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Fiorillo A, Sampogna G, Albert U, Maina G, Perugi G, Pompili M, Rosso G, Sani G, Tortorella A. Facts and myths about the use of lithium for bipolar disorder in routine clinical practice: an expert consensus paper. Ann Gen Psychiatry 2023; 22:50. [PMID: 38057894 DOI: 10.1186/s12991-023-00481-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/20/2023] [Indexed: 12/08/2023] Open
Abstract
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.
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Affiliation(s)
- Andrea Fiorillo
- Department of Psychiatry, University of Campania "L. Vanvitelli", Largo Madonna delle Grazie, Naples, Italy
| | - Gaia Sampogna
- Department of Psychiatry, University of Campania "L. Vanvitelli", Largo Madonna delle Grazie, Naples, Italy.
| | - Umberto Albert
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Giuseppe Maina
- San Luigi Gonzaga Hospital, University of Turin, Turin, Italy
- Department of Neurosciences "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Giulio Perugi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital - Sapienza University of Rome, Rome, Italy
| | - Gianluca Rosso
- San Luigi Gonzaga Hospital, University of Turin, Turin, Italy
- Department of Neurosciences "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Gabriele Sani
- Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168, Rome, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
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Janiri D, Sampogna G, Albert U, Caraci F, Martinotti G, Serafini G, Tortorella A, Zuddas A, Fiorillo A, Sani G. Lithium use in childhood and adolescence, peripartum, and old age: an umbrella review. Int J Bipolar Disord 2023; 11:8. [PMID: 36781741 PMCID: PMC9925650 DOI: 10.1186/s40345-023-00287-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 01/24/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Lithium is one of the most consistently effective treatment for mood disorders. However, patients may show a high level of heterogeneity in treatment response across the lifespan. In particular, the benefits of lithium use may vary in special clinical conditions. The aim of this study was to test this hypothesis by conducting an umbrella review on the efficacy and safety of lithium in childhood and adolescence, peripartum and old age. METHODS We applied the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria (PRISMA) to identify systematic reviews/meta-analyses on the efficacy and/or safety of lithium in mood disorders in special clinical conditions: (i) childhood and adolescence; (ii) peripartum (pregnancy, postpartum and lactation); (iii) old age. The Risk of Bias Assessment Tool for Systematic Reviews (ROBIS) tool was used to assess the risk of bias. Overlap in primary studies across systematic reviews was calculated through the Corrected Covered Area (CCA). RESULTS We included 20 independent studies, for a total of 8209 individuals treated with lithium. Regarding paediatric age, efficacy and safety results suggested that lithium may be superior to placebo in bipolar disorders (BD) and not associated with serious adverse events. Nevertheless, primary available data are very limited. Efficacy in paediatric major depressive disorder (MDD) is not clear. During peripartum, lithium use was superior to non-lithium in preventing mood episodes and it was associated with low risk of congenital anomalies and with normal child neurodevelopment. Regarding old age, limited evidence supported lithium as an effective treatment in BD and resistant MDD; low doses should be used in this population. Systematic reviews on paediatric age showed the lowest risk of bias (80% of the studies at low risk). The CCA range of included studies was 13-47%. CONCLUSIONS This umbrella review supports the use of lithium across the lifespan, including special clinical condition. Nevertheless, more studies with increased methodological homogeneity are needed.
