Bipolar disorder is a psychiatric disorder involving mood episodes that alternate between euphoric highs (mania or hypomania) and deep lows (depression). It’s also associated with a higher rate of
suicidal thoughts and behaviors than people without the condition, research shows.
People with bipolar disorder have a
suicide rate that’s 20 to 30 times higher than the general population, according to research. About 15 to 20 percent of people with bipolar disorder die by suicide, and about one-third to one-half attempt suicide at least once in their lives.
Here, find out what the risk factors are, the warning signs to look for, and how to reduce your risk and get help when you have bipolar disorder.
“The elevated risk of suicidal thoughts is primarily associated with the depressive phase of the disorder,” says Caroline Fenkel, LCSW, a doctor of social work and the cofounder and chief clinical officer at Charlie Health, a mental health care practice in Malvern, Pennsylvania.
“During depressive episodes, individuals may experience intense sadness, hopelessness, and a loss of interest in activities they once enjoyed,” Dr. Fenkel says. “These symptoms, coupled with the potential impairment of functioning and disrupted sleep patterns, can contribute to an increased risk of suicidal thoughts.”
Other potential symptoms of depressive episodes include:
- Appetite changes, resulting in unintentional weight loss or gain
- Fatigue or lack of energy
- Slowed movements or restlessness
- Difficulty concentrating or making decisions
The risk of suicide during
mania, hypomania (a less severe form of mania), or neutral moods is much lower, according to research.
Importantly, most deaths by suicide happen among people whose bipolar disorder is untreated. The longer bipolar disorder goes untreated, the higher the risk for suicide, according to one research review.
- Prior suicide attempts or thoughts (especially if they involve violent or highly effective methods)
- Family history of attempted or completed suicide
- Family history of mood disorders
- Recent discharge from inpatient psychiatric treatment
- Previous hospitalizations
- Earlier age of bipolar disorder onset (when it started)
- Earlier stage of illness
- Co-occurring mental or physical health conditions or substance use disorders
- Rapid cycling mood episodes (meaning extreme mood changes happen more frequently)
- Number of previous depressive episodes
- Bipolar disorder with predominantly depressive episodes
- Bipolar with psychotic symptoms that don’t match the mood state (mood-incongruent)
- Stressors related to the mental, emotional, social, and spiritual effects of bipolar disorder
- Male sex (for completed suicide; females have higher risk of attempted suicide)
- Being unmarried, divorced, or widowed
- Not having children
- Living alone
- Age below 35 or over 75
- Caucasian
- Unemployment
- Prior abuse, trauma
- Permanent adverse life situations
- Impulsive or aggressive behavior
- Living at higher altitudes
- Lack of social support
“The warning signs of suicidal ideation are pretty similar for individuals with
bipolar disorder compared with the general population,” says Fenkel. Common warning signs that someone is having suicidal thoughts include:
- Talking about wanting to die
- Saying they feel guilty or like a burden to others
- Feeling trapped, hopeless, empty, or that there’s no reason to live
- Feeling agitated, anxious, or filled with rage
- Feeling extreme sadness and emotional or physical pain
- Withdrawing from family and friends
- Saying goodbye to loved ones or drafting a will with seemingly no logical reason for doing so
- Having intense mood swings
- Increasing their drug or alcohol use
- Engaging in dangerous behaviors like unsafe driving
- Sleeping or eating more or less than usual
- Researching ways to die or making a plan
One warning sign that’s more specific to some people with bipolar disorder, including some who experience rapid cycling: “Sudden shifts from depressive symptoms to extreme euphoria or agitation could be indicative of heightened suicide risk in individuals with bipolar disorder,” Fenkel says.
Another potential sign is a shift from extreme agitation to sudden calm. “While this change may seem like an improvement in their mood, it can signify a sense of ‘peace’ resulting from having a plan to end their life,” Fenkel says.
Recognizing suicidal thoughts in yourself or a loved one can be scary.
But, not everyone with bipolar disorder is affected by these symptoms. And there are things that you can do to help decrease the risk of acting on these thoughts and even the frequency of suicidal thoughts if you experience them, experts say.
1. Stick to Your Bipolar Disorder Treatment
As mentioned earlier, many people with bipolar disorder who die by suicide are not following a treatment plan for the condition. “Professional treatment is a huge aspect of managing the risk of suicide, and can help monitor symptoms and provide necessary support,” says Fenkel.
