders are prevalent, often severe, and disabling illnesses with elevated lethality largely due to suicide. Suicide rates average ∼1% annually, or perhaps 60 times higher than the international population rate of 0.015% annually. Suicidal acts typically occur early in bipolar disorders and in association with severe depressive or mixed states. The high lethality of suicidal acts in bipolar disorders is suggested by a much lower ratio of attempts:suicide (∼3:1) than in the general population (∼30:1). Risk factors can help to identify patients at increased suicidal risk, but ongoing clinical assessment is essential to limit risk. Empirical short-term interventions to manage acute suicidal risk include close clinical supervision, rapid hospitalization, and electroconvulsive therapy. Remarkably, however, evidence of the long-term effectiveness of most treatments against suicidal behavior is rare. A notable exception is lithium prophylaxis, which is associated with consistent evidence of major (∼80%), sustained relative reductions of risk of suicides and attempts, and lower lethality (increased attempts:suicide ratio). Such benefits are unproved for other treatments commonly used to treat bipolar disorder patients, including anticonvulsants, antipsychotics, antidepressants, and psychosocial interventions. Applying available knowledge systematically, with close and sustained clinical supervision, can enhance management of suicidal risk in bipolar disorders patients.

Type
Review Articles
Information
CNS Spectrums , Volume 11 , Issue 6 , June 2006 , pp. 465 - 471
Copyright
Copyright © Cambridge University Press 2006

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References

REFERENCES

1.Tondo, L, Isacsson, G, Baldessarini, RJ. Suicidal behavior in bipolar disorder: risk and prevention. CNS Drugs. 2003;17:491–511.CrossRefGoogle ScholarPubMed
2.Tondo, L, Baldessarini, RJ. Suicidal risk in bipolar disorder. Clin Neuropsychiatry. 2005;2:55–65.Google Scholar
3.Baldessarini, RJ, Tondo, L, Davis, P, Pompili, M, Goodwin, FK, Hennen, J. Decreased suicidal risk during long-term lithium treatment: A meta-analysis. Bipolar Disord. In press.Google Scholar
4.Baldessarini, RJ, Pompili, M, Tondo, L. Bipolar Disorder. In: Simon, RI, Hales, RE, eds. American Psychiatric Publishing Textbook of Suicide Assessment and Management. Washington, DC: American Psychiatric Publishing; 2006:277–299.Google Scholar
5.Goodwin, FK, Jamison, KR. Manic-Depressive Illness. New York, NY: Oxford University Press; 1990.Google Scholar
6.Kessler, RC, Chiu, WT, Demler, O, Merikangas, KR, Walters, EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:617–627.CrossRefGoogle ScholarPubMed
7.Ahrens, B, Müller-Oerlinghausen, B, Schou, M, et, al. Excess cardiovascular and suicide mortality of affective disorders may be reduced by lithium prophylaxis. J Affect Disord. 1995;33:67–75.CrossRefGoogle ScholarPubMed
8.Harris, EC, Barraclough, B. Suicide as an outcome for mental disorders: A meta-analysis. Br J Psychiatry. 1997;170:205–228.CrossRefGoogle ScholarPubMed
9.Sharma, R, Markar, HR. Mortality in affective disorder. J Affect Disord. 1994;31:91–96.CrossRefGoogle ScholarPubMed
10.Hawton, K, Arensman, E, Wasserman, D, et al.Relations between attempted suicide and suicide rates among young people in Europe. J Epidemiol Community Health. 1998;52:191–194.CrossRefGoogle ScholarPubMed
11.Kessler, RC, Berglund, P, Borges, G, Nock, M, Wang, PS. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. JAMA. 2005;293:2487–2495.CrossRefGoogle ScholarPubMed
12.Goodwin, FK, Fireman, B, Simon, GE, Hunkeler, EM, Lee, J, Revicki, D. Suicide risk in bipolar disorder during treatment with lithium and divalproex. JAMA. 2003;290:1467–1473.CrossRefGoogle ScholarPubMed
