Journal of Affective Disorders 176 (2015) 171–175

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Research Report

Comorbidity of ADHD and suicide attempts among adolescents and young adults with bipolar disorder: A nationwide longitudinal study Wen-Hsuan Lan a, Ya-Mei Bai a,b, Ju-Wei Hsu a,b, Kai-Lin Huang a,b, Tung-Ping Su a,b, Cheng-Ta Li a,b, Albert C. Yang a,b, Wei-Chen Lin a,b, Wen-Han Chang a, Tzeng-Ji Chen c,d, Shih-Jen Tsai a,b,n, Mu-Hong Chen a,b,n a

Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan Division of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, Taiwan Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan d Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan b c

art ic l e i nf o

a b s t r a c t

Article history: Received 20 January 2015 Received in revised form 6 February 2015 Accepted 6 February 2015 Available online 17 February 2015

Background: Suicide is among the leading causes of death among people with bipolar disorder and has gained substantial attention in the psychiatric and public health fields. However, the role of attention deficit hyperactivity disorder (ADHD) in suicide among adolescents and young adults with bipolar disorder remains unknown. Methods: Using Taiwan's National Health Insurance Research Database, we identified 500 adolescents and young adults from 2002 to 2008 aged between 15 and 24 years with bipolar disorder and ADHD. The sample was matched according to age and sex with 1500 (1:3) patients with bipolar disorder only and observed until the end of 2011. The patients who attempted suicide during the follow-up period were identified. Results: Adolescents and young adults with bipolar disorder and ADHD had a greater incidence of attempted suicide than did those with bipolar disorder only (3.0% vs. 1.1%, p ¼0.005). After adjustment for demographic factors and psychiatric comorbidities, a Cox regression analysis determined that ADHD was an independent risk factor for attempted suicide (hazard ratio: 2.38, 95% confidence interval: 1.13–5.00) later in life among adolescents and young adults with bipolar disorder. Discussion: Adolescents and young adults with bipolar disorder and ADHD had an increased likelihood of attempted suicide compared with adolescents and young adults with bipolar disorder only. Further study is required to investigate the possible pathophysiology among ADHD, bipolar disorder, and attempted suicide, and to assess whether prompt intervention for ADHD may reduce the risk of attempted suicide. & 2015 Elsevier B.V. All rights reserved.

Keywords: ADHD Bipolar disorder Suicide

1. Introduction Suicide among adolescents and young adults has gained substantial clinical attention in the psychiatric field in the recent decade and has become a major public health concern worldwide (Ceylan et al., 2012; Fazel et al., 2013). The U.S. National Institute of Mental Health reported that suicide was the country's third leading cause of mortality among adolescents and young adults aged 15–24 years (Ceylan et al., 2012; Fazel et al., 2013). In Taiwan, the Ministry of Health and Welfare n Correspondence to: Department of Psychiatry, No. 201, Shih-Pai Road, Sec. 2, 11217, Taipei, Taiwan. Tel./fax: þ 886 2 28344012. E-mail addresses: [email protected] (S.-J. Tsai), [email protected] (M.-H. Chen).

http://dx.doi.org/10.1016/j.jad.2015.02.007 0165-0327/& 2015 Elsevier B.V. All rights reserved.

indicated that suicide was the second leading cause of mortality among adolescents and young adults, accounting for the death of 7.1/ 100,000 adolescents and young adults (Allison et al., 2007). Previous studies have demonstrated that more than 70% of adolescents and young adults who attempt suicide or have suicidal ideation have psychiatric disorders, including major depressive disorder, bipolar disorder, anxiety disorders, disruptive behavior disorders, and alcohol and substance use disorders (Brent et al., 1994; Gould et al., 1998; Kelly et al., 2002; Hauser et al., 2013). Suicide is among the leading causes of mortality among patients with bipolar disorder (Latalova et al., 2014). Between 25% and 50% of patients with bipolar disorder attempt suicide at least once, and as many as 15% of patients with bipolar disorder complete suicide (Latalova et al., 2014). The risk factors for suicide among people with

