Suicide attempts in bipolar patients

Comparison of the efficacy of venlafaxine and bupropion in the treatment of depressive episode in patients with bipolar II disorder

Objective

Depressive disorders are common among those with bipolar disorder II (BD II) and may necessitate the use of antidepressants. Because of the lack of quality evidence, there is controversy about the use of antidepressants in BD II. The aim was to compare the efficacy of venlafaxine and bupropion in the treatment of depressive episode in BD II.

Materials and Methods

This randomized triple-blind clinical trial study was conducted on patient with depressive episode of BD II (based on diagnostic and statistical manual of disorders [DSM-V] criteria) referred to the specialized clinic of Golestan Hospital. A total of 40 patients were randomly divided into two groups of receiving venlafaxine (75 mg/day) or bupropion (100 mg/day) for 4 weeks. At the end of the intervention, the effectiveness of treatment was assessed using the Hamilton Depression Rating Scale (HDRS).

Results

The results of this study showed that the HDRS score before treatment (P = 0.43) and after treatment (P = 0.15) was not significantly different between the two groups. HDRS score in both groups significantly decreased after 4 weeks (P < 0.0001). Although the rate of decrease in depression score was more in venlafaxine than in bupropion, these differences were not significant (% 36.7 ± 21.8 vs. % 45.3 ± 17.9, P value = 0.17).

Conclusion

Our study showed that short-term (4-weeks) treatments of venlafaxine and bupropion were equally effective and could be a safe and effective antidepressant monotherapy for BD II major depression. It is suggested that more studies be conducted with larger sample size and over longer periods of time in a multicenter manner.

Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review

BACKGROUND

Lifetime psychotic symptoms are present in over half of the patients with bipolar disorder (BD) and can have an adverse effect on its course, outcome, and treatment. However, despite a considerable amount of research, the impact of psychotic symptoms on BD remains unclear, and there are very few systematic reviews on the subject.

AIM

To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. An electronic literature search of six English-language databases and a manual search was undertaken to identify published articles on psychotic symptoms in BD from January 1940 to December 2021. Combinations of the relevant Medical Subject Headings terms were used to search for these studies. Articles were selected after a screening phase, followed by a review of the full texts of the articles. Assessment of the methodological quality of the studies and the risk of bias was conducted using standard tools.

RESULTS

This systematic review included 339 studies of patients with BD. Lifetime psychosis was found in more than a half to two-thirds of the patients, while current psychosis was found in a little less than half of them. Delusions were more common than hallucinations in all phases of BD. About a third of the patients reported first-rank symptoms or mood-incongruent psychotic symptoms, particularly during manic episodes. Psychotic symptoms were more frequent in bipolar type I compared to bipolar type II disorder and in mania or mixed episodes compared to bipolar depression. Although psychotic symptoms were not more severe in BD, the severity of the illness in psychotic BD was consistently greater. Psychosis was usually associated with poor insight and a higher frequency of agitation, anxiety, and hostility but not with psychiatric comorbidity. Psychosis was consistently linked with increased rates and the duration of hospitalizations, switching among patients with depression, and poorer outcomes with mood-incongruent symptoms. In contrast, psychosis was less likely to be accompanied by a rapid-cycling course, longer illness duration, and heightened suicidal risk. There was no significant impact of psychosis on the other parameters of course and outcome.

CONCLUSION

Though psychotic symptoms are very common in BD, they are not always associated with an adverse impact on BD and its course and outcome.

Factors associated with lifetime suicide attempts: findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

AIM

To evaluate the risk factors associated with lifetime suicide attempts in bipolar disorder (BD) patients.

METHODOLOGY

773 BD patients with a duration of illness of at least ten years, currently in clinical remission, were evaluated for suicidal attempts in their lifetime. Those with and without lifetime suicide attempt(s) were compared for various demographic and clinical risk factors.

RESULTS

242 (31.3%) patients had a history of at least one lifetime suicide attempt. Compared to those without lifetime suicide attempts, those with suicidal attempts were less educated, were more often females, spent more time in episodes, and had a significantly more number of total episodes (in the lifetime, first five years of illness, and per year of illness), had significantly more number of total depressive episodes (in the lifetime, first five years of illness, and per year of illness), spent more time in depressive episodes, had more severe depressive episodes, more often had depression as the first episode in the lifetime, spent more time in mania/hypomania/mixed episodes, had higher residual depressive and manic symptoms, more often had rapid cycling affective disorder pattern in the lifetime, use of cannabis in dependence pattern, had poorer insight into their illness and had a higher level of disability (especially in three out of the four domains of Indian disability evaluation assessment scale).

CONCLUSIONS

About one-third of the patients with BD have at least one-lifetime suicidal attempt, and those with suicide attempts usually have a poorer course of illness.

A systematic review of suicide and suicide attempts in adolescents with psychotic disorders

BACKGROUND

Suicide is the main cause of premature death in patients with psychosis. Therefore, the goal of the present study was to review suicide in adolescents with psychotic disorders by evaluating factors associated with suicidal acts. Ours is the first systematic review of suicide in this population.

METHOD

We performed a systematic review of suicide in adolescents (10 to 19 years) with psychotic disorder.

RESULTS

We identified 10 studies, only 2 of which were randomized clinical trials. The results revealed high rates of suicidal behaviour in this population: the times of higher risk were the time before admission and the period immediately following discharge. The factors most associated with suicide attempts were depression, distress with psychotic symptoms, fewer negative symptoms at baseline, positive symptoms, and anxiety disorders. Associated factors included previous psychiatric history or psychiatric admissions, female sex, prior suicidal behaviour, family history of completed suicide, and nicotine dependence.

LIMITATIONS

Clinical and methodological diversity of the studies.

CONCLUSIONS

Adolescents with psychotic disorders had a major risk of suicidal behaviour, and specific factors were associated with the act. Early detection of adolescents with psychosis is vital, since it has been found that early intervention can prevent suicidal acts in young people. However, it is necessary to perform more studies, particularly randomized controlled trials, on suicide and suicide attempts, particularly in adolescents.

Impulsivity as a Risk Factor for Suicide in Bipolar Disorder

The accurate assessment of suicide risk in psychiatric, especially affective disorder diagnosed patients, remains a crucial clinical need. In this study, we applied temperament and character inventory (TCI), Barratt impulsiveness scale 11 (BIS-11), PEBL simple reaction time (SRT) test, continuous performance task (CPT), and Iowa gambling task (IGT) to seek for variables linked with attempted suicide in bipolar affective disorder group (n = 60; attempters n = 17). The main findings were: strong correlations between self-report tool scores and objective parameters in CPT; the difference between attempters and non-attempters was found in the number of correctly responded trials in IGT; only one parameter differed between attempters and non-attempters in BPI diagnosis; and no significant differences between suicide attempters and non-attempters in TCI, BIS-11, and SRT were found. These justify the conclusion that impulsivity itself is not a strong predictor, and used as a single variable might not be sufficient to indicate the high suicide risk group among bipolar patients.

Suicidal behaviour and cognition: A systematic review with special focus on prefrontal deficits

BACKGROUND

Suicide is a major health concern worldwide, thus, identifying risk factors would enable a more comprehensive understanding and prevention of this behaviour. Neuropsychological alterations could lead to difficulties in interpreting and managing life events resulting in a higher risk of suicide.

METHOD

A systematic literature search from 2000 to 2020 was performed in Medline (Pubmed), Web of Science, SciELO Citation Index, PsycInfo, PsycArticles and Cochrane Library databases regarding studies comparing cognition of attempters versus non-attempters that share same psychiatric diagnosis.

RESULTS

1.885 patients diagnosed with an Affective Disorder (n = 1512) and Schizophrenia/ Schizoaffective Disorder (n = 373) were included. In general comparison, attention was found to be clearly dysfunctional. Regarding diagnosis, patients with Schizophrenia and previous history of suicidal behaviour showed a poorer performance in executive function. Patients with current symptoms of an Affective Disorder and a previous history of suicidal attempt had poorer performance in attention and executive function. Similarly, euthymic affective patients with history of suicidal behaviour had worse decision-making, attention and executive function performance compared to euthymic non-attempters.