13.Dilsaver, SC, Chen, Y-W, Swann, AC, Shoaib, AM, Tsai-Dilsaver, Y, Krajewski, KJ. Suicidality, panic disorder and psychosis in bipolar depression, depressive-mania and pure mania. Psychiatry Res. 1997;73:47–56.CrossRefGoogle ScholarPubMed
14.Baethge, C, Tondo, L, Bratti, IM, et al.Prophylaxis latency and outcome in bipolar disorders. Can J Psychiatry. 2003;48:449–457.CrossRefGoogle ScholarPubMed
15.Faedda, GL, Baldessarini, RJ, Suppes, T, Tondo, L, Becker, I, Lipschitz, D. Pediatric-onset bipolar disorder: a neglected clinical and public health problem. Harv Rev Psychiatry. 1995;3:171–195.CrossRefGoogle ScholarPubMed
16.Blair-West, GW, Cantor, CH, Mellsop, GW, Eyeson-Annan, ML. Lifetime suicide risk in major depression: sex and age determinants. J Affect Disord. 1999;55:171–178.CrossRefGoogle ScholarPubMed
17.Ösby, U, Brandt, L, Correia, N, Ekbom, A, Sparen, P. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry. 2001;58:844–850.CrossRefGoogle ScholarPubMed
18.Jacobs, DG, ed. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(11 Suppl):1–60.Google Scholar
19.Tondo, L, Albert, M, Baldessarini, RJ. Suicide rates in relation to health-care access in the United States. J Clin Psychiatry. 2006;67:517–523.CrossRefGoogle ScholarPubMed
20.Tondo, L, Baldessarini, RJ, Hennen, J, Floris, G, Silvetti, F, Tohen, M. Lithium treatment and risk of suicidal behavior in bipolar disorder patients. J Clin Psychiatry. 1998;59:405–414.CrossRefGoogle ScholarPubMed
21.Isometsá, ET, Henriksson, MM, Aro, HM, Lonnqvist, JK. Suicide in bipolar disorder in Finland. Am J Psychiatry. 1994;151:1020–1024.Google ScholarPubMed
22.Arató, M, Demeter, E, Rihmer, Z, Somogyi, E. Retrospective psychiatric assessment of 200 suicides in Budapest. Acta Psychiatr Scand. 1988;77:454–456.CrossRefGoogle ScholarPubMed
23.Rihmer, Z, Pestality, P. Bipolar II disorder and suicidal behavior. Psychiatr Clin North Am. 1999;22:667–673.CrossRefGoogle ScholarPubMed
24.Ghaemi, SN, Rosenquist, KJ, Ko, JY, Baldassano, CF, Kontos, NJ, Baldessarini, RJ: Antidepressant treatment in bipolar versus unipolar depression. Am J Psychiatry. 2004;161:163–165.CrossRefGoogle ScholarPubMed
25.Perlis, RH, Stern, TA. Suicide. In: Stern, TA, Herman, JB, eds. Psychiatry Update and Board Preparation. New York, NY: McGraw-Hill; 2000:409–413.Google Scholar
26.Pirkis, J, Burgess, P. Suicide and recency of health care contacts. A systematic review. Br J Psychiatry. 1998;173:462–474.CrossRefGoogle ScholarPubMed
27.Andersen, UA, Andersen, M, Rosholm, JU, Gram, LF. Psychopharmacological treatment and psychiatric morbidity in 390 cases of suicide with special focus on affective disorders. Acta Psychiatr Scand. 2001;104:458–465.CrossRefGoogle ScholarPubMed
28.Miller, CL, Druss, B. Datapoints: suicide and access to care. Psychiatr Serv. 2001;52:1566–1567.CrossRefGoogle ScholarPubMed
29.Baldessarini, RJ, Tondo, L, Hennen, J, Viguera, AC: Is lithium still worth using? An update of selected recent research. Harv Rev Psychiatry. 2002;10:59–75.CrossRefGoogle ScholarPubMed
30.Baldessarini, RJ, Tarazi, FI. Drugs and the treatment of psychiatric disorders. In: Brunton, LL, Lazo, JS, Parker, KL, eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 11th ed. New York, NY: McGraw-Hill Professional; 2005:429–500.Google Scholar
31.Cipriani, A, Pretty, H, Hawton, K, Geddes, JR. Lithium in the prevention of suicidal behavior and all-cause mortality in patients with mood disorders: a systematic review of randomized trials. Am J Psychiatry. 2005;162:1805–1819.CrossRefGoogle ScholarPubMed
32.Fawcett, JA. Lithium combinations in acute and maintenance treatment of unipolar and bipolar depression. J Clin Psychiatry. 2003;64(Suppl 5):32–37.Google ScholarPubMed
