Suicide and Bipolar Disorder

  • Zoltán RihmerEmail author
  • Péter Döme
Part of the Milestones in Drug Therapy book series (MDT)


Bipolar disorders are common but frequently under-referred, underdiagnosed, and undertreated illnesses with markedly elevated premature mortality. Up to 15 % of patients with bipolar disorder (BD) die by suicide, and about half of them make at least one suicide attempt in their lifetime. The suicide rate of (untreated) BD patients is 20–25 times higher than the same rate in the general population. Suicidal behavior (completed suicide and suicide attempt) in BD patients occurs almost exclusively during the severe major (often mixed) depressive episode and less frequently in mania with mixed features but very rarely during euphoric mania, hypomania, or euthymia; this suggests that suicidal behavior in BD patients is a state- and severity-dependent phenomenon. However, since the majority of BD patients never commit suicide (and up to 50 % of them never attempt it), risk factors other than BD itself also play a significant contributory role. This chapter summarizes the clinically most relevant suicide risk and protective factors in BD and also briefly explores the most effective suicide prevention strategies.


Bipolar disorder Unipolar depression Major depressive episode Suicide Suicide attempt Suicide ideation Suicide risk factors Suicide protective factors Suicide prevention 


  1. Ahrens B, Muller-Oerlinghausen B (2001) Does lithium exert an independent antisuicidal effect? Pharmacopsychiatry 34(4):132–136CrossRefPubMedGoogle Scholar
  2. Akiskal H (2007) Targeting suicide prevention to modifiable risk factors: has bipolar II been overlooked? Acta Psychiatr Scand 116(6):395–402CrossRefPubMedGoogle Scholar
  3. Akiskal HS, Hantouche EG, Allilaire JF (2003) Bipolar II with and without cyclothymic temperament: “dark” and “sunny” expressions of soft bipolarity. J Affect Disord 73(1–2):49–57CrossRefPubMedGoogle Scholar
  4. Akiskal HS, Benazzi F, Perugi G, Rihmer Z (2005) Agitated “unipolar” depression re-conceptualized as a depressive mixed state: implications for the antidepressant-suicide controversy. J Affect Disord 85(3):245–258CrossRefPubMedGoogle Scholar
  5. Altamura AC, Dell’Osso B, Berlin HA, Buoli M, Bassetti R, Mundo E (2010) Duration of untreated illness and suicide in bipolar disorder: a naturalistic study. Eur Arch Psychiatry Clin Neurosci 260(5):385–391CrossRefPubMedGoogle Scholar
  6. Angst J, Angst F, Gerber-Werder R, Gamma A (2005) Suicide in 406 mood-disorder patients with and without long-term medication: a 40 to 44 years’ follow-up. Arch Suicide Res 9(3):279–300CrossRefPubMedGoogle Scholar
  7. Angst J, Cui L, Swendsen J, Rothen S, Cravchik A, Kessler RC, Merikangas KR (2010) Major depressive disorder with subthreshold bipolarity in the National Comorbidity Survey Replication. Am J Psychiatry 167(10):1194–1201CrossRefPubMedPubMedCentralGoogle Scholar
  8. Balazs J, Lecrubier Y, Csiszer N, Kosztak J, Bitter I (2003) Prevalence and comorbidity of affective disorders in persons making suicide attempts in Hungary: importance of the first depressive episodes and of bipolar II diagnoses. J Affect Disord 76(1–3):113–119CrossRefPubMedGoogle Scholar
  9. Balazs J, Benazzi F, Rihmer Z, Rihmer A, Akiskal KK, Akiskal HS (2006) The close link between suicide attempts and mixed (bipolar) depression: implications for suicide prevention. J Affect Disord 91(2–3):133–138CrossRefPubMedGoogle Scholar
