The association of comorbid anxiety disorders with suicide attempts and suicidal ideation in outpatients with bipolar disorder

Untangling the complex relationship between bipolar disorder and anxiety: a comprehensive review of prevalence, prognosis, and therapy

Bipolar disorder (BD) frequently coexists with anxiety disorders, creating complex challenges in clinical therapy and management. This study investigates the prevalence, prognostic implications, and treatment strategies for comorbid BD and anxiety disorders. High comorbidity rates, particularly with generalized anxiety disorder, underscore the necessity of thorough clinical assessments to guide effective management. Our findings suggest that anxiety disorders may serve as precursors to BD, especially in high-risk populations, making early detection of anxiety symptoms crucial for timely intervention and prevention. We also found that comorbid anxiety can negatively affect the course of BD, increasing clinical severity, reducing treatment responsiveness, and worsening prognosis. These complexities highlight the need for caution in using antidepressants, which may destabilize mood. Alternatively, cognitive-behavioral therapy presents a promising, targeted approach for managing BD with comorbid anxiety. In summary, this study provides essential insights for clinicians and researchers, enhancing understanding of BD and anxiety comorbidity and guiding more precise diagnostics and tailored interventions to improve overall patient care.

Common and differential variables of anxiety and depression in adolescence: a nation-wide smartphone-based survey

BACKGROUND

Mental health in adolescence is critical in its own right and a predictor of later symptoms of anxiety and depression. To address these mental health challenges, it is crucial to understand the variables linked to anxiety and depression in adolescence.

METHODS

Here, we analyzed data of 278 adolescents that were collected in a nation-wide survey provided via a smartphone-based application during the COVID-19 pandemic. We used an elastic net regression machine-learning approach to classify individuals with clinically relevant self-reported symptoms of depression or anxiety. We then identified the most important variables with a combination of permutation feature importance calculation and sequential logistic regressions.

RESULTS

40.30% of participants reported clinically relevant anxiety symptoms, and 37.69% reported depressive symptoms. Both machine-learning models performed well in classifying participants with depressive (AUROC = 0.77) or anxiety (AUROC = 0.83) symptoms and were significantly better than the no-information rate. Feature importance analyses revealed that anxiety and depression in adolescence are commonly related to sleep disturbances (anxiety OR = 2.12, depression OR = 1.80). Differentiating between symptoms, self-reported depression increased with decreasing life satisfaction (OR = 0.43), whereas self-reported anxiety was related to worries about the health of family and friends (OR = 1.98) as well as impulsivity (OR = 2.01).

CONCLUSION

Our results show that app-based self-reports provide information that can classify symptoms of anxiety and depression in adolescence and thus offer new insights into symptom patterns related to adolescent mental health issues. These findings underscore the potentials of health apps in reaching large cohorts of adolescence and optimize diagnostic and treatment.

The Impact on Anxiety Symptoms of an Immersive Virtual Reality Remediation Program in Bipolar Disorders: A Randomized Clinical Trial

Background: The objective of this work is to investigate the effectiveness of a cognitive remediation intervention on anxiety symptoms in people with bipolar disorder and the therapeutic effect on people whose anxiety symptoms were above the threshold for a screener and whose comorbidity could be identified as an anxiety disorder. Methods: The experimental intervention included 24 sessions (around 45 min each), two for each week over three months. The entire program was inspired by user-centered rehabilitation principles in a recovery-oriented perspective and an approach to bipolar disorder in an evolutionary and non-discriminating vision. The primary outcomes measure the score of the Zung Self-Rating Anxiety Scale (SAS), hypothesizing a higher decrease in the experimental group than in the control group. The survey has been conducted per the CONSORT guidelines for feasibility studies. Results: We evaluate a decrease in the overall SAS score from T0 to T1 to be higher in the experimental group compared to the control group, indicating an improvement in anxiety symptoms (p < 0.0001). Conclusions: The study suggests that virtual reality could have a role in treating anxiety symptoms and disorders in young adults with bipolar disorders or anxiety symptoms in people with hyperactivity and novelty-seeking behaviorsunder stress and high risk for bipolar disorder.

Indirect effect of impulsivity on suicide risk through self-esteem and depressive symptoms in a population with treatment-resistant depression: A FACE-DR study

INTRODUCTION

Suicide is a major health issue. Its prevalence is particularly high in subjects presenting major depression disorder (MDD), making this a key suicide-related risk factor. Suicide attempts in severe forms of MDD were assumed to be linked to impulsivity and loss of control. Nevertheless, we failed to find data specifically investigating the link between impulsivity and suicide risk in treatment-resistant depression (TRD). This study seeks to review this relationship.

METHOD

Patients were recruited for a prospective cohort. Suicide risk and impulsivity were assessed using the International Neuropsychiatric Interview and Barratt Impulsiveness Scale, Version 10, respectively, while the severity of depressive symptoms was assessed using the Montgomery-Asberg Depression Rating Scale, anxiety with the State-Trait Anxiety Inventory and childhood maltreatment using the Childhood Trauma Questionnaire.

RESULTS

220 TRD patients were enrolled in the study. The impulsivity score was correlated with self-esteem, marital status, professional status and anxiety. There was no direct link to suicide risk. However, impulsivity was associated with self-esteem (coefficient: -0.24; p value 0.043) and depressive symptom severity (coefficient: 0.; p value 0.045). The suicide risk was significantly correlated with depressive symptom severity (coefficient = 0.38, p < 0.001) and self-esteem (coefficient = -0.34, p = 0.01). Considering these correlations, we postulated that the effect of impulsivity on suicide risk could be mediated by self-esteem in terms of depressive symptom severity and we finally found a relevant mediation model within impulsivity having an indirect effect on suicide risk by impacting self-esteem and depressive symptoms with anxiety also playing a significant role as a covariable.

CONCLUSION

We found that impulsivity could play an indirect role with the involvement of self-esteem and depressive symptoms and the contributing role of anxiety.

Cognitive behavioural therapy for social anxiety disorder in people with bipolar disorder: a case series

BACKGROUND

Social anxiety disorder increases the likelihood of unfavourable outcomes in people with bipolar disorder. Cognitive behavioural therapy (CBT) is the first-line treatment for social anxiety disorder. However, people with bipolar disorder have been excluded from the studies that this recommendation is based on.  METHOD: We completed a case series to obtain initial data on whether CBT is an acceptable, safe, and effective treatment for social anxiety disorder in people with bipolar disorder.

RESULTS

Eleven euthymic participants with bipolar disorder attended up to sixteen treatment and three follow-up sessions of CBT for social anxiety disorder. Participants attended on average 95% of the offered CBT sessions. No adverse events were reported. Participants' mean score on the Social Phobia Inventory decreased from 46.5 (SD 6.6) before the treatment to 19.8 (SD 11.9) at the end of the sixteen-session intervention and further to 15.8 (SD 10.3) by the end of the 3-month follow-up. This degree of improvement is equivalent to the effect observed in studies of CBT for social anxiety disorder in people without severe mental illness.

CONCLUSIONS

This case series provides preliminary evidence that CBT is acceptable, safe, and effective for treating social anxiety disorder in people with bipolar disorder during euthymia. A randomized controlled trial is needed to confirm these findings, and to establish whether treatment for social anxiety disorder improves the course of bipolar disorder.

Suicidal risk and protective factors in major affective disorders: A prospective cohort study of 4307 participants

BACKGROUND

Suicidal behavior is strongly associated with major affective disorders, but there is a need to quantify and compare specific risk and protective factors in bipolar disorder (BD) and major depressive disorder (MDD).

METHODS

In 4307 extensively evaluated major affective-disorder participants with BD (n = 1425) or MDD (n = 2882) diagnosed by current international criteria, we compared characteristics among those with versus without suicidal acts from illness-onset through 8.24 years of follow-up.

RESULTS

Suicidal acts were identified in 11.4 % of participants; 25.9 % were violent and 6.92 % (0.79 % of all participants) were fatal. Associated risk factors included: diagnosis (BD > MDD), manic/psychotic features in first-episodes, family history of suicide or BD, separation/divorce, early abuse, young at illness-onset, female sex with BD, substance abuse, higher irritable, cyclothymic or dysthymic temperament ratings, greater long-term morbidity, and lower intake functional ratings. Protective factors included marriage, co-occurring anxiety disorder, higher ratings of hyperthymic temperament and depressive first episodes. Based on multivariable logistic regression, five factors remained significantly and independently associated with suicidal acts: BD diagnosis, more time depressed during prospective follow-up, younger at onset, lower functional status at intake, and women > men with BD.