LIMITATIONS

The number of papers included in this review is limited to the few studies using non-attempter clinically-matched control group and therefore results regarding diagnosis, symptomatology and time of the attempt are modest and contradictory.

CONCLUSIONS

Patients who have attempted suicide have a poorer neuropsychological functioning than non-attempters with a similar psychiatric disorder in attention and executive function. These alterations increase vulnerability for suicide.

Study of Risk Factors Associated with Suicide Attempt in Patients with Bipolar Disorder Type I

Background  Suicide is the leading contributor to mortality in bipolar disorder (BD). A history of suicidal attempt is a robust predictive marker for future suicide attempts. Personality profiles and coping strategies are the areas of contemporary research in bipolar suicides apart from clinical and demographic risk factors. However, similar research in developing countries is rarer.

Objectives  The present study aimed to identify the risk factors associated with suicidal attempts in BD type I (BD-I).

Materials and Methods  Patients with BD-I currently in clinical remission ( N = 102) were recruited. Sociodemographic details and the clinical data were collected using a semistructured pro forma. The psychiatric diagnoses were confirmed using the Mini-International Neuropsychiatric Interview 5.0. The National Institute of Mental Health–Life Chart Methodology Clinician Retrospective Chart was used to chart the illness course. Presumptive Stressful Life Events Scale, Coping Strategies Inventory Short Form, Buss–Perry aggression questionnaire, Past Feelings and Acts of Violence, and Barratt Impulsivity scale were used to assess the patient’s stress scores, coping skills, aggression, violence, and impulsivity, respectively.

Statistical Analysis  Descriptive statistics were used for demographic details and characteristics of the illness course. Binary logistic regression analyses were performed to identify the predictors for lifetime suicide attempt in BD-I.

Results  A total of 102 patients (males = 49 and females = 53) with BD-I were included. Thirty-seven subjects (36.3%) had a history of suicide attempt. The illness course in suicide attempters more frequently had an index episode of depression, was encumbered with frequent mood episodes, especially in depression, and had a higher propensity for psychiatric comorbidities. On binary logistic regression analysis, the odds ratios (ORs) for predicting a suicide attempt were highest for positive family history of suicide (OR: 13.65, 95% confidence interval [CI]: 1.28–145.38, p = 0.030), followed by the presence of an index depressive episode (OR: 6.88, 95% CI: 1.70–27.91, p = 0.007), and lower scores on problem-focused disengagement (OR: 0.72, 95% CI: 0.56–0.92, p = 0.009).

Conclusion  BD-I patients with lifetime suicide attempt differ from non-attempters on various course-related and temperamental factors. However, an index episode depression, family history of suicide, and lower problem-focused engagement can predict lifetime suicide attempt in patients with BD-I.

Psychoeducation and cognitive-behavioral therapy for patients with refractory bipolar disorder: A 5-year controlled clinical trial

Objective:

The aim of this research, which represents an additional and longer follow-up to a previous trial, was to evaluate a 5-year follow-up study of a combined treatment (pharmacological + psychoeducational and cognitive-behavioral therapy) as compared with a standard pharmacological treatment in patients with refractory bipolar disorder.

Method:

Forty patients were randomly assigned to either an Experimental group–under combined treatment — or a Control group — under pharmacological treatment. Data were analyzed by analysis of variance (ANOVA), with repeated measures at different evaluation time points.

Results:

Between-group differences were significant at all evaluation time points after treatment. Experimental group had less hospitalization events than Control group in the 12-month evaluation (P = 0.015). The Experimental group showed lower depression and anxiety in the 6-month (P = 0.006; P = 0.019), 12-month (P = 0.001; P < 0.001) and 5-year (P < 0.001, P < 0.001) evaluation time points. Significant differences emerged in mania and misadjustment already in the post-treatment evaluation (P = 0.009; P < 0.001) and were sustained throughout the study (6-month: P = 0.006, P < 0.001; 12-month: P < 0.001, P < 0.001; 5-year: P = 0.004, P < 0.001). After 5-year follow-up, 88.9% of patients in the Control group and 20% of patients in the Experimental group showed persistent affective symptoms and/or difficulties in social-occupational functioning.

Conclusions:

A combined therapy is long-term effective for patients with refractory bipolar disorder. Suggestions for future research are commented.

Expert consensus on information sheet proposals for patients under treatment with lithium

INTRODUCTION

Lithium is one of the first therapeutic options for bipolar disorder, which is characterized by recurrent mood swings that strongly reduce quality of life. Our purpose was to achieve professional consensus criteria to define the contents of an information sheet for patients with bipolar disorder that are starting treatment with lithium.

MATERIAL AND METHODS

A modified Delphi method in two rounds was used. The Scientific Committee-made up by nine psychiatrists-created a 20-item questionnaire about the information that must be given to the patient treated with lithium and selected a panel of ambulatory and hospital psychiatric experts to agree on this information. Panelists scored each item based on a Likert scale of 9 points and could add comments in a confidential manner. It was considered consensus in agreement when median scores were within the range of [7-9] and in disagreement within the range of [1-3].

RESULTS

A high level of consensus was reached. In the first round, there was agreement on 17 out of 20 items and, after the second round, there was disagreement on just one item containing information about the discovery of lithium. Finally, said item was modified in the Patient's Information Sheet based on the comments suggested by the panelists.

CONCLUSIONS

This study allowed to create an information sheet for patients with bipolar disorder under treatment with lithium, with information agreed upon by a group of experts from different health care settings.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

LIMITATIONS

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

DISCUSSION

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

Association between completed suicide and bipolar disorder: A systematic review of the literature

BACKGROUND

Completed suicide is a major cause of death in bipolar disorder (BD) patients.

OBJECTIVE

The aim of this paper is to provide an overall review of the existing literature of completed suicide in BD patients, including clinical and genetic data DATA SOURCES: We performed a systematic review of English and non-English articles published on MEDLINE/PubMed, PsycInfo and Cochrane database (1970-2017). Additional studies were identified by contacting clinical experts, searching bibliographies, major textbooks and website of World Health Organization. Initially we did a broad search for the association of bipolar disorder and suicide and we were narrowing the search in terms included "bipolar disorder" and "completed suicide".

STUDY SELECTION

Inclusion criteria were articles about completed suicide in patients with BD. Articles exclusively focusing on suicide attempts and suicidal behaviour have been excluded. We used PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) consensus for drafting this systematic review.

RESULTS

The initial search generated 2806 articles and a total of 61 meeting our inclusion criteria. We reviewed epidemiological data, genetic factors, risk factors and treatment of completed suicide in BD. Suicide rates in BD vary between studies but our analyses show that they are approximately 20-30-fold greater than in general population. The highest risk of successful suicide was observed in BD-II subjects. The heritability of completed suicide is about 40% and some genes related to major neurotransmitter systems have been associated with suicide. Lithium is the only treatment that has shown anti-suicide potential.

LIMITATIONS

The most important limitation of the present review is the limited existing literature on completed suicide in BD.

CONCLUSIONS

BD patients are at high risk for suicide. It is possible to identify some factors related to completed suicide, such as early onset, family history of suicide among first-degree relatives, previous attempted suicides, comorbidities and treatment. However it is necessary to promote research on this serious health problem.

Evaluating the Effect of Coenzyme Q10 Augmentation on Treatment of Bipolar Depression: A Double-Blind Controlled Clinical Trial

BACKGROUND

Bipolar disorder (BPD) is a chronic and recurrent mood disorder characterized by episodes of mania, hypomania, and major depression. Based on available evidence, mitochondrial dysfunction, oxidative stress, and inflammation have important roles in the pathophysiology of bipolar depression. More specifically, it seems that coenzyme Q10 (CoQ10), a mitochondrial modulator, as well as an antioxidant and anti-inflammatory agent, might be effective in modulating these pathophysiological pathways. Accordingly, the aim of this study was to investigate whether and to what extent, compared with placebo, adjuvant CoQ10 might improve symptoms of depression in patients with BPD.

