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Suicide and Bipolar Disorder Suicide and Bipolar Disorder Suicide and Bipolar Disorder Kay Redfield Jamison, Ph.D. Suicide, which is both a stereotypic yet highly individualized act, is a common endpoint for many patients with severe psychiatric illness. The mood disorders (depression and bipolar manic- © Copyrightdepression) are by far 2000the most common Physicians psychiatric conditions Postgraduate associated with suicide. Press, At least 25% Inc. to 50% of patients with bipolar disorder also attempt suicide at least once. With the exception of lith- ium—which is the most demonstrably effective treatment against suicide—remarkably little is known about specific contributions of mood-altering treatments to minimizing mortality rates in persons with major mood disorders in general and bipolar depression in particular. Suicide is usually a manifesta- tion of severe psychiatric distress that is often associated with a diagnosable and treatable form of de- pression or other mental illness. In a clinical setting, an assessment of suicidal risk must precede any attempt to treat psychiatric illness. (J Clin Psychiatry 2000;61[suppl 9]:47–51) Unless someone lives an unthinkably boring life, has no hopes For many, it is both—a brash moment of action taken dur- that can be shattered, no love that can be lost, or transits from ing a span of settled and suicidal hopelessness. The suffer- birth to death in a bubble above the Onefrays ofpersonal earth, he or copy she maying beof printedthe suicidal person is private and inexpressible, experiences the same griefs or strains that, for a few, become which leaves family members, friends, and colleagues to the ‘cause’ of death.1 deal with an almost unfathomable kind of loss as well as guilt. The aftermath of a suicidal act is at a level of confu- he relationship between the events of life, stress, and sion and devastation that is, for the most part, beyond de- T psychiatric illness is not always straightforward. scription. Psychological pain or stress alone—however profound the Suicide, which is both a stereotypic yet highly indi- loss, disappointment, shame, or rejection—is rarely suffi- vidualized act, is a common endpoint for many patients cient cause for suicide. Much of the decision to die lies in with severe psychiatric illness. While no single illness or the construing of events, and most people, when healthy, set of circumstances can predict suicide, certain vulner- do not construe any event as devastating enough to war- abilities, illnesses, and events make some individuals far rant killing themselves. Nonetheless, more than 30,000 more likely than others to kill themselves. The most com- Americans commit suicide every year and nearly half a mon element in suicide and serious suicide attempts is million others make a suicide attempt that is serious psychopathology. Of the numerous mental illnesses, a enough to warrant medical treatment in a hospital emer- relative few are particularly and powerfully bound to self- gency room.1 inflicted death: these are the mood disorders (depression Suicide is the anchor point on a continuum of suicidal and bipolar manic-depression), schizophrenia, borderline thoughts and behaviors. This continuum is one that ranges and antisocial personality disorders, alcoholism, and drug from risk-taking behaviors at one end, extends through abuse. Mood disorders, especially when comorbid with al- different degrees and types of suicidal thinking, and ends cohol and drug abuse, are by far the most common psychi- with suicide attempts and suicide. For some people, sui- atric conditions associated with suicide. cide is a sudden act; for others, it is a long-considered de- cision based on cumulative despair or dire circumstances. SUICIDE AND MOOD DISORDERS Understanding the origins of suicide is the first step in preventing it. Mann and colleagues2 at the New York State From the Department of Psychiatry and Behavioral Psychiatric Institute have proposed a stress-diathesis Sciences, Johns Hopkins University School of Medicine, Baltimore, Md. model to explain the relationship between the underlying Excerpted in part from Night Falls Fast: Understanding biological predisposition to suicide and the precipitants Suicide. Jamison KR. New York, NY: Knopf; 1999. that trigger it. Several factors influence the predisposition Supported by an unrestricted educational grant from Solvay Pharmaceuticals, Inc. to commit suicide, and together they act to establish a Reprint requests to: Kay Redfield Jamison, Ph.D., threshold for suicidal behavior. These factors include ge- Department of Psychiatry, The Johns Hopkins School of Medicine. Meyer 3–181, 600 North Wolfe St., Baltimore, MD netic vulnerabilities such as family history and compro- 21287. mised serotonergic functioning in the