33.Müller-Oerlinghausen, B. Arguments for the specificity of the antisuicidal effect of lithium. Eur Arch Psychiatry Clin Neurosci. 2001;251(Suppl 2):72–75.CrossRefGoogle ScholarPubMed
34.Ahrens, B. Müller-Oerlinghausen, B. Does lithium exert an independent antisuicidal effect? Pharmacopsychiatry. 2001;34:132–136.CrossRefGoogle ScholarPubMed
35.Angst, F, Stassen, HH, Clayton, PJ, Angst, J. Mortality of patients with mood disorders: follow-up over 34-38 years. J Affect Disord. 2002;68:167–181.CrossRefGoogle ScholarPubMed
36.Waddington, D, McKenzie, IP. Overdose rates in lithium-treated versus antidepressant-treated outpatients. Acta Psychiatr Scand. 1994;90:50–52.CrossRefGoogle ScholarPubMed
37.Watson, WA, Litovitz, TL, Klein-Schwartz, W, et al.2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System (TESS). Am J Emerg Med. 2004;22:335–404.CrossRefGoogle Scholar
38.Greil, W, Kleindienst, N. The comparative prophylactic efficacy of lithium and carbamazepine in patients with bipolar I disorder. Int Clin Psychopharmacol. 1999;14:277–281.CrossRefGoogle ScholarPubMed
39.Bowden, CL, Calabrese, JR, Sachs, G, et al.A placebo-controlled 18-month trial of lamotrigine and lithium maintenance treatment in recently manic or hypomanic patients with bipolar I disorder. Arch Gen Psychiatry. 2003;60:392–400.CrossRefGoogle ScholarPubMed
40.Calabrese, JR, Bowden, CL, Sachs, G, et al.A placebo-controlled 18-month trial of lamotrigine and lithium maintenance treatment in recently depressed patients with bipolar I disorder. J Clin Psychiatry. 2003;64:1013–1024.CrossRefGoogle ScholarPubMed
41.Meltzer, HY, Alphs, L, Green, Al, et al.Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry. 2003;60:82–91.CrossRefGoogle ScholarPubMed
42.Hennen, J, Baldessarini, RJ. Suicidal risk during treatment with clozapine: a metaanalysis. Schizophr Res. 2005;73:139–145.CrossRefGoogle ScholarPubMed
43.Modestin, J, Dal Pian, D, Agarwalla, P. Clozapine diminishes suicidal behavior: a retrospective evaluation of clinical records. J Clin Psychiatry. 2005;66:534–538.CrossRefGoogle ScholarPubMed
44.Gardner, DM, Baldessarini, RJ, Waraich, P. Modern antipsychotic drugs: A critical overview. CMAJ. 2005;172:1703–1711.CrossRefGoogle ScholarPubMed
45.Grunebaum, MF, Ellis, SP, Li, S, Oquendo, MA, Mann, JJ. Antidepressants and suicide risk in the United States, 1985–1999. J Clin Psychiatry. 2004;65:1456–1462.CrossRefGoogle ScholarPubMed
46.Helgason, T, Tomasson, H, Zoega, T. Antidepressants and public health in Iceland. Time series analysis of national data. Br J Psychiatry. 2004;184:157–162.CrossRefGoogle Scholar
47.Gibbons, RD, Hur, K, Bhaumik, DK, Mann, JJ. The relationship between antidepressant medication use and rate of suicide. Arch Gen Psychiatry. 2005;62:165–172.CrossRefGoogle Scholar
48.Khan, A, Khan, S, Kolts, R, Brown, WA. Suicide rates in clinical trials of SSRIs, other antidepressants, and placebo: analysis of FDA reports. Am J Psychiatry. 2003;160:790–792.CrossRefGoogle ScholarPubMed
49.Fergusson, D, Doucette, S, Glass, KC, et al.Association between suicide attempts and selective serotonin reuptake inhibitors: systematic review of randomized controlled trials. BMJ. 2005;330:396–403.CrossRefGoogle Scholar
50.Gunnell, D, Saperia, J, Ashby, D. Selective serotonin reuptake inhibitors (SSRIs) and suicide in adults: meta-analysis of drug company data from placebo controlled, randomized controlled trials submitted to the MHRA's safety review. BMJ. 2005;330:385–388.CrossRefGoogle Scholar
51.Martinez, C, Rietbrock, S, Wise, L, et al.Antidepressant treatment and the risk of fatal and non-fatal self harm in first episode depression: nested case-control study. BMJ. 2005;330:389–396.CrossRefGoogle ScholarPubMed
