Psychological Pain as a Risk Factor for Suicidal Ideation: An Ecological Momentary Assessment Study on Inpatients With Depression With and Without Comorbid Borderline Personality Disorder.

Objective: Psychological pain (PP) is a potentially important risk factor for suicide. However, its temporal stability and association with suicidal ideation (SI) remain obscure. Whether PP represents a risk factor for SI independently of depression, anxiety, and hopelessness or is more prominent and temporally unstable in patients with depression and borderline personality disorder (BPD) is also unclear.Methods: From November 2020 to December 2022, psychiatric inpatients with depression without (N = 37) and with (N = 30) BPD were recruited to an ecological momentary assessment (EMA) study, wherein their PP, severity of depression, SI, and hopelessness were assessed 3 times daily using visual analog scales. Multilevel regression models were estimated.Results: Altogether, 4,320 EMA observations were collected. PP correlated with hopelessness (r = 0.417), depression (r = 0.339), and anxiety (r = 0.496), but the between-patient variance of PP remained at 1.26 (95% CI, 1.025-1.533) after controlling for these variables. The within-patient variance of PP was associated with SI (ß = 0.17 [95% CI, 0.12-0.22]) with a magnitude comparable to hopelessness (ß = 0.1 [95% CI, 0.05-0.15]) and depression (ß = 0.12 [95% CI, 0.08-0.17]). Patients with depression and BPD reported higher daily PP and SI (P < .001) and a more prominent within-patient variation in PP.Conclusions: In psychiatric inpatients with depression, besides depression and hopelessness, PP represents an independent risk factor for SI, varying within a timescale of days. Depressive patients with BPD may experience more prominent and temporally unstable PP, likely underlying their higher vulnerability to SI.

Affect dimensions and variability during major depressive episodes: Ecological momentary assessment of unipolar, bipolar, and borderline patients and healthy controls.

Differentiating major depressive episodes (MDEs) of major depressive disorder (MDD), bipolar disorder (MDE/BD) and the MDEs comorbid with borderline personality disorder (MDE/BPD) is crucial for appropriate treatment, and knowledge of phenomenological differences may aid this. However, studies comparing affect experiences of these three patient groups and healthy subjects are scarce. In our study, participants (N = 114), including patients with MDD (n = 34), MDE/BD (n = 27), and MDE/BPD (n = 24), and healthy controls (HC, n = 29) responded to ecological momentary assessment (EMA) with ten circumplex model affect items ten times daily for seven days (7709 recordings). Explorative factor analysis resulted in two affect dimensions. The positive dimension included active, excited, cheerful (high arousal), and content (low arousal) affects, and the negative dimension irritated, angry, and nervous (high arousal) affects. Relative to HC, patients reported 3.5-fold negative affects (mean MDD 1.36 (SD 0.92), MDE/BD 1.43 (0.76), MDE/BPD 1.81 (0.95) vs. HC 0.44 (0.49) (p < 0.01)) but 0.5-fold positive affects (2.01 (0.90), 1.95 (0.89), 2.24 (1.03), vs. 3.2 (0.95), respectively (p < 0.01)). We used multilevel modelling. Negative-affect within-individual stability was lowest in MDE/BPD and highest in MDD. Negative affect predicted concurrent positive affect more in MDE/BPD than in MDD. Moderate size of subcohorts and no inpatients were limitations. Despite apparently similar MDEs, affective experiences may differ between BPD, BD, and MDD patients. Clinical subgroups of patients with depression may vary in affective instability and concurrent presence of negative and positive affects during depression.

Do Suicide Attempts of Mood Disorder Patients Directly Increase the Risk for a Reattempt?

