Suicide Risk Factors in Bipolar Disorder Identified

Liam Davenport

April 03, 2017

FLORENCE, Italy — Patients with bipolar disorder (BD) with depressed polarity, comorbid anxiety, and an anxious temperament may be at increased risk for suicide, new research suggests.

"Hyperthymic temperament in our population might be a protective factor against suicidality in bipolar patients, whereas depressed polarity, anxiety comorbidity, and anxious temperament seem to elevate the risk for suicidality. So, especially in these patient subgroups, suicidality should be closely monitored," the investigators, led by Uta Ouali, MD, Razi Hospital, Mannouba, Tunisia, report.

The findings were presented here at the European Psychiatric Association (EPA) 25th Congress.

A "Major Concern"

Dr Ouali noted that the high of frequency suicidality in patients with BD is "a major concern" and that the identification of subgroups at particularly increased risk is important.

The investigators conducted a retrospective, cross-sectional study of 100 BD patients who had a history of suicide attempts to explore the sociodemographic and clinical characteristics of such patients. They compared these factors with those of patients who had never attempted suicide. All patients had been diagnosed with type 1 BD on the basis DSM-5 criteria and were clinically stable.

Twenty-three patients in the study had made at least one suicide attempt. Women were substantially overrepresented among such patients, at 61.9%.

The results showed that patients who attempted suicide were more likely to have a family history of any psychiatric disorder, at 82.6%, vs 57.1% for those who had not attempted suicide. Those who attempted suicide were also more likely to have a history of affective disorder, at 43.5% vs 33.8%.

The mean number of pure depressive episodes was significiantly higher for patients who had attempted suicide than for those who had not, at 2.52 vs 0.96 (P = .001). The mean number of depressive episodes with mixed and psychotic features was also significantly higher among those who had attempted suicide, at 0.22 vs 0.01 (P = .002).

The mean number of manic episodes with mixed features was also significantly higher among patients who had attempted suicide than among those who had not, at 1.35 vs 0.44 (P = .032), as was the mean number of manic episodes with mixed and psychotic features, at 0.70 vs 0.23 (P = .012).

The interepisode quality was worse among those who had attempted suicide than among those who had not, with only partial resolution of mood symptoms in patients in the suicide group.

Dr Ouali noted that anxiety comorbidity was significantly higher in the suicide group, "and this was mainly true for generalized anxiety disorder and social phobia."

Alcohol dependence was nonsignificantly greater among the suicide group than among those who had not attempted suicide (P = .079), which is in contrast to previous studies. Dr Ouali suggested that this may be an artifact of the stigmatization of alcohol and substance abuse in Tunisian society, leading to underreporting.

"As for affective temperaments, hyperthymic temperament was shown to be a protective factor against suicide attempts, whereas anxious temperament was a risk factor," she said.

The team found that diagnostic delay was greater among the patients who had attempted suicide than among those who had not, at 6.61 years vs 4.58 years. Those who had attempted suicide were also more likely to have received an initial diagnosis other than BP than the patients who had not attempted suicide, at 79.3% vs 53.2%.

Consider Suicide Risk Early

Noting that similar studies have been carried out in other countries, session chair Andreas Erfurth, MD, from Otto-Wagner-Spital, Vienna, Austria, encouraged "everybody in the room to replicate studies in his or her own surroundings, because people are very different in different parts of the world, and what might by true for the United States might not be true for Tunisia, for Taiwan or for Austria."

He said the findings highlight the importance of the initial diagnosis.

He advised clinicians to consider a diagnosis of BD in young patients with unipolar depression, because it may be they have "not yet had a manic or hypomanic episode.

"If you have a diagnosis of personality disorders, especially in people who meet the criteria for emotionally unstable personality...so if they belong to the bipolar spectrum, they have a very high risk of suicide, so consider suicide risk early on," Dr Erfurth added.

Dr Erfurth also noted that although alcoholism may have been underreported, owing to religious stigma, "it's somehow obvious that the more you go to the south, the less problems with alcoholism you have."

He gave the example of Italy, where there is a much larger alcohol problem in Venice or Trieste than in Palermo. "It's the same Catholic religion, so it might have to do something with north and south."

A member of the audience asked whether Dr Ouali thought religion may protect against suicide.

She noted that clinically, "that's what we noticed with our patients."

"When you try to evaluate the suicide risk, a lot of them will tell you: 'Yes, it's true, I think about it, but I will never do it because it's written in the Quran and it's forbidden, and so I'm not doing it,'" she said.

No relevant financial relationships have been disclosed.

European Psychiatric Association (EPA) 25th Congress. Abstract O023, presented April 2, 2017.

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