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	Since this article does not have an abstract, we have provided the first 132 words of the full text and any section headings.

To the Editor: In their retrospective study, Dr Goodwin and colleagues¹ reported that lithium was associated with a lower risk of suicide attempt and suicide death than was divalproex among patients with bipolar disorder.

We are concerned that the authors did not measure risk factors for suicide in bipolar disorder, such as history of suicide attempts, mixed episodes, mood cycling in the episode, depression, severe anxiety, personality disorders, or comorbid substance abuse.^2-4 Furthermore, although the authors claimed that lithium might exert an antisuicide effect, patients who received lithium did not have significantly lower event rates for suicide attempts and deaths than patients who received no drug treatment. In one of the authors' samples, patients who received lithium had a higher risk of suicide attempts and deaths than those who received no treatment.

Charles Bowden, MD
bowdenc@uthscsa.edu
Department of Psychiatry
University of Texas Health Science Center
San Antonio

Jan Fawcett, MD
Department of Psychiatry
Rush University Medical Center
Chicago, Ill

1. Goodwin FK, Fireman B, Simon GE, Hunkeler EM, Lee J, Revicki D. Suicide risk in bipolar disorder during treatment with lithium and divalproex. JAMA. 2003;290:1467-1473. FREE FULL TEXT 2. Fawcett J, Scheftner WA, Fogg L, et al. Time-related predictors of suicide in major affective disorder. Am J Psychiatry. 1990;147:1189-1194. FREE FULL TEXT 3. Goodwin FK, Ghaemi SN. The impact of mood stabilizers on suicide in bipolar disorder: a comparative analysis. CNS Spectr. 2000;5(suppl 1):12-18. 4. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry. 2002;159(4 Suppl):1-50. PUBMED

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2004;291:939.

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