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bipolar disorder include early onset of bipolar disorder, history of attempted suicide, family history of suicide, and substance use disorder and personality disorder comorbidities (Latalova et al., 2014). Previous studies have discovered a common comorbidity between attention deficit hyperactivity disorder (ADHD) and bipolar disorder, and have demonstrated that the ADHD comorbidity is clinically and scientifically critical in the trajectory of bipolar disorder (McIntyre et al., 2010; Nierenberg et al., 2005). Assessing the lifetime prevalence of ADHD among 1000 patients with bipolar disorder, Nierenberg et al. (2005) reported that 14.7% of male patients and 5.8% of female patients had lifetime ADHD, and patients with ADHD had an earlier onset of bipolar disorder, were more frequently depressed, and had a more severe course of bipolar disorder than did patients without ADHD. Our previous study demonstrated that adolescents with ADHD had an increased risk (hazard ratio [HR]: 5.24, 95% confidence interval [CI]: 2.44–11.24) of developing bipolar disorder in later life compared to those without ADHD (Chen et al., 2013c). McIntyre et al. (2010) determined that 17.6% of patients with bipolar disorder had ADHD and a lower quality of life than did those without ADHD. Perroud et al. (2014) revealed that patients with comorbid bipolar disorder and ADHD exhibited more anxiety and borderline personality symptoms and had a higher risk of alcohol use disorders and substance use disorders than did those with bipolar disorder only. Furthermore, a growing body of evidence has suggested that ADHD plays a role in the risk of self-harm or suicide (Balazs et al., 2014; Patros et al., 2013; Taylor et al., 2014; Chronis-Tuscano et al., 2010). For example, Balazs et al. (2014) examined suicidality among 418 medication-naïve children and adolescents with ADHD or subthreshold ADHD using the Mini International Neuropsychiatric Interview for Children and Adolescents, and found that ADHD symptoms were associated with an increased risk of suicidality, including ideas of death and suicidal ideation. Using a self-report questionnaire, Patros et al. (2013) showed that both hyperactivity– impulsivity and inattention symptoms were related to depressed mood, suicidal ideation, and attempted suicide among undergraduate students. Swensen et al. (2002) reported that patients with ADHD had a risk of completed suicide (OR: 3.0, 95% CI: 0.8– 12.0, p o0.11). Among 42 children and adolescents aged 9–17 years who had attempted suicide, Gould et al. (1998) reported that 9.5% of them were diagnosed as having ADHD. But, they also revealed that young patients with attempted suicide did not exhibit a significantly increased risk of having ADHD (odds ratio [OR]: 2.6, 95% CI: 0.9–7.9) compared to the control group (Gould et al., 1998). However, these studies had limitations, including small sample sizes and the use of self-report questionnaires rather than psychiatrist diagnoses. Furthermore, the role of ADHD in suicidality among adolescents and young adults with bipolar disorder was not examined. Using a large sample taken from Taiwan's National Health Insurance Research Database (NHIRD) and a longitudinal study design, we investigated the role of ADHD in suicidality among adolescents and young adults with bipolar disorder. We hypothesized that adolescents and young adults with bipolar disorder and ADHD have an elevated risk of attempted suicide later in life compared with those with bipolar disorder only.

2. Methods 2.1. Data source Taiwan's National Health Insurance is a mandatory universal health insurance program that was inaugurated in 1995 and covers up to 99% of the country's 23 million residents (http://www.nhi.gov.tw/). The NHIRD is administered by the National Health Research Institute and

