First of all you should make an distinction of bipolar disorder type I (severe mood episodes from mania to depression in a cycling mode) and type II (severe depression periods, milder episodes of hypomania ). In the bipolar disorder type I you have more frequent drug abuse hypersexuality and spending a lot o money in the mania episodes. In bipolar disorder II you don´t have such severe mania episodes, frequently you will find increased energy, with hyperactivity and a decreased need for sleep. Answering the question which "pole" brings more risk I would say depends on personality and individual differences, social environment, protective and risk factors. There are studies about differences between suicidal ideation and attempts in bipolar I and II disorders.

Alexander,

You are absolutely right - risk varies enormously between Bipolar I and Bipolar II. A corollary to my original question would be: Is there a substantial risk of suicide or suicide attempts in the depression phase of Bipolar II?

Probably you are interested in reading this study, couldn´t find the full-text.

http://www.ncbi.nlm.nih.gov/pubmed/16420084

Alexander,

Thanks for the reference. The abstract of the article you cited indicated that the prevalence of suicidal attempts was similar for Bipolar I and Bipolar II, which suggests to me that it is a function of the depressive phase and not connected principally to manic or hypomanic symptoms.

In my opinion: Manic phase, a greater danger to society. Because, in this case the patient is more likely to be present in the community. But Depressed people more likely to have isolation.

Risk of suicide seems greater in the depressive phave of both type1 and type 11. Apart from personality, previous attempts, enviromental opportunity may very well facilitate the further attempt at suicide.

I believe that the client or patient that is suffering from Bipolar Disorder suffers from the greater risk when they are in the manic stage, they are more apt to take greater risks not only with substance abuse but they seem to develop an attitude where they have an ideation that they are indestructible and will purposely attempt to test fate and place themselves into harm’s way. I have witnessed firsthand where a client will purposely provoke another client into a potentially lethal situation, but through staff intervention and redirection was saved from serious injury.

Conversely, I have seen the same patient days later searching for some type of respite or consolation from internal strife and they were definitely more manageable.

I read these posts where the client is faceless, a patient, a risk, a disease, a condition, a diagnosis, someone to be treated, managed, stabilized and normalized. Yet our history has been created and enriched by people who are out of the box, have experienced emotional, even irrational, highs and lows, wrote poetry, plays, movie scripts, music, are actors, comics, innovators, inventors, presidents and prime ministers, even faithfully followed religious leaders. How can a person know what the box of social conditioning looks like unless they leave it from time to time?

I worry about what is happening to the children of today who have the potential to be creative beyond imagination and make history we enjoy in the future? I agree that protection from suicide and trying to fly off buildings is important but no medication or treatment should be mandatory or enforced or even highly recommended by someone who is afraid of the experience. A person should be able to chose a middle road of 'a bit crazy or depressed from time to time but with support able to remain passionately creative, in all of its expressions'.

Due to a particular family history of my own, I have given much thought to this query. A brief background for perspective; my Dad, an MD that taught me true medicine, not holistic just not full of bull shit. To illustrate; he would take me on house calls with him as a distraction, a happy wish, perhaps, all the sentiment and sincerity of a Southern Norman Rockwell, ya know with sweet tea and all. He was also the President of the local hospital, and as such, had patients he saw. On average his patients were prescribed four different medications, those not under his care were choking down over eleven pills. To the contrary, indeed, of need. There were no contra-indicative resulting data such as rising deaths, either, just to be clear. However, my older brother suffers from and an endocrine disorder, low testosterone, and I am certain that there is a basic chemical imbalance that theoretically could be fixed with a pill-a balance. You may also be surprised by the "happy pill" popping protocol for my stepmother, whom I suspect was wildly bi-polar, at minimum. She smiles and giggles, still gets nervous, and scared as she is alive inside still, not over-medicated and zombie-fied. Once again, a balance. A balance and happiness found in at least one case to be successful. My brother on the other hand, struggles. Hormones are certainly more tricky to be accurate, only to be down-played by the extreme emotion attached to the conversation and a grave stubborness that reeks of self denial. To sum up his machismo; he won the National Ironman Dirt Bike (Motorcross) Enduro, twice, back to back. The second time he not only won, but could have slept the last 3 hours of the race, gotten on his bike and rolled it across the finish line to take the trophy. An enduro is a 24 hour race that the only rule is that the bike that starts the race, ends the race, who cares how many people ride. There were teams 2-12 or so, that he still beat by that sort of margin=STUBBORN EGO

The result of inapt attempts to self medicate a core, fundamental, inherent element of self and identity, to say the least.

