Clinical and dimensional characteristics of euthymic bipolar patients with or without suicidal behavior

The Types of Psychosocial Factors Associated with Suicidality Outcomes for People Living with Bipolar Disorder: A Scoping Review

Bipolar Disorder is associated with high rates of suicidal thoughts, behaviors, and outcomes, yet the lived experience of suicidality and Bipolar Disorder is not particularly well understood. Understanding the role of psychosocial aetiologies in suicidality outcomes for those living with Bipolar Disorder is key for developing appropriately targeted interventions focusing on factors that are amenable to change. In line with PRISMA guidance, we conducted a scoping review to identify the types of psychosocial factors studied in relation to the experience of suicidality for people living with Bipolar Disorder diagnoses. Systematic literature searches identified a sample of 166 articles from which key study data were extracted and charted. A narrative synthesis of the reviewed literature is presented ordered by the factors investigated across studies, a frequency count of the types of psychological/social aetiologies studied, and a brief overview of the key findings for each aetiology. Most of the identified literature took the form of quantitative cross-sectional studies, with only one qualitative study and 18 quantitative prospective studies. The most studied aetiologies were trauma (specifically early adverse experiences and childhood traumas) and stressful life events, impulsivity (primarily subjective self-reported trait impulsivity), social support and functioning, and personality/temperament factors. Only six studies in the final sample reported basing their research questions and/or hypotheses on an explicit theoretical model of suicide. The literature was primarily focused on using self-report measurements of key aetiologies and on factors which lead to worsened suicidality rather than focusing on potentially protective or buffering factors. Future research needs to better justify the aetiologies investigated in relation to suicidality outcomes for people living with Bipolar Disorder, including a firmer basis in theory and hypothesis testing, more prospective designs, and the use of alternative assessments of psychosocial aetiologies in addition to self-report questionnaires.

The prevalence and clinical correlates of suicide attempts in patients with bipolar disorder misdiagnosed with major depressive disorder: Results from a national survey in China

BACKGROUND AND AIM

Suicide is nearly always associated with underlying mental disorders. Risk factors for suicide attempts (SAs) in patients with bipolar disorder (BD) misdiagnosed with major depressive disorder (MDD) remain unelucidated. This study was to evaluate the prevalence and clinical risk factors of SAs in Chinese patients with BD misdiagnosed with MDD.

METHODS

A total of 1487 patients with MDD from 13 mental health institutions in China were enrolled. Mini International Neuropsychiatric Interview (MINI) was used to identify patients with BD who are misdiagnosed as MDD. The general sociodemographic and clinical data of the patients were collected and MINI suicide module was used to identify patients with SAs in these misdiagnosed patients.

RESULTS

In China, 20.6% of patients with BD were incorrectly diagnosed as having MDD. Among these misdiagnosed patients, 26.5% had attempted suicide. These patients tended to be older, had a higher number of hospitalizations, and were more likely to experience frequent and seasonal depressive episodes with atypical features, psychotic symptoms, and suicidal thoughts. Frequent depressive episodes and suicidal thoughts during depression were identified as independent risk factors for SAs. Additionally, significant sociodemographic and clinical differences were found between individuals misdiagnosed with MDD in BD and patients with MDD who have attempted suicide.

CONCLUSIONS

This study highlights the importance of accurate diagnosis in individuals with BD and provide valuable insights for the targeted identification and intervention of individuals with BD misdiagnosed as having MDD and those with genuine MDD, particularly in relation to suicidal behavior.

The association between variability, intensity, and persistence of suicidal ideation and prospective suicidal behavior in the systematic treatment enhancement program for bipolar disorder (STEP-BD) study

Background

This study sought to examine the association between prospective suicidal behavior and variability, intensity, and persistence of suicidal ideation (SI) in bipolar disorder (BD).

Methods

Data were drawn from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), a naturalistic study of 4360 outpatients 15 years or older with BD. In separate models, logistic regressions with suicidal behavior (first attempt or death by suicide) as the outcome variable and SI variability (fluctuating levels of SI over time, measured as ordinal dispersion of SI score), intensity (median SI score over time in study), or persistence (number of visits with reported SI) as the explanatory variables were used to examine the relationship between SI characteristics and odds of future suicidal behavior events.

Results

After adjusting for possible confounders, the odds of prospective suicidal behavior were 1.2 times greater per 10% increase in SI variability. SI persistence was not associated with suicidal behavior. For SI intensity, a median SI score of ‘rare/fleeting’ or ‘several days’ of SI was not associated with suicidal behavior, but the odds of prospective suicidal behavior were nearly five times greater for participants with the highest observed median SI intensity score of ‘nearly every day’.

Conclusions

The findings suggest that, in BD participants, monitoring SI variability may be clinically useful for assessing suicide risk.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00263-7.

[Suicidal behaviors in bipolar disorder type 1]

OBJECTIVES

Bipolar disorder is one of the most common and severe psychiatric conditions. It is frequently complicated by suicidal behaviors, and patients with BD are among those at higher risk of suicide. The aims of our study were to evaluate the predictive factors of suicidal behaviors in patients with BD type 1, through the assessment of their socio-demographic, clinical and evolutionary characteristics as well as to study the implications of the childhood traumas and impulsivity as predictive factors for suicidal behaviors in these patients with bipolar disorder.

METHODS

One hundred patients with bipolar disorder type 1were recruited in order to conduct a cross-sectional, analytical and comparative study. The recruitment involved a first group made up of 40 patients suffering from type 1 bipolar disorder with a history of suicidal acts. This group was compared with a second group made up of 60 patients with no history of attempted suicide. We used a pre-established collection sheet for collecting socio-demographic, clinical and therapeutic data. We also used the Childhood Trauma Questionnaire for the assessment of childhood adversities, the Barratt Impulsivity Scale in its eleventh version for the assessment of impulsivity levels and the Global Assessment of Functioning Scale for the evaluation of overall functioning.

RESULTS

The suicidal behaviors in patients with bipolar disorder were significantly associated with: female gender (P<0.001), professional instability (P=0.002), family history of BD (P=0.02), family history of other psychiatric disorders (P=0.003), frequency of depressive episodes (P=0.002), shorter remission (P=0.025), more subsyndromal symptoms (P=0.029), sexual abuse dimension (P=0.009), and a high level of impulsivity (P<0.001). The predictive factors for suicidal behaviors in multivariate analysis, after adjusting for the confounding variables were: childhood sexual abuse (P=0.01; adjusted OR 4.5; 95% CI 1.44-14.2), a high level of impulsivity (P=0.002; adjusted OR 6.6; 95% CI 2-20), a higher rate of depressive episodes (P=0.003; adjusted OR 5; 95% CI 1.69-14.2) and more subyndromal symptoms (P=0.007; adjusted OR 5.8; 95% CI 1.63-20).

CONCLUSIONS

Suicide prevention is an important mental health subject. It would be imperative to include systematic screening for childhood adversities and adequate management of bipolar disorder and impulsivity.

