Arguments for the specificity of the antisuicidal effect of lithium

Treatment Outcome

Abstract

Affective disorders are characterized by first a high recurrence risk, second a 30–50 times increased suicide risk and third a 2- to 3 times increased overall mortality. In contrast to a populistic belief no scientific evidence exists that antidepressant treatment, particularly long-term treatment, could reduce the the risk of suicidal acts in depressive patients with a history of suicide attempts. Data, however, coming from international, systematic, retrospective analyses of well-documented long-term courses of illness in reliably diagnosed patients, and from a large national, prospective long-term trial on the prophylactic efficacy of lithium versus carbamazepine and amitriptyline has accumulated in the last 10–15 years strongly supporting a (possibly specific) antisuicidal effect of lithium. The large collaborative IGSLI study (International Group for the Study of Lithium-treated Patients) covering 5,616 patient years clearly showed that adequate long-term lithium treatment significantly reduces and even normalizes the excess mortality of patients with affective disorders. A metaanalysis on 17,000 patients pooled from 28 studies demonstrated that the rate of suicidal acts is 8.6 fold higher in patients without lithium as compared to those with regular lithium treatment.

A post-hoc analysis of a large multicenter, controlled long-term trial found no suicidal acts in 146 patients randomized to lithium compared to 9 suicidal acts in 139 patients randomized to carbamazepine.

Reanalysis of the data from the IGSLI study supports the concept of the specificity of lithium, i.e., evidence could be provided that lithium also reduces suicidal behavior in patients who do not benefit from the lithium treatment in terms of episode reduction.

Conclusion Lithium has to be considered as a first line mood stabilizer in affective disorders, particularly in patients with a history of suicide attempts. Extreme caution is required when lithium is discontinued or a patient is switched to another mood stabilizer, because such a patient might have been protected against suicidal impulses in spite of an incomplete response as to the number and quality of depressive/manic episodes.

Key words

Suicide lithium specificity carbamazepine affective disorders 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Ahrens B, Müller-Oerlinghausen B (2001) Does lithium exert an independent antisuicidal effect? Pharmacopsychiatry 34:132–136PubMedCrossRefGoogle Scholar
  2. Ahrens B et al. (1995) Excess cardiovascular and suicide mortality of affective disorders may be reduced by lithium prophylaxis. J Affect Disord 33:67–75PubMedCrossRefGoogle Scholar
  3. Barraclough B (1972) Suicide prevention, recurrent affective disorder and lithium. Br J Psychiatry 121:391–392PubMedCrossRefGoogle Scholar
  4. Causemann B, Müller-Oerlinghausen B (1988) Does lithium prevent suicides and suicidal attempts? In: Birch NJ (Ed) Lithium: Inorganic Pharmacology and Psychiatric Use. IRL Press Limited, Oxford, pp 23–24Google Scholar
  5. Coppen A et al. (1991) Does lithium reduce the mortality of recurrent mood disorders? J Affect Disord 23:1–7PubMedCrossRefGoogle Scholar
  6. Felber W, Kyber A (1994) Suizide and Parasuizide während und außerhalb einer Lithumprophylaxe. In: Mueller-Oerlinghausen B, Berghoefer A (Eds) Ziele und Ergebnisse der medikamentösen Prophylaxe affektiver Psychosen. Thieme, Stuttgart, pp 53–59Google Scholar
  7. Ghaemi SN, Goodwin FK (1999) Use of atypical antipsychotic agents in bipolar and schizoaffective disorders: review of the empirical literature. J Clin Psychopharmacol 19:354–361PubMedCrossRefGoogle Scholar
  8. Hanus K, Zapletälek M (1984) Sebrevrazednä aktivita nemocnych aktivnimi poruuchmi v prübehu lithioprophylaxe. Ceskoslovenskä Psychiatrie 80:97–100PubMedGoogle Scholar
  9. Kallner G et al. (2000) Mortality in 497 patients with affective disorders attending a lithium clinic or after having left it. Pharmacopsychiatry 33: 8–12PubMedGoogle Scholar
  10. Lenz G et al. (1994) Mortalität nach Ausscheiden aus der Lithiumambulanz. In: Mueller-Oerlinghausen B, Berghoefer A (Eds) Ziele und Ergebnisse der medikamentösen Prophylaxe affektiver Psychosen. Thieme, Stuttgart, pp 49–52Google Scholar
  11. Modestin J, Schwarzenbach F (1992) Effects of psychopharmacotherapy on suicide risk in discharged psychiatric inpatients. Acta Psych Scand 85:173–175CrossRefGoogle Scholar
  12. Müller-Oerlinghausen B et al. (1992) Suicides and parasuicides in a high-risk patient group on and off lithium long-term medication. J Affect Disord 25:261–270PubMedCrossRefGoogle Scholar
  13. Müller-Oerlinghausen B et al. (1992) The effect of long-term lithium treatment on the mortality of patients with manic-depressive and schizoaffective illness. Acta Psych Scand 86:218–222CrossRefGoogle Scholar
  14. Müller-Oerlinghausen B et al. (2001) Manic-depressive disorder. The Lancet (in press)Google Scholar
  15. Nilsson A (1995) Mortality in recurrent mood disorders during periods on and off lithium: a complete population study in 362 patients. Pharmacopsychiatry 28: 8–13PubMedCrossRefGoogle Scholar
  16. Schou M (1998) The effect of prophylactic lithium treatment on mortality and suicidal behaviour: a review for clinicians. J Affect Disord 50:253–259PubMedCrossRefGoogle Scholar
  17. Thies-Flechtner K et al. (1996) Effect of prophylactic treatment on suicide risk patients with major affective disorders. Pharmacopsychiatry 29:103–107PubMedCrossRefGoogle Scholar
  18. Tondo L et al. (1997) Effect of lithium maintenance on suicidal behaviour in major mood disorders. In: Stoff JM, Mann JJ (Eds) The Neurobiology of Suicide: From the Bench to the Clinic. Ann N Y Acad Sei 836: 339–351Google Scholar
  19. van Praag HM (1992) Depression, aggression, and anxiety: a biological hypothesis about their interrelation. Eur Neuropsychopharmacol 2: 393–402PubMedCrossRefGoogle Scholar

Copyright information

© Steinkopff Verlag 2001

Authors and Affiliations

  1. 1.BerlinGermany

Personalised recommendations