- Email: [email protected]
Association between history of suicide attempts and family functioning in bipolar disorder
Journal of Affective Disorders 192 (2016) 28–33
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Review article
Association between history of suicide attempts and family functioning in bipolar disorder Mariangeles Berutti a,n, Rodrigo Silva Dias a, Vivian Alves Pereira a, Beny Lafer a, Fabiano G. Nery a,b a b
Bipolar Disorder Program (PROMAN), Department of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 6 October 2015 Received in revised form 19 November 2015 Accepted 11 December 2015 Available online 12 December 2015
Objectives: To investigate the association between history of suicide attempts (SA) and family functioning in bipolar disorder (BD) patients. Methods: Thirty-one BD type I patients with lifetime history of SA, 31 BD type I with no lifetime history of SA, participating in the Outpatient Clinic of the Bipolar Disorder Program at the Institute of Psychiatry of the University of São Paulo Medical School were recruited for this study. We used the Family Assessment Device (FAD) to evaluate family functioning. We compared these two groups on demographic and clinical variables to identify which variables were associated with family functioning impairment. Fifty-one relatives of the same patients were also asked to complete a FAD. Results: BD patients with SA presented more psychiatric hospitalizations, higher frequency of psychotic symptoms, and higher scores on depressive, manic, and suicidal ideation than BD patients without SA. BD patients with SA presented significantly higher scores in several subscales of the FAD, including Problem Solving (p¼ 0.042), Communication (p¼0.009), Roles (p ¼0.006), and General Functioning (p¼ 0.025), when compared with BD patients without SA. Relatives of BD patients with SA presented significantly higher scores in Communication, Roles, Affective Responsiveness, and General Functioning than relatives of BD patients without SA. Limitations: Cross-sectional study and long time elapsed since last SA. Conclusion: History of SA in BD is associated with worse family functioning in several domains of FAD, including Problem Solving, Communication, Roles, and General Functioning. As suicide attempts are routinely assessed in clinical practice, these findings may help to identify patients with poorer family functioning and may suggest a role for environmental risk factors in suicidal behavior among BD patients. & 2015 Published by Elsevier B.V.
Keywords: Bipolar disorder Family functioning Suicide attempt
Contents 1. 2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Psychiatric assessments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Family Functioning Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Demographic and clinical characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Characteristics of suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Family functioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4. Bivariate correlations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29 29 29 29 30 30 30 30 30 30 30
n Correspondence to: Institute & Department of Psychiatry, University of Sao Paulo Medical School, Rua Dr. Ovidio Pires de Campos, 785, Cerqueira Cesar, Sao Paulo, SP 05403-010, Brazil. E-mail address: [email protected] (M. Berutti).
http://dx.doi.org/10.1016/j.jad.2015.12.010 0165-0327/& 2015 Published by Elsevier B.V.
M. Berutti et al. / Journal of Affective Disorders 192 (2016) 28–33
3.5. Linear regression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6. FAD scores in relatives of BD patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction Bipolar disorder (BD) is a serious, recurrent and highly disabling psychiatric illness. Suicidal behavior is a serious clinical problem in BD. Studies reported that up to 59% of BD patients have suicidal ideation and 25–56% present at least one suicide attempt during lifetime (Abreu et al., 2009). In addition, along with cardiovascular diseases and cancer, suicide is one of the leading causes of mortality among BD patients (Pompili et al., 2013). BD patients have a 20–30 times greater chance of committing suicide than the general population and up to 15% of BD patients commit suicide (Goodwin and Jamison, 2007; Abreu et al., 2009; Pompili et al., 2013). Although it has been hypothesized that suicidal behavior among BD patients is caused by a complex interplay of genetic, neurobiological and environmental factors (Oquendo et al., 2004; Ghaemi et al., 2008; Abreu et al., 2009), little is known about possible modifiable environmental factors that could mitigate or attenuate this complex clinical problem. BD symptoms interfere significantly with family, social and work relationships (Spalt, 1975; Bauwens et al., 1991; American Psychiatric Association, 2002). Many BD patients and their families report difficulties such as extramarital experiences, promiscuous behavior, and low marital adjustment levels (Spalt, 1975; Bauwens et al., 1991). Divorce rates are higher among BD patients compared with the general population (American Psychiatric Association, 2002). Other problems include violence, propensity to accidents and suicidal behavior, already mentioned (Khalsa et al., 2008). As expected, these individual difficulties related to the BD symptomatology and functional impairment might be associated with significant burden among families of BD patients (Pompili, 2014). Recent studies suggest that there may be a bi-directional relationship between some clinical aspects of BD and family environment or functioning (Ellis et al., 2014; Weinstein et al., 2015). Indeed, mounting evidence suggests that BD patients report worse family functioning when compared with healthy subjects and with patients suffering from other psychiatric disorders (Friedmann et al., 1997, Koyama et al., 2004, Unal et al., 2004, Uebelacker et al., 2006, Townsend et al., 2007). The impact of suicidal behavior on family environment or functioning (and vice versa) in BD has been poorly investigated. In children and adolescents with BD, suicidal ideation is associated with higher levels of parental expressed emotion, higher family rigidity (Ellis et al., 2014; Weinstein et al., 2015) and lower adaptability (Goldstein et al., 2009) Worse family functioning is associated with suicidal ideation and with history of suicide attempts (SA) (Algorta et al., 2011). Among patients with major depressive disorder (MDD), worse family functioning is associated with history of suicide attempts, particularly in domains such as problem solving and communication (Keitner et al., 1990; McDermut et al., 2001). To the best of our knowledge, no study investigating family functioning and suicidal behavior in adult BD patients has been published. Furthermore, no previous study has evaluated family functioning among relatives of BD patients The aim of this study was to investigate associations between history of SA and family functioning in BD patients. Our hypothesis was that families of BD patients with history of SA would present worse functioning than families of BD patients without SA. The findings of this study might help clinicians to identify
29
31 31 31 32
characteristic associated with SA, and to help to plan targeted psychosocial interventions to mitigate suicidal behavior among BD patients.
