Suicide in bipolar disorder: a review.

BACKGROUND Suicide is a leading cause of death in patients with bipolar disorder. Risk factors and prevention of suicide in this illness are the focus of considerable current research. METHODS MEDLINE data base was searched for the key words "bipolar disorder" with "suicide", "lithium" with "suicide", "anticonvulsants" with "bipolar disorder", and "anticonvulsants" with "bipolar disorder" and with "suicide". No language or time constraints were applied. The lists of references were searched manually to find additional articles. RESULTS It is estimated that 25% to 50% of patients with bipolar disorder will attempt suicide at least once over their lifetime, and that 8% to 19% will complete suicide. Mortality rates from cardiovascular diseases are elevated in bipolar disorder. Risk factors for suicide include younger age of onset of the illness, history of past suicidal behavior, family history of suicide acts, comorbid borderline personality disorder and substance use disorders, and hopelessness. The warning signs calling for immediate action include the patients threatening to harm themselves, or looking for ways to kill themselves (seeking access to pills or weapons), or the patient talking or writing about death. Robust evidence supports the effects of lithium treatment in reducing suicidal attempts and completions in bipolar disorder. The evidence for antisuicidal effects of anticonvulsants is weaker. Nevertheless, valproate and other anticonvulsants are frequently prescribed as mood stabilizers. There have been controversial suggestions that this treatment may elevate the risk of suicide, but the data supporting this are not convincing. Psychoeducation can reduce the number of suicide attempts and completions. CONCLUSIONS Suicide in bipolar disorder is a major public health problem. Recent research has expanded our knowledge of risk factors and warning signs. Nevertheless, it appears that the introduction of lithium treatment in the 1970s was the most recent important breakthrough in the prevention of suicide in this illness.