Depressive symptoms carry an increased risk for suicidal ideation and behavior in bipolar disorder without any additional contribution of mixed symptoms

•Depressive symptoms are a strong and robust predictor of concomitant suicidal ideation and behavior in bipolar disorder.•Mixed depressive and manic symptoms appear to convey no greater risk for suicidal ideation and behavior than that conveyed by the co-occurring depressive symptomatology.•Suicidal ideation and behavior was significantly more frequent in women with manic symptoms than in men with manic symptoms.•Clinicians should pay particular attention to depressive symptoms and syndromes in bipolar disorder for the purpose of suicide risk assessment and management. To determine whether the risk of suicidal ideation or behavior during mixed states exceeds that attributable to the depressive components of these states alone in bipolar disorder. We utilized real-world, longitudinal clinical data collected on 290 patients with bipolar disorders (bipolar I, bipolar II, and bipolar not otherwise specified (NOS)) from the National Network of Depression Centers (NNDC) Clinical Care Registry (CCR) seen for 891 visits over a mean of 27.5 weeks. Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9), manic symptoms with the Altman Self-Rating Mania (ASRM), and suicidal ideation and behavior with the Columbia-Suicide Severity Rating Scale (C-SSRS), obtained as part of the routine, measurement-based care provided across the NNDC. The relations between depressive symptoms, manic symptoms, and the interaction thereof (mixed symptoms) on coinciding suicidal ideation and behavior were modeled in generalized linear mixed models. Depressive symptoms, as measured by the PHQ-9, were strongly associated with suicidal ideation and behavior (p