Prevalence and
Characteristics of Suicide in
Bipolar Disorder
ISBD Task Force on Suicide
Doris Hupfeld Moreno, MD, PhD...
Faculty Disclosure
Nothing to disclose
Objectives
 Prevalence of suicide attempts in clinical and
epidemiological BD samples
 Rates on death from suicide th...
 Methodological diversity
 Different definitions of suicide attempts
 Distinct periods of time covered
 Lack of inf...
Suicide Attempts in BD
Suicide Attempts in BDI vs. BDII
Novick DM et al. Suicide attempts in bipolar I and bipolar II disorder: a review and met...
Attempted suicide rates
epidemiological studies
Study Sample (N) Lifetime Prevalence
ECA US
18,000 subjects
29.2%
Ch...
Attempted suicide rates
prospective clinical studies
Study Sample (N) Duration Rates
Simon et al., 2007. U.S.
Health p...
Attempted suicide rates
retrospective clinical studies
Study Sample (N) Lifetime prevalence
Azorin et al., 2009
1,090 ...
Suicide Deaths in BD
Suicide Deaths in BD
Tondo L, Isacsson G, Baldessarini R. Suicidal behaviour in bipolar disorder: risk and prevention. CN...
Suicide review and meta-analysis
 Review of 34 papers, selected according to a quality score, depending on
 representa...
ISBD Task Force
Suicide Rate for People with Bipolar Disorder: Pooled by Sample Size
and by Exposure Years
Paper Year N...
Methods used
Study n Self-
Poisoning
Jump Cutting/
Stabbing
Hanging Fire -
arm
Other
Tsai et al., 1999 53 30.2% 13.2%* 22.7% - -...
Methods used for suicide
completion
Study n Self-
Poisoning
Hanging Jump Fire-arm
Cutting/
Stabbing
Other
Rihmer e...
BD vs. Other Major
Mental Illness
suicide attempts
Association between DSM-IV disorders and a
subsequent suicide attempt – World Mental
Health Survey (n=27,963) – 11 count...
Attempted suicide rates
compared to MDD and other Axis I
disorders
Study Sample (N) Results
Chen & Dilsaver,
1996
18...
BD vs. Other Major
Mental Illness
suicide
Suicide in Taiwan
n = 12,391 suicides (coroner’s records)
N %
Bipolar disorder 482 3.9
Major depression 895 7.2
Neuro...
Suicide rates compared to MDD and
other Axis I disorders
Study Sample (N) Results
Osby et al., 2001
Sweden
Inpatient ...
Cumulative incidence of suicide by time since the
first psychiatric contact among men (A) and women (B)
Copyright restri...
Conclusions
 Lifetime suicide attempts occured in ¼ of individuals in population-based
studies and more than 1/3 in cli...
We have to consider...
 Impact of DSM5 on suicide rates – mixed episodes?
 BD undertreated, rates are underestimated
...
Acknowledgments
 Ayal Schaffer
 Mark Synior
 Laura Andrade
 Kyooseob Ha
 Lars Kessing
 Catherine Reis
Thank you!
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Prevalence and Characteristics of Suicide in Bipolar Disorder

Prevalence and Characteristics of Suicide in Bipolar Disorder, presented by Dr. Doris Hupfeld Moreno
Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Prevalence and Characteristics of Suicide in Bipolar Disorder

  • 1. Prevalence and Characteristics of Suicide in Bipolar Disorder ISBD Task Force on Suicide Doris Hupfeld Moreno, MD, PhD Medical Assistant and Resident Supervisor of the Institute of Psychiatry, University of São Paulo School of Medicine Researcher in the Section on Epidemiology and the Mood Disorders Unit of the Institute of Psychiatry Member of the Task Force on Suicide of the ISBD
  • 2. Faculty Disclosure Nothing to disclose
  • 3. Objectives  Prevalence of suicide attempts in clinical and epidemiological BD samples  Rates on death from suicide through different reviews  Methods used for suicide attempts  Comparison with rates of MDD and other major mental illness
  • 4.  Methodological diversity  Different definitions of suicide attempts  Distinct periods of time covered  Lack of information, i.e., regarding methods used for suicidal acts, rate of bipolar I, II or NOS  Sample heterogeneity Problems
  • 5. Suicide Attempts in BD
  • 6. Suicide Attempts in BDI vs. BDII Novick DM et al. Suicide attempts in bipolar I and bipolar II disorder: a review and meta-analysis of the evidence. Bipolar Disord. 2010;12(1):1-9.
