Patients with bipolar disorder who exhibit suicidal ideation are more
likely to be prescribed antidepressants and second-generation antipsychotics
(SGA) than lithium, despite lithium's reputation for an antisuicide
Data published in the December 2005 Psychiatric Services by the
team running the Systematic Treatment Enhancement Program for Bipolar Disorder
(STEP-BD) indicates that lithium appears to be "reserved for those
patients with more severe illness characteristics." The report provides
a snapshot of current medications taken by the first 1,000 patients who
entered the STEP-BD study, which was funded by the National Institute of
Mental Health (NIMH).
For many years lithium has been thought to exert an antisuicide effect,
with some researchers reporting that in patients with bipolar disorder,
lithium is associated with up to a six-to eightfold reduction in the risk of
suicide attempt or completion compared with placebo. Other researchers
reported that suicide completion was 2.7 times more likely to occur in
patients with bipolar disorder on divalproex compared with those on
Yet these earlier studies did not control for other medications taken
concomitantly or for severity of illness at baseline relative to prescription
choice. In addition, "little is known about the antisuicidal benefits of
other new agents for bipolar disorder, particularly the second-generation
STEP-BD investigators, led by Gary Sachs, M.D., a professor of psychiatry
at Massachusetts General Hospital and Harvard University, enrolled nearly
5,000 patients aged 15 and older with bipolar disorder I, II, or NOS, or
cyclothymia, at 11 academic research centers across the U.S. The researchers'
goal of the current report was to provide "a description of
community-based pharmacotherapy treatments relative to suicidal
ideation" in the first 1,000 patients to enter the study. The study
group was assessed between November 1999 and April 2001 to determine"
prevalence of prescriptions for mood stabilizers, second-generation
antipsychotics, and antidepressants and the clinical features of patients who
received these different classes of medications."
A battery of assessments was administered to each patient, yielding
demographic details, past and current signs and symptoms of mental illness,
and past and current treatments.
At baseline, 605 of 998 patients were euthymic (61 percent), 58 (6 percent)
were manic or hypomanic, 87 (9 percent) were mixed or cycling, and 248 (25
percent) were depressed (two patients did not complete the entire baseline
Among the 998 patients, 211 (21 percent) exhibited signs of suicidal
ideation. Suicidal ideation was significantly more common among persons who
were experiencing depressive (49 percent) or mixed episodes (47 percent) than
those who were manic or hypomanic (9 percent) or euthymic (7 percent).
Sachs and his coauthors reported that 362 (36 percent) patients were taking
lithium at baseline, and 349 (35 percent) were taking divalproex. Of the 270
patients (27 percent) who were taking an antipsychotic, nearly all (264) were
taking an SGA. Of those taking an SGA, about two-thirds were also taking
either lithium or divalproex.
The number of patients taking an antidepressant was 418 (42 percent); 346
(83 percent) were taking one antidepressant, while 72 (17 percent) were taking
at least two antidepressants at the beginning of the study.
Finally, Sachs and his colleagues reported that "rates of suicidal
ideation were similar between patients who were taking any lithium and those
who were not. Rates of suicidal ideation were also not statistically
significantly different between those taking divalproex and those who didn't
take divalproex. However, the mean number of prescribed medicines for patients
with suicidal thoughts was higher than for those without suicidal
"Our findings suggest," Sachs and his colleagues wrote,"
that after use of other medications and baseline severity indices were
controlled for (such as severity of illness and history of suicide attempts),
psychiatrists may be more likely to prescribe lithium for suicidal patients
with bipolar disorder."
"Suicidal Ideation and Pharmacotherapy Among STEP-BD
Patients" is posted at<http://ps.psychiatryonline.org/cgi/content/full/56/12/1534>.▪