All this to say, there are several reasons one should take the "happy pill", but with moderation and with the right tool for the job. Some things you can fix that way, thankfully, and I can accept that some are far too precise for us to fathom. Over medicating for profit or personal perks is a disgusting bastardization of humanity-forget who or what their profession, but basic humanity. It occurs far to often. Another grave injustice is the ignorant medication concoctions we misguidedly consume at an alarming rate. Often Paxil, Welbutrin, etc given for anxiety that is the result of a CNS tic, not a behavioral instability. You wouldn't treat a headache with a laxative, would you? The drugs are powerful, too, and the access, yikes! Drug testing protocols have always made me leary, it's not long enough of a process, give anything 5-10 years and it will be on the 1-800-bad-drug lawsuit hotline. Oxycotin! Don't get me started on the most evil pill on the planet: poison.

Sorry, I have put a lot of thought into the idea of pill perfection passivity, and hope you found my intent within the ranting and ramblings of my personal anecdotes meant to illustrate my opinion, as well as it's justification.

People who are severely depressed are actually at a fairly low risk of suicide. I'm talking about SEVERE modes of depression. Death in this case would be due to self care failure. People who are slowly working out of depression can be more prone to suicide attempts and completions because they simply have more energy. I believe the effect is called "rebounding". Not well enough to care about living and with the motivation to kill/hurt themselves.

When the inertia of the profound depression lifts a client may experience sufficient energy and impulsivity to act upon suicidal ideation in the manic phase. Both poles interfere with the individuals ability to consider alternate modes of healthy coping and problem solving. This would be an interesting archive study to examine behavioral presentation prior to suicide by reviewing post mortem reports shared by volunteer family members who had adequate grieving time and were willing to participate.

There is nothing called greater clinical risk. In both depression and mania there are risks which are inherent to the nature of clinical presentation. In depressive phase there can be death due to suicidal risk, whilst in Manic phase the same can happen due to diving a vehicle in high speed from excitement. So the risks are equal but the presentations might differ. For relatives/ care givers it's manic phase which is difficult to come to terms with and they feel in depressed phase the affected individual is easier to handle

The standard thought in the field is that clients are more likely to actually commit suicide as they are entering a manic phase because they have the energy to act. But the picture is more complex. First of all, with certain forms of suicide, it doesn't take much energy or even initiative to act, so you'll see some suicides in the during the crash into depression after the first long sleep after the manic phase.

Another complexity: my understanding is that there is more suicide in Bipolar II than Bipolar I. Why? Not sure: maybe the Bipolar II people are less likely to be in therapy, or they don't have full mania to look forward to, or they are more likely to be misdiagnosed as depressed and be on the wrong medication and get a hypomanic phase triggered for the first time by an SSRI.

Other than suicide, I agree that the general risks are greater during a manic phase, although even a hypomanic phase can include impulsive shopping and problematic sexual behavior. The key for a clinician is to find a way to stay in touch with the client during this phase or at least, after it's done, help them see that the "happy" phase didn't have such happy outcomes, and help them decide to smooth out the ups and the downs in their moods so life won't feel so out of control (another suicide trigger).

Best wishes for stability and direction to those suffering with bipolar disorder and to the loved ones and clinicians in their lives!

Depression is a high risk of suicide, depending on severity/type. Similarly, mania is equally dangerous as sleep lessens, the mind is perhaps rapid cycling thus irrational high risk acting out behavior is imminent. Danger for accidental death as well as possible problems with the law.

As a clinician, there is a related matter that is close to this question. When I am dealing with a patient with depression, or panic, if we decide together that their medication should be reduced or stopped, I am usually confident that, if the decision proves to be wrong, the patient will come back and tell me about it.

Whereas, with patients who are sometimes manic, hypomanic or psychotic, if I reduce their medication and they have a relapse, they may very well not return to me for a correction. They might even decide to completely stop their medication, avoid all psychiatrists, and run seriously amok.

Thus the second type of patient requires more conservative management than the first, unless, of course, there is significant suicide risk.

I work closely with physicians in a medical clinic and from a practical perspective I find that the greatest risk to bipolar disorder patients is misdiagnosis in the dysphoric phase as this is often diagnosed as 'simple' depression.

Many bipolar patients end up in show business, and their antics during manic phases provide endless tabloid copy, where they are mercilessly criticized and pilloried by people who do not understand mental illness. I think in many cases this tips them over the edge.

