Bipolar disorder may be the deadliest of all mental illnesses because of the extreme suicide rate among people living with the condition. To prevent bipolar-related suicides, it’s imperative to grasp the inherent difficulties in diagnosing it and appreciate the daily struggles of people with bipolar.
I believe understanding the bipolar-suicide connection is of primary importance for both professionals and non-professionals alike. In this post, I’ll highlight why bipolar is so lethal, and what we can do to prevent such needless loss of life.
Let’s begin with some disturbing facts about bipolar and suicide. First, bipolar disorder is at least 20 times higher in prevalence compared to the general population (Berk, Scott, Macmillan, Callaly and Christensen, 2013). Additionally, there is a 20% lifetime risk of suicide in people with bipolar, and that risk increases with age, especially if the person goes untreated for the disorder. And if these statistics aren’t striking enough, this one is particularly jarring: According to the DSM-5, one-fourth of all deaths by suicide may be related to bipolar disorder (APA, 2013). Based on data from Drapeau and McIntosh (2018), that’s nearly 12,000 lives lost every year in the US alone!
I believe there are several reasons why suicide is so prevalent in people with bipolar, but what is more important is that suicide is definitely preventable during the course of bipolar symptom development. So let’s begin to examine the very issues that many people with bipolar disorder face and what we can do about to improve their chances for success.
The 10-Year Gap in Treatment
When I first meet with a therapy patient who has either been diagnosed with bipolar disorder for a while or one who is newly diagnosed, it appears typical that he or she has gone through tremendous suffering as the result of misdiagnosis and incorrect treatment applications. I’m constantly reminded of the Drancourt et. al (2012) study, which showed that, on mean average, patients will have waited nearly 10 years from their first bipolar mood episode to the time they receive a mood-stabilizing treatment specifically for bipolar disorder.
Another study worth remembering revealed that about two-thirds of bipolar patients are misdiagnosed and treated as having other psychiatric disorders (mostly major depression), while those patients had consulted a mean average of nearly 4 clinicians before receiving appropriate care (Hirschfeld, Lewis, & Vornik, 2003). Because of this 10-year gap in treatment, we have a whole population of underlying bipolar disorder presenting as relational dysfunction, substance abuse, unipolar depression, attention deficits, self-harm, personality disorders, domestic violence, workplace conflicts and many other common presentations to outpatient therapy.
In addition to witnessing this unsettling reality in my therapy patients, I began writing about the 10-year treatment gap for my book and for the Bipolar Network. The responses I received from people all over the world solidified in my mind how tragically accurate this is. In fact, just from the correspondence I obtained, 10 years was less the average and more the minimum for people compelled to write about their bipolar experiences. The sheer breadth of time feeling ignored, lost, and desperate illuminates how easily people with bipolar are overcome with suicidal impulses. And how many of them will never be able to tell their stories.
Thus, confronting the 10-year gap begins with the mental health profession. It may come as a shock to some but despite the prevalence of bipolar disorder, which is up to 5% of the population (Ketter, 2010), many clinicians lack the appropriate diagnostic skills to uncover bipolar accurately.
This probably relates to how the drug lithium was introduced to North America in the 1970s. Lithium was so revolutionary in how it stabilized the bipolar mood swings of mania and depression, that many psychiatrists, including the most ardent defenders of psychoanalysis, came to believe that all you had to do was get people with bipolar on the medication. The one-hour therapy session would be forever replaced by the 15-minute med check…or so the thinking went.
I believe that this mentality actually hamstrung a whole generation or two of upcoming therapists who didn’t receive adequate clinical training for the accurate diagnosis and comprehensive treatment of bipolar disorder. Thankfully, this mindset appears to be changing. In the clinical trainings I offer, I see an increasing number of highly interested and motivated professionals who recognize how unidentified bipolar disorder can result in other complicated mental health conditions.
One important factor is the need to delve deeply into an individual’s mental health history. Often, people present with depression, substance abuse, and other presentations that don’t include evidence of mania upfront. Certainly, a bipolar-related depressive episode is often profound and requires immediate attention, since the risk for suicide would be particularly elevated. However, further inquiry into possible manic involvement could suggest that there’s more diagnostically than meets the eye.
Another important factor is a family's mental health history, if available. Bipolar disorder is predominantly genetic in its etiology, so bipolar or any serious mental illness in the immediate or extended family tree can offer big clues to what may have been missing in the person’s psychological patterns.
While sometimes a history of manic symptoms is not presented right away, it’s also common for those symptoms to be confused with other mental health conditions, such as ADHD or OCD. One typical variable that helps clinicians distinguish bipolar mania from anything else is the intermittent nature of bipolar mood swings. That is to say, bipolar mania and depression usually come and go in episodes; therefore, there are referred to as “episodic.”
Other conditions can have symptoms that wane a bit from time to time, but they are not as drastic and variable as in bipolar disorder. Thus, these other disorders are thought of as more “pervasive,” since they pervade the person’s daily life, especially if untreated. Knowing the important differences among these mental disorders helps reduce the time it takes for people with bipolar get to the right treatment plan.
And if they don’t, one of the frequent consequences involves obtaining the wrong medication. Specifically, they often receive antidepressant medication to treat major depression, anxiety, OCD, or other clinical problems, but certain antidepressants alone can induce mania in people with the genetic foundations of bipolar. I believe this error often accounts for how people with bipolar not only wait longer in their lives for the right care, but also how their condition worsens to the point of suicide.
We already saw how treatment for major depression can go forward without uncovering any previous episodes of mania, but mania itself can be perplexing and not always recognizable when active.
This is due in part to how manic episodes can present in different dimensions. We usually think of mania as marked by euphoria with wonderful feelings of grandiosity. But mania can also be dysphoric, in which the person is highly irritable and agitated. If dysphoric mania is confused for major depression, then antidepressant medication will not only make the condition worse, it may also feel like the patient will need greater doses or additional antidepressants. The potential result is a deepening bipolar crisis that can persist for a very long time.
So if you’ve heard that antidepressants can cause suicidal thoughts, you may want to consider that this sometimes is the result of an underlying bipolar condition that’s been aggravated by improper treatment.
Anyone who has dealt with addictions understands how denial can drive individuals and families away from treatment, and therefore make the condition worse over time. Denial works similarly in bipolar disorder. In fact, I believe denial is an expected part of the pre-stabilization phase of bipolar therapy and a necessary factor to be treated therapeutically.
The approach doesn’t view denial as people simply acting resistant or oppositional. Instead, it is seen as a coping mechanism that says they are not ready to collaborate fully with treatment due to any number of reasons. People who are in denial about bipolar disorder typically have underlying fears about the diagnosis and how treatment might change them. They may certainly fear what they don’t yet understand simply out of ignorance about the disorder. But in particular, people struggling with bipolar don’t want to give up the amazing feelings and sense of creativity that accompanies mania. And family members can fear the “label” of bipolar disorder, or that it will become an excuse for impulsive behaviors pushed by mania.
Treating denial in patients and family requires listening and anticipating any variety of fears, whether they can be deemed reasonable or not. Below are examples of how I may treat denial taken from my book, Owning Bipolar: How Patients and Families Can Take Control of Bipolar Disorder (Citadel Press, 2018). The first one reflects a common desire to admit depression but still cling to mania along the way.
Patient 1: I only get depressed at times. When I’m not depressed, things are really good.
[This tells me the patient doesn’t see mania as bad, only depression. Mania still is perceived as a defense against depression. I may just focus on depression prevention as an opening to discuss mania’s role in the overall disease.]
Me: Your history tells me your brain’s response to depression can go to extremes. It probably does feel good to get as far away from depression as possible, and it’s scary to think you could go back to depression. Let’s talk about better ways to keep you away from depression, without the fear of returning to that dark place (p. 48-49).
The next one shows how a spouse can try to wipe away a husband’s bipolar condition.
