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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
Open accessAbstract
Objectives: Many factors influence the likelihood of suicide attempts or deaths in persons with bipolar disorder. One key aim of the International Society for Bipolar Disorders Task Force on Suicide was to summarize the available literature on the presence and magnitude of effect of these factors. Methods: A systematic review of studies published from 1 January 1980 to 30 May 2014 identified using keywords ‘bipolar disorder’ and ‘suicide attempts or suicide’. This specific paper examined all reports on factors putatively associated with suicide attempts or suicide deaths in bipolar disorder samples. Factors were subcategorized into: (1) sociodemographics, (2) clinical characteristics of bipolar disorder, (3) comorbidities, and (4) other clinical variables. Results: We identified 141 studies that examined how 20 specific factors influenced the likelihood of suicide attempts or deaths. While the level of evidence and degree of confluence varied across factors, there was at least one study that found an effect for each of the following factors: sex, age, race, marital status, religious affiliation, age of illness onset, duration of illness, bipolar disorder subtype, polarity of first episode, polarity of current/recent episode, predominant polarity, mood episode characteristics, psychosis, psychiatric comorbidity, personality characteristics, sexual dysfunction, first-degree family history of suicide or mood disorders, past suicide attempts, early life trauma, and psychosocial precipitants. Conclusion: There is a wealth of data on factors that influence the likelihood of suicide attempts and suicide deaths in people with bipolar disorder. Given the heterogeneity of study samples and designs, further research is needed to replicate and determine the magnitude of effect of most of these factors. This approach can ultimately lead to enhanced risk stratification for patients with bipolar disorder.
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“Only male sex and first‐degree family history of suicide have been significantly associated with suicide deaths.50, 51”
From Canadian Network for Mood and Anxiety Treatments ( CANMAT ) and International Society for Bipolar Disorders ( ISBD ) 2018 guidelines for the management of patients with bipolar disorder (2018) · cites this paper as [50]
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“Comorbidity impacts the course of BDs by increasing the likelihood of treatment resistance and suicide risk, and also by increasing the time spent with impairing symptoms.34, 50, 669, 670”
From Canadian Network for Mood and Anxiety Treatments ( CANMAT ) and International Society for Bipolar Disorders ( ISBD ) 2018 guidelines for the management of patients with bipolar disorder (2018) · cites this paper as [50]
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“Factors reported to be significantly associated with suicidal attempt include female sex, younger age of illness onset, depressive polarity of first illness episode, depressive polarity of current or more recent episode, comorbid anxiety disorder, comorbid SUD, comorbid cluster B/borderline personality disorder, first‐degree family history of suicide, and previous suicide attempts.”
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BackgroundBipolar Disorders: Evaluation and Treatment.
Marzani-Nissen, G., & Neff, A. P. (2021) · PubMed · Cited by 15
Buoli, M., Cesana, B. M., Bolognesi, S., Fagiolini, A. M., Albert, U., Salvo, G. D., Maina, G., de Bartolomeis, A., Pompili, M., Palumbo, C., et al. (2021) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-021-01343-y · Cited by 16
“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].”
ResultJha, S., Chan, G., & Orji, R. (2023) · Human Behavior and Emerging Technologies · doi:10.1155/2023/3923097 · Cited by 23
Molecular Changes Associated with Suicide
Navarro, D., Marín, M., Gasparyan, A., García‐Gutiérrez, M. S., Rubio, G., & Manzanares, J. (2023) · International Journal of Molecular Sciences · doi:10.3390/ijms242316726 · Cited by 19
“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].”
BackgroundInfluentialBipolar II Disorder: Understudied and Underdiagnosed
Swartz, H. A., & Suppes, T. M. (2023) · FOCUS The Journal of Lifelong Learning in Psychiatry · doi:10.1176/appi.focus.20230015 · Cited by 19
(2022) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9780890425787.x03_bipolar_and_related_disorders · Cited by 17
Suicidality risk among adults with binge‐eating disorder
Bulik, C. M., Bertoia, M. L., Lu, M. J., Seeger, J. D., & Spalding, W. M. (2021) · Suicide and Life-Threatening Behavior · doi:10.1111/sltb.12768 · Cited by 13
“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).”
