Skip to main content Accessibility help

Do risk factors for suicidal behavior differ by affective disorder polarity?

  • J. G. Fiedorowicz (a1), A. C. Leon (a2), M. B. Keller (a3), D. A. Solomon (a3), J. P. Rice (a4) and W. H. Coryell (a1)...



Suicide is a leading cause of death and has been strongly associated with affective disorders. The influence of affective disorder polarity on subsequent suicide attempts or completions and any differential effect of suicide risk factors by polarity were assessed in a prospective cohort.


Participants with major affective disorders in the National Institute of Mental Health (NIMH) Collaborative Depression Study (CDS) were followed prospectively for up to 25 years. A total of 909 participants meeting prospective diagnostic criteria for major depressive and bipolar disorders were followed through 4204 mood cycles. Suicidal behavior was defined as suicide attempts or completions. Mixed-effects, grouped-time survival analysis assessed risk of suicidal behavior and differential effects of risk factors for suicidal behavior by polarity. In addition to polarity, the main effects of age, gender, hopelessness, married status, prior suicide attempts and active substance abuse were modeled, with mood cycle as the unit of analysis.


After controlling for age of onset, there were no differences in prior suicide attempts by polarity although bipolar participants had more prior severe attempts. During follow-up, 40 cycles ended in suicide and 384 cycles contained at least one suicide attempt. Age, hopelessness and active substance abuse but not polarity predicted suicidal behavior. The effects of risk factors did not differ by polarity.


Bipolarity does not independently influence risk of suicidal behavior or alter the influence of well-established suicide risk factors within affective disorders. Suicide risk assessment strategies may continue to appraise these common risk factors without regard to mood polarity.


Corresponding author

*Address for correspondence: J. G. Fiedorowicz, M.D., M.S., 200 Hawkins Drive W278 GH, Iowa City, IA 52242, USA. (Email:


