{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T01:09:12Z","timestamp":1760058552197,"version":"build-2065373602"},"reference-count":35,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2025,4,7]],"date-time":"2025-04-07T00:00:00Z","timestamp":1743984000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"FCT\/MECI, Funda\u00e7\u00e3o para a Ci\u00eancia e Tecnologia and Minist\u00e9rio da Educa\u00e7\u00e3o, Ci\u00eancia e Inova\u00e7\u00e3o","award":["UID\/50006"],"award-info":[{"award-number":["UID\/50006"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background\/Objectives: Higher lithium (Li) levels in drinking water have been linked to lower suicide rates in the general population in several ecological studies, though this relationship is not always consistent. The main limitation of such studies is the assumption that Li content in drinking water is directly correlated with total Li intake, which may not always be the case for several reasons. Methods: In this context, we conducted a biomonitoring study to compare urinary Li levels\u2014assumed as a reliable indicator of total Li intake\u2014among individuals from three regions with different suicide relative risks (RRs): Porto Metropolitan Area (PMA; low RR), Central region (CT; intermediate RR), and Tr\u00e1s-os-Montes region (TM; high RR). Each participant provided a urine sample (first morning) and two water samples (drinking water and environmental water). Li concentrations were determined using ICP-MS. Results: A total of 311 individuals participated in this study. The median (P25\u2013P75) urinary Li concentration was 21.9 (15.1\u201346.0) in PMA, 19.0 (12.6\u201330.4) in CT, and 24.2 (14.6\u201338.7) \u00b5g\/L in TM, with no statistically significant differences between regions (Kruskal\u2013Wallis test with Bonferroni correction). Urinary Li was weakly correlated with Li in drinking water (\u03c1 = 0.174; p = 0.002) but not with Li in environmental water (\u03c1 = \u22120.036; p = 0.694). Conclusions: These findings do not support a protective role of natural Li exposure in suicide risk at the low levels found in drinking (P75 = 3.75 \u00b5g\/L) and environmental (P75 = 6.87 \u00b5g\/L) water. More robust and comprehensive biomonitoring studies are needed to clarify the potential impact of natural Li exposure on suicide rates.<\/jats:p>","DOI":"10.3390\/nu17071283","type":"journal-article","created":{"date-parts":[[2025,4,7]],"date-time":"2025-04-07T03:23:07Z","timestamp":1743996187000},"page":"1283","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Association Between Natural Lithium Exposure and Suicide Rate: An Ecological and Biomonitoring Study in Portugal"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8837-9163","authenticated-orcid":false,"given":"Carolina","family":"Gon\u00e7alves","sequence":"first","affiliation":[{"name":"Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0539-7022","authenticated-orcid":false,"given":"Rui","family":"Azevedo","sequence":"additional","affiliation":[{"name":"LAQV\/REQUIMTE, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2264-5603","authenticated-orcid":false,"given":"Cristina","family":"Couto","sequence":"additional","affiliation":[{"name":"LAQV\/REQUIMTE, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal"},{"name":"Associate Laboratory i4HB, Institute for Health and Bioeconomy, University Institute of Health Sciences\u2014CESPU, 4585-116 Gandra, Portugal"},{"name":"UCIBIO-Applied Molecular Biosciences Unit, Forensics and Biomedical Sciences Research Laboratory, University Institute of Health Sciences (1H-TOXRUN, IUCS-CESPU), 4585-116 Gandra, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4371-8330","authenticated-orcid":false,"given":"Mary","family":"Duro","sequence":"additional","affiliation":[{"name":"LAQV\/REQUIMTE, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal"},{"name":"Nordestelab Clinical Analysis Laboratory Dra. Matilde Sampaio, 5300-252 Mogadouro, Portugal"},{"name":"Higher School of Health, Fernando Pessoa Foundation, 4200-253 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1396-4234","authenticated-orcid":false,"given":"Agostinho","family":"Santos","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal"},{"name":"LAQV\/REQUIMTE, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal"},{"name":"National Institute of Legal Medicine and Forensic Sciences, North Branch, 4050-167 Porto, Portugal"},{"name":"School of Health Sciences, Minho University, 4710-057 Braga, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6542-4256","authenticated-orcid":false,"given":"Laura","family":"Cain\u00e9","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal"},{"name":"LAQV\/REQUIMTE, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal"},{"name":"National Institute of Legal Medicine and Forensic Sciences, North Branch, 4050-167 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1297-3198","authenticated-orcid":false,"given":"Agostinho","family":"Almeida","sequence":"additional","affiliation":[{"name":"LAQV\/REQUIMTE, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal"}]}],"member":"1968","published-online":{"date-parts":[[2025,4,7]]},"reference":[{"key":"ref_1","unstructured":"World Health Organization (WHO) (2022, December 02). Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/suicide."},{"key":"ref_2","unstructured":"World Health Organization (WHO) (2022, December 02). Available online: https:\/\/www.who.int\/data\/gho\/data\/themes\/mental-health\/suicide-rates."},{"key":"ref_3","unstructured":"Royal Society of Chemistry (2022, December 18). Available online: https:\/\/www.rsc.org\/periodic-table\/element\/3\/lithium."},{"key":"ref_4","unstructured":"National Health Service (NHS) (2022, December 19). Available online: https:\/\/www.nhs.uk\/medicines\/lithium\/."},{"key":"ref_5","first-page":"36","article-title":"O L\u00edtio na bioqu\u00edmica e terap\u00eautica","volume":"V8","author":"Almeida","year":"2020","journal-title":"Rev. Ci\u00eancia Elem."},{"key":"ref_6","unstructured":"Chokhawala, K., Lee, S., and Saadabadi, A. (2024). Lithium, StatPearls Publishing."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1111\/bdi.12609","article-title":"Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder","volume":"20","author":"Yatham","year":"2018","journal-title":"Bipolar Disord."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1275","DOI":"10.1007\/s40263-021-00869-y","article-title":"The Impact of Lithium on Brain Function in Bipolar Disorder: An Updated Review of Functional Magnetic Resonance Imaging Studies","volume":"35","author":"Bergamelli","year":"2021","journal-title":"CNS Drugs"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"641","DOI":"10.1007\/s12403-019-00324-w","article-title":"Dietary Estimated Intake of Trace Elements: Risk Assessment in an Italian Population","volume":"12","author":"Filippini","year":"2020","journal-title":"Expo. Health"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1007\/BF02990271","article-title":"Lithium in drinking water and the incidences of crimes, suicides, and arrests related to drug addictions","volume":"25","author":"Schrauzer","year":"1990","journal-title":"Biol. Trace Elem. Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1177\/0004867420963740","article-title":"The association between lithium in drinking water and neuropsychiatric outcomes: A systematic review and meta-analysis from across 2678 regions containing 113 million people","volume":"55","author":"Mahendran","year":"2021","journal-title":"Aust. N. Z. J. Psychiatry"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1097\/YIC.0000000000000048","article-title":"Lithium in drinking water and suicide prevention: A review of the evidence","volume":"30","author":"Vita","year":"2015","journal-title":"Int. Clin. Psychopharmacol."},{"key":"ref_13","unstructured":"Leal, I. (2020). Rela\u00e7\u00e3o Entre a Mortalidade por Suic\u00eddio e a Concentra\u00e7\u00e3o de L\u00edtio Nas \u00c1guas de Consumo P\u00fablico: Revis\u00e3o Sistem\u00e1tica, Faculdade de Medicina da Universidade de Coimbra. Artigo de Revis\u00e3o Sistem\u00e1tica."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"667","DOI":"10.1192\/bjp.2020.128","article-title":"Association between naturally occurring lithium in drinking water and suicide rates: Systematic review and meta-analysis of ecological studies","volume":"217","author":"Memon","year":"2020","journal-title":"Br. J. Psychiatry"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1016\/j.neubiorev.2020.06.017","article-title":"Lithium and suicide prevention in mood disorders and in the general population: A systematic review","volume":"116","author":"Muscas","year":"2020","journal-title":"Neurosci. Biobehav. Rev."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"516","DOI":"10.1016\/j.jad.2021.11.045","article-title":"Association between lithium levels in drinking water and suicide rates: Role of affective disorders","volume":"298","author":"Liaugaudaite","year":"2022","journal-title":"J. Affect. Disord."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1016\/j.jpsychires.2012.12.002","article-title":"Lithium in the public water supply and suicide mortality in Texas","volume":"47","author":"Regier","year":"2013","journal-title":"J. Psychiatr. Res."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"464","DOI":"10.1192\/bjp.bp.108.055798","article-title":"Lithium levels in drinking water and risk of suicide","volume":"194","author":"Ohgami","year":"2009","journal-title":"Br. J. Psychiatry"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Knudsen, N.N., Schullehner, J., Hansen, B., J\u00f8rgensen, L.F., Kristiansen, S.M., Voutchkova, D.D., Gerds, T.A., Andersen, P.K., Bihrmann, K., and Gr\u00f8nb\u00e6k, M. (2017). Lithium in Drinking Water and Incidence of Suicide: A Nationwide Individual-Level Cohort Study with 22 Years of Follow-Up. Int. J. Environ. Res. Public Health, 14.","DOI":"10.3390\/ijerph14060627"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"47","DOI":"10.20344\/amp.10744","article-title":"Lithium in Public Drinking Water and Suicide Mortality in Portugal: Initial Approach","volume":"32","author":"Oliveira","year":"2019","journal-title":"Acta M\u00e9dica Port."