Prevalence and Characteristics of Suicide in Bipolar Disorder

ISBD Task Force on Suicide

Doris Hupfeld Moreno, MD, PhD

Medical Assistant and Resident Supervisor of the Institute of Psychiatry, University of São Paulo School of Medicine

Researcher in the Section on Epidemiology and the Mood Disorders Unit of the Institute of Psychiatry

Member of the Task Force on Suicide of the ISBD

Faculty Disclosure

Nothing to disclose

Prevalence of suicide attempts in clinical and epidemiological BD samples

Rates on death from suicide through different reviews

Methods used for suicide attempts

Comparison with rates of MDD and other major mental illness

Objectives

Methodological diversity

Different definitions of suicide attempts

Distinct periods of time covered

Lack of information, i.e., regarding methods used for suicidal acts, rate of bipolar I, II or NOS

Sample heterogeneity

Problems

Suicide Attempts in BD

Suicide Attempts in BDI vs. BDII

Novick DM et al. Suicide attempts in bipolar I and bipolar II disorder: a review and meta-analysis of the evidence. Bipolar Disord. 2010;12(1):1-9.

Study Sample (N) Lifetime Prevalence

ECA USChen & Dilsaver, 1996

18,000 subjects186 BD

29.2%

NESARC Oquendo et al., 2010

43,093 subjects1,643 BDI/II

25.3% with alcohol use disoders (AUD)14.8 % w/o AUD

WMHSMerikangas et al., 2011

61,392 subjects11 countries

25.6% BDI20.8% BDII9.5% BD NOS

NESARCBlanco et al., 2012

990 BDI 24.7%

Attempted suicide ratesepidemiological studies

ECA – Epidemiologic Catchment Area Study

NESARC - National Epidemiologic Survey on Alcohol and Related ConditionsWMHS – World Mental Health Survey

Study Sample (N) Duration Rates

Simon et al., 2007. U.S.Health plan records

32,360 BD Mean 2.7 years 5.3%

Khalsa et al., 2008, U.S. 216 BDI first episode 4.2 ± 2.7 (range:0.5–9.2) years

18.1% requiring re-hospitalization: 17.6%

Altamura et al., 2010, Italy

128 BDI192 BDII

5 years 22%

Gonzalez-Pinto et al., 2011

120 BDI Up to 10 years 18.3%

Dennehy et al., 2011STEP-BD

4.360 Mean 16 months 6.0% (1/3 > 1 attempt)

Attempted suicide ratesprospective clinical studies

Study Sample (N) Lifetime prevalence

Azorin et al., 2009French National Cohort

1,090 BDI 35.0%

Garcia-Amador et al., 2009Spain

305 BD 25.9%

Bellivier et al., 2011Europe EMBLEM

3,684 BDI 29.9%

Ghanizadeh and Sahraian, 2008Iran

176 BDI inpatients 34.1% 70% only one attempt

Ryu et al., 2010Korea

579 BD 13.1% 89.5% BDI , 7.9% BDII, 2.6% BDNOS

Cassidy et al., 2011USA

157 BD 37.6%

Dennehy et al., 2011STEP-BD

4.360 BD 36%

Attempted suicide ratesretrospective clinical studies

Suicide Deaths in BD

Suicide Deaths in BD

Tondo L, Isacsson G, Baldessarini R. Suicidal behaviour in bipolar disorder: risk and prevention. CNS Drugs. 2003;17(7):491-511.

Review of 34 papers, selected according to a quality score, depending on

representativeness of sample, if only BD patients were included, duration offollow-up > 1 year, controlling of confounding variables, reliably identificatedcases, etc

Suicide review and meta-analysis

Pompili et al., Bipolar Disorders, 2013, 15:457-490

Type of study Prevalence/incidence of BD

Retrospective Risk for suicide was up to 20-30 times greater than for general population

Prospective Among psychiatric diagnoses, BD strongest association withsuicide – 25% of all suicides

Prevalence data are conflicting

Psychological autopsystudies

22% - 61%

Paper Year No. of Suicides Duration in

Years

Exposure

(person-years)

Suicide Rate (per

100 person years)

