Lithium...is the lightest of the solid elements and it is perhaps not surprising that it should in consequence possess certain modest magical qualities.
-- G.P.Hartigan

Lithium is the most effective, most extensively studied, and best-documented antisuicide medication now available. It has been used since 1949 to stabilize the dangerous mood swings and erratic behavior associated with manic-depressive illness and, by Europeans particularly, to prevent recurrent depressions. Its effectiveness in preventing suicide is probably due to its impact on two of the most potent risk factors for suicide: its putative capacity to enhance serotonin turnover in the brain (as well as its effects on other neurotransmitters)—and thereby to decrease aggression, agitation, and impulsivity—and its power to decrease or eliminate mania and depression in most people who have manic-depressive illness.

If lithium works so well to prevent recurrences of mania and depression, and if it has such a potent effect in decreasing suicidal behaviors, why isn't everyone who suffers from a major mood disorder taking lithium? Indeed, why isn't everyone who is suicidal taking lithium...? For whatever reasons, lithium is seen by many patients as a stigmatizing treatment, or else it is seen as toxic, an attitude not helped by the attitudes and practices of many in the medical community. These attitudes are subtly pervasive in clinical practice, especially in the United States, and are the result of many factors: lithium requires monitoring of blood levels to prevent toxicity, and side effects—such as blunting of emotions, slowed thinking, and problems in coordination—affect a number of patients.

Some of the marginalization of lithium is due to other important advances in medical research. Many new medications used for treating mood disorders—the anticonvulsant drugs (which were first used to treat epilepsy, but now are used to treat manic-depression as well) and the newer antidepressants: for example, the selective serotonin reuptake inhibitors such as citalopram, fluvoxamine, paroxetine, fluoxetine, and sertraline (Celexa, Luvox, Paxil, Prozac, and Zoloft, respectively)—are more easily administered than lithium by general practitioners, internists, and psychiatrists. This ease of prescription is largely to the good, although it makes it more likely that highly effective and relatively inexpensive drugs such as lithium—which, in fact, is generally not that difficult to prescribe or monitor properly—will be bypassed for other, better-marketed drugs. It also increases the likelihood that the more popular and easier-to-prescribe antidepressants may be given to patients who would benefit more from a mood-stabilizing drug such as lithium and who may actually get worse on antidepressants (that is, their episodes may increase in frequency and intensity, and they may experience severely agitated or mixed states). Often, antidepressants and mood-stabilizing drugs need to be used together in order to obtain the best therapeutic results.

In recent years, advances in psychiatric research have made the highly profitable marketplace for mood-altering drugs far more competitive. Patients unresponsive to lithium or unwilling to take it now have good alternatives available to them. The most commercially successful of these, valproate (Depakote), an anticonvulsant, has now overtaken lithium as the most widely prescribed, and often the first prescribed, medication for bipolar disorder, or manic-depressive illness. This is a striking reversal in prescription patterns. There has also been a marked increase in the total number of prescriptions written for depression and bipolar disorder over the course of the past five years (a trend even more dramatic for the prescription of antidepressants), which reflects an increase in media and public awareness of the availability of effective medical treatment for mood disorders; impressive educational work on the part of patient advocacy groups; and highly effective physician and public marketing campaigns financed by the major pharmaceutical companies.

The ability of the anticonvulsant medications (valproate, carbamazepine, gabapentin, lamotrigine, and topirameate) to prevent suicide is unproven, however. Hypothetically, because they stabilize moods and have an impact on agitated and aggressive states, they should have an impact on suicide rates as well.

It may well be that future research will show an antisuicidal effect of the anticonvulsant medications. Certainly they provide a real and important alternative to lithium for many patients. But in light of the many studies demonstrating lithium's ability to prevent suicide in high-risk patients and the utter dearth of studies documenting this for the anticonvulsants, caution is in order. The clinical problem is complex, however. Not everyone who has depression or manic-depression is suicidal. If a patient refuses to take lithium or does not respond to it, anticonvulsants provide an important and often more agreeable treatment alternative. Lithium is effective in preventing suicide only if patients are willing to take it and if they respond to it. Not everyone will take it. Not everyone will respond to it.

Ultimately, the best course of treatment for many patients may be a combination of lithium, used as a hedge against suicide, with another mood stabilizer or with an antipsychotic, antidepressant, or antianxiety medication. Because the cost of lithium is far less than that of valproate, the economic factor is a further issue, although the additional expense for the newer antidepressant, anticonvulsant, and antipsychotic medications is often cost-effective and clinically warranted due to increased compliance and greater safety efficacy.

What is unequivocal, however, is that in every investigation of individuals who have committed suicide, researchers have demonstrated that depression has been underdiagnosed and antidepressants have been under-prescribed. Even when antidepressants have been prescribed, they have been given at inadequate dosages or for too short a period of time for them to take effect. The undertreatment of depression is consistent with research showing that doctors in general woefully underprescribe antidepressants and lithium for patients who could benefit from them.

