Substance use disorders and suicide attempts in bipolar subtypes

Alcohol and substance use differentially impact suicidal ideation in a longitudinal cohort of bipolar disorder

BACKGROUND

Across bipolar disorders (BSDs), alcohol and substance use and suicidal ideation (SI) contribute to increased rates of morbidity and mortality. The goal of the present study was to investigate temporal relationships between the intensity/frequency (I/F) of use and impairment related to alcohol and substance use and SI in a longitudinal BSD cohort.

METHODS

Participants with BDI (n=565), BDII (n=162), and BD NOS (n=61) were included (median enrollment=72 months). Alcohol and substance use were measured using a modified version of the AUDIT administered every 6 months. SI was measured every 2 months using item 9 from the PHQ-9. Linear mixed effects models tested concurrent associations and Dynamic Structural Equation Models tested prospective associations between alcohol and substance use I/F and impairment with SI.

RESULTS

Cocaine I/F and alcohol and substance use impairment were concurrently associated with SI. When a person had more frequent and intense cannabis use compared to average, they had higher SI at the next timepoint. When individuals experienced more alcohol and substance use impairment than average, they had higher SI at the next timepoint.

CONCLUSIONS

I/F of cannabis use and alcohol and substance use impairment appear to lead to future increases in SI for those with BSDs.

Association between a large change between the minimum and maximum monthly values of solar insolation and a history of suicide attempts in bipolar I disorder

BACKGROUND

The rate of suicide attempts by patients with bipolar disorder is high. In addition to patient and country specific factors, environmental factors may contribute to suicidal behavior. Sunlight has multiple diverse impacts on human physiology and behavior. Solar insolation is defined as the electromagnetic energy from the sun striking a surface area on earth. We previously found that a large change in solar insolation between the minimum and maximum monthly values was associated with an increased risk of suicide attempts in patients with bipolar I disorder.

METHODS

The association between solar insolation and a history of suicide attempts in bipolar disorder was again investigated using an international database with 15% more data and more sites at diverse locations and countries.

RESULTS

Data were available from 5641 patients with bipolar I disorder living at a wide range of latitudes in 41 countries in both hemispheres. A large change in solar insolation between the minimum and maximum monthly values was associated with a history of suicide attempts in patients with bipolar I disorder, a replication of our prior analysis. The estimated model also associated state sponsored religion in the onset country, female gender, a history of alcohol or substance abuse, and being part of a younger birth cohort with a history of suicide attempts.

CONCLUSIONS

A large change between the minimum and maximum monthly values of solar insolation was associated with a history of suicide attempts in bipolar I disorder, replicating our prior research. Physicians should be aware that daylight has wide ranging physiological and psychiatric impacts, and that living with large changes in solar insolation may be associated with an increased suicide risk.

Identifying unique subgroups in suicide risks among psychiatric outpatients

BACKGROUND

The presence of psychiatric disorders is widely recognized as one of the primary risk factors for suicide. A significant proportion of individuals receiving outpatient psychiatric treatment exhibit varying degrees of suicidal behaviors, which may range from mild suicidal ideations to overt suicide attempts. This study aims to elucidate the transdiagnostic symptom dimensions and associated suicidal features among psychiatric outpatients.

METHODS

The study enrolled patients who attended the psychiatry outpatient clinic at a tertiary hospital in South Korea (n = 1, 849, age range = 18-81; 61% women). A data-driven classification methodology was employed, incorporating a broad spectrum of clinical symptoms, to delineate distinctive subgroups among psychiatric outpatients exhibiting suicidality (n = 1189). A reference group of patients without suicidality (n = 660) was included for comparative purposes to ascertain cluster-specific sociodemographic, suicide-related, and psychiatric characteristics.

RESULTS

Psychiatric outpatients with suicidality (n = 1189) were subdivided into three distinctive clusters: the low-suicide risk cluster (Cluster 1), the high-suicide risk externalizing cluster (Cluster 2), and the high-suicide risk internalizing cluster (Cluster 3). Relative to the reference group (n = 660), each cluster exhibited distinct attributes pertaining to suicide-related characteristics and clinical symptoms, covering domains such as anxiety, externalizing and internalizing behaviors, and feelings of hopelessness. Cluster 1, identified as the low-suicide risk group, exhibited less frequent suicidal ideation, planning, and multiple attempts. In the high-suicide risk groups, Cluster 2 displayed pronounced externalizing symptoms, whereas Cluster 3 was primarily defined by internalizing and hopelessness symptoms. Bipolar disorders were most common in Cluster 2, while depressive disorders were predominant in Cluster 3.

DISCUSSION

Our findings suggest the possibility of differentiating psychiatric outpatients into distinct, clinically relevant subgroups predicated on their suicide risk. This research potentially paves the way for personalizing interventions and preventive strategies that address cluster-specific characteristics, thereby mitigating suicide-related mortality among psychiatric outpatients.

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.

CaMKK2 as an emerging treatment target for bipolar disorder

Current pharmacological treatments for bipolar disorder are inadequate and based on serendipitously discovered drugs often with limited efficacy, burdensome side-effects, and unclear mechanisms of action. Advances in drug development for the treatment of bipolar disorder remain incremental and have come largely from repurposing drugs used for other psychiatric conditions, a strategy that has failed to find truly revolutionary therapies, as it does not target the mood instability that characterises the condition. The lack of therapeutic innovation in the bipolar disorder field is largely due to a poor understanding of the underlying disease mechanisms and the consequent absence of validated drug targets. A compelling new treatment target is the Ca2+-calmodulin dependent protein kinase kinase-2 (CaMKK2) enzyme. CaMKK2 is highly enriched in brain neurons and regulates energy metabolism and neuronal processes that underpin higher order functions such as long-term memory, mood, and other affective functions. Loss-of-function polymorphisms and a rare missense mutation in human CAMKK2 are associated with bipolar disorder, and genetic deletion of Camkk2 in mice causes bipolar-like behaviours similar to those in patients. Furthermore, these behaviours are ameliorated by lithium, which increases CaMKK2 activity. In this review, we discuss multiple convergent lines of evidence that support targeting of CaMKK2 as a new treatment strategy for bipolar disorder.

Predictors of suicide ideation among South Korean adolescents: A machine learning approach

BACKGROUND

The current study developed a predictive model for suicide ideation among South Korean (Korean) adolescents using a comprehensive set of factors across demographic, physical and mental health, academic, social, and behavioral domains. The aim of this study was to address the pressing public health concerns of adolescent suicide in Korea and the methodological limitations of suicidal research.

METHODS

This study used machine learning methods (decision tree, logistic regression, naive Bayes classifier) to improve the accuracy of predicting suicidal ideation and related factors among a nationally representative sample of Korean middle school students (N = 6666).

RESULTS

Factors within all domains, including demographic characteristics, physical and mental health, and academic, social, and behavioral, were important in predicting suicidal thoughts among Korean adolescents, with mental health being the most important factor.

LIMITATIONS

The predictive model of the current research does not infer causality, and there may have been some loss of information due to measurement issues.

CONCLUSIONS

Study results provide insights for taking a multidimensional approach when identifying adolescents at risk of suicide, which may be used to further address their needs through intervention programs within the school setting. Considering the cultural stigma attached to disclosing suicidal ideation and behavior, the current study proposes the need for a preventive screening process based on the observation and assessment of adolescents' general characteristics and experiences in everyday life.

Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management

BACKGROUND

Bipolar Disorder (BD) is a highly comorbid condition, and rates of cooccurring disorders are even higher in youth. Comorbid disorders strongly affect clinical presentation, natural course, prognosis, and treatment.