Suicide Rate-

Male

Suicide Rate-

Female

Morrison et al. 1982 12/443 8.5 3766 0.319

Martin et al. 1985 0/19 9 171 0.000

Weeke and Vaeth 1986 17/417 7 2919 0.582

Black et al. 1988 7/586 7 4102 0.171

Dingman et al. 1988 1/19 15 285 0.351

Friis et al. 1991 2/14 7 98 2.041

Newman and Bland 1991 19/1429 4.8 6859 0.277

Sharma and Marker 1994 9/472 9 4248 0.212

Koukopoulos et al. 1995 5/89 2.75 245 2.043

Thies-flechtner et al. 1996 8/146 2.5 365 2.192

Angst et al. 1998 11/220 28 6160 0.179

Bocchetta et al. 1998 5/47 5.6 263 1.900

Brodersen et al. 2000 7/61 16 976 0.717

Kallner et al. 2000 7/106 8.2 869 0.805

Kleindienst and Greil 2000 1/85 2.5 213 0.471

Osby et al. 2001 672/15386 11.1 170615 0.394 0.498 0.323

Gladstone et al. 2001 5/813 5 4065 0.123

Dutta et al. 2007 8/235 18.8 4422 0.181 0.369 0.040

Simon GE et al. 2007 73/32360 2.7 87372 0.106 0.171 0.071

Tondo et al. 2007 22/901 3.56 3208 0.686 1.059 0.391

Osborn et al. 2008 41/10742 4.7 50487 0.080

Dennehy et al. 2011 8/4360 1.3 5668 0.140 0.252 0.065

Sani et al. 2011 57/1765 2.9 5119 1.110 1.458 0.869

Gonzalez-Pinto et al. 2011 3/169 10 1690 0.178

Nordentoft et al. 2011 175/5927 18 106686 0.160 0.210 0.129

Total 1175/76811 8.436a 471035 0.617a

Pooled (by sample size) 0.215b 0.330 0.161

Pooled (by exposure years) 0.253b 0.368 0.218

ISBD Task ForceSuicide Rate for People with Bipolar Disorder: Pooled by Sample Size and by Exposure Years

Total 1175/76811 8.436a 471035 0.617a

Pooled (by sample size) 0.215b

Pooled (by exposure years) 0.253b

Methods used

Study n Self-Poisoning

Jump Cutting/Stabbing

Hanging Fire -arm

Other

Tsai et al., 1999 53 30.2% 13.2%* 22.7% - - Drowning 7.5% Gas inhalation 5.7%

Oquendo et al., 2009

146 80.1% 4.8% 8.2% 0.7% 1.4% Immolation 2.1% drowning 0.7%

Ryu et al., 2010 76 34.2% 13.2% 19.7% 10.5% - Unknown 18.4% immolation 1.3%

D’Ambrosia et al., 2012

220 63.4% 12.7% 5.6% 7.0% 4.2% Gas inhalation 2.8% Collision 1.4%

Ruengorn et al., 2012

58 40.1% 12.3% 21.4% 26.3% - Collision 7%Drowning 3.5%

Methods used in suicide attempts

Study n Self-Poisoning

Hanging Jump Fire-arm

Cutting/Stabbing

Other

Rihmer et al., 1990

47 53% 17% 26% - - -

Osby et al., 2001 672 29.8% 31.0% 13.7% 5.2% 2.7% Drowning 11%Other 6.7%

Tsai et al, 2002 43 23.2% 11.6% 23.2% - - Drowning 25.6%Gas inhalation 9.3%Other 7%

Chen et al., 2009 482 24.9% 32.2% 17.4% - - Charcoal burning 13.5%Other 12.0%

Keks et al., 2009 35 17% 46% - - - CO poisoning 17% Collision 11%

Gos et al., 2009 7 42.9% 28.6% - - 14.3% Electrocution 14.3%

Dennehy et al., 2011

8 25% 25% - 25% - Unknown 25%

Methods used for suicide completion

BD vs. Other Major Mental Illness

suicide attempts

DSM-IV disorders Bivariate modelsOR (95% CI)

Developed Developing

Panic disorder 5.1 (4.0-6.40 5.0 (3.4-7.3)

PTSD 6.5 (5.4-7.6) 8.3 (6.0-11.6)

GAD 5.6 (4.6-6.7) 5.4 (3.9-7.5)

MDD 5.8 (5.0-6.8) 5.1 (4.2-6.1)

Bipolar disorder 7.1 (5.5-9.3) 6.7 (4.4-10.0)

ODD 5.3 (4.1-6.7) 6.7 (4.1-10.9)

Conduct disorder 4.8 (3.6-6.4) 8.9 (5.6-14-2)

