Suicide rarely occurs in the absence of serious mental health problems. Research shows that psychiatric disorders occurs in up to 90% of young people who die by suicide. In particular, so-called affective disorders, such as major depression and bipolar disorder, occur in 44–76% of cases.
This means that severe mental illness is the most influential and preventable predictor death by suicide.
Bipolar disorder is a serious mental condition characterized by recurrent, alternating episodes of elevated (manic) and depressed mood. That is roughly the basis 5% of all suicides among young people.
The majority of adults with bipolar disorder begin to experience mood symptoms in their youth. But there is often a long delay between the onset of symptoms and proper diagnosis and treatment.
So the question is whether this gap puts vulnerable young people at risk of suicide. Our new research, published in JAMA Psychiatry, suggests that this may be the case. We found fewer suicides among boys in Swedish regions with more bipolar diagnoses.
National register data indicate that severe mental disorders in Swedish youth are unequally recognized and treated in general. And despite national treatment guidelines advocating their use, our research seems to suggest that major academic hospitals do not consistently prioritize evidence-based treatments like the mood stabilizer lithium or electroconvulsive therapy for young people.
Conversely, smaller counties with hospitals not affiliated with universities appear to be leading suppliers of such treatments.
These findings indicate that there is a potential gap in knowledge about the diagnosis and treatment of serious mental illness in young people at Swedish universities. And such unequal access is likely to be found in many places outside of Sweden.
Important, we recently demonstrated that Swedish regions with a higher implementation rate of evidence-based psychiatric treatment in Swedish 15-19-year-old males also had a significant reduction in the number of suicide deaths among young people.
This indicates that early diagnosis and treatment of serious mental illness may be the key to successful suicide prevention in male youth worldwide.
We know that the onset of bipolar disorder in adolescents is associated with more relapses, higher rates of substance abuse, and a greater likelihood of suicide attempts and violence. But there are good treatments, with lithium be the most effective to reduce suicide in adults.
Treatments for adolescents have been less researched. There is compelling evidence that lithium is associated with reduced suicide attempts, less depression, and better psychological and social functioning, compared to other mood stabilizing medication.
However, the specific potential of lithium treatment to prevent suicidal death in adolescent bipolar disorder has not been extensively investigated.
Although retrospective studies show that more than half of adults with bipolar disorder experience their first mood symptom before the age of 18, methods of diagnosing the disease in young people have been controversial. Doctors may be hesitant to diagnose and treat young people if they are wrong.
There are also indications of widespread clinical misattribution of serious mental illness symptoms to alternative causes, such as autism, obsessive compulsive disorder or pediatric acute neuropsychiatric syndrome (Shavings).
International clinical guidelines therefore have different recommendations for the diagnosis of bipolar disorder. For example, UK National Institute for Health and Care Excellence guidelines set significantly stricter criteria for diagnosing bipolar disorder in adolescents than in adults. It demands presence of mania) for a diagnosis, which is not always a symptom in the beginning.
This is not the case for the American Academy of Child and Adolescent Psychiatry. The recommend adheres to the standard classification system, the Diagnostic and Statistical Manual of Mental Disorders (DSM), for both children and adults.
We know that early on pharmacological and non-pharmacological treatments for bipolar disorder have been shown to be effective in improving long-term outcomes.
But effective treatment depends on a correct diagnosis. And this is often delayed for bipolar disorder. In fact, research suggests that an average time to diagnosis is about 6.7 years from disease onset.
Our latest research was based on cross-sectional data from Swedish national registers over the years 2008-2021. This included 585 confirmed suicide deaths.
There were significant regional variations. Some regions reported up to six times the national average, while others reported no cases at all. Notably, 87.5% of the regions with the highest diagnoses were not affiliated with medical research universities.
Among the university-affiliated regions, Uppsala stood out by diagnosing approximately five times more young people with bipolar disorder compared to other large Swedish regions such as Stockholm, Gothenburg and Skåne.
We showed that regional diagnoses of bipolar disorder in adolescent males were strongly linked to lower suicide mortality – about 4.7% lower than the national average. Psychiatric care and the presence of depression and schizophrenia, on the other hand, had no effect on suicide.
This association could not be confirmed in girls. This may be due to statistical problems or the potential widespread misdiagnosis of bipolar disorder in women. Female teenagers were about three times more likely to be diagnosed with bipolar disorder than males. And men were also almost twice as likely to die by suicide.
The picture of how to prevent suicide in young people is becoming increasingly clear. Not only have we shown that evidence-based treatment can help prevent youth suicide, but now also that early diagnosis of bipolar disorder can play a role. This is probably data that health authorities worldwide need to take seriously.
There may be more insights coming soon. Our research group remains committed to investigating the full extent and implications of health inequalities in the diagnosis and treatment of youth with serious mental illness.
Author: Adrian Desai Bostrm – Postdoctoral fellow in psychiatry, Karolinska Institutet | Peter Andersson – Doctoral student in psychiatry, Karolinska Institutet