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Table 3 Treatments aimed at reducing suicidal risk in bipolar disorder patients

From: Bipolar depression: a major unsolved challenge

Intervention Timing Findings Comments
Antidepressants Short-term benefits are not clear; long-term effects are virtually untested Research findings are inconclusive. Suicidal risk may increase with agitation, and in youth but may be lower in older adults Studies lack long-term randomization with suicidal acts as an explicit outcome measure
Antipsychotics Short-term benefits are not adequately tested. Clozapine is probably beneficial long-term in schizophrenia (with FDA approval) but untested in BD Except for clozapine, testing remains inadequate and inconclusive Effects of clozapine rely mainly on a single randomized trial vs. olanzapine, without reduction of mortality
Anticonvulsants Short-term effects are not established; long-term benefits have been proposed Valproate most studied; anticonvulsants may be less effective than lithium Studies lack suicidal acts as an explicit outcome
Lithium Very likely effective long-term Consistent decrease of risk of suicide and attempts in controlled and uncontrolled studies; not clear if effect is via reducing risk of depression, impulsivity, or specific anti-suicidal action Even randomized trials lack suicidal behavior as explicit outcome measure. Long-term acceptance and tolerance suggests some self-selection; potentially toxic on overdose
Other pharmacological treatments Only short-term effects have been tested Ketamine can reduce suicidal ideation; effects on suicidal behavior are untested; newer NMDA agents untested Ketamine has a short-term antidepresant effect in BD
Other somatic treatments If there are benefits, they are probably short-term ECT, magnetic, vagal nerve, or deep-brain stimulations can benefit depression Inadequate testing vs. suicidal behavior specifically
Psychotherapies Effects not established, but widely assumed to be helpful clinically Cognitive-behavioral, dialectic and interpersonal methods best studied, but research results for suicide are inconclusive Psychotherapy involves self-selection
  1. References to relevant studies are provided in the text