Suicidality and symptoms of anxiety, irritability, and agitation in patients experiencing manic episodes with depressive symptoms: a naturalistic study

PURPOSE

Patients with a bipolar I disorder (BD-I) manic episode meeting the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), criteria for "with mixed features" have a high incidence of suicide attempts and of anxiety, irritability, and agitation (AIA) symptoms. The aim of this analysis was to explore the relationship between suicidality and AIA symptoms in patients with BD-I experiencing mania with depressive symptoms, using data from a previous naturalistic study.

PATIENTS AND METHODS

Psychiatrists completed an online questionnaire about their adult patients who had a current BD-I manic episode. Questions covered the DSM-5 "with mixed features" specifier, the severity of AIA symptoms, the frequency and controllability of suicidal ideation, and the number of suicide attempts.

RESULTS

Of 1,035 patients with BD-I mania who were included in the analyses, 348 (33.6%) met the criteria for the DSM-5 "with mixed features" specifier (three or more depressive symptoms). These patients were further stratified according to the severity of their AIA symptoms: "mild AIA" (zero or one AIA symptom above a severity threshold; 105 patients) or "severe AIA" (all three AIA symptoms above a severity threshold; 167 patients). A greater incidence of suicidal ideation was observed in the severe AIA group (71.9%) than in the mild AIA group (47.6%). Twice as many patients had easily controlled suicidal ideation than difficult-to-control suicidal ideation in both subgroups. The mean number of suicide attempts was higher in the severe AIA group than in the mild AIA group, during the current episode (0.84 vs 0.34 attempts, respectively; P<0.05) and over the patient's lifetime (1.56 vs 1.04 attempts, respectively).

CONCLUSION

The high risk of suicide among BD-I mania patients with depressive symptoms is further increased when they experience severe AIA symptoms. Recognizing AIA symptoms in BD-I mania could provide a means of identifying patients with depressive symptoms, as well as those who may be suicidal, thereby allowing for appropriate, tailored treatment.

Evaluating depressive symptoms in mania: a naturalistic study of patients with bipolar disorder

OBJECTIVE

This study aimed to evaluate patients with bipolar I disorder (BD-I) who have mania with depressive symptoms and who meet the new "with mixed features" specifier of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

METHOD

This prospective, multinational, naturalistic study surveyed psychiatrists and their patients with BD-I from October 2013 to March 2014. Eligible patients had BD-I, had a (current) manic episode, and had experienced onset of a manic episode within the previous 3 months. Psychiatrists provided patient information on depressive symptoms (DSM-5 criteria); symptoms of anxiety, irritability, and agitation; suicide attempts; and physician satisfaction with treatment response. Data were stratified according to whether patients met the criteria for the BD-I "with mixed features" specifier of DSM-5 (≥3 depressive symptoms) or not, and characteristics were compared between the two subgroups. Patients also self-reported on depressive symptoms using the Mini-International Neuropsychiatric Interview module questionnaire.

RESULTS

Overall, 34% of 1,035 patients met the criteria for BD-I "with mixed features," exhibiting ≥3 depressive symptoms during their current manic episode. This correlated with the matched patient self-reports of depressive symptoms. During their current manic episode, BD-I patients "with mixed features" had more severe symptoms of anxiety, irritability, and agitation (average composite severity score of 4.1 vs 3.4), a higher incidence of suicide attempts (38% vs 9%), and more physician dissatisfaction with treatment response (22% vs 14%), compared to patients with 0-2 depressive symptoms (all P<0.05).

CONCLUSION

This study found that patients with BD-I "with mixed features" (ie, ≥3 depressive symptoms during a manic episode), suffered, on average, from a greater burden of disease than patients with pure mania. Improved identification of these patients may help to optimize treatment outcomes.