brain; temperamen- J Clin Psychiatry 2000;61 (suppl 9) 47 Kay Redfield Jamison tal variables such as aggressiveness and impulsivity; pleted suicide has not been well documented in patients chronic alcohol and drug abuse; chronic medical condi- with bipolar disorder. Second, interpreting suicide rates is tions; and certain social factors such as the early death of a complicated. Most cohort studies are of an untreated or parent, social isolation, or a childhood history of physical partially compliant population, and ethical considerations or sexual abuse. One factor, brain serotonergic function- preclude a clinical study of suicidality in medicated versus ing, is particularly important in setting an individual’s nonmedicated patients. Third, few, if any, studies of sui- threshold for acting on suicidal impulses.3 Researchers cide separate patients by severity of illness. Most studies have shown that serotonin function is lower in suicide are done with hospitalized patients, which slants the data attempters than in controls by measuring serotonin me- toward severely ill patients. Fourth, changes in suicide tabolites in cerebrospinal fluid and prolactin response to rates are difficult to decipher since diagnostic criteria vary fenfluramine.© 4 CopyrightPostmortem studies 2000of suicide Physiciansvictims also across Postgraduate time and treatments change. Press, Finally, Inc. methodologi- reveal decreased serotonin activity in the ventrolateral cal problems confound interpretation; for example, the prefrontal cortex.5 distinctions between bipolar and unipolar disorder became Alcohol and drugs can precipitate acute episodes of standard in the literature in the past decade only. There- psychosis, worsen the overall course of the underlying ill- fore, the enormous variability across follow-up studies has ness, and undermine the individual’s willingness to seek resulted in uncertainty concerning suicide risk. clinical treatment. In a review of 504 patients with mood For many years, the lifetime suicide risk in bipolar dis- disorders who were hospitalized in 4 psychiatric units in order was accepted as 15%. However, because of sam- Sardinia, there was a significant association of substance pling bias (e.g., severely depressed inpatients), the actual use disorders with suicide attempts.6 Substance use disor- lifetime suicide risk may be somewhat lower. Inskip et ders were diagnosed in 28% of the subjects: substance al.10 used mathematical modeling techniques to reassess abuse was found in 26% and dependenceOne inpersonal 2%. The mostcopy maythe belifetime printed risk of suicide in individuals with mood disor- frequent substance abused was alcohol (15%) followed by ders and concluded that the overall suicide risk in mood cannabis (4%) and heroin (3%). Substance abuse was most disorders is lower (6%) than generally accepted but is par- commonly found in patients with bipolar I disorder, ticularly high around the time of diagnosis. A meta- whereas the presence and annual rate of suicide attempts analysis of the suicide risk among patients with bipolar were much higher in patients with bipolar II and major de- disorder was performed by Harris and Barraclough11 and pressive disorders. The mood state associated with suicide was based on a combined population of 3700 bipolar pa- attempts was more commonly dysphoric-mixed or depres- tients from 14 studies in 7 countries. The population was sive than manic. treated between 1900 and 1985, and some patients had Substance use disorders typically start in adolescence been followed for 60 to 70 years. Expected values were and thus may play a particularly ominous role in the 3-fold either given in the articles studied or were estimated using increase in adolescent suicides in the last 30 years. In this World Health Organization statistical reports. Combining age group, substance abuse may be associated with high the studies gave a total suicide risk 15 times the expected rates of depression and bipolar disorder as well as the value; the wide range (0–133 times) indicated the variabil- common tendency toward youthful risk-taking. A study of ity across studies. The meta-analysis also showed that in- suicides in adolescents under the age of 20 years revealed creased suicide risks were associated with past suicide at- that 90% of the suicide victims had a diagnosable psychi- tempts, alcohol abuse, and the amount of time elapsed atric disorder at the time of their death, and more than half after discharge from hospital—from recent discharge to 5 of these individuals had experienced significant symptoms years prior to suicide. for longer than 2 years.7 In a Swedish retrospective inves- The Epidemiologic Catchment Area study12 revealed a tigation of 58 consecutive suicides by adolescents and much higher
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