LITHIUM TREATMENT AND RISK OF SUICIDAL-BEHAVIOR IN BIPOLAR DISORDER PATIENTS

Background: Lithium may exert an antisuicidal effect in bipolar disord er patients, but this hypothesis requires further testing by direct co mparison of patients with and without lithium treatment. Method: Risk of life-threatening suicidal acts over time and associated factors wer e analyzed in 310 patients with DSM-IV bipoIar I (N = 186) or II (N = 124) disorder evaluated for a mean of 8.3 years before, and prospectiv ely during, a mean of 6.4 years of lithium maintenance in a mood disor der clinic; 185 were also followed for a mean of 3.7 years after clini cally discontinuing lithium. Results: In 5233 patient-years of observa tion, 58 patients made 90 suicide attempts (8 were fatal). Survival an alyses with Weibull modeling with adjustments for covariates indicated a highly significant 6.4-fold adjusted hazard ratio during versus bef ore and 7.5-fold ratio after versus during lithium maintenance. Suicid al acts were more common early in the course of illness before lithium and were associated with prior suicide attempts, greater proportion o f time depressed, and younger age. After the discontinuation of lithiu m, suicidal acts were mon frequent in the first year than at later tim es or before start of lithium treatment. Fatalities were 9 times more frequent after versus during treatment. Conclusion: Lithium maintenanc e was associated with marked reduction of life-threatening suicidal ac ts, the number of which sharply increased after discontinuing lithium. Suicidal behavior was strongly associated with prior suicide attempts , more time depressed, and younger age or recent onset. Greater attent ion to suicidal risk in patients with bipolar depression and assessmen t of all proposed mood-stabilizing agents for antisuicidal effects are strongly encouraged.