General Information On Suicide

Individuals with depressive and bipolar manic-depressive illnesses are far more likely to commit suicide than individuals in any other psychiatric or medical risk group, and the mortality rate for untreated manic-depressive illness is higher than for many types of heart disease and cancer. Nineteenth century psychiatrist Emil Kraepelin described the grim, virtually incomprehensible level of anguish and desperation that tormented his untreated manic-depressive patients:  "The patients, therefore, often try to starve themselves, to hang themselves, to cut their arteries; they beg that they may be burned, buried alive, driven out into the woods and there allowed to die. . . . One of my patients struck his neck so often on the edge of a chisel fixed on the ground that all the soft parts were cut through to the vertebrae."

Rates of Suicide in Manic-Depressive Illness
In an extensive clinical investigation carried out in Sweden, suicide was almost 80 times more likely among patients with depressive illness -- unipolar or bipolar -- than in individuals with no psychiatric disorder. In thirty studies of manic-depressive patients' deaths that I reviewed in a book co-authored with Dr. Frederick Goodwin, between nine percent and 60 percent of the patients died by suicide. On the average, suicide was the cause of death for one-fifth of the patients in these studies. Among people who commit suicide, more than two-thirds have suffered from depressive or manic-depressive illness. In a recent study of adolescents who died by suicide, four risk factors accounted for more than 80 percent of the suicides: a diagnosis of bipolar manic-depressive illness, coexisting alcohol or drug abuse, lack of prior treatment, and the availability of firearms. The strongest of these risk factors was the diagnosis of manic-depressive illness.  Despite the compelling evidence of these recent studies, the lethal potential of manic-depressive illness is still often overlooked, likely because of the misconception that suicide is not the pathological expression of such a disease state, but is instead a volitional, existential reaction to adverse life circumstances. Unfortunately, for many who suffer from untreated manic-depressive illness suicide is a central "hard-wired" outcome of the disease that depends relatively little on external events, much as myocardial infarction is the outcome for those who have occluded coronary arteries.

  Rates of Attempted Suicide in Manic-Depressive Illness
Twenty-five to fifty percent of bipolar patients attempt suicide at least once. Women appear far more likely than men to attempt suicide; the suicide attempt rate for men is consistently lower, ranging from 4 to 27 percent. In the large Epidemiological Catchment Area survey of more than twenty thousand people, the lifetime rate for attempted suicide in individuals with no history of mental disorder was 1 percent; for those with major depressive illness it was 18 percent, and for those suffering from manic-depressive illness it was 24 percent. Similarly, a recent epidemiological study of bipolar illness in ten countries, headed by Dr. Myrna Weissman of Columbia University, confirmed suicide attempt rates in bipolar individuals ranging between 15 and 50 percent.

  Gender Differences in Suicide
More women than men attempt suicide, both among manic-depressives and in the general population. However, while more men than women complete suicide in the general population, this is not true among manic-depressives: three of seven studies actually noted a predominance of women among the suicide victims. Completed suicide and dangerously violent attempts were equally common in men and women in the series of 67 bipolar and 20 unipolar patients studied by Roy-Byrne and his colleagues. Linkowski's group found that a family history of suicide -- especially suicide utilizing violent methods -- greatly increased the frequency of violent suicidal behavior in both depressed males and females.

  Evidence of sex differences among suicide attempters may be marred by reporting biases when patients are asked about past suicidal behavior: bipolar women may more readily admit attempts, whereas men may be more prone to behaviors that are not recognized to be suicidal equivalents such as extreme risk-taking, car accidents, and substance abuse.

  The course of the illness may also affect men and women differently. Johnson and Hunt found that at the onset of their manic-depressive illness, more men (42 percent) than women (17 percent) attempted suicide, although this sex difference vanished as the illness progressed. The womens' suicide attempts were distributed evenly across the first 15 years after the onset of the illness, while mens' attempts were more frequent and were bimodally distributed: 60 percent of the men attempting suicide did so within two years of the onset of the illness, while the other 40 percent attempted suicide after 23 years or more.

  Many explanations have been proposed to account for these sex differences: for example, that women may learn better to accommodate to mood swings by experiencing the mood changes in the course of the menstrual cycle. Cultural and sexual differences in adaptation to catastrophe or acute stress may also be responsible.

  Suicide and the Course of Illness
A fairly consistent body of evidence suggests there is an increased risk of suicide early in the first episode of manic-depressive or depressive illness. Tsuang and Woolson found that for patients with manias and depressions, the increased risk for suicide was largely limited to the first decade after the initial admission. Weeke determined that 40 percent of suicides occurred within six months of the first admission, and more than 50 percent occurred within the first year.

  Himmelhoch has suggested that suicide may be simultaneously psychologically and neuronally kindled. That is, in addition to the biological aspects of kindling, patients also become increasingly less tolerant with each new episode of depression, increasing their risk of suicide. These findings underscore the importance of early recognition, accurate diagnosis, and aggressive treatment, as well as the need for continuous reappraisal of suicidal risk.

