Suicide risk assessment and intervention in people with mental illness

Suicidal Risk, Bipolar Disorder , and Mixed Affective States.
Mark Agius Clare College Cambridge, Department of Psychiatry University of Cambridge
Delia Annear FY2 Bedford Hospital
We were interested to read Bolton et al’s article (1) on Suicide risk assessment and intervention in people with mental illness. The article highlights that suicide is a major public health problem and how the risk of suicide is greater during the first few months after diagnosis of any mental disorder.

The article rightly mentions ‘mental illnesses’ as being in itself a cause of suicide risk. However, this article fails to highlight the importance of diagnosing mood disorders correctly.
In particular, while identifying unipolar depression as a cause of suicide, it is important to also identify bipolar illness-both Bipolar I and Bipolar II- as important causes of suicide(2).
Often, bipolar desorder is underdiagnosed and misdiagnosed as unipolar depression(3). Both mental illnesses are mood disorders but their treatment is essentially different and improper treatment of bipolar depression as unipolar depression can be ineffective and can cause doctors to miss the opportunity to reduce suicide risk . NICE recommends treatment of bipolar depression with Olanzapine combined with Fluoxetine or with Quetiapine (4) while unipolar depression is treated with antidepressants (5).
In particular , it is not only important to correctly identify bipolar disorder, including Bipolar II , but to also identify specific phases of bipolar illness, such as rapid cycling and affective mixed states, since there is an increased suicide risk in these phases of the illness(6)(7)(8).

It is important that mixed affective states and rapid cycling are identified and treated, (presumably in the UK context within Crisis Teams Community Mental Health Teams and Wards), and that these states be appropriately treated if rates of suicide are to be effectively reduced.

References
(1) Bolton J.M., Gunnell D., Turecki G. Suicide risk assessment and intervention in people with mental illness BMJ 2015;351:h4978

(2) RihmerZ, Prediction and Prevention of Suicide in Bipolar Disorder Clin Neuropsychiatry, 2005; 2: 48-54.

(3) Hirschfeld RM, Calabrese JR, Weissman MM, Reed M, Davies MA, Frye MA, Keck PE Jr, Lewis L, McElroy SL, McNulty JP, Wagner KD. Screening for bipolar disorder in the community. J Clin Psychiatry. 2003 Jan;64(1):53-9.

(4) NICE Bipolar Disorder Guidelines 2014

(5) NICE Depression in adults: recognition and management 2009.

(6) Akiskal HS, Benazzi F, Perugi G, Rihmer Z. Agitated "unipolar" depression re-conceptualized as a depressive mixed state: implications for the antidepressant-suicide controversy. J Affect Disord. 2005 Apr;85(3):245-58.

(7) Balázs J, Benazzi F, Rihmer Z, Rihmer A, Akiskal KK, Akiskal HS. The close link between suicide attempts and mixed (bipolar) depression: implications for suicide prevention. J Affect Disord. 2006 Apr;91(2-3):133-8.

(8) Carvalho AF, Dimellis D, Gonda X, Vieta E, Mclntyre RS, Fountoulakis KN.Rapid cycling in bipolar disorder: a systematic review. J Clin Psychiatry. 2014 Jun;75(6):e578-86.