Background: Preceding suicide attempts strongly predict future suicidal acts. However, whether attempting suicide per se increases the risk remains undetermined. We longitudinally investigated among patients with mood disorders whether after a suicide attempt future attempts occur during milder depressive states, indicating a possible lowered threshold for acting. Methods: We used 5-year follow-up data from 581 patients of the Jorvi Bipolar Study, Vantaa Depression Study, and Vantaa Primary Care Depression Study cohorts. Lifetime suicide attempts were investigated at baseline and during the follow-up. At follow-up interviews, life-chart data on the course of the mood disorder were generated and suicide attempts timed. By using individual-level data and multilevel modeling, we investigated at each incident attempt the association between the lifetime ordinal number of the attempt and the major depressive episode (MDE) status (full MDE, partial remission, or remission). Results: A total of 197 suicide attempts occurred among 90 patients, most during MDEs. When the dependencies between observations and individual liabilities were modeled, no association was found between the number of past suicide attempts at the time of each attempt and partial remissions. No association between adjusted inter-suicide attempt times and the number of past attempts emerged during follow-up. No indication for direct risk-increasing effects was found. Conclusion: Among mood disorder patients, repeated suicide attempts do not tend to occur during milder depressive states than in the preceding attempts. Previous suicide attempts may indicate underlying diathesis, future risk being principally set by the course of the disorder itself.

Suicides in Mood Disorders in Psychiatric Settings in Nordic National Register-Based Studies.

OBJECTIVE: Although risk factors for nonfatal suicidal behavior in mood disorders have been vastly investigated, rate and risk factors of suicide deaths are less well known. Extensive health care and other population registers in the Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden) allow national-level studies of suicide rates and risk factors. This systematic review examined Nordic studies of suicide in mood disorders. METHODS: National Nordic studies published after 1.1.2000 reporting on suicide mortality or relative risk in diagnosed unipolar depression or bipolar disorder treated in psychiatric settings; temporal variations in suicide risk after discharge, or risk factors for suicide were systematically reviewed. RESULTS: Altogether 16 longitudinal studies reported on rate and risk of suicide in depression. They found 2%-8% of psychiatric inpatients with depression to have died by suicide. However, in Finland suicide risk among depressive inpatients halved since the early 1990s. Nine studies investigated suicide risk in bipolar disorder, finding 4-8% of patients having died by suicide in long term. The relative risk of suicide was consistently found extremely high (SMR > 100) during the first weeks postdischarge, declining steeply over time to approximately SMR of five after five years. Male gender, preceding suicide attempts, high severity of depression and substance abuse were found risk factors for suicide in depression, with only minor gender differences in risk factors, but major differences in lethal methods. Three studies investigated risk factors for suicide in bipolar disorder, finding male gender, preceding suicide attempts, and depressive episodes and psychiatric comorbidity to be associated with risk. CONCLUSIONS: Overall, of psychiatric inpatients with depressive of bipolar disorders in the Nordic countries, 2%-8% have died by suicide in the last few decades, but current rates may be lower. Suicide risk is approximately similar or somewhat higher among patients with bipolar disorder, risk factor studies of whom are fewer. Risk of suicide is remarkably high immediately after discharge, and higher among males than females, those with preceding suicide attempts, high severity of depression, or concurrent substance abuse. Generalizability of findings from these Nordic studies to other countries need to be investigated, and their methodological limitations understood.

Diagnostic conversion from unipolar depression to bipolar disorder, schizophrenia, or schizoaffective disorder: A nationwide prospective 15-year register study on 43 495 inpatients.

OBJECTIVE: To examine temporal patterns and predictors for diagnostic conversion from unipolar depression (UD) to bipolar disorder (BD), schizophrenia, and schizoaffective disorder (SAD). METHODS: A prospective nationwide register-based cohort (n = 43 495) of all first psychiatric hospitalizations due to UD during 1996-2011 was followed up to 15 years. We used cumulative incidence function (CIF) analyses and the Fine-Gray subdistribution model to define the cumulative incidence of the conversions and subdistribution hazard ratios (SHRs) for predictors. RESULTS: The overall 15-year cumulative incidence of conversion was 11.1% (95% CI 10.7-11.6): 7.4% (95% CI 7.0-7.8) for BD, 2.5% (95% CI 2.3-2.7) for schizophrenia, and 1.3% (95% CI 1.1-1.4) for SAD. The highest crude incidence rate emerged during the first year. Psychotic depression predicted higher conversion risk to BD (SHR = 2.0, 95% CI 1.5-2.7), schizophrenia (SHR = 5.3, 95% CI 3.3-8.7), and SAD (SHR = 10.6, 95% CI 4.0-28.4) than mild depression. Female sex, greater overall disturbance, and comorbid personality disorder predicted conversion to BD, whereas young age and male sex to psychotic disorders. CONCLUSIONS: Among patients with first hospitalization due to UD, approximately one in nine converts to another major psychiatric disorder during 15 years, with the highest risk occurring within the first year. Patients with psychotic depression are particularly vulnerable for conversion to other major psychiatric disorders. Conversion to psychotic disorders occurs earlier than to BD. Males are at higher risk for progression to psychotic disorders, whereas females, patients with recurrent depressive episodes, severe disturbance of overall functioning, and personality disorder are at higher risk for converting to BD.

