Bipolar Disorder and Suicide Risk: What You Should Know

Bipolar disorder is a psychiatric disorder involving mood episodes that alternate between euphoric highs (mania) and deep lows (depression). It’s also associated with a higher rate of suicidal thoughts and behaviors than people without the condition, research shows.

People with bipolar disorder have a suicide rate that’s 10 to 30 times higher than the general population, according to a review published in August 2019 in Medicina. Twenty percent of people with bipolar disorder die by suicide, and 20 to 60 percent attempt suicide at least once in their lives, per the same review.

“The elevated risk of suicidal thoughts is primarily associated with the depressive phase of the disorder,” says Caroline Fenkel, doctor of social work, a licensed clinical social worker and the co-founder and chief clinical officer at Charlie Health, a mental health care practice for young people, who’s based in Malvern, Pennsylvania.

“During depressive episodes, individuals may experience intense sadness, hopelessness, and a loss of interest in activities they once enjoyed,” Dr. Fenkel explains. “These symptoms, coupled with the potential impairment of functioning and disrupted sleep patterns, can contribute to an increased risk of suicidal thoughts.”

Other potential symptoms of depressive episodes, according to Mayo Clinic, include:

• Appetite changes, resulting in unintentional weight loss or gain
• Fatigue or lack of energy
• Slowed movements or restlessness
• Difficulty concentrating or making decisions

The risk of suicide during mania, hypomania (a less severe form of mania), or neutral moods is much lower, the Medicina review states.

Importantly, most deaths by suicide happen among people whose bipolar disorder is untreated. The longer bipolar disorder goes untreated, the higher the risk for suicide, according to the aforementioned Medicina review.

Other risk factors for suicide among people with bipolar disorder, per the Medicina review, include:

• Prior suicide attempts
• Family history of mood disorders or prior suicide attempts
• Recent discharge from the hospital
• Frequent prior hospitalizations
• Recent diagnosis of bipolar disorder
• Cooccurring mental or physical health conditions or substance use disorders
• Rapid cycling mood episodes (meaning extreme mood changes happen more frequently)
• Bipolar disorder with predominantly depressive episodes
• Male sex
• Being unmarried, divorced, or a single parent
• Living in social isolation
• Age below 35 or over 75
• Unemployment
• Prior abuse, trauma, or adversity

“The warning signs of suicidal ideation are pretty similar for individuals with bipolar disorder compared to the general population,” says Fenkel. Common warning signs that someone is having suicidal thoughts, according to the National Institute of Mental Health, include:

• Talking about wanting to die
• Saying they feel guilty or like a burden to others
• Feeling trapped, hopeless, empty, or that there’s no reason to live
• Feeling agitated, anxious, or filled with rage
• Feeling extreme sadness or physical pain
• Withdrawing from family and friends
• Saying goodbye to loved ones or drafting a will with seemingly no logical reason for doing so
• Having intense mood swings
• Increasing their drug or alcohol use
• Engaging in dangerous behaviors like unsafe driving
• Sleeping more or less than usual
• Researching ways to die or making a plan

One warning sign that’s more specific to some people with bipolar disorder, including some who experience rapid cycling: “Sudden shifts from depressive symptoms to extreme euphoria or agitation could be indicative of heightened suicide risk in individuals with bipolar disorder,” Fenkel explains.

Another potential sign is a shift from extreme agitation to sudden calm. “While this change may seem like an improvement in their mood, it can signify a sense of ‘peace’ resulting from having a plan to end their life,” Fenkel warns.

RELATED: What It's Like to Live With Suicidal Thoughts

Recognizing suicidal thoughts in yourself or a loved one can be scary.

But, not everyone with bipolar disorder is affected by these symptoms. And there are things that you can do to help decrease the risk of acting on these thoughts and even the frequency of suicidal thoughts if you experience them, experts say.

