Suicide Prediction

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There are characteristics that are overrepresented in bipolar patients with suicidality (Table 5-1): hopelessness, aggressivity, severity of depressed mood, and suicidal ideation have been repeatedly found to be associated with suicidality (Ahrens and Linden 1996; Beck et al. 1993; Brown et al. 2000; Minkoff et al. 1973; Oquendo and Mann 200l). These symptoms are neither specific to bipolar disorder, nor easily accounted for by any component of the clinical presentation of the patient with bipolar disorder. A complex matrix of mood disorder, family history and genetics, comorbidity (especially anxiety and substance use, including nicotine), medical history (including head injury), and social and economic factors may contribute to the presence and severity of these symptoms. While not all are amenable to clinical intervention, many are, and awareness by the clinician and the social network of the bipolar patient may contribute to reducing risk and increasing the probability of suicide prevention.

Mann and Oquendo have proposed a stress diathesis model of suicide in bipolar disorder, in which aggressive or suicidal behavior is influenced by a cascade of factors (Mann et al. 1999b; Oquendo and Mann 2001). The interaction of mood disorder and social factors leads to hopelessness, impulsivity, and suicidal ideation, in part influenced by trait factors (such as serotonin functioning), decreased cognitive functioning due to head injury, and substance use (including drugs, alcohol, and nicotine). Mann et al. (1999b) suggests that the monitoring of these separate factors should be a part of ongoing suicide prevention in bipolar disorder.

Accurate suicide prediction, however, is nearly impossible. As Sachs et al. (2001) have explained, the positive predictive value—the true positives for an outcome divided by the total positives (true positives plus

TABLE 5-1. Prominent risk factors for suicide in bipolar disorder

• Past suicide attempt

• Early in course of illness

• Period immediately after hospital admission

• Period immediately after hospital discharge

• Recurrent depressive episodes (>4)

• Adult or childhood sexual abuse

Social isolation

Nicotine dependence

• Other substance or alcohol dependence

• Comorbid anxiety disorder

• Cluster B personality disorder

• Hopelessness

• Impulsivity

• Depression

• Mixed state or mania with significant depressive symptoms

• Suicidal ideation false positives)—of suicide assessment is extremely low. They proposed that a model for suicide prevention should include an assessment of factors that may increase inclination for suicide (e.g., suicidal ideation and hopelessess) on a matrix with an assessment of the opportunity for making a suicide attempt (e.g., owning a weapon, having a large stock of pills, being alone). Inclination and opportunity can each be estimated as high, moderate, or low, and the intervention can be tailored to the estimated risk. The lowest risk would merit a treatment plan to manage the development of suicidal ideation, along with preventative psycho-pharmacologic management, such as lithium. The highest risk would merit an emergency intervention, such as hospitalization, but may include the mobilization of social supports, the removal of the means for suicide, and acute treatment for depression. The goal for management is to match intervention to need.

Clinicians should first use treatments in bipolar disorder that have sound scientific underpinnings. For high-risk patients, a trial of lithium and ongoing management with it may be the intervention with the greatest likelihood of success. The reduction of depression and depressive recurrence should be a hallmark of care, and until the anti-suicide effects of a specific treatment can be established in larger trials, the treatment approach should be based on current research.

Although they are not proven to prevent suicide, interventions targeting comorbid conditions may decrease the theoretical risk of it. Anx iety disorders should be adequately treated, both with pharmacological interventions and with psychotherapy effective for the specific disorder. The use of antidepressants to treat anxiety should be undertaken cautiously, but prominent anxiety symptoms should be minimized as much as possible. Interventions to reduce substance use are rarely used in bipolar disorder, but clinicians should be prepared to access them, both in terms of psychopharmacology (e.g., buprenorphine for opiate dependence, acamprosate for alcohol dependence) and psychosocial treatments.

One of the most prominent comorbidities in bipolar disorder, nicotine dependence, is a most powerful predictor of suicide. Although no interventions for smoking cessation have been validated in bipolar disorder and the impact of quitting smoking on suicide risk is unknown, it may nevertheless be of great benefit to the patient to stop smoking. Current standard treatments for smoking cessation are likely safe, if not effective, in bipolar disorder.

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