"I worry about what is happening to the children of today who have the potential to be creative beyond imagination and make history we enjoy in the future? I agree that protection from suicide and trying to fly off buildings is important but no medication or treatment should be mandatory or enforced or even highly recommended by someone who is afraid of the experience"

From someone not being 'afraid of the experience', creativity and imagination are not just seen in bipolar persons, and although these traits are associated with bipolar disorder, when these individuals are in the throes of mania leading to psychosis or in the depths of a deep depression, the peak of creativity may not be worth achieving, not to mention that under the right set of circumstances much of that attribute is within reach. There is a reason that the alleles in this disease do not die out. Relatives of bipolar persons can be hypomanic, productive persons having abundant creativity and imagination without the complication of being in a state of depression or mania leading to psychosis. There is a narrow window for the creativity and imagination to be expressed when a good portion of the picture is spent being in a dysfunctional state, worrying friends and family and being without the lowest dose of a functional cocktail on board. There is too much drama to be functionally creative. Hypomania is the best state to be creative in, but only if there is relative stability. A bipolar person has a much better chance of having some expression of creativity, maybe not their deepest potential (which by the way comes at a very high price in the way of relationships, unemployment, possibility of becoming homeless, or loss of life) if he/she is on a minimal dose of a well proven cocktail of drugs, under optimal stress conditions and is fortunate enough to have a good support system.

Or has addressed the causes to the point where medication is no longer needed... ie found the hidden infection, food allergy, nutritional imbalance, environmental toxin, moved away from a toxic relationship, given up drugs or drink or smoking, is eating better, sorted their sleep pattern, balanced their hormones, done a heavy metal elimination, no longer drinking several liters of diet coke a day or more than 4 coffees.

What cracks me up is the junk food and soda dispenser or free coffee that can be found in the waiting rooms of so called health professionals. If they were serious about health and not profit there would be pure water, fruit and health bars. Lets get creative in a health way rather than rely on functional mind numbing cocktails.

"Or has addressed the causes to the point where medication is no longer needed... ie found the hidden infection, food allergy, nutritional imbalance, environmental toxin, moved away from a toxic relationship, given up drugs or drink or smoking, is eating better, sorted their sleep pattern, balanced their hormones, done a heavy metal elimination, no longer drinking several liters of diet coke a day or more than 4 coffees. "

After doing quite a bit of research to find evidence bolstering your claims, I must say that I found some credible evidence to support your assertions. So I do agree with your ideas to some extent. I do wish that you would show how your claims are supported with objective evidence rather than subjective chatter. Even though I feel more comfortable with your position, I do not believe that all of the reasons given that you claim contribute to mental illness that leads to psychosis can be erased so easily, for example a case of an infection to the mother during pregnancy leading to developmental problems concerning the brain, or similarly like the following article that I found which appears to affect brain development in the fetus and in the developing child:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963051/

"Developmental Vitamin D Deficiency and Risk of Schizophrenia: A Ten Year Update"

Margaret my knowledge comes from my own lived experience or survival story as it is sometimes called. I have researched from lots of sources over about 8 years and its little snippets from all over the place. The best source is the orthomolecular scientists Abram Hoffer and Linus Pauling who had astounding success in the 1950's with the use of supplements which of course included nutritious food. Their work is easy to understand and is covered in Patrick Holfords book Ultimate nutrition for the Mind. Its a must read and should be available in any library.

Then the are the people who have seriously questioned the psychiatric view of mental health... Thomas Szasz, Peter Breggin, Richard Benattal, Robert Whitaker, David Pilgrim and many more. Others such as David Healy (who is both a pharmacist and psychologist as well as chair of the British Psychology Society) question our readiness to drug first and ask questions later. There is the ISPS society with members such as John Read and a growing movement to explore other options as well as causes.

I like to look at the big picture rather than focus on one thing or another (scientists are too ready to isolate issues and make them the be all). Mostly I feel that emotional and mental overwhelm comes from many contributing sources and the last straw that breaks the camels back is not the sole reason for a break down. Anything that is robbing nutrients, bringing down the immune system and exhausting the coping ability of a person sets them up for distress. Compound that with poor coping and attempts to self medicate, sleep deprivation and escalating distress and psychosis is the result. It can happen to anyone given enough stress so why give it the labels, stigma, fear, separation, judgement and harsh medical shutting down? I enjoyed some of my manic episodes as they gave me a spiritual emergence experience I would not have had otherwise.

