Anxiety often undertreated in bipolar disorder patients.

CHICAGO -- Patients with bipolar disorder are at high risk for suicide and should be carefully and continuously assessed for acute and chronic risk factors, Dr. Frederick Goodwin said at the annual meeting of the American Academy of Clinical Psychiatrists.

Previous suicide attempts do not robustly predict suicide in adults or adolescents. There are, however, clinically modifiable risk factors that are under-treated, and if ignored, can put clinicians at greater medical-legal risk.

The most important is the presence of severe depression with anxiety, agitation, or an inability to fall or stay asleep. Anxiety is often undertreated because of the large tendency for clinicians to assume that any anxiolytic will not help or will make depression worse, said Dr. Goodwin, research professor of psychiatry, George Washington University Medical Center in Washington. He noted that in one study, only 14% of inpatients who killed themselves had been adequately treated for anxiety (J. Clin. Psychiatry 2003;64:14-9).

Another toxic combination is a mixed state because a patient has the pain of depression and the energy of mania, which can override the lethargy that typically keeps patients with depression from acting on their suicidal thoughts.

Sudden changes in mood within an episode are also very high risk.

"It's one thing to be in a depression--locked in it, adapted to it--it's quite a different thing to have felt wonderful one day and terrible the next day," Dr. Goodwin said. "The contrast of feeling really good and really terrible is very painful."

Comorbid substance abuse is another risk factor for suicide in bipolar because it lowers judgment, and increases impulsivity and aggressiveness.

All four items were significantly associated with death at 1-year in a large prospective National Institute of Mental Health study (Am. J. Psychiatry 1990;147: 1189-94), and thus have attracted the attention of attorneys, Dr. Goodwin said.

"These are the data that are putting people at risk," he said. "If they have a patient suffering from any of these problems, which are statistically predicted to relate to suicide at 1-year, they are at greater medical-legal risk." Suicide is the number one reason for which psychiatrists are sued, he said.

Psychiatrists are also eagerly awaiting the Centers for Disease Control and Prevention's release of its updated suicide statistics through 2007. In 2004, the CDC reported that suicide was the 11th leading cause of death in the United States, accounting for 32,439 deaths.

Dr. Goodwin also stressed the importance of ongoing communication about suicide and the underlying bipolar disorder with patients and families. Practical things to discuss include the potential for drugs and alcohol to undermine the efficacy of medication and increase the likelihood of mixed states, the high-risk nature of the recovery period, and the presence of firearms in the home.

Should a suicide occur, Dr. Goodwin recommends physicians attend the funeral or memorial service and send a sympathy or condolence card. Many physicians avoid taking those steps because they don't want family members to think about them.

"That's a big mistake," he said. "It's the right thing to do, the human thing to do. It decreases the morbidity in the family and, of course, from a self-interest point of view, it's very important for risk management."

Dr. Goodwin said he is a consultant for Pfizer, BristolMyersSquibb, and Schering-Plough, and is on the speakers bureau for GlaxoSmithKline.