Suicide Assessment and Prevention in Bipolar Disorder: How Current Evidence Can Inform Clinical Practice
Abstract
Bipolar disorder is associated with a considerable risk of suicide, and this fact must be incorporated into management of all patients with the condition. This article highlights the importance of a more nuanced understanding of the factors associated with the increased risk of suicidal behavior in people diagnosed as having bipolar disorder and interventions that could mitigate it. Several sociodemographic, clinical, environmental, and other variables have been associated with suicide attempts or deaths in bipolar disorder. Youths with bipolar disorder are a particularly vulnerable group, and their trajectory of illness could be modified by early interventions. Several medications have been studied regarding their relationship to suicide risk in bipolar disorder, and interventional psychiatry is a newer area of research focus. Finally, community-based approaches can be incorporated into a comprehensive approach to suicide prevention. This article summarizes the current understanding of key variables that can help inform a clinical risk assessment of individuals and interventions that can be employed in suicide prevention in bipolar disorder.
People diagnosed as having bipolar disorder are at a substantially elevated risk of suicide death, estimated at 164 deaths per 100,000 per year, or 10 to 20 times above the general population risk (1). Among those with bipolar disorder who enter into the mental health care system, 5%–8% will ultimately die by suicide (2). With such increased risk, suicide risk assessment and intervention are invariably at the core of the assessment and management of patients with bipolar disorder. This article summarizes the available literature on correlates of suicide-related behavior among those with bipolar disorder and provides clinicians with an understanding of which specific elements of the clinical history may be most impactful when developing a person-specific risk evaluation. A special focus on youths is included to assist in the assessment process for this distinctive patient group.
This article takes a broad approach at suicide prevention strategies and summarizes not only what is known about diagnosis-specific interventions, but also the broader clinical and community-based literature. Particular emphasis is given to the emerging area of interventional psychiatry and to population-based strategies. As the evidence has become clearer that risk assessments are ultimately limited in their predictive value, the management for all patients with bipolar disorder should incorporate suicide prevention strategies irrespective of perceived risk or treatment setting. It should be noted that the information presented in this article does not establish a clear hierarchy or ranking of risk factors, nor is a patient-specific risk calculator for suicide available for general clinical use. The extant data should rather be used to inform a general understanding of correlates of suicide-related behaviors in patients diagnosed as having bipolar disorder.
Factors Correlated With Suicide Risk in Bipolar Disorder
Despite the absence of a consensus set of predictors or risk models of suicide in the general bipolar disorder population, the extant literature provides key information on specific variables of importance (Figure 1). Several sociodemographic factors have been linked to suicide attempt and/or death risk in bipolar disorder. Females with bipolar disorder have higher rates of suicide attempts (odds ratio [OR]=1.54) (1), whereas males with bipolar disorder are twice as likely to die by suicide. However, the sex ratio is smaller than general population samples, which suggests that the impact of the illness on population-level risk is uneven, so that women with bipolar disorder are at higher relative risk. Some studies have shown a higher risk for suicide in patients with bipolar disorder who are younger (under age 35) or older (over age 75), single, separated or divorced, unemployed, or without children (3–5). There have been mixed results on the role of religion; some studies have shown that a religious affiliation is protective, whereas other studies have suggested that increased religious preoccupation in a subset of patients with bipolar disorder could lead to higher levels of distress and suicide-related behavior (3).
FIGURE 1. Factors correlated with risk of suicide attempt and death in bipolar disorder
aFactors associated with suicide death.
Among course of illness and clinical variables, the strongest association has been found with depressive polarity of the most recent episode (OR=5.99). Furthermore, those with depressive polarity of the first episode are twice as likely to attempt suicide (1). The time in which a person emerges from a hypomanic episode and experiences depression is often characterized by a highly contrasted shift from positive to negative cognitive appraisals and can be a specific moment of increased risk (6). Overall, the stratification of absolute risk from highest to lowest between the episode types appears to be depressive, mixed, and manic/hypomanic (7). Despite a higher relative risk of suicide attempts during mixed states compared with depressive episodes, the absolute risk of suicide attempt during depressive episodes remains higher due to patients spending substantially more time in depressive than mixed episodes. Additionally, some studies suggest that increased risk of suicide in mixed states is related to the overall increased length of depressive symptoms in this subgroup and can be statistically explained by the presence of depressive symptoms alone (8). Longer duration of illness and untreated episodes, rapid cycling, and symptoms such as agitation, insomnia, and anxiety are correlated with elevated suicide risk (9). There are inconsistent results regarding the association between psychotic symptoms and suicide-related behavior, with some studies identifying reduced organization and planning capacity in patients with bipolar disorder with psychotic symptoms being associated with lower rates of suicide attempts (10). Patients with early maladaptive schemas and developmental trauma appear to be at higher risk for suicide attempts and lifetime suicide risk (11). Earlier age at onset is a strong correlate of suicide attempt risk, and the average age at onset is 3 years younger in patients with bipolar disorder with a history of suicide attempts (1). It is unclear if this is related to a more severe illness associated with earlier onset, or because of more years spent with the illness resulting in a higher cumulative probability of suicide (12).
