Suicide and suicide prevention in patients with bipolar disorders

Author/s
Zoltan Rihmer
Citation
Issue 3 Summer 2013
CEPiP.2013;1:31-42
Abstract

Bipolar disorders are quite prevalent but frequently underdiagnosed and undertreated. The early recognition and appropriate treatment is particularly important, since out of all psychiatric illnesses, (untreated) bipolar disorders carry the highest risk of both attempted and completed suicide. Studies show that suicidal behaviour in patients with bipolar disorders is state and severity dependent; that means that suicidality markedly decreases or vanishes after clinical recovery. However, since the majority of mood disorder patients never commit suicide and more than half of them never attempt suicide, special clinical characteristics of the disorder as well as some familial and psychosocial factors should also play a contributory role. Considering the clinically explorable suicide risk factors in patients with bipolar disorders (family and/or personal history of suicidal behaviour, early onset, severe depressive episode/hopelessness, agitated/mixed depression, bipolar II diagnosis, rapid cycling, comorbid Axis I and Axis II disorders, adverse life situations, lack of social and medical support, cyclothymic temperament, impulsive aggressive personality features, etc.), there is a good chance that suicidal behaviour is predictable. There is also much evidence that (successful) acute and long-term pharmacotherapy of bipolar patients reduces the risk of attempted and completed suicide by more than 80 percent, even in this high-risk population. Recent studies also show that supplementary psychosocial interventions (psychoeducation, and targeted psychotherapies) further improve the results.

Keywords: bipolar disorders, suicidal behaviour, suicide prevention, antidepressants, mood stabilizers, suicide risk factors, psychosocial interventions.

Cite as: Cutting Edge Psychiatry in Practice 2013, 3(1):31-42; https://doi.org/10.65031/ezar1673

References

  1. Hawton K, van Heeringen K. Suicide. Lancet 2009; 373:1372-81. https://doi.org/10.31234/osf.io/c49nz
  2. Akiskal HS. Targeting suicide prevention to modifiable risk factors: Has bipolar II been overlooked? (Editorial). Acta Psychiatrica Scandinavica 2007; 116: 395-402. https://doi.org/10.1111/j.1600-0447.2007.01115.x
  3. Rihmer Z. Prediction and prevention of suicide in bipolar disorders. Clin Neuropsychiatry 2005; 2: 48-54.           
  4. Rihmer Z. Suicide risk in mood disorders. Current Opinion in Psychiatry 2007; 20: 17-22. https://doi.org/10.1097/yco.0b013e3280106868
  5. Cheng ATA, Chen THH, Chen CC, Jenkies R. Psychological and psychiatric risk factors for suicide. Case-control psychological autopsy study. British Journal of Psychiatry 2000; 177: 360-365. https://doi.org/10.1192/bjp.177.4.360
  6. Goodwin FK, Jamison KR. Manic-Depressive Illness. Oxford University Press, New York; 1990.            
  7. Rihmer Z, Belső N, Kiss K. Strategies for suicide prevention. Current Opinion in Psychiatry 2002; 15: 83-87. https://doi.org/10.1097/00001504-200201000-00014
  8. Pompili M, Rihmer Z, Innamorati M, Lester D, Girardi P, Tatarelli R. Assessment and treatment of suicide risk in bipolar disorders. Expert Rev Neurother 2009;9: 109-136. https://doi.org/10.1586/14737175.9.1.109
  9. Guze SB, Robins E. Suicide and primary affective disorders. British Journal of Psychiatry 1970;117: 437-438. https://doi.org/10.1192/bjp.117.539.437
  10. Harris EC, Barraclough B. Suicide as an outcome for mental disorders. British Journal of Psychiatry 1997;170: 205-228.       