METHODS

A total of 69 patients with BPD with a current depressive episode were randomly assigned either to the adjuvant CoQ10 (200 mg/d) or to the placebo group. Standard medication consisting of mood stabilizers and antidepressants was consistent 2 months prior and during the study. Depression severity for each patient was assessed based on the Montgomery-Asberg Depression Rating Scale scores at baseline, fourth week, and eighth week of the study.

RESULTS

Symptoms of depression decreased over time in both groups. Compared with the placebo group, adjuvant CoQ10 to a standard medication improved symptoms of depression after 8 weeks of treatment. In addition, at the end of the study, it turned out that more responders were observed in the CoQ10 group, compared with the placebo group. CoQ10 had minimal adverse effects and was well tolerated.

CONCLUSIONS

The present pattern of results suggests that among patients with BPD, compared with placebo, adjuvant CoQ10 probably because of its antioxidant and anti-inflammatory properties can improve symptoms of depression over a period of 8 weeks.

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

Background

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

Objectives

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

Design

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

Setting

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

Participants

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

Interventions

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

Main outcome measures

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

Results

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

Limitations

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

Conclusion

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

Future work

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

Trial registration

Current Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583.

Funding

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

Adjunctive antidepressants in bipolar depression: A cohort study of six- and twelve-months rehospitalization rates

Although antidepressants (ADs) are widely used in bipolar depression, there is weak evidence for their effectiveness and safety in this condition. Furthermore, there is a paucity of studies on the risk-benefit ratio of AD maintenance treatment in bipolar disorder (BD). We compared rehospitalization rates of patients with BD-I depressive episode who were discharged with mood stabilizers (MSs) and/or atypical antipsychotics (AAPs) with or without adjunctive AD. Ninety-eight patients with BD-I who were hospitalized with a depressive episode between 2005 and 2013 were retrospectively followed for 6-months and 1-year rehospitalization rates, as well as time to rehospitalization, according to treatment at discharge: MSs and/or AAPs with or without AD. Multivariable survival models adjusted for covariates known to influence rehospitalization were conducted. Six-months and 1-year rehospitalization rates were significantly lower in the adjunctive-AD treatment group compared to the no-AD group (9.2% vs. 36.4%, P = .001, power = 0.87 and 12.3% vs. 42.4%, P = .001, power = 0.89, respectively). Time to rehospitalization within 6-months and 1-year was significantly longer in the adjunctive-AD treatment group (169.9 vs 141 days, P = .001 and 335.6 vs 252.3 days, P = .001, respectively). Adjunctive-AD treatment at discharge reduced significantly the adjusted risk of rehospitalization within 6-months (HR = 0.081, 95% CI: 0.016-0.412, P = 0.002) and 1-year (HR = 0.149, 95% CI: 0.041-0.536, P = 0.004). Moreover, adjunctive-AD treatment did not increase rehospitalization rates of manic episode. In conclusion, adjunctive-AD therapy to MS/AAP at discharge from BD-I depressive episode hospitalization is associated with a lower rate of and a longer time to rehospitalization during a 1-year follow up period.

History of Lifetime suicide attempt in bipolar I disorder: its correlates and effect on illness course

OBJECTIVES

To identify the prevalence and correlates of bipolar I patients with a lifetime history of suicide attempt.

MATERIALS AND METHODS

Bipolar I disorder was diagnosed in 150 patients as per DSM-IV-TR criteria. Their lifetime suicide risk was assessed using the Columbia Suicide Severity Rating Scale. NIMH retrospective Life Chart Methodology was used to chart the illness course. Medication Adherence Rating Scale (MARS) and Pittsburgh Sleep Quality Index (PSQI) were used to assess the recent adherence and subjective sleep quality, respectively. The suicide attempters were compared with non-attempters on individual variables.

RESULTS

Around 23% had a positive lifetime history of suicide attempt. They were predominantly female, had an index (first ever) episode of depression, spent more proportion of time being ill, especially in depressive or mixed episode phase. Comorbid substance use disorder along with suicidal attempts was seen only in males. Suicide attempters displayed poor medication adherence attitudes for medications taken during the past week and reported impaired sleep quality for the previous month.

CONCLUSIONS

A positive history of lifetime suicide attempt was significantly associated with a worse course of bipolar I disorder. Effective treatment of depressive episodes, addressing non-adherence, substance use and sleep problems can reduce the suicide risk in such patients. Retrospective design of the study and recall bias are some of the limitations.

Substance Use Disorders and Poverty as Prospective Predictors of Adult First-Time Suicide Ideation or Attempt in the United States

This study examined whether substance use disorders (SUD) and poverty predicted first-time suicide ideation or attempt in United States national data. Respondents without prior histories of suicide ideation or attempt at Wave 1 of the NESARC (N = 31,568) were analyzed to determine the main and interactive effects of SUD and poverty on first-time suicide ideation or attempt by Wave 2, 3 years later. Adjusted for controls, poverty (AOR = 1.35, CI = 1.05-1.73) and drug use disorders (AOR = 2.10, CI = 1.07-4.14) independently increased risk for first-time suicide ideation or attempt at Wave 2. SUD and poverty did not interact to differentially increase risk for first-time suicide ideation or attempt, prior to or after adjustment for controls. This study reinforces the importance of SUD and poverty in the risk for first-time suicide ideation or attempt. Public health efforts should target messages to drug users and the impoverished that highlight their increased risk for first-time suicide.

Personality traits as an endophenotype in genetic studies on suicidality in bipolar disorder

Introduction The influence of personality traits on suicidal behaviour risk has been well documented. Personality traits and suicidal behaviour are partially genetically determined and personality has been described as an endophenotype of suicidal behaviour. The aim of this study was to investigate a possible association between personality traits with suicidal behaviour and selected serotonergic gene polymorphisms.

METHODS

In the study we included 156 patients meeting DSM-IV criteria for bipolar disorder (BP) and 93 healthy controls. The personality dimensions were assessed using the Temperament and Character Inventory (TCI). We genotyped two selected polymorphisms of the tryptophan hydroxylase 1 (TPH1) gene (rs1800532 218A>C and rs1799913 779A>C) and polymorphism in the promoter region of serotonin transporter gene (5-HTTLPR, rs25531) related to serotoninergic neurotransmission. Multiple poisson regression, logistic regression and Kruskal-Wallis tests were applied.

RESULTS

We found numerous differences between the BP patients and the control group in terms of their TCI dimensions/subdimensions. Significant differences were found between patients with, and without, suicidal attempts in fatigability and asthenia (Ha4), as well as in harm avoidance (Ha). We also found that the interactions between TCI subdimensions (the interaction of disordiness (Ns4) and spiritual acceptance (St3), disordiness (Ns4) and integrated conscience (C5), extravagance (Ns3) and resourcefulness (Sd3)) were significantly contributing for suicidal behaviour risk. We found association between all studied genetic polymorphisms and several TCI dimensions and subdimensions.

CONCLUSION

Our results confirm that personality traits are partially determined by genes. Both personality traits and the interactions between temperament and character traits, may be helpful in predicting suicidal behaviour.

Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990-2015: Systematic review and meta-analysis

BACKGROUND

Comorbidity between substance use disorders (SUDs) and bipolar disorder (BD) is highly prevalent to the extent it may almost be regarded the norm. This systematic review and meta-analysis aimed to estimate the prevalence rates of SUDs in treatment seeking patients diagnosed with BD in both inpatient and outpatient settings.

METHODS

A comprehensive literature search of Medline, EMBASE, psychINFO and CINAHL databases was conducted from 1990 to 2015. Prevalence of co-morbid SUDs and BD were extracted and odds ratios (ORs) were calculated using random effects meta-analysis.