In terms of subtypes of bipolar disorder, earlier studies suggested that bipolar II disorder had a higher risk for suicide attempt, owing to predominantly depressed and mixed states (3); however, recent studies have shown mixed results. Some studies show a higher rate of suicide attempts in bipolar II disorder (13), whereas recent meta-analyses suggest there is no difference in suicide attempts between bipolar I and II disorder (1). Prior history of suicide attempts, recent admission, and upcoming discharge have additionally been associated with heightened suicide risk (14). Finally, first-degree family history of death by suicide is strongly associated with suicide attempts and deaths and may predict earlier attempts (1, 3).
In terms of comorbid conditions, the presence of a lifetime anxiety disorder is strongly associated with risk of suicide attempts in bipolar disorder. Although this has been observed as a lifetime association, it remains unclear if the onset of the anxiety disorder precedes the occurrence of the suicide attempt (1). Alcohol and substance use disorders, with the exception of cannabis use disorder, have been shown to be significantly associated with risk of suicide attempt in bipolar disorder, with the highest risk shown for alcohol (1, 4). Impulsivity may be the mediating factor between alcohol use and suicide attempts (1). Cluster B personality disorders, and borderline personality disorder in particular, are strongly associated with risk of suicide attempt. There is currently insufficient data on other personality clusters (1).
Most studies have focused on factors correlated with suicide attempts rather than suicide deaths in bipolar disorder. Overall, a prior suicide attempt increases risk of death by suicide 37-fold in bipolar disorder (7). Suicide-related behavior in individuals diagnosed as having bipolar disorder tends to be more lethal than that observed in the general population, particularly among women (12). There is seasonal variability in bipolar disorder suicide deaths, with more deaths occurring in spring and summer compared with fall and winter (4). There is an absence of data linking lifetime substance use with increased risk of suicide deaths in bipolar disorder, but this should be interpreted with caution as data are limited and contrast with findings in depression and schizophrenia (1). Additionally, psychosis has not been shown to have any significant association with suicide deaths (1).
There are several other environmental and individual factors that remain under study for associations with suicide risk in bipolar disorder. Studies have reviewed higher altitude, genetic components, biological factors such as cortisol level, and other factors such as criminal conviction and public holidays as possible risk factors (3, 4), but the results remain preliminary.
Suicide Risk in Youths With Bipolar Disorder
Youths with bipolar disorder are an important subgroup in which to understand suicide risk. The risk of death by suicide among youths with bipolar disorder is higher than any other psychiatric disorder in adolescence (15, 16), including major depressive disorder (17). Although the relative rarity of suicide in this age group makes it challenging to establish an accurate rate of suicide deaths, the available evidence suggests that the suicide rate among youths with bipolar disorder is in line with the well-established 10 to 30 times increased risk of suicide in adults with bipolar disorder (18). A meta-analysis including data from 15 countries reported a pooled annual rate of suicide attempts of ∼7.5% among youths with bipolar disorder (17). Similarly, the estimated prevalence of lifetime suicidal ideation and suicide attempts in youths with bipolar disorder range as high as 35%–46% (16, 19–21) and 14%–21% (16, 19, 21), respectively.
Among the numerous demographic, clinical, and psychosocial risk factors associated with suicide-related behavior among youths with bipolar disorder, one of the most robust is female sex (22). Similar to the adult population, the female-to-male suicide mortality ratio is narrower than for other psychiatric conditions or the general population (23). Data from coroner cases of suicide show that individuals with bipolar disorder are more likely to be female and younger than those without bipolar disorder (24). Given that the prevalence of bipolar disorder is higher among females compared with males in adolescence (15, 25) but not at any other point in the lifespan, the elevated risk of suicide among adolescent females with bipolar disorder may necessitate targeted and sex-specific intervention.
Younger age at bipolar disorder illness onset is also a clinical risk factor for suicide, with several studies noting an association between earlier age at illness onset and increased suicide attempts (16, 26). In terms of illness course among youths with bipolar disorder, mixed episodes (16, 21), increased number of mood episodes (27), and presence of depressive symptoms (16, 21) are correlated with increased risk of a suicide attempt. Comorbid psychiatric conditions, specifically anxiety disorders (19), posttraumatic stress disorder (19), substance use disorders (16, 19), and eating disorders (19) further contribute to risk of suicide attempts in youths with bipolar disorder. Familial risk factors such as history of depression (16, 19), suicide and/or suicide-related behavior (16, 19), as well as poor family functioning (21) are also linked to suicidal ideation (20) and suicide attempts (21) among youths with bipolar disorder. Other psychosocial risk factors include a history of sexual and/or physical abuse (19). Data on correlates of suicide-related behaviors in youths with bipolar disorder have informed the creation of a risk calculator to more efficiently assess suicide attempt risk in this vulnerable population (28). Although work in this area is preliminary, risk calculators may effectively complement traditional risk assessment measures and clinical judgment to identify youths with bipolar disorder who are at an elevated risk for suicide-related behavior.