METHODS

This review focuses on the clinical and treatment implications of the comorbidity between BD and Attention-Deficit/Hyperactivity Disorder, disruptive behavior disorders (Oppositional Defiant Disorder and/or Conduct Disorder), alcohol and substance use disorders, Autism Spectrum Disorder, anxiety disorders, Obsessive-Compulsive Disorder, and eating disorders.

RESULTS

These associations define specific conditions which are not simply a sum of different clinical pictures, but occur as distinct and complex combinations with specific developmental pathways over time and selective therapeutic requirements. Pharmacological treatments can improve these clinical pictures by addressing the comorbid conditions, though the same treatments may also worsen BD by inducing manic or depressive switches.

CONCLUSION

The timely identification of BD comorbidities may have relevant clinical implications in terms of symptomatology, course, treatment and outcome. Specific studies addressing the pharmacological management of BD and comorbidities are still scarce, and information is particularly lacking in children and adolescents; for this reason, the present review also included studies conducted on adult samples. Developmentally-sensitive controlled clinical trials are thus warranted to improve the prognosis of these highly complex patients, requiring timely and finely personalized therapies.

Which Clinical and Biochemical Parameters Are Associated with Lifetime Suicide Attempts in Bipolar Disorder?

Introduction: Bipolar Disorder (BD) is a disabling condition with suicidal behavior as one of the most common adverse outcomes. The purpose of the present research is to investigate the relationship between lifetime suicide attempts and the clinical factors/biochemical parameters in a large sample of bipolar patients. Methods: A total of 561 patients, consecutively hospitalized for BD in Milan and Monza (Italy), were recruited. Data about the demographic and clinical variables, as well as the values of blood analyses, were collected. The groups identified according to the presence/absence of lifetime suicide attempts were compared using univariate analyses. Then, three preliminary binary logistic regressions and a final logistic regression model were performed to identify the clinical and biochemical parameters associated with lifetime suicide attempts in BD. Results: Lifetime suicide attempts in BD were predicted by a longer duration of untreated illness (DUI) (p = 0.005), absence of lifetime psychotic symptoms (p = 0.025), presence of poly-substance use disorders (p = 0.033), comorbidity with obesity (p = 0.022), a last mood episode of manic polarity (p = 0.044), and lower bilirubin serum levels (p = 0.002); higher total cholesterol serum levels showed a trend toward statistical significance (p = 0.058). Conclusions: BD patients with lifetime suicide attempts present unfavorable clinical features. Some specific biochemical characteristics of bipolar patients may represent potential markers of suicidal behavior and need to be better investigated to identify new targets of treatment in the framework of personalized medicine. These preliminary findings have to be confirmed by further studies in different clinical settings.

Multimodal Correlates of Cannabis Use among U.S. Veterans with Bipolar Disorder: An Integrated Study of Clinical, Cognitive, and Functional Outcomes

Objective: Cannabis use (CU) is common among persons with bipolar disorder (BD). Evidence suggests that CU is associated with poorer outcomes among persons with BD; however, these findings remain inconsistent. The present exploratory study aims to examine clinical, functional, and cognitive correlates of CU among persons with BD. Methods: U.S. veterans with BD type I who participated in a large-scale, nationwide study were categorized into four groups: current CU, past CU, past other drug use, and no drug use. Bivariate analyses, univariate analyses of covariance, and Levene's Test for Equality of Variance were used to compare groups on clinical, cognitive, and functional measures. Results: Of 254 (84.6% male) veterans with BD type I included in the analyses, 13 (5.1%) had current CU, 37 (14.5%) past CU, 77 (30.3%) past other drug use, and 127 (50%) reported no drug use. BD with CU was associated with post-traumatic stress disorder (PTSD) and experiencing lifetime suicidal ideation. Notably, current CU was associated with higher working memory performance, compared to both past CU and no drug use. Likewise, current CU was associated with higher functional capacity, compared to past CU as well as no drug use. Conclusions: These findings contribute to the growing literature on the complex effects of cannabis on BD. As the commercialization and legalization of cannabis increases, further research in this area is warranted to quantify posed risks to this population, and thereby guide clinical decision-making.

Predicting Sex-Specific Nonfatal Suicide Attempt Risk Using Machine Learning and Data From Danish National Registries

Suicide attempts are a leading cause of injury globally. Accurate prediction of suicide attempts might offer opportunities for prevention. This case-cohort study used machine learning to examine sex-specific risk profiles for suicide attempts in Danish nationwide registry data. Cases were all persons who made a nonfatal suicide attempt between 1995 and 2015 (n = 22,974); the subcohort was a 5% random sample of the population at risk on January 1, 1995 (n = 265,183). We developed sex-stratified classification trees and random forests using 1,458 predictors, including demographic factors, family histories, psychiatric and physical health diagnoses, surgery, and prescribed medications. We found that substance use disorders/treatment, prescribed psychiatric medications, previous poisoning diagnoses, and stress disorders were important factors for predicting suicide attempts among men and women. Individuals in the top 5% of predicted risk accounted for 44.7% of all suicide attempts among men and 43.2% of all attempts among women. Our findings illuminate novel risk factors and interactions that are most predictive of nonfatal suicide attempts, while consistency between our findings and previous work in this area adds to the call to move machine learning suicide research toward the examination of high-risk subpopulations.

Bipolar Disorder and Comorbid Use of Illicit Substances

Substance use disorders (SUD) are highly prevalent in bipolar disorder (BD) and significantly affect clinical outcomes. Incidence and management of illicit drug use differ from alcohol use disorders, nicotine use of behavioral addictions. It is not yet clear why people with bipolar disorder are at higher risk of addictive disorders, but recent data suggest common neurobiological and genetic underpinnings and epigenetic alterations. In the absence of specific diagnostic instruments, the clinical interview is conducive for the diagnosis. Treating SUD in bipolar disorder requires a comprehensive and multidisciplinary approach. Most treatment trials focus on single drugs, such as cannabis alone or in combination with alcohol, cocaine, or amphetamines. Synopsis of data provides limited evidence that lithium and valproate are effective for the treatment of mood symptoms in cannabis users and may reduce substance use. Furthermore, the neuroprotective agent citicoline may reduce cocaine consumption in BD subjects. However, many of the available studies had an open-label design and were of modest to small sample size. The very few available psychotherapeutic trials indicate no significant differences in outcomes between BD with or without SUD. Although SUD is one of the most important comorbidities in BD with a significant influence on clinical outcome, there is still a lack both of basic research and clinical trials, allowing for evidence-based and specific best practices.

Characteristics of depressed suicide attempters with remitted substance use disorders

Substance use disorder (SUD) comorbidity in mood disorders increases suicide risk. Suicide attempters with active SUD appear to have distinct characteristics but little is known whether these characteristics persist during remission and if they are related to different aspects of suicidal behavior. In this study, suicide attempters with a DSM mood disorder and remitted SUD (AT+SUD) (N = 135) were compared to those without lifetime SUD (AT-SUD) (N = 219) in terms of demographic, clinical and suicidal behavioral characteristics. Factor analyses were conducted to generate subjective distress and impulsivity/aggression factors - previously identified by our group to predict suicide risk in mood disorders. Associations between these traits and SUD history and suicidal behavior characteristics were then tested. Compared with AT-SUD, AT+SUD were more likely to be male, less educated and to have a Cluster B personality disorder. AT+SUD individuals had greater impulsivity/aggression factor scores, but comparable subjective distress scores. AT+SUD made a greater number of suicide attempts, with higher lethality, despite comparable suicide intent and degree of planning with AT-SUD. Impulsivity/aggression was higher in multiple versus single attempters, but did not correlate with suicide attempt lethality. Among suicide attempters with mood disorders, a history of lifetime SUD was associated with more frequent and more lethal suicide attempts. Among other correlates of lifetime SUD in this sample, impulsive/aggressive traits may explain greater frequency of suicide attempts. The results underscore that persons with mood disorders and lifetime SUD are at particularly high risk of frequent and lethal suicide attempts where more intensive prevention efforts are warranted.

