Most suicidal behavior (thoughts, attempts and completion) occurs in the context of a psychiatric illness, of which bipolar disorder (BD) is associated with the highest risk for suicide. Several studies and meta-analyses have shown that 34 to 50% of individuals with bipolar disorder have a lifetime history of suicide attempts. Epidemiological studies show a 10-15% mortality rate by suicide in BD. Finally, the standardized mortality ratio for suicide deaths has been reported to be 10to 30-fold in BD compared to the general population. This leads to suicide being a main factor in the 10-13 years of premature mortality in BD. Given the magnitude of the problem, it is essential to strengthen the study of risk factors associated with suicidal behavior in BD. Moreover, it is important to investigate which factors make suicide more prevalent in BD than other psychiatric disorders and whether risk factors associated with suicidal behavior in the general population have a different role and impact in BD. Suicidal behavior is influenced by several factors. Understanding the diathesis together with the precipitating factors that trigger the behavior is fundamental. Some of the most relevant predisposing and precipitating individual risk factors for suicidal behavior in BD include gender (females have higher rates of attempts and males have higher rates of completion), prior suicide attempt, family history of suicide, rapid cycling, bipolar type I, early onset, aggression and impulsivity, stressful life events, drug and alcohol abuse/misuse disorders, comorbid anxiety disorders, Axis II comorbidities, and child abuse and maltreatment. Distal life stressors such as childhood adversity, especially child abuse, have been increasingly associated with suicidal behavior in BD. Child maltreatment (CM) is highly prevalent in BD and is associated with a worse course and prognosis. More specifically, early physical and sexual abuse have been associated with an elevated risk of suicide. Agnew-Blas & Danese have published a meta-analysis that associated CM in bipolar disorder with several unfavorable clinical features and outcomes, including a higher risk of suicide attempts compared with BD patients who were not abused. Genetics and early negative life events are vulnerability factors and may contribute to the development of specific neurobiological abnormalities, including stress response system dysfunction, neuroinflammation, impaired neural plasticity, serotonergic and glutamatergic dysfunction, etc. These effects may ultimately lead to an abnormal neural substrate that leaves the individual more vulnerable to stressful life events later on in life that could lead to suicidal behavior. There is increasing evidence that different types of early life events may contribute distinctively to suicide risk and behavior in BD. The impact of childhood sexual and physical abuse, emotional abuse and emotional and physical neglect on suicidal behavior may differ. However, the impact of CM on the course of and suicidality in BD has been previously evaluated with different instruments, resulting in high heterogeneity in assessments and outcome measures. In this issue of the Brazilian Journal of Psychiatry, Duarte et al. try to address some of these issues by performing a systematic review and metaanalysis of published studies. In this review, the authors aimed to decrease heterogeneity by selecting studies that used a single instrument to assess CM, the Childhood Trauma Questionnaire (CTQ). The CTQ is the most widely used quantitative measure of CM in the literature. It generates a general total score but also assesses five different types of CM (childhood sexual and physical abuse, emotional abuse and emotional and physical neglect). The authors’ objective was to evaluate a more homogeneously assessed sample compared to previous meta-analyses, such as that of Agnew-Blas and Danese. In the meta-analysis of 6 published studies, they found that bipolar suicide attempters had a higher frequency of CM and had higher total CTQ scores. Moreover, some types of CM had larger effect sizes (sexual and emotional abuse) than others (emotional neglect and physical abuse and neglect). This new meta-analysis confirms the findings of previous studies and adds important new data. In addition, the medium and small effect sizes they found confirm that CM is one of several factors that play a role in

中文翻译：

---

消极的早期生活经历是双相情感障碍自杀行为的危险因素

大多数自杀行为（想法、企图和完成）发生在精神疾病的背景下，其中双相情感障碍 (BD) 与最高的自杀风险相关。多项研究和荟萃分析表明，34% 至 50% 的双相情感障碍患者终生有自杀企图。流行病学研究表明，BD 中的自杀死亡率为 10-15%。最后，据报道，与普通人群相比，BD 中自杀死亡的标准化死亡率是 10 到 30 倍。这导致自杀成为 BD 中 10-13 年过早死亡的主要因素。鉴于问题的严重性，有必要加强对 BD 中与自杀行为相关的危险因素的研究。而且，重要的是调查哪些因素使 BD 中的自杀比其他精神疾病更普遍，以及与一般人群中自杀行为相关的风险因素是否在 BD 中具有不同的作用和影响。自杀行为受多种因素影响。了解素质以及触发行为的诱发因素是基础。BD 中自杀行为的一些最相关的诱发和诱发个体风险因素包括性别（女性尝试自杀率较高，男性完成率较高）、既往自杀未遂、自杀家族史、快速循环、双相 I早发性、攻击性和冲动性、压力性生活事件、药物和酒精滥用/误用障碍、共病焦虑症、Axis II 共病、和虐待儿童。远期生活压力源，如童年逆境，尤其是虐待儿童，越来越多地与 BD 的自杀行为相关联。虐待儿童 (CM) 在 BD 中非常普遍，并且与更差的病程和预后相关。更具体地说，早期的身体和性虐待与自杀风险升高有关。Agnew-Blas 和 Danese 发表了一项荟萃分析，将双相情感障碍中的 CM 与几个不利的临床特征和结果联系起来，包括与未受虐待的 BD 患者相比，自杀未遂的风险更高。遗传和早期负面生活事件是脆弱因素，可能导致特定神经生物学异常的发展，包括应激反应系统功能障碍、神经炎症、神经可塑性受损、5-羟色胺能和谷氨酸能功能障碍等。这些影响可能最终导致异常的神经基质，使个体在以后的生活中更容易受到压力生活事件的影响，这可能导致自杀行为。越来越多的证据表明，不同类型的早期生活事件可能对 BD 的自杀风险和行为有不同的影响。儿童期性虐待和身体虐待、情感虐待以及情感和身体忽视对自杀行为的影响可能不同。然而，CM 对 BD 病程和自杀倾向的影响以前曾用不同的工具进行过评估，导致评估和结果测量的高度异质性。在本期《巴西精神病学杂志》中，Duarte 等人。尝试通过对已发表研究进行系统回顾和荟萃分析来解决其中的一些问题。在这篇综述中，作者旨在通过选择使用单一工具评估 CM 的研究来减少异质性，即儿童创伤问卷 (CTQ)。CTQ 是文献中使用最广泛的 CM 定量度量。它生成一个总体总分，但也评估五种不同类型的 CM（儿童性虐待和身体虐待、情感虐待以及情感和身体忽视）。与之前的荟萃分析（例如 Agnew-Blas 和 Danese 的荟萃分析）相比，作者的目标是评估评估更均匀的样本。在对 6 项已发表研究的荟萃分析中，他们发现双相自杀未遂者的 CM 频率更高，总 CTQ 得分更高。而且，某些类型的 CM（性虐待和情感虐待）比其他类型（情感忽视和身体虐待和忽视）具有更大的影响。这项新的荟萃分析证实了先前研究的结果并增加了重要的新数据。此外，他们发现的中小效应量证实了 CM 是影响