  11. Akiskal HS, Maser JD, Zeller PJ, Endicott J, Coryell W, Keller M. Switching form “unipolar” to bipolar II: n 11-year prospective study of clinical and temperamental predictors in 559 patients. Archives of General Psychiatry 1995;52: 114-123. https://doi.org/10.1001/archpsyc.1995.03950140032004
  12. Akiskal HS, Benazzi F, Perugi G, Rihmer Z. Agitated “unipolar” depression re-conceptualized as a depressive mixed state: Implications for the antidepressant-suicide controversy. Journal of Affective Disorders 2005;85: 245-258. https://doi.org/10.1016/j.jad.2004.12.004
  13. Goldberg JF., Harrow M., Whiteside JE. Risk for bipolar illness in patients initially hospitalized for unipolar depression. American Journal of Psychiatry 2001;158: 1265-1270. https://doi.org/10.1176/appi.ajp.158.8.1265
  14. Akiskal HS, Hantouche F-G, Allilare J-F, Sechter D, Bourgeois ML, Azorin J-M, Chatenet-Duchene L, Lancrenon S. Validating antidepressant-associated hypomania (bipolar III): a systematic comparison with spontaneous hypomania (bipolar II). Journal of Affective Disorders 2003;50: 143-151. https://doi.org/10.1016/s0165-0327(02)00325-7
  15. Benazzi F, Akiskal HS. Refining the evaluation of bipolar II: Beyond the SCID-IV guidelines for hypomania. Journal of Affective Disorders 2003a;73: 33-38. https://doi.org/10.1016/s0165-0327(02)00327-0
  16. Ghaemi SN, Boima EE, Goodwin FK. Diagnosing bipolar disorder and the effect of antidepressants: A naturalistic study. Journal of Clinical Psychiatry 2000;61: 804-808. https://doi.org/10.4088/jcp.v61n1013
  17. Sani G, Tondo L, Koukopoulos A, Reginaldi D, Kotzalidis GD, Koukopoulos AE, et al. Suicide in a large population of former psychiatric inpatients. Psychiatry Clin Neurosci. 2011; 65:286-95. https://doi.org/10.1111/j.1440-1819.2011.02205.x
  18. Schaffer A, Cairney J, Veldhuizen S, Kurdyak P, Cheung A, Levitt A. A population-based analysis of distinguishers of bipolar disorder from major depressive disorder. J Affect Disord 2011;125: 103-110. https://doi.org/10.1016/j.jad.2010.02.118
  19. Dunner DL, Gershon ES, Goodwin FK. Heritable factors in the severity of affective illness. Biological Psychiatry 1976;11: 31-42.            
  20. Akiskal HS. Classification, diagnosis and boundaries of bipolar disorders: A review. In Bipolar disorder. Maj M, Akiskal HS, Lopez-Ibor JJ, Sartorius N (eds), John Wiley and Sons, Chichester, pp. 1-52; 2002 https://doi.org/10.1192/bjp.183.3.268
  21. Tondo L, Baldessarini RJ, Hennen J, Minnai GP, Salis P, Scamonatti L, Masisa M, Ghiani C, Mannu P. Suicide attempts in major affective disorder patients with comorbid substance use disorders. Journal of Clinical Psychiatry 1999;60 (Suppl. 2): 63-69. https://doi.org/10.1017/s1461145705005948
  22. Tondo L, Lepri B, Baldessarini R. Suicidal risk among 2826 Sardinian major affective disorder patients. Acta Psychiat Scand, 2007;116: 419-28. https://doi.org/10.1111/j.1600-0447.2007.01066.x
  23. Dennehey EB, Marangell LB, Allen MH, Chessick C, Wisniewski SR, Thase ME. Suicide and suicide attempts in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BP). J Affect Disord 2011;133: 423-427. https://doi.org/10.1016/j.jad.2011.04.036
  24. Rihmer Z, Barsi J, Arató M, Demeter E. Suicide in subtypes of primary major depression. Journal of Affective Disorders 1990;18: 221-225. https://doi.org/10.1016/0165-0327(90)90039-b
  25. Rihmer Z, Rutz W, Pihlgren H. Depression and suicide on Gotland. An intensive study of all suicides before and after a depression-training programme for general practitioners. Journal of Affective Disorders 1995;35: 147-152. https://doi.org/10.1016/0165-0327(95)00055-0
  26. Angst J. The emerging epidemiology of hypomania and bipolar II disorder. Journal of Affective Disorders 1998;50: 143-151. https://doi.org/10.1016/s0165-0327(98)00142-6
  27. Szádóczky E, Papp Zs, Vitrai J, Rihmer Z, Füredi J. The prevalence of major depressive and bipolar disorders in Hungary. Journal of Affective Disorders 1998;50: 153-162. https://doi.org/10.1016/s0165-0327(98)00056-1
  28. Angst J, Cui L, Swendsen J, Rothen S, Cravchik A, Kessler RC, Merikangas KR. Major depressive disorder with subthreshold bipolarity in the National Comorbidity Survey Replication. Amer J Psychiatry 2010;167: 1194-1201. https://doi.org/10.1176/appi.ajp.2010.09071011
  29. Judd LL, Akiskal HS. The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases. Journal of Affective Disorders 2003; 73: 123-131. https://doi.org/10.1016/s0165-0327(02)00332-4
