Dynamic risk factors
Dynamic factors can be causally related to suicidal ideation, suicide attempts, and completed suicide. Dynamic risk factors relate to mood state and shifts in mood state. The probability of attempting or completing suicide is related to the amount of time that a person is in a dysphoric state.
Judd and associates13 published the results of the first prospective study on the natural history of the weekly symptomatic status of patients with bipolar I disorder (BDI). The patients were followed for an average of 12.8 years, and on average, they had depressive symptoms during 31.9% of the total follow-up weeks. They were in cycling or mixed states during 5.9% of the time; manic/hypomanic symptoms predominated only 8.9% of the time.
In another study encompassing 20 years of longitudinal evaluation, patients were depressed much more often than they were manic/hypomanic.14 Patients with BDI spent about 30% of the year with depressive symptoms and slightly less than 10% in states of mood elevation. In contrast, patients with bipolar II disorder (BDII) spent, on average, 51.9% of the year with depression and only 1.9% with hypomania. The most powerful predictor for risk of suicide may well be the duration of time that persons spend in a depressive/ mixed phase of the disease; therefore, the substantially greater period that patients with BDII spend in dysphoric states likely puts them at higher risk for suicide than patients with BDI.15
Of the 2 dysphoric states, mixed states may be more lethal. In 1936, Jameison16 reviewed the case histories of 100 persons who committed suicide. He found that patients with mixed states were at highest risk for suicide.
Patients in mixed states can easily be mistakenly viewed as being depressed. This error can lead to maltreatment and even fatal treatment decisions.17 The use of antidepressants may have the capacity to greatly worsen the condition of mixed patients and increase the risk of suicidal behavior. For this reason, all patients with BD must be carefully screened for the presence of even subtle hints that they are in a mixed phase.
When even subthreshold symptoms of hypomania/mania are present in the context of depressive symptoms, it is critical to avoid the use of antidepressants. In this author's experience, patients with this symptomatology can almost certainly be effectively treated with atypical antipsychotics in combination with divalproex, lithium(Drug information on lithium), or lamotrigine(Drug information on lamotrigine). Atypical antipsychotics have antimanic properties, some of them may stabilize mood, and one (quetiapine) has an FDA indication for depression. Lithium and lamotrigine have confirmed antidepressant properties.
Many patients with BD, in the midst of a major depressive episode (MDE) or even with subsyndromal symptoms of MDE contaminated by hypomanic/ manic features simultaneously meet the criteria for generalized anxiety disorder, panic disorder, social phobia, or PTSD. These patients can be aggressively treated with benzodiazepines. Alternatively, some clinicians might elect to use gabapentin(Drug information on gabapentin) or valproate(Drug information on valproate), but in this author's judgment, these are second-line drugs. If one asks patients in these states, "What causes you more suffering, the depressive element of your illness or the anxiety?" Essentially all will respond, "The anxiety!" The magnitude of the global severity of anxiety is linked to the risk of completed suicide.18
If the patient is at risk for panic attacks, it is critical to select a benzodiazepine with proven antipanic effects. The drug should be given on a schedule because once a panic attack starts these drugs will not abort the attack. A reasonable initial dosing schedule in a benzodiazepine-naive patient aged 65 or younger who is having panic attacks, is 1 mg of clonazepam(Drug information on clonazepam) every 8 hours. It is important to caution patients not to drive or use potentially dangerous equipment if they experience sedation as an adverse effect.
Patients with severe anxiety must be very carefully monitored. The first task is to determine whether the patient needs to be hospitalized. A highly significant portion of patients require this intervention. Hospitalization allows for very aggressive treatment in a safe environment. However, in patients for whom outpatient treatment is appropriate, a telephone call to assess progress within 24 to 48 hours of the start of treatment demonstrates the physician's concern and provides an opportunity to ascertain whether the anxiolytic/anti- panic medication is adequately effective. If it is not, a dosage change is in order—unless adverse effects are limiting, which is extremely rare. Dosages of 1.5 to 2.0 mg of clonazepam every 8 hours may be required.
An alternative to clonazepam is either immediate- or extended-release alprazolam(Drug information on alprazolam). A reasonable starting dosage for the immediate-release preparation is 1.0 mg every 6 hours or, more practically, 4 times a day. A reasonable initial regimen for extended-release alprazolam is 1.0 to 1.5 mg every 12 hours.
Shifts from states of euthymia, or relative euthymia, to subsyndromal and syndromal states of depression or into subthreshold or veritable mixed states, greatly increase the risk of suicidal behavior. The term "mixed state" includes not only MDE features as defined in DSM-IV but also the amalgam of an MDE and a full-hypomanic syndrome. The term also includes subsyndromal mixed states—an MDE contaminated by features of hypomania/mania. An MDE with any degree of contamination by hypomanic or manic features may constitute the most lethal of all clinical states.