Through the Peaks and Valleys: Assessing and Addressing Suicide Risk in Bipolar Disorder

CATEGORY 1 CME

Premiere Date: November 20, 2025

Expiration Date: May 20, 2027

This activity offers CE credits for:

1. Physicians (CME)

2. Other

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

ACTIVITY GOAL

To provide psychiatrists with knowledge and practical skills to comprehensively assess suicide risk in patients with bipolar disorder and implement interdisciplinary approaches for suicide prevention in clinical and community settings.

LEARNING OBJECTIVES

1. To analyze the epidemiology, risk factors, and theoretical models of suicide in bipolar disorder to enhance the understanding and adoption of comprehensive suicide risk assessment.

2. To increase awareness of evidence-based pharmacological and psychosocial interventions, including adopting patient-centered care strategies and interdisciplinary approaches for suicide prevention in clinical and community settings.

TARGET AUDIENCE

This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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Physicians’ Education Resource, LLC designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits.™ Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is funded entirely by Physicians’ Education Resource, LLC. No commercial support was received.

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There is consensus that assessing suicide risk and implementing preventive strategies are crucial components in the management of bipolar disorder (BD). Despite this, many clinicians remain unsure about the most effective way to approach concerns about suicide in BD. This uncertainty stems not only from the inherent complexity of suicide risk assessment in BD but also from the lack of clear guidance on which interventions are both tailored to BD and grounded in a broader suicide prevention approach. Most research on suicide prevention strategies has been conducted in broader populations, making it challenging to determine how general findings can be adapted for use in patients with BD. Additionally, while much is known about risk factors and warning signs for suicidal behavior, there is ambiguity regarding whether these indicators can be applied directly to individuals with BD or if modifications are necessary for this specific population.

Suicide Epidemiology in Bipolar Disorder

Individuals with BD who enter into the mental health care system account for 5% to 8% of all suicide deaths based on longitudinal cohort data.¹ The International Society for Bipolar Disorders (ISBD) Task Force on Suicide in BD conducted a pooled analysis to estimate the absolute risk of suicide among individuals with BD. Drawing from both clinical and population-based samples, the analysis found a suicide rate of 164 deaths per 100,000 person-years—approximately 10 to 20 times higher than the rate observed in the general population.² Given that national suicide rates already include individuals with BD, the relative risk for patients with BD compared with non-BD or nonclinical populations may be even greater. Estimates from other studies vary depending on sample characteristics and methods. For instance, an earlier pooled analysis by Tondo et al reported a standardized mortality ratio (SMR) of 22.1 (95% CI, 20.0-24.1) compared with the general population.³ More recent systematic review data, including a meta-analysis of 57 studies of mortality in BD, estimated a relative risk of 11.69 (95% CI, 9.22-14.81) for suicide deaths compared with the general population.⁴

At the level of individual studies, findings are influenced by factors such as sample characteristics (eg, population-based vs clinical), follow-up periods (eg, duration, relation to illness state or health care contract), and ascertainment sources of the suicide data. Evidence from national cohort studies, including population-based samples from Sweden, showed that suicide was the second leading cause of death after cardiovascular disease among individuals with BD after decades of follow-up.⁵ While the age of the cohort affects mortality rates from other causes (eg, cancer and respiratory disease), these data underscore the significant contribution of suicide to premature mortality in BD. These data offer estimates of the long-term suicide risk among patients with BD, which can serve as a baseline level of risk whereby additional risk factors or protective factors can be added to tailor the risk assessment for individual patients.

Appropriate Screening and Assessment for Suicidal Risk

Several established models explore factors associated with the development and advancement of the suicidal process. The Bipolar Suicidality Model (BSM) developed by Malhi et al suggests that suicidal ideation in BD involves a balanced appraisal system.⁶ Patients are more likely to positively appraise their circumstances if they are adherent, respond well to treatment, and possess protective genes with an optimistic personality. These factors may lead to adaptive coping but can also be maladaptive in the case of euphoric states such as hypomania and/or mania. When these protective factors are impacted (eg, with neurocognitive dysfunction), engagement in a negative appraisal system may occur, which can lead to perceived defeat and entrapment. An excess amount of this ideation can enhance the need to escape from reality and give rise to suicide being perceived as a viable option.