Identifying subtypes of bipolar disorder based on clinical and neurobiological characteristics

The ability to classify patients with bipolar disorder (BD) is restricted by their heterogeneity, which limits the understanding of their neuropathology. Therefore, we aimed to investigate clinically discernible and neurobiologically distinguishable BD subtypes. T1-weighted and resting-state functional magnetic resonance images of 112 patients with BD were obtained, and patients were segregated according to diagnostic subtype (i.e., types I and II) and clinical patterns, including the number of episodes and hospitalizations and history of suicide and psychosis. For each clinical pattern, fewer and more occurrences subgroups and types I and II were classified through nested cross-validation for robust performance, with minimum redundancy and maximum relevance, in feature selection. To assess the proportion of variance in cognitive performance explained by the neurobiological markers, multiple linear regression between verbal memory and the selected features was conducted. Satisfactory performance (mean accuracy, 73.60%) in classifying patients with a high or low number of episodes was attained through functional connectivity, mostly from default-mode and motor networks. Moreover, these neurobiological markers explained 62% of the variance in verbal memory. The number of episodes is a potentially critical aspect of the neuropathology of BD. Neurobiological markers can help identify BD neuroprogression.

Alterations in gray matter volumes and intrinsic activity in the prefrontal cortex are associated with suicide attempts in patients with bipolar disorder

Bipolar disorder (BD) is associated with increased suicidal behavior. Understanding the neural features of suicide attempts (SA) in patients with BD is critical to preventing suicidal behavior. The prefrontal cortex (PFC) is a key region related to SA. In this study, forty BD patients with a history of SA (BD+SA), 70 BD patients without a history of SA (BD-SA), and 110 individuals in a healthy control (HC) group underwent structural magnetic resonance imaging (MRI) and resting-state functional MRI. We used voxel-based morphometry (VBM) and amplitude of low frequency fluctuations (ALFF) techniques to examine the gray matter volumes (GMVs) and ALFF values in the PFC. Compared with the HC group, both the BD+SA and BD-SA groups had lower GMVs and higher ALFF values in the medial PFC (MPFC), ventral PFC (VPFC), and dorsolateral PFC (DLPFC). The ALFF values in the MPFC, VPFC, and DLPFC in the BD+SA group were significantly higher than those in the BD-SA group. These findings suggest that BD patients with SA have intrinsic activity abnormalities in PFC regions. This provides potentially identifiable neuroimaging markers in BD patients with SA that could be used to increase our understanding of suicidal behavior.

Altered Functional Connectivity Differences in Salience Network as a Neuromarker of Suicide Risk in Euthymic Bipolar Disorder Patients

Objective

The occurrence of death by suicide in patients diagnosed with bipolar disorder is as much as 60 times greater than in the general population. Even during the state of euthymia patients are characterized by suicide risk. The aim of the study is to investigate the baseline brain activity in euthymic bipolar disorder patients in regard to suicide risk. We hypothesized that patients compared to healthy control group will demonstrate altered functional connectivity among resting state networks which will be directly related to current suicide risk.

Method

41 subjects were enrolled in the study consisting control group (n = 21) and euthymic bipolar disorder patients group (n = 20). Functional magnetic resonance imaging was used to evaluate resting state brain activity and ROI-ROI functional connectivity analysis was performed. Suicidal risk was estimated using The Suicide Behaviors Questionnaire-Revised.

Results

A two sample t-test revealed decreased functional connectivity between regions involved in the salience network in patients compared to the control group. This decrease was negatively correlated with current suicide risk.

Conclusion

Obtained results suggest the association between risk of suicide and activity of regions responsible for functions such as learning from mistakes, prospective thinking, and sensory integration.

Assessing Relationships Among Impulsive Sensation Seeking, Reward Circuitry Activity, and Risk for Psychopathology: A Functional Magnetic Resonance Imaging Replication and Extension Study

BACKGROUND

High trait impulsive sensation seeking (ISS), the tendency to engage in behavior without forethought and to seek out new or extreme experiences, is a transdiagnostic risk factor for externalizing and mood disorders, particularly bipolar disorder. We published a positive association between trait ISS and reward expectancy-related activity in the left ventrolateral prefrontal cortex (L vlPFC) and the ventral striatum. We aimed to replicate this finding and extend it by testing for mediation effects of ISS on relationships between reward expectancy-related activity and measures denoting hypomania.

METHODS

A transdiagnostic sample of 127 adults, 18 to 25 years of age, completed a card-guessing functional magnetic resonance imaging task as well as measures of ISS (inattention, motor impulsivity, fun seeking, positive and negative urgency) and the Moods Spectrum as a measure of hypomania. An original sample of 98 was included for confirmatory and mediation analyses.

RESULTS

We replicated a positive relationship between reward expectancy-related L vlPFC activity and negative urgency, an ISS component (β = .28, t = 2.44, p = .0169). We combined these data with the original sample, confirming this finding (β = .27, t = 2.41, p = .0184). Negative urgency statistically mediated the relationship between reward expectancy-related L vlPFC activity and Moods Spectrum factors associated with hypomania. No other associations between ISS measures and reward expectancy-related activity were replicated.

CONCLUSIONS

We replicated findings showing that reward expectancy-related L vlPFC activity is a biomarker for negative urgency, the tendency to react with frustration during distressing conditions. Negative urgency also statistically mediated the relationship between L vlPFC activity and measures indicative of hypomanic symptoms.

Sexual and Religious Obsessions in Relation to Suicidal Ideation in Bipolar Disorder

OBJECTIVES

Obsessions and suicidal behavior are common among patients with bipolar disorder. The relation between them and their impact on disease severity should be a focus of attention. This study aimed at assessment of the presence of sexual and religious obsessions in patients with bipolar disorder and their relation to suicide ideation.

METHODS

Ninety patients diagnosed with bipolar I disorder were recruited consecutively and subdivided into two groups: bipolar disorder with and without sexual/religious obsessions. Both groups were subjected to Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS), Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HAMD), and Beck Scale for Suicide Ideation (BSSI).

RESULTS

Patients with bipolar disorder and sexual/religious obsessions were 54.4% (n = 49) of the total sample, and they showed significantly higher number of suicidal attempts, more severe depression, and suicidal ideation than those without sexual/religious obsessions. BSSI showed significantly positive correlation with HAMD and DY-BOCS sexual and religious obsessions dimension-related distress.

CONCLUSION

Sexual and religious obsessions tend to be more frequent among patients with bipolar disorder. Higher depression and obsessive-related distress potentially contribute to the increased risk of suicidal ideation.

Preliminary examination of gray and white matter structure and longitudinal structural changes in frontal systems associated with future suicide attempts in adolescents and young adults with mood disorders

BACKGROUND

Mood disorders are major risk factors for suicidal behavior. While cross-sectional studies implicate frontal systems, data to aid prediction of suicide-related behavior in mood disorders are limited. Longitudinal research on neuroanatomical mechanisms underlying suicide risk may assist in developing targeted interventions. Therefore, we conducted a preliminary study investigating baseline gray and white matter structure and longitudinal structural changes associated with future suicide attempts.