  30. Chen YW, Dilsaver SC. Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other axis I disorders. Biological Psychiatry 1996;3: 896-899. https://doi.org/10.1016/0006-3223(95)00295-2
  31. Zimmermann P, Bruckl T, Nocon A, Pfister H, Lieb R, Wittchen HU, et al. Heterogeneity of DSM-IV major depressive disorder as a consequence of subthreshold bipolarity. Archives of general psychiatry. 2009; 66:1341-52. https://doi.org/10.1001/archgenpsychiatry.2009.158
  32. Valtonen H, Suominen K, Mantere O, Leppamaki S, Arvilommi P, Isometsa ET. Suicidal ideation and attempts in bipolar I and II disorders. J Clin Psychiatry. 2005; 66:1456-62. https://doi.org/10.4088/jcp.v66n1116
  33. Baek JH, Park DY, Kim JS, Choi JS, Ha K, Kwon JS, Lee D, Hong KS. (2011) Differences between bipolar I and bipolar II disorders in clinical features, comorbidity and family history. J Affect Disord, 131: 59-67. https://doi.org/10.1016/j.jad.2010.11.020
  34. Balázs J, Lecrubier Y, Csiszér N, Koszták J, Bitter I (2003) Prevalence and comorbidity of affective disorders in persons making suicide attempts in Hungary: importance of the first depressive episodes and of bipolar II diagnoses. Journal of Affective Disorders, 76, 113-119. https://doi.org/10.1016/s0165-0327(02)00084-8
  35. Raja M, Azzoni A (2004) Suicide attempts: Differences between unipolar and bipolar patients and among groups with different lethality risk. J Affect Disord, 82: 437-442. https://doi.org/10.1016/j.jad.2004.02.001
  36. Isometsä ET, Henriksson MM, Aro HM, Lönnqvist JK (1994) Suicide in bipolar disorder in Finland. American Journal of Psychiatry, 151, 1020-1024. https://doi.org/10.1176/ajp.151.7.1020
  37. Sánchez-Gistau V, Colom F, Mané A, Romero S, Sugranyes G, Vieta E (2009) Atypical depression is associated with suicide attempt in bipolar disorder. Acta Psychiatrica Scandinavica, 120, 30-36. https://doi.org/10.1111/j.1600-0447.2008.01341.x
  38. Akiskal HS (1981) Subaffective disorders. Dysthymic, cylothymic and bipolar II disorders in the “borderline” realm. Psychiatric Clinics of North America, 4, 25-46. https://doi.org/10.1016/s0193-953x(18)30935-3
  39. Rihmer Z, Szádóczky E, Füredi J, Kiss K, Papp Zs (2001) Anxiety disorders comorbidity in bipolar I, bipolar II and unipolar major depression: Results from a population-based study in Hungary. Journal of Affective Disorders, 67, 175-179. https://doi.org/10.1016/s0165-0327(01)00309-3
  40. Brieger P (2000) Comorbidity in bipolar affective disorder. In Bipolar disorders. 100 years after manic depressive insanity, Marneros A, Angst J (eds), Kluwer Academic Publishers, Dordrecht, pp. 215-229. https://doi.org/10.1007/0-306-47521-9_11
  41. Benazzi F, Akiskal HS (2003b) Clinical and factor-analytic validation of depressive mixed states: A report from the Ravenna-San Diego collaboration. Current Opinion in Psychiatry, 16 (Suppl. 2), 70-78. https://doi.org/10.1097/00001504-200304002-00011
  42. Koukopoulos A, Koukopoulos A (1999) Agitated depressions as a mixed state and the problem of melancholia. Psychiatric Clinics of North America, 22, 547-563. https://doi.org/10.1016/s0193-953x(05)70095-2
  43. Maser JD, Akiskal HS, Schettler P, Scheftner W, Mueller T, Andicott J, Solomon D, Clayton P (2002) Can temperament identify affectively ill patients who engage in lethal or non-lethal suicidal behavior? A 14-year prospective study. Suicide and Life-Threatening Behavior, 32, 10-32. https://doi.org/10.1521/suli.32.1.10.22183
  44. Balázs J, Benazzi F, Rihmer Z, Rihmer A, Akiskal KK, Akiskal HS (2006) The close link between suicide attempts and mixed (bipolar) depression: Implications for suicide prevention. Journal of Affective Disorders, 91, 133-138. https://doi.org/10.1016/j.jad.2005.12.049
  45. Rihmer Z, Akiskal HS (2006) Do antidepressants t (h)reat (en) depressives? Toward a clinically judicious formulation of the antidepressant-suicidality FDA advisory in light of declining national suicide statistics from nay countries. Journal of Affective Disorders, 94, 3-13. https://doi.org/10.1016/j.jad.2006.04.003
  46. Valtonen, HM., Suominen, K., Haukka, J., Mantere, O., Leppamaki, S., Arvilomni, P., Isometsa ET. (2008) Differences in incidence of suicide attempts during phases of bipolar I and bipolar II disorders. Bipolar Disorders, 10, 588-96. https://doi.org/10.1111/j.1399-5618.2007.00553.x
  47. Rihmer Z, Akiskal KK, Rihmer A, Akiskal HS (2010) Current research on affective temperaments. Current Opinion in Psychiatry, 23, 12-18. https://doi.org/10.1097/yco.0b013e32833299d4