An established broader framework for suicidal behavior is the integrated motivational-volitional (IMV) model. This model posits that suicide emerges from a sense of defeat and/or humiliation, leading to feelings of entrapment with no hope of improvement—a cognitive process that may be especially prevalent in those prone to rumination.⁷ This sequence of events is especially relevant for individuals with BD, especially during depressive episodes, which is the most common illness state for individuals with BD. According to the IMV model, those who feel trapped may develop suicidal ideation when additional factors are present, such as feelings of burdensomeness or social disconnection. The IMV model emphasizes the role of moderating factors that drive the transition from suicidal thoughts to suicidal behavior, with access to means being a key factor. Because psychopharmacological treatment is central to BD management, and some of the medications used have relatively high potential toxicity, individuals with BD may have increased access to potentially lethal means of suicide. This combination of psychological vulnerabilities and environmental factors highlights why individuals with BD face a significantly elevated risk of suicide compared with the general population, particularly during depressive episodes.

The ISBD Task Force on Suicide developed a basic model that categorized various factors influencing suicide risk into distinct groups: baseline risk, general factors, the impact of BD on these general factors, and illness-specific factors.⁸ This categorization aims to facilitate a BD-specific suicide risk assessment (Figure 1) and operationalizes the idea that the diagnosis of BD is not only crucial for estimating suicide risk but also because many characteristics of the disorder itself can directly and indirectly affect that risk. By assessing and incorporating the contributions of each of these factors, clinicians can achieve a more tailored and potentially accurate estimation of suicide risk in individuals with BD.

Risk Factors for Suicide

There is sound evidence that numerous sociodemographic and clinical factors significantly influence suicide risk.^9,10 These include age, sex, race, adverse childhood experiences, economic and psychosocial stressors, physical pain or medical conditions, feelings of hopelessness, social isolation, suicidal ideation, previous suicide attempts or self-harm, and family history of suicide. These factors are relevant across various psychiatric diagnoses and should be integral to comprehensive suicide risk assessments.

Several BD-specific clinical factors significantly influence suicide risk, including earlier age of illness onset, depressive polarity of the first illness episode, overall illness duration, number of mood episodes, predominant depressive polarity, most recent or current episode polarity, presence of mixed features, and anxious distress. An unresolved debate also remains as to whether bipolar II disorder may incur a higher risk than bipolar I disorder for suicide completion based on the extensive duration spent with depressive symptoms.¹¹ Baseline symptom severity is also widely regarded as a risk factor for suicidal behavior in bipolar disorder.¹² With respect to substance use, the intensity and frequency of cocaine and cannabis use have been shown to correlate with the longitudinal development of suicidal ideation in patients with BD.¹³ Also, having a comorbid alcohol use disorder is an established risk factor for suicide attempts in BD (OR, 2.25).¹⁴ Comorbid BD and other psychiatric conditions, particularly studied in patients with borderline personality disorder, have been associated with elevated suicide risk.^15,16 Both disorders contribute to overlapping and additive effects on suicidality.¹⁷ Incorporating these BD-specific variables (Table⁸) into the suicide risk assessment model facilitates a more comprehensive risk evaluation. In addition to establishing the baseline risk, identifying general suicide risk factors, and BD illness–specific factors, it is crucial to examine BD’s impact on the general suicide risk factors. This interplay is particularly pronounced in sex-based differences in suicide deaths. For instance, although the population-based literature on suicide highlights a 3-fold or higher ratio of suicide deaths when comparing men with women, the ISBD Task on Suicide identified a lower ratio in BD.¹⁸ Sex-based analyses from 11 studies, including a large sample size of 75,055 patients with BD and a total of 1139 suicide deaths, found that men with BD have an OR of 1.83 (95% CI, 1.41-2.39; P < .0001) for suicide deaths compared with their female counterparts. These findings highlight that the presence of BD illness amplifies suicide risk more significantly for women when compared with men.

Although the Table summarizes various elements of the clinical presentation that may affect suicide risk estimates, merely listing these factors does not yield an accurate predictive model. Ideally, a precise predictive framework would involve complex calculations that account for interactions and effects, perhaps utilizing machine learning approaches, but such validated models are not currently available in clinical practice. Recent efforts have aimed to create a more structured approach to risk estimation, including the development of a BD-specific risk calculator based on data from the Course and Outcome of Bipolar Youth study.¹⁹ This calculator, which aimed to predict suicide attempts rather than deaths, showed promising results with a model comprising 10 predictors. A subsequent validation study in an adult sample demonstrated acceptable accuracy (area under the curve , 0.78) for predicting suicidal behaviors over one year.²⁰ Emerging methodologies, including artificial intelligence (AI) platforms, hold potential for enhancing the accuracy of suicide prediction; however, these have yet to achieve the level of precision necessary for clinical application, and most existing models concentrate on suicidal behaviors rather than suicide deaths, which are ultimately distinct.

