High secondary attack rate and persistence of SARS-CoV-2 antibodies in household transmission study participants, Finland 2020-2021.

Background: Household transmission studies offer the opportunity to assess both secondary attack rate (SAR) and persistence of SARS-CoV-2 antibodies over time. Methods: In Spring 2020, we invited confirmed COVID-19 cases and their household members to four visits, where we collected nasopharyngeal and serum samples over 28 days after index case onset. We calculated SAR based on the presence of SARS-CoV-2 neutralizing antibodies (NAb) and assessed the persistence of NAb and IgG antibodies (Ab) against SARS-CoV-2 spike glycoprotein and nucleoprotein. Results: SAR was 45% (39/87), including 35 symptomatic secondary cases. During the initial 28-day follow-up, 62% (80/129) of participants developed NAb. Of those that seroconverted, 90% (63/70), 85% (63/74), and 78% (45/58) still had NAb to early B-lineage SARS-CoV-2 3, 6, and 12 months after the onset of the index case. Anti-spike IgG Ab persisted in 100% (69/69), 97% (72/74), and 93% (55/59) of seroconverted participants after 3, 6, and 12 months, while anti-nucleoprotein IgG Ab levels waned faster, persisting in 99% (68/69), 78% (58/74), and 55% (39/71) of participants, respectively. Conclusion: Following detection of a COVID-19 case in a household, other members had a high risk of becoming infected. NAb to early B-lineage SARS-CoV-2 persisted for at least a year in most cases.

Long-term work disability due to type I and II bipolar disorder: findings of a six-year prospective study.

BACKGROUND: Bipolar disorder (BD) is one of the leading causes of disability worldwide. However, the prevalence and predictors of long-term work disability among patients with type I and II BD have scarcely been studied. We investigated the clinical predictors of long-term work disability among patients with BD. METHODS: The Jorvi Bipolar Study (JoBS) is a naturalistic prospective cohort study (n = 191) of adult psychiatric in- and out-patients with DSM-IV type I and II BD in three Finnish cities. Within JoBS we examined the prevalence and predictors of disability pension being granted during a six-year follow-up of the 152 patients in the labor force at baseline and collected information on granted pensions from national registers. We determined the predictors of disability pension using logistic regression models. RESULTS: Over the 6 years, 44% of the patients belonging to the labor force at baseline were granted a disability pension. Older age; type I BD; comorbidity with generalized anxiety disorder, post-traumatic stress disorder or avoidant personality disorder; and duration of time with depressive or mixed symptoms predicted disability pensions. Including disability pensions granted before baseline increased their total prevalence to 55.5%. The observed predictors were similar. CONCLUSION: This regionally representative long-term prospective study found that about half of patients with type I or II bipolar disorder suffer from persistent work disability that leads to disability pension. In addition to the severity of the clinical course and type I bipolar disorder, the longitudinal accumulation of time depressed, psychiatric comorbidity, and older age predicted pensioning.

Predominant polarity in bipolar I and II disorders: A five-year follow-up study.

BACKGROUND: Patients with bipolar disorder (BD) differ in their relative predominance of types of episodes, yielding predominant polarity, which has important treatment implications. However, few prospective studies of predominant polarity exist. METHODS: In the Jorvi Bipolar Study (JoBS), a regionally representative cohort of 191 BD I and BD II in- and outpatients was followed for five years using life-chart methodology. Differences between depressive (DP), manic (MP), and no predominant polarity (NP) groups were examined regarding time ill, incidence of suicide attempts, and comorbidity. RESULTS: At baseline, 16% of patients had MP, 36% DP, and 48% NP. During the follow-up the MP group spent significantly more time euthymic, less time in major depressive episodes, and more time in manic states than the DP and NP groups. The MP group had significantly lower incidence of suicide attempts than the DP and NP group, lower prevalence of comorbid anxiety disorders but more psychotic symptoms lifetime and more often (hypo)manic first phase of the illness than the DP group. Classification of predominant polarity was influenced by the timeframe used. LIMITATIONS: The retrospective counting of former phases is vulnerable to recall bias. Assignment of dominant polarity may necessitate a sufficient number of illness phases. CONCLUSIONS: Predominant polarity has predictive value in predicting group differences in course of illness, but individual patients' classification may change over time. Patients with manic polarity may represent a more distinct subgroup than the two others regarding illness course, suicide attempts, and psychiatric comorbidity.