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Affiliation(s)
- Delfina Janiri
- grid.8142.f0000 0001 0941 3192Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy ,grid.411075.60000 0004 1760 4193Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Gaia Sampogna
- grid.9841.40000 0001 2200 8888Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Umberto Albert
- grid.5133.40000 0001 1941 4308Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy ,Department of Mental Health, Azienda Sanitaria Universitaria Giuliano Isontina - ASUGI, Trieste, Italy
| | - Filippo Caraci
- grid.8158.40000 0004 1757 1969Department of Drug and Health Sciences, University of Catania, 95125 Catania, Italy ,grid.419843.30000 0001 1250 7659Oasi Research Institute-IRCCS, 94018 Troina, Italy
| | - Giovanni Martinotti
- grid.412451.70000 0001 2181 4941Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D’Annunzio, 66100 Chieti, Italy
| | - Gianluca Serafini
- grid.5606.50000 0001 2151 3065Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy ,grid.410345.70000 0004 1756 7871IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alfonso Tortorella
- grid.9027.c0000 0004 1757 3630Department of Psychiatry, University of Perugia, Perugia, Italy
| | - Alessandro Zuddas
- grid.7763.50000 0004 1755 3242Department of Biomedical Sciences, Section of Neuroscience & Clinical Pharmacology, University of Cagliari, Cagliari, Italy ,Child & Adolescent Neuropsychiatry Unit, “A. Cao” Paediatric Hospital, Cagliari, Italy
| | - Andrea Fiorillo
- grid.9841.40000 0001 2200 8888Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Gabriele Sani
- Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168, Rome, Italy. .,Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
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Lithium produces bi-directionally regulation of mood disturbance, acts synergistically with anti-depressive/-manic agents, and did not deteriorate the cognitive impairment in murine model of bipolar disorder. Transl Psychiatry 2022; 12:359. [PMID: 36055984 PMCID: PMC9440114 DOI: 10.1038/s41398-022-02087-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 07/16/2022] [Accepted: 07/21/2022] [Indexed: 11/08/2022] Open
Abstract
Lithium (Li) is a well-established mood disorder treatment and may be neuroprotective. Bi-directional regulation (i.e. affecting manic symptoms and depressive symptoms) by Li has not been demonstrated. This study explored: (1) bidirectional regulation by Li in murine models of depression, mania, and bipolar disorder (BP); and (2) potential Li synergism with antidepressant/anti-mania agents. The chronic unpredictable mild stress (CUMS) and ketamine-induced mania (KM) models were used. These methods were used in series to produce a BP model. In vivo two-photon imaging was used to visualize Ca2+ activity in the dorsolateral prefrontal cortex. Depressiveness, mania, and cognitive function were assessed with the forced swim task (FST), open field activity (OFA) task, and novel object recognition task, respectively. In CUMS mice, Ca2+ activity was increased strongly by Li and weakly by lamotrigine (LTG) or valproate (VPA), and LTG co-administration reduced Li and VPA monotherapy effects; depressive immobility in the FST was attenuated by Li or LTG, and attenuated more strongly by LTG-VPA or LTG-Li; novel object exploration was increased strongly by Li and weakly by LTG-Li, and reduced by LTG, VPA, or LTG-VPA. In KM mice, Li or VPA attenuated OFA mania symptoms and normalized Ca2+ activity partially; Li improved cognitive function while VPA exacerbated the KM alteration. These patterns were replicated in the respective BP model phases. Lithium had bi-directional, albeit weak, mood regulation effects and a cognitive supporting effect. Li co-administration with antidepressant/-manic agents enhanced mood-regulatory efficacy while attenuating their cognitive-impairing effects.