Interventions for Suicide Prevention in Bipolar Disorder
There are several factors that can help inform an approach to risk assessment for people with bipolar disorder and contribute to the optimization of intervention strategies at the individual and group levels. Approximately 50% of patients with bipolar disorder who die by suicide are not receiving treatment at the time of death, which highlights the importance of interventions for all people with bipolar disorder (7).
Although this article explores many aspects of treatment that are focused on bipolar disorder, there are general elements of care that should also be considered as foundational for suicide prevention. At an individual level, a key foundational element is authentic and nonformulaic questioning about suicide-related thoughts and behaviors that conveys genuine curiosity and warmth (29). Evidence-based aspects of suicide prevention for all mental health patients include the creation of an ongoing and dynamic safety plan, means restriction strategies when applicable, ensuring timely access to ambulatory and inpatient services during high-risk periods, and paying special clinical attention to readily reversible acute warning signs, such as insomnia and acute pain (29). Psychotherapeutic and psychosocial measures can be used as long-term interventions, but they have not been sufficiently studied for antisuicidal effects in bipolar disorder (5, 30).
Pharmacotherapeutic and Other Biological Approaches
Multiple meta-analyses have shown that long-term treatment with lithium is strongly associated with a reduced risk of suicide in unipolar and bipolar depression, an effect that can be present even without achieving mood stabilization (9, 30, 31). Furthermore, abrupt lithium discontinuation can increase suicide risk, which can be partially mitigated by a slow taper (5). However, prospective randomized controlled trials (RCTs) of lithium’s putative antisuicide effect in bipolar disorder have been underpowered, and thus top-level evidence on the question of a specific and unique antisuicide effect remains elusive. Treatment with anticonvulsants such as valproic acid, lamotrigine, and carbamazepine has also been associated with reduced suicide risk in some studies, albeit to a lesser degree, and this is not universally observed (9, 31). A 2018 meta-analysis found no protective effect from valproic acid against suicide attempts and deaths in bipolar disorder. This could be attributed to less effective antidepressant effects from this agent in bipolar disorder (32). Further studies are needed to clarify how the anticonvulsants compare with each other and if their effects are independent of mood stabilization (9, 31). There has been no clear evidence for antisuicide effects with antipsychotics, and the effects shown for clozapine appear to be specific to schizophrenia (9). There is mixed evidence for antidepressants, and they may increase risk in case of emergence of insomnia and agitation (except for the combination of olanzapine and fluoxetine) (5). There is preliminary evidence suggesting that combination of chronotherapies (light therapy and sleep deprivation) with lithium can provide rapid reduction in suicidality in patients with bipolar depression; however, there is need for further studies and randomized trials to confirm this potential effect. Furthermore, there is no evidence identified with regard to the effect of other strategies such as use of melatonin or blue-blocking glasses on suicide-related outcomes in bipolar disorder (33).
Role of Interventional Psychiatry
The proposed subspecialty of interventional psychiatry (34) describes treatments that are more procedural and invasive than general medical care within psychiatry. Extending beyond treatments that deliver energy directly to the brain, such as repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT), these interventions now include certain novel pharmacological treatments such as ketamine, which have similar peri- and postprocedural monitoring requirements as ECT (35). Although there is burgeoning interest in exploring the therapeutic potential of interventional approaches in treating patients with bipolar disorder, the published data for these treatments in this population are relatively limited in comparison with major depressive disorder (36).
Ketamine
Intravenous ketamine and intranasal esketamine are promising treatment strategies that have the potential for rapid onset of therapeutic effects for individuals with refractory psychiatric conditions (37). Recently, the antisuicide ideation effect of ketamine has been reported in bipolar disorder. In an RCT of 156 participants with active suicidal ideation, including 52 with bipolar disorder, there was remission of suicidal ideation by day 3 in 63.0% of participants who received a single 40-minute intravenous infusion of ketamine (0.5 mg/kg) versus 31.6% in the saline sham group (38). Patients with bipolar disorder had a greater likelihood of achieving this outcome than those with major depressive disorder (OR=14.1 vs. OR=1.3). An open-label study of 66 patients with bipolar I or II disorder who received 4 doses of IV ketamine (0.5–0.75 mg/kg) delivered over 2 weeks found a sustained reduction in the mean score of the Quick Inventory of Depression Symptomatology (QIDS-SR16) suicide item at 1 week (39).
ECT
The effectiveness of ECT in reducing suicide risk in bipolar disorder has been examined through meta-analyses; the majority of studies reported effects in small and mixed diagnostic samples. A recent meta-analysis of 11 studies comprising 1,100 subjects with a mood disorder (bipolar disorder or major depressive disorder) treated with ECT and 6,077 controls showed a 23% reduction in suicide deaths at a trend level of statistical significance (OR=0.77, p=0.053) (40); however, there were no significant associations between suicide death and ECT in the four studies that included patients with bipolar disorder. Another study found a protective effect for suicide in bipolar depression (OR=0.81), but not for manic and mixed states (41). A more recent retrospective cohort study that examined patients with mood disorders, including bipolar disorder, found that ECT significantly reduced suicide risk in depression (OR=0.53), but when stratified by diagnosis, the effects were only significant for unipolar (N=4,236) but not bipolar depression (N=746) (42).
rTMS and Magnetic Seizure Therapy
A meta-analysis of 10 RCTs that investigated the efficacy of rTMS in reducing suicidal ideation during a major depressive episode found that rTMS significantly reduced ideation in open-label but not sham-controlled studies across patients (43). The interpretation of these findings is limited principally to unipolar depression, as only two of the rTMS trials included individuals with bipolar disorder. In a secondary analysis of an open-label clinical trial of magnetic seizure therapy (MST)—a form of convulsive therapy that uses high-frequency repetitive magnetic stimulation to induce a therapeutic seizure—patients with bipolar disorder (N=19) experienced a significant reduction in suicidal ideation, with a complete resolution in 47.4% of the sample after 19.5 (SD=5.0) treatments on average (44).
In summary, although the application of interventional psychiatry treatments to patients with bipolar disorder is in a nascent stage (36), the current literature provides some preliminary support for these treatments as promising approaches to address suicide outcomes in bipolar disorder. Further trials in bipolar disorder are needed to determine the effects of other forms of noninvasive neuromodulation such as rTMS and MST on suicidal ideation and their impact on reducing suicide mortality in this population in the longer-term.
Interventions for Suicide Prevention in Youths
Early intervention for youths with bipolar disorder has the potential to dramatically affect the life trajectory of these patients. The literature on suicide prevention among youths with bipolar disorder is limited, when compared with adults with bipolar disorder and to youths with other psychiatric conditions; however, there are promising findings that warrant discussion and future investigation. The prevention of suicide among youths with bipolar disorder begins with the clinical interview of youths who present with major depression. “Red flags” such as early age and/or rapid symptom onset, psychomotor retardation, psychotic features, family history of bipolar disorder, and severe and/or refractory depressive symptoms have high specificity for predicting bipolar disorder (45). Accurate and timely detection of subthreshold or threshold hypomanic or manic symptoms is another opportunity for early intervention and, hence, suicide prevention (46).
Pharmacotherapy is the mainstay of treatment among youths with bipolar disorder. There is some preliminary evidence for suicide risk reduction in adolescents with bipolar disorder who receive lithium (47), and that lithium can also improve the overall long-term outcomes of bipolar disorder. Therefore, just as for adults, the relationship between suicide risk reduction and lithium among youths with bipolar disorder merits a more refined exploration. Psychotherapy, another principal component of treatment for bipolar disorder in youths, is also an intervention that has the potential for direct suicide prevention. Evidence-based treatments for bipolar disorder in youths, such as family-focused therapy, reduce depressive symptoms (48), whereas interpersonal and social rhythm therapy (49) helps lower depressive and manic symptoms, and improves overall functioning, thereby likely indirectly reducing the risk of suicide. Importantly, there is recent early evidence that dialectical behavior therapy tailored toward adolescents and families reduces suicidal ideation and suicide attempts among adolescents with bipolar disorder (50). In conclusion, future research that replicates and builds upon the promising findings to date, as well as resources targeted toward efficient and widespread implementation of these strategies, must be a priority in this field.
Community- and Population-Based Interventions
Broad-based suicide prevention interventions can be effective in reducing suicide risk in general, while improving mental health and well-being, and should be considered as part of a comprehensive approach for suicide prevention for individuals with bipolar disorder. The World Health Organization’s guide to suicide prevention emphasizes an array of interventions, including means restriction, responsible media reporting, developing socio-emotional skills in adolescents, and early identification and treatment of those experiencing suicidality (51). Building on this framework, we summarize several community-based suicide prevention interventions along a continuum, consistent with a disease prevention approach (52).
Public Education and Awareness Campaigns
Education and awareness campaigns include public service announcements, social media outreach, and community events. Awareness campaigns have been shown to help reduce stigma surrounding mental illness and suicide, promote early identification and treatment, enhance help-seeking behavior, and prevent suicide-related behavior and attempts (53). Critical to successful awareness campaigns are the use of narratives that emphasize survival and pathways to survival (54) that simultaneously deter suicide-related behaviors and promote help-seeking behaviors—something that is especially relevant for bipolar disorder. There are a number of community organizations focused on bipolar disorder that have taken the lead in these types of campaigns, and they represent a crucial resource within a broad approach to suicide prevention. Special note is made of organizations such as the Depression and Bipolar Support Alliance, the International Bipolar Foundation, the Ryan Licht Sang Bipolar Foundation, and the American Foundation for Suicide Prevention, among others.