Incidence and predictors of suicide attempts in bipolar I and II disorders: A 5-year follow-up study.

OBJECTIVES: Few long-term studies on bipolar disorder (BD) have investigated the incidence and risk factors of suicide attempts (SAs) specifically related to illness phases. We examined the incidence of SAs during different phases of BD in a long-term prospective cohort of bipolar I (BD-I) and bipolar II (BD-II) patients, and risk factors specifically for SAs during major depressive episodes (MDEs). METHODS: In the Jorvi Bipolar Study (JoBS), 191 BD-I and BD-II patients were followed using life-chart methodology. Prospective information on SAs of 177 patients (92.7%) during different illness phases was available up to 5 years. The incidence of SAs and their predictors were investigated using logistic and Poisson regression models. Analyses of risk factors for SAs occurring during MDEs were conducted using two-level random-intercept logistic regression models. RESULTS: During the 5 years of follow-up, 90 SAs per 718 patient-years occurred. The incidence was highest, over 120-fold higher than in euthymia, during mixed states (765/1000 person-years; 95% confidence interval [CI] 461-1269 person-years), and also very high in MDEs, almost 60-fold higher than in euthymia (354/1000 person-years; 95% CI 277-451 person-years). For risk of SAs during MDEs, the duration of MDEs, severity of depression, and cluster C personality disorders were significant predictors. CONCLUSIONS: We confirmed in this long-term study that the highest incidences of SAs occur in mixed and major depressive illness phases. The variations in incidence rates between euthymia and illness phases were remarkably large, suggesting that the question "when" rather than "who" may be more relevant for suicide risk in BD. However, risk during MDEs is likely also influenced by personality factors.

Predictors of long-term work disability among patients with type I and II bipolar disorder: a prospective 18-month follow-up study.

OBJECTIVES: Bipolar disorder (BD) is one of the leading causes of disability worldwide. However, vocational ability and predictors of long-term work disability have rarely been studied among patients with BD. We investigated clinical predictors of work disability among patients with BD in psychiatric care. METHODS: The Jorvi Bipolar Study (JoBS) is a naturalistic prospective cohort study (N = 191) representing adult (18-59 years) psychiatric inpatients and outpatients with DSM-IV bipolar I disorder (BD-I) and bipolar II disorder (BD-II) in three Finnish cities. Within the JoBS, we investigated the prevalence of disability pensions at baseline, and predictors for being granted a disability pension during an 18-month follow-up of the 151 patients in the labor force at baseline. Cox models were used to determine predictors for onset of disability pension. RESULTS: At baseline, 21% (40/191) of the patients already had a disability pension. During the follow-up, a further 38 patients (25% of the 151 followed) were granted a new disability pension. The predictors included older age, male gender, depressive index episode, higher number of psychiatric hospitalizations, generalized anxiety disorder, avoidant personality disorder, and depressive burden during follow-up. However, the predictors differed depending on bipolar subtype, age, and gender. CONCLUSIONS: BD-I and BD-II are associated with a major risk of long-term work disability, the proportion of patients with a disability pension rising to 41% in the medium-term follow-up of the Finnish cohort investigated in the present study. Severe clinical course, depression, comorbidities, age, and gender are likely to be the main predictors but predictors may vary depending on the subgroup.

Five-year outcome of bipolar I and II disorders: findings of the Jorvi Bipolar Study.

OBJECTIVES: The long-term outcome of bipolar disorder (BD) has been extensively investigated. However, previous studies may be biased towards hospitalized patients with bipolar I disorder (BD-I), and generalizability to the current treatment era remains uncertain. In this naturalistic study, we followed a secondary-care cohort of patients with BD. METHODS: In the Jorvi Bipolar Study, 191 patients with BD-I and bipolar II disorder (BD-II) were followed using a life-chart method. Interviews were conducted at six months, 18 months, and five years. Time to full remission, time to first recurrence, total time ill, their predictors, and BD-I versus BD-II differences were investigated among the 151 patients remaining in follow-up. RESULTS: Nearly all subjects recovered from the index episode, but almost all (90%) had a recurrence, and most had multiple recurrences. The patients spent about one-third of their time in illness episodes and 15% of their time with subthreshold symptoms; half of the time they were euthymic. After controlling for confounders, no difference in time spent in depressive states between patients with BD-I and BD-II persisted. Among patients with a depressive index phase, cluster C personality disorders [hazard ratio (HR) = 0.452, p = 0.040] and higher 17-item Hamilton Depression Scale score (HR = 0.951, p = 0.022) predicted longer time to remission, whereas lifetime psychotic symptoms (HR = 2.162, p = 0.016) predicted shorter time to first recurrence. CONCLUSIONS: Among patients with BD, chronicity as uninterrupted persistence of illness was rare, but multiple recurrences were the norm. Patients with BD spent only half of their time euthymic. Patients with BD-I and BD-II may differ little in proneness to depressive states. Severity of depression, cluster C personality disorders, and psychotic symptoms predicted outcome.

