Rates of attempted suicide are, as would be expected, higher than rates of suicide. Fombonne et al. (2001) reported a 20-year follow-up of a sample of individuals who had been depressed as youths. The suicide risk in the sample was 2.5%, but 44% had attempted suicide at least once. This sample of early-onset depression may represent an unusually high risk of attempts. Most other studies have found lower rates of a history of attempted suicide in depressed patients. For example, Bottlender et al. (2000) reported a history of self-harm in 27% of bipolar patients and 18% of unipolar patients. As in the case for suicide in bipolar patients, depression seems to be key. Lopez et al. (2001) found that 33% of their sample of 169 bipolar I disorder patients in northern Spain reported one or more previous suicide attempts. Severity of depressive episodes was one factor that distinguished those with and without a history of attempts.
How many of those who are depressed have suicidal ideation? Of course, it depends on what is meant by suicidal ideation, but it is probably accurate to say that more than half of depressed people have suicidal thoughts (Lonnqvist, 2000). For example, Schaffer et al. (2000) retrospectively reviewed 533 patients with major depression and found that 58% had suicidal ideation. There are also high rates of suicidal thoughts in bipolar patients, though it seems to be mainly accounted for by levels of depression rather than mania. Dilsaver et al. (1994) studied a sample of bipolar I patients, some of whom also met criteria for concurrent major depression, which they termed 'depressive mania'. Of the 49 pure mania patients, only one exhibited suicidal ideation. In contrast, 24 out of 44 depressive mania patients showed suicidal thoughts. Strakowski et al. (1996) also found higher rates of suicidal ideation in patients with mixed bipolar disorder than those with manic bipolar disorder. Further analysis showed that depression levels rather than group status (mixed versus manic) predicted suicide ideation. Oquendo et al. (2000) found that bipolar patients who had a history of suicide attempts had more episodes of depression than did those without a suicidal history.
There is no doubt that the relative risk of suicide, attempted suicide, and suicide ideation is very substantially increased in depression, both unipolar and bipolar. However, estimates do vary, influenced mainly by the particular samples studied and the methods used. A reasonable estimate would be that just over half of depressed patients have suicidal ideation and somewhere between 20% and 33% have a non-fatal attempt. Lifetime suicide risk in unipolar depression is almost certainly lower than the 15% commonly cited. The evidence is that bipolar disorder carries a lower risk than unipolar disorder, and depressive episodes would seem to be the key factor for suicide risk in bipolar disorder.
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