A 42-year-old married man with a 10-year history of bipolar disorder type I presents to the emergency department with his wife. He reports feeling "empty and hopeless" for the past 3 weeks, with poor sleep, anhedonia, and psychomotor retardation. His wife notes he has been giving away his possessions and has written a detailed suicide note found in his desk drawer. On examination, he appears depressed, makes poor eye contact, and admits to passive death wishes but denies active suicidal intent at this moment. He has a past history of one previous suicide attempt 5 years ago (overdose, hospitalized for 2 weeks). What is his most significant suicide risk factor in this clinical context?

Explanation

## Suicide Risk Assessment in Bipolar Disorder **Key Point:** A history of previous suicide attempt is one of the strongest predictors of future suicide completion, particularly in patients with bipolar disorder. This patient's past overdose attempt represents a critical risk factor. ### Risk Stratification in This Case | Risk Factor | Significance | Present in This Patient? | |---|---|---| | **History of previous attempt** | **Strongest predictor of future attempt** | **Yes** | | Current severe depression | High risk, especially in bipolar disorder | Yes | | Detailed suicide plan (note) | Indicates intent and preparation | Yes | | Psychomotor retardation | Associated with higher lethality | Yes | | Male gender | 3–4× higher completion rate | Yes | | Age 40–50 years | Peak risk period for males | Yes | | Passive ideation only | Lower immediate risk than active intent | Yes | | Social support (married) | Protective factor | Yes | **High-Yield:** The **Columbia-Suicide Severity Rating Scale (C-SSRS)** and **SAD PERSONS scale** both weight prior attempt history as a major risk factor. A prior attempt increases the risk of future completion by 5–10 fold. **Clinical Pearl:** In bipolar disorder, the depressive phase carries the highest suicide risk—higher than in unipolar depression. Combined with a prior attempt, this patient requires immediate hospitalization and close monitoring. ### Why This Patient Is High Risk 1. **Prior attempt** (overdose) = demonstrated intent and method knowledge 2. **Current severe depression** in bipolar disorder (highest-risk phase) 3. **Concrete planning** (written note, giving away possessions) 4. **Demographic vulnerability** (male, middle-aged) 5. **Anhedonia + psychomotor retardation** = high lethality risk **Warning:** Do not be reassured by his denial of "active intent at this moment." Passive ideation can rapidly escalate, and the presence of a detailed note indicates serious planning. The combination of prior attempt + current severe depression + concrete preparation = **imminent risk**. **Mnemonic — SAD PERSONS:** Sex (male), Age (40–50), Depression, Previous attempt, **Ethanol/substance use, Rational thinking loss, Social support loss, Organized plan, No spouse, Sickness (medical/psychiatric)**. This patient scores high on multiple domains.