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.

Predictors of adherence to psychopharmacological and psychosocial treatment in bipolar I or II disorders - an 18-month prospective study.

BACKGROUND: Poor treatment adherence among patients with bipolar disorder (BD) is a common clinical problem. However, whether adherence is mostly determined by patient characteristics or attitudes, type of treatment or treatment side-effects remains poorly known. METHODS: The Jorvi Bipolar Study (JoBS) is a naturalistic prospective 18-month study representing psychiatric in- and outpatients with DSM-IV BD I and II in three Finnish cities. During the 18-month follow-up we investigated the continuity of, attitudes towards and adherence to various types of psychopharmacological and psychosocial treatments among 168 psychiatric in- and outpatients with BD I or II. RESULTS: One-quarter of the patients using mood stabilizers or atypical antipsychotics discontinued medication during at least one treatment phase of the follow-up autonomously, mostly during depression. When pharmacotherapy continued, adherence was compromised in one-third. Rates of non-adherence to mood stabilizers or antipsychotics did not differ, but the predictors did. One-quarter of the patients receiving psychosocial treatments were non-adherent to them. LIMITATIONS: Serum concentrations were not estimated. CONCLUSIONS: More than one-half of BD patients either discontinue pharmacotherapy or use it irregularly. Autonomous discontinuation takes place mostly in depression. Although rates of non-adherence do not necessarily differ between mood-stabilizing medications, the predictors for nonadherence do. Moreover, adherence to one medication does not guarantee adherence to another, nor does adherence at one time-point ensure later adherence. Attitudes towards treatments affect adherence to medications as well as to psychosocial treatments and should be repeatedly monitored. Non-adherence to psychosocial treatment should be given more attention.

[Assessment of a self-destructive patient]. / Itsetuhoisen potilaan arviointi.

Previous suicide attempt signifies an almost 40-fold suicidal risk. When assessing the danger of suicide the patient should always be asked directly about possible suicidal thoughts or plans. Since most persons having committed or attempted suicide have a psychiatric illness, the diagnosis and treatment of these illnesses are important means to prevent self-destructive behavior. Besides active and intensive therapy, the mediation of hope in all engagements is essential. The mental status of a person having attempted suicide must be assessed, and appropriate follow-up care should be arranged.

Concomitants of family histories of mood disorders and alcoholism in a clinical cohort of patients with bipolar I and II disorder.

We diagnosed 191 secondary-care outpatients and inpatients with DSM-IV BD I or II. Sociodemographic and clinical characteristics, including axis I and II comorbidity, neuroticism, and prospective life-chart were evaluated at intake and at 6 and 18 months. The family history (FH) of mood disorders, alcoholism, or any major psychiatric disorders among first-degree relatives was investigated in a semistructured interview. Most (74%) patients had some positive FH; 55% of mood disorder, 36% of alcoholism. Positive FH was associated with psychiatric comorbidity and depressive course in the proband. Based on a multinomial logistic regression model, patients with an FH of mood disorder and alcoholism had an odds ratio of 4.8 (p = 0.001) for having an anxiety disorder. Overall, the first-degree relatives of patients with BD have multiple types of mental disorders, which correlate with bipolar patients' course of illness and psychiatric comorbidity. The strongest associations are between FH of mood disorders and presence of comorbid anxiety disorders.

[Maintenance therapy in bipolar affective disorder]. / Ylläpitohoito kaksisuuntaisessa mielialahäiriössä.