METHODS

High-resolution structural magnetic resonance imaging, diffusion tensor imaging, and suicide-related behavioral assessment data for 46 adolescents and young adults with mood disorders [baseline age_mean = 18 years; 61% female] were collected at baseline and at follow-up (interval_mean = 3 years). Differences in baseline and longitudinal changes in gray matter volume and white matter fractional anisotropy in frontal systems that distinguished the participants who made future attempts from those who did not were investigated.

RESULTS

Seventeen (37%) of participants attempted suicide within the follow-up period. Future attempters (those attempting suicide between their baseline and follow-up assessment), compared to those who did not, showed lower baseline ventral and rostral prefrontal gray matter volume and dorsomedial frontal, anterior limb of the internal capsule, and dorsal cingulum fractional anisotropy, as well as greater decreases over time in ventral and dorsal frontal fractional anisotropy (p < 0.005, uncorrected).

LIMITATIONS

Sample size was modest.

CONCLUSIONS

Results suggest abnormalities of gray and white matter in frontal systems and differences in developmental changes of frontal white matter may increase risk of suicide-related behavior in youths with mood disorders. Findings provide potential new leads for early intervention and prevention strategies.

The Association of Lifetime Suicide Attempts With Anxiety Disorders in Patients With Bipolar Disorder

The association of lifetime suicidal behaviors with anxiety disorders (ADs) in patients with bipolar disorder (BD) has been controversial. In this study, we hypothesized that certain types of ADs were related to the occurrence of past suicide attempts (SAs) independent of the severity of the BD, including the presence of past affective episodes. Lifetime diagnoses of BD and ADs were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders (SCID-I). Of the total sample of 200 patients with BD, 32.0% had at least 1 past SA. The mean number of previous hospitalizations, a history of social AD, and a history of posttraumatic stress disorder were strongly associated with past SAs in patients with bipolar I disorder. The presence of lifetime social AD was associated with lifetime SAs independent of previous depressive episodes. Therefore, we suggest that social AD itself is associated with a greater risk for SAs in patients with BD independent of the presence of depression.

Clinical characterization of Italian suicide attempters with bipolar disorder

IntroductionBipolar disorder (BD) is a chronic, highly disabling condition associated with psychiatric/medical comorbidity and substantive morbidity, mortality, and suicide risks. In prior reports, varying parameters have been associated with suicide risk.

OBJECTIVES

To evaluate sociodemographic and clinical variables characterizing Italian individuals with BD with versus without prior suicide attempt (PSA).

METHODS

A sample of 362 Italian patients categorized as BD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) was assessed and divided in 2 subgroups: with and without PSA. Sociodemographic and clinical variables were compared between prior attempters and non-attempters using corrected multivariate analysis of variance (MANOVA).

RESULTS

More than one-fourth of BD patients (26.2%) had a PSA, with approximately one-third (31%) of these having>1 PSA. Depressive polarity at onset, higher number of psychiatric hospitalizations, comorbid alcohol abuse, comorbid eating disorders, and psychiatric poly-comorbidity were significantly more frequent (p<.05) in patients with versus without PSA. Additionally, treatment with lithium, polypharmacotherapy (≥4 current drugs) and previous psychosocial rehabilitation were significantly more often present in patients with versus without PSA.

CONCLUSIONS

We found several clinical variables associated with PSA in BD patients. Even though these retrospective findings did not address causality, they could be clinically relevant to better understanding suicidal behavior in BD and adopting proper strategies to prevent suicide in higher risk patients.

Prevalence and Associated Features of Anxiety Disorder Comorbidity in Bipolar Disorder: A Meta-Analysis and Meta-Regression Study

Objective: Bipolar disorder is highly comorbid with anxiety disorders, however current and lifetime comorbidity patterns of each anxiety disorder and their associated features are not well studied. Here, we aimed to conduct a meta-analysis and meta-regression study of current evidence. Method: We searched PubMed to access relevant articles published until September 2015, using the keywords "Bipolar disorder" or "Affective Psychosis" or "manic depressive" separately with "generalized anxiety," "panic disorder," "social phobia," "obsessive compulsive," and "anxiety." Variables for associated features and prevalence of anxiety disorders were carefully extracted. Results: Lifetime any anxiety disorder comorbidity in BD was 40.5%; panic disorder (PD) 18.1%, generalized anxiety disorder (GAD) 13.3%, social anxiety disorder (SAD) 13.5% and obsessive compulsive disorder (OCD) 9.7%. Current any anxiety disorder comorbidity in BD is 38.2%; GAD is 15.2%, PD 13.3%, SAD 11.7%, and OCD 9.9%. When studies reporting data about comorbidities in BDI or BDII were analyzed separately, lifetime any anxiety disorder comorbidity in BDI and BDII were 38% and 34%, PD was 15% and 15%, GAD was 14% and 16.6%, SAD was 8% and 13%, OCD was 8% and 10%, respectively. Current any DSM anxiety disorder comorbidity in BDI or BDII were 31% and 37%, PD was 9% and 13%, GAD was 8% and 12%, SAD was 7% and 11%, and OCD was 8% and 7%, respectively. The percentage of manic patients and age of onset of BD tended to have a significant impact on anxiety disorders. Percentage of BD I patients significantly decreased the prevalence of panic disorder and social anxiety disorder. A higher rate of substance use disorder was associated with greater BD-SAD comorbidity. History of psychotic features significantly affected current PD and GAD. Conclusions: Anxiety disorder comorbidity is high in BD with somewhat lower rates in BDI vs BDII. Age of onset, substance use disorders, and percentage of patients in a manic episode or with psychotic features influences anxiety disorder comorbidity.

Childhood trauma, dimensions of psychopathology and the clinical expression of bipolar disorders: A pathway analysis

BACKGROUND

This study aims at testing for paths from childhood abuse to clinical indicators of complexity in bipolar disorder (BD), through dimensions of affective dysregulation, impulsivity and hostility.

METHOD

485 euthymic patients with BD from the FACE-BD cohort were included from 2009 to 2014. We collect clinical indicators of complexity/severity: age and polarity at onset, suicide attempt, rapid cycling and substance misuse. Patients completed questionnaires to assess childhood emotional, sexual and physical abuses, affective lability, affect intensity, impulsivity, motor and attitudinal hostility.

RESULTS

The path-analysis demonstrated significant associations between emotional abuse and all the affective/impulsive dimensions (p < 0.001). Sexual abuse was moderately associated with emotion-related dimensions but not with impulsivity nor motor hostility. In turn, affect intensity and attitudinal hostility were associated with high risk for lifetime presence of suicide attempts (p < 0.001), whereas impulsivity was associated with a higher risk of lifetime presence of substance misuse (p < 0.001). No major additional paths were identified when including Emotional and Physical Neglect in the model.

