Psychological Medicine

Original Articles

Do risk factors for suicidal behavior differ by affective disorder polarity?

J. G. Fiedorowicza1 c1, A. C. Leona2, M. B. Kellera3, D. A. Solomona3, J. P. Ricea4 and W. H. Coryella1

a1 Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA

a2 Department of Psychiatry, Weill Medical College of Cornell University, New York, NY, USA

a3 Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI, USA

a4 Department of Psychiatry, Washington University School of Medicine, St Louis, MO, USA


Background Suicide is a leading cause of death and has been strongly associated with affective disorders. The influence of affective disorder polarity on subsequent suicide attempts or completions and any differential effect of suicide risk factors by polarity were assessed in a prospective cohort.

Method Participants with major affective disorders in the National Institute of Mental Health (NIMH) Collaborative Depression Study (CDS) were followed prospectively for up to 25 years. A total of 909 participants meeting prospective diagnostic criteria for major depressive and bipolar disorders were followed through 4204 mood cycles. Suicidal behavior was defined as suicide attempts or completions. Mixed-effects, grouped-time survival analysis assessed risk of suicidal behavior and differential effects of risk factors for suicidal behavior by polarity. In addition to polarity, the main effects of age, gender, hopelessness, married status, prior suicide attempts and active substance abuse were modeled, with mood cycle as the unit of analysis.

Results After controlling for age of onset, there were no differences in prior suicide attempts by polarity although bipolar participants had more prior severe attempts. During follow-up, 40 cycles ended in suicide and 384 cycles contained at least one suicide attempt. Age, hopelessness and active substance abuse but not polarity predicted suicidal behavior. The effects of risk factors did not differ by polarity.

Conclusions Bipolarity does not independently influence risk of suicidal behavior or alter the influence of well-established suicide risk factors within affective disorders. Suicide risk assessment strategies may continue to appraise these common risk factors without regard to mood polarity.

(Received July 02 2007)

(Revised June 19 2008)

(Accepted June 21 2008)

(Online publication July 30 2008)


c1 Address for correspondence: J. G. Fiedorowicz, M.D., M.S., 200 Hawkins Drive W278 GH, Iowa City, IA 52242, USA. (Email: