Differences in incidence of suicide attempts during phases of bipolar I and II disorders
ABSTRACT Differences in the incidence of suicide attempts during various phases of bipolar disorder (BD), or the relative importance of static versus time-varying risk factors for overall risk for suicide attempts, are unknown.
We investigated the incidence of suicide attempts in different phases of BD as a part of the Jorvi Bipolar Study (JoBS), a naturalistic, prospective, 18-month study representing psychiatric in- and outpatients with DSM-IV BD in three Finnish cities. Life charts were used to classify time spent in follow-up in the different phases of illness among the 81 BD I and 95 BD II patients.
Compared to the other phases of the illness, the incidence of suicide attempts was 37-fold higher [95% confidence interval (CI) for relative risk (RR): 11.8-120.3] during combined mixed and depressive mixed states, and 18-fold higher (95% CI: 6.5-50.8) during major depressive phases. In Cox's proportional hazards regression models, combined mixed (mixed or depressive mixed) or major depressive phases and prior suicide attempts independently predicted suicide attempts. No other factor significantly modified the risks related to these time-varying risk factors; their population-attributable fraction was 86%.
The incidence of suicide attempts varies remarkably between illness phases, with mixed and depressive phases involving the highest risk by time. Time spent in high-risk illness phases is likely the major determinant of overall risk for suicide attempts among BD patients. Studies of suicidal behavior should investigate the role of both static and time-varying risk factors in overall risk; clinically, management of mixed and depressive phases may be crucial in reducing risk.
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ABSTRACT: Bipolar disorder is characterized by debilitating episodes of depression and mood elevation (mania or hypomania). For most patients, depressive symptoms are more pervasive than mood elevation or mixed symptoms, and thus have been reported in individual studies to impose a greater burden on affected individuals, caregivers, and society. This article reviews and compiles the literature on the prevalence and burden of syndromal as well as subsyndromal presentations of depression in bipolar disorder patients. The PubMed database was searched for English-language articles using the search terms "bipolar disorder," "bipolar depression," "burden," "caregiver burden," "cost," "costs," "economic," "epidemiology," "prevalence," "quality of life," and "suicide." Search results were manually reviewed, and relevant studies were selected for inclusion as appropriate. Additional references were obtained manually from reviewing the reference lists of selected articles found by computerized search. In aggregate, the findings support the predominance of depressive symptoms compared with mood elevation/mixed symptoms in the course of bipolar illness, and thus an overall greater burden in terms of economic costs, functioning, caregiver burden, and suicide. This review, although comprehensive, provides a study-wise aggregate (rather than a patient-wise meta-analytic) summary of the relevant literature on this topic. In light of its pervasiveness and prevalence, more effective and aggressive treatments for bipolar depression are warranted to mitigate its profound impact upon individuals and society. Such studies could benefit by including metrics not only for mood outcomes, but also for illness burden. Copyright © 2014 Elsevier B.V. All rights reserved.Journal of Affective Disorders 12/2014; 169S1:S3-S11. DOI:10.1016/S0165-0327(14)70003-5 · 3.71 Impact Factor
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ABSTRACT: Bipolar depression is more pervasive than mania, but has fewer evidence-based treatments. Using data from multicenter, randomized, double-blind, placebo-controlled trials and meta-analyses, we assessed the number needed to treat (NNT) for response and the number needed to harm (NNH) for selected side effects for older and newer acute bipolar depression treatments. The 2 older FDA-approved treatments for bipolar depression, olanzapine-fluoxetine combination (OFC) and quetiapine (QTP) monotherapy, were efficacious (response NNT=4 for OFC, NNT=6 for QTP), but similarly likely to yield harms (OFC weight gain NNH=6; QTP sedation/somnolence NNH=5). Commonly used unapproved agents (lamotrigine monotherapy and adjunctive antidepressants) tended to be well-tolerated (with double-digit NNHs), although this advantage was at the cost of inadequate efficacy (response NNT=12 for lamotrigine, NNT=29 for antidepressants). In contrast, the newly approved agent lurasidone was not only efficacious (response NNT=5 for monotherapy, NNT=7 as adjunctive therapy), but also had enhanced tolerability (NNH=15 for akathisia [monotherapy], NNH=16 for nausea [adjunctive]). Although adjunctive armodafinil appeared well tolerated, its efficacy in bipolar depression has not been consistently demonstrated in randomized controlled trials. NNT and NNH are categorical metrics; only selected NNHs were assessed; limited generalizability of efficacy (versus effectiveness) studies. For acute bipolar depression, older approved treatments may have utility in high-urgency situations, whereas lamotrigine and antidepressants may have utility in low-urgency situations. Newly approved lurasidone may ultimately prove useful in diverse situations. New drug development needs to focus on not only efficacy but also on tolerability. Copyright © 2014 Elsevier B.V. All rights reserved.Journal of Affective Disorders 12/2014; 169S1:S24-S33. DOI:10.1016/S0165-0327(14)70006-0 · 3.71 Impact Factor
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ABSTRACT: People with bipolar disorder may be at increased risk of suicidal behaviour but there are few prospective studies of self-harm in this group. Our aim was to describe the characteristics and outcome (in terms of repetition) for individuals with bipolar disorder who presented to hospital following self-harm.MethodA nested case-control study was carried out using a large prospective self-harm database (1997–2010) in Manchester, UK. Characteristics of bipolar cases and non-bipolar controls were compared using conditional logistic regression, and outcomes were assessed via survival analyses.ResultsBipolar cases (n=103) were more likely to repeat self-harm than controls (n=515): proportion with at least one repeat episode 58% vs. 25%, HR 3.08 (95% CI; 2.2–4.18). Previous self-harm, unemployment, contact with psychiatric services and sleep disturbance were all more common in cases than controls. Even after adjustment for known risk factors, the risk of repetition remained higher in the bipolar group (adjusted HR 1.68; 95% CI; 1.10–2.56).LimitationsThe study covers cases from hospital sites in Manchester, UK, and therefore only includes self-harm that was serious enough to present at hospital emergency departments.Conclusion People with bipolar disorder who self-harm have a higher risk of repetition than people who self-harm more generally. Adjusting for some known risk factors moderated, but did not abolish, this finding. Other factors, such as impulsivity, may also be important.Journal of Affective Disorders 10/2014; 173. DOI:10.1016/j.jad.2014.10.012 · 3.71 Impact Factor