Long-term therapy with lithium in a private practice clinic: a naturalistic study

Licht R, P. V. Straszek S, Hansen AS, H. Young A, Duffy A, Müller-Oerlinghausen B, Seemueller F, Sani G, Rubakowski J, Priller J, Vedel Kessing L, Tondo L, Alda M, Manchia M, Grof P, Ritter P, Hajek T, Lewitzka U, Bergink V, Bauer M, Nielsen RE. Lithium induced hypercalcemia: an expert opinion and management algorithm

BACKGROUND

Lithium is the gold standard prophylactic treatment for bipolar disorder. Most clinical practice guidelines recommend regular calcium assessments as part of monitoring lithium treatment, but easy-to-implement specific management strategies in the event of abnormal calcium levels are lacking.

METHODS

Based on a narrative review of the effects of lithium on calcium and parathyroid hormone (PTH) homeostasis and its clinical implications, experts developed a step-by-step algorithm to guide the initial management of emergent hypercalcemia during lithium treatment.

RESULTS

In the event of albumin-corrected plasma calcium levels above the upper limit, PTH and calcium levels should be measured after two weeks. Measurement of PTH and calcium levels should preferably be repeated after one month in case of normal or high PTH level, and after one week in case of low PTH level, independently of calcium levels. Calcium levels above 2.8 mmol/l may require a more acute approach. If PTH and calcium levels are normalized, repeated measurements are suggested after six months. In case of persistent PTH and calcium abnormalities, referral to an endocrinologist is suggested since further examination may be needed.

CONCLUSIONS

Standardized consensus driven management may diminish the potential risk of clinicians avoiding the use of lithium because of uncertainties about managing side-effects and consequently hindering some patients from receiving an optimal treatment.

Posttranslational modifications & lithium's therapeutic effect-Potential biomarkers for clinical responses in psychiatric & neurodegenerative disorders

Several neurodegenerative diseases and neuropsychiatric disorders display aberrant posttranslational modifications (PTMs) of one, or many, proteins. Lithium treatment has been used for mood stabilization for many decades, and is highly effective for large subsets of patients with diverse neurological conditions. However, the differential effectiveness and mode of action are not fully understood. In recent years, studies have shown that lithium alters several protein PTMs, altering their function, and consequently neuronal physiology. The impetus for this review is to outline the links between lithium's therapeutic mode of action and PTM homeostasis. We first provide an overview of the principal PTMs affected by lithium. We then describe several neuropsychiatric disorders in which PTMs have been implicated as pathogenic. For each of these conditions, we discuss lithium's clinical use and explore the putative mechanism of how it restores PTM homeostasis, and thereby cellular physiology. Evidence suggests that determining specific PTM patterns could be a promising strategy to develop biomarkers for disease and lithium responsiveness.

Multisystemic Side Effects of an Indispensable Old Drug: A Case Report of Chronic Lithium Use (A Patient with Multiple Side Effects of Lithium)

Presented here is a case of long-term lithium use, with multiple emerging lithium-associated side effects. An 82-year-old woman was brought into the emergency department because of loss of consciousness. According to the physical examination and laboratory analyses, patient was diagnosed with lithium-associated hypercalcemia, hyperparathyroidism, nephrogenic diabetes insipidus (NDI), symptomatic sinus bradycardia, and thyroid dysfunction. In the literature, there is a limited number of case reports with lithium induced multiple clinical conditions. Multiple clinical manifestations due to the side effects of chronic lithium use might be seen. Health care professionals should keep in mind that lithium-related side effects might trigger or exacerbate each other. To avoid toxicity, close follow-up and clinical supervision are important for the early diagnosis and treatment of these side effects, due to the narrow therapeutic index and obscure clinical signs and symptoms of toxicity.

Beyond the guidelines for bipolar disorder: practical issues in long-term treatment with lithium

OBJECTIVE

Several treatment guidelines are available for clinicians working with patients with bipolar disorder (BD), but some of the more nuanced aspects of lithium therapy go beyond the scope of such guidelines. Therefore, in this perspective, our objective was to focus on specific practical issues of lithium treatment, including the selection and initiation of long-term treatment, and management and discontinuation (if indicated) of lithium prophylaxis.

METHOD

We conducted a focused review of the relevant literature on the treatment of BD.

RESULTS

Consultation requests to a BD specialty service often relate to issues for which there is limited evidence, including when to initiate long-term treatment, whether choice of mood stabilizer is specific, how long to treat acute episodes, whether to switch or add on medication when treatment fails, how long to continue effective treatment, and what medication to use when a lithium-responsive patient must discontinue lithium.

CONCLUSION

Optimal long-term treatment of BD will require more research as well as better alignment of clinical and training programs.

