Bipolar disorders are common illnesses with markedly elevated premature mortality, but they remain frequently under-referred, under-diagnosed, and under-treated. Suicide is the cause of death in up to 15% of patients with bipolar disorders, and about half of them make at least one suicide attempt in their lifetime. The suicide rate of (untreated) bipolar patients is 25 times higher than the same rate in the general population. Suicidal behaviour in bipolar patients occurs almost exclusively during severe major depressive episodes, and less frequently in mixed affective episodes or in dysphoric mania. In contrast, suicidal behaviour occurs very rarely during euphoric mania, hypomania, or euthymia, suggesting that suicidal behaviour in bipolar patients is a state- and severity-dependent phenomenon. However, because the majority of bipolar patients never commit (and up to 50% of them never attempt) suicide, risk factors other than bipolar disorder itself also play a significant contributory role. This chapter summarises the clinically most relevant suicide risk and protective factors in bipolar disorders, and touches briefly on the most effective suicide prevention strategies.


Bipolar Disorder Suicide Attempt Bipolar Patient Bipolar Spectrum Disorder Suicide Risk Factor 
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  1. 1.
    Rihmer Z, Angst J (2005) Epidemiology of bipolar disorder. In: S Kasper, RMA Hirschfeld (eds): Handbook of bipolar disorder. Taylor and Francis, New York, 21–35Google Scholar
  2. 2.
    Hawton K, Sutton L, Haw C, Sinclair J, Harris L (2005) Suicide and attempted suicide in bipolar disorder: A systematic review of risk factors. J Clin Psychiatry 66: 693–704PubMedGoogle Scholar
  3. 3.
    Tondo L, Isacsson G, Baldessarini RJ (2003) Suicidal behavior in bipolar disorder. CNS Drugs 17: 491–511PubMedCrossRefGoogle Scholar
  4. 4.
    Rihmer Z (2005) Prediction and prevention of suicide in bipolar disorder. Clin Neuropsychiatry 2: 48–54Google Scholar
  5. 5.
    Goodwin FK, Jamison KR (2007) Manic-Depressive Illness: Bipolar disorders and recurrent depression. Oxford University Press, New YorkGoogle Scholar
  6. 6.
    Dunner DL (2003) Clinical consequences of under-recognized bipolar spectrum disorder. Bipolar Disord 5: 456–463PubMedCrossRefGoogle Scholar
  7. 7.
    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 Suic Res 9: 279–300CrossRefGoogle Scholar
  8. 8.
    Rihmer Z (2007) Pharmacological prevention of suicide in bipolar patients—A realizable target. (Editorial). J Affect Disord 103: 1–3PubMedCrossRefGoogle Scholar
  9. 9.
    Akiskal HS (2007) Targeting suicide prevention to modifiable risk factors: Has bipolar II been overlooked? (Editorial). Acta Psychiat Scand 116: 395–402PubMedCrossRefGoogle Scholar
  10. 10.
    Harris EC, Barraclough B (1997) Suicide as an outcome for mental disorders: A meta-analysis. Br J Psychiatry 170: 205–228PubMedCrossRefGoogle Scholar
  11. 11.
    Goldberg JF, Harrow M, Whiteside JE (2001) Risk for bipolar illness in patients initially hospitalized for unipolar depression. Am J Psychiatry 158: 1265–1270PubMedCrossRefGoogle Scholar
  12. 12.
    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: 245–258PubMedCrossRefGoogle Scholar
  13. 13.
    Benazzi F (2006) Mood patterns and classification in bipolar disorder. Curr Opin Psychiatry 19: 1–8PubMedCrossRefGoogle Scholar
  14. 14.
    Tondo L, Lepri B, Baldessarini R (2007) Suicidal risk among 2826 Sardinian major affective disorder patients. Acta Psychiat Scand 116: 419–428PubMedCrossRefGoogle Scholar
  15. 15.
    Rihmer Z (2007) Suicide risk in mood disorders. Curr Opin Psychiatry 20: 17–22PubMedCrossRefGoogle Scholar
  16. 16.
    Valtonen H, Suominen K, Mantere O, Leppamaki S, Arvilommi P, Isometsa E (2005) Suicidal ideation and attempts in bipolar I and bipolar II disorders. J Clin Psychiatry 66: 1456–1462PubMedCrossRefGoogle Scholar