In bipolar affective disorder, the patients exhibit life-long susceptibility to periodic episodes of depression, mania, hypomania, including mixed phases. Maintenance therapy aims to prevent new episodes of affective disorder and associated self-destructive behavior, to prevent milder symptoms occurring between the actual episodes and to maintain functional capacity. Maintenance therapy is always initiated upon the diagnosis of bipolar affective disorder. In a type II disorder with mild symptoms, gradual termination of maintenance therapy can be considered while monitoring the status of the patient. The drug is chosen on the basis of individual benefit/risk ratio.

P2RX7 gene is associated consistently with mood disorders and predicts clinical outcome in three clinical cohorts.

We investigated the effect of nine candidate genes on risk for mood disorders, hypothesizing that predisposing gene variants not only elevate the risk for mood disorders but also result in clinically significant differences in the clinical course of mood disorders. We genotyped 178 DSM-IV bipolar I and II and 272 major depressive disorder patients from three independent clinical cohorts carefully diagnosed with semistructured interviews and prospectively followed up with life charts for a median of 60 (range 6-83) months. Healthy control subjects (n = 1322) were obtained from the population-based national Health 2000 Study. We analyzed 62 genotyped variants within the selected genes (BDNF, NTRK2, SLC6A4, TPH2, P2RX7, DAOA, COMT, DISC1, and MAOA) against the presence of mood disorder, and in post-hoc analyses, specifically against bipolar disorder or major depressive disorder. Estimates for time ill were based on life charts. The P2RX7 gene variants rs208294 and rs2230912 significantly elevated the risk for a familial mood disorder (OR = 1.35, P = 0.0013, permuted P = 0.06, and OR = 1.44, P = 0.0031, permuted P = 0.17, respectively). The results were consistent in all three cohorts. The same risk alleles predicted more time ill in all cohorts (OR 1.3, 95% CI 1.1-1.6, P = 0.0069 and OR 1.7, 95% CI 1.3-2.3, P = 0.0002 with rs208294 and rs2230912, respectively), so that homozygous carriers spent 12 and 24% more time ill. P2RX7 and its risk alleles predisposed to mood disorders consistently in three independent clinical cohorts. The same risk alleles resulted in clinically significant differences in outcome of patients with major depressive and bipolar disorder.

A prospective latent analyses study of psychiatric comorbidity of DSM-IV bipolar I and II disorders.

OBJECTIVE: To test two hypotheses of psychiatric comorbidity in bipolar disorder (BD): (i) comorbid disorders are independent of BD course, or (ii) comorbid disorders associate with mood. METHODS: In the Jorvi Bipolar Study (JoBS), 191 secondary-care outpatients and inpatients with DSM-IV bipolar I disorder (BD-I) or bipolar II disorder (BD-II) were evaluated with the Structured Clinical Interview for DSM-IV Disorders, with psychotic screen, plus symptom scales, at intake and at 6 and 18 months. Three evaluations of comorbidity were available for 144 subjects (65 BD-I, 79 BD-II; 76.6% of 188 living patients). Structural equation modeling (SEM) was used to examine correlations between mood symptoms and comorbidity. A latent change model (LCM) was used to examine intraindividual changes across time in depressive and anxiety symptoms. Current mood was modeled in terms of current illness phase, Beck Depression Inventory (BDI), Young Mania Rating Scale, and Hamilton Depression Rating Scale; comorbidity in terms of categorical DSM-IV anxiety disorder diagnosis, Beck Anxiety Inventory (BAI) score, and DSM-IV-based scales of substance use and eating disorders. RESULTS: In the SEM, depression and anxiety exhibited strong cross-sectional and autoregressive correlation; high levels of depression were associated with high concurrent anxiety, both persisting over time. Substance use disorders covaried with manic symptoms (r = 0.16-0.20, p < 0.05), and eating disorders with depressive symptoms (r = 0.15-0.32, p < 0.05). In the LCM, longitudinal intraindividual improvements in BDI were associated with similar BAI improvement (r = 0.42, p < 0.001). CONCLUSIONS: Depression and anxiety covary strongly cross-sectionally and longitudinally in BD. Substance use disorders are moderately associated with manic symptoms, and eating disorders with depressive mood.

Differences in neuroticism and extraversion between patients with bipolar I or II and general population subjects or major depressive disorder patients.

