Differences in incidence of suicide attempts during phases of bipolar I and II disorders

Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland.
Bipolar Disorders (Impact Factor: 4.97). 07/2008; 10(5):588-96. DOI: 10.1111/j.1399-5618.2007.00553.x
Source: PubMed


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.

Download full-text


Available from: Erkki Isometsä, Jun 22, 2015
  • Source
    • "Compared with euthymia, the incidence of SAs during major depressive phases is 25-fold and during mixed illness episodes in BD 65-fold (Holma et al., 2014). Among patients with mood disorders, suicidal acts in the absence of an illness episode are rare (Holma et al., 2010, 2014; Riihimaki et al., 2014a; Valtonen et al., 2008). Both comorbid DSM- IV cluster B (Skodol et al., 2011) and C (Oleski et al., 2012) PDs have been shown to increase time that an individual spends in major depressive episodes (MDEs). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Comorbid personality disorders may predispose patients with mood disorders to suicide attempts (SAs), but factors mediating this effect are not well known. Methods: Altogether 597 patients from three prospective cohort studies (Vantaa Depression Study, Jorvi Bipolar Study, and Vantaa Primary Care Depression Study) were interviewed at baseline, at 18 months, and in VDS and PC-VDS at 5 years. Personality disorders (PDs) at baseline, number of previous SAs, life-charted time spent in major depressive episodes (MDEs), and precise timing of SAs during follow-up were determined and investigated. Results: Overall, 219 (36.7%) patients had a total of 718 lifetime SAs; 88 (14.7%) patients had 242 SAs during the prospective follow-up. Having any PD diagnosis increased the SA rate, both lifetime and prospectively evaluated, by 90% and 102%, respectively. All PD clusters increased the rate of new SAs, although cluster C PDs more than the others. After adjusting for time spent in MDEs, only cluster C further increased the SA rate (by 52%). Mediation analyses of PD effects on prospectively ascertained SAs indicated significant mediated effects through time at risk in MDEs, but also some direct effects. Limitations: Findings generalizable only to patients with mood disorders. Conclusions: Among mood disorder patients, comorbid PDs increase the risk of SAs to approximately two-fold. The excess risk is mostly due to patients with comorbid PDs spending more time in depressive episodes than those without. Consequently, risk appears highest for PDs that most predispose to chronicity and recurrences. However, also direct risk-modifying effects of PDs exist.
    Full-text · Article · Nov 2015 · Journal of Affective Disorders
  • Source
    • "DMX has been extensively studied recently and is observed predominantly in patients with bipolar depression, particularly those with bipolar II disorder (BP-II), than in those with monopolar depression, i.e., MDD (Akiskal and Benazzi, 2005; Benazzi, 2005; Takeshima et al., 2008; Takeshima and Oka, 2013; Vieta and Suppes, 2008). This state has also recently drawn attention as one of the strongest risk factors for suicidality (Balázs et al., 2006; Undurraga et al., 2012; Valtonen et al., 2008). In line with the phenomenological similarities between AS and DMX, Akiskal and Benazzi (2006) and Rihmer and Akiskal (2006) argued that AS could be understood as antidepressant-induced DMX. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Activation syndrome (AS) is a cluster of symptoms listed by the US Food and Drug Administration as possible suicidality precursors during antidepressant treatment. We aimed to clarify whether AS is associated with bipolar II disorder (BP-II) and its related disorder, i.e., bipolar disorder not otherwise specified (BP-NOS), which are often mistreated as major depressive disorder (MDD), as well as bipolar suggestive features in outpatients with depression. The frequency of AS, bipolar suggestive features, and background variables in consecutive outpatients with a major depressive episode (MDE) due to BP-II/BP-NOS or MDD, who were naturalistically treated with antidepressants, were investigated and analyzed retrospectively. Of 157 evaluable patients (46 BP-II/BP-NOS, 111 MDD), 39 (24.8%) experienced AS. Patients with BP-II/BP-NOS experienced AS significantly more frequently than patients with MDD (52.2% of BP-II/BP-NOS vs. 13.5% of MDD, p<0.01). Univariate analysis revealed that BP-II/BP-NOS diagnosis, cyclothymic temperament, early age at onset of first MDE, psychiatric comorbidities, and depressive mixed state (DMX) were significantly associated with AS development in the entire sample. Multivariate analysis revealed that BP-II/BP-NOS diagnosis and DMX were independent risk factors for AS. This is a retrospective and naturalistic study; therefore, patient selection bias could have occurred. Cautious monitoring of AS is needed during antidepressant trials in patients with BP-II/BP-NOS. Clinicians should re-evaluate underlying bipolarity when they confront AS. Antidepressants should be avoided for treating a current DMX beyond the unipolar-bipolar dichotomy. Prospective studies are needed to confirm these results.
    Full-text · Article · Jun 2013 · Journal of Affective Disorders
  • Source
    • "As one in two completed suicides (Isometsä & Lönnqvist, 1998) and suicides accompanied by major depression (Isometsä et al. 1994) are preceded by at least one attempt, and up to one-fifth of attempters eventually die by suicide (Suominen et al. 2004), the study of suicide attempts as a feasible proxy outcome would be informative with regard to completed suicide. Medium-and long-term studies among depressive psychiatric care patients have documented risk factors such as severity of symptoms and duration of time spent in depression (Sokero et al. 2005; Valtonen et al. 2008; Holma et al. 2012). A 5-year prospective study found the incidence of suicide attempts during major depressive episodes (MDEs) to be 21-fold that during full remission (Holma et al. 2010). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: No previous study has prospectively investigated incidence and risk factors for suicide attempts among primary care patients with depression. Method: In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 patients was screened for depression, and Structured Clinical Interviews for DSM-IV used to diagnose Axis I and II disorders. A total of 137 patients were diagnosed with a DSM-IV depressive disorder. Altogether, 82% of patients completed the 5-year follow-up. Information on timing of suicide attempts, plus major depressive episodes (MDEs) and partial or full remission, or periods of substance abuse were examined with life charts. Incidence of suicide attempts and their stable and time-varying risk factors (phases of depression/substance abuse) were investigated using Cox proportional hazard and Poisson regression models. Results: During the follow-up there were 22 discrete suicide attempts by 14/134 (10.4%) patients. The incidence rates were 0, 5.8 and 107 during full or partial remission or MDEs, or 22.2 and 142 per 1000 patient-years during no or active substance abuse, respectively. In Cox models, current MDE (hazard ratio 33.5, 95% confidence interval 3.6-309.7) was the only significant independent risk factor. Primary care doctors were rarely aware of the suicide attempts. Conclusions: Of the primary care patients with depressive disorders, one-tenth attempted suicide in 5 years. However, risk of suicidal acts was almost exclusively confined to MDEs, with or without concurrent active substance abuse. Suicide prevention among primary care patients with depression should focus on active treatment of major depressive disorder and co-morbid substance use, and awareness of suicide risk.
    Full-text · Article · Apr 2013 · Psychological Medicine
Show more