A comprehensive systematic review published in 2019 highlighted the significant challenges associated with predicting both the occurrence and timing of suicide deaths.²¹ Suicide can occur at any point from adolescence to late older age, and most prediction models exhibit very low positive predictive values, sometimes nearing zero. The lack of a reliable risk calculator for suicide deaths in the general clinical population suggests that it is equally unlikely for such a tool to exist soon, specifically for BD.

A probabilistic risk calculator (ie, one used for suicide risk prediction in BD) estimates the likelihood or probability of suicidal behavior based on collective risk factors but cannot provide the deterministic certainty for any individual. Given the lack of deterministic certainty, it cannot definitively predict who will or will not engage in suicidal behavior. For example, relating this concept to the Framingham score for myocardial infarctions (MIs), which quantifies relative risk but cannot accurately predict if an MI event will occur, illustrates the inherent unpredictability of highly multidetermined outcomes such as suicide or MIs. Thus, we may very well never have complete predictability, and expecting a highly predictive tool for individual outcomes is an unrealistic way to conceptualize risk assessment and management.

This situation places clinicians in a challenging position, as there are often unrealistic expectations from both individuals and systems that mental health professionals can accurately predict suicidal behavior in a way that supports evidence-based clinical decisions. However, the literature strongly indicates that, to date, predicting suicide remains elusive, regardless of the predictive model employed. This does not suggest that efforts to develop risk models or calculators should cease; rather, until these tools demonstrate consistent and robust predictive capacity for specific clinical subgroups, they should not be depended upon.

Fortunately, extensive research and clinical and policy initiatives have been underway for decades, focusing less on predicting suicide deaths and more on implementing diverse strategies to prevent them across all risk levels. This inability to rely solely on prediction shifts the approach toward ensuring that all patients with BD receive suicide prevention strategies and interventions, regardless of their assessed risk. By alleviating the unrealistic expectation for clinicians to predict suicide, there is potential for a more robust commitment to widespread prevention efforts, which is likely to yield greater long-term effectiveness.

Psychopharmacological Management

The clinical approach for preventing suicide in patients with BD should encompass 2 key components, both conceptually and practically. First, effective acute and maintenance treatment for the underlying symptoms of BD and any co-occurring conditions is crucial, as this foundational approach can significantly reduce suicide risk.^22,23 However, addressing these symptoms alone is insufficient. It is also critically important to implement evidence-based interventions specifically designed to reduce suicide risk, which may not necessarily correlate directly with the severity of symptoms.

For many years, the emphasis on suicide prevention in BD has largely centered on lithium as a potential antisuicide treatment. Lithium is well recognized as a first-line mood stabilizer due to its effectiveness in preventing recurrence and its benefits for specific subgroups of patients who respond to it. However, the direct evidence supporting its antisuicide effects beyond general illness management is more complex. Evidence from meta-analyses indicates that lithium treatment is associated with a reduced risk of suicide; however, most of these data originate from large observational or epidemiological studies, which, while informative, carry significant limitations. The available randomized controlled trial (RCT) data examining suicide deaths as an outcome are limited due to methodological challenges in adequately powering these studies. Although combined RCT findings across various mood disorder diagnostic groups suggest a likely specific antisuicide effect, these results remain open to some interpretation.²⁴

Rather than reiterate the extensive literature on this subject, we adopt a perspective where lithium is a gold-standard mood stabilizer and patients taking lithium are considerably less likely to die by suicide. Furthermore, lithium may exhibit specific antisuicide effects compared with other treatments for BD, although the current state of the evidence should temper confidence in this assertion.

There is, however, only moderate evidence on the use of other pharmacological agents for suicide risk reduction, with most of the data not being specific to BD and/or of limited quality. Findings from several studies have confirmed that anticonvulsant use is not associated with increased suicide risk, refuting a previous concern that was an area of study.^25,26 Data remain inconclusive regarding a difference between lithium and anticonvulsants in effectively reducing rates of suicide attempts and/or suicides, though data from nonrandomized observational studies report higher rates of suicide-related behavior during periods of anticonvulsant use vs lithium use.^27-29