BACKGROUND: Whether levels of neuroticism or extraversion differ between patients with bipolar disorder (BD), major depressive disorder (MDD) and subjects from the general population, or between BD I and BD II patients, remains unclear. METHODS: BD patients (n=191) from the Jorvi Bipolar Study, and MDD patients (n=358) from both the Vantaa Depression Study and the Vantaa Primary Care Depression Study cohorts, were interviewed at baseline and at 18 months. A general population comparison group (n=347) was surveyed by mail. BD patients' neuroticism and extraversion scores, measured by Eysenck Personality Inventory, were compared at an index interview, when the levels of depression and mania were lowest, with scores of MDD patients and general population controls. Comparisons were also made between BD I (n=99) and BD II (n=92) patients. RESULTS: In multinomial logistic regression, BD patients had higher neuroticism (OR=1.17, p<0.001) and lower extraversion (OR=0.92, p=0.003) than the general population. When entered simultaneously into the model, the effect of extraversion disappeared. In logistic regression, the levels of neuroticism and extraversion did not differ between BD and MDD patients, or between BD I and II patients. LIMITATIONS: Patients' personality scores were not pre-morbid. CONCLUSIONS: Levels of neuroticism and extraversion are unlikely to differ between BD and MDD patients, or between BD I and II patients. The overall level of neuroticism is moderately higher and extraversion somewhat lower in BD patients than in the general population. High neuroticism may be an indicator of vulnerability to both bipolar and unipolar mood disorders.

Maintenance treatment received by patients with bipolar I and II disorders--a naturalistic prospective study.

BACKGROUND: We investigated the adequacy of maintenance phase pharmacotherapy received by psychiatric in- and outpatients with bipolar I or II disorder, including patients both with and without a clinical diagnosis of bipolar disorder (BD). METHODS: In the Jorvi Bipolar Study (JoBS), a naturalistic prospective 18-month study representing psychiatric in- and outpatients with DSM-IV BD I and II in three Finnish cities, we studied the adequacy of pharmacological treatment received by 154 patients during the first maintenance phase after index episode. Information on treatments prescribed during the follow-up was gathered in interviews and from psychiatric records. RESULTS: Of the patients with a maintenance phase in follow-up, adequate maintenance treatment was received by 75.3% for some time, but by only 61.0% throughout the maintenance phase and for 69.3% of the time (783/1129 patient months) indicated. Uninterrupted adequate maintenance treatment received was most strongly independently associated with having a clinical diagnosis of BD; other associations included inpatient treatment, rapid cycling and not having a personality disorder. LIMITATIONS: Adequacy of dosage, duration or serum concentrations were not estimated. Findings represent an upper limit for adequate treatment within the cohort. CONCLUSIONS: Provision or continuity of maintenance treatment was found to be compromised in more than one-third of BD patients during their first follow-up maintenance phase. As expected, clinical diagnosis of BD has a decisive role in determining adequacy of maintenance treatments. However, also rapid cycling may facilitate provision of adequate maintenance treatment, whereas outpatients and those with comorbid personality disorders may be disadvantaged subgroups.

Outcome of patients with major depressive disorder after serious suicide attempt.

OBJECTIVE: To investigate the outcome of subjects with major depressive disorder after serious suicide attempt and to examine the effect of psychotic symptoms on their outcome. METHOD: The study population included all individuals aged 16 years or older in Finland who were hospitalized with ICD-10 diagnoses of major depressive disorder and attempted suicide from 1996 to 2003 (N = 1,820). The main outcome measures were completed suicides, overall mortality, and repeated suicide attempts during drug treatment versus no treatment. RESULTS: During the 4-year follow-up period, 13% of patients died, 6% completed suicide, and 31% made a repeat suicide attempt. Subjects with major depression with psychotic features completed suicide more often than subjects without psychotic features during the follow-up (hazard ratio [HR] 3.32; 95% CI, 1.95 - 5.67). Antidepressant treatment reduced all-cause mortality by 24% (HR 0.74; 95% CI, 0.56 - 0.97) but did not reduce suicide mortality (HR 1.06; 95% CI, 0.71 - 1.58). CONCLUSIONS: Psychotic symptoms during major depressive episode increase the risk of completed suicide after serious suicide attempt. The quality of treatment for major depression with psychotic features after attempted suicide should be improved to prevent suicide.

How suicidal bipolar patients are depends on how suicidal ideation is defined.

