Lithium for the control of aggressive and self-mutilating behaviour

A review of the evidence supporting the use of lithium augmentation therapy for the reduction of suicidal behavior in patients with unipolar depression: Revisiting an overlooked benefit of an older medication

Major depressive disorder is a serious, recurrent condition with significant impact on a person's quality of life and functioning, which carries a significant risk of premature death due to suicide. There is evidence that supports the effectiveness of lithium as an augmentation strategy for treatment-resistant depression, as well as for reducing suicidality in this population. This review introduces several theories regarding the proposed mechanism behind lithium's anti-suicidal effects and summarizes a selection of the pertinent literature supporting lithium's beneficial effects on suicidality.

The role of psychopharmacology in suicide prevention

The potential role of psychopharmacology in suicide prevention is often minimised. This may to some extent reflect that few medication trials have specifically focussed on prevention of suicidal behaviour – indeed this outcome is often not reported in trials. However, there is reasonably strong evidence that lithium may reduce risk of suicide, the postulated mechanism being a specific effect on aggression. Evidence is lacking with regard to any protective effect of other mood stabilizers. Clozapine may reduce suicidal behaviour in patients with schizophrenia, with reduction of affective symptoms being a possible explanation. The role of antidepressants in relation to suicide risk is highly controversial, especially in children and adolescents. It is unclear whether minor tranquillizers or hypnotics can assist in suicide prevention, although they can reduce the anxiety symptoms that may occur during initial treatment with SSRI antidepressants. Itis also uncertain whether psychopharmacology has a role in preventing suicidal behaviour in people with personality disorders. Despite the limitations of the evidence we contend that suicide risk should be an important factor in deciding when and what to prescribe.

Declaration of Interest: We have no interests to declare.

Pharmacotherapy of suicidal behavior in bipolar disorder

Patients with Bipolar Disorder (BD) are at particularly high risk for both attempted and completed suicides. The period of highest risk for completed suicide is during the 2 years following discharge from a hospitalization. To date, pharmacological studies of suicidal behavior in BD have been quite limited. While strong evidence has been found regarding the anti-suicidal effects of lithium, evidence for such properties in other commonly prescribed medications for BD, including anticonvulsants, SSRIs and anti-psychotics, has been largely unexplored. Considering the high risk of suicidal acts in patients with BD, further research on the pharmacotherapy of suicidal behavior is crucial.

Antisuicide properties of psychotropic drugs: a critical review

The authors consider the extent to which psychotropic medications demonstrate benefits in the prevention of suicidal behavior in psychiatric patients. Results of a MedLine search are critically reviewed for lithium, divalproex and other anticonvulsants, conventional and atypical antipsychotics, and antidepressants. The existing literature is almost entirely limited to noncontrolled, often retrospective studies that do not control for potential biases in treatment selection, the use of multiple medications, the impact of medication nonadherence, and nonrandomized treatment discontinuations. Nevertheless, an extensive literature has arisen regarding observed reductions in suicidal behavior with lithium for mood disorders and, to a lesser extent, with clozapine for schizophrenia. A substantially smaller literature suggests more negative than positive data with divalproex or carbamazepine in bipolar disorder, while minimal information exists regarding suicidality with atypical antipsychotics other than clozapine. Studies of antidepressants have mostly been short-term and have focused more on whether they induce (rather than ameliorate) suicidal thoughts or behaviors. The sum of existing studies is generally inconclusive about whether antidepressants appreciably reduce risk for suicide completions. Relatively little is known about pharmacotherapy effects on suicidal ideation as distinct from behaviors. Possible mechanistic considerations for understanding antisuicide properties include a therapeutic impact on depression, impulsivity, or aggression, potentially mediated through serotonergic or other neuromodulatory systems. Recommendations are provided to guide future research as well as clinical practice.