  • 7. Attempted suicide rates epidemiological studies Study Sample (N) Lifetime Prevalence ECA US 18,000 subjects 29.2% Chen & Dilsaver, 186 BD 1996 NESARC Oquendo et al., 2010 43,093 subjects 1,643 BDI/II 25.3% with alcohol use disoders (AUD) 14.8 % w/o AUD WMHS Merikangas et al., 2011 61,392 subjects 11 countries 25.6% BDI 20.8% BDII 9.5% BD NOS NESARC Blanco et al., 2012 990 BDI 24.7% ECA – Epidemiologic Catchment Area Study NESARC - National Epidemiologic Survey on Alcohol and Related Conditions WMHS – World Mental Health Survey
  • 8. Attempted suicide rates prospective clinical studies Study Sample (N) Duration Rates Simon et al., 2007. U.S. Health plan records 32,360 BD Mean 2.7 years 5.3% Khalsa et al., 2008, U.S. 216 BDI first episode 4.2 ± 2.7 (range: 0.5–9.2) years 18.1% requiring re-hospitalization: 17.6% Altamura et al., 2010, Italy 128 BDI 192 BDII 5 years 22% Gonzalez-Pinto et al., 2011 120 BDI Up to 10 years 18.3% Dennehy et al., 2011 STEP-BD 4.360 Mean 16 months 6.0% (1/3 > 1 attempt)
  • 9. Attempted suicide rates retrospective clinical studies Study Sample (N) Lifetime prevalence Azorin et al., 2009 1,090 BDI 35.0% French National Cohort Garcia-Amador et al., 2009 Spain 305 BD 25.9% Bellivier et al., 2011 Europe EMBLEM 3,684 BDI 29.9% Ghanizadeh and Sahraian, 2008 Iran 176 BDI inpatients 34.1% 70% only one attempt Ryu et al., 2010 Korea 579 BD 13.1% 89.5% BDI , 7.9% BDII, 2.6% BDNOS Cassidy et al., 2011 USA 157 BD 37.6% Dennehy et al., 2011 STEP-BD 4.360 BD 36%
  • 10. Suicide Deaths in BD
  • 11. Suicide Deaths in BD Tondo L, Isacsson G, Baldessarini R. Suicidal behaviour in bipolar disorder: risk and prevention. CNS Drugs. 2003;17(7):491-511.
  • 12. Suicide review and meta-analysis  Review of 34 papers, selected according to a quality score, depending on  representativeness of sample, if only BD patients were included, duration of follow-up > 1 year, controlling of confounding variables, reliably identificated cases, etc Pompili et al., Bipolar Disorders, 2013, 15:457-490 Type of study Prevalence/incidence of BD Retrospective Risk for suicide was up to 20-30 times greater than for general population Prospective Among psychiatric diagnoses, BD strongest association with suicide – 25% of all suicides Prevalence data are conflicting Psychological autopsy studies 22% - 61%
  • 13. ISBD Task Force Suicide Rate for People with Bipolar Disorder: Pooled by Sample Size and by Exposure Years Paper Year No. of Suicides Duration in Years Exposure (person-years) Suicide Rate (per 100 person years) Suicide Rate- Male Suicide Rate- Female Morrison et al. 1982 12/443 8.5 3766 0.319 Martin et al. 1985 0/19 9 171 0.000 Weeke and Vaeth 1986 17/417 7 2919 0.582 Black et al. 1988 7/586 7 4102 0.171 Dingman et al. 1988 1/19 15 285 0.351 Friis et al. 1991 2/14 7 98 2.041 Newman and Bland 1991 19/1429 4.8 6859 0.277 Sharma and Marker 1994 9/472 9 4248 0.212 Koukopoulos et al. 1995 5/89 2.75 245 2.043 Thies-flechtner et al. 1996 8/146 2.5 365 2.192 Angst et al. 1998 11/220 28 6160 0.179 Bocchetta et al. 1998 5/47 5.6 263 1.900 Brodersen et al. 2000 7/61 16 976 0.717 Kallner et al. 2000 7/106 8.2 869 0.805 Kleindienst and Greil 2000 1/85 2.5 213 0.471 Osby et al. 2001 672/15386 11.1 170615 0.394 0.498 0.323 Gladstone et