LIMITATIONS

Reported findings may or may not apply consistently in other cultures and locations.

CONCLUSIONS

Suicidal acts including violent acts and suicides were more prevalent with BD than MDD. Of identified risk (n = 31) and protective factors (n = 4), several differed with diagnosis. Their clinical recognition should contribute to improved prediction and prevention of suicide in major affective disorders.

Sex-specific risk profiles for suicide mortality in bipolar disorder: incidence, healthcare utilization and comorbidity

BACKGROUND

Evidence on sex-specific incidence and comorbidity risk factors of suicide among patients with bipolar disorder is scarce. This study investigated the sex-specific risk profiles for suicide among the bipolar disorder population in terms of incidence, healthcare utilization and comorbidity.

METHODS

Using data from the Taiwan National Health Insurance Research Database between 1 January 2000 and 31 December 2016, this nationwide cohort study included patients with bipolar disorder (N = 46 490) and individuals representative of the general population (N = 185 960) matched by age and sex at a 1:4 ratio. Mortality rate ratios (MRRs) of suicide were calculated between suicide rates of bipolar disorder cohort and general population. In addition, a nested case-control study (1428 cases died by suicide and 5710 living controls) was conducted in the bipolar disorder cohort to examine the sex-specific risk of healthcare utilization and comorbidities.

RESULTS

Suicide risk was considerably higher in the cohort (MRR = 21.9) than in the general population, especially among women (MRR = 35.6). Sex-stratified analyses revealed distinct healthcare utilization patterns and physical comorbidity risk profiles between the sexes. Although female patients who died by suicide had higher risks of nonhypertensive cardiovascular disease, pneumonia, chronic kidney disease, peptic ulcer, irritable bowel syndrome, and sepsis compared to their living counterparts, male patients who died by suicide had higher risks of chronic kidney disease and sepsis compared to the living controls.

CONCLUSIONS

Patients with bipolar disorder who died by suicide had sex-specific risk profiles in incidence and physical comorbidities. Identifying these modifiable risk factors may guide interventions for suicide risk reduction.

Death anxiety and mental health: Requiem for a dreamer

Recently, there has been an increased interest in the role of death anxiety in a broad range of mental health disorders. It has been argued that the fear of death may be a transdiagnostic variable contributing to the development and maintenance of many chronic mental health problems. Further, it has been suggested that death anxiety may be responsible for relapse and the emergence of new disorders in patients that have received successful treatment for earlier conditions in their lives. Given this, the purpose of the present selective review is to: (1) explore contemporary theoretical accounts of the role of death anxiety in a broad range of human behaviours; (2) examine evidence for death anxiety as a key variable in mental health disorders; (3) examine evidence on the treatment of death anxiety in both non-clinical and clinical populations; (4) describe the limitations of the current literature, and; (5) provide a detailed description of the critical future directions for this field.

The Impact of Posttraumatic Stress Disorder on Pharmacologic Intervention Outcomes for Adults With Bipolar Disorder: A Systematic Review

BACKGROUND

The prevalence of posttraumatic stress disorder (PTSD) co-occurring in people with bipolar disorder (BD) is high. People with BD and PTSD may experience different outcomes and quality of life after pharmacologic treatment than those with BD alone. This review systematically explores the impact of PTSD on pharmacologic treatment outcomes for adults with BD.

METHODS

We conducted a systematic search up to November 25, 2021, using MEDLINE Complete, Embase, American Psychological Association PsycInfo, and the Cochrane Central Register of Controlled Trials to identify randomized and nonrandomized studies of pharmacologic interventions for adults with BD that assessed for comorbid PTSD. We used the Newcastle-Ottawa Scale and Cochrane Risk of Bias tool to assess the risk of bias.

RESULTS

The search identified 5093 articles, and we reviewed 62 full-text articles. Two articles met inclusion criteria (N = 438). One article was an observational study, and the other was a randomized comparative effectiveness trial. The observational study examined lithium response rates and found higher response rates in BD alone compared with BD plus PTSD over 4 years. The randomized trial reported more severe symptoms in the BD plus PTSD group than in those with BD alone following 6 months of quetiapine treatment. There was no significant difference in the lithium treatment group at follow-up.

CONCLUSIONS

Comorbid PTSD may affect quetiapine and lithium treatment response in those with BD. Because of the high risk of bias and low quality of evidence, however, these results are preliminary. Specific studies exploring comorbid BD and PTSD are required to inform pharmacotherapy selection and guidelines appropriately. (International Prospective Register of Systematic Reviews ID: CRD42020182540).

The clinical characterization of the adult patient with bipolar disorder aimed at personalization of management

Bipolar disorder is heterogeneous in phenomenology, illness trajectory, and response to treatment. Despite evidence for the efficacy of multimodal-ity interventions, the majority of persons affected by this disorder do not achieve and sustain full syndromal recovery. It is eagerly anticipated that combining datasets across various information sources (e.g., hierarchical "multi-omic" measures, electronic health records), analyzed using advanced computational methods (e.g., machine learning), will inform future diagnosis and treatment selection. In the interim, identifying clinically meaningful subgroups of persons with the disorder having differential response to specific treatments at point-of-care is an empirical priority. This paper endeavours to synthesize salient domains in the clinical characterization of the adult patient with bipolar disorder, with the overarching aim to improve health outcomes by informing patient management and treatment considerations. Extant data indicate that characterizing select domains in bipolar disorder provides actionable information and guides shared decision making. For example, it is robustly established that the presence of mixed features - especially during depressive episodes - and of physical and psychiatric comorbidities informs illness trajectory, response to treatment, and suicide risk. In addition, early environmental exposures (e.g., sexual and physical abuse, emotional neglect) are highly associated with more complicated illness presentations, inviting the need for developmentally-oriented and integrated treatment approaches. There have been significant advances in validating subtypes of bipolar disorder (e.g., bipolar I vs. II disorder), particularly in regard to pharmacological interventions. As with other severe mental disorders, social functioning, interpersonal/family relationships and internalized stigma are domains highly relevant to relapse risk, health outcomes, and quality of life. The elevated standardized mortality ratio for completed suicide and suicidal behaviour in bipolar disorder invites the need for characterization of this domain in all patients. The framework of this paper is to describe all the above salient domains, providing a synthesis of extant literature and recommendations for decision support tools and clinical metrics that can be implemented at point-of-care.

The association between variability, intensity, and persistence of suicidal ideation and prospective suicidal behavior in the systematic treatment enhancement program for bipolar disorder (STEP-BD) study

Background

This study sought to examine the association between prospective suicidal behavior and variability, intensity, and persistence of suicidal ideation (SI) in bipolar disorder (BD).

Methods

Data were drawn from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), a naturalistic study of 4360 outpatients 15 years or older with BD. In separate models, logistic regressions with suicidal behavior (first attempt or death by suicide) as the outcome variable and SI variability (fluctuating levels of SI over time, measured as ordinal dispersion of SI score), intensity (median SI score over time in study), or persistence (number of visits with reported SI) as the explanatory variables were used to examine the relationship between SI characteristics and odds of future suicidal behavior events.

Results

After adjusting for possible confounders, the odds of prospective suicidal behavior were 1.2 times greater per 10% increase in SI variability. SI persistence was not associated with suicidal behavior. For SI intensity, a median SI score of ‘rare/fleeting’ or ‘several days’ of SI was not associated with suicidal behavior, but the odds of prospective suicidal behavior were nearly five times greater for participants with the highest observed median SI intensity score of ‘nearly every day’.

Conclusions

The findings suggest that, in BD participants, monitoring SI variability may be clinically useful for assessing suicide risk.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00263-7.

Applying ideation-to-action theories to predict suicidal behavior among adolescents

BACKGROUND

Although many risk factors for adolescent suicidal behavior have been identified, less is known about distinct risk factors associated with the progression from suicide ideation to attempts. Based on theories grounded in the ideation-to-action framework, we used structural equation modeling to examine risk and protective factors associated with the escalation from suicide ideation to attempts in adolescents.

METHODS

In this cross-sectional study, data from the 2013 and 2015 Hawaii High School Youth Risk Behavior Surveys (N = 8,113) were analyzed. The sample was 54.0% female and racially/ethnically diverse. Risk factors included depression, victimization, self-harm, violent behavior, disinhibition, and hard substance use, and protective factors included adult support, sports participation, academic achievement and school safety.

