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Aminoff SR, Onyeka IN, Ødegaard M, Simonsen C, Lagerberg TV, Andreassen OA, Romm KL, Melle I. Lifetime and point prevalence of psychotic symptoms in adults with bipolar disorders: a systematic review and meta-analysis. Psychol Med 2022; 52:2413-2425. [PMID: 36016504 PMCID: PMC9647517 DOI: 10.1017/s003329172200201x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 05/14/2022] [Accepted: 06/14/2022] [Indexed: 12/24/2022]
Abstract
Psychotic symptoms, that we defined as delusions or hallucinations, are common in bipolar disorders (BD). This systematic review and meta-analysis aims to synthesise the literature on both lifetime and point prevalence rates of psychotic symptoms across different BD subtypes, including both BD type I (BDI) and BD type II (BDII). We performed a systematic search of Medline, PsycINFO, Embase and Cochrane Library until 5 August 2021. Fifty-four studies (N = 23 461) of adults with BD met the predefined inclusion criteria for evaluating lifetime prevalence, and 24 studies (N = 6480) for evaluating point prevalence. Quality assessment and assessment of publication bias were performed. Prevalence rates were calculated using random effects meta-analysis, here expressed as percentages with a 95% confidence interval (CI). In studies of at least moderate quality, the pooled lifetime prevalence of psychotic symptoms in BDI was 63% (95% CI 57.5-68) and 22% (95% CI 14-33) in BDII. For BDI inpatients, the pooled lifetime prevalence was 71% (95% CI 61-79). There were no studies of community samples or inpatient BDII. The pooled point prevalence of psychotic symptoms in BDI was 54% (95 CI 41-67). The point prevalence was 57% (95% CI 47-66) in manic episodes and 13% (95% CI 7-23.5) in depressive episodes. There were not enough studies in BDII, BDI depression, mixed episodes and outpatient BDI. The pooled prevalence of psychotic symptoms in BDI may be higher than previously reported. More studies are needed for depressive and mixed episodes and community samples.Prospero registration number: CRD 42017052706.
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Affiliation(s)
- S. R. Aminoff
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Early Intervention in Psychosis Advisory Unit for South East Norway, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - I. N. Onyeka
- Department of Psychology, Sociology & Politics, Sheffield Hallam University, Sheffield, UK
| | - M. Ødegaard
- University of Oslo Library, University of Oslo, Oslo, Norway
| | - C. Simonsen
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Early Intervention in Psychosis Advisory Unit for South East Norway, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - T. V. Lagerberg
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - O. A. Andreassen
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - K. L. Romm
- Early Intervention in Psychosis Advisory Unit for South East Norway, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - I. Melle
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital & Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Lage RR, de Assis da Silva R, Tancini MB, Nardi AE, Mograbi DC, Cheniaux E. Suicidal Ideation in Bipolar Disorder: The Relation with Clinical and Sociodemographic Variables. Psychiatr Q 2022; 93:453-461. [PMID: 34664176 DOI: 10.1007/s11126-021-09965-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 07/31/2021] [Accepted: 09/30/2021] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Bipolar disorder (BD) has the highest risk of suicide among all mental disorders. Thus, identifying factors related to suicidal ideation is essential for a better assessment of the risk of suicide in BD. OBJECTIVE To analyze the relationship between suicidal ideation and clinical and sociodemographic characteristics in BD patients. METHOD This is a cross-sectional study that included eighty individuals with BD. Information regarding sociodemographic data and history of attempted suicide were collected, and the Hamilton Depression Scale, Young Mania Rating Scale, Positive And Negative Syndrome Scale/positive symptom subscale, Clinical Global Impressions Scale for use in bipolar illness, Insight Scale for Affective Disorders, and Barratt Impulsiveness Scale were administered. The presence and severity of suicidal ideation were assessed using the Beck Scale for Suicidal Ideation. RESULTS All regression models significantly predicted suicidal ideation. In the model that had the lowest AIC score and the highest cross-validity, the severity of depressive and of manic symptoms (standardized β = 0.49, p < 0.001; standardized β = 0.42, p = 0.007), the insight level (standardized β = - 0.38, p = 0.012) and previous suicide attempt (standardized β = 0.20, p = 0.036) acted as predictors of suicidal ideation, while degree of impulsivity (β standardized = 0.13, p = 0.229) and educational level (standardized β = - 0.16, p = 0.108) did not give a significant contribution. CONCLUSION According to our results, more severe depression and mania symptoms, higher level of insight and a history of suicide attempt indicate the occurrence of suicidal ideation in BD.
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Affiliation(s)
- Renata Reis Lage
- Institute of Psychiatry, Federal University of Rio de Janeiro (UFRJ), Av. Venceslau Brás, 71, fundos, CEP 22290-140, Rio de Janeiro, RJ, Brazil.
| | - Rafael de Assis da Silva
- Department of Psychology, Pontifícia Universidade Católica-Rio, Rio de Janeiro, Brazil.,School of Medicine and Surgery, Federal University of the State of Rio de Janeiro (Unirio), Rio de Janeiro, Brazil
| | - Marcelo Baggi Tancini
- Department of Psychology, Pontifícia Universidade Católica-Rio, Rio de Janeiro, Brazil
| | - Antonio Egidio Nardi
- Institute of Psychiatry, Federal University of Rio de Janeiro (UFRJ), Av. Venceslau Brás, 71, fundos, CEP 22290-140, Rio de Janeiro, RJ, Brazil
| | - Daniel C Mograbi
- Institute of Psychiatry, Federal University of Rio de Janeiro (UFRJ), Av. Venceslau Brás, 71, fundos, CEP 22290-140, Rio de Janeiro, RJ, Brazil.,Department of Psychology, Pontifícia Universidade Católica-Rio, Rio de Janeiro, Brazil.,Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Elie Cheniaux
- Institute of Psychiatry, Federal University of Rio de Janeiro (UFRJ), Av. Venceslau Brás, 71, fundos, CEP 22290-140, Rio de Janeiro, RJ, Brazil.,Medical Sciences College, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
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Prevalence and psychiatric correlates of suicidal ideation in UK university students. J Affect Disord 2020; 272:191-197. [PMID: 32379615 DOI: 10.1016/j.jad.2020.03.185] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/16/2020] [Accepted: 03/30/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Evidence highlights increased susceptibility to thoughts and behaviors related to suicide (i.e. suicidal ideation) in the student population, often in co-occurrence with mental health difficulties. Typically, studies focus on specific symptoms, with few providing comprehensive examination of risk factors. In this study we examined the prevalence of suicidal ideation among UK university students and assessed the association with multiple psychiatric risk factors. METHODS A total of N = 1273 students completed online measures of suicidal ideation, anxiety, depression, insomnia, mania, psychosis, and perceived stress. RESULTS 37.3% students were classified as high-risk for suicidal behaviour. Moreover, 42.2% of students contemplated suicide at least once within the past twelve months, and 25.1% reported telling someone about these thoughts at least once. Logistic regression analysis showed that suicidal ideation was significantly associated with symptoms of depression, mania, psychosis, and stress. LIMITATIONS The cross-sectional nature of ours study does not allow us to infer causality in the observed associations. CONCLUSIONS Our results indicate the prevalence of suicidal ideation in a large sample of university students in the UK, and highlight associated mental health risk factors associated with it. Our findings have implications for mental health practitioners working with University students.
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Mazereeuw G, Gomes T, Macdonald EM, Greaves S, Li P, Mamdani MM, Redelmeier DA, Juurlink DN. Oxycodone, Hydromorphone, and the Risk of Suicide: A Retrospective Population-Based Case-Control Study. Drug Saf 2020; 43:737-743. [PMID: 32328907 DOI: 10.1007/s40264-020-00924-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Opioids have been increasingly associated with suicide, but whether they are independent contributors is unclear. Oxycodone and hydromorphone are commonly prescribed high-potency opioids that can differentially affect mood. OBJECTIVE The objective of this study was to explore whether oxycodone and hydromorphone are differentially associated with suicide. METHODS We conducted a retrospective population-based case-control study in Ontario, Canada, from 1992 to 2014. Using coronial data, we defined case subjects as individuals who died by suicide involving an opioid overdose. Each of these was matched with up to four controls who died of accidental opioid overdose. We ascertained exposure to oxycodone, hydromorphone, and other opioids from postmortem toxicology testing. We used odds ratios and 95% confidence intervals to examine whether opioid-related suicide was disproportionately associated with oxycodone relative to hydromorphone. RESULTS We identified 438 suicides and 1212 accidental deaths, each of which involved either oxycodone or hydromorphone but not both. The median age at death was 49 years and 51% were men. After adjusting for a history of self-harm, psychiatric illness, and exposure to other opioids, we found that oxycodone was more strongly associated with suicide than hydromorphone (adjusted odds ratio 1.59; 95% confidence interval 1.20-2.11). In a secondary analysis, we observed a trend of similar magnitude in which combined exposure to oxycodone and hydromorphone was more strongly associated with suicide than hydromorphone alone (adjusted odds ratio 1.68; 95% confidence interval 0.92-3.09). CONCLUSIONS While preliminary, these findings support the possibility that some high-potency opioids might independently influence the risk of suicide in susceptible individuals.
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Affiliation(s)
- Graham Mazereeuw
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Erin M Macdonald
- The Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Simon Greaves
- The Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Ping Li
- The Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Muhammad M Mamdani
- Li Ka Shing Centre for Healthcare Analytics Research and Training, Toronto, ON, Canada
| | | | - David N Juurlink
- The Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue G106, Toronto, ON, M4N 3M5, Canada.
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Filgueiras A, Nunes A, Silveira L, de Assis da Silva R, da Silva R, Landeira-Fernandez J, Cheniaux E. Latent structure of the symptomatology of hospitalized patients with bipolar mania. Eur Psychiatry 2020; 29:431-6. [DOI: 10.1016/j.eurpsy.2014.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/30/2014] [Accepted: 02/09/2014] [Indexed: 10/25/2022] Open
Abstract
AbstractSeveral studies have attempted to understand the dimensions of psychiatric symptoms in manic episodes, but only a few have been able to model the latent structure of mania in bipolar disorder patients using confirmatory factor analysis. The objective of the present study was to search for the best model of the symptomatology of hospitalized manic patients. To achieve this goal, 117 manic inpatients during a manic crisis participated in this research. Exploratory factor analysis was conducted followed by confirmatory factor analysis using an exploratory factor analysis solution and three other theory-based models. The exploratory factor analysis results revealed a six-factor structure: depression, suicide, insomnia, mania, psychosis, and anxiety. This solution also presented the best fit to the data when tested with confirmatory factor analysis. A five-factor solution, without suicide as a separate dimension, appeared to be more theoretically suitable. Another important finding was that anxiety was an independent dimension in mania. Some hypotheses are discussed in light of contemporary theories, and future studies should investigate this aspect further.