ResultLin, R., López, J. P., Cruceanu, C., Pierotti, C. E., Fiori, L. M., Squassina, A., Chillotti, C., Dieterich, C., Mellios, N., & Turecki, G. (2021) · Translational Psychiatry · doi:10.1038/s41398-021-01746-4 · Cited by 13
Self-citationDepp, C. A., Thompson, W. K., Frank, E., & Swartz, H. A. (2016) · Journal of Affective Disorders · doi:10.1016/j.jad.2016.09.054 · Cited by 13
Clinical characterization of Italian suicide attempters with bipolar disorder
Dell’Osso, B. M., Vismara, M. E. M., Dobrea, C., Cremaschi, L., Grancini, B. M., Arici, C., Benatti, B., Buoli, M., Ketter, T. A., & Altamura, A. C. (2017) · CNS Spectrums · doi:10.1017/s1092852917000384 · Cited by 12
“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…”
BackgroundResilience and insight in euthymic patients with bipolar disorder
Şenormancı, G., Güçlü, O., Özben, İ., Karakaya, F. N., & Şenormancı, Ö. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.01.079 · Cited by 12
Mash, H. B. H., Ursano, R. J., Kessler, R. C., Naifeh, J. A., Fullerton, C. S., Aliaga, P. A., Dinh, H. M., Sampson, N. A., Kao, T., & Stein, M. B. (2023) · BMC Psychiatry · doi:10.1186/s12888-023-04872-z · Cited by 11
“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].”
BackgroundResultAlcohol use disorders in patients with bipolar disorder: a systematic review and meta-analysis
Pedro, M. O. P., Pedro, M. P., Martins, S. S., & Castaldelli-Maia, J. M. (2023) · International Review of Psychiatry · doi:10.1080/09540261.2023.2249548 · Cited by 14
“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).”
BackgroundKim, S., Dunn, N., Moon, K., Casement, M. D., Nam, Y., Yeom, J. W., Cho, C., & Lee, H. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.06.012 · Cited by 11
Cavalera, C., Ferrari, C., Bianconi, G., Bulgari, V., Candini, V., Carrà, G., Clerici, M., Conte, G. L., Cricelli, M., Ferla, M. T., et al. (2020) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/0004867420963732 · Cited by 10
“As found by Schaffer et al. (2015), current use behavior is also a significant predictor of self-aggressive behavior among patients with mental disorders.”
BackgroundMichaels, M. S., Balthrop, T., Pulido, A. N., Rudd, M. D., & Joiner, T. E. (2017) · Archives of Suicide Research · doi:10.1080/13811118.2017.1319308 · Cited by 10
Guidelines for the management of psychosis in the context of mood disorders
Bassett, D. L., Boyce, P. M., Lyndon, B., Mulder, R., Parker, G. B., Porter, R., Singh, A., Bell, E., Hamilton, A., Morris, G., et al. (2022) · Schizophrenia Research · doi:10.1016/j.schres.2022.01.047 · Cited by 10
Patino, L. R., Tallman, M. J., Wen, H., Adler, C. M., Welge, J. A., & DelBello, M. P. (2023) · Journal of Affective Disorders · doi:10.1016/j.jad.2023.06.030 · Cited by 9
Cui, L., Zhu, Y., Li, Y., Zhou, J., Xu, G., Pan, M., Chen, Z., Li, W., Jiao, Z., Li, M., et al. (2025) · BMC Psychiatry · doi:10.1186/s12888-025-06750-2 · Cited by 9
“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].”
Cheung, G., Chai, Y., Troya, M. I., & Luo, H. (2020) · International Psychogeriatrics · doi:10.1017/s1041610220003853 · Cited by 9
“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).”
BackgroundInfluentialLéda‐Rêgo, G., Studart‐Bottó, P., Sarmento, S., Silva, T. C., Bezerra‐Filho, S., & Miranda‐Scippa, Â. (2023) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-023-01562-5 · Cited by 9
“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].”
BackgroundIazzolino, A. M., Valenza, M., D’Angelo, M., Longobardi, G., Stefano, V. D., Visalli, G., Steardo, L., Scuderi, C., & Steardo, L. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13030673 · Cited by 9
“…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].”