Suicidal behaviour in bipolar disorder: risk and prevention

Bipolar (manic-depressive) disorder is a common and severe illness. It is also potentially fatal as a result of accidents and increased mortality associated with comorbid substance use and medical illnesses, but its highest lethality results from suicide. Suicide rates, averaging 0.4% per year in men and women diagnosed with bipolar disorder, are >20-fold higher than in the general population. Suicidal acts often occur early in the illness course and in association with severe depressive and dysphoric-agitated mixed phases of illness, especially following repeated, severe depressions. Systematic consideration of risk and protective factors enhances assessment of potentially suicidal patients. Short-term interventions employed empirically to manage acute suicidality include close clinical supervision, rapid hospitalisation and use of electroconvulsive treatment. Several plausible therapeutic interventions have limited evidence of long-term effectiveness against mortality risks associated with any psychiatric disorder, including antidepressant, antimanic, antipsychotic and electroconvulsive, as well as psychosocial, treatments. However, in bipolar disorder and other major affective disorders, lithium maintenance treatment is a notable exception, with strong and consistent evidence that it reduces suicidal risk. The growing range of drugs being introduced to treat acute and long-term phases of bipolar disorder, including antiepileptic drugs, atypical antipsychotics and relatively safe, modern antidepressants, require research assessment for their ability to limit premature mortality from suicide and other causes. For now, however, more can be done to improve treatment in major affective illnesses by application of current knowledge in a systematic fashion, with close and sustained clinical follow-up of patients at risk, hopefully with a resulting reduction of mortality rates.

Lithium: poisonings and suicide prevention

This study concerns 81 cases of lithium poisoning and shows that deliberate intoxications are prevalent during the first 3 years of lithium treatment as well as in cases with a previous history of suicide attempt. Therapeutic intoxications could generally be avoided by education concerning hygiene and diet and careful monitoring in cases of intercurrent diseases.

Clinical and theoretical issues in self-injurious behavior

This article presents an overview of pathological self-injurious behavior (SIB). Historical and cultural aspects, epidemiology, classification and clinical aspects and pathogenesis are described. The importance of comprehensive assessment of symptomatology and functions of SIB for treatment planning are discussed.

Capillary ion analysis of lithium concentrations in biological fluids and tissues of Poecilia (teleost)

Capillary ion analysis (CIA) is a form of capillary electrophoresis that uses the differential electrophoretic mobility of ions to perform a separation of an ionic mixture. Application of this technique for detection of lithium concentrations in plasma and tissues of Poecilia was the purpose of this investigation. CIA was performed using a 75 microm ID x 60 cm length fused-silica capillary and a run electrolyte of 67.7 mg hydroxyisobutyric acid (HIBA), 52.8 mg 18-crown-6-ether and 64 microL UV-CAT-1 reagent (4-methylbenzylamine) in a volume of 100 mL water (18 (M)omega) with a voltage of 20 kV using ultraviolet absorption detection at 214 nm. Migration times were: potassium, 2.98 min; calcium, 3.48 min; sodium, 3.60 min; barium (internal standard), 4.15 min and lithium, 4.26 min. Lithium and barium migration times were stable and reproducible. Correlation coefficients (r) between peak area ratios of lithium/barium for concentrations ranging from 0.1 to 2.0 mM were from 0.976 to 0.996. Coefficients of variation (CV) for lithium concentrations ranged from 4.07 to 15.71% between days and 4.38 to 7.76% within-day. Application of this methodology for determination of lithium concentrations in the plasma, brains and livers of fish dosed with lithium for 23 days are presented. CIA is applicable to analysis of lithium concentrations in biological fluids and tissues of fish.

On the functions of lithium: the mood stabilizer

Lithium, despite its simple structure, has numerous biological effects. It also has a remarkable therapeutic effect in the prophylactic treatment of manic depression, and is finding a role in controlling aggressive and self-mutilating behavior. The special feature of lithium is that it only acts on overactive systems to bring them back to normal, without affecting the stable system. The mechanisms of action of this simple cation are still largely unknown although the inositol depletion theory is the most widely accepted model. A recent paper described a different molecular mechanism for its effect on development, which may also explain its action in manic depression.

Lithium. Current status in psychiatric disorders

Lithium is the recommended treatment for the prophylaxis of bipolar affective disorder. The drug is also effective in the prophylactic treatment of recurrent unipolar depression, although many psychiatrists prefer to use antidepressant drugs for this indication. The efficacy of lithium is well established in the short term treatment of mania, although neuroleptic drugs are required at the start of treatment for more severely disturbed patients. Lithium augmentation of antidepressant drugs is increasingly popular for the treatment of resistant depression. It is now common practice to maintain serum lithium concentrations in the range 0.5 to 0.8 mmol/L, which is generally as effective as higher concentrations while reducing the incidence of adverse effects and intoxication. Some individuals may nevertheless require higher serum concentrations. Most adverse effects such as tremor and gastrointestinal upset are usually minor and often transient. There is no good evidence of nephrotoxicity with long term treatment, but persistent polyuria can occur. Hypothyroidism, with or without goitre, can occur uncommonly during long term lithium therapy. Prescribers should be alert to, and patients should be educated about, the predisposing factors and early symptoms relating to lithium intoxication. Specialist mood disorder clinics can facilitate safer and more effective lithium treatment.

