Lithium Treatment and Risk of Suicidal Behavior in Bipolar Disorder Patients
J Clin Psychiatry 1998;59(8):405-414
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Background: Lithium may exert an antisuicidal effect in bipolar disorder
patients, but this hypothesis requires further testing by direct comparison of patients
with and without lithium treatment.
Method: Risk of life-threatening suicidal acts over time and associated
factors were analyzed in 310 patients with DSM-IV bipolar I (N=186) or II (N=124) disorder
evaluated for a mean of 8.3 years before, and prospectively during, a mean of 6.4 years of
lithium maintenance in a mood disorder clinic; 185 were also followed for a mean of 3.7
years after clinically discontinuing lithium.
Results: In 5233 patient-years of observation, 58 patients made 90
suicide attempts (8 were fatal). Survival analyses with Weibull modeling with adjustments
for covariates indicated a highly significant 6.4-fold adjusted hazard ratio during versus
before and 7.5-fold ratio after versus during lithium maintenance. Suicidal acts were more
common early in the course of illness before lithium and were associated with prior
suicide attempts, greater proportion of time depressed, and younger age. After the
discontinuation of lithium, suicidal acts were more frequent in the first year than at
later times or before start of lithium treatment. Fatalities were 9 times more frequent
after versus during treatment.
Conclusion: Lithium maintenance was associated with marked reduction of
life-threatening suicidal acts, 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 attention to suicidal risk in patients
with bipolar depression and assessment of all proposed mood-stabilizing agents for
antisuicidal effects are strongly encouraged.