Media Reporting Guidelines
There is evidence that media reporting about suicide, particularly if it involves the death of a celebrity, can trigger suicide-related behavior through social contagion (55, 56). In the context of bipolar disorder, a notable example is the more than 1,800 suicide deaths above expected in the U.S. during the period after the widely publicized suicide death of Robin Williams. Conversely, media reports about people who overcome suicidal crises may be followed by lower suicide rates (54). Media guidelines that support responsible reporting of suicide, such as reducing graphic or sensational depictions, while challenging stigma and providing information about crisis resources, can reduce suicide rates and improve awareness and help-seeking (57). There is also emerging evidence that the overarching narrative of suicide-related media exposures is a crucial factor that affects suicide rates (58).
Means Restriction
Means restriction is one of the mainly empirically supported population-based suicide prevention interventions (59). As a broad-based public health strategy, it involves modification of the environment whereby lethal means are removed or restricted for an entire population rather than only for high-risk individuals. Means restriction has been shown to reduce suicide rates in some countries (59), for example by restricting access to firearms, reducing easy access to large quantities of prescription and over-the-counter medication (60), or by erecting physical barriers to points commonly used in suicide by jumping (61). Means restriction that specifically targets methods that are commonly associated with bipolar disorder, such as self-poisoning, can be an especially effective suicide prevention strategy for this high-risk population (5). Although clearly effective, there is an ongoing need for multisectoral collaboration to continue to implement effective means-restriction policies (59).
Community Gatekeeper Training
Gatekeeper training is a capacity-building suicide prevention strategy that provides guidance for laypersons and other noncontent experts on how to identify individuals who display warning signs of suicide, encourage their help-seeking, and facilitate timely referral to mental health treatment. This is especially relevant for a condition such as bipolar disorder, which tends to onset in youth, when there are many potential community-based gatekeepers involved. Although controlled trials of gatekeeper training are few and results are mixed (62), gateway training increases trainee knowledge of suicide risk factors and warning signs. Evidence suggests that enhanced gatekeeper knowledge, skills, and attitudes can translate into behavioral interventions that prevent suicidal crises and ultimately lower rates of suicide (63).
Peer Support
Community-based peer-led support programs (e.g., Wellness Recovery Action Plan) have been shown to reduce psychiatric symptoms, decrease use of maladaptive coping behaviors, and increase hopefulness, self-advocacy, empowerment, and recovery for people with severe mental health conditions, including bipolar disorder (64). Although there is relatively limited evidence compared with other suicide prevention interventions (65), some peer-led programs, particularly those supported by peer specialists with lived experience of suicidal thoughts, can help these individuals identify and manage triggers that lead to suicidal ideation, and reduce suicide risk (64).
Collaborative Care
Collaborative care involves embedding psychiatric expertise within a primary care setting to provide timely, appropriate, and comprehensive care for individuals with mental illness, including bipolar disorder (66). This model facilitates coordination of care between primary care providers, mental health specialists, and community-based services. Prior studies have shown that 92% of individuals with bipolar disorder who died by suicide had some form of health care contact in the preceding year (67), and that primary care practitioners see close to 45% of future suicide decedents in the 30 days prior to suicide (62). Therefore, training of primary care doctors and nurses in both the screening and treatment of mental illness can lead to lower suicidal ideation, nonfatal suicide attempts, and suicide rates (62).
Crisis Services
Crisis services provide immediate access to care for individuals in suicidal crisis, including many who may face barriers to accessing traditional mental health care. Local and national suicide prevention hotlines have been shown to reduce suicide risk and enhance continuity of care for individuals at elevated risk (68). Mobile crisis outreach services assertively respond to those who are in distress, suicidal, or at risk of self-harm (69). Evidence supporting the positive impact of crisis services includes significant decreases in suicidality and self-harm ideation, as well as decreased hopelessness and psychological pain in both adult and youth populations (68, 70).
In summary, an important signal from the recent literature is that suicide can be prevented by strengthening universal strategies that are directed to an entire population, yet can be tailored to address means, methods, and risk profiles associated with the bipolar disorder population. Multifaceted approaches are likely more effective than single-intervention approaches alone (71). Of the community-based interventions described above, collaborative care, gatekeeper training, and reducing access to means have shown the greatest impact on reducing suicide deaths (72). If all evidence-based suicide prevention strategies were synergistically integrated into a single, comprehensive suicide prevention strategy, modeling studies suggest that close to one-quarter of all suicides could be prevented (Figure 2) (71, 72).
FIGURE 2. Multidimensional approach to suicide prevention in bipolar disordera
aECT=electroconvulsive therapy; MST=magnetic seizure therapy; rTMS=repetitive transcranial magnetic stimulation.
One of the biggest challenges in suicide prevention remains the continued focus on risk-prediction rather than on broad-based risk prevention. A multidimensional, systems-based approach should integrate all elements of suicide prevention, ranging from targeted individual treatments to community-based interventions, supported by evidence-based public health policy (52).