2. Methods 2.1. Patients The sample was comprised of 62 BD type I patients. Subjects were recruited from the Outpatient Clinic of the Bipolar Disorder Program at the Institute of Psychiatry of the University of São Paulo Medical School. Patients were recruited by word of mouth, when they attended their regular appointments, after a brief screening was presented to verify whether they met inclusion and exclusion criteria. The local Institutional Ethics Committee approved the study, and all the patients gave voluntary written informed consent before participating in the study. Inclusion criteria for patients were: age over 18 and a DSM-IV BD I diagnosis, living with at least one first-degree family member (father, mother, siblings, partner). Exclusion criteria were: alcohol or drug abuse during the previous year, pregnancy, living alone, and CNS illnesses including neurological illness, and/or serious medical condition such as hypertension or mellitus diabetes. To include the family perception of family members other than the patients’, and to explore the consistency of responses within the families, for every patient included in the study we invited one relative (patients’ caregiver) to complete the Family Functioning Assessment (please see below). Inclusion criteria for relatives had to meet at least three of five criteria established by Pollak and Perlick:As for the inclusion criteria for relatives, they had to meet at least three of five criteria established by Pollak and Perlick: (1) being a spouse or parent; (2) having more frequent contact with the patient than any other caregiver; (3) helping to support the patient financially; (4) being the contact persona available for treatment staff in case of emergency; (5) being involved in the patient's treatment (Pollack and Perlick, 1991) and living with the patients at the time of last SA. Fifty-one relatives completed the FAD assessment. FAD assessment data is shown below and their data are presented here. 2.2. Psychiatric assessments Diagnostic assessments were all conducted by researchtrained, Board-certified psychiatrists, using the Structured Clinical Interview for DSM-IV Disorders (SCID), Patient Version (First, 2002). The 17-item Hamilton Depression Rating Scale (HAMD-17) (Hamilton, 1960) and the Young Mania Rating Scale (YMRS) (Young et al., 1978) were administered to assess the current severity of depressive and manic symptoms, respectively. Demographic and clinical characteristics of the disease, including psychotic symptoms, psychiatric hospitalizations, family history of mood disorders was obtained using the same standardized protocol and information from the SCID. Suicidal behavior, including number of SA, lethality and severity of SA was evaluated using the Columbia Suicide Severity Rating Scale (C-SSRS) (Oquendo and Mann, 2003). Suicidal ideation in the week prior to participating in the study was evaluated using the Beck Scale for Suicide Ideation
30
M. Berutti et al. / Journal of Affective Disorders 192 (2016) 28–33
(BSS) (Cunha, 2001). 2.3. Family Functioning Assessment The Family Assessment Device (FAD) measures the general family climate and functioning. It is a self-report questionnaire with 60 items which measures family functioning across 6 dimensions: Problem Solving, which represents the family's ability to resolve problems at a level that maintains affective family functioning; Communication, which shows how information is exchanged within the family; Roles, which makes reference to recurrent patterns of behavior by which individuals fulfil family functions; Affective Responsiveness, which means the ability of the family to respond to a range of stimuli with the appropriate quality and quantity of feelings; Affective Involvement, which expresses the degree to which the family as a whole shows interest in and values the activities and interests of individual family members; Behavioral Control, which represents the ways in which the family expresses and maintains behavioral patterns; and General Functioning, which reflects common interactions of the family as a whole. Higher scores on the total scale or on its subdomains correspond to lower family functioning. Mean scores above 2 indicated impaired functioning (Ridenour et al., 1999; Miller et al., 1986; Friedmann et al., 1997; Ryan et al., 2005; Stevenson-Hinde and Akister, 1995). The FAD has shown to have test–retest reliability, internal scale reliability, factorial validity, and discriminant validity (Miller et al., 1994). 2.4. Statistical analysis Participants were divided into two groups: BD patients with history of SA and BD patients without history of SA, and relatives of patients with or without history of SA. Demographic and clinical characteristics of these groups (BD patients with/without history of SA, and relatives of BD patients with/without history of SA) were compared using exact X2 tests for cross-tabulated categorical data and Mann–Whitney U test or T test for ordinal and interval scale data. We used Pearson correlation test to measure the strength and direction of the association between family functioning scores and mood, and suicide ideation rating scores in the patients group. We used linear regression to explore the contributory role of different demographic and clinical variables for each FAD scores in the group of BD patients with history of SA. We selected demographic and clinical variables that were either related to suicidal behavior in the literature, or that were significant in the bivariate correlations. Caregivers were divided into two groups: BD patient's relatives with history of SA and BD patient's relatives without history of SA. FAD scores of these two groups were compared using exact X2 tests. We also compared relatives scores with patients scores using exact X2 tests. Significance was set at p ¼0.05 (two-tailed), and no adjustment for multiple comparisons was made. SPSS (SPSS, Inc., Chicago, IL) version 14.0 was used to perform all the analyses.
3. Results 3.1. Demographic and clinical characteristics There was no statistical difference between the two groups regarding age, sex, socio-economic level and marital status. BD patients with lifetime SA presented a significantly higher number of psychiatric hospitalizations, more history of psychotic symptoms, and higher scores on HAMD, YMRS, and BSS than BD patients without SA. These two groups did not differ in number of
mood, manic, depressive or mixed episodes. Details of demographic and clinical characteristics of the sample are displayed in Table 1. 3.2. Characteristics of suicide Patients with lifetime SA had a mean (7 SD) number of SA of 3 (73). The mean 7 SD age of the first SA among patients with history SA was 27.37 9.0, ranging from 17 to 47 years old. The mean 7SD of years since first SA was 13 78 and the mean 7SD of time elapsed since the last SA was 9.7 77.3 years, ranging from 1 to 34 years. Regarding mood episode during last SA, 29% reported that they were in a manic episode, while 71% reported being in a depressive episode. As regards types of SA, we observed that the most frequently used method was medication overdose (61.3%), followed by cutting wrists (16.1%), jumping from building (3.2%), jumping from a moving car (3.2%), hanging (3.2%), overdose þknife injury (3.2%), overdose þalcohol abuse (3.2%), overdose þjumping in front of a car (3.2%), and gunshot (3.2%). 3.3. Family functioning BD patients with lifetime SA presented significantly higher FAD scores in the Problem Solving (p¼ 0.042), Communication (p ¼0.009), Roles (p ¼0.006) and General Functioning (p ¼0.025) domains when compared with BD patients without SA. There was no statistical difference in Affective Responsiveness (p = 0.052), Affective Involvement (p = 0.172) and Behavior Control (p = 0.684). Mean and SD values as well as statistics of tests are displayed in Table 2. 3.4. Bivariate correlations Among all BD patients, FAD scores in Communication (R¼ 0.28, p ¼0.032); Roles (R ¼ 0.34, p ¼0.008); Affective Responsiveness (R ¼ 0.39, p¼ 0.002) and General Functioning (R¼ 0.34, p¼ 0.010) were significantly correlated with YMRS scores. Among BD patients with SA, FAD Roles scores were correlated with the number of suicide attempts (R ¼ 0.62, p ¼0.001) and years since last SA (R¼ 0.47, p ¼0.014). There were no Table 1 Demographic and clinical characteristics of BD patients with and without history of SA. Characteristics
BD without SA (n¼ 31)
BD with SA (n¼ 31)
P-value
Age in years, mean (SD) Female, n (%) Age of illness onset in years, mean (SD) Illness duration in years, mean (SD) Lifetime psychiatric hospitalization, n (%) Number of psychiatric hospitalizations, mean (SD) Lifetime psychosis, n (%) YMRS score, mean (SD) HAMD score, mean (SD) Number of mood episodes, mean (SD) Number of manic episodes, mean (SD) Number of depressive episodes, mean (SD) Suicide ideation Beck scores mean (SD) Suicide ideation Beck lower than 6 n (%)
42 (9) 16 (51.6) 22.48 (7.54)
40 (8) 23 (74.2) 20.97 (8.98)
0.40 0.11 0.374
19.53 (11.78) 13 (41.93)
20.11 (8.95) 20 (64.51)
0.731 0.152
1 (2)
3 (4)
0.025
14 (45.16) 2 (3) 2 (3) 23.40 (23.54)
23 (74.19) 3 (4) 6 (5) 30.63 (20.11)
0.037 0.001 0.006 0.306
10 (12)
11 (10)
0.643
17 (14)
17 (14)
0.733
0.77 (3.11)
6.25(10.32)
0.014
30 (96.7)
23 (74.1)
0.024
M. Berutti et al. / Journal of Affective Disorders 192 (2016) 28–33
Table 2 Family Assessment Device (FAD) scores in groups of BD patients with and without history of SA.
