{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T00:45:08Z","timestamp":1787013908928,"version":"build-2736575974"},"reference-count":33,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2017,8,23]],"date-time":"2017-08-23T00:00:00Z","timestamp":1503446400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"funder":[{"DOI":"10.13039\/100000050","name":"National Heart, Lung, and Blood Institute","doi-asserted-by":"publisher","award":["NHLBIP01HL014388"],"award-info":[{"award-number":["NHLBIP01HL014388"]}],"id":[{"id":"10.13039\/100000050","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Bipolar Disorders"],"published-print":{"date-parts":[[2018,2]]},"abstract":"\n Objective<\/jats:title>\n To assess whether suicidal behavior during mixed states exceeds that expected from the manic or depressive components alone.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n This study included 429 participants with bipolar disorder from the National Institute of Mental Health Collaborative Depression Study (\n CDS<\/jats:styled-content>\n ). Mood and suicidal behavior were captured using the Longitudinal Interval Follow\u2010up Evaluation and the Schedule of Affective Disorders and Schizophrenia. Suicidal behavior during each mood state, relative to euthymia, was analyzed using Cox regression to allow for repeated events, with a frailty term to account for intra\u2010participant correlation. Mixed states were modeled as a depression\u2010by\u2010mania interaction.\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Individuals with a history of mixed states were at higher risk of suicidal behavior and spent more time depressed, compared to subjects with no such history. In bipolar I disorder, risk increased during episodes of mania (hazard ratio [\n HR<\/jats:styled-content>\n ]: 1.96, 95% confidence interval [\n CI<\/jats:styled-content>\n ]: 1.28\u20102.99,\n P<\/jats:italic>\n \u00a0=\u00a0.0019) and depression (\n HR<\/jats:styled-content>\n : 5.49, 95%\n CI<\/jats:styled-content>\n : 4.01\u20107.51,\n P<\/jats:italic>\n \u00a0<\u00a0.0001) and there was a less than additive effect of mixed states. In bipolar\n II<\/jats:styled-content>\n disorder, risk was increased during episodes of depression (\n HR<\/jats:styled-content>\n : 3.66, 95%\n CI<\/jats:styled-content>\n : 2.51\u20105.35,\n P<\/jats:italic>\n \u00a0<\u00a0.0001) and there was no excess risk during mixed states beyond that attributable to the depressed component. Most of the excess risk (71%) among those with a history of mixed states was attributable to a depression predominant course of illness.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Individuals with mixed states are at high risk of suicidal behavior, largely due to more time spent depressed. Clinicians should aggressively treat depression to mitigate suicide risk for patients with or without mixed states.<\/jats:p>\n <\/jats:sec>","DOI":"10.1111\/bdi.12538","type":"journal-article","created":{"date-parts":[[2017,8,23]],"date-time":"2017-08-23T08:22:49Z","timestamp":1503476569000},"page":"35-41","source":"Crossref","is-referenced-by-count":54,"title":["Mixed state and suicide: Is the effect of mixed state on suicidal behavior more than the sum of its parts?"],"prefix":"10.1111","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2393-6886","authenticated-orcid":false,"given":"Jane E","family":"Persons","sequence":"first","affiliation":[{"name":"Department of Epidemiology College of Public Health The University of Iowa Iowa City IA USA"},{"name":"Department of Psychiatry Roy J. and Lucille A. Carver College of Medicine Iowa City IA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William H","family":"Coryell","sequence":"additional","affiliation":[{"name":"Department of Psychiatry Roy J. and Lucille A. Carver College of Medicine Iowa City IA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David A","family":"Solomon","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Human Behavior Brown University School of Medicine Providence RI USA"},{"name":"UpToDate Waltham MA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin B","family":"Keller","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Human Behavior Brown University School of Medicine Providence RI USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean","family":"Endicott","sequence":"additional","affiliation":[{"name":"Department of Psychiatry Columbia University College of Physicians and Surgeons New York NY, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jess G","family":"Fiedorowicz","sequence":"additional","affiliation":[{"name":"Department of