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Swann AC, Lijffijt M, Simonetti A. Temporal Structure of Mixed States: Does Sensitization Link Life Course to Episodes? Psychiatr Clin North Am 2020; 43:153-165. [PMID: 32008682 DOI: 10.1016/j.psc.2019.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Susceptibility to combined depressive and manic syndromes correlates strongly with arousal-related symptoms including impulsivity, anxiety and agitation. This relationship to a driven, "mixed" activation-depression state, generated by a life-long process, was described in classical times. Course of illness in mixed states includes increased episode frequency, duration, earlier onset, and association with addiction- and trauma/stress-related disorders. Mixed episodes have catecholamine and hypothalamic-pituitary-adrenocortical activity increased beyond nonmixed states of similar symptom severity. These properties resemble behavioral sensitization, where salient, survival-related stimuli (traumatic or rewarding) can generate persistently exaggerated responses with disrupted arousal and reward, with potential for suicide and other severe consequences.
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Affiliation(s)
- Alan C Swann
- Department of Psychiatry, Baylor College of Medicine, 1977 Butler Boulevard, Suite E4.400, Houston, TX 77030, USA; Mental Health Care Line, Michael E. DeBakey VAMC, 2002 East Holcombe Boulevard, Houston, TX 77030, USA.
| | - Marijn Lijffijt
- Department of Psychiatry, Baylor College of Medicine, 1977 Butler Boulevard, Suite E4.400, Houston, TX 77030, USA
| | - Alessio Simonetti
- Department of Psychiatry, Baylor College of Medicine, 1977 Butler Boulevard, Suite E4.400, Houston, TX 77030, USA; Department of Psychiatry and Neurology, Sapienza University of Rome, Rome, Italy
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Uğur K, Tamam L, Özpoyraz N, Demirkol ME. Bipolar bozuklukta özkıyım davranışlarının değerlendirilmesi. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.503328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Khosravani V, Mohammadzadeh A, Sharifi Bastan F, Amirinezhad A, Amini M. Early maladaptive schemas and suicidal risk in inpatients with bipolar disorder. Psychiatry Res 2019; 271:351-359. [PMID: 30529318 DOI: 10.1016/j.psychres.2018.11.067] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 11/29/2018] [Accepted: 11/30/2018] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Vahid Khosravani
- Clinical Research Development Center of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | | | | | - Ali Amirinezhad
- Psychosocial Injuries Research Centre, Ilam University of Medical Sciences, Ilam, Iran
| | - Marziyeh Amini
- Clinical Psychology, Mohaghegh Ardebili University, Ardabil, Iran
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Lenz B, Röther M, Bouna-Pyrrou P, Mühle C, Tektas OY, Kornhuber J. The androgen model of suicide completion. Prog Neurobiol 2018; 172:84-103. [PMID: 29886148 DOI: 10.1016/j.pneurobio.2018.06.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 09/02/2017] [Accepted: 06/05/2018] [Indexed: 10/14/2022]
Abstract
Suicide is a devastating public health issue that imposes severe psychological, social, and economic burdens not only for the individuals but also for their relatives, friends, clinicians, and the general public. Among the different suicidal behaviors, suicide completion is the worst and the most relevant outcome. The knowledge of biological etiopathological mechanisms involved in suicide completion is limited. Hitherto, no objective markers, either alone or in combination, can reliably predict who will complete a suicide. However, such parameters are strongly needed to establish and optimize prediction and prevention. We introduce here a novel ideation-to-completion framework in suicide research and discuss the problems of studies aiming at identifying and validating clinically useful markers. The male gender is a specific risk factor for suicide, which suggests that androgen effects are implicated in the transition from suicidal ideation to suicide completion. We present multiple lines of direct and indirect evidence showing that both an increased prenatal androgen load (with subsequent permanent neuroadaptations) and increased adult androgen activity are involved in suicide completion. We also review data arguing that modifiable maternal behavioral traits during pregnancy contribute to the offspring's prenatal androgen load and increase the risk for suicide completion later in life. We conclude that in utero androgen exposure and adult androgen levels facilitate suicide completion in an synergistic manner. The androgen model of suicide completion provides the basis for the development of novel predictive and preventive strategies in the future.
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Affiliation(s)
- Bernd Lenz
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany.
| | - Mareike Röther
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany
| | - Polyxeni Bouna-Pyrrou
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany
| | - Christiane Mühle
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany
| | - Ozan Y Tektas
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany
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10
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Berk L, Hallam KT, Venugopal K, Lewis AJ, Austin DW, Kulkarni J, Dodd S, de Castella A, Fitzgerald PB, Berk M. Impact of irritability: a 2-year observational study of outpatients with bipolar I or schizoaffective disorder. Bipolar Disord 2017; 19:184-197. [PMID: 28470892 DOI: 10.1111/bdi.12486] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 03/12/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Many people experience irritability when manic, hypomanic, or depressed, yet its impact on illness severity and quality of life in bipolar and schizoaffective disorders is poorly understood. This study aimed to examine the relationship between irritability and symptom burden, functioning, quality of life, social support, suicidality, and overall illness severity in a naturalistic cohort of people with bipolar I or schizoaffective disorder. METHODS We used data from 239 adult outpatients with bipolar I or schizoaffective disorder in the Bipolar Comprehensive Outcomes Study (BCOS) - a non-interventional observational study with a 2-year follow-up period. Baseline demographic and clinical characteristics of participants with and without irritability were compared. A mixed-model repeated measures analysis was conducted to examine the longitudinal effect of irritability on clinical and quality-of-life variables over follow-up using significant baseline variables. RESULTS At baseline, 54% of participants were irritable. Baseline irritability was associated with illness severity, mania, depression, psychotic symptoms, suicidality, poor functioning, and quality of life, but not diagnosis (schizoaffective/bipolar disorder). Participants with irritability were less likely to have a partner and perceived less adequate social support. On average, over follow-up, those with irritability reported more symptoms, functional impairment, and suicidality. Furthermore, the effects of irritability could not be fully explained by illness severity. CONCLUSIONS Irritability was associated with more negative symptomatic, functional, and quality-of-life outcomes and suicidality. The identification, monitoring, and targeted treatment of irritability may be worth considering, to enhance health and wellbeing outcomes for adults with bipolar and schizoaffective disorders.
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Affiliation(s)
- Lesley Berk
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, Vic., Australia.,Department of Psychiatry, University of Melbourne, Parkville, Vic., Australia.,Melbourne School of Global and Population Health, University of Melbourne, Parkville, Vic., Australia
| | - Karen T Hallam
- Department of Psychology, The University of Melbourne, Parkville, Vic., Australia.,Department of Psychology, Victoria University, Melbourne, Vic., Australia
| | - Kamalesh Venugopal
- South Australian Department for Health and Ageing, Adelaide, SA, Australia
| | - Andrew James Lewis
- School of Psychology & Exercise Science, Murdoch University, Murdoch, WA, Australia.,Harry Perkins Institute of Medical Research, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - David W Austin
- School of Psychology, Faculty of Health, Deakin University, Burwood, Vic., Australia
| | - Jayashri Kulkarni
- Monash Alfred Psychiatry Research Centre (MAPrc), Monash University Central Clinical School and The Alfred, Melbourne, Vic., Australia
| | - Seetal Dodd
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, Vic., Australia.,Department of Psychiatry, University of Melbourne, Parkville, Vic., Australia.,Centre for Youth Mental Health, University of Melbourne, Parkville, Vic., Australia
| | - Anthony de Castella
- Monash Alfred Psychiatry Research Centre (MAPrc), Monash University Central Clinical School and The Alfred, Melbourne, Vic., Australia
| | - Paul B Fitzgerald
- Monash Alfred Psychiatry Research Centre (MAPrc), Monash University Central Clinical School and The Alfred, Melbourne, Vic., Australia
| | - Michael Berk
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, Vic., Australia.,Department of Psychiatry, University of Melbourne, Parkville, Vic., Australia.,Centre for Youth Mental Health, University of Melbourne, Parkville, Vic., Australia.,Florey Institute for Neuroscience and Mental Health, Parkville, Vic., Australia
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11
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[Differences in Subjective Experience Between Unipolar and Bipolar Depression]. ACTA ACUST UNITED AC 2016; 45:162-9. [PMID: 27569010 DOI: 10.1016/j.rcp.2015.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 08/09/2015] [Accepted: 09/25/2015] [Indexed: 11/22/2022]
Abstract
INTRODUCTION It is important to make distinction between bipolar and unipolar depression because treatment and prognosis are different. Since the diagnosis of the two conditions is purely clinical, find symptomatic differences is useful. OBJECTIVES Find differences in subjective experience (first person) between unipolar and bipolar depression. METHODS Phenomenological-oriented qualitative exploratory study of 12 patients (7 with bipolar depression and 5 with unipolar depression, 3 men and 9 women). We used a semi-structured interview based on Examination of Anomalous Self-Experience (EASE). RESULTS The predominant mood in bipolar depression is emotional dampening, in unipolar is sadness. The bodily experience in bipolar is of a heavy, tired body; an element that inserts between the desires of acting and performing actions and becomes an obstacle to the movement. In unipolar is of a body that feels more comfortable with the stillness than activity, like laziness of everyday life. Cognition and the stream of consciousness: in bipolar depression, compared with unipolar, thinking is slower, as if to overcome obstacles in their course. There are more difficult to understand what is heard or read. Future perspective: in bipolar depression, hopelessness is stronger and broader than in unipolar, as if the very possibility of hope was lost. CONCLUSIONS Qualitative differences in predominant mood, bodily experience, cognition and future perspective were found between bipolar and unipolar depression.