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Zhuo C, Chen G, Chen J, Tian H, Ma X, Li Q, Yang L, Zhang Q, Li R, Song X, Huang C. Lithium bidirectionally regulates depression- and mania-related brain functional alterations without worsening cognitive function in patients with bipolar disorder. Front Psychiatry 2022; 13:963005. [PMID: 36186884 PMCID: PMC9520085 DOI: 10.3389/fpsyt.2022.963005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/15/2022] [Indexed: 01/10/2023] Open
Abstract
Lithium monotherapy has been proposed to have antidepressant and antimanic effects in patients with bipolar disorder (BP). However, so far, it is lack of evidence to support this proposition. The main aim of this study was to test the hypothesis that lithium bidirectionally regulates depression- and mania-related brain functional abnormalities in patients with BP. We also assessed the effects of lithium, alone and in combination with other pharmacological treatments, on patients' cognitive performance. We enrolled 149 drug-naïve patients with BP; 99 patients experiencing first depressive episodes were allocated randomly to four treatment groups [lithium (DP/Li), lithium with lamotrigine (LTG; DP/Li+LTG), LTG (DP/LTG), and valproate (VPA) with LTG (DP/VPA+LTG)], and 50 experiencing first hypo-manic episodes were allocated to two treatment groups (MA/Li and MA/VPA). For comparative analysis, 60 age-matched healthy individuals were also recruited. Whole-brain global and regional resting-state cerebral blood flow (rs-CBF) and cognitive alterations were examined before and after 12-week treatment. We have the following findings: DP/Li+LTG, and to a lesser extent DP/Li, alleviated the depression-related reduction in rs-CBF. MA/VPA and MA/Li reversed the mania-related elevation of rs-CBF completely and partially, respectively. Lithium alone improved cognitive performance during depressive and manic episodes; other tested treatments have no such effect or worsened cognitive ability. Our results showed that lithium bidirectionally regulates depression- and mania-associated brain functional abnormalities in patients with BP. Lithium monotherapy has a better antimanic effect than VPA, is superior to other tested treatments in improving cognition during the course of BP, and has satisfactory antidepressant effects in patients with BP.
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Affiliation(s)
- Chuanjun Zhuo
- Key Laboratory of Real Time Tracing of Brain Circuits of Neurology and Psychiatry (RTBNP_Lab), Tianjin Fourth Center Hospital Affiliated to Tianjin Medical University, Tianjin Fourth Center Hospital, Tianjin, China.,Department of Psychiatry, Wenzhou Seventh Peoples Hospital, Wenzhou, China.,Key Laboratory of Psychiatric-Neuroimaging-Genetics Laboratory (PNGC_Lab), Tianjin Mental Health Center of Tianjin Medical University, Tianjin Anding Hospital, Tianjin, China.,Department of Psychiatry, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guangdong Chen
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, Wenzhou, China
| | - Jiayue Chen
- Key Laboratory of Real Time Tracing of Brain Circuits of Neurology and Psychiatry (RTBNP_Lab), Tianjin Fourth Center Hospital Affiliated to Tianjin Medical University, Tianjin Fourth Center Hospital, Tianjin, China
| | - Hongjun Tian
- Key Laboratory of Real Time Tracing of Brain Circuits of Neurology and Psychiatry (RTBNP_Lab), Tianjin Fourth Center Hospital Affiliated to Tianjin Medical University, Tianjin Fourth Center Hospital, Tianjin, China
| | - Xiaoyan Ma
- Key Laboratory of Psychiatric-Neuroimaging-Genetics Laboratory (PNGC_Lab), Tianjin Mental Health Center of Tianjin Medical University, Tianjin Anding Hospital, Tianjin, China
| | - Qianchen Li
- Key Laboratory of Real Time Tracing of Brain Circuits of Neurology and Psychiatry (RTBNP_Lab), Tianjin Fourth Center Hospital Affiliated to Tianjin Medical University, Tianjin Fourth Center Hospital, Tianjin, China
| | - Lei Yang
- Key Laboratory of Real Time Tracing of Brain Circuits of Neurology and Psychiatry (RTBNP_Lab), Tianjin Fourth Center Hospital Affiliated to Tianjin Medical University, Tianjin Fourth Center Hospital, Tianjin, China
| | - Qiuyu Zhang
- Key Laboratory of Real Time Tracing of Brain Circuits of Neurology and Psychiatry (RTBNP_Lab), Tianjin Fourth Center Hospital Affiliated to Tianjin Medical University, Tianjin Fourth Center Hospital, Tianjin, China
| | - Ranli Li
- Key Laboratory of Psychiatric-Neuroimaging-Genetics Laboratory (PNGC_Lab), Tianjin Mental Health Center of Tianjin Medical University, Tianjin Anding Hospital, Tianjin, China
| | - Xueqin Song
- Department of Psychiatry, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chunhai Huang
- Department of Psychiatry, Wenzhou Seventh Peoples Hospital, Wenzhou, China
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Abstract
