European Child & Adolescent Psychiatry

, Volume 22, Issue 3, pp 139–151

Juvenile bipolar disorder and suicidality: a review of the last 10 years of literature

  • Natacha Halfon
  • Réal Labelle
  • David Cohen
  • Jean-Marc Guilé
  • Jean-Jacques Breton


Although children and adolescents with bipolar disorder (BD) are at elevated risk for suicide, little research to date has been conducted on suicidality in this population. The purpose of this descriptive review of the past 10 years of scientific literature on suicidality in youths with BD was to identify the risk and protective factors associated with this phenomenon, and to discuss the implications for research and clinical practice. Searches on Medline and PsycINFO databases for the period from early 2002 to mid-2012 yielded 16 relevant articles, which were subsequently explored using an analysis grid. Note that the authors employed a consensus analysis approach at all stages of the review. Four primary categories of risk factors for suicidality in youths with BD were identified: demographic (age and gender), clinical (depression, mixed state or mixed features specifier, mania, anxiety disorders, psychotic symptoms, and substance abuse), psychological (cyclothymic temperament, hopelessness, poor anger management, low self-esteem, external locus of control, impulsivity and aggressiveness, previous suicide attempts, and history of suicide ideation, non-suicidal self-injurious behaviors and past psychiatric hospitalization), and family/social (family history of attempted suicide, family history of depression, low quality of life, poor family functioning, stressful life events, physical/sexual abuse, and social withdrawal). Youths with BD who experienced more complex symptomatic profiles were at greater risk of suicidality. Few protective factors associated with suicidality have been studied among youths with BD. One protective factor was found in this descriptive literature review: the positive effects of dialectical behavior therapy. This article allows a better appreciation of the risk and protective factors associated with suicidality among youth with BD. Greater awareness of risk factors is the first step in suicide prevention.


