Suicide Risk in Mixed States: Clinical and Preventive Perspectives

Patients with mixed states are at high risk of presenting with suicidal behavior. The article provides a broader picture of features commonly associated with suicide risk in mixed states. The authors performed a literature search using the following terms: “suicide” OR “suicidality” OR “suicidal” AND “mixed” AND “bipolar.” Studies that did not report data on suicidal behaviors in mixed states and articles not written in English were excluded. Mania with mixed features, anxiety, psychomotor agitation and irritability, racing/crowded thoughts, severity of intra-episodic depressive symptoms, and time spent with depressive symptoms were associated with a greater risk of suicidal behavior. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, criteria for bipolar disorder “with mixed features” seeks to capture a significant number of these patients. The key is to recognize patients with mixed states and stabilize their mood through medication to prevent future suicidal behaviors.