Medscape: What do you think clinicians should consider when evaluating suicide risk for patients with bipolar disorder?
Jan A. Fawcett, MD: Clinicians should know that, on average in the United States, 1 suicide occurs for every 30 attempts. In bipolar patients, it's 1 suicide for every 3 attempts, which confirms the increased risk of suicide in patients with bipolar disorder: their attempts are 10 times more lethal.
Since suicidal behavior is much more likely to result in death in bipolar patients than in the general public, one wants to be as careful as possible with these patients. The first thing the clinician wants to know is the patient's current clinical state and whether he or she is having any suicidal ideation.
If a patient is having suicidal ideation, the clinician should inquire about specific suicidal plans by asking questions like, "Have you made a suicide attempt? Have you been thinking about it? Have you been planning it?" A lot of people have vague suicidal ideation, but not as many have specific plans. Some people rehearse plans in their mind, and that is a very serious situation.
You also want to know if the patient is severely agitated. Bipolar patients sometimes have mixed mood states, in which they're both depressed and manic at the same time. In other words, they're not euphoric like most manic patients, they're irritable and they have increased energy. That's a particularly risky situation for a bipolar patient.
Medscape: Why does the bipolar mixed state pose such a risk?
Dr. Fawcett: The mixed state, specifically the rapidity of mood changes, is harder to monitor. You can't treat the patient's depression with antidepressants because that can induce mood cycling. Although the patient may show an initial improvement, the patient's course may deteriorate into mixed states or rapid-cycling bipolar disorder. And the increased energy and impulsiveness of a mixed state combined with the pain and hopelessness of depression create a situation in which the likelihood of suicidal behavior is increased. Those are unstable states that should be prevented.
The other issue, which goes into some of my own research, is if the patient is experiencing severe anxiety, such as anxious thoughts the patient can't stop. This could be a serious risk factor for suicide. In a recent study of 32,000 bipolar patients' records, the highest risk factor for suicide was being male and having a comorbid anxiety disorder, compared with being young and having a substance-use disorder, which predicted attempts but not necessarily suicide.
Medscape: What are the challenges inherent to medicating patients with bipolar disorder who might be at risk for suicide?
Dr. Fawcett: Depressed patients with bipolar disorder often don't remember their manias very well. So sometimes it's difficult to get a history of a prior mania because patients forget them or believe that they were normal during their mania. If you treat such patients with an antidepressant, you may worsen their condition, putting them at greater risk if they develop mood cycling or a mixed manic state. So that's one thing that makes the treatment of depression in a bipolar patient more complicated than it is in a unipolar patient. The other challenging situation is the patient with current agitation or rapid cycling who has to be more stable before you can address the depression.
Medscape: In a 2005 article you wrote for Medscape, you said, "Certain forms of psychotherapy, particularly dialectic behavioral therapy, and perhaps cognitive behavioral therapy and interpersonal therapy, may reduce long-term suicide risk." Please explain that.
Dr. Fawcett: When assessing patients with bipolar disorder for suicide risk, the clinician should have 2 issues in mind. One is short-term risk, which requires treating the patient's anxiety or the severity of the mood cycles. This would be treated as discussed above with medications that can rapidly reduce anxiety and agitation. That's not when the patient needs the psychotherapy. In long-term risk management, however, these therapies might be effective. Dialectic behavioral therapy can help people with impulsive behavior and destructive impulses, which is particularly helpful for people with a personality disorder, who tend to act out their conflicts instead of thinking or talking about them. Traditional cognitive behavioral therapy addresses the state of hopelessness, which is related to suicide and the feeling that nothing's going to improve. The rate of reduction of suicide is greatest in bipolar patients who stay on sustained medication treatment for 6 months or more.
Medscape: What are you most hopeful about in treating bipolar patients who are at risk for suicide?
Dr. Fawcett: Well, I think the growing recognition of the importance of anxiety as a treatable factor in reducing suicide risks is very exciting. This has emerged only during the past 5-7 years, with studies showing a greater risk for suicidal behavior in patients with comorbid anxiety disorders. Meanwhile, Greg Simon showed that suicide, not just suicide attempts, was related to anxiety. Severe anxiety symptoms may require additional treatment with clonazepam or second-generation antipsychotic medications, which have been found effective in reducing severe anxiety and agitation when given in addition to other mood-stabilizing medications.
Medscape: What's the biggest challenge clinicians face in reducing suicide and suicide risk among patients with bipolar disorder?
Dr. Fawcett: Well, the challenging part is obtaining information to assess the immediate risk of a patient for suicide, which is a difficult assessment to make. Every study that's tried to determine predictors of suicide has found that there are no predictors -- at least not statistically significant ones -- that tell a clinician that a patient is going to commit suicide. We need much more information on what makes suicide highly foreseeable in the immediate future. I think that would help clinicians a great deal.
You don't want to overdiagnose bipolar disorder, but you don't want to miss it. The clinician must know if a patient has a history of suicidal behavior or plans. If the patient is having significant anxiety, the clinician wants to know that too, and address it in treatment because antidepressant and mood-stabilizing medications alone don't help that.
Still, it's very much an uphill battle to diagnose and intervene to prevent suicide in a free society where patients have choices and, because of depression, hopelessness and discouragement, may have given up on the possibilities for recovery. It's probably the clinician's most difficult task. There are people at high risk that we're losing; we need to find ways to treat them. It's a constant challenge.
This interview is published in collaboration with NARSAD, the World's Leading Charity Dedicated to Mental Health Research.