Gender, suicidality and bipolar mixed states in adolescents

Dilsaver, Steven C.; Benazzi, Franco; Rihmer, Zoltan; Akiskal, Kareen K.; Akiskal, Hagop S.

doi:10.1016/j.jad.2005.02.003

« Previous Next »Journal of Affective Disorders
Volume 87, Issue 1 , Pages 11-16, July 2005

Gender, suicidality and bipolar mixed states in adolescents

Steven C. Dilsaver
- Community Mental Health Clinic, Rio Grande City, TX, USA
- Merced Department of Mental Health, P.O. Box 839, Merced, California, USA
- Corresponding author. Merced Department of Mental Health, P.O. Box 839, Merced, California, USA. Tel.: +1 209 722 4953; fax: +1 209 381 7511.
Franco Benazzi
- E Hecker Outpatient Center, Ravenna, Italy
- Department of Psychiatry, National Health Service, Forli, Italy
Zoltan Rihmer
- National Institute for Psychiatry and Neurology, Budapest, Hungary
Kareen K. Akiskal
- National Union of Depressive and Manic-Depressive Associations, Rennes, France
- International Mood Disorders Program, La Jolla, CA, USA
Hagop S. Akiskal
- National Union of Depressive and Manic-Depressive Associations, Rennes, France
- International Mood Disorders Program, La Jolla, CA, USA
- San Diego Veterans Administration Medical Center, USA

Received 5 December 2004; accepted 10 February 2005.

Abstract

Background

The purpose of this study was to determine the relationship between mixed states and suicidality among adolescent outpatients presenting with a DSM-IV defined major depressive episode (MDE).

Methods

Two-hundred and forty-seven adolescents meeting the criteria for MDE were screened for the presence of concurrent, intra-MDE hypomania/mania (i.e., mixed states). All patients were asked whether they had current suicidal ideation or had recently attempted any self-destructive physical act associated with the thought of dying (i.e., a suicide attempt). The data were subjected to analysis using univariate logistic regression.

Results

One hundred of the 247 (40.5%) adolescents were bipolar type I or type II. Of these, 82% were in mixed states. Of the patients with suicidal ideation, 62.8% were girls, and of those with histories of a suicide attempt, 69.4% were girls. Girls had more than twice the risk of having suicidal ideation (OR=2.2, p=0.004) and nearly 3 times the risk of having histories of a suicide attempt than boys (OR=2.87, p<0.0001). Being in a mixed state per se did not predict either suicidal ideation or a suicide attempt among all of the 247 patients. However, mixed states apparently independently contributed to the risk of (non-fatal) suicidal behavior among girls only. Of the mixed states, girls had nearly 4 times the risk of having made a suicide attempt compared with those without mixed states (OR=3.9, p=0.003). Age, presence of psychotic features and family history of mood disorder had little or no bearing on suicidality.

Limitations

Correlational chart review study, no data collection on Axis I and Axis II comorbidity and adverse life-events.

Conclusions

This report of greater suicidality in adolescent girls in a mixed state parallels the well-known adult literature of high frequency of mixed states in women. The findings are of relevance to the controversy of antidepressants and suicidality in juvenile depressives in that they identify a vulnerable group. In line with earlier suggestions by the senior author [Akiskal, H.S., 1995. Developmental pathways to bipolarity: are juvenile-onset depressions pre-bipolar? J. Am. Acad. Child Adolesc. Psych. 34, 754–763], our data highlight the public health importance of the wider recognition of bipolar mixed states in juvenile patients masquerading as unipolar depression. Finally, it appears to us that it is the failure of our formal nosology on mixed states–rather than the antidepressants per se–which is the root problem in this controversy.

Keywords: Adolescents, Affective disorders, Bipolar disorder, Depression, Mania, Mixed states, Suicidality, Suicide