Prophylactic lithium: another therapeutic myth? An examination of the evidence to date

Lithium in the time of COVID: forever vigilant

BACKGROUND

There have been case reports of renal dysfunction with lithium toxicity among severely ill COVID-19 patients. Lithium levels may be affected by comorbid conditions and the presence of infective disease states like the SARS-CoV-2 which clearly adds systemic health burden. This study aimed to review the effect SARS-CoV-2 has on serum Li levels and the possible mechanism underlying it.

METHODS

Retrospective data from all clinical service encounters within the University of Michigan health system between September 2019 and September 2023 were reviewed. The study cohort included 98 patients with an average age of 45 years (62% female) who were diagnosed with any subtype of bipolar disorder, actively taking Li, and infected with SARS-CoV-2 during the study timeframe.

RESULTS

There was no overarching effect of a SARS-CoV-2 infection on Li chemistry in the overall sample. Higher serum Li levels were not significantly associated with SARS-CoV-2 infection nor total comorbidity index. However, higher Li levels were observed in males while infected with SARS-CoV-2 when compared with no infection. eGFR remained unassociated with serum Li level. Receiving COVID vaccination was associated with lower serum Li levels (Coeff. = - 0.88, p = 0.048).

CONCLUSIONS

Patients with a diagnosis of BD, treated with Li, and infected with SARS-CoV-2 were not likely to present with elevated Li levels unless they are male or unvaccinated. Elevated serum Li level was not associated with significant renal dysfunction in this cohort. The case reports of severe renal complications and Li toxicity may be among cases of greater overall clinical severity of COVID-19. These findings are reassuring that Li may be used in the context of a COVID-19 illness but emphasize the ongoing need for clinical vigilance.

Effectiveness of ultra-long-term lithium treatment: relevant factors and case series

BACKGROUND

The phenomenon of preventing the recurrences of mood disorders by the long-term lithium administration was discovered sixty years ago. Such a property of lithium has been unequivocally confirmed in subsequent years, and the procedure makes nowadays the gold standard for the pharmacological prophylaxis of bipolar disorder (BD). The efficacy of lithium prophylaxis surpasses other mood stabilizers, and the drug has the longest record as far as the duration of its administration is concerned. The continuation of lithium administration in case of good response could be a lifetime and last for several decades. The stability of lithium prophylactic efficacy in most patients is pretty steady. However, resuming lithium after its discontinuation may, in some patients, be less efficient.

MAIN BODY

In the article, the clinical and biological factors connected with the prophylactic efficacy of long-term lithium administration are listed. Next, the adverse and beneficial side effects of such longitudinal treatment are presented. The main problems of long-term lithium therapy, which could make an obstacle to lithium continuation, are connected with lithium's adverse effects on the kidney and, to lesser extent, on thyroid and parathyroid functions. In the paper, the management of these adversities is proposed. Finally, the case reports of three patients who have completed 50 years of lithium therapy are described.

CONCLUSIONS

The authors of the paper reckon that in the case of good response, lithium can be given indefinitely. Given the appropriate candidates for such therapy and successful management of the adverse effects, ultra-long term lithium therapy is possible and beneficial for such patients.

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.

Mood Stabilizers of First and Second Generation

The topic of this narrative review is mood stabilizers. First, the author's definition of mood-stabilizing drugs is provided. Second, mood-stabilizing drugs meeting this definition that have been employed until now are described. They can be classified into two generations based on the chronology of their introduction into the psychiatric armamentarium. First-generation mood stabilizers (FGMSs), such as lithium, valproates, and carbamazepine, were introduced in the 1960s and 1970s. Second-generation mood stabilizers (SGMSs) started in 1995, with a discovery of the mood-stabilizing properties of clozapine. The SGMSs include atypical antipsychotics, such as clozapine, olanzapine, quetiapine, aripiprazole, and risperidone, as well as a new anticonvulsant drug, lamotrigine. Recently, as a candidate for SGMSs, a novel antipsychotic, lurasidone, has been suggested. Several other atypical antipsychotics, anticonvulsants, and memantine showed some usefulness in the treatment and prophylaxis of bipolar disorder; however, they do not fully meet the author's criteria for mood stabilizers. The article presents clinical experiences with mood stabilizers of the first and second generations and with "insufficient" ones. Further, current suggestions for their use in preventing recurrences of bipolar mood disorder are provided.

Lithium - past, present, future

OBJECTIVES

A narrative review of past, present, and future of lithium use in psychiatry.

METHODS

The most important references on the topic were reviewed with special emphasis on the author's works.

RESULTS

The history of medical and psychiatric use of lithium dates back to more than one and a half-century ago. However, modern psychiatric history began with the publication of John Cade, in 1949, showing a therapeutic effect of lithium in mania. Currently, lithium is a drug of choice as a mood-stabilizer for the maintenance treatment of the bipolar disorder. The second most important use of lithium is probably augmentation of antidepressants in treatment-resistant depression. In addition to its mood-stabilizing properties, lithium exerts anti-suicidal, immunomodulatory, and neuroprotective action. The drug may protect against dementia and some promising effects of lithium in neurodegenerative disorders have been observed.

CONCLUSION

Given the clinical and biological properties of lithium, this drug is presently greatly underutilized in mood disorders. Therefore, the efforts should be undertaken for challenging a skepticism about the use of lithium and optimizing its long-term administration. In such a way, more patients with mood disorders can become the beneficiaries of lithium's therapeutic action. KEY POINTS Lithium is a drug of choice as a mood-stabiliser for the maintenance treatment of bipolar disorder. Augmentation of antidepressants by lithium is one of the best strategies in treatment-resistant depression. Lithium exerts anti-suicidal, immunomodulatory, and neuroprotective action and may protect against dementia. Despite the evidence for the efficacy and added favourable properties, lithium is greatly underutilised in mood disorders. Challenging a scepticism about the use of lithium and optimising its long-term administration can make more patients with mood disorders the beneficiaries of lithium's therapeutic action.

Clinical use of lithium salts: guide for users and prescribers

BACKGROUND

Lithium has been used clinically for 70 years, mainly to treat bipolar disorder. Competing treatments and exaggerated impressions about complexity and risks of lithium treatment have led to its declining use in some countries, encouraging this update about its safe clinical use. We conducted a nonsystematic review of recent research reports and developed consensus among international experts on the use of lithium to treat major mood disorders, aiming for a simple but authoritative guide for patients and prescribers.

MAIN TEXT

We summarized recommendations concerning safe clinical use of lithium salts to treat major mood disorders, including indications, dosing, clinical monitoring, adverse effects and use in specific circumstances including during pregnancy and for the elderly.

CONCLUSIONS

Lithium continues as the standard and most extensively evaluated treatment for bipolar disorder, especially for long-term prophylaxis.

Long-acting injectable antipsychotics as maintenance treatments for bipolar disorder-A critical review of the evidence

OBJECTIVES

The maintenance phase of bipolar disorder is arguably the most important. The aim of management during this time is to maintain wellness and prevent future episodes of illness. Medication is often the mainstay of treatment during this phase, but adherence to treatment is a significant problem. In recent years, long-acting injectable (LAI) solutions have been proposed, but these too have limitations. This paper discusses the options that are currently available and critically appraises the effectiveness of this strategy.

METHOD

The authors reviewed the small number of open-label and randomised studies on LAI medications in bipolar disorder and evaluated the efficacy and safety of these medications.

RESULTS

The studies reviewed show benefit of LAIs for the management of bipolar disorder but have several key limitations to the generalisability of findings to routine practice.

CONCLUSIONS

LAIs have an emerging role in the management of bipolar disorder and, although it is not without limitations, this strategy addresses some issues of long-term treatment and medication. Patients with bipolar disorder that are non-adherent or have an unstable illness with a predilection towards mania are possibly better suited to the use of LAIs, though more research is required to fully assess the effectiveness of this approach.

A History of the Pharmacological Treatment of Bipolar Disorder

In this paper, the authors review the history of the pharmacological treatment of bipolar disorder, from the first nonspecific sedative agents introduced in the 19th and early 20th century, such as solanaceae alkaloids, bromides and barbiturates, to John Cade's experiments with lithium and the beginning of the so-called "Psychopharmacological Revolution" in the 1950s. We also describe the clinical studies and development processes, enabling the therapeutic introduction of pharmacological agents currently available for the treatment of bipolar disorder in its different phases and manifestations. Those drugs include lithium salts, valproic acid, carbamazepine, new antiepileptic drugs, basically lamotrigine and atypical antipsychotic agents (olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole, asenapine, cariprazine and lurasidone). Finally, the socio-sanitary implications derived from the clinical introduction of these drugs are also discussed.