Hide All
Akiskal, HS, Maser, JD, Zeller, PJ, Endicott, J, Coryell, W, Keller, M, Warshaw, M, Clayton, P, Goodwin, F (1995). Switching from ‘unipolar’ to bipolar II. An 11-year prospective study of clinical and temperamental predictors in 559 patients. Archives of General Psychiatry 52, 114123.
Akiskal, HS, Walker, P, Puzantian, VR, King, D, Rosenthal, TL, Dranon, M (1983). Bipolar outcome in the course of depressive illness. Phenomenologic, familial, and pharmacologic predictors. Journal of Affective Disorders 5, 115128.
Angst, F, Stassen, HH, Clayton, PJ, Angst, J (2002). Mortality of patients with mood disorders: follow-up over 34–38 years. Journal of Affective Disorders 68, 167181.
Angst, J, Angst, F, Gerber-Werder, R, Gamma, A (2005 a). Suicide in 406 mood-disorder patients with and without long-term medication: a 40 to 44 years' follow-up. Archives of Suicide Research 9, 279300.
Angst, J, Sellaro, R, Stassen, HH, Gamma, A (2005 b). Diagnostic conversion from depression to bipolar disorders: results of a long-term prospective study of hospital admissions. Journal of Affective Disorders 84, 149157.
Beautrais, AL (2001). Suicides and serious suicide attempts: two populations or one? Psychological Medicine 31, 837845.
Black, DW, Winokur, G, Nasrallah, A (1988). Effect of psychosis on suicide risk in 1593 patients with unipolar and bipolar affective disorders. American Journal of Psychiatry 145, 849852.
Cassano, GB, Akiskal, HS, Savino, M, Musetti, L, Perugi, G (1992). Proposed subtypes of bipolar II and related disorders: with hypomanic episodes (or cyclothymia) and with hyperthymic temperament. Journal of Affective Disorders 26, 127140.
CDC (2005). Years of Potential Life Lost (YPLL) before age 65, 1999–2002 United States. In WISQARS Years of Potential Life Lost (YPLL) Reports, 1999–2002. Centers for Disease Control and Prevention ( Accessed 21 October 2005.
Chen, YW, Dilsaver, SC (1996). Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other Axis I disorders. Biological Psychiatry 39, 896899.
Coryell, W, Andreasen, NC, Endicott, J, Keller, M (1987). The significance of past mania or hypomania in the course and outcome of major depression. American Journal of Psychiatry 144, 309315.
Coryell, W, Arndt, S, Turvey, C, Endicott, J, Solomon, D, Mueller, T, Leon, AC, Keller, M (2001). Lithium and suicidal behavior in major affective disorder: a case-control study. Acta Psychiatrica Scandinavica 104, 193197.
Coryell, W, Endicott, J, Reich, T, Andreasen, N, Keller, M (1984). A family study of bipolar II disorder. British Journal of Psychiatry 145, 4954.
Coryell, W, Haley, J, Endicott, J, Solomon, D, Leon, AC, Keller, M, Turvey, C, Maser, JD, Mueller, T (2002). The prospectively observed course of illness among depressed patients who commit suicide. Acta Psychiatrica Scandinavica 105, 218223.
Coryell, W, Keller, M, Endicott, J, Andreasen, N, Clayton, P, Hirschfeld, R (1989). Bipolar II illness: course and outcome over a five-year period. Psychological Medicine 19, 129141.
Dalton, EJ, Cate-Carter, TD, Mundo, E, Parikh, SV, Kennedy, JL (2003). Suicide risk in bipolar patients: the role of co-morbid substance use disorders. Bipolar Disorders 5, 5861.
Dunner, DL, Gershon, ES, Goodwin, FK (1976). Heritable factors in the severity of affective illness. Biological Psychiatry 11, 3142.
Endicott, J, Nee, J, Andreasen, N, Clayton, P, Keller, M, Coryell, W (1985). Bipolar II. Combine or keep separate? Journal of Affective Disorders 8, 1728.
Endicott, J, Spitzer, RL (1978). A diagnostic interview: the Schedule for Affective Disorders and Schizophrenia. Archives of General Psychiatry 35, 837844.
Endicott, J, Spitzer, RL (1979). Use of the Research Diagnostic Criteria and the Schedule for Affective Disorders and Schizophrenia to study affective disorders. American Journal of Psychiatry 136, 5256.
Fawcett, J, Scheftner, W, Clark, D, Hedeker, D, Gibbons, R, Coryell, W (1987). Clinical predictors of suicide in patients with major affective disorders: a controlled prospective study. American Journal of Psychiatry 144, 3540.
Fawcett, J, Scheftner, WA, Fogg, L, Clark, DC, Young, MA, Hedeker, D, Gibbons, R (1990). Time-related predictors of suicide in major affective disorder. American Journal of Psychiatry 147, 11891194.
Fiedorowicz, JG, Coryell, WH (2007). Cholesterol and suicide attempts: a prospective study of depressed inpatients. Psychiatry Research 152, 1120.
Goldberg, JF, Harrow, M (2004). Consistency of remission and outcome in bipolar and unipolar mood disorders: a 10-year prospective follow-up. Journal of Affective Disorders 81, 123131.
Goldberg, JF, Harrow, M, Whiteside, JE (2001). Risk for bipolar illness in patients initially hospitalized for unipolar depression. American Journal of Psychiatry 158, 12651270.
Goldstein, RB, Black, DW, Nasrallah, A, Winokur, G (1991). The prediction of suicide. Sensitivity, specificity, and predictive value of a multivariate model applied to suicide among 1906 patients with affective disorders. Archives of General Psychiatry 48, 418422.
Hedeker, D, Siddiqui, O, Hu, FB (2000). Random-effects regression analysis of correlated grouped-time survival data. Statistical Methods in Medical Research 9, 161179.
Hoyer, EH, Olesen, AV, Mortensen, PB (2004). Suicide risk in patients hospitalised because of an affective disorder: a follow-up study, 1973–1993. Journal of Affective Disorders 78, 209217.
