Bipolar disorder suicidality

Depression occurring as part of bipolar disorder may be severe and accompanied by ideas of guilt and hopelessness, an inability to function at work because of poor concentration and psychomotor retardation or agitation, poor judgement and suicidal ideation. The lifelong risk of suicide in people with this condition is as high as 15%. Factors associated with suicide risk include alcohol misuse, marital separation or divorce, living alone and unemployment, and these are all common secondary consequences of the illness. 

The mean age of onset of bipolar disorder is 20, although onset may occur in early childhood to the mid-40s.1 If the onset of symptoms occurs after 60 years of age, the condition is probably secondary to medical causes. Early onset of bipolar disorder is associated with greater comorbidities, more mood episodes, a greater proportion of days depressed, and greater lifetime risk of suicide attempts, compared to bipolar disorder with a later onset. Substance abuse and anxiety disorders are more common in patients with an early onset. Patients with bipolar disorder also have higher rates of suicidal thinking, suicidal attempts, and completed suicides. 

Patients with bipolar disorder have a high risk of suicide. Factors that increase that risk are early age at disease onset, high number of depressive episodes, comorbid alcohol abuse, personal history of antidepressant-induced mania, and family history of suicidal behavior.15 In those with bipolar disorder, 1 of 5 suicide attempts are lethal, in contrast to 1 of 10 to 1 of 20 in the general population. 

Lifetime prevalence rates of psychiatric comorbidity co-existing with bipolar disorder are 42% to 50%.16 Comorbidities, especially substance abuse, make it difficult to establish a definitive diagnosis and complicate treatment. Comorbidities also place the patient at risk for a poorer outcome, high rates of suicidal-ity, and onset of depression.2 Psychiatric comorbidities include ... 

In depressed patients, cortical-hypothalamic-pituitary-adrenal axis hyperactivity can be explained by the hypersecretion of CRF, and secondary pituitary and adrenal gland hypertrophy. Impaired negative feedback at various CNS sites, including the hippocampus and pituitary are also likely to contribute. Downregulation of hippocampal mineralocorticoid receptors and expression is reported in depressed suicides [50]. In bipolar disorder, hyperactivity of the cortical-hypothalamic-pituitary-adrenal axis has been observed [51]. This increase in cortical-hypothalamic-pituitary-adrenal axis activity has also been observed in mixed mood states, mania and in depression in rapidcycling patients. Partial reversal of HPA overactivity is associated with treatment and recovery from depression. 

Suicide attempts occur in up to 50% of patients with bipolar disorder, and approximately 10% to 19% of individuals with bipolar I disorder commit suicide. Bipolar II patients may be more likely than bipolar I patients to attempt suicide. 

Mood disorders, such as depression, Bipolar Disorder, and suicidal behaviors... 

Lithium is the simplest therapeutic agent for the treatment of depression and has been used for over 100 years—lithium carbonate and citrate were described in the British Pharmacopoeia of 1885. Lithium therapy went through periods when it was in common use, and periods when it was discouraged. Finally, in 1949, J.J.F. Cade reported that lithium carbonate could reverse the symptoms of patients with bipolar disorder (manic-depression), a chronic disorder that affects between 1% and 2% of the population. The disease is characterized by episodic periods of elevated or depressed mood, severely reduces the patients quality of life and dramatically increases their likelihood of committing suicide. Today, it is the standard treatment, often combined with other drugs, for bipolar disorder and is prescribed in over 50% of bipolar disorder patients. It has clearly been shown to reduce the risk of suicide in mood disorder patients, and its socioeconomic impact is considerable—it is estimated to have saved around 9 billion in the USA alone in 1881. 

The pharmacological management of bipolar disorder involves treatment of both the acute and the longer-term maintenance phase of the illness. Longterm maintenance is necessary to reduce or prevent the recurrence of the symptoms, and to minimize the risk of suicide. 

Suicide The possibility of a suicide attempt is inherent in Bipolar Disorder, and close supervision of high-risk patients should accompany drug therapy. Write prescriptions for lamotrigine for the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of overdose. Overdoses have been reported for lamotrigine, some of which have been fatal. 

Neuropsychiatric events Life-threatening or fatal neuropsychiatric events, including suicide, suicidal and homicidal ideation, depression, relapse of drug addiction/overdose, and aggressive behavior have occurred in patients with and without a previous psychiatric disorder during peginterferon alfa-2b treatment and follow-up. Psychoses, hallucinations, bipolar disorders, and mania have been observed in patients treated with alpha interferons. 

The most common mood disorders are major depression (unipolar depression) and manic-depressive illness (bipolar disorder). Major depression is a common disorder that continues to result in considerable morbidity and mortality despite major advances in treatment. Approximately 1 in 10 Americans will be depressed during their lifetime. Of the 40,000 suicides occurring in the United States each year, 70% can be accounted for by depression. Antidepressants are now the mainstay of treatment for this potentially lethal disorder, with patients showing some response to treatment 65 to 80% of the time. 

There is no empirical evidence available for clinical use in children and adolescents. Yet, Hypericum seems to be used for the treatment of mild to moderate depression in the young (Walter et ah, 2000). St. John s wort should be avoided in young patients with severe depression and bipolar disorder (given the lack of adult data about effectiveness and risk of manic induction, respectively) and in those who have significant suicide risk. Treatments of proven efficacy (e.g., SSRIs, mood stabilisers) should be preferred in these cases. However, St. John s wort may be considered in cases of unipolar depression where conventional treatments have failed and prior to the use of combinations of drugs that have an increased risk of side effects and whose efficacy has not been demonstrated. 