Conclusions
This article summarizes the available literature and key aspects of our understanding of suicide risk and prevention for people diagnosed as having bipolar disorder. Growing interest in key target groups such as youths with bipolar disorder and emerging areas of research such as interventional psychiatry highlights the dynamic nature of knowledge in this area. Embedding diagnosis-specific approaches into broader strategies for suicide prevention facilitates a real-world integration of methodologies that can be the source of hope for reducing the terrible burden of suicide for our patients and all those with bipolar disorder.
References
1.
Schaffer A, Isometsä ET, Tondo L, et al: 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. Bipolar Disord 2015; 17:1–16
2.
Nordentoft M, Mortensen PB, Pedersen CB: Absolute risk of suicide after first hospital contact in mental disorder. Arch Gen Psychiatry 2011; 68:1058–1064
3.
da Silva Costa L, Alencar ÁP, Nascimento Neto PJ, et al: Risk factors for suicide in bipolar disorder: a systematic review. J Affect Disord 2015; 170:237–254
4.
Plans L, Barrot C, Nieto E, et al: Association between completed suicide and bipolar disorder: a systematic review of the literature. J Affect Disord 2019; 242:111–122
5.
Tondo L, Vázquez GH, Baldessarini RJ: Prevention of suicidal behavior in bipolar disorder. Bipolar Disord 2021; 23:14–23
6.
Malhi GS, Outhred T, Das P, et al: Modeling suicide in bipolar disorders. Bipolar Disord 2018; 20:334–348
7.
Miller JN, Black DW: Bipolar disorder and suicide: a review. Curr Psychiatry Rep 2020; 22:6
8.
Fiedorowicz JG, Persons JE, Assari S, et al: Depressive symptoms carry an increased risk for suicidal ideation and behavior in bipolar disorder without any additional contribution of mixed symptoms. J Affect Disord 2019; 246:775–782
9.
Holma KM, Haukka J, Suominen K, et al: Differences in incidence of suicide attempts between bipolar I and II disorders and major depressive disorder. Bipolar Disord 2014; 16:652–661
10.
Seo HJ, Wang HR, Jun TY, et al: Factors related to suicidal behavior in patients with bipolar disorder: the effect of mixed features on suicidality. Gen Hosp Psychiatry 2016; 39:91–96
11.
Khosravani V, Mohammadzadeh A, Sharifi Bastan F, et al: Early maladaptive schemas and suicidal risk in inpatients with bipolar disorder. Psychiatry Res 2019; 271:351–359
12.
Tondo L, Pompili M, Forte A, et al: Suicide attempts in bipolar disorders: comprehensive review of 101 reports. Acta Psychiatr Scand 2016; 133:174–186
13.
Karanti A, Kardell M, Joas E, et al: Characteristics of bipolar I and II disorder: a study of 8766 individuals. Bipolar Disord 2020; 22:392–400
14.
Dome P, Rihmer Z, Gonda X: Suicide risk in bipolar disorder: a brief review. Medicina 2019; 55:403
15.
Lewinsohn PM, Klein DN, Seeley JR: Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course. J Am Acad Child Adolesc Psychiatry 1995; 34:454–463
16.
Goldstein TR, Ha W, Axelson DA, et al: Predictors of prospectively examined suicide attempts among youth with bipolar disorder. Arch Gen Psychiatry 2012; 69:1113–1122
17.
Serra G, De Crescenzo F, Maisto F, et al: Suicidal behavior in juvenile bipolar disorder and major depressive disorder patients: systematic review and meta-analysis. J Affect Disord 2022; 311:572–581
18.
Hawton K, Sutton L, Haw C, et al: Suicide and attempted suicide in bipolar disorder: a systematic review of risk factors. J Clin Psychiatry 2005; 66:693–704
19.
Khoubaeva D, Dimick M, Timmins VH, et al: Clinical correlates of suicidality and self-injurious behaviour among Canadian adolescents with bipolar disorder. Eur Child Adolesc Psychiatry 2023; 32:41–51
20.
Sewall CJR, Goldstein TR, Salk RH, et al: Interpersonal relationships and suicidal ideation in youth with bipolar disorder. Arch Suicide Res 2020; 24:236–250
21.
Algorta GP, Youngstrom EA, Frazier TW, et al: Suicidality in pediatric bipolar disorder: predictor or outcome of family processes and mixed mood presentation? Bipolar Disord 2011; 13:76–86
22.
Parker G, Ricciardi T: The risk of suicide and self-harm in adolescents is influenced by the “type” of mood disorder. J Nerv Ment Dis 2019; 207:1–5
23.
Diflorio A, Jones I: Is sex important? Gender differences in bipolar disorder. Int Rev Psychiatry 2010; 22:437–452
24.
Schaffer A, Sinyor M, Reis C, et al: Suicide in bipolar disorder: characteristics and subgroups. Bipolar Disord 2014; 16:732–740
25.
Merikangas KR, He JP, Burstein M, et al: Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry 2010; 49:980–989
26.
