A review of factors associated with greater likelihood of suicide attempts and suicide deaths in bipolar disorder: Part II of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder

“While two studies replicated the independent association between anxiety disorder comorbidity and suicide attempt rates (Sala et al., 2012; Simon et al., 2007a), others did not (Leverich et al., 2003; Marangell et al., 2006; Neves et al., 2009).”

“Efforts to better understand and prevent suicidal behavior must therefore utilize the breadth of all available knowledge (Brown et al., 2000; Gonda et al., 2012; Mann et al., 2005; Zisook et al., 2013), with a special emphasis on diagnosis-specific information (Foster, 2013; Gonda et al., 2012).”

“There are inconsistent results with regard to age and risk of suicide death in BD. Ösby et al. (2001) reported a higher SMR among younger patients (less than 30 years) in their sample of 15,386 BD patients, while an even larger Health Maintenance Organization (HMO) sample of 32,360 BD suicides (Simon et al., 2007a) di…”

“…of mood disorders and more specifically BD has been reported more commonly among BD patients who attempt or die by suicide (Antypa and Serretti, 2014; Berutti et al., 2014; Brent et al., 1993b; Manchia et al., 2013; Sanchez-Gistau et al., 2009), but not in all studies (Tidemalm et al., 2014).”

“A number of excellent reviews of this area have been published over the years (Baethge and Cassidy, 2013; Gonda et al., 2012; Hawton et al., 2005b; Malhi et al., 2013; Mathews et al., 2013; Pompili et al., 2013; Yerevanian and Choi, 2013), and our ISBD task force also separately conducted a series…”

“98, respectively) although the sex differences were no longer apparent when controlling for other sociodemographics and substance use disorders (Crump et al., 2013).”

“A number of excellent reviews of this area have been published over the years (Baethge and Cassidy, 2013; Gonda et al., 2012; Hawton et al., 2005b; Malhi et al., 2013; Mathews et al., 2013; Pompili et al., 2013; Yerevanian and Choi, 2013), and our ISBD task force also separately conducted a series…”

“Higher impulsivity has been associated with increased medical severity of suicide attempt in one BD clinical sample (Swann et al., 2005), but with lower lethality of attempts in another sample (Gilbert et al.”

“…record of this being accomplished in the area of schizophrenia, for which a diagnosis-specific Australian & New Zealand Journal of Psychiatry, 49(11) approach to suicide has been widely accepted (De Hert et al., 2001; Hawton et al., 2005a; Hunt et al., 2006; Reutfors et al., 2009; Siris, 2001).”

“…Hoyer et al., 2000; Ilgen et al., 2010; Nordentoft et al., 2011; Schaffer et al., 2014b; Simon et al., 2007a; Weeke and Vaeth, 1986), in a meta-analyses of 28 studies, Tondo et al. (2003) reported a numerical, but not statistically significant higher standardized mortality rate (SMR) for women.”

“A number of excellent reviews of this area have been published over the years (Baethge and Cassidy, 2013; Gonda et al., 2012; Hawton et al., 2005b; Malhi et al., 2013; Mathews et al., 2013; Pompili et al., 2013; Yerevanian and Choi, 2013), and our ISBD task force also separately conducted a series of meta-analyses on…”

“…a Australian & New Zealand Journal of Psychiatry, 49(11) greater likelihood of suicide attempt, in the range of 18–62 fold and 27–74 fold higher rates, respectively, compared to pure mania (Dalton et al., 2003; Dilsaver et al., 1994; Liu et al., 1996; Tondo et al., 1999; Valtonen et al., 2008).”

“Schaffer et al. (2014b) reported higher rates of past suicide attempts among suicide completers with BD compared to those without BD (47.1% vs 25.8%).”

“In a more recent study, Ilgen et al. (2010) also reported adjusted hazard ratios (HRs) for suicide death to be higher in female US veterans (HR = 6.33) compared to male veterans (HR = 2.98).”

“The presence of a depressive predominant polarity has been consistently associated with greater likelihood of lifetime suicide attempts than a manic predominant polarity (Baldessarini et al., 2012; Carvalho et al., 2014; Colom et al., 2006; Popovic et al., 2014).”

“The number of lifetime manic or depressive episodes or a history of rapid cycling have also been correlated with likelihood of a suicide attempt (Fagiolini et al., 2004; Oquendo et al., 2000; Song et al., 2012; Undurraga et al., 2012).”

“…significantly increases the likelihood of suicide attempt in patients with BD (Antypa et al., 2013; Antypa and Serretti, 2014; Cassidy, 2011; Dalton et al., 2003; Dennehy et al., 2011; Engstrom et al., 2004; Finseth et al., 2012; Galfalvy et al., 2006; Guillaume et al., 2010; Hantouche et…”

“…record of this being accomplished in the area of schizophrenia, for which a diagnosis-specific Australian & New Zealand Journal of Psychiatry, 49(11) approach to suicide has been widely accepted (De Hert et al., 2001; Hawton et al., 2005a; Hunt et al., 2006; Reutfors et al., 2009; Siris, 2001).”

“Among 587 patients with BD, emotional abuse and sexual abuse were each found to be independently associated with history of suicide attempt (Etain et al., 2013).”

“A number of excellent reviews of this area have been published over the years (Baethge and Cassidy, 2013; Gonda et al., 2012; Hawton et al., 2005b; Malhi et al., 2013; Mathews et al., 2013; Pompili et al., 2013; Yerevanian and Choi, 2013), and our ISBD task force also separately conducted a series of meta-analyses on…”

“…al., 2012; Gazalle et al., 2007; Goldberg et al., 1998; Grunebaum et al., 2006; Leverich et al., 2003; Malloy-Diniz et al., 2009; Nery et al., 2014; Oquendo et al., 2010; Perroud et al., 2007; Potash et al., 2000; Sanchez-Gistau et al., 2009; Simon et al., 2007a; Simon et al., 2007b; Sublette et…”

“Australian & New Zealand Journal of Psychiatry, 49(11) greater likelihood of suicide attempt, in the range of 18–62 fold and 27–74 fold higher rates, respectively, compared to pure mania (Dalton et al., 2003; Dilsaver et al., 1994; Liu et al., 1996; Tondo et al., 1999; Valtonen et al., 2008).”

