***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE In a naturalistic follow-up of adult bipolar patients , the authors examined the contributions of demographic , phenomenological , and clinical variables , including antidepressant use , to prospect ively observed mood episode frequency . METHOD For 1,742 bipolar I and II patients in the Systematic Treatment Enhancement Program for Bipolar Disorder ( STEP-BD ) , episodes of mood disorders were evaluated for up to 1 year of treatment . RESULTS At entry , 32 % of the patients met the DSM-IV criteria for rapid cycling in the pre study year . Of the 1,742 patients , 551 ( 32 % ) did not complete 1 year of treatment . Among the 1,191 patients remaining , those with prior rapid cycling ( N=356 ) were more likely to have further recurrences , although not necessarily more than four episodes per year . At the end of 12 months , only 5 % ( N=58 ) of the patients could be classified as rapid cyclers ; 34 % ( N=409 ) had no further mood episodes , 34 % ( N=402 ) experienced one episode , and 27 % ( N=322 ) had two or three episodes . Patients who entered the study with earlier illness onset and greater severity were more likely to have one or more episodes in the prospect i ve study year . Antidepressant use during follow-up was associated with more frequent mood episodes . CONCLUSIONS While DSM-IV rapid cycling was prospect ively observed in only a small percentage of patients , the majority of these patients had continued recurrences at lower but clinical ly significant rates . This suggests that cycling is on a continuum and that prevention of recurrences may require early intervention and restricted use of antidepressants To determine the risk factors for suicide , 6,891 psychiatric out patients were evaluated in a prospect i ve study . Subsequent deaths for the sample were identified through the National Death Index . Forty-nine ( 1 % ) suicides were determined from death certificates obtained from state vital statistics offices . Specific psychological variables that could be modified by clinical intervention were measured using st and ardized scales . Univariate survival analyses revealed that the severity of depression , hopelessness , and suicide ideation were significant risk factors for eventual suicide . A multivariate survival analysis indicated that several modifiable variables were significant and unique risk factors for suicide , including suicide ideation , major depressive disorder , bipolar disorder , and unemployment status BACKGROUND Clinical factors related to suicide and suicide attempts have been studied much more extensively in unipolar depression compared with bipolar disorder . We investigated demographic and course-of-illness variables to better underst and the incidence and potential clinical correlates of serious suicide attempts in 648 out patients with bipolar disorder . METHOD Patients with bipolar I or II disorder ( DSM-IV criteria ) diagnosed with structured interviews  were evaluated using self-rated and clinician-rated question naires to assess incidence and correlates of serious suicide attempts prior to study entry .  Clinician prospect i ve ratings of illness severity were compared for patients with and without a history of suicide attempt . RESULTS The 34 % of patients with a history of suicide attempts , compared with those without such a history , had a greater positive family history of drug abuse and suicide ( or attempts ) ; a greater personal history of early traumatic stressors and more stressors both at illness onset and for the most recent episode ; more hospitalizations for depression ; a course of increasing severity of mania ; more Axis I , II , and III comorbidities ; and more time ill on prospect i ve follow-up . In a hierarchical logistic regression , a history of sexual abuse , lack of confidant prior to illness onset , more prior hospitalizations for depression , suicidal thoughts when depressed , and cluster B personality disorder remained significantly associated with a serious suicide attempt . CONCLUSION Our retrospective findings , supplemented by prospect i ve follow-up , indicate that a history of suicide attempts is associated with a more difficult course of bipolar disorder and the occurrence of more psychosocial stressors at many different time domains . Greater attention to recognizing those at highest risk for suicide attempts and therapeutic efforts aim ed at some of the correlates identified here could have an impact on bipolar illness-related morbidity and mortality ABSTRACT There is no data on the variation in the suicide risk over lifetime and on the suicide-preventive effect of the long-term treatment of mood-disorder patients with antidepressants and neuroleptics .  