Goldstein TR, Birmaher B, Axelson D, et al: History of suicide attempts in pediatric bipolar disorder: factors associated with increased risk. Bipolar Disord 2005; 7:525–535
27.
Hauser M, Galling B, Correll CU: Suicidal ideation and suicide attempts in children and adolescents with bipolar disorder: a systematic review of prevalence and incidence rates, correlates, and targeted interventions. Bipolar Disord 2013; 15:507–523
28.
Goldstein TR, Merranko J, Hafeman D, et al: A risk calculator to predict suicide attempts among individuals with early-onset bipolar disorder. Bipolar Disord 2022; 24:749–757
29.
Hawton K, Lascelles K, Pitman A, et al: Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management. Lancet Psychiatry 2022; 9:922–928
30.
Baldessarini RJ, Vázquez GH, Tondo L: Bipolar depression: a major unsolved challenge. Int J Bipolar Disord 2020; 8:1
31.
Alda M, Manchia M: Personalized management of bipolar disorder. Neurosci Lett 2018; 669:3–9
32.
Chen TY, Kamali M, Chu CS, et al: Divalproex and its effect on suicide risk in bipolar disorder: a systematic review and meta-analysis of multinational observational studies. J Affect Disord 2019; 245:812–818
33.
Benedetti F, Riccaboni R, Locatelli C, et al: Rapid treatment response of suicidal symptoms to lithium, sleep deprivation, and light therapy (chronotherapeutics) in drug-resistant bipolar depression. J Clin Psychiatry 2014; 75:133–140
34.
Giacobbe P, Ng E, Blumberger DM, et al: Interventional psychiatry: an idea whose time has come? Can J Psychiatry 2021; 66:316–318
35.
Giacobbe P, Burhan AM, Waxman R, et al: Interventional psychiatry and neuro technologies: education and ethics training. Can J Neurol Sci 2023; 50:s10–s16
36.
Mutz J: Brain stimulation treatment for bipolar disorder. Bipolar Disord 2023; 25:9–24
37.
McIntyre RS, Rosenblat JD, Nemeroff CB, et al: Synthesizing the evidence for ketamine and esketamine in treatment-resistant depression: an international expert opinion on the available evidence and implementation. Am J Psychiatry 2021; 178:383–399
38.
Abbar M, Demattei C, El-Hage W, et al: Ketamine for the acute treatment of severe suicidal ideation: double blind, randomised placebo controlled trial. BMJ 2022; 376:e067194
39.
Fancy F, Rodrigues NB, Di Vincenzo JD, et al: Real-world effectiveness of repeated ketamine infusions for treatment-resistant bipolar depression. Bipolar Disord 2023; 25:99–109
40.
Wilkinson ST, Trujillo Diaz D, Rupp ZW, et al: Pharmacological and somatic treatment effects on suicide in adults: a systematic review and meta-analysis. Depress Anxiety 2022; 39:100–112
41.
Liang CS, Chung CH, Ho PS, et al: Superior anti-suicidal effects of electroconvulsive therapy in unipolar disorder and bipolar depression. Bipolar Disord 2018; 20:539–546
42.
Kaster TS, Blumberger DM, Gomes T, et al: Risk of suicide death following electroconvulsive therapy treatment for depression: a propensity score-weighted, retrospective cohort study in Canada. Lancet Psychiatry 2022; 9:435–446
43.
Mehta S, Konstantinou G, Weissman CR, et al: The effect of repetitive transcranial magnetic stimulation on suicidal ideation in treatment-resistant depression: a meta-analysis. J Clin Psychiatry 2022; 83:21r13969
44.
Tang VM, Blumberger DM, Hill AT, et al: Magnetic seizure therapy for the treatment of suicidality in bipolar depression. Biol Psychiatry 2021; 90:e51–e53
45.
Strober M, Carlson G: Bipolar illness in adolescents with major depression: clinical, genetic, and psychopharmacologic predictors in a three- to four-year prospective follow-up investigation. Arch Gen Psychiatry 1982; 39:549–555
46.
Fiedorowicz JG, Endicott J, Leon AC, et al: Subthreshold hypomanic symptoms in progression from unipolar major depression to bipolar disorder. Am J Psychiatry 2011; 168:40–48
47.
Hafeman DM, Rooks B, Merranko J, et al: Lithium versus other mood-stabilizing medications in a longitudinal study of youth diagnosed with bipolar disorder. J Am Acad Child Adolesc Psychiatry 2020; 59:1146–1155
48.
Miklowitz DJ, Axelson DA, Birmaher B, et al: Family-focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. Arch Gen Psychiatry 2008; 65:1053–1061
49.
Inder ML, Crowe MT, Luty SE, et al: Randomized, controlled trial of interpersonal and social rhythm therapy for young people with bipolar disorder. Bipolar Disord 2015; 17:128–138
50.