  48. Roy A (1983) Family history of suicide. Archives of General Psychiatry, 40, 971-974.          
  49. Tondo L, Baldessarini RJ, Hennen J, Floris G (1998) Lithium maintenance treatment of depression and mania in bipolar I and bipolar II disorders. American Journal of Psychiatry, 155, 638-645. https://doi.org/10.1176/ajp.155.5.638
  50. Caraballo JJ, Harkvay-Friedman J, Burke AK, Sher L, Baca-Garcia E, Sullivan GM, Grunebaum MF, Parsey RV, Mann JJ, Oquendo MA (2008) Family history of suicidal behaviour and early traumatic experiences: Additive effect on suicidality and course of bipolar illness? J Affect Disord, 109: 57-63. https://doi.org/10.1016/j.jad.2007.12.225
  51. Sarchiapone M, Jaussent I, Roy A, Carli V, Guillaume S, Jollant F, Malafosse A, Courtet P. (2009) Childhood trauma as a correlative factor of suicidal behavior – via aggression traits. Similar results in an Italian and French sample. Eur Psychiatry, 24: 57-62. https://doi.org/10.1016/j.eurpsy.2008.07.005
  52. Guillaume S, Jaussent I, Jollant F, Rihmer Z, Malafosse A, Courtet P. (2010) Suicide attempt characteristics may orientate toward a bipolar disorder in attempters with recurrent depression. J Affect Disord, 122: 53-59. https://doi.org/10.1016/j.jad.2009.06.006
  53. Isacsson G (2000) Suicide prevention — a medical breakthrough? Acta Psychiatrica Scandinavica, 102, 113-117. https://doi.org/10.1034/j.1600-0447.2000.102002113.x
  54. Rihmer Z, Kiss K (2002) Bipolar disorders and suicide risk. Clinical Approaches in Bipolar Disorders, 1, 15-21. https://doi.org/10.1034/j.1399-5618.4.s1.3.x
  55. Luoma JB, Martin CE, Pearson JL (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. Amer J Psychiatry, 159, 909-916. https://doi.org/10.1176/appi.ajp.159.6.909
  56. Berardi D, Menchetti M, Cevenini N, Scaini S, Versari M, De Ronchi D (2005). Increased recognition of depression in primary care. Psychotherapy and Psychosomatics, 74, 225-230. https://doi.org/10.1159/000085146
  57. Rihmer Z. and Rutz W. Treatment of attempted suicide and suicidal patients in primary care. In. Oxford Textbook of Suicidology and Suicide Prevention, (Eds: Wasserman, D, Wasserman C.), Oxford University Press, New York, 2009, pp: 463-470. https://doi.org/10.1093/med/9780198570059.003.0062
  58. Baldessarini RJ, Tondo L, Davis P, Pompili M, Goodwin FK, Hennen J (2006) Decreased risk of suicides and attempts during long-term lithium treatment: A meta-analytic review. Bipolar Disorders, 8, 625-639. https://doi.org/10.1111/j.1399-5618.2006.00344.x
  59. Sondergard L, Lopez AG, Andersen PK, Kessing LV (2008) Mood stabilizing pharmacological treatment in bipolar disorders and risk of suicide. Bipolar Disorders, 10: 87-94. https://doi.org/10.1111/j.1399-5618.2008.00464.x
  60. Tondo L., Baldessarini RJ., (2000) Reduced suicide risk during lithium maintenance treatment. Journal of Clinical Psychiatry, 61 (Suppl. 9) 97-104.