RESULTS

One in 6 adolescents (16.4%) reported suicide ideation, and nearly 1 in 10 (9.8%) adolescents had made a suicide attempt. Overall, disinhibition predicted the escalation to attempts among adolescents with suicide ideation, and higher academic performance was associated with lower suicide attempt risk. Depression and victimization were associated with suicide ideation.

LIMITATIONS

This study examined data from the Youth Risk Behavior Survey, and other known risk factors such as anxiety and family history of suicide were not available in these data.

CONCLUSIONS

Findings provide guidance for targets for clinical interventions focused on suicide prevention. Programs that incorporate behavioral disinhibition may have the greatest potential for reducing suicide attempt risk in adolescents with suicidal thoughts.

Neurometabolic alterations in bipolar disorder with anxiety symptoms: A proton magnetic resonance spectroscopy study of the prefrontal whiter matter

To identify the pathophysiological mechanism of bipolar disorder (BD) patients with anxiety symptoms, we analyzed the differences of brain biochemical metabolism in BD patients with and without anxiety symptoms. We collected 39 BD patients who had been untreated with drugs in one month and were divided into the anxiety symptoms group (20 cases) and non-anxiety symptoms group (19 cases) according to whether they had anxiety symptoms. We used proton magnetic resonance spectroscopy (¹H-MRS) to detect the biochemical metabolite ratios of the prefrontal whiter matter (PWM) in all patients. The right PWM mI/Cr ratios in BD patients with anxiety symptoms were higher than those in BD patients without anxiety symptoms and the Cho/Cr ratios in the left PWM were negatively correlated with age and age of onset in BD patients with anxiety symptoms. These findings indicated that BD patients with anxiety symptoms have increased levels of inositol metabolism in the right PWM. Furthermore, the level of membrane phospholipid catabolism in the left PWM of BD patients with anxiety symptoms decreased with increasing age and onset age. Our results provide some references for the pathophysiological mechanism in BD patients with anxiety symptoms.

Are anxiety disorders a pathway to obsessive-compulsive disorder? Different trajectories of OCD and the role of death anxiety

OBJECTIVES

A body of research has demonstrated high rates of comorbidity among individuals with obsessive-compulsive disorder (OCD). Further, recent empirical evidence has demonstrated the relevance of death anxiety in OCD. Given that the trajectory towards OCD remains unclear, the current study aimed to examine which disorders individuals typically experience prior to the onset of this disorder. Further, the study aimed to explore the role of death anxiety in the developmental pathways to the disorder.

METHODS

The present study involved administering a measure of death anxiety and conducting structured diagnostic interviews among a treatment-seeking sample of 98 individuals with OCD.

RESULTS

First, the findings revealed a number of anxiety-related disorders commonly experienced prior to the development of OCD, the most frequent of which were separation anxiety disorder, specific phobias, and generalised anxiety disorder. Second, consistent with hypotheses, individuals with higher death anxiety experienced more disorders prior to the onset of OCD. Conversely, those with lower fears of death were significantly more likely to develop OCD as their first disorder.

CONCLUSIONS

These findings support the argument that death anxiety may influence the trajectory towards OCD, and the comorbidity among anxiety-related disorders. However, further research is needed to clarify whether death anxiety plays a causal role in this trajectory.

Bipolar disorder: Prevalence, help-seeking and use of mental health care in England. Findings from the 2014 Adult Psychiatric Morbidity Survey

BACKGROUND

To date, the lifetime prevalence of Bipolar Disorder (BD) and BD patients' access to mental health care in England has not been systematically studied.

METHODS

We used data from the Adult Psychiatric Morbidity Survey 2014 (N = 7546). The Mood Disorders Questionnaire (MDQ) was used to screen for BD. Associations between sociodemographic and clinical variables and use of mental health services were investigated. Weighted regression modelling established factors associated with being in receipt of care for mental health problems over the last year.

RESULTS

The lifetime prevalence of BD in the community in England was 1.7%. Approximately 40% had not received mental health care in the last year, and only 16.9% had received BD specific treatment. 14.6% had asked for a specific form of help but not received it. Psychopathology differed between individuals who successfully sought care and those who didn't. Obtaining care was independently associated with female sex (p<0.0001, odds ratio(OR):4.65 (Confidence Interval (CI):2.18-10.30), unemployment (p = 0.02, OR: 2.65 (C.I: 1.23-5.88) and suicidal ideation (p = 0.04, OR: 3.36, (C.I: 1.04-10.89).

LIMITATIONS

The MDQ is less sensitive than some of the longer measures, especially in the general population. Some between-group comparisons may have suffered from limited power.

CONCLUSIONS

The lifetime prevalence of BD in England was similar to rates worldwide. Most people with BD had not received any specific treatment for the condition in the last year, while 1 in 7 had requested specific help but did not receive it. Secondary mental health services in England for BD appear suboptimal.

Psychotic symptoms during bipolar depressive episodes and suicidal ideation

BACKGROUND

Psychotic symptoms during bipolar depressive episodes, especially in outpatients, are under recognized and studied by clinicians and researchers. We examined the relationship between psychotic symptoms during a depressive episode and suicidal ideation in bipolar patients.

METHODS

Participants (N = 351) were adult, depressed outpatients with bipolar disorder (BD) in a comparative effectiveness study of quetiapine versus lithium. Psychotic symptoms were assessed via Bipolar Inventory of Signs and Symptoms Scale (BISS) and depressive episodes via Mini-International Neuropsychiatric Interview (MINI). Because only 4.84% (N = 17) endorsed psychotic symptoms, we performed iterative multivariate matching with non-psychotic participants. On every matched population, a multiple regression analysis examined whether psychotic symptoms were associated with suicidal ideation, via the Concise Health Risk Taking scale (CHRT-12).

RESULTS

Averaged across the 50 matched populations, current psychotic symptoms predicted active suicidal ideation on the CHRT, but not a passive propensity toward suicide or total CHRT scores, after adjusting for common correlates of suicidality (e.g., previous suicidal behavior) (β=0.59, p=.01, R2= 0.41).

LIMITATIONS

Our study was limited by three factors. First, the generalizability of our study was limited as the sample included only outpatients. Next, the analysis was cross-sectional and does not allow for causal interpretation. Lastly, our study lacked information regarding the content and mood congruency of participants' psychosis.

CONCLUSION

While a small proportion of BD outpatients had current symptoms of psychosis during their depressive episode, those who did were more likely to endorse active suicidal thoughts, including suicide methods and plans.

Sleep quality moderates the association between psychotic-like experiences and suicidal ideation among help-seeking university students

Suicide is a leading cause of death for young adults, and college-enrolled students are at markedly high risk for suicide. Psychotic-like experiences (PLEs) and sleep difficulties are prevalent among college students and have been linked to increased suicidal ideation (SI). This cross-sectional study examined the relation between PLEs and SI, moderated by sleep quality, in a sample of 442 students at a university counseling center. The Behavioral Health Measure-43 (BHM-43) was used to evaluate mental health symptoms, including sleep quality and SI. The PRIME Screen-Revised was used to measure PLEs. Regression results indicated that higher PRIME scores statistically predicted greater SI. There was a significant interaction between PRIME and sleep quality in predicting SI. Among individuals with greater sleep difficulties, PLEs were positively, significantly associated with SI. The PRIME was not a significant predictor of SI at lower levels of sleep difficulties (i.e. better sleep quality). This interaction effect remained significant when controlling for age and the BHM-43 depression and bipolar subscales. Findings suggest that sleep difficulties may be linked to increased SI for individuals with PLEs, and better sleep may be protective. Further research is needed to explore treatment targeting PLEs and/or sleep to mitigate suicide risk among university students.

Polygenic risk for anxiety influences anxiety comorbidity and suicidal behavior in bipolar disorder

Bipolar disorder is often comorbid with anxiety, which is itself associated with poorer clinical outcomes, including suicide. A better etiologic understanding of this comorbidity could inform diagnosis and treatment. The present study aims to test whether comorbid anxiety in bipolar disorder reflects shared genetic risk factors. We also sought to assess the contribution of genetic risk for anxiety to suicide attempts in bipolar disorder. Polygenic risk scores (PRS) were calculated from published genome-wide association studies of samples of controls and cases with anxiety (n = 83,566) or bipolar disorder (n = 51,710), then scored in independent target samples (total n = 3369) of individuals with bipolar disorder who reported or denied lifetime anxiety disorders or suicidal attempts in research interviews. Participants were recruited from clinical and nonclinical settings and genotyped for common genetic variants. The results show that polygenic risk for anxiety was associated with comorbid anxiety disorders and suicide attempts in bipolar disorder, while polygenic risk for bipolar disorder was not associated with any of these variables. Our findings point out that comorbid anxiety disorders in bipolar disorder reflect a dual burden of bipolar and anxiety-related genes; the latter may also contribute to suicide attempts. Clinical care that recognizes and addresses this dual burden may help improve outcomes in people living with comorbid bipolar and anxiety disorders.

Comorbid Anxiety Increases Suicidal Risk in Bipolar Depression: Analysis of 9720 Adolescent Inpatients

Objective: To evaluate the risk of association between suicidal behaviors and comorbid anxiety disorders in adolescents with bipolar depression. Methods: We conducted a cross-sectional study using the nationwide inpatient sample (NIS) from the United States. This study included 9720 adolescent inpatients with bipolar depression and further grouped by co-diagnosis of anxiety disorders. Logistic regression analysis was used to evaluate the odds ratio (OR) of suicidal behaviors due to comorbid anxiety after controlling demographic confounders and psychiatric comorbidities. Results: Out of total inpatients, 34.8% (n = 3385) had comorbid anxiety disorders with a predominance in females (70.3%) and White patients (67.7%). About 54.1% of inpatients with comorbid anxiety had suicidal behaviors versus 44.6% in the non-anxiety cohort (p < 0.001). Comorbid anxiety disorders were associated with 1.35 times higher odds (95% CI 1.23–1.47, p < 0.001) for suicidal behaviors. Conclusion: Suicidal behaviors are significantly prevalent in bipolar depression adolescents with comorbid anxiety disorders. Anxiety disorders are an independent risk factor in bipolar depression that increase the risk of suicidal behaviors by 35%. This necessitates careful assessment and management of comorbid anxiety disorders in bipolar youth to mitigate suicidality.

Post-traumatic stress burden in a sample of hospitalized patients with Bipolar Disorder: Which impact on clinical correlates and suicidal risk?

BACKGROUND

Increasing evidence suggests Bipolar Disorder (BD) to be frequently associated to a history of traumatic experiences and Post-traumatic Stress Disorder (PTSD), with consequent greater symptoms severity, number of hospitalizations and worsening in quality of life. The aim of the present study was to investigate the lifetime exposure to traumatic events and PTSD rates in-patients with BD and to analyze the relationships between PTSD symptoms, clinical characteristics and severity of the mood disorder.

METHODS

A consecutive sample of 212 in-patients with a DSM-5 diagnosis of BD was enrolled at the psychiatric unit of a major University hospital in Italy and assessed by the SCID-5 and MOOD Spectrum-Self Report lifetime version (MOODS-SR). Socio-demographic characteristics, clinical features, substance or alcohol abuse, history of suicide related behaviors were also collected.

RESULTS

Lifetime trauma exposure emerged in 72.3% subjects, with a DSM-5 PTSD diagnosis reported by 35.6%. Patients with PTSD showed more frequently a (hypo)manic episode at onset, alcohol or substance abuse, psychotic features, suicide behaviors, higher scores in almost all the MOODS-SR domains, compared to those without PTSD.

LIMITATIONS

Cross sectional study. Lack of data about the time since trauma exposure or PTSD onset.

CONCLUSIONS

Our findings show a history of multiple traumatic experiences in hospitalized patients with BD besides high rates of PTSD, with the co-occurrence of these conditions appearing to be related to a more severe BD. Detailed investigation of post-traumatic stress symptoms is recommended for the relevant implications on the choice of a tailored treatment and the prognosis assessment.

Bipolar depression and suicidal ideation: Moderators and mediators of a complex relationship

INTRODUCTION

Not all patients with bipolar depression have suicidal ideation (SI). This study examines some factors that link bipolar depression to SI.

METHODS

482 individuals with bipolar I or II were randomized to either lithium or quetiapine plus adjunctive personalized therapy in a 24 week comparative effectiveness trial. Severity of depression and SI were assessed with the Bipolar Inventory of Symptoms Scale (BISS). We examined potential moderators (age, gender, age of illness onset, bipolar type, comorbid anxiety, substance use, past suicide attempts, childhood abuse and treatment arm) and mediators (severity of anxiety, mania, irritability, impairment in functioning (LIFE-RIFT) and satisfaction and enjoyment of life (Q-LES-Q)) of the effect of depression on SI. Statistical analyses were conducted using generalized estimating equations with repeated measures.

RESULTS

Bipolar type and past suicide attempts moderated the effect of depression on SI. Life satisfaction mediated the effect of depression and SI. The relationship between anxiety, depression and SI was complex due to the high level of correlation. Treatment with lithium or quetiapine did not moderate the effect of depression on SI.

LIMITATIONS

Suicide assessment was only done using an item on BISS. Patient population was not specifically chosen for high suicide risk.

DISCUSSION

Individuals with Bipolar II experienced more SI with lower levels of depression severity. A history of suicide predisposed patients to higher levels of SI given the same severity of depression. Reduced life satisfaction mediates the effect of depression on SI and may be a target for therapeutic interventions.

Differences in metacognitive beliefs among patients with bipolar disorder with or without previous suicide attempts

Purpose: The aim of this study is to compare differences in metacognitive beliefs between patients with bipolar disorder type I (BPDI) with previous suicide attempts (BPDI+), those without suicide attempts (BPDI-), and a control group. It also discusses the relationship between metacognitive beliefs and suicidal behavioral parameters. Materials and methods: The study included 72 BPDI+ and 73 BPDI- euthymic patients and 86 healthy age- and gender-matched individuals. All participants completed a sociodemographic data form, the Beck Depression Inventory, Metacognition Questionnaire-30 (MCQ-30), Suicide Behaviors Questionnaire, and Structured Clinical Interview for DSM-IV Axis I. In addition, the Young Mania Rating Scale was used for the patient groups. Results: Both the BPDI+ and BPDI- patients had higher MCQ-30 scores than the control group (p < .01). Scores for the 'need to control thoughts' subscale were higher in the BPDI+ group than in the BPDI- group and were also higher in both the BPDI+ and BPDI- groups compared to the control group (p < .01). In addition, the 'cognitive self-consciousness' sub-scores of the BPDI- group were higher than those of the BPDI+ and the control group. Conclusion: The scores of 'cognitive self-consciousness' and 'need to control thoughts' vary across BPDI+ and BPDI- patients. It seems important to consider metacognitive beliefs regarding 'need to control thoughts' and 'cognitive self-consciousness' in terms of suicide prevention.

The tide does turn: Predictors of remission from suicidal ideation and attempt among Canadians who previously attempted suicide

The objectives of this study were to identify factors that contribute to (1) remission from suicidal ideation, and (2) remission from suicide attempt, among Canadians with a lifetime history of suicide attempt. Data for this study came from Statistics Canada's nationally representative 2012 Canadian Community Health Survey-Mental Health. A sample of 769 adult respondents who had ever attempted suicide was analyzed with remission from past year suicidal ideation and remission from past year suicide attempt as outcome variables. Of the 769 respondents who had ever attempted suicide, more than two-thirds (69%) were free from suicidal ideation within the past year, and approximately 87% were free from suicide attempts within the past year. Compared to men, odds were 2.66 times greater for women to be free of suicide attempt and 2.65 times greater to be free of suicidal ideation in the past year. Older age, being free of sleep problems and major depressive episode, having no history of chronic childhood physical abuse, and having two or fewer previous suicide attempts were associated with higher odds of remission from both suicide attempt and ideation in the past year.

Directionality of change in obsessive compulsive disorder (OCD) and suicidal ideation over six years in a naturalistic clinical sample✰

BACKGROUND

Obsessive compulsive disorder (OCD) is associated with elevated suicide risk, but the directionality of the association between OCD severity and suicidal ideation has not been established, which was the goal of this study.

METHODS

Participants (n = 325) were adults with either a current or past diagnosis of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) OCD who were assessed annually for suicidal ideation and OCD symptom severity for six years. Cross-lagged panel analyses statistically compared unidirectional and bidirectional models over time. Serious suicide-related adverse events were reported.