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12
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Stange JP, Kleiman EM, Sylvia LG, Vieira da SilvaMagalhães P, Berk M, Nierenberg AA, Deckersbach T. SPECIFIC MOOD SYMPTOMS CONFER RISK FOR SUBSEQUENT SUICIDAL IDEATION IN BIPOLAR DISORDER WITH AND WITHOUT SUICIDE ATTEMPT HISTORY: MULTI-WAVE DATA FROM STEP-BD. Depress Anxiety 2016; 33:464-72. [PMID: 26756163 PMCID: PMC4889534 DOI: 10.1002/da.22464] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/04/2015] [Accepted: 12/12/2015] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Little is known about specific mood symptoms that may confer risk for suicidal ideation (SI) among patients with bipolar disorder (BD). We evaluated prospectively whether particular symptoms of depression and mania precede the onset or worsening of SI, among adults with or without a history of a suicide attempt. METHODS We examined prospective data from a large (N = 2,741) cohort of patients participating in the Systematic Treatment Enhancement Program for BD (STEP-BD). We evaluated history of suicide attempts at baseline, and symptoms of depression and mania at baseline and follow-up visits. Hierarchical linear modeling tested whether specific mood symptoms predicted subsequent levels of SI, and whether the strength of the associations differed based on suicide attempt history, after accounting for the influence of other mood symptoms and current SI. RESULTS Beyond overall current depression and mania symptom severity, baseline SI, and illness characteristics, several mood symptoms, including guilt, reduced self-esteem, psychomotor retardation and agitation, increases in appetite, and distractibility predicted more severe levels of subsequent SI. Problems with concentration, distraction, sleep loss and decreased need for sleep predicted subsequent SI more strongly among individuals with a suicide attempt history. CONCLUSIONS Several specific mood symptoms may confer risk for the onset or worsening of SI among treatment-seeking patients with BD. Individuals with a previous suicide attempt may be at greater risk in part due to greater reactivity to certain mood symptoms in the form of SI. However, overall, effect sizes were small, suggesting the need to identify additional proximal predictors of SI.
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Affiliation(s)
- Jonathan P. Stange
- Department of Psychology, Temple University, Philadelphia, Pennsylvania, USA
| | - Evan M. Kleiman
- Department of Psychology, Harvard University, Cambridge, Massachusetts, USA
| | - Louisa G. Sylvia
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Pedro Vieira da SilvaMagalhães
- National Institute for Translational Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Michael Berk
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Barwon Health, Geelong, Victoria, Australia,Orygen, The National Centre of Excellence in Youth Mental Health, Department of Psychiatry and The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia
| | - Andrew A. Nierenberg
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Beyer JL, Weisler RH. Suicide Behaviors in Bipolar Disorder: A Review and Update for the Clinician. Psychiatr Clin North Am 2016; 39:111-23. [PMID: 26876322 DOI: 10.1016/j.psc.2015.09.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- John L Beyer
- Duke University Medical Center, Box 3519, Durham, NC 27710, USA.
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Ostacher MJ, Nierenberg AA, Rabideau D, Reilly-Harrington NA, Sylvia LG, Gold AK, Shesler LW, Ketter TA, Bowden CL, Calabrese JR, Friedman ES, Iosifescu DV, Thase ME, Leon AC, Trivedi MH. 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). J Psychiatr Res 2015; 71:126-33. [PMID: 26476489 PMCID: PMC6778403 DOI: 10.1016/j.jpsychires.2015.10.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 08/11/2015] [Accepted: 10/01/2015] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Michael J. Ostacher
- VA Palo Alto Health Care System, Palo Alto, CA, USA,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Corresponding author. VA Palo Alto Health Care System 3801 Miranda Ave, Mail Code 151-T Palo Alto, CA 94304, USA. (M.J. Ostacher)
| | - Andrew A. Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Dustin Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Noreen A. Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Louisa G. Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Alexandra K. Gold
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Leah W. Shesler
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Terence A. Ketter
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Charles L. Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Joseph R. Calabrese
- Bipolar Disorders Research Center, University Hospital’s Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Edward S. Friedman
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dan V. Iosifescu
- Department of Psychiatry, Icahn School of medicine at Mount Sinai, New York, NY, USA
| | - Michael E. Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, USA
| | - Andrew C. Leon
- Biostatistics in Psychiatry & Public Health, Weill Cornell Medical College, New York, NY, USA
| | - Madhukar H. Trivedi
- Department of Psychiatry, The University of Texas Southwestern Medical Center, USA
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Umamaheswari V, Avasthi A, Grover S. Risk factors for suicidal ideations in patients with bipolar disorder. Bipolar Disord 2014; 16:642-51. [PMID: 24467510 DOI: 10.1111/bdi.12179] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Accepted: 08/29/2013] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To identify the risk factors for suicidal ideation in subjects with bipolar depression. METHODS One-hundred and thirty subjects diagnosed with bipolar depression were evaluated on the following scales: Beck Depression Inventory (BDI), Beck Hopelessness Scale (BHS), Patient Health Questionnaire-15 (PHQ-15), Barrat's Impulsivity Scale (BIS), Irritability, Anxiety, and Depression (IDA) Scale, Young Mania Rating Scale (YMRS), Buss-Durke Hostile Inventory (BDHI), and Brief Psychiatric Rating Scale (BPRS). RESULTS Based on the BDI suicidal thoughts and wishes item (score of ≥ 1), the study sample was divided into those with and those without suicidal ideation. Compared to those without suicidal ideations, patients with bipolar depression with suicidal ideation had significantly higher scores on the BDI, YMRS, BPRS total score, IDA total score, PHQ-15, BHS total score, and most of the hostility subscales of the BHI. [corrected]. On binary logistic regression analysis, the odds ratio (OR) for [corrected] presence of suicidal ideations was more than one and was significant for the BHS [OR = 1.53, [corrected] 95% confidence interval (CI): 1.24-1.99], the IDA-irritability directed inwards (OR = 1.48, 95% CI: 1.03-2.13), and the total hostility score (OR = 1.10, 95% CI: 1.02-1.20). Other factors for which the OR was more than one but the difference was not statistically significant were: Hindu religion (OR = 3.13, 95% CI: 0.76-12.99), lifetime mean duration of depressive episodes (OR = 1.08, 95% CI: 0.74-1.57), past history of hospitalization (OR = 1.10, 95% CI: 0.24-6.16), any preceding life events (OR = 1.45, 95% CI: 0.28-7.52), subsyndromal manic symptoms (OR = 1.01, 95% CI:0.53-1.92), presence of psychotic symptoms (OR = 1.06, 95% CI: 0.92-1.22), and irritability directed outwards (OR = 1.14, 95% CI: 0.92-1.41). [corrected]. CONCLUSION Among the various predictors of suicidal ideations, the severity of hopelessness, irritability directed inwards, and hostility are the most important risk factors for suicidal ideations in patients with bipolar disorder. [corrected]. Hence, patients with these risk factors should be closely monitored to prevent suicide attempts and completed suicides.
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Affiliation(s)
- Vanamoorthy Umamaheswari
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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16
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Isometsä E. Suicidal behaviour in mood disorders--who, when, and why? CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2014; 59:120-30. [PMID: 24881160 PMCID: PMC4079239 DOI: 10.1177/070674371405900303] [Citation(s) in RCA: 180] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE About one-half to two-thirds of all suicides are by people who suffer from mood disorders; preventing suicides among those who suffer from them is thus central for suicide prevention. Understanding factors underlying suicide risk is necessary for rational preventive decisions. METHOD The literature on risk factors for completed and attempted suicide among subjects with depressive and bipolar disorders (BDs) was reviewed. RESULTS Lifetime risk of completed suicide among psychiatric patients with mood disorders is likely between 5% and 6%, with BDs, and possibly somewhat higher risk than patients with major depressive disorder. Longitudinal and psychological autopsy studies indicate suicidal acts usually take place during major depressive episodes (MDEs) or mixed illness episodes. Incidence of suicide attempts is about 20- to 40-fold, compared with euthymia, during these episodes, and duration of these high-risk states is therefore an important determinant of overall risk. Substance use and cluster B personality disorders also markedly increase risk of suicidal acts during mood episodes. Other major risk factors include hopelessness and presence of impulsive-aggressive traits. Both childhood adversity and recent adverse life events are likely to increase risk of suicide attempts, and suicidal acts are predicted by poor perceived social support. Understanding suicidal thinking and decision making is necessary for advancing treatment and prevention. CONCLUSION Among subjects with mood disorders, suicidal acts usually occur during MDEs or mixed episodes concurrent with comorbid disorders. Nevertheless, illness factors can only in part explain suicidal behaviour. Illness factors, difficulty controlling impulsive and aggressive responses, plus predisposing early exposures and life situations result in a process of suicidal thinking, planning, and acts.
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Affiliation(s)
- Erkki Isometsä
- Professor of Psychiatry, Department of Psychiatry, University of Helsinki, Helsinki, Finland; Research Professor, Department of Mental Health and Substance Use Services, National Institute for Health and Welfare, Helsinki, Finland
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17
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Paterniti S, Bisserbe JC. Pharmacotherapy for bipolar disorder and concordance with treatment guidelines: survey of a general population sample referred to a tertiary care service. BMC Psychiatry 2013; 13:211. [PMID: 23941445 PMCID: PMC3751340 DOI: 10.1186/1471-244x-13-211] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 08/05/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many new approaches have been adopted for the treatment of bipolar disorder (BD) in the past few years, which strived to produce more positive outcomes. To enhance the quality of care, several guideline recommendations have been developed. For study purposes, we monitored the prescription of psychotropic drugs administered to bipolar patients who had been referred to tertiary care services, and assessed the degree to which treatment met specific guidelines. METHODS Between December 2006 and February 2009, we assessed 113 individuals suffering from BD who had been referred to the Royal Ottawa Mental Health Centre (ROMHC) Mood Disorders Program by physicians within the community, mostly general practitioners. The Structured Clinical Interview for DSM-IV-TR was used to assess diagnosis. The prescribed treatment was compared with specific Canadian guidelines (CANMAT, 2009). Univariate analyses and logistic regression were used to assess the contribution of demographic and clinical factors for concordance of treatment with guidelines. RESULTS Thirty-two subjects had BD type I (BD-I), and 81 subjects had BD type II (BD-II). All subjects with BD-I, and 90% of the BD-II group were given at least one psychotropic treatment. Lithium was more often prescribed for subjects with BD-I (62%) than those with BD-II (19%). Antidepressants were the most frequently prescribed class of psychotropics. Sixty-eight percent of subjects received treatment concordant with guidelines by medication and dose. The presence of a current hypomanic episode was independently associated with poorer concordance to guidelines. In more than half the cases, the inappropriate use of antidepressants was at the origin of the non concordance of treatment with respect to guidelines. Absence of psychotropic treatment in bipolar II patients and inadequate dosage of mood stabilizers were the two other main causes of non concordance with guidelines. CONCLUSIONS The factors related to treatment not concordant with guidelines should be further explored to determine appropriate strategies in implementing the use of guidelines in clinical practice.
