Clinicians' preferences and attitudes towards the use of lithium in the maintenance treatment of bipolar disorders around the world: a survey from the ISBD Lithium task force

Trends and determinants of prescription of lithium and antidepressants for bipolar disorder in a large health care system between 2017 and 2022

BACKGROUND

Previous studies raised concerns about declining use of lithium and increased use of antidepressants in treatment of bipolar disorder (BP). We describe recent trends in prescription of psychotropic medications for BP and examine demographic, socioeconomic and clinical factors associated with their prescription.

METHODS

We analyzed data from the electronic health records on 12,824 patients with BP in a large academic health system between 2017 and 2022. We calculated annual prescription rates for BP medications, and then used logistic regression to examine factors associated with their prescription.

RESULTS

We found a modest increase in lithium prescription and a slight decrease for antidepressants. Lithium was prescribed to 27 % of patients, while antidepressants were prescribed to 52 % of patients, nearly half without a concomitant mood stabilizer. Patients who were Black (odds ratio [OR] = 0.70 95 % confidence interval [CI] = 0.65-0.76), had public insurance (OR = 0.87, 95 % CI = 0.81-0.94), lived in areas of higher social deprivation (OR = 0.84, 95 % CI = 0.76-0.93), or were seen in primary care (OR = 0.21, 95 % CI = 0.17-0.24) were less likely to be prescribed lithium. Patients who lived in areas of greater deprivation (OR = 1.42, 95 % CI = 1.20-1.68), were older (60+; OR = 2.64, 95 % CI = 1.96-3.58), and were seen in primary care (OR = 7.46, 95 % CI = 6.43-8.66) were more likely to be prescribed antidepressants without a concomitant mood stabilizer.

CONCLUSIONS

Lithium remains underutilized even though it is a first-line treatment for BP, especially among certain sub-groups. Antidepressants are widely used to treat BP, often without mood stabilizers despite caution by most clinical guidelines. These findings underscore the need for continued efforts to promote use of best evidence-treatments for BP and reduce disparities in their use.

Challenges of lithium prescription in bipolar disorders in Nigeria

BACKGROUND

Lithium prescription rates have witnessed a significant downward trend over the years in different continents despite evidence of its clinical efficacy in the acute and long-term maintenance treatment of Bipolar Disorder (BD). Nigeria has a paucity of data on lithium use in BD management. Hence, we aim to investigate the lithium prescription rate and factors influencing its use among Nigerian psychiatrists and trainee psychiatrists.

METHODS

A cross-sectional survey involving 203 respondents working in different accredited psychiatric training facilities in Nigeria was conducted between April and May 2024 using a predesigned online Google form. Information relating to lithium use in managing the different phases of BD and factors influencing its use were assessed.

RESULTS

The mean age of the respondents was 37.98 (± 6.85) years. The lithium prescription rate is low (10.89%). There is a significant association between the respondents' awareness of clinical practice guidelines (CPG) and good adherence to CPG (p = 0.003), but this did not significantly influence lithium prescription among them. Older years of practice influence prescribing lithium (p = < 0.001). Monitoring and availability of lithium constituted significant concerns for lithium use, among other factors (p = 0.032).

CONCLUSION

The study revealed a low lithium prescription rate among Nigerian psychiatrists and trainee psychiatrists compared to international studies. There is a need for concerted efforts towards addressing the identified factors. A review of the existing local CPG in line with the best evidence is warranted for improved clinical outcomes.

ETHICS REGISTRATION

The study was approved by the Hospital Research and Ethical Committee (HREC) of the University of Port Harcourt Teaching Hospital (UPTH) with approval protocol number (UPTH/ADM/90/S.11/VOL.XI/1688).

CLINICAL TRIAL NUMBER

Not applicable.

