Mixed states and suicidal behavior: a systematic review

Abstract

Introduction The objective of this study was to identify whether mixed states in bipolar disorder (BD) are associated with more frequent suicidal behavior when compared to manic/hypomanic and depressive episodes. Method We performed a systematic search of the scientific literature on the subject using the PubMed, ISI Web Of Science, PsycINFO and SciELO databases. The terms chosen for the search were (bipolar) AND (suicid*) AND (mixed). We selected original studies comparing suicidal behavior of patients in mixed states and suicidal behavior of patients in other BD phases. Results Sixteen papers fit the selection criteria. Twelve of the original 16 studies compared suicidal behavior in mixed states and pure mania, and the majority of these studies (n = 11) revealed that suicidal behavior was more frequent among individuals in mixed states. Five of the papers compared suicidal behavior between depressive and mixed phases of BD. One of these five papers reported more severe suicidal behavior in patients in mixed states and another described more frequent suicidal behavior in patients with pure depression. There were no significant statistical differences between groups in the remaining three of these five studies. Conclusion During acute BD episodes, suicidal behavior is more strongly associated with mixed states than with pure mania or hypomania. However, it was not possible to demonstrate that the association between suicidal behavior and mixed states is stronger than the association between suicidal behavior and depressive phases. The results hereby presented are worth considering in clinical practice to better evaluate suicide risk and to prevent suicide.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) recommendations for the management of patients with bipolar disorder with mixed presentations

“…61 Emerging research further suggests that the increase in suicide risk may be primarily attributable to the severity of depressive symptoms; the risk is higher in mania + mixed features compared with mania but equivalent between depression + mixed features and depression. 62,63 As described in the 2018 CANMAT/ISBD Guidelines, 5 it is imperative for clinicians to review suicide risk factors and determine an appropriate treatment setting to address safety issues. Safety planning, psychological support, and self-care strategies to support ongoing management of suicidal ideation should be encouraged for all persons at risk, including those with prior attempts and/or those in the post-hospitalization period.…”

Interactions between mood and paranoid symptoms affect suicidality in first-episode affective psychoses

“…Another key finding in our study was the limitations to suicidality appearing with the presence of both depressive and manic symptoms. This was surprising, considering that mixed subtypes are known to face higher risk of suicide (Miller and Black, 2020), especially among young patients (Lage et al, 2019;Saxena et al, 2020). A previous long-term prospective study reported that patients with bipolar or unipolar disorders with a history of mixed states were more likely to attempt suicide (Persons et al, 2018).…”

The bipolarity of Alberto Santos-Dumont: flights and falls of the “Father of Aviation”

“…ASD's mental illness had a tragic outcome: he killed himself at 59. Among mental disorders, bipolar disorder is the one that is most associated with suicide, especially during depressive and mixed episodes 16 . Family history of suicide is among the risk factors for suicide 10 , and, as mentioned, the aviator's mother had also taken her own life.…”