provides comprehensive patient information, such as demographic data, clinical visit dates, and disease diagnoses. All identities are encrypted to ensure patient privacy. The diagnostic codes used are based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The NHIRD has been used extensively in many epidemiologic studies in Taiwan (Li et al., 2012; Chen et al., 2013a, 2013b; Shen et al., 2013). 2.2. Inclusion criteria for patients with bipolar disorder and ADHD Adolescents and young adults aged 15–24 years who were diagnosed with bipolar disorder (ICD-9-CM codes: 296.0x, 296.1x, 296.4x–296.7x, 296.80, 296.81, and 296.89) and ADHD (ICD-9CMcode: 314) by board-certificated psychiatrists based on their clinical judgment and the standard psychiatric interview between January 1, 2002, and December 31, 2008, and who had no history of attempted suicide (ICD-9-CM codes: E950–E959) were included in our study as the bipolar disorder þADHD cohort. Patients matched according to age and sex (1:3) for the control cohort (bipolar disorder only cohort) were randomly identified from among all bipolar patients in the same database after elimination of patients who had been diagnosed with ADHD at any time or had attempted suicide. Both cohorts (bipolar disorderþ ADHD and bipolar disorder only) were observed until December 31, 2011, and patients who attempted suicide (ICD-9-CM codes: E950– E959) were identified. In addition, we assessed other psychiatric comorbidities, including anxiety disorder, disruptive behavior disorders, substance use disorders, and alcohol use disorders, and the risk of attempted suicide. All diagnoses were made at least twice by corresponding psychiatrists to ensure diagnostic validity. Moreover, level of urbanization (Level 1 [most urbanized area] to Level 5 [least urbanized area]) was assessed. 2.3. Statistical analysis For between-group comparisons, the independent t test was used for continuous variables and Pearson's χ2 test was used for nominal variables when appropriate. After adjustment for demographic factors and psychiatric comorbidities, a Cox regression model was used to investigate the hazard ratios (HR) and 95% CIs of attempted suicide between patients with bipolar disorder with or without ADHD. A 2-tailed p Value of less than 0.05 was considered statistically significant. All data processing and statistical analysis were performed using Statistical Package for Social Science (SPSS) Version 17 (SPSS Inc.) and Statistical Analysis Software (SAS) Version 9.1 (SAS Institute, Cary, NC).

3. Results In total, 2000 patients with bipolar disorder aged 15–24 years, namely 500 patients with comorbid bipolar disorder and ADHD and 1500 controls with bipolar disorder only, were observed in this study (Table 1). During the follow-up period, patients with bipolar disorder and ADHD had a higher incidence of attempted suicide (3.0% vs. 1.1%, p¼ 0.005) than did patients with bipolar disorder only (Table 1). In addition, patients with bipolar disorder and ADHD had a higher prevalence of anxiety disorder (25.6% vs. 15.8%, po 0.001) and disruptive behavior disorders (13.2% vs. 2.7%, po 0.001) (Table 1). The bipolar disorder þADHD cohort included significantly more patients in less urbanized areas (p ¼0.015) and with lower incomes (p ¼0.014) (Table 1). The Kaplan–Meier survival curve and a log-rank test demonstrated that patients with bipolar disorder and ADHD had an increased risk of attempted suicide compared with patients with bipolar disorder only (Fig. 1). We established 3 Cox regression

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Table 1 Demographic characteristics and incidence of suicide attempt among adolescents and young adults with bipolar disorder with or without ADHD. Bipolar disorder (n¼ 2000)

Age at bipolar disorder (years, SD) Sex (%) Male Female Incidence of cases with any suicide attempt (n, %) Age at first suicide attempt (years, SD) Duration between enrollment and the first suicide attempt (years, SD) Psychiatric comorbidities (n, %) Anxiety disorder Disruptive behavior disorder Alcohol use disorder Substance use disorder Level of urbanization 1 (most urbanized) 2 3 4 5 (most rural) Income-related insured amount r 15,840 NTD/month 15,841–25,000 NTD/month Z 25,001 NTD/month

p-Value

With ADHD (n¼ 500)

Without ADHD (n¼ 1500)

19.11 (2.84)

19.11 (2.84)

331 169 15 22.52 2.80

(66.2) (33.8) (3.0) (4.11) (2.43)

993 507 16 21.58 1.95

(66.2) (33.8) (1.1) (2.98) (2.38)

128 66 18 32

(25.6) (13.2) (3.6) (6.4)

237 40 34 70

(15.8) (2.7) (2.3) (4.7)

125 171 44 34 126

(25.0) (34.2) (8.8) (6.8) (25.2)

377 477 184 151 311

(25.1) (31.8) (12.3) (10.1) (20.7)

0.005 0.469 0.330 o 0.001 o 0.001 0.107 0.128 0.015

0.014 341 (68.2) 118 (23.6) 41 (8.2)

915 (61.0) 422 (28.1) 163 (10.9)

ADHD: Attention-deficit hyperactivity disorder; SD: standard deviation; and NTD: New Taiwan Dollar.