RESULTS

The best-fitting and most parsimonious model included paths predicting suicidal ideation from OCD symptom severity, but not vice versa. These results were confirmed by comparing a model with cross-lagged paths constrained equal to a freely estimated model. Higher OCD symptom severity in a given year was associated with a higher suicidal ideation severity in the subsequent year. Five suicide-related adverse events were reported throughout the duration of the study, including two suicide deaths and three suicide attempts.

LIMITATIONS

The study relied on a single-item, annual measure of suicidal ideation in adults, with substantial variability in severity of suicide risk, and missing data increased with later observations in the study.

DISCUSSION

OCD symptom severity predicted next year suicidal ideation severity. In contrast, suicidal ideation severity in a given year did not predict next-year OCD symptom severity in this OCD sample. Thus, rather than waiting for suicidal ideation to resolve, clinicians should consider providing empirically supported treatments for OCD.

Altered Electroencephalographic Resting-State Large-Scale Brain Network Dynamics in Euthymic Bipolar Disorder Patients

Background: Neuroimaging studies provided evidence for disrupted resting-state functional brain network activity in bipolar disorder (BD). Electroencephalographic (EEG) studies found altered temporal characteristics of functional EEG microstates during depressive episode within different affective disorders. Here we investigated whether euthymic patients with BD show deviant resting-state large-scale brain network dynamics as reflected by altered temporal characteristics of EEG microstates. Methods: We used high-density EEG to explore between-group differences in duration, coverage, and occurrence of the resting-state functional EEG microstates in 17 euthymic adults with BD in on-medication state and 17 age- and gender-matched healthy controls. Two types of anxiety, state and trait, were assessed separately with scores ranging from 20 to 80. Results: Microstate analysis revealed five microstates (A-E) in global clustering across all subjects. In patients compared to controls, we found increased occurrence and coverage of microstate A that did not significantly correlate with anxiety scores. Conclusion: Our results provide neurophysiological evidence for altered large-scale brain network dynamics in BD patients and suggest the increased presence of A microstate to be an electrophysiological trait characteristic of BD.

Early maladaptive schemas and suicidal risk in inpatients with bipolar disorder

The present study aimed to assess the associations of early maladaptive schemas (EMSs) and clinical factors (hypomanic/manic and depressive symptoms) with suicidal risk (current suicidal ideation and lifetime suicide attempts) in inpatients with bipolar disorder (BD). One hundred inpatients with BD completed the Young Schema Questionnaire-Short Form (YSQ-SF), the Bipolar Depression Rating Scale (BDRS), the Young Mania Rating Scale (YMRS), and the Beck Scale for Suicide Ideation (BSSI). 59% of patients had lifetime suicide attempts and 59% showed high suicidal risk (BSSI ≥ 6). BD patients with lifetime suicide attempts had higher scores on the entitlement and social isolation schemas, depression, and hypomanic/manic symptoms than those without such attempts. Patients with high suicidal risk had higher levels of depressive and hypomanic/manic symptoms as well as some EMSs than those without high suicidal risk. Logistic regression analyses revealed that hypomanic/manic symptoms as well as the entitlement and defectiveness schemas were significantly associated with current suicidal ideation. Also, the entitlement and social isolation schemas were associated with lifetime suicide attempts. These results suggest that the entitlement, social isolation, and defectiveness schemas may relate to suicidal risk in patients with BD.

The Association of Lifetime Suicide Attempts With Anxiety Disorders in Patients With Bipolar Disorder

The association of lifetime suicidal behaviors with anxiety disorders (ADs) in patients with bipolar disorder (BD) has been controversial. In this study, we hypothesized that certain types of ADs were related to the occurrence of past suicide attempts (SAs) independent of the severity of the BD, including the presence of past affective episodes. Lifetime diagnoses of BD and ADs were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders (SCID-I). Of the total sample of 200 patients with BD, 32.0% had at least 1 past SA. The mean number of previous hospitalizations, a history of social AD, and a history of posttraumatic stress disorder were strongly associated with past SAs in patients with bipolar I disorder. The presence of lifetime social AD was associated with lifetime SAs independent of previous depressive episodes. Therefore, we suggest that social AD itself is associated with a greater risk for SAs in patients with BD independent of the presence of depression.

Reducing relapse and suicide in bipolar disorder: practical clinical approaches to identifying risk, reducing harm and engaging service users in planning and delivery of care – the PARADES (Psychoeducation, Anxiety, Relapse, Advance Directive Evaluation and Suicidality) programme

Background

Bipolar disorder (BD) costs £5.2B annually, largely as a result of incomplete recovery after inadequate treatment.

Objectives

A programme of linked studies to reduce relapse and suicide in BD.

Design

There were five workstreams (WSs): a pragmatic randomised controlled trial (RCT) of group psychoeducation (PEd) versus group peer support (PS) in the maintenance of BD (WS1); development and feasibility RCTs of integrated psychological therapy for anxiety in bipolar disorder (AIBD) and integrated for problematic alcohol use in BD (WS2 and WS3); survey and qualitative investigations of suicide and self-harm in BD (WS4); and survey and qualitative investigation of service users’ (SUs) and psychiatrists’ experience of the Mental Capacity Act 2005 (MCA), with reference to advance planning (WS5).

Setting

Participants were from England; recruitment into RCTs was limited to certain sites [East Midlands and North West (WS1); North West (WS2 and WS3)].

Participants

Aged ≥ 18 years. In WS1–3, participants had their diagnosis of BD confirmed by the Structural Clinical Interview for theDiagnostic and Statistical Manual of Mental Disorders.

Interventions

In WS1, group PEd/PS; in WS3 and WS4, individual psychological therapy for comorbid anxiety and alcohol use, respectively.

Main outcome measures

In WS1, time to relapse of bipolar episode; in WS2 and WS3, feasibility and acceptability of interventions; in WS4, prevalence and determinants of suicide and self-harm; and in WS5, professional training and support of advance planning in MCA, and SU awareness and implementation.

Results

Group PEd and PS could be routinely delivered in the NHS. The estimated median time to first bipolar relapse was 67.1 [95% confidence interval (CI) 37.3 to 90.9] weeks in PEd, compared with 48.0 (95% CI 30.6 to 65.9) weeks in PS. The adjusted hazard ratio was 0.83 (95% CI 0.62 to 1.11; likelihood ratio testp = 0.217). The interaction between the number of previous bipolar episodes (1–7 and 8–19, relative to 20+) and treatment arm was significant (χ2 = 6.80, degrees of freedom = 2;p = 0.034): PEd with one to seven episodes showed the greatest delay in time to episode. A primary economic analysis indicates that PEd is not cost-effective compared with PS. A sensitivity analysis suggests potential cost-effectiveness if decision-makers accept a cost of £37,500 per quality-adjusted life-year. AIBD and motivational interviewing (MI) cognitive–behavioural therapy (CBT) trials were feasible and acceptable in achieving recruitment and retention targets (AIBD:n = 72, 72% retention to follow-up; MI-CBT:n = 44, 75% retention) and in-depth qualitative interviews. There were no significant differences in clinical outcomes for either trial overall. The factors associated with risk of suicide and self-harm (longer duration of illness, large number of periods of inpatient care, and problems establishing diagnosis) could inform improved clinical care and specific interventions. Qualitative interviews suggested that suicide risk had been underestimated, that care needs to be more collaborative and that people need fast access to good-quality care. Despite SUs supporting advance planning and psychiatrists being trained in MCA, the use of MCA planning provisions was low, with confusion over informal and legally binding plans.

Limitations

Inferences for routine clinical practice from WS1 were limited by the absence of a ‘treatment as usual’ group.

Conclusion

The programme has contributed significantly to understanding how to improve outcomes in BD. Group PEd is being implemented in the NHS influenced by SU support.

Future work

Future work is needed to evaluate optimal approaches to psychological treatment of comorbidity in BD. In addition, work in improved risk detection in relation to suicide and self-harm in clinical services and improved training in MCA are indicated.

Trial registration

Current Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 6. See the NIHR Journals Library website for further project information.

Attention-deficit/hyperactivity disorder symptoms and suicidal behavior in adult psychiatric outpatients

AIM

We aimed to examine the association between attention-deficit/hyperactivity disorder (ADHD) symptoms and suicidal behavior in psychiatric outpatients and whether this association differs among patients with different psychiatric disorders.