CONCLUSIONS

This study provides refinement of the links between early adversity, dimensions of psychopathology and the complexity/severity of BD. Mainly, dimensions of affective dysregulation, impulsivity/hostility partially mediate the links between childhood emotional to suicide attempts and substance misuse in BD.

Bipolar disorders: is there an influence of seasonality or photoperiod?

Objective:

To increase understanding of the influence of photoperiod variation in patients with bipolar disorders.

Methods:

We followed a sample of Italian bipolar patients over a period of 24 months, focusing on inpatients. All patients admitted to the Psychiatric Inpatient Unit of San Luigi Gonzaga Hospital in Orbassano (Turin, Italy) between September 1, 2013 and August 31, 2015 were recruited. Sociodemographic and clinical data were collected.

Results:

Seven hundred and thirty patients were included. The admission rate for bipolar patients was significantly higher during May, June and July, when there was maximum sunlight exposure, although no seasonal pattern was found. Patients with (hypo)manic episodes were admitted more frequently during the spring and during longer photoperiods than those with major depressive episodes.

Conclusions:

Photoperiod is a key element in bipolar disorder, not only as an environmental factor but also as an important clinical parameter that should be considered during treatment.

Affect lability predicts occurrence of suicidal ideation in bipolar patients: a two-year prospective study

OBJECTIVE

The aim of our study was to investigate, in bipolar patients, whether affect lability was associated with suicidal ideation incidence during 2-year follow-up, and which subtype of affect lability was associated with suicidal ideation.

METHOD

A total of 319 euthymic or mildly depressed bipolar outpatients recruited in the French FondaMental Advanced Centres of Expertise for Bipolar Disorder were divided into two subgroups according to the occurrence of suicidal ideation during a 2-year follow-up. Affect lability was assessed by the French version of the Affect Lability Scale.

RESULTS

Bipolar patients with high affect lability were more likely to report suicidal ideation during follow-up, even after adjustment for age, study level, rapid cycling, current depression level, anxiety disorder, and lifetime history SA (OR = 2.47; 95% CI [1.15-5.30], P = 0.01). The risk of suicidal ideation increased with the level of affect lability. More specifically, the propensity to switch from neutral to elation affect, from anxious to depressive affect (or inversely), and from neutral to anger affect predicted suicidal ideation.

CONCLUSION

Reducing affective lability could become a new therapeutic target of suicidal prevention in bipolar disorder.

Impact of irritability: a 2-year observational study of outpatients with bipolar I or schizoaffective disorder

OBJECTIVES

Many people experience irritability when manic, hypomanic, or depressed, yet its impact on illness severity and quality of life in bipolar and schizoaffective disorders is poorly understood. This study aimed to examine the relationship between irritability and symptom burden, functioning, quality of life, social support, suicidality, and overall illness severity in a naturalistic cohort of people with bipolar I or schizoaffective disorder.

METHODS

We used data from 239 adult outpatients with bipolar I or schizoaffective disorder in the Bipolar Comprehensive Outcomes Study (BCOS) - a non-interventional observational study with a 2-year follow-up period. Baseline demographic and clinical characteristics of participants with and without irritability were compared. A mixed-model repeated measures analysis was conducted to examine the longitudinal effect of irritability on clinical and quality-of-life variables over follow-up using significant baseline variables.

RESULTS

At baseline, 54% of participants were irritable. Baseline irritability was associated with illness severity, mania, depression, psychotic symptoms, suicidality, poor functioning, and quality of life, but not diagnosis (schizoaffective/bipolar disorder). Participants with irritability were less likely to have a partner and perceived less adequate social support. On average, over follow-up, those with irritability reported more symptoms, functional impairment, and suicidality. Furthermore, the effects of irritability could not be fully explained by illness severity.

CONCLUSIONS

Irritability was associated with more negative symptomatic, functional, and quality-of-life outcomes and suicidality. The identification, monitoring, and targeted treatment of irritability may be worth considering, to enhance health and wellbeing outcomes for adults with bipolar and schizoaffective disorders.

Affective lability mediates the association between childhood trauma and suicide attempts, mixed episodes and co-morbid anxiety disorders in bipolar disorders

BACKGROUND

Many studies have shown associations between a history of childhood trauma and more severe or complex clinical features of bipolar disorders (BD), including suicide attempts and earlier illness onset. However, the psychopathological mechanisms underlying these associations are still unknown. Here, we investigated whether affective lability mediates the relationship between childhood trauma and the severe clinical features of BD.

METHOD

A total of 342 participants with BD were recruited from France and Norway. Diagnosis and clinical characteristics were assessed using the Diagnostic Interview for Genetic Studies (DIGS) or the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). Affective lability was measured using the short form of the Affective Lability Scale (ALS-SF). A history of childhood trauma was assessed using the Childhood Trauma Questionnaire (CTQ). Mediation analyses were performed using the SPSS process macro.

RESULTS

Using the mediation model and covariation for the lifetime number of major mood episodes, affective lability was found to statistically mediate the relationship between childhood trauma experiences and several clinical variables, including suicide attempts, mixed episodes and anxiety disorders. No significant mediation effects were found for rapid cycling or age at onset.

CONCLUSIONS

Our data suggest that affective lability may represent a psychological dimension that mediates the association between childhood traumatic experiences and the risk of a more severe or complex clinical expression of BD.

Association between childhood dimensions of attention deficit hyperactivity disorder and adulthood clinical severity of bipolar disorders

BACKGROUND

Clinical features of attention deficit hyperactivity disorder can be frequently observed in cases with bipolar disorders and associated with greater severity of bipolar disorders. Although designed as a screening tool for attention deficit hyperactivity disorder, the Wender Utah Rating Scale could, given its factorial structure, be useful in investigating the early history of impulsive, inattentive or mood-related symptoms among patients with bipolar disorders.

METHODS

We rated the Wender Utah Rating Scale in 276 adult bipolar disorder cases and 228 healthy controls and tested its factorial structure and any associations with bipolar disorder phenomenology.

RESULTS

We confirmed a three-factor structure for the Wender Utah Rating Scale (' impulsivity/temper', ' inattentiveness' and ' mood/self-esteem'). Cases and controls differed significantly on Wender Utah Rating Scale total score and sub-scale scores ( p-values < 10^-5). About 23% of bipolar disorder cases versus 5% of controls were classified as ' WURS positive' (odds ratio = 5.21 [2.73-9.95]). In bipolar disorders, higher Wender Utah Rating Scale score was associated with earlier age at onset, severity of suicidal behaviors and polysubstance misuse; multivariate analyses, controlling for age and gender, confirmed the associations with age at onset ( p = 0.001) and alcohol and substance misuse ( p = 0.001).

CONCLUSION

Adults with bipolar disorders who reported higher levels of childhood symptoms on the Wender Utah Rating Scale presented a more severe expression of bipolar disorders in terms of age at onset and comorbidity. The Wender Utah Rating Scale could be employed to screen for attention deficit hyperactivity disorder but also for ' at-risk behaviors' in adult bipolar disorder cases and possibly for prodromal signs of early onset in high-risk subjects.