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Hauser M, Galling B, Correll CU. Suicidal ideation and suicide attempts in children and adolescents with bipolar disorder: a systematic review of prevalence and incidence rates, correlates, and targeted interventions. Bipolar Disord 2013; 15:507-23. [PMID: 23829436 PMCID: PMC3737391 DOI: 10.1111/bdi.12094] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 04/25/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Pediatric bipolar disorder (PBD) is associated with poor outcomes, including suicidal ideation (SI) and suicide attempt (SA). However, frequencies and risk factors of SI/SA and targeted intervention trials for SI/SA in PBD have not been reviewed systematically. METHODS We conducted a systematic PubMed review, searching for articles reporting on prevalences/incidences, correlates and intervention studies targeting SI/SA in PBD. Weighted means were calculated, followed by an exploratory meta-regression of SI and SA correlates. RESULTS Fourteen studies (n = 1595), in which 52.1% of patients were male and the mean age was 14.4 years, reported data on SI/SA prevalence (N = 13, n = 1508) and/or correlates (N = 10, n = 1348) in PBD. Weighted mean prevalences were: past SI = 57.4%, past SA = 21.3%, current SI = 50.4%, and current SA = 25.5%; incidences (mean 42 months of follow-up) were: SI = 14.6% and SA = 14.7%. Regarding significant correlates, SI (N = 3) was associated with a higher percentage of Caucasian race, narrow (as opposed to broad) PBD phenotype, younger age, and higher quality of life than SA. Significant correlates of SA (N = 10) included female sex, older age, earlier illness onset, more severe/episodic PBD, mixed episodes, comorbid disorders, past self-injurious behavior/SI/SA, physical/sexual abuse, parental depression, family history of suicidality, and poor family functioning. Race, socioeconomic status, living situation, and life events were not clearly associated with SA. In a meta-regression analysis, bipolar I disorder and comorbid attention-deficit hyperactivity disorder were significantly associated with SA. Only one open label study targeting the reduction of SI/SA in PBD was identified. CONCLUSIONS SI and SA are very common but under-investigated in PBD. Exploration of predictors and protective factors is imperative for the establishment of effective preventive and intervention strategies, which are urgently needed.
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Affiliation(s)
- Marta Hauser
- The Zucker Hillside Hospital, Glen Oaks, Hempstead, NY, USA,The Feinstein Institute for Medical Research, Manhasset, Hempstead, NY, USA,Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA
| | - Britta Galling
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatic Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Christoph U Correll
- The Zucker Hillside Hospital, Glen Oaks, Hempstead, NY, USA,The Feinstein Institute for Medical Research, Manhasset, Hempstead, NY, USA,Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA,Albert Einstein College of Medicine, Bronx, New York, USA
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19
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Yerevanian BI, Choi YM. Impact of psychotropic drugs on suicide and suicidal behaviors. Bipolar Disord 2013; 15:594-621. [PMID: 23869907 DOI: 10.1111/bdi.12098] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 03/25/2013] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To examine the impact of psychotropic drugs on suicide and suicidal behaviors in bipolar disorders. METHODS A Medline search of articles published from January 1960 to January 2013 was performed using relevant keywords to identify studies examining the relationship of psychotropic drugs to suicidal behaviors. The publications were further reviewed for relevant references and information. Additionally, the US Food and Drug Administration Center for Drug Evaluation Research website was searched. RESULTS The available studies used differing methodologies, making interpretation of the findings difficult. Studies suggest that antidepressants may increase suicidal risk in bipolar disorder, this possibly being related to the induction of broadly defined mixed states. There is no evidence that antiepileptic drugs as a class increase suicidal risk in patients with bipolar disorder. Only lithium provides convincing data that it reduces the risk of suicide over the long term. There is little known regarding the effects of antipsychotics, as well as anti-anxiety and hypnotic drugs, on suicidal behavior. CONCLUSIONS The available evidence for the impact of psychotropics on suicidal risk in patients with bipolar disorder is largely methodologically flawed and, except for a few instances, clinically not useful at this point. Adequately powered, prospective randomized controlled studies are needed to assess the impact of each class of psychotropic and each psychotropic as well as common combination therapies. Until such studies have been carried out, clinicians are urged to exercise caution in using these drugs and rely on the traditional means of carefully assessing and monitoring patients with bipolar disorder who are at high risk for suicide.
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Affiliation(s)
- Boghos I Yerevanian
- Department of Psychiatry, Greater Los Angeles VA Healthcare System, Sepulveda Ambulatory Care Center, North Hills, CA 91343, USA.
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20
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Pawlak J, Dmitrzak-Węglarz M, Skibińska M, Szczepankiewicz A, Leszczyńska-Rodziewicz A, Rajewska-Rager A, Zaremba D, Czerski P, Hauser J. Suicide attempts and clinical risk factors in patients with bipolar and unipolar affective disorders. Gen Hosp Psychiatry 2013; 35:427-32. [PMID: 23643033 DOI: 10.1016/j.genhosppsych.2013.03.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 03/18/2013] [Accepted: 03/19/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Suicide is an important clinical problem in psychiatric patients. The highest risk of suicide attempts is noted in affective disorders. OBJECTIVE The aim of the study was to look for suicide risk factors among sociodemographic and clinical factors, family history and stressful life events in patients with diagnosis of unipolar and bipolar affective disorder (597 patients, 563 controls). METHOD In the study, the Structured Clinical Interview for DSM-IV Axis I Disorders and the Operational Criteria Diagnostic Checklist questionnaires, a questionnaire of family history, and a questionnaire of personality disorders and life events were used. RESULTS In the bipolar and unipolar affective disorders sample, we observed an association between suicidal attempts and the following: family history of psychiatric disorders, affective disorders and psychoactive substance abuse/dependence; inappropriate guilt in depression; chronic insomnia and early onset of unipolar disorder. The risk of suicide attempt differs in separate age brackets (it is greater in patients under 45 years old). No difference in family history of suicide and suicide attempts; marital status; offspring; living with family; psychotic symptoms and irritability; and coexistence of personality disorder, anxiety disorder or substance abuse/dependence with affective disorder was observed in the groups of patients with and without suicide attempt in lifetime history.
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Affiliation(s)
- Joanna Pawlak
- Laboratory of Psychiatric Genetics, Department of Psychiatry, University of Medical Sciences, ul Szpitalna 27/33, 60-572 Poznan, Poland.
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21
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Gonda X, Pompili M, Serafini G, Montebovi F, Campi S, Dome P, Duleba T, Girardi P, Rihmer Z. Suicidal behavior in bipolar disorder: epidemiology, characteristics and major risk factors. J Affect Disord 2012; 143:16-26. [PMID: 22763038 DOI: 10.1016/j.jad.2012.04.041] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 04/19/2012] [Accepted: 04/19/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Suicide is one of the leading causes of death and a major public health problem worldwide, and the majority of suicide attempters and completers suffer from some major affective disorder at the time of their death, which, in the majority of cases is unrecognized, under- or misdiagnosed and untreated. METHODS Based on a systematic literature search, the authors give a detailed and critical overview of established risk factors of suicide in bipolar disorder. RESULTS Among affective disorders, bipolar disorder carries the highest risk of suicide, yet not all bipolar patients commit or even attempt suicide during their illness. While the general suicide risk factors also apply for bipolar disorders, there are several disease-specific risk factors as well which should be taken into account when evaluating suicide risk in case of patients. CONCLUSION It is crucial to identify suicide risk factors in bipolar disorder to be able to differentiate those patients within this already increased-risk illness group who are at especially high risk and therefore to allow for better prediction and prevention of suicidal acts.
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Affiliation(s)
- Xenia Gonda
- Department of Clinical and Theoretical Mental Health, Kútvölgyi Clinical Center, Semmelweis University, Kútvölgyi ut 4., 1125 Budapest, Hungary.
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22
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M'Bailara K, Atzeni T, Colom F, Swendsen J, Gard S, Desage A, Henry C. Emotional hyperreactivity as a core dimension of manic and mixed states. Psychiatry Res 2012; 197:227-30. [PMID: 22414662 DOI: 10.1016/j.psychres.2011.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 08/30/2011] [Accepted: 12/01/2011] [Indexed: 11/16/2022]
Abstract
Despite its obvious importance in mood disorders, characterization of emotional reactivity has been neglected in bipolar disorders. Concerning manic states and the current classification, the main criterion is the presence of an elevated or expansive mood. In contrast to this characteristic and often prolonged mood state, emotional reactivity refers to a brief evoked response to salient emotional stimuli. The goal of this study was to assess the intensity of emotional responses triggered by viewing slides in bipolar patients with manic or mixed states. Our hypothesis was that all emotional responses are exacerbated, whatever the valence of the stimuli. We compared 33 patients with manic or mixed states with 33 matched euthymic patients and 33 healthy control subjects. Arousal and attribution of valence were assessed while subjects viewed slides taken from the International Affective Picture System (positive, neutral and negative slides). Patients with manic or mixed states reported a higher arousal when viewing all types of slides in comparison with the other groups. Concerning attribution of valence, patients with manic or mixed states assessed neutral slides as more pleasant. When bipolar patients with manic and mixed states are placed in front of positive, neutral and negative slides, the slides trigger a higher intensity of emotions, whatever the valence of the emotional stimuli. These results strengthen the importance of emotional hyperreactivity as a core dimension in manic and mixed states in bipolar disorder.
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Affiliation(s)
- Katia M'Bailara
- Laboratory of Psychology, University Bordeaux Segalen, Bordeaux, France.
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23
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Ryu V, Jon DI, Cho HS, Kim SJ, Lee E, Kim EJ, Seok JH. Initial depressive episodes affect the risk of suicide attempts in Korean patients with bipolar disorder. Yonsei Med J 2010; 51:641-7. [PMID: 20635436 PMCID: PMC2908881 DOI: 10.3349/ymj.2010.51.5.641] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Suicide is a major concern for increasing mortality in bipolar patients, but risk factors for suicide in bipolar disorder remain complex, including Korean patients. Medical records of bipolar patients were retrospectively reviewed to detect significant clinical characteristics associated with suicide attempts. MATERIALS AND METHODS A total of 579 medical records were retrospectively reviewed. Bipolar patients were divided into two groups with the presence of a history of suicide attempts. We compared demographic characteristics and clinical features between the two groups using an analysis of covariance and chi-square tests. Finally, logistic regression was performed to evaluate significant risk factors associated with suicide attempts in bipolar disorder. RESULTS The prevalence of suicide attempt was 13.1% in our patient group. The presence of a depressive first episode was significantly different between attempters and nonattempters. Logistic regression analysis revealed that depressive first episodes and bipolar II disorder were significantly associated with suicide attempts in those patients. CONCLUSION Clinicians should consider the polarity of the first mood episode when evaluating suicide risk in bipolar patients. This study has some limitations as a retrospective study and further studies with a prospective design are needed to replicate and evaluate risk factors for suicide in patients with bipolar disorder.
