The association between suicidality and diagnoses of mixed mania, as defined using both DSM-IV and Cincinnati criteria, was studied in 576 consecutive manic inpatients. Of the whole sample, 51 (8.9%) had suicidal ideation and 13 (2.3%) attempted suicide during the index episode. Suicidality was significantly more frequent in patients with a diagnosis of mixed mania, whether the diagnosis was made by DSM-IV or Cincinnati criteria. A multiple logistic regression analysis revealed that an additive combination of a diagnosis of mixed mania, the depression severity, and the Global Assessment of Functioning (GAF) score was significant in predicting suicidal ideation, when using the DSM-IV criteria. A diagnosis of mixed mania alone was significant in a similar analysis, when using the Cincinnati criteria. The adjusted odds ratio for a diagnosis of mixed mania to having suicidality was much higher when using the latter criteria (4.0 v 14.0). A subsequent logistic regression analysis indicated that the Cincinnati mixed mania alone, rather than an additive combination of the DSM-IV mixed mania and the depression severity, achieved the most appropriate prediction of suicidal ideation in the sample. These findings did not differ, even when suicidality was defined as having a suicide attempt during the index episode. Our finding that suicidality was more strongly associated with Cincinnati mixed mania than with DSM-IV mixed mania is probably due to that suicidal patients who do not meet DSM-IV criteria for mixed mania are classified into mixed mania, or/and that the depressive syndrome, related to suicidality, is more appropriately assessed among manic patients, when using the Cincinnati criteria. There was no evidence that marital status, employment, a lifetime history of alcohol or substance abuse, or a history of suicide attempts before the index episode was significantly associated with suicidality in the sample. Manic patients with suicidality may have a greater severity of residual depressive symptoms at discharge.
SUICIDE RISK in bipolar patients is generally high. An exhaustive review by Goodwin and Jamison1 showed that 18.9% of deaths in bipolar patients were due to suicide. Although previous studies on suicidality in bipolar patients tended to be restricted to depressive episodes, several recent studies have emphasized that mixed states (or mixed mania), as defined as a simultaneous admixture of both depressive and manic syndromes, may also mediate the high suicide risk in bipolar patients.2, 3, 4, 5 and 6 Using a narrow definition of mixed mania that requires patients to simultaneously meet both full manic and depressive syndromes, Dilsaver et al.2 reported that 54.5% of patients with mixed mania had suicidal ideation, in contrast to 2.0% of patients with pure mania. Strakowski et al.3 also found a significantly higher frequency of suicidal ideation in patients simultaneously meeting DSM-III-R criteria for both manic and major depressive episodes than in pure manic patients.
Interestingly, Strakowski et al.3 provided evidence that the severity of current depressive symptoms, rather than the presence of a full depressive syndrome per se, is associated with suicidal ideation among manic patients, suggesting that narrow definitions of mixed mania may not play a definite role in predicting suicidality in these patients. DSM-III-R and DSM-IV adopt a narrow definition of mixed mania. However, there are several studies indicating that broader definitions of mixed states result in a more meaningful subtyping of mixed mania in terms of demographic variables,7, 8, 9, 10 and 11 natural course,7, 8, 9, 11 and 12 and specific treatment responses.13 and 14 The association between a broader definition of mixed mania and suicidality has not been well studied. One study reported that suicidal ideation is not infrequent in manic patients, even when full major depression does not accompany mania.5 and 6 However, it is unclear whether or not a broader definition of mixed mania plays a more definite role in predicting suicidality in manic patients, as compared with a narrow definition of mixed mania.
McElroy et al.4 and 11 proposed one of well-known broad definitions of mixed mania, the Cincinnati criteria, which require the presence of three or more symptoms of major depression during a full manic episode. The present study examined the association between mixed mania and suicidality in 576 hospitalized patients with acute mania. For diagnosing mixed mania, both Cincinnati and DSM-IV criteria were used.