Our research focused on 186 unipolar ( D ) , 60 bipolar II ( Dm ) , 130 nuclear bipolar I ( MD ) , and 30 preponderantly manic patients ( M/Md ) ; that were followed-up from 1963 to 2003 . By 2003 , 45 ( 11.1 % ) of the 406 patients had committed suicide . Suicide rates were highest among D patients ( St and ardized Mortality Ratio , SMR = 26.4 ) , MD ( SMR = 13.6 ) , Dm ( SMR = 10.6 ) and lowest among M/Md patients ( SMR = 4.7 ) . Prospect ively , the suicide rate decreased over the 44 years ' follow-up ; Lithium , neuroleptics and antidepressants reduced suicides significantly . Long-term treatment also reduced overall mortality , and combined treatments proved more effective than mono-therapy OBJECTIVE Antidepressants are supposed to be withdrawn during a manic episode . The aim of this study was to analyze the characteristics of manic patients who received antidepressants during a manic phase in a large , naturalistic study . METHOD The European Mania in Bipolar Longitudinal Evaluation of Medication was a 2-year prospect i ve observational study of in patients and out patients with acute mania/mixed mania ( DSM-IV or ICD-10 criteria ) conducted in 14 European countries . Of 2,416 manic patients who continued into the maintenance phase of the study , 345 ( 14 % ) were taking an antidepressant  and 2,071 ( 86 % ) were not taking an antidepressant at baseline , week 1 , and /or week 2 postbaseline . Demographic and clinical variables were collected at baseline and each study visit up to 24 months . Outcome measures included the Clinical Global Impressions-Bipolar Disorder scale ( CGI-BP overall , mania , and depression scores ) at 12 weeks and 24 months , the 5-item Hamilton Depression Rating Scale ( HDRS-5 ) , and the Young Mania Rating Scale ( YMRS ) at 12 weeks only . The present study was conducted from December 2002 to June 2004 . RESULTS More antidepressant maintenance use was seen in patients with mixed episodes ( P < .001 ) , rapid cyclers ( P < .02 ) , patients with more previous depressive episodes ( P < .001 ) , and patients with higher mean HDRS-5 score at baseline ( P < .001)-specifically patients with anxiety ( P = .013 ) . Patients in the antidepressant group had significantly higher CGI-BP depression scores ( P < .001 ) and a significantly higher rate of depression relapse ( P < .001 ) at both 12 weeks and 24 months . CONCLUSIONS Patients with mania receiving antidepressants are more likely to be out patients with mixed episodes , anxiety , or rapid cycling and have a higher risk of depression relapse during follow-up BACKGROUND Bipolar disorder ( BD ) is associated with a high prevalence of suicide attempt and completion . Family history of suicidal behavior and personal history of childhood abuse are reported risk factors for suicide among BD subjects . METHODS BD individuals with family history of suicidal behavior and personal history of childhood abuse ( BD-BOTH ) , BD individuals with family history of suicidal behavior or personal history of childhood abuse ( BD-ONE ) , and BD individuals with neither of these two risk factors ( BD-NONE ) were compared with regard to demographic variables and clinical measures . RESULTS Almost 70 % of the sample had a history of a previous suicide attempt . There were significantly higher rates of previous suicide attempts in the BD-BOTH and BD-ONE relative to the BD-NONE group . BD-BOTH were significantly younger at the time of their first suicide attempt and had higher number of suicide attempts compared with BD-NONE . BD-BOTH were significantly younger at the time of their first episode of mood disorder and first psychiatric hospitalization and had significantly higher rates of substance use and borderline personality disorders compared to BD-NONE . LIMITATIONS Retrospective study . Use of semi-structured interview for the assessment of risk factors . CONCLUSIONS BD individuals with a familial liability for suicidal behavior and exposed to physical and /or sexual abuse during childhood are at a greater risk to have a more impaired course of bipolar illness and greater suicidality compared to those subjects with either only one or none of these risk factors . Prospect i ve studies are needed to confirm these findings OBJECTIVE To detect risk factors for rapid cycling in bipolar disorder , the authors compared characteristics of  rapid-cycling and non-rapid-cycling patients both from a categorical and a dimensional perspective . METHOD Out patients with bipolar I disorder ( N=419 ) , bipolar II disorder ( N=104 ) , and bipolar disorder not otherwise specified ( N=16 ) were prospect ively evaluated