PURPOSE OF REVIEW With more individuals reaching older ages, bipolar disorder is no longer a rare illness in the elderly. Despite the growing number of the older individuals with the illness, there are few studies that focus on bipolar disorder in the geriatric population leading to gaps in clinical knowledge and treatment. The aim of this study is therefore to increase understanding by summarizing the available literature on the epidemiology, symptomatology, comorbidities, and treatment recommendations in this cohort, as well as to suggest areas for future clinical and research focus. RECENT FINDINGS The prevalence of bipolar disorder is underestimated in the geriatric population. The illness maintains the main features observed in the other cohorts but it also has some specific characteristics in the older individuals. In this cohort, psychiatric and medical comorbidities tend to be the rule rather than the exception. Higher rates of cognitive impairments than age- and education-matched groups present across all of the illness phases. Treatment is more challenging in the elderly individuals due to higher rates of comorbidities and susceptibility to medication side effects. Two cohorts of older individuals with bipolar disorder can be recognized, those with symptoms that start earlier in life and those with late-life onset. Although the knowledge about elderly bipolar disorder is only slowly growing, it is increasingly recognized as an illness with unique features. More work is needed to improve diagnosis and to establish treatment guidelines.
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Affiliation(s)
- Ahmad Shobassy
- Department of Psychiatry, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA.
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Shah K, Mansuri Z, Jain S. Letter to the Editor Regarding the Article, "Lithium in Late-Life Mania: A Systematic Review" [Letter]. Neuropsychiatr Dis Treat 2021; 17:1229-1230. [PMID: 33953558 PMCID: PMC8091420 DOI: 10.2147/ndt.s314159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 04/15/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Kaushal Shah
- Department of Psychiatry, Griffin Memorial Hospital, Norman, OK, USA
| | - Zeeshan Mansuri
- Department of Psychiatry, Boston Children's Hospital/Harvard Medical School, Boston, MA, USA
| | - Shailesh Jain
- Department of Psychiatry, Texas Tech University Health Science Center at Odessa/Permian Basin, Odessa, TX, USA
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McLean M, Li Y, Peckham SB, Vasudev A. Medicines for bipolar disorder in older people. Hippokratia 2020. [DOI: 10.1002/14651858.cd013598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Michelle McLean
- Department of Psychiatry, Schulich School of Medicine & Dentistry; Western University; London, Ontario Canada
- London Health Sciences Centre; Victoria Hospital; London, Ontario Canada
| | - Yingxiang Li
- Department of Psychiatry, Schulich School of Medicine & Dentistry; Western University; London, Ontario Canada
- London Health Sciences Centre; Victoria Hospital; London, Ontario Canada
| | - S Benjamin Peckham
- Department of Psychiatry, Schulich School of Medicine & Dentistry; Western University; London, Ontario Canada
| | - Akshya Vasudev
- Department of Psychiatry, Schulich School of Medicine & Dentistry; Western University; London, Ontario Canada
- London Health Sciences Centre; Victoria Hospital; London, Ontario Canada
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Hlaing PM, Isoardi KZ, Page CB, Pillans P. Neurotoxicity in chronic lithium poisoning. Intern Med J 2020; 50:427-432. [PMID: 31211493 DOI: 10.1111/imj.14402] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 05/26/2019] [Accepted: 06/12/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lithium-induced neurotoxicity typically occurs with chronic accumulation rather than following acute overdose. There is little emphasis in the literature on the protracted nature of lithium neurotoxicity long after the lithium concentration returns to the therapeutic range. AIMS To characterise lithium neurotoxicity, with a view of increasing awareness of this important phenomenon. METHODS This is a retrospective observational study of patients presenting with lithium-induced neurotoxicity over a 5-year period to a clinical toxicology unit. Patients were identified through the unit's database, and clinical notes were analysed. RESULTS There were 22 patients, with a median age of 65 (range: 36-89) years. Six patients (27%) had previous lithium toxicity, and nine (41%) were regularly prescribed medications that impair lithium excretion. The median lithium concentration on presentation was 2.2 mmol/L, taking a median of 3 days to return to the therapeutic range. Reversible acute kidney injury was observed in 21 patients (95%) on presentation. The median length of stay was 13 (range: 3-95) days due mostly to delayed neurological recovery. Confusion was the predominant symptom, present in 21 (95%) patients, followed by tremors (18(82%)) and ataxia (16(73%)). Multiple investigations were performed to exclude delirium differentials, including 11 computed tomography (CT) and five magnetic resonance imaging (MRI) brain scans, all unremarkable. CONCLUSIONS Lithium neurotoxicity has a prolonged course. Its severity correlates poorly with lithium concentrations, which normalise quickly. Most poisonings occur in elderly patients with acute kidney injury. Prolonged delirium often prompts multiple unnecessary investigations. Rationalisation of lithium therapy is important in elderly patients.