METHODS

Cross-sectional data came from the Japan Prevalence Study of Adult ADHD at Psychiatric Outpatient Care, which included psychiatric outpatients aged 18-65 years recruited from one university hospital and three general psychiatric outpatient clinics in Kitakyushu City, Fukuoka, Japan from April 2014 to January 2015 (N = 864). The Adult ADHD Self-Report Scale (ASRS) Screener was used to collect information on ADHD symptoms. Reports of current and lifetime suicidal behavior were also obtained. A multivariable Poisson regression analysis was used to examine the association between ADHD symptoms and suicidal behavior.

RESULTS

After adjusting for covariates there was a strong association between possible ADHD (ASRS ≥14) and suicidal behavior with prevalence ratios ranging from 1.17 (lifetime suicidal ideation) to 1.59 (lifetime suicide attempt) and 2.36 (current suicidal ideation). When ASRS strata were used, there was a dose-response association between increasing ADHD symptoms and suicidal ideation and suicide attempts. Analyses of individual ICD-10 psychiatric disorders showed that associations varied across disorders and that for anxiety disorder, ADHD symptoms were significantly linked to all forms of suicidal behavior.

CONCLUSION

ADHD symptom severity is associated with an increased risk for suicidal behavior in general psychiatric outpatients. As ADHD symptoms are common among adult psychiatric outpatients, detecting and treating ADHD in this population may be important for preventing suicidal behavior.

The role of lifetime anxiety history in the course of bipolar spectrum disorders

Individuals with bipolar spectrum disorder (BSD) frequently meet criteria for comorbid anxiety disorders, and anxiety may be an important factor in the etiology and course of BSDs. The current study examined the association of lifetime anxiety disorders with prospective manic/hypomanic versus major depressive episodes. Participants were 244 young adults (aged 17-26) with milder forms of BSDs (i.e., bipolar-II, cyclothymia, BD-NOS). First, bivariate analyses assessed differences in baseline clinical characteristics between participants with and without DSM-IV anxiety diagnoses. Second, negative binomial regression analyses tested whether lifetime anxiety predicted number of manic/hypomanic or major depressive episodes developed during the study. Third, survival analyses evaluated whether lifetime anxiety predicted time to onset of manic/hypomanic and major depressive episodes. Results indicated that anxiety history was associated with greater illness severity at baseline. Over follow-up, anxiety history predicted fewer manic/hypomanic episodes, but did not predict number of major depressive episodes. Anxiety history also was associated with longer time to onset of manic/hypomanic episodes, but shorter time to onset of depressive episodes. Findings corroborate past studies implicating anxiety disorders as salient influences on the course of BSDs. Moreover, results extend prior research by indicating that anxiety disorders may be linked with reduced manic/hypomanic phases of illness.

Associations of Comorbid Anxiety With Medication Adherence and Psychiatric Symptomatology in a Population of Nonadherent Bipolar Disorder Subjects

This analysis was conducted on baseline data from 178 nonadherent bipolar disorder subjects in a randomized controlled trial. Medication adherence was measured with Tablets Routine Questionnaire as percentage of days with missed doses. Inclusion criteria required at least 20% nonadherence. Medication adherence, symptomatology, and functioning in individuals with and without a comorbid anxiety disorder were compared. There were 78.9% of subjects who had at least one or more current anxiety disorder, with the most common being posttraumatic stress disorder, panic disorder, and generalized anxiety disorder. The percentage of days with missed doses over the past month was significantly lower in those with anxiety disorders compared with those without (40.1% vs 50.5%, p = 0.03). Those with comorbid anxiety disorders and those with greater number of anxiety disorder diagnoses had significantly worse mean scores on the Montgomery-Åsberg Depression Rating Scale, Brief Psychiatric Rating Scale, Clinical Global Impression-Bipolar Version, and Global Assessment of Functioning.

ERP investigation of attentional disengagement from suicide-relevant information in patients with major depressive disorder

BACKGROUND

Previous studies suggest the presence of attentional bias towards suicide-relevant information in suicidal individuals. However, the findings are limited by their reliance on behavioral measures. This study investigates the role of difficulty in disengaging attention from suicide-relevant stimuli using the P300 component of event-related potentials (ERPs).

METHODS

Forty-four adults with Major Depressive Disorder (MDD) were administered the spatial cueing task using suicide-relevant and negatively-valenced words as cue stimuli. Disengagement difficulty was measured using reaction time and P300 during invalid trials.

RESULTS

P300 amplitudes at Pz were higher in suicide-relevant compared to negatively-valenced word condition on invalid trials for participants with low rates of suicidal behavior. However, no such difference was found among participants with high rates of suicidal behavior. P300 amplitudes for suicide-relevant word condition were negatively correlated with "lifetime suicide ideation and attempt" at Pz. No significant results were found for the reaction time data, indicating that the ERP may be more sensitive in capturing the attentional disengagement effect.

LIMITATIONS

The groups were divided according to Suicidal Behaviors Questionnaire-Revised (SBQ-R) total score. Neutral stimulus was not included as cue stimuli. Most participants were under medication during the experiment.

CONCLUSIONS

Our results indicate that patients with MDD and low rates of suicidal behavior show difficulty in disengaging attention from suicide-relevant stimuli. We suggest that suicide-specific disengagement difficulties may be related to recentness of suicide attempt and that acquired capability for suicide may contribute to reduced disengagement difficulties.

Increased Suicidal Ideation in Patients with Co-Occurring Bipolar Disorder and Post-Traumatic Stress Disorder

Suicide risk increases for those with Bipolar Disorder or PTSD, however little research has focused on risk for co-occurring Bipolar Disorder and PTSD. The aim of this article was to evaluate increased suicide risk in co-occurring disorders, and differences in suicide risk for patients with Bipolar I versus Bipolar II. This study evaluated suicide risk in patients with co-occurring PTSD and Bipolar Disorder (n = 3,158), using the MADRS and Suicide Questionnaire. Those with history of PTSD had significantly higher suicidal ideation than those without (U = 1063375.00, p < .0001). Those with Bipolar I had higher risk than those with Bipolar II. Patients with Bipolar I and PTSD were at higher risk for suicidal ideation, implying the importance of diagnosis and risk assessment.

Are comorbid anxiety disorders a risk factor for suicide attempts in patients with mood disorders? A two-year prospective study

BACKGROUND

Comorbid anxiety disorders have been considered a risk factor for suicidal behavior in patients with mood disorders, although results are controversial. The aim of this two-year prospective study was to determine if lifetime and current comorbid anxiety disorders at baseline were risk factors for suicide attempts during the two-year follow-up.

METHODS

We evaluated 667 patients with mood disorders (504 with major depression and 167 with bipolar disorder) divided in two groups: those with lifetime comorbid anxiety disorders (n=229) and those without (n=438). Assessments were performed at baseline and at 3, 12, and 24 months. Kaplan-Meier survival analysis and log-rank test were used to evaluate the relationship between anxiety disorders and suicide attempts. Cox proportional hazard regression was performed to investigate clinical and demographic variables that were associated with suicide attempts during follow-up.

RESULTS

Of the initial sample of 667 patients, 480 had all three follow-up interviews. During the follow-up, 63 patients (13.1%) attempted suicide at least once. There was no significant difference in survival curves for patients with and without comorbid anxiety disorders (log-rank test=0.269; P=0.604). Female gender (HR=3.66, P=0.001), previous suicide attempts (HR=3.27, P=0.001) and higher scores in the Buss-Durkee Hostility Inventory (HR=1.05, P≤0.001) were associated with future suicide attempts.

CONCLUSIONS

Our results suggest that comorbid anxiety disorders were not risk factors for suicide attempts. Further studies were needed to determine the role of anxiety disorders as risk factors for suicide attempts.

Early maladaptive schemas and suicidal risk in an Iranian sample of patients with obsessive-compulsive disorder

There are few studies on suicidal risk and its related factors in patients diagnosed with obsessive-compulsive disorder (OCD). This study investigated the associations of early maladaptive schemas, OC symptom dimensions, OCD severity, depression and anxiety with suicidality (i.e., suicidal ideation and suicide attempts) in OCD patients. Sixty OCD outpatients completed the Scale for Suicide Ideation (SSI), the Young Schema Questionnaire-Short Form (YSQ-SF), the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Dimensional Obsessive-Compulsive Scale (DOCS) and the Depression Anxiety Stress Scales (DASS-21). 51.7% of patients had lifetime suicide attempts and 75% had suicidal ideation. OCD patients with lifetime suicide attempts exhibited significantly higher scores on early maladaptive schemas than those without such attempts. Logistic regression analysis revealed that the mistrust/abuse schema and the OC symptom dimension of unacceptable thoughts explained lifetime suicide attempts. The mistrust/abuse schema, unacceptable thoughts and depression significantly predicted suicidal ideation. These findings indicated that the mistrust/abuse schema may contribute to high suicidality in OCD patients. Also, patients suffering from unacceptable thoughts need to be assessed more carefully for warning signs of suicide.