Lithium: A classic drug-Frequently discussed, but, sadly, seldom prescribed!

OBJECTIVE

Distinguished authors in the field have repeatedly alerted psychiatrists of the alarming trends in the treatment of bipolar disorders: decline of lithium use, paralleled by the increase of prescribing anticonvulsants and second-generation antipsychotic drugs. Research has been conducted in order to explore the factors that led to this development and to provide arguments for the need to reverse this trend.

METHOD

This paper represents a narrative review of the literature containing retrieved research articles focusing on the efficacy of lithium. The papers included in this overview were published prior to June 2016; additional papers were identified by searching the reference lists of reviewed articles. Taking into account the amount of literature available, no search can be exhaustive; on the other hand, the studies consulted, all of which explore the effectiveness of various compounds, may have their own limitations as well.

RESULTS

The evidence of the effectiveness of lithium in the treatment of acute mania, acute bipolar depression and the prevention of manic and depressive episodes is compelling. Lithium is the most effective augmentation agent in treatment-resistant depression. Its anti-suicidal effects are well established. The neuroprotective effects of lithium have been demonstrated in case-control studies and in population-based research. It has been established that starting lithium early in the course of the disorder reduces the rates of treatment non-response.

CONCLUSIONS

Despite abundant evidence regarding the efficacy of lithium and its effectiveness in the treatment of bipolar disorders, its use is declining at the beginning of the 21st century. It is of paramount importance to keep reminding psychiatrists and educating physicians about the unique properties of lithium and about monitoring patients treated with lithium, since it has been suggested that lithium should once again become the first-line treatment for bipolar disorders.

Does long term use of psychiatric drugs cause more harm than good?

We could stop almost all psychotropic drug use without deleterious effect, says Peter C Gøtzsche, questioning trial designs that underplay harms and overplay benefits. Allan H Young and John Crace disagree, arguing that evidence supports long term use

Lithium for prevention of mood episodes in bipolar disorders: systematic review and meta-analysis

Background

In a previous meta-analysis of randomized controlled trials comparing lithium with placebo as a long-term treatment in bipolar disorders, we observed a clear preventative effect for manic episodes; however, the effect was equivocal for depressive episodes. Since then, the evidence base has grown further. In this update, we furthermore present the data on efficacy of lithium in comparison to alternative drug treatments. In addition, we analyze the data comparing lithium with placebo and other treatments regarding drop-outs due to reasons other than a mood episode and completion of study (no mood episode and no drop-out to reasons other than a mood episode).

Methods

Randomized controlled trials (RCTs) were sought comparing lithium with placebo and lithium with an alternative treatment in bipolar disorders where the stated intent of treatment was prevention of mood episodes. To this purpose, the Cochrane Central Register of Controlled Trials (CENTRAL) was searched. Reference lists of relevant papers and major textbooks of mood disorders were examined. Authors, other experts in the field, and pharmaceutical companies were contacted for knowledge of suitable trials, published or unpublished.

Results

For the comparison of lithium with placebo, seven trials (1,580 participants) were included. Lithium was more effective than placebo in preventing overall mood episodes (random effects RR 0.66, 95% CI 0.53 to 0.82), manic episodes (random effects RR 0.52, 95% CI 0.38 to 0.71), and, dependent on the type of analyses applied, depressive episodes (random effects RR 0.78, 95% CI 0.59 to 1.03; fixed effect RR 0.73, 95% CI 0.60 to 0.88). Lithium was inferior to placebo in leading to drop-outs for reasons other than a mood episode (random effects RR 1.33, 95% CI 1.07 to 1.65) but superior to placebo on study completion (random effects RR 1.69, 95% CI 1.12 to 2.55).

For the comparison of lithium with anticonvulsants, seven trials were included (n = 1,305). In prevention of manic episodes, lithium showed superiority compared to anticonvulsants (random effects RR 0.66, 95% CI 0.44 to 1.00). However, there was no significant difference regarding prevention of overall mood episodes, depressive episodes, dropping-out to reasons other than a mood episode, or study completion.

