Suicide Risk in Mood Disorders

Zoltán Rihmer


Curr Opin Psychiatry. 2007;20(1):17-22. 

In This Article

Abstract and Introduction


Purpose of Review: The aim of this review is to highlight the traditional and newly recognized suicide risk factors in patients with mood disorders.
Recent Findings: Current research findings clearly suggest that suicidal behaviour in patients with mood disorder is a 'state-dependent' phenomenon. Recently, there is, however, a growing body of evidence that besides the well accepted clinically explorable suicide risk factors in mood disorders (e.g., severe depression, prior suicide attempt, comorbid anxiety, substance use, personality disorders and so on), mixed state of depression could also be an important precursor of suicidal behaviour. This might be particularly true in unrecognized cases of bipolar depressives, when antidepressant monotherapy (unprotected by mood stabilizers or atypical antipsychotics) can worsen the clinical picture and rarely induce an aggressive or self-destructive behaviour.
Summary: In the majority of patients with mood disorders, suicidal behaviour is predictable and preventable, with a good chance. A careful and systematic exploration of suicide risk factors in patients with mood disorder helps clinicians to identify patients at high suicide risk. A successful, acute and long-term treatment of these patients substantially reduces the suicidal behaviour even in this high-risk population.


In spite of the great decline in suicide mortality in most countries with traditionally high baseline suicide rates during the last two decades,[1*] completed and attempted suicides still remain a major public health problem. Suicidal behaviour is neither a 'normal' response to the levels of stress experienced by most people nor a linear consequence of major mental disorders. Suicide is a very complex, multicausal human behaviour with many 'causes' and several biological as well as psychosocial and cultural components. In our previous studies,[2,3] we had proposed the hierarchical classification of suicide risk factors demonstrating that suicidal behaviour is associated with a number of (a) psychiatric (e.g., major mental disorders), (b) psychosocial (e.g., adverse life situations) and (c) demographic (e.g., male gender) risk factors with varying prognostic utility. Although the statistical relationship between the different demographic and psychosocial risk factors and suicidal behaviour is well demonstrated, it has a very limited value in predicting suicide in individual cases, particularly at the level of general population. As suicides and attempted suicides are very rare in the absence of current major mental disorders,[2,3,4,5,6,7] psychiatric suicide risk factors (current major depression, substance use disorder and schizophrenia particularly with prior suicide attempt), however, are the most powerful and clinically useful predictors of suicide, especially if secondary (psychosocial) and tertiary (demographic) risk factors are also present[2,3] ( Table 1 ). More than 90% of suicide victims and attempters have at least one current axis I (mainly untreated) major mental disorder, most frequently major depressive episode (MDE) (56-87%), substance use disorders (26-55%) and schizophrenia (6-13%). Comorbid anxiety and personality disorders as well as concomitant serious medical disorders are also frequently present, but they are quite rare as principal (or only) diagnoses.[3,4,5,6,7]

Prospective and retrospective studies[8,9,10,11**] clearly support the evident clinical observation that if patients with major mood disorder commit or attempt suicide, they do it mostly during their MDE (78-89%) and less frequently in dysphoric mania (11-20%) but very rarely during euphoric mania and euthymia (0-7%), indicating that suicidal behaviour in patients with mood disorder is a 'state-dependent' phenomenon. Therefore, to treat acute mood episodes effectively and to stabilize the period of euthymia is essential for suicide prevention. As the vast majority of patients with mood disorder never commit suicide and about half of them never attempt suicide,[5,6,11**,12*] special clinical characteristics of mood disorder as well as some familial and psychosocial factors, however, should also play a contributory role in self-destructive behaviour.

The purpose of this review is to summarize the well known and most recent research findings on the clinically explorable suicide risk factors in patients with mood disorders, particularly in the light of currently emerging debate on the relationship between suicidal behaviour and antidepressant medication.[1*] As the risk factors for attempted and completed suicide show only a few differences[4,5,6,7,12*] and suicide attempt is the most powerful predictor of committed suicide, particularly in patients with mood disorder,[12*,13,14,15,16**,17*] the risk factors for attempted and completed suicide are not discussed separately in this review. Similarly, as repeated suicide attempters frequently change their method from nonviolent/nonlethal to violent/lethal (but the opposite is quite rare),[18,19] this is also the case for violent/lethal and nonviolent/nonlethal suicide attempts.


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