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Affiliation(s)
- Vin Ryu
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Duk-In Jon
- Department of Psychiatry, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hyun Sang Cho
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Se Joo Kim
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Lee
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Joo Kim
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Ho Seok
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
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Chessick CA, Perlick DA, Miklowitz DJ, Dickinson LM, Allen MH, Morris CD, Gonzalez JM, Marangell LB, Cosgrove V, Ostacher M. Suicidal ideation and depressive symptoms among bipolar patients as predictors of the health and well-being of caregivers. Bipolar Disord 2009; 11:876-84. [PMID: 19922556 PMCID: PMC2796426 DOI: 10.1111/j.1399-5618.2009.00765.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Few studies have addressed the physical and mental health effects of caring for a family member with bipolar disorder. This study examined whether caregivers' health is associated with changes in suicidal ideation and depressive symptoms among bipolar patients observed over one year. METHODS Patients (N = 500) participating in the Systematic Treatment Enhancement Program for Bipolar Disorder and their primary caregivers (N = 500, including 188 parental and 182 spousal caregivers) were evaluated for up to one year as part of a naturalistic observational study. Caregivers' perceptions of their own physical health were evaluated using the general health scale from the Medical Outcomes Study 36-item Short-Form Health Survey. Caregivers' depression was evaluated using the Center for Epidemiological Studies of Depression Scale. RESULTS Caregivers of patients who had increasing suicidal ideation over time reported worsening health over time compared to caregivers of patients whose suicidal ideation decreased or stayed the same. Caregivers of patients who had more suicidal ideation and depressive symptoms reported more depressed mood over a one-year reporting period than caregivers of patients with less suicidal ideation or depression. The pattern of findings was consistent across parent caregivers and spousal caregivers. CONCLUSIONS Caregivers, rightly concerned about patients becoming suicidal or depressed, may try to care for the patient at the expense of their own health and well-being. Treatments that focus on the health of caregivers must be developed and tested.
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Affiliation(s)
- Cheryl A Chessick
- Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, CO 80045, USA.
| | | | - David J Miklowitz
- Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, CO,University of Colorado, Boulder, CO
| | - L Miriam Dickinson
- Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, CO
| | - Michael H Allen
- Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, CO
| | - Chad D Morris
- Department of Psychiatry, University of Colorado Denver School of Medicine, Denver, CO
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25
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Abreu LND, Lafer B, Baca-Garcia E, Oquendo MA. Suicidal ideation and suicide attempts in bipolar disorder type I: an update for the clinician. REVISTA BRASILEIRA DE PSIQUIATRIA 2009; 31:271-80. [DOI: 10.1590/s1516-44462009005000003] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 04/01/2009] [Indexed: 12/18/2022]
Abstract
OBJECTIVE: This article reviews the evidence for the major risk factors associated with suicidal behavior in bipolar disorder. METHOD: Review of the literature studies on bipolar disorder, suicidal behavior and suicidal ideation. RESULTS: Bipolar disorder is strongly associated with suicide ideation and suicide attempts. In clinical samples between 14-59% of the patients have suicide ideation and 25-56% present at least one suicide attempt during lifetime. Approximately 15% to 19% of patients with bipolar disorder die from suicide. The causes of suicidal behavior are multiple and complex. Some strong predictors of suicidal behavior have emerged in the literature such as current mood state, severity of depression, anxiety, aggressiveness, hostility, hopelessness, comorbidity with others Axis I and Axis II disorders, lifetime history of mixed states, and history of physical or sexual abuse. CONCLUSION: Bipolar disorder is the psychiatric condition associated with highest lifetime risk for suicide attempts and suicide completion. Thus it is important to clinicians to understand the major risk factors for suicidal behavior in order to choose better strategies to deal with this complex behavior.
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Differences in cholesterol and metabolic syndrome between bipolar disorder men with and without suicide attempts. Acta Neuropsychiatr 2009; 21 Suppl 2:66-9. [PMID: 25384877 DOI: 10.1017/s0924270800032798] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patient with mental illnesses such as schizophrenia and bipolar disorder have an increased prevalence of metabolic syndrome (MetS) and its components compared to general population. Among psychiatric disorders, bipolar disorder ranks highest in suicidality with a relative risk ratio of completed suicide of about 25 compared to the general population. Regarding the biological hypotheses of suicidality, low blood cholesterol level has been extensively explored, although results are still conflicting. The aim of this study was to investigate whether there were differences in the serum cholesterol levels in hospitalized bipolar disorder men patients with history of suicide attempts (n= 20) and without suicide attempts (n= 20). Additionally, we investigated if there were differences in the prevalence of MetS according to NCEP ATP-III criteria in these two groups of patients. Results of the study indicated significantly lower serum cholesterol levels (P = 0.013) and triglyceride levels (P = 0.047), in the bipolar disorder men with suicide attempts in comparison to bipolar disorder men without suicide attempts. The overall prevalence of MetS was 11/40 (27.5%). On this particular sample it was higher in the non-attempters 8/20 (40.0%) than in attempters 3/20 (15.0%) bipolar men group, but without statistical significance. Lower concentrations of serum cholesterol might be useful biological markers of suicidality in men with bipolar disorder.
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Vuksan-Cusa B, Marcinko D, Nad S, Jakovljević M. Differences in cholesterol and metabolic syndrome between bipolar disorder men with and without suicide attempts. Prog Neuropsychopharmacol Biol Psychiatry 2009; 33:109-12. [PMID: 19026707 DOI: 10.1016/j.pnpbp.2008.10.017] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2008] [Revised: 10/08/2008] [Accepted: 10/25/2008] [Indexed: 01/12/2023]
Abstract
Patient with mental illnesses such as schizophrenia and bipolar disorder have an increased prevalence of metabolic syndrome (MetS) and its components compared to general population. Among psychiatric disorders, bipolar disorder ranks highest in suicidality with a relative risk ratio of completed suicide of about 25 compared to the general population. Regarding the biological hypotheses of suicidality, low blood cholesterol level has been extensively explored, although results are still conflicting. The aim of this study was to investigate whether there were differences in the serum cholesterol levels in hospitalized bipolar disorder men patients with history of suicide attempts (N=20) and without suicide attempts (N=20). Additionally, we investigated if there were differences in the prevalence of MetS according to NCEP ATP-III criteria in these two groups of patients. Results of the study indicated significantly lower serum cholesterol levels (p=0.013) and triglyceride levels (p=0.047), in the bipolar disorder men with suicide attempts in comparison to bipolar disorder men without suicide attempts. The overall prevalence of MetS was 11/40 (27.5%). On this particular sample it was higher in the non-attempters 8/20 (40.0%) than in attempters 3/20 (15.0%) bipolar men group, but without statistical significance. Lower concentrations of serum cholesterol might be useful biological markers of suicidality in men with bipolar disorder.
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Affiliation(s)
- Bjanka Vuksan-Cusa
- University Hospital Centre Zagreb, Department of Psychiatry, Zagreb, Croatia.
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Elizabeth Sublette M, Carballo JJ, Moreno C, Galfalvy HC, Brent DA, Birmaher B, John Mann J, Oquendo MA. Substance use disorders and suicide attempts in bipolar subtypes. J Psychiatr Res 2009; 43:230-8. [PMID: 18590916 PMCID: PMC2671238 DOI: 10.1016/j.jpsychires.2008.05.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 04/25/2008] [Accepted: 05/13/2008] [Indexed: 11/19/2022]
Abstract
Bipolar disorder (BD) is associated with high rates of suicide attempt and completion. Substance use disorders (SUD) have been identified as potent risk factors for suicidal behavior in BD. However, little is known concerning differences between BD subtypes with regard to SUD as a risk factor for suicidal behavior. We studied previous suicidal behavior in adults with a major depressive episode in context of BD type I (BD-I; N=96) or BD type II (BD-II; N=42), with and without history of SUD. Logistic regressions assessed the association between SUD and suicide attempt history by BD type, and exploratory analyses examined the effects of other clinical characteristics on these relationships. SUD were associated with suicide attempt in BD-I but not BD-II, an effect not attributable to sample size differences. The higher suicide attempt rate associated with alcoholism in BD-I was mostly explained by higher aggression scores, and earlier age of BD onset increased the likelihood that alcohol use disorder would be associated with suicide attempt(s). The higher suicide attempt rate associated with other drug use disorders in BD-I was collectively explained by higher impulsivity, hostility, and aggression scores. The presence of both alcohol and drug use disorders increased odds of a history of suicide attempt in a multiplicative fashion: 97% of BD-I who had both co-morbid drug and alcohol use disorders had made a suicide attempt. A critical next question is how to target SUD and aggressive traits for prevention of suicidal behavior in BD-I.
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Affiliation(s)
- M Elizabeth Sublette
- Department of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, 1051 Riverside Drive, Unit 42, 10032, United States.
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Rosa AR, Franco C, Martínez-Aran A, Sánchez-Moreno J, Salamero M, Valenti M, Tabarés-Seisdedos R, González-Pinto A, Kapczinski F, Vieta E. Functional impairment and previous suicide attempts in bipolar disorder. Acta Neuropsychiatr 2008; 20:300-6. [PMID: 25384411 DOI: 10.1111/j.1601-5215.2008.00339.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of the present study was to assess the association between previous suicide attempts and functional impairment among euthymic patients with bipolar disorder (BD). METHODS Seventy-one Diagnostic Statistical Manual IV (DSM-IV) patients with BD and 61 healthy volunteers were recruited from the Bipolar Disorder Program at the Clinic Hospital of Barcelona. Patients with (n = 36, 50.7%) and without (n = 35, 49.3%) previous suicide attempts were assessed using the Structured Clinical Interview for DSM-IV-TR (SCID-P). Previous suicide attempts were carefully investigated by means of patient and caregiver interview and by a standard structured interview from the protocol of our BD Program. The Functioning Assessment Short Test (FAST) was employed to assess functional impairment. RESULTS Euthymic patients with previous suicide attempts showed functional impairment, particularly in occupational (F = 30.39; p = 0.001) and cognitive functioning (F = 18.43; p = 0.001). In addition, family history of psychiatric illness (χ2: 6.49; degrees of freedom (df) = 2;132; p = 0.010), family history of affective disorders (χ2 = 5.57; p = 0.017), psychotic symptoms (χ2 = 5.88; p = 0.014) and axis II comorbidity were associated with previous suicide attempts (χ2 = 5.16; p = 0.021). CONCLUSION Bipolar patients with previous suicide attempts had lower overall functioning than patients who did not attempt suicide. Previous suicide attempts were particularly associated with the occupational and cognitive domains of functioning.