Spouse: I don’t believe in bipolar disorder. It’s just an excuse for my husband’s bad behavior.
[Spouses often feel hurt by the consequences of the disorder. Even when treatment starts, they still worry their own pain won’t be addressed.]
Me: Bipolar disorder is never an excuse for bad behavior. It’s an explanation of what’s been going on. With that explanation, your husband can begin taking ownership of that behavior, and we can talk honestly about how it’s affected you (p. 50).
There are, of course, other examples of denial, each one potentially contributing to the 10-year gap in treatment. But while there is certainly urgency to move forward on proper bipolar care, it’s important to uncover as many fears as possible to assist in building trust in the treatment specialist and confidence in the overall treatment process. Because bipolar disorder is a genetically-based neurological disorder, no one is to blame for bipolar in their lives. But it’s necessary for professionals, family members, and society at large to support individuals suffering from mood swings, especially to help them move from bipolar denial to bipolar acceptance.
Stigma and Shame
And speaking of society, how people with any mental illness have been treated by others has an enduring effect on both patients and families. The long and often ugly history of stigma around mental illness and against pursuing mental health treatments permeates in the minds of people with bipolar and their loved ones. And with it, a persistent feeling of shame that forces many to bury the truth of bipolar in their lives.
I have come to believe that the greatest problem with stigma is the avoidance of treatment, and alongside the problem, a real, insidious threat of suicide. We as an informed and compassionate society makes a difference in the lives of people with bipolar, especially when we are empowered to discuss bipolar disorder’s role in suicide potential. This includes the need for us to speak candidly to treatment providers.
Several years ago, a mother came to me worried about her son’s aggression towards her, in what appeared to be episodes of dysphoric mania. She said that a previous doctor feared “labeling” her child with a bipolar diagnosis and likewise would not prescribe the appropriate medication.
When I first saw her son, he was suffering greatly—irritable, impulsive, and unable to foresee to consequences of his actions. During our initial therapy work together, a new physician prescribed a mood-stabilizing medication, and we worked together through the son’s fears about how medication might affect him personally. After a few days of treatment, he was better prepared to discuss the aggression he felt against himself in the form of suicidal ideation. The right treatment gave him the best chance to save his life and avoid becoming another bipolar-related suicide statistic.
With thousands of lives lost every year to bipolar-related suicide, it’s vital for all of us to increase our collective sense of awareness of the prevalence of bipolar disorder among us, and close the 10-year gap in treatment. From better diagnostics to reducing stigma, people with bipolar disorder can be more empowered to seek proper treatment and find greater purpose to thrive.
American Psychiatric Association, (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington VA: American Psychiatric Publishing.
Berk, M., Scott, J., Macmillan, I., Callaly, T. & Christensen, H.M. (2013). The need for specialist services for serious and recurrent mood disorders. Australian & New Zealand Journal of Psychiatry, 47 (9), 815-818.
Drancourt, N., Etain, B., Lajnef, M., Henry, C., Raust, A., Cochet. B., et al. (2012). Duration of untreated bipolar disorder: Missed opportunities on the long road to optimal treatment. Acta Psychiatrica Scandinavica, 127(2), 136-144.
Drapeau, C. W., & McIntosh, J. L. (for the American Association of Suicidology) (2018). U.S.A. suicide 2017: Official final data. Washington, DC: American Association of Suicidology. Retrieved from http:// www.suicidology.org
Hirschfeld R.M., Lewis, L., Vornik, L.A. (2003). Perceptions and impact of bipolar disorder: How far have we really come? Results of the National Depressive and Manic-Depressive Association 200 survey of individuals with bipolar disorder. Journal of Clinical Psychiatry, 64(2). 161-174.
Ketter, T.A. (2010). Diagnostic features, prevalence, and impact of bipolar disorder. Journal of Clinical Psychiatry, 71. e14.
Pipich, M.G. (2018). Owning Bipolar: How Patients and Families Can Take Control of Bipolar Disorder. New York NY: Citadel Press. 48-50.