A Survey Exploring People's Experiences With Lithium Bought as a Supplement: Une enquête sur l'expérience des personnes avec le lithium en supplément

ObjectiveLithium, despite its evidence base and range of indications, is often underutilized due to safety concerns associated with high-dose prescriptions and consequent necessity for regular blood monitoring. Emerging evidence suggests its potential benefits at lower doses, especially for its pro-cognitive effects and positive safety profile. While accessible as a supplement, empirical human evidence on neuropsychiatric effects is lacking. This study aimed to provide preliminary evidence regarding the utilization and perceived effects of low-dose lithium supplements (LiS) in the community.MethodsCross-sectional, opportunistic survey of 211 participants aged ≥18 years who disclosed taking over-the-counter lithium supplements. The survey assessed sample demographics, supplement details, overall perspectives, and personal experiences related to the use of LiS.ResultsThe most common form of LiS taken was aspartate at 10 mg once per day, although lithium orotate and ionic lithium were also frequently used. The most common beliefs regarding the benefits of using lithium as a supplement concern efficacy for anxiety, but the most common improvements experienced was in the domain of cognition, closely followed by anxiety and mood. Mood was most commonly reported as the greatest improvement. Side effects and withdrawal phenomena were more prevalent than anticipated.ConclusionThis study revealed a diverse range of lithium supplements taken, in terms of dosage, formulation, frequency, and duration of intake. Anecdotal evidence highlighted prevalent perceived benefits and adverse effects. The study is, however, limited notably by its cross-sectional opportunistic design; more robust evidence, especially from controlled trials, is needed to fully establish the specific benefits and drawbacks associated with different forms and doses of accessible lithium supplements.Plain Language Summary TitleA survey exploring people's experiences with lithium bought as a supplement.Plain Language SummaryLithium is the oldest effective medication used in psychiatry and holds an important place today. However, there are challenges with lithium in high doses and it may still be effective in low doses. Lower doses of lithium can be bought as a supplement over the counter, but this version of lithium has not been studied in research. We did a survey aiming to tell us some information about the experiences of people who have taken this supplementary lithium ("LiS"). From 211 adults who completed our study, results suggested that LiS is taken in many different forms, at different doses, frequencies and for different durations. People commonly believed and/or found that LiS was beneficial for anxiety, mood and cognition. Side effects and symptoms after stopping LiS were, however, more common than expected. Because this was just an initial survey, more in depth and rigorous research studies are needed to fully understand the exact benefits and drawbacks associated with different forms and doses of accessible lithium supplements.

Prediction of Treatment Outcome in Bipolar Disorder: When Can We Expect Clinical Relevance?

Long-term pharmacological treatment is the cornerstone of the management of bipolar disorder (BD). Clinicians typically select mood-stabilizing medications from among several options through trial and error. This process could be optimized by using robust predictors of treatment response. We review clinical features and biological markers studied in relation to outcome of long-term treatment of BD. To date, the literature focuses mostly on lithium and to a lesser extent on the anticonvulsants valproate and lamotrigine. The most promising results show association of lithium response with certain clinical features (episodic clinical course and absence of rapid cycling, low rates of comorbid conditions, family history of BD and lithium response) as well as low polygenic risk for schizophrenia and major depression. The clinical application of these findings remains limited, however, due to heterogeneity of the illness as well as unanswered questions about specificity of the effects of different medications.

Twenty-four years of prescription patterns in bipolar disorder inpatients with vs without lithium: a pharmacoepidemiological analysis of 8,707 cases in German-speaking countries

BACKGROUND

Global pharmacoepidemiological evidence suggests dynamically changing prescription patterns in patients with bipolar disorders. We assessed trends in the use of pharmacological agents used in the management of bipolar disorders in inpatients.

METHODS

We examined drug use data provided by the Drug Safety in Psychiatry Programme AMSP (German: "Arzneimittelsicherheit in der Psychiatrie"), including psychiatric hospitals in Germany, Austria and Switzerland. We included data from adult inpatients with bipolar disorders (ICD-10: F31) treated between 1994 and 2017. We compared prescription patterns between patients receiving therapeutic regimens with vs. without lithium. Patients with manic and depressive episodes were also analyzed separately.

