prevalence and characteristics of suicide in bipolar disorder
TRANSCRIPT
Prevalence and Characteristics of Suicide in Bipolar Disorder
ISBD Task Force on Suicide
Doris Hupfeld Moreno, MD, PhD
Medical Assistant and Resident Supervisor of the Institute of Psychiatry, University of São Paulo School of Medicine
Researcher in the Section on Epidemiology and the Mood Disorders Unit of the Institute of Psychiatry
Member of the Task Force on Suicide of the ISBD
Prevalence of suicide attempts in clinical and epidemiological BD samples
Rates on death from suicide through different reviews
Methods used for suicide attempts
Comparison with rates of MDD and other major mental illness
Objectives
Methodological diversity
Different definitions of suicide attempts
Distinct periods of time covered
Lack of information, i.e., regarding methods used for suicidal acts, rate of bipolar I, II or NOS
Sample heterogeneity
Problems
Suicide Attempts in BDI vs. BDII
Novick DM et al. Suicide attempts in bipolar I and bipolar II disorder: a review and meta-analysis of the evidence. Bipolar Disord. 2010;12(1):1-9.
Study Sample (N) Lifetime Prevalence
ECA USChen & Dilsaver, 1996
18,000 subjects186 BD
29.2%
NESARC Oquendo et al., 2010
43,093 subjects1,643 BDI/II
25.3% with alcohol use disoders (AUD)14.8 % w/o AUD
WMHSMerikangas et al., 2011
61,392 subjects11 countries
25.6% BDI20.8% BDII9.5% BD NOS
NESARCBlanco et al., 2012
990 BDI 24.7%
Attempted suicide ratesepidemiological studies
ECA – Epidemiologic Catchment Area Study
NESARC - National Epidemiologic Survey on Alcohol and Related ConditionsWMHS – World Mental Health Survey
Study Sample (N) Duration Rates
Simon et al., 2007. U.S.Health plan records
32,360 BD Mean 2.7 years 5.3%
Khalsa et al., 2008, U.S. 216 BDI first episode 4.2 ± 2.7 (range:0.5–9.2) years
18.1% requiring re-hospitalization: 17.6%
Altamura et al., 2010, Italy
128 BDI192 BDII
5 years 22%
Gonzalez-Pinto et al., 2011
120 BDI Up to 10 years 18.3%
Dennehy et al., 2011STEP-BD
4.360 Mean 16 months 6.0% (1/3 > 1 attempt)
Attempted suicide ratesprospective clinical studies
Study Sample (N) Lifetime prevalence
Azorin et al., 2009French National Cohort
1,090 BDI 35.0%
Garcia-Amador et al., 2009Spain
305 BD 25.9%
Bellivier et al., 2011Europe EMBLEM
3,684 BDI 29.9%
Ghanizadeh and Sahraian, 2008Iran
176 BDI inpatients 34.1% 70% only one attempt
Ryu et al., 2010Korea
579 BD 13.1% 89.5% BDI , 7.9% BDII, 2.6% BDNOS
Cassidy et al., 2011USA
157 BD 37.6%
Dennehy et al., 2011STEP-BD
4.360 BD 36%
Attempted suicide ratesretrospective clinical studies
Suicide Deaths in BD
Tondo L, Isacsson G, Baldessarini R. Suicidal behaviour in bipolar disorder: risk and prevention. CNS Drugs. 2003;17(7):491-511.
