Mood stabilizer loading versus titration in acute mania: audit of clinical practice

Physiological Measurements for Prescribing Psychotropic Medications

Prescribing for individuals with mental health problems requires a thorough initial assessment that includes extensive interviewing of the client and significant others, review of medical records, and physical appraisals, such as vital signs, laboratory tests, and electrocardiography. Arriving at a diagnosis and treatment plan includes ruling out comorbid conditions as well as medical conditions that mimic psychiatric disorders. Because substance use frequently coincides with other psychiatric disorders and has serious health consequences, this potential for misuse of substances must also be considered. The current article focuses on the physiological assessments necessary for prescribing and monitoring psychotropic medications. [Journal of Psychosocial Nursing and Mental Health Services, 57(8), 7-10.].

Use of Lithium in Severe Acute Manic Episodes: Retrospective Prescription Practice From a Tertiary Inpatient Unit

OBJECTIVE

A retrospective chart review was performed to investigate the common preferences of clinicians for the pharmacological treatment of acute manic episodes, with particular regard to lithium use, and to assess the adherence of clinical practice to established guidelines.

METHODS

Cases of manic episodes in patients admitted to Bakirköy Mazhar Osman Mental Health and Neurological Diseases Education and Research Hospital were retrospectively reviewed. Length of stay, medication data, serum levels, and adverse effects were evaluated for patients who received lithium therapy (N=98).

RESULTS

On the first day of lithium treatment, 81 patients received 900 to 1200 mg of lithium. In total, 44 patients were discharged with the same dose as that given on the first day of treatment. With the exception of 1 patient, the dose was increased by 300 to 600 mg in the remaining patients within the first 10 days on the basis of serum drug concentrations. The mean serum concentrations of lithium in the first week were 0.67±0.17 mEq/L in patients with no dose increase, and 0.51±0.15 mEq/L in patients who did receive a dose increase. In total, 94 patients received at least 1 antipsychotic medication in addition to lithium.

CONCLUSIONS

Clinicians attempted to maintain serum lithium levels above 0.60 mEq/L at the time of acute treatment initiation, consistent with established guidelines. Clinical practice in large inpatient settings may force clinicians to use lithium in combination with antipsychotics for the treatment of acute mania; the delayed action of lithium and the need for rapid stabilization may drive these practices.

How to initiate lithium therapy: a systematic review of dose estimation and level prediction methods

BACKGROUND

Throughout the past decades, several methods have been developed to achieve therapeutic lithium blood levels as quick and safe as possible. The present study will systematically review the methods developed and studied for lithium dose estimation or level prediction at the initiation of therapy.

METHODS

A systematic computerized Medline search was performed for papers published in English, French or Dutch between 1966 and April 2012 describing or studying methods for dosing lithium or predicting the lithium level on a certain dosage. References of relevant articles were screened for additional papers.

RESULTS

Of 273 unique references retrieved, 65 met the inclusion criteria. Apart from the empirical titration method, 38 predictive methods for initiating lithium were identified. These methods can be classified into two categories: the a priori predictive methods, and the test-dose predictive methods requiring the administration of a test dose of lithium prior to starting treatment.

LIMITATIONS

The methodological strength was not taken into account for a study to be included in the review.

CONCLUSIONS

The most important distinction between the empirical titration method and the predictive methods appears to be the shorter time the latter need to achieve the targeted lithium level. The vast majority of predictive methods, however, show inconsistent or poor results or have not been replicated since their initial description. The empirical titration method, although not extensively studied, appears to be a time-honored method that can be recommended for use in daily clinical practice.