Problem Solving mean (SD) Communication mean (SD) Roles mean (SD) Affective Responsiveness mean (SD) Affective Involvement mean (SD) Behavior Control mean (SD) General Functioning mean (SD)
BD without SA (n¼ 31)
BD with SA (n¼ 31) P-value
2.11 (0.51)
2.45 (0.71)
0.042
2.23 (0.49)
2.62 (0.55)
0.009
2.40 (0.33) 2.27 (0.63)
2.66 (0.42) 2.58 (0.66)
0.006 0.052
2.42 (0.37)
2.54 (0.54)
0.172
2.10 (0.37)
2.10 (0.44)
0.684
2.12 (0.60)
2.47 (0.60)
0.025
Abbreviations: BD (bipolar disorder); SA (suicide attempts); SD (standard deviation)
significant correlations between FAD scores and BSS (R values all ranging from 0.004 to 1; p values ranging from 0.344 to 0.941). 3.5. Linear regression Linear regression for each of the FAD dimensions, controlled by age, gender, HAMD scores, YMRS scores, BSS scores, number of SA, and time elapsed since last SA, using only the BD group with SA showed that only age was associated with changes in Affective Responsiveness scores (t¼ 2.7, p ¼0.02; 95% CI 0.01–0.08). Post hoc analysis dividing the BD patients into those with (n ¼33) and without (n ¼29) psychiatric hospitalizations, and those with (n ¼37) and without (n ¼24) history of psychotic symptoms, showed that these variables were not associated with differences in FAD scores (all p values 40.26). 3.6. FAD scores in relatives of BD patients Relatives of BD patients with history of SA did not significantly differ from relatives of BD patients without SA regarding age (mean7 SD: 48 713.2 versus 52 714.3 years old, respectively, p ¼0.27) and gender (22 women, 71% vs 19 women, 66%, p ¼0.78). Relatives of BD patients with history of SA presented higher scores in Communication (p¼ 0.019), Roles (p ¼0.027) and Affective Responsiveness (p ¼0.002) when compared with relatives of BD patients without history of SA. There were no significant differences in the other FAD domains between groups of relatives of BD patients with or without history of SA (See Table 3 for details). FAD scores of BD patients were positively correlated with FAD scores of relatives in all domains (R values ranging from 0.359 to 0.674; p values ranging from o0 to 0.013)
4. Discussion The main goal in this study was to investigate the association between family functioning and history of SA among BD patients. In order to accomplish our objective, we compared the perception of family functioning between BD patients who presented at least one SA in their lifetime with BD patients who never presented any SA. We found that BD patients with lifetime SA presented significantly higher scores in several subscales of the FAD, including Problem Solving, Communication, Roles, and General Functioning, when compared with BD patients without SA. This suggests that patients with lifetime SA perceived their families as having a
31
Table 3 Family Assessment Device (FAD) scores in groups of relatives of BD patients with or without history of SA. FAD scores, mean (SD)
Relatives of BD patients without SA (n¼ 29)
Relatives of BD patients with SA (n¼ 22)
P value
Problem Solving Communication Roles Affective Responsiveness Affective Involvement Behavior Control General Functioning
2.09 2.23 2.45 1.96
2.28 2.58 2.69 2.53
(0.51) (0.53) (0.36) (0.63)
0.224 0.019 0.027 0.002
2.32 (0.47) 2.16 (0.43) 2.36 (0.57)
0.702 0.461 0.035
(0.59) (0.43) (0.39) (0.55)
2.27 (0.40) 2.08 (0.31) 2.02 (0.51)
Abbreviations: BD (bipolar disorder); SA (suicide attempts); SD (standard deviation).
worse family functioning than patients without SA history. Moreover, among BD patients with lifetime SA, FAD subscores of Roles were negatively correlated with number of SA and time elapsed since last SA. Ours results are in line with two previous studies that investigated the association between suicidal behavior and family environment or functioning in adolescents with BD (Goldstein et al., 2009; Algorta et al., 2011). Goldstein et al. (2009) used the Family Adaptability and Cohesion Evaluation Scale in 446 youth BD patients and found that young BD patients with current suicidal ideation perceived their families as presenting lower adaptability levels than BD patients without suicidal ideation. Algorta et al. (2011) used a shorter version of the FAD to evaluate family functioning among 138 youth with BD (lifetime SA and current suicidal ideation) and found that young BD patients with lifetime SA present worse family functioning than young BD patients without SA. In this study, the groups of BD patients were mostly similar in regard to the clinical characteristics of the disease. It is worth mentioning that BD patients with history of SA had higher number of psychiatric hospitalizations, and higher frequency of psychotic symptoms than BD patients without history of SA. This is expected, as patients with SA are more likely to be hospitalized following their attempts. Psychosis has been linked to suicidal behavior in BD (Chen et al., 2014), in borderline personality disorder (Zeng et al., 2015), and in schizophrenia as well (Finseth et al., 2014). It is noteworthy that, on a post hoc analysis, we subdivided the groups according to the presence of lifetime psychotic symptoms or psychiatric hospitalizations, and we found no differences in FAD scores between the groups. This suggests that, in our sample, those factors were not related with worse family functioning. Both BD groups had low depressive and manic symptoms scores, and their mean scores were below a proposed threshold for euthymia, suggesting that our sample was mostly euthymic or with subthreshold symptomatology. On the other hand, despite relatively low mood symptoms scores, patients with lifetime SA presented higher suicidal ideation scores than BD patients without SA. This may suggest dissociation between mood symptoms and suicidal ideation, which may reflect a suicidal diathesis among BD patients despite current mood state. On the other hand, linear regression analyses for each FAD scores in the group with SA showed that only age was associated with changes in FAD scores (specifically Affective Responsiveness), while other variables such as age, gender, current depressive or manic symptoms, current suicidal ideation, number of SA, time since last SA, did not predict changes in FAD scores in the group with SA. This suggests that: (1) current mood symptoms are less likely to affect the response of FAD, which is important to consider given that it is a self-report
32
M. Berutti et al. / Journal of Affective Disorders 192 (2016) 28–33
questionnaire; (2) current suicidal ideation does not explain the association between prior SA and worse FAD scores; (3) the number of times a person attempted suicide does not affect his/ her family functioning or at least the way they perceive their families, to a certain extent in most of the FAD domains. Among BD patients with lifetime SA, the Roles subdomain has a negative correlation with number of SA and with time elapsed since last hospitalization. This suggests that the family functioning of Roles is worse over a shorter period since the last SA, which is expected. The negative correlation between Roles score and number of SA is counterintuitive. We can only speculate that, with an increased number of SA and as a need to cope with it, family functioning may evolve to achieve a better definition of roles within that family. More research is necessary to confirm and further understand this relationship. Our results also suggest that family members of BD patients tend to perceive their families largely in the same way of patients. Relatives of BD patients with lifetime SA presented higher scores in FAD in at least 3 of the FAD subscales (i.e., Communications, Roles, and Affective Responsiveness), and in the General Functioning scale. The responses of patients and relatives were also largely consistent, as suggested by the strong correlations between both groups in all FAD scores. This is consistent with the findings of Koyama et al. (2004), who also found that family functioning perception was positively correlated between BD patients and its relatives. It is worth highlighting that these findings should be interpreted with caution. Their relevance lies on the assumption that relatives might have a perception of their family that is less biased by the clinical characteristics of the disease that are inherent to the patient, such as current mood symptoms or current suicidal ideation, or by subjective experiences related to the SA. However, it should be noted that we have not examined the relatives for the presence of psychiatric diseases or mood symptomatology, which could potentially influence their responses. The results of this study have to be considered in the light of some limitations. It is a cross-sectional study, and inferences of causality between family functioning and SA cannot be made. Moreover, the time elapsed since the last SA was very long for some of the patients, and it is possible that a family constellation might have evolved and changed since the last SA. However, we recruited only patients who were still living with the same relative at the time of the last SA. On the other hand, the fact that worse FAD scores are present in families of BD patients who attempted suicide long time ago may suggest that family functioning might still be dysfunctional for a long time after a SA, either because family functioning is characterized by enduring patterns, or because SA are part of a suicidal diathesis that is trait-like and keeps influencing family functioning over time. Third, even though the sample was well characterized regarding clinical characteristics of BD and suicide, the sample size was small, limiting the power to detect potential relevant associations between suicidal attempts and female gender. Also, we excluded BD patients with alcohol or drug abuse during the previous year, pregnancy, or living alone, which limits the geralizability of our findings. Finally, our results are not corrected for multiple comparisons; thus they should be considered preliminary. Confirmation by further studies is needed. As for the strength of this study and to the best of our knowledge, this is the first research work to evaluate the association between family functioning and SA in adult BD patients. Our sample was well characterized regarding clinical characteristics of BD, and every effort was made to verify if other characteristics of BD influenced our results. Moreover, in our sample, depressive, manic, and suicide ideation rating scores were very low and they were not likely to influence our results. In conclusion, we found that BD patients who attempted suicide at least once in their life present worse family functioning
than BD patients who never attempted suicide, specifically in areas such as Problem Solving, Communication, Roles and General Functioning. Worse family functioning was not associated with other characteristics of BD. We also found that among BD patients with lifetime SA, the family functioning of Roles is worse with shorter time since the last SA, and with less number of SA. Family members of BD patients with SA tend to perceive their family functioning largely in the same way as patients. Further studies could investigate the association between family functioning and suicide attempts in bipolar disorder in a prospective fashion or on a timeline that is closer to the suicide attempt. If worse family functioning is causally associated with higher probability of suicide attempts, intervention tools such as family therapy might help to mitigate the morbidity and mortality associated with suicidal behavior in BD.
