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Citation
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Bschor T, Adli M, Alda M, Baethge C, Etain B, Glenn T, Grof P, Hajek T, Hayes J, Manchia M, Muller-Oerlinghausen B, Nielsen RE, Ritter P, Rybakowski JK, Sani G, Selo ML, Young AH, Tondo L. Epidemiol. Psychiatr. Sci. 2022; 31: e84. |
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Abstract
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In their current meta-analysis, Nabi et al. (Reference Nabi, Stansfeld, Plöderl, Wood and Moncrieff2022) conclude that there is no convincing evidence that lithium reduces suicide or suicidal behaviour. This conclusion thus contradicts previous high-quality meta-analyses and previous reviews (e.g. Cipriani et al., Reference Cipriani, Hawton, Stockton and Geddes2013; Smith and Cipriani, Reference Smith and Cipriani2017; Baldessarini and Tondo Reference Baldessarini and Tondo2022).
Since the outcome of a meta-analysis depends on which studies are included (Walker et al., Reference Walker, Hernandez and Kattan2008), the reasons for the discrepancy between the findings of Nabi et al. and previous meta-analyses may depend on the seemingly arbitrary inclusion and exclusion of randomised controlled trials (RCTs) and on an unsatisfactory reinterpretation of data compared to the original publications.
The decision to exclude RCTs published prior to 2000 is puzzling. As a result, more RCTs were excluded (N = 15) from the primary analysis than those included (N = 12). Also questionable and not justified by the authors is the inclusion of only RCTs comparing lithium against placebo or treatment as usual, but not against an active comparator. At least three studies were excluded on this basis: (1) the randomised comparison of lithium v. lamotrigine in bipolar II disorder (Parker et al., Reference Parker, Ricciardi, Tavella and Hadzi-Pavlovic2021), (2) the comparison of lithium v. valproic acid or carbamazepine in the maintenance therapy of bipolar disorder (Peselow et al., Reference Peselow, Clevenger and IsHak2016) and (3) the comparison of lithium plus quetiapine v. quetiapine in the treatment of bipolar depression (AstraZeneca, 2009). Lamotrigine, valproic acid, carbamazepine, and quetiapine are usual treatments for bipolar disorder and we question why these trials were excluded.
Furthermore, the authors state that in a sensitivity analysis they included trials published before 2000, using data extracted in a previous meta-analysis by Cipriani et al. (Reference Cipriani, Pretty, Hawton and Geddes2005). This procedure does not seem accurate, since three key studies from Cipriani et al.'s meta-analysis are missing (Greil et al., Reference Greil, Ludwig-Mayerhofer, Erazo, Engel, Czernik, Giedke, Müller-Oerlinghausen, Osterheider, Rudolf, Sauer, Tegeler and Wetterling1996, Reference Greil, Ludwig-Mayerhofer, Erazo, Engel, Czernik, Giedke, Müller-Oerlinghausen, Osterheider, Rudolf, Sauer, Tegeler and Wetterling1997a, Reference Greil, Ludwig-Mayerhofer, Erazo, Schochlin, Schmidt, Engel, Czernik, Giedke, Müller-Oerlinghausen, Osterheider, Rudolf, Sauer, Tegeler and Wetterling1997b).
In addition, the authors' assumption that no suicides took place in studies with no information on suicide events is flawed...
Language: en |