The most common
treatments for bipolar disorder include:
- Medication Medicines like mood stabilizers or antipsychotics, for instance, can help reduce your bipolar symptoms and balance your moods, both acutely and in the long term.
- Psychotherapy Attending psychotherapy (also known as "talk therapy") with a licensed mental health professional can help you learn to manage triggers and difficult emotions, and practice strategies for managing your bipolar symptoms.
- Hospitalization If you’re behaving dangerously, feeling imminently suicidal, or develop psychosis (meaning you become detached from reality and have hallucinations or delusions), you may need to receive psychiatric treatment in a hospital. Doing so can help stabilize your mood and keep you calm.
- Intensive Outpatient or Partial Hospitalization Programs These offer several hours of treatment daily for a period of several weeks, either to prevent hospitalization or to support you after discharge.
- Treatment for Substance Misuse Without treating substance use issues, it can be hard to manage bipolar disorder.
- Support Groups Support groups for people with bipolar disorder can help you connect with and find support from others going through similar challenges in their lives.
One medication with well-documented effects on suicide risk is lithium, according to research. Lithium, a mood stabilizer, has been shown reduce the risk of death by suicide by 60 to 80 percent among people with bipolar disorder who use it long-term. But not taking medication as prescribed increases the risk of suicide.
Other
medications have also been shown to prevent suicide, though they don’t reduce the risk as dramatically as lithium. These include valproate (Depakote, Depakote ER), lamotrigine (Lamictal, Lamictal XR), and carbamazepine (Tegretol, Carbatrol, Equetro).
If you’ve been prescribed lithium or other medications for bipolar disorder, it’s important to take them consistently, even when you’re feeling well. Doing so is vital for keeping your moods stable and, in turn, lowering your risk of suicide.
Never make changes to your treatment plan without talking to your doctor, or suddenly stop taking your medication. “Going off of medication completely can increase the risk for destabilization and contribute to worsening psychiatric symptoms,” says Justin Kei, MD, a psychiatrist and the medical director of the Debra Simon Center for Integrative Behavioral Health and Wellness at Hackensack Meridian Health in Maywood, New Jersey.
2. Limit Access to Tools That Can Be Used for Suicide
Among people who die by suicide, the method that a person uses to end their life is often something they can easily access, according to research. And in countries where access to tools and sites commonly used for suicide is restricted, suicide rates have declined, according to other research.
Restricting access to tools that a person might use to end their life, such as firearms, can play a big role in keeping them safe. “Removing access to weapons has been shown to help reduce suicide risk,” says Dr. Kei.
3. Create a Safety Plan With Your Therapist or Loved Ones
A safety plan is a tool that can help someone with suicidal thoughts and their loved ones protect them in the event of a suicidal crisis. “Developing a safety plan can also help to alleviate some of the risk,” says Fenkel. “This involves identifying triggers, warning signs, and coping strategies to manage suicidal thoughts.”
A good safety plan should include steps that the person decides in advance that they or a loved one will take if they feel suicidal, such as going to an emergency room or knowing what number they’ll call in case of an emergency.
You can create a safety plan with loved ones you trust if you feel comfortable doing so or with your therapist or psychiatric provider, using templates like the one provided by Samaritans, a suicide prevention organization in the United Kingdom.
“Knowing when and how to seek help during a crisis is crucial,” says Fenkel. “Loved ones should be familiar with emergency hotlines, local mental health resources, and have a plan in place for accessing immediate professional assistance when needed.”
If you feel that you or a loved one are in immediate danger of suicide, call 911. You can also reach the
988 Suicide & Crisis Lifeline at any time by calling or texting 988, or the
Crisis Text Line by texting HOME to 741741, for a confidential conversation with a trained crisis counselor. In addition, you could contact your or your loved one’s doctor for help, though this is not the best option when you need to speak with someone immediately.
If possible, don’t leave a loved one alone if you worry they’re at risk of suicide. If you’re not able to stay, ensure another family member or friend can stay with them until they’re under the care of a medical professional.
If you or a loved one is considering suicide, dial 988 to reach the Suicide and Crisis Lifeline, which is available 24 hours a day, seven days a week.
Rachel Green
Rachel Davis
Derek Schulz
Sophia Martinez
Dr. Amara Okafor