RESULTS

There were 151 articles identified by electronic searches that yielded 22 large, multi-site studies and 56 individual studies describing comorbid rates of SUDs amongst community dwelling, BD inpatients or outpatients. The SUDs with the highest prevalence in BD were alcohol use (42%) followed by cannabis use (20%) and other illicit drug use (17%). Meta-analysis showed males had higher lifetime risks of SUDs compared to females. BD and comorbid SUDS were associated with earlier age of onset and slightly more hospitalisations than non-users.

LIMITATIONS

The results do not take into account the possibility that individuals may have more than one comorbid disorder, such as having more than one SUD, anxiety disorder, or other combination. Some of the meta-analyses were based on relatively few studies with high rates of heterogeneity. Most included studies were cross-sectional and therefore causality cannot be inferred.

CONCLUSIONS

This systematic review shows comorbidity between SUDs and bipolar illness is highly prevalent in hospital and community-based samples. The prevalence of SUDs was similar in patients with bipolar I and bipolar II disorders. This study adds to the literature demonstrating that SUDs are common in BD and reinforces the need to provide better interventions and properly conducted treatment trials to reduce the burden conferred by comorbid SUD and BD.

Clinical Correlates of Suicide in Suicidal Patients with Schizophrenia Spectrum Disorders and Affective Disorders

BACKGROUND

The most common psychiatric illnesses in the background of suicide are schizophrenia spectrum disorders (SSD) and affective disorders (AD). While depression and hopelessness are important factors for suicide in psychiatric patients, the role of psychotic symptoms is unclear. We examine the comparative differences in the clinical correlates of suicide in SSD and AD patients with suicidal risk.

MATERIALS AND METHODS

One hundred and twenty suicidal psychiatric patients (aged between 17-60 years) were evaluated for depression severity, hopelessness, past attempts, and reasons for wanting to commit suicide at the emergency psychiatry centre. Of these 29% had SSD, 65% AD, and 6% other disorders.

RESULTS

Lifetime history of suicide attempts and suicide attempts in previous month were higher in SSD patients. Mean Beck Depression scores, Hopelessness, and Suicide Intention scores were significantly lower in patients with SSD as compared to AD (P ≤ 0.05). More than 60% patients with SSD attributed psychotic symptoms as a reason for wanting to commit suicide, while more than 50% patients with AD attributed it to family and personal stressors (P ≤ 0.001).

CONCLUSIONS

Factors associated with suicidal ideations were significantly different between SSD and AD patients. Hence, suicide prevention strategies should be based on the specific risk factors for each group, SSD and AD.

[Differences in Subjective Experience Between Unipolar and Bipolar Depression]

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.

Is age of onset associated with severity, prognosis, and clinical features in bipolar disorder? A meta-analytic review

OBJECTIVES

To identify clinical characteristics and adverse outcomes associated with an earlier age of onset of bipolar disorder.

METHODS

A comprehensive search yielded 15 empirical papers comparing clinical presentation and outcomes in individuals with bipolar disorder grouped according to age of onset (total N=7370). The following variables were examined to determine odds ratios (ORs) and 95% confidence intervals (CIs): presence of Axis I comorbidity, rapid cycling, psychotic symptoms, mixed episodes (DSM-IV), lifetime suicide attempts, lifetime alcohol and substance abuse, symptom severity, and treatment delay.

RESULTS

Early age of onset was found to be associated with longer delay to treatment (Hedges' g=0.39, P=.001), greater severity of depression (Hedges' g=0.42, P<.001), and higher levels of comorbid anxiety (OR=2.34, P<.001) and substance use (OR=1.80, P<.001). Surprisingly, no association was found between early age of onset and clinical characteristics such as psychotic symptoms or mixed episodes as defined by DSM-IV.

CONCLUSIONS

Earlier age of onset of bipolar disorder is associated with factors that can negatively impact long-term outcomes such as increased comorbidity. However, no association was found between early onset and indicators of severity or treatment resistance such as psychotic symptoms. Clinical features found to have the strongest relationship with early age of onset were those potentially amenable to pharmacological and psychological treatment. Results highlight the importance of early identification and provide potential areas of focus for the development of early intervention in bipolar disorder.

The number of past manic episodes is the best predictor of antidepressant-emergent manic switch in a cohort of bipolar depressed patients

The present study sought to identify factors associated with the onset of a manic or hypomanic episode during the month following a new antidepressant therapy in depressed bipolar patients. Patients receiving mood stabilizers for ≥3 months were screened from 400 French centers and were assessed for a 4-week period following prescription of a first or a new antidepressant. Of the 1242 included participants, 4.8% (n=60) experienced antidepressant-emergent manic switch (AEMS). AEMS was more frequently associated with lifetime manic, depressive, and total mood episodes, and with past AEMS. A higher score at two items of the Montgomery-Åsberg Depression Rating Scale (pessimistic and suicidal thoughts) were significantly associated with AEMS. Logistic regression analysis showed that the number of lifetime manic episodes and past AEMS were the two most factors associated with an AEMS. Having more than four past manic episodes was associated with a 2.84 fold increased risk of AEMS. Cumulative number of past mood episodes seems to be the most important factor for switching to a manic episode following antidepressants in patients with bipolar disorder. Longer-term studies are required to further delineate antidepressant causality from natural disease course.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

National trends in hospital-treated self-harm events among middle-aged adults

OBJECTIVE

To assess national trends in hospital-treated self-harm events focusing on adults aged 45-64years.

METHOD

Healthcare Cost and Utilization Project data from 2001 (N=7,452,727) to 2011 (N=7,893,587) were used to assess national trends in hospital stays for suicide and self-inflicted injury among youth (0-24years), young adults (35-44years), middle-aged adults (45-64years) and older adults (≥65years).

RESULTS

Among middle-aged adults, hospital-treated self-harm events increased from 5.1 (2001) to 7.1 (2011) per 10,000 population (OR=1.4, 95% CI=1.2, 1.6). This increase was larger than corresponding changes among youth (5.2-4.9) (interaction P=.0003), young adults (10.0-10.6) (interaction P=.006) or older adults (2.2-2.4) (interaction P=.07). Among middle-aged adults, hospital-treated self-harm events per 100 hospital discharges significantly increased (OR=1.4, 95% CI=1.3, 1.6), but there was not a significant increase in self-harm discharges per 100 mental disorder discharges (OR=1.2, 95% CI=1.0, 1.4).

CONCLUSIONS

Between 2001 and 2011, there was a disproportionate national increase in hospital-treated self-harm events among middle-aged adults that mirrored national trends in suicide. Because the increase was largely accounted for by an overall increase in mental health hospitalizations of middle-aged adults, the rising rate of hospital-treated self-harm events may reflect broader population-based mental health challenges facing US middle-aged adults.

Attempted suicide in people with co-occurring bipolar and substance use disorders: systematic review and meta-analysis

BACKGROUND

Both individuals with bipolar (BD) and those with alcohol (AUD) and other substance (SUD) use disorders are likely to attempt suicide. Comorbidity of BD and AUD/SUD may increase the likelihood of suicide attempts. We conducted a meta-analysis to estimate the association of comorbid AUD/SUD and suicide attempts in subjects with BD in the literature to date.

METHODS

Electronic databases through January 2013 were searched. Studies reporting rates of suicide attempts in people with co-occurring BD and AUD/SUD were retrieved. Comorbid AUD and SUD and suicide attempts rates as well as demographic, clinical, and methodological variables were extracted from each publication or obtained directly from its authors.