Borderline Personality Disorder With Depression Confers Significant Risk of Suicidal Behavior in Mood Disorder Patients-A Comparative Study.

OBJECTIVE: We investigated risk factors for suicidal ideation and behavior among currently depressed patients with major depressive disorder (MDD), major depressive episode (MDE) in bipolar disorder (BD), or MDE with comorbid borderline personality disorder (MDE/BPD). We compared current and lifetime prevalence of suicidal ideation and behavior, and investigated dimensional measures of BPD or mixed affective features of the MDE as indicators of risk. METHODS: Based on screening of 1,655 referrals, we recruited 124 psychiatric secondary care outpatients with MDE and stratified them into three subcohorts (MDD, BD, and MDE/BPD) using the Structured Clinical Interview for DSM-IV I and II. We examined suicidal ideation and behavior with the Columbia Suicide Severity Rating Scale (CSSRS). In addition, we quantified the severity of BPD symptoms and BD mixed features both categorically/diagnostically and dimensionally (using instruments such as the Borderline Personality Disorder Severity Index) in two time frames. RESULTS: There were highly significant differences between the lifetime prevalences of suicide attempts between the subcohorts, with attempts reported by 16% of the MDD, 30% of the BD, and 60% of the BPD subcohort. Remarkably, the lifetime prevalence of suicide attempts in patients with comorbid BD and BPD exceeded 90%. The severity of BPD features was independently associated with risk of suicide attempts both lifetime and during the current MDE. It also associated in a dose-dependent manner with recent severity of ideation in both BPD and non-BPD patients. In multinominal logistic regression models, hopelessness was the most consistent independent risk factor for severe suicidal ideation in both time frames, whereas younger age and more severe BPD features were most consistently associated with suicide attempts. CONCLUSIONS: Among patients with major depressive episodes, diagnosis of bipolar disorder, or presence of comorbid borderline personality features both imply remarkably high risk of suicide attempts. Risk factors for suicidal ideation and suicidal acts overlap, but may not be identical. The estimated severity of borderline personality features seems to associate with history of suicidal behavior and current severity of suicidal ideation in dose-dependent fashion among all mood disorder patients. Therefore, reliable assessment of borderline features may advance the evaluation of suicide risk.

Role of Hopelessness in Suicidal Ideation Among Patients With Depressive Disorders.

OBJECTIVE: The cognitive theory of suicide postulates that hopelessness is an essential precondition for suicidal ideation in patients with depressive disorder . However, the explanatory power and predictive value of hopelessness for suicidal ideation remain uncertain. METHODS: From 1997 to 2007, patients with depressive disorder who were cohorts from the Vantaa Depression Studies (n = 406) completed the Scale for Suicide Ideation (SSI), Beck Hopelessness Scale (BHS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Perceived Social Support Scale-Revised (PSSS-R), and Eysenck Personality Inventory-Q (EPI-Q) at baseline, 6 and 18 months, and 5 years. We conducted a mixed-effects generalized linear regression and clustered receiver-operating characteristics analysis to test how well BDI and BHS predict severe suicidal ideation within and between patients. RESULTS: BHS predicted clinically significant suicidal ideation (odds ratio [OR] = 2.8), explaining 13.1% of between-patient and and 3.5% of within-patient variance of SSI. Adjusting for the fixed effect of BDI removed a substantial part of the effect of BHS on SSI (adjusted OR = 1.38, P = .018). BAI moderated the effect of BHS on SSI, whereas EPI-Q and PSSS-R did not. BDI detected suicidal ideation more accurately (area under the receiver-operating characteristics curve [AUC] = 0.846) than BHS (AUC = 0.754). CONCLUSIONS: In patients with depressive disorder, hopelessness explains suicidal ideation, but largely because it covaries with depressive symptoms. The role of hopelessness as a central determinant of suicidal ideation in depression may have been overestimated. Symptoms of anxiety moderate the association between hopelessness and suicidal ideation. Severity of depressive symptoms may predict suicidal ideation more accurately than hopelessness.