"Mostly I feel that emotional and mental overwhelm comes from many contributing sources and the last straw that breaks the camels back is not the sole reason for a break down. Anything that is robbing nutrients, bringing down the immune system and exhausting the coping ability of a person sets them up for distress. Compound that with poor coping and attempts to self medicate, sleep deprivation and escalating distress and psychosis is the result. It can happen to anyone given enough stress "

Heather,

I also feel that emotional and mental overwhelm is multi-factorial, and some cases may require nutritional approaches coupled with minimizing stress, while some will require medical intervention, stress reduction and therapy.

What do you think about multiple incidences in one familial generation as opposed to isolated incidences? Was your case an isolated case or do you have a history of your experience in your family?

Thank-you for your explanation. It helps me to understand you more fully, and I will take a look at Patrick Holfords book Ultimate nutrition for the Mind.

"I will take a look at Patrick Holfords book Ultimate nutrition for the Mind."

I suggest you also Google "Patrick Holford quack".

Quack is an emotive word which really dosnt mean anything. Ultimate nutrition for the mind is almost simplistic nutrition pathways and the effects of deficits, supported by good studies, there really isn't anything controversial in it. The amazing thing is how little knowledge is applied... for example anorexia is hard to treat while zinc levels are low as the body shuts down appetite in order to conserve zinc. This isn't rocket science yet even eating disorder mental health specialists don't know this. By force feeding the anorexic without zinc supplementation they make people sicker.

Thank your for asking me a question Margret, this is rare on this site. Two of my great grandfathers committed suicide and I have one cousin who is autistic. I tested positive for Pyroluria which is genetic so perhaps this will explain a tendency towards mental health issues as a stress response. I prefer this to having cancer express as my stress response. I am currently looking at something called a 4-4 antigen profile which may be genetic and renders this group of people more susceptible to accumulated heavy metals.

I know I suffered mental confusion when as a young teen the dental nurse filled every molar tooth. At 32 and again at 47 when I experienced problems it was after dental work and a lot of amalgam exposure (50% mercury). With Pyroluria there is already too little zinc and B6 and further compromise tipped the balance. Throw in a complicated child birth with eventual C-section, giardia, sleep deprivation and postpartum hormonal swings and its easy to be in the 1 in 500 postpartum psychosis group. The second time around was more dental work, early perimenopause, relationship breakup and a hidden failed root canal.

I do not believe I was an isolated case in terms of cause. In terms of recovery I might be because I am extremely stubborn and kept my medication to the minimum thereby possibility avoiding dependence, obesity, diabetes and heart disease. I was and still am proactive in self care, education, nutrition and life balance. A year of psychotherapy and doing a degree helped, although I have never seen anything in the DSM which remotely makes any sense. The experience is much more human overload, expanded senses and altered state of consciousness than disease and illness in nature. Also by the time intervention came the experience had all but run its course and I later proved this by having a mania (triggered by the root canal removal) over 4 days with no medication apart from supplements and intravenous Vit C. Two days later I was back at university with no ill effects and it was to be my last episode.

"Quack is an emotive word which really dosnt mean anything."

I think quackery does have a precise meaning. Here are some thoughts on the subject still relevant today from an editorial in Medical Times, April 25, 1846:

"[Horace Augenio] preferred catching hold of their credulity with an instrument not likely to lose a victim, having once fairly hooked him. This instrument was a TESTIMONIAL...Personal avowals... are very difficult to contradict...

Only let him have capital enough to command a nook in some newspaper of fair circulation, and the money he expends in advertisements will be returned to him a hundred fold!..

Often has a thickhead, in a prodigality of invective, raised himself into repute by a wholesale denunciation of some particular drug...

So it is in physic -- do something to distinguish yourself, no matter what -- get your name up, and you will get your fortune!...Make a book--if you can, by writing something up; if not, by writing something down..

Sylvius was not a quack at heart... He conceived sundry notions about acids and alkalies, in the system; and according as one predominated, he prescribed the other. He made such a fair show of reasoning upon the matter, that many were converted to his faith; and not a little was rational pathology retarded by the absurd fancy that the living machine was nothing better than a laboratory...

This toying with chemistry we have curiously watched for some time past...We are old patrons of it ourselves...We desire to see it honourably enlisted in the cause of practice of physic; but we do earnestly hope that, in the hands of adventurers, it may not be made an ostentatious means of fostering and furthering quackery...

Chemistry, as applied to the practice of physic, is a most useful adjunct, both of diagnosis and therapeutics, in the hands of men sufficiently well skilled to be competent to form upon it a rational opinion. In the hands of inexperienced men-- to whom we fear its serious truths are being too often committed -- we do not hesitate to say that they are worse than worthless."