RESULTS

We identified a total of 8,707 patients (58% females, mean age 50.8 ± 14.8 years). Our analysis revealed a decrease of lithium use (up to 2004) and a consistent increase of prescription rates for second-generation antipsychotics (SGA) among which quetiapine (n = 2,677) and olanzapine (n = 1,536) were the most common. Among psychotropic drugs, quetiapine was most frequently combined with lithium (n = 716, 25.6%). Lithium-treated patients received a higher number of drugs compared to patients not receiving lithium (mean number of drugs in patients with vs. without lithium 4.99, n = 2,796 vs. 4.75, n = 5,911, p = 0.002). Thyroid therapeutics were given more often, valproate and quetiapine less often in the lithium group. Antidepressants were consistently prescribed to more than 60% of patients with bipolar depressive episodes.

CONCLUSIONS

Our findings suggest that SGAs are gradually becoming the mainstay treatment option in bipolar disorder, continuously replacing lithium. The use of antidepressants remains concerningly high. We call for action to improve adherence to evidence-based guidelines.

Comprehensive bibliometric analysis of pharmacotherapy for bipolar disorders: Present trends and future directions

BACKGROUND

Bipolar disorder (BD) is a severe mental illness characterized by significant mood swings. Effective drug treatment modalities are crucial for managing BD.

AIM

To analyze the current status and future trends of global research on BD drug treatment over the last decade.

METHODS

The Web of Science Core Collection database spanning from 2015 to 2024 was utilized to retrieve literature related to BD drug treatment. A total of 2624 articles were extracted. Data visualization and analysis were conducted using CiteSpace, VOSviewer, Pajek, Scimago Graphica, and R-studio bibliometrix to identify research hotspots, key contributors, and future trends.

RESULTS

The United States, China, and the United Kingdom have made the most significant contributions to research on BD drug treatment and formed notable research collaboration networks. The University of Pittsburgh, Massachusetts General Hospital, and the University of Michigan have been identified as the major research institutions in this field. The Journal of Affective Disorders is the most influential journal. A keyword analysis revealed research hotspots related to clinical symptoms, drug efficacy, and genetic mechanisms. A citation analysis identified the management guidelines published by Yatham et al in 2018 as the most cited paper.

CONCLUSION

This study provides a detailed overview of the field of BD drug treatment, highlighting key contributors, research hotspots, and future directions. The study findings can be employed as a reference for future research and policymaking, which may enable further development and optimization of BD pharmacotherapy.

Areas of interest and sentiment analysis towards second generation antipsychotics, lithium and mood stabilizing anticonvulsants: Unsupervised analysis using Twitter

BACKGROUND

Severe mental disorders like Schizophrenia and related psychotic disorders (SRD) or Bipolar Disorder (BD) require pharmacological treatment for relapse prevention and quality of life improvement. Yet, treatment adherence is a challenge, partly due to patients' attitudes and beliefs towards their medication. Social media listening offers insights into patient experiences and preferences, particularly in severe mental disorders.

METHODS

All tweets posted between 2008 and 2022 mentioning the names of the main drugs used in SRD and BD were analyzed using advanced artificial intelligence techniques such as machine learning, and deep learning, along with natural language processing.

RESULTS

In this 15-year study analyzing 893,289 tweets, second generation antipsychotics received more mentions in English tweets, whereas mood stabilizers received more tweets in Spanish. English tweets about economic and legal aspects displayed negative emotions, while Spanish tweets seeking advice showed surprise. Moreover, a recurring theme in Spanish tweets was the shortage of medications, evoking feelings of anger among users.

LIMITATIONS

This study's analysis of Twitter data, while insightful, may not fully capture the nuances of discussions due to the platform's brevity. Additionally, the wide therapeutic use of the studied drugs, complicates the isolation of disorder-specific discourse. Only English and Spanish tweets were examined, limiting the cultural breadth of the findings.

CONCLUSION

This study emphasizes the importance of social media research in understanding user perceptions of SRD and BD treatments. The results provide valuable insights for clinicians when considering how patients and the general public view and communicate about these treatments in the digital environment.

Evaluating the efficacy and safety of the currently available once-every-two months long-acting injectable formulations of aripiprazole for the treatment of schizophrenia or as a maintenance monotherapy for bipolar I disorder in adults

INTRODUCTION

An aripiprazole long-acting injectable (LAI) antipsychotic is now available for gluteal administration every 2 months via two different formulations: aripiprazole lauroxil (AL) and aripiprazole monohydrate (Ari 2MRTU). These longer dosing regimens of aripiprazole LAI offer new potential benefits for patients.

AREAS COVERED

The authors review the evidence supporting the efficacy and safety of aripiprazole LAIs given every 2 months for the treatment of schizophrenia or bipolar disorder (BD) in adults. The article culminates with the authors' expert perspectives on the subject.

EXPERT OPINION

AL 1064 mg every 2 months has established efficacy for the treatment of schizophrenia based on pharmacokinetic bridging studies and prospective data for treatment of an acute exacerbation of schizophrenia. In an open-label trial, Ari 2MRTU showed efficacy for the treatment of schizophrenia and BD type I based on pharmacokinetic parameters (comparable to aripiprazole once-monthly 400 mg); it also showed efficacy regarding the secondary endpoints. Multiple doses of AL 1064 mg or Ari 2MRTU 960 mg are generally well tolerated, in line with the safety profile of oral aripiprazole, with the exception of the injection-site reactions. While AL may require a 1-day initiation regimen, Ari 2MRTU 960 covers all the recommended doses of oral aripiprazole (10-20 mg).

Why is lithium [not] the drug of choice for bipolar disorder? a controversy between science and clinical practice

BACKGROUND

During over half a century, science has shown that lithium is the most efficacious treatment for bipolar disorder but despite this, its prescription has consistently declined internationally during recent decades to approximately 35% ever use or less of patients with bipolar disorder.

CONTENT

This narrative review provides an overview of the decreasing use of lithium in bipolar disorder internationally, shortly summarises the evidence for lithium's acute and prophylactic effects in bipolar disorder, discuss the challenges in relation to lithium including side effects, long-term risks and myths around lithium and provides two detailed examples on how specialised care models may result in successful increase of the use of lithium to 70% of patients with bipolar disorder largescale and improve care regionally and nationally.

CONCLUSIONS

Decades of scientific investigations and education and teaching of clinicians and the public has not increased the use of lithium on a population-based large scale. It is argued that lithium should be the drug of choice for maintenance therapy as the single first-line treatment and that organizational changes are needed with specialised care for bipolar disorder to systematically and long-term change the use of lithium on a large-scale population-level.

Epidemiology studies on effects of lithium salts in pregnancy are confounded by the inability to control for other potentially teratogenic factors

INTRODUCTION

In bipolar women who took lithium during pregnancy, several epidemiology studies have reported small increases in a rare fetal cardiac defect termed Ebstein's anomaly.

METHODS

Behavioral, environmental, and lifestyle-associated risk factors associated with bipolar disorder and health insurance status were determined from an Internet search. The search was conducted from October 1, 2023, through October 14, 2023. The search terms employed included the following: bipolar, bipolar disorder, mood disorders, pregnancy, congenital heart defects, Ebstein's anomaly, diabetes, hypertension, Medicaid, Medicaid patients, alcohol use, cigarette smoking, marijuana, cocaine, methamphetamine, narcotics, nutrition, diet, obesity, body mass index, environment, environmental exposures, poverty, socioeconomic status, divorce, unemployment, and income. No quotes, special fields, truncations, etc., were used in the searches. No filters of any kind were used in the searches.

