Bipolar Disorder and Suicide

Michel Bourin; Michel Bourin

ISSN: 2455-5460

Archives of Depression and Anxiety

Mini Review Open Access Peer-Reviewed

Bipolar Disorder and Suicide

Michel Bourin*

Neurobiology of anxiety and mood disorders, University of Nantes, 98, rue Joseph Blanchart, 44100 Nantes, France

Author and article information

*Corresponding authors: Michel Bourin, Neurobiology of anxiety and mood disorders, University of Nantes, 98, rue Joseph Blanchart, 44100 Nantes, France, Email: [email protected]

ORCiD : https://orcid.org/0000-0002-7268-4590

doi : 10.17352/2455-5460.000097

Received: 14 October, 2024 | Accepted: 21 October, 2024 | Published: 22 October, 2024

Keywords: Digital media; Psychological dimension; Subjective well-being; User characteristics; Use and gratification; Social reference

Cite this as

Bourin M. Bipolar Disorder and Suicide. Arch Depress Anxiety. 2024;10(2):071-074. Available from: 10.17352/2455-5460.000097

Copyright

© 2024 Bourin M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Suicide is a dramatic and frequent consequence of bipolar disorder. Prevention of suicidal behavior involves an assessment of suicidal vulnerability factors (history of suicidal behavior, impulsive personality, etc.), characteristics of depression (agitated depression, a subtype of bipolar disorder, etc.), psychiatric comorbidities, and stress factors. Psychosocial at the same time with the characteristics of suicidal behavior in a depressed subject (severe or repeated gestures in particular) make it possible to direct the diagnosis towards a bipolar disorder rather than a major depressive disorder. In addition to training caregivers to screen for bipolar disorder and assess suicidal behavior, the withdrawal of lethal means, networking, and treatment of depression reduce the risk of suicidal behavior. At the medicinal level, the use of lithium salts could be of particular interest in subjects at high risk of suicide.

Main article text

Introduction

Patients suffering from bipolar disorder are among the patients at higher risk of suicide. 20% to 56% of patients suffering from bipolar disorder will suicide attempts (SA) in their lifetime and 10% to 15% will die by suicide [1]. These rates which are 15 to 30 times higher than those in the general population have bipolar disorder one of the diseases most at risk of suicide resulting from SA. Prospective and retrospective data show that patients most often engage in suicidal behavior during a major depressive episode (78% - 89% of SA) [2]. The period of depression is elsewhere a critical period due to frequent diagnostic errors that can lead to inadequate treatment that can encourage action. A detailed assessment of suicidal risk as well as screening and treatment burden of bipolar disorder are therefore essential to bring these numbers down.

Suicidal risk assessment in bipolar disorder

Schematically these risk factors can be grouped into four large groups:

Suicidality characteristics as a marker of bipolar depression

Since major depressive episodes are found in both bipolar disorder and major depressive disorder, diagnostic errors are common. The tendency is to overdiagnose major depressive disorders and underdiagnose bipolar disorders. Bipolar disorder is often denied among patients, even the psychiatrists, the bipolar spectrum is wider than health professionals believe. It is important to note that the characteristics of suicidal acts in a depressed suicidal patient can in themselves guide the diagnosis. Bipolar disorder more particularly during the depressive phase is associated with actions with high lethality [10]. At the epidemiological level, this probably explains why the lethal risk is high as indicated by the ratio of the number of SA to the number of completed suicides which is 3.9 in these patients, while it varies from 20 to 40 in the general population. Data show that in a depressed patient, a family history of suicide as well as a personal history of frequent or serious suicidal behavior (i.e. violent actions such as hanging, the use of a firearm, or requiring a visit to intensive care) are much more common [11]. Thus, in daily clinical practice, the presence of one or more of these characteristics in a depressed suicidal patient should suggest bipolar disorder. In this subgroup of patients, a careful search for manic or hypomanic episodes (if necessary, using diagnostic tools) is necessary in order to initiate appropriate treatment [12].