“In the only study focused on suicide death in children or youth with BD, Brent et al. (1993a) reported on 67 BD suicide deaths compared to matched controls and found mixed states (odds ratio [OR] = 9.0) and comorbid substance abuse disorders (OR = 17.0) to each be significantly associated with higher risk of death by…”

“In a Finnish study of 28 suicide deaths in BD, 78% occurred during a MDE, 11% during a mixed episode and 11% during or soon after a manic episode with psychotic features (Isometsä et al., 1994).”

“For instance, Simon et al. (2007a) reported that a past-year diagnosis of a substance use disorder was significantly associated with suicide attempts leading to hospitalization (HR = 2.53) and suicide attempts not leading to hospitalization (HR = 2.86) among over 32,000 BD subjects.”

“…et al. (2009) reported a lower mean psychosis score during the index manic episode among suicide attempters compared to non-attempters with BD. Psychotic BD has also not been associated with risk of suicide deaths (Black et al., 1988; Dennehy et al., 2011; Tondo et al., 2007; Tsai et al., 2002).”

“The incidence of suicide attempts in the BD group during periods of subthreshold depression, full major depression and mixed/depressive mixed was 87.1, 410.7 and 878.0 per 1000 patient-years, respectively (Holma et al., 2014; Valtonen et al., 2008).”

“In a systematic review of studies involving youth with BD (mean age = 14.4 years), a pooled frequency of 21.3% lifetime history of suicide attempt was reported, with a 14.7% rate of suicide attempt in prospective studies with a mean 3.5 years duration (Hauser et al., 2013).”

“For instance, Simon et al. (2007a) reported that a past-year diagnosis of a substance use disorder was significantly associated with suicide attempts leading to hospitalization (HR = 2.53) and suicide attempts not leading to hospitalization (HR = 2.86) among over 32,000 BD subjects.”

“Benedetti et al. (2011) also reported that patients with BD who had attempted suicide identified higher levels of early life stress.”

“…of illness (Azorin et al., 2008; Bellivier et al., 2011; Michaelis et al., 2004; Roy-Byrne et al., 1988), with two exceptions that reported a significantly shorter duration of illness in prospective (Valtonen et al., 2006) and retrospective (Manchia et al., 2013) samples of suicide attempters.”

“…samples reported significant association between recent cannabis use and lifetime suicide attempt (Aas et al., 2013; Kvitland et al., 2014); however, several other studies failed to show a consistent correlation (Bellivier et al., 2000; Cassidy, 2011; Parmentier et al., 2012; Tondo et al., 1999).”

“, 2011) impulsivity traits being associated with suicide attempts, or no effect being found (Perroud et al., 2011).”

“…associated with increased risk of future suicide attempts and deaths in BD (Aizenberg et al., 2006; Guillaume et al., 2010; Michaelis et al., 2003; Tsai et al., 2002; Valtonen et al., 2006), with an analysis of STEP-BD data finding it to be the strongest predictor of a prospectively identified…”

“…reviews of this area have been published over the years (Baethge and Cassidy, 2013; Gonda et al., 2012; Hawton et al., 2005b; Malhi et al., 2013; Mathews et al., 2013; Pompili et al., 2013; Yerevanian and Choi, 2013), and our ISBD task force also separately conducted a series of meta-analyses…”

“…disorder or anxiety symptoms increases the likelihood of suicide attempts in individuals with BD (Baldassano, 2006; Gazalle et al., 2007; Malloy-Diniz et al., 2009; Moor et al., 2012; Perroud et al., 2007; Sala et al., 2012; SanchezGistau et al., 2009; Simon et al., 2007a; Thibodeau et al., 2013).”

“On the other hand, current or lifetime cigarette smoking has been consistently associated with suicide attempts in BD (Baethge et al., 2009; Ostacher et al., 2006, 2009).”

“Depressive polarity of first mood episode has been consistently associated with a lifetime history of suicide attempts (Azorin et al., 2009; Bellivier et al., 2011; Finseth et al., 2012; Ryu et al., 2010; Sanchez-Gistau et al., 2009; Undurraga et al., 2012; Valtonen et al., 2006) and a higher number of suicide attempt…”

“In an elegant study of BD subjects and their religious affiliation, Dervic et al. (2011) reported a significantly lower rate of lifetime suicide attempt among the 149 patients with religious affiliation compared to the 49 patients without (63.1% vs 80.4%), and showed that moral or religious…”

“While men with BD clearly have significantly higher absolute rates of suicide deaths (Clements et al., 2013; Hoyer et al., 2000; Ilgen et al., 2010; Nordentoft et al., 2011; Schaffer et al., 2014b; Simon et al., 2007a; Weeke and Vaeth, 1986), in a meta-analyses of 28 studies, Tondo et al. (2003)…”

“…numerous factors within each study will also permit for greater clarity as to the presence of collinearity or interactions across variables, and will facilitate transitioning toward standardization of risk assessments that are of great interest to researchers and clinicians (Bernert et al., 2014).”

“The incidence of suicide attempts in the BD group during periods of subthreshold depression, full major depression and mixed/depressive mixed was 87.1, 410.7 and 878.0 per 1000 patient-years, respectively (Holma et al., 2014; Valtonen et al., 2008).”

“2% of BD II patients, a non-significant difference (Sani et al., 2011).”

