Suicide and Bipolar Disorder

Antidepressant-Resistant Depression and Antidepressant-Associated Suicidal Behaviour: The Role of Underlying Bipolarity

“…Family history data, demographic variables as well as long-term course, indicate that depressive mixed state, even in the frame of unipolar depression belongs to the broader bipolar spectrum [22–25, 28–30]. The recognition of depressive mixed state has important practical implications as several studies have shown that compared to pure major depressive episode the risk of suicidal behaviour is markedly elevated in mixed depressive episode both in DSM-IV diagnosed unipolar and bipolar depression [13, 22, 27, 31–34].…”

“…The rarely occurring antidepressant-associated suicidality among depressed patients is relatively most frequent in children and adolescents and less common in middle-aged persons and in the elderly both in RCTs [44–46] and observational studies [47]. As early age at onset of major depressive episode is a powerful clinical marker of bipolarity [16–18], and the manic component of bipolar disorder (and possible its biological background) shows a declining tendency with age [30]. The “suicide-inducing” potential of antidepressants, occurring almost exclusively among young patients, seems to be really related to the underlying bipolarity.…”

“…As combination of antidepressants and mood stabilizers reduces the “iatrogenic” hypomanic/manic mood switch [4, 29, 37–39] this treatment strategy could be also useful in avoiding both AD-RD and “antidepressant-associated” suicidal behaviour. This is important, because a significant part (30–40%) of DSM-IV diagnosed unipolar depressives really have subthreshold bipolar II or bipolar spectrum disorder [3, 12, 24, 25, 30] that means that about one-third of DSM-IV diagnosed unipolar depressives are really bipolar depressives. …”

“…As antidepressants can worsen depression but it is not the case for placebo, this new view can explain why antidepressant-induced suicidal behaviour is more common among patients treated with antidepressants compared to those who receive placebo in Randomized Controlled Trials (RCTs) on antidepressant monotherapy in unipolar major depression: subthreshold bipolar depressives and bipolar spectrum depressives (including agitated depressives and depressed patients with family history of bipolar disorder) are not excluded from this trials resulting in a significant part of bipolar depressives among this study population [12, 30]. …”

Bipolar Disorder and Suicide

“…As for suicide prevention, the main target should not only be persons who are acutely suicidal, but all depressive (and other psychiatric) patients. Their treatment should start as early as possible in order to prevent the progression of the illness and the development of suicidal thoughts and behaviour /Rihmer & Kiss, 2004/. We are, of course, unable to prevent all suicides. However, our present pharmacological and psychosocial intentions are effective enough to minimize the chance of suicide in patients with BD that represents the highest risk of self-inflicted death /Rihmer, 2006/.…”