Growing up, my best friend’s mother suffered from bipolar disorder. In addition to watching my friend try to cope with the daily effects of the illness, I had to watch as she coped with her mother’s suicide. Her mother was not medicated or treated at all for her disease. So when I first began work for this paper, I knew that I was interested in bipolar disorder. Realizing that was huge topic, worthy of far more research than this small sampling, I decided to narrow my focus to bipolar disorder and suicide.
When I did a simple Google search for the same topic, I found hundreds of listings with information about the relationship between suicide and bipolar disorder. The two I chose to examine more closely, Caruso’s ”Bipolar Disorder and Suicide” and a similiarly titled page at neurotransmitter. net, both claim an extreme linkage between bipolar disease and suicide. Caruso (2007) claims that as many as 50 percent of the people diagnosed as bipolar attempt to take their own lives at some point.Since he specifically discusses documented attempts, I think there is some argument that the numbers may be even higher when they include risky behavior likely to cause death.
The neurotransmitter site claimed that the suicide frequency was a little less, about one-third of patients attempting suicide, but essentially agreed in the findings. As anecdotal evidence, I have a male friend who was diagnosed as bipolar in the mid-1980s.He was treated shortly with lithium before insisting that he hated the way it made him feel and getting off the treatment completely.
Since then, he has attempted to self-medicate with alcohol, but has never sought professional treatment. He tells me that he knows during his manic phases he sometimes engages in behavior that could be classified as suicidal, though he has never taken steps to end his own life. Risky behaviors include everything from picking fights to driving unsafely because he feels that “nothing bad” can happen to him when he is in this state.
My friend’s experience is fairly typical of bipolar disorder, a major psychological disease characterized by periods of mania, depression and in many cases, mixed states. The disorder has in recent years been split into different classifications depending on the severity of symptoms and was once known as manic-depression because of the two distinctive states. For the purposes of diagnosis, bipolar disorder is usually indicated by the presence of at least one manic episode in a lifetime. The more regular the manic episodes, the more severe the diagnosis.Patients with bipolar disorder often have long periods where their symptoms are subclinical or manifest in depression only. Often the disease has been associated with creative genius, as Virginia Woolf, William Blake and Ernest Hemingway were all diagnosed with bipolar disorder, or retroactive life studies tend to indicate they had the disease. With these personal insights, the first of these articles I considered was “Suicidality in Bipolar I Disorder”.
Because of my friend’s mother’s suicide and because of the abstract for this study, I was immediately hooked.This article and the corresponding study look at the linkages between treatments and suicide in bipolar patients with an emphasis on treatments affecting the depressive stages of the disease, including depressive symptoms which exhibit in mixed phases, where the patient is both manic and depressed. The study also looked for evidence that anxiety disorders as caused by the bipolar disorder could lead to increased suicidality and that when these symptom variations were accounted for, hypothesized that drug treatment would have an insignificant correlation to suicidality. The methods used for this study were interesting as well.My first impression of the study was that it was rather small in scope, only 91 patients, and of them, one committed suicide during the course of the study. In my own mind, that emphasized the need for this type of research.
That one patient was able to complete suicide and that so many others had suicidal thoughts during the study emphasizes the deadly nature of bipolar disorder. This study used very standard psychological tests to identify independent variables which might effect the study results and then provided a statistical analysis controlling for those variables.With variable control, they were able to account for more than half of the differences which led some patients to suicidal thoughts and actions. The importance of this study, if its results can be replicated, is enormous. Contrary to researcher expectations, lithium did have some effect on the suicidality rates and treatment of depression may have increased the suicidal thoughts and actions in the first 10 days of anti-depressant treatment.Personally, I believe the indications from this study may mean that when dealing with severely depressed or bipolar patients experiencing depressive symptoms or in a mixed state, the indications for anti-depressant treatment should be more often coupled with in-patient therapy.
This study tends to indicate that it is imperative that patients placed on anti-depressants to modify these conditions need more monitoring than previously assumed. The researchers are willing to point to te flaws in their study, including the age range of patients involved and the inability to control for medication interaction.Regardless, this study has profound implications for the treatment of bipolar disorder. With this study, it becomes clear that we as professionals must diligently attempt to identify the cyclical nature of bipolar disorder and the interaction of its phases and must be willing and able to monitor medication usage during times when the patient is most depressive. Traditionally, because we know patients tend to forgo their medication during manic phases, much of the medication compliance studies have centered on manic phases.It is clear from this study that we need to monitor all medication usage more carefully and be constantly assessing varying dependent diagnosis related to the core diagnosis.