Thank-you for the explanation Heather. No information is too much and since I believe that any disease is multifactorial I like to look at all positions and find the right context to look at new information in order to form my own opinion.

Anthony,

I did find this piece of information in Wikipedia that I found quite disturbing. It does throw up a big red flag for me:

Holford has been the subject of criticism for his promotion of medically dubious techniques and products including hair analysis, his support of the now struck off doctor Andrew Wakefield, and advocating the use of "non-drug alternatives for mental health" for which he has been given an award by the Church of Scientology-backed Citizens Commission on Human Rights.[13]

I am not a fan of the 'Church of Scientology'.

Anthony,

Earlier in a posting I shared some information about firsthand experiences of patient viewpoint in psychosis.  You commented that it (patient accounts) are rarely seen in scientific literature.  There is a book that includes this information interwoven with the scientific text.  You may have already read or heard of it.  It is called "Manic-Depressive Illness" by Frederick K. Goodwin and Kay Redfield Jamison,  "The revolution in psychiatry that began mid-century (20th) had lead to dramatic advances in the understanding and treatment of manic-depressive illness.  No other mental disorder has been the subject of such clinically useful and scientifically productive research.  This book is the first to survey this massive body of evidence comprehensively and to assess its meaning for both clinician and scientist.  The book also vividly portrays the experience of manic-depressive illness from the perspective of patients, their doctors and researchers."  It covers all aspects and subjects related to bipolar illness and was, I believe, ten years in the making and published in 1990.  I have had this book since about 1995 and I am just now getting around to reading it (it looked pretty daunting to me, nearly 800 pages of dense text and more than 100 pages of scholarly references.  I thought that you might be interested.  It was praised by Dr. James Watson of Watson and Crick fame and I am aware that you are interested in the genetic viewpoint of psychosis.

Anthony,

In an earlier discussion, I can't remember whether it concerned schizophrenia or bipolar disorder, but it had to do with monozygotic twin studies.  I am reading the book "Manic-Depressive Illness" by Frederick K. Goodwin and Kay Redfield Jamison.  At least in "data from monozygotic twin pairs showing when one twin is diagnosed as manic-depressive, the co-twin, if not actually manic-depressive is very frequently cyclothymic" (Bertelsen et al., 1977).  And if manic depression is based on the diathesis-stress model leading to a continuum or spectrum scale for manic depression, then this result would make sense.  Both twins are vulnerable to developing bp disorder, say genetically, but one twin receives an (several) environmental stressor(s) allowing him/her to exceed the threshold for developing the disease, leading to the phenotype of manic depression, while the co-twin is subjected to a lesser amount of stress or different stressors, or has a more positive experience in his/her environment, then the less severe form of the disease (cyclothymia) develops.  If schizophrenia is also on this continuum (no basis actually known for this example, just a hunch), then this principle would also apply.

 "It is called "Manic-Depressive Illness" by Frederick K. Goodwin and Kay Redfield Jamison"

I have just been checking the second edition of this -- much bigger than the first ed I'm afraid!   Nevertheless, I could find only one sentence relevant to my hunt for the prodromal syndrome of psychosis.  I believe Meniere Spectrum Disoder is intimately connected with incipient schizophrenia, at least for the auditory hallucinations, so was looking to see if there was any evidence in MD illness as well, but all there was was a reference to audiosensitivity in mania.

In Manic-Depressive Disease by J D Campbell (1953), on the other hand, there was abundant evidence for MSD as an integral part of the psychosis.   See these extracts from detailed patient histories:

"My ears ring and I feel woozy. I have a feeling my head is blowing up, getting bigger and bigger, and then comes down again. Do you think I am losing my mind?" p 57

"There was a dull, 'woozy' feeling in her head which interfered with concentration.  The headache was definitely aggravated by noise...Her vision was blurred, she felt dizzy, and was too unsteady on her feet to walk. The patient described a pressure feeling in her head, particularly in or about the ears which, she admitted, along with other symptoms, had aroused fears of impending insanity" p 59

"I began to feel dizzy, couldn't think clearly, and felt like I might pass out...Ears feel like they are stopped up and roar all the time" p.100

"These tantrums result from endogenous factors (fear, anxiety, sensitiveness and intolerance to noise)." p 111

"Most manic-depressive patients have a hyperacusis or hypersensitiveness to noise.  Indeed, long before the psychosis occurs, as indicated by the history, the patient "never could stand any fuss or noise"". p 188

"He had a 'woozey' feeling in his head which, along with oher symptoms, aroused fears of insanity" p.309

"Tinnitus, pressure or roaring sensations in the ears, and gastric distress, often accompany the headache.   The patient describes this symptom on one occasion as a pain or headache, on another occasion as a pressure sensation and still at another time as a 'woozy', 'crazy' or 'addled' feeling in the head".