  10. Benazzi F (2003) Major depressive disorder with anger: a bipolar spectrum disorder? Psychother Psychosom 72(6):300–306CrossRefPubMedGoogle Scholar
  11. Benazzi F (2005) Suicidal ideation and depressive mixed states. Psychother Psychosom 74(1):61–62CrossRefPubMedGoogle Scholar
  12. Benazzi F (2006) Mood patterns and classification in bipolar disorder. Curr Opin Psychiatry 19(1):1–8CrossRefPubMedGoogle Scholar
  13. Bostwick JM, Pankratz VS (2000) Affective disorders and suicide risk: a reexamination. Am J Psychiatry 157(12):1925–1932CrossRefPubMedGoogle Scholar
  14. Brent DA, Melhem NM, Oquendo M, Burke A, Birmaher B, Stanley B, Biernesser C, Keilp J, Kolko D, Ellis S, Porta G, Zelazny J, Iyengar S, Mann JJ (2015) Familial pathways to early-onset suicide attempt: a 5.6-year prospective study. JAMA Psychiatry 72(2):160–168CrossRefPubMedPubMedCentralGoogle Scholar
  15. Bulik CM, Carpenter LL, Kupfer DJ, Frank E (1990) Features associated with suicide attempts in recurrent major depression. J Affect Disord 18(1):29–37CrossRefPubMedGoogle Scholar
  16. Carvalho AF, Dimellis D, Gonda X, Vieta E, McLntyre RS, Fountoulakis KN (2014) Rapid cycling in bipolar disorder: a systematic review. J Clin Psychiatry 75(6):e578–e586CrossRefPubMedGoogle Scholar
  17. Chang CK, Hayes RD, Perera G, Broadbent MT, Fernandes AC, Lee WE, Hotopf M, Stewart R (2011) Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London. PLoS One 6(5), e19590CrossRefPubMedPubMedCentralGoogle Scholar
  18. Chaudhury SR, Grunebaum MF, Galfalvy HC, Burke AK, Sher L, Parsey RV, Everett B, Mann JJ, Oquendo MA (2007) Does first episode polarity predict risk for suicide attempt in bipolar disorder? J Affect Disord 104(1–3):245–250CrossRefPubMedPubMedCentralGoogle Scholar
  19. Chen YW, Dilsaver SC (1996) Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other Axis I disorders. Biol Psychiatry 39(10):896–899CrossRefPubMedGoogle Scholar
  20. Chesney E, Goodwin GM, Fazel S (2014) Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry 13(2):153–160CrossRefPubMedPubMedCentralGoogle Scholar
  21. Clements C, Morriss R, Jones S, Peters S, Roberts C, Kapur N (2013) Suicide in bipolar disorder in a national English sample, 1996–2009: frequency, trends and characteristics. Psychol Med 43(12):2593–2602CrossRefPubMedGoogle Scholar
  22. Costa Lda S, Alencar AP, Nascimento Neto PJ, dos Santos Mdo S, da Silva CG, Pinheiro Sde F, Silveira RT, Bianco BA, Pinheiro RF Jr, de Lima MA, Reis AO, Rolim Neto ML (2015) Risk factors for suicide in bipolar disorder: a systematic review. J Affect Disord 170:237–254CrossRefPubMedGoogle Scholar
  23. Crump C, Sundquist K, Winkleby MA, Sundquist J (2013) Comorbidities and mortality in bipolar disorder: a Swedish national cohort study. JAMA Psychiatry 70(9):931–939CrossRefPubMedGoogle Scholar
  24. Dennehy EB, Marangell LB, Allen MH, Chessick C, Wisniewski SR, Thase ME (2011) Suicide and suicide attempts in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). J Affect Disord 133(3):423–427CrossRefPubMedPubMedCentralGoogle Scholar
  25. Dervic K, Oquendo MA, Grunebaum MF, Ellis S, Burke AK, Mann JJ (2004) Religious affiliation and suicide attempt. Am J Psychiatry 161(12):2303–2308CrossRefPubMedGoogle Scholar
  26. Driver K, Abed RT (2004) Does having offspring reduce the risk of suicide in women? Int J Psychiatry Clin Pract 8(1):25–29CrossRefPubMedGoogle Scholar
