Untreated and unsuccesfully treated major major mood disorder (particularly the acute, severe major depressive episode) is the main cause of attempted and completed suicide, particularly in the presence of comorbid Axis I/Axis II psychiatric disorders and other (psycho-social) suicide risk factors. Since the majority of mood disorder patients never committ or attempt suicide, other clinically explorable suicide risk factors in major depressive episode (like high level of severity, hopelessness, agitation, aggressive/impulsive personality features, prior suicide attempt, familiy history of suicide, adverse life situations etc.) also play a contributory role in the self-destructive behaviour.
A relatively newly recognised important proximate suicide risk factor in major depressive episode is the depressive mixed state (3 or more simultaneoulsy co-occuring non-euphoric intra-depressive hypomanic symptoms = DMX-3), and the most common hypomanic symptoms of mixed depression are irritability, psychomotor agitation, mental overactivity (flight of ideas, racing thoughts, crowded thoughts), and more talkativeness. Frequency of mixed depression is around 60% in bipolar II and 30% in unipolar major depressive episode, and there are several evidences that depressive mixed state and agitated depression are greatly overlapping phenomena. Several prior studies have found that the rate of past suicide attempts and current suicidal ideations is much higher among mixed than nonmixed unipolar and bipolar major depressives. On the other hand, however, one of our recent study have found a significantly higher rate of DMX-3 among the 29 bipolar (I+II) depressive and 60 unpolar depressive suicide attempters (90% vs 62% respectively) than in nonsuicidal 241 bipolar (I+II) and 104 unipolar major depressive outpatients (59% vs 29% respectively). These findings suggest that suicide attempters come mainly from mixed depressives with predominantly bipolar II base, and can explain, at least in part, why bipolar II patients carry the highest risk of suicidal behaviour in patients with major mood disorders.
The recognition of depressive mixed states as possible suicide risk factor has important implications for suicide prevention, since antidepressant monotherapy (unprotected by mood stabilizers or atypical antipsychotics) in depressed patients with unrecognised bipolarity can worsen depression via augmenting mixed depression or generating de novo mixed states.
Balázs J, et al, J Affect Disord, 2006, 91: 133-138.
Benazzi F, Curr Opin Psychiat, 2006; 19: 1-8.
Rihmer Z, Akiskal HS, J Affect Disord, 2006; 94. 3-13
This post was submitted by Prof Zoltan Rihmer.