These symptoms, especially in tandem, are of aural origin and indicative of Endolymphatic Hydrops.

Hi Anthony,

'"It is called "Manic-Depressive Illness" by Frederick K. Goodwin and Kay Redfield Jamison"

I have just been checking the second edition of this -- much bigger than the first ed I'm afraid!'

Thank-you for pointing me in the direction of the second edition.  It gave me an adrenalin rush.  I am still recovering from it.  I don't like to feel this way, but I am excited to have ordered this updated version.  I am only on the fifth chapter of the first edition, and I can sell it at Half Price Books when I receive the second edition.

"Nevertheless, I could find only one sentence relevant to my hunt for the prodromal syndrome of psychosis. I believe Meniere Spectrum Disoder is intimately connected with incipient schizophrenia, at least for the auditory hallucinations, so was looking to see if there was any evidence in MD illness as well, but all there was was a reference to audiosensitivity in mania.

In Manic-Depressive Disease by J D Campbell (1953), on the other hand, there was abundant evidence for MSD as an integral part of the psychosis."

A very interesting idea.  I will keep that in mind.  If I find anything of interest I will let you know.

"one twin receives an (several) environmental stressor(s) allowing him/her to exceed the threshold for developing the disease, leading to the phenotype of manic depression, while the co-twin is subjected to a lesser amount of stress or different stressors, or has a more positive experience in his/her environment, then the less severe form of the disease (cyclothymia) develops."

This is the clear conclusion from behaviour genetic research on many psychiatric conditions.  However, the other important conclusion that seems to have been missed is that these stressors must be specific to the individual, not acting on both twins.  This rules out the vast majority of the favourite stressors studied by psychologists and sociologists over the last century.   

" However, the other important conclusion that seems to have been missed is that these stressors must be specific to the individual, not acting on both twins. This rules out the vast majority of the favourite stressors studied by psychologists and sociologists over the last century.  "

Of course these stressors must be specific to the individual, otherwise it wouldn't make sense that there were differences between monozygotic twins at such a high frequency concerning manic-depressive illness and schizophrenia.  Both of these diseases are expressed fairly late in life however, so one can't control the environment such that the two individuals have different stressors growing up.  I don't see how the experiment can be done.  Parents treat children differently even if the children are identical twins, and identical twins do experience a different environment growing up whether in the same household or in two independent households.  The only environment that can even remotely be considered identical for monozygotic twins is the in utero environment, and even that is different, because not all placental connections are identical, and so there could be competition for nutrients, oxygen, etc., if my thinking is correct.

The question is In Bipolar Disorder, which pole presents a greater clinical risk: Depression or Mania?

To properly answer this question risk, particularly clinical risk needs clarification. Of course Depression will almost always have a great deal of clinical risk when suicidal behaviour presents itself. Clinically speaking an individual's suicidal behaviour presents a risk to him or herself. The aftermath of attempted and/or completed suicide will be painful for loved ones, friends and other patients who may have been in hospital at the time.

One might then imagine that depression and  suicidal behaviour and suicide  will always present the greater clinical risk.

However, many, if not all, manic patients become extremely irritated and frustrated when attempts are made to curb the behavioural manifestations of mania. On wards and in the community this irritation, frustration generally results in anger and impulsive aggressiveness causing risk to both self and others.

Another high risk for manic patients is their propensity to spend much more money than they have.  This behaviour has not only caused many social and financial problems for the patient but also for their families. There are those that  have lost jobs and even their house as a result of their overspend.

From this perspective I think that both of these clinical risks are as great as each other in different ways and that both will always require clinical vigilance in observation, education, and treatment.

William

The risk to bipolar patients from depression is present during manic as well as depressive episodes. Mania characterized by a mixture of anger, excitement, and labile moods-that may include sadness and thoughts of suicide- are more common than euphoric mania. 

Exactly correct Richard. From that perspective bipolar disorder in itself presents many risks all of which need to be assessed and then minimised with effective treatments.

William

My husband works with homeless individuals who occasionally have bipolar problems.  The hardest phase in that situation is the manic/euphoric: stops taking medication, no need to change anything, and is a know-it-all.