“…2006; Leverich et al., 2003; Malloy-Diniz et al., 2009; Nery et al., 2014; Oquendo et al., 2010; Perroud et al., 2007; Potash et al., 2000; Sanchez-Gistau et al., 2009; Simon et al., 2007a; Simon et al., 2007b; Sublette et al., 2009; Swann et al., 2005; Tondo et al., 1999; Valtonen et al., 2006).”

“…not been correlated with likelihood of a suicide attempt (Bellivier et al., 2011; Dennehy et al., 2011; Finseth et al., 2012; Gazalle et al., 2007; Goldberg et al., 1998; Malloy-Diniz et al., 2009; Ryu et al., 2010; Valtonen et al., 2006), with one exception being a Korean sample (Song et al.,…”

“…et al., 2006), and specifically cluster B or borderline personality disorder are associated with higher risk of suicide attempts (Apfelbaum et al., 2013; Galfalvy et al., 2006; Garno et al., 2005; Joyce et al., 2010; Malloy-Diniz et al., 2009; Moor et al., 2012; Sanchez-Gistau et al., 2009).”

“…most report no significant difference (Chen et al., 2014; Dalton et al., 2003; Dennehy et al., 2011; Engstrom et al., 2004; Finseth et al., 2012; Galfalvy et al., 2006; Grunebaum et al., 2006; Hantouche et al., 2010; Leverich et al., 2003; Perroud et al., 2007; Sanchez-Gistau et al., 2009;…”

“In a clinical sample of 166 BD patients, 40% reported childhood physical or sexual abuse, which was significantly associated with an increased rate of suicide attempts (Carballo et al., 2008).”

“…severity of depressive symptoms (Fagiolini et al., 2004; Hantouche et al., 2010; Michaelis et al., 2004), hopelessness (Acosta et al., 2012; Valtonen et al., 2007) or suicidal ideation (Allen et al., 2005; Azorin et al., 2009; Grunebaum et al., 2006; Roy-Byrne et al., 1988; Umamaheswari et…”

“The large majority of studies on substance use report higher rates of suicide attempts among BD subjects with lifetime or current substance use disorders (Azorin et al., 2009; Dalton et al., 2003; Finseth et al., 2012; Gazalle et al., 2007; Goldberg et al., 1998; Grunebaum et al., 2006; Leverich et al., 2003; Malloy-D…”

“…al., 2014; Ryu et al., 2010; Song et al., 2012; Tondo et al., 1999), others have found higher rates in BD I (Antypa et al., 2013; Bega et al., 2012; Joyce et al., 2010), but most report no significant difference (Chen et al., 2014; Dalton et al., 2003; Dennehy et al., 2011; Engstrom et al., 2004;…”

“…of mood disorders and more specifically BD has been reported more commonly among BD patients who attempt or die by suicide (Antypa and Serretti, 2014; Berutti et al., 2014; Brent et al., 1993b; Manchia et al., 2013; Sanchez-Gistau et al., 2009), but not in all studies (Tidemalm et al., 2014).”

“The presence of a depressive predominant polarity has been consistently associated with greater likelihood of lifetime suicide attempts than a manic predominant polarity (Baldessarini et al., 2012; Carvalho et al., 2014; Colom et al., 2006; Popovic et al., 2014).”

“Not surprisingly, patients who present with increased severity of depressive symptoms (Fagiolini et al., 2004; Hantouche et al., 2010; Michaelis et al., 2004), hopelessness (Acosta et al.”

“Depressive polarity of first mood episode has been consistently associated with a lifetime history of suicide attempts (Azorin et al., 2009; Bellivier et al., 2011; Finseth et al., 2012; Ryu et al., 2010; Sanchez-Gistau et al., 2009; Undurraga et al., 2012; Valtonen et al., 2006) and a higher number of suicide attempt…”

“While men with BD clearly have significantly higher absolute rates of suicide deaths (Clements et al., 2013; Hoyer et al., 2000; Ilgen et al., 2010; Nordentoft et al., 2011; Schaffer et al., 2014b; Simon et al., 2007a; Weeke and Vaeth, 1986), in a meta-analyses of 28 studies, Tondo et al.”

“The presence of a depressive predominant polarity has been consistently associated with greater likelihood of lifetime suicide attempts than a manic predominant polarity (Baldessarini et al., 2012; Carvalho et al., 2014; Colom et al., 2006; Popovic et al., 2014).”

“…record of this being accomplished in the area of schizophrenia, for which a diagnosis-specific Australian & New Zealand Journal of Psychiatry, 49(11) approach to suicide has been widely accepted (De Hert et al., 2001; Hawton et al., 2005a; Hunt et al., 2006; Reutfors et al., 2009; Siris, 2001).”

“Depressive polarity of first mood episode has been consistently associated with a lifetime history of suicide attempts (Azorin et al., 2009; Bellivier et al., 2011; Finseth et al., 2012; Ryu et al., 2010; Sanchez-Gistau et al., 2009; Undurraga et al., 2012; Valtonen et al., 2006) and a higher…”

“, 2012) and cyclothymic temperament (Azorin et al., 2009; Pompili et al., 2012) have similarly been significantly associated with suicide attempts in BD samples.”

“There is highly consistent evidence that women with BD are significantly more likely than men with BD to attempt suicide (Antypa et al., 2013; Bellivier et al., 2011; Bronisch et al., 2005; Dilsaver et al., 2005; Engstrom et al., 2004; Simon et al., 2007a; Tidemalm et al., 2014; Tsai et al., 1999; Undurraga et al., 20…”

“…are significantly associated with increased risk of future suicide attempts and deaths in BD (Aizenberg et al., 2006; Guillaume et al., 2010; Michaelis et al., 2003; Tsai et al., 2002; Valtonen et al., 2006), with an analysis of STEP-BD data finding it to be the strongest predictor of a…”

“, 2007) or suicidal ideation (Allen et al., 2005; Azorin et al., 2009; Grunebaum et al., 2006; Roy-Byrne et al., 1988; Umamaheswari et al., 2014) carry an increased lifetime risk of suicide attempts.”

