1. Confirmed: Lithium prevents suicide
What it showed
Lithium can prevent 12% of suicides in patients with bipolar disorder.
How it adds to our knowledge
The suicide rate is elevated 10-fold in patients with recurrent mood disorders, and epidemiologic studies suggest that lithium lowers that risk to a level comparable to that in the general population (Figure). What those studies have lacked is a controlled design, but controlled trials are usually underpowered to detect rare events like suicide. This new study bridges that gap by combining a large cohort (50,000 patients over an 8-year period) and a case-control design in which each patient served as his or her own control. The anti-suicide effects were unique to lithium and not seen with valproate. Lithium even lowered the suicide risk among patients with features thought more responsive to valproate (eg, mixed states, rapid cycling, and comorbid substance abuse).
How it changes practice:
Concerns about overdose on lithium often limit its use in suicidal and impulsive patients, but that practice does not remove the means of suicide and instead may rob those patients of a treatment that can prevent those dangerous impulses. Lithium can prevent suicide even when it does not improve mood, and it should be considered for all bipolar and unipolar patients with elevated risks of suicide. Abrupt discontinuation of lithium can significantly raise the suicide risk, so the medicine should be tapered slowly over several months.
About the author
Dr. Aiken is the Director of the Mood Treatment Center and an Instructor in Clinical Psychiatry at the Wake Forest University School of Medicine. He does not accept honoraria from pharmaceutical companies but receives honoraria from W.W. Norton & Co. for Bipolar, Not So Much, which he coauthored with James Phelps, MD.
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