Review of 34 papers, selected according to a quality score, depending on
representativeness of sample, if only BD patients were included, duration offollow-up > 1 year, controlling of confounding variables, reliably identificatedcases, etc
Suicide review and meta-analysis
Pompili et al., Bipolar Disorders, 2013, 15:457-490
Type of study Prevalence/incidence of BD
Retrospective Risk for suicide was up to 20-30 times greater than for general population
Prospective Among psychiatric diagnoses, BD strongest association withsuicide – 25% of all suicides
Prevalence data are conflicting
Psychological autopsystudies
22% - 61%
Paper Year No. of Suicides Duration in
Years
Exposure
(person-years)
Suicide Rate (per
100 person years)
Suicide Rate-
Male
Suicide Rate-
Female
Morrison et al. 1982 12/443 8.5 3766 0.319
Martin et al. 1985 0/19 9 171 0.000
Weeke and Vaeth 1986 17/417 7 2919 0.582
Black et al. 1988 7/586 7 4102 0.171
Dingman et al. 1988 1/19 15 285 0.351
Friis et al. 1991 2/14 7 98 2.041
Newman and Bland 1991 19/1429 4.8 6859 0.277
Sharma and Marker 1994 9/472 9 4248 0.212
Koukopoulos et al. 1995 5/89 2.75 245 2.043
Thies-flechtner et al. 1996 8/146 2.5 365 2.192
Angst et al. 1998 11/220 28 6160 0.179
Bocchetta et al. 1998 5/47 5.6 263 1.900
Brodersen et al. 2000 7/61 16 976 0.717
Kallner et al. 2000 7/106 8.2 869 0.805
Kleindienst and Greil 2000 1/85 2.5 213 0.471
Osby et al. 2001 672/15386 11.1 170615 0.394 0.498 0.323
Gladstone et al. 2001 5/813 5 4065 0.123
Dutta et al. 2007 8/235 18.8 4422 0.181 0.369 0.040
Simon GE et al. 2007 73/32360 2.7 87372 0.106 0.171 0.071
Tondo et al. 2007 22/901 3.56 3208 0.686 1.059 0.391
Osborn et al. 2008 41/10742 4.7 50487 0.080
Dennehy et al. 2011 8/4360 1.3 5668 0.140 0.252 0.065
Sani et al. 2011 57/1765 2.9 5119 1.110 1.458 0.869
Gonzalez-Pinto et al. 2011 3/169 10 1690 0.178
Nordentoft et al. 2011 175/5927 18 106686 0.160 0.210 0.129
Total 1175/76811 8.436a 471035 0.617a
Pooled (by sample size) 0.215b 0.330 0.161
Pooled (by exposure years) 0.253b 0.368 0.218
ISBD Task ForceSuicide Rate for People with Bipolar Disorder: Pooled by Sample Size and by Exposure Years
Total 1175/76811 8.436a 471035 0.617a
Pooled (by sample size) 0.215b
Pooled (by exposure years) 0.253b
Study n Self-Poisoning
Jump Cutting/Stabbing
Hanging Fire -arm
Other
Tsai et al., 1999 53 30.2% 13.2%* 22.7% - - Drowning 7.5% Gas inhalation 5.7%
Oquendo et al., 2009
146 80.1% 4.8% 8.2% 0.7% 1.4% Immolation 2.1% drowning 0.7%
Ryu et al., 2010 76 34.2% 13.2% 19.7% 10.5% - Unknown 18.4% immolation 1.3%
D’Ambrosia et al., 2012
220 63.4% 12.7% 5.6% 7.0% 4.2% Gas inhalation 2.8% Collision 1.4%
Ruengorn et al., 2012
58 40.1% 12.3% 21.4% 26.3% - Collision 7%Drowning 3.5%
Methods used in suicide attempts
Study n Self-Poisoning
Hanging Jump Fire-arm
Cutting/Stabbing
Other
Rihmer et al., 1990
47 53% 17% 26% - - -
Osby et al., 2001 672 29.8% 31.0% 13.7% 5.2% 2.7% Drowning 11%Other 6.7%
Tsai et al, 2002 43 23.2% 11.6% 23.2% - - Drowning 25.6%Gas inhalation 9.3%Other 7%
Chen et al., 2009 482 24.9% 32.2% 17.4% - - Charcoal burning 13.5%Other 12.0%
Keks et al., 2009 35 17% 46% - - - CO poisoning 17% Collision 11%
Gos et al., 2009 7 42.9% 28.6% - - 14.3% Electrocution 14.3%
Dennehy et al., 2011
8 25% 25% - 25% - Unknown 25%
Methods used for suicide completion
DSM-IV disorders Bivariate modelsOR (95% CI)
Developed Developing
Panic disorder 5.1 (4.0-6.40 5.0 (3.4-7.3)
PTSD 6.5 (5.4-7.6) 8.3 (6.0-11.6)
GAD 5.6 (4.6-6.7) 5.4 (3.9-7.5)
MDD 5.8 (5.0-6.8) 5.1 (4.2-6.1)
Bipolar disorder 7.1 (5.5-9.3) 6.7 (4.4-10.0)