Beyond lithium and anticonvulsants, data on suicide-related outcomes in patients with BD using antipsychotics or antidepressants are limited. Clozapine’s antisuicidal effect appears specific to schizophrenia, though these antisuicidal properties have not been studied outside the schizophrenia spectrum disorders. Additionally, antidepressant use in BD is associated with an increased risk of emergent mixed or manic symptoms, which could, in turn, exacerbate suicide risk, although direct data examining this are still limited and mixed regarding findings.^12,30 Chronotherapy (eg, light therapy and sleep deprivation), in conjunction with lithium, has been shown to produce a rapid reduction in suicidal ideation during the bipolar depression phase, but this preliminary evidence needs to be further studied.³¹ Emerging evidence suggests the use of interventional approaches (eg, repetitive transcranial magnetic stimulation) in observational studies to treat patients with BD, as well as supporting evidence of the use of ketamine, although most of these studies involve mixed mood disorder samples.^32,33

Psychosocial Prevention Strategies

A broad suicide prevention literature exists on approaches that span both clinical and public health settings. Relevant evidence-based interventions pertaining to BD populations include systematic screening for suicidal thoughts and behaviors, coordinating follow-up care after contact with acute care services, general practitioner training, increased access to psychotherapeutic treatments, peer support, and means restriction involving reduced access to lethal means. From a public health-related perspective, key evidence-based interventions include the implementation of media guidelines on safer reporting of suicides, public awareness campaigns, gatekeeper training, and having physical infrastructure that limits access to hotspot sites for suicide. When these interventions are widely implemented, there is an estimated 20% to 25% reduction in potential suicides.³⁴

Specific psychotherapy modalities have been associated with a reduction in suicide-related behaviors and should be considered in the management of patients with BD. Evidence from broad diagnostic groups supports the use of dialectical behavioral therapy, cognitive behavioral therapy for suicide prevention, and the Collaborative Assessment and Management of Suicidality.^35-37 Novel interventions involving postdischarge follow-up messages referred to as “caring contacts,” after delivery of acute mental health services, have also demonstrated a risk reduction of suicide-related behavior and deaths.³⁸ Figure 2 highlights key evidence-based suicide prevention interventions that are highly relevant for BD, which take into account the pharmacological and psychosocial perspectives. These steps and safeguards would ensure the delivery of key suicide prevention interventions throughout the patient’s mental health care journey. Given the risk of the bystander effect across silos of care in a patient with multiple health care providers across several settings, including acute care, community care, and inpatient care, clarifying role expectations should be taken into consideration. Every member of a patient’s health care team plays a vital role, and interventions should be integrated into comprehensive care across all treatment settings.

Common Challenges

Ongoing efforts to develop suicide prediction models for individuals with BD would benefit from integrating large epidemiological or observational data sets with person-specific data highlighting warning signs, clinical details, and protective factors. Efforts are underway to passively collect vast amounts of data on individuals with BD, and incorporating these data sets into predictive models will likely require collaboration with data scientists specializing in artificial intelligence modeling. Given that clinically applicable prediction tools for BD may still be limited and not achieve sufficiently high predictive value, the growing focus should shift toward a care model in which all individuals with BD receive proactive care focused on suicide prevention in combination with the management of their symptomatology. This shift may prompt new quality improvement efforts that align health care delivery systems and care pathways, which are the current foundation and priority of care for patients with BD. Ultimately, all health care providers involved in the care of patients with BD should be involved in planning and implementing suicide prevention strategies. This approach brings opportunities for more interdisciplinary efforts to move beyond siloed care and toward integrated methods. Notably, the perspectives of individuals with lived experience have been largely absent in the literature, underscoring the necessity for future studies to incorporate the voices of these patients and families into the design, study, and implementation of suicide prevention strategies.

Concluding Thoughts

Suicide prevention arguably stands as one of the most critical aspects of care in patients with BD. Although there have been advancements in prediction models for suicidal behavior, both broadly and within BD, these tools remain imperfect and are currently of limited clinical utility. In some cases, these models may even lead to false reassurance or an over-concentration of resources in high-risk settings, rather than supporting more widespread preventive interventions. Suicides occur across all risk levels, and the ideal approach is for all individuals with BD to have access to suicide prevention strategies. These interventions must be integrated into clinical care settings and applied by all health care providers. Moreover, suicide prevention is both a systems-level and public health priority, and the progress made in these approaches is particularly relevant to individuals with BD. Although suicide rates remain distressingly high, there is reason for optimism that the suite of evidence-based interventions discussed here can be successfully implemented, yielding positive outcomes.

Dr Nguyen is a psychiatry resident in the Department of Psychiatry at Sunnybrook Health Sciences Centre, University of Toronto, Canada. Dr Schaffer is a professor in the Department of Psychiatry at Sunnybrook Health Sciences Centre, University of Toronto, Canada.

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