  27. Dunner DL (2003) Clinical consequences of under-recognized bipolar spectrum disorder. Bipolar Disord 5(6):456–463CrossRefPubMedGoogle Scholar
  28. Fiedorowicz JG, Jancic D, Potash JB, Butcher B, Coryell WH (2014) Vascular mortality in participants of a bipolar genomics study. Psychosomatics 55(5):485–490CrossRefPubMedPubMedCentralGoogle Scholar
  29. Fitzpatrick KK, Euton SJ, Jones JN, Schmidt NB (2005) Gender role, sexual orientation and suicide risk. J Affect Disord 87(1):35–42CrossRefPubMedGoogle Scholar
  30. Goldberg JF, Harrow M, Whiteside JE (2001) Risk for bipolar illness in patients initially hospitalized for unipolar depression. Am J Psychiatry 158(8):1265–1270CrossRefPubMedGoogle Scholar
  31. Gonda X, Pompili M, Serafini G, Montebovi F, Campi S, Dome P, Duleba T, Girardi P, Rihmer Z (2012) Suicidal behavior in bipolar disorder: epidemiology, characteristics and major risk factors. J Affect Disord 143(1–3):16–26CrossRefPubMedGoogle Scholar
  32. Goodwin F, Jamison KR (2007) Manic-depressive illness: bipolar disorders and recurrent depression. Oxford University Press, New York, NYGoogle Scholar
  33. Hantouche EG, Akiskal HS, Lancrenon S, Allilaire JF, Sechter D, Azorin JM, Bourgeois M, Fraud JP, Chatenet-Duchene L (1998) Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multi-site study (EPIDEP). J Affect Disord 50(2–3):163–173CrossRefPubMedGoogle Scholar
  34. Harris EC, Barraclough B (1997) Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry 170:205–228CrossRefPubMedGoogle Scholar
  35. Hawton K, van Heeringen K (2009) Suicide. Lancet 373(9672):1372–1381CrossRefPubMedGoogle Scholar
  36. Hawton K, Sutton L, Haw C, Sinclair J, Harriss L (2005) Suicide and attempted suicide in bipolar disorder: a systematic review of risk factors. J Clin Psychiatry 66(6):693–704CrossRefPubMedGoogle Scholar
  37. Hayes JF, Miles J, Walters K, King M, Osborn DP (2015) A systematic review and meta-analysis of premature mortality in bipolar affective disorder. Acta Psychiatr Scand 131(6):417–425CrossRefPubMedPubMedCentralGoogle Scholar
  38. Holma KM, Haukka J, Suominen K, Valtonen HM, Mantere O, Melartin TK, Sokero TP, Oquendo MA, Isometsa ET (2014) Differences in incidence of suicide attempts between bipolar I and II disorders and major depressive disorder. Bipolar Disord 16(6):652–661CrossRefPubMedGoogle Scholar
  39. Hoyer EH, Olesen AV, Mortensen PB (2004) Suicide risk in patients hospitalised because of an affective disorder: a follow-up study, 1973–1993. J Affect Disord 78(3):209–217CrossRefPubMedGoogle Scholar
  40. Hoyer EH, Licht RW, Mortensen PB (2009) Risk factors of suicide in inpatients and recently discharged patients with affective disorders. A case-control study. Eur Psychiatry 24(5):317–321CrossRefPubMedGoogle Scholar
  41. Isometsa ET, Lonnqvist JK (1998) Suicide attempts preceding completed suicide. Br J Psychiatry 173:531–535CrossRefPubMedGoogle Scholar
  42. Isometsa ET, Henriksson MM, Aro HM, Lonnqvist JK (1994) Suicide in bipolar disorder in Finland. Am J Psychiatry 151(7):1020–1024CrossRefPubMedGoogle Scholar
  43. Isometsa E, Heikkinen M, Henriksson M, Aro H, Lonnqvist J (1995) Recent life events and completed suicide in bipolar affective disorder. A comparison with major depressive suicides. J Affect Disord 33(2):99–106CrossRefPubMedGoogle Scholar
