Lithium Use for Suicide Prevention, Revisited

The literature on lithium’s role in suicide prevention is rife with competing interpretations and diverging opinions, in part stemming from the complexity of the underlying literature base. Conclusions that lithium unequivocally offers suicide prevention benefits do not appear warranted based on the strength of existing studies. Given the evidence along with the indisputable risks associated with lithium (especially in overdose), and the need for sustained therapeutic dosing to achieve any theoretical antisuicide benefit, it seems evident that any potential role for lithium in suicide prevention is far narrower than originally hypothesized. As such, the goal of this article is to provide an evidence-informed, therapeutic risk management approach to clinical decision-making concerning the use of lithium for suicide prevention to ensure that such prescribing is done in a patient-centered fashion that mitigates, to the extent possible, the potential risks of lithium use. This includes a review of potential justifications for not employing lithium for suicide prevention, given the recommendations in the existing guidelines. Clinicians should approach this clinical decision in an individualized fashion with full consideration of the potential risks associated with lithium use and availability, as well as potential alternative treatment options. An individualized risk/benefit analysis must also take into consideration the presence of comorbid conditions; the acuity of suicide risk, and any history of self-directed violence, with special attention to suicide attempts via overdose; treatment adherence, past and present; the presence and/or strength of a therapeutic relationship; and other viable treatment options.