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To the Editor: We have several concerns about the study by Dr Goodwin and colleagues.¹ First, the lack of clinical record review makes it difficult to attribute the findings entirely to the effects of the drugs, especially since nonadherence is common among patients with bipolar disorder. We suspect that pharmacy records may not correlate well with documentation by physician progress notes. Thus, durings periods that Goodwin et al counted as exposure to medication, some patients may have actually been receiving no medication, with an associated increase in risk of suicide. This phenomenon has been described for rapid discontinuation of lithium.²

Second, approximately 75% of the patients were prescribed antidepressants. Even controlling for frequency of antidepressant use in both groups, the comparison of the combination of lithium and an antidepressant vs the combination of divalproex and an antidepressant is not the same as the comparison of lithum vs divalproex, as antidepressants . . . [Full Text of this Article]

Boghos I. Yerevanian, MD
byerevan@ucla.edu

Ralph J. Koek, MD; Jamie D. Feusner, MD
Department of Psychiatry and Bio-behavioral Sciences
University of California, Los Angeles, School of Medicine

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