NEW YORK – The likelihood that patients with major mood disorders will attempt or complete suicide appears to be related to the amount of time they spend in high-risk states of illness, results of longitudinal studies suggest.
"Among mood disorder patients, in any setting, there is a very strong association between suicidal acts and mood state," said Dr. Erkki T. Isometsä, professor of psychiatry at the University of Helsinki.
"Time spent in high-risk illness states is a major determinant of overall risk. Thus, for prevention of suicidal acts, reducing time in high-risk illness states is essential," he said at the American Psychiatric Association annual meeting.
Neil Osterweil/Frontline Medical News
Dr. Erkki T. Isometsä
Providing effective acute therapies and maintenance-phase treatment and improving continuity of care has the potential to significantly decrease suicidal acts, Dr. Isometsä said.
He noted that half of all suicides are committed by people who suffer from major mood disorders such as depression and bipolar disorder. A recently published meta-analysis and systematic review found that factors significantly associated with suicide were male sex (odds ratio, 1.76); a family history of psychiatric disorder (OR, 1.41); previous suicide attempt (OR, 4.84); more severe depression (OR, 2.20); hopelessness (OR, 2.20); and comorbid disorders, including anxiety (OR, 1.59) and substance misuse (OR, 2.17) (J. Affect. Disord. 2013;147:17-28).
Dr. Isometsä pointed to an International Society for Bipolar Disorders (ISBD) task force on suicide, whose members identified risk variables associated with suicide attempts and suicide deaths.
Suicide attempts were more likely in patients with bipolar disorder who had depressive polarity of their first, current, or most recent illness episode; comorbid cluster/borderline personality disorder; any comorbid anxiety or substance use disorder; history of suicide in a first-degree relative; female sex; and younger age of illness at onset.
However, only suicide of a first-degree relative and male sex were significantly associated with suicide deaths.
Longitudinal studies
Dr. Isometsä was the lead investigator for two longitudinal studies of Finnish patients with mood disorders: the Vantaa Primary Care Depression Study and the Jorvi Bipolar Study. Both studies looked at the incidence of suicide attempts over time across variable mood states.
In the depression study, the investigators compared the incidence of suicide attempts among depressed patients during major depressive episodes, partial remissions, and full remissions over 5 years of follow-up and found that 78% of the attempts (adjusted population attributable fraction [PAF]) occurred during major depressive episodes.
Factors significantly associated with suicide attempts were a prior attempt (OR, 4.39), partial vs. full remission (OR, 4.20), and major depressive episode (OR, 7.74).
Protective factors included age (OR, 0.94), married or cohabiting (OR, 0.43), intermediate social support (OR, 0.36), and high social support (OR, 0.28).
In the Jorvi Bipolar Study, which looked at patients with both bipolar disorders I and II, the incidence was of suicide attempts was 37 times higher when patients were in combined mixed and depressive mixed states and 18-fold higher during major depressive phases, compared with other illness states. In this study, the PAF for time spent in high-risk illness phase was 86%.
In each study, suicidal acts during mood episodes also was more likely among patients who had hopelessness, a history of abuse in childhood, poor social support, concurrent substance use, cluster B personality disorders, and those with impulsive-aggressive traits.
But of all of the associated factors, time spent in high-risk phases of illness appeared to be the predominant, modifiable driver of suicidal acts, Dr. Isometsä concluded.
The Vantaa and Jorvi studies were supported by the National Institute for Health and Welfare, Finland. Dr. Isometsä reported having no conflicts of interest.