al. 2001 5/813 5 4065 0.123 Dutta et al. 2007 8/235 18.8 4422 0.181 0.369 0.040 Simon GE et al. 2007 73/32360 2.7 87372 0.106 0.171 0.071 Tondo et al. 2007 22/901 3.56 3208 0.686 1.059 0.391 Osborn et al. 2008 41/10742 4.7 50487 0.080 Dennehy et al. 2011 8/4360 1.3 5668 0.140 0.252 0.065 Sani et al. 2011 57/1765 2.9 5119 1.110 1.458 0.869 Gonzalez-Pinto et al. 2011 3/169 10 1690 0.178 Nordentoft et al. 2011 175/5927 18 106686 0.160 0.210 0.129 Total 1175/76811 8.436a 471035 0.617a Pooled (by sample size) 0.215b 0.330 0.161 Pooled (by exposure years) 0.253b 0.368 0.218 Total 1175/76811 8.436a 471035 0.617a Pooled (by sample size) 0.215b Pooled (by exposure years) 0.253b
  • 14. Methods used
  • 15. Study n Self- Poisoning Jump Cutting/ Stabbing Hanging Fire - arm Other Tsai et al., 1999 53 30.2% 13.2%* 22.7% - - Drowning 7.5% Gas inhalation 5.7% Oquendo et al., 2009 146 80.1% 4.8% 8.2% 0.7% 1.4% Immolation 2.1% drowning 0.7% Ryu et al., 2010 76 34.2% 13.2% 19.7% 10.5% - Unknown 18.4% immolation 1.3% D’Ambrosia et al., 2012 220 63.4% 12.7% 5.6% 7.0% 4.2% Gas inhalation 2.8% Collision 1.4% Ruengorn et al., 2012 58 40.1% 12.3% 21.4% 26.3% - Collision 7% Drowning 3.5% Methods used in suicide attempts
  • 16. Methods used for suicide completion Study n Self- Poisoning Hanging Jump Fire-arm Cutting/ Stabbing Other Rihmer et al., 1990 47 53% 17% 26% - - - Osby et al., 2001 672 29.8% 31.0% 13.7% 5.2% 2.7% Drowning 11% Other 6.7% Tsai et al, 2002 43 23.2% 11.6% 23.2% - - Drowning 25.6% Gas inhalation 9.3% Other 7% Chen et al., 2009 482 24.9% 32.2% 17.4% - - Charcoal burning 13.5% Other 12.0% Keks et al., 2009 35 17% 46% - - - CO poisoning 17% Collision 11% Gos et al., 2009 7 42.9% 28.6% - - 14.3% Electrocution 14.3% Dennehy et al., 2011 8 25% 25% - 25% - Unknown 25%
  • 17. BD vs. Other Major Mental Illness suicide attempts
  • 18. Association between DSM-IV disorders and a subsequent suicide attempt – World Mental Health Survey (n=27,963) – 11 countries DSM-IV disorders Bivariate models OR (95% CI) Developed Developing Panic disorder 5.1 (4.0-6.40 5.0 (3.4-7.3) PTSD 6.5 (5.4-7.6) 8.3 (6.0-11.6) GAD 5.6 (4.6-6.7) 5.4 (3.9-7.5) MDD 5.8 (5.0-6.8) 5.1 (4.2-6.1) Bipolar disorder 7.1 (5.5-9.3) 6.7 (4.4-10.0) ODD 5.3 (4.1-6.7) 6.7 (4.1-10.9) Conduct disorder 4.8 (3.6-6.4) 8.9 (5.6-14-2) Alcohol abuse/dependency 4.4 (3.7-5.3) 4.8 (3.7-6.1) Drug abuse/ dependency 4.9 (3.8-6.2) 7.5 (5.4-10.4)
  • 19. Attempted suicide rates compared to MDD and other Axis I disorders Study Sample (N) Results Chen & Dilsaver, 1996 18,000 subjects ECA U.S. 186 BD BD (29.2%) > MDD (15.9%) > other Axis I (4.2%) BD vsMDD - OR 2.0 (df=1, x(2)=697.9, p<0.0001) Tondo et al., 2007 2,826 mood disorder patients %patients/y BDI (1.52) > BDII (0.82) > MDD (0.48) Bader & Dunner, 2007 305 BDI/II/NOS 130 MDD Tertiary care unit BDI > BDII = MDD recurrent (p=0.001) and BD NOS (p=0.007)
  • 20. BD vs. Other Major Mental Illness suicide
  • 21. Suicide in Taiwan n = 12,391 suicides (coroner’s records) N % Bipolar disorder 482 3.9 Major depression 895 7.2 Neurotic disorder 2,741 22.1 Schizophrenia 703 5.7 Other disorders 2,273 18.3 No diagnosis 5,297 42.8 Chen YY et al. Methods of suicide in different psychiatric diagnostic groups. J Affect Disord. 2009 Nov;118(1-3):196-200.