“For instance, Pacchiarotti et al. (2011) found that patients with an illness course of elevated mood states characterized by only mixed episodes had a higher lifetime risk of suicide attempt (60”

“…et al. (2009) reported a lower mean psychosis score during the index manic episode among suicide attempters compared to non-attempters with BD. Psychotic BD has also not been associated with risk of suicide deaths (Black et al., 1988; Dennehy et al., 2011; Tondo et al., 2007; Tsai et al., 2002).”

“…record of this being accomplished in the area of schizophrenia, for which a diagnosis-specific Australian & New Zealand Journal of Psychiatry, 49(11) approach to suicide has been widely accepted (De Hert et al., 2001; Hawton et al., 2005a; Hunt et al., 2006; Reutfors et al., 2009; Siris, 2001).”

“Depressive polarity of first mood episode has been consistently associated with a lifetime history of suicide attempts (Azorin et al., 2009; Bellivier et al., 2011; Finseth et al., 2012; Ryu et al., 2010; Sanchez-Gistau et al., 2009; Undurraga et al., 2012; Valtonen et al., 2006) and a higher…”

“There is consistent evidence that past suicide attempts are significantly associated with increased risk of future suicide attempts and deaths in BD (Aizenberg et al., 2006; Guillaume et al., 2010; Michaelis et al., 2003; Tsai et al., 2002; Valtonen et al., 2006), with an analysis of STEP-BD data…”

“The effect of mixed symptoms during the first illness episode has not been well studied, with the exception being a cohort study of 1090 BD patients which found that among suicide attempters whose first episode was mania, the episode was more likely to be characterized by coexisting depressive symptoms (Azorin et al.,…”

“Keks et al. (2009) found a relatively high rate of lifetime psychosis (63”

“In a prospective study of 405 adolescents with BD, Goldstein et al. (2012) found BD I to be associated with higher rates of lifetime suicide attempt than BD not otherwise specified (NOS), with no difference between BD I and II, while Algorta et al. (2011) found no differences between BD subtypes.”

“Two recent studies with partially overlapping samples reported significant association between recent cannabis use and lifetime suicide attempt (Aas et al., 2013; Kvitland et al., 2014); however, several other studies failed to show a consistent correlation (Bellivier et al., 2000; Cassidy, 2011;…”

“The presence of an eating disorder was also significantly prospectively associated with higher rates of suicide attempt (OR = 1.85) (Tidemalm et al., 2014).”

“Gonzalez-Pinto et al. (2011) reported the results of a 10-year follow-up study of 120 BD patients, in which 29.5% of subjects presenting with an index mixed episode attempted suicide, compared to 13.0% of subjects who presented with a non-mixed episode.”

“Efforts to better understand and prevent suicidal behavior must therefore utilize the breadth of all available knowledge (Brown et al., 2000; Gonda et al., 2012; Mann et al., 2005; Zisook et al., 2013), with a special emphasis on diagnosis-specific information (Foster, 2013; Gonda et al., 2012).”

“…of 60 BD patients, sexual dysfunction characterized by impaired desire or difficulty with excitement or orgasm was significantly associated with a lifetime history of suicide attempt (Dell’Osso et al., 2009) although whether this effect is mediated by a global decline in interest is not clear.”

“With regard to personality traits, a number of studies reported higher scores on tests of aggression and hostility among those with BD who attempt suicide (Azorin et al., 2009; Chaudhury et al., 2007; Grunebaum et al., 2006; Michaelis et al., 2004; Rocca et al., 2010; Sher et al., 2006).”

“Tsai et al. (1999) identified interpersonal and occupational problems to be more common among attempters in their clinical sample of 101 BD patients.”

“…2003; Finseth et al., 2012; Gazalle et al., 2007; Goldberg et al., 1998; Grunebaum et al., 2006; Leverich et al., 2003; Malloy-Diniz et al., 2009; Nery et al., 2014; Oquendo et al., 2010; Perroud et al., 2007; Potash et al., 2000; Sanchez-Gistau et al., 2009; Simon et al., 2007a; Simon et al.,…”

“While men with BD clearly have significantly higher absolute rates of suicide deaths (Clements et al., 2013; Hoyer et al., 2000; Ilgen et al., 2010; Nordentoft et al., 2011; Schaffer et al., 2014b; Simon et al., 2007a; Weeke and Vaeth, 1986), in a meta-analyses of 28 studies, Tondo et al. (2003)…”

“Data from patients with purging type bulimia nervosa identified significantly higher rates of suicide attempt among patients with comorbid BD (Favaro et al., 2008).”

“…disorder or anxiety symptoms increases the likelihood of suicide attempts in individuals with BD (Baldassano, 2006; Gazalle et al., 2007; Malloy-Diniz et al., 2009; Moor et al., 2012; Perroud et al., 2007; Sala et al., 2012; SanchezGistau et al., 2009; Simon et al., 2007a; Thibodeau et al., 2013).”

“A number of excellent reviews of this area have been published over the years (Baethge and Cassidy, 2013; Gonda et al., 2012; Hawton et al., 2005b; Malhi et al., 2013; Mathews et al., 2013; Pompili et al., 2013; Yerevanian and Choi, 2013), and our ISBD task force also separately conducted a series…”

“…Dalton et al., 2003; Dennehy et al., 2011; Engstrom et al., 2004; Goldberg et al., 1998; Grunebaum et al., 2006; Leverich et al., 2003; Parmentier et al., 2012; Perroud et al., 2007; Ryu et al., 2010; Sanchez-Gistau et al., 2009; Song et al., 2012; Suominen et al., 2009; Tidemalm et al., 2014).”