Suicidality in Bipolar Disorder: The Role of Emotion-Triggered Impulsivity

A growing body of research suggests that impulsive responses to emotion more robustly predict suicidality than do other forms of impulsivity. This issue has not yet been examined within bipolar disorder, however. Participants diagnosed with bipolar I disorder (n = 133) and control participants (n = 110) diagnosed with no mood or psychotic disorder completed self-report measures of emotion-triggered impulsivity (Negative and Positive Urgency Scales) and interviews concerning lifetime suicidality. Analyses examined the effects of emotion-triggered impulsivity alone and in combination with gender, age of onset, depression severity, comorbid anxiety, comorbid substance use, and medication. A history of suicide ideation and attempts, as well as self-harm, were significantly more common in the bipolar disorder group compared with the control group. Impulsive responses to positive emotions related to suicide ideation, attempts, and self-harm within the bipolar group. Findings extend research on the importance of emotion-triggered impulsivity to a broad range of key outcomes within bipolar disorder. The discussion focuses on limitations and potential clinical implications.

Current irritability robustly related to current and prior anxiety in bipolar disorder

BACKGROUND

Although current irritability and current/prior anxiety have been associated in unipolar depression, these relationships are less well understood in bipolar disorder (BD). We investigated relationships between current irritability and current/prior anxiety as well as other current emotions and BD illness characteristics.

METHODS

Outpatients referred to the Stanford Bipolar Disorders Clinic during 2000-2011 were assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation. Prevalence and clinical correlates of current irritability and current/prior anxiety and other illness characteristics were examined.

RESULTS

Among 497 BD outpatients (239 Type I, 258 Type II; 58.1% female; mean ± SD age 35.6 ± 13.1 years), 301 (60.6%) had baseline current irritability. Patients with versus without current irritability had significantly higher rates of current anxiety (77.1% versus 42.9%, p < 0.0001) and history of anxiety disorder (73.1% versus 52.6%, p < 0.0001). Current irritability was more robustly related to current anxiety than to current anhedonia, sadness, or euphoria (all p < 0.001), and current irritability-current anxiety associations persisted across current predominant mood states. Current irritability was more robustly related to past anxiety than to all other assessed illness characteristics, including 1° family history of mood disorder, history of alcohol/substance use disorder, bipolar subtype, and current syndromal/subsyndromal depression (all p < 0.05).

LIMITATIONS

Limited generalizability beyond our predominately white, female, educated, insured American BD specialty clinic sample.

CONCLUSIONS

In BD, current irritability was robustly related to current/prior anxiety. Further studies are warranted to assess longitudinal clinical implications of relationships between irritability and anxiety in BD.

Current irritability associated with hastened depressive recurrence and delayed depressive recovery in bipolar disorder

Background

Current irritability is associated with greater retrospective and current bipolar disorder (BD) illness severity; less is known about prospective longitudinal implications of current irritability. We examined relationships between current irritability and depressive recurrence and recovery in BD.

Methods

Outpatients referred to the Stanford BD Clinic during 2000–2011 were assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation at baseline, and with the Clinical Monitoring Form during follow-up during up to 2 years of naturalistic treatment. Prevalence and clinical correlates of any current irritability in depressed and recovered (euthymic ≥8 weeks) BD patients were assessed. Kaplan–Meier analyses (Log-Rank tests) assessed relationships between current irritability and longitudinal depressive severity, with Cox Proportional Hazard analyses assessing potential mediators.

Results

Recovered BD outpatients with vs. without current irritability had significantly higher rates of 13/19 (68.4 %) other baseline unfavorable illness characteristics/current mood symptoms and hastened depressive recurrence (Log-Rank p = 0.020), driven by lifetime history of anxiety disorder and prior year rapid cycling, and attenuated by history of psychosis. Depressed BD outpatients with vs. without current irritability had significantly higher rates of 7/19 (36.8 %) other unfavorable illness characteristics/current mood symptoms and delayed depressive recovery (Log-Rank p = 0.034), NOT mediated by any assessed parameter.

Limitations

Limited generalizability beyond our predominately white, female, educated, insured American BD specialty clinic sample.

Conclusions

Current irritability was associated with hastened depressive recurrence and delayed depressive recovery in BD. Treatment studies targeting irritability may yield strategies to mitigate increased longitudinal depressive burden.

Clinical features, impulsivity, temperament and functioning and their role in suicidality in patients with bipolar disorder

OBJECTIVE

Our aim was to analyse sociodemographic and clinical differences between non-suicidal (NS) bipolar patients (BP), BP reporting only suicidal ideation (SI) and BP suicide attempters according to Columbia-Suicide Severity Rating Scale (C-SRSS) criteria. Secondarily, we also investigated whether the C-SRSS Intensity Scale was associated with emergence of suicidal behaviour (SB).

METHOD

A total of 215 euthymic bipolar out-patients were recruited. Semistructured interviews including the C-SRSS were used to assess sociodemographic and clinical data. Patients were grouped according to C-SRSS criteria: patients who scored ≤1 on the Severity Scale were classified as NS. The remaining patients were grouped into two groups: 'patients with history of SI' and 'patients with history of SI and SB' according to whether they did or did not have a past actual suicide attempt respectively.

RESULTS

Patients from the three groups differed in illness onset, diagnosis, number of episodes and admissions, family history, comorbidities, rapid cycling and medication, as well as level of education, functioning, impulsivity and temperamental profile.

CONCLUSION

Our results suggest that increased impulsivity, higher rates of psychiatric admissions and a reported poor controllability of SI significantly increased the risk for suicidal acts among patients presenting SI.

Factors related to suicidal behavior in patients with bipolar disorder: the effect of mixed features on suicidality

OBJECTIVES

The aim of the present study was to investigate various risk factors of suicidal behaviors, including the mixed features specifier, in patients with bipolar disorder.

METHODS

We retrospectively reviewed medical charts from 2005 to 2014. A total of 334 patients diagnosed with bipolar disorder using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision were enrolled. Subjects were categorized into two groups according to their history of suicidal behavior and the demographic and clinical characteristics of the groups were compared, including the mixed features specifier. We reevaluated the index episode using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria and classified subjects into an index episode with mixed features group and an index episode without mixed features group. Logistic regression was performed to evaluate significant risk factors associated with suicidal behavior.

RESULTS

Suicidal behavior had an independent relationship to mixed features at the index episode using DSM-5 criteria [odds ratio (OR)=3.39; 95% confidence interval (CI): 1.57-7.34] and number of previous depressive episodes (OR=1.62; 95% CI: 1.34-1.95) in bipolar patients. The mixed feature specifier was the strongest risk factor for suicidal behavior in the present study.

