A small study from Australia has reviewed the treatment factors that may have contributed to completed suicide in 35 patients with bipolar disorder between 1993 and 2001 (Austr NZ J Psychiatry 2009;43:503-8).

The average age of the 22 men and 13 women was 40 years; the average duration of illness was 12 years and 63 per cent had experienced psychosis. For 86 per cent there had been at least one previous suicide attempt and 83 per cent were in a depressed phase. Life stressors were present in 77 per cent within the last 12 months and 46 per cent within the last four weeks.

Almost one-third of patients had never been treated with lithium. Fifteen had taken lithium in the last four weeks of life but levels were subtherapeutic in five and confirmed as therapeutic in only four. Medical review concluded that use of a mood stabiliser had been adequate in 43 per cent of patients and inadequate in 40 per cent. Appropriate use of antipsychotics in the previous 12 months was found in 63 per cent; 46 per cent were taking an antidepressant at the time of death. Psychosocial interventions were not adequate in 57 per cent.

Overall, medical treatment was assessed as below standard in 57 per cent of patients in the last 12 months and 60 per cent in the last four weeks prior to suicide. This was due to inadequate medication (38 per cent) and inadequate follow-up (33 per cent). Non-adherence in the last four weeks was estimated at 47 per cent.