SUICIDE BEHAVIORS IN BIPOLAR DISORDER: REVIEW & UPDATE

ABSTRACT

Psychiatr Clin North Am. 2016 Mar;39(1):111-23. doi: 10.1016/j.psc.2015.09.002.

Epub 2015 Dec 22.

SUICIDE BEHAVIORS IN BIPOLAR DISORDER: 

A REVIEW AND UPDATE FOR THE CLINICIAN.

Beyer JL,  Weisler RH.

Author information:

Duke University Medical Center, Box 3519, Durham, NC 27710, USA.

Suicide behaviors (ideation, attempts, and completions) are unfortunately common in patients with bipolar disorder. It is estimated that 25 to 50% attempt suicide at least once during their lifetime, and 6% to 19% complete suicide. Risk factors include a family history of suicide, previous suicide attempts, younger age of onset, comorbid psychiatric illnesses, and psychological constructs like hopelessness.

Pharmacologic treatment may impact suicidal behaviors, either

increasing vulnerability or resilience. Clinicians need to be particularly

sensitive to their patient's thoughts and beliefs about death, particularly

during stressful times of life or when in a depressive/mixed episode of bipolar disorder.

KEY POINTS

Bipolar disorder is highly associated with suicide behaviors; among all the psychiatric illnesses, bipolar disorder seems to have the highest risk for suicide attempts and completions.

The greatest risk factors for suicide completion are previous suicide attempts and a family history of suicide.

Although frequently used to treat bipolar depression, antidepressants may have a suicideprovoking effect in younger adults and adolescents.

Lithium seems to have suicide-preventing effects.

ANTIDEPRESSANTS ARE COUNTERPRODUCTIVE IN BIPOLAR DISORDER

ALAN EPPEL

For decades, one of the most controversial issues within psychiatry has being whether or not antidepressants have any role to play in the treatment of bipolar disorder.

Bipolar disorder consists of periods of depression and periods of mood elevation. On the face of it, it has seemed logical to many psychiatrists and researchers that antidepressants should be used to treat depressive episodes in bipolar disorder.

On the other side of this debate many authors have pointed out the potential adverse effects that antidepressants may have in bipolar disorder :

1. antidepressants may cause switches into mania or hypomania

2. antidepressants may cause repeated cycles of depression even without switches into mania.

3. antidepressants may induce mixed states. Mixed states consist of dark feelings of depression and despair combined with high energy, overactivity, racing thoughts and irritability. Mixed states pose a very high risk of suicide.

Now two articles in the January 2016 issue of the Psychiatric Clinics of North America confirm many of the reservations about the use of antidepressants in bipolar disorder.

Robert Post a long-time researcher and member of the Bipolar Collaborative Network concludes that:

 "Conventional treatment of bipolar depression toward the end of the twentieth century typically included antidepressant augmentation of mood stabilizers.

However, the past decade has seen increasing evidence that this is not only a generally ineffective treatment approach, but one that may be counterproductive."

The article reaffirms the primary place of lithium in the treatment of bipolar disorder and the use of lamotrigine, valproate and carbamazepine as mood stabilizers.

Post makes the case for the adjunctive use of several of the second-generation antipsychotic medications if needed. [However the potential serious adverse effects of these medications, including metabolic syndrome and tardive dyskinesia limit their application].

In the same edition of  Psychiatric Clinics , John Beyer and Richard Weisler in discussing the risk of suicidal behavior in bipolar disorder state that:

"Overall, the best available evidence suggests that antidepressant use in bipolar disorder does contribute to suicidal behaviors. In fact, the new onset of suicidal thoughts after introduction of an antidepressant in depressed patients should raise the clinician’s suspicion of an underlying bipolar illness".

These articles reinforce the findings of the International Society for Bipolar Disorders task force on the use of antidepressants in bipolar disorder:

“The evidence continues to accumulate that antidepressants alone and in combination with mood stabilizers have a very small role if any, in the pharmacological management of bipolar depression. There is increasing acknowledgement that antidepressants can be harmful. Antidepressants can lead to long-term mood instability, cycle acceleration, mood switching, mixed states and increased risk of suicide.”