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Affiliation(s)
- Adriane R Rosa
- 1Bípolar Disorders Program, Molecular Psychiatry Laboratory, Hospital de Clinicas de Porto Alegre, Ramiro Barcelos, Porto Alegre, RS, Brazil
| | - Carolina Franco
- 2Bipolar Disorders Program, Clinical Institute of Neuroscience, Hospital Clinic of Barcelona, CIBERSAM, Villarroel, Barcelona, Spain
| | - Anabel Martínez-Aran
- 2Bipolar Disorders Program, Clinical Institute of Neuroscience, Hospital Clinic of Barcelona, CIBERSAM, Villarroel, Barcelona, Spain
| | - Jose Sánchez-Moreno
- 2Bipolar Disorders Program, Clinical Institute of Neuroscience, Hospital Clinic of Barcelona, CIBERSAM, Villarroel, Barcelona, Spain
| | - Manel Salamero
- 2Bipolar Disorders Program, Clinical Institute of Neuroscience, Hospital Clinic of Barcelona, CIBERSAM, Villarroel, Barcelona, Spain
| | - M Valenti
- 2Bipolar Disorders Program, Clinical Institute of Neuroscience, Hospital Clinic of Barcelona, CIBERSAM, Villarroel, Barcelona, Spain
| | - Rafael Tabarés-Seisdedos
- 5Teaching Unit of Psychiatry and Psychological Medicine, Department of Medicine, University of Valencia, CIBERSAM, Spain
| | - Ana González-Pinto
- 6Department of Psychiatry, Santiago Apostol Hospital, Osakidetza Mental Health System, CIBERSAM, Vitoria, Spain
| | - Flávio Kapczinski
- 1Bípolar Disorders Program, Molecular Psychiatry Laboratory, Hospital de Clinicas de Porto Alegre, Ramiro Barcelos, Porto Alegre, RS, Brazil
| | - Eduard Vieta
- 2Bipolar Disorders Program, Clinical Institute of Neuroscience, Hospital Clinic of Barcelona, CIBERSAM, Villarroel, Barcelona, Spain
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Valtonen HM, Suominen K, Haukka J, Mantere O, Leppämäki S, Arvilommi P, Isometsä ET. Differences in incidence of suicide attempts during phases of bipolar I and II disorders. Bipolar Disord 2008; 10:588-96. [PMID: 18657243 DOI: 10.1111/j.1399-5618.2007.00553.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Differences in the incidence of suicide attempts during various phases of bipolar disorder (BD), or the relative importance of static versus time-varying risk factors for overall risk for suicide attempts, are unknown. METHODS We investigated the incidence of suicide attempts in different phases of BD as a part of the Jorvi Bipolar Study (JoBS), a naturalistic, prospective, 18-month study representing psychiatric in- and outpatients with DSM-IV BD in three Finnish cities. Life charts were used to classify time spent in follow-up in the different phases of illness among the 81 BD I and 95 BD II patients. RESULTS Compared to the other phases of the illness, the incidence of suicide attempts was 37-fold higher [95% confidence interval (CI) for relative risk (RR): 11.8-120.3] during combined mixed and depressive mixed states, and 18-fold higher (95% CI: 6.5-50.8) during major depressive phases. In Cox's proportional hazards regression models, combined mixed (mixed or depressive mixed) or major depressive phases and prior suicide attempts independently predicted suicide attempts. No other factor significantly modified the risks related to these time-varying risk factors; their population-attributable fraction was 86%. CONCLUSIONS The incidence of suicide attempts varies remarkably between illness phases, with mixed and depressive phases involving the highest risk by time. Time spent in high-risk illness phases is likely the major determinant of overall risk for suicide attempts among BD patients. Studies of suicidal behavior should investigate the role of both static and time-varying risk factors in overall risk; clinically, management of mixed and depressive phases may be crucial in reducing risk.
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Affiliation(s)
- Hanna M Valtonen
- Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland
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Abstract
The presence of depressive symptomatology during acute mania has been termed mixed mania, dysphoric mania, depressive mania or mixed bipolar disorder. Highly prevalent, mixed mania occurs in at least 30% of bipolar patients. Correct diagnosis is a major challenge. The DSM diagnostic criteria, the most widely adopted clinical convention, require a complete manic and complete depressive syndrome co-occurring for at least 1 week. However, recent alternative categorical and dimensional studies of manic phenomenology have shown that there are certain depressive symptoms or constellations that have special clinical importance when describing mixed states, such as depressed mood and anxiety symptomatology that do not overlap with manic symptoms. Patients with mixed mania are over-represented in the subgroup with severe and treatment-resistant symptoms. The course and prognosis of mixed mania are worse than that of pure manic forms in the medium and long term, with higher recurrence rates, higher frequency of co-morbid substance abuse and greater risk of suicidal ideation and attempts. Moreover, mixed manic episodes are usually associated with increased depression during follow-up, greater risk of rapid cycling course and higher prevalence of physical co-morbidities, principally related to thyroid function. All these factors are very relevant to selection of treatment. There are three crucial steps in the treatment of mixed mania--making the correct diagnosis, starting treatment early, and considering not only the acute state but also maintenance treatment and the patient's long-term outcome. Although challenging, acute mixed episodes are treatable. To date there have been no controlled studies devoted exclusively to treatment of mixed mania, and the only controlled data available therefore derive from sub-analyses of randomised clinical trials. Both short-term and maintenance treatments of patients with mixed mania require experience and usually involve the combination of different treatments. As a general rule, there is some consensus about discontinuing antidepressants during mixed mania. Olanzapine, aripiprazole or valproate semisodium (divalproex sodium) are first-line drugs for mild episodes; severe episodes of mixed mania usually require treatment with a combination of valproate semisodium or lithium plus an antipsychotic, preferably an atypical agent. Carbamazepine is also useful for the treatment of mixed mania. High-dose medications are sometimes needed to control the episode, and time to remission is usually longer than in pure mania. Importantly, patients with mixed manic episodes have more adverse events of psychopharmacological treatment. In some cases, electroconvulsive therapy is required.
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Affiliation(s)
- Ana González-Pinto
- Stanley International Mood Disorders Research Center, Hospital Santiago Apóstol, University of the Basque Country, Vitoria, Spain.
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Abstract
BACKGROUND Bipolar illness is frequently misdiagnosed. Several studies have focused on the underdiagnosis of this condition and the frequent long delay in its recognition. However, the illness is difficult to diagnose and many of its symptoms are shared by other conditions. In order to determine the accuracy of the diagnosis of bipolar illness among subjects with substance abuse, we carried out a study in patients with a previous diagnosis of bipolar disorder (BD) and known history of substance abuse or dependence, who were currently engaged in treatment for substance abuse. METHODS Individuals participating in a community-based substance treatment program and who had a previous diagnosis of BD were invited to undergo a structured clinical interview for diagnosis performed by a psychiatrist. In addition to the interview, previous hospital records were reviewed whenever possible. Diagnosis was made following strict DSM-IV criteria. RESULTS Only 9 of 21 (42.9%) subjects met diagnostic criteria for BD. Seven were BD type II and two were BD I. CONCLUSIONS Bipolar disorder is frequently misdiagnosed following strict DSM-IV criteria. Among subjects with substance abuse, it may be overdiagnosed by psychiatrists.
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Affiliation(s)
- Christopher Stewart
- Mood Disorders Research Program, Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY 40202, USA
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Valtonen HM, Suominen K, Mantere O, Leppämäki S, Arvilommi P, Isometsä E. Suicidal behaviour during different phases of bipolar disorder. J Affect Disord 2007; 97:101-7. [PMID: 16837060 DOI: 10.1016/j.jad.2006.05.033] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Revised: 05/31/2006] [Accepted: 05/31/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are no previous studies comparing the prevalence and risk factors for suicidal behaviour during different phases of bipolar disorder. METHODS In the Jorvi Bipolar Study (JoBS), 1630 psychiatric in- and outpatients were screened for bipolar disorders with the Mood Disorder Questionnaire. Using SCID I and II interviews, 191 patients were diagnosed with bipolar disorders (90 bipolar I, 101 bipolar II). Suicidal ideation was measured using the Scale for Suicidal Ideation (SSI). Prevalence and risk factors for ideation and attempts during different phases (depressive, mixed, depressive mixed and hypomanic/manic phases) were investigated. RESULTS There were marked differences between phases regarding suicide attempts and level of suicidal ideation. Hopelessness predicted suicidal behaviour during the depressive phase, whereas a subjective rating of severity of depression and younger age predicted suicide attempts during mixed phases. LIMITATIONS The relatively small sample size in some phases. CONCLUSIONS Suicidal behaviour varied markedly between different phases of BD. Suicide attempts and suicidal ideation were related to phases which are associated with depressive aspects of the illness. Hopelessness and severity of depression were key indicators of risk in all phases.
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Affiliation(s)
- Hanna M Valtonen
- Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland
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Zajecka JM. Calming the bipolar storm: treating acute mania and mixed episodes in patients with bipolar disorder. CNS Spectr 2006; 11:1-11; discussion 12-3; quiz 14-6. [PMID: 17075560 DOI: 10.1017/s1092852900025840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Bipolar disorder is a seriously debilitating psychiatric disorder that greatly affects patients and their loved ones. Although bipolar disorder is one of the most frequently occurring mental disorders worldwide, many patients, particularly those with mixed mania, remain misdiagnosed. Compared to pure mania, mixed episodes of bipolar disorder present with symptoms that can be more challenging to treat. However, proper diagnosis and early treatment can usually alter the course of the illness, and remission is certainly possible. This expert roundtable supplement reviews the differences between acute manic and mixed episodes in patients with bipolar disorder, explains proper dosing and the advantages of different dosage formulations, and identifies the rationale for monotherapy and combination therapy in these patient populations. The aim is to educate clinicians about ways to diagnose and treat the mood state aggressively and safely, especially in light of the many new treatment options available.