“…increased likelihood of suicide attempts (Antypa et al., 2013; Azorin et al., 2009; Azorin et al., 2013a; Coryell et al., 2013; Dalton et al., 2003; Dennehy et al., 2011; Engstrom et al., 2004; Goldberg et al., 1998; Grunebaum et al., 2006; Leverich et al., 2003; Parmentier et al., 2012; Perroud…”

“…age of illness onset is associated with an increased likelihood of suicide attempts (Antypa et al., 2013; Azorin et al., 2009; Azorin et al., 2013a; Coryell et al., 2013; Dalton et al., 2003; Dennehy et al., 2011; Engstrom et al., 2004; Goldberg et al., 1998; Grunebaum et al., 2006; Leverich et…”

“Several large studies found no significant association between any substance use disorder and risk of death by suicide in BD (Cassidy, 2011; Nordentoft et al., 2011; Simon et al., 2007a; Tsai et al., 2002) although the Nordentoft study reported a substantial numerical increased incidence rate in…”

“Goldstein et al. (2013) also reported higher rates of lifetime suicide attempt among obese BD subjects compared to non-obese BD subjects in the NESARC sample.”

“While men with BD clearly have significantly higher absolute rates of suicide deaths (Clements et al., 2013; Hoyer et al., 2000; Ilgen et al., 2010; Nordentoft et al., 2011; Schaffer et al., 2014b; Simon et al., 2007a; Weeke and Vaeth, 1986), in a meta-analyses of 28 studies, Tondo et al.”

“…evidence that earlier age of illness onset is associated with an increased likelihood of suicide attempts (Antypa et al., 2013; Azorin et al., 2009; Azorin et al., 2013a; Coryell et al., 2013; Dalton et al., 2003; Dennehy et al., 2011; Engstrom et al., 2004; Goldberg et al., 1998; Grunebaum et…”

“Studies examining the relationship between age and suicide attempts in BD have found that attempters are significantly younger than non-attempters (Antypa et al., 2013; Neves et al., 2009; Pawlak et al., 2013; Ryu et al., 2010).”

“…evidence that earlier age of illness onset is associated with an increased likelihood of suicide attempts (Antypa et al., 2013; Azorin et al., 2009; Azorin et al., 2013a; Coryell et al., 2013; Dalton et al., 2003; Dennehy et al., 2011; Engstrom et al., 2004; Goldberg et al., 1998; Grunebaum et…”

“On the other hand, current or lifetime cigarette smoking has been consistently associated with suicide attempts in BD (Baethge et al., 2009; Ostacher et al., 2006, 2009).”

“, 2007) or suicidal ideation (Allen et al., 2005; Azorin et al., 2009; Grunebaum et al., 2006; Roy-Byrne et al., 1988; Umamaheswari et al., 2014) carry an increased lifetime risk of suicide attempts.”

“…alcohol and other substances generally found both types of use to be associated with suicide attempts (Bellivier et al., 2011; Gazalle et al., 2007; Moor et al., 2012); however, there were exceptions with Oquendo et al. (2010) finding that only alcohol use disorders were associated with suicide…”

“There is highly consistent evidence that women with BD are significantly more likely than men with BD to attempt suicide (Antypa et al., 2013; Bellivier et al., 2011; Bronisch et al., 2005; Dilsaver et al., 2005; Engstrom et al., 2004; Simon et al., 2007a; Tidemalm et al., 2014; Tsai et al., 1999; Undurraga et al., 20…”

“, 2014); however, several other studies failed to show a consistent correlation (Bellivier et al., 2000; Cassidy, 2011; Parmentier et al., 2012; Tondo et al., 1999).”

“There is evidence that childhood abuse or early life stress is positively associated with suicide attempts in BD (Erten et al., 2014; Maniglio, 2013).”

“The findings on effect of impulsivity are more complex, with contradictory reports of higher (Azorin et al., 2009; Storosum et al., 2005; Swann et al., 2005) or lower (Gilbert et al., 2011) impulsivity traits being associated with suicide attempts, or no effect being found (Perroud et al., 2011).”

“There is highly consistent evidence that women with BD are significantly more likely than men with BD to attempt suicide (Antypa et al., 2013; Bellivier et al., 2011; Bronisch et al., 2005; Dilsaver et al., 2005; Engstrom et al., 2004; Simon et al., 2007a; Tidemalm et al., 2014; Tsai et al., 1999; Undurraga et al., 20…”

“…BD II (Holma et al., 2014; Ryu et al., 2010; Song et al., 2012; Tondo et al., 1999), others have found higher rates in BD I (Antypa et al., 2013; Bega et al., 2012; Joyce et al., 2010), but most report no significant difference (Chen et al., 2014; Dalton et al., 2003; Dennehy et al., 2011;…”

“Women are reported to be significantly less likely to attempt suicide by violent methods (Perroud et al., 2007).”

“A number of excellent reviews of this area have been published over the years (Baethge and Cassidy, 2013; Gonda et al., 2012; Hawton et al., 2005b; Malhi et al., 2013; Mathews et al., 2013; Pompili et al., 2013; Yerevanian and Choi, 2013), and our ISBD task force also separately conducted a series of meta-analyses on…”

“…(Chen et al., 2014; Dalton et al., 2003; Dennehy et al., 2011; Engstrom et al., 2004; Finseth et al., 2012; Galfalvy et al., 2006; Grunebaum et al., 2006; Hantouche et al., 2010; Leverich et al., 2003; Perroud et al., 2007; Sanchez-Gistau et al., 2009; Simon et al., 2007b; Valtonen et al., 2006).”

“…higher rates of suicide attempts among BD subjects with lifetime or current substance use disorders (Azorin et al., 2009; Dalton et al., 2003; Finseth et al., 2012; Gazalle et al., 2007; Goldberg et al., 1998; Grunebaum et al., 2006; Leverich et al., 2003; Malloy-Diniz et al., 2009; Nery et…”

“While two studies replicated the independent association between anxiety disorder comorbidity and suicide attempt rates (Sala et al., 2012; Simon et al., 2007a), others did not (Leverich et al., 2003; Marangell et al., 2006; Neves et al., 2009).”