  44. Isometsa E, Sund R, Pirkola S (2014) Post-discharge suicides of inpatients with bipolar disorder in Finland. Bipolar Disord 16(8):867–874CrossRefPubMedGoogle Scholar
  45. Judd LL, Schettler PJ, Akiskal H, Coryell W, Fawcett J, Fiedorowicz JG, Solomon DA, Keller MB (2012) Prevalence and clinical significance of subsyndromal manic symptoms, including irritability and psychomotor agitation, during bipolar major depressive episodes. J Affect Disord 138(3):440–448CrossRefPubMedPubMedCentralGoogle Scholar
  46. Kessing LV, Vradi E, McIntyre RS, Andersen PK (2015) Causes of decreased life expectancy over the life span in bipolar disorder. J Affect Disord 180:142–147CrossRefPubMedGoogle Scholar
  47. Kessler RC, Borges G, Walters EE (1999) Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry 56(7):617–626CrossRefPubMedGoogle Scholar
  48. Kim CD, Seguin M, Therrien N, Riopel G, Chawky N, Lesage AD, Turecki G (2005) Familial aggregation of suicidal behavior: a family study of male suicide completers from the general population. Am J Psychiatry 162(5):1017–1019CrossRefPubMedGoogle Scholar
  49. Kochman FJ, Hantouche EG, Ferrari P, Lancrenon S, Bayart D, Akiskal HS (2005) Cyclothymic temperament as a prospective predictor of bipolarity and suicidality in children and adolescents with major depressive disorder. J Affect Disord 85(1–2):181–189CrossRefPubMedGoogle Scholar
  50. Lan WH, Bai YM, Hsu JW, Huang KL, Su TP, Li CT, Yang AC, Lin WC, Chang WH, Chen TJ, Tsai SJ, Chen MH (2015) Comorbidity of ADHD and suicide attempts among adolescents and young adults with bipolar disorder: a nationwide longitudinal study. J Affect Disord 176:171–175CrossRefPubMedGoogle Scholar
  51. Leon AC, Fiedorowicz JG, Solomon DA, Li C, Coryell WH, Endicott J, Fawcett J, Keller MB (2014) Risk of suicidal behavior with antidepressants in bipolar and unipolar disorders. J Clin Psychiatry 75(7):720–727CrossRefPubMedPubMedCentralGoogle Scholar
  52. Leverich GS, Altshuler LL, Frye MA, Suppes T, Keck PE Jr, McElroy SL, Denicoff KD, Obrocea G, Nolen WA, Kupka R, Walden J, Grunze H, Perez S, Luckenbaugh DA, Post RM (2003) Factors associated with suicide attempts in 648 patients with bipolar disorder in the Stanley Foundation Bipolar Network. J Clin Psychiatry 64(5):506–515CrossRefPubMedGoogle Scholar
  53. MacKinnon DF, Potash JB, McMahon FJ, Simpson SG, Depaulo JR Jr, Zandi PP, National Institutes of Mental Health Bipolar Disorder Genetics I (2005) Rapid mood switching and suicidality in familial bipolar disorder. Bipolar Disord 7(5):441–448CrossRefPubMedGoogle Scholar
  54. Mann JJ, Waternaux C, Haas GL, Malone KM (1999) Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 156(2):181–189PubMedGoogle Scholar
  55. Marzuk PM, Tardiff K, Leon AC, Hirsch CS, Portera L, Hartwell N, Iqbal MI (1997) Lower risk of suicide during pregnancy. Am J Psychiatry 154(1):122–123CrossRefPubMedGoogle Scholar
  56. Michalak EE, Yatham LN, Lam RW (2004) The role of psychoeducation in the treatment of bipolar disorder: a clinical perspective. Clin Appr Bipolar Disord 3(1):5–11Google Scholar
  57. Miller S, Dell’Osso B, Ketter TA (2014) The prevalence and burden of bipolar depression. J Affect Disord 169(Suppl 1):S3–S11CrossRefPubMedGoogle Scholar
  58. Musil R, Zill P, Seemuller F, Bondy B, Meyer S, Spellmann I, Bender W, Adli M, Heuser I, Fisher R, Gaebel W, Maier W, Rietschel M, Rujescu D, Schennach R, Moller HJ, Riedel M (2013) Genetics of emergent suicidality during antidepressive treatment–data from a naturalistic study on a large sample of inpatients with a major depressive episode. Eur Neuropsychopharmacol 23(7):663–674CrossRefPubMedGoogle Scholar