The second article I evaluated was “Psychological Treatment of Bipolar Disorder”, a review of the book by the same name. The reviewer quickly points out that this book has little impact on the actual treatment of bipolar disorders and therefore is interesting to read, but of little value to the practice of abnormal psychology.Landwehr writes in her evaluation that she loves “psych testing” and that she acknowledges it usefulness as a diagnostic tool, but that most psychiatrists and psychologists rarely use them in private practice (2005). The most interesting part of this review is that her observations regarding current treatment practices for bipolar disorder and most abnormal psychology virtually negates the usefulness of studies like the previous one. If patients are unable to have continuing diagnostic testing to monitor their conditions, then the objectives of the first study become harder to meet as the only form of diagnosis is observation.If a therapist is not trained well enough to recognize the interdependent treatment variables, it seems likely that she will be unable to meet the treatment needs of the patients involved and will risk higher suicidality in her patients. The third article I investigated was “Dimensions of Impulsivity and Aggression Associated with Suicide Attempts Among Bipolar Patients: A Preliminary Study” by Benjamin Michaelis and others, published in 2004. This study attempts to related suicidality with hostility and impulsiveness, behaviors associated more frequently with patients in the manic phase than in a depressive phase.
This article indicates that within this study, while differences among demographic variables were negligible, there seemed to be a high correlation between subjects that tested high on impulsivity and hostility tests and those who had attempted suicide. In my opinion, this study did little to contribute to the overall understanding of bipolar disorder and its relationship to suicide. To begin with, the study sample was incredibly small—just 52 patients. And, half of them were in a facility-based treatment program.The severity of the disorder seems to be a variable that the researchers did not control for and yet with half the participants already in residential treatment, it seems that severity would be a logical variable to consider and control for. In addition, the study did not examine the timing of the hostile and impulsive actions in relationship to the suicidality. I believe this is a major flaw in the study as it seems reasonable that most bipolar personalities would exhibit these behaviors to some degree while in a manic phase. It seems to be more redundant than actually educational.
To me, the usefulness of this study is nil. It appears to tell me that , “Yup, people with bipolar disorder are sometimes hostile and impulsive and that sometimes those people also attempt suicide. ” There is no new information contained in the study and the their conclusions are almost givens when coupled with the nature of the disease being studied. Finally, I reviewed the article “Prospective Study of Clinical Predictors of Suicidal Acts After a Major Depressive Episode in Patients With Major Depressive Disorder or Bipolar Disorder” by the team led by Marie Oquendo and published in 2004.This study argues that major life events can precipitate depression and that aggressively treating depression can prevent relapses into suicidality. It further argues that suicidality in itself can be a factor into future depression and suicide attempts, i. e. if you tried it once, you are more likely to be depressed about it and try again.
The study has some value as a longitudinal look at suicide rates among those with serious depressive disorders, but did not specifically identify patients with bipolar disorder.This was a large study group than the other two studies discussed earlier, but a broader spectrum of mental illness and 80 percent were residential treatment patients. Again, this presents an inherent bias in the stuidy. First, these patients were ill enough to have considered and accepted inpatient care.
Second, it is generally more difficult to act on suicidal urges while an inpatient. The usefulness of this study is questionable. It tells us that major depressive episodes treated aggressively with drug therapy can reduce the threat of recurrence of suicide thoughts.However, I tend to be skeptical. Again, since these patients began the study in residential treatment, their compliance with drug treatment was more closely monitored and their immediate reaction to anti-depressants could be monitored and patients removed from some forms of drug treatment if they reacted poorly to a drug. This was at least a much more responsible survey on the part of the researchers as the patients were generally very accessible and able to be monitored, but that does not make the study more useful to those practicing abnormal psychology.
In fact, the usefulness of this study is almost completely limited to those practicing in a residential facility. My review of the literature regarding bipolar disorder and suicide leads me to the conclusion that while some studies may be on the right track, a great deal more study is needed to determine how best to treat these patients. In general, it appears that teaching them coping skills and using minimal medication may be the best option for non-residential treatment. If residential treatment is considered, then more aggressive drug therapy to treat depressive episodes might be worth consideration.None of these studies dispute the correlation between bipolar disorder and suicide, but the attempts to identify the cause and then determine appropriate treatment seems to be slow going at best.
I would like to see some real effort made to determine how to reduce the suicide risk in these patients and for the studies to reflect treatment methods that are available to the average treatment professional. “Bipolar Disorder and Suicide”, http://www. neurotransmitter. net/bipolarsuicide. html, July 18, 2007.
Caruso, Kevin. “Bipolar Disorder and Suicide” http://www. suicide. org/bipolar-disorder-and-suicide. html, July 18, 2007.