[Late onset first manic episode: role of lithium]

This case reports on a first manic episode occurring to a 68 year old patient. Until now this male patient had been diagnosed with a recurrent depressive disorder. This depressive illness started 29 years ago and was punctuated by several depressive episodes. During one of these episodes associated to psychotic features, following the lithium discontinuation, the patient committed a homicide-suicide. He was found not to be responsible for his crime and treatment was subsequently restarted. For the next fifteen years the patient was stabilized using the association of antidepressant plus lithium, then lithium alone. Until the current manic episode subsequent to a further lithium discontinuation, the patient thanks to the mood stabilizer, could enjoy a good quality of life with a very satisfying social and professional adjustment. Following the case report, an analysis of published data on epidemiological parameters and risk factors associated was conducted. Findings show that perpetrators of murder suicides are mainly males (> 85%) suffering from depression (40% to 75%). Cases of homicide-suicide more frequently involve individuals committing a violent suicide shortly after (minutes or hours) committing one or more homicides. These cases often occur within a disturbed family context with drugs or alcohol abuse, social or cultural stresses such as poor social level or unemployment being other risk factors. Fire-arms are the most frequently used in suicides. Reported annual incidence is similar every year, ranging from 0.2 to 0.3 per 100,000 in the United States and other countries. Due to suicide but also to other disorders, mortality and morbidity rates are higher with patients suffering from mood disorders. A long term treatment with lithium results in a decrease of morbidity rate and suicidal risk in the general population.