Oquendo et al. instead attacked the problem directly, and while the statistical power ultimately does not permit us to reach a definitive conclusion about the difference between lithium and valproate, we can nonetheless value their attempt for what it shows us about the challenges in caring for sick patients. Even in a leading research center devoted to the study and treatment of suicide, one-third of the patients made a suicide attempt during the study. For the clinician, the work of Oquendo et al. should not meaningfully change the evidence-based pharmacotherapy of bipolar disorder. Compelling reasons remain for favoring lithium for long-term treatment of bipolar disorder. APA treatment guidelines and their international counterparts continue to highlight lithium as a first-line treatment (7, 8), based on over 40 years of accumulated understanding of its strengths and limitations. The suggestive, albeit indirect, evidence of additional antisuicide benefit was simply another reason to choose lithium, and the inability of the Oquendo et al. study to confirm a very large effect of lithium compared with valproate does not diminish either rationale.