4. Discussion

Fig. 1. Survival curve of developing any suicide attempt among adolescents and young adults with bipolar disorder with or without ADHD.

models to investigate the risk of attempted suicide among bipolar patients with or without ADHD (Table 2). The primary model, adjusted for demographic factors, determined that ADHD was associated with an elevated risk of attempted suicide later in life (HR: 2.84, 95% CI: 1.4–5.78); the secondary model, with further adjustment for anxiety disorder, determined that ADHD increased the risk of attempted suicide later in life (HR: 2.82, 95% CI: 1.38– 5.77); the tertiary model, with additional adjustments for disruptive behavior disorders, alcohol use disorders, and substance use disorders, determined that ADHD remained an independent risk factor for attempted suicide (HR: 2.38, 95% CI: 1.13–5.00) (Table 2). Alcohol use disorders were also associated with an increased risk of attempted suicide (HR: 20.32, 95% CI: 8.96–46.08) (Table 2).

A comprehensive literature review indicated that this is the first longitudinal study to investigate the impact of ADHD in suicidality among adolescents and young adults with bipolar disorder. The results supported the hypothesis that adolescents and young adults with comorbid bipolar disorder and ADHD have an elevated likelihood of attempted suicide later in life compared with adolescents and young adults with bipolar disorder only. After adjustment for demographic factors and psychiatric comorbidities, including alcohol use disorders and substance use disorders, ADHD was still an independent risk factor for attempted suicide among adolescents and young adults with bipolar disorder. A growing body of evidence indicates that ADHD is associated with a small but definite increase in the risk of suicide (Nigg, 2013). A National Comorbidity Survey Replication study in the United States including 8098 adults revealed that 16% of the 365 participants with ADHD had a history of attempted suicide, a rate that was significantly higher than the 11% rate among those without ADHD (Agosti et al., 2011). However, the researchers found that ADHD became nonsignificant in relation to attempted suicide after adjusting for comorbid psychiatric disorders (Agosti et al., 2011). Balazs et al. (2014) reported that suicidality among medication-naïve patients with ADHD was related to the inattention and hyperactive–impulsive symptoms of ADHD and mediated by comorbid psychiatric disorders such as anxiety disorder, depressive disorder, and substance use disorders. In contrast to the results of these previous studies, our results suggested that ADHD is an independent risk factor for attempted suicide among patients with bipolar disorder after adjustment for demographic factors, anxiety disorder, disruptive behavior disorders, alcohol use disorders, and substance use disorders. We propose several hypotheses to explain the significant predictive effect of ADHD on attempted suicide among adolescents and young adults with bipolar disorder. First, mounting evidence has indicated that ADHD is a substantial risk factor for other psychiatric comorbidities, including mood disorders, substance use disorders, and disruptive behavior disorders (Pliszka 1998; Taurines et al.,

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Table 2 Cox regression analysis of the risk of subsequent suicide attempt among adolescents and young adults with bipolar disorder with or without ADHD. Model 1

ADHD (presence vs. absence) Psychiatric comorbidities (presence vs. absence) Anxiety disorder Disruptive behavior disorder Substance use disorder Alcohol use disorder

Model 2

Model 3

HR

95% CI

HR

95% CI

HR

95% CI

2.84

1.40–5.78

2.82

1.38–5.77

2.38

1.13–5.00

– – – –

– – – –

1.07 – – –

0.46–2.51 – – –

1.05 2.03 0.54 20.32

0.42–2.64 0.67–6.20 0.14–2.07 8.96–46.08

HR: hazard ratio; and CI: confidence interval. Model 1: adjusted for demographic data. Model 2: adjusted for demographic data and anxiety disorder. Model 3: adjusted for demographic data, anxiety disorder, and behavior disorders. Bold type means statistical significance.

