To the Editor: I indeed thank Dr. Terao for the thought-provoking comments. As Dr. Terao explicitly notes, the overview did not attempt to comprehensively review treatment for aggression, nor did it address suicide. However, I agree that lithium may decrease limbic irritability, as do anticonvulsants, and increase “top-down brakes,” perhaps in part by enhancing serotonergic activity (1). There is indeed limited evidence that lithium is superior to anticonvulsants in the prevention of suicide (2), although a suicide-protective effect was not found in the data for 4,360 bipolar patients in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study (3).
1.Birkenhager TK, van den Broek WW, Fekkes D, Mulder PG, Moleman P, Bruijn JA: Lithium addition in antidepressant-resistant depression: effects on platelet 5-HT, plasma 5-HT and plasma 5-HIAA concentration. Prog Neuropsychopharmacol Biol Psychiatry 2007; 31:1084–10882.Sondergard L, Lopez AG, Andersen PK, Kessing LV: Mood-stabilizing pharmacological treatment in bipolar disorders and risk of suicide. Bipolar Disord 2008; 10:87–943.Marangell LB, Dennehy EB, Wisniewski SR, Bauer MS, Miyahara S, Allen MH, Martinez M, Al Jurdi RK, Thase ME: Case-control analyses of the impact of pharmacotherapy on prospectively observed suicide attempts and completed suicides in bipolar disorder: findings from STEP-BD. J Clin Psychiatry 2008; 8:e1–e7
+The author’s disclosures accompany the original article.
+This letter (doi: 10.1176/appi.ajp.2008.08040598r) was accepted for publication in June 2008.