1. Caroline Clements Project lead, Professor Nav Kapur
Suicidal behaviour in bipolar disorder: Who is most at risk and how can mental health services provide better care?
Caroline Clements Project lead, Professor Nav Kapur
Slides in this talk present independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (RP-PG ). Further support was received from primary care trusts, mental health trusts, the Mental Health Research Network and Comprehensive Local Research Networks in North West England.
The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

2. Suicidal behaviour in bipolar disorder
Context
Characteristics and risk factors for suicide in bipolar disorder
Characteristics of self-harm in bipolar disorder
The experiences of people with suicidal behaviour in bipolar disorder

3. Suicidal and self-harm in the UK
6000
50%+ of those who die by suicide have a history of self-harm
Risk of suicide increased fold in the year after self-harm
men
mid-life

4. Suicide in bipolar disorder
How many people with bipolar disorder die by suicide?

5. Suicide in bipolar disorder
How many people with bipolar disorder die by suicide?
8% (men)
Nordentoft et al., 2011

6. Suicide in bipolar disorder
How many people with bipolar disorder die by suicide?
8% (men)
5% (women)
Nordentoft et al., 2011

7. Suicide in bipolar disorder
At least 5% of people with bipolar disorder die by suicide
Nordentoft et al., 2011; Baldessarini et al., 2012

8. Self-harm in bipolar disorder
Around 60% of people with bipolar disorder will self-harm at some point in their lifetime
Baldessarini et al., 2006; Simon et al., 2007

9. Self-harm in bipolar disorder
Around 60% of people with bipolar disorder will self-harm at some point in their lifetime
Tend to use more dangerous methods
Baldessarini et al., 2006; Simon et al., 2007

10. Previous studies on suicidal behaviour in bipolar disorder
Small samples
Single site
Hospitalised patients
Limited information
Real world impact?

11. Aim of the suicide and self-harm study
To understand
Frequency and characteristics
Risk factors
Key real world experiences
of people with bipolar disorder who died by suicide or harmed themselves

12. Suicidal behaviour in bipolar disorder
Context
Characteristics and risk factors for suicide in bipolar disorder
Characteristics of self-harm in bipolar disorder
The experiences of people with suicidal behaviour in bipolar disorder

13. Characteristics and risk factors for suicide in bipolar disorder
Reviewed the full suicide database of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness ( )

14. Characteristics of suicide in bipolar disorder
Key results
1489 suicide deaths on NCI database had primary diagnosis of bipolar disorder - 10% of all Inquiry deaths
Around 116 per year
No significant trends over time (while suicide fell in the general population)
Clements et al., 2013, Psychological Medicine

15. Characteristics of suicide in bipolar disorder
Variable
Bipolar disorder n=1489(%)
All other diagnoses
n=13976(%)
Duration of primary diagnosis
Over 5 years
1057 (71.4)
6766 (50.3)
Under drug/alcohol services*
39(5.9)
701 (11.9)
More than 5 admissions to in-patient care
469 (32.4)
1754 (13.3)
Last contact before death
<7 days
904 (61.2)
6577 (48.8)
Immediate suicide risk
none or low
1230 (86.1)
11004 (86.0)
Clements et al., 2013

16. Risk factors for suicide in bipolar disorder
Inquiry case-control study of current and recent in-patients
63 people with BPD who died by suicide vs 63 people with BPD who had not died

17. Risk factors for suicide in bipolar disorder
Live alone
Depression
Previous self-harm
Suicide
Life events
Alcohol misuse

18. Suicidal behaviour in bipolar disorder
Context
Characteristics and risk factors for suicide in bipolar disorder
Characteristics of self-harm in bipolar disorder
The experiences of people with suicidal behaviour in bipolar disorder

19. Characteristics of self-harm in bipolar disorder
Reviewed the self-harm database of the Manchester Self-Harm Project

20. Characteristics of self-harm in bipolar disorder
Nested case-control analyses within MaSH database
vs. Outcome = repeat self-harm
103 bipolar disorder
515 date matched controls