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Affiliation(s)
- John M Zajecka
- Treatment Research Center, Department of Psychiatry, Rush University Medical Center, Chicago, Ill, USA
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Abstract
Patients with bipolar disorder are at very high risk for suicidal ideation, non-fatal suicidal behaviors and suicide and are frequently treated with antidepressants. However, no prospective, randomized, controlled study specifically evaluating an antidepressant on suicidality in bipolar disorder has yet been completed. Indeed, antidepressants have not yet been shown to reduce suicide attempts or suicide in depressive disorders and may increase suicidal behavior in pediatric, and possibly adult, major depressive disorder. Available data on the effects of antidepressants on suicidality in bipolar disorder are mixed. Considerable research indicates that mixed states are associated with suicidality and that antidepressants, especially when administered as monotherapy, are associated with both suicidality and manic conversion. In contrast, growing research suggests that antidepressants administered in combination with mood stabilizers may reduce depressive symptoms in patients with bipolar depression. Further, the only prospective, long-term study evaluating antidepressant treatment and mortality in bipolar disorder, although open-label, found antidepressants and/or antipsychotics in combination with lithium, but not lithium alone, reduced suicide in bipolar and unipolar patients (Angst F, et al. J Affect Disord 2002: 68: 167-181). We conclude that antidepressants may induce suicidality in a subset of persons with depressive (and probably anxious) presentations; that this induction may represent a form of manic conversion, and hence a bipolar phenotype, and that lithium's therapeutic properties may include the ability to prevent antidepressant-induced suicidality.
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Affiliation(s)
- Susan L McElroy
- Psychopharmacology Research Program, Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0559, USA.
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Galfalvy H, Oquendo MA, Carballo JJ, Sher L, Grunebaum MF, Burke A, Mann JJ. Clinical predictors of suicidal acts after major depression in bipolar disorder: a prospective study. Bipolar Disord 2006; 8:586-95. [PMID: 17042832 DOI: 10.1111/j.1399-5618.2006.00340.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study determined the clinical predictors of suicidal behavior during a 2-year follow-up of patients with bipolar disorder presenting with a major depressive episode (MDE). METHOD Sixty four patients with DSM-III-R bipolar disorder were assessed at presentation for treatment of an MDE. Correlates of past suicidal behavior were determined by comparing patients with and without a history of suicide attempts using a t-test, Wilcoxon test or chi-squared test of independence on individual explanatory variables. Putative predictors of attempts during the follow-up period were tested separately using Cox proportional hazards regression analysis. RESULTS Twelve of 64 patients had at least one suicide attempt in the follow-up period, five of them attempted in the first 2 months and seven around or shortly after the 1-year follow-up visit. All attempters had a history of past suicide attempts. Most predictors of future suicidal behavior were correlates of past suicidal behavior. Family history of suicide acts and comorbid borderline personality disorder predicted early attempts, while younger age, high hostility scores, number of past attempts, subjective pessimism as reflected in depression and suicidal ideation, and few reported reasons for living predicted suicidal acts during the whole period. CONCLUSION In this data set of bipolar patients we noted an intriguing picture of two clusters of suicide attempts. Hostility was the strongest risk factor. These findings may have implications in both the identification of at-risk patients and the timing of clinical interventions including aggressive pharmacotherapeutic prophylaxis to prevent relapse or recurrence of depressive symptomatology.
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Affiliation(s)
- Hanga Galfalvy
- Department of Neuroscience, Columbia University/New York State Psychiatric Institute, New York, NY 10032, USA.
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Grunebaum MF, Ramsay SR, Galfalvy HC, Ellis SP, Burke AK, Sher L, Printz DJ, Kahn DA, Mann JJ, Oquendo MA. Correlates of suicide attempt history in bipolar disorder: a stress-diathesis perspective. Bipolar Disord 2006; 8:551-7. [PMID: 17042828 DOI: 10.1111/j.1399-5618.2006.00304.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Distinguishing clinical characteristics of bipolar patients who have made a suicide attempt may help to identify at-risk individuals. We sought to identify such factors and to consider them within a stress-diathesis model of suicidal behavior. METHODS Patients with bipolar disorder (N = 96) were compared with respect to the presence or absence at baseline evaluation of a history of suicide attempt. We used multiple logistic regression analysis to assess the unique associations of independent variables to history of a past suicide attempt. RESULTS The regression analysis showed that a history of suicide attempt in bipolar disorder was associated with greater recent suicidal ideation, more psychiatric hospitalizations, lifetime aggressive traits and an earlier age at onset of a first mood episode. CONCLUSIONS Aggressive traits and early treatment of mood disorders, especially major depressive episodes, are potential targets for suicide prevention in bipolar disorder.
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Affiliation(s)
- Michael F Grunebaum
- Department of Neuroscience, New York State Psychiatric Institute and Columbia University, New York, NY 10032, USA.
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39
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Allen MH, Chessick CA, Miklowitz DJ, Goldberg JF, Wisniewski SR, Miyahara S, Calabrese JR, Marangell L, Bauer MS, Thomas MR, Bowden CL, Sachs GS. Contributors to suicidal ideation among bipolar patients with and without a history of suicide attempts. Suicide Life Threat Behav 2005; 35:671-80. [PMID: 16552982 DOI: 10.1521/suli.2005.35.6.671] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This study was designed to develop models for vulnerability to suicidal ideation in bipolar patients. Logistic regression models examined correlates of suicidal ideation in patients who had versus had not attempted suicide previously. Of 477 patients assessed, complete data on demographic, illness history, and personality variables were available on 243. The regression models achieved positive predictive values of 55% and 59% for the attempter (N = 92) and nonattempter groups (N = 151), respectively. Depression was cross-sectionally associated with suicidal ideation in both the attempter and nonattempter groups but made a smaller contribution among attempters. Poor psychosocial adaptation and the personality factor "openness" were stronger contributors to suicidal ideation among prior attempters while anxiety and extraversion appeared protective against ideation. Among nonattempters, depression, anxiety, and neuroticism were the predominant influences on suicidal ideation. Bipolar patients with suicidal ideation may benefit from different treatment strategies depending on their prior attempt status.
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Affiliation(s)
- Michael H Allen
- University of Colorado Health Science Center, University North Pavilion, 4455 East 12th Avenue, Denver, CO, USA.
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MacKinnon DF, Potash JB, McMahon FJ, Simpson SG, Depaulo JR, Zandi PP. Rapid mood switching and suicidality in familial bipolar disorder. Bipolar Disord 2005; 7:441-8. [PMID: 16176437 DOI: 10.1111/j.1399-5618.2005.00236.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Rapidly alternating or mixed mood states in bipolar disorder are associated with a particularly high risk for suicidal behavior. Are individuals with these patterns of illness more likely to develop suicidal intentions, or are they less able to resist them? This analysis examines the specific contribution of rapid switching and other variables to the relative likelihood of having or acting on self-reported suicidal thought and action, in a large group of individuals with bipolar disorder. METHODS The analysis included 1574 family members with bipolar disorder interviewed for a multi-site bipolar disorder genetic linkage study. Two models were tested, using the same set of demographic and clinical data points as independent variables. One model tested the influence of rapid switching and other variables on self-reported suicidal thought or action (i.e., suicidality), while the other tested the influences on suicidal action only among those who reported a history of suicidality. RESULTS Over 75% of subjects had contemplated suicide and 38% reported a history of suicidal behavior. A history of rapid switching was associated with higher likelihood of a history of suicidality, as was panic disorder. Familial suicidal behavior, as well as drug abuse, increased the likelihood of suicidal action among suicidal individuals, but did not increase the likelihood of becoming suicidal. Female sex, early age at onset, and several demographic factors were associated with both facets of suicidality. CONCLUSIONS Factors associated with high acuity of distress, such as panic attacks and unstable moods, appear to enhance the risk of suicidality in general. Factors that affected the threshold for action without increasing suicidality overall can also be seen as markers of impulsive decision-making. Of the two distinct kinds of suicidal risk, the latter - the likelihood of action given intent - appears to be the more familial.
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Affiliation(s)
- Dean F MacKinnon
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Akiskal HS, Benazzi F. Psychopathologic correlates of suicidal ideation in major depressive outpatients: is it all due to unrecognized (bipolar) depressive mixed states? Psychopathology 2005; 38:273-80. [PMID: 16179814 DOI: 10.1159/000088445] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2005] [Accepted: 05/19/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND Recent transatlantic concern about suicidality in patients receiving antidepressants prompted us to examine the psychopathologic correlates of suicidal ideation occurring in clinically depressed patients. METHODS The study sample, which consisted of 644 consecutive major depressive outpatients, of which 58.0% had bipolar II disorder (BP-II), was systematically interviewed with the SCID, in order to delineate the diagnostic and psychopathologic correlates of suicidal ideation. RESULTS Such ideation, which was present in 49.5% [and favoring BP-II vs. major depressive disorder (MDD)] at an odds ratio (OR) of 1.3 (95% confidence interval = 0.98-1.8), was clinically significantly associated with depressive mixed state (racing/crowded thoughts and psychomotor agitation/activation during index depression), mood lability, decreased self-esteem, anorexia, as well as melancholic and psychotic features. Multiple logistic regression of suicidal ideation versus depressive symptoms and intradepressive excitatory symptoms revealed that decreased self-esteem (OR = 3.3), racing/crowded thoughts (OR = 1.5), and psychomotor agitation/activation (OR = 1.4) were independent and clinically significant correlates of suicidal ideation, irrespective of depression severity. DISCUSSION From a psychopathologic standpoint, suicidality might be conferred by a combination of both the excited (mixed) depressive and agitated (melancholic) clusters. Trait mood lability appears to favor the genesis of these affective clusters. Within the framework of Kraepelinian psychiatry, both clusters represent depressive mixed states. Given that such states are more prevalent in BP-II, our data provide a possible explanation for the greater suicidality in BP-II patients reported in the literature. In light of the higher odds of suicidal ideation in BP-II versus MDD patients, we hypothesize that the higher prevalence of mental and psychomotor activation in BP-II might be one factor among others that favors the greater likelihood of the transition from suicidal ideation to suicidal action in BP-II. Our analyses delineate a mixed depressive substrate at risk for suicidality. To what extent, if any, antidepressant monotherapy might contribute to the genesis of such states and/or suicidality cannot be answered with the methodology of the present study.
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Affiliation(s)
- Hagop S Akiskal
- International Mood Center, University of California at San Diego, Calif. 92161, USA.
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Weiss RD. Treating patients with bipolar disorder and substance dependence: lessons learned. J Subst Abuse Treat 2005; 27:307-12. [PMID: 15610832 DOI: 10.1016/j.jsat.2004.10.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2003] [Revised: 08/23/2004] [Accepted: 09/24/2004] [Indexed: 11/21/2022]
Abstract
Although bipolar disorder is the Axis I psychiatric disorder associated with the highest rate of co-occurring substance use disorders, little research has focused on treatments specifically designed for these patients. The author and his colleagues have developed and studied Integrated Group Therapy (IGT) for this population. This paper describes common themes that have emerged in carrying out IGT for patients with bipolar disorder and substance dependence. These include the strong emphasis on depression, as opposed to mania; the predominance of hopelessness; specific patterns of medication noncompliance; and the implications of patients' labeling their substance use as self-medication. Therapeutic aspects involved in addressing these themes are discussed.