Goldstein TR, Fersch-Podrat RK, Rivera M, et al: Dialectical behavior therapy for adolescents with bipolar disorder: results from a pilot randomized trial. J Child Adolesc Psychopharmacol 2015; 25:140–149
51.
Live Life: An Implementation Guide for Suicide Prevention in Countries. Geneva, World Health Organization, 2021
52.
Gordon RS, Jr.: An operational classification of disease prevention. Public Health Rep 1983; 98:107–109
53.
Pirkis J, Rossetto A, Nicholas A, et al: Suicide prevention media campaigns: a systematic literature review. Health Commun 2019; 34:402–414
54.
Niederkrotenthaler T, Till B, Kirchner S, et al: Effects of media stories of hope and recovery on suicidal ideation and help-seeking attitudes and intentions: systematic review and meta-analysis. Lancet Public Health 2022; 7:e156–e168
55.
Niederkrotenthaler T, Voracek M, Herberth A, et al: Role of media reports in completed and prevented suicide: Werther v. Papageno effects. Br J Psychiatry 2010; 197:234–243
56.
Fink DS, Santaella-Tenorio J, Keyes KM: Increase in suicides the months after the death of Robin Williams in the US. PLoS One 2018; 13:e0191405
57.
Sinyor M, Schaffer A, Heisel MJ, et al: Media guidelines for reporting on suicide: 2017 update of the Canadian Psychiatric Association policy paper. Can J Psychiatry 2018; 63:182–196
58.
Hawley LL, Niederkrotenthaler T, Zaheer R, et al: Is the narrative the message? The relationship between suicide-related narratives in media reports and subsequent suicides. Aust N Z J Psychiatry 2023; 57:758–766
59.
Yip PS, Caine E, Yousuf S, et al: Means restriction for suicide prevention. Lancet 2012; 379:2393–2399
60.
Nordentoft M, Qin P, Helweg-Larsen K, et al: Time-trends in method-specific suicide rates compared with the availability of specific compounds. The Danish experience. Nord J Psychiatry 2006; 60:97–106
61.
Fredin-Knutzén J, Hadlaczky G, Andersson AL, et al: A pilot study evaluating the effectiveness of preventing railway suicides by mid-track fencing, which restrict easy access to high-speed train tracks. J Safety Res 2022; 83:232–237
62.
Mann JJ, Michel CA, Auerbach RP: Improving suicide prevention through evidence-based strategies: a systematic review. Am J Psychiatry 2021; 178:611–624
63.
Litteken C, Sale E: Long-term effectiveness of the Question, Persuade, Refer (QPR) Suicide Prevention Gatekeeper Training Program: lessons from Missouri. Community Ment Health J 2018; 54:282–292
64.
Cook JA, Copeland ME, Jonikas JA, et al: Results of a randomized controlled trial of mental illness self-management using wellness recovery action planning. Schizophr Bull 2012; 38:881–891
65.
Fuhr DC, Salisbury TT, De Silva MJ, et al: Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol 2014; 49:1691–1702
66.
Cerimele JM, Blanchard BE, Johnson M, et al: Effectiveness of collaborative care and co located specialty care for bipolar disorder in primary care: a secondary analysis of a randomized clinical trial. J Acad Consult Liaison Psychiatry 2023; 64:349–356
67.
Schaffer A, Sinyor M, Kurdyak P, et al: Population-based analysis of health care contacts among suicide decedents: identifying opportunities for more targeted suicide prevention strategies. World Psychiatry 2016; 15:135–145
68.
Gould MS, Lake AM, Galfalvy H, et al: Follow-up with callers to the National Suicide Prevention Lifeline: evaluation of callers’ perceptions of care. Suicide Life Threat Behav 2018; 48:75–86
69.
Tyuse SW: Crisis Intervention Team (CIT) programs and suicide. J Psychosoc Rehabil Ment Health 2020; 7:221–229
70.
Kohls E, Guenthner L, Baldofski S, et al: Suicidal ideation among children and young adults in a 24/7 messenger-based psychological chat counseling service. Front Psychiatry 2022; 13:862298
71.
While D, Bickley H, Roscoe A, et al: Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study. Lancet 2012; 379:1005–1012
72.
Krysinska K, Batterham PJ, Tye M, et al: Best strategies for reducing the suicide rate in Australia. Aust N Z J Psychiatry 2016; 50:115–118
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Published in print: Fall 2023
Published online: 16 October 2023
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Competing Interests
Dr. Mitchell reports receiving an honorarium from Medscape and salary support from the University of Toronto, and Sunnybrook Health Sciences Centre, Department of Psychiatry Academic Scholar Award. Dr. Giacobbe reports receiving grants and/or research support from Canadian Institutes of Health Research and PSI Foundation, and reports receiving salary support from University of Toronto, Department of Psychiatry Academic Scholar Funds. Dr. Sinyor reports receiving salary support from Academic Scholar Awards from the Departments of Psychiatry at Sunnybrook Health Sciences Centre and the University of Toronto. The other authors report no financial relationships with commercial interests.
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