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A new study published in the Journal of Translational Psychiatry looked at a combined clinical and genetic approach to the assessment of suicide and death in bipolar affective disorder.

“When we think about the risk for suicide, we often think about what is happening in a person’s life at the time: the loss of a job, a major change in a relationship,” study author Eric Monson told us. “Not many people are aware that genetics play an important role in risk. In fact, the heritability for suicidality is estimated to be 30-50%, meaning that a significant proportion of risk arises from genetic sources.”

The study focused on trying to identify clinical and genetic risk factors for suicide death and attempt within bipolar disorder.

“As suicide is an inherently preventable outcome, our hope was that the identification of such risk factors, specific for suicide death, could then direct further research and even aid in improving screening practices for suicide,” study author Virginia Willour told us.

The primary theory going in was that suicide attempt and death likely had differences in their risk factors, particularly when considering that only an estimated 2.8% of all individuals with a prior suicide attempt go on to die by suicide. This is an important theory to address as suicide attempt is frequently used as a proxy for suicide death in almost all suicide risk studies.

“This topic is of considerable importance due to suicide consistently ranking as a top-10 cause of death across all age groups in the United States, per the CDC,” Monson told us. “Suicide leads to over 40k deaths annually in the US alone, more than homicides and car accidents. Despite this, we still know very little about how to effectively predict and prevent suicide, even with considerable prior research efforts, which, as noted, have primarily focused on suicide attempt.”

In addition, the researchers’ multi-site collaboration provides access to unique, large samples of individuals with and without bipolar disorder who have died from suicide (through the Utah Suicide Genetic Risk Study and Utah Population Database), individuals with bipolar disorder with or without a suicide attempt history (collected through a multisite NIMH genetics initiative effort), and psychiatrically screened controls (also a multisite effort through the NIMH). These unique resources placed them in a position to complete this study in a systematic way on the largest possible samples.

“Finally, working toward understanding and, ultimately, preventing suicide is not simply a job for us, it is a mission,” Willour told us. “Many of the researchers engaged in this work have been affected by suicide, both of us included, serving as a source of considerable drive toward these research pursuits.”

The study included five types of subjects: 1) individuals with bipolar disorder who died from suicide; 2) individuals without bipolar disorder who died from suicide; 3) individuals with bipolar disorder with a history of one or more suicide attempts; 4) individuals with bipolar disorder with no history of a prior suicide attempt; and 5) psychiatrically screened controls.

The goal was to determine whether the presence of co-morbid (co-existing) clinical diagnoses and/or clinically-related genetic risk factors could be used to differentiate between the groups.

“We found both clinical and genetic support for trauma associated diagnoses (especially PTSD) being associated specifically with suicide death,” Monson told us. “This suggests that individuals who have a genetic predisposition for the development of PTSD and/or are exposed to significant prior trauma, all in the setting of a diagnosis of bipolar disorder, may be at significantly greater risk of death by suicide.”

Researchers also observed genetic predispositions for ADHD and insomnia potentially contributing risk to suicide death.

“While we were hoping for some evidence of risk factors that were specific to suicide death in bipolar disorder as compared with suicide attempt, we were surprised to see such converging evidence that consistently pointed at trauma playing a role in this risk,” Willour told us. “It has been long known that trauma worsens the severity of essentially all mental health conditions, and that it also confers some risk for suicidal behavior, but this is the first time, to our knowledge, that clinical and genetic evidence have converged to show this risk to be of specific importance to suicide death.”

While considerable research is still needed, these results demonstrate that suicide death is, indeed, different from attempt, and is worth investigating independently. It is hoped this will encourage other groups to pursue this severe clinical outcome more directly by collecting additional samples from individuals who have died from suicide.

“It is also hoped that these results will serve as direction for specific areas to investigate further, including trauma and stress response, in future research efforts,” Monson told us. “Finally, it is hoped that this study will provide some direction in considering what is screened for in patients when considering an individual’s risk for suicide. This is a critical consideration due to the highly limited resource that mental health care is, and more effective screening may allow more efficacious focusing of those resources to individuals at greatest risk.”