seven countries, for a total population of 3700 people with bipolar disorder, found a rate of suicide 15-fold higher than would be expected in the general population. The risk of death from suicide in bipolar disorder is greater than the mortality rate for some types of heart disease (Goodwin and Jamison, 1990).

Bipolar disorder (also called manic depressive disorder), is a biological disorder with significant genetic heritability (Alda, 1997; Blackwood et al., 2001). Bipolar disorder includes depressive and manic episodes (APA, 1994). Depressive episodes are described in the section above on depressive disorders and include long-lasting sad, apathetic or irritable mood, altered thinking, activity, and bodily functions. Manic episodes include periods of abnormally and persistently elevated, expansive, or irritable mood; inflated self-esteem; decreased need for sleep; extreme talkativeness; distractibility; high levels of activity; and increased pleasure-seeking and risk-taking behaviors. Symptoms of psychosis including delusions and hallucinations can also occur in bipolar disorder (APA, 1994). Currently, there are two recognized types of bipolar disorder, Type I and Type II. Bipolar II may have an increased risk for suicide and differs from Type I in that the manic periods are less severe and thus are termed hypomania. Bipolar II disorder is frequently misdiagnosed as major depression (Goodwin and Jamison, 1990).

Whereas much is known about variables associated with increased risk for all of those with mood disorders, few studies have examined bipolar disorder separately. Unlike the usual gender difference with more men than women completing suicide, women with bipolar illness complete suicide at a rate almost equal to that of men with bipolar illness (Weeke, 1979). The greatest risk of suicide is early in the course of illness, within the first 5 years of the initial diagnosis (Guze and Robins, 1970; Roy-Byrne et al., 1988; Weeke, 1979). Severity of the disorder is also associated with increased risk for suicide (Hagnell et al., 1981), and those with more severe cases of bipolar disorder will have more frequent hospitalizations. Discharge from the hospital is a period of high risk. Inadequate treatment, whether due to non-adherence, unavailability, or lack of treatment response, is associated with increased suicide risk; inadequate levels of mood stabilizers or antidepressants are found in the majority of those who die by suicide (Isometsa et al., 1994). The time after discharge from the hospital may also carry high risk because the person must rebuild their life while facing a future with a recurrent, life-disrupting disorder. In addition, family and employers may inadvertently increase stress on the individual by having unrealistic expectations of an immediate return to full functioning (Appleby, 2000; Goodwin and Jamison, 1990).

Those with bipolar type II disorder, which includes periods of hypomania, but not mania, is associated with increased risk of suicide (Dunner

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