A. Schaffer et al. wrote in Bipolar Disorders (2025) about the suicide deaths of 340 people with bipolar disorder (BD) in the city of Toronto from 1998 to 2020 compared to 4,948 non-bipolar people. Lithium was present in only 5.8% of decedents with BD. There was a significant decrease in the presence of mood stabilizers across time (33.3% vs. 13.5%, p = 0.006), and antidepressants (48.9%) and benzodiazepines (46.7%) were the most commonly present medications among people with BD, at a proportion similar to the non-BD group. They concluded: “The findings of this study suggest that a substantial proportion of people with BD who die by suicide were not receiving first-line treatments at the time of death.”

Editors Note: As with the large number of people with BD in the US, the cases of those who died by suicide in Canada highlight that patients with BD often receive routine care that is inferior and of low quality. This is not only associated with suicide, but also leads to progressive disability and dysfunction, more episodes, and more cognitive impairment.

Patients need to ask their physicians and physicians need to ask themselves why lithium, first-line mood stabilizers, and well-tolerated atypicals with antidepressant properties are not being used more often. Routine care of BD in the US leads to an intolerable amount of suffering. Lithium is now considered a disease modifying drug and needs to be used earlier and more often (Post et al Lancet Psychiatry, 2025). The overwhelming data now contradict the uninformed views of RF Kennedy, Jr. which are dangerous to children’s and adolescents’ health.

Patients should mood chart their course of illness on a daily basis, and in the absence of a good long-term response, insist on revision of their care and/or a consultation.

Clinicians, please do everything possible to ensure that people with bipolar disorder receive the quality care they deserve.

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Bibliography                                                                                                                                                                                

(1.)Post RM: What patients need to know about lithium in Pharmaceuticals (Basel;. 2024, Sept. 17;17(9):1223. doi: 10.3390/ph17091223)

(2.) Post RM, Li VW, Berk M, et al: Lithium as a disease-modifying drug for bipolar disorder.  The Lancet Psychiatry. 9 June 2025; https://doi.org/10.1016/S2215-0366(25)00097-5

(3.) Aron, L., Ngian, Z.K., Qiu, C., et al: Lithium deficiency and the onset of Alzheimer’s disease. Nature. 2025; Aug 6. doi: 10.1038/s41586-025-09335-x.

(4.) Rhee TG, Olfson M, Nierenberg AA, et al: 20-Year Trends in the Pharmacologic Treatment of Bipolar Disorder by Psychiatrists in Outpatient Care Settings. Am J Psychiatry 2020; 177(8): 706-15.

(5.) Post RM, Altshuler LL, Kupka R, et al: More childhood-onset bipolar disorder in the United States than Canada or Europe: Implications for treatment and prevention. Neurosci Biobehav Rev 2017; 74(Pt A): 204-13.

(6.) Kessing LV, Bauer M, Nolen WA et al: Effectiveness of maintenance therapy of lithium vs other mood stabilizers in monotherapy and in combinations: a systematic review of evidence from observational studies. Bipolar Disord 2018.  doi:10.1111/bdi.12623. Online ahead of print.

(7.) Orestes V Forlenza et al. Br J Psychiatry. Clinical and biological effects of long-term lithium treatment in older adults with amnestic mild cognitive impairment: randomised clinical trial. Br J Psychiatry 2019; Nov;215(5):668-674.doi: 10.1192/bjp.2019.76.

(8.) Nunes MA, Viel TA, Buck HS et al. Microdose lithium treatment stabilized cognitive pg.9 impairment in patients with Alzheimer's disease. Curr Alzheimer Res 2013; 10(1): 104-7.191