  59. Nery-Fernandes F, Quarantini LC, Guimaraes JL, de Oliveira IR, Koenen KC, Kapczinski F, Miranda-Scippa A (2012) Is there an association between suicide attempt and delay of initiation of mood stabilizers in bipolar I disorder? J Affect Disord 136(3):1082–1087CrossRefPubMedGoogle Scholar
  60. Neves FS, Malloy-Diniz LF, Barbosa IG, Brasil PM, Correa H (2009) Bipolar disorder first episode and suicidal behavior: are there differences according to type of suicide attempt? Rev Bras Psiquiatr 31(2):114–118PubMedGoogle Scholar
  61. Nordentoft M, Mortensen PB, Pedersen CB (2011) Absolute risk of suicide after first hospital contact in mental disorder. Arch Gen Psychiatry 68(10):1058–1064CrossRefPubMedGoogle Scholar
  62. Oquendo MA, Galfalvy H, Russo S, Ellis SP, Grunebaum MF, Burke A, Mann JJ (2004) Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder. Am J Psychiatry 161(8):1433–1441CrossRefPubMedGoogle Scholar
  63. Pacchiarotti I, Bond DJ, Baldessarini RJ, Nolen WA, Grunze H, Licht RW, Post RM, Berk M, Goodwin GM, Sachs GS, Tondo L, Findling RL, Youngstrom EA, Tohen M, Undurraga J, Gonzalez-Pinto A, Goldberg JF, Yildiz A, Altshuler LL, Calabrese JR, Mitchell PB, Thase ME, Koukopoulos A, Colom F, Frye MA, Malhi GS, Fountoulakis KN, Vazquez G, Perlis RH, Ketter TA, Cassidy F, Akiskal H, Azorin JM, Valenti M, Mazzei DH, Lafer B, Kato T, Mazzarini L, Martinez-Aran A, Parker G, Souery D, Ozerdem A, McElroy SL, Girardi P, Bauer M, Yatham LN, Zarate CA, Nierenberg AA, Birmaher B, Kanba S, El-Mallakh RS, Serretti A, Rihmer Z, Young AH, Kotzalidis GD, MacQueen GM, Bowden CL, Ghaemi SN, Lopez-Jaramillo C, Rybakowski J, Ha K, Perugi G, Kasper S, Amsterdam JD, Hirschfeld RM, Kapczinski F, Vieta E (2013) The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders. Am J Psychiatry 170(11):1249–1262CrossRefPubMedPubMedCentralGoogle Scholar
  64. Pompili M, Rihmer Z, Innamorati M, Lester D, Girardi P, Tatarelli R (2009) Assessment and treatment of suicide risk in bipolar disorders. Expert Rev Neurother 9(1):109–136CrossRefPubMedGoogle Scholar
  65. Pompili M, Innamorati M, Rihmer Z, Gonda X, Serafini G, Akiskal H, Amore M, Niolu C, Sher L, Tatarelli R, Perugi G, Girardi P (2012) Cyclothymic-depressive-anxious temperament pattern is related to suicide risk in 346 patients with major mood disorders. J Affect Disord 136(3):405–411CrossRefPubMedGoogle Scholar
  66. Pompili M, Gonda X, Serafini G, Innamorati M, Sher L, Amore M, Rihmer Z, Girardi P (2013) Epidemiology of suicide in bipolar disorders: a systematic review of the literature. Bipolar Disord 15(5):457–490CrossRefPubMedGoogle Scholar
  67. Popovic D, Benabarre A, Crespo JM, Goikolea JM, Gonzalez-Pinto A, Gutierrez-Rojas L, Montes JM, Vieta E (2014) Risk factors for suicide in schizophrenia: systematic review and clinical recommendations. Acta Psychiatr Scand 130(6):418–426CrossRefPubMedGoogle Scholar
  68. Radomsky ED, Haas GL, Mann JJ, Sweeney JA (1999) Suicidal behavior in patients with schizophrenia and other psychotic disorders. Am J Psychiatry 156(10):1590–1595CrossRefPubMedGoogle Scholar
  69. Rihmer Z (2005) Prediction and prevention of suicide in bipolar disorder. Clin Neuropsychiatry 2:48–54Google Scholar