Association between solar insolation and a history of suicide attempts in bipolar I disorder.

In many international studies, rates of completed suicide and suicide attempts have a seasonal pattern that peaks in spring or summer. This exploratory study investigated the association between solar insolation and a history of suicide attempt in patients with bipolar I disorder. Solar insolation is the amount of electromagnetic energy from the Sun striking a surface area on Earth. Data were collected previously from 5536 patients with bipolar I disorder at 50 collection sites in 32 countries at a wide range of latitudes in both hemispheres. Suicide related data were available for 3365 patients from 310 onset locations in 51 countries. 1047 (31.1%) had a history of suicide attempt. There was a significant inverse association between a history of suicide attempt and the ratio of mean winter solar insolation/mean summer solar insolation. This ratio is smallest near the poles where the winter insolation is very small compared to the summer insolation. This ratio is largest near the equator where there is relatively little variation in the insolation over the year. Other variables in the model that were positively associated with suicide attempt were being female, a history of alcohol or substance abuse, and being in a younger birth cohort. Living in a country with a state-sponsored religion decreased the association. (All estimated coefficients p < 0.01). In summary, living in locations with large changes in solar insolation between winter and summer may be associated with increased suicide attempts in patients with bipolar disorder. Further investigation of the impacts of solar insolation on the course of bipolar disorder is needed.

Self-reported treatment adherence among psychiatric in- and outpatients.

BACKGROUND: Poor adherence to psychiatric treatment is a common clinical problem, leading to unfavourable treatment outcome and increased healthcare costs. AIM: The aim of this study was to investigate the self-reported adherence and attitudes to outpatient visits and pharmacotherapy in specialized care psychiatric patients. METHODS: Within the Helsinki University Psychiatric Consortium (HUPC) pilot study, in- and outpatients with schizophrenia or schizoaffective disorder (SSA, n = 113), bipolar disorder (BD, n = 99), or depressive disorder (DD, n = 188) were surveyed about their adherence and attitudes towards outpatient visits and pharmacotherapy. Correlates of self-reported adherence to outpatient and drug treatment were investigated using regression analysis. RESULTS: The majority (78.5%) of patients reported having attended outpatient visits regularly or only partly irregularly. Most patients (79.2%) also reported regular use of pharmacotherapy. Self-reported non-adherence to preceding outpatient visits was consistently and significantly more common among inpatients than outpatients across all diagnostic groups (p < .001). Across all groups, hospital setting was the strongest independent correlate of poor adherence to outpatient visits (SSA ß = -2.418, BD ß = -3.417, DD ß = -2.766; p < .001 in all). Another independent correlate of non-adherence was substance use disorder (SSA ß = -1.555, p = .001; BD ß = -1.535, p = .006; DD ß = -2.258, p < .000). No other socio-demographic or clinical factor was significantly associated with poor adherence in multivariate regression models. CONCLUSIONS: Irrespective of diagnosis, self-reported adherence to outpatient care among patients with schizophrenia or schizoaffective disorder, bipolar disorder, and depression is associated strongly with two factors: hospital setting and substance use disorders. Thus, detection of adherence problems among former inpatients and recognition and treatment of substance misuse are important to ensure proper outpatient care.

State and trait hopelessness in a prospective five-year study of patients with depressive disorders.

BACKGROUND: Hopelessness is a common experience of patients with depressive disorders (DD) and an important predictor of suicidal behaviour. However, stability and factors explaining state and trait variation of hopelessness in patients with DD over time are poorly known. METHODS: Patients with DD (n = 406) from the Vantaa Depression Study and the Vantaa Primary Care Depression Study filled in the Beck Hopelessness Scale (BHS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Perceived Social Support Scale-Revised (PSSS-R), and Eysenck Personality Inventory-Q (EPI-Q) at baseline, at six and eighteen months, and at five years. We conducted a multilevel linear regression analyses predicting BHS with these covariates. RESULTS: During the five-year follow-up half of the variance in BHS was attributable to between-patient variance (50.6%, CI = 41.2-61.5%), and the rest arose from within-patient variance and measurement errors. BDI and BAI explained 5.6% of within-patient and 28.4% of between-patient variance of BHS. High Neuroticism and low Extraversion explained 2.6% of the between-patient variance of BHS. PSSS-R explained 5% of between-patient variance and 1.7% of within-patient variance of BHS. LIMITATIONS: No treatment effects were controlled. CONCLUSIONS: Hopelessness varies markedly over time both within and between patients with depression; it is both state- and trait-related. Concurrent depressive and anxiety symptoms and low social support explain both state and trait variance, whereas high Neuroticism and low Extraversion explain only trait variance of hopelessness. These variations influence the utility of hopelessness as an indicator of suicide risk.

