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

From: Bipolar depression: a major unsolved challenge

AntidepressantsShort-term benefits are not clear; long-term effects are virtually untestedResearch findings are inconclusive. Suicidal risk may increase with agitation, and in youth but may be lower in older adultsStudies lack long-term randomization with suicidal acts as an explicit outcome measure
AntipsychoticsShort-term benefits are not adequately tested. Clozapine is probably beneficial long-term in schizophrenia (with FDA approval) but untested in BDExcept for clozapine, testing remains inadequate and inconclusiveEffects of clozapine rely mainly on a single randomized trial vs. olanzapine, without reduction of mortality
AnticonvulsantsShort-term effects are not established; long-term benefits have been proposedValproate most studied; anticonvulsants may be less effective than lithiumStudies lack suicidal acts as an explicit outcome
LithiumVery likely effective long-termConsistent 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 actionEven randomized trials lack suicidal behavior as explicit outcome measure. Long-term acceptance and tolerance suggests some self-selection; potentially toxic on overdose
Other pharmacological treatmentsOnly short-term effects have been testedKetamine can reduce suicidal ideation; effects on suicidal behavior are untested; newer NMDA agents untestedKetamine has a short-term antidepresant effect in BD
Other somatic treatmentsIf there are benefits, they are probably short-termECT, magnetic, vagal nerve, or deep-brain stimulations can benefit depressionInadequate testing vs. suicidal behavior specifically
PsychotherapiesEffects not established, but widely assumed to be helpful clinicallyCognitive-behavioral, dialectic and interpersonal methods best studied, but research results for suicide are inconclusivePsychotherapy involves self-selection
  1. References to relevant studies are provided in the text