CONCLUSIONS

This study may help clinicians understand potential risk factors and manage bipolar disorders with suicidal behaviors. Clinicians should carefully monitor patients with bipolar disorder who exhibit numerous depressive episodes or mixed features for suicidal behavior.

Suicide attempts in bipolar disorders: comprehensive review of 101 reports

OBJECTIVE

Assess reported risk of suicide attempts by patients with bipolar disorder (BD).

METHOD

Systematic searching yielded 101 reports from 22 countries (79 937 subjects). We analyzed for risk (%) and incidence rates (%/year) of attempts, comparing sex and diagnostic types, including by meta-analysis.

RESULTS

Attempt risk averaged 31.1% [CI: 27.9-34.3] of subjects, or 4.24 [3.78-4.70]%/year. In BD-I (43 studies) and BD-II subjects (30 studies), risks (29.9%, 31.4%) and incidence rates (4.01, 4.11%/year) were similar and not different by meta-analysis. Among women vs. men, risks (33.7% vs. 25.5%) and incidence (4.50 vs. 3.21%/year) were greater (also supported by meta-analysis: RR = 1.35 [CI: 1.25-1.45], P < 0.0001). Neither measure was related to reporting year, % women/study, or to onset or current age. Risks were greater with longer exposure, whereas incidence rates decreased with longer time at risk, possibly through 'dilution' by longer exposure.

CONCLUSION

This systematic update of international experience underscores high risks of suicide attempts among patients with BD (BD-I = BD-II; women > men). Future studies should routinely include exposure times and incidence rates by diagnostic type and sex for those who attempt suicide or not.

The role of childhood trauma in bipolar disorders

This review will discuss the role of childhood trauma in bipolar disorders. Relevant studies were identified via Medline (PubMed) and PsycINFO databases published up to and including July 2015. This review contributes to a new understanding of the negative consequences of early life stress, as well as setting childhood trauma in a biological context of susceptibility and discussing novel long-term pathophysiological consequences in bipolar disorders. Childhood traumatic events are risk factors for developing bipolar disorders, in addition to a more severe clinical presentation over time (primarily an earlier age at onset and an increased risk of suicide attempt and substance misuse). Childhood trauma leads to alterations of affect regulation, impulse control, and cognitive functioning that might decrease the ability to cope with later stressors. Childhood trauma interacts with several genes belonging to several different biological pathways [Hypothalamic–pituitary–adrenal (HPA) axis, serotonergic transmission, neuroplasticity, immunity, calcium signaling, and circadian rhythms] to decrease the age at the onset of the disorder or increase the risk of suicide. Epigenetic factors may also be involved in the neurobiological consequences of childhood trauma in bipolar disorder. Biological sequelae such as chronic inflammation, sleep disturbance, or telomere shortening are potential mediators of the negative effects of childhood trauma in bipolar disorders, in particular with regard to physical health. The main clinical implication is to systematically assess childhood trauma in patients with bipolar disorders, or at least in those with a severe or instable course. The challenge for the next years will be to fill the gap between clinical and fundamental research and routine practice, since recommendations for managing this specific population are lacking. In particular, little is known on which psychotherapies should be provided or which targets therapists should focus on, as well as how childhood trauma could explain the resistance to mood stabilizers.

A review of factors associated with greater likelihood of suicide attempts and suicide deaths in bipolar disorder: Part II of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder

OBJECTIVES

Many factors influence the likelihood of suicide attempts or deaths in persons with bipolar disorder. One key aim of the International Society for Bipolar Disorders Task Force on Suicide was to summarize the available literature on the presence and magnitude of effect of these factors.

METHODS

A systematic review of studies published from 1 January 1980 to 30 May 2014 identified using keywords 'bipolar disorder' and 'suicide attempts or suicide'. This specific paper examined all reports on factors putatively associated with suicide attempts or suicide deaths in bipolar disorder samples. Factors were subcategorized into: (1) sociodemographics, (2) clinical characteristics of bipolar disorder, (3) comorbidities, and (4) other clinical variables.

RESULTS

We identified 141 studies that examined how 20 specific factors influenced the likelihood of suicide attempts or deaths. While the level of evidence and degree of confluence varied across factors, there was at least one study that found an effect for each of the following factors: sex, age, race, marital status, religious affiliation, age of illness onset, duration of illness, bipolar disorder subtype, polarity of first episode, polarity of current/recent episode, predominant polarity, mood episode characteristics, psychosis, psychiatric comorbidity, personality characteristics, sexual dysfunction, first-degree family history of suicide or mood disorders, past suicide attempts, early life trauma, and psychosocial precipitants.

CONCLUSION

There is a wealth of data on factors that influence the likelihood of suicide attempts and suicide deaths in people with bipolar disorder. Given the heterogeneity of study samples and designs, further research is needed to replicate and determine the magnitude of effect of most of these factors. This approach can ultimately lead to enhanced risk stratification for patients with bipolar disorder.

Is religiosity a protective factor against suicidal behavior in bipolar I outpatients?

BACKGROUND

Several risk factors have been associated with suicidal behavior (SB) in bipolar disorder (BD), but little is known regarding possible protective factors. Religiosity has been related to favorable outcomes in mental health and to a reduction in the risk of SB, although the relation between BD, religiosity and SB remains under-investigated. The objective of this study was to evaluate the association between religiosity and SB in euthymic bipolar I outpatients.

METHOD

In this study, 164 outpatients with BD type I with and without a history of suicide attempts were assessed and compared using a questionnaire to collect clinical and sociodemographic characteristics, the Structured Clinical Interview for DSM-IV, the Hamilton Depression Rating Scale, the Young Mania Rating Scale, the Duke Religious Index, and the Barratt Impulsivity Scale.

RESULTS

The suicide attempters (SA) group had more psychiatric comorbidity (p=0.007), more rapid cycling (p=0.004), higher levels of impulsivity in all domains (p=0.000), and less religious affiliation (p=0.006) compared with the non-SA group. In the multivariate analysis, after controlling for covariates, non-organizational religious activities (OR, 0.66; 95% CI, 0.50-0.86) and intrinsic religiosity (OR, 0.70; 95% CI, 0.60-0.81) were associated with less SB.

LIMITATIONS

A small sample size, the cross-sectional design that precluded the possibility of assessing cause and effect relationships, and the infeasibility of determining the time lapse between the last suicide attempt and the period when the patients were evaluated.

CONCLUSION

Non-organizational religious activities and intrinsic religiosity dimensions exert a protective effect against SB in bipolar I outpatients, even when controlling for variables that may affect the outcome in question.

Attempted suicide in people with co-occurring bipolar and substance use disorders: systematic review and meta-analysis

BACKGROUND

Both individuals with bipolar (BD) and those with alcohol (AUD) and other substance (SUD) use disorders are likely to attempt suicide. Comorbidity of BD and AUD/SUD may increase the likelihood of suicide attempts. We conducted a meta-analysis to estimate the association of comorbid AUD/SUD and suicide attempts in subjects with BD in the literature to date.

