The suicide prevention effect of lithium: more than 20 years of evidence—a narrative review

Lewitzka, Ute; Severus, Emanuel; Bauer, Rita; Ritter, Philipp; Müller‐Oerlinghausen, B.; Bauer, Michael

doi:10.1186/s40345-015-0032-2

Cited by 162 publications

(94 citation statements)

References 75 publications

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“…Furthermore, it would be of eminent interest whether lithium would also possess acute anti-suicidal effects in patients with varying psychiatric diagnoses particularly those with unipolar depression (Lewitzka et al 2015a, b). …”

Section: Resultsmentioning

confidence: 99%

Lithium in the episode and suicide prophylaxis and in augmenting strategies in patients with unipolar depression

Abou‐Saleh

Müller‐Oerlinghausen

Coppen³

2017

Int J Bipolar Disord

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BackgroundDepressive disorders are a leading cause of the global burden of disease and are associated with high recurrent often continuing morbidity and high excess mortality by suicide and cardiovascular disease. Whilst there are established, effective and cost-effective treatments for depression, their long-term management is often neglected: there is continuing controversy over the case of need for long-term treatment including lifelong treatment and safety issues.Objective and methodsIn this narrative review, we critically examine the evidence for the effectiveness and safety of lithium salts in the long-term management of unipolar depression. We refer to existing recent international guidelines as well as the scientific literature selectively and against the background of our longstanding experience with patients suffering from unipolar depression who are often under treated or inappropriately treated.Results and discussionAccording to many studies mostly dating back to the 1970/1980s, lithium is efficacious in the prophylaxis of unipolar depression particularly depression with melancholia and delusional depression and showing a clearly episodic course. Also the efficacy of lithium maintenance treatment following recovery by ECT has been clearly shown. Moreover, convincing evidence exists that lithium has added value and benefit for its unique anti-suicidal effects as well as reducing mortality by other causes. The anti-suicidal effect has been convincingly demonstrated in bipolar as well as in unipolar patients. Nevertheless its use in the management of patients with unipolar depression has not been properly recognized by a majority of textbooks and guidelines. Whilst it has been well considered as an effective treatment for depression that has not responded to antidepressants as an adjunct treatment, also called augmentation, it has been much less recommended for the prevention of recurrent episodes of unipolar depression. One of the reasons for this neglect is the blurring of the diagnosis “unipolar depression” by modern diagnostic tools. Lithium will hardly work in a patient with “unipolar depression spectrum disease”.ConclusionsWe conclude that lithium is an effective prophylactic treatment for carefully selected patients with unipolar depression and is safe when prescribed in recommended doses/plasma lithium levels and with regular, careful monitoring. We propose that lithium prophylaxis can be indicated in patients with unipolar depression and that the occurrence of 2 episodes of depression within 5 years is a practical criterion for starting lithium prophylaxis particularly in severe depression with psychotic features and high suicidal risk. Furthermore, an indication might be considered especially in unipolar patients in whom a bipolar background is suspected. In some cases, lithium prophylaxis may be recommended after a single episode of depression that is severe with high suicidal risk and continued life-long.

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Section: Resultsmentioning

confidence: 99%

Lithium in the episode and suicide prophylaxis and in augmenting strategies in patients with unipolar depression

Abou‐Saleh

Müller‐Oerlinghausen

Coppen³

2017

Int J Bipolar Disord

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“…Close clinical monitoring of patients at risk for suicide is imperative. A psychopharmacological option in the prevention of suicide is lithium [70]. …”

Section: Resultsmentioning

confidence: 99%

Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants: A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder

Braun¹,

Bschor

Franklin

et al. 2016

Psychother Psychosom

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Background: It is unclear whether antidepressants can prevent suicides or suicide attempts, particularly during long-term use. Methods: We carried out a comprehensive review of long-term studies of antidepressants (relapse prevention). Sources were obtained from 5 review articles and by searches of MEDLINE, PubMed Central and a hand search of bibliographies. We meta-analyzed placebo-controlled antidepressant RCTs of at least 3 months' duration and calculated suicide and suicide attempt incidence rates, incidence rate ratios and Peto odds ratios (ORs). Results: Out of 807 studies screened 29 were included, covering 6,934 patients (5,529 patient-years). In total, 1.45 suicides and 2.76 suicide attempts per 1,000 patient-years were reported. Seven out of 8 suicides and 13 out of 14 suicide attempts occurred in antidepressant arms, resulting in incidence rate ratios of 5.03 (0.78-114.1; p = 0.102) for suicides and of 9.02 (1.58-193.6; p = 0.007) for suicide attempts. Peto ORs were 2.6 (0.6-11.2; nonsignificant) and 3.4 (1.1-11.0; p = 0.04), respectively. Dropouts due to unknown reasons were similar in the antidepressant and placebo arms (9.6 vs. 9.9%). The majority of suicides and suicide attempts originated from 1 study, accounting for a fifth of all patient-years in this meta-analysis. Leaving out this study resulted in a nonsignificant incidence rate ratio for suicide attempts of 3.83 (0.53-91.01). Conclusions: Therapists should be aware of the lack of proof from RCTs that antidepressants prevent suicides and suicide attempts. We cannot conclude with certainty whether antidepressants increase the risk for suicide or suicide attempts. Researchers must report all suicides and suicide attempts in RCTs.

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“…For example, lithium is a mood stabilizing agent and is known to have suicide protective effects. Trace amounts of lithium are found in drinking water; areas with higher lithium content in the drinking water have shown lower suicide rates in many existing studies (131,132). For example, Kapusta et al (133) explored the relationship between lithium in drinking water and suicide rates across 99 Austrian districts (average population 8,297,964, SD = 65,050).…”

Section: Resultsmentioning

confidence: 99%

Air pollution, aeroallergens and suicidality: a review of the effects of air pollution and aeroallergens on suicidal behavior and an exploration of possible mechanisms

Ragguett

Danielle

Subramaniapillai

et al. 2017

Reviews on Environmental Health

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Objective: Risk factors for suicide can be broadly categorized as sociodemographic, clinical and treatment. There is interest in environmental risk and protection factors for suicide. Emerging evidence suggests a link between environmental factors in the form of air pollution and aeroallergens in relation to suicidality. Methods: Herein, we conducted a systematic review of 15 articles which have met inclusion criteria on the aforementioned effects. Results: The majority of the reviewed articles reported an increased suicide risk alongside increased air pollutants or aeroallergens (i.e. pollen) increase; however, not all environmental factors were explored equally. In specific, studies that were delimited to evaluating particulate matter (PM) reported a consistent association with suicidality. We also provide a brief description of putative mechanisms (e.g. inflammation and neurotransmitter dysregulation) that may mediate the association between air pollution, aeroallergens and suicidality. Conclusion:Available evidence suggests that exposure to harmful air quality may be associated with suicidality. There are significant public health implications which are amplified in regions and countries with greater levels of air pollution and aeroallergens. In addition, those with atopic sensitivity may represent a specific subgroup that is at risk.

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The suicide prevention effect of lithium: more than 20 years of evidence—a narrative review

Cited by 162 publications

References 75 publications

Lithium in the episode and suicide prophylaxis and in augmenting strategies in patients with unipolar depression

Lithium in the episode and suicide prophylaxis and in augmenting strategies in patients with unipolar depression

Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants: A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder

Air pollution, aeroallergens and suicidality: a review of the effects of air pollution and aeroallergens on suicidal behavior and an exploration of possible mechanisms

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