Dr. Siever Replies

To the Editor: I indeed thank Dr. Terao for the thought-provoking comments. As Dr. Terao explicitly notes, the overview did not attempt to comprehensively review treatment for aggression, nor did it address suicide. However, I agree that lithium may decrease limbic irritability, as do anticonvulsants, and increase “top-down brakes,” perhaps in part by enhancing serotonergic activity (1) . There is indeed limited evidence that lithium is superior to anticonvulsants in the prevention of suicide (2), although a suicide-protective effect was not found in the data for 4,360 bipolar patients in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study (3) .