Clinical Course

Severity of illness appears to be associated with suicide. First episodes requiring hospitalization may be particularly high risk. The time immediately after hospital admission and immediately after discharge ap pears to be a particularly vulnerable period for suicide. Hoyer et al. (2004) examined the characteristics of all first hospitalizations for affective disorder in Denmark between 1973 and 1993, finding that 3,141 of 53,466 patients committed suicide (6%), and that the suicide risk was highest on the day following discharge and the day following admission. The risk declined over time, remaining high for 6 months following discharge. Interestingly, the risk associated with time after discharge declined with increasing duration of illness, supporting the notion that suicide risk is highest early in the course of affective illnesses, including in bipolar disorder.

Individuals appear to be most at risk for suicidality following their index affective episode, regardless of episode polarity (Fagiolini et al. 2004; Roy-Byrne et al. 1988). Baldessarini et al. (1999), in an analysis of 104 suicide attempts considered over a period of 40 years, demonstrated that over 50% occurred within 7.5 years of the initial affective episode. It is also important to note that, within this same sample, the time to suicide attempt was well before the time to lithium maintenance treatment. It follows that younger patients and those with an earlier age at onset may also find themselves at greater risk for suicidality as a result of the lag in time between illness onset and appropriate treatment. This also demonstrates the inherent dangers involved in misdiagnosing unipolar depression for bipolar individuals following an index depressive episode. These individuals may not be represented in current research as a result and may instead be victims of misdiagnosis and inappropriate clinical care.

Fagiolini et al. (2004) reported that in a cohort of 175 patients with bipolar disorder, suicide attempts tended to occur at a relatively young age and in the early part of the patients' illnesses. A history of suicide was also associated with a greater number of prior episodes, higher depression scores at entry, and higher body mass index (BMI) (Fagiolini et al. 2004). Tsai et al. (2002) found that in Chinese patients with bipolar disorder, suicide tended to occur in the first 7 to 12 years of illness, and the risk was greatest prior to age 35.

In addition to young age being a factor in suicide attempts, the age at onset of bipolar disorder is also associated with later suicide and is commonly seen as one measure of illness severity. Early-onset and very early-onset bipolar disorder predisposes patients to a more chronic and severe course of illness and predicts a greater likelihood of making a suicide attempt. This assumption is echoed in suicide research, in which an earlier age at bipolar onset tends to be associated with a greater risk of suicidality in bipolar patients (Coryell et al. 2003; Fagiolini et al. 2004; Goodwin and Jamison 1990; Guze and Robins 1970; Levine et al. 2001).

Therefore, it is likely that younger bipolar patients may be a high-risk group for suicide attempts and completion.

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