Conclusions

The evidence base for lithium in the long-term treatment of bipolar disorders has strengthened. With no other drug available having such ample and consistent evidence for its efficacy lithium remains the most valuable treatment option in this indication.

The history of lithium therapy

The use of lithium in psychiatry goes back to the mid-19th century. Early work, however, was soon forgotten, and John Cade is credited with reintroducing lithium to psychiatry for mania in 1949. Mogens Schou undertook a randomly controlled trial for mania in 1954, and in the course of that study became curious about lithium as a prophylactic for depressive illness. In 1970, the United States became the 50th country to admit lithium to the marketplace. Meanwhile, interest in lithium for the prophylaxis of depression was growing apace and today the agent is widely prescribed for that indication, even though it has not been accepted by the Food and Drug Administration. Lithium was almost derailed by a small group of opponents from the Maudsley Hospital and its status today is threatened by the "mood stabilizers."

A critical appraisal of lithium's efficacy and effectiveness: the last 60 years

The history that depicts the evaluation of lithium's efficacy presents an interesting contrast: on the one hand, conviction that, of all psychotropic drugs, lithium has the best demonstrated efficacy; on the other hand, repeated attempts to question it. Those contesting lithium's stabilizing abilities have argued from several angles, for example that the proof was methodologically incorrect or insufficient, that the number of responders is small, or that the response is poor in practice and does not last. But there is a good explanation for this paradox. While the early challenges to lithium's value in recurrent mood disorders reflected mainly that psychiatry had not yet developed a methodology suitable for testing long-term efficacy, more recent questioning has resulted mostly from retesting its efficacy and effectiveness in a substantially broadened bipolar spectrum, outside the classical diagnosis. Lithium, however, continues to stabilize very well the patients suffering from typical bipolar disorder--the condition for which its efficacy was originally demonstrated. More recently, lithium has also proven to dramatically reduce suicidal behavior and mortality and to augment markedly the efficacy of antidepressants in unresponsive patients.

Lithium treatment at 52

The paper reviews briefly and comments in detail on selected events in the history of lithium treatment. The events include Cade's discovery of lithium's antimanic action, the discovery and establishment of its prophylactic action, the ensuing debate, amelioration and prevention of side effects and risks, use during pregnancy, non-compliance, selection of patients, information and instruction, the question whether new and better prophylactic agents are about to oust lithium, the use of combination treatment, the effect of lithium on suicidal behavior, the benefits of prophylactic lithium treatment, and the design of future comparative trials.

Lithium for maintenance treatment of mood disorders

BACKGROUND

Mood disorders are common, disabling and tend to be recurrent. They carry a high risk of suicide. Maintenance treatment, aimed at the prevention of relapse, is therefore of vital importance. Lithium has been used for some years as the mainstay of maintenance treatment in bipolar affective disorder, and to a lesser extent in unipolar disorder. However, the efficacy and effectiveness of prophylactic lithium therapy has been disputed. Low suicide rates in lithium-treated patients have led to claims that lithium has a specific anti-suicidal effect. If so, this is of considerable importance as treatments for mental disorders in general have not been shown convincingly to be effective in suicide prevention.

OBJECTIVES

1. To investigate the efficacy of lithium treatment in the prevention of relapse in recurrent mood disorders. 2. To examine the effect of lithium treatment on consumers' general health and social functioning, its acceptability to consumers, and the side-effects of treatment. 3. To investigate the hypothesis that lithium has a specific effect in reducing the incidence of suicide and deliberate self-harm in persons with mood disorders.

SEARCH STRATEGY

The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR) and The Cochrane Controlled Clinical Trials Register (CCTR) were searched. Reference lists of relevant papers and major text books of mood disorder were examined. Authors, other experts in the field and pharmaceutical companies were contacted for knowledge of suitable trials, published or unpublished. Specialist journals concerning lithium were hand searched.

SELECTION CRITERIA

Randomised controlled trials comparing lithium with placebo, where the stated intent of treatment was maintenance or prophylaxis. Participants were males and females of all ages with diagnoses of mood disorder. Discontinuation studies (in which all participants had been stable on lithium for some time before being randomised to either continued lithium treatment or placebo substitution) were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted from the original reports independently by two reviewers. The main outcomes studied were related to the objectives stated above. Data were analysed for all diagnoses of mood disorder and for bipolar and unipolar disorder separately. Data were analysed using Review Manager version 4.0.