1. Stick to Your Bipolar Disorder Treatment

As mentioned earlier, many people with bipolar disorder who die by suicide are not following a treatment plan for the condition. “Professional treatment is a huge aspect of managing the risk of suicide, and can help monitor symptoms and provide necessary support,” says Fenkel.

The most common evidence-based treatments for bipolar disorder, per Mayo Clinic, include:

• Medication Medicines like mood stabilizers or antipsychotics, for instance, can help reduce your bipolar symptoms and balance your moods, both acutely and in the long term.
• Psychotherapy Attending psychotherapy — also known as "talk therapy" — with a licensed mental health professional can help you learn to manage triggers and difficult emotions, and practice strategies for managing your bipolar symptoms.
• Hospitalization If you’re behaving dangerously, feeling imminently suicidal, or develop psychosis (meaning you become detached from reality), you may need to receive psychiatric treatment in a hospital. Doing so can help stabilize your mood and keep you calm.
• Support Groups Support groups for people with bipolar disorder can help you connect with and find support from others going through similar challenges in their lives.

One medication with well-documented effects on suicide risk is lithium, according to a meta-review published in November 2017 in Bipolar Disorders. Lithium has been shown reduce the risk of suicide by as much as 60 percent among people with bipolar disorder, per the aforementioned Medicina review.

If you’ve been prescribed lithium or other medicines for bipolar disorder, it’s important to take them consistently, even when you’re feeling well. Doing so is vital for keeping your moods stable and, in turn, lowering your risk of suicide, according to Mayo Clinic.

Never make changes to your treatment plan without talking to your doctor, or suddenly stop taking your medication. “Going off of medication completely can increase the risk for destabilization and contribute to worsening psychiatric symptoms,” says Justin Kei, MD, a psychiatrist and the medical director of The Debra Simon Center for Integrative Behavioral Health and Wellness at Hackensack Meridian Health in Maywood, New Jersey.

2. Limit Access to Tools That Can Be Used for Suicide

Among people who die by suicide, the method that a person uses to end their life is often what they can most easily access, according to prior research published in Current Psychiatry Reports. And in countries where access to tools commonly used for suicide is restricted, suicide rates have declined, per the same research.

Restricting access to tools that a person might use to end their life, such as firearms, can play a big role in keeping them safe. “ Removing access to weapons has been shown to help reduce suicide risk,” says Dr. Kei.

3. Create a Safety Plan With Your Therapist or Loved Ones

A safety plan is a tool that can help someone with suicidal thoughts and their loved ones protect them in the event of a suicidal crisis. “Developing a safety plan can also help to alleviate some of the risk,” says Fenkel. “This involves identifying triggers, warning signs, and coping strategies to manage suicidal thoughts.”

A good safety plan should include steps that the person decides in advance that they or a loved one will take if they feel suicidal, such as going to an emergency room or knowing what number they’ll contact in case of an emergency, according to Samaritans, a crisis line in the United Kingdom.

You can create a safety plan with loved ones you trust if you feel comfortable doing so or with your therapist or psychiatric provider, using templates like the one provided by Samaritans.

RELATED: How to Tell Your Doctor You’re Having Suicidal Thoughts

“Knowing when and how to seek help during a crisis is crucial,” says Fenkel. “Loved ones should be familiar with emergency hotlines, local mental health resources, and have a plan in place for accessing immediate professional assistance when needed.”

If you feel that you or a loved one are in immediate danger of suicide, call 911. You can also reach the 988 Suicide and Crisis Lifeline at any time by calling or texting 988, or the Crisis Text Line by texting HOME to 741-741, for a confidential conversation with a trained counselor. In addition, you could contact your or your loved one’s doctor for help, according to the Depression and Bipolar Support Alliance (DBSA).

If possible, don’t leave a loved one alone if you worry they’re at risk of suicide, per DBSA. If you’re not able to stay, ensure a family member or friend can stay with them until emergency help arrives.

If you or a loved one is considering suicide, dial 988 to reach the Suicide and Crisis Lifeline, which is available 24 hours a day, seven days a week.