23Bipolar disorder (BD) is a highly heritable mood disorder with complex genetic architecture and 24 poorly understood etiology. We performed a whole blood transcriptome analysis in a BD case-25 control sample (Nsubjects = 480) by RNA sequencing. While we observed widespread differential 26 gene expression patterns between affected and unaffected individuals, these effects were largely 27 linked to lithium treatment at the time of blood draw (FDR < 0.05, Ngenes = 976) rather than BD 28 diagnosis itself (FDR < 0.05, Ngenes = 6). These lithium-associated genes were enriched for cell 29 signaling and immune response functional annotations, among others, and were associated with 30 neutrophil cell-type proportions, which were elevated in lithium users. Neither genes with altered 31 expression in cases nor in lithium users were enriched for BD, schizophrenia, and depression 32 genetic risk based on information from genome-wide association studies, nor was gene 33 expression associated with polygenic risk scores for BD. Our findings suggest that BD is 34 associated with minimal changes in whole blood gene expression independent of medication use 35 but underline the importance of accounting for medication use and cell type heterogeneity in 36 psychiatric transcriptomic studies. The results of our study add to mounting evidence of lithium's 37 cell signaling and immune-related mechanisms. 38 39 strategy for uncovering disease mechanisms. Many such studies have been carried out for BD, 48and in Table 1 we present a summary that reveals a lack of consistency between findings likely 49 owing to clinical heterogeneity, differing study designs, and the low numbers of samples 50 investigated (N ≤ 62 BD subjects) . Moreover, there are many potential confounds that impact 51 gene expression, including medication. 52 Therefore, to explore gene expression changes associated with BD, we generated RNA 53 sequencing data from peripheral whole blood collected in a large, well-characterized case-control 54 cohort from The Netherlands. We examined gene expression differences between groups both at 55 the individual gene level and at the level of gene co-expression. Upon correction for technical and 56 biological variables including the use of lithium, the most widely used prescription drug in our 57 cohort, gene expression differences between subjects with BD and controls were minor. 58Differences in subjects being treated with lithium compared to those who are not, however, were 59 widespread. These differences were partially but not entirely explained by differences in cell-type 60 composition, driven by elevated neutrophil proportions in lithium users. The lithium-associated 61 changes in gene expression were independent of psychiatric genetic risk, though. Our results 62 suggest nominal BD-related gene expression effects in blood but numerous effects related to 63 lithium treatment. This work highlights the importance of accounting for medication use in 64 psychiatric transcriptomic studies and provides insight into lithium's mole...