Suicidal risk and protective factors in major affective disorders: A prospective cohort study of 4307 participants
Open accessAbstract
BACKGROUND: Suicidal behavior is strongly associated with major affective disorders, but there is a need to quantify and compare specific risk and protective factors in bipolar disorder (BD) and major depressive disorder (MDD). METHODS: In 4307 extensively evaluated major affective-disorder participants with BD (n = 1425) or MDD (n = 2882) diagnosed by current international criteria, we compared characteristics among those with versus without suicidal acts from illness-onset through 8.24 years of follow-up. RESULTS: Suicidal acts were identified in 11.4 % of participants; 25.9 % were violent and 6.92 % (0.79 % of all participants) were fatal. Associated risk factors included: diagnosis (BD > MDD), manic/psychotic features in first-episodes, family history of suicide or BD, separation/divorce, early abuse, young at illness-onset, female sex with BD, substance abuse, higher irritable, cyclothymic or dysthymic temperament ratings, greater long-term morbidity, and lower intake functional ratings. Protective factors included marriage, co-occurring anxiety disorder, higher ratings of hyperthymic temperament and depressive first episodes. Based on multivariable logistic regression, five factors remained significantly and independently associated with suicidal acts: BD diagnosis, more time depressed during prospective follow-up, younger at onset, lower functional status at intake, and women > men with BD. LIMITATIONS: Reported findings may or may not apply consistently in other cultures and locations. CONCLUSIONS: Suicidal acts including violent acts and suicides were more prevalent with BD than MDD. Of identified risk (n = 31) and protective factors (n = 4), several differed with diagnosis. Their clinical recognition should contribute to improved prediction and prevention of suicide in major affective disorders.
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Suicidal risks in rural versus urban populations in Sardinia
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Cited by
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Favaretto, E., Bedani, F., Brancati, G. E., Berardis, D. D., Giovannini, S., Scarcella, L., Martiadis, V., Martini, A., Pampaloni, I., Perugi, G., et al. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.07.011 · Cited by 80 · see citing works
Baldini, V., Gottardi, C., Di Stefano, R., Rindi, L. V., Pazzocco, G., Varallo, G., Purgato, M., De Ronchi, D., Barbui, C., & Ostuzzi, G. (2025) · European Psychiatry · doi:10.1192/j.eurpsy.2025.2452 · Cited by 41 · see citing works
Pharmacoepidemiology and Clinical Correlates of Lithium Treatment for Bipolar Disorder in Asia
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Self-citationAffective temperaments: Effects on treatment response for major depression
Baldessarini, R. J., Miola, A., & Tondo, L. (2024) · Asian Journal of Psychiatry · doi:10.1016/j.ajp.2024.104335 · Cited by 5 · see citing works
Self-citationUnipolar Mania: Prevalence and Patient Characteristics
Manchia, M., Miola, A., Tondo, L., & Baldessarini, R. J. (2025) · Acta Psychiatrica Scandinavica · doi:10.1111/acps.13798 · Cited by 5 · see citing works
Self-citationMiola, A., Gardea‐Resendez, M., Ortiz‐Orendain, J., Núñez, N. A., Ercis, M., Coombes, B. J., Salgado, M. F., Gruhlke, P. M., Michel, I. M., Bostwick, J. M., et al. (2023) · International Journal of Bipolar Disorders · doi:10.1186/s40345-023-00318-3 · Cited by 4 · see citing works
“There has been ample literature that has shown an association between substance use and higher prevalence of suicide attempts in affective disorders [Tondo et al. 1999; Miola et al. 2023] and SZ [Fuller-Thomson and Hollister 2016].”
BackgroundResultSelf-citationGender differences in 4466 mood disorder patients
Miola, A., Tondo, L., & Baldessarini, R. J. (2025) · The European Journal of Psychiatry · doi:10.1016/j.ejpsy.2025.100303 · Cited by 3 · see citing works
Self-citationNew pharmacotherapies to tackle the unmet needs in bipolar disorder: a focus on acute suicidality
Kotzalidis, G. D., Fiaschè, F., Alcibiade, A., Monti, L., Segni, F. D., Mazza, M., & Sani, G. (2024) · Expert Opinion on Pharmacotherapy · doi:10.1080/14656566.2024.2334425 · Cited by 3 · see citing works
Guo, Z., Xie, Z., Wang, P., Li, S., Xin, X., & Wang, X. (2024) · Scientific Reports · doi:10.1038/s41598-024-63432-x · Cited by 2 · see citing works
Wang, W.-L., Liu, J.-K., Sun, Y., Liu, X., Ma, Y., Gao, X.-Z., Chen, L.-M., Zhou, Z., & Zhou, H. (2024) · World Journal of Psychiatry · doi:10.5498/wjp.v14.i10.1484 · Cited by 1 · see citing works
Lin, Q.-X., Zhang, J.-Q., Wang, W.-J., Tan, C.-X., Wu, X.-H., & Zhao, J.-B. (2025) · Depression and Anxiety · doi:10.1155/da/1671972 · Cited by 3 · see citing works
“During the follow-up period, BD patients who experienced depressive episodes for a higher proportion of time showed a signi fi cant association with increased suicide risk [8].”