Patterns and clinical correlates of lifetime alcohol consumption in women and men with bipolar disorder: Findings from the UK Bipolar Disorder Research Network

OBJECTIVES

Despite previous literature on comorbid alcohol use disorders (AUDs) in bipolar disorder (BD), little is known about patterns of alcohol use more widely in this population. We have examined lifetime heaviest average weekly alcohol consumption levels in a large well-characterised UK sample including lifetime clinical correlates of increasing levels of alcohol use.

METHODS

Participants were 1203 women and 673 men with bipolar I disorder interviewed by semi-structured interview who had consumed alcohol regularly at any point in their life.

RESULTS

Over half of both women (52.3%) and men (73.6%) had regularly consumed over double the current UK recommended guideline for alcohol consumption. In women and men increasing levels of lifetime alcohol consumption were significantly associated with the presence of suicide attempts (women: OR 1.82, P < .001; men: OR 1.48, P = .005) and rapid cycling (women: OR 1.89, P < .001; men: OR 1.88, P < .001). In women only, increasing levels of alcohol consumption were significantly associated with more episodes of depression (OR 1.35, P < .001) and mania (OR 1.30, P < .004) per illness year, less impairment in functioning during the worst episode of mania (OR 1.02, P < .001), fewer psychiatric admissions (OR 0.51, P < .001), comorbid panic disorder (OR 2.16, P < .001) and eating disorder (OR 2.37, P < .001).

CONCLUSIONS

Our results highlight the clinical importance of obtaining detailed information on levels of alcohol consumption among patients with BD. Increased levels of alcohol use, not necessarily reaching criteria for AUD, may be helpful in predicting BD illness course, in particular eating disorders comorbidity in women.

Suicidal Risks in 12 DSM-5 Psychiatric Disorders

OBJECTIVE

As modern studies evaluating suicidal behaviors in large samples of major psychiatric disorder patients are rare, we compared suicidal risks associated with a variety of psychiatric diagnoses.

METHODS

We quantified rates of intake suicidal ideation and lifetime attempts, suicides, and violent acts (attempts + suicides) in 6050 adult patients in a European psychiatric center, diagnosed with 12 prevalent, DSM-5 psychiatric disorders.

RESULTS

Ideation ranged from 53.9% of subjects with bipolar disorder (BD) with mixed features, to 8.70% in anxiety disorders. Subjects making at least one suicide attempt were most prevalent in BD with mixed or psychotic features. Suicide rates ranked: substance abuse > BD with psychotic features > psychotic disorders ≥ BD-I > major depressive disorder (MDD). Suicidal intensity (acts/100 PEY) was highest with BD, psychotic disorders, and MDD; lethality (lower attempt/suicide ratio) was greatest with substance abuse, psychotic disorders, and BD with psychotic features. Rates of suicidal acts in BD vs. MDD were similarly high among ever-hospitalized subjects but much lower in never-hospitalized MDD subjects. Women had higher overall risks of ideation and attempts, but violent acts and suicide were more likely among men, whereas SMR for suicide was greater among women, presumably reflecting very low risks among women in the regional general population.

CONCLUSIONS

Suicidal risks were particularly high in BD with psychotic or mixed features as well as with substance abuse and in severe MDD with hospitalization.

The interactive effect of the serotonin transporter genotype and drug use on suicidal behaviors in patients diagnosed with bipolar disorder

BACKGROUND

Suicide is a public health crisis, accounting for more than 47,000 deaths in the United States annually. Individuals with Bipolar Disorder (BD) are at a disproportionately greater risk of suicidal behaviors. Prior studies indicate the significant role of genotype and drug use individually on suicidal behaviors. We hypothesized that, consistent with the gene X environment (GXE) framework, an interaction between serotonin receptor (5-HTTLPR) gene and drug use would influence suicidal behaviors in BD patients.

METHODS

One hundred and fifty BD patients at a public urban behavioral health clinic enrolled. The majority were females (n  104, 69.3%), between 19 and 65 years of age (M  39.5, SD= 10.9), African American (n  110, 73.3%), unemployed (78.7%, n  118) with 32% identifying as homeless (n  48). Measures of current mood symptoms, historic suicidal behaviors, and recent substance use were completed, and buccal swabs collected. A moderation analysis was employed for data analysis.

RESULTS

Suicidal behaviors were significantly associated with genotype X drug use interaction (B  0.41, 95%CI= [0.06, 0.77], p= .03) followed by gender (B = 1.92, 95%CI= [0.59, 3.25], p= .005), genotype (B= -1.93, 95%CI= [-3.49, -0.36], p= .02), and employment (B= -1.72, 95%CI= [-3.12, -0.31], p= .02).

LIMITATIONS

The relatively small sample size primarily comprised of an indigent urban population may limit generalizability. Drug use and suicide risk measures were self-reported and potentially influenced by social desirability bias.

CONCLUSIONS

The 5-HTTLPR plays a moderating role on the association between drug use-suicidal behaviors with a differential impact of short and long alleles.

Prevalence of suicide attempts in bipolar disorder: a systematic review and meta-analysis of observational studies

AIMS

Bipolar disorder (BD) is a severe psychiatric disorder associated with a high risk of suicide. This meta-analysis examined the prevalence of suicide attempts (SA) in patients with BD and its associated factors.

METHODS

A systematic literature search was conducted in the PubMed, PsycINFO, EMBASE and Web of Science databases from their inception to 11 June 2018. The prevalence of SA in BD was synthesised using the random-effects model.

RESULTS

The search identified 3451 articles of which 79 studies with 33 719 subjects met the study entry criteria. The lifetime prevalence of SA was 33.9% (95% CI 31.3-36.6%; I2 = 96.4%). Subgroup and meta-regression analyses revealed that the lifetime prevalence of SA was positively associated with female gender, BD-I, BD Not Otherwise Specified and rapid cycling BD subtypes, income level and geographic region.

CONCLUSION

This meta-analysis confirmed that SA is common in BD and identified a number of factors related to SA. Further efforts are necessary to facilitate the identification and prevention of SA in BD. Long-term use of mood stabilisers coupled with psycho-social interventions should be available to BD patients to reduce the risk of suicidal behaviour.

Addiction and Suicide: A Review

(Reprinted with permission from The American Journal on Addictions 24: 98-104, 2015).

A preliminary investigation of impulsivity, aggression and white matter in patients with bipolar disorder and a suicide attempt history

BACKGROUND

Impulsivity and aggression may be associated with suicide attempts in bipolar disorder (BD), but findings have been inconsistent. Abnormalities in anterior white matter tracts that project to the frontal lobes mediate top-down regulation of emotion and may contribute to this clinical phenomenology.

METHODS

We assessed white matter (i.e., fractional anisotropy) in anterior and posterior brain regions using diffusion tensor imaging in 18 patients with BD and no prior suicide attempt (BD-S), 12 patients with BD and a prior suicide attempt (BD+S), and 12 healthy volunteers. Patients completed the Urgency, Premeditation, Perseverance, Sensation Seeking, Positive Urgency (UPPS-P) Impulsive Behavior Scale and Impulsive Premeditated Aggression Scale (IPAS). All individuals completed the Barratt Impulsiveness Scale (BIS-11).

RESULTS

Patients with BD+S had higher overall impulsivity (assessed using both the UPPS-P Impulsive Behavior Scale and BIS-11) and premeditated aggression compared to patients with BD-S. There were no significant group differences on measures of fractional anisotropy (FA). In patients with BD+S, however, higher FA in the anterior (but not the posterior) brain regions correlated with greater overall impulsivity on the UPPS-P Impulsive Behavior Scale. There were no significant correlations between either anterior or posterior brain regions with clinical measures in patients with BD-S.

