Back to top Open menu arrow
Purchase PDF Reprints

The Journal of
Clinical Psychiatry
Members only

The Journal of Clinical Psychiatry

Original Research Focus on Suicide August 10, 2026

Association of Lithium Use With Suicide and Self-Harm Among Chinese Adolescents and Adults With Bipolar Disorder: A Nationwide Multicenter Retrospective Cohort Study

; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ;

J Clin Psychiatry 2026;87(3):25m16219

Abstract

Objective: Bipolar disorder (BD) greatly increases the risk of suicide. While lithium is recognized for reducing suicide and suicidal behaviors, evidence regarding its association with suicidal ideation remains limited. This study evaluated lithium’s association with reduced suicidal ideation and behaviors among adolescents and adults with BD in China.

Method: This multicenter, retrospective cohort study included participants aged 12–45 years from 15 psychiatric centers across mainland China who met DSM-IV criteria for BD, recruited between April 19, 2024, and November 30, 2024. Patients receiving lithium for ≥80% of the first 6 months in the preceding year formed the lithium group; those without lithium exposure served as controls. The primary outcome was suicidal ideation assessed by the Columbia-Suicide Severity Rating Scale; secondary outcomes included suicidal behaviors, nonsuicidal self-injury (NSSI), and aggression.

Results: Of 603 screened patients, 585 (290 lithium; 295 controls) met inclusion criteria. At 1-year follow-up, lithium use was significantly associated with a lower likelihood of suicidal ideation (adjusted odds ratio [aOR] = 0.57, 95% CI = 0.38–0.86, P = .008) and suicidal behaviors (aOR= 0.60, 95% CI = 0.39–0.90, P = .02). No difference was observed in NSSI, while lithium users reported lower hostility scores (P = .01). Subgroup analyses indicated more pronounced protective associations among females, adults, higher-income individuals, and those without comorbid anxiety, rapid cycling, or predominantly depressive episodes, regardless of psychotic symptoms.

Conclusions: Lithium was associated with a 40% lower risk of suicidal ideation and reduced suicidal behaviors in BD. These findings reinforce lithium as a first-line treatment for suicide prevention and highlight its comprehensive antisuicidal role—from lower rates of ideation to fewer behaviors—supporting confident, evidence-based clinical use.

J Clin Psychiatry 2026;87(3):25m16219

Author affiliations are listed at the end of this article.

Also from JCP

Effect of a Nationwide Aftercare Program for Self-Harm Presentations on the Risk of Self-Harm Repetition and Suicide Systematic Review and Meta-Analysis of Use of Mood Stabilizers in Adolescents With Nonsuicidal Self-Injury Efficacy and Safety of a Single Dose of Psilocybin for Chronic Suicidal Ideation

From the Editors

New Series The JCP Podcast Stigma may still block care even after access and cost barriers are removed, and medical mistrust may be the expected response clinicians need to validate before they can reduce. This conversation makes the case that a simple patient story, delivered well, might function as a real clinical intervention.

Members Only Content

This full article is available exclusively to Professional tier members. Subscribe now to unlock the HTML version and gain unlimited access to our entire library plus all PDFs. If you're already a subscriber, please log in below to continue reading.

Subscribe Now

Already a member? Log in

  1. Plans L, Nieto E, Benabarre A, et al. Completed suicide in bipolar disorder patients: a cohort study after first hospitalization. J Affect Disord. 2019;257:340–344 PubMed CrossRef
  2. Schaffer A, Isometsä ET, Tondo L, et al. Epidemiology, neurobiology and pharmacological interventions related to suicide deaths and suicide attempts in bipolar disorder: part I of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder. Aust N Z J Psychiatry. 2015;49(9):785–802. PubMed CrossRef
  3. Tondo L, Pompili M, Forte A, et al. Suicide attempts in bipolar disorders: comprehensive review of 101 reports. Acta Psychiatr Scand. 2016;133(3):174–186. PubMed
  4. Hu FH, Jia YJ, Zhao DY, et al. Gender differences in suicide among patients with bipolar disorder: a systematic review and meta-analysis. J Affect Disord. 2023;339:601–614. PubMed
  5. Wang L, Liu J, Yang Y, et al. Prevalence and risk factors for non-suicidal self-injury among patients with depression or bipolar disorder in China. BMC Psychiatry. 2021;21(1):389. PubMed
  6. Pérez De Mendiola X, Hidalgo-Mazzei D, Vieta E, et al. Overview of lithium’s use: a nationwide survey. Int J Bipolar Disord. 2021;9(1):10. PubMed
  7. Smith KA, Cipriani A. Lithium and suicide in mood disorders: updated meta-review of the scientific literature. Bipolar Disord. 2017;19(7):575–586. PubMed CrossRef
  8. Tondo L, Baldessarini RJ. Prevention of suicidal behavior with lithium treatment in patients with recurrent mood disorders. Int J Bipolar Disord. 2024;12(1):6. PubMed
  9. Fitzgerald C, Christensen RHB, Simons J, et al. Effectiveness of medical treatment for bipolar disorder regarding suicide, self-harm and psychiatric hospital admission: between- and within-individual study on Danish national data. Br J Psychiatry. 2022;221(5):692–700. PubMed
  10. Kessing LV, Søndergård L, Kvist K, et al. Suicide risk in patients treated with lithium. Arch Gen Psychiatry. 2005;62(8):860–866. PubMed
  11. Rezapur-Shahkolai F, Khezeli M, Hazavehei SMM, et al. The effects of suicidal ideation and constructs of theory of planned behavior on suicidal intention in women: a structural equation modeling approach. BMC Psychiatry. 2020;20(1):217. PubMed CrossRef
  12. Pompili M. On mental pain and suicide risk in modern psychiatry. Ann Gen Psychiatry. 2024;23(1):6. PubMed
  13. Wang JX, Le GH, Wong S, et al. The efficacy of lithium in the treatment of suicidal ideation, behavior and suicide: an updated systematic review and meta-analysis of randomized controlled trials. J Affect Disord. 2025;387:119487. PubMed
  14. Gitlin M, Bauer M. Lithium: current state of the art and future directions. Int J Bipolar Disord. 2024;12(1):40. PubMed
  15. Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168(12):1266–1277. PubMed CrossRef
  16. Ji Y, Liu X, Zheng S, et al. Validation and application of the Chinese version of the Columbia-Suicide Severity Rating Scale: suicidality and cognitive deficits in patients with major depressive disorder. J Affect Disord. 2023;342:139–147. CrossRef
  17. Nixon MK, Levesque C, Preyde M, et al. The Ottawa Self-Injury Inventory: evaluation of an assessment measure of nonsuicidal self-injury in an inpatient sample of adolescents. Child Adolesc Psychiatry Ment Health. 2015;9:26. PubMed CrossRef
  18. Buss AH, Perry M. The Aggression Questionnaire. J Pers Soc Psychol. 1992;63(3):452–459. PubMed
  19. Beck AT, Ward CH, Mendelson M, et al. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561–571. PubMed
  20. Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157(11):1873–1875. PubMed CrossRef
  21. Hauser M, Galling B, Correll CU. Suicidal ideation and suicide attempts in children and adolescents with bipolar disorder: a systematic review of prevalence and incidence rates, correlates, and targeted interventions. Bipolar Disord. 2013;15(5):507–523. PubMed CrossRef
  22. Ko A, Swampillai B, Timmins V, et al. Clinical characteristics associated with lithium use among adolescents with bipolar disorder. J Child Adolesc Psychopharmacol. 2014;24(7):382–389. PubMed
  23. Katz IR, Rogers MP, Lew R, et al. Lithium treatment in the prevention of repeat suicide-related outcomes in veterans with major depression or bipolar disorder: a randomized clinical trial. JAMA Psychiatry. 2022;79(1):24–32. PubMed
  24. Nierenberg AA, Friedman ES, Bowden CL, et al. Lithium Treatment Moderate-Dose Use Study (LiTMUS) for bipolar disorder: a randomized comparative effectiveness trial of optimized personalized treatment with and without lithium. Am J Psychiatry. 2013;170(1):102–110. PubMed CrossRef
  25. Pompili M, Berardelli I, Sarubbi S, et al. New episodes and suicidal risks in bipolar and major depressive disorder patients during versus before long-term treatment with lithium. Acta Psychiatr Scand. 2025;152(4):290–298. PubMed
  26. Khan A, Khan SRF, Hobus J, et al. Differential pattern of response in mood symptoms and suicide risk measures in severely ill depressed patients assigned to citalopram with placebo or citalopram combined with lithium: role of lithium levels. J Psychiatr Res. 2011;45(11):1489–1496. PubMed CrossRef
  27. Chan JKN, Wong CSM, Fang CZ, et al. Mortality risk and mood stabilizers in bipolar disorder: a propensity-score-weighted population-based cohort study in 2002–2018. Epidemiol Psychiatr Sci. 2024;33:e31. PubMed
  28. Carvalho AF, Hsu CW, Vieta E, et al. Mortality and lithium-protective effects after first-episode mania diagnosis in bipolar disorder: a nationwide retrospective cohort study in Taiwan. Psychother Psychosom. 2024;93(1):36–45. PubMed
  29. Dervic K, Sher L, Galfalvy HC, et al. Antisuicidal effect of lithum in bipolar disorder: is there an age-specific effect?. J Affect Disord. 2023;341:8–11. PubMed
  30. Hafeman DM, Rooks B, Merranko J, et al. Lithium versus other mood-stabilizing medications in a longitudinal study of youth diagnosed with bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2020;59(10):1146–1155. PubMed
  31. Raschke N, Mohsenpour A, Aschentrup L, et al. Socioeconomic factors associated with suicidal behaviors in South Korea: systematic review on the current state of evidence. BMC Public Health. 2022;22(1):129. PubMed
  32. Hui TP, Kandola A, Shen L, et al. A systematic review and meta-analysis of clinical predictors of lithium response in bipolar disorder. Acta Psychiatr Scand. 2019;140(2):94–115. PubMed CrossRef
  33. Rhee TG, Olfson M, Nierenberg AA, et al. 20-Year trends in the pharmacologic treatment of bipolar disorder by psychiatrists in outpatient care settings. Am J Psychiatry. 2020;177(8):706–715. PubMed
  34. Hidalgo-Mazzei D, Mantingh T, Pérez De Mendiola X, et al. Clinicians’ preferences and attitudes towards the use of lithium in the maintenance treatment of bipolar disorders around the world: a survey from the ISBD Lithium Task Force. Int J Bipolar Disord. 2023;11(1):20. PubMed
  35. Zarzar TR. Clozapine proficiency as a milestone in psychiatric training. JAMA Psychiatry. 2024;81(7):639–640. PubMed
  36. Gomes FA, Brietzke E, Bauer M, et al. A call for improving lithium literacy among clinicians and patients. Int J Bipolar Disord. 2022;10(1):5. PubMed
  37. Bayliss LT, Lui ID, Chan LF, et al. Uplifting ethnic minority voices in the Western Pacific region: a priority for regional suicide research. Lancet Reg Health - West Pac. 2025;57:101540. PubMed

About the Authors

Buy PDF for $40

Please sign in or purchase this PDF for $40.

The Journal of Clinical Psychiatry June 2026 cover with featured article titles

Vol 87 • 2026 • Number 2

Read the Current Issue

Original Research

CBT following Esketamine for Major Depression and Suicidal Ideation for Relapse Prevention: The CBT-ENDURE Randomized Trial

Original Research

Neuropsychiatric Symptom Clusters and Brain Structure in Alzheimer’s Disease

Systematic Review

Thirty Years of the Diagnostic Criteria for Psychosomatic Research

Original Research

Efficacy of Olanzapine/Samidorphan on Negative Symptoms

Original Research

Comparing Risk Prediction for Suicide Attempts and Deaths After Emergency Department Visits

Clinical and Practical Psychopharmacology

Insomnia, Sleep, and the Use of Sedative-Hypnotic Drugs: Practical Notes
View current Issue

Learn More About Psychedelics in Psychiatry

Explore the Collection
Neural network illustration symbolizing psychedelic research advancements

Subscribe to read
more articles

Subscribe