Therapeutic Management of the Suicidal Patient: Lithium, Electroconvulsive therapy (ECT)

Lithium

Lithium shows consistent antisuicidal effects (Tondo et al., 2001a). Tondo and colleagues (2001b) performed a meta-analysis of the suicide risk with long-term lithium treatment. They included 22 studies, 13 of which provided data on suicide rates with and without lithium (N 5647 patients), and analyzed suicide com-pletions, not attempts. Suicide rates were higher without lithium in all of the studies except one. Four of the studies were exclusive to patients with bipolar disorder. Suicide rates were significantly lower (81.8%) during lithium treatment. Notably, suicide rates in this population were significantly higher than in international general populations. This is probably reflective of differences between clinical and general populations, inclusion of highly sui-cidal individuals in the study samples, partial or failed treatment, and possible noncompliance (Tondo et al., 2001b).

As reviewed by Goodwin (1999), there has been increasing use of anticonvulsants in the management of bipolar disorder. Anticonvulsants may have an advantage in rapid cycling, mixed states, comorbid substance abuse, or history of poor response to lithium. There is little data about the suicide preventive impact of the anticonvulsants, although a comparison of lithium and carbamazepine was more favorable to lithium (Thies-Flechtner et al., 1996). Both lithium and anticonvulsants can have a positive impact on suicide risk factors of impulsivity and aggression (Goodwin, 1999).

ECT

Electroconvulsive therapy (ECT) has long played a role in the treatment of severe, and treatment refractory depression. Thus, ECT is indicated for illnesses frequently associated with suicidal symptoms, and is noted for relatively quick efficacy. It can have a profound impact on acute suicidal symptoms, in both respond-ers and nonresponders. The authors conclude that although an acute treatment, ECT’s long-term impact on mortality may be a function of repeated use in treating or preventing (via continua-tion and maintenance ECT) relapse and recurrence (Prudic and Sackeim, 1999).