MAIN RESULTS

Nine studies were included in the review, reporting on 825 participants randomly allocated to lithium or placebo. Lithium was found to be more effective than placebo in preventing relapse in mood disorder overall, and in bipolar disorder. The most consistent effect was found in bipolar disorder (random effects OR 0.29; 95% CI 0.09 to 0.93 ). In unipolar disorder, the direction of effect was in favour of lithium, but the result (when heterogeneity between studies was allowed for) did not reach statistical significance. Considerable heterogeneity was found between studies in all groups of patients. The direction of effect was the same in all studies; no study found a negative effect for lithium. Heterogeneity may have been due to differences in selection of participants, and to differing exposures to lithium in the pre-study phase resulting in variable influence of a discontinuation effect. There was little reported data on overall health and social functioning of participants under the different treatment conditions, or on the participants' own views of their treatment. Descriptive analysis showed that assessments of general health and social functioning generally favoured lithium. Small absolute numbers of deaths and suicides, and the absence of data on non-fatal suicidal behaviours, made it impossible to draw meaningful conclusions about the place of lithium therapy in suicide prevention.

REVIEWER'S CONCLUSIONS

This systematic review indicates that lithium is an efficacious maintenance treatment for bipolar disorder. In unipolar disorder the evidence of efficacy is less robust. This review does not cover the relative efficacy of lithium compared with other maintenance treatments, which is at present unclear. There is no definitive evidence from this review as to whether or not lithium has an anti-suicidal effect. Systematic reviews and large scale randomised studies comparing lithium with other maintenance treatments (e.g. anti-convulsants, antidepressants) are necessary. Outcomes relating to death and suicidal behaviour should be included in all future maintenance studies of mood disorder.

Historical perspectives and natural history of bipolar disorder

A review of two centuries' literature on the natural history of bipolar disorder, including modern naturalistic studies and new data from a lifelong follow-up study of 220 bipolar patients, reaches the following conclusions: the findings of modern follow-up studies are closely compatible with those of studies conducted before the introduction of modern antidepressant and mood-stabilizing treatments. Bipolar disorder has always been highly recurrent and considered to have a poor prognosis. Bipolar patients who have been hospitalized spend about 20% of their lifetime from the onset of their disorder in episodes. Fifty percent of bipolar episodes last between 2 and 7 months (median 3 months). The intervals between the first few episodes tend to shorten; later the episodes return at an irregular rhythm of about 0.4 episodes per year with high interindividual variability. Switches from mania into mild depression and from depression into hypomania were frequently reported in the 19th century and the first half of the 20th. Antidepressant and antimanic drugs have to be given as long as the natural episode lasts. Given the poor outcome of bipolar disorders found in naturalistic follow-up studies and our lifelong investigation, intensive antidepressant, antimanic, and mood-stabilizing treatments are required in most cases. Despite modern treatments the outcome into old age is still poor, full recovery without further episodes rare, recurrence of episodes with incomplete remission the rule, and the development of chronicity and suicide still frequent.

The early European lithium studies

Cade's discovery of lithium's antimanic effect soon became known in Europe and was confirmed by a Danish controlled trial. The same investigators discovered a prophylactic action of lithium against both manic and depressive recurrences, which was confirmed by a Swiss-Czech-Danish cooperative trial. The evidence of these studies was met with skepticism based on methodological speculations, but a Danish randomised, placebo-controlled, double-blind trial of discontinuation design established the prophylactic action of lithium, as did a number of European controlled trials of start design and discontinuation design. The review ends with personal memories of John Cade.

Mood stabilizers in the prevention of recurrent affective disorders: a meta-analysis

OBJECTIVE

To determine by meta-analysis the efficacy of mood stabilizers in preventing recurrence of bipolar or unipolar mood disorders and to consider the evidence for a lithium withdrawal-induced relapse syndrome.

METHOD

Controlled studies of lithium, valproate and carbamazepine in preventing future episodes of affective disorders were classified according to methodological rigour, and meta-analyses were performed overall and on each type.

