Suicidality and symptoms of anxiety, irritability, and agitation in patients experiencing manic episodes with depressive symptoms: a naturalistic study

Abstract

PurposePatients with a bipolar I disorder (BD-I) manic episode meeting the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), criteria for “with mixed features” have a high incidence of suicide attempts and of anxiety, irritability, and agitation (AIA) symptoms. The aim of this analysis was to explore the relationship between suicidality and AIA symptoms in patients with BD-I experiencing mania with depressive symptoms, using data from a previous naturalistic study.Patients and methodsPsychiatrists completed an online questionnaire about their adult patients who had a current BD-I manic episode. Questions covered the DSM-5 “with mixed features” specifier, the severity of AIA symptoms, the frequency and controllability of suicidal ideation, and the number of suicide attempts.ResultsOf 1,035 patients with BD-I mania who were included in the analyses, 348 (33.6%) met the criteria for the DSM-5 “with mixed features” specifier (three or more depressive symptoms). These patients were further stratified according to the severity of their AIA symptoms: “mild AIA” (zero or one AIA symptom above a severity threshold; 105 patients) or “severe AIA” (all three AIA symptoms above a severity threshold; 167 patients). A greater incidence of suicidal ideation was observed in the severe AIA group (71.9%) than in the mild AIA group (47.6%). Twice as many patients had easily controlled suicidal ideation than difficult-to-control suicidal ideation in both subgroups. The mean number of suicide attempts was higher in the severe AIA group than in the mild AIA group, during the current episode (0.84 vs 0.34 attempts, respectively; P<0.05) and over the patient’s lifetime (1.56 vs 1.04 attempts, respectively).ConclusionThe high risk of suicide among BD-I mania patients with depressive symptoms is further increased when they experience severe AIA symptoms. Recognizing AIA symptoms in BD-I mania could provide a means of identifying patients with depressive symptoms, as well as those who may be suicidal, thereby allowing for appropriate, tailored treatment.

The effectiveness of ketamine on anxiety, irritability, and agitation: Implications for treating mixed features in adults with major depressive or bipolar disorder

“…It is notable that participants with AIA, a group known to be at especially high risk of suicide, experienced similar anti-SI effects as participants without AIA. 9,37,38 We did not observe any evidence of treatment-emergent mania or psychosis, nor were there any other notable tolerability or safety concerns in this population.…”

Anxiety, irritability, and agitation as indicators of bipolar mania with depressive symptoms: a post hoc analysis of two clinical trials

“…This replicates the findings of a naturalistic study, in which anxiety and irritability were more common in BD-I patients with three or more depressive symptoms, whereas agitation was not (Young and Eberhard 2015 ). Thus, anxiety and irritability, and the combination of all three AIA symptoms, could potentially be used as non-specific indicators, or ‘gateway symptoms’, to help psychiatrists identify bipolar mania with depressive symptoms (Eberhard and Weiller 2016 ). At present, the DSM-5 does not highlight or discuss AIA symptoms in the ‘with mixed features’ specifier section.…”

“…In BD-I (unlike in MDD) there has been relatively little prior investigation into whether patient characteristics (including AIA) within an episode can affect treatment response and other health outcomes (Feske et al 2000 ). A recent analysis showed that the presence of AIA symptoms raises the already high suicide risk among patients with BD-I mania with depressive symptoms (Eberhard and Weiller 2016 ). Additionally, a subtype of bipolar depression, characterised by anxiety and irritability among other symptoms, is associated with a greater likelihood of receiving government financial support, suggesting that this pattern of symptoms is particularly malignant (Perich et al 2016 ).…”

<p>Metabonomics reveals peripheral and central short-chain fatty acid and amino acid dysfunction in a naturally occurring depressive model of macaques</p>

“…Depression can be long-lasting or recurrent, substantially impairing not only patients’ quality of life but also of their families. Moreover, depression can also lead to suicide, which is the second leading cause of death in adolescents 3,4. However, the underlying molecular mechanisms of depression remain largely unknown 5…”