 Perhaps this debate can now be put to rest.

References

Post R.  Treatment of Bipolar Depression Evolving Recommendations Psychiatric Clinics of North America 39 (2016) 11–33.

Beyer J, Weisler R. Suicide Behaviors in Bipolar Disorder: A Review and Update for the Clinician Psychiatric Clinics of North America 39 (2016) 111–123.

The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders.  Am J Psychiatry. 2013 Nov 1;170(11):1249-62.

Eppel AB: Antidepressants in the Treatment of Bipolar Disorder: Decoding Contradictory Evidence and Opinion', Harvard Review of Psychiatry 2008; 16:3, 205 - 209.

BIPOLAR DISORDER: WHY LITHIUM IS STILL FIRST CHOICE

Journal Abstracts

Nervenarzt. 2014 Sep;85(9):1166-70. doi: 10.1007/s00115-014-4083-x.

[New facts of long-term prophylaxis for bipolar affective disorder].

[Article in German]

Bschor T1, Müller-Oerlinghausen B, Stoppe G, Hiemke C.

              

Lithium and with restrictions, carbamazepine, valproic acid, lamotrigine, olanzapine, aripiprazole and quetiapine, are approved in Germany for maintenance treatment of bipolar disorder. 

 Lithium is the only drug that (I) proved to be effective for the prevention of depressive as well as manic episodes in state-of-the-art studies without an enriched design and that (II) is approved for the maintenance treatment of bipolar disorders without restrictions. It (III) is also the only drug which is recommended for maintenance treatment by the current German S3 guidelines on bipolar disorders with the highest degree of recommendation (A) and (IV) is the only drug with a well proven suicide preventive effect. Hence, lithium is the mood stabilizer of first choice.

No patient should be deprived of lithium without a specific reason. Side effects and risks are manageable if both the physician and the patient are well informed.

For patients who do not respond sufficiently to lithium, have contraindications or non-tolerable side effects, other mood stabilizers should be used. Restrictions in their respective approval as well as specific side effects and risks have to be taken into account. 

Because maintenance treatment is a long-term treatment, particular concern should be paid to drugs with the potential risk of a metabolic syndrome, particularly atypical antipsychotics.

             

  Harv Rev Psychiatry. 2014 Nov-Dec;22(6):353-7. Factors associated

  with lithium efficacy in bipolar disorder.

              

              

 Rybakowski JK.

About one-third of lithium-treated, bipolar patients are excellent lithium responders; that is, lithium monotherapy totally prevents further episodes of bipolar disorder for ten years and more. These patients are clinically characterized by an episodic clinical course with complete remission, a bipolar family history, low psychiatric comorbidity, mania-depression episode sequences, a moderate number of episodes, and a low number of hospitalizations in the pre-lithium period.

 Recently, it has been found that temperamental features of hypomania (a hyperthymic temperament) and a lack of cognitive disorganization predict the best results of lithium prophylaxis.

             

  Lithium exerts a neuroprotective effect, in which increased expression of brain-derived neurotrophic factor (BDNF) and inhibition of the glycogen synthase kinase-3 (GSK-3) play an important role. The response to lithium has been connected with the genotype of the BDNF gene and serum BDNF levels. A better response to lithium is connected with the Met allele of the BDNF Val/Met polymorphism, as is a hyperthymic temperament.

              

  Excellent lithium responders have normal cognitive functions and serum BDNF levels, even after long-term duration of the illness. The preservation of cognitive functions in long-term lithium-treated patients may be connected with the stimulation of the BDNF system, with the resulting prevention of affective episodes exerting deleterious cognitive effects, and possibly also with lithium's antiviral effects.

            

   A number of candidate genes that are related to neurotransmitters, intracellular signaling, neuroprotection, circadian rhythms, and other pathogenic mechanisms of bipolar disorder were found to be associated with the lithium prophylactic response. The Consortium on Lithium Genetics (ConLiGen) has recently performed the first genome-wide association study on the lithium response in bipolar disorder.