RESULTS

Twenty-nine of 222 studies assessed for eligibility met the inclusion criteria, comprising a total of 31,294 individuals with BD, of whom 6308 (20.1%) had documented suicide attempts. There were consistent findings across the studies included. As compared to controls, subjects with BD and comorbid AUD/SUD were more likely to attempt suicide. The cross-sectional association estimates showed random-effects pooled crude ORs of 1.96 (95% CI=1.56-2.47; p<0.01), 1.72 (95% CI=1.52-1.95; p<0.01), and 1.77 (95% CI=1.49-2.10; p<0.01), for combined AUD/SUD, AUD, and SUD. There was no publication bias and sensitivity analyses based on the highest quality studies confirmed core results.

LIMITATIONS

The effects of the number and the type of suicide attempts could not be investigated due to insufficient information.

CONCLUSIONS

Comorbid AUD and SUD in individuals with BD are significantly associated with suicide attempts. Individuals with this comorbidity should be targeted for intensive suicide prevention efforts.

A qualitative investigation into the relationships between social factors and suicidal thoughts and acts experienced by people with a bipolar disorder diagnosis

BACKGROUND

The prevalence rate of completed suicide in bipolar disorder is estimated to be as high as 19%. Social factors or influences, such as stigmatisation and family conflict, contribute to the development of suicidal ideation in clinical and non-clinical populations. Yet, there is a lack of studies examining suicidality from a psychosocial perspective in people who experience bipolar disorder.

METHOD

Semi-structured interviews were used to collect qualitative data from 20 participants with bipolar disorder. The interview focused on the effects of social factors upon participants׳ experiences of suicidality (suicidal thoughts, feelings or behaviours). A thematic analysis was used to understand the data.

RESULTS

Social or interpersonal factors which participants identified as protective against suicidality included, 'the impact of suicide on others' and, 'reflecting on positive social experiences'. Social factors which triggered suicidal thoughts included, 'negative social experiences' and, 'not being understood or acknowledged'. Social factors which worsened suicidal thoughts or facilitated suicidal behaviour were, 'feeling burdensome,' and 'reinforcing negative self-appraisals'.

LIMITATIONS

Some participants had not experienced suicidal thoughts for many years and were recalling experiences which had taken place over ten years ago. The accuracy and reliability of these memories must therefore be taken into consideration when interpreting the results.

CONCLUSIONS

The themes help to enhance current understanding of the ways in which social factors affect suicidality in people who experience bipolar disorder. These results highlight the importance of considering the social context in which suicidality is experienced and incorporating strategies to buffer against the effects of negative social experiences in psychological interventions which target suicide risk in bipolar disorder.

Risk factors for suicide in bipolar disorder: a systematic review

BACKGROUND

Bipolar disorder confers the highest risk of suicide among major psychological disorders. The risk factors associated with bipolar disorder and suicide exist and are relevant to clinicians and researchers.

OBJECTIVE

The aim of the present study was to conduct a systematic review of articles regarding the suicide risk factors in bipolar disorder.

METHODS

A systematic review of articles on suicide risk factors in bipolar disorder, published from January 1, 2010 to April 05, 2014, on SCOPUS and PUBMED databases was carried out. Search terms were "Suicide" (medical subject headings [MeSH]), "Risk factors" (MeSH), and "Bipolar" (keyword). Of the 220 retrieved studies, 42 met the eligibility criteria.

RESULTS

Bipolar disorder is associated with an increased rate death by suicide which contributes to overall mortality rates. Studies covered a wide range of aspects regarding suicide risk factors in bipolar disorder, such as risk factors associated to Sociodemographic conditions, Biological characteristics, Drugs Relationships, Psychological Factors, Genetic Compound, Religious and Spirituals conditions. Recent scientific literature regarding the suicide risk factors in bipolar disorder converge to, directly or indirectly, highlight the negative impacts of risk factors to the affected population quality of life.

CONCLUSION

This review demonstrated that Bipolar disorders commonly leads to other psychiatric disorders and co-morbidities involving risk of suicide. Thus the risk factors are relevant to have a better diagnosis and prognosis of BD cases involving risk of suicide.

Association of testosterone levels and future suicide attempts in females with bipolar disorder

BACKGROUND

Considerable evidence suggests that testosterone may play a role in the pathophysiology of mood disorders in females. This is the first prospective study to examine whether blood testosterone levels predict suicide attempts in females with bipolar disorder.

METHODS

Females with a DSM-IV diagnosis of a bipolar disorder in a depressive or mixed episode with at least one past suicide attempt were enrolled. Demographic and clinical parameters were assessed and recorded. Plasma testosterone was assayed using a double antibody radioimmunoassay procedure. Patients were followed up prospectively for up to 2.5 years.

RESULTS

At baseline, testosterone levels positively correlated with the number of previous major depressive episodes and suicide attempts. Cox proportional hazards regression analysis found that higher baseline testosterone levels predicted suicide attempts during the follow-up period.

LIMITATIONS

A limitation of the study is that the sample size is modest. Another limitation is that we did not have a bipolar nonattempter or healthy volunteer control group for comparison.

CONCLUSION

Testosterone levels may predict suicidal behavior in women with bipolar disorder.

Risk factors for suicidal ideations in patients with bipolar disorder

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.

Acute interventions and referral of patients with bipolar disorder by the psychiatric consultation liaison service in a general hospital in Germany: a retrospective analysis

OBJECTIVE

To investigate the population of bipolar patients in a general hospital in Germany who required treatment by a consultant psychiatrist.

METHOD

A retrospective analysis was conducted of the clinical records of 47 patients diagnosed with bipolar disorder (DSM-IV-TR criteria) who were treated by a consultant psychiatrist between 2009 and 2012 in one of the general hospitals of Charité Berlin, Campus Benjamin Franklin, Berlin, Germany. We investigated the sections of the hospital that requested psychiatric consultations for bipolar patients, the status of these patients, and their primary cause of treatment, as well as the intervention (including pharmacotherapy) recommended by the consultant psychiatrist.

RESULTS

For more than half of the patients, their psychiatric illness was either directly or indirectly the reason they presented to the hospital. The remaining bipolar patients were treated for various somatic illnesses unrelated to their bipolar disorder throughout the hospital, with a relative overrepresentation of patients in the neurology department. More than half of the patients were referred to a psychiatric hospital by the consultant psychiatrist. Benzodiazepines were the most commonly administered drugs for acute pharmacologic intervention.

CONCLUSIONS

Psychiatric consultations are not frequently requested for bipolar patients compared to those with other psychiatric disorders. However, more than half of the bipolar patients needed further psychiatric treatment in a psychiatric hospital. This finding emphasizes the importance of psychiatric consultations in a general hospital for bipolar patients. The administration of benzodiazepines as an acute treatment seems to be the standard pharmacologic procedure, not a specific pharmacotherapy like mood stabilizers.

Association between family history of mood disorders and clinical characteristics of bipolar disorder: results from the Brazilian bipolar research network

OBJECTIVES

To compare clinical characteristics of bipolar disorder (BD) in patients with and without a family history of mood disorders (FHMD) in a large sample from the Brazilian Research Network of Bipolar Disorders.

METHODS

Four-hundred eighty-eight DSM-IV BD patients participating in the Brazilian Research Network of Bipolar Disorders were included. Participants were divided between those with FHMD (n=230) and without FHMD (n=258). We compared these two groups on demographic and clinical variables and performed a logistic regression to identify which variables were most strongly associated with positive family history of mood disorders.

RESULTS

BD patients with FHMD presented with significantly higher lifetime prevalence of any anxiety disorder, obsessive-compulsive disorder, social phobia, substance abuse, and were more likely to present history of suicide attempts, family history of suicide attempts and suicide, and more psychiatric hospitalizations than BD patients without FHMD. Logistic regression showed that the variables most strongly associated with a positive FHMD were any comorbid anxiety disorder, comorbid substance abuse, and family history of suicide.

LIMITATIONS

Cross-sectional study and verification of FHMD by indirect information.