Epidemiology College of Public Health The University of Iowa Iowa City IA USA"},{"name":"Department of Psychiatry Roy J. and Lucille A. Carver College of Medicine Iowa City IA USA"},{"name":"Department of Internal Medicine The University of Iowa Iowa City IA, USA"},{"name":"Francois M. Abboud Cardiovascular Research Center The University of Iowa Iowa City IA, USA"},{"name":"Iowa Neuroscience Institute The University of Iowa Iowa City IA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2017,8,23]]},"reference":[{"key":"e_1_2_6_2_1","first-page":"45","article-title":"The importance of depressive mixed states in suicidal behaviour","volume":"10","author":"Rihmer A","year":"2008","journal-title":"Neuropsychopharmacol Hung."},{"key":"e_1_2_6_3_1","doi-asserted-by":"publisher","DOI":"10.1176\/appi.ajp.2012.12030301"},{"key":"e_1_2_6_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2014.10.061"},{"key":"e_1_2_6_5_1","doi-asserted-by":"publisher","DOI":"10.1111\/bdi.12087"},{"key":"e_1_2_6_6_1","doi-asserted-by":"publisher","DOI":"10.1002\/j.2051-5545.2009.tb00245.x"},{"key":"e_1_2_6_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0165-0327(98)00016-0"},{"key":"e_1_2_6_8_1","doi-asserted-by":"publisher","DOI":"10.1176\/appi.ajp.2008.08050746"},{"key":"e_1_2_6_9_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2011.03.037"},{"key":"e_1_2_6_10_1","doi-asserted-by":"publisher","DOI":"10.1176\/ajp.153.5.674"},{"key":"e_1_2_6_11_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jad.2005.12.049"},{"key":"e_1_2_6_12_1","doi-asserted-by":"publisher","DOI":"10.4088\/JCP.09m05483yel"},{"key":"e_1_2_6_13_1","doi-asserted-by":"publisher","DOI":"10.1521\/suli.2005.35.6.681"},{"key":"e_1_2_6_14_1","doi-asserted-by":"publisher","DOI":"10.1097\/PSY.0b013e3181acee26"},{"key":"e_1_2_6_15_1","doi-asserted-by":"publisher","DOI":"10.1111\/bdi.12072"},{"key":"e_1_2_6_16_1","doi-asserted-by":"publisher","DOI":"10.1159\/000334779"},{"key":"e_1_2_6_17_1","doi-asserted-by":"publisher","DOI":"10.1017\/S0033291708004078"},{"key":"e_1_2_6_18_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1399-5618.2012.01041.x"},{"key":"e_1_2_6_19_1","doi-asserted-by":"publisher","DOI":"10.1176\/appi.ajp.2010.10030328"},{"key":"e_1_2_6_20_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.psychres.2009.01.001"},{"key":"e_1_2_6_21_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.psychres.2006.09.003"},{"key":"e_1_2_6_22_1","doi-asserted-by":"crossref","first-page":"720","DOI":"10.4088\/JCP.13m08744","article-title":"Risk of suicidal behavior with antidepressants in bipolar and unipolar disorders","volume":"75","author":"Leon AC","year":"2014","journal-title":"J Clin Psychiatry"},{"key":"e_1_2_6_23_1","doi-asserted-by":"publisher","DOI":"10.4088\/JCP.10m06552"},{"key":"e_1_2_6_24_1","doi-asserted-by":"publisher","DOI":"10.1176\/appi.ajp.2011.11060948"},{"key":"e_1_2_6_25_1","doi-asserted-by":"publisher","DOI":"10.1001\/archpsyc.1978.01770310043002"},{"key":"e_1_2_6_26_1","doi-asserted-by":"publisher","DOI":"10.1176\/ajp.136.1.52"},{"key":"e_1_2_6_27_1","doi-asserted-by":"publisher","DOI":"10.1176\/appi.ajp.2010.09050627"},{"key":"e_1_2_6_28_1","doi-asserted-by":"publisher","DOI":"10.1093\/ije\/dyu222"},{"key":"e_1_2_6_29_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpsychires.2012.03.024"},{"key":"e_1_2_6_30_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11920-014-0540-2"},{"key":"e_1_2_6_31_1","doi-asserted-by":"publisher","DOI":"10.1111\/bdi.12271"},{"key":"e_1_2_6_32_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1399-5618.2007.00357.x"},{"key":"e_1_2_6_33_1","doi-asserted-by":"publisher","DOI":"10.4088\/JCP.12m08049"},{"key":"e_1_2_6_34_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1399-5618.2009.00686.x"}],"container-title":["Bipolar Disorders"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.wiley.com\/onlinelibrary\/tdm\/v1\/articles\/10.1111%2Fbdi.12538","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/bdi.12538","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,9,24]],"date-time":"2023-09-24T09:50:09Z","timestamp":1695549009000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/bdi.12538"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2017,8,23]]},"references-count":33,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2018,2]]}},"alternative-id":["10.1111\/bdi.12538"],"URL":"https:\/\/doi.org\/10.1111\/bdi.12538","archive":["Portico"],"relation":{},"ISSN":["1398-5647","1399-5618"],"issn-type":[{"value":"1398-5647","type":"print"},{"value":"1399-5618","type":"electronic"}],"subject":[],"published":{"date-parts":[[2017,8,23]]}}}