Lithium intoxication: a coordinated treatment approach

This case illustrates the clinical features of lithium intoxication and the problems in treating it that may arise as a result of lithium's effects on the kidney. It also demonstrates the difficulties that can develop when a delicate physiologic balance is inadvertently disrupted by nonpharmacologic interventions such as seclusion and consequent restriction of access to food and water. Patients with lithium-induced urine-concentrating defects are especially at risk for dehydration, and care must be taken to ensure adequate fluid and salt intake. This case also shows how intense negative feelings evoked by chronically mentally ill patients can adversely affect their psychiatric and medical care. While such feelings are inevitable, their impact may be lessened by improved communication and coordination between the medical and psychiatric systems of care and by the presence of psychiatrists in the general medical hospital.

About the centrality of mood lowering in mood disorders. Plenary Lecture ECNP Congress, Monte Carlo, October 1991

5-HT disturbances in depression (as exemplified by lowered CSF 5-HIAA) are not syndrome specific but related to components of the depressive syndrome, specifically to increased anxiety and aggression. These 5-HT disturbances are probably core pathogenetic processes not derivative features. I hypothesized that in this subtype of depression, i.e. in "5-HT related depression", the key psychopathological disturbances are dysregulation of anxiety and aggression, while mood lowering is a "by-product". Based on this hypothesis it was predicted that agents which ameliorate anxiety and/or aggression via harmonization of 5-HT ergic transmission will, in addition, exert overall antidepressant effect in "5-HT related depression". The study of the relative "weight" of the various psychopathological components of depression is a basic exercise in understanding the nature of that condition and could, as such, greatly facilitate the goal-directed search for new and innovative antidepressants.

Clomipramine treatment of stereotypic behaviors and self-injury in patients with developmental disabilities

The authors report an open clinical trial of clomipramine for chronic stereotypic and self-injurious behaviors in 11 consecutive patients with concomitant developmental disorders. Ten patients (91%) had marked decreases in rates of target behaviors. No seizures occurred despite the inclusion of six patients with previous histories of epileptic events, and improvement was evident regardless of level of mental retardation. These findings support both the clinical use of serotonergic medications in this population and the need for further research.

The effect of long-term lithium treatment on the mortality of patients with manic-depressive and schizoaffective illness

Clinical research centers in Aarhus, Berlin, Hamilton and Vienna collected mortality data for 827 manic-depressive and schizoaffective patients given lithium treatment for more than 6 months. The average duration of the treatment was 81 months and the total time on lithium 5600 patient-years. For each patient, the mortality risk was calculated by entering the appropriate national life tables for the general population. The number of observed deaths was 44; the number of expected deaths was 49.7. The standardized mortality ratio, 0.89, did not differ significantly from 1.0. The mortality of manic-depressive patients is 2-3 times that of the general population. Our data show that the mortality of manic-depressive and schizoaffective patients given long-term lithium treatment does not differ significantly from that of the general population.

Drug treatment of the personality disorders

Many people with well defined borderline and schizotypal personality disorders may benefit considerably from small doses of neuroleptics. Depression that occurs with personality disorders, which is frequent, responds poorly to tricyclics but may respond better to neuroleptics, while the response to ECT is usually short lived. Selected borderline subjects may respond to MAOIs, particularly where there is a history of childhood hyperactivity. Carbamazepine and lithium may help some individuals with episodic behavioural dyscontrol and aggression, even in the absence of epileptic, affective or organic features. Drug treatments can be combined with psychotherapy, but further placebo-controlled trials are needed to clarify which drugs are most useful, and whether there are any useful clinical predictors of drug responsiveness.