Overall, the clinical picture of childhood MDD parallels the symptoms of adult MDD (Birmaher et ak, 1996b). There are some developmental differences, however. Symptoms of melancholia (e.g., lack of appetite, insomnia, lack of interest in anything), delusions, suicide attempts, especially high-lethality ones, are all less prevalent in young children and increase with age. In contrast, symptoms of anxiety, behavioral problems, and perhaps auditory and visual hallucinations seem to occur more frequently in children (AA-CAP, 1998 Birmaher et ah, 1996a). Also, it appears that the rate of onset of bipolar disorder is higher in... 

By far, the most important contributor to suicide is a serious psychiatric disorder, with MOD, bipolar disorder, schizophrenia, and substance abuse being most closely associated with suicide. The male-to-female ratio is less pronounced among psychiatric patients than in the general population, with a higher rate in unmarried psychiatric patients living alone. The lifetime probability of death by suicide in various psychiatric disorders is estimated to be between 10% and 15%, contrasting with less than a 1 % lifetime probability in those without a psychiatric disorder. 

Older persons account for one-third of all suicides in the United States even though this group represents only 12% of the population ( 36). Suicide is even more often related to major depression in the elderly than in younger individuals in whom other causes such as substance abuse, bipolar disorder, schizophrenia, and personality disorders often play a major role. In fact, suicide rates are highest in older white men relative to any other segment of the population. For example, white men older than 85 years age commit suicide 30 times as frequently as black women. 

Middle-aged or older individuals who complete suicide tend to suffer from a depressive disorder. Younger individuals who complete suicide usually suffer from schizophrenia or a bipolar disorder. The risk factors for suicide attempts versus completions are the following ... 

Murphy and Wetzel (45) concluded that the current estimate of 11 % to 15% lifetime risk of suicide in alcoholics was not tenable based on a more careful examination of the data, and was probably more in the range of 2% to 3.4%. This percentage is still in contrast with the approximate 1% annual incidence of suicide in the United States. Much of the increase, however, could be related to another Axis I diagnosis (e.g., bipolar disorder). 

To underscore the importance of adequate treatment for bipolar disorder, we note that it is estimated that one of every four or five untreated or inadequately treated patients commits suicide during the course of the illness, particularly during depressed or mixed episodes. Further, an increase in deaths secondary to accidents or intercurrent illnesses contributes to the greater mortality rate seen in this disorder in comparison with the general population. Unfortunately, recent epidemiological studies have indicated that only one third of bipolar patients are in active treatment despite the availability of effective therapies. 

Jamison KR. Suicide and bipolar disorder. J din Psychiatry 2000 61(suppl 9) 47-51. 

For more than 40 years, lithium has been the standard drug therapy for bipolar disorder, primarily because of the quantity and the quality of evidence supporting its role as an effective maintenance and prophylactic treatment. This latter point is a very important consideration, given the recurrent nature of this disorder. Thus, clinicians must choose the optimal strategy for acute treatment with the realization that most patients will need to continue drug therapy indefinitely. In addition, there is support for maintenance lithium s beneficial impact on the suicide rate in bipolar patients ( 73, 74). The author of these reports notes that the lower suicide risk associated with lithium treatment may be due to the following ... 

BPD is characterized by a pervasive pattern of unstable affect, stormy interpersonal relationships, and behavioral dyscontrol. An estimated 1% to 2% of the general population manifest this syndrome. It is also a co-morbid condition with major mood disorders (i.e., different studies estimate from 25% to 75% of these patients have a major depression and 5% to 20% a bipolar disorder). Furthermore, as many as 25% of bulimics may also suffer from BPD, and approximately 70% of BPD patients abuse alcohol or drugs. Self-mutilation, suicide attempts, and completed suicides are all too frequent. Indeed, it is estimated that 3% to 10% of these patients will take their own lives. 

Bipolar affective (manic-depressive) disorder occurs in 1-3% of the adult population. It may begin in childhood, but most cases are first diagnosed in the third and fourth decades of life. The key symptoms of bipolar disorder in the manic phase are excitement, hyperactivity, impulsivity, disinhibition, aggression, diminished need for sleep, psychotic symptoms in some (but not all) patients, and cognitive impairment. Depression in bipolar patients is phenomenologically similar to that of major depression, with the key features being depressed mood, diurnal variation, sleep disturbance, anxiety, and sometimes, psychotic symptoms. Mixed manic and depressive symptoms are also seen. Patients with bipolar disorder are at high risk for suicide. 

De Luca V, Mueller DJ, Tharmalingam S, King N, Kennedy JL.Analysis of the novel TPH2 gene in bipolar disorder and suicidality. Mol Psychiatry 2004 9(10) 896-897... 

Baldessarini, R. J., Tondo, L., Davis, P., Pompili, M., Goodwin, R K., Hennen, J. 2006, Decreased risk of suicides and attempts during long-term lithium treatment a meta-analytic review, Bipolar.Disord., vol. 8, no. 5, Pt 2, pp. 625-639. 

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