“On the other hand, current or lifetime cigarette smoking has been consistently associated with suicide attempts in BD (Baethge et al., 2009; Ostacher et al., 2006, 2009).”

“The presence of a depressive predominant polarity has been consistently associated with greater likelihood of lifetime suicide attempts than a manic predominant polarity (Baldessarini et al., 2012; Carvalho et al., 2014; Colom et al., 2006; Popovic et al., 2014).”

“In a large Brazilian outpatient sample, obesity was significantly associated with a history of suicide attempt (Gomes et al., 2010).”

“With regard to personality traits, a number of studies reported higher scores on tests of aggression and hostility among those with BD who attempt suicide (Azorin et al., 2009; Chaudhury et al., 2007; Grunebaum et al., 2006; Michaelis et al., 2004; Rocca et al., 2010; Sher et al., 2006).”

“There is evidence that childhood abuse or early life stress is positively associated with suicide attempts in BD (Erten et al., 2014; Maniglio, 2013).”

“A recent review of impulsivity in BD only identified a weak independent link with suicidal intent or acts (Watkins and Meyer, 2013).”

“, 2007) or suicidal ideation (Allen et al., 2005; Azorin et al., 2009; Grunebaum et al., 2006; Roy-Byrne et al., 1988; Umamaheswari et al., 2014) carry an increased lifetime risk of suicide attempts.”

“…that a first-degree family history of suicide significantly increases the likelihood of suicide attempt in patients with BD (Antypa et al., 2013; Antypa and Serretti, 2014; Cassidy, 2011; Dalton et al., 2003; Dennehy et al., 2011; Engstrom et al., 2004; Finseth et al., 2012; Galfalvy et al.,…”

“While an exhaustive review of suicidal behavior among youth with BD is beyond the scope of this paper and has been reviewed elsewhere (Halfon et al., 2013), there are several key studies that reported data on this issue.”

“, 2004), hopelessness (Acosta et al., 2012; Valtonen et al., 2007) or suicidal ideation (Allen et al.”

“In a more recent study by Hoyer et al. (2009) of 30 BD suicide deaths, 27 occurred during a MDE and 3 during a manic episode.”

“Depressive polarity of first mood episode has been consistently associated with a lifetime history of suicide attempts (Azorin et al., 2009; Bellivier et al., 2011; Finseth et al., 2012; Ryu et al., 2010; Sanchez-Gistau et al., 2009; Undurraga et al., 2012; Valtonen et al., 2006) and a higher number of suicide attempt…”

“In a recent US study, BD and borderline personality disorder were found to have independent and additive effects on whether a prior suicide attempt had been made (Zimmerman et al., 2013).”

“A large national Finnish study of suicides posthospitalization for BD found that intra-episodic suicide attempt was a significant predictor of suicide death after hospitalization for bipolar depression (HR = 8.05) or mixed episodes (HR = 11.1) (Isometsä et al., 2014).”

“There is consistent evidence that past suicide attempts are significantly associated with increased risk of future suicide attempts and deaths in BD (Aizenberg et al., 2006; Guillaume et al., 2010; Michaelis et al., 2003; Tsai et al., 2002; Valtonen et al., 2006), with an analysis of STEP-BD data finding it to be the…”

“While two studies replicated the independent association between anxiety disorder comorbidity and suicide attempt rates (Sala et al., 2012; Simon et al., 2007a), others did not (Leverich et al., 2003; Marangell et al., 2006; Neves et al., 2009).”

“, 2007) or suicidal ideation (Allen et al., 2005; Azorin et al., 2009; Grunebaum et al., 2006; Roy-Byrne et al., 1988; Umamaheswari et al., 2014) carry an increased lifetime risk of suicide attempts.”

“…been correlated with likelihood of a suicide attempt (Bellivier et al., 2011; Dennehy et al., 2011; Finseth et al., 2012; Gazalle et al., 2007; Goldberg et al., 1998; Malloy-Diniz et al., 2009; Ryu et al., 2010; Valtonen et al., 2006), with one exception being a Korean sample (Song et al., 2012).”

“A number of excellent reviews of this area have been published over the years (Baethge and Cassidy, 2013; Gonda et al., 2012; Hawton et al., 2005b; Malhi et al., 2013; Mathews et al., 2013; Pompili et al., 2013; Yerevanian and Choi, 2013), and our ISBD task force also separately conducted a series of meta-analyses on…”

“With regard to personality traits, a number of studies reported higher scores on tests of aggression and hostility among those with BD who attempt suicide (Azorin et al., 2009; Chaudhury et al., 2007; Grunebaum et al., 2006; Michaelis et al., 2004; Rocca et al., 2010; Sher et al., 2006).”

“Schaffer et al. (2014b) reported higher rates of past suicide attempts among suicide completers with BD compared to those without BD (47.1% vs 25.8%).”

“, 2010), but most report no significant difference (Chen et al., 2014; Dalton et al., 2003; Dennehy et al., 2011; Engstrom et al., 2004; Finseth et al., 2012; Galfalvy et al., 2006; Grunebaum et al., 2006; Hantouche et al., 2010; Leverich et al., 2003; Perroud et al., 2007; Sanchez-Gistau et al., 2009; Simon et al., 2…”

“…states, a significantly higher mean altitude of residence was present among BD suicide victims compared to suicide victims with other psychiatric diagnoses (Huber et al., 2014), with the authors speculating on a possible role of mitochondrial dysfunction as a contributor to suicidal behavior in BD.”