21. Characteristics of self-harm in bipolar disorder
Results
Clements et al., 2015, Journal of Affective Disorders

22. Characteristics of self-harm in bipolar disorder
Results
Hazard ratio >3
4% of cases with bipolar disorder died by suicide
1% of general self-harm cases died by suicide
Clements et al., 2015

23. Suicidal behaviour in bipolar disorder
Context
Characteristics and risk factors for suicide in bipolar disorder
Characteristics of self-harm in bipolar disorder
The experiences of people with suicidal behaviour in bipolar disorder

24. The experiences of people with suicidal behaviour in bipolar disorder
22 in-depth interviews with 2 target populations
Relatives or carers of people with bipolar disorder who died by suicide (n=11)
People with bipolar disorder who had self- harmed (n=11)

25. The experiences of people with suicidal behaviour in bipolar disorder
Are seen by services within 7 days of suicide
60%
80%
Report being in contact with services when they self-harm

26. The ‘merry-go-round’ of access to mental health care for suicidal behaviour in bipolar disorder

27. Undiagnosed bipolar disorder
The ‘merry-go-round’ of access to mental health care for suicidal behaviour in bipolar disorder
Help-seeking
Navigating the system
Gate-keepers
Undiagnosed bipolar disorder
Screaming for help
Access to care

28. Undiagnosed bipolar disorder
The ‘merry-go-round’ of access to mental health care for suicidal behaviour in bipolar disorder
Help-seeking
“Because I know where I am and what’s going on and I can express what I think’s going on in my head, they don’t realise that I’m ill… as ill as I am. I get to a critical desperate point where I have to scream for help.”[2s]
“We didn’t realise that we had a pass, if you like, back into the mental health system, so we went back to the GP” [6]
Navigating the system
Gate-keepers
Undiagnosed bipolar disorder
Screaming for help
Access to care
“Just like a merry-go-round.” [1s]

29. Routes and roadblocks in communication about suicidal behaviour in bipolar disorder

30. Routes and roadblocks in communication about suicidal behaviour in bipolar disorder
Patient
MHS
Carer
Hidden suicidal intent
Conflict with MHS
Denial of problem
Concern for privacy
Burden on family/carer
Conflict with family
Denial of problem
Poor relationship with family
Collaboration
Evaluating quality of care
Shut out via patient confidentiality
Conflict with MHS to be involved

31. Routes and roadblocks in communication about suicidal behaviour in bipolar disorder
“She had attempted it maybe about four times, but she didn’t want us to know, she didn’t want to worry us.” [7]
Patient
MHS
Carer
Hidden suicidal intent
Conflict with MHS
Denial of problem
Concern for privacy
Burden on family/carer
Collaboration
Evaluating quality of care
Shut out via patient confidentiality
Conflict with MHS to be involved

32. Routes and roadblocks in communication about suicidal behaviour in bipolar disorder
“He certainly, sort of, was able to give the, the consultant the impression that, you know, ‘I’m alright’”[4]
Patient
MHS
Carer
Burden on family/carer
Conflict with family
Denial of problem
Poor relationship with family
Hidden suicidal intent
Collaboration
Evaluating quality of care
Shut out via patient confidentiality
Conflict with MHS to be involved

33. Evaluating quality of care Conflict with MHS to be involved
Routes and roadblocks in communication about suicidal behaviour in bipolar disorder
Patient
MHS
Carer
Burden on family/carer
Conflict with family
Denial of problem
Poor relationship with family
Hidden suicidal intent
Conflict with MHS
Denial of problem
Concern for privacy
Collaboration
You just got told on many, many occasions that, you know, it’s patient confidentiality. But, when your dealing with somebody who’s suffering from mental health [problems], and if I turn round and said to them, I said ‘if my son had cancer you would have involved me, to care for him quite well at home’” [4]
Evaluating quality of care
Conflict with MHS to be involved

34. Suicide and self-harm in bipolar disorder
Implications
Clinicians should be aware of the suicide risk in those with BPD
Some risks are shared
Some risks may be unique
Improvements in services response to suicidal behaviour in bipolar disorder

35. Many thanks to:
All participants who gave their time and shared their stories
The National Confidential Inquiry into Suicide
The Manchester Self-Harm project
Bipolar UK and affiliated support groups