Bipolar Suicidality Youths Review 


  1. 1.
    Van Meter A, Moreira AL, Youngstrom EA (2011) Meta-analysis of epidemiological studies of pediatric bipolar disorder. J Clin Psychiat 72:1250–1256CrossRefGoogle Scholar
  2. 2.
    Brent DA, Perper JA, Goldstein CE, Kolko DJ, Allan MJ, Allman CJ, Zelenak JP (1988) Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry 45:581–588PubMedCrossRefGoogle Scholar
  3. 3.
    Brent DA, Perper JA, Moritz G, Allman C, Friend A, Roth C, Schwers J, Balach L, Baugher M (1993) Psychiatric risk factors for adolescent suicide: a case-controlled study. J Am Acad Child Adolesc Psychiatry 32(3):521–529PubMedCrossRefGoogle Scholar
  4. 4.
    Lewinsohn PM, Klein DN, Seeley JR (1995) Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity and course. J Am Acad Child Adolesc Psychiatry 34:454–463PubMedCrossRefGoogle Scholar
  5. 5.
    Strober M, Schmidt-Lackner S, Freeman R, Bower S, Lambert C, De Antonio M (1995) Recovery and relapse in adolescents with bipolar affective illness: a five-year naturalistic, prospective follow-up. J Am Acad Child Adolesc Psychiatry 34:724–731PubMedCrossRefGoogle Scholar
  6. 6.
    Slama F, Bellivier F, Henry C, Rousseva A, Etain B, Rouillon F, Leboyer M (2004) Bipolar patients with suicidal behavior: toward the identification of a clinical subgroup. J Clin Psychiatry 65(8):1035–1039PubMedCrossRefGoogle Scholar
  7. 7.
    Carter TD, Mundo E, Parikh SV, Kennedy JL (2003) Early age at onset as a risk factor for poor outcome of bipolar disorder. J Psychiatr Res 37:297–303PubMedCrossRefGoogle Scholar
  8. 8.
    Jolin EM, Weller EB, Weller RA (2007) Suicide risk factors in children and adolescent with bipolar disorder. Curr Psychiatry Rep 9:122–128PubMedCrossRefGoogle Scholar
  9. 9.
    Goldstein TR (2009) Suicidality in pediatric bipolar disorder. Child Adolesc Psychiatr Clin N Am 18(2):339–352PubMedCrossRefGoogle Scholar
  10. 10.
    Geller B, Luby J (1997) Child and adolescent bipolar disorder: review of the past ten years. J Am Acad Child Adolesc Psychiatry 36(9):1168–1176PubMedCrossRefGoogle Scholar
  11. 11.
    Goldstein TR, Birmaher B, Axelson D, Ryan ND, Strober MA, Gill MK, Valeri S, Chiappetta L, Leonarg HJ, Bridge JA, Brent DA, Keller M (2005) History of suicide attempts in pediatric bipolar disorder: factors associated with increased risk. Bipolar Disord 7(6):525–535PubMedCrossRefGoogle Scholar
  12. 12.
    Algorta GP, Youngstrom EA, Frazier TW, Freeman AJ, Youngstrom JK, Findling RL (2011) Suicidality in pediatric bipolar disorder predictor or outcomes of family processes and mixed mood presentation? Bipolar Disord 13:76–83PubMedCrossRefGoogle Scholar
  13. 13.
    Axelson D, Birmaher B, Strober MA, Gill MK, Valeri S, Chiappetta L, Ryan N, Leonard H, Hunt J, Iyengar S, Bridge J, Keller M (2006) Phenomenology of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry 63(10):1139–1148PubMedCrossRefGoogle Scholar
  14. 14.
    Birmaher B, Axelson D, Strober M, Gill MK, Yang M, Ryan N, Goldstein B, Esposito-Smythers C, Lyengar S, Goldstein T, Chiappetta L, Keller M, Leonard H (2009) Comparison of manic and depressive symptoms between children and adolescents with bipolar spectrum disorders. Bipolar Disord 11:52–62PubMedCrossRefGoogle Scholar
  15. 15.
    Caetano SC, Olivera RL, Hunter K, Hatch JP, Najt P, Bowden C, Pliszka S, Soares JC (2006) Association of psychosis with suicidality in pediatric bipolar I, II and bipolar NOS patients. J Affect Disord 91(1):33–37PubMedCrossRefGoogle Scholar
  16. 16.
    Dilsaver SC, Benazzi F, Rihmer Z, Akiskal KK, Akiskal HS (2005) Gender, suicidality and bipolar mixed states in adolescents. J Affect Disord 87(1):11–16PubMedCrossRefGoogle Scholar
  17. 17.