  Johnson and Hunt were among the first to study the timing of serious suicide attempts in bipolar patients. These authors found that 30 percent of the suicide attempts occurred at the onset of the illness or during the first episode of depression. The median age was 5.5 years, indicating that the risk was greatest early in the course of illness. Their data show that half of the serious suicide attempts occurred within five years of the onset of illness, yet the range -- 0 to 27 years -- is of considerable interest.

  Suicide and Clinical State
Robins and colleagues, in their study of 134 suicides, found that no one committed suicide in the manic phase; all were depressed at the time of death. Winokur and coworkers also found no suicide attempts during mania, although suicidal idiation occurred during 7 percent of manic episodes. They did find suicidal thoughts or attempts in 13 percent of depressive episodes following mania, and a strikingly high rate of suicide threats and attempts in mixed states (43 percent). Suicidal thoughts or behavior during these mixed states (characterized by simultaneous symptoms of both mania and depression) were reported only in women. Kotin and Goodwin also described the coexistence of suicidal behavior and mixed states, as did Kraepelin in his original clinical monograph.

  In a study conducted in the 1930s, Jameison found that mixed states were the most dangerous clinical phase of illness. In his study of one hundred suicides, half of whom had manic-depressive psychosis, he noted that the combination of depressive symptoms, mental alertness, and tense apprehensive, restless behavior was especially lethal; many subsequent studies have found this as well. Mixed states represent a critical combination of dysphoric mood and depressed thoughts combined with an exceptionally perturbed, agitated, and unpleasant physical state that is usually accompanied by a heightened energy level and increased impulsivity.

Other symptomatic and behavioral clues to suicide have been studied. Insomnia and excessive concern about sleep disturbances have been noted as correlates of increased potential for suicide, as has the presence of pervasive hopelessness. Concomitant substance abuse has been noted to increase the risk of suicide, particularly in the young.

Severe depression, not surprisingly, correlates with increased lethality. Weeke found that, at the time of death, 58 percent of patients were in a constant or worsening depressive state. Of particular interest, however, is the fact that fully 30 percent of the patients were classified as "depressive state, recovering," a finding consistent with that of Jameison and Wall, who found a sudden improvement in depression in many of their patients immediately before suicide.

  Fawcett and co-workers, in their prospective study of 955 bipolar and unipolar patients, found that risk factors among the 14 who committed suicide within one year of assessment were anhedonia, severe psychic anxiety, moderate alcohol abuse, and panic attacks. The abuse of alcohol in addition to another drug is a significant risk factor, especially in males. Another 13 of these patients went on to kill themselves over the next four years. These late suicides -- those completed after the first year -- were most associated with severe hopelessness, somatic anxiety, suicidal ideation, and a history of suicide attempts. The findings of Fawcett and colleagues underscore the importance of assessing patients in terms of acute vs. long-term suicide risk.

  One of the most replicated findings in biological psychiatry today is the association between suicide and low levels in the cerebrospinal fluid of 5-HIAA, the serotonin metabolite. The suicide-serotonin metabolite relationship has been observed in a variety of diagnostic groups other than depressed patients, including those with schizophrenia, adjustment disorders, various personality disorders, and depression, but its relevance to bipolar patients is unclear.

  Prevention
The most reliable method of preventing suicide in patients with manic-depressive illness is to diagnose it early and accurately, and then to aggressively treat the underlying illness. Highly effective treatments exist for manic-depressive and unipolar major depressive illnesses. Lithium has radically altered the consequences of manic-depressive illness, allowing most patients to live reasonably normal lives. A large number of studies now document lithium's strong effect on suicidal behavior in bipolar patients. In recent years, carbamazepine and divalproex sodium have provided alternative treatment for patients unable to take lithium and those who are unresponsive to it. A wide variety of antidepressants, and electroconvulsive therapy, have proven exceptionally powerful in the treatment of major depressive illnesses. Psychotherapy, in conjunction with medication, is often essential to the complete healing and prevention of possible recurrences.

More Information

The following links contain more information on this subject.

Getting Help

The following resources are available both on and offline for help in recognizing and treating depressive disorders.

If you are having suicidal thoughts, please talk to someone about it right away. The National Hopeline Network (1-800-SUICIDE) has counselors available 24 hours a day, 7 days a week. You can also use their online directory to find centers in the US and abroad:
Hopeline Network: 1-800-SUICIDE

Surviving Suicide

If you've lost a friend or loved one to suicide, there are many places across the net to find support, such as the following:

• Living with Suicide
• Healing ... In the aftermath of a suicide
• Surviving Suicide
• Explaining suicide to children
• Suicide Loss Rights
• Tears Are Forever
• 1000 Deaths
• Survivors of Suicide

 

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