Caroline V Clements, University of Manchester Degree title: Doctor of Philosophy, submitted 31.03.2017 Suicidal behaviour in bipolar disorder: a multiple-methods investigation of the characteristics, risk factors, and experiences of people at risk. Abstract Background: Suicide prevention strategies recognise the need to address suicide in high-risk groups, such as people with psychiatric illness. People with bipolar disorder are known to be at particularly high risk of suicide and self-harm, with around half of people diagnosed with bipolar disorder making at least one suicide attempt during their lifetime. It is important that clinicians can identify who is most at risk among people with bipolar disorder so that interventions that meet the needs of this high risk group can be implemented. Method: A multiple-methods approach was used to explore suicidal behaviour in bipolar disorder. Descriptive analysis, case-control methods, and survival analysis were used on data held by The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI), and the Manchester Self-Harm (MaSH) Project, to identify characteristics and risk factors associated with suicide in bipolar disorder. Semi-structure interviews were carried out with people who had a range of experiences of suicidal behaviour in bipolar disorder, and these data were analysed using Thematic Analysis to add context and depth to the quantitative results. Results: Suicidal behaviours were common in people with bipolar disorder, accounting for around 10% of all psychiatric suicide deaths in England; this rate was fairly stable over time. Characteristics associated with suicidal behaviour in bipolar disorder included; being aged 45 to 64 years old, experiencing negative life events, comorbid alcohol use, multiple inpatient admissions; there was a particularly strong association with a history of self-harm. It is clinically important that people with bipolar disorder were often seen by services in the 24 hours before they died. This both emphasises the weaknesses in current risk assessment, and highlights the potential for successful intervention if risk can be determined more accurately. Key issues identified in the interview study included being able to access care rapidly during time periods when risk was elevated, the importance of obtaining a correct diagnosis of bipolar disorder, and the potential benefits of including family in the care of people with bipolar disorder. Conclusion: Suicidal behaviours are common in people with bipolar disorder. People with bipolar disorder who die by suicide tend to have several markers that may indicate a more severe (e.g. multiple inpatient admission, history of self-harm) and complex course of illness (e.g. comorbid alcohol use, personality disorder). Diagnosis-specific risk assessment is needed to better identify risk of suicide in an illness that is often characterised by fluctuating mood states. Family involvement in care may aid detection of increased suicide risk.