  70. Rihmer Z (2007a) Pharmacological prevention of suicide in bipolar patients – a realizable target. J Affect Disord 103(1–3):1–3CrossRefPubMedGoogle Scholar
  71. Rihmer Z (2007b) Suicide risk in mood disorders. Curr Opin Psychiatry 20(1):17–22CrossRefPubMedGoogle Scholar
  72. Rihmer Z, Akiskal H (2006) Do antidepressants t(h)reat(en) depressives? Toward a clinically judicious formulation of the antidepressant-suicidality FDA advisory in light of declining national suicide statistics from many countries. J Affect Disord 94(1–3):3–13CrossRefPubMedGoogle Scholar
  73. Rihmer Z, Angst J (2009) Mood disorders – epidemiology. In: Sadock B, Sadock V, Ruiz P (eds) Kaplan and Sadock’s comprehensive textbook of psychiatry, 9th edn. Lippincott Williams and Wilkins, Philadelphia, PAGoogle Scholar
  74. Rihmer Z, Gonda X (2013) Pharmacological prevention of suicide in patients with major mood disorders. Neurosci Biobehav Rev 37(10 Pt 1):2398–2403CrossRefPubMedGoogle Scholar
  75. Rihmer Z, Barsi J, Arato M, Demeter E (1990) Suicide in subtypes of primary major depression. J Affect Disord 18(3):221–225CrossRefPubMedGoogle Scholar
  76. Rihmer Z, Kantor Z, Rihmer A, Seregi K (2004) Suicide prevention strategies–a brief review. Neuropsychopharmacol Hung 6(4):195–199PubMedGoogle Scholar
  77. Rihmer Z, Benazzi F, Gonda X (2007) Suicidal behavior in unipolar depression: focus on mixed states. In: Tatarelli R, Pompili M, Girardi P (eds) Suicide in psychiatric disorders. Nova Science, New York, NY, pp 223–235Google Scholar
  78. Rucci P, Frank E, Kostelnik B, Fagiolini A, Mallinger AG, Swartz HA, Thase ME, Siegel L, Wilson D, Kupfer DJ (2002) Suicide attempts in patients with bipolar I disorder during acute and maintenance phases of intensive treatment with pharmacotherapy and adjunctive psychotherapy. Am J Psychiatry 159(7):1160–1164CrossRefPubMedGoogle Scholar
  79. Sanchez-Gistau V, Colom F, Mane A, Romero S, Sugranyes G, Vieta E (2009) Atypical depression is associated with suicide attempt in bipolar disorder. Acta Psychiatr Scand 120(1):30–36CrossRefPubMedGoogle Scholar
  80. Sani G, Tondo L, Koukopoulos A, Reginaldi D, Kotzalidis GD, Koukopoulos AE, Manfredi G, Mazzarini L, Pacchiarotti I, Simonetti A, Ambrosi E, Angeletti G, Girardi P, Tatarelli R (2011) Suicide in a large population of former psychiatric inpatients. Psychiatry Clin Neurosci 65(3):286–295CrossRefPubMedGoogle Scholar
  81. Sato T, Bottlender R, Kleindienst N, Moller HJ (2005) Irritable psychomotor elation in depressed inpatients: a factor validation of mixed depression. J Affect Disord 84(2–3):187–196CrossRefPubMedGoogle Scholar
  82. Schaffer A, Isometsa ET, Tondo L, Moreno DH, Turecki G, Reis C, Cassidy F, Sinyor M, Azorin JM, Kessing LV, Ha K, Goldstein T, Weizman A, Beautrais A, Chou YH, Diazgranados N, Levitt AJ, Zarate CA Jr, Rihmer Z, Yatham LN (2015) 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. Bipolar Disord 17(1):1–16CrossRefPubMedGoogle Scholar
  83. Simon GE, Hunkeler E, Fireman B, Lee JY, Savarino J (2007) Risk of suicide attempt and suicide death in patients treated for bipolar disorder. Bipolar Disord 9(5):526–530CrossRefPubMedGoogle Scholar
  84. Sokero P, Eerola M, Rytsala H, Melartin T, Leskela U, Lestela-Mielonen P, Isometsa E (2006) Decline in suicidal ideation among patients with MDD is preceded by decline in depression and hopelessness. J Affect Disord 95(1–3):95–102CrossRefPubMedGoogle Scholar
  85. Sondergard L, Lopez AG, Andersen PK, Kessing LV (2008) Mood-stabilizing pharmacological treatment in bipolar disorders and risk of suicide. Bipolar Disord 10(1):87–94CrossRefPubMedGoogle Scholar
  86. Swann AC, Moeller FG, Steinberg JL, Schneider L, Barratt ES, Dougherty DM (2007) Manic symptoms and impulsivity during bipolar depressive episodes. Bipolar Disord 9(3):206–212CrossRefPubMedPubMedCentralGoogle Scholar
  87. Szadoczky E, Vitrai J, Rihmer Z, Furedi J (2000) Suicide attempts in the Hungarian adult population. Their relation with DIS/DSM-III-R affective and anxiety disorders. Eur Psychiatry 15(6):343–347CrossRefPubMedGoogle Scholar
  88. Takeshima M, Oka T (2013) Association between the so-called “activation syndrome” and bipolar II disorder, a related disorder, and bipolar suggestive features in outpatients with depression. J Affect Disord 151(1):196–202CrossRefPubMedGoogle Scholar
  89. Tidemalm D, Haglund A, Karanti A, Landen M, Runeson B (2014) Attempted suicide in bipolar disorder: risk factors in a cohort of 6086 patients. PLoS One 9(4), e94097CrossRefPubMedPubMedCentralGoogle Scholar
  90. Tondo L, Isacsson G, Baldessarini R (2003) Suicidal behaviour in bipolar disorder: risk and prevention. CNS Drugs 17(7):491–511CrossRefPubMedGoogle Scholar
  91. Tondo L, Lepri B, Baldessarini RJ (2007) Suicidal risks among 2826 Sardinian major affective disorder patients. Acta Psychiatr Scand 116(6):419–428CrossRefPubMedGoogle Scholar
  92. Undurraga J, Baldessarini RJ, Valenti M, Pacchiarotti I, Vieta E (2012) Suicidal risk factors in bipolar I and II disorder patients. J Clin Psychiatry 73(6):778–782CrossRefPubMedGoogle Scholar
  93. Valtonen H, Suominen K, Mantere O, Leppamaki S, Arvilommi P, Isometsa ET (2005) Suicidal ideation and attempts in bipolar I and II disorders. J Clin Psychiatry 66(11):1456–1462CrossRefPubMedGoogle Scholar
  94. Vieta E, Benabarre A, Colom F, Gasto C, Nieto E, Otero A, Vallejo J (1997) Suicidal behavior in bipolar I and bipolar II disorder. J Nerv Ment Dis 185(6):407–409CrossRefPubMedGoogle Scholar
  95. Weiner M, Warren L, Fiedorowicz JG (2011) Cardiovascular morbidity and mortality in bipolar disorder. Ann Clin Psychiatry 23(1):40–47PubMedPubMedCentralGoogle Scholar
  96. Yerevanian BI, Koek RJ, Mintz J (2007a) Bipolar pharmacotherapy and suicidal behavior. Part 3: impact of antipsychotics. J Affect Disord 103(1–3):23–28CrossRefPubMedGoogle Scholar
  97. Yerevanian BI, Koek RJ, Mintz J (2007b) Bipolar pharmacotherapy and suicidal behavior. Part I: Lithium, divalproex and carbamazepine. J Affect Disord 103(1–3):5–11CrossRefPubMedGoogle Scholar
  98. Yerevanian BI, Koek RJ, Mintz J, Akiskal HS (2007c) Bipolar pharmacotherapy and suicidal behavior. Part 2: The impact of antidepressants. J Affect Disord 103(1–3):13–21CrossRefPubMedGoogle Scholar
  99. Zalsman G, Braun M, Arendt M, Grunebaum MF, Sher L, Burke AK, Brent DA, Chaudhury SR, Mann JJ, Oquendo MA (2006) A comparison of the medical lethality of suicide attempts in bipolar and major depressive disorders. Bipolar Disord 8(5 Pt 2):558–565CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland (outside the USA)  2016

Authors and Affiliations

  1. 1.Faculty of Medicine, Department of Clinical and Theoretical Mental HealthSemmelweis UniversityBudapestHungary
  2. 2.Laboratory for Suicide Research and PreventionNational Institute of Psychiatry and AddictionsBudapestHungary

Personalised recommendations