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Affiliation(s)
- Phyu M Hlaing
- Department of Internal Medicine, Redland Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Katherine Z Isoardi
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Clinical Toxicology Unit and Emergency Department, Brisbane, Queensland, Australia
| | - Colin B Page
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Clinical Toxicology Unit and Emergency Department, Brisbane, Queensland, Australia
| | - Peter Pillans
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Clinical Pharmacology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Chehovich C, Demler TL, Leppien E, Trigoboff E. The Role of Serum Lithium Concentration on Pill Burden in Psychiatric Populations. INNOVATIONS IN CLINICAL NEUROSCIENCE 2020; 17:18-22. [PMID: 32802588 PMCID: PMC7413334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Objective: Current research validates the use of lithium as a first-line agent in bipolar disorder, yet it remains underutilized. This might, in part, be the result of lithium's risk of toxicity. A lower serum lithium concentration would decrease the risk of toxicity. This study examined whether lithium serum concentrations are associated with an additional medication burden resulting from psychiatric polypharmacy. Methods: The retrospective data of adult inpatients receiving lithium who had at least one serum lithium concentration recorded were extracted from the computerized patient record system, bar code medication administration, and mental health automated health record system. Results: 38 patient charts were reviewed and a total of 192 individual serum lithium concentrations were analyzed. There was no statistically significant difference (increase or decrease) in the number of psychiatric medications prescribed or the number of scheduled psychiatric medication doses administered. There was a statistically significant increase in the number of psychiatric medications prescribed over the Food and Drug Administration (FDA) recommended maximum daily dose (MDD) following a serum lithium concentration record. Individuals with a serum lithium concentration below 0.6mEq/L were more likely to be prescribed medications over the MDD. Conclusion: Serum lithium concentrations did not increase or decrease the overall psychiatric pill burden. The number of psychiatric medications an individual is prescribed remained the same regardless of their serum lithium concentration. Overall pill burden did not change with the serum lithium concentration; however, lower serum lithium concentrations might necessitate prescribing of psychiatric medications in doses exceeding the MDD.
