Psychosis and Suicidality in Patients with Bipolar Depression

Suicide is a primary cause of premature mortality in those with bipolar disorder (BD).  Those with untreated bipolar disorder face a 10 to 30-fold increased risk of premature death compared with the general population, and approximately 1% of BD patients complete suicide each year.  While various risk factors for suicide in this population have been identified, the strongest correlate of suicidality in BD is depression, either current or most recent episode.

Using data collected in the multi-site Bipolar CHOICE study, researchers from the Dauten Family Center for Bipolar Treatment Innovation explore the relationship between psychotic symptoms during a depressive episode and suicidal ideation in patients with bipolar disorder.  Data analyzed in the study was collected as part of the Clinical and Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder study (Bipolar CHOICE), a 6-month, 10-site randomized comparative effectiveness study of quetiapine versus lithium. 

A total of 351 participants with bipolar disorder and current depressive symptoms were included in the analysis. Psychotic symptoms were assessed using the Bipolar Inventory of Signs and Symptoms Scale (BISS). Depressive episodes were identified using the Mini-International Neuropsychiatric Interview (MINI). 

In this cohort, only 4.84% (N = 17) endorsed psychotic symptoms. The researchers observed that, while only a small proportion of these outpatients with bipolar depression reported current symptoms of psychosis, those who did were more likely to endorse active suicidal thoughts, considering suicide methods and plans. 

This finding remained significant after controlling for other factors associated with suicidal ideation and behaviors, including age, gender identity, race, level of education, household income, marital status, previous suicide attempts, severity of depression, overall illness severity, comorbid anxiety disorders, substance use disorder within the past 12 months, and active cigarette smoking.

This is the first study to evaluate active and passive suicidal ideation and behaviors in BD patients with psychotic depression. The study demonstrates that psychotic symptoms during bipolar depressive episodes predict active, but not passive, suicidal thinking.

Psychotic symptoms during bipolar depressive episodes, especially in non-hospitalized patients, are under-recognized.  It is estimated that psychotic symptoms occur in 10%−28% of bipolar patients, although actual rates may be considerably higher, as psychotic features are often missed.  Previous research indicates that clinicians typically focus more on mood symptoms to the exclusion of psychotic features, and therefore often miss the diagnosis of psychotic depression.  The findings of the current study highlight the importance of carefully assessing for psychotic symptoms and active suicidal ideation in those with bipolar depression.

Kuperberg M, Katz D, Greenebaum SLA, George N, Sylvia LG, Kinrys G, Desrosiers A, Nierenberg AA.  Psychotic symptoms during bipolar depressive episodes and suicidal ideation.  J Affect Disord. 2021 Mar 1;282:1241-1246. 

Nierenberg AA, McElroy SL, Friedman ES, Ketter TA, et al.  Bipolar CHOICE (Clinical Health Outcomes Initiative in Comparative Effectiveness): a pragmatic 6-month trial of lithium versus quetiapine for bipolar disorder.  J Clin Psychiatry. 2016 Jan;77(1):90-9.