Pharmacological and psychosocial treatment of depression in primary care: Low intensity and poor adherence and continuity.

BACKGROUND: Primary health care bears the main responsibility for treating depression in most countries. However, few studies have comprehensively investigated provision of pharmacological and psychosocial treatments, their continuity, or patient attitudes and adherence to treatment in primary care. METHODS: In the Vantaa Primary Care Depression Study, 1111 consecutive primary care patients in the City of Vantaa, Finland, were screened for depression with Prime-MD, and 137 were diagnosed with DSM-IV depressive disorders via SCID-I/P and SCID-II interviews. The 100 patients with current major depressive disorder (MDD) or partly remitted MDD at baseline were prospectively followed up to 18 months, and their treatment contacts and the treatments provided were longitudinally followed. RESULTS: The median number of patients' visits to a general practitioner during the follow-up was five; of those due to depression two. Antidepressant treatment was offered to 82% of patients, but only 50% commenced treatment and adhered to it adequately. Psychosocial support was offered to 49%, but only 29% adhered to the highly variable interventions. Attributed reasons for poor adherence varied, including negative attitude, side effects, practical obstacles, or no perceived need. About one-quarter (23%) of patients were referred to specialized care at some time-point. LIMITATIONS: Moderate sample size. Data collected in 2002-2004. CONCLUSIONS: The majority of depressive patients in primary health care had been offered pharmacotherapy, psychotherapeutic support, or both. However, effectiveness of these efforts may have been limited by lack of systematic follow-up and poor adherence to both pharmacotherapy and psychosocial treatment.

Temperament, character, and suicide attempts in unipolar and bipolar mood disorders.

OBJECTIVE: Personality features may indicate risk for both mood disorders and suicidal acts. How dimensions of temperament and character predispose to suicide attempts remains unclear. METHOD: Patients (n = 597) from 3 prospective cohort studies (Vantaa Depression Study [VDS], Jorvi Bipolar Study [JoBS], and Vantaa Primary Care Depression Study [PC-VDS]) were interviewed at baseline, at 18 months, and, in VDS and PC-VDS, at 5 years (1997-2003). Personality was measured with the Temperament and Character Inventory-Revised (TCI-R), and follow-up time spent in major depressive episodes (MDEs) as well as lifetime (total) and prospectively ascertained suicide attempts during the follow-up were documented. RESULTS: Overall, 219 patients had 718 lifetime suicide attempts; 88 patients had 242 suicide attempts during the prospective follow-up. The numbers of both the total and prospective suicide attempts were associated with low self-directedness (ß = -0.266, P = .004, and ß = -0.294, P < .001, respectively) and high self-transcendence (ß = 0.287, P = .002, and ß = 0.233, P = .002, respectively). Total suicide attempts were linked to high novelty seeking (ß = 0.195, P = .05). Prospective, but not total, suicide attempts were associated with high harm avoidance (ß = 0.322, P < .001, and ß = 0.184, P = .062, respectively) and low reward dependence (ß = -0.274, P < .001, and ß = -0.134, P = .196, respectively), cooperativeness (ß = -0.181, P = .005, and ß = -0.096, P = .326, respectively), and novelty seeking (ß = -0.137, P = .047). No association remained significant when only prospective suicide attempts during MDEs were included. After adjustment was made for total time spent in MDEs, only high persistence predicted suicide attempts (ß = 0.190, P < .05). Formal mediation analyses of harm avoidance and self-directedness on prospectively ascertained suicide attempts indicated significant mediated effect through time at risk in MDEs, but no significant direct effect. CONCLUSIONS: Among mood disorder patients, suicide attempt risk is associated with temperament and character dimensions. However, their influence on predisposition to suicide attempts is likely to be mainly indirect, mediated by more time spent in depressive episodes.

