CQAIMH - center for quality assessment and improvement in mental health



Bipolar Disorder or Depression: Assessment for risk of suicide


This measure assesses the percentage of patients diagnosed with bipolar disorder, or with unipolar depression, who receive an initial assessment that considers the risk or suicide.

Clinical Rationale:

Bipolar Disorder and Risk of Suicide

  • Unipolar depression and bipolar disorder are associated with a significant risk of suicide
    The risk of completed suicide is higher in bipolar disorder than in unipolar depression (1,2)
  • Patients with bipolar disorder are at high risk for suicide; rates as high as 80% of patients with bipolar disorder have been reported with either suicidal ideation or suicide attempts (3)
  • Suicide completion rates in patients with bipolar I disorder have been reported as high as 10-15% with some studies reporting higher rates in patients with bipolar II disorder (3)
  • Among the phases of bipolar disorder, depression is associated with the highest suicide risk, followed by mixed states and presence of psychotic symptoms with episodes of mania being least associated with suicide (4)
  • Data from a large study reporting STEP-BD baseline data identified that of patients with bipolar disorder, 60% had a history of prior suicide attempts and that this finding was consistent with other large studies that show a strong association between prior history of suicide attempts and new attempts or completed suicide in patients with bipolar disorder (5)

Assessing Risk of Suicide

  • All patients should be asked about suicidal ideation, intention to act on these ideas, and extent of plans or preparation for suicide (4)

Denominator Population:

Patients diagnosed with bipolar disorder
Patients diagnosed with unipolar depression

Data Sources:

  • Administrative data
  • Medical Record

Numerator Population:

Patients who receive an initial assessment for bipolar disorder (or unipolar depression) that includes an appraisal of the risk of suicide

Data Source:

  • Medical Record

Initial Case-finding Guidance:

Patients with a diagnosis involving bipolar disorder
ICD9CM or DSM IV TR: 296.0x; 296.1x; 296.4x; 296.5x; 296.6x; 296.7; 296.80-82; 296.89; or 301.13
Patients with a diagnosis involving unipolar depression
ICD9CM or DSM IV TR:  296.2x; 296.3x; 300.4 or 311

STABLE Resource Toolkit:

The following instruments are recommended by the STABLE National Coordinating Council for use in assessing the risk of suicide.  The tools are available in the corresponding section of the STABLE Resource Toolkit.

  • Suicide Behaviors Questionnaire-revised (SBQ-R):  Brief self-report tool
  • The Suicidal Ideation and Risk Level Assessment: Brief clinician-administered tool


  1. Raja M, Azzoni A, Suicide attempts: differences between unipolar and bipolar patients and among groups with different lethality risk, J Affect Disord. 2004 Nov 1; 82(3); 437-42
  2. Zalsman G, Braun M, Arendt M, et al., A comparison of the medical lethality of suicide attempts in bipolar and major depressive disorders, Bipolar Disord. 2006 Oct; 8 (5 Pt 2): 558-65
  3. Valtonen H, Suominen K, Mantere O, et al., Suicidal ideation and attempts in bipolar I and II disorders, J Clin Psych, 2005 Nov; 66 (11): 1456-62
  4. American Psychiatric Association, Practice Guideline for the Treatment of Patients with Bipolar Disorder, Am J Psychiatry 159: 4, April 2002 Supplement
  5. Marangell LB, Bauer MS, Dennehy EB, et al. Prospective predictors of suicide and suicide attempts in 1,556 patients with bipolar disorder followed for up to 2 years, Bipolar Disorders 2006: 8: 566-575

Copyright 2007 by the Center for Quality Assessment and Improvement in Mental Health