RESULTS

A total of 19 blinded, randomized, controlled trials of prophylaxis in 865 patients found lithium highly effective (74% recurrence on placebo vs. 29% on lithium). In the mirror-image studies, whose substantial lithium vs. prior treatment difference cannot be explained by withdrawal relapse, lithium reduced relapse by 50% (bipolar) and 58%(unipolar).

CONCLUSION

Maintenance lithium produces a highly significant reduction in relapses. The mirror-image studies had not been systematically analysed previously, and they support the effectiveness of lithium. We also failed to find sufficient evidence to prove that the lithium-withdrawal relapse phenomenon exists.

Lithium: balancing risks and benefits

More than 20 years have passed since publication of the pivotal studies of efficacy upon which our use of lithium in acute mania and the prophylaxis of bipolar disorder are based. Since then, two of the most important discoveries about lithium have been the phenomenon of lithium withdrawal mania, and the recognition of permanent neurological sequelae after lithium toxicity. The use of lithium survived earlier criticism from the Institute of Psychiatry (Blackwell & Shepherd, 1968), but the new discoveries call for a reappraisal of the studies and reconsideration of whether lithium has a place in treatment, for which patients it should be recommended, what information and supervision should be given to patients on lithium, and what doctors should be expected to know of it.

Lithium treatment and prophylaxis in unipolar depression: a meta-analysis

Meta-analysis was used to establish the efficacy of lithium in acute treatment and prophylaxis of depressive illness from existing published clinical trials. Effect sizes were measured by the odds ratio using the Mantel-Haenszel method and the Pearson product-moment correlation coefficient. Some benefit from lithium, compared with other treatments, emerged from trials of acute treatment. Lithium was clearly superior to placebo in the acute treatment of bipolar depressed patients. In controlled studies of lithium prophylaxis over five months to three years, an impressive effect was found for lithium when compared with placebo. For uncontrolled studies there was a similar-sized effect, corresponding to an improvement in the rate of favourable outcome from 35% for placebo to 70% with lithium treatment. The comparison of lithium with other antidepressants in prophylaxis showed no conclusive advantage for lithium in unipolar illness. There is no reason to doubt the efficacy of lithium in the prophylaxis of unipolar depressive illness.

Can reliance be placed on a single meta-analysis?

Meta-analysis replaced statistical significance with effect size in the hope of resolving controversy concerning evaluation of treatment effects. Statistical significance measured reliability of the effect of treatment, not its efficacy. It was strongly influenced by the number of subjects investigated. Effect size as assessed originally, eliminated this influence but by standardizing the size of the treatment effect could distort it. Meta-analyses which combine the results of studies which employ different subject types, outcome measures, treatment aims, no-treatment rather than placebo controls or therapists with varying experience can be misleading. To ensure discussion of these variables meta-analyses should be used as an aid rather than a substitute for literature review. While meta-analyses produce contradictory findings, it seems unwise to rely on the conclusions of an individual analysis. Their consistent finding that placebo treatments obtain markedly higher effect sizes than no treatment hopefully will render the use of untreated control groups obsolete.

Lithium therapy: from clinical trials to practical management

Controlled trials have shown that lithium significantly reduces the morbidity of recurrent affective disorders. We describe here the ongoing affective morbidity in unipolar, bipolar and schizoaffective illness treated primarily by low dosage, once daily lithium, supplemented as necessary by antidepressant or neuroleptic medication. Seventy-eight percent of unipolar patients and 73% of bipolar and schizoaffective patients had no or only slight morbidity during the study year. The treatment was equally effective for both older (age greater than 70 years) and younger patients. Unipolar patients rated as endogenous on the Newcastle Scale had significantly lower morbidity than the nonendogenous patients. Subjective side effects were minimal. These patients, whose untreated morbidity is known to be high, derive considerable benefit from regular supervision in an affective disorder clinic.

A long-term retrospective follow-up study of patients treated with prophylactic lithium carbonate

Patients suffering from unipolar and bipolar affective illness, who began treatment with prophylactic lithium carbonate during a 5-year period, were followed up and 59 out of 101 interviewed. Most had been taking lithium for at least 13 years: 49% had a complete remission, 41% a partial but significant response, and 10% no response. No specific individual or illness factor was found to correlate with favourable outcome, and no correlation between average serum lithium level and outcome. No side-effects could be associated specifically with the long-term use of lithium, but there was a surprisingly high incidence of clinical hypothyroidism.