LIMITATIONS

Cross-sectional study, sample size and possible contribution of psychotropic medications.

CONCLUSION

Impulsivity and aggression may be risk factors for a suicide attempt in BD. White matter in the anterior limb of the internal capsule and anterior corona radiata may play a role in this phenomenology.

Impulsivity differences between bipolar and unipolar depression

BACKGROUND

Even though particularly bipolar depression and unipolar depression seem to be similar, they show differences in terms of the etiology, phenomenology, course, and treatment process. Bipolar depression is associated with mood lability, motor retardation, and hypersomnia to a larger extent. Early age of onset, a high frequency of depressive episodes, and history of bipolar disease in the family are suggestive of bipolar disorder (BD) rather than major depression. Bipolar and unipolar disorders are also associated with increased impulsivity during illness episodes. However, there is little information about impulsivity during euthymia in these mood disorders. The aim of this study was to illustrate the difference in impulsivity in euthymic bipolar and unipolar patients.

MATERIALS AND METHODS

Impulsivity was evaluated by the Barratt Impulsiveness Scale (BIS-11A), in 78 interepisode BD patients, 72 interepisode unipolar disorder patients, and 70 healthy controls. The diagnosis was established by severe combined immunodeficiency. One-way between-groups ANOVA was used to compare the BIS-11A mean scores for all three groups.

RESULTS

Impulsivity scores of the bipolar and unipolar disorder patients were significantly higher than controls on total and all subscales measures. There was no difference between the bipolar and unipolar disorder groups on total, attentional, and nonplanning impulsivity measures. However, BD patients scored significantly higher than the unipolar patients on motor impulsivity measures.

CONCLUSIONS

Both interepisode bipolar and unipolar disorder patients had increased impulsivity compared to healthy individuals. There was no significant difference on attention and nonplanning impulsivity subscales; however, on the motor subscale, bipolar patients were more impulsive than unipolar disorder patients.

Reducing relapse and suicide in bipolar disorder: practical clinical approaches to identifying risk, reducing harm and engaging service users in planning and delivery of care – the PARADES (Psychoeducation, Anxiety, Relapse, Advance Directive Evaluation and Suicidality) programme

Background

Bipolar disorder (BD) costs £5.2B annually, largely as a result of incomplete recovery after inadequate treatment.

Objectives

A programme of linked studies to reduce relapse and suicide in BD.

Design

There were five workstreams (WSs): a pragmatic randomised controlled trial (RCT) of group psychoeducation (PEd) versus group peer support (PS) in the maintenance of BD (WS1); development and feasibility RCTs of integrated psychological therapy for anxiety in bipolar disorder (AIBD) and integrated for problematic alcohol use in BD (WS2 and WS3); survey and qualitative investigations of suicide and self-harm in BD (WS4); and survey and qualitative investigation of service users’ (SUs) and psychiatrists’ experience of the Mental Capacity Act 2005 (MCA), with reference to advance planning (WS5).

Setting

Participants were from England; recruitment into RCTs was limited to certain sites [East Midlands and North West (WS1); North West (WS2 and WS3)].

Participants

Aged ≥ 18 years. In WS1–3, participants had their diagnosis of BD confirmed by the Structural Clinical Interview for theDiagnostic and Statistical Manual of Mental Disorders.

Interventions

In WS1, group PEd/PS; in WS3 and WS4, individual psychological therapy for comorbid anxiety and alcohol use, respectively.

Main outcome measures

In WS1, time to relapse of bipolar episode; in WS2 and WS3, feasibility and acceptability of interventions; in WS4, prevalence and determinants of suicide and self-harm; and in WS5, professional training and support of advance planning in MCA, and SU awareness and implementation.

Results

Group PEd and PS could be routinely delivered in the NHS. The estimated median time to first bipolar relapse was 67.1 [95% confidence interval (CI) 37.3 to 90.9] weeks in PEd, compared with 48.0 (95% CI 30.6 to 65.9) weeks in PS. The adjusted hazard ratio was 0.83 (95% CI 0.62 to 1.11; likelihood ratio testp = 0.217). The interaction between the number of previous bipolar episodes (1–7 and 8–19, relative to 20+) and treatment arm was significant (χ2 = 6.80, degrees of freedom = 2;p = 0.034): PEd with one to seven episodes showed the greatest delay in time to episode. A primary economic analysis indicates that PEd is not cost-effective compared with PS. A sensitivity analysis suggests potential cost-effectiveness if decision-makers accept a cost of £37,500 per quality-adjusted life-year. AIBD and motivational interviewing (MI) cognitive–behavioural therapy (CBT) trials were feasible and acceptable in achieving recruitment and retention targets (AIBD:n = 72, 72% retention to follow-up; MI-CBT:n = 44, 75% retention) and in-depth qualitative interviews. There were no significant differences in clinical outcomes for either trial overall. The factors associated with risk of suicide and self-harm (longer duration of illness, large number of periods of inpatient care, and problems establishing diagnosis) could inform improved clinical care and specific interventions. Qualitative interviews suggested that suicide risk had been underestimated, that care needs to be more collaborative and that people need fast access to good-quality care. Despite SUs supporting advance planning and psychiatrists being trained in MCA, the use of MCA planning provisions was low, with confusion over informal and legally binding plans.

Limitations

Inferences for routine clinical practice from WS1 were limited by the absence of a ‘treatment as usual’ group.

Conclusion

The programme has contributed significantly to understanding how to improve outcomes in BD. Group PEd is being implemented in the NHS influenced by SU support.

Future work

Future work is needed to evaluate optimal approaches to psychological treatment of comorbidity in BD. In addition, work in improved risk detection in relation to suicide and self-harm in clinical services and improved training in MCA are indicated.

Trial registration

Current Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 6. See the NIHR Journals Library website for further project information.

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.

The relative influence of individual risk factors for attempted suicide in patients with bipolar I versus bipolar II disorder

OBJECTIVES

To compare the relative influence (RI) of individual predictors for lifetime attempted suicide between adults with bipolar I (BDBD-I) and bipolar II disorder (BDBD-II).

METHODS

We conducted an analysis of data from 1465 enrollees in the Mayo Clinic Bipolar Disorder Biobank. Demographic and clinical variables and history of attempted suicide were ascertained using standardized questionnaires. Height and weight were assessed to determine body mass index (BMI); obesity was defined as BMI ≥30kg/m². The frequencies of these variables were compared between persons with and without self-reported lifetime suicide attempts both overall, and within BD-I and BD-II subgroups. Gradient boosting machine (GBM) models were used to quantify the RI of study variables on the risk of lifetime attempted suicide.

RESULTS

Nearly one-third of patients reported having a lifetime suicide attempt. Attempted suicide rates were higher in patients with BD-I than BD-II, but absolute differences were small. Lifetime attempted suicide was associated with female sex, BD-I subtype, psychiatric and substance use comorbidities, binge eating behavior, lifetime history of rapid cycling, other indicators of adverse illness course, and early age of bipolar illness onset in the entire cohort. Differences in the rank-ordering of RI for predictors of attempted suicide between BD-I and BD-II patients were modest. Rapid cycling was a strong risk factor for attempted suicide, particularly in men with BD-I.

LIMITATIONS

Actively psychotic or suicidal patients needing psychiatric hospitalization were initially excluded, but were approached after these acute psychiatric problems resolved.

CONCLUSIONS

The prevalence of lifetime attempted suicide was significantly higher in BD-I than BD-II in this large, cross-sectional cohort. Predictors of attempted suicide were similar in BD-I and BD-II subgroups.