Bipolar Children & Family History

Accurate diagnosis and the appropriate treatment of psychiatrically ill children and adolescents are material problems. A survey of pediatricians and family doctors found that only eight percent of those prescribing antidepressants for children felt they had received adequate training in treating childhood depression. Many children with early-onset manic-depression, or bipolar disorder, are mistakenly diagnosed as suffering from attention deficit disorder and hyperactivity, either because doctors do not recognize the symptoms of manic-depression in children or because they are unduly sensitive to subtle pressures from parents and teachers who feel there is less stigma attached to attention deficit disorder than there is to a major psychiatric illness. Although there are overlapping symptoms—hyperactivity, distractibility, and irritability, for instance—and the differential diagnosis can be difficult, there are many distinguishing features: bipolar children are more likely to have a family history of bipolar illness or depression, to have mood instability, euphoria, grandiosity, hypersexuality, less need for sleep, racing thoughts, and to be suicidal. Their pre-illness social and academic histories tend to be good and their illness is often a sharp departure from their normal level of functioning. The correct diagnosis is important because the primary treatment for attention deficit disorder is stimulant medication, which may aggravate the condition of a child with bipolar disorder (a disorder that generally requires a mood stabilizer such as lithium or an anticonvulsant). The long-term effect of the combined use of antidepressants and stimulants in a child or adolescent with bipolar illness is problematic.

The Role of Omega-3

Omega-3 fatty acids, implicated by some (but by no means all) researchers in both depression and suicide, have been tested in recent clinical studies at Harvard. On discharge from a psychiatric hospital, patients with bipolar illness were, in addition to their regular dosages of valproate or lithium, given either omega-3 fatty acids if a placebo. After four months, 64 percent of those taking fatty acids were in remission but only 16 percent of those on placebo remained well. The results were sufficiently significant that the researchers were obliged to "break the blind" of the experimental condition, in order that those who were on the placebo could be treated with the omega-3 fatty acids. To date, although the research is very preliminary, there have been no serious adverse effects from the fatty acids given to the patients in the study. A seventeen-year epidemiological study of fish consumption in 265,000 Japanese adults—which found a 19 percent reduction in suicides in those who consumed large amounts of fish rich I omega-3 fatty acids—adds further suggestive evidence to the fatty-acid hypothesis of depression. Still, the theory remains unproven until the research findings are replicated.

Seeking Help

There are several excellent advocacy and research organizations, many of which have patients and family support groups and all of which are actively involved in issues having to do with suicide prevention and mental illness.
Often it is helpful, when a potentially suicidal person is improved or well, to have a contingency planning meeting that involves the doctor or therapist, family members, and friends. Not only is the individual who is at risk less likely to be guarded or confused, he or she is better able to express clear and highly specific wishes for treatment: who is to be contacted and how, what others can do that is helpful, what others may do that is not helpful. Patients who decide, when rational, that if they again become suicidal they wish to be hospitalized or receive antipsychotic medications or undergo electroconvulsive therapy, but who also know that they are unlikely, when ill, to consent to this, may in some areas of the country draw up "Odysseus" arrangements. Based on the mythic character's request to be strapped to the mast of his ship so that he might avoid the inevitable call of the Sirens, Odysseus agreements (or advanced instruction directive) allow patients to agree to certain treatments in advance.

Parents, if there is a history of mental illness or suicide in the family, can help their children who may be at risk. By knowing their family's psychiatric histories, being educated about the symptoms and available treatments for mental illness, and discussing these issues openly and in a matter-of-fact way with their children, parents make it more likely that the children will seek help if they become depressed or start using alcohol or drugs.

College-age children are at particular risk for mental illness and suicide because first episodes of depressive illnesses or schizophrenia are most likely to occur at this time; they are away from home for the first time and subject to new stresses; they may use alcohol or drugs more heavily; or they may radically alter their sleep pattern, which can, in turn, precipitate a psychotic episode.

I am often amazed at how many parents who will check into the social and athletic facilities of a college, visit the libraries and residence halls, and request the success rate of the college in getting its graduates into law school, medical school, or doctoral programs do not inquire into the quality and accessibility of its student health facilities. Counseling and psychiatric services vary enormously in quality from campus to campus, and it can be helpful to make inquiries about how well the student health center deals with students who have mental illness. It is also a good idea to obtain from the psychiatry department of the nearest teaching hospital or medical school of list of clinicians who are specialized and competent in the treatment of psychiatric disorders. Mental health advocacy groups such as the Natinoal Alliance for the Mentally Ill and the National Depressive and Manic-Depressive Association also can be helpful in providing information about local clinicians and support groups. The list will hopefully never be used, but getting it in advances makes sense .The same parents who have ensured that their children are educated about AIDS, sexually transmitted diseases, and drug abuse often do not discuss the symptoms of depression, an illness that is common, potentially lethal, and highly treatable. Yet only accidents are more likely than suicide to cause death in this vulnerable age group.