BACKGROUND: Suicidal ideation indicates risk for suicidal acts. How different definitions and measures for suicidal ideation influence its prevalence, correlates and predictive validity among bipolar disorder (BD) patients is unknown. METHODS: Among the 191 BD patients in the Jorvi Bipolar Study (JoBS), suicidal ideation at baseline was measured using the Scale for Suicidal Ideation (SSI), Hamilton Depression Scale (HAM-D) item 3 and Beck Depression Inventory (BDI) item 9 and by asking whether patients had seriously considered suicide. The predictive value of different definitions of ideation on suicide attempts during a six-month follow-up was investigated. RESULTS: Altogether 74% of patients had suicidal ideation as defined in at least one of the above-mentioned ways, but only 29% met the criteria for all ways; agreement between definitions ranged from low to moderate (kappa coefficient 0.15 to 0.70). The correlates of suicidal ideation overlapped, but were not identical. Of the measures investigated, a baseline SSI score >or=8 had the best combination of sensitivity (0.81) and specificity (0.69) and a positive predictive value (PPV) of 32% for an attempted suicide during follow-up. LIMITATIONS: All plausible measures for suicidal ideation could not be investigated. CONCLUSIONS: Who is classified as having suicidal ideation depends strongly on the definition and means of measurement among BD patients. Different measures for ideation have the potential to cause inconsistency when correlates of suicidal ideation are investigated. For clinically predicting suicide attempts during the next few months, an SSI score >or=8 may best combine sensitivity and specificity.

Hopelessness across phases of bipolar I or II disorder: a prospective study.

BACKGROUND: Hopelessness, a key risk factor for suicidal behaviour overall, has been studied little among bipolar disorder (BD) patients. For purposes of prevention, it is important to know whether it is predominantly a patient's permanent trait or merely reflects the highly variable illness states. We investigated the degree to which hopelessness is trait- or state-related during the course of BD. METHODS: The Jorvi Bipolar Study (JoBS) is a naturalistic prospective study representing psychiatric in- and outpatients with DSM-IV BD I and II. Repeated measurements with the Beck Hopelessness Scale of 188 patients at baseline, 6 months and 18 months were analysed using a linear regression model with general estimation equations. Factors covarying with hopelessness during follow-up were investigated. RESULTS: Levels of hopelessness varied markedly between illness phases, being highest in depressive and mixed phases, and lowest in euthymia, hypomania or mania. Hopelessness was independently associated with concurrent severity of depression (estimate 0.231, p<0.001), anxiety (0.105, p<0.001), fewer manic symptoms (-0.096, p=0.001) and comorbid personality disorder (1.741, p=0.001). However, the strongest predictor of degree of hopelessness during follow-up was previous hopelessness (0.403, p<0.001). LIMITATIONS: After baseline, relatively few patients had manic, hypomanic, mixed or depressive mixed phases. Hopelessness was measured at only three time-points. CONCLUSIONS: Level of hopelessness varies markedly between patients in different phases of BD, but is also, to a degree, a permanent feature. Among BD patients, hopelessness appears to be both a trait- and state-related characteristic.

Differences in incidence of suicide attempts during phases of bipolar I and II disorders.

BACKGROUND: Differences in the incidence of suicide attempts during various phases of bipolar disorder (BD), or the relative importance of static versus time-varying risk factors for overall risk for suicide attempts, are unknown. METHODS: We investigated the incidence of suicide attempts in different phases of BD as a part of the Jorvi Bipolar Study (JoBS), a naturalistic, prospective, 18-month study representing psychiatric in- and outpatients with DSM-IV BD in three Finnish cities. Life charts were used to classify time spent in follow-up in the different phases of illness among the 81 BD I and 95 BD II patients. RESULTS: Compared to the other phases of the illness, the incidence of suicide attempts was 37-fold higher [95% confidence interval (CI) for relative risk (RR): 11.8-120.3] during combined mixed and depressive mixed states, and 18-fold higher (95% CI: 6.5-50.8) during major depressive phases. In Cox's proportional hazards regression models, combined mixed (mixed or depressive mixed) or major depressive phases and prior suicide attempts independently predicted suicide attempts. No other factor significantly modified the risks related to these time-varying risk factors; their population-attributable fraction was 86%. CONCLUSIONS: The incidence of suicide attempts varies remarkably between illness phases, with mixed and depressive phases involving the highest risk by time. Time spent in high-risk illness phases is likely the major determinant of overall risk for suicide attempts among BD patients. Studies of suicidal behavior should investigate the role of both static and time-varying risk factors in overall risk; clinically, management of mixed and depressive phases may be crucial in reducing risk.