“…al., 2012; Gazalle et al., 2007; Goldberg et al., 1998; Grunebaum et al., 2006; Leverich et al., 2003; Malloy-Diniz et al., 2009; Nery et al., 2014; Oquendo et al., 2010; Perroud et al., 2007; Potash et al., 2000; Sanchez-Gistau et al., 2009; Simon et al., 2007a; Simon et al., 2007b; Sublette et…”

“Depressive polarity of first mood episode has been consistently associated with a lifetime history of suicide attempts (Azorin et al., 2009; Bellivier et al., 2011; Finseth et al., 2012; Ryu et al., 2010; Sanchez-Gistau et al., 2009; Undurraga et al., 2012; Valtonen et al., 2006) and a higher number of suicide attempt…”

“, 2010) or self-directedness (Sarisoy et al., 2012) and cyclothymic temperament (Azorin et al.”

“Romero et al. (2007) did report higher rates of cluster C personality disorders among BD patients with a family history of suicide as compared to those with no family history.”

“Finally, Isometsä (2005) found that 40% of recent stressful life events occurred within the week prior to suicide death, and speculated that these events may have been dependent on the persons own behavior, possibly linked to manic or mixed presentations.”

“The findings on effect of impulsivity are more complex, with contradictory reports of higher (Azorin et al., 2009; Storosum et al., 2005; Swann et al., 2005) or lower (Gilbert et al., 2011) impulsivity traits being associated with suicide attempts, or no effect being found (Perroud et al., 2011).”

“There is highly consistent evidence that women with BD are significantly more likely than men with BD to attempt suicide (Antypa et al., 2013; Bellivier et al., 2011; Bronisch et al., 2005; Dilsaver et al., 2005; Engstrom et al., 2004; Simon et al., 2007a; Tidemalm et al., 2014; Tsai et al., 1999; Undurraga et al., 20…”

“Classification of youth with BD as being irritable-only, elated-only or both irritable and elated within the Course and Outcomes of Bipolar Youth (COBY) prospective cohort study did not reveal any differences in risk of suicide attempt (Hunt et al., 2013).”

“Several studies reported that subjects with suicide attempts had a significantly longer duration of illness (Azorin et al., 2008; Bellivier et al., 2011; Michaelis et al., 2004; Roy-Byrne et al., 1988), with two exceptions that reported a significantly shorter duration of illness in prospective…”

“Efforts to better understand and prevent suicidal behavior must therefore utilize the breadth of all available knowledge (Brown et al., 2000; Gonda et al., 2012; Mann et al., 2005; Zisook et al., 2013), with a special emphasis on diagnosis-specific information (Foster, 2013; Gonda et al., 2012).”

“…suicide attempts among BD subjects with lifetime or current substance use disorders (Azorin et al., 2009; Dalton et al., 2003; Finseth et al., 2012; Gazalle et al., 2007; Goldberg et al., 1998; Grunebaum et al., 2006; Leverich et al., 2003; Malloy-Diniz et al., 2009; Nery et al., 2014; Oquendo et…”

“, 2013), mixed states (BaniFatemi et al., 2013; Berutti et al., 2014), severity of depressive symptoms at intake (Bani-Fatemi et al.”

“For instance, analysis of United States epidemiological data found a higher lifetime history of suicide attempt among current smokers even when controlling for other factors (OR = 1.35) (Baek et al., 2013).”

“Rates of suicide attempt history were significantly higher in a United States sample of BD patients with comorbid binge eating disorder (McElroy et al., 2013).”

“Other personality traits or characteristics such as extreme attributional style (Stange et al., 2014), lower social skills (Rocca et al., 2010) or self-directedness (Sarisoy et al., 2012) and cyclothymic temperament (Azorin et al., 2009; Pompili et al., 2012) have similarly been significantly…”

“A number of excellent reviews of this area have been published over the years (Baethge and Cassidy, 2013; Gonda et al., 2012; Hawton et al., 2005b; Malhi et al., 2013; Mathews et al., 2013; Pompili et al., 2013; Yerevanian and Choi, 2013), and our ISBD task force also separately conducted a series of meta-analyses on…”

“, 2013), history of non-suicidal self-harm behaviors (Bani-Fatemi et al., 2013), family history of suicide or depression (Bani-Fatemi et al.”

“Efforts to better understand and prevent suicidal behavior must therefore utilize the breadth of all available knowledge (Brown et al., 2000; Gonda et al., 2012; Mann et al., 2005; Zisook et al., 2013), with a special emphasis on diagnosis-specific information (Foster, 2013; Gonda et al., 2012).”

“With regard to personality traits, a number of studies reported higher scores on tests of aggression and hostility among those with BD who attempt suicide (Azorin et al., 2009; Chaudhury et al., 2007; Grunebaum et al., 2006; Michaelis et al., 2004; Rocca et al., 2010; Sher et al., 2006).”

“As reviewed in the ISBD Task Force on Suicide in Bipolar Disorder (50), a number of sociodemographic and clinical risk factors need to be considered in determining the level of suicide risk (Table 2.”

“All bipolar patients are at risk of suicide, especially if admit-ted to hospital, when their first episode is depressive, if prone to recurrent depression and mixed states, have co-morbid anxiety (Harris and Barraclough, 1997; Schaffer et al., 2015) or co-morbid drug and alcohol use disorders (Webb et al.”

“…address: 54.70.40.11, on 08 Dec 2019 at 18:17:26, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms and suicide in first-degree relatives (Leverich et al., 2003; Hawton et al., 2005; Shabani et al., 2013; Schaffer et al., 2015a, 2015b; Bobo et al., 2018).”

“Greater prevalence among younger men and women may reflect the early age of onset of the disorder or premature death due medical complications among as individuals with bipolar I disorder (Crump et al., 2013; Goldstein et al., 2015) or by suicide (Schaffer et al., 2015).”

“history of suicide, and psychiatric comorbidity (17).”