52.Hammad, TA, Laughren, T, Racoosin, L. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry. 2006;63:332–339.CrossRefGoogle ScholarPubMed
53.Beasley, CM Jr, Dornseif, BE, Bosomworth, JC, et al.Fluoxetine and suicide: a metaanalysis of controlled trials of treatment for depression. BMJ. 1991;303:685–692.CrossRefGoogle ScholarPubMed
54.Filteau, MJ, Lapierre, YD, Bakish, D, Blanchard, A. Reduction in suicidal ideation with SSRIs: a review of 459 depressed patients. J Psychiatry Neurosci. 1993;18:114–119.Google ScholarPubMed
55.Lapierre, YD. Suicidality with selective serotonin reuptake inhibitors: Valid claim? J Psychiatry Neurosci. 2003;28:340–347.Google ScholarPubMed
56.Pedersen, AG. Escitalopram and suicidality in adult depression and anxiety. Int Clin Psychopharmacol. 2005;20:139–143.CrossRefGoogle ScholarPubMed
57.Acharya, N, Rosen, A, Polzer, J, D'Souza, DN, Perahia, DG, Cavazzoni, P, Baldessarini, RJ. Duloxetine. Meta-analyses of suicidal behaviors and ideation in clinical trials for major depressive disorder. Poster presented at: The 44th Annual Meeting of American College of Neuropsychopharmacoly (ACNP): December 11, 2005: Waikaloa, HI.Google Scholar
58.Fawcett, J. The detection and consequences of anxiety in clinical depression. J Clin Psychiatry. 1997;58(Suppl 8):35–40.Google ScholarPubMed
59.Baldessarini, RJ, Pompili, M, Tondo, L, et al.Antidepressants and suicidal behavior: Are we hurting or helping? Clin Neuropsychiatry. 2005;2:73–75.Google Scholar
60.Berk, M, Dodd, S. Are treatment emergent suicidality and decreased response to antidepressants in younger patients due to bipolar disorder being misdiagnosed as unipolar depression? Med Hypotheses. 2005;65:39–43.CrossRefGoogle ScholarPubMed
61.Faedda, GL, Baldessarini, RJ, Glovinsky, IP, Austin, NB. Treatment-emergent mania in pediatric bipolar disorder: a retrospective case review. J Affect Disord. 2004;82:149–158.CrossRefGoogle ScholarPubMed
62.Baldessarini, RJ, Faedda, GL, Hennen, J. Risk of mania with antidepressants. Arch Pediatr Adolesc Med. 2005;159:298–299.CrossRefGoogle ScholarPubMed
63.Weinger, RD, ed. Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. A Task Force Report of the American Psychiatric Association. 2nd ed. Washington, DC: American Psychiatric Publishing: 2001.Google Scholar
64.Huxley, NA, Parikh, SV, Baldessarini, RJ. Effectiveness of psychosocial treatments in bipolar disorder: state of the evidence. Harv Rev Psychiatry. 2000;8:126–140.CrossRefGoogle ScholarPubMed
65.Gray, SM, Otto, MW. Psychosocial approaches to suicide prevention: applications to patients with bipolar disorder. J Clin Psychiatry. 2001;62(suppl 25):56–64.Google ScholarPubMed
66.Egan, MP. Contracting for safety: a concept analysis. Crisis. 1997;18:17–23.CrossRefGoogle ScholarPubMed
67.Nilsson, A. Mortality in recurrent mood disorders during periods on and off lithium. A complete population study in 362 patients. Pharmacopsychiatry. 1995;28:8–13.CrossRefGoogle ScholarPubMed
68.Angst, J, Sellaro, R, Angst, F. Long-term outcome and mortality of treated vs. untreated bipolar and depressed patients: a preliminary report. Int J Psychiatr Clin Practice. 1998;2:115–119.CrossRefGoogle Scholar
69.Müller-Oerlinghausen, B, Berghofer, A, Ahrens, B. The antisuicidal and mortalityreducing effect of lithium prophylaxis: consequences for guidelines in clinical psychiatry. Can J Psychiatry. 2003;48:433–439.CrossRefGoogle ScholarPubMed
70.Maj, M, Starace, F, Nolfe, G, Kemali, D. Minimum plasma lithium levels required for effective prophylaxis in DSM-III bipolar disorder: a prospective study. Pharmacopsychiatry. 1986;19:420–423.CrossRefGoogle ScholarPubMed