Self-harm and suicide
The BAP, CANMAT and SIGN guidelines detail that ‘lithium may have particular efficacy’ in lowering suicide rates in patients with bipolar disorder, and these three guidelines all give similar figures for the suicide rates of people with the diagnosis. Whereas NICE states that, ‘A limited quantity of psychotropic medication should be prescribed for patients during periods of high risk of suicide.’
Crisis and risk management plans
If a patient is at risk of suicide, exploitation or severe self-neglect, is a significant risk to others (including neglect of dependents), or has a history of recurrent admissions, particularly compulsory admissions, a crisis plan should be developed in collaboration with the patient, covering:
- a list of identified or potential personal, social or environmental triggers, and early warning symptoms of relapse.
- a protocol for increasing the dose of medication or taking additional medication (which may be given to the patient in advance) for patients who are at risk of rapid onset of mania and for whom clear early warning signs can be identified – protocols should be monitored regularly, and are not a substitute for an urgent review.
- how primary and secondary healthcare services have agreed to respond to any identified increase in risk, for example by increased contact.
- how the patient (and where appropriate their carer) can access help, and the names of healthcare professionals in primary and secondary care who have responsibilities in the crisis plan.
A limited quantity of psychotropic medication should be prescribed for patients during periods of high risk of suicide.
Suicide is a major long-term risk for patients with bipolar disorder. For patients identified by admission to hospital, rates are approximately 10% over long-term follow-up. As a rule, suicide is associated with depression, and risk assessment is always emphasized during acute episodes of depression in bipolar patients. However, an equally important perspective is a potential for successful long-term treatment to reduce suicide risk by preventing new episodes or reducing chronic symptoms. Suicide has never been the primary outcome measure for a clinical trial in bipolar disorder, because, in practice, observable rates are too low. However, naturalistic studies suggest that suicide rates are lower in patients who receive long-term treatment. Furthermore, lithium may have particular efficacy. This conclusion is again based primarily on naturalistic comparison of patient cohorts on and off lithium, but the findings from different centres are consistent and the treatment effect is very large. One long-term RCT also found suicides and attempted suicides to be associated with carbamazepine and not lithium treatment.
There is an increased risk of suicide among patients with bipolar disorder, estimated at 17-19%, or 15-20 times more than that of the general population. As many as 25-50% of patients with bipolar disorder attempt suicide at least once during their lifetime. While some controversies exist over the research methods used to make these estimates, the high risk of suicidality is undeniable.
Several risk factors for suicidal behaviour have been identified, and many of these are additive. Therefore, in addition to obtaining a history of personal and family suicidal behaviour, it is important to assess a patient’s history of depression, current level of pessimism, aggressive/impulsive traits, and comorbidity with substance use disorders, to help identify patients at risk for suicidal behaviour.
A treatment programme in a maximally supportive clinical environment can reduce suicidal behaviour in high-risk patients. Long-term maintenance pharmacotherapy with lithium may substantially reduce the risk of suicide in these patients, however, this must be balanced against its risk of toxicity and high lethality in overdose.
The risk of suicide is increased in patients with bipolar illness. Estimates range from mortality ratios of 12 to 22, standardised to age of admission and time of follow up, or a lifetime risk of 8-20%. Bipolar affective disorder, as with other psychiatric diagnoses, is an important risk factor and predictor of suicide. It is not known whether symptom removal can effectively reduce suicide risk.
Suicide and attempted suicide have been explored in observational studies, with published evidence for reduced mortality during long term lithium treatment, for increased mortality after discontinuation of lithium and for lower mortality in patients treated with lithium compared to patients treated with carbamazepine and amitriptyline. Suicides in patients with bipolar illness appear to be associated with no lithium treatment, non-compliance and inappropriate treatment. The greater intensity of follow up in lithium clinics (including blood tests and supportive psychotherapy) is a possible confounder in studies examining effect of lithium on suicide frequency. The efficacy of other suicide prevention strategies, such as antidepressant medication and psychosocial treatment, has been difficult to prove in studies with small sample sizes and patient selection bias.
Acute and maintenance lithium treatment of patients with bipolar affective disorders should be optimised to make every effort to minimise the risk of suicide (D evidence).
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