Brief report
A collaborative therapeutic relationship and risk of suicidal ideation in patients with bipolar disorder

https://doi.org/10.1016/j.jad.2008.07.019Get rights and content

Abstract

Background

A diagnosis of Bipolar Disorder (BD) is among the strongest known risk factors for suicide. The present study examines the relative impact of current mood state (depressed, manic or mixed) and patient perceptions of the therapeutic relationship on suicidal ideation in veterans with BD.

Methods

We conducted analyses of the baseline data from a naturalistic cohort study of veterans receiving care for BD (N = 432) at a large urban VA mental health clinic. Logistic regression was used to examine the relative impact of patient- and treatment-related factors on suicidal ideation within the two weeks prior to recruitment.

Results

Over 49% (213/432) of veterans receiving current outpatient treatment for BD reported at least some suicidal ideation within the two weeks prior to recruitment. After accounting for current mood state and other identified risk factors, even minimal increases (i.e., per point increase on a 0–60 rating scale) in the extent to which the therapeutic relationship is perceived as collaborative (OR = 0.97; p < .01) were associated with a reduction in risk of suicidal ideation.

Limitations

This study is cross sectional and relies exclusively on patient self-report.

Conclusions

Mental health treatment providers should be aware of the high rate of suicidal ideation in patients with BD. Successful management of suicidal ideation likely involves a focus on improving symptoms as well as establishing a collaborative therapeutic relationship.

Introduction

Bipolar disorder (BD) is a debilitating, chronic mental illness associated with considerable healthcare costs and high rates of premature mortality (Bauer et al., 2002, Kleinman et al., 2003, Laursen et al., 2007). Also, BD is among the strongest risk factors for suicide of all psychiatric conditions (Harris and Barraclough, 1997), and BD is linked to increased rates of suicide attempts and suicidal ideation (Chen and Dilsaver, 1996, Kessler et al., 1999). Anywhere from 33% (López et al., 2001) to 80% (Valtonen et al., 2005) of bipolar patients report suicidal ideation and/or attempts during their lifetime.

In patients with BD, current episode is often the strongest indicator of risk for suicidal ideation and attempts. Suicidal ideation and attempts are more common during depressive or mixed episodes than manic episodes (Valtonen et al., 2005, Valtonen et al., 2007, Dilsaver et al., 1997). Isometsä et al. (1994) found that 79% of suicides occurred during a depressive episode; 11% during a mixed episode. In addition to symptoms of BD, other indicators of poor psychiatric functioning related to suicide risk include: comorbid anxiety disorder, an axis II diagnosis and greater number of prior psychiatric hospitalizations (Oquendo et al., 2000, Simon et al., 2007, Valtonen et al., 2005). Also, depending on the sample, alcohol or drug problems are associated with increased risk of suicidal ideation and attempts (Grunebaum et al., 2006, Slama et al., 2004, Tondo et al., 1999, Valtonen et al., 2005).

Additionally, it is important to examine the characteristics of the treatment experience that could influence suicide risk in BD patients. Pharmacological treatment for BD is associated with reduced suicide risk in this population (Angst et al., 2002, Baldessarini et al., 1999, Yerevanian et al., 2003, Yerevanian et al., 2007), but the broader influence of the therapeutic relationship has received little attention. Although the therapeutic relationship has not been closely examined in the suicide literature, the provider–patient relationship is thought to be a potentially important factor in mitigating suicide risk (American Psychiatric Association, 2003, Leenaars, 2006). Moreover, a poor staff–patient relationship was cited as a key factor associated with preventability of suicide among patients who received psychiatric care prior to committing suicide (Burgess et al., 2000). An improved therapeutic relationship has been linked to better depression treatment outcomes (Klein et al., 2003, Krupnick et al., 1996), and greater collaboration between patient and provider is associated with improved medication adherence in BD patients (Zeber et al., 2008). Given these previously established relationships, it is important to examine the association between the collaborative nature of the therapeutic relationship and suicidal ideation after accounting for current mood and medication adherence.

The present study examined the hypothesis that, even after controlling for current mood state, several correlates of increased suicidal ideation would be identified including: greater substance use, lower general functioning, poorer medication adherence and a less collaborative therapeutic relationship. Examining suicidal ideation has significant implications because suicidal ideation is an important precursor of suicide attempts and suicide (Crandall et al., 2006, Kuo et al., 2001).

Section snippets

Participants

Participants included 432 patients from the Continuous Improvement for Veterans in Care-Mood Disorders (CIVIC-MD) study, a population-based, naturalistic study of veterans receiving inpatient and outpatient mental health treatment for BD (Kilbourne et al., 2007). Among participants, 14% were women, 77% were Caucasian, 13% were African American, and 10% were from other racial/ethnic groups; mean age was 49 years (SD = 11). Patients were eligible for the study if they were diagnosed with BD (I, II,

Results

Approximately 32% (140/432) of the sample reported suicidal ideation for several days, 9% (38/432) reported suicidal ideation more than half of the days, and 8% (35/432) reported suicidal ideation nearly every day. Overall, some suicidal ideation within the past two weeks was reported in 49% (213/432) of the sample.

In bivariate analyses, rates of suicidal ideation differed based on current mood state, with the lowest rates in euthymic individuals and the highest rates in those with mixed mood

Discussion

Suicidal ideation is common in patients treated for BD, with close to half of all patients reporting some suicidal ideation within the past two weeks. Suicidal ideation is particularly common in men, those with poorer general functioning and mental health and those with elevated bipolar symptoms, particularly depressed or mixed mood states. Even after controlling for these patient characteristics, a collaborative stance by the provider in the therapeutic relationship was associated with a

Role of funding source

Funding for this study was provided by VA HSR and D IIR 02-283 and MRP 05-137; the VA had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgements

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

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