Balsak, H., Özel, M., & Balsak, H. N. (2025) · Anatolian Journal of Health Research · doi:10.61534/anatoljhr.1716820 · Cited by 1 · see citing works
Miola, A., Tondo, L., & Baldessarini, R. J. (2026) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2026.03.006 · Cited by 1 · see citing works
Self-citationMaluenda-Gatica, R., Araya, C., Morán, J., Ríos, U., Möritz, S., & MacBeth, A. M. (2026) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.70260 · Cited by 1 · see citing works
“Bipolar disorder (BD) remains a major psychiatric condition characterised by functional impairment, high comorbidity and elevated risk of suicide (Arnone et al. 2024; Berk et al. 2025; Cui et al. 2025; Glaus et al. 2025; Hu et al. 2023; Léda-Rêgo et al. 2023, 2024; Miola et al. 2023).”
Guo, Z., Zhenwen, X. I. E., Peng, W. A. N. G., Li, S., Xin, X., & Wang, X. (2024) · Research Square · doi:10.21203/rs.3.rs-3850398/v1
Screening and Clinical Risk Assessment for Suicide and Self-directed Violence
Reis, D. J., Matarazzo, B. B., & Wortzel, H. S. (2025) · Journal of Psychiatric Practice · doi:10.1097/pra.0000000000000850
“56 A recent umbrella review found evidence that strong social support and healthy sleep are protective in adolescents and young adults.”
Analysis of Russian studies of suicidal behavior in patients with bipolar affective disorder
Patrikeeva, O. N., Mokhnacheva, Y. V., & Kibitov, A. O. (2025) · S S Korsakov Journal of Neurology and Psychiatry · doi:10.17116/jnevro202512507125
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“This fi nding is consistent with the prevailing use of mood stabilizers therapies for the treatment of major affective disorders, which are the most prevalent diagnoses in our sample and are known to be associated with an elevated risk of suicide attempts 11,12,54 .”
Choi, W.-S., & Min, K. J. (2026) · Springer eBooks · doi:10.1007/978-981-92-1323-8_12
The missing numbers: Why India needs more data on deaths by suicide in severe mental illness
Menon, V., Sarkel, S., & Andrade, C. (2026) · Indian Journal of Psychiatry · doi:10.4103/indianjpsychiatry_981_26
“[20] For schizophrenia, living with family or having social support, and receiving adequate treatment with good adherence were found to be protective.”
Bahremand, A., Maheu, S., Miniaoui, M., Stip, É., Cailhol, L., Pinard, G.-F., Do, A., & Armoon, B. (2026) · Journal of Affective Disorders · doi:10.1016/j.jad.2026.122471
Lifetime Substance Use Disorder in 4250 Bipolar and Major Depressive Disorder Patients
Miola, A., Tondo, L., & Baldessarini, R. J. (2026) · International Journal of Mental Health and Addiction · doi:10.1007/s11469-026-01718-z
Self-citationDamiani, S., Marika, O., Provenzani, U., Bortolin, E., Rovida, M., Stefanelli, R., Addington, J., Alameda, L., Arango, C., Breitborde, N. J. K., et al. (2026) · Acta Psychiatrica Scandinavica · doi:10.1111/acps.70138
Ko, S.-L., Hsu, J.-W., Bai, Y., Tsai, S., Chen, L.-C., & Chen, M. (2026) · Neuropsychobiology · doi:10.1159/000553593
- Authors
- Miola, A., Tondo, L., Pinna, M., Contu, M., & Baldessarini, R. J.
- Affiliations
- University of Padua (IT)
- Harvard University (US)
- University of Cagliari (IT)
- Corresponding author
- Miola, Alessandro
- Venue
- Journal of Affective Disorders
- Publisher
- Elsevier BV
- Published
- 2023-10
- Volume
- 338
- Pages
- 189-198
- ISSN
- 0165-0327 (ISSN-L)
- OpenAlex
- W4379879760
- Cited by
- 26
- References
- 95
- Citations by year
- 2026: 11 · 2025: 7 · 2024: 7 · 2023: 1
- FWCI
- 7.55
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Journal of Affective Disorders (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Padua Research Archive (University of Padova) (submittedVersion, cc-by)
- Funders
- Bruce J Anderson Foundation
- Aretaeus Foundation of Rome
- Topics
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Health Sciences › Medicine › Psychiatry and Mental health › Bipolar Disorder and Treatment
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Keywords
- suicidal behavior, bipolar disorder, major depressive disorder, suicide risk factors, protective factors, violent suicide, suicide prevention, manic episodes, family history of suicide, temperament, functional status, sex differences, substance abuse
- MeSH terms
- Major Depressive Disorder, Female, Humans, Male, Prospective Studies, Puerperal Disorders, Risk Factors, Suicide, Temperament, Suicidal Ideation, Protective Factors
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