CONCLUSION

BD patients with FHMD differ from BD patients without FHMD in rates of comorbid anxiety disorder and substance abuse, number of hospitalizations and suicide attempts. As FHMD is routinely assessed in clinical practice, these findings may help to identify patients at risk for particular manifestations of BD and may point to a common, genetically determined neurobiological substrate that increases the risk of conditions such as comorbidities and suicidality in BD patients.

Sociodemographic and clinical differences between suicide ideators and attempters: a study of mood disordered patients 50 years and older

Our study sought to characterize mood disordered suicide ideators and attempters 50 years and older admitted to a psychiatric ward either for a recent suicide attempt or for ongoing suicidal ideation. We enrolled 50 patients with suicide ideation consecutively admitted to an inpatient department and 50 patients admitted for a suicide attempt made in the last 48 hours. Suicide attempters more frequently had low social support and an age of onset of mood disorder of 46 years and older, and less frequently had a history of suicidal behaviors in the family members and pharmacological treatment, despite the fact that the groups did not differ with regard to antidepressants prescribed. The groups were not distinguishable based on several variables assumed to be risk factors for suicide behavior, such as proximal life events and stressors or alcohol use disorders. In both samples, comorbidity with organic diseases, the presence of stressful life events in the past 12 months, and a diagnosis of major depression were frequently reported. In conclusion, the presence of low social support and the absence of a pharmacotherapy may increase suicidal behaviors in patients at risk.

Treatment of bipolar depression: focus on pharmacologic therapies

Recent studies have highlighted significant limitations in our capacity to effectively treat bipolar depression. This article reviews the present status of treatments for this condition, highlighting emerging new pharmacotherapies such as lamotrigine, olanzapine and quetiapine, while also addressing modern psychologic interventions such as cognitive behavioral therapy and psychoeducation. The role of older treatments such as lithium and the antidepressants is also discussed, particularly as a recent meta-analysis has thrown into question current heightened concern over antidepressant-induced mania. The advent of new pharmacologic and psychologic treatments provides optimism for improved outcomes for this highly disabling condition.

Suicide in bipolar disorder in a national English sample, 1996-2009: frequency, trends and characteristics

BACKGROUND

Bipolar disorder (BD) has been reported to be associated with high risk of suicide. We aimed to investigate the frequency and characteristics of suicide in people with BD in a national sample.

METHOD

Suicide in BD in England from 1996 to 2009 was explored using descriptive statistics on data collected by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI). Suicide cases with a primary diagnosis of BD were compared to suicide cases with any other primary diagnosis.

RESULTS

During the study period 1489 individuals with BD died by suicide, an average of 116 cases/year. Compared to other primary diagnosis suicides, those with BD were more likely to be female, more than 5 years post-diagnosis, current/recent in-patients, to have more than five in-patient admissions, and to have depressive symptoms. In BD suicides the most common co-morbid diagnoses were personality disorder and alcohol dependence. Approximately 40% were not prescribed mood stabilizers at the time of death. More than 60% of BD suicides were in contact with services the week prior to suicide but were assessed as low risk.

CONCLUSIONS

Given the high rate of suicide in BD and the low estimates of risk, it is important that health professionals can accurately identify patients most likely to experience poor outcomes. Factors such as alcohol dependence/misuse, personality disorder, depressive illness and current/recent in-patient admission could characterize a high-risk group. Future studies need to operationalize clinically useful indicators of suicide risk in BD.

Genetic variability at IMPA2, INPP1 and GSK3β increases the risk of suicidal behavior in bipolar patients

Bipolar patients (BP) are at high risk of suicide. Causal factors underlying suicidal behavior are still unclear. However, it has been shown that lithium has antisuicidal properties. Genes involved in its putative mechanism of action such as the phosphoinositol and the Wnt/β-catenine pathways could be considered candidates for suicidal behavior (SB). Our aim was to investigate the association of the IMPA1 and 2, INPP1, GSK3α and β genes with suicidal behavior in BP. 199 BP were recruited. Polymorphisms at the IMPA1 (rs915, rs1058401 and rs2268432) and IMPA2 (rs66938, rs1020294, rs1250171 and rs630110), INPP1 (rs3791809, rs4853694 and 909270), GSK3α (rs3745233) and GSK3β (rs334558, rs1732170 and rs11921360) genes were genotyped. All patients were grouped and compared according to the presence or not of history of SB (defined as the presence of at least one previous suicidal attempt). Single SNP analyses showed that suicide attempters had higher frequencies of AA genotype of the rs669838-IMPA2 and GG genotype of the rs4853694-INPP1gene compared to non-attempters. Results also revealed that T-allele carriers of the rs1732170-GSK3β gene and A-allele carriers of the rs11921360-GSK3β gene had a higher risk for attempting suicide. Haplotype analysis showed that attempters had lower frequencies of A:A haplotype (rs4853694:rs909270) at the INPP1 gene. Higher frequencies of the C:A haplotype and lower frequencies of the A:C haplotype at the GSK-3β gene (rs1732170:rs11921360) were also found to be associated to SB in BP. Therefore, our results suggest that genetic variability at IMPA2, INPP1 and GSK3β genes is associated with the emergence of SB in BP.

Suicide attempts and clinical risk factors in patients with bipolar and unipolar affective disorders

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.

Risk factors for secondary substance use disorders in people with childhood and adolescent-onset bipolar disorder: opportunities for prevention

BACKGROUND

Compared to other mental illnesses, bipolar disorder is associated with a disproportionately high rate of substance use disorders (SUDs), and the co-occurrence is associated with significant morbidity and mortality. Early diagnosis of primary bipolar disorder may provide opportunities for SUD prevention, but little is known about the risk factors for secondary SUD among individuals with bipolar disorder. The purposes of this study were to describe the population of people with childhood and adolescent-onset primary bipolar disorder, and to identify risk factors for secondary SUD in this population.

METHODS

Using data collected from the National Comorbidity Survey Replication study, we identified 158 individuals with childhood-onset (<13 years) or adolescent-onset (13-18 years) primary bipolar disorder (I, II or subthreshold). Survival analysis was used to identify risk factors for SUD.

RESULTS

Compared to adolescent-onset, people with childhood-onset bipolar disorder had increased likelihoods of attention deficit hyperactivity disorder (ADHD) (adjusted odds ratio=2.81) and suicide attempt (aOR=3.61). Males were more likely than females to develop SUD, and did so at a faster rate. Hazard ratios of risk factors for SUD were: lifetime oppositional defiant disorder (2.048), any lifetime anxiety disorder (3.077), adolescent-onset bipolar disorder (1.653), and suicide attempt (15.424). SUD was not predicted by bipolar disorder type, family history of bipolar disorder, hospitalization for a mood episode, ADHD or conduct disorder.

CONCLUSIONS

As clinicians struggle to help individuals with bipolar disorder, this study provides information that might be useful in identifying individuals at higher risk for SUD. Future research can examine whether targeting these risk factors may help prevent secondary SUD.

Suicide attempts and psychological risk factors in patients with bipolar and unipolar affective disorder

Suicide is an important clinical problem in psychiatric patients. The highest risk of suicide attempts is noted in affective disorders. The aim of the study was looking for suicide risk factors among personality dimensions and value system in patients with diagnosis of unipolar and bipolar affective disorder (n=189 patients, n=101 controls). To establish the diagnosis, we used SCID (Structured clinical interview for diagnostic and statistical manual of mental disorders, fourth edition) questionnaire, TCI (Temperament and Character Inventory) questionnaire and Value Survey--to assess the personality. The main limitations of the study are number of participants, lack of data about stressful life events and treatment with lithium. Novelty seeking and harm avoidance dimensions constituted suicide attempt risk factors in the group of patients with affective disorders. Protective role of cooperativeness was discovered. Patients with and without suicide attempt in lifetime history varied in self-esteem position in Value Survey.

Correlates of current suicide risk among Thai patients with bipolar I disorder: findings from the Thai Bipolar Disorder Registry

BACKGROUND

The Thai Bipolar Disorder Registry was a prospective, multisite, naturalistic study conducted in 24 hospitals across Thailand. This study aimed to examine the correlates of current suicide risk in Thai patients with bipolar I disorder.

