Suicide in psychiatric disorders: rates, risk factors, and therapeutics

Prevention of suicidal behavior in bipolar disorder

“…In addition, clinical and demographic factors contributing to, or sparing suicidal risk require attention, including marriage, children, personal relationships, employment, and religious interests. In general, it is important not to avoid the topic of suicide with patients, as it can helpfully be addressed cautiously and repeatedly 42,43 . If several risk factors are identified or increasing, it may be necessary to arrange for psychiatric hospitalization.…”

“…Even widely employed clinical methods of managing suicidal persons rarely are adequately supported by empirical research evidence, and studies specifically aimed at suicide prevention with BD patients are especially rare. This circumstance leaves tension between the obligation to intervene clinically, often rapidly, despite a lack of secure evidence about how best to do it 30,43 . Several types of treatments have been considered for their potential ability to reduce the risk of suicide in BD patients.…”

“…Antidepressant treatment for bipolar depression remains controversial, inadequately studied for short‐ and especially for long‐term use, may have emotionally destabilizing effects, and lacks explicit regulatory approval for use in BD, with the exception of the combination of fluoxetine with olanzapine 23,24,35 . Antidepressants may even increase suicidal risk, especially when dysphoric agitation, anger, restlessness, irritability, or insomnia emerge, and in mood states with mixed features, including dysphoric mania and agitated depression 30,33,34,43 . Evidence of lower suicidal risk during treatment with an antidepressant than with a placebo is based largely on questionable use of suicide‐related items in depression rating scales, which are weighted toward suicidal ideation rather than behavior and likely to be contaminated by overall impressions of general clinical improvement 40,41 .…”

“…Control treatments were a potent sedative, or saline alone or with an added bitter compound when compared with esketamine to support blinding. Findings from several RCTs included significantly reduced ratings of suicidal ideation within 12 hours that were highly significant by 24 hours, and persisted up to 3 days, although statistical separation of responses to ketamine versus controls was significant in only 40% of trials individually 43,80 . Risk of inducing mood switching with ketamine for bipolar depressed patients remains uncertain, but it has been used successfully in depressed BD patients with mixed symptoms 79 …”

“…Other neurostimulating treatments, including repeated transcranial magnetic stimulation (rTMS), 87–89 vagal nerve stimulation, 90 and other experimental forms of superficial or deep brain stimulation (DBS), 91 may be effective for the treatment bipolar depression, whereas effects on suicidal behavior in BD patients require testing. Treatments relevant to preventing suicidal risks in BD are summarized in Table 3 30,33,43 …”