Suicides and parasuicides in a high-risk patient group on and off lithium long-term medication

68 patients with affective disorders, and receiving lithium prophylaxis in a specialized lithium clinic were followed up for 8 years on average. Patients were selected for this study according to 2 criteria: They had been given lithium for at least 12 months, and they had attempted suicide at least once before onset of lithium prophylaxis. Outcome was analysed in terms of suicidal and parasuicidal behaviour. 55 patients took their lithium regularly, 13 discontinued or dropped the medication. One third of those patients having discontinued the medication died from suicide. Only one suicide occurred in patients with regular lithium intake and proven compliance during the last check before death. An impressive drop of parasuicides was observed in responders as well as in apparent non-responders. In total, 11 of 13 patients showed suicidal or parasuicidal behaviour 2 weeks-44 months after lithium discontinuation, which in about half of these cases took place on advice or with consent of the treating psychiatrist. It is concluded that lithium may have specific anti-suicidal properties, possibly related to its anti-aggressive effect, and that patients apparently not responding satisfactorily in terms of reduced number of episodes may still be protected against suicide or parasuicide.

Modification of severe behaviour problems following herpes simplex encephalitis

Violent and sexually disinhibited behaviour together with poor self-care developed in a 38-year-old teacher following herpes simplex encephalitis. These behaviours were sufficiently severe to make rehabilitation difficult and return to the community impossible. Initially, only violent behaviour was treated, both by medication and a behaviour programme, and sexual disinhibition subsequently by the latter. In order to implement the programme a special (psychiatric) nurse was required on a 24 h basis. The incidence of violent behaviour was reduced from up to 55 times per day to zero over a period of 2 months. Whether this was affected by medication or behaviour management, or by spontaneous recovery, is discussed. Sexual disinhibition was eliminated in supervised settings, but continued to occur if left unsupervised and this improvement resulted from behaviour management. Poor personal hygiene also improved markedly over the 6-month period. The goal of returning the patient home to live with her family was achieved and she remained there at follow-up. This intervention was carried out in a rehabilitation unit that does not specialize in the treatment of such cases; clearly this has implications for cost and quality of care.

Two-tier diagnosing in psychiatry

This article addresses the question: what is the most productive way to systematize abnormal behavior in order to study its biological roots? Though nosology still occupies the premier position in biological psychiatry, it is, in and by itself, a treacherous beacon. Syndromal organization of psychopathology is likewise seriously flawed. A functional organization of psychopathology is considered the most appropriate framework for biological research and a plea is made for a two-tier diagnostic system of psychiatric disorders. Tier one comprises the nosological diagnosis, and tier two a detailed depiction of the component psychological dysfunctions. Such a two-tier diagnostic system would bring psychopathology onto a true scientific footing.

Central serotonergic function in parasuicide

1. Central 5-HT is thought to be involved in neuronal inhibition and as such as a modulating influence in restraining the organism from responding to (e.g., especially adverse) stimuli. 2. Evidence for a role of central 5-HT in suicide arises from reduced concentrations of brain 5-HT or 5-HIAA in brain stem, reduced binding of [3-H]-IMI in brain tissue of frontal cortex/hypothalamus, and increased binding of radioligands to 5-HT-2 receptors in the frontal cortex. 3. Evidence for a role of central 5-HT in parasuicide arises from reduced concentrations of lumbar CSF 5-HIAA, reduced PRL responses to d,l-fenfluramine challenge, and increased CORT responses to 5-HTP challenge. 4. Since reduced central 5-HT activity appears to be consistently associated with impulsive aggression, it is possible that suicidal and parasuicidal acts in individuals with evidence of reduced central 5-HT activity are a manifestation of reduced impulse control. 5. Agents which enhance central 5-HT function and/or diminish the activity of neuronal systems involved in arousal (e.g. norepinephrine or dopamine) should be efficacious in reducing parasuicidal behavior.

Clinical issues in the use of carbamazepine in psychiatry: a review

Evidence is presented here in support of the efficacy of carbamazepine (CBZ) in a variety of different psychiatric conditions. While there is now considerable evidence to support the use of CBZ in the acute treatment of mania and in the prophylaxis of bipolar affective disorder, particularly as a second-line drug, its usefulness in other conditions is less well documented. Overactivity, aggression and poor impulse control appear to improve in a variety of different diagnostic categories, and it may possibly be more appropriately prescribed to control or prevent these symptoms than as a treatment for a particular disease entity. The use of CBZ as an anti-depressant is not well proven. Most of the adverse effects reported are due to rapid initial escalation of dosage, which can be avoided, or are reversible such as drug rashes. Severe adverse effects have been reported but are rare. Frequent monitoring of drug plasma concentration is not required. Some reports of synergism with lithium have appeared and combination therapy may be a useful strategy. Drug interactions, the need for clinical monitoring, and the possible pharmacological mode of action of CBZ are also discussed.