2010). We found that patients with bipolar disorder and ADHD had a higher prevalence of anxiety disorder and disruptive behavior disorders than did those without ADHD. These adverse psychiatric comorbidities may further increase the risk of suicide. Second, previous studies have indicated that impulsivity, a primary symptom of ADHD, may be associated with increased risks of attempted suicide and completed suicide (Dvorak et al., 2013; Klonsky and May, 2010; Lin et al., 2014). Klonsky and May (2010) found that people who attempted suicide exhibited less premeditation (a diminished ability to think through the consequences of actions) than did people with suicidal ideation. Our findings further demonstrate that ADHD is an independent factor that can be used to predict attempted suicide among patients with bipolar disorder. Third, a growing body of evidence has suggested that ADHD exacerbates the clinical course of bipolar disorder and reduces the prognosis of bipolar disorder, further increasing the risk of suicide among patients with bipolar disorder (Nierenberg et al., 2005; Tamam et al., 2008). Nierenberg et al. (2005) showed that patients with bipolar disorder and ADHD had an earlier onset of bipolar disorder, longer periods of depression, and lower quality of life compared with patients without ADHD. Tamam et al. (2008) demonstrated that the inattention and impulsivity symptoms of ADHD resulted in a poor medication adherence among patients with bipolar disorder and prevented them from receiving optimal medication treatment, thus increasing the relapse of mood episodes and the risk of function deterioration. These ADHD-related adverse events among patients with bipolar disorder have been associated with an elevated risk of suicide (Costa et al., 2015; Hawton et al., 2005). Chen et al. (2014) compared the incidence of suicide-related events during ADHD drug treatment periods with the incidence during nontreatment periods. They found that patients with ADHD were associated with an increase of suiciderelated events (HR: 1.31, 95% CI: 1.19 –1.44) compared to the population; however, this risk was reduced during stimulant treatment periods (HR: 0.81, 95% CI: 0.70–0.94). This finding may imply that the decreased risk of suicide was attributable to the effect of treatment on ADHD symptoms but not on mood symptoms and may support our result that ADHD was an independent risk factor for attempted suicide among patients with bipolar disorder (Chen et al., 2014). Of course, the medications for ADHD that may produce undesired effects among young patients with Bipolar Disorder also should be carefully considered in the clinical practice. Finally, previous studies have shown the relationship between alcohol use problems and suicidality in young population (Lamis et al., 2014; Rossow and Norstrom 2014; Tuisku et al., 2014). For example, Lamis et al. (2014) examined the association between alcohol use and suicide proneness among 1100 college students, and found that suicide proneness was positively related to alcohol use, alcohol-related problems, and negative life events. Rossow

and Norstrom (2014) reported that heavy episodic drinking increased the risk of attempted suicide (OR: 1.64, 95% CI: 1.11–2.42) among 2647 adolescents and young adults. Compatible with previous studies, our result also reported that alcohol use disorder was associated with an extremely high risk of attempted suicide among young patients with bipolar disorder. This study had several limitations. First, the incidence of attempted suicide may have been underestimated because only patients who sought medical assistance and consultation were identified. However, the diagnoses of the patients in our study were made by boardcertified psychiatrists or physicians, yielding a high diagnostic validity, although it was still possible that the significant heterogeneity in the assessment was likely to be present due to the absence of standardized instruments for diagnosis. Second, we did not investigate the use of ADHD and bipolar disorder medications, which were complicated during the long follow-up period and would have been difficult to adjust for in the regression model. Further clinical study is required to clarify the effect of ADHD and bipolar disorder treatment on suicide among patients with bipolar disorder. Third, we focused on the adolescent and young adult population in our study so the role of ADHD comorbidity among mid- and older-adult population required the further investigation. Fourth, we were unable to examine the influence of factors not included in the NHIRD patient information, such as disorder severity (of ADHD and bipolar disorder), information about completed suicide, family history, personal lifestyle, cultural developmental characteristics, and environmental factors. In conclusion, this is the first study to reveal an independent effect of ADHD on suicidality among adolescents and young adults with bipolar disorder. After adjusting for demographic data and psychiatric comorbidities, we determined that adolescents and young adults with comorbid bipolar disorder and ADHD had an elevated likelihood of attempted suicide later in life compared with those with bipolar disorder only. Further study is required to investigate the underlying pathophysiology among bipolar disorder, ADHD, and suicide, and to clarify whether prompt intervention for ADHD can reduce the risk of suicide among adolescents and young adults with bipolar disorder.

