MIRECC / CoE

Recommendation Resources

Although there is competing evidence in relation to lithium's anti-suicidal properties, several cohort studies and systematic reviews suggest that lithium maintenance is associated with reduced suicidal behaviors and deaths. Lithium has a narrow therapeutic window, and a variety of potential side effects which may complicate treatment adherence. Lithium can be lethal in overdose, and so it is vital that prescribers attend to that risk and limit the amount of lithium dispersed when indicated. Options to reduce risk of toxicity in overdose include dispensing smaller quantities, safe medication storage options, or even having a caregiver or family member store the medication. If suicide plans, or prior attempts, involve overdose, providers should consider alternatives to lithium for treatment.

• Training
• Webinars
• Articles

Training Resources

This section includes links to training resources about offering lithium to decrease the risk of death to suicide in patients with bipolar disorder or unipolar depression:

Considerations informing individualized risk-benefit analysis regarding lithium for suicide prevention (Wortzel et al., 2022)

 

Does the patient have psychiatric conditions in addition to mood disorder, or applicable medical conditions?

Evidence suggests that Lithium's potential anti-suicide benefits may be diminished in the setting of additional mental health conditions, such as substance use disorders, personality disorders, or PTSD. Various medical conditions (e.g., kidney disease, thyroid disease, TBI) may compromise the safety, efficacy, and/or tolerability of lithium.

Is the patient at acute risk for suicide? Is there a history of suicide attempts involving overdose?

Though evidence suggests that lithium may be able to mitigate chronic risk in some cases (i.e., patients with mood disorders maintained at therapeutic levels for extended periods), it is unlikely to significantly impact acute risk, or a suicide crisis in progress. In that setting, the provision of a potential lethal means for suicide is dangerous, especially in the setting of prior suicide attempts via overdose. The weak evidence that lithium might mitigate suicide risk will seldom overcome histories of repeated suicide attempts via overdose when conducting risk-benefit analysis (i.e., justify the provision of a potentially lethal means), especially when other treatment options exist.

Does the patient have the capacity/willingness to sustain long-term treatment adherence with lithium and the associated monitoring?

Many patients struggle with sustained treatment adherence, to include those at risk for suicide. Absent the ability/willingness to sustain long-term treatment at therapeutic levels, and the required associated monitoring, lithium's potential anti-suicidal benefits are unlikely to be realized.

Has a therapeutic relationship been established, and what is the strength of the relationship?

The sustained treatment and monitoring required to realize anti-suicidal benefits from lithium seem far more feasible in the context of an established and strong therapeutic relationship. That relationship may also serve to diminish or address issues relating to the provision of a potential lethal means for suicide.

Are there other viable treatment options that are favorable in terms of efficacy, safety, and feasibility?

Lithium's anti-suicidal effects are less clear when compared to other psychotropic medications (as opposed to placebo), many of which may carry the potential for analogous benefits while being more safe, tolerable, and feasible.

Webinars

This section includes links to webinars that are recommended about offering lithium to decrease the risk of death to suicide in patients with bipolar disorder or unipolar depression:

Lithium for Suicide — a Therapeutic Risk Management Informed Approach Presented by Dr. Hal Wortzel

Articles

This section includes links to recommended articles about offering lithium to decrease the risk of death to suicide in patients with bipolar disorder or unipolar depression:

Baldessarini, R. J., Tondo, L., Davis, P., Pompili, M., Goodwin, F. K., & Hennen, J. (2006). Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review. Bipolar disorders, 8(5 Pt 2), 625-639. https://doi.org/10.1111/j.1399-5618.2006.00344.x

Cipriani, A., Hawton, K., Stockton, S., & Geddes, J. R. (2013). Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis.. BMJ (Clinical research ed.), 346, f3646. https://doi.org/10.1136/bmj.f3646

Cipriani, A., Pretty, H., Hawton, K., & Geddes, J. R. (2005). Lithium in the prevention of suicidal behavior and all-cause mortality in patients with mood disorders: a systematic review of randomized trials. The American journal of psychiatry, 162(10), 1805-1819. https://doi.org/10.1176/appi.ajp.162.10.1805

Ernst, C. L., & Goldberg, J. F. (2004). Antisuicide properties of psychotropic drugs: a critical review. Harvard review of psychiatry, 12(1), 14-41. https://doi.org/10.1080/10673220490425924

Goodwin, F. K., Fireman, B., Simon, G. E., Hunkeler, E. M., Lee, J., & Revicki, D. (2003). Suicide risk in bipolar disorder during treatment with lithium and divalproex. JAMA, 290(11), 1467-1473. https://pubmed.ncbi.nlm.nih.gov/13129986/

Katz I.R., Rogers M.P., Lew R., et al. (2022). Lithium Treatment in the Prevention of Repeat Suicide-Related Outcomes in Veterans With Major Depression or Bipolar Disorder: A Randomized Clinical Trial. JAMA Psychiatry, 79(1), 24-32. https://doi.org/10.1001/jama.290.11.1467

Müller-Oerlinghausen, B., Felber, W., Berghöfer, A., Lauterbach, E., & Ahrens, B. (2005). The impact of lithium long-term medication on suicidal behavior and mortality of bipolar patients. Archives of suicide research : official journal of the International Academy for Suicide Research, 9(3), 307-319. https://doi.org/10.1080/13811110590929550

Nabi, Z., Stansfeld, J., Plöderl, M., Wood, L., & Moncrieff, J. (2022). Effects of lithium on suicide and suicidal behaviour: a systematic review and meta-analysis of randomised trials. Epidemiology and psychiatric sciences, 31, e65. https://doi.org/10.1017/S204579602200049X

Oquendo, M. A., Galfalvy, H. C., Currier, D., Grunebaum, M. F., Sher, L., Sullivan, G. M., Burke, A. K., Harkavy-Friedman, J., Sublette, M. E., Parsey, R. V., & Mann, J. J. (2011). Treatment of suicide attempters with bipolar disorder: a randomized clinical trial comparing lithium and valproate in the prevention of suicidal behavior. The American journal of psychiatry, 168(10), 1050-1056. https://doi.org/10.1176/appi.ajp.2011.11010163

Wortzel, H. S., Simonetti, J. A., Oslin, D. W., Hermes, E., & Matarazzo, B. B. (2023). Lithium Use for Suicide Prevention, Revisited. Journal of psychiatric practice, 29(1), 51-57. https://doi.org/10.1097/PRA.0000000000000680