References Abreu, L.N., Lafer, B., Baca-Garcia, E., Oquendo, M.A., 2009. Suicidal ideation and suicide attempts in bipolar disorder type I: an update for the clinician. Rev. Bras. Psiquiatr. 31 (3), 271–280. Algorta, G.P., Youngstrom, E.A., Frazier, T.W., Freeman, A.J., Youngstrom, J.K., Findling, R.L., 2011. Suicidality in pediatric bipolar disorder: predictor or outcome of family processes and mixed mood presentation? Bipolar Disord. 13 (1), 76–86. American Psychiatric Association, 2002. Practice guideline for the treatment of patients with bipolar disorder (revision). Am. J. Psychiatry 159 (4 Suppl.), 1–50. Bauwens, F., Tracy, A., Pardoen, D., Vander Elst, M., Mendlewicz, J., 1991. Social adjustment of remitted bipolar and unipolar out-patients. A comparison with age- and sex-matched controls. Br. J. Psychiatry 159, 239–244. Chen, C.-Y., Yeh, H.-H., Huang, N., Lin, Y.-C., 2014. Socioeconomic and clinical characteristics associated with repeat suicide attempts among young people. J. Adolesc. Health 54 (5), 550–557. Cunha, J.A., 2001. Manual da Versão em Português dasEscalas Beck. Casa do Psicólogo, São Paulo. Ellis, A.J., Portnoff, L.C., Axelson, D.A., Kowatch, R.A., Walshaw, P., Miklowitz, D.J., 2014. Parental expressed emotion and suicidal ideation in adolescents with bipolar disorder. Psychiatry Res. 216 (2), 213–216. Finseth, P.I., Sønderby, I.E., Djurovic, S., Agartz, I., Malt, U.F., Melle, I., Tesli, M., 2014. Association analysis between suicidal behaviour and candidate genes of bipolar disorder and schizophrenia. J. Affect. Disord. 163, 110–114. First, M.B., 2002. The DSM series and experience with DSM-IV. Psychopathology 35 (2–3), 67–71. Friedmann, M.S., McDermut, W.H., Solomon, D.A., Ryan, C.E., Keitner, G.I., Miller, I. W., 1997. Family functioning and mental illness: a comparison of psychiatric and nonclinical families. Fam. Process. 36 (4), 357–367. Ghaemi, S.N., Bauer, M., Cassidy, F., Malhi, G.S., Mitchell, P., Phelps, J., Vieta, E., Youngstrom, E., ISBD Diagnostic Guidelines Task Force, 2008. Diagnostic guidelines for bipolar disorder: a summary of the International Society for Bipolar Disorders Diagnostic Guidelines Task Force Report. Bipolar Disord. 10 (1 Pt 2), 117–128. Goldstein, T.R., Birmaher, B., Axelson, D., Goldstein, B.I., Gill, M.K., Esposito-Smythers, C., Keller, M., 2009. Family environment and suicidal ideation among bipolar youth. Arch. Suicide Res. 13 (4), 378–388. Goodwin, F.K., Jamison, KR., 2007. Manic-depressive illness: bipolar disorder and recurrent depression. Oxford University Press, Oxford. Hamilton, M., 1960. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 23, 56–62. Keitner, G.I., Ryan, C.E., Miller, I.W., Epstein, N.B., Bishop, D.S., Norman, W.H., 1990. Family functioning, social adjustment, and recurrence of suicidality. Psychiatry 53 (1), 17–30. Khalsa, H.M., Salvatore, P., Hennen, J., Baethge, C., Tohen, M., Baldessarini, R.J., 2008. Suicidal events and accidents in 216 first-episode bipolar I disorder patients: predictive factors. J. Affect. Disord. 106 (1–2), 179–184. Koyama, A., Akiyama, T., Miyake, Y., Kurita, H., 2004. Family functioning perceived by patients and their family members in three diagnostic and statistical manual-IV diagnostic groups. Psychiatry Clin. Neurosci. 58 (5), 495–500. McDermut, W., Miller, I.W., Solomon, D., Ryan, C.E., Keitner, G.I., 2001. Family functioning and suicidality in depressed adults. Compr. Psychiatry 42 (2), 96–104. Miller, I.W., Kabacoff, R.I., Keitner, G.I., Epstein, N.B., Bishop, D.S., 1986. Family functioning in the families of psychiatric patients. Compr. Psychiatry 27 (4), 302–312. Miller, I.W., Kabacoff, R.I., Epstein, N.B., Bishop, D.S., Keitner, G.I., Baldwin, L.M., van der Spuy, H.I., 1994. The development of a clinical rating scale for the McMaster model of family functioning. Fam. Process. 33 (1), 53–69. Oquendo, M.A., Mann, J.J., 2003. Intervention research for suicidal behaviour. Lancet 362 (9387), 844–845. Oquendo, M.A., Galfalvy, H., Russo, S., Ellis, S.P., Grunebaum, M.F., Burke, A., Mann, J. J., 2004. Prospective study of clinical predictors of suicidal acts after a major
M. Berutti et al. / Journal of Affective Disorders 192 (2016) 28–33
depressive episode in patients with major depressive disorder or bipolar disorder. Am. J. Psychiatry 161 (8), 1433–1441. Pollak, C.P., Perlick, D., 1991. Sleep problems and institutionalization of the elderly. J Geriatr Psychiatry Neurol. 4 (4), 204–210. Pompili, M., 2014. Suicide prevention and the role of the psychiatrist. Riv. Psichiatr. 49 (5), 197–198. Pompili, M., Gonda, X., Serafini, G., Innamorati, M., Sher, L., Amore, M., Girardi, P., 2013. Epidemiology of suicide in bipolar disorders: a systematic review of the literature. Bipolar Disord. 15 (5), 457–490. Ridenour, T.A., Daley, J.G., Reich, W., 1999. Factor analyses of the family assessment device. Fam. Process. 38 (4), 497–510. Spalt, L., 1975. Demorgraphic characteristics in affective disorders. Dis. Nerv. Syst. 36 (4), 209–214. Stevenson-Hinde, J., Akister, J., 1995. The McMaster Model of Family Functioning: observer and parental ratings in a nonclinical sample. Fam. Process. 34 (3), 337–347. Ryan, C.E., Epstein, N.B., Keitner, G.I., Miller, E.W., Bishop, DS., 2005. Evaluating and treating families: The McMaster approach. Taylor & Francis, New York. Townsend, L.D., Demeter, C.A., Youngstrom, E., Drotar, D., Findling, R.L., 2007.
33
Family conflict moderates response to pharmacological intervention in pediatric bipolar disorder. J. Child. Adolesc. Psychopharmacol. 17 (6), 843–852. Uebelacker, L.A., Beevers, C.G., Battle, C.L., Strong, D., Keitner, G.I., Ryan, C.E., Miller, I.W., 2006. Family functioning in bipolar I disorder. J. Fam. Psychol. 20 (4), 701–704. Unal, S., Kaya, B., Cekem, B., Ozişik, H.I., Cakil, G., Kaya, M., 2004. Family functioning in patients with schizophrenia, bipolar affective disorder and epilepsy. Turk. Psikiyatr. Derg. 15 (4), 291–299. Weinstein, S.M., Van Meter, A., Katz, A.C., Peters, A.T., West, A.E., 2015. Cognitive and family correlates of current suicidal ideation in children with bipolar disorder. J. Affect. Disord. 173, 15–21. http://dx.doi.org/10.1016/j.jad.2014.10.058 (Fonte). Young, R.C., Biggs, J.T., Ziegler, V.E., Meyer, D.A., 1978. A rating scale for mania: reliability, validity and sensitivity. Br. J. Psychiatry 133, 429–435. Zeng, R., Cohen, L.J., Tanis, T., Qizilbash, A., Lopatyuk, Y., Yaseen, Z.S., Galynker, I., 2015. Assessing the contribution of borderline personality disorder and features to suicide risk in psychiatric inpatients with bipolar disorder, major depression and schizoaffective disorder. Psychiatry Res. 226 (1), 361–367.
