• Open Access

Cognitions in bipolar affective disorder and unipolar depression: imagining suicide


  • GMG has received grants from Sanofi-aventis and Servier in the past, and honoraria from various pharmaceutical companies. EAH has received funding from a Wellcome Trust Clinical Fellowship (WT088217); and grants from the Lupina Foundation, Royal Society, Medical Research Council, and the Economic and Social Research Council in the UK. SAH and CD have no conflicts of interest to report.

  • Re-use of this article is permitted in accordance with the Terms and Conditions set out at http://wileyonlinelibrary.com/onlineopen#OnlineOpen_Terms.

Corresponding author:
Dr. Susie A. Hales
Department of Psychiatry
Warneford Hospital
Oxford OX3 7JX, UK
Fax: +44-(0)-1865-793101
E-mail: susie.hales@psych.ox.ac.uk


Hales SA, Deeprose C, Goodwin GM, Holmes EA. Cognitions in bipolar affective disorder and unipolar depression: imagining suicide.
Bipolar Disord 2011: 13: 651–661. © 2011 The Authors. Journal compilation © 2011 John Wiley & Sons A/S.

Objective:  Bipolar disorder has the highest rate of suicide of all the psychiatric disorders. In unipolar depression, individuals report vivid, affect-laden images of suicide or the aftermath of death (flashforwards to suicide) during suicidal ideation but this phenomenon has not been explored in bipolar disorder. Therefore the authors investigated and compared imagery and verbal thoughts related to past suicidality in individuals with bipolar disorder (n = 20) and unipolar depression (n = 20).

Methods:  The study used a quasi-experimental comparative design. The Structured Clinical Interview for DSM-IV was used to confirm diagnoses. Quantitative and qualitative data were gathered through questionnaire measures (e.g., mood and trait imagery use). Individual interviews assessed suicidal cognitions in the form of (i) mental images and (ii) verbal thoughts.

Results:  All participants reported imagining flashforwards to suicide. Both groups reported greater preoccupation with these suicide-related images than with verbal thoughts about suicide. However, compared to the unipolar group, the bipolar group were significantly more preoccupied with flashforward imagery, rated this imagery as more compelling, and were more than twice as likely to report that the images made them want to take action to complete suicide. In addition, the bipolar group reported a greater trait propensity to use mental imagery in general.

Conclusions:  Suicidal ideation needs to be better characterized, and mental imagery of suicide has been a neglected but potentially critical feature of suicidal ideation, particularly in bipolar disorder. Our findings suggest that flashforward imagery warrants further investigation for formal universal clinical assessment procedures.