Personality disorders and suicide attempts in unipolar and bipolar mood disorders.

BACKGROUND: Comorbid personality disorders may predispose patients with mood disorders to suicide attempts (SAs), but factors mediating this effect are not well known. METHODS: Altogether 597 patients from three prospective cohort studies (Vantaa Depression Study, Jorvi Bipolar Study, and Vantaa Primary Care Depression Study) were interviewed at baseline, at 18 months, and in VDS and PC-VDS at 5 years. Personality disorders (PDs) at baseline, number of previous SAs, life-charted time spent in major depressive episodes (MDEs), and precise timing of SAs during follow-up were determined and investigated. RESULTS: Overall, 219 (36.7%) patients had a total of 718 lifetime SAs; 88 (14.7%) patients had 242 SAs during the prospective follow-up. Having any PD diagnosis increased the SA rate, both lifetime and prospectively evaluated, by 90% and 102%, respectively. All PD clusters increased the rate of new SAs, although cluster C PDs more than the others. After adjusting for time spent in MDEs, only cluster C further increased the SA rate (by 52%). Mediation analyses of PD effects on prospectively ascertained SAs indicated significant mediated effects through time at risk in MDEs, but also some direct effects. LIMITATIONS: Findings generalizable only to patients with mood disorders. CONCLUSIONS: Among mood disorder patients, comorbid PDs increase the risk of SAs to approximately two-fold. The excess risk is mostly due to patients with comorbid PDs spending more time in depressive episodes than those without. Consequently, risk appears highest for PDs that most predispose to chronicity and recurrences. However, also direct risk-modifying effects of PDs exist.

A review of factors associated with greater likelihood of suicide attempts and suicide deaths in bipolar disorder: Part II of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder.

OBJECTIVES: Many factors influence the likelihood of suicide attempts or deaths in persons with bipolar disorder. One key aim of the International Society for Bipolar Disorders Task Force on Suicide was to summarize the available literature on the presence and magnitude of effect of these factors. METHODS: A systematic review of studies published from 1 January 1980 to 30 May 2014 identified using keywords 'bipolar disorder' and 'suicide attempts or suicide'. This specific paper examined all reports on factors putatively associated with suicide attempts or suicide deaths in bipolar disorder samples. Factors were subcategorized into: (1) sociodemographics, (2) clinical characteristics of bipolar disorder, (3) comorbidities, and (4) other clinical variables. RESULTS: We identified 141 studies that examined how 20 specific factors influenced the likelihood of suicide attempts or deaths. While the level of evidence and degree of confluence varied across factors, there was at least one study that found an effect for each of the following factors: sex, age, race, marital status, religious affiliation, age of illness onset, duration of illness, bipolar disorder subtype, polarity of first episode, polarity of current/recent episode, predominant polarity, mood episode characteristics, psychosis, psychiatric comorbidity, personality characteristics, sexual dysfunction, first-degree family history of suicide or mood disorders, past suicide attempts, early life trauma, and psychosocial precipitants. CONCLUSION: There is a wealth of data on factors that influence the likelihood of suicide attempts and suicide deaths in people with bipolar disorder. Given the heterogeneity of study samples and designs, further research is needed to replicate and determine the magnitude of effect of most of these factors. This approach can ultimately lead to enhanced risk stratification for patients with bipolar disorder.

Epidemiology, neurobiology and pharmacological interventions related to suicide deaths and suicide attempts in bipolar disorder: Part I of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder.