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Affiliation(s)
- Charisse Chehovich
- Drs. Chehovich, Demler, and Trigoboff are affiliated with the Buffalo Psychiatric Center, New York State Office of Mental Health in Buffalo, New York and with the University at Buffalo School of Pharmacy and Pharmaceutical Sciences in Buffalo, New York
- Drs. Demler and Trigoboff are also affiliated with the Department of Psychiatry, University at Buffalo School of Medicine in Buffalo, New York
- Dr. Leppien is affiliated with the Binghamton University School of Pharmacy and Pharmaceutical Sciences in Johnson City, New York
| | - Tammie Lee Demler
- Drs. Chehovich, Demler, and Trigoboff are affiliated with the Buffalo Psychiatric Center, New York State Office of Mental Health in Buffalo, New York and with the University at Buffalo School of Pharmacy and Pharmaceutical Sciences in Buffalo, New York
- Drs. Demler and Trigoboff are also affiliated with the Department of Psychiatry, University at Buffalo School of Medicine in Buffalo, New York
- Dr. Leppien is affiliated with the Binghamton University School of Pharmacy and Pharmaceutical Sciences in Johnson City, New York
| | - Emily Leppien
- Drs. Chehovich, Demler, and Trigoboff are affiliated with the Buffalo Psychiatric Center, New York State Office of Mental Health in Buffalo, New York and with the University at Buffalo School of Pharmacy and Pharmaceutical Sciences in Buffalo, New York
- Drs. Demler and Trigoboff are also affiliated with the Department of Psychiatry, University at Buffalo School of Medicine in Buffalo, New York
- Dr. Leppien is affiliated with the Binghamton University School of Pharmacy and Pharmaceutical Sciences in Johnson City, New York
| | - Eileen Trigoboff
- Drs. Chehovich, Demler, and Trigoboff are affiliated with the Buffalo Psychiatric Center, New York State Office of Mental Health in Buffalo, New York and with the University at Buffalo School of Pharmacy and Pharmaceutical Sciences in Buffalo, New York
- Drs. Demler and Trigoboff are also affiliated with the Department of Psychiatry, University at Buffalo School of Medicine in Buffalo, New York
- Dr. Leppien is affiliated with the Binghamton University School of Pharmacy and Pharmaceutical Sciences in Johnson City, New York
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McKnight RF, de La Motte de Broöns de Vauvert SJ, Chesney E, Amit BH, Geddes J, Cipriani A. Lithium for acute mania. Cochrane Database Syst Rev 2019; 6:CD004048. [PMID: 31152444 PMCID: PMC6544558 DOI: 10.1002/14651858.cd004048.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Bipolar disorder is a common condition associated with high morbidity; developing efficacious, safe treatments is therefore essential. Lithium is an effective maintenance treatment for bipolar disorder. It acts as mood stabiliser and reduces the risk of suicide. However, evidence assessing the efficacy of lithium in the treatment of acute mania is less robust. Current evidence-based guidelines cite multiple anti-dopaminergic and mood-stabilising agents as initial treatments: more definite evidence is needed to decide if lithium should be the first-line therapy. OBJECTIVES 1. To assess the effects of lithium in comparison with placebo or other active treatment in alleviating the acute symptoms of a manic or mixed episode in people with bipolar disorder.2. To review the acceptability and tolerability of treatment with lithium in comparison with placebo or other active treatments in alleviating the acute symptoms of a manic or mixed episode in people with bipolar disorder. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register, CENTRAL, MEDLINE, Embase, and PsycINFO. We also searched the World Health Organization trials portal (ICTRP) and ClinicalTrials.gov. We checked the reference lists of all included studies and relevant systematic reviews. We have incorporated studies from searches to 18 May 2018 into the current analyses. SELECTION CRITERIA Prospective randomised controlled studies comparing lithium with placebo or alternative drug treatment in treatment of acute mania. We included anyone with bipolar disorder, male and female, of any age. DATA COLLECTION AND ANALYSIS At least two review authors independently extracted data and assessed methodological quality. We used odds ratios (ORs) to analyse binary efficacy outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuously distributed outcomes. We used a fixed-effect model unless heterogeneity was moderate or substantial, in which case we used a random-effects model. We used