METHODS

Electronic databases through January 2013 were searched. Studies reporting rates of suicide attempts in people with co-occurring BD and AUD/SUD were retrieved. Comorbid AUD and SUD and suicide attempts rates as well as demographic, clinical, and methodological variables were extracted from each publication or obtained directly from its authors.

RESULTS

Twenty-nine of 222 studies assessed for eligibility met the inclusion criteria, comprising a total of 31,294 individuals with BD, of whom 6308 (20.1%) had documented suicide attempts. There were consistent findings across the studies included. As compared to controls, subjects with BD and comorbid AUD/SUD were more likely to attempt suicide. The cross-sectional association estimates showed random-effects pooled crude ORs of 1.96 (95% CI=1.56-2.47; p<0.01), 1.72 (95% CI=1.52-1.95; p<0.01), and 1.77 (95% CI=1.49-2.10; p<0.01), for combined AUD/SUD, AUD, and SUD. There was no publication bias and sensitivity analyses based on the highest quality studies confirmed core results.

LIMITATIONS

The effects of the number and the type of suicide attempts could not be investigated due to insufficient information.

CONCLUSIONS

Comorbid AUD and SUD in individuals with BD are significantly associated with suicide attempts. Individuals with this comorbidity should be targeted for intensive suicide prevention efforts.

The Use of Cannabis as a Predictor of Early Onset of Bipolar Disorder and Suicide Attempts

Introduction. Bipolar disorder (BD) implies risk of suicide. The age at onset (AAO) of BD carries prognostic significance. Substance abuse may precede the onset of BD and cannabis is the most common illicit drug used. The main goal of this study is to review the association of cannabis use as a risk factor for early onset of BD and for suicide attempts. Materials and Methods. PubMed database was searched for articles using key words “bipolar disorder,” “suicide attempts,” “cannabis,” “marijuana,” “early age at onset,” and “early onset.” Results. The following percentages in bipolar patients were found: suicide attempts 3.6–42%; suicide attempts and substance use 5–60%; suicide attempts and cannabis use 15–42%. An early AAO was associated with cannabis misuse. The mean age of the first manic episode in individuals with and without BD and cannabis use disorder (CUD) was 19.5 and 25.1 years, respectively. The first depressive episode was at 18.5 and 24.4 years, respectively. Individuals misusing cannabis showed increased risk of suicide. Discussion. Cannabis use is associated with increased risk of suicide attempts and with early AAO. However, the effect of cannabis at the AAO and suicide attempts is not clear.

International Society for Bipolar Disorders Task Force on Suicide: meta-analyses and meta-regression of correlates of suicide attempts and suicide deaths in bipolar disorder

OBJECTIVES

Bipolar disorder is associated with a high risk of suicide attempts and suicide death. The main objective of the present study was to identify and quantify the demographic and clinical correlates of attempted and completed suicide in people with bipolar disorder.

METHODS

Within the framework of the International Society for Bipolar Disorders Task Force on Suicide, a systematic review of articles published since 1980, characterized by the key terms bipolar disorder and 'suicide attempts' or 'suicide', was conducted, and data extracted for analysis from all eligible articles. Demographic and clinical variables for which ≥ 3 studies with usable data were available were meta-analyzed using fixed or random-effects models for association with suicide attempts and suicide deaths. There was considerable heterogeneity in the methods employed by the included studies.

RESULTS

Variables significantly associated with suicide attempts were: female gender, younger age at illness onset, depressive polarity of first illness episode, depressive polarity of current or most recent episode, comorbid anxiety disorder, any comorbid substance use disorder, alcohol use disorder, any illicit substance use, comorbid cluster B/borderline personality disorder, and first-degree family history of suicide. Suicide deaths were significantly associated with male gender and first-degree family history of suicide.

CONCLUSIONS

This paper reports on the presence and magnitude of the correlates of suicide attempts and suicide deaths in bipolar disorder. These findings do not address causation, and the heterogeneity of data sources should limit the direct clinical ranking of correlates. Our results nonetheless support the notion of incorporating diagnosis-specific data in the development of models of understanding suicide in bipolar disorder.

Risk factors for suicide in bipolar disorder: a systematic review

BACKGROUND

Bipolar disorder confers the highest risk of suicide among major psychological disorders. The risk factors associated with bipolar disorder and suicide exist and are relevant to clinicians and researchers.

OBJECTIVE

The aim of the present study was to conduct a systematic review of articles regarding the suicide risk factors in bipolar disorder.

METHODS

A systematic review of articles on suicide risk factors in bipolar disorder, published from January 1, 2010 to April 05, 2014, on SCOPUS and PUBMED databases was carried out. Search terms were "Suicide" (medical subject headings [MeSH]), "Risk factors" (MeSH), and "Bipolar" (keyword). Of the 220 retrieved studies, 42 met the eligibility criteria.

RESULTS

Bipolar disorder is associated with an increased rate death by suicide which contributes to overall mortality rates. Studies covered a wide range of aspects regarding suicide risk factors in bipolar disorder, such as risk factors associated to Sociodemographic conditions, Biological characteristics, Drugs Relationships, Psychological Factors, Genetic Compound, Religious and Spirituals conditions. Recent scientific literature regarding the suicide risk factors in bipolar disorder converge to, directly or indirectly, highlight the negative impacts of risk factors to the affected population quality of life.

CONCLUSION

This review demonstrated that Bipolar disorders commonly leads to other psychiatric disorders and co-morbidities involving risk of suicide. Thus the risk factors are relevant to have a better diagnosis and prognosis of BD cases involving risk of suicide.

Alterations in circadian/seasonal rhythms and vegetative functions are related to suicidality in DSM-5 PTSD

BACKGROUND

Alterations in rhythmicity and vegetative functions have been reported as correlates of suicidality, particularly in patients with mood disorders. No investigation has addressed their impact on patients with post-traumatic stress disorder (PTSD). Aim of the present study was to fulfill this gap.

METHODS

Sixty-five out- and inpatients with DSM-5 PTSD were assessed by using the Mood Spectrum-Self Report-Lifetime Version (MOODS-SR), a questionnaire for lifetime mood spectrum symptomatology including alterations in circadian/seasonal rhythms and vegetative functions. Six items of the MOODS-SR were combined and dichotomized to assess suicidal ideation and/or attempts.

RESULTS

Significant and positive associations were found between symptoms of lifetime dysregulations in rhythmicity and vegetative functions and suicidal ideation and/or attempts. All MOODS-SR sub-domains (rhythmicity, sleep, appetite/weight, sexual function, physical symptoms) were associated with an increased likelihood of suicidal ideation, but only changes in appetite/weight were associated with greater odd ratios of suicide attempts (OR = 2.099, 95% CI 1.148-3.841).

CONCLUSIONS

Our results suggest that lifetime dysregulations in rhythmicity and vegetative functions may represent correlates of suicidality in patients with DSM-5 PTSD.