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Review article
Association between history of suicide attempts and family functioning in bipolar disorder Mariangeles Berutti a,n, Rodrigo Silva Dias a, Vivian Alves Pereira a, Beny Lafer a, Fabiano G. Nery a,b a b
Bipolar Disorder Program (PROMAN), Department of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil Department of Psychiatry & Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 6 October 2015 Received in revised form 19 November 2015 Accepted 11 December 2015 Available online 12 December 2015
Objectives: To investigate the association between history of suicide attempts (SA) and family functioning in bipolar disorder (BD) patients. Methods: Thirty-one BD type I patients with lifetime history of SA, 31 BD type I with no lifetime history of SA, participating in the Outpatient Clinic of the Bipolar Disorder Program at the Institute of Psychiatry of the University of São Paulo Medical School were recruited for this study. We used the Family Assessment Device (FAD) to evaluate family functioning. We compared these two groups on demographic and clinical variables to identify which variables were associated with family functioning impairment. Fifty-one relatives of the same patients were also asked to complete a FAD. Results: BD patients with SA presented more psychiatric hospitalizations, higher frequency of psychotic symptoms, and higher scores on depressive, manic, and suicidal ideation than BD patients without SA. BD patients with SA presented significantly higher scores in several subscales of the FAD, including Problem Solving (p¼ 0.042), Communication (p¼0.009), Roles (p ¼0.006), and General Functioning (p¼ 0.025), when compared with BD patients without SA. Relatives of BD patients with SA presented significantly higher scores in Communication, Roles, Affective Responsiveness, and General Functioning than relatives of BD patients without SA. Limitations: Cross-sectional study and long time elapsed since last SA. Conclusion: History of SA in BD is associated with worse family functioning in several domains of FAD, including Problem Solving, Communication, Roles, and General Functioning. As suicide attempts are routinely assessed in clinical practice, these findings may help to identify patients with poorer family functioning and may suggest a role for environmental risk factors in suicidal behavior among BD patients. & 2015 Published by Elsevier B.V.
Keywords: Bipolar disorder Family functioning Suicide attempt
Contents 1. 2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Psychiatric assessments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Family Functioning Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Demographic and clinical characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Characteristics of suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Family functioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4. Bivariate correlations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29 29 29 29 30 30 30 30 30 30 30
n Correspondence to: Institute & Department of Psychiatry, University of Sao Paulo Medical School, Rua Dr. Ovidio Pires de Campos, 785, Cerqueira Cesar, Sao Paulo, SP 05403-010, Brazil. E-mail address: [email protected] (M. Berutti).
http://dx.doi.org/10.1016/j.jad.2015.12.010 0165-0327/& 2015 Published by Elsevier B.V.
M. Berutti et al. / Journal of Affective Disorders 192 (2016) 28–33
3.5. Linear regression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6. FAD scores in relatives of BD patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction Bipolar disorder (BD) is a serious, recurrent and highly disabling psychiatric illness. Suicidal behavior is a serious clinical problem in BD. Studies reported that up to 59% of BD patients have suicidal ideation and 25–56% present at least one suicide attempt during lifetime (Abreu et al., 2009). In addition, along with cardiovascular diseases and cancer, suicide is one of the leading causes of mortality among BD patients (Pompili et al., 2013). BD patients have a 20–30 times greater chance of committing suicide than the general population and up to 15% of BD patients commit suicide (Goodwin and Jamison, 2007; Abreu et al., 2009; Pompili et al., 2013). Although it has been hypothesized that suicidal behavior among BD patients is caused by a complex interplay of genetic, neurobiological and environmental factors (Oquendo et al., 2004; Ghaemi et al., 2008; Abreu et al., 2009), little is known about possible modifiable environmental factors that could mitigate or attenuate this complex clinical problem. BD symptoms interfere significantly with family, social and work relationships (Spalt, 1975; Bauwens et al., 1991; American Psychiatric Association, 2002). Many BD patients and their families report difficulties such as extramarital experiences, promiscuous behavior, and low marital adjustment levels (Spalt, 1975; Bauwens et al., 1991). Divorce rates are higher among BD patients compared with the general population (American Psychiatric Association, 2002). Other problems include violence, propensity to accidents and suicidal behavior, already mentioned (Khalsa et al., 2008). As expected, these individual difficulties related to the BD symptomatology and functional impairment might be associated with significant burden among families of BD patients (Pompili, 2014). Recent studies suggest that there may be a bi-directional relationship between some clinical aspects of BD and family environment or functioning (Ellis et al., 2014; Weinstein et al., 2015). Indeed, mounting evidence suggests that BD patients report worse family functioning when compared with healthy subjects and with patients suffering from other psychiatric disorders (Friedmann et al., 1997, Koyama et al., 2004, Unal et al., 2004, Uebelacker et al., 2006, Townsend et al., 2007). The impact of suicidal behavior on family environment or functioning (and vice versa) in BD has been poorly investigated. In children and adolescents with BD, suicidal ideation is associated with higher levels of parental expressed emotion, higher family rigidity (Ellis et al., 2014; Weinstein et al., 2015) and lower adaptability (Goldstein et al., 2009) Worse family functioning is associated with suicidal ideation and with history of suicide attempts (SA) (Algorta et al., 2011). Among patients with major depressive disorder (MDD), worse family functioning is associated with history of suicide attempts, particularly in domains such as problem solving and communication (Keitner et al., 1990; McDermut et al., 2001). To the best of our knowledge, no study investigating family functioning and suicidal behavior in adult BD patients has been published. Furthermore, no previous study has evaluated family functioning among relatives of BD patients The aim of this study was to investigate associations between history of SA and family functioning in BD patients. Our hypothesis was that families of BD patients with history of SA would present worse functioning than families of BD patients without SA. The findings of this study might help clinicians to identify
29
31 31 31 32
characteristic associated with SA, and to help to plan targeted psychosocial interventions to mitigate suicidal behavior among BD patients.