Alcohol use and bipolar disorders: Risk factors associated with their co-occurrence and sequence of onsets

BACKGROUND

Little is known about the sequence of onsets in patients affected by comorbid alcohol use and bipolar disorder. This study examines the risk factors associated with their co-occurrence and order of onset.

METHOD

The demographic, clinical, and temperament characteristics as well as the course of illness were analyzed within our sample of 1090 DSM-IV bipolar I manic patients. Our sample was categorized according to the presence of comorbid alcohol use disorder and the sequence of onsets of bipolar and alcohol use disorders i.e., alcohol first (AUD-BD) and bipolar first (BD-AUD).

RESULTS

Regression analyses revealed that alcohol use disorder (52.5%) was associated with the male gender, additional substance use disorders, as well as an irritable and a hyperthymic temperament. The AUD-BD group (6.6%) was older than the BD-AUD group (45.8%) and showed higher rates of comorbid sedative use, organic, and anxiety disorders with higher levels of irritable temperament, and a bipolar subtype characterized by depressive polarity at onset. The BD-AUD group had high levels of hyperthymic temperament with higher rates of comorbid stimulant use disorder and a manic polarity at onset.

CONCLUSIONS

In the AUD-BD group, alcohol might have been used to reduce stress and tension caused by the presence of an irritable temperament as well as anxious and organic disorders, leading to first depressive episode. In the BD-AUD group, stimulant use might have triggered the first manic episode, and alcohol abuse result from mania severity.

Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990-2015: Systematic review and meta-analysis

BACKGROUND

Comorbidity between substance use disorders (SUDs) and bipolar disorder (BD) is highly prevalent to the extent it may almost be regarded the norm. This systematic review and meta-analysis aimed to estimate the prevalence rates of SUDs in treatment seeking patients diagnosed with BD in both inpatient and outpatient settings.

METHODS

A comprehensive literature search of Medline, EMBASE, psychINFO and CINAHL databases was conducted from 1990 to 2015. Prevalence of co-morbid SUDs and BD were extracted and odds ratios (ORs) were calculated using random effects meta-analysis.

RESULTS

There were 151 articles identified by electronic searches that yielded 22 large, multi-site studies and 56 individual studies describing comorbid rates of SUDs amongst community dwelling, BD inpatients or outpatients. The SUDs with the highest prevalence in BD were alcohol use (42%) followed by cannabis use (20%) and other illicit drug use (17%). Meta-analysis showed males had higher lifetime risks of SUDs compared to females. BD and comorbid SUDS were associated with earlier age of onset and slightly more hospitalisations than non-users.

LIMITATIONS

The results do not take into account the possibility that individuals may have more than one comorbid disorder, such as having more than one SUD, anxiety disorder, or other combination. Some of the meta-analyses were based on relatively few studies with high rates of heterogeneity. Most included studies were cross-sectional and therefore causality cannot be inferred.

CONCLUSIONS

This systematic review shows comorbidity between SUDs and bipolar illness is highly prevalent in hospital and community-based samples. The prevalence of SUDs was similar in patients with bipolar I and bipolar II disorders. This study adds to the literature demonstrating that SUDs are common in BD and reinforces the need to provide better interventions and properly conducted treatment trials to reduce the burden conferred by comorbid SUD and BD.

Impulsivity in bipolar disorders in a Tunisian sample

Impulsivity as a trait characteristic is increased in bipolar disorder and may be a core factor of the illness. The objectives of our work are to evaluate the level of impulsivity among patients with bipolar disorder and to study its relation with mood state, alcohol misuse, suicide attempts and other socio-demographic and clinical factors. We measured impulsivity in 60 subjects with bipolar disorder in relationship to socio-demographic and clinical variables. The subjects completed Data included socio-demographic details and clinical variables, the Barratt Impulsiveness Scale (BIS-11) in an Arabic version to assess impulsivity, The Mini International Neuropsychiatric Interview "MINI" version 05 to screen for alcohol abuse or dependence and mood graphic rate scale (MGRS) to evaluate mood state. Our results show that the mean score of BIS-11 was 71.5. Fifty-five per cent of the patients had a high level of impulsiveness. No differences were found relating to mood state. Impulsivity was related to Male gender, lower educational level, early age of onset, smoking, alcohol and drug misuse and prior suicide attempts. The treatment of patients with BD should consider to reduce impulsivity to improve morbidity.

Identification of Susceptible Loci and Enriched Pathways for Bipolar II Disorder Using Genome-Wide Association Studies

BACKGROUND

This study aimed to identify susceptible loci and enriched pathways for bipolar disorder subtype II.

METHODS

We conducted a genome-wide association scan in discovery samples with 189 bipolar disorder subtype II patients and 1773 controls, and replication samples with 283 bipolar disorder subtype II patients and 500 controls in a Taiwanese Han population using Affymetrix Axiom Genome-Wide CHB1 Array. We performed single-marker and gene-based association analyses, as well as calculated polygeneic risk scores for bipolar disorder subtype II. Pathway enrichment analyses were employed to reveal significant biological pathways.

RESULTS

Seven markers were found to be associated with bipolar disorder subtype II in meta-analysis combining both discovery and replication samples (P<5.0×10^-6), including markers in or close to MYO16, HSP90AB3P, noncoding gene LOC100507632, and markers in chromosomes 4 and 10. A novel locus, ETF1, was associated with bipolar disorder subtype II (P<6.0×10^-3) in gene-based association tests. Results of risk evaluation demonstrated that higher genetic risk scores were able to distinguish bipolar disorder subtype II patients from healthy controls in both discovery (P=3.9×10^-4~1.0×10^-3) and replication samples (2.8×10^-4~1.7×10^-3). Genetic variance explained by chip markers for bipolar disorder subtype II was substantial in the discovery (55.1%) and replication (60.5%) samples. Moreover, pathways related to neurodevelopmental function, signal transduction, neuronal system, and cell adhesion molecules were significantly associated with bipolar disorder subtype II.

CONCLUSION

We reported novel susceptible loci for pure bipolar subtype II disorder that is less addressed in the literature. Future studies are needed to confirm the roles of these loci for bipolar disorder subtype II.

Different characteristics associated with suicide attempts among bipolar I versus bipolar II disorder patients

BACKGROUND

Suicide attempts are common in patients with bipolar disorder (BD), and consistently associated with female gender and certain unfavorable BD illness characteristics. Findings vary, however, regarding effects of BD illness subtype and yet other illness characteristics upon prior suicide attempt rates. We explored the effects of demographics and BD illness characteristics upon prior suicide attempt rates in patients stratified by BD illness subtype (i.e., with bipolar I disorder (BDI) versus bipolar II disorder (BDII)).

METHODS

Outpatients referred to the Stanford BD Clinic during 2000-2011 were assessed with the Systematic Treatment Enhancement Program for BD Affective Disorders Evaluation. Rates of prior suicide attempt were compared in patients with and without diverse demographic and BD illness characteristics stratified by BD subtype.

RESULTS

Among 494 BD outpatients (mean ± SD age 35.6 ± 13.1 years; 58.3% female; 48.6% BDI, 51.4% BDII), overall prior suicide attempt rates in were similar in BDI versus BDII patients, but approximately twice as high in BDI (but not BDII) patients with compared to without lifetime eating disorder, and in BDII (but not BDI) patients with compared to without childhood BD onset. In contrast, current threshold-level suicidal ideation and lifetime alcohol use disorder robustly but less asymmetrically increased prior suicide attempt risk across BD subtypes.

LIMITATIONS

American tertiary bipolar disorder clinic referral sample, cross-sectional design.

CONCLUSIONS

Further studies are needed to assess the extent to which varying clinical characteristics of samples of patients with BDI and BDII could yield varying prior suicide attempt rates in patients with BDI versus BDII.

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.

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.

Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses

Purpose

This review article provides an overview of the frequency, burden of illness, diagnosis, and treatment of bipolar disorder (BD) from the perspective of the advanced practice nurses (APNs).

Data sources

PubMed searches were conducted using the following keywords: “bipolar disorder and primary care,” restricted to dates 2000 to present; “bipolar disorder and nurse practitioner”; and “bipolar disorder and clinical nurse specialist.” Selected articles were relevant to adult outpatient care in the United States, with a prioritization of articles written by APNs or published in nursing journals.

Conclusions

BD has a substantial lifetime prevalence in the population at 4%. Because the manic or depressive symptoms of BD tend to be severe and recurrent over a patient's lifetime, the condition is associated with significant burden to the individual, caregivers, and society. Clinician awareness that BD may be present increases the likelihood of successful recognition and appropriate treatment. A number of pharmacological and nonpharmacological treatments are available for acute and maintenance treatments, with the prospect of achieving reduced symptom burden and increased functioning for many patients.

Implications for practice

Awareness of the disease burden, diagnostic issues, and management choices in BD has the potential to enhance outcome in substantial proportions of patients.

Characteristics of Bipolar I patients grouped by externalizing disorders

BACKGROUND

Bipolar disorder co-occurs with a number of disorders with externalizing features. The aim of this study is to determine whether Bipolar I (BPI) subjects with comorbid externalizing disorders and a subgroup with externalizing symptoms prior to age 15 have different clinical features than those without externalizing disorders and whether these could be attributed to specific genetic variations.

METHODS

A large cohort (N=2505) of Bipolar I subjects was analyzed. Course of illness parameters were compared between an Externalizing Group, an Early-Onset Subgroup and a Non-Externalizing Group in the Discovery sample (N=1268). Findings were validated using an independent set of 1237 BPI subjects (Validation sample). Genetic analyses were carried out.

RESULTS

Subjects in the Externalizing Group (and Early-Onset Subgroup) tended to have a more severe clinical course, even in areas specifically related to mood disorder such as cycling frequency and rapid mood switching. Regression analysis showed that the differences are not completely explainable by substance use. Genetic analyses identified nominally associated SNPs; calcium channel genes were not enriched in the gene variants identified.

LIMITATIONS

Validation in independent samples is needed to confirm the genetic findings in the present study.

CONCLUSIONS

Our findings support the presence of an externalizing disorder subphenotype within BPI with greater severity of mood disorder and possible specific genetic features.

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 co-occurrence of aggression and self-harm: systematic literature review

BACKGROUND

Epidemiological research supports an association between aggression and self-harm through data on the frequency with which individuals exhibit both behaviours. Unbiased evidence, however, is needed to draw conclusions about the nature and extent of co-occurrence.

METHOD

Systematic review of published studies was undertaken to evaluate whether or not the frequency with which aggression and self-harm co-occur is beyond that which would be expected by chance. Outcome measures included: (a) between-group differences on a standardised aggression/self-harm measure - the groups defined by scores on a measure of the other behaviour; (b) correlations between the two behaviours; (c) co-occurrence rates in populations defined by the presence of either behaviour; (d) co-occurrence rates in populations not defined by either behaviour. Odds ratios were calculated for studies presenting complete frequency data.

RESULTS

123 studies, some yielding more than one type of result, met the inclusion criteria. Most case-control studies found elevated levels of aggression in self-harming populations (or self-harm in aggressive populations) compared to controls. The majority of correlational, co-occurrence rate, and odds ratio data found aggression and self-harm to be associated.

LIMITATIONS

Results were subject to descriptive synthesis only and thus, unable to report an overall effect size.

CONCLUSIONS

Evidence suggests that aggression and self-harm frequently co-occur. Such evidence necessitates more theoretical discussion and associated research on the source and nature of co-occurrence. Nonetheless, individuals who present with one behaviour may be considered an 'at-risk' group in terms of exhibiting the other. Such evidence holds implications for practice (e.g. risk assessment).

Addiction and suicide: A review

BACKGROUND

Addiction specialists frequently find themselves faced with suicidal behavior in their addictions patients. Although many addiction treatment programs will not accept clients with recent suicidal behavior, up to 40% of patients seeking treatment for substance dependence report a history of suicide attempt(s).(1-3) Risk factors for suicide have been studied in the general population and among people with mental illness, less is known about risk factors in those with substance use disorders and co-occurring disorders.

METHODS

Studies, psychological autopsies and recent reviews on risk factors for suicide and suicide attempts in patients with alcohol and drug use disorders and the relationship with co-occurring mental illness were examined.

RESULTS AND CONCLUSIONS

Suicidal behavior is a significant problem for people with co-occurring disorders seeking addiction treatment. Several predisposing and precipitating risk factors such as marital and interpersonal relationship disruption, occupational and financial stressors, recent heavy substance use and intoxication as well as a history of previous suicide attempts and sexual abuse combine in an additive fashion with personality traits and mental illnesses to intensify risk for suicidal behavior in addiction patients. Major depression, bipolar disorder, borderline personality disorder and post-traumatic stress disorder are especially associated with suicidal behavior in people with addictive disorders.

DISCUSSION AND SCIENTIFIC SIGNIFICANCE

Treatment implications of these findings are discussed. Addiction treatment providers should routinely gather information about client's suicidal histories, thoughts, and plans in order to assess risk and develop treatment plans for suicidality at various points in treatment.

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.

Bipolar I and II versus unipolar depression: clinical differences and impulsivity/aggression traits

OBJECTIVE

To investigate distinguishing features between bipolar I, II and unipolar depression, and impulsivity/aggression traits in particular.

METHODS

Six hundred and eighty-five (n=685) patients in a major depressive episode with lifetime Unipolar (UP) depression (n=455), Bipolar I (BP-I) disorder (n=151), and Bipolar II (BP-II) (n=79) disorder were compared in terms of their socio-demographic and clinical characteristics.

RESULTS

Compared to unipolar patients, BP-I and BP-II depressed patients were significantly younger at onset of their first depressive episode, and were more likely to experience their first depressive episode before/at age of 15. They also had more previous affective episodes, more first- and second-degree relatives with history of mania, more current psychotic and subsyndromal manic symptoms, and received psychopharmacological and psychotherapy treatment at an earlier age. Furthermore, BP-I and BP-II depressed patients had higher lifetime impulsivity, aggression, and hostility scores. With regard to bipolar subtypes, BP-I patients had more trait-impulsivity and lifetime aggression than BP-II patients whereas the latter had more hostility than BP-I patients. As for co-morbid disorders, Cluster A and B Personality Disorders, alcohol and substance abuse/dependence and anxiety disorders were more prevalent in BP-I and BP-II than in unipolar patients. Whereas the three groups did not differ on other socio-demographic variables, BP-I patients were significantly more often unemployed that UP patients.

CONCLUSION

Our findings comport with major previous findings on differences between bipolar and unipolar depression. As for trait characteristics, bipolar I and II depressed patients had more life-time impulsivity and aggression/hostility than unipolar patients. In addition, bipolar I and II patients also differed on these trait characteristics.

Diagnosis and management of bipolar disorder in primary care: a DSM-5 update

This review discusses the diagnosis and detection of bipolar disorder in the primary care population with recent changes introduced by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the pharmacotherapy and psychosocial management of this psychiatric condition.

Simple Measures of Hopelessness and Impulsivity are Associated with Acute Suicidal Ideation and Attempts in Patients in Psychiatric Crisis

OBJECTIVE

To explore the authors' predictions 1) that hopelessness would positively correlate with suicidal ideation and that impulsivity (either transient urges to self-harm or impulsive acting out) would positively correlate with suicidal behavior, and 2) that the recent or long-standing nature of the traits will have corresponding effects on reported histories of suicidal ideation and behavior.