OBJECTIVES: Bipolar disorder is associated with elevated risk of suicide attempts and deaths. Key aims of the International Society for Bipolar Disorders Task Force on Suicide included examining the extant literature on epidemiology, neurobiology and pharmacotherapy related to suicide attempts and deaths in bipolar disorder. METHODS: Systematic review of studies from 1 January 1980 to 30 May 2014 examining suicide attempts or deaths in bipolar disorder, with a specific focus on the incidence and characterization of suicide attempts and deaths, genetic and non-genetic biological studies and pharmacotherapy studies specific to bipolar disorder. We conducted pooled, weighted analyses of suicide rates. RESULTS: The pooled suicide rate in bipolar disorder is 164 per 100,000 person-years (95% confidence interval = [5, 324]). Sex-specific data on suicide rates identified a 1.7:1 ratio in men compared to women. People with bipolar disorder account for 3.4-14% of all suicide deaths, with self-poisoning and hanging being the most common methods. Epidemiological studies report that 23-26% of people with bipolar disorder attempt suicide, with higher rates in clinical samples. There are numerous genetic associations with suicide attempts and deaths in bipolar disorder, but few replication studies. Data on treatment with lithium or anticonvulsants are strongly suggestive for prevention of suicide attempts and deaths, but additional data are required before relative anti-suicide effects can be confirmed. There were limited data on potential anti-suicide effects of treatment with antipsychotics or antidepressants. CONCLUSION: This analysis identified a lower estimated suicide rate in bipolar disorder than what was previously published. Understanding the overall risk of suicide deaths and attempts, and the most common methods, are important building blocks to greater awareness and improved interventions for suicide prevention in bipolar disorder. Replication of genetic findings and stronger prospective data on treatment options are required before more decisive conclusions can be made regarding the neurobiology and specific treatment of suicide risk in bipolar disorder.

Influence of light exposure during early life on the age of onset of bipolar disorder.

BACKGROUND: Environmental conditions early in life may imprint the circadian system and influence response to environmental signals later in life. We previously determined that a large springtime increase in solar insolation at the onset location was associated with a younger age of onset of bipolar disorder, especially with a family history of mood disorders. This study investigated whether the hours of daylight at the birth location affected this association. METHODS: Data collected previously at 36 collection sites from 23 countries were available for 3896 patients with bipolar I disorder, born between latitudes of 1.4 N and 70.7 N, and 1.2 S and 41.3 S. Hours of daylight variables for the birth location were added to a base model to assess the relation between the age of onset and solar insolation. RESULTS: More hours of daylight at the birth location during early life was associated with an older age of onset, suggesting reduced vulnerability to the future circadian challenge of the springtime increase in solar insolation at the onset location. Addition of the minimum of the average monthly hours of daylight during the first 3 months of life improved the base model, with a significant positive relationship to age of onset. Coefficients for all other variables remained stable, significant and consistent with the base model. CONCLUSIONS: Light exposure during early life may have important consequences for those who are susceptible to bipolar disorder, especially at latitudes with little natural light in winter. This study indirectly supports the concept that early life exposure to light may affect the long term adaptability to respond to a circadian challenge later in life.

International Society for Bipolar Disorders Task Force on Suicide: meta-analyses and meta-regression of correlates of suicide attempts and suicide deaths in bipolar disorder.

OBJECTIVES: Bipolar disorder is associated with a high risk of suicide attempts and suicide death. The main objective of the present study was to identify and quantify the demographic and clinical correlates of attempted and completed suicide in people with bipolar disorder. METHODS: Within the framework of the International Society for Bipolar Disorders Task Force on Suicide, a systematic review of articles published since 1980, characterized by the key terms bipolar disorder and 'suicide attempts' or 'suicide', was conducted, and data extracted for analysis from all eligible articles. Demographic and clinical variables for which ≥ 3 studies with usable data were available were meta-analyzed using fixed or random-effects models for association with suicide attempts and suicide deaths. There was considerable heterogeneity in the methods employed by the included studies. RESULTS: Variables significantly associated with suicide attempts were: female gender, younger age at illness onset, depressive polarity of first illness episode, depressive polarity of current or most recent episode, comorbid anxiety disorder, any comorbid substance use disorder, alcohol use disorder, any illicit substance use, comorbid cluster B/borderline personality disorder, and first-degree family history of suicide. Suicide deaths were significantly associated with male gender and first-degree family history of suicide. CONCLUSIONS: This paper reports on the presence and magnitude of the correlates of suicide attempts and suicide deaths in bipolar disorder. These findings do not address causation, and the heterogeneity of data sources should limit the direct clinical ranking of correlates. Our results nonetheless support the notion of incorporating diagnosis-specific data in the development of models of understanding suicide in bipolar disorder.

Relationship between sunlight and the age of onset of bipolar disorder: an international multisite study.