    Dilsaver SC, Akiskal HS, Akiskal KK, Benazzi F (2006) Dose-response relationship between number of comorbid anxiety disorders in adolescent bipolar/unipolar disorders, and psychosis, suicidality, substance abuse and familiality. J Affect Disord 96(3):249–258PubMedCrossRefGoogle Scholar
  18. 18.
    Goldstein BI, Strober MA, Birmaher B, Axelson D, Esposito-Smythers C, Goldstein TR, Leonard H, Hunt J, Gill MK, Lyuengan S, Grimm C, Yang M, Ryan ND, Kelly MB (2008) Substance use disorders among adolescents with bipolar spectrum disorders. Bipolar Disord 10:469–478PubMedCrossRefGoogle Scholar
  19. 19.
    Goldstein TR, Axelson D, Birmaher B, Brent D (2007) Dialectical behavior therapy for adolescents with bipolar disorder: a 1-year open trial. J Am Acad Child Adolesc Psychiatry 46(7):820–830PubMedCrossRefGoogle Scholar
  20. 20.
    Goldstein TR, Ha W, Axelson D, Goldstein BI, Liao F, Gill MK, Ryan ND, Yen S, Hunt J, Hower H, Keller M, Strober M, Birmaher B (2012). Predictors of prospectively examined suicide attempts among youth with bipolar disorder. Arch Gen Psychiatry doi:10.1001/archgenpsychiatry.2012.650
  21. 21.
    Kochman FJ, Hantouche EG, Ferrari P, Lancrenon S, Bayart D, Akiskal HS (2005) Cyclothymic temperament as a prospective predictor of bipolarity and suicidality in children and adolescents with major depressive disorder. J Affect Disord 85(1–2):181–189PubMedCrossRefGoogle Scholar
  22. 22.
    Rende R, Birmaher B, Axelson D (2007) Childhood-onset bipolar disorder: evidence for increased familial loading of psychiatric illness. J Am Acad Child Adolesc Psychiatry 46(2):197–204PubMedCrossRefGoogle Scholar
  23. 23.
    Rucklidge JJ (2006) Psychosocial functioning of adolescents with and without paediatric bipolar disorder. J Affect Disord 91(2–3):181–188PubMedCrossRefGoogle Scholar
  24. 24.
    Bronisch T, Schwender L, Höfler M, Wittchen HU, Lieb R (2005) Mania, hypomania, and suicidality: findings from a prospective community study. Arch Suicide Res 9(3):267–278PubMedCrossRefGoogle Scholar
  25. 25.
    Lewinsohn PM, Seeley JR, Buckley PM, Klein DN (2002) Bipolar disorder in adolescence and young adulthood. Child Adolesc Psychiatr Clin 11:461–475CrossRefGoogle Scholar
  26. 26.
    Papolos D, Hennen J, Cockerham MS (2005) Factors associated with parent-reported suicide threats by children and adolescents with community-diagnosed bipolar disorder. J Affect Disord 86(2–3):267–275PubMedCrossRefGoogle Scholar
  27. 27.
    Breton JJ, Tousignant M, Bergeron L, Berthiaume C (2002) Informant-specific correlates of suicidal behavior in a community survey of 12- to 14-year-olds. J Am Acad Child Adolesc Psychiatry 41(6):723–730PubMedCrossRefGoogle Scholar
  28. 28.
    Bridge JA, Goldstein TR, Brent DA (2006) Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry 47(3–4):372–394PubMedCrossRefGoogle Scholar
  29. 29.
    Yang B, Clum GA (2000) Childhood stress leads to later suicidality via its effect on cognitive functioning. Suicide Life Threat Behav 30(3):183–198PubMedGoogle Scholar
  30. 30.
    Goodwin FK, Fireman B, Simon GE, Hunkeler EM, Lee J, Revicki D (2003) Suicide risk in bipolar disorder during treatment with lithium and divalproex. J Am Med Assoc 290(11):1467–1473CrossRefGoogle Scholar
  31. 31.
    Baldessarini RJ, Tondo L, Davis P, Pompili M, Goodwin FR, Hennen J (2006) Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review. Bipolar Disord 8:625–639PubMedCrossRefGoogle Scholar
  32. 32.
    Hennen J (2003) Statistical methods for longitudinal research on bipolar disorders. Bipolar Disord 5:156–168PubMedCrossRefGoogle Scholar
  33. 33.
    American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders, 4th edn. APA, Washington, DCGoogle Scholar
  34. 34.
    Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, Williamson D, Ryan N (1997) Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36(7):980–988PubMedCrossRefGoogle Scholar
  35. 35.