The relation of childhood trauma to suicide ideation in patients suffering from obsessive-compulsive disorder with lifetime suicide attempts

The aim of this study was to evaluate the relations of childhood trauma (CT) and obsessive-compulsive (OC) symptom dimensions to suicide ideation in patients with obsessive-compulsive disorder (OCD). Seventy OCD outpatients with lifetime suicide attempts and 60 controls were included. Participants completed the Scale for Suicide Ideation (SSI), the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Dimensional Obsessive-Compulsive Scale (DOCS) and the Depression Anxiety Stress Scales (DASS-21). Among OCD patients, 97.1% had current suicide ideation. OCD patients revealed higher scores on CT, suicide ideation, depression and anxiety than controls. The CT history of sexual abuse (SA) and OC symptom dimension of unacceptable thoughts explained suicide ideation. It was concluded that SA and unacceptable thoughts may contribute to high suicidality and have important implications for the assessment and treatment of suicide risk in OCD patients with lifetime suicide attempts.

Impulsivity and its relationship with anxiety, depression and stress

We aimed to assess the association between depression, anxiety, stress and impulsivity with respect to age. The Depression, Anxiety and Stress Scale (DASS-42) and the Barratt Impulsiveness Scale (BIS-11) were administered to 145 individuals. Due to a negative correlation between age, BIS-11 and DASS-42 subscales, participants were divided into three groups: young-aged (18-30years), middle-aged (31-49years) and old-aged (≥50years). Subjects from old-aged group had significantly lower scores of depression, anxiety, stress and impulsivity compared to those from younger groups. Anxiety, followed by stress and depression, was the strongest predictor of BIS-11 total score in young-aged and middle-aged individuals. There were no significant differences in the correlations between BIS-11 total score, depression, anxiety and stress in old-aged individuals. Our results indicate that the levels of depression, anxiety, stress and impulsivity decrease with age. Additionally, age might moderate the effect of depression, anxiety and stress on impulsivity.

Tracking medication changes to assess outcomes in comparative effectiveness research: A bipolar CHOICE study

BACKGROUND

Comparative effectiveness research uses multiple tools, but lacks outcome measures to assess large electronic medical records and claims data. Aggregate changes in medications in response to clinical need may serve as a surrogate outcome measure. We developed the Medication Recommendation Tracking Form (MRTF) to record the frequency, types, and reasons for medication adjustments in order to calculate Necessary Clinical Adjustments (NCAs), medication adjustments to reduce symptoms, maximize treatment response, or address problematic side effects.

METHODS

The MRTF was completed at every visit for 482 adult patients in Bipolar CHOICE, a 6-month randomized comparative effectiveness trial.

RESULTS

Responders had significantly fewer NCAs compared to non-responders. NCAs predicted subsequent response status such that every additional NCA during the previous visit decreased a patient's odds of response by approximately 30%. Patients with more severe symptoms had a greater number of NCAs at the subsequent visit. Patients with a comorbid anxiety disorder demonstrated a significantly higher rate of NCAs per month than those without a comorbid anxiety disorder. Patients with greater frequency, intensity, and interference of side effects had higher rates of NCAs. Participants with fewer NCAs reported a higher quality of life and decreased functional impairment.

LIMITATIONS

The MRTF has not been examined in community clinic settings and did not predict response more efficiently than the Clinical Global Impression-Bipolar Version (CGI-BP).

CONCLUSIONS

The MRTF is a feasible proxy of clinical outcome, with implications for clinical training and decision-making. Analyses of big data could use changes in medications as a surrogate outcome measure.

Do Atypical Antipsychotics Have Antisuicidal Effects? A Hypothesis-Generating Overview

Modern antipsychotic drugs are employed increasingly in the treatment of mood disorders as well as psychoses, stimulating interest in their possible contributions to altering suicidal risk. Clozapine remains the only treatment with an FDA-recognized indication for reducing suicidal risk (in schizophrenia). We carried out a systematic, computerized search for reports of studies involving antipsychotic drug treatment and suicidal behaviors. A total of 19 reports provide data with preliminary support for potential suicide risk-reducing effects of olanzapine, quetiapine, ziprasidone, aripiprazole, and asenapine in addition to clozapine, and provide some support for antipsychotic drug treatment in general. These preliminary findings encourage further testing of antipsychotics for effects on suicidal behavior, making use of explicit, pre-planned assessments of suicidal behavior.

Prevalence, impact and treatment of generalised anxiety disorder in bipolar disorder: a systematic review and meta-analysis

QUESTION

Recent data suggest that anxiety disorders are as often comorbid with bipolar disorder (BD) as with unipolar depression; however, less attention has been paid to comorbidity of anxiety disorders with BD. Generalised anxiety disorder (GAD) is one of the most prevalent anxiety disorders that is highly comorbid with other mental disorders. We carried out a systematic review and meta-analysis to assess the degree of comorbidity between GAD and BD.

STUDY SELECTION AND ANALYSIS

We searched for all studies, which included primary data concerning the existence of GAD in patients with BD. The literature search strategy, selection of publications and the reporting of results have been conducted with PRISMA guidelines. The meta-analysis calculated prevalence estimates using the variance-stabilising Freeman-Tukey double arcsine transformation. We applied the inverse variance method using both fixed-effects and random-effects models to estimate summary effects for all combined studies. Heterogeneity was assessed and measured with Cochran's Q and I(2) statistics, respectively.

FINDINGS

The current meta-analysis analysed data from 28 independent studies and a total of 2975 patients from point prevalence studies and 4919 patients from lifetime studies. The overall random-effects point prevalence of GAD in patients with BD was 12.2% (95% CI 10.9% to 13.5%) and the overall random-effects lifetime estimate was 15.1% (95% CI 9.7% to 21.5%). Both estimates reported significant heterogeneity (94.0% and 94.7%, respectively).

CONCLUSIONS

Published studies report prevalence rates with high heterogeneity and consistently higher than those typically reported in the general population. It is believed that comorbid GAD might be associated with a more severe BD course and increased suicidality, and it is unknown how best to treat such conditions. The current meta-analysis confirms that GAD is highly prevalent in BD and the rate is higher in comparison to those in the general population.

Serious Suicide Attempts: Evidence on Variables for Manage and Prevent this Phenomenon

The aim of this study is to investigate the variables shown to be linked to serious suicide attempts. Cases requiring emergency admission to intensive care were collected from medical records of the University Hospital in Messina (Italy) for the years 2006-2010. 107 cases of serious attempted suicide were examined, 39 of which ended in the death of the patient. The results showed the following variables to be linked highly significantly (P < 0.01) and have good nominal association (V > 0.30) with a fatal suicidal attempt: the year of the attempt, deceased father, history of physical illness prior to hospitalization and method used to carry out the suicide attempt. These results confirm the severity and the multidisciplinary importance of this phenomenon.

Acute risk factors for suicide attempts and death: prospective findings from the STEP-BD study

OBJECTIVES

Suicide is unfortunately common in psychiatric practice, but difficult to predict. The present study sought to assess which clinical symptoms increase in the months before suicidal behavior in a sample of psychiatric outpatients with bipolar disorder.

METHODS

Data from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial were used. A total of 103 participants who attempted suicide or died by suicide during the trial were included; a 15% random sample of the remaining participants (n = 427) was used as a comparison sample. Linear mixed models in the six months before suicidal behavior were conducted for each of five proposed acute risk factors for suicidal behavior. Participants were assessed using the Clinical Monitoring Form (CMF) at each visit for the following potential acute risk factors for suicidal behavior: suicidal ideation, loss of interest, anxiety, psychomotor agitation, and high-risk behavior.

RESULTS

Each of the five symptoms was elevated overall in individuals who engaged in suicidal behavior (p < 0.05). The severity of both suicidal ideation and loss of interest significantly increased in the months before suicidal behavior (p < 0.001). Anxiety demonstrated comparable effect sizes across multiple models. Psychomotor agitation and high-risk behavior were not significantly elevated before suicidal behavior.