An approach to long-term sedative-hypnotic use

Insomnia is a common, often chronic medical disorder with significant medical and socioeconomic repercussions. However, unlike other medical conditions, there is intense debate as to whether the long-term treatment of insomnia is clinically appropriate. The perceived deleterious side effect of sedative-hypnotic medications may result in patients remaining untreated or undertreated. This review proposes that a more subtle approach needs to be taken in the management of patients with chronic insomnia and that long-term use of the newer sedative-hypnotics may be a feasible and effective treatment option when used in conjunction with thorough medical assessment and regular patient follow-up. This review discusses these issues and discusses the pros and cons of long-term sedative-hypnotic use.

Lithium therapy for unipolar and bipolar depression among the middle-aged and older adult patient subpopulation

Affective disorders are a major cause of morbidity and disability among middle-aged and older people. Thus, the prophylaxis of both unipolar depression and bipolar disorder in this patient subpopulation is an important task of psychiatrists and other physicians. Although lithium remains an effective prophylactic and treatment agent in younger individuals with bipolar disorder, its prophylactic efficacy and tolerability has not been thoroughly investigated among middle aged and older people with unipolar depression and bipolar disorder. Our study is based on a mirror-image design that compared the clinical course with lithium treatment and the clinical course prior to lithium treatment based on a retrospective chart review. We examined the results obtained with long-term lithium maintenance in a group of 60 middle-aged and older adult patients (age >60 years) with unipolar depression and bipolar disorder. More specifically, we analyzed changes of frequency, severity, and duration of depressive or manic relapses, rate and duration of hospitalizations and suicidal behavior (thoughts or attempts), and various assessments of outcome. A significant reduction was found on all indices during lithium therapy compared to before lithium treatment, attesting to the prophylactic efficacy of long-term lithium in unipolar depression and bipolar disorder. The range of side effects in our sample was similar to that found in other reports in this age group. The probability of relapse and recurrence in patients with bipolar disorder and with unipolar depression can be significantly decreased by lithium prophylaxis. Further investigation is mandated to confirm these findings under double-blind conditions.

Long-term outcome of patients with bipolar disorder commenced on lithium prophylaxis during hospitalization: a complete 15-year register-based follow-up

OBJECTIVES

From placebo-controlled studies of up to two years duration, it has been established that lithium has preventive efficacy in bipolar disorder (BD). However, the effectiveness of lithium under routine conditions seems less pronounced. In the present study, the overall 15.3-year outcome in BD patients commenced on lithium is described.

METHODS

Ninety-one patients with BD consecutively commenced on prophylactic lithium treatment during hospitalization at the Aarhus University Psychiatric Hospital from 1981 to 1983 were followed until death or censoring occurred during up to 15.3 years of observation. Register-based outcome measures, available for all patients, included accumulated duration of admission and number of admissions. In addition, serious attempts were made to collect detailed information on treatment during follow up. Simple descriptive statistics were applied; potential independent associations between baseline variables and outcome were examined using logistic regression models.

RESULTS

Of the 91 patients, 27 patients died (six from suicide) during the observation period, which was an excess mortality compared to the general population. Fifty percent of the patients were admitted for more than one month per 20 months of observation and admitted more than once for each four years of observation. Only 19 (21%) patients were not admitted to hospital during the observation period. No statistically significant predictors of poor outcome could be identified. In addition to lithium prophylaxis given for variable lengths of time, the majority of the 36 (40%) patients, from whom treatment data were available, received various other drug treatments during follow-up.

CONCLUSIONS

The overall outcome in patients beginning prophylactic treatment is unsatisfactory. However, due to the observational design and the lack of detailed treatment information during the long follow-up period, inferences about the efficacy of lithium cannot be made from this study.

Rapid cycling bipolar disorder: historical overview and focus on emerging treatments

OBJECTIVE

Rapid cycling bipolar disorder presents a significant challenge with respect to treatment. The cyclical nature of bipolar disorder has been well recognised for over a century, and following Dunner and Fieve's landmark paper in 1974, investigators have increasingly turned their attention to issues such as the definition of rapid cycling, demographic characterisation, treatment response and pharmacologic intervention.

METHODS

A literature search using Medline was performed, and selected articles which consider important developments in the definition, demographics and course of rapid cycling are reviewed. In addition, a systematic review of the literature published during the past 5 years (1999-2004) relating to treatment was conducted.

RESULTS

Relevant articles are reviewed.

CONCLUSIONS

This review highlights the important developments in our understanding of rapid cycling bipolar disorder, and focuses particularly on the recent literature regarding treatment.

Evaluating treatments for the mood disorders: time for the evidence to get real

OBJECTIVE

To detail limitations to level I evidence derived from randomised controlled trials of antidepressant treatments and which is held to be fundamental to the development and validity of treatment guidelines.

METHOD

Recent efficacy studies and meta-analyses of treatments of major depression are considered.

RESULTS

The largest database in psychiatry--demonstrating that all principal treatments are of similar efficacy, and that antidepressant drugs are not distinctly superior to placebo treatment--is unlikely to be valid.

CONCLUSION

Excessive belief in and weighting of the evidence emerging from randomised controlled trials deserves to be criticized. An argument is put for adopting alternative approaches to evaluating the likely effectiveness of any antidepressant treatment.