DESIGN

Questionnaire validation trial in which each subject received every measure in counterbalanced fashion.

SETTING

Inpatient and outpatient psychiatric settings associated with a medium-sized medical school in the southeastern United States.

PARTICIPANTS

Forty-five subjects presenting with varying levels of suicidal ideation and behavior completed measures providing information about their histories of suicidal ideation and behavior, recent feelings of hopelessness, feelings of general hopelessness, recent feelings of difficulty controlling urges to self-harm, and feeling about general levels of impulsivity.

MEASUREMENTS

The InterSePT Scale for Suicidal Thinking-Plus, the Sheehan-Suicidality Tracking Scale, the Columbia-Suicide Severity Rating Scale, and six additional questions to assess hopelessness and impulsivity.

RESULTS

Recent and trait hopelessness correlated positively with suicidal ideation. Patients who reported any suicide attempt endorsed higher levels of general impulsivity than those who did not report a history of at least one suicide attempt. Those enrolled in the study secondary to a very recent suicide attempt reported more difficulties with recent suicidal impulses.

CONCLUSION

Simple measures of hopelessness and impulsivity are associated with suicidal ideation and attempts and may add to determination of suicide risk.

Risk and protective factors associated with substance use disorders in adolescents with first-episode mania

OBJECTIVE

Adolescents with bipolar disorder (BD) are more likely to develop substance use disorders (SUDs) than adolescents without psychiatric disorders; however, to our knowledge, specific risk factors underlying this relationship have not been prospectively examined. The purpose of this study was to identify predictors of developing SUDs after a first manic episode.

METHOD

Participants aged 12 to 20 years and hospitalized with their first manic episode associated with bipolar I disorder (BP-I) were recruited as part of the University of Cincinnati First-Episode Mania Study and prospectively evaluated for patterns of substance use. Follow-up ranged between 17 and 283 weeks (mean = 113 weeks, SD = 71.9 weeks). Demographic and clinical variables were compared between adolescents with and without SUDs.

RESULTS

Of the 103 adolescents with BD, 49 (48%) either had a SUD at baseline or developed one during follow-up. Of the 71 participants who did not have a SUD at study entry, 17 (24%) developed one during follow-up (median = 40 weeks). Later onset of BD, manic (versus mixed) mood episode, and comorbid disruptive behavior disorders were associated with an increased risk of developing a SUD in univariate analyses. Adolescents treated with psychostimulant treatment before their first manic episode were significantly less likely to develop a SUD independent of attention-deficit/hyperactivity disorder (ADHD) diagnosis. Comorbid posttraumatic stress disorder (PTSD) and psychotic symptoms were the strongest predictors of SUD development.

CONCLUSION

Our results confirm high rates of SUD in adolescents with BD. In addition, our findings identify potential risk factors associated with SUDs in adolescents with BD. These data are preliminary in nature and should be explored further in future studies.

Prevalence and clinical correlates of alcohol use disorders among bipolar disorder patients: results from the Brazilian Bipolar Research Network

OBJECTIVES

To investigate prevalence rates and clinical correlates of alcohol use disorders (AUD) among bipolar disorder (BD) patients in a large sample from the Brazilian Bipolar Research Network.

METHODS

Four hundred and eighty-three DSM-IV BD patients, divided according to the presence or absence of a lifetime AUD diagnosis (BD-AUD vs. BD-nonAUD), were included. Demographic and clinical characteristics of these two groups were compared. Logistic regression was performed to identify which characteristics were most strongly associated with a lifetime AUD diagnosis.

RESULTS

Nearly 23% presented a lifetime AUD diagnosis. BD-AUD patients were more likely to be male, to present rapid cycling, post-traumatic stress disorder (PTSD), anorexia, other substance use disorders (SUD), family history of SUD, any substance misuse during the first mood episode, history of psychosis, suicide attempts, and younger age at onset of illness than BD-nonAUD patients. Logistic regression showed that the variables most strongly associated with a lifetime AUD diagnosis were SUD (non-alcohol), any substance misuse during the first mood episode, PTSD, male gender, suicide attempt, family history of SUD, and younger age at onset of BD.

CONCLUSIONS

BD-AUD patients begin their mood disorder earlier and present more suicidal behaviors than BD-nonAUD patients. Personal and family history of SUD may be good predictors of comorbid AUD among BD patients. These variables are easily assessed in the clinical setting and may help to identify a particularly severe subgroup of BD patients.

Association between family history of mood disorders and clinical characteristics of bipolar disorder: results from the Brazilian bipolar research network

OBJECTIVES

To compare clinical characteristics of bipolar disorder (BD) in patients with and without a family history of mood disorders (FHMD) in a large sample from the Brazilian Research Network of Bipolar Disorders.

METHODS

Four-hundred eighty-eight DSM-IV BD patients participating in the Brazilian Research Network of Bipolar Disorders were included. Participants were divided between those with FHMD (n=230) and without FHMD (n=258). We compared these two groups on demographic and clinical variables and performed a logistic regression to identify which variables were most strongly associated with positive family history of mood disorders.

RESULTS

BD patients with FHMD presented with significantly higher lifetime prevalence of any anxiety disorder, obsessive-compulsive disorder, social phobia, substance abuse, and were more likely to present history of suicide attempts, family history of suicide attempts and suicide, and more psychiatric hospitalizations than BD patients without FHMD. Logistic regression showed that the variables most strongly associated with a positive FHMD were any comorbid anxiety disorder, comorbid substance abuse, and family history of suicide.

LIMITATIONS

Cross-sectional study and verification of FHMD by indirect information.

CONCLUSION

BD patients with FHMD differ from BD patients without FHMD in rates of comorbid anxiety disorder and substance abuse, number of hospitalizations and suicide attempts. As FHMD is routinely assessed in clinical practice, these findings may help to identify patients at risk for particular manifestations of BD and may point to a common, genetically determined neurobiological substrate that increases the risk of conditions such as comorbidities and suicidality in BD patients.

Substance use disorders increase the odds of subsequent mood disorders

BACKGROUND

There is a well-known association between mood disorders and substance use disorders (SUD), but little research has been conducted on SUDs as risk factors for the development of subsequent mood disorders.

METHODS

We analyzed data from the National Comorbidity Survey Replication study. Diagnoses were determined using DSM-IV criteria. Odds ratios (aORs) of subsequently developing mood disorders were adjusted for age, sex and race/ethnicity.

RESULTS

Data from 5217 individuals were included (6.6% male; mean age 45.3 years; 72.6% White, 11.2% Black, 12.5% Hispanic and 3.7% other). Subsequent mood disorders developed in 26.4% of individuals with primary adolescent-onset SUD (12-17 years), 21.7% of those with SUD onset at 18-25 years, and 14.0% of those with SUD onset between the ages of 26 and 34 years. The mean lagtime between SUD onset and development of a mood disorder was about 11 years. Controlling for demographic variables, the aORs of developing a mood disorder in these three age groups were 2.44, 3.65, and 3.25. Substance dependence was associated with higher odds of mood disorders than was abuse. Among the specific mood disorders, the increased odds of developing bipolar disorder were particularly high among individuals with drug dependence.

CONCLUSIONS

Individuals with adolescent and young adult-onset SUD had increased odds of developing a secondary mood disorder. This indicates that adolescents and young adults with SUD should be closely monitored for both positive and negative mood symptoms. SUD treatment and aftercare offer opportunities for the early identification of secondary mood disorders.

Other- and self-directed forms of violence and their relationships to DSM-IV substance use and other psychiatric disorders in a national survey of adults

OBJECTIVE

To examine associations between DSM-IV psychiatric disorders and other- and self-directed violence in the general population.