Judd, LL, Akiskal, HS, Schettler, PJ, Coryell, W, Maser, J, Rice, JA, Solomon, DA, Keller, MB (2003). The comparative clinical phenotype and long term longitudinal episode course of bipolar I and II: a clinical spectrum or distinct disorders? Journal of Affective Disorders 73, 1932.
Judd, LL, Akiskal, HS, Schettler, PJ, Endicott, J, Maser, J, Solomon, DA, Leon, AC, Rice, JA, Keller, MB (2002). The long-term natural history of the weekly symptomatic status of bipolar I disorder. Archives of General Psychiatry 59, 530537.
Kallner, G, Lindelius, R, Petterson, U, Stockman, O, Tham, A (2000). Mortality in 497 patients with affective disorders attending a lithium clinic or after having left it. Pharmacopsychiatry 33, 813.
Keller, MB, Lavori, PW, Friedman, B, Nielsen, E, Endicott, J, McDonald-Scott, P, Andreasen, NC (1987). The Longitudinal Interval Follow-up Evaluation. A comprehensive method for assessing outcome in prospective longitudinal studies. Archives of General Psychiatry 44, 540548.
Krupinski, M, Fischer, A, Grohmann, R, Engel, R, Hollweg, M, Moller, HJ (1998). Risk factors for suicides of inpatients with depressive psychoses. European Archives of Psychiatry and Clinical Neuroscience 248, 141147.
Kupfer, DJ, Carpenter, LL, Frank, E (1988). Is bipolar II a unique disorder? Comprehensive Psychiatry 29, 228236.
Leon, AC, Friedman, RA, Sweeney, JA, Brown, RP, Mann, JJ (1990). Statistical issues in the identification of risk factors for suicidal behavior: the application of survival analysis. Psychiatry Research 31, 99108.
Mann, JJ, Apter, A, Bertolote, J, Beautrais, A, Currier, D, Haas, A, Hegerl, U, Lonnqvist, J, Malone, K, Marusic, A, Mehlum, L, Patton, G, Phillips, M, Rutz, W, Rihmer, Z, Schmidtke, A, Shaffer, D, Silverman, M, Takahashi, Y, Varnik, A, Wasserman, D, Yip, P, Hendin, H (2005). Suicide prevention strategies: a systematic review. Journal of the American Medical Association 294, 20642074.
Maser, JD, Akiskal, HS, Schettler, P, Scheftner, W, Mueller, T, Endicott, J, Solomon, D, Clayton, P (2002). Can temperament identify affectively ill patients who engage in lethal or near-lethal suicidal behavior? A 14-year prospective study. Suicide and Life-Threatening Behavior 32, 1032.
McMahon, FJ, Stine, OC, Chase, GA, Meyers, DA, Simpson, SG, DePaulo, Jr. JR (1994). Influence of clinical subtype, sex, and lineality on age at onset of major affective disorder in a family sample. American Journal of Psychiatry 151, 210215.
Murphy, GE, Wetzel, RD, Robins, E, McEvoy, L (1992). Multiple risk factors predict suicide in alcoholism. Archives of General Psychiatry 49, 459463.
Oquendo, MA, Bongiovi-Garcia, ME, Galfalvy, H, Goldberg, PH, Grunebaum, MF, Burke, AK, Mann, JJ (2007). Sex differences in clinical predictors of suicidal acts after major depression: a prospective study. American Journal of Psychiatry 164, 134141.
Oquendo, MA, Waternaux, C, Brodsky, B, Parsons, B, Haas, GL, Malone, KM, Mann, JJ (2000). Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters. Journal of Affective Disorders 59, 107117.
Rice, J, Reich, T, Andreasen, NC, Endicott, J, Van Eerdewegh, M, Fishman, R, Hirschfeld, RM, Klerman, GL (1987). The familial transmission of bipolar illness. Archives of General Psychiatry 44, 441447.
Rice, JP, McDonald-Scott, P, Endicott, J, Coryell, W, Grove, WM, Keller, MB, Altis, D (1986). The stability of diagnosis with an application to bipolar II disorder. Psychiatry Research 19, 285296.
Rice, JP, Rochberg, N, Endicott, J, Lavori, PW, Miller, C (1992). Stability of psychiatric diagnoses. An application to the affective disorders. Archives of General Psychiatry 49, 824830.
Rihmer, Z (1996). Strategies of suicide prevention: focus on health care. Journal of Affective Disorders 39, 8391.
Scheftner, WA, Young, MA, Endicott, J, Coryell, W, Fogg, L, Clark, DC, Fawcett, J (1988). Family history and five-year suicide risk. British Journal of Psychiatry 153, 805809.
Schneider, B, Muller, MJ, Philipp, M (2001). Mortality in affective disorders. Journal of Affective Disorders 65, 263274.
Serretti, A, Mandelli, L, Lattuada, E, Cusin, C, Smeraldi, E (2002). Clinical and demographic features of mood disorder subtypes. Psychiatry Research 112, 195210.
Spitzer, RL, Endicott, J, Robins, E (1978). Research diagnostic criteria: rationale and reliability. Archives of General Psychiatry 35, 773782.
Tondo, L, Baldessarini, RJ, Hennen, J, Minnai, GP, Salis, P, Scamonatti, L, Masia, M, Ghiani, C, Mannu, P (1999). Suicide attempts in major affective disorder patients with comorbid substance use disorders. Journal of Clinical Psychiatry 60 (Suppl. 2), 6369; discussion 75–66, 113116.
Tondo, L, Lepri, B, Baldessarini, RJ (2007). Suicidal risks among 2826 Sardinian major affective disorder patients. Acta Psychiatrica Scandinavica 116, 419428.
Valtonen, H, Suominen, K, Mantere, O, Leppamaki, S, Arvilommi, P, Isometsa, ET (2005). Suicidal ideation and attempts in bipolar I and II disorders. Journal of Clinical Psychiatry 66, 14561462.
Young, MA, Fogg, LF, Scheftner, WA, Fawcett, JA (1994). Interactions of risk factors in predicting suicide. American Journal of Psychiatry 151, 434435.


Do risk factors for suicidal behavior differ by affective disorder polarity?

  • J. G. Fiedorowicz (a1), A. C. Leon (a2), M. B. Keller (a3), D. A. Solomon (a3), J. P. Rice (a4) and W. H. Coryell (a1)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed