title: Understanding the link between anxiety symptoms and suicidal ideation and behaviors in outpatients with bipolar disorder.
abstract: BACKGROUND
  Prior studies suggest an association between anxiety comorbidity and suicidal ideation and behaviors in bipolar disorder. However, the nature of this association remains unclear.
  
  
  METHODS
  We examined a range of anxiety symptoms, including panic, phobic avoidance, anxiety sensitivity, worry and fear of negative evaluation, in 98 patients with bipolar disorder. We predicted that each anxiety dimension would be linked to greater suicidal ideation and behavior as measured by Linehan's Suicide Behaviors Questionnaire (SBQ), greater depressive rumination, and poorer emotional processing and expression.
  
  
  RESULTS
  Each anxiety dimension except fear of negative evaluation was associated with greater SBQ score, greater rumination, and lower levels of emotional processing in univariate analyses. Depressive rumination was a significant predictor of higher SBQ scores in a stepwise multivariate model controlling for age, gender, bipolar subtype, and bipolar recovery status; the association between the anxiety symptom dimensions and SBQ score was found to be redundant with depressive rumination. Emotional processing emerged as protective against suicidal ideation and behaviors in men only, while emotional expression was a significant predictor of lower SBQ scores for women and for the full sample; however, emotional expression was not significantly correlated with anxiety symptoms. Confirmatory analyses examining only those in recovery or recovered (n=68) indicated that the link between rumination and suicidality was not explained by depression.
  
  
  CONCLUSIONS
  Interpretation is limited by the cross-sectional study design.
  
  
  CONCLUSIONS
  These findings indicate that increased ruminations may mediate the association between anxiety and suicidal ideation/behavior. In men, lower emotional processing may also play a role in this relationship.
authors.affiliation: Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston MA 02114, United States. NSIMON@Partners.org
authors.forename: Naomi M
authors.initials: NM
authors.lastname: Simon
authors.forename: Mark H
authors.initials: MH
authors.lastname: Pollack
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Ostacher
authors.forename: Alyson K
authors.initials: AK
authors.lastname: Zalta
authors.forename: Candice W
authors.initials: CW
authors.lastname: Chow
authors.forename: Diana
authors.initials: D
authors.lastname: Fischmann
authors.forename: Christina M
authors.initials: CM
authors.lastname: Demopulos
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Nierenberg
authors.forename: Michael W
authors.initials: MW
authors.lastname: Otto
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D000553:Ambulatory Care; D001008:Anxiety Disorders / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology*; D001288:Attention; D001714:Bipolar Disorder / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology*; D015897:Comorbidity; D003430:Cross-Sectional Studies; D003674:Defense Mechanisms; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016584:Panic Disorder / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology; D010555:Personality Inventory; D010698:Phobic Disorders / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology; D012737:Sex Factors; D012803:Sick Role; D013223:Statistics as Topic; D013406:Suicide, Attempted / Q000523:psychology* / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires