Risk for completed suicide in bipolar disorder (BP) is among the highest of all psychiatric disorders (Baldessarini & Tondo, 2003
). Between 25 and 50% of adult patients with BP make at least one suicide attempt in their lifetime, and 8–19% of individuals with BP will die from suicide (Goodwin & Jamison, 1990
Despite the fact that up to 65% of adults with BP report illness onset in childhood (Goldstein & Levitt, 2006
; Lish, Dime-Meehan, Whybrow et al., 1994
; Perlis, Miyahara, Marangell et al., 2004
), attention has only recently focused on the study of pediatric BP. Such studies also document high rates of suicidal ideation and behavior among BP youth. In a large epidemiological sample, Lewinsohn and colleagues (2003)
reported that 66% of adolescents with BP endorsed current suicidal ideation and 45% reported making a suicide attempt at some point in their lifetime. Among clinical samples of youth with BP, lifetime rates of suicide attempt range from 33–47% (Bhangoo, Dell, Towbin et al., 2003
; Goldstein, Birmaher, Axelson et al., 2005
). Furthermore, BP conveys substantially increased risk for completed suicide among adolescents (Brent, Perper, Moritz et al., 1993
Youth with BP clearly represent a population at increased risk for suicidal ideation and behavior, yet little is known about specific risk factors associated with suicidal ideation in this group. In contrast, a larger body of literature has been devoted to understanding factors associated with suicidal ideation and behavior among depressed youth, elucidating relevant targets in multiple domains (e.g., cognitive, behavioral, and social). Given the crucial role of the family throughout childhood and adolescence, it is not surprising that risk for suicidal ideation and behavior among depressed youth has been associated with multiple aspects of the family environment.
Studies indicate family conflict is associated with suicidal ideation and behavior in depressed youth. Paluszny and colleagues (1991)
found that adolescent suicide attempters and ideators reported more family problems and greater family chaos than nonsuicidal psychiatric controls. Similarly, Skinner, Williams, Gibbon et al. (1983) found that depressed attempters and ideators perceived their families as more dysfunctional, and particularly the mother-child relationship as more conflicted, than nonsuicidal psychiatric subjects and healthy controls. Epstein and colleagues (1983)
also showed an association between overall family dysfunction and suicidal ideation and attempts in high school students.
Although some posit that depressed youth from non-intact families may be at greater risk for suicidality, the research findings on this question are mixed. Some studies report no differences in the rates of marital separation and divorce in the families of adolescent suicide attempters, ideators, and nonsuicidal adolescents (Kovacs, Goldston, & Gatsonis, 1993
), whereas others report higher rates of divorce and separation among suicidal youth (Paluszny, Davenport, & Kim, 1991
The circumplex model of family systems proposes two dimensions of family functioning: cohesion and adaptability (Olsen, 1993
). Family cohesion refers to the level of warmth and emotional closeness between family members, whereas family adaptability focuses on the ability of the family to change in response to situational stressors. Studies consistently find lower levels of cohesion among the families of suicidal youth as compared with the families of nonsuicidal psychiatric subjects and healthy controls (Campbell, Milling, Laughlin et al., 1993
). Only one study has demonstrated less family adaptability among the families of youth who have ideated and attempted (Adams, Overholser, & Lehnert et al., 1994
A link between suicidality and family stress has also been established among depressed youth. Changes in caregivers and living situations, as well as family member unemployment have been documented at higher rates among the families of adolescent suicide attempters as compared with nonsuicidal depressed and healthy adolescents. Illness of a family member has also been associated with suicidal behavior in teens (Davies & Cunningham, 1999
). Additionally, loss of a significant other emerged as a strong predictor of suicidal behavior among adolescent inpatients (Morano, Cisler, & Lemerond, 1993
Thus, among depressed youth, data support a link between suicidal ideation and behavior and the family environment—specifically family conflict, adaptability and cohesion, and family stress. Although youth with BP are also at high risk for suicidality, little is known about the association between family environment and suicidal ideation in this group. Identification of such risk factors may serve to inform the development of both preventive and therapeutic interventions for this high-risk group. We therefore examined the association between family environment and current suicidal ideation among youth diagnosed with BP. The low base rate of suicide attempts within the current mood episode at intake provides insufficient statistical power to examine the association between family environment and suicide attempts at present. Future papers using longitudinal data from the sample will be sufficiently powered to examine this question. We hypothesized that BP youth with current suicidal ideation, as compared with those without, would report (a) greater family conflict, (b) less family adaptability and cohesion, and (c) higher rates of stressful family events.