title: Lithium is associated with decrease in all-cause and suicide mortality in high-risk bipolar patients: A nationwide registry-based prospective cohort study.
abstract: BACKGROUND
  Mortality rates, in particular due to suicide, are especially high in bipolar patients. This nationwide, registry-based study analyses the associations of medication use with hospitalization due to attempted suicides, deaths from suicide, and overall mortality across different psychotropic agents in bipolar patients.
  
  
  METHODS
  Altogether 826 bipolar patients hospitalized in Finland between 1996-2003 because of a suicide attempt were followed-up for a mean of 3.5 years. The relative risk of suicide attempts leading to hospitalization, completed suicide, and overall mortality during lithium vs. no-lithium, antipsychotic vs. no-antipsychotic, valproic acid vs. no-valproic acid, antidepressant vs. no-antidepressant and benzodiazepine vs. no-benzodiazepine treatment was measured.
  
  
  RESULTS
  The use of valproic acid (RR=1.53, 95% CI: 1.26-1.85, p<0.001), antidepressants (RR=1.49, 95% CI: 1.23-1.8, p<0.001) and benzodiazepines (RR=1.49, 95% CI: 1.23-1.80, p<0.001) was associated with increased risk of attempted suicide. Lithium was associated with a (non-significantly) lower risk of suicide attempts, and with significantly decreased suicide mortality in univariate (RR=0.39, 95% CI: 0.17-0.93, p=0.03), Cox (HR=0.37, 95% CI: 0.16-0.88, p=0.02) and marginal structural models (HR=0.31, 95% CI: 0.12-0.79, p=0.02). Moreover, lithium was related to decreased all-cause mortality by 49% (marginal structural models).
  
  
  CONCLUSIONS
  Only high-risk bipolar patients hospitalized after a suicide attempt were studied. Diagnosis was not based on standardized diagnostic interviews; treatment regimens were uncontrolled.
  
  
  CONCLUSIONS
  Maintenance therapy with lithium, but not with other medications, is linked to decreased suicide and all-cause mortality in high-risk bipolar patients. Lithium should be considered for suicide prevention in high-risk bipolar patients.
authors.affiliation: Department of Health, National Institute for Health and Welfare, Helsinki, Finland. Electronic address: elena.toffol@thl.fi.
authors.forename: Elena
authors.initials: E
authors.lastname: Toffol
authors.affiliation: Finnish Student Health Service, Helsinki, Helsinki, Finland; Department of Psychiatry, University of Helsinki, Helsinki, Finland.
authors.forename: Taina
authors.initials: T
authors.lastname: Hätönen
authors.affiliation: Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Antti
authors.initials: A
authors.lastname: Tanskanen
authors.affiliation: Department of Health, National Institute for Health and Welfare, Helsinki, Finland; Department of Psychiatry, University of Helsinki, Helsinki, Finland.
authors.forename: Jouko
authors.initials: J
authors.lastname: Lönnqvist
authors.affiliation: Department of Health, National Institute for Health and Welfare, Helsinki, Finland; The Finnish Association for Mental Health, Helsinki, Finland.
authors.forename: Kristian
authors.initials: K
authors.lastname: Wahlbeck
authors.affiliation: Department of Psychiatry, Helsinki University Hospital, Helsinki, Finland.
authors.forename: Grigori
authors.initials: G
authors.lastname: Joffe
authors.affiliation: Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Jari
authors.initials: J
authors.lastname: Tiihonen
authors.affiliation: Department of Health, National Institute for Health and Welfare, Helsinki, Finland; Department of Public Health, University of Helsinki, Helsinki, Finland.
authors.forename: Jari
authors.initials: J
authors.lastname: Haukka
authors.affiliation: Department of Health, National Institute for Health and Welfare, Helsinki, Finland.
authors.forename: Timo
authors.initials: T
authors.lastname: Partonen
mesh_terms: D000328:Adult; D000368:Aged; D000928:Antidepressive Agents / Q000627:therapeutic use*; D001714:Bipolar Disorder / Q000188:drug therapy* / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D005387:Finland / Q000453:epidemiology; D006801:Humans; D018020:Lithium Compounds / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011619:Psychotropic Drugs / Q000627:therapeutic use; D012042:Registries; D013405:Suicide / Q000706:statistics & numerical data; D000092864:Suicide Prevention
chemical_list: D000928:Antidepressive Agents; D018020:Lithium Compounds; D011619:Psychotropic Drugs
keywords: Attempted suicide; Bipolar; Lithium; Mortality; Suicide