Financial disclosure All authors have no financial relationships relevant to this article to disclose.

Acknowledgment We thank Mr. I-Fan Hu's friendship and support. We thank Dr. WHL, Dr. MHC, and Dr. SJT, who designed the study, wrote the protocol and manuscripts, Dr. JWH, Dr. KLH, Dr. WCL, Dr. ACY, Dr. TPS, Dr. YMB, and Dr. CTL, who assisted with the

W.-H. Lan et al. / Journal of Affective Disorders 176 (2015) 171–175 preparation and proof-reading of the manuscript, and Dr. MHC, Dr. TJC, Ms WHC, and Dr. YMB, who provided the advices on statistical analysis.

References Agosti, V., Chen, Y., Levin, F.R., 2011. Does attention deficit hyperactivity disorder increase the risk of suicide attempts? J. Affect. Disord. 133 (3), 595–599. Allison, K.C., et al., 2007. Binge eating disorder and night eating syndrome in adults with type 2 diabetes. Obesity 15 (5), 1287–1293. Balazs, J., et al., 2014. Attention-deficit hyperactivity disorder and suicidality in a treatment naive sample of children and adolescents. J. Affect. Disord., 152–154 (282–287). Brent, D.A., et al., 1994. Suicide in affectively ill adolescents: a case–control study. J. Affect. Disord. 31 (3), 193–202. Ceylan, M.F., et al., 2012. Changes in oxidative stress and cellular immunity serum markers in attention-deficit/hyperactivity disorder. Psychiatry Clin. Neurosci. 66 (3), 220–226. Chen, M.H., et al., 2013a. Asthma and attention-deficit/hyperactivity disorder: a nationwide population-based prospective cohort study. J. Child Psychol. Psychiatry 54 (11), 1208–1214. Chen, M.H., et al., Comorbidity of allergic and autoimmune diseases among patients with ADHD: a nationwide population-based study. J. Atten. Disord., 2013b. Chen, M.H., et al., 2013c. Higher risk of developing mood disorders among adolescents with comorbidity of attention deficit hyperactivity disorder and disruptive behavior disorder: a nationwide prospective study. J. Psychiatr. Res. 47 (8), 1019–1023. Chen, Q., et al., 2014. Drug treatment for attention-deficit/hyperactivity disorder and suicidal behaviour: register based study. BMJ 348, g3769. Chronis-Tuscano, A., et al., 2010. Very early predictors of adolescent depression and suicide attempts in children with attention-deficit/hyperactivity disorder. Arch. Gen. Psychiatry 67 (10), 1044–1051. Costa, L.D., et al., 2015. Risk factors for suicide in bipolar disorder: a systematic review. J. Affect. Disord. 170, 237–254. Dvorak, R.D., Lamis, D.A., Malone, P.S., 2013. Alcohol use, depressive symptoms, and impulsivity as risk factors for suicide proneness among college students. J. Affect. Disord. 149 (1–3), 326–334. Fazel, S., Wolf, A., Geddes, J.R., 2013. Suicide in prisoners with bipolar disorder and other psychiatric disorders: a systematic review. Bipolar Disord. 15 (5), 491–495. Gould, M.S., et al., 1998. Psychopathology associated with suicidal ideation and attempts among children and adolescents. J. Am. Acad. Child Adolesc. Psychiatry 37 (9), 915–923. Hauser, M., Galling, B., Correll, C.U., 2013. Suicidal ideation and suicide attempts in children and adolescents with bipolar disorder: a systematic review of prevalence and incidence rates, correlates, and targeted interventions. Bipolar Disord. 15 (5), 507–523. Hawton, K., et al., 2005. Suicide and attempted suicide in bipolar disorder: a systematic review of risk factors. J. Clin. Psychiatry 66 (6), 693–704.