2. Methods 2.1. Patients The sample was comprised of 62 BD type I patients. Subjects were recruited from the Outpatient Clinic of the Bipolar Disorder Program at the Institute of Psychiatry of the University of São Paulo Medical School. Patients were recruited by word of mouth, when they attended their regular appointments, after a brief screening was presented to verify whether they met inclusion and exclusion criteria. The local Institutional Ethics Committee approved the study, and all the patients gave voluntary written informed consent before participating in the study. Inclusion criteria for patients were: age over 18 and a DSM-IV BD I diagnosis, living with at least one first-degree family member (father, mother, siblings, partner). Exclusion criteria were: alcohol or drug abuse during the previous year, pregnancy, living alone, and CNS illnesses including neurological illness, and/or serious medical condition such as hypertension or mellitus diabetes. To include the family perception of family members other than the patients’, and to explore the consistency of responses within the families, for every patient included in the study we invited one relative (patients’ caregiver) to complete the Family Functioning Assessment (please see below). Inclusion criteria for relatives had to meet at least three of five criteria established by Pollak and Perlick:As for the inclusion criteria for relatives, they had to meet at least three of five criteria established by Pollak and Perlick: (1) being a spouse or parent; (2) having more frequent contact with the patient than any other caregiver; (3) helping to support the patient financially; (4) being the contact persona available for treatment staff in case of emergency; (5) being involved in the patient's treatment (Pollack and Perlick, 1991) and living with the patients at the time of last SA. Fifty-one relatives completed the FAD assessment. FAD assessment data is shown below and their data are presented here. 2.2. Psychiatric assessments Diagnostic assessments were all conducted by researchtrained, Board-certified psychiatrists, using the Structured Clinical Interview for DSM-IV Disorders (SCID), Patient Version (First, 2002). The 17-item Hamilton Depression Rating Scale (HAMD-17) (Hamilton, 1960) and the Young Mania Rating Scale (YMRS) (Young et al., 1978) were administered to assess the current severity of depressive and manic symptoms, respectively. Demographic and clinical characteristics of the disease, including psychotic symptoms, psychiatric hospitalizations, family history of mood disorders was obtained using the same standardized protocol and information from the SCID. Suicidal behavior, including number of SA, lethality and severity of SA was evaluated using the Columbia Suicide Severity Rating Scale (C-SSRS) (Oquendo and Mann, 2003). Suicidal ideation in the week prior to participating in the study was evaluated using the Beck Scale for Suicide Ideation
30
M. Berutti et al. / Journal of Affective Disorders 192 (2016) 28–33
(BSS) (Cunha, 2001). 2.3. Family Functioning Assessment The Family Assessment Device (FAD) measures the general family climate and functioning. It is a self-report questionnaire with 60 items which measures family functioning across 6 dimensions: Problem Solving, which represents the family's ability to resolve problems at a level that maintains affective family functioning; Communication, which shows how information is exchanged within the family; Roles, which makes reference to recurrent patterns of behavior by which individuals fulfil family functions; Affective Responsiveness, which means the ability of the family to respond to a range of stimuli with the appropriate quality and quantity of feelings; Affective Involvement, which expresses the degree to which the family as a whole shows interest in and values the activities and interests of individual family members; Behavioral Control, which represents the ways in which the family expresses and maintains behavioral patterns; and General Functioning, which reflects common interactions of the family as a whole. Higher scores on the total scale or on its subdomains correspond to lower family functioning. Mean scores above 2 indicated impaired functioning (Ridenour et al., 1999; Miller et al., 1986; Friedmann et al., 1997; Ryan et al., 2005; Stevenson-Hinde and Akister, 1995). The FAD has shown to have test–retest reliability, internal scale reliability, factorial validity, and discriminant validity (Miller et al., 1994). 2.4. Statistical analysis Participants were divided into two groups: BD patients with history of SA and BD patients without history of SA, and relatives of patients with or without history of SA. Demographic and clinical characteristics of these groups (BD patients with/without history of SA, and relatives of BD patients with/without history of SA) were compared using exact X2 tests for cross-tabulated categorical data and Mann–Whitney U test or T test for ordinal and interval scale data. We used Pearson correlation test to measure the strength and direction of the association between family functioning scores and mood, and suicide ideation rating scores in the patients group. We used linear regression to explore the contributory role of different demographic and clinical variables for each FAD scores in the group of BD patients with history of SA. We selected demographic and clinical variables that were either related to suicidal behavior in the literature, or that were significant in the bivariate correlations. Caregivers were divided into two groups: BD patient's relatives with history of SA and BD patient's relatives without history of SA. FAD scores of these two groups were compared using exact X2 tests. We also compared relatives scores with patients scores using exact X2 tests. Significance was set at p ¼0.05 (two-tailed), and no adjustment for multiple comparisons was made. SPSS (SPSS, Inc., Chicago, IL) version 14.0 was used to perform all the analyses.
3. Results 3.1. Demographic and clinical characteristics There was no statistical difference between the two groups regarding age, sex, socio-economic level and marital status. BD patients with lifetime SA presented a significantly higher number of psychiatric hospitalizations, more history of psychotic symptoms, and higher scores on HAMD, YMRS, and BSS than BD patients without SA. These two groups did not differ in number of
mood, manic, depressive or mixed episodes. Details of demographic and clinical characteristics of the sample are displayed in Table 1. 3.2. Characteristics of suicide Patients with lifetime SA had a mean (7 SD) number of SA of 3 (73). The mean 7 SD age of the first SA among patients with history SA was 27.37 9.0, ranging from 17 to 47 years old. The mean 7SD of years since first SA was 13 78 and the mean 7SD of time elapsed since the last SA was 9.7 77.3 years, ranging from 1 to 34 years. Regarding mood episode during last SA, 29% reported that they were in a manic episode, while 71% reported being in a depressive episode. As regards types of SA, we observed that the most frequently used method was medication overdose (61.3%), followed by cutting wrists (16.1%), jumping from building (3.2%), jumping from a moving car (3.2%), hanging (3.2%), overdose þknife injury (3.2%), overdose þalcohol abuse (3.2%), overdose þjumping in front of a car (3.2%), and gunshot (3.2%). 3.3. Family functioning BD patients with lifetime SA presented significantly higher FAD scores in the Problem Solving (p¼ 0.042), Communication (p ¼0.009), Roles (p ¼0.006) and General Functioning (p ¼0.025) domains when compared with BD patients without SA. There was no statistical difference in Affective Responsiveness (p = 0.052), Affective Involvement (p = 0.172) and Behavior Control (p = 0.684). Mean and SD values as well as statistics of tests are displayed in Table 2. 3.4. Bivariate correlations Among all BD patients, FAD scores in Communication (R¼ 0.28, p ¼0.032); Roles (R ¼ 0.34, p ¼0.008); Affective Responsiveness (R ¼ 0.39, p¼ 0.002) and General Functioning (R¼ 0.34, p¼ 0.010) were significantly correlated with YMRS scores. Among BD patients with SA, FAD Roles scores were correlated with the number of suicide attempts (R ¼ 0.62, p ¼0.001) and years since last SA (R¼ 0.47, p ¼0.014). There were no Table 1 Demographic and clinical characteristics of BD patients with and without history of SA. Characteristics
BD without SA (n¼ 31)
BD with SA (n¼ 31)
P-value
Age in years, mean (SD) Female, n (%) Age of illness onset in years, mean (SD) Illness duration in years, mean (SD) Lifetime psychiatric hospitalization, n (%) Number of psychiatric hospitalizations, mean (SD) Lifetime psychosis, n (%) YMRS score, mean (SD) HAMD score, mean (SD) Number of mood episodes, mean (SD) Number of manic episodes, mean (SD) Number of depressive episodes, mean (SD) Suicide ideation Beck scores mean (SD) Suicide ideation Beck lower than 6 n (%)
42 (9) 16 (51.6) 22.48 (7.54)
40 (8) 23 (74.2) 20.97 (8.98)
0.40 0.11 0.374
19.53 (11.78) 13 (41.93)
20.11 (8.95) 20 (64.51)
0.731 0.152
1 (2)
3 (4)
0.025
14 (45.16) 2 (3) 2 (3) 23.40 (23.54)
23 (74.19) 3 (4) 6 (5) 30.63 (20.11)
0.037 0.001 0.006 0.306
10 (12)
11 (10)
0.643
17 (14)
17 (14)
0.733
0.77 (3.11)
6.25(10.32)
0.014
30 (96.7)
23 (74.1)
0.024
M. Berutti et al. / Journal of Affective Disorders 192 (2016) 28–33
Table 2 Family Assessment Device (FAD) scores in groups of BD patients with and without history of SA.
