From the Guidelines
Yes, a bipolar mixed episode can significantly increase the risk of suicidal ideation (SI). Mixed episodes, which involve simultaneous symptoms of both mania and depression, are particularly dangerous because they combine the depressive thoughts and hopelessness with the energy, impulsivity, and agitation of mania. This combination creates a perfect storm where someone might have both the desire and the energy to act on suicidal thoughts.
Key Points to Consider
- Patients experiencing mixed episodes should be closely monitored and receive immediate psychiatric evaluation.
- Treatment typically includes mood stabilizers like lithium (600-1200mg daily), valproate (750-1500mg daily), or carbamazepine (400-1200mg daily), often combined with atypical antipsychotics such as olanzapine (5-20mg daily), quetiapine (300-800mg daily), or risperidone (2-6mg daily) 1.
- Benzodiazepines like lorazepam (0.5-2mg as needed) may be used short-term for severe agitation.
- Hospitalization should be strongly considered if there is any risk of self-harm.
- The underlying neurobiological dysregulation in mixed states affects both serotonergic and dopaminergic systems, creating emotional instability that can make suicidal thoughts more intense and dangerous than in pure depressive or manic episodes.
Important Considerations for Treatment
- Lithium has been shown to greatly reduce the rate of both suicides and suicide attempts in adults with bipolar disorder 1.
- Selective serotonin reuptake inhibitors (SSRIs) can reduce suicidal ideation and suicide attempts in nondepressed adults with cluster B personality disorders, but may have a disinhibiting effect in some patients 1.
- Tricyclic antidepressants should not be prescribed for the suicidal child or adolescent as a first line of treatment due to their potential lethality and lack of proven effectiveness in children and adolescents 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Bipolar Mixed Episode and Suicidal Ideation
- The relationship between bipolar mixed episodes and suicidal ideation (SI) is complex, with some studies suggesting that mixed episodes may not necessarily increase the risk of SI beyond the risk conveyed by depressive symptoms alone 2, 3.
- Depressive symptoms are strongly associated with suicidal ideation and behavior in bipolar disorder, and represent an important and potentially modifiable risk factor for suicide 2, 4, 3.
- Manic symptoms, on the other hand, do not appear to convey an elevated risk for suicidal ideation or behavior beyond that explained by the depressive symptoms alone 2, 3.
- Some studies suggest that the addition of an atypical antipsychotic-antimanic agent, such as olanzapine, may help to reduce suicidal ideation in bipolar disorder patients, particularly those with mixed episodes 5.
- Lithium has been shown to have a protective effect against suicide attempts in patients with bipolar disorder, and may be an effective treatment option for reducing suicidal ideation 6, 4.
Risk Factors for Suicidal Ideation in Bipolar Disorder
- Depressive symptoms are a major risk factor for suicidal ideation and behavior in bipolar disorder 2, 4, 3.
- Male gender, living alone, divorced, no children, Caucasian, younger age (< 35 years), elderly age (> 75 years), unemployment, and a personal history of suicide attempt and family history of suicide attempt or suicide completion are also risk factors for suicide in bipolar disorder 4.
- Mixed symptoms do not appear to convey an elevated risk for suicidal ideation or behavior beyond that explained by the depressive symptoms alone 2, 3.
Treatment and Prevention of Suicidal Ideation in Bipolar Disorder
- Early intervention and treatment with anti-suicidal medications, such as lithium, along with close observation and follow-up is the best way to mitigate suicide in patients with bipolar disorder 4.
- Understanding clinical and demographic risk factors for suicide in bipolar disorder remains the best way to prevent suicidal behavior 4.
- The use of mood stabilizing agents, such as lithium and antiepileptics, may have a protective effect against suicide attempts in patients with bipolar disorder 6.