Chris Aiken, MD.
Editor-in-Chief of The Carlat Psychiatry Report. Practicing psychiatrist, Winston-Salem, NC.
Dr. Aiken has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Lithium stands in stark contrast to most other psychiatric medications, which carry a widely debated black box warning about increased suicidality. There is no evidence that lithium raises the suicide risk, and there is strong evidence that it does the opposite. People with mood disorders carry a risk of suicide that’s 10–20 times higher than the general population, but when they take lithium, that risk falls to a level that is indistinguishable from the norm. This is true for completed and attempted suicide, in both unipolar and bipolar disorders, and is based on data encompassing over 110,000 person years (Tondo L et al, Curr Psychiatry Rep 2016;18(9):88).
That’s impressive, but it’s just observational data, and it could hide a bias. Perhaps doctors steer away from lithium in suicidal patients, which would explain the low suicide rates in patients treated with lithium. Randomized controlled trials (RCTs) suggest otherwise. In a meta-analysis of RCTs involving 2,400 patients, lithium reduced the risk of completed suicide by 60% compared to placebo (Smith KA et al, Bipolar Disord 2017;19(7):575–586). Those results were quickly followed by a case-controlled study of 50,000 patients, which confirmed that this protective effect was unique to lithium and not seen with other mood stabilizers (Song J et al, Am J Psychiatry 2017;174(8):795–802).
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