with daily mood ratings  for 1 year . Subjects were classified as having rapid cycling ( defined by the DSM-IV criterion of four or more manic or depressive episodes within 1 year ) or not having rapid cycling , and the two groups ' demographic and retrospective and prospect i ve illness characteristics were compared . Associated factors were also evaluated in relationship to episode frequency . RESULTS Patients with rapid cycling ( N=206 ; 38.2 % ) significantly differed from those without rapid cycling ( N=333 ) with respect to the following independent variables : history of childhood physical and /or sexual abuse , bipolar I disorder subtype , number of lifetime manic or depressive episodes , history of rapid cycling , and history of drug abuse . The prevalence of these characteristics increased progressively with episode frequency . The proportion of  women  was greater than the proportion of men only among patients with eight or more episodes per year . The average time spent manic/hypomanic increased as a function of episode frequency , but the average time spent depressed was comparable in patients with one episode and in those with more than one episode . Brief episodes were as frequent as full- duration DSM-IV-defined episodes . CONCLUSIONS A number of heterogeneous risk factors were progressively associated with increasing episode frequency . Depression predominated in all bipolar disorder patients , but patients with rapid cycling were more likely to be characterized by manic features . The findings overall suggest that rapid cycling is a dimensional course specifier arbitrarily defined on a continuum of episode frequency Patients with Bipolar Disorder ( BD ) have high rates of suicide compared to the general population . The present study investigates the predictive power of baseline clinical , psychological and environmental characteristics as risk factors of prospect i ve suicide events ( attempts and completions ) . Data was collected from the Systematic Treatment Enhancement Program for Bipolar Disorder ( STEP-BD ) study . 3083 bipolar patients were included in this report , among these 140 ( 4.6 % ) had a suicide event  ( 8 died by suicide and 132 attempted suicide ) .  Evaluation and assessment forms  were used to collect clinical , psychological and socio-demographic information . Chi-square and independent t-tests were used to evaluate baseline characteristics . Potential prospect i ve predictors were selected on the basis of prior literature and using a screening analysis of all risk factors that were associated with a history of suicide attempt at baseline and were tested using a Cox regression analysis . The strongest predictor of a suicide event was a history of suicide attempt ( hazard ratio = 2.60 , p-value < 0.001 ) in line with prior literature . Additional predictors were : younger age , a high total score on the personality disorder question naire and a high percentage of days spent depressed in the year prior to study entry . In conclusion , the present findings may help clinicians to identify patients at high risk for suicidal behavior upon presentation for treatment OBJECTIVES To evaluate the baseline characteristics and follow-up outcomes of rapid-cycling ( RC ) bipolar I patients in a large , prospect i ve , observational study . METHODS EMBLEM ( European Mania in Bipolar Longitudinal Evaluation of Medication ) is a long-term prospect i ve observational study of in- and out patients with an acute mania/mixed episode conducted in 14 European countries . Demographic and clinical variables were collected at baseline , including the presence or absence of DSM-IV rapid-cycling during the past year . Outcome measures included the 5-item Hamilton Depression Rating Scale ( HAMD-5 ) and Young Mania Rating Scale ( YMRS ) over 12 weeks , as well as the Clinical Global Impressions-Bipolar Disorder Scale ( CGI-BP overall , mania and depression ) over 12 months . RESULTS Of 3684 patients enrolled , 3089 patients provided reliable data to qualify for either RC ( N=535 , 17.3 % ) or non-RC ( NRC , N=2554 ) , according to DSM-IV . RC prevalence varied across countries ( p<0.001 ) . Baseline and 12 week outcomes on the YMRS and HAMD-5 , 12 month ratings on the CGI-BP subscales and work impairment at 12 months were significantly different ( p<0.001 ) between groups , being worse in RC . RC patients were more likely to receive  antidepressants and lamotrigine  ( p<0.001 ) . Using logistic regression , RC was associated to country ( p<0.001 ) , female sex ( p=0.029 ) , out patients ( p=0. 
    Output:
    
This meta- analysis confirmed that SA is common in BD and identified a number of factors related to SA .