MEASURE Resource Module

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MEASURE Resource Module
 
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Approved/Unapproved Use

• The following presentation may contain
  information concerning a use that has not been
  approved by the US Food and Drug Administration.
  Any unlabeled/investigational discussion of drugs
  will be disclosed during the presentation.

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Suicide and Bipolar Disorder
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Patients Will Visit a Physician Before Suicide

• Consulted with a physician at least once
• Within 1 year of dying 75
• Consulted with a general practitioner
• Within 1 month of dying 66
• Consulted with a primary-care physician
• Within 1 year of dying 83
• Within 1 week of dying 20
• Consulted with a psychiatrist
• Within 1 month of dying 46
• Within 1 week of dying 36
• Recently discharged from a psychiatric or general
  hospital 20
• Medical or psychiatric contacts
• Women gt men
• Younger adults gt elderly, children, or adolescents

Miller CL, Druss B. Psychiatry Serv.
2001521566-1567. Pirkis J, Burgess P. Br J
Psychiatry. 1998173462-474. Andersen UA et al.
Acta Psychiatr Scand. 2000102126-134. Tondo L
et al. CNS Drugs. 200317491-511.
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A Stress-Diathesis Model of Suicidal Behavior
Depression or psychosis Life events
Objective state
HopelessnessPerception of depressionSuicidal
ideation
Subjective state and traits
Suicidal planning
Low serotonin activity
Aggression
Impulsivity/restraint
Suicidal act
Alcoholism, smoking, substance abuse, head injury
Adapted from Oquendo MA, Mann JJ. J Clin
Psychiatry. 200162(suppl 25)31-34.
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Suicide Risk Factors

• Gender
• Completed suicides 41 (malefemale) suicide
  attempts 13 (malefemale)
• History of prior (impulsive) attempts
• Prior attempts characterizes a bipolar
  subpopulation at highest risk
• Course
• Major depressive episode pattern, rapid cycling,
  mixed episodes
• Race/ethnicity
• Caucasians at higher risk
• Age
• Adolescents and elderly are high-risk groups
• Marital status
• Higher risk in nonmarried individuals, especially
  those with no dependents
• First year postdiagnosis
• Heightened risk in the first year postdiagnosis

Adapted from Sachs GS et al. J Clin Psychiatry.
200162(suppl 25)3-11.
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Variables Associated With Suicide Attempts
Inadequate mental health/medical insurance
1.31
Stanley Foundation Bipolar Network Data N
219 P lt 0.05 P lt 0.10
1.44
No college education
1.50
Income lt 20,000
History of anxiety disorder
1.21
Axis II Cluster B comorbidity
1.99


Suicidal thoughts when depressed
2.02


gt4 hospitalizations for depression
12.31
Suicidal thought when manic
1.21

No confidant prior to illness
2.00

2.27
Early sexual abuse

Early physical abuse
1.77
Family history of suicide
1.05
1
0
2
4
6
8
10
12
14
Odds Ratio
Values gt 1 suggest an increased likelihood of
having a past suicide attempt
Adapted from Leverich GS et al. J Clin
Psychiatry. 200364506-515.
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Suicidal Behavior in Bipolar Disorder

• Suicide rates average 0.4 per year in patients
  diagnosed with bipolar disorder
• More than 20-fold higher rate than in general
  population
• Tondo et al data from 28 suicide-risk studies
  from 1945 to 2001
• of Suicides Total of Subjects Men Women
  Overall
• 828 21,484 14.9 21.1
  22.1

Standardized mortality ratio
Tondo L et al. CNS Drugs. 200317491-511.
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Suicide in Bipolar Disorder
Expected
Country
Date
Report
Suicides (N)
Observed
1986 1987 1968 1974 1991 1976 1991 1977 1945 199
2 1991 1975 1966 1978
1.36 0.48 0.09 0.03 0.12 0.06 0.02 0.41
0.15 1.00 0.05 1.38 0.14 0.23 0.66
13 7 4 2 0 8 2 3 0 18 3 19
6 3 5
Switzerland USA Norway USA England USA Norway Swed
en Prelithium Postlithium Sweden Germany
Canada Norway Sweden USA
Angst Black et al Bratfos and Haug Carlson et
al Coppen et al Dunner et al Friis et al Kay and
Petterson Lundquist Müller-Oerlinghausen et
al Newman and Bland Noreik Perris and
dElia Tsuang
Standardized mortality ratio 1505 (95 CI,
1225-1844) total observed suicides 93
expected total suicides 6.18 Expected total
mortality ratio calculated by the authors
Simpson SG, Jamison KR. J Clin Psychiatry.
199960(suppl 2)53-56.
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Serious Suicide Attempts in Stanley Foundation
Bipolar Network
Patients With Lifetime History of Suicide
Attempt(s) ()
Suicide Attempts
Adapted from Leverich GS et al. J Clin
Psychiatry. 200364506-551.
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Inclination-Opportunity Matrix and Some Possible
Interventions
Opportunity
High Lethal means readily available and
frequently alone
Moderate Some lethal means available or
frequently alone
Low No readily available lethal means
Eliminate access to lethal means hospitalize,
unless supports are adequate to assure safety

Treat acute episode consider ECT or medication
to reduce suicidal ideation
High (moderate-to-severe depression/active
suicidal ideation)
Inclination

Reduce access to lethal means treat current
episode

Moderate (mild-to-moderate depression/passive
suicidal ideation)
Reduce unnecessary exposure to lethal means
prophylactic treatment (lithium)
Avoid unnecessary exposure to lethal means
prophylactic treatment (lithium)
Avoid unnecessary exposure to lethal means
prophylactic treatment
Low (not acutely depressed manic or mixed
episode)
Sachs GS et al. J Clin Psychiatry. 200162(suppl
25)3-11.
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Standard Elements of a Suicide Prevention Program

• Effective and appropriate clinical care for
  mental, physical, and substance abuse disorders
• Overrehearsal of help options for times of
  distress
• Training in emotional tolerance, problem-solving
  skills, conflict resolution, and nonviolent
  handling of disputes
• Cognitive restructuring of hopelessness-based
  cognitions
• Enhancement of reasons for living
• Restricted access to highly lethal methods of
  suicide

Gray SM, Otto MW. J Clin Psychiatry.
200162(suppl 25)56-64. U.S. Public Health
Service. The Surgeon Generals Call To Action To
Prevent Suicide. Washington, DC 1999.
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Summary of Effects of Treatments on
SuicidalBehavior in Patients With Bipolar
Disorder
Treatment
Effect
Tondo L et al. CNS Drugs. 200317491511.
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Summary of Effects of Treatments on
SuicidalBehavior in Patients With Bipolar
Disorder (cont.)
Treatment
Effect
Tondo L et al. CNS Drugs. 200317491511.