METHODS

Participants were adult inpatients or outpatients with bipolar disorder, based on the Diagnosis and Statistical Manual of Mental Disorders, fourth edition. All were assessed by using the Mini International Neuropsychiatric Interview (MINI), version 5. The severity of current suicide risk was determined by using the total score of the MINI suicidality module. Mood symptoms were assessed by using the Young Mania Rating Scale and the Montgomery Asberg Depression Rating Scale.

RESULTS

The data of 383 bipolar I disorder patients were included in the analyses. Of these, 363 (94.8%) were outpatients. The mean (standard deviation) of the MINI suicide risk score was 1.88 (5.0). The demographic/clinical variables significantly associated with the MINI suicide risk scores included age, number of overall previous episodes, the Young Mania Rating Scale score, the Montgomery Asberg Depression Rating Scale scores, and the Clinical Global Impression Severity of Illness Scale for Bipolar Disorder mania score, depression score, and overall score. The variables affecting the differences of suicide risk scores between or among groups were type of first mood episode, a history of rapid cycling, anxiety disorders, and alcohol use disorders. The stepwise multiple linear regression model revealed that the Montgomery Asberg Depression Rating Scale score (β=0.10), a history of rapid cycling (β=6.63), anxiety disorders (β=2.16), and alcohol use disorders (β=2.65) were significantly correlated with the suicide risk score (all P<0.01).

CONCLUSION

A history of rapid cycling, severity of depressive episode, current anxiety disorders, and current alcohol use disorders correlate with current suicide risk among Thai bipolar I disorder patients. Further studies in larger sample sizes are warranted.

Assessment of risk factors related to suicide attempts in patients with bipolar disorder

We compared the characteristics of patients with bipolar disorder with and without a history of suicide attempts to identify the risk factors of suicide in this disorder. Among 212 patients with bipolar disorder, 44 (21.2%) patients had histories of suicide attempts. Suicide attempters were younger and more likely to be diagnosed with bipolar II. The variables that differentiated those who did from those who did not attempt suicide included age at first contact, lifetime history of antidepressant use, major depressive episode, mixed episode, auditory hallucinations, rapid cycling, the number of previous mood episodes, age of first depressive episode, and age of first psychotic symptoms. Strong predictors of suicide attempts were younger age at onset, lifetime history of auditory hallucinations, and history of antidepressant use. Antecedent depressive episodes and psychotic symptoms predicted the first suicide attempt in patients with bipolar disorder. This study could help clinicians to understand the major risk factors of suicidal behavior in bipolar disorder.

Hopelessness and suicidal risk in bipolar disorder. A study in clinically nonsyndromal patients

OBJECTIVE

Attempted suicide and death due to suicide are not uncommon among patients with bipolar disorder. Although some risk factors for suicidality in bipolar patients have been identified, little is known about hopelessness and other possible trait or diathesis-related factors. Consequently, the objective of this study was to investigate variables associated with suicidal risk in clinically nonsyndromal bipolar patients.

METHODS

A sample of 102 outpatients with a diagnosis of bipolar disorder according to International Classification of Diseases, 10th Revision criteria during nonsyndromal stage were evaluated. On the basis of suicidal history, patients were divided into suicide attempt, suicidal ideation, and nonsuicidal groups. Sociodemographic, clinical, and psychopathological variables were assessed.

RESULTS

As compared with the nonsuicidal group, female sex, combined psychopharmacologic treatment, and hopelessness were independently associated with suicide attempt. Hopelessness and insight into having a mental disorder were independently associated with history of suicidal ideation.

CONCLUSIONS

Patients with bipolar disorder and suicidal history are characterized by the presence of hopelessness, which probably confers greater vulnerability for suicidal behavior in the presence of stress factors. This identification of the risk profile for suicidal behavior in nonsyndromal bipolar patients adds complementary information to risk factors established for suicidality during acute phases of the disease, allows for differentiated preventive and treatment approaches of patients at risk, and suggests psychotherapy as an advisable intervention in this group of patients.

Risk factors related to lifetime suicide attempts in acutely admitted bipolar disorder inpatients

OBJECTIVE

The main aim of this study was to assess possible clinical characteristics of acutely admitted bipolar I disorder (BD-I) and bipolar II disorder (BD-II) inpatients at high risk of suicide by comparing patients who had made one or several serious suicide attempts with patients who had not.

METHODS

A total of 206 consecutive patients (mean age 42 ± 15 years; 54.9% women) with DSM-IV diagnosed BD-I (n = 140) and BD-II (n= 66) acutely admitted to a single psychiatric hospital department from November 2002 through June 2009 were included. Using a detailed retrospective questionnaire, patients with a history of a serious suicide attempt were compared to those with no history of a suicide attempt.

RESULTS

Ninety-three patients (45.1%) had a history of one or more serious suicide attempts. These constituted 60 (42.9%) of the BD-I patients and 33 (50%) of the BD-II patients (no significant difference). Lifetime suicide attempt was associated with a higher number of hospitalizations due to depression (p < 0.0001), antidepressant (AD)-induced hypomania/mania (p = 0.033), AD- and/or alcohol-induced affective episodes (p = 0.009), alcohol and/or substance use (p = 0.002), and a family history of alcohol abuse and/or affective disorder (p = 0.01). Suicide attempt was negatively associated with a higher Positive and Negative Syndrome Scale for Schizophrenia (PANSS) Positive Subscale score (p = 0.022) and more hospitalizations due to mania (p = 0.006).

CONCLUSIONS

The lifetime suicide attempt rate in BD inpatients is high. Risk factors of suicide attempts were: (i) a predominant depressive course of illness, (ii) comorbid alcohol and substance use disorders, and (iii) a history of AD- and/or alcohol-induced affective episodes. Risk-reducing factors were a preponderant manic or psychotic course of the illness. These risk factors may be signs of a clinical subgroup at risk of suicidal behaviour, and seem to be important for suicide risk assessment in acutely admitted BD patients.

A cross-sectional study of co-occurring suicidal and psychotic symptoms in inpatients at mathari psychiatric hospital, nairobi, kenya

To investigate the prevalence of suicidal symptoms and their co-occurrence with psychotic symptoms in patients at Mathari Hospital.

METHOD

A descriptive cross-sectional study was conducted in June 2004 on inpatients at Mathari Hospital, the national psychiatric teaching and referral hospital. Data on sociodemographic characteristics and clinical diagnoses of inpatients were extracted from their clinical notes. The Structured Clinical Interview for DSM-IV (SCID) Screening Module was used to elicit information on psychotic and suicidal symptoms.

RESULTS

A total of 691 patients were interviewed, of whom 308 (44.6%) had suicidal symptoms. There were significant positive correlations (p < .05) between psychotic and suicidal symptoms diagnosed according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) suggesting co-existence of these 2 sets of disorders.

CONCLUSIONS

There is a high prevalence of suicidal symptoms in the patients admitted at Mathari Hospital with predominantly psychotic disorders. Although these prevalence rates are much lower than those reported elsewhere, especially for schizophrenia, they are still a cause for concern given that these suicidal symptoms were not being managed.

Predictors of good outcome in patients with refractory bipolar disorder after a drug or a drug and cognitive-behavioral treatment

OBJECTIVE

The objective of the present research study was to analyze the variables involved in the favorable prognosis of patients with refractory bipolar disorder after a drug or a drug and cognitive-behavioral treatment.