  61. Benazzi F (2003) How could antidepressants worsen unipolar depression? (ltr) Pychotherapy and Psychosomatics, 72, 107-108. https://doi.org/10.1159/000068683
  62. Henry C, Sorbara F, Lacoste J, Gindre C, Leboyer M (2001) Antidepressant-induced mania in bipolar patients: Identification of risk factors. Journal of Clinical Psychiatry, 62, 249-255. https://doi.org/10.4088/jcp.v62n0406
  63. Koukopoulos A, Caliari B, Tundo A, Floris G, Reginaldi D, Tondo L (1983) Rapid cyclers, temperament and antidepressants. Comprehensive psychiatry, 24, 249-258. https://doi.org/10.1016/0010-440x(83)90076-7
  64. Goodwin FK (1999) Anticonvulsant therapy and suicide risk in affective disorders. Journal of Clinical Psychiatry, 60 (Suppl. 2), 89-93.   
  65. Maj M, Tortorella A, Bartoli L (2000) Mood stabilizers in bipolar disorder. In Bipolar disorders. 100 years after manic depressive insanity, Marneros A, Angst J (eds), Kluwer Academic Publishers, Dordrecht, pp. 351-372. https://doi.org/10.1007/0-306-47521-9_17
  66. Bowden CL (2002) Pharmacological treatment of bipolar disorder: A review. In Bipolar disorder, Maj M, Akiskal HS, Lopez-Ibor JJ, Sartorius N (eds), John Wiley and Sons, Chichester, pp. 191-221. https://doi.org/10.1192/bjp.183.3.268
  67. Mundo E, Cattaneo E, Russo M, Altamura AC (2006) Clinical variables related to antidepressant- induced mania in bipolar disorder. J Affect Disord, 92: 227-230. https://doi.org/10.1016/j.jad.2006.01.028
  68. Ahrens B, Müller-Oerlinghausen B (2001) Does lithium exert an independent antisuicidal effect? Pharmacopsychiatry, 34, 132-136. https://doi.org/10.1055/s-2001-15878
  69. Angst F, Stassen HH, Clayton PJ, Angst J (2002) Mortality of patients with mood disorders: follow-up over 34-38 years. Journal of Affective Disorders, 68, 167-181. https://doi.org/10.1016/s0165-0327(01)00377-9
  70. Thies-Flechtner K, Müller-Oerlinghausen B, Seibert W, Walther A, Greil W (1996) Effect of prophylactic treatment on suicide risk in patients with major affective disorders. Pharmacopsychiatry, 29, 103-107. https://doi.org/10.1055/s-2007-979553
  71. Ohgami H, Tearao T, Shiotsuki I, Ishii N, Iwata N. (2009) Lithium in drinking water and risk of suicide. British Journal of Psychiatry, 194, 464-465. https://doi.org/10.1192/bjp.bp.108.055798
  72. Kapusta, N.A., Mossaheb, N., Etzersdorfer E., Hlavin, G., Thau, K., Willeit, M., Praschack-Rieder, N., Sonjneck, G., Leithner-Dziubas, K., 2011. Lithium in drinking water and suicide mortality. Brit J Psychiatry. 198: 346-350. https://doi.org/10.1192/bjp.bp.110.091041
  73. Yerevanian BI, Koek RJ, Mintz J (2003) Lithium, anticonvulsants and suicidal behavior in bipolar disorder. Journal of Affective Disorders, 73, 223-228. https://doi.org/10.1016/s0165-0327(02)00302-6
  74. Yerevanian BI, Koek RJ, Mintz J (2007a) Bipolar pharmacotherapy and suicidal behaviour. Part 1: Lithium, divalproex and carbamazepine. Journal of Affective Disord, 103, 5-11. https://doi.org/10.1016/j.jad.2007.05.019
  75. Goodwin FK, Fireman B, Simon GE, Hunkeler EM, Lee Y, Revicki D (2003) Suicide risk in bipolar disorder during treatment with lithium and divalproex. Journal of American Medical Association, 290, 1467-1473. https://doi.org/10.1001/jama.290.11.1467
  76. Collins JC, McFarland BH. (2008) Divalproex, lithium and suicide among Medicaid patients with bipolar disorder. Journal of Affective Disorders, 107, 23-28. https://doi.org/10.1016/j.jad.2007.07.014