“There was no information on individual parameters associated with suicide attempts including marital status, education, income, employment, childhood trauma, family history of suicide, psychiatric and medical comorbidities, temperament, and individual religiosity (Borges et al. 2010; Hansson et al., 2018; Isometsä, 20…”

“…that increase risk for suicide attempts, which are also present in this study sample, including comorbid A/SUDs, anxiety disorders, and/or past suicide attempt (Algorta et al., 2011; Goldstein et al., 2012; Hauser et al., 2013; Malone et al., 1995; Schaffer et al., 2015a; Strober et al., 1995).”

“In terms of factors associated with sexual dysfunction, this study reported that those with sexual dysfunction were older, had lower level of functioning, experienced higher number of other side effects associated with lithium, and were poorly adherent to medications.[81]”

“In the context of BD, anxiety is associated with a more severe course of illness (Boylan et al., 2004), including an earlier age at onset (Bauer et al., 2005) and increased suicide ideation and attempt (Dilsaver et al., 2006; Schaffer et al., 2015; Young et al., 1993).”

“Furthermore, SA, NSSI, and SI had significantly higher prevalence of sexual abuse and PTSD than the CG, as no cases of sexual abuse or PTSD were reported in the CG, which aligns with previous work associating sexual abuse and PTSD as risk factors for suicidality and self-injury across BD age groups [11, 42, 72].”

“For instance, bipolar disorder patients with a lifetime suicide attempt have been reported to have higher mean BMI than those without (Schaffer et al., 2015).”

“history of trauma is required for PTSD [32] and is correlated with a more severe course [33] with an increased risk for suicidal behavior in BP [34, 35].”

“, 2014; Turecki & Brent, 2016), gender (Nolen-Hoeksema, 2012; Schaffer et al., 2015) and comorbidity with personality disorder belonging to Cluster B (Hakim Shooshtari et al.”

“In subsamples defined by the presence or absence of a prior history of SA, multivariate Poisson regression analyses confirmed previous findings that rapid cycling pattern of illness and lifetime history of AUD and/ or SUD are risk factors for future SA (4, 31).”

“When mixed features are present, close follow-up and monitoring are even further merited, given that mixed states are associated with an increased risk of affective switching and suicidality.(23) For patients with MDD with mixed features, close monitoring after resolution of the mood episode may also be of benefit; th…”

“Previous literature suggested that the risk of suicide death was more strongly associated with longer disease duration [66, 67].”

“Suicide rates are generally quite higher in people suffering from mood 58 disorders, while the frequency of attempts is lower, which might indicate a higher risk for death in individuals 59 suffering from affective disorders [19].”

“Even though several studies have found associations between suicidality and psychiatric comorbidity [13], studies regarding this association in patients with MSAs are scarce.”

“The greater the intensity of depressive symptoms, the more severe these factors will be, with patients with a history of SA having twice as many current depressive or mixed episodes at the time of hospitalization than patients without a history of SA [10,11].”

“With regard to marital status, our findings seem to contradict previous literature revealing that people who are single or divorced present a greater vulnerability to suicide [7].”

“Other personality traits related to suicidality in BD patients include impulsivity, aggressiveness, difficulties in emotion regulation, a low tolerance to stress, extreme attributional style, lower social skills, and self-directedness [15,28].”

“This finding is consistent with other studies that have reported that prior suicidal behavior increases risk for future suicidality (Deisenhammer et al., 2019; Schaffer et al., 2015).”

“Other factors associated with PSA in BD patients include early age at onset; long duration of illness(15,16); long duration of untreated illness (DUI)(16,17); positive family history for suicide; higher lifetime number of hospitalizations(21); comorbid alcohol/substance use(4,15,16); eating,(16) anxiety,(4) and person…”

“Similar to our findings, other studies report that individuals with bipolar disorder who attempt suicide are more likely to experience a current depressive (or mixed state) episode [35].”

“The increased risk of suicide, self-harm, and other health problems are also prevalent in individuals with bipolar disorder and AUD (Farren et al., 2012; Schaffer et al., 2015).”

“As found by Schaffer et al. (2015), current use behavior is also a significant predictor of self-aggressive behavior among patients with mental disorders.”

“Previous studies have identified factors associated with SA in BD, including a current or recent depressive [8] or mixed episode [30], depressive polarity of the first episode, younger age of onset (AOO), female gender, family history of suicide, comorbid anxiety and SUD, and childhood trauma [31].”

“The relationship between age and risk of suicide in bipolar disorder is mixed (Schaffer et al., 2015a), but there is evidence that bipolar disorder suicide attempters are significantly younger than non-attempters (Schaffer et al., 2015a).”

“Besides that, evidence suggests that lifetime PC can cause a deleterious impact on illness course, contribute to poorer clinical outcomes, increase the prevalence of suicide attempts (SA), and contribute to treatment resistance[5, 6].”

“…that firstly, patients with BD who endorsed prior suicide attempts exhibited significantly higher rates of trauma exposure than those with BD who negated a history of suicide attempts [33]; secondly, patients with cPTSD reported higher depression, anxiety, and self-harm compared to PTSD [34].”

“A clear consensus exists of a suicide attempt being a major risk indicator for a subsequent attempt (25, 26).”

“4 – 14% of suicide deaths among those with bipolar disorder, and, moreover, 23–26% of people with bipolar disorder were found to have attempted suicide (27).”

“The ISBD taskforce on suicide identified numerous risk factors for suicide attempts in bipolar disorder, including depressive polarity (a greater risk than purely manic symptoms), comorbid anxiety and substance use disorders, and family history of suicide [60, 61] .”

“…we can also incorporate personality trait scores or psychological indicators from relevant studies [45], [46], [47], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65] into this feature set, which have the potential to provide meaningful and valuable insights, as we will…”

“In parallel, mixed states are well-established risk factors for suicide behaviour (Balázs et al. 2006; Schaffer et al. 2015; Pallaskorpi et al. 2017), with mixed features in a depressive episode doubling the risk for suicide (Baldessarini et al. 2012a).”