Preliminary communication
Does first episode polarity predict risk for suicide attempt in bipolar disorder?

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Abstract

Background

Defining bipolar disorder (BD) subtypes with increased risk of suicidal behavior may help clinical management. We tested the hypothesis that the polarity of a patient's first mood episode would be a marker for BD subtypes with differential risk for suicidality.

Methods

One hundred thirteen subjects with DSM-IV defined BD were classified based on whether their first reported episode was manic/hypomanic (FM) or depressed (FD). They were compared on demographic and clinical variables. Logistic regression adjusting for potential confounds tested the association between first episode polarity and history of suicide attempt.

Results

Multiple logistic regression analysis showed that FD group membership was associated with eightfold odds of a past suicide attempt, adjusting for years ill and total number of lifetime major depressive episodes.

Limitations

Sample size, retrospective design, recall bias, assessment during a mood episode, and imprecise recall of hypomania.

Conclusions

Polarity of patients' first reported mood episode suggested a depression-prone subtype with a greater probability of past suicide attempt. The FM group had more alcoholism and psychosis, but less likelihood of past suicide attempt. Validation of these putative subtypes requires prospective study.

Introduction

Better understanding of clinical heterogeneity in BD may aid research and improve treatment. Almost 30% of persons with BD make a suicide attempt (Chen et al., 1996). Bipolar patients are most at risk for suicidal behavior during depressive episodes (Goldberg et al., 2002) and dysphoric mania (Rihmer et al., 2002).

Some studies suggest that the course of BD is associated with the polarity of the initial episode (Perlis et al., 2005, Perris and D'Elia, 1966, Perugi et al., 2000, Roy-Byrne et al., 1985). Quitkin et al. suggested the existence of two subtypes of BD — a manic-prone subtype with a tendency to have more lifetime manic episodes, and a depressive-prone subtype with a higher frequency of depressive episodes (Quitkin et al., 1986). Calabrese found that mood state at study entry predicts polarity at relapse (Calabrese et al., 2004). Perlis et al. found that, in BD-I patients, those whose initial episode was depressive had more lifetime depressive episodes and greater probability of suicide attempt although the latter finding was not significant after adjustment for confounds (Perlis et al., 2005).

In this retrospective study, we attempted to replicate the findings of Quitkin and Perlis in an independent sample, with a focus on suicidal behavior. We hypothesized that a first episode of depressive polarity would be associated with increased likelihood of past suicidal behavior.

Section snippets

Subjects

The sample comprised consecutively enrolled inpatients (N = 73, 65%) and outpatients (N = 40, 35%) diagnosed with BD who sought evaluation and treatment in our research clinic. Axis I and II diagnoses were based on the Structured Clinical Interview for DSM-IV (SCID) (First et al., 1994) and a consensus conference in which all available data were reviewed by experienced research clinicians. Patients were in a mood episode, mostly depressive, at study entry. After complete description of the study,

Socio-demographic and clinical factors

Seventy-five patients (66.4%) were diagnosed with BD-I at baseline, while 38 (33.4%) were diagnosed with BD-II. The mean age was 38 years (SD = 12.6, range 17–73 years), 29% were married, and 57% were female. Seventy-four patients (66%) reported at least one suicide attempt in a lifetime. Suicide attempters in the sample had made an average of 2.6 attempts (SD = 1.9, range 1–11), defined as self-injury with intent to die.

Bonferonni correction for 22 tests would set significance at p < 0.002. Using

Discussion

The main finding of this study is that in persons with BD, a first reported mood episode of depressive polarity is associated with eightfold greater odds of suicide attempt. This was not explained by years ill, lifetime number of major depressive episodes, or BD-I vs. II/NOS subtype. Hostility was associated with suicide attempt risk, consistent with previous reports from our group (Grunebaum et al., 2006, Oquendo et al., 2000). Reasons for living appeared to be an important protective factor.

Acknowledgement

Clinical ratings were completed by members of the Clinical Evaluation Core of the Conte Center for the Neuroscience of Mental Disorders.

References (31)

  • F. Stallone et al.

    Statistic predictions of suicide in depressives

    Compr. Psychiatry

    (1980)
  • R.J. Baldessarini et al.

    Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review

    Bipolar Disord.

    (2006)
  • E.S. Barratt

    Factor analysis of some psychometric measures of impulsiveness and anxiety

    Psychol. Rep.

    (1965)
  • A.T. Beck et al.

    Classification of suicidal behaviors: I. Quantifying intent and medical lethality

    Am. J. Psychiatry

    (1975)
  • A.T. Beck et al.

    Assessment of suicidal intention: the scale for suicide ideation

    J. Consult. Clin. Psychol.

    (1979)
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    Supported by PHS grants MH59710 (Pharmacotherapy of High-Risk Bipolar Disorder), MH48514 and MH62185 (Conte Neuroscience Center) and the Stanley Medical Research Institute. Dr. Grunebaum is supported by NARSAD, NIMH K23 MH076049--01 and has received investigator-initiated support from GlaxoSmithKline unrelated to this study. The authors have no conflicts of interest to disclose in connection with this manuscript.

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