  17. 17.
    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: 95–102PubMedCrossRefGoogle Scholar
  18. 18.
    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: 896–899PubMedCrossRefGoogle Scholar
  19. 19.
    Kessler RC, Borges G, Walters EE(1999) Prevalence and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry 56: 617–626PubMedCrossRefGoogle Scholar
  20. 20.
    Szádóczky E, Vitrai J, Rihmer Z, Füredi J (2000) Suicide attempts in the Hungarian adult population. Their relation with DIS/DSM-III-R affective and anxiety disorders. Eur Psychiatry 15: 610–617CrossRefGoogle Scholar
  21. 21.
    Hantouche EG, Akiskal HS, Lancreon S, Allilare J-F, Sechter D, Azorin J-M, Burgeois M, Fraud J-P, Chatenet-Duchèn ne L (1998) Systematic clinical methodology for validating bipolar II disorder: Data in mid-stream from a French national multi-site study. J Affect Disord 50: 163–173PubMedCrossRefGoogle Scholar
  22. 22.
    Benazzi F (2005) Suicidal ideation and depressive mixed states. Psychother Psychosom 74: 107–108Google Scholar
  23. 23.
    Sato T, Bottlender R, Kleindienst N, Müller H-J (2005) Irritable psychomotor elation in depressed inpatients: A factor validation of mixed depression. J Affect Disord 84: 187–196PubMedCrossRefGoogle Scholar
  24. 24.
    Rihmer Z, Akiskal HS (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: 3–13PubMedCrossRefGoogle Scholar
  25. 25.
    Balázs 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: 133–138PubMedCrossRefGoogle Scholar
  26. 26.
    Rihmer Z, Benazzi F, Gonda X (2007) Suicidal behavior in unipolar depression: Focus on mixed states. In: R Tatarelli, M Pompili, P Girardi (eds): Suicide in psychiatric disorders. Nova Science Publishers Inc, New York, 223–235Google Scholar
  27. 27.
    MacKinnon DF, Potash JB, McMahon FJ, Simpson SG, dePaulo Jr, JR, the National Institutes of Mental Health Bipolar Disorder Genetics Initiative, Zandi PP (2005) Rapid mood switching and suicidality in familial bipolar disorder. Bipolar Disord 7: 441–448PubMedCrossRefGoogle Scholar
  28. 28.
    Bulik CM, Carpenter L, Kupfer DJ, Frank E (1990) Features associated with suicide attempts in recurrent depression. J Affect Disord 18: 29–37PubMedCrossRefGoogle Scholar
  29. 29.
    Rihmer Z, Barsi J, Arató M, Demeter E (1990) Suicide in subtypes of primary major depression. J Affect Disord 18: 221–225PubMedCrossRefGoogle Scholar
  30. 30.
    Balázs J, Lecrubier Y, Csiszèr N, Koszták J, Bitter I (2003) Prevalence and comorbidity of affective disorders in persons making suicide attempts in Hungary: Importance of the first episode and of bipolar II diagnosis. J Affect Disord 76: 113–119PubMedCrossRefGoogle Scholar
  31. 31.
    Leverich GS, Altshuler Frye MA, Suppes T, Keck PE, McElroy SL, Denicoff KD, Obrocea G, Nolen WA, Kupka R, Walden J et al (2003) Factors associated with suicide attempts in 684 patients with bipolar disorder in the Stanley Foundation Bipolar Network. J Clin Psychiatry 64: 506–515PubMedCrossRefGoogle Scholar
  32. 32.
    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: 526–530PubMedCrossRefGoogle Scholar
  33. 33.
    Zalsman G, Braun M, Arendt M, Grunebaum MF, Sher L, Burke AK, Brent D, Chaudhury SR, Mann JJ, Oquendo MA (2006) A comparison of the medical lethality of suicide attempts in bipolar and major depressive disorder. Bipolar Disord 8: 558–565PubMedCrossRefGoogle Scholar
  34. 34.
    Vieta E, Benabarre A, Colom F, Gastó C, Nieto C, Otero A (1997) Suicidal behavior in bipolar I and bipolar II disorder. J Nerv Ment Dis 185: 407–409PubMedCrossRefGoogle Scholar
  35. 35.
    Mann JJ, Waternaux C, Haas GL, Malone KM (1999) Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 156: 181–189PubMedGoogle Scholar
  36. 36.