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Affiliation(s)
- Roger D Weiss
- Alcohol and Drug Abuse Treatment Program, McLean Hospital, Belmont, MA 02478, USA.
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Abstract
OBJECTIVE Mixed episodes comprise up to 40% of acute bipolar admissions. They are difficult-to-treat, complex clinical pictures. This review provides an overview of the available literature on the pharmacotherapy of manic-depressive mixed states and suggests treatment options. METHOD Literature was identified by searches in Medline, Embase and the Cochrane Controlled Trials Register. Studies were considered relevant if they contained the keywords mixed mania, mixed state(s), mixed episode(s), treatment, therapy, study or trial. RESULTS Overall, there were very few double-blind, placebo-controlled studies specifically designed to treat manic-depressive mixed states. Rather, patients with mixed states comprised a sub-group of the examined patient cohorts. Nevertheless, the data show that acute mixed states do not respond favourably to lithium. Instead, valproate and olanzapine are drugs of first choice. Carbamazepine may play a role in the prevention of mixed states. Antidepressants should be avoided, because they may worsen intraepisodic mood lability. Lamotrigine may be useful in treating mixed states with predominantly depressive symptoms. CONCLUSIONS More treatment studies specifically designed to treat the complex clinical picture of mixed states are clearly needed. Current treatment recommendations for clinical practice based on the available literature can only target select aspects of these episodes.
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Affiliation(s)
- Stephanie Krüger
- Center for Addiction and Mental Health, Clarke Institute of Psychiatry, Mood and Anxiety Disorders Division, University of Toronto, Toronto, Canada.
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Abstract
OBJECTIVE To explore diagnostic and treatment issues concerning bipolar mixed states. METHOD Bipolar mixed states are described and concerns about diagnostic and treatment difficulties are summarized and discussed. RESULT Mixed states can present with equal admixtures of depressive or manic symptoms, or more commonly one component predominates. There is fair consensus, although little data, regarding the management of manic mixed states. However depressive mixed states are far more complex both in terms of recognition and management. People suffering from mixed states characteristically present with complaints of depression. CONCLUSIONS The boundaries between depressive mixed states and agitated depression are vague, yet carry substantial therapeutic implications. Bipolar mixed states are often difficult to treat, and tend to take much longer to settle than either pure mania or depression. Furthermore there is data that treatment with antidepressants can worsen the course of mixed states. Hence missed diagnoses can potentially have negative clinical implications. Therefore in this paper the clinical presentation, diagnosis and therapy of mixed states is reviewed with a view to improving management.
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Affiliation(s)
- Michael Berk
- Barwon Health and The Geewong Clinic, Swanston Centre, PO Box 281, Geelong, Victoria 3220, Australia.
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Dougherty DM, Mathias CW, Marsh DM, Moeller FG, Swann AC. Suicidal behaviors and drug abuse: impulsivity and its assessment. Drug Alcohol Depend 2004; 76 Suppl:S93-S105. [PMID: 15555820 DOI: 10.1016/j.drugalcdep.2004.08.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2004] [Accepted: 08/04/2004] [Indexed: 10/26/2022]
Abstract
Impulsivity appears to play an important role in suicidal behaviors and drug abuse, which are two psychiatric problems that may interact with one another. Interpretation of the literature on impulsivity in these behaviors may be complicated by the variety of measurement techniques for the assessment of impulsivity. There are three general types of impulsivity assessment: self-report, biological, and laboratory behavioral. Because laboratory behavioral measures both meet an operational definition of impulsivity and are sensitive to state-dependent changes in impulsivity, this paper presents data that focuses on laboratory behavioral performance among samples emitting suicidal behaviors or substance abuse. To better account for influence of impulsivity in these psychiatric disturbances, no single source of measurement should be used without the consideration of other types of instruments.
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Affiliation(s)
- Donald M Dougherty
- Neurobehavioral Research Laboratory and Clinic, Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at Houston, 1300 Moursund Street, Houston, TX 77030, USA.
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Levin FR, Hennessy G. Bipolar disorder and substance abuse. Biol Psychiatry 2004; 56:738-48. [PMID: 15556118 DOI: 10.1016/j.biopsych.2004.05.008] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2004] [Revised: 04/27/2004] [Accepted: 05/12/2004] [Indexed: 11/18/2022]
Abstract
Substance use disorders are overrepresented in individuals with bipolar and bipolar spectrum disorders. Although awareness of this phenomenon has increased over the past 20 years, few empirically based treatment strategies have been developed for this challenging patient population. This review examines the relationship between bipolar and substance use disorders and treatment options that have been studied in this patient population. First, we examine the high prevalence rates of substance use disorders in individuals diagnosed with bipolar disorder, the common problems associated with establishing a bipolar disorder diagnosis in individuals who abuse substances, the possible explanations for the frequent coexistence of bipolar and substance use disorders, and the negative effect of substance abuse on the course of and treatment outcomes for bipolar disorder. The review then focuses on treatment approaches for this patient population, including integrated group therapy for co-occurring bipolar and substance use disorders and pharmacotherapies that target both disorders. Finally, we present suggestions for medications that might be tested for their efficacy in treating both disorders in specific subgroups of patients with bipolar and substance use disorders.
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Affiliation(s)
- Frances R Levin
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, New York 10032, USA.
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Goldberg JF, Wankmuller MM, Sutherland KH. Depression with versus without manic features in rapid-cycling bipolar disorder. J Nerv Ment Dis 2004; 192:602-6. [PMID: 15348976 DOI: 10.1097/01.nmd.0000138227.25832.e7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Depression has been identified as a hallmark feature of rapid-cycling bipolar disorder, although less attention has been paid to the presence of manic features accompanying depression in rapid cyclers. To provide greater information about the extent to which depression arises with or without salient manic features in rapid cycling, we conducted a preliminary study of rapid cycling in outpatients seeking treatment at an academic specialty center for bipolar disorder. Forty DSM-IV affectively symptomatic bipolar outpatients with past year DSM-IV rapid cycling underwent systematic evaluation of symptoms and illness characteristics. Manic and depressive symptoms, treatments, and clinical features were rated by standardized scales. Major depression was present in most rapid cyclers (85%), but salient manic features were also evident in half of all depressed rapid cyclers. A lifetime history of suicide attempts was significantly more common in rapid cyclers who presented with major depression plus salient manic features than in those who presented with pure depression or pure mania (p = .033). Antidepressants were being prescribed for approximately one third of depressed rapid cycling patients regardless of the presence of concomitant manic features, whereas mood stabilizers tended to be used less often when manic features accompanied depression. Depression in conjunction with manic symptoms, rather than pure depression alone, may be more common among rapid-cycling bipolar patients who seek treatment. Lifetime suicide risk may be greater among rapid cycling patients whose depression occurs in tandem with manic symptoms. Prescribing habits in the community that favor antidepressants over mood stabilizers may promote further mood destabilization in this population. Further studies with larger sample sizes are needed to affirm these provisional findings.
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Affiliation(s)
- Joseph F Goldberg
- Bipolar Disorders Research Program, Department of Psychiatry Research, Zucker Hillside Hospital, North Shore Long Island Jewish Health System, Glen Oaks, NY 11004, USA
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Sato T, Bottlender R, Tanabe A, Möller HJ. Cincinnati criteria for mixed mania and suicidality in patients with acute mania. Compr Psychiatry 2004; 45:62-9. [PMID: 14671739 DOI: 10.1016/s0010-440x(03)00145-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The association between suicidality and diagnoses of mixed mania, as defined using both DSM-IV and Cincinnati criteria, was studied in 576 consecutive manic inpatients. Of the whole sample, 51 (8.9%) had suicidal ideation and 13 (2.3%) attempted suicide during the index episode. Suicidality was significantly more frequent in patients with a diagnosis of mixed mania, whether the diagnosis was made by DSM-IV or Cincinnati criteria. A multiple logistic regression analysis revealed that an additive combination of a diagnosis of mixed mania, the depression severity, and the Global Assessment of Functioning (GAF) score was significant in predicting suicidal ideation, when using the DSM-IV criteria. A diagnosis of mixed mania alone was significant in a similar analysis, when using the Cincinnati criteria. The adjusted odds ratio for a diagnosis of mixed mania to having suicidality was much higher when using the latter criteria (4.0 v 14.0). A subsequent logistic regression analysis indicated that the Cincinnati mixed mania alone, rather than an additive combination of the DSM-IV mixed mania and the depression severity, achieved the most appropriate prediction of suicidal ideation in the sample. These findings did not differ, even when suicidality was defined as having a suicide attempt during the index episode. Our finding that suicidality was more strongly associated with Cincinnati mixed mania than with DSM-IV mixed mania is probably due to that suicidal patients who do not meet DSM-IV criteria for mixed mania are classified into mixed mania, or/and that the depressive syndrome, related to suicidality, is more appropriately assessed among manic patients, when using the Cincinnati criteria. There was no evidence that marital status, employment, a lifetime history of alcohol or substance abuse, or a history of suicide attempts before the index episode was significantly associated with suicidality in the sample. Manic patients with suicidality may have a greater severity of residual depressive symptoms at discharge.
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Affiliation(s)
- Tetsuya Sato
- Psychiatrische Klinik und Poliklinik, Ludwig-Maximilians-Universität, Mūnchen, Germany
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Abstract
Bipolar disorder may be more prevalent than previously believed. Because a substantial number of patients with bipolar disorder present with an index depressive episode, it is likely that many are misdiagnosed with unipolar major depression. Even if a correct diagnosis is made, depressive symptoms in bipolar disorder are notoriously difficult to treat. Patients are often treated with antidepressants, which, if used improperly, are known to induce mania and provoke rapid cycling. This article explores diagnostic conundrums in bipolar depression and their possible solutions, based on current research evidence. It also elucidates current evidence regarding the risks and benefits associated with antidepressant use and evaluates alternative treatment regimens for the depressed bipolar population, including the use of traditional mood stabilizers such as lithium, novel anticonvulsants such as lamotrigine, and atypical antipsychotics.
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Affiliation(s)
- Joseph F Goldberg
- Zucker Hillside Hospital/North Shore Long Island Jewish Health System, Glen Oaks, NY 11002, USA
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