RESULTS

Women who remain on lithium in the United States throughout their pregnancy are likely to be experiencing mania symptoms and/or suicidal ideation refractory to other drugs. Pregnant women administered the highest doses of lithium salts would be expected to have been insufficiently responsive to lower doses. Any small increases in the retrospectively determined risk of fetal cardiac anomalies in bipolar women taking lithium salts cannot be disentangled from potential developmental effects resulting from very high rates of cigarette smoking, poor diet, alcohol abuse, ingestion of illegal drugs like cocaine or opioids, marijuana smoking, obesity, and poverty.

CONCLUSIONS

The small risks in fetal cardiac abnormalities reported in the epidemiology literature do not establish a causal association for lithium salts and Ebstein's anomaly.

Facts and myths about the use of lithium for bipolar disorder in routine clinical practice: an expert consensus paper

BACKGROUND

Bipolar disorder is one of the most burdensome severe mental disorders, characterized by high levels of personal and social disability. Patients often need an integrated pharmacological and non-pharmacological approach. Lithium is one of the most effective treatments available not only in psychiatry, but in the whole medicine, and its clinical efficacy is superior to that of other mood stabilizers. However, a declining trend on lithium prescriptions has been observed worldwide in the last 20 years, supporting the notion that lithium is a 'forgotten drug' and highlighting that the majority of patients with bipolar disorder are missing out the best available pharmacological option. Based on such premises, a narrative review has been carried out on the most common "misconceptions" and "stereotypes" associated with lithium treatment; we also provide a list of "good reasons" for using lithium in ordinary clinical practice to overcome those false myths.

MAIN TEXT

A narrative search of the available literature has been performed entering the following keywords: "bipolar disorder", "lithium", "myth", "mythology", "pharmacological treatment", and "misunderstanding". The most common false myths have been critically revised and the following statements have been proposed: (1) Lithium should represent the first choice for the treatment of patients with bipolar disorder; (2) lithium treatment is effective in different patients' groups suffering from bipolar disorder; (3) Drug-drug interaction risk can be easily managed during lithium treatment; (4) The optimal management of lithium treatment includes periodical laboratory tests; (5) Slow-release lithium formulation has advantages compared to immediate release formulation; (6) Lithium treatment has antisuicidal properties; (7) Lithium can be carefully managed during pregnancy.

CONCLUSIONS

In recent years, a discrepancy between evidence-based recommendations and clinical practice in using lithium treatment for patients with bipolar disorder has been highlighted. It is time to disseminate clear and unbiased information on the clinical efficacy, effectiveness, tolerability and easiness to use of lithium treatment in patients with bipolar disorder. It is necessary to reinvigorate the clinical and academic discussion about the efficacy of lithium, to counteract the decreasing prescription trend of one of the most effective drugs available in the whole medicine.

Countering the declining use of lithium therapy: a call to arms

For over half a century, it has been widely known that lithium is the most efficacious treatment for bipolar disorder. Yet, despite this, its prescription has consistently declined over this same period of time. A number of reasons for this apparent disparity between evidence and clinical practice have been proposed, including a lack of confidence amongst clinicians possibly because of an absence of training and lack of familiarity with the molecule. Simultaneously, competition has grown within the pharmacological armamentarium for bipolar disorder with newer treatments promoting an image of being safer and easier to prescribe primarily because of not necessitating plasma monitoring, which understandably is appealing to patients who then exercise their preferences accordingly. However, these somewhat incipient agents are yet to reach the standard lithium has attained in terms of its efficacy in providing prophylaxis against the seemingly inevitable recrudescence of acute episodes that punctuates the course of bipolar disorder. In addition, none of these mimics have the additional benefits of preventing suicide and perhaps providing neuroprotection. Thus, a change in strategy is urgently required, wherein myths regarding the supposed difficulties in prescribing lithium and the gravity of its side-effects are resolutely dispelled. It is this cause to which we have pledged our allegiance and it is to this end that we have penned this article.