{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T10:10:11Z","timestamp":1788948611791,"version":"build-2803163510"},"reference-count":37,"publisher":"Wiley","issue":"7","license":[{"start":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T00:00:00Z","timestamp":1788912000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T00:00:00Z","timestamp":1788912000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Bipolar Disorders"],"published-print":{"date-parts":[[2026,11]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Lithium has long been associated with reduced suicide risk in bipolar disorder; however, evidence from real\u2010world clinical populations remains susceptible to confounding, and the behavioral correlates related to this association are not well characterized.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      In this multicenter cross\u2010sectional study, 616 individuals aged 12\u201345\u2009years with bipolar disorder were recruited from 14 psychiatric centers, of whom 585 had complete data for the present analyses. Lithium exposure within the past year was determined from clinical records. The primary outcome was a composite of suicide\u2010related behaviors, including suicidal ideation, suicide attempts, and non\u2010suicidal self\u2010injury. A pre\u2010specified analytical framework was applied, with multivariable logistic regression as the primary analysis and propensity score matching (PSM) as the principal approach to improve covariate balance. Regression\u2010based decomposition analyses were conducted to examine whether aggression was statistically associated with the exposure\u2010outcome relationship, and restricted cubic spline models were used to characterize the dose\u2013response association between aggression and suicide\u2010related behaviors. Robustness analyses included inverse probability of treatment weighting (IPTW), alternative matching specifications,\n                      <jats:italic>E<\/jats:italic>\n                      \u2010value analyses, cluster\u2010robust standard errors, and exploratory age\u2010stratified analyses.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Lithium exposure was associated with lower odds of suicide\u2010related behaviors in both the fully adjusted model (OR\u2009=\u20090.55, 95% CI: 0.34\u20130.89) and the propensity score\u2010matched sample (OR\u2009=\u20090.53, 95% CI: 0.33\u20130.86). Higher aggression scores were linearly associated with increased suicide\u2010related risk. Exploratory regression\u2010based decomposition analyses indicated that approximately 20.93% of the observed lithium\u2010outcome association was statistically accounted for by aggression. Results from robustness analyses were directionally consistent with the primary findings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>In this multicenter clinical sample, lithium exposure was consistently associated with lower odds of suicide\u2010related behaviors across multiple analytic approaches. Aggression was independently associated with suicide\u2010related risk and statistically accounted for part of the observed association between lithium exposure and suicide\u2010related outcomes. However, causal inference is limited by the cross\u2010sectional design, and residual confounding\u2014particularly confounding by indication\u2014remains a key concern. Prospective longitudinal studies are required to clarify temporal relationships and disentangle treatment effects from selection processes.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/bdi.70180","type":"journal-article","created":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T09:53:26Z","timestamp":1788947606000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Association Between Lithium Use and Suicide\u2010Related Behaviors in Bipolar Disorder: A Multicenter Study"],"prefix":"10.1111","volume":"28","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-3155-7480","authenticated-orcid":false,"given":"Xin","family":"Guan","sequence":"first","affiliation":[{"name":"Qingdao University Medical College  Qingdao China"},{"name":"Qingdao Mental Health Center  Qingdao 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