Symptom trajectories in the months before and after a suicide attempt in individuals with bipolar disorder: A STEP-BD study

Elizabeth D. Ballard, Cristan A. Farmer, Bridget Shovestul, Jennifer Vande Voort, Rodrigo Machado-Vieira, Lawrence Park, Kathleen R. Merikangas, Carlos A. Zarate

Research output: Contribution to journalArticlepeer-review


Objectives: The suicide crisis is a relatively short-lived psychiatric emergency, with transient symptoms that ebb and flow around the suicide attempt. Understanding the dynamic processes of symptoms before and after suicide attempt may aid future prevention efforts. Methods: Data were drawn from the NIMH STEP-BD study, which followed 4,360 patients with bipolar disorder; a subset attempted suicide during the trial (245/4100 or 5.97% of the sample eligible for analysis). This analysis focused on change in suicidal ideation (SI) in the 120 days before and 120 days after suicide attempt; similar analyses were conducted for other depressive symptoms. Generalized linear mixed models with a two-piece linear function of time corresponding to pre- and post-suicide attempt trends were used. Results: SI ratings from 216 individuals were analyzed (n = 1,231 total; n = 395 pre-attempt, n = 126 circa-attempt, n = 710 post-attempt) and compared to data from a matched sample of 648 non-attempters. SI worsened in the 120 days pre-attempt but improved afterwards, reaching non-attempter levels by 90 days post-attempt. A similar pattern was found for other depressive symptoms, including depressed mood, loss of interest, guilt, and self-esteem. Pre/post differences in tension/activating symptoms of depression—anxiety, agitation, and irritability—were less pronounced and more time-limited. Conclusions: The suicide crisis is dynamic, and the days before and after suicide attempt may be particularly critical. The findings extend previous research on proximal symptoms of suicide and underscore that some SI and affective/cognitive symptoms of depression can remain elevated up to 90 days post-attempt in individuals with bipolar disorder.

Original languageEnglish (US)
Pages (from-to)245-254
Number of pages10
JournalBipolar disorders
Issue number3
StatePublished - May 1 2020


  • anhedonia
  • anxiety
  • bipolar disorder
  • suicide
  • suicide ideation

ASJC Scopus subject areas

  • Psychiatry and Mental health
  • Biological Psychiatry


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