Preliminary communicationDoes first episode polarity predict risk for suicide attempt in bipolar disorder?☆
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)
Evolutionary recasting: ADHD, mania and its variants
J. Affect. Disord.
(2001)- et al.
Aggression in human correlates with cerebrospinal fluid amine metabolites
Psychiatry Res.
(1979) - et al.
Mood state at study entry as predictor of the polarity of relapse in bipolar disorder
Biol. Psychiatry
(2004) - et al.
Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other axis I disorders
Biol. Psychiatry
(1996) - et al.
Clinical correlates of first-episode polarity in bipolar disorder
Compr. Psychiatry
(2006) - et al.
Bipolar II. Combine or keep separate?
J. Affect. Disord.
(1985) - et al.
Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters
J. Affect. Disord.
(2000) - et al.
Revisiting depressive-prone bipolar disorder: polarity of initial mood episode and disease course among bipolar I systematic treatment enhancement program for bipolar disorder participants
Biol. Psychiatry
(2005) - et al.
Polarity of the first episode, clinical characteristics, and course of manic depressive illness: a systematic retrospective investigation of 320 bipolar I patients
Compr. Psychiatry
(2000) - et al.
Suicide in subtypes of primary major depression
J. Affect. Disord.
(1990)
Statistic predictions of suicide in depressives
Compr. Psychiatry
Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review
Bipolar Disord.
Factor analysis of some psychometric measures of impulsiveness and anxiety
Psychol. Rep.
Classification of suicidal behaviors: I. Quantifying intent and medical lethality
Am. J. Psychiatry
Assessment of suicidal intention: the scale for suicide ideation
J. Consult. Clin. Psychol.
Cited by (45)
The use of antidepressant medications for Bipolar I and II disorders
2021, Psychiatry ResearchSuicidal Behavior Associated with Mixed Features in Major Mood Disorders
2020, Psychiatric Clinics of North AmericaSuicide in psychiatric disorders: rates, risk factors, and therapeutics
2020, Ketamine for Treatment-Resistant Depression: Neurobiology and ApplicationsCourse and naturalistic treatment seeking among persons with first episode mania in India: A retrospective chart review with up to five years follow-up
2018, Journal of Affective DisordersCitation Excerpt :First episode polarity can influence the subsequent course. A depressive polarity at onset predicts a depression-predominant course (Chaudhury et al., 2007; Forty et al., 2009) while early manic episodes predict mania-predominance (Etain et al., 2012). Indian studies have consistently found a mania-predominant course in contrast to western studies (Miller et al., 2014; Rangappa et al., 2016).
Onset polarity in bipolar disorder: A strong association between first depressive episode and suicide attempts
2017, Journal of Affective DisordersCitation Excerpt :In contrast with some earlier reports focusing on BD I patients (Perugi et al., 2000; Perlis et al., 2005; Cha et al., 2009; Forty et al., 2009; Azorin et al., 2011), both bipolar subtypes were included in our sample, although BD II subjects comprised only about one-quarter of the whole sample. Our BD II and BD I patients more frequently experienced DO and EO, respectively, consistently with prior studies involving both subtypes of bipolar subjects (Daban, 2006; Chaudhury et al., 2007; Neves et al., 2009; Tundo et al., 2015). In our analysis, age at onset (i.e., age at first mood episode) did not vary according to OP, consistently with several previous reports (Perugi et al., 2005; Cha et al., 2009; Neves et al., 2009; Tundo et al., 2015).
Onset polarity and illness course in bipolar i and II disorders: The predictive role of broadly defined mixed states
2015, Comprehensive PsychiatryCitation Excerpt :It also conversely shows the absence of a Polarity*Diagnosis interaction. In accordance with results from previous research [4–10], our study found depression to be the most common first episode, followed by the highly similar HM-o and (broadly defined) MX-o rates. The present study also yielded further interesting findings.
- ☆
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.