ODD 5.3 (4.1-6.7) 6.7 (4.1-10.9)
Conduct disorder 4.8 (3.6-6.4) 8.9 (5.6-14-2)
Alcohol abuse/dependency 4.4 (3.7-5.3) 4.8 (3.7-6.1)
Drug abuse/ dependency 4.9 (3.8-6.2) 7.5 (5.4-10.4)
Association between DSM-IV disorders and a subsequent suicide attempt – World Mental Health Survey (n=27,963) – 11 countries
Study Sample (N) Results
Chen & Dilsaver, 1996
18,000 subjectsECA U.S.186 BD
BD (29.2%) > MDD (15.9%) > other Axis I (4.2%)
BD vs MDD - OR 2.0 (df=1, x(2)=697.9, p<0.0001)
Tondo et al., 2007 2,826 mooddisorder patients
%patients/y BDI (1.52) > BDII (0.82) > MDD (0.48)
Bader & Dunner, 2007
305 BDI/II/NOS130 MDDTertiary care unit
BDI > BDII = MDD recurrent (p=0.001) and BD NOS (p=0.007)
Attempted suicide ratescompared to MDD and other Axis I disorders
N %
Bipolar disorder 482 3.9
Major depression 895 7.2
Neurotic disorder 2,741 22.1
Schizophrenia 703 5.7
Other disorders 2,273 18.3
No diagnosis 5,297 42.8
Suicide in Taiwan
n = 12,391 suicides (coroner’s records)
Chen YY et al. Methods of suicide in different psychiatric diagnostic groups. J Affect Disord. 2009 Nov;118(1-3):196-200.
Study Sample (N) Results
Osby et al., 2001Sweden
Inpatient register1973-1995BD=15,386UP=39,182
SMR: UP (20.9 Male/27.0 Female) vs. BD (15.0 Male/22.4 Female)
Ilgen et al., 2006U.S.
6,913 National Violent Death Reporting System 2004
MDD 34.7%BD 6.1% In any other Axis I disorder
Tondo et al., 2007Italy
2,826 mooddisorder patients
suicide rate (% patients/year): BDII (0.16) > BDI (0.14) > MDD(0.05)
Osborn et al., 2008Cohort study within the UK
43,136 SMI patients vs no SMIBD=10,742
HR: 8.74 BD vs. 7.00 SCZ vs. 7.85 other SMI
Sani et al., 2011Italy
4,441 inpatients1964-1998
BDII (4.2%)>BDI (2.8%)>MDD (1.9%)
Suicide rates compared to MDD andother Axis I disorders
SMI - severe mental illness
Copyright restrictions may apply.Nordentoft M, Mortensen PB, Pedersen CB. Absolute risk of suicide after first hospital contact in mental disorder. Arch Gen Psychiatry.
2011;68(10):1058-64.
Cumulative incidence of suicide by time since the first psychiatric contact among men (A) and women (B)
N = 176,347 individuals with mental health contact N = 881,735 controls
Follow-up 36 years, median 18 years
Men 7.77% (95% CI, 6.01%-10.05%)
Women4.78% (95% CI, 3.48%-6.56%)
Lifetime suicide attempts occured in ¼ of individuals in population-basedstudies and more than 1/3 in clinical studies
Rates were lower (9.5%) for subthreshold BD, but higher than in normal controls
The rate of suicide was 0.215 per 100 person years
the risk of suicide is 20-30 times greater than of the general population
poisoning was the most frequently used method in suicide attempts (30% -80%), followed by cutting/stabbing (5.6% - 22.7%) , and jumping (4.8% -13.2%)
suicides - most frequently used methods: poisoning (17% - 53%) and hanging(11.6% - 46%), followed by jumping (13.7 – 26% in 4/7 studies), - to a lesserextent cutting/stabbing (2.7% and 14.3% in 2/7 studies)
BD accounts for a substantial proportion of suicides in both clinical and epidemiological samples comparable to or, in some cases, greater than what is seen in MDD, schizophrenia and other major mental illness.
Conclusions
Impact of DSM5 on suicide rates – mixed episodes?
BD undertreated, rates are underestimated
Lack of studies comparing patients with one or more suicide attempts. Who is going to attempt suicide again?
Better determination of types of methods used, ifplanned/not planned, lethality
Risk factors
Protective factors
Improve and implement preventative strategies
We have to consider...