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Suicide

Suicidal Ideation in Bipolar Disorder

Passive and active suicidal thoughts in the bipolar brain.

Key points

  • Bipolar disorder has the highest rate of suicide among psychiatric conditions, and is about 20 times higher than that of the general population.
  • As many as half of those with bipolar disorder attempt suicide at least once, and approximately 15 to 20 percent of attempts are lethal.
  • Great strides have been made toward understanding the neurobiological mechanisms underlying suicidal thoughts and behaviors.
 Wikimedia Commons/public domain.
Vincent van Gogh: Self-portrait (1889). Van Gogh is thought to have suffered from bipolar disorder. He committed suicide in 1890.
Source: Wikimedia Commons/public domain.

Death is before me today

As a man longs to see his house

When he has spent years in captivity.

The Dispute with His Soul of One Who Is Tired of Life, 12th Dynasty of the Middle Kingdom in Egypt (circa 1937-1759 B.C.)

“Do you have thoughts of suicide?”

The words hung in the air as I sat hunched over in the examination room of the emergency mental health facility.

I had been in the same room almost exactly a year before. That time I was caught in the frenzy of a severe manic episode. I vacillated between answering the intake questions with responses that were either animated and earnestly introspective or agitated and belligerently guarded.

This time I was in the throes of the flip side of my bipolar disorder: an intractable depression. I had responded quickly to antipsychotic medications to control that manic episode. Unfortunately, the ensuing depression had been stubbornly resistant to the various drug regimens I had been prescribed. Not only was I no longer able to work, but I could barely get out of bed to go lay on the couch.

And I thought about suicide. A lot. Thoughts that I didn’t want to go on living. That I just wanted to escape the despair and intense anxiety that accompanied my depression. My brain felt utterly overwhelmed by every neural impulse, whether generated by the external world or memories sparked from within. The idea of being able to turn that off had some appeal.

But I knew that my psychiatrists and counselors over the years had all made a distinction between thinking about suicide in general terms and having a particularized desire to kill yourself.

“Yes, but no plans,” I said.

“No preparations or plans for how you’d do it?”

“No, nothing like that.”

“More like, ‘Wouldn’t it just be easier if I weren’t here?’”

“Yes,” I nodded. I’d been truthful but I couldn’t help feeling like I was hiding something. No, I didn’t have a plan, but thoughts about suicide had been consistent and frequent. I wasn’t going to jump off a building but if I suddenly found myself in the path of an oncoming car, I wasn’t sure I would get out of the way. That couldn’t be good.

But I didn’t volunteer this information and I wasn’t asked. I trusted that there was a reason why the trigger for concern was set at “having a plan” and answered accordingly.

Image by Лечение Наркомании from Pixabay.
Source: Image by Лечение Наркомании from Pixabay.

Suicide and Bipolar Disorder

Whensoever my affliction assails me, methinks I have the keys of my prison in mine own hand, and no remedy presents itself so soon to my heart, as mine own sword.

― John Donne, Biathanatos (1608)

More than any other psychiatric condition, bipolar disorder is associated with the highest rate of suicide, which is up to 20 times higher than that of the general population. As many as half of those with bipolar disorder attempt suicide at least once, with approximately 15 to 20 percent of suicide attempts being lethal.

In her book, Night Falls Fast: Understanding Suicide, renowned clinical psychologist Dr. Kay Redfield Jamison describes her experiences with suicidal thoughts and behaviors, both as a clinician and as someone with bipolar disorder who has attempted suicide and lost friends to suicide.

Image by Stormseeker on Unsplash.
Source: Image by Stormseeker on Unsplash.

Jamison recounts that when she was 28, she took a massive overdose of lithium after a prolonged depression set in after a psychotic manic episode. At the time she was a young faculty member in a department of academic psychiatry, so as she recovered, she dove into all the research she could find about the psychological and biological determinants of suicide.

Her book provides a fascinating and poignant natural history of suicide, including a discussion of the earliest known “suicide note” written by a depressed and possibly psychotic Egyptian 4,000 years ago, and of the landmark 1608 treatise on suicide Biathanatos by the dean of St Paul’s Cathedral, John Donne. Contrary to church teachings, Donne declared that suicide was certainly understandable and, on occasion, justified.

Ultimately, Jamison’s survey leads her to conclude:

Psychologists are deciphering the motivations for suicide and piecing together the circumstances that so dangerously ignite the brain's vulnerabilities. But I have become more impatient as a result of writing this book. I cannot rid my mind of the desolation, confusion and guilt I have seen in the relatives and friends of those who kill themselves. For every moment of exuberance in the science, or in the success of governments, there is a matching and terrible reality of the deaths themselves; the young deaths, the violent deaths, the unnecessary deaths.

That was just over 20 years ago. Since that time, researchers have made great strides toward understanding the neurobiological mechanisms underlying suicidal thoughts and behaviors.

Part Two of this blog post will discuss research on the connection between suicidal thoughts and behaviors and dysfunction in corticolimbic circuits, particularly functional differences in prefrontal cortical areas that may underlie the shift from suicidal ideation to action.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 contact the National Suicide Prevention Lifeline, 1-800-273-TALK, or the Crisis Text Line by texting TALK to 741741. To find a therapist near you, see the Psychology Today Therapy Directory.

References

Barredo, J., Bozzay, M. L., Primack, J. M. et al. (2021). Translating interventional neuroscience to suicide: It’s about time. Biological Psychiatry, 89(11):P1073-1083. https://doi.org/10.1016/j.biopsych.2021.01.013.

Jamison, K. R. (1999). Night falls fast: Understanding suicide. Alfred A. Knopf.

Jamison, K. R. (2000, November 10). ‘No remedy presents itself so soon to my heart as mine own sword.’ The Guardian. www.theguardian.com.

Schaffer, A., Isometsä, E. T., Tondo, L. et al. (2015). International Society for Bipolar Disorders Task Force on Suicide: Meta-analyses and meta-regression of correlates of suicide attempts and suicide deaths in bipolar disorder. Bipolar Disorders, 17(1):1–16. https://doi.org/10.1111/bdi.12271.

Schmaal, L., van Harmelen, A. L., Chatzi, V. et al. (2020). Imaging suicidal thoughts and behaviors: A comprehensive review of 2 decades of neuroimaging studies. Molecular Psychiatry, 25:408–427. https://doi.org/10.1038/s41380-019-0587-x.

Vieta, E., Berk, M., Schulze, T. et al. (2018). Bipolar disorders. Nature Reviews Disease Primers, 4:18008. https://doi.org/10.1038/nrdp.2018.8.

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