    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 and bipolar disorder. Am J Psychiatry 161: 1433–1441PubMedCrossRefGoogle Scholar
  37. 37.
    Swann AC, Moeller FG, Steinberg JL, Schneider L, Barratt ES, Dougherty DM (2007) Manic symptoms and impulsivity during bipolar depressive episode. Bipolar Disord 9: 206–212PubMedCrossRefGoogle Scholar
  38. 38.
    Benazzi F (2003) Major depressive disorder with anger: A bipolar spectrum disorder? Psychother Psychosom 72: 300–306PubMedCrossRefGoogle Scholar
  39. 39.
    Akiskal HS, Hantouche EG, Allilare JF (2003) Bipolar II with and without cyclothymic temperament: dark and sunny expressions of soft bipolarity. J Affect Disord 73: 49–57PubMedCrossRefGoogle Scholar
  40. 40.
    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: 181–189PubMedCrossRefGoogle Scholar
  41. 41.
    Fritzpatrick KK, Euton SJ, Jones JN, Schmidt NB (2005) Gender role, sexual orientation and suicide risk. J Affect Disord 87: 35–42CrossRefGoogle Scholar
  42. 42.
    Isometsa E, Heikkinen M, Henriksson M, Aro H, Lünnqvist J (1995) Recent life events and completed suicide in bipolar affective disorder: A comparison with major depressive disorder in Finland. J Affect Disord 33: 99–106PubMedCrossRefGoogle Scholar
  43. 43.
    Kim CD, Seguin M, Therrien N, Riopel G, Chawkay N, Lesege AD, Turecki G (2005) Familial aggregation of suicidal behavior: A family study of male suicide completers from the general population. Am J Psychiatry 162: 1017–1019PubMedCrossRefGoogle Scholar
  44. 44.
    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: 122–123PubMedGoogle Scholar
  45. 45.
    Dervic K, Oquendo MA, Grunebaum MF, Ellis S, Burke AK, Mann JJ (2004) Religious affiliation and suicide attempt. Am J Psychiatry 161: 2303–2308PubMedCrossRefGoogle Scholar
  46. 46.
    Driver K, Abed R (2004) Does having offspring reduce the risk of suicide in women? Int J Psychiat Clin Pract 8: 25–29CrossRefGoogle Scholar
  47. 47.
    Rihmer Z (2004) Suicide prevention strategies—A brief review. Neuropsychopharmacol Hung 6: 195–199PubMedGoogle Scholar
  48. 48.
    Isometsa ET, Henriksson MM, Aro HM, Lünnqvist JK (1994) Suicide in bipolar disorder in Finland. Am J Psychiatry 151: 1020–1024PubMedGoogle Scholar
  49. 49.
    Isometsa ET, Lünnqvist JK (1998) Suicide attempts preceding completed suicide. Br J Psychiatry 173: 531–533PubMedCrossRefGoogle Scholar
  50. 50.
    Sondergard L, Lopez AG, Andersen PK, Kessing LV (2008) Mood stabilizing pharmacological treatment in bipolar disorders and the risk of suicide. Bipolar Disord 10: 87–94PubMedGoogle Scholar
  51. 51.
    Yerevanian BI, Koek RJ, Mintz J (2007) Bipolar pharmacotherapy and suicidal behavior. Part I: Lithium, divalproex and carbamazepine. J Affect Disord 103: 5–11PubMedCrossRefGoogle Scholar
  52. 52.
    Yerevanian BI, Koek RJ, Mintz J, Akiskal HS (2007) Bipolar pharmacotherapy and suicidal behavior. Part 2: The impact of antidepressants. J Affect Disord 103: 13–21PubMedCrossRefGoogle Scholar
  53. 53.
    Yerevanian BI, Koek RJ, Mintz J (2007) Bipolar pharmacotherapy and suicidal behavior. Part 3: Impact of antipsychotics. J Affect Disord 103: 23–28PubMedCrossRefGoogle Scholar
  54. 54.
    Michalak EE,Y atham LN, Lam RW (2004) The role of psychoeducation in the treatment of bipolar disorder: A clinical perspective. Clin Appr Bipol Disord 3: 5–11Google Scholar
  55. 55.
    Rucci P, Frank E, Kostelnik B, Fagiolini A, Malinger 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: 1160–1164PubMedCrossRefGoogle Scholar

Copyright information

© Birkhäuser Verlag/Switzerland 2009

Authors and Affiliations

  • Zoltán Rihmer
    • 1
  1. 1.Department of Clinical and Theoretical Mental Health, and Department of Psychiatry and PsychotherapySemmelweis Medical University, Kútvülgyi Clinical CentreBudapestHungary

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