METHODS

Data were obtained from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 & 2 (n=34,653). Four violence categories were derived from a latent class analysis (LCA) of 5 other-directed and 4 self-directed violent behavior indicators. Multinomial logistic regression examined class associations for gender, race-ethnicity, age and DSM-IV substance use, mood, anxiety, and personality disorders.

RESULTS

Approximately 16% of adults reported some form of violent behavior distributed as follows: other-directed only, 4.6%; self-directed only, 9.3%; combined self- and other-directed, 2.0%; and no violence, 84.1%. The majority of the DSM-IV disorders included in this study were significantly and independently related to each form of violence. Generally, other-directed violence was more strongly associated with any substance use disorders (81%) and any personality disorders (42%), while self-directed violence was more strongly associated with mood (41%) and anxiety disorders (57%). Compared with these two forms of violence, the smaller group with combined self- and other-directed violence was more strongly associated with any substance use disorders (88%), mood disorders (63%), and personality disorders (76%).

CONCLUSION

Findings from this study are consistent with recent conceptualizations of disorders as reflecting externalizing disorders and internalizing disorders. The identification of the small category with combined forms of violence further extends numerous clinical studies which established associations between self- and other-directed violent behaviors. The extent to which the combined violence category represents a meaningful and reliable category of violence requires further detailed studies.

Is there an empirical link between impulsivity and suicidality in bipolar disorders? A review of the current literature and the potential psychological implications of the relationship

OBJECTIVES

Suicide is highly prevalent among individuals with bipolar disorder and understanding the factors that increase risk for suicide may help to develop targeted interventions to prevent attempts. Impulsivity is thought to be an influential factor associated with suicidality and is also discussed as a key construct of bipolar disorder. The aim of this paper was to systematically review the current evidence to examine the association between impulsivity and suicidality in bipolar disorder.

METHODS

PsycInfo, Medline, and Web of Knowledge databases were searched for articles published up until March 2012. Papers were included if they assessed an adult sample of individuals with bipolar disorders, focused on suicidality (ideation with intent to die, suicide attempts, or completion), and used a validated measure to determine impulsivity.

RESULT

Sixteen papers were identified. Contrary to widespread belief, we found (i) a very inconsistent picture of results including positive, negative, and insignificant associations between impulsivity and suicidality; and (ii) some studies do not take into account important aspects such as state-trait or measurement issues.

CONCLUSIONS

The link between suicidality and impulsivity is less straightforward than often assumed. Drawing clear conclusions about the association is hampered by factors such as inconsistencies in defining suicidality, measuring impulsivity, and differentiating between impulsivity as a personality trait and impulsivity as a state (e.g., a consequence of substance use or premeditation of the attempt). We suggest that the association is less direct and that psychological models (e.g., Joiner's theory of suicidality) can help foster a more in-depth understanding regarding the relationship.

Comorbid anxiety disorders in Canadians with bipolar disorder: clinical characteristics and service use

OBJECTIVE

To examine the impact of anxiety disorders comorbid to bipolar disorder (BD) in a large, nationally representative sample, to describe the sociodemographic and clinical profiles of Canadians living with BD and with or without comorbid anxiety disorders, to identify the characteristics uniquely associated with comorbid anxiety, and to examine treatment patterns.

METHOD

We analyzed data from the Canadian Community Health Survey: Mental Health and Well-Being, conducted among 38 492 Canadians. People meeting the criteria for BD (n = 808) were compared based on the presence or absence of an assessed anxiety disorder (that is, social phobia, panic disorder, and agoraphobia).

RESULTS

People with BD and a comorbid anxiety disorder fare worse in terms of BD relapses, suicidality, and sleep disturbance, and are more likely to be taking psychiatric medication. They have more impairment in their work and social functioning and rate their health and life satisfaction lower. Despite the greater severity, they are not receiving additional psychological treatment, they feel they are not receiving the treatment they need, and they report more barriers to treatment.

CONCLUSIONS

This study confirms the critical impact of comorbid anxiety on the course of BD in a large, nationally representative sample and reveals that the psychological treatment needs of this population are not being met. Clinical and research implications are discussed.

Risk factors for secondary substance use disorders in people with childhood and adolescent-onset bipolar disorder: opportunities for prevention

BACKGROUND

Compared to other mental illnesses, bipolar disorder is associated with a disproportionately high rate of substance use disorders (SUDs), and the co-occurrence is associated with significant morbidity and mortality. Early diagnosis of primary bipolar disorder may provide opportunities for SUD prevention, but little is known about the risk factors for secondary SUD among individuals with bipolar disorder. The purposes of this study were to describe the population of people with childhood and adolescent-onset primary bipolar disorder, and to identify risk factors for secondary SUD in this population.

METHODS

Using data collected from the National Comorbidity Survey Replication study, we identified 158 individuals with childhood-onset (<13 years) or adolescent-onset (13-18 years) primary bipolar disorder (I, II or subthreshold). Survival analysis was used to identify risk factors for SUD.

RESULTS

Compared to adolescent-onset, people with childhood-onset bipolar disorder had increased likelihoods of attention deficit hyperactivity disorder (ADHD) (adjusted odds ratio=2.81) and suicide attempt (aOR=3.61). Males were more likely than females to develop SUD, and did so at a faster rate. Hazard ratios of risk factors for SUD were: lifetime oppositional defiant disorder (2.048), any lifetime anxiety disorder (3.077), adolescent-onset bipolar disorder (1.653), and suicide attempt (15.424). SUD was not predicted by bipolar disorder type, family history of bipolar disorder, hospitalization for a mood episode, ADHD or conduct disorder.

CONCLUSIONS

As clinicians struggle to help individuals with bipolar disorder, this study provides information that might be useful in identifying individuals at higher risk for SUD. Future research can examine whether targeting these risk factors may help prevent secondary SUD.

Schema therapy for bipolar disorder: a conceptual model and future directions

Schema therapy (ST) is an integrative form of psychotherapy developed for complex, chronic psychological disorders with a characterlogical underpinning. Bipolar disorder is just such a disorder--complex and often comorbid, with demonstrated stable cognitive and personality features that complicate the course of illness. This article presents the reasons justifying the application of ST to bipolar disorder and proposes a treatment rationale and future directions for treatment and research. If well adapted to the characteristics of bipolar disorder, ST might prove to be an effective adjunctive psychotherapy option that attenuates emotional reactivity, reduces symptoms and improves quality of life.

Aggression in bipolar II disorder and its relation to the serotonin transporter

BACKGROUND

Aggression is frequently observed in patients diagnosed with bipolar disorder (BD). Previous studies found a negative association between aggression and serotoninergic function in patients with BD, as well as in healthy subjects. The objective of this study was to determine whether there is an association between aggression and the availability of the serotonin transporter (SERT) in euthymic BD II patients.

METHODS

Thirty-eight age-matched healthy controls (HCs) and 24 BD II patients were recruited. BD II patients were under stable treatment in the euthymic state. The Overt Aggression Scale (OAS) was used for the assessment of aggression. Single photon emission computed tomography with (123)I-ADAM was used for SERT imaging. A specific uptake ratio, which represents availability, was the primary measured outcome.

RESULTS

The total OAS scores, as well as the scores on all of the sub-items, were significantly higher in BD II patients than in the HCs group. There was no significant difference in SERT availability between BD II and HCs subjects in different brain regions. The Pearson's correlation between the total OAS scores and the sub-item aggression and SERT availability was significant.

LIMITATION

The OAS was used for the assessment of the past week of the patients' condition and thus did not reflect their trait status.

CONCLUSIONS

The higher total scores of OAS in euthymic BD II patients than in HCs support the idea that aggression might be a trait marker for BD. Although SERT availability in euthymic BD II patients and in HCs did not differ significantly, the correlation of SERT availability and total OAS provides the possible explanation of aggression in BD II.