Problem Solving mean (SD) Communication mean (SD) Roles mean (SD) Affective Responsiveness mean (SD) Affective Involvement mean (SD) Behavior Control mean (SD) General Functioning mean (SD)
BD without SA (n¼ 31)
BD with SA (n¼ 31) P-value
2.11 (0.51)
2.45 (0.71)
0.042
2.23 (0.49)
2.62 (0.55)
0.009
2.40 (0.33) 2.27 (0.63)
2.66 (0.42) 2.58 (0.66)
0.006 0.052
2.42 (0.37)
2.54 (0.54)
0.172
2.10 (0.37)
2.10 (0.44)
0.684
2.12 (0.60)
2.47 (0.60)
0.025
Abbreviations: BD (bipolar disorder); SA (suicide attempts); SD (standard deviation)
significant correlations between FAD scores and BSS (R values all ranging from 0.004 to 1; p values ranging from 0.344 to 0.941). 3.5. Linear regression Linear regression for each of the FAD dimensions, controlled by age, gender, HAMD scores, YMRS scores, BSS scores, number of SA, and time elapsed since last SA, using only the BD group with SA showed that only age was associated with changes in Affective Responsiveness scores (t¼ 2.7, p ¼0.02; 95% CI 0.01–0.08). Post hoc analysis dividing the BD patients into those with (n ¼33) and without (n ¼29) psychiatric hospitalizations, and those with (n ¼37) and without (n ¼24) history of psychotic symptoms, showed that these variables were not associated with differences in FAD scores (all p values 40.26). 3.6. FAD scores in relatives of BD patients Relatives of BD patients with history of SA did not significantly differ from relatives of BD patients without SA regarding age (mean7 SD: 48 713.2 versus 52 714.3 years old, respectively, p ¼0.27) and gender (22 women, 71% vs 19 women, 66%, p ¼0.78). Relatives of BD patients with history of SA presented higher scores in Communication (p¼ 0.019), Roles (p ¼0.027) and Affective Responsiveness (p ¼0.002) when compared with relatives of BD patients without history of SA. There were no significant differences in the other FAD domains between groups of relatives of BD patients with or without history of SA (See Table 3 for details). FAD scores of BD patients were positively correlated with FAD scores of relatives in all domains (R values ranging from 0.359 to 0.674; p values ranging from o0 to 0.013)
4. Discussion The main goal in this study was to investigate the association between family functioning and history of SA among BD patients. In order to accomplish our objective, we compared the perception of family functioning between BD patients who presented at least one SA in their lifetime with BD patients who never presented any SA. We found that BD patients with lifetime SA presented significantly higher scores in several subscales of the FAD, including Problem Solving, Communication, Roles, and General Functioning, when compared with BD patients without SA. This suggests that patients with lifetime SA perceived their families as having a
31
Table 3 Family Assessment Device (FAD) scores in groups of relatives of BD patients with or without history of SA. FAD scores, mean (SD)
Relatives of BD patients without SA (n¼ 29)
Relatives of BD patients with SA (n¼ 22)
P value
Problem Solving Communication Roles Affective Responsiveness Affective Involvement Behavior Control General Functioning
2.09 2.23 2.45 1.96
2.28 2.58 2.69 2.53
(0.51) (0.53) (0.36) (0.63)
0.224 0.019 0.027 0.002
2.32 (0.47) 2.16 (0.43) 2.36 (0.57)
0.702 0.461 0.035
(0.59) (0.43) (0.39) (0.55)
2.27 (0.40) 2.08 (0.31) 2.02 (0.51)
Abbreviations: BD (bipolar disorder); SA (suicide attempts); SD (standard deviation).
worse family functioning than patients without SA history. Moreover, among BD patients with lifetime SA, FAD subscores of Roles were negatively correlated with number of SA and time elapsed since last SA. Ours results are in line with two previous studies that investigated the association between suicidal behavior and family environment or functioning in adolescents with BD (Goldstein et al., 2009; Algorta et al., 2011). Goldstein et al. (2009) used the Family Adaptability and Cohesion Evaluation Scale in 446 youth BD patients and found that young BD patients with current suicidal ideation perceived their families as presenting lower adaptability levels than BD patients without suicidal ideation. Algorta et al. (2011) used a shorter version of the FAD to evaluate family functioning among 138 youth with BD (lifetime SA and current suicidal ideation) and found that young BD patients with lifetime SA present worse family functioning than young BD patients without SA. In this study, the groups of BD patients were mostly similar in regard to the clinical characteristics of the disease. It is worth mentioning that BD patients with history of SA had higher number of psychiatric hospitalizations, and higher frequency of psychotic symptoms than BD patients without history of SA. This is expected, as patients with SA are more likely to be hospitalized following their attempts. Psychosis has been linked to suicidal behavior in BD (Chen et al., 2014), in borderline personality disorder (Zeng et al., 2015), and in schizophrenia as well (Finseth et al., 2014). It is noteworthy that, on a post hoc analysis, we subdivided the groups according to the presence of lifetime psychotic symptoms or psychiatric hospitalizations, and we found no differences in FAD scores between the groups. This suggests that, in our sample, those factors were not related with worse family functioning. Both BD groups had low depressive and manic symptoms scores, and their mean scores were below a proposed threshold for euthymia, suggesting that our sample was mostly euthymic or with subthreshold symptomatology. On the other hand, despite relatively low mood symptoms scores, patients with lifetime SA presented higher suicidal ideation scores than BD patients without SA. This may suggest dissociation between mood symptoms and suicidal ideation, which may reflect a suicidal diathesis among BD patients despite current mood state. On the other hand, linear regression analyses for each FAD scores in the group with SA showed that only age was associated with changes in FAD scores (specifically Affective Responsiveness), while other variables such as age, gender, current depressive or manic symptoms, current suicidal ideation, number of SA, time since last SA, did not predict changes in FAD scores in the group with SA. This suggests that: (1) current mood symptoms are less likely to affect the response of FAD, which is important to consider given that it is a self-report
32
M. Berutti et al. / Journal of Affective Disorders 192 (2016) 28–33
questionnaire; (2) current suicidal ideation does not explain the association between prior SA and worse FAD scores; (3) the number of times a person attempted suicide does not affect his/ her family functioning or at least the way they perceive their families, to a certain extent in most of the FAD domains. Among BD patients with lifetime SA, the Roles subdomain has a negative correlation with number of SA and with time elapsed since last hospitalization. This suggests that the family functioning of Roles is worse over a shorter period since the last SA, which is expected. The negative correlation between Roles score and number of SA is counterintuitive. We can only speculate that, with an increased number of SA and as a need to cope with it, family functioning may evolve to achieve a better definition of roles within that family. More research is necessary to confirm and further understand this relationship. Our results also suggest that family members of BD patients tend to perceive their families largely in the same way of patients. Relatives of BD patients with lifetime SA presented higher scores in FAD in at least 3 of the FAD subscales (i.e., Communications, Roles, and Affective Responsiveness), and in the General Functioning scale. The responses of patients and relatives were also largely consistent, as suggested by the strong correlations between both groups in all FAD scores. This is consistent with the findings of Koyama et al. (2004), who also found that family functioning perception was positively correlated between BD patients and its relatives. It is worth highlighting that these findings should be interpreted with caution. Their relevance lies on the assumption that relatives might have a perception of their family that is less biased by the clinical characteristics of the disease that are inherent to the patient, such as current mood symptoms or current suicidal ideation, or by subjective experiences related to the SA. However, it should be noted that we have not examined the relatives for the presence of psychiatric diseases or mood symptomatology, which could potentially influence their responses. The results of this study have to be considered in the light of some limitations. It is a cross-sectional study, and inferences of causality between family functioning and SA cannot be made. Moreover, the time elapsed since the last SA was very long for some of the patients, and it is possible that a family constellation might have evolved and changed since the last SA. However, we recruited only patients who were still living with the same relative at the time of the last SA. On the other hand, the fact that worse FAD scores are present in families of BD patients who attempted suicide long time ago may suggest that family functioning might still be dysfunctional for a long time after a SA, either because family functioning is characterized by enduring patterns, or because SA are part of a suicidal diathesis that is trait-like and keeps influencing family functioning over time. Third, even though the sample was well characterized regarding clinical characteristics of BD and suicide, the sample size was small, limiting the power to detect potential relevant associations between suicidal attempts and female gender. Also, we excluded BD patients with alcohol or drug abuse during the previous year, pregnancy, or living alone, which limits the geralizability of our findings. Finally, our results are not corrected for multiple comparisons; thus they should be considered preliminary. Confirmation by further studies is needed. As for the strength of this study and to the best of our knowledge, this is the first research work to evaluate the association between family functioning and SA in adult BD patients. Our sample was well characterized regarding clinical characteristics of BD, and every effort was made to verify if other characteristics of BD influenced our results. Moreover, in our sample, depressive, manic, and suicide ideation rating scores were very low and they were not likely to influence our results. In conclusion, we found that BD patients who attempted suicide at least once in their life present worse family functioning
than BD patients who never attempted suicide, specifically in areas such as Problem Solving, Communication, Roles and General Functioning. Worse family functioning was not associated with other characteristics of BD. We also found that among BD patients with lifetime SA, the family functioning of Roles is worse with shorter time since the last SA, and with less number of SA. Family members of BD patients with SA tend to perceive their family functioning largely in the same way as patients. Further studies could investigate the association between family functioning and suicide attempts in bipolar disorder in a prospective fashion or on a timeline that is closer to the suicide attempt. If worse family functioning is causally associated with higher probability of suicide attempts, intervention tools such as family therapy might help to mitigate the morbidity and mortality associated with suicidal behavior in BD.
References Abreu, L.N., Lafer, B., Baca-Garcia, E., Oquendo, M.A., 2009. Suicidal ideation and suicide attempts in bipolar disorder type I: an update for the clinician. Rev. Bras. Psiquiatr. 31 (3), 271–280. Algorta, G.P., Youngstrom, E.A., Frazier, T.W., Freeman, A.J., Youngstrom, J.K., Findling, R.L., 2011. Suicidality in pediatric bipolar disorder: predictor or outcome of family processes and mixed mood presentation? Bipolar Disord. 13 (1), 76–86. American Psychiatric Association, 2002. Practice guideline for the treatment of patients with bipolar disorder (revision). Am. J. Psychiatry 159 (4 Suppl.), 1–50. Bauwens, F., Tracy, A., Pardoen, D., Vander Elst, M., Mendlewicz, J., 1991. Social adjustment of remitted bipolar and unipolar out-patients. A comparison with age- and sex-matched controls. Br. J. Psychiatry 159, 239–244. Chen, C.-Y., Yeh, H.-H., Huang, N., Lin, Y.-C., 2014. Socioeconomic and clinical characteristics associated with repeat suicide attempts among young people. J. Adolesc. Health 54 (5), 550–557. Cunha, J.A., 2001. Manual da Versão em Português dasEscalas Beck. Casa do Psicólogo, São Paulo. Ellis, A.J., Portnoff, L.C., Axelson, D.A., Kowatch, R.A., Walshaw, P., Miklowitz, D.J., 2014. Parental expressed emotion and suicidal ideation in adolescents with bipolar disorder. Psychiatry Res. 216 (2), 213–216. Finseth, P.I., Sønderby, I.E., Djurovic, S., Agartz, I., Malt, U.F., Melle, I., Tesli, M., 2014. Association analysis between suicidal behaviour and candidate genes of bipolar disorder and schizophrenia. J. Affect. Disord. 163, 110–114. First, M.B., 2002. The DSM series and experience with DSM-IV. Psychopathology 35 (2–3), 67–71. Friedmann, M.S., McDermut, W.H., Solomon, D.A., Ryan, C.E., Keitner, G.I., Miller, I. W., 1997. Family functioning and mental illness: a comparison of psychiatric and nonclinical families. Fam. Process. 36 (4), 357–367. Ghaemi, S.N., Bauer, M., Cassidy, F., Malhi, G.S., Mitchell, P., Phelps, J., Vieta, E., Youngstrom, E., ISBD Diagnostic Guidelines Task Force, 2008. Diagnostic guidelines for bipolar disorder: a summary of the International Society for Bipolar Disorders Diagnostic Guidelines Task Force Report. Bipolar Disord. 10 (1 Pt 2), 117–128. Goldstein, T.R., Birmaher, B., Axelson, D., Goldstein, B.I., Gill, M.K., Esposito-Smythers, C., Keller, M., 2009. Family environment and suicidal ideation among bipolar youth. Arch. Suicide Res. 13 (4), 378–388. Goodwin, F.K., Jamison, KR., 2007. Manic-depressive illness: bipolar disorder and recurrent depression. Oxford University Press, Oxford. Hamilton, M., 1960. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 23, 56–62. Keitner, G.I., Ryan, C.E., Miller, I.W., Epstein, N.B., Bishop, D.S., Norman, W.H., 1990. Family functioning, social adjustment, and recurrence of suicidality. Psychiatry 53 (1), 17–30. Khalsa, H.M., Salvatore, P., Hennen, J., Baethge, C., Tohen, M., Baldessarini, R.J., 2008. Suicidal events and accidents in 216 first-episode bipolar I disorder patients: predictive factors. J. Affect. Disord. 106 (1–2), 179–184. Koyama, A., Akiyama, T., Miyake, Y., Kurita, H., 2004. Family functioning perceived by patients and their family members in three diagnostic and statistical manual-IV diagnostic groups. Psychiatry Clin. Neurosci. 58 (5), 495–500. McDermut, W., Miller, I.W., Solomon, D., Ryan, C.E., Keitner, G.I., 2001. Family functioning and suicidality in depressed adults. Compr. Psychiatry 42 (2), 96–104. Miller, I.W., Kabacoff, R.I., Keitner, G.I., Epstein, N.B., Bishop, D.S., 1986. Family functioning in the families of psychiatric patients. Compr. Psychiatry 27 (4), 302–312. Miller, I.W., Kabacoff, R.I., Epstein, N.B., Bishop, D.S., Keitner, G.I., Baldwin, L.M., van der Spuy, H.I., 1994. The development of a clinical rating scale for the McMaster model of family functioning. Fam. Process. 33 (1), 53–69. Oquendo, M.A., Mann, J.J., 2003. Intervention research for suicidal behaviour. Lancet 362 (9387), 844–845. Oquendo, M.A., Galfalvy, H., Russo, S., Ellis, S.P., Grunebaum, M.F., Burke, A., Mann, J. J., 2004. Prospective study of clinical predictors of suicidal acts after a major
M. Berutti et al. / Journal of Affective Disorders 192 (2016) 28–33
depressive episode in patients with major depressive disorder or bipolar disorder. Am. J. Psychiatry 161 (8), 1433–1441. Pollak, C.P., Perlick, D., 1991. Sleep problems and institutionalization of the elderly. J Geriatr Psychiatry Neurol. 4 (4), 204–210. Pompili, M., 2014. Suicide prevention and the role of the psychiatrist. Riv. Psichiatr. 49 (5), 197–198. Pompili, M., Gonda, X., Serafini, G., Innamorati, M., Sher, L., Amore, M., Girardi, P., 2013. Epidemiology of suicide in bipolar disorders: a systematic review of the literature. Bipolar Disord. 15 (5), 457–490. Ridenour, T.A., Daley, J.G., Reich, W., 1999. Factor analyses of the family assessment device. Fam. Process. 38 (4), 497–510. Spalt, L., 1975. Demorgraphic characteristics in affective disorders. Dis. Nerv. Syst. 36 (4), 209–214. Stevenson-Hinde, J., Akister, J., 1995. The McMaster Model of Family Functioning: observer and parental ratings in a nonclinical sample. Fam. Process. 34 (3), 337–347. Ryan, C.E., Epstein, N.B., Keitner, G.I., Miller, E.W., Bishop, DS., 2005. Evaluating and treating families: The McMaster approach. Taylor & Francis, New York. Townsend, L.D., Demeter, C.A., Youngstrom, E., Drotar, D., Findling, R.L., 2007.
33
Family conflict moderates response to pharmacological intervention in pediatric bipolar disorder. J. Child. Adolesc. Psychopharmacol. 17 (6), 843–852. Uebelacker, L.A., Beevers, C.G., Battle, C.L., Strong, D., Keitner, G.I., Ryan, C.E., Miller, I.W., 2006. Family functioning in bipolar I disorder. J. Fam. Psychol. 20 (4), 701–704. Unal, S., Kaya, B., Cekem, B., Ozişik, H.I., Cakil, G., Kaya, M., 2004. Family functioning in patients with schizophrenia, bipolar affective disorder and epilepsy. Turk. Psikiyatr. Derg. 15 (4), 291–299. Weinstein, S.M., Van Meter, A., Katz, A.C., Peters, A.T., West, A.E., 2015. Cognitive and family correlates of current suicidal ideation in children with bipolar disorder. J. Affect. Disord. 173, 15–21. http://dx.doi.org/10.1016/j.jad.2014.10.058 (Fonte). Young, R.C., Biggs, J.T., Ziegler, V.E., Meyer, D.A., 1978. A rating scale for mania: reliability, validity and sensitivity. Br. J. Psychiatry 133, 429–435. Zeng, R., Cohen, L.J., Tanis, T., Qizilbash, A., Lopatyuk, Y., Yaseen, Z.S., Galynker, I., 2015. Assessing the contribution of borderline personality disorder and features to suicide risk in psychiatric inpatients with bipolar disorder, major depression and schizoaffective disorder. Psychiatry Res. 226 (1), 361–367.