Mortality and Suicide Prevention Affective disorders are strongly associated with increased mortality, primarily from suicide, but also from cardiovascular events. Excess mortality in these patients is 20 to 30 times higher than in the normal population. For bipolar disorder, excess mortality is estimated to be as much as 50 to 100 times higher. In the early 1980s, Prof. Müller-Oerlinghausen at the Berlin Lithium Clinic (Freie Universität Berlin) became aware of the fact that the mortality in his patients was comparably low. Only 8 patients out of 200 had died over 15 years, 5 of them by documented or suspected suicide. This observation sparked intensive research efforts, including projects on the serotoninergic system and aggression. Prof. Müller-Oerlinghausen advanced the hypothesis that regular lithium prophylaxis would decrease the number of expected suicides and possibly also the number of suicide attempts. At that point in time there was only very limited data on the possible association between lithium prophylaxis and a decrease in suicidality. The first presentation of Müller-Oerlinghausen’s findings coincided with the foundation of IGSLI. Replicating and broadening the preliminary findings from Berlin was the IGSLI’s first project. The so-called MORTA-projects were based on suitable protocols agreed upon by all IGSLI centres. Original patient data were extracted and converted into a “clean file” related on a case-by-case basis to the corresponding national mortality statistics and analysed using the standardized mortality ratio (SMR). The first analysis showed an impressive mortality-lowering effect for lithium long-term prophylaxis in unipolar, bipolar, and schizoaffective patients (Müller-Oerlinghausen et al. 1992). It became clear that it might be impossible to perform a confirmatory study by including a control group comprised of affectively ill patients who were not on lithium prophylaxis. One way to corroborate the evidence from the retrospective study was to analyse data from patients who had discontinued lithium (Müller-Oerlinghausen et al. 1996), and by comparing mortality ratios from patients during initial and during later lithium treatment (Müller-Oerlinghausen et al. 1994). After discontinuing lithium treatment, patients’ mortality again rose dramatically. At first, analysing the data based on the successive year-per-year cumulation of SMR led to the interpretation that a reduction in mortality could only be seen after several years of uninterrupted lithium treatment. However, reanalysing the data using another mathematical approach revealed this assumption to be the result of an artefact (Wolf et al. 1996). The mortality-lowering effect of lithium starts much earlier after treatment initiation. Implementing evidence in routine treatment Affective disorders are devastating for patients and their families. This, and the high mortality rates involved, require effective, safe, and evidence-based treatment strategies. Therefore, the antisuicidal effect of lithium should be considered when deciding which treatment option is the most appropriate. It is, however, frustrating to note that even modern therapeutic recommendations and consensus documents do not give proper consideration to this important and life-saving aspect of lithium treatment. It took more than ten years and the joint efforts of a highly motivated group of international researchers to detect the antisuicidal effect of lithium and to accumulate empirical evidence of this important effect. It is now supported by more recent data and excellent reviews of existing evidence. It will require further efforts and more years to spread the message to other countries and to implement the evidence in the routine treatment of patients with affective disorders. top >>