This material was presented in the 25th European Congress of Psychiatry which was organised by the European Psychiatry Association in Florence, Italy from 1-4th April 2017. I had access to the material as I attended the full Congress. Please note that this material remains the intellectual property of the European Psychiatry Association and its authors and any citation should include a full reference to it. For more information on the EPA and how to become a member, please visit: http://www.europsy.net/

1. Risk Factors for Suicide Behaviors in Bipolar Disorder
A Closer Look
D. Durães1
, J. Gomes1
, R. Borralho2
Psychiatry Department – Centro Hospitalar Barreiro-Montijo E.P.E., Barreiro, Portugal
1—Psychiatry Resident; 2—Attending Psychiatrist
INTRODUCTION
Suicide behaviors (suicide acts and suicide attempts) are a major
concern for clinicians treating patients with psychiatric disorders, since
more than 90% of suicides are committed by psychiatric patients.
Among them, patients with bipolar disorder have the highest preva-
lence of suicide behaviors, accounting for up to one-quarter of all com-
pleted suicides. Additionally, suicide remains the leading cause of avoid-
able death in patients with bipolar disorder.
AIMS & METHODS
This work aims to review the main risk factors for suicide behaviors
in patients with bipolar disorder.
The MEDLINE/Pubmed database was searched using the keywords
“bipolar disorder” with: “suicide”; “suicide attempt”; and “suicide risk
factors”. Articles published in the last 10 years were considered.
RESULTS
It is estimated that 25-50% of patients with bipolar disorder will
attempt suicide at least once in their lifetime and, that 10-15% will die.
The risk factors for suicide behaviors in patients with bipolar disorder
have been widely studied and their knowledge is crucial for identifying
patients at risk.
Sociodemographic factors have been identified and include: first-
degree family history of suicide and male gender. Some bipolar-specific
risk factors have also been acknowledged. It has been shown that early
age of onset is associated with a more severe course of illness and also
with higher risks of suicide attempts. Depressive polarity of the first
mood episode and depressive polarity of the latest mood episode
seems to have the strongest association with suicide attempts. Inter-
estingly, suicides during mania seem to be relatively rare. Additionally,
rapid cycling, increasing severity of affective episodes and mixed affec-
tive states represent risk factors for suicide behaviors.
There are co-morbid conditions that also increase the risk for sui-
cide behaviors, namely: comorbid anxiety disorders, substance use dis-
orders and cluster B personality disorders. Furthermore, previous sui-
cide attempts, and hopelessness have also been identified as main risk
factors (Table 1).
Research data suggests that antidepressant use in bipolar disorder
may contribute to suicide attempts, but additional research is needed to
confirm these data.
RESULTS (CONT.)
On the other hand, lithium seems to have suicide-preventing
effects in long term use, decreasing suicide rates significantly even in
cases of high genetic risk for suicidal behavior. The evidence for anti sui-
cidal effects of anticonvulsants in bipolar patients is weaker.
To understand if a delay on the beginning of treatment had an im-
pact on suicide behavior, Nery-Fernands et al. investigated the associa-
tion between delay of mood stabilizer treatment and lifetime history of
suicide attempts and found that the patients who received their first
mood stabilizer later than 5 years after the first episode showed a sig-
nificantly higher lifetime prevalence of suicide attempts than the ones
who initiated treatment earlier, highlighting the importance of early di-
agnosis and treatment in suicide prevention.
CONCLUSIONS
Suicide remains a leading cause of death in patients with bipolar
disorder, which makes the prevention of suicide behaviors crucial when
treating these patients. Therefore, the knowledge of these risk factors is
of extreme importance in order to promptly identify patients at risk and
adopt the proper preventive therapeutic interventions.
Additionally, one important factor in the prevention of suicide is de-
creasing the time patients may spend in high-risk, suicide vulnerable ep-
isodes, which we know is a difficult task. However, certain drugs, like
lithium seems to have an effect on suicide prevention, when used long-
term.
Main Risk Factors
Previous suicide attempts; Hopelessness
Sociodemographic
First-degree family history of suicide; Male gender
Bipolar Disorder Specific
Early age of onset; Depressive polarity of the first mood episode;
Depressive polarity of the latest mood episode; Rapid cycling;
Increasing severity of affective episodes; Mixed affective states
Comorbidities
Anxiety disorders; Substance use disorders; Cluster B personality
disorders
Table 1— Risk factors for suicide behaviors in patients with bipolar disorder.
References
[1] Beyer J. L., Weisler R. H.: Suicide Behaviors in Bipolar Disorder: A Review and Update for the Clinician. Psychiatr Clin North Am. 2016 Mar;39(1):111-23.
[2] Latalova K., Kamaradova D., Prasko J.: Suicide in Bipolar Disorder: a Review. Psychiatria Danubina. 2014; Vol 26, Nº 2, 108-114.
[3]Hawton K., Sutton L., Haw C., Sinclair J., Harriss L.: Suicide and Attempted Suicide in Bipolar Disorder: a Systematic Review of Risk Factors. J Clin Psychiatry. 2005 Jun;66(6):693-704.
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