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"598","DOI":"10.1016\/j.jad.2024.08.239","article-title":"Too early to add lithium to drinking water? No association between lithium and suicides in a pre-registered Swiss study","volume":"367","author":"Pichler","year":"2024","journal-title":"J. Affect. Disord."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"170","DOI":"10.20344\/amp.11945","article-title":"L\u00edtio na \u00e1gua p\u00fablica em Portugal","volume":"32","author":"Prazeres","year":"2019","journal-title":"Acta Med. Port."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"38","DOI":"10.20344\/amp.9423","article-title":"Mortalidade por suic\u00eddio nos munic\u00edpios de Portugal Continental: Evolu\u00e7\u00e3o esp\u00e1cio temporal entre 1980 e 2015","volume":"31","author":"Loureiro","year":"2018","journal-title":"Acta Med. Port."},{"key":"ref_24","unstructured":"Centers for Disease Control and Prevention (CDC) (2012). Laboratory Procedure Manual: Urine Multi-Element ICP-DRC-MS Method No. 3018.3, Department of Health and Human Services."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1007\/s12011-018-1455-2","article-title":"Is Lithium a Micronutrient? From Biological Activity and Epidemiological Observation to Food Fortification","volume":"189","author":"Szklarska","year":"2019","journal-title":"Biol. Trace Elem. Res."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1080\/07315724.2002.10719188","article-title":"Lithium: Occurrence, dietary intakes, nutritional essentiality","volume":"21","author":"Schrauzer","year":"2002","journal-title":"J. Am. Coll. Nutr."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Araya, P., Mart\u00ednez, C., and Barros, J. (2022). Lithium in Drinking Water as a Public Policy for Suicide Prevention: Relevance and Considerations. Front. Public Health, 10.","DOI":"10.3389\/fpubh.2022.805774"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"274","DOI":"10.1093\/phe\/phz002","article-title":"Adding Lithium to Drinking Water for Suicide Prevention\u2014The Ethics","volume":"12","author":"Ng","year":"2019","journal-title":"Public Health Ethics"},{"key":"ref_29","unstructured":"Environmental Protection Agency (EPA) (2008). Provisional Peer Reviewed Toxicity Values for Lithium (CASRN 7439-93-2), Environmental Protection Agency. EPA\/690\/R-08\/016F."},{"key":"ref_30","unstructured":"French Agency for Food Environmental and Occupational Health & Safety (ANSES) (2011). Second French Total Diet Study (FTDS2) Report 1. Inorganic Contaminants, Minerals, Persistent Organic Pollutants, Mycotoxins and Phytoestrogens, Bialec."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1080\/026520399283876","article-title":"Dietary exposure estimates of 30 elements from the UK Total Diet Study","volume":"16","author":"Ysart","year":"1999","journal-title":"Food Addit. Contam."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"856","DOI":"10.1016\/j.fct.2013.10.026","article-title":"Dietary intake of barium, bismuth, chromium, lithium, and strontium in a Spanish population (Canary Islands, Spain)","volume":"62","author":"Rubio","year":"2013","journal-title":"Food Chem. Toxicol."},{"key":"ref_33","first-page":"15","article-title":"Sociodemographic Variables Most Associated with Suicidal Behaviour and Suicide Methods in Europe and America. A Systematic Review","volume":"10","year":"2017","journal-title":"Eur. J. Psychol. Appl. Leg. Context"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"148","DOI":"10.1136\/ebmental-2022-300549","article-title":"Risk factors for suicide in adults: Systematic review and meta-analysis of psychological autopsy studies","volume":"25","author":"Favril","year":"2022","journal-title":"Evid. Based Ment. Health"},{"key":"ref_35","first-page":"2726","article-title":"Suicide risk factors in university students: A review from the literature","volume":"6","year":"2022","journal-title":"Cienc. Lat. Rev. Cient\u00edfica Multidiscip."}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/17\/7\/1283\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:11:22Z","timestamp":1760029882000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/17\/7\/1283"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,4,7]]},"references-count":35,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2025,4]]}},"alternative-id":["nu17071283"],"URL":"https:\/\/doi.org\/10.3390\/nu17071283","relation":{},"ISSN":["2072-6643"],"issn-type":[{"type":"electronic","value":"2072-6643"}],"subject":[],"published":{"date-parts":[[2025,4,7]]}}}