METHODS

A sample of 40 patients was divided into 2 groups: (1) combined drug plus psychoeducational and cognitive-behavioral treatment or (2) drug treatment only (control group). We used a multigroup design with repeated measures at different times (baseline, posttreatment, 6-month follow-up, and 12-month follow-up) to evaluate the following variables: age, sex, number of hospitalizations, type of treatment, mania (Young Mania Rating Scale, or YMRS) and depression (Beck Depression Index, or BDI) symptoms, subsyndromal symptoms (BDI >7; YMRS >6), global suffering index, general index of social ability, self-esteem (Rosenberg scale), inadaptation (inadaptation Scale), anxiety (State-Trait Anxiety Inventory), quality of life (Global Activity Functioning), and health (European Quality of Life Scale). We considered favorable prognosis for subjects without persistent affective symptoms (BDI <7; YMRS <6) and/or without relevant difficulties in adaptation (Inadaptation Scale <14) in a 12-month follow-up.

RESULTS

A binary logistic regression showed that the type of treatment (combined therapy corresponded to better progression), the number of prior hospitalizations (fewer hospitalizations corresponded to better progression), and self-esteem (higher self-esteem corresponded to better prognosis) were statistically significant.

CONCLUSIONS

The type of treatment, the number of prior hospitalizations, and the level of self-esteem were the most influencing factors for a favorable progression of refractory bipolar disorder. Differently from other studies, no significant influences of age, sex, subsyndromal symptoms, anxiety, and depression symptoms on the prognosis of refractory bipolar disorder were observed in our study.

Number of prior episodes and the presence of depressive symptoms are associated with longer length of stay for patients with acute manic episodes

BACKGROUND

Few studies have analyzed predictors of length of stay (LOS) in patients admitted due to acute bipolar manic episodes. The purpose of the present study was to estimate LOS and to determine the potential sociodemographic and clinical risk factors associated with a longer hospitalization. Such information could be useful to identify those patients at high risk for long LOS and to allocate them to special treatments, with the aim of optimizing their hospital management.

METHODS

This was a cross-sectional study recruiting adult patients with a diagnosis of bipolar disorder (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) criteria) who had been hospitalized due to an acute manic episode with a Young Mania Rating Scale total score greater than 20. Bivariate correlational and multiple linear regression analyses were performed to identify independent predictors of LOS.

RESULTS

A total of 235 patients from 44 centers were included in the study. The only factors that were significantly associated to LOS in the regression model were the number of previous episodes and the Montgomery-Åsberg Depression Rating Scale (MADRS) total score at admission (P < 0.05).

CONCLUSIONS

Patients with a high number of previous episodes and those with depressive symptoms during mania are more likely to stay longer in hospital. Patients with severe depressive symptoms may have a more severe or treatment-resistant course of the acute bipolar manic episode.

Suicide attempts are associated with worse quality of life in patients with bipolar disorder type I

BACKGROUND

The association between suicidal behavior and quality of life (QoL) in bipolar disorder (BD) is poorly understood. Worse QoL has been associated with suicide attempts and suicidal ideation in schizophrenic patients, but this relationship has not been investigated in BD. This study tested whether a history of suicide attempts was associated with poor QoL in a well-characterized sample of patients with BD, as has been observed in other psychiatric disorders and in the general population.

METHODS

One hundred eight patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BD type I (44 with previous suicide attempts, 64 without previous suicide attempts) were studied. Quality of life was assessed using the World Health Organization's Quality of Life Instrument-Short Version. Depressive and manic symptoms were assessed using the Hamilton Depression Rating Scale-17 items and the Young Mania Rating Scale.

RESULTS

Patients with BD and previous suicide attempts had significantly lower scores in all the 4 domains of the World Health Organization's Quality of Life Instrument-Short Version scale than did patients with BD but no previous suicide attempts (physical domain P = .001; psychological domain P < .0001; social domain P = .001, and environmental domain P = .039). In the euthymic subgroup (n = 70), patients with previous suicide attempts had significantly lower scores only in the psychological and social domains (P = .020 and P = .004).

LIMITATIONS

This was a cross-sectional study, and no causal associations can be assumed.

CONCLUSIONS

Patients with BD and a history of previous suicide attempts seem to have a worse QoL than did patients who never attempted suicide. Poorer QoL might be a marker of poor copying skills and inadequate social support and be a risk factor for suicidal behavior in BD. Alternatively, poorer QoL and suicidal behavior might be different expressions of more severe BD.

Early determinants of four-year clinical outcomes in bipolar disorder with psychosis

OBJECTIVE

Bipolar disorder with psychosis is common in inpatient settings and is associated with diverse outcomes after hospital discharge, which can range from a return to premorbid functioning with no recurrence, to a chronic or recurring illness. Less is known, however, about factors that can predict a better or worse clinical outcome. The present study sought to assess four-year clinical outcomes and their predictors in patients hospitalized for bipolar I disorder with psychosis.

METHODS

Participants from the Suffolk County Mental Health Project (SCMHP) with a baseline diagnosis of bipolar I disorder with psychotic features (N=126) were reassessed using face-to-face interviews at six months, two years, and four years following their first hospitalization. At each time point, clinical status, role functioning, and treatment were assessed by highly trained interviewers using standardized instruments.

RESULTS

The majority of participants (73.2%) returned to their premorbid level of role functioning by the four-year follow-up and the median percentage of time ill during the interval was less than 20%. Nevertheless, almost half of the sample (46.9%) was rehospitalized at least once. Psychotic symptoms at baseline (particularly Schneiderian symptoms), depressive phenomenology, childhood psychopathology, and younger age at first hospitalization predicted worse outcome, whereas mood-incongruent psychotic features and age of mood disorder onset did not.

CONCLUSIONS

The four-year outcomes of a first-admission cohort with bipolar I disorder with psychosis were generally favorable. Poorer premorbid functioning, Schneiderian delusions, greater depressive symptoms, and a younger age of first hospitalization portend a worse course.

Bipolar Disorder Differences between Genders: Special Considerations for Women

The objective of this article is to review clinical differences between men and women with bipolar disorder. The secondary objective is to analyze the differences in adherence to medication between genders. Men usually present with manic episodes and have comorbid drug abuse, while women usually present with major depressive episode, the onset is often later, comorbidity of physical pathology is common and adherence to medication is greater than in men. In women who have an earlier onset of the illness and are single, the risk of nonadherence is higher than in other groups of women. There are two time periods that are very important in women: pregnancy and postpartum. Both are critical periods and a relapse or recurrence of symptoms at either stage can have serious consequences for the woman and/or her baby. In addition, the effect of medication on the fetus is unclear. In conclusion, there is a clear need for more studies on gender differences in bipolar disorder and how to improve adherence to treatment. Moreover, a better understanding of how to treat women with bipolar disorder during pregnancy and lactation will undoubtedly lead to improved outcomes for both the mother and her child.

Clinical and dimensional characteristics of euthymic bipolar patients with or without suicidal behavior

BACKGROUND

The clinical and dimensional features associated with suicidal behaviour in bipolar patients during euthymic states are not well characterised.

METHODS

In a sample of 652 euthymic bipolar patients, we assessed clinical features with the Diagnostic Interview for Genetics Studies (DIGS) and dimensional characteristics with questionnaires measuring impulsivity/hostility and affective lability/intensity. Bipolar patients with and without suicidal behaviour were compared for these clinical and dimensional variables.

RESULTS

Of the 652 subjects, 42.9% had experienced at least one suicide attempt. Lifetime history of suicidal behaviour was associated with being a woman, a history of head injury, tobacco misuse and indicators of severity of bipolar disorder including early age at onset, high number of depressive episodes, positive history of rapid cycling, alcohol misuse and social phobia. Indirect hostility and irritability were dimensional characteristics associated with suicidal behaviour in bipolar patients, whereas impulsivity and affective lability/intensity were not associated with suicidal behaviour.

LIMITATIONS

This study had a retrospective design with no replication sample.

CONCLUSIONS

Bipolar patients with earlier onset, mood instability (large number of depressive episodes, rapid cycling) and/or particular addictive and anxiety comorbid disorders might be at high risk of suicidal behaviour. In addition, hostility dimensions (indirect hostility and irritability), may be trait components associated with suicidal behaviour in euthymic bipolar patients.