BACKGROUND: The onset of bipolar disorder is influenced by the interaction of genetic and environmental factors. We previously found that a large increase in sunlight in springtime was associated with a lower age of onset. This study extends this analysis with more collection sites at diverse locations, and includes family history and polarity of first episode. METHODS: Data from 4037 patients with bipolar I disorder were collected at 36 collection sites in 23 countries at latitudes spanning 3.2 north (N) to 63.4 N and 38.2 south (S) of the equator. The age of onset of the first episode, onset location, family history of mood disorders, and polarity of first episode were obtained retrospectively, from patient records and/or direct interview. Solar insolation data were obtained for the onset locations. RESULTS: There was a large, significant inverse relationship between maximum monthly increase in solar insolation and age of onset, controlling for the country median age and the birth cohort. The effect was reduced by half if there was no family history. The maximum monthly increase in solar insolation occurred in springtime. The effect was one-third smaller for initial episodes of mania than depression. The largest maximum monthly increase in solar insolation occurred in northern latitudes such as Oslo, Norway, and warm and dry areas such as Los Angeles, California. LIMITATIONS: Recall bias for onset and family history data. CONCLUSIONS: A large springtime increase in sunlight may have an important influence on the onset of bipolar disorder, especially in those with a family history of mood disorders.

Differences in incidence of suicide attempts between bipolar I and II disorders and major depressive disorder.

OBJECTIVES: Whether risk of suicide attempts (SAs) differs between patients with bipolar disorder (BD) and patients with major depressive disorder (MDD) is unclear. We investigated whether cumulative risk differences are due to dissimilarities in time spent in high-risk states, incidence per unit time in high-risk states, or both. METHODS: Incidence rates for SAs during various illness phases, based on prospective life charts, were compared between patients from the Jorvi Bipolar Study (n = 176; 18 months) and the Vantaa Depression Study (n = 249; five years). Risk factors and their interactions with diagnosis were investigated with Cox proportional hazards models. RESULTS: By 18 months, 19.9% of patients with BD versus 9.5% of patients with MDD had attempted suicide. However, patients with BD spent 4.6% of the time in mixed episodes, and more time in major depressive episodes (MDEs) (35% versus 21%, respectively) and in subthreshold depression (39% versus 31%, respectively) than those with MDD. Compared with full remission, the combined incidence rates of SAs were 5-, 25-, and 65-fold in subthreshold depression, MDEs, and BD mixed states, respectively. Between cohorts, incidence of attempts was not different during comparable symptom states. In Cox models, hazard was elevated during MDEs and subthreshold depression, and among patients with preceding SAs, female patients, those with poor social support, and those aged < 40 years, but was unrelated to BD diagnosis. CONCLUSIONS: The observed higher cumulative incidence of SAs among patients with BD than among those with MDD is mostly due to patients with BD spending more time in high-risk illness phases, not to differences in incidence during these phases, or to bipolarity itself. BD mixed phases contribute to differences involving very high incidence, but short duration. Diminishing the time spent in high-risk phases is crucial for prevention.

Depression and smoking: a 5-year prospective study of patients with major depressive disorder.

BACKGROUND: Major depressive disorder (MDD) and smoking are major public health problems and epidemiologically strongly associated. However, the relationship between smoking and depression and whether this is influenced by common confounding factors remain unclear, in part due to limited longitudinal data on covariation. METHODS: In the Vantaa Depression Study, psychiatric out- and inpatients with DSM-IV MDD and aged 20-59 years at were followed from baseline to 6 months, 18 months, and 5 years. We investigated course of depression, smoking, and comorbid alcohol-use disorders among the 214 patients (79.6% of 269) participating at least three time points; differences between smoking versus nonsmoking patients, and covariation of MDD, smoking, and alcohol-use disorders. RESULTS: Overall, 31.3% of the patients smoked regularly, 41.1% intermittently, and 27.6% never. Smokers were younger, had more alcohol-use disorders and Cluster B and C personality disorder symptoms, a higher frequency of lifetime suicide attempts, higher neuroticism, smaller social networks, and lower perceived social support than never smokers. Smoking and depression had limited longitudinal covariation. Depression, smoking, and alcohol-use disorders all exhibited strong autoregressive tendencies. CONCLUSIONS: Among adult psychiatric MDD patients, smoking is strongly associated with substance-use and personality disorders, which may confound research on the impact of smoking. Rather than depression or smoking covarying or predicting each other, depression, smoking, and alcohol-use disorders each have strong autoregressive tendencies. These findings are more consistent with common factors causing their association than either of the conditions strongly predisposing to the other.