Review Manager 5 to analyse data. We assessed the certainty of evidence for individual outcomes using the GRADE approach. MAIN RESULTS We found 36 randomised controlled studies comparing lithium with placebo, one of 12 drugs, or electroconvulsive therapy for treatment of acute mania. Studies included male and female participants (n = 4220), of all ages, who all fitted criteria for a manic episode within the context of a diagnosis of bipolar disorder.Risk of bias was variable; 12 studies had a high risk of bias in one domain and 27 gave inadequate information on randomisation leading to an 'unclear' rating for selection bias.Lithium versus placeboHigh-certainty evidence found that lithium was an effective treatment for acute mania and was more effective than placebo at inducing a response (OR 2.13, 95% confidence interval (CI) 1.73 to 2.63; participants = 1707; studies = 6; I2 = 16%; high-certainty evidence), or remission (OR 2.16, 95% CI 1.73 to 2.69; participants = 1597; studies = 5; I2 = 21%; high-certainty evidence).Lithium was more likely than placebo to cause tremor (OR 3.25, 95% CI 2.10 to 5.04; participants = 1241; studies = 6; I2 = 0%; high-certainty evidence), and somnolence (OR 2.28, 95% CI 1.46 to 3.58; participants = 1351; studies = 7; I2 = 0%; high-certainty evidence).There was insufficient evidence to determine the effect of lithium for all-cause dropouts (OR 0.76; 95% CI 0.46 to 1.25; participants = 1353; studies = 7; I2 = 75%; moderate-certainty evidence), and weight gain (OR 1.48, 95% CI 0.56 to 3.92; participants = 735, studies = 3; I2= 51%; moderate-certainty evidence).Lithium versus antipsychotics or mood stabilisersFor the outcome of inducing a response, there was only very low-certainty evidence regarding lithium compared to haloperidol (MD -2.40, 95% CI -6.31 to 1.50; participants = 80; studies = 3; I2 = 95%), quetiapine (OR 0.66, 95% CI 0.28 to 1.55; participants = 335; studies = 2; I2 = 71%), and carbamazepine (SMD 0.21, 95% CI -0.18 to 0.60; participants = 102; studies = 3; I2 = 0%).Lithium was probably less likely to induce a response than olanzapine (OR 0.44, 95% CI 0.20 to 0.94; participants = 180; studies = 2; I2 = 0%; moderate-certainty evidence).Lithium may be less likely to induce a response than risperidone (MD 7.28, 95% CI 5.22 to 9.34; participants = 241; studies = 3; I2 = 49%; low-certainty evidence).There was no evidence of a difference between lithium and valproate (OR 1.22, 95% CI 0.87 to 1.70; participants = 607; studies = 5; I2 = 22%; moderate-certainty evidence).There was moderate-certainty evidence that lithium was more effective than topiramate at treating acute mania (OR 2.28, 95% CI 1.63 to 3.20; participants = 660; studies = 1).Data on adverse events for these comparisons contained too few studies to provide high-certainty evidence. AUTHORS' CONCLUSIONS This systematic review indicates that lithium is more effective than placebo as a treatment for acute mania but increases the risk for somnolence and tremor. Limited evidence suggests little or no difference between lithium and other mood stabilisers (valproate, carbamazepine) or antipsychotics (risperidone, quetiapine, haloperidol). Olanzapine may be an exception, as it is probably slightly more effective than lithium. There is uncertain evidence that risperidone may also be more effective than lithium. Lithium is probably more effective at treating acute mania than topiramate. When compared to placebo, lithium was more likely to cause adverse events. However, when compared to other drugs, too few studies provided data on adverse effects to provide high-certainty evidence. More, rigorously designed, large-scale studies are needed to definitively conclude if lithium is superior to other interventions in treating acute mania.
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Affiliation(s)
- Rebecca F McKnight
- University of OxfordDepartment of PsychiatryWarneford HospitalWarneford LaneOxfordUKOX3 7JX
| | | | - Edward Chesney
- Institute of Psychiatry, Psychology and Neuroscience, King's College LondonDepartment of Psychosis StudiesDe Crespigny ParkLondonUKSE5 8AF
| | - Ben H Amit
- Tel Aviv UniversityDepartment of Psychiatry, Sackler Faculty of MedicineTel AvivIsrael
| | - John Geddes
- University of OxfordDepartment of PsychiatryWarneford HospitalWarneford LaneOxfordUKOX3 7JX
- Oxford Health NHS Foundation TrustWarneford HospitalOxfordUK
| | - Andrea Cipriani
- University of OxfordDepartment of PsychiatryWarneford HospitalWarneford LaneOxfordUKOX3 7JX
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