Illness-course modulates suicidality-related prefrontal gray matter reduction in women with bipolar disorder

OBJECTIVE

Explore interrelationships between suicide attempt history (Objective 1) or suicide attempt severity (Objective 2) with prefrontal cortex gray matter (PFCGM ) volume and illness-course in patients with bipolar disorder (BD).

METHOD

Ninety-three women with BD-I or -II diagnosis (51 with and 42 without suicide attempt history) underwent structural MRI and filled out questionnaires. Measured were GM volumes of 11 PFC regions, BD illness-course, and attempt history and severity. Effects were examined with repeated measures GLM or logit analyses.

RESULTS

Objective 1: Attempt history was associated with increased trait impulsivity and aggression, and higher prevalence of BD-I, past drug use disorder, and past psychiatric hospitalization. PFCGM volume was lower in patients with than without attempt history in those with past psychiatric hospitalization. PFCGM volume was higher in patients with than without attempt history in those without hospitalization. Higher trait aggression predicted attempt history. Objective 2: Increased frontal pole volume and younger age at first hospitalization predicted many suicide attempts.

CONCLUSION

Attempt history in patients with BD related to PFCGM volume reduction or increase. Volume modulation by psychiatric hospitalization could reflect effects of illness-course or care. Attempt severity was not related to volume reduction. Research on suicidality-brain relationships should include illness-course and attempt severity measures.

Reconsidering the link between impulsivity and suicidal behavior

It is widely accepted that suicidal behavior often occurs with little planning. We propose, however, that suicidal behavior is rarely if ever impulsive-that it is too frightening and physically distressing to engage in without forethought-and that suicidal behavior in impulsive individuals is accounted for by painful and fearsome behaviors capable of enhancing their capacity for suicide. We conducted a meta-analysis of the association between trait impulsivity and suicidal behavior and a critical review of research considering the impulsiveness of specific suicide attempts. Meta-analytic results suggest the relationship between trait impulsivity and suicidal behavior is small. Furthermore, studies examining a mediating role of painful and provocative behaviors have uniformly supported our model. Results from our review suggest that researchers have been unable to adequately measure impulsivity of attempts and that measures sensitive to episodic planning must be developed to further our understanding of this phenomenon.

Emotional and behavioral dyscontrol after traumatic brain injury

Emotional and behavioral dyscontrol are relatively common neuropsychiatric sequelae of traumatic brain injury and present substantial challenges to recovery and community participation. Among the most problematic and functionally disruptive of these types of behaviors are pathologic laughing and crying, affective lability, irritability, disinhibition, and aggression. Managing these problems effectively requires an understanding of their phenomenology, epidemiology, and clinical evaluation. This article reviews these issues and provides clinicians with brief and practical suggestions for the management of emotional and behavioral dyscontrol.

Suicide risk in major affective disorder: results from a national survey in China

BACKGROUND

This study investigated suicide risk and its correlates among major affective disorder patients in China and examined possible risk factors for future suicide among individuals with major affective disorder to inform appropriate interventions and management approaches to minimize and prevent suicide.

METHODS

A total of 1478 major affective disorder patients were consecutively examined in 13 mental health centers in China. The patients' socio-demographic and clinical characteristics were recorded using a standardized protocol and data collection procedure. DSM-IV diagnoses were established using the Mini International Neuropsychiatric Interview (MINI), and suicide risk was assessed by the suicide risk module of the MINI.

RESULTS

Of the patients, 963 (65.2%) were in the nonsuicidal risk group and 515 (34.8%) were in the suicidal risk group. Compared to major depressive disorder patients, bipolar disorder patients had higher suicide risk levels (χ2=10.0, df=1, P=0.002); however, there were no statistically significant differences (χ2=2.6, df=1, P=0.1) between bipolar disorder-I and bipolar disorder-II patients. Suicide risk factors were associated with 6 variables in major affective disorder patients, as follows: male gender, unemployed, more frequent depressive episodes (>4 in the past year), depressive episodes with suicidal ideation and attempts, depressive episodes with psychotic symptoms, and no current antidepressant use.

LIMITATIONS

Most of the data were retrospectively collected and, therefore, subject to recall bias.

CONCLUSIONS

This study suggested that bipolar disorder patients have a higher suicide risk than major depressive disorder patients. The factors that were significantly associated with suicide risk may aid in identifying major affective disorder patients who are at risk for future suicidal behavior.

[Current status and management of patients with bipolar disorder in France: the MONTRA survey]

OBJECTIVES

The objectives were to assess the characteristics of patients with bipolar disorder (BD) and to evaluate the prescribing practices.

METHODS

MONTRA is a quantitative survey conducted between December 2010 and February 2011. Data were extracted by the psychiatrists from the medical files of BD patients seen on four consecutive days of consulting.

RESULTS

Four hundred and thirty-nine psychiatrists included 2529 patients (inpatients, n=319; outpatients from mental clinics, n=1090; outpatients consulting in private practice, n=1020). In the total patient population (mean age: 47 years; women, 58%), BD was distributed as follows: BD type I, 56%; BD type II, 40%; other types of BD, 4%; rapid cyclers, 10%. The prevalence of psychiatric comorbidities was high (anxiety disorders, 48%; abuse and dependence on toxic substances, 17 and 10% respectively), 36% of the patients had a history of suicide attempt and the risk of suicide, when assessed, was 6%. In about half the patients (48%), the polarity of the initial bipolar episode was of the depressive type (versus 39% for the manic/hypomanic type). Outpatients were globally independent and did not require assistance in the management of their disease or its treatment whereas the social and professional lives of inpatients were negatively affected by their condition. Based on the psychiatrist's declarations, 39 to 50% of the outpatients were symptom-free, 36 to 40% were in the intercurrent phase with residual symptoms, 11 to 17% presented either a manic or depressive acute BP episode, and 3 to 4% were in a mixed state; among inpatients, 52% presented an acute episode either manic or depressive, 38% were in the intercurrent phase and 9% were in a mixed state. In the symptomatic patients from the total population (61%), the most prevalent symptoms were depressive and corresponded to acute symptoms (patients with a depressive episode, 14%) or residual symptoms (patients in the intercurrent phase, 27%). The predominant depressive polarity was observed in both hospitalized and outpatients. The pharmacological treatment of BD included polytherapy in 73% of the patients. In the manic episodes (n=126), the patients were treated with a Mood Stabilizer (MS, 56%) or an atypical antipsychotic (AAP, 52%) in association. In the depressive episodes (n=342), the patients received an antidepressant drug associated with a MS or an AAP (70%). In symptom-free or symptomatic intercurrent periods (n=1943), the patients were treated with a MS (49-58%) or an AAP (37-49%), in association.

CONCLUSION

BD patients evaluated in our survey were in majority diagnosed with BD type I, associated with considerable comorbidity. In the symptomatic patients, the most prevalent symptoms, either acute or residual, were of the depressive type. In the majority of the patients, whatever the clinical status, polytherapy was prescribed for the BD.