ResultAportaciones de la medicina forense en la mejora del conocimiento del suicidio
Vera-Varela, C., Barbería, E., Giner, L., Xifró, A., Suelves, J. M., & Guija, J. A. (2019) · Revista Española de Medicina Legal · doi:10.1016/j.reml.2019.03.001 · Cited by 9
Do Suicide Attempts of Mood Disorder Patients Directly Increase the Risk for a Reattempt?
Aaltonen, K. I., Rosenström, T. H., Jylhä, P. J., Holma, I. A. K., Holma, M., Pallaskorpi, S. K., Riihimäki, K., Suominen, K. H., Vuorilehto, M. S., & Isometsä, E. T. (2020) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.547791 · Cited by 10
“A clear consensus exists of a suicide attempt being a major risk indicator for a subsequent attempt (25, 26).”
BackgroundSelf-citationTrauma history in veterans with bipolar disorder and its impact on suicidality
Fijtman, A., Clausen, A. N., Kauer‐Sant’Anna, M., & Morey, R. A. (2022) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2022.10.063 · Cited by 7
Suicidal Ideation in Bipolar Disorder: The Relation with Clinical and Sociodemographic Variables
Lage, R. R., da Silva, R. D. A., Tancini, M. B., Nardi, A. E., Mograbi, D. C., & Cheniaux, E. (2021) · Psychiatric Quarterly · doi:10.1007/s11126-021-09965-0 · Cited by 7
Cortisol Levels and Suicide in Bipolar I Disorder
Giurgiuca, A. (2017) · Acta Endocrinologica (Bucharest) · doi:10.4183/aeb.2017.188 · Cited by 7
“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).”
BackgroundInfluentialWand, A. P. F., & Reppermund, S. (2021) · International Psychogeriatrics · doi:10.1017/s1041610220004147 · Cited by 6
DSM‐5‐TR diagnosis as a guide to suicide risk assessment
Felthous, A. R., Kulkarni, N., & Belean, C. (2023) · Behavioral Sciences & the Law · doi:10.1002/bsl.2617 · Cited by 6
Outpatient Management of Bipolar Disorder in Older Adults
Donley, B. E., & Garcia-Pittman, E. C. (2024) · Current Psychiatry Reports · doi:10.1007/s11920-024-01576-3 · Cited by 5
“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] .”
Online Social Behaviors: Robust and Stable Features for Detecting Microblog Bots
Zhang, X., Zhu, T., & Li, B. (2024) · IEEE Transactions on Computational Social Systems · doi:10.1109/tcss.2024.3502357 · Cited by 4
“…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…”
Malhi, G. S., Gessler, D., Fritz, K., Allwang, C., Outhred, T., & Das, P. (2016) · Springer eBooks · doi:10.1007/978-3-319-45923-3_11 · Cited by 4
Abel, E. A., Travaglini, L. E., Snow, J. L., & Goulet, J. L. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.10.028 · Cited by 3
Suicide Deaths in People With Bipolar Disorder: Characteristics and Treatments at Time of Death
Schaffer, A., Chan, P. P. M., Men, V. Y., Steinberg, R. J., Mitchell, R. H. B., Malhi, G. S., Yatham, L. N., & Sinyor, M. (2025) · Bipolar Disorders · doi:10.1111/bdi.70061 · Cited by 3
Self-citationHerrera, M. (2018) · Springer eBooks · doi:10.1007/978-3-319-74391-2_2 · Cited by 3
Development and Validation of “Divorcing the Self-Incompatible Scale” (DSIS)
Khodadady, E., & Bagheri, S. (2022) · Journal of Clinical Research and Reports · doi:10.31579/2690-1919/230 · Cited by 3
Singh, B., & Baweja, R. K. (2026) · Journal of Affective Disorders · doi:10.1016/j.jad.2026.121702 · Cited by 2
Salloum, I. M., & Christodoulou, G. N. (2016) · Springer eBooks · doi:10.1007/978-3-319-39724-5_26 · Cited by 2
Díaz, A. P., Cuellar, V. A., Vinson, E., Suchting, R., Durkin, K., Fernandes, B. S., Scaini, G., Kazimi, I. F., Zunta‐Soares, G. B., Quevedo, J., et al. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.671840 · Cited by 1
Religiosity as a protective factor for suicidality among inpatients with bipolar disorder.