    Posner K, Oquendo MA, Gould M, Stanley B, Davies M (2007) Columbia Classification Algorithm of Suicide Assessment (C-CASA): classification of suicidal events in the FDA’s pediatric suicidal risk analysis of antidepressants. Am J Psychiatry 164(7):1035–1043PubMedCrossRefGoogle Scholar
  36. 36.
    Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, Currier GW, Melvin GA, Greeenhill L, Shen S, Mann JJ (2011) The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry 168(12):1266–1277PubMedCrossRefGoogle Scholar
  37. 37.
    Bellivier F, Etain B, Malafosse A, Henry C Kahn JP, Elgrabi-Wajsbrot O, Jamain S, Azorin JM, Frank E, Scott J, Grochocinski V, Kupper DJ, Golmard JL, Leboyer M (2011) Age at onset in bipolar I affective disorder in the USA and Europe. World J Biol Psychiatry 71(8,s):27s–27sGoogle Scholar
  38. 38.
    Chaudhury SR, Grunebaum MF, Galfalvy HC, Burke AK, Sher L, Parsey RV et al (2007) Does first episode polarity predict risk for suicide attempt in bipolar disorder? J Affect Disorders 104(1–3):245–250PubMedCrossRefGoogle Scholar
  39. 39.
    Oquendo MA, Waternaux C, Brodsky B, Parsons B, Haas GL, Malone KM et al (2000) Suicidal behavior in bipolar mood disorder: clinical characteristics of attempters and nonattempters. J Affect Disorders 59(2):107–117PubMedCrossRefGoogle Scholar
  40. 40.
    Dervic K, Carballo JJ, Baca-Garcia E, Galfalvy HC, Mann JJ, Brent DA, Oquendo MA (2011) Moral or religious objections to suicide may protect against suicidal behavior in bipolar disorder. J Clin Psychiatry 72(10):1390–1396PubMedCrossRefGoogle Scholar
  41. 41.
    Consoli A, Deniau E, Huynh C, Mazet P, Cohen D (2006) Traitement des troubles bipolaires de type I de l’enfant et de l’adolescent (Treatments in child and adolescent bipolar disorders). Neuropsychiatr Enfance Adolesc 54:217–227CrossRefGoogle Scholar
  42. 42.
    Consoli A, Deniau E, Huynh C, Puper D, Cohen D (2007) Treatments in child and adolescent bipolar disorder. Eur Child Adolesc Psychiatry 16:187–198PubMedCrossRefGoogle Scholar
  43. 43.
    Tondo L, Baldessarini R (2006) Reduced suicide risk during lithium maintenance treatment. J Clin Psychiatry 61(suppl 9):97–104Google Scholar
  44. 44.
    Sondergard L, Lopez AG, Anderson PK, Kessing LV (2008) Mood stabilizing pharmacological treatment in bipolar disorders and the risk of suicide. Bipolar Disord 10:87–94PubMedCrossRefGoogle Scholar
  45. 45.
    Strober M, Schmidt-Lackner S, Freeman R, Bower S, Lampert C, DeAntonio M (1995) Recovery and relapse in adolescents with bipolar affective illness: a five-year naturalistic, prospective follow-up. J Am Acad Child Adolesc Psychiatry 34(6):724–731PubMedCrossRefGoogle Scholar
  46. 46.
    Daley LF, Townsend SW, Dysken MW, Kuskowski MA (2005) Recidivism in medication-noncompliant serious juvenile offenders with bipolar disorder. J Clin Psychiatry 66(4):477–484Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Natacha Halfon
    • 1
    • 4
    • 5
    • 7
  • Réal Labelle
    • 1
    • 2
    • 4
    • 5
    • 7
  • David Cohen
    • 3
    • 7
    • 8
  • Jean-Marc Guilé
    • 2
    • 7
    • 8
    • 9
  • Jean-Jacques Breton
    • 2
    • 5
    • 6
    • 7
  1. 1.Département de psychologieUniversité du Québec à MontréalMontrealCanada
  2. 2.Département de psychiatrieUniversité de MontréalMontrealCanada
  3. 3.Département de psychiatrieUniversité Pierre et Marie CurieParisFrance
  4. 4.Centre de recherche et d’intervention sur le suicide et l’euthanasieMontrealCanada
  5. 5.Centre de recherche Fernand-SeguinMontrealCanada
  6. 6.McGill Group for Suicide StudiesMontrealCanada
  7. 7.Clinique des troubles de l’humeur et Service de rechercheHôpital Rivière-des-PrairiesMontrealCanada
  8. 8.Service de Psychiatrie de l’Enfant et de l’Adolescent du Groupe Hospitalier Pitié-SalpêtrièreParisFrance
  9. 9.Centre de consultation et de cure ambulatoireCrépy-en-ValoisFrance

Personalised recommendations