Acute risk factors for suicide attempts and death: prospective findings from the STEP-BD study

Abstract

Objectives: Suicide is unfortunately common in psychiatric practice, but difficult to predict. The present study sought to assess which clinical symptoms increase in the months before suicidal behavior in a sample of psychiatric outpatients with bipolar disorder.

Methods: Data from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial were used. A total of 103 participants who attempted suicide or died by suicide during the trial were included; a 15% random sample of the remaining participants (n = 427) was used as a comparison sample. Linear mixed models in the six months before suicidal behavior were conducted for each of five proposed acute risk factors for suicidal behavior. Participants were assessed using the Clinical Monitoring Form (CMF) at each visit for the following potential acute risk factors for suicidal behavior: suicidal ideation, loss of interest, anxiety, psychomotor agitation, and high-risk behavior.

Results: Each of the five symptoms was elevated overall in individuals who engaged in suicidal behavior (p < 0.05). The severity of both suicidal ideation and loss of interest significantly increased in the months before suicidal behavior (p < 0.001). Anxiety demonstrated comparable effect sizes across multiple models. Psychomotor agitation and high-risk behavior were not significantly elevated before suicidal behavior.

Conclusions: Suicidal ideation, loss of interest and, to a lesser extent, anxiety may represent acute suicide risk factors up to four months before suicidal behavior in outpatients with bipolar disorder. Further investigation of these potential acute risk factors in prospective analyses is warranted.

Trial registration: ClinicalTrials.gov NCT00012558 NCT00088699.

Keywords: anhedonia; anxiety; bipolar disorder; suicidal ideation; suicide.

Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

Figures

Figure 1

1A–1E. Median clinical symptoms in the six months before suicide attempt/death, compared to random sample of non-attempters. All assessments were taken from the Clinical Monitoring Form (CMF). Due to the use of linear mixed models, all figures include estimated marginal means and standard errors of these mean estimates.

Figure 1

1A–1E. Median clinical symptoms in the six months before suicide attempt/death, compared to random sample of non-attempters. All assessments were taken from the Clinical Monitoring Form (CMF). Due to the use of linear mixed models, all figures include estimated marginal means and standard errors of these mean estimates.

Figure 1

1A–1E. Median clinical symptoms in the six months before suicide attempt/death, compared to random sample of non-attempters. All assessments were taken from the Clinical Monitoring Form (CMF). Due to the use of linear mixed models, all figures include estimated marginal means and standard errors of these mean estimates.

Fig. 2

Differences in symptom trajectories in the six months before suicidal behavior in patients with versus without prospective suicidal behavior.