Lithium therapy for mania and depression

The literature on lithium carbonate was reviewed for clues to the processes involved in mania. Lithium has proved effective therapeutically and prophylactically for mania and depressive disorders. Children and adolescents as well as adults tolerate lithium well. Side effects rarely are serious enough to necessitate having lithium therapy. Some success with schizophrenia and schizoaffective disorders has broadened the scope of lithium's therapeutic efficacy but also blunted the expectation for a direct relationship between lithium and the processes involved in mania. Research points to neurotransmitters as contributing to the etiology and symptom pattern of mania.

Continuation therapy with lithium and amitriptyline in unipolar depressive illness: a randomized, double-blind, controlled trial

A detailed analysis of the results of a multi-centre clinical trial shows that, while the relapse rate following recovery from an operationally defined depressive illness was smaller among patients subsequently treated with either amitryptiline or lithium than with a placebo, there was no clinically significant difference between the prophylactic efficacy of the 2 antidepressants. An account is given of the relative adverse effects of the treatments, and the implications of the findings are discussed.

Pharmacokinetics of ordinary and sustained-release lithium carbonate in manic patients after acute dosage

An ordinary and a sustained-release lithium carbonate preparation were administered acutely at equivalent dosage (1.80 g = 24.3 mmol) in a crossover fashion to manic patients. Serum lithium levels were determined by atomic absorption spectroscopy and pharmacokinetic parameters were calculated. Maximum mean serum levels of 1.13 mmol/l and 0.78 mmol/l were achieved at 6 h and 12 h respectively with the ordinary and sustained-release forms. The mean half-lives of absorption, redistribution and elimination were 0.78 h +/- 0.05 (SE), 5.06 h +/- 0.23, 26.8 h +/- 4.5 and 3.73 h +/- 0.37 (SE), 4.42 h +/- 0.28 and 25.6 h +/- 5.5 for the ordinary and sustained-release forms respectively. In healthy volunteers the ordinary preparation was completely absorbed but only 85% of the sustained-release form was absorbed in the manic subjects. Lithium ion distributed into two kinetic compartments and the final compartment appeared to correspond to total body water.

A mirror image Out-patient study at a depot phenothiazine clinic

This Mirror Image Study, at a specialised clinic, has shown a significant reduction in days spent in Hospital. Individual features of the sample include sex and age difference in the sub-groups for dosage, duration of treatment and anti-Parkinsonian medication. Preliminary cost-effectiveness analysis has been reported.

The effectiveness of lithium in affective and schizo-affective psychoses

Recently, though the value of lithium salts has been supported by a number of careful studies (1–6), it has become increasingly evident that as a preventive of affective and schizoaffective psychoses the use of lithium is far from being universally effective and that it does not always lead to a complete disappearance of phases and attacks (7–8). The most generally held view (9–13) of lithium as a prophylactic drug is that it is of most value in preventing the recurrent affective attacks of patients with manic-depressive psychosis and cyclothymia.

Role of fluphenazine decanoate in lessening the burden of chronic schizophrenics on the community

This paper reports the social results of a double-blind placebo controlled trial of fluphenazine decanoate. Among patients on placebo there was a deterioration in family relationships, which was due to an increase in aggression, noisiness, talking about delusions, and socially embarrassing behaviour after withdrawal of active drug.

Outpatient maintenance of chronic schizophrenic patients with long-acting fluphenazine: double-blind placebo trial. Report to the Medical Research Council Committee on Clinical Trials in Psychiatry

A double-blind placebo trial of fluphenazine decanoate, a long-acting phenothiazine, was carried out to determine its value in maintenance therapy of chronic schizophrenic outpatients already established on the drug for a minimum period of eight weeks. In low doses it was significantly more effective than placebo in preventing relapse and admission to hospital. Relapse was accompanied by a resurgence of specifically schizophrenic symptoms and by an increase in abnormalities described by the relatives. There was no difference between the experimental and control groups in the treatment required for depression. The group on active medication required more treatment for Parkinsonism, but this difference did not reach statistical significance.In the context of a well-run special clinic for outpatient follow-up of chronic schizophrenic patients these results confirm the usefulness of long-acting fluphenazine. By inference, the benefit of this treatment highlights the need for adequate community services to deal with the residual chronic disabilities which are characteristic of these patients.