175

Kelly, T.M., Cornelius, J.R., Lynch, K.G., 2002. Psychiatric and substance use disorders as risk factors for attempted suicide among adolescents: a case control study. Suicide Life Threat. Behav. 32 (3), 301–312. Klonsky, E.D., May, A., 2010. Rethinking impulsivity in suicide. Suicide Life Threat. Behav. 40 (6), 612–619. Lamis, D.A., Malone, P.S., Jahn, D.R., 2014. Alcohol use and suicide proneness in college students: a proposed model. Ment. Health Subst. Use 7 (1), 59–72. Latalova, K., Kamaradova, D., Prasko, J., 2014. Suicide in bipolar disorder: a review. Psychiatr. Danub. 26 (2), 108–114. Li, C.T., et al., 2012. Association between antidepressant resistance in unipolar depression and subsequent bipolar disorder: cohort study. Br. J. Psychiatry 200 (1), 45–51. Lin, W., et al., 2014. Associations between impulsivity, aggression, and suicide in Chinese college students. BMC Public Health 14 (1), 551. McIntyre, R.S., et al., 2010. Attention-deficit/hyperactivity disorder in adults with bipolar disorder or major depressive disorder: results from the international mood disorders collaborative project. Prim. Care Companion J. Clin. Psychiatry 12, 3. Nierenberg, A.A., et al., 2005. Clinical and diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants. Biol. Psychiatry 57 (11), 1467–1473. Nigg, J.T., 2013. Attention-deficit/hyperactivity disorder and adverse health outcomes. Clin. Psychol. Rev. 33 (2), 215–228. Patros, C.H., et al., 2013. Symptoms of attention-deficit/hyperactivity disorder (ADHD) moderate suicidal behaviors in college students with depressed mood. J. Clin. Psychol. 69 (9), 980–993. Perroud, N., et al., 2014. Comorbidity between attention deficit hyperactivity disorder (ADHD) and bipolar disorder in a specialized mood disorders outpatient clinic. J. Affect. Disord. 168, 161–166. Pliszka, S.R., 1998. Comorbidity of attention-deficit/hyperactivity disorder with psychiatric disorder: an overview. J. Clin. Psychiatry 59 (Suppl. 7), S50–S58. Rossow, I., Norstrom, T., 2014. Heavy episodic drinking and deliberate self-harm in young people: a longitudinal cohort study. Addiction 109 (6), 930–936. Shen, C.C., et al., 2013. Risk of Parkinson disease after depression: a nationwide population-based study. Neurology 81 (17), 1538–1544. Swensen, A., et al., 2002. Increased risk of self-injury and suicide for patients with attention-deficit/hyperactivity disorder. Eur. Neuropsychopharmacol. 12, S421. Tamam, L., Karakus, G., Ozpoyraz, N., 2008. Comorbidity of adult attention-deficit hyperactivity disorder and bipolar disorder: prevalence and clinical correlates. Eur. Arch. Psychiatry Clin. Neurosci. 258 (7), 385–393. Taurines, R., et al., 2010. Developmental comorbidity in attention-deficit/hyperactivity disorder. Atten. Defic. Hyperact. Disord. 2 (4), 267–289. Taylor, M.R., J.M. Boden, and J.J. Rucklidge, The relationship between ADHD symptomatology and self-harm, suicidal ideation, and suicidal behaviours in adults: a pilot study. Atten. Defic. Hyperact. Disord., 2014. Tuisku, V., et al., 2014. Depressed adolescents as young adults – predictors of suicide attempt and non-suicidal self-injury during an 8-year follow-up. J. Affect. Disord. 152–154, 313–319.

Comorbidity of ADHD and suicide attempts among adolescents and young adults with bipolar disorder: A nationwide longitudinal study.

Suicide is among the leading causes of death among people with bipolar disorder and has gained substantial attention in the psychiatric and public hea...
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