  • 22. Suicide rates compared to MDD and other Axis I disorders Study Sample (N) Results Osby et al., 2001 Sweden Inpatient register 1973-1995 BD=15,386 UP=39,182 SMR: UP (20.9 Male/27.0 Female) vs. BD (15.0 Male/22.4 Female) Ilgen et al., 2006 U.S. 6,913 National Violent Death Reporting System 2004 MDD 34.7% BD 6.1%  In any other Axis I disorder Tondo et al., 2007 Italy 2,826 mood disorder patients suicide rate (% patients/year): BDII (0.16) > BDI (0.14) > MDD(0.05) Osborn et al., 2008 Cohort study within the UK 43,136 SMI patients vs no SMI BD=10,742 HR: 8.74 BD vs. 7.00 SCZ vs. 7.85 other SMI Sani et al., 2011 Italy 4,441 inpatients 1964-1998 BDII (4.2%)>BDI (2.8%)>MDD (1.9%) SMI - severe mental illness
  • 23. Cumulative incidence of suicide by time since the first psychiatric contact among men (A) and women (B) Copyright restrictions may apply. N = 176,347 individuals with mental health contact N = 881,735 controls Follow-up 36 years, median 18 years Men 7.77% (95% CI, 6.01%-10.05%) Women 4.78% (95% CI, 3.48%-6.56%) Nordentoft M, Mortensen PB, Pedersen CB. Absolute risk of suicide after first hospital contact in mental disorder. Arch Gen Psychiatry. 2011;68(10):1058-64.
  • 24. Conclusions  Lifetime suicide attempts occured in ¼ of individuals in population-based studies and more than 1/3 in clinical studies  Rates were lower (9.5%) for subthreshold BD, but higher than in normal controls  The rate of suicide was 0.215 per 100 person years  the risk of suicide is 20-30 times greater than of the general population  poisoning was the most frequently used method in suicide attempts (30% - 80%), followed by cutting/stabbing (5.6% - 22.7%) , and jumping (4.8% - 13.2%)  suicides - most frequently used methods: poisoning (17% - 53%) and hanging (11.6% - 46%), followed by jumping (13.7 – 26% in 4/7 studies), - to a lesser extent cutting/stabbing (2.7% and 14.3% in 2/7 studies)  BD accounts for a substantial proportion of suicides in both clinical and epidemiological samples comparable to or, in some cases, greater than what is seen in MDD, schizophrenia and other major mental illness.
  • 25. We have to consider...  Impact of DSM5 on suicide rates – mixed episodes?  BD undertreated, rates are underestimated  Lack of studies comparing patients with one or more suicide attempts. Who is going to attempt suicide again?  Better determination of types of methods used, if planned/not planned, lethality  Risk factors  Protective factors  Improve and implement preventative strategies
  • 26. Acknowledgments  Ayal Schaffer  Mark Synior  Laura Andrade  Kyooseob Ha  Lars Kessing  Catherine Reis
  • 27. Thank you!

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