  77. Oquendo MA, Galfalvy HC, Currier D, Grunebaum MF, her L, Sulivan GM, Burke AK, Harkavy- Friedman J, Sublette ME, Parsey RV, Mann JJ. (2011) Treatment of suicide attempters with bipolar disorder: A randomized clinical trial comparing lithium and valproate in the prevention of suicidal behavior. Amer J Psychiatry, 168: 1050-1056. https://doi.org/10.1176/appi.ajp.2011.11010163
  78. Keck PE, Jr, McElroy S (2003) Redefining mood stabilization. Journal of Affective Disorders, 73, 163-169. https://doi.org/10.1016/s0165-0327(01)00355-x
  79. Tohen M, Greil W, Calabrese JR, Sachs GS, Yatham LN, Müller-Oerlinghausen BM, Koukopoulos A, Cassano GB, Grunze H, Licht RW, Dell’Osso L, Evans AR, Risser R, Baker RW, Crane H, Dossenbach MR, Bowden CL. (2005) Olanzapine versus lithium in the maintenance treatment of bipolar disorder: A 12-month, randomized, double-blind, controlled clinical trial. American Journal of Psychiatry, 162: 1281-1290. https://doi.org/10.1176/appi.ajp.162.7.1281
  80. Young A, McElroy S, Olausson B, et al. (2008): Quetiapine monotherapy up to 52 weeks in patients with bipolar depression: Continuation phase data from EMBOLDEN I and EMBOLDEN II. (Abstract). 21th ECNP Conference, 2008, Barcelona, Spain. https://doi.org/10.1016/j.eurpsy.2008.01.451
  81. Yatham LN, Kennedy SH, Schaffer A, Parikh SV, O’Donovan C, MacQueen G, McIntyre RS, Sharma V, Ravindran V, Young LT, Young AH, Alda M, Milev R, Vieta E, Calabrese JR, Berk M, Ha K, Kapczinski F (2009): Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: Update 2009. Bipol Disord, 11: 225-255. https://doi.org/10.1111/j.1399-5618.2009.00672.x
  82. Yerevanian BI, Koeck RJ, Mintz J, Akiskal HS (2007b) Bipolar pharmacotherapy and suicidal behaviour. Part 2: The impact of antidepressants. Journal of Affective Disorders, 103, 13-21. https://doi.org/10.1016/j.jad.2007.05.017
  83. Yerevanian BI, Koek RJ, Mintz J (2007c) Bipolar pharmacotherapy and suicidal behaviour. Part 3: Impact of antipsychotics. Journal of Affective Disorders, 103, 23-28. https://doi.org/10.1016/j.jad.2007.05.018
  84. Bauer MS (2002) Psychosocial interventions for bipolar disorder: A review In Bipolar disorder, Maj M, Akiskal HS, Lopez-Ibor JJ, Sartorius N (eds), John Wiley and Sons, Chichester, pp. 281-313. https://doi.org/10.1192/bjp.183.3.268
  85. Fountoulakis KN, Gonda X, Siamouli M, Rihmer Z (2009) Psychotherapeutic intervention and suicide risk reduction in bipolar disorder: A review of the evidence. Journal of Affective Disorders, 113, 21-29. https://doi.org/10.1016/j.jad.2008.06.014
  86. Colom F, Vieta E (2002) Treatment adherence in bipolar patients. Clinical Approaches in Bipolar Disorders, 1, 49-56.           
  87. Lam DH, Watkins ER, Hayward P, Bright J, Wright K, Kerr N, Parr-Davis G, Sham P (2003) A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder. Archives of General Psychiatry, 60, 145-152. https://doi.org/10.1001/archpsyc.60.2.145
  88. Fava GA, Bartolucci G, Rafanelli C, Mangelli L (2001) Cognitive-behavioral management of patients with bipolar disorder who relapsed while on lithium prophylaxis. Journal of Clinical Psychiatry, 62, 556-559. https://doi.org/10.4088/jcp.v62n07a10
  89. Wolf T, Müller-Oerlinghausen B (2002) The influence of successful prophylactic drug treatment on cognitive dysfunction in bipolar disorders. Bipolar Disorders, 4, 263-270. https://doi.org/10.1034/j.1399-5618.2002.00136.x