CONCLUSIONS

Suicidal ideation, loss of interest and, to a lesser extent, anxiety may represent acute suicide risk factors up to four months before suicidal behavior in outpatients with bipolar disorder. Further investigation of these potential acute risk factors in prospective analyses is warranted.

Review of Cohort Studies for Mood Disorders

This paper aimed to review currently available cohort studies of subjects with mood disorders such as major depressive disorder (MDD) and bipolar disorder (BD). Using the PubMed and KoreaMed databases, we reviewed eight major cohort studies. Most studies recruited participants with MDD and BD separately, so direct comparison of factors associated with diagnostic changes was difficult. Regular and frequent follow-up evaluations utilizing objective mood ratings and standardized evaluation methods in a naturalistic fashion are necessary to determine detailed clinical courses of mood disorders. Further, biological samples should also be collected to incorporate clinical findings in the development of new diagnostic and therapeutic approaches. An innovative cohort study that can serve as a platform for translational research for treatment and prevention of mood disorders is critical in determining clinical, psychosocial, neurobiological and genetic factors associated with long-term courses and consequences of mood disorders in Korean patients.

Factors related to suicidal behavior in patients with bipolar disorder: the effect of mixed features on suicidality

OBJECTIVES

The aim of the present study was to investigate various risk factors of suicidal behaviors, including the mixed features specifier, in patients with bipolar disorder.

METHODS

We retrospectively reviewed medical charts from 2005 to 2014. A total of 334 patients diagnosed with bipolar disorder using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision were enrolled. Subjects were categorized into two groups according to their history of suicidal behavior and the demographic and clinical characteristics of the groups were compared, including the mixed features specifier. We reevaluated the index episode using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria and classified subjects into an index episode with mixed features group and an index episode without mixed features group. Logistic regression was performed to evaluate significant risk factors associated with suicidal behavior.

RESULTS

Suicidal behavior had an independent relationship to mixed features at the index episode using DSM-5 criteria [odds ratio (OR)=3.39; 95% confidence interval (CI): 1.57-7.34] and number of previous depressive episodes (OR=1.62; 95% CI: 1.34-1.95) in bipolar patients. The mixed feature specifier was the strongest risk factor for suicidal behavior in the present study.

CONCLUSIONS

This study may help clinicians understand potential risk factors and manage bipolar disorders with suicidal behaviors. Clinicians should carefully monitor patients with bipolar disorder who exhibit numerous depressive episodes or mixed features for suicidal behavior.

Suicide Behaviors in Bipolar Disorder: A Review and Update for the Clinician

Suicide behaviors (ideation, attempts, and completions) are unfortunately common in patients with bipolar disorder. It is estimated that 25 to 50% attempt suicide at least once during their lifetime, and 6% to 19% complete suicide. Risk factors include a family history of suicide, previous suicide attempts, younger age of onset, comorbid psychiatric illnesses, and psychological constructs like hopelessness. Pharmacologic treatment may impact suicidal behaviors, either increasing vulnerability or resilience. Clinicians need to be particularly sensitive to their patient's thoughts and beliefs about death, particularly during stressful times of life or when in a depressive/mixed episode of bipolar disorder.

Suicide attempts in bipolar disorders: comprehensive review of 101 reports

OBJECTIVE

Assess reported risk of suicide attempts by patients with bipolar disorder (BD).

METHOD

Systematic searching yielded 101 reports from 22 countries (79 937 subjects). We analyzed for risk (%) and incidence rates (%/year) of attempts, comparing sex and diagnostic types, including by meta-analysis.

RESULTS

Attempt risk averaged 31.1% [CI: 27.9-34.3] of subjects, or 4.24 [3.78-4.70]%/year. In BD-I (43 studies) and BD-II subjects (30 studies), risks (29.9%, 31.4%) and incidence rates (4.01, 4.11%/year) were similar and not different by meta-analysis. Among women vs. men, risks (33.7% vs. 25.5%) and incidence (4.50 vs. 3.21%/year) were greater (also supported by meta-analysis: RR = 1.35 [CI: 1.25-1.45], P < 0.0001). Neither measure was related to reporting year, % women/study, or to onset or current age. Risks were greater with longer exposure, whereas incidence rates decreased with longer time at risk, possibly through 'dilution' by longer exposure.

CONCLUSION

This systematic update of international experience underscores high risks of suicide attempts among patients with BD (BD-I = BD-II; women > men). Future studies should routinely include exposure times and incidence rates by diagnostic type and sex for those who attempt suicide or not.

Team-Based Telecare for Bipolar Disorder

INTRODUCTION

Numerous randomized controlled trials indicate that collaborative chronic care models improve outcome in a wide variety of mental health conditions, including bipolar disorder. However, their spread into clinical practice is limited by the need for a critical mass of patients and specialty providers in the same locale. Clinical videoconferencing has the potential to overcome these geographic limitations.

MATERIALS AND METHODS

A videoconference-based collaborative care program for bipolar disorder was implemented in the Department of Veterans Affairs. Program evaluation assessed experience with the first 400 participants, guided by five domains specified by the American Telemedicine Association: treatment engagement, including identification of subpopulations at risk for not being reached; participation in treatment; clinical impact; patient safety; and quality of care.

RESULTS

Participation rates resembled those for facility-based collaborative care. No participant characteristics predicted nonengagement. Program completers demonstrated significant improvements in several clinical indices, without evidence of compromise in patient safety. Guideline-based quality of care assessment after 1 year indicated increased lithium use, decreased antidepressant use, and increased prazosin use in individuals with comorbid post-traumatic stress disorder, but no impact on already high rates of lithium serum level monitoring.

DISCUSSION

Clinical videoconferencing can extend the reach of collaborative care models for bipolar disorder. The next step involves assessment of the videoconference-based collaborative care for other serious mental health conditions, investigation of barriers and facilitators of broad implementation of the model, and evaluation of the business case for deployment and sustainability in clinical practice.

Review of the efficacy of treatments for bipolar disorder and substance abuse

The aim of this study was to provide a descriptive overview of different psychological and pharmacological interventions used in the treatment of patients with bipolar disorder and substance abuse, in order to determine their efficacy. A review of the current literature was performed using the databases Medline and PsycINFO (2005-2015). A total of 30 experimental studies were grouped according to the type of therapeutic modality described (pharmacological 19; psychological 11). Quetiapine and valproate have demonstrated superiority on psychiatric symptoms and a reduction in alcohol consumption, respectively. Group psychological therapies with education, relapse prevention and family inclusion have also been shown to reduce the symptomatology and prevent alcohol consumption and dropouts. Although there seems to be some recommended interventions, the multicomponent base, the lack of information related to participants during treatment, experimental control or the number of dropouts of these studies suggest that it would be irresponsible to assume that there are well established treatments.

A clinical measure of suicidal ideation, suicidal behavior, and associated symptoms in bipolar disorder: Psychometric properties of the Concise Health Risk Tracking Self-Report (CHRT-SR)

OBJECTIVE

People with bipolar disorder are at high risk of suicide, but no clinically useful scale has been validated in this population. The aim of this study was to evaluate the psychometric properties in bipolar disorder of the 7- and 12-item versions of the Concise Health Risk Tracking Self-Report (CHRT-SR), a scale measuring suicidal ideation, suicidal behavior, and associated symptoms.

METHODS

The CHRT was administered to 283 symptomatic outpatients with bipolar I or II disorder who were randomized to receive lithium plus optimized personalized treatment (OPT), or OPT without lithium in a six month longitudinal comparative effectiveness trial. Participants were assessed using structured diagnostic interviews, clinician-rated assessments, and self-report questionnaires.

RESULTS

The internal consistency (Cronbach α) was 0.80 for the 7-item CHRT-SR and 0.90 for the 12-item CHRT-SR with a consistent factor structure, and three independent factors (current suicidal thoughts and plans, hopelessness, and perceived lack of social support) for the 7-item version. CHRT-SR scores are correlated with measures of depression, functioning, and quality of life, but not with mania scores.

CONCLUSIONS

The 7- and 12-item CHRT-SR both had excellent psychometric properties in a sample of symptomatic subjects with bipolar disorder. The scale is highly correlated with depression, functioning, and quality of life, but not with mania. Future research is needed to determine whether the CHRT-SR will be able to predict suicide attempts in clinical practice.