Alcohol abuse/dependency 4.4 (3.7-5.3) 4.8 (3.7-6.1)

Drug abuse/ dependency 4.9 (3.8-6.2) 7.5 (5.4-10.4)

Association between DSM-IV disorders and a subsequent suicide attempt – World Mental Health Survey (n=27,963) – 11 countries

Study Sample (N) Results

Chen & Dilsaver, 1996

18,000 subjectsECA U.S.186 BD

BD (29.2%) > MDD (15.9%) > other Axis I (4.2%)

BD vs MDD - OR 2.0 (df=1, x(2)=697.9, p<0.0001)

Tondo et al., 2007 2,826 mooddisorder patients

%patients/y BDI (1.52) > BDII (0.82) > MDD (0.48)

Bader & Dunner, 2007

305 BDI/II/NOS130 MDDTertiary care unit

BDI > BDII = MDD recurrent (p=0.001) and BD NOS (p=0.007)

Attempted suicide ratescompared to MDD and other Axis I disorders

BD vs. Other Major Mental Illness

suicide

N %

Bipolar disorder 482 3.9

Major depression 895 7.2

Neurotic disorder 2,741 22.1

Schizophrenia 703 5.7

Other disorders 2,273 18.3

No diagnosis 5,297 42.8

Suicide in Taiwan

n = 12,391 suicides (coroner’s records)

Chen YY et al. Methods of suicide in different psychiatric diagnostic groups. J Affect Disord. 2009 Nov;118(1-3):196-200.

Study Sample (N) Results

Osby et al., 2001Sweden

Inpatient register1973-1995BD=15,386UP=39,182

SMR: UP (20.9 Male/27.0 Female) vs. BD (15.0 Male/22.4 Female)

Ilgen et al., 2006U.S.

6,913 National Violent Death Reporting System 2004

MDD 34.7%BD 6.1% In any other Axis I disorder

Tondo et al., 2007Italy

2,826 mooddisorder patients

suicide rate (% patients/year): BDII (0.16) > BDI (0.14) > MDD(0.05)

Osborn et al., 2008Cohort study within the UK

43,136 SMI patients vs no SMIBD=10,742

HR: 8.74 BD vs. 7.00 SCZ vs. 7.85 other SMI

Sani et al., 2011Italy

4,441 inpatients1964-1998

BDII (4.2%)>BDI (2.8%)>MDD (1.9%)

Suicide rates compared to MDD andother Axis I disorders

SMI - severe mental illness

Copyright restrictions may apply.Nordentoft M, Mortensen PB, Pedersen CB. Absolute risk of suicide after first hospital contact in mental disorder. Arch Gen Psychiatry.

2011;68(10):1058-64.

Cumulative incidence of suicide by time since the first psychiatric contact among men (A) and women (B)

N = 176,347 individuals with mental health contact N = 881,735 controls

Follow-up 36 years, median 18 years

Men 7.77% (95% CI, 6.01%-10.05%)

Women4.78% (95% CI, 3.48%-6.56%)

Lifetime suicide attempts occured in ¼ of individuals in population-basedstudies and more than 1/3 in clinical studies

Rates were lower (9.5%) for subthreshold BD, but higher than in normal controls

The rate of suicide was 0.215 per 100 person years

the risk of suicide is 20-30 times greater than of the general population

poisoning was the most frequently used method in suicide attempts (30% -80%), followed by cutting/stabbing (5.6% - 22.7%) , and jumping (4.8% -13.2%)

suicides - most frequently used methods: poisoning (17% - 53%) and hanging(11.6% - 46%), followed by jumping (13.7 – 26% in 4/7 studies), - to a lesserextent cutting/stabbing (2.7% and 14.3% in 2/7 studies)

BD accounts for a substantial proportion of suicides in both clinical and epidemiological samples comparable to or, in some cases, greater than what is seen in MDD, schizophrenia and other major mental illness.

Conclusions

Impact of DSM5 on suicide rates – mixed episodes?

BD undertreated, rates are underestimated

Lack of studies comparing patients with one or more suicide attempts. Who is going to attempt suicide again?

Better determination of types of methods used, ifplanned/not planned, lethality

Risk factors

Protective factors

Improve and implement preventative strategies

We have to consider...

Ayal Schaffer

Mark Synior

Laura Andrade

Kyooseob Ha

Lars Kessing

Catherine Reis

Acknowledgments

Thank you!