Suicidal behavior and bipolar disorder

The frequency of suicidal behavior but also the severity of the characteristics of AS in bipolar disorder could also suggest certain common vulnerability traits between bipolar disorder and suicide. Thus, cognitive decision-making function has been shown to be disrupted in bipolar disorder and in suicidal patients independently of psychiatric comorbidities [13]. Neuroanatomical relationships involving abnormalities in emotional regulation have also been suggested [14,15]. These common vulnerability factors could partly explain the frequency of occurrence of suicidal behavior in bipolar disorder. Furthermore, this suggests the possibility of testing the effect of treatments on these common “endophenotypes” such as the effect of lithium salts on aggressive impulsivity which could explain its anti-suicide effect [16].

Prevention of suicide risk in bipolar depression

The first action to prevent suicidal behavior in bipolar disorder consists of improving our ability to recognize the disorder when faced with a depressed subject [17]. Thus, it takes on average five years before correct detection of the disorder [18]. Non-specific interventions for bipolar disorder have also shown their effectiveness: this involves the withdrawal of lethal means (particularly firearms), networking with the various care providers (general practitioner, psychiatrist, psychologist, etc.), and raising awareness among doctors about screening and management of suicide risk [19]. It has been shown that the majority of bipolar patients who commit suicide are in contact with care and that a large number of these patients communicated their suicidal intentions shortly before committing suicide [20]. This observation justifies that the assessment of suicide risk is carried out systematically and regularly in our bipolar patients, with certain elements being expected to change (acute psychiatric disorders, life events), and others less so (vulnerability factors) [21]. Chief among the modifiable factors is depression. Thus, studies like that of Gotland show that correct management of depression is strongly associated with a reduction in the risk of suicide. In bipolar depression, the question of choosing an optimal treatment currently remains a subject of study. The rule must be to do no harm to patients [22]. The choice of treatment must take into account the targets envisaged: melancholic characteristics, anxiety, agitation, high suicidal risk, impulsivity and violence, rapid cycles, and substance abuse. If none of the current recommendations propose specific therapeutic strategies for bipolar depression with a high suicidal risk, Suicidal acts including violent acts and suicides were more prevalent with BD than MDD [23]. Indeed, abundant literature tends to prove that lithium salts in particular have a particularly preventive effect with regard to suicidal behavior. Lithium has a protective effect against completed suicides as well as SA in bipolar patients but also in patients with recurrent depressive disorder. Results of a growing number of randomized, controlled studies of lithium treatment for suicide prevention including comparisons with placebos or alternative treatments, and comment on the severe challenges of such trials [24]. Lithium would reduce the rate of suicidal behavior by almost five and this anti-suicide effect could be partially independent of the mood-regulating effect itself [25]. It should be noted that stopping (and especially suddenly stopping) lithium leads to an increase in the risk of suicide. The benefits of using antidepressants remain very controversial. This controversy concerns their potential increases in suicide risk but also their effectiveness [26]. Regarding suicidal risk, there is to date no prospective study or randomized controlled trial specifically evaluating whether antidepressants modify short- or longer-term suicidal risk in depressed bipolar patients [27]. On the other hand, electroconvulsive therapy (ECT) significantly reduces the risk of suicide death while also being a medically safe procedure [28]. Electroconvulsive therapy use is, however, inhibited by fear of electricity, unreasoned prejudice, legislative restrictions, and the limited availability of trained professionals and adequate facilities.

Conclusion

Suicide is a dramatic and frequent consequence of bipolar depression. Preventing suicidal behavior requires improving our capacity for early diagnosis of the disorder, and carrying out a careful and repeated systematic assessment of suicidal risk. In addition to the treatment of depression, comorbidities and the prevention of psychosocial consequences must also be integrated into management strategies. Recent data showing a decrease in suicide rates in studies conducted in recent years compared to older ones show that these behaviors can be prevented with correct diagnosis and treatment of the mood disorder, and through accurate assessment of suicidal risk factors [29].

In my idea, to prevent suicide risk, there are 2 directions:

- Progress in the identification of predictive factors (clinical, environmental, and biological) for the occurrence of suicidal behavior, based on a follow-up study of subjects at high suicidal risk (suicide ideas and attempts).

- Improve the measurement and monitoring of suicide risk in real-time through the development of connected tools.

The most important in clinical practice is to tell bipolar patients that suicide ideas are part of the illness and not that they want to die.