Moral or religious objections to suicide may protect against suicidal behavior in bipolar disorder

Objective: Patients with bipolar disorder are prone to suicidal behavior, yet possible protective mechanisms are rarely studied. We investigated a possible protective role for moral or religious objections to suicide against suicidal ideation and attempts in depressed bipolar patients. Method: A retrospective case control study of 149 depressed bipolar patients (DSM-III-R criteria) in a tertiary care university research clinic was conducted. Patients who reported religious affiliation were compared with 51 patients without religious affiliation in terms of sociodemographic and clinical characteristics and history of suicidal behavior. The primary outcome measure was the moral or religious objections to suicide subscale of the Reasons for Living Inventory (RFLI). Results: Religiously affiliated patients had more children and more family-oriented social networks than nonaffiliated patients. As for clinical variables, religiously affiliated patients had fewer past suicide attempts, had fewer suicides in first-degree relatives, and were older at the time of first suicide attempt than unaffiliated patients. Furthermore, patients with religious affiliation had comparatively higher scores on the moral or religious objections to suicide subscale of the RFLI, lower lifetime aggression, and less comorbid alcohol and substance abuse and childhood abuse experience. After controlling for confounders, higher aggression scores (P = .001) and lower score on the moral or religious objections to suicide subscale of the RFLI (P < .001) were significantly associated with suicidal behavior in depressed bipolar patients. Moral or religious objections to suicide mediated the effects of religious affiliation on suicidal behavior in this sample. Conclusions: Higher score on the moral or religious objections to suicide subscale of the RFLI is associated with fewer suicidal acts in depressed bipolar patients. The strength of this association was comparable to that of aggression scores and suicidal behavior, and had an independent effect. A possible protective role of moral or religious objections to suicide deserves consideration in the assessment and treatment of suicidality in bipolar disorder.