Olmos, C., Pigott, T., Soares, J., & Sanches, M. (2021) · Asian Journal of Psychiatry · doi:10.1016/j.ajp.2021.102875 · Cited by 1
The role of predominant polarity in older age bipolar disorder
Sommerhoff, C., Bort, M., D’Alessandro, G., Fico, G., Prisco, M. D., Oliva, V., Solé, B., Torrent, C., Murru, A., Ruíz, A., et al. (2025) · International Journal of Bipolar Disorders · doi:10.1186/s40345-025-00392-9 · Cited by 1
“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).”
Risk Factors for Rehospitalization among Bipolar Patients
Moneam, O. A. H. A., EL-Hamady, M. M., Abd-Elmaksoud, S. F., & Mahmoud, M. M. (2022) · The Egyptian Journal of Hospital Medicine · doi:10.21608/ejhm.2022.266008 · Cited by 1
Assessment and Management of Suicidal Risk
Melvin, G. A., Oquendo, M. A., Stanley, B., & Posner, K. (2023) · Springer eBooks · doi:10.1007/978-3-030-42825-9_67-1 · Cited by 1
Trastornos afectivos, trastornos depresivos y trastorno bipolar
Florido, V. D. S., Rodríguez-Quiroga, A., Gragera, D. M., & Rojo, S. F. (2023) · Medicine - Programa de Formación Médica Continuada Acreditado · doi:10.1016/j.med.2023.08.003 · Cited by 1
Negative early life experiences as risk factors for suicidal behavior in bipolar disorders
Lafer, B., & Oquendo, M. A. (2020) · Brazilian Journal of Psychiatry · doi:10.1590/1516-4446-2020-0018 · Cited by 1
Older Age Bipolar Disorder and Substance Use
Bhuvaneswaran, C., Hargrave, R., & Brown, E. S. (2017) · Springer eBooks · doi:10.1007/978-3-319-48912-4_5
Metadata
- Authors
- Schaffer, A., Isometsä, E. T., Azorin, J.-M., Cassidy, F., Goldstein, T., Rihmer, Z., Sinyor, M., Tondo, L., Moreno, D. H., Turecki, G., Reis, C., Kessing, L. V., Ha, K., Weizman, A., Beautrais, A., Chou, Y.-H., Diazgranados, N., Levitt, A. J., Zarate, C. A., & Yatham, L.
- Affiliations
- Sunnybrook Health Science Centre (CA)
- University of Helsinki (FI)
- Aix-Marseille Université (FR)
- Duke University (US)
- University of Pittsburgh (US)
- Semmelweis University (HU)
- Harvard University (US)
- Universidade de São Paulo (BR)
- McGill University (CA)
- University of Copenhagen (DK)
- Seoul National University Bundang Hospital (KR)
- Tel Aviv University (IL)
- Yale University (US)
- Taipei Veterans General Hospital (TW)
- National Institutes of Health (US)
- National Institute of Mental Health (US)
- University of British Columbia (CA)
- Corresponding author
- Schaffer, Ayal
- ORCID
- Venue
- Australian & New Zealand Journal of Psychiatry
- Publisher
- SAGE Publications
- Published
- 2015-07-14
- Volume
- 49
- Issue
- 11
- Pages
- 1006-1020
- ISSN
- 0004-8674 (ISSN-L)
- 1440-1614
- PMC
- PMC5858693
- OpenAlex
- W2283508123
- Cited by
- 120
- References
- 156
- Citations by year
- 2026: 4 · 2025: 9 · 2024: 11 · 2023: 14 · 2022: 9 · 2021: 11 · 2020: 14 · 2019: 13 · 2018: 11 · 2017: 14 · 2016: 10
- FWCI
- 1.60
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Australian & New Zealand Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Research at the University of Copenhagen (University of Copenhagen) (submittedVersion)
- Funders
- National Institutes of Health (Z99 MH999999)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Bipolar Disorder and Treatment
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Keywords
- bipolar disorder, suicide attempts, suicide mortality, risk factors, risk stratification, comorbidities, psychosis, early trauma, family history of suicide, sexual dysfunction, personality traits
- MeSH terms
- Bipolar Disorder, Humans, Risk Factors, Suicide, Attempted, Comorbidity, Advisory Committees
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