Our results are consistent with the view that people with MAD are highly vulnerable to suicidal behavior, and the women were the group were more likely to have attempted suicide than were the men. This is also consistent with the study by Schneider and colleagues (2001)
who, analyzing mortality data from a prospective study of 354 outpatients with affective disorders during a follow-up period of 5 years, observed nearly three times (SMR 2.9) the number of deaths expected on the basis of age- and sex-standardized reference population rates. Death from unnatural causes was 28.8 times higher than expected. Women with affective disorders had a very high risk of dying from unnatural causes (SMR 47.1). It seems that dysregulation of emotion follows different patterns of externalization/internalization in women and men with MAD. In stress-provoking situations, women are more likely to attempt suicide, while men report more external physical aggressiveness. Given the high risk of completed suicide in those patients suffering from major affective disorders and judged to be at high risk of suicide, it is crucial to perform a comprehensive assessment of suicide. Lester (1993)
performed a meta-analysis of studies of suicidal behavior in patients with bipolar and unipolar affective disorders and found two possible trends: an excess of subsequent completed suicide in unipolar patients and an excess of subsequent attempted suicide in bipolar patients.
Our results indicated that impulsivity may be a strong predictor for suicide intent. MAD patients with problems of impulse control are at higher risk for suicide. Impulsivity was able to predict suicide even when controlling for diagnosis, anxiety and depression severity, and sociodemographic variables. Those variables were identified as important risk factors for suicide by the US Surgeon General in the 1999 document entitled “Call to action to prevent suicide”, a milestone for the dissemination of warnings to mental health professionals and general population alike (US Public Health Service 1999
). Moreover, Dumais and colleagues (2005)
found that impulsive-aggressive personality disorders and alcohol abuse/dependence were two independent predictors of suicide in major depression, and impulsive and aggressive behaviors seem to underlie these risk factors.
The analysis indicated differences in the drug therapy between patients at risk of suicide and patients without risk. Patients reporting more hopelessness are more likely to have been prescribed antidepressants (SSRI) and less likely to have been prescribed mood stabilizers (lithium, carbamazepine, lamotrigine) and antipsychotics (olanzapine, quetiapine), the effect sizes of this difference being low/moderate. This might be due to the strong relationship between depression and hopelessness; however, suicide risk may be understood as constriction, tunneling, or focusing or narrowing the range of options usually available to an individual’s consciousness, when the individual cannot see any way out and therefore loses any positive expectation about the future, which leads to a hopeless feeling regardless of diagnosis. The fact that those experiencing hopelessness were prescribed more antidepressants should be viewed with caution. In fact, evidence emerging from clinical practice is suggestive that mood stabilizers can decrease the feelings of anguish and despair that are often associated with hopelessness both in unipolar and bipolar patients. Moreover, such drugs reduce the agitation components of depressive-dysphoric states which often are correlated with impulsiveness and aggression and often found in suicidal crisis.
Baldessarini and colleagues (2006d)
suggested that the antisuicidal properties of lithium in bipolar disorder may act upon these components. Moreover, lithium has proven to be the best antisuicidal treatment even in major depression (Guzzetta et al 2007
). However, we had no access to medical records regarding past pharmacotherapy in our patients, and we cannot know if any causal relationship exists between the variables. This could be important because there is growing evidence for suicidal risk reduction with long-term lithium maintenance (Thies Flechtner et al 1996
; Baldessarini et al 2003
Inconsistent with data reported elsewhere (Fawcett et al 1990
), neither a history of previous suicide attempts nor psychic anxiety was able to predict suicide risk in our sample of MAD patients. On the contrary, we found that the somatic symptomatology of anxiety predicts suicide risk.
Lastly, pharmacotherapy was a strong predictor of suicide risk. It was the strongest predictor of suicide risk even after controlling for diagnosis, anxiety and depression severity, and sociodemographic variables. Mood stabilizer use as whole (considering both lithium and anticonvulsants) was the only protective factor for suicide risk in our analysis, but only before controlling for clinical and sociodemographic variables. This latter result could be explained by our inclusion of both lithium and anticonvulsants as mood stabilizers.
In March 2004, the US FDA issued a public health advisory regarding worsening depression and suicidality in pediatric and adult patients being treated with several antidepressants (FDA 2004
). Although, the question is still controversial (Simon et al 2006
), Kahn and colleagues (Khan et al 2000
) provided data on suicides and attempts extracted from controlled premarketing trials submitted to the FDA for several modern antidepressants, including SSRIs (paroxetine, sertraline) and other agents (mirtazapine, nefazodone), the older, standard drugs, and placebos. These pooled trials yielded relevant data for large numbers of subjects (2,709–5,921), but for only brief exposures averaging 3–7 months. Minor differences were found in suicidal risk among the non-SSRI agents (3.46%/year) and placebos (3.06%/year), with a somewhat higher risk for SSRIs (6.75%/year). As suggested by Baldessarini collegues (2006b)
, suicidal ideation, but usually not suicidal behavior, can been reduced with antidepressant treatment. These considerations suggest that, suicidal acts require more than depressed mood and thoughts of death. The utility of the findings of the meta-analysis as a basis for sound clinical practice and regulatory policy is limited by the low levels of “suicidal events” reported, even lower frequency of actual suicidal behaviors, and variable outcomes across trials and treatments (Baldessarini et al 2006b
Although the use of antidepressants seems not to be associated with an elevated suicide risk, there are circumstances when it is compulsory not to use antidepressants. Administration of antidepressants may lead to a switch from depression to mania or increase the irritable component of the disorder, a condition often associated with high suicide risk. In contrast, when high-voltage manic individuals slow down and their mood switches into depression, the reduced impetuousness and happiness can indicate an elevated suicide risk.
The role of mood-stabilizers appears to be the better remedy for the violent agitation that may precede suicide in bipolar disorders. Especially in mixed states, which may occur as a transitional condition when depression escalates into mania, the correct dosage of a mood stabilizer may determine whether or not an individual develops a high risk of suicide. Volatile and erratic moods associated with dysphoria and agitation should always lead clinicians to treat this condition carefully, monitoring suicide risk at all time. Antidepressants should be used only after careful assessment regarding the absence of such states (Rihmer and Akiskal 2006).
Psychiatric inpatients should always be followed-up soon after discharge as periods following hospitalization are often marked with high suicide risk, especially when patients face daily difficulties and cannot rely on family members or any social contact for support (Pompili et al 2005
The present study had a number of limitations. The small sample size and the lack of information regarding long-term pharmacotherapy limit the generalization of the findings. Another limitation is that use of the BHS may have drawbacks which are shared by all self-administered psychometric instruments. Nevertheless, this simple, self-administered method has been reported as an important tool for the prediction of suicide (Beck et al 1989
). The generalizability of our findings is limited by the usual difficulties of a retrospective assessment of suicide attempts and the review of clinical chart records. Furthermore, suicide attempts could not be classified retrospectively for their potential lethality. Finally, our patients had in some cases complex treatment regimens, including antidepressants administered alone, in combination or as add-on therapy. It could be argued that suicidality in these patients was affected by the antidepressant treatment. However clear scientific evidence supporting this notion is still lacking. One major point for further investigation is to take into consideration past pharmachological treatment including time and dosage.
In conclusion, we stress the need to better screen MAD patients for aggressiveness and impulsivity as well as suicide intent. The use of proper pharmacological therapy (especially lithium) can dramatically decrease deaths from suicide.