Dosing strategies for lithium monotherapy in children and adolescents with bipolar I disorder

Efficacy and Safety of Lithium for Suicide and Suicide-Related Behaviors in Youth: A Review of the Literature

OBJECTIVES

This systematic review evaluates the anti-suicidal properties of Lithium in children and adolescents with Bipolar Disorder (BD), addressing gaps in evidence regarding its efficacy and safety in reducing suicidality and self-harming behaviors.

METHODS

A comprehensive literature search was conducted across PubMed, Web of Science, and Scopus up to February 2024. Eligible studies were those focusing on patients aged 25 years or younger, examining Lithium therapy and its impact on suicidal ideation and behaviors. The review included randomized controlled trials, longitudinal prospective and retrospective studies, and cross-sectional studies, while excluding expert opinions and case reports.

RESULTS

Evidence generally supports the efficacy of Lithium in reducing suicidal ideation and self-harming behaviors in youth with BD, though results are mixed. Randomized controlled trials demonstrated its effectiveness in mitigating suicidal thoughts during acute manic episodes, with effects persisting post-treatment. Longitudinal studies suggested that Lithium might offer superior outcomes compared to other mood stabilizers, although its specific impact on suicidality remains inconclusive. Cross-sectional studies and retrospective analyses reveal associations between Lithium use and reduced self-harming behaviors, but causality remains uncertain. While mood-stabilizing effects of Lithium offer potential benefits for reducing suicidality in youth, evidence on its direct impact on emotional dysregulation (ED) and long-term efficacy is limited. Variability in individual responses and adherence issues underscore the need for further research. Future studies should include larger, diverse samples, focus on ED symptoms, and explore Lithium mechanisms in suicidality prevention.

CONCLUSIONS

Lithium remains a promising treatment for mood stabilization and reduction in suicidality in youth with BD.

An open label pilot trial of low-dose lithium for young people at ultra-high risk for psychosis

AIM

Lithium, even at low doses, appears to offer neuroprotection against a wide variety of insults. In this controlled pilot, we examined the safety (i.e., side-effect profile) of lithium in a sample of young people identified at ultra-high risk (UHR) for psychosis. The secondary aim was to explore whether lithium provided a signal of clinical efficacy in reducing transition to psychosis compared with treatment as usual (TAU).

METHODS

Young people attending the PACE clinic at Orygen, Melbourne, were prescribed a fixed dose (450 mg) of lithium (n = 25) or received TAU (n = 78). The primary outcome examined side-effects, with transition to psychosis, functioning and measures of psychopathology assessed as secondary outcomes.

RESULTS

Participants in both groups were functionally compromised (lithium group GAF = 56.6; monitoring group GAF = 56.9). Side-effect assessment indicated that lithium was well-tolerated. 64% (n = 16) of participants in the lithium group were lithium-adherent to week 12. Few cases transitioned to psychosis across the study period; lithium group 4% (n = 1); monitoring group 7.7% (n = 6). There was no difference in time to transition to psychosis between the groups. No group differences were observed in other functioning and symptom domains, although all outcomes improved over time.

CONCLUSIONS

With a side-effect profile either comparable to, or better than UHR antipsychotic trials, lithium might be explored for further research with UHR young people. A definitive larger trial is needed to determine the efficacy of lithium in this cohort.

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.

Why lithium should be used in patients with bipolar disorder? A scoping review and an expert opinion paper

INTRODUCTION

Lithium treatment is considered the gold standard for the long-term management of bipolar disorder and recurrent unipolar depression. It is also extremely effective in other psychiatric conditions characterized by impulsivity and aggression, and for the prevention of suicidal behaviours.

AREAS COVERED

This paper provides a scoping review and an expert commentary regarding the use of lithium in adult patients. Available information about efficacy, tolerability, dosing, and switching is analyzed, and the strategies that may be most useful in real-world clinical settings are highlighted.

EXPERT OPINION

Lithium is effective on different domains of bipolar disorder, including the long-term prevention of recurrences of affective episodes, management of acute mania as well as in the prophylaxis of all affective episodes. Lithium has been defined a 'forgotten drug,' since its use in routine clinical practice has been declined over the last 20 or 30 years. Reasons for this trend include lack of adequate training on the management of lithium side effects. Considering its efficacy, use of lithium in ordinary clinical practice should be promoted. Several strategies, such as using slow-release formulations, can be easily implemented in order to minimize lithium side effects and improve its tolerability profile.

Pharmacologic Treatment and Management of Bipolar Disorder in Adolescents

INTRODUCTION

The importance of the appropriate therapeutic interventions in children and adolescents with bipolar disorder (BD) cannot be overstated since treatment choices and their consequences may have effects into adulthood.

AREAS COVERED

Randomized clinical trials (RCTs) investigating treatment of mania, bipolar depression, and maintenance in adolescents with BD are reviewed. When RCTs are not available or are inadequate, naturalistic data or open studies are also reviewed.

EXPERT OPINION

Efficacy and safety of pharmaceutical agents in adolescents with BD appear to mirror adults with BD. Lithium/mood stabilizers are preferred first line agents over antipsychotic medications, but the latter are second line agents particularly in bipolar depression. When lithium is used, serum levels approaching 1.0 mEq/L are reasonable since younger people appear to require/tolerate higher levels. Among the antipsychotics, quetiapine appeared to be minimally better than risperidone while risperidone was associated with greater adverse events. Antipsychotics with antidepressant activity in adults, also appear to have antidepressant effects in youths. Use of antidepressants in bipolar depression is generally not recommended although it may be reasonable in specific clinical situations. The similarities between adolescent and adult outcomes suggest that it is reasonable to utilize adult data to aid with clinical decision making in adolescents with BD, especially when pediatric-specific data are unavailable.

Long-Term Effects of Lithium Use on Children and Adolescents: A Retrospective Study from Turkey

Background: The aim of this study was to evaluate the long-term effects of lithium treatment on white blood cell (WBC) count, serum creatinine, and thyroid-stimulating hormone (TSH) levels in children and adolescents with bipolar disorder (BD) and non-BD in a Turkish children and adolescent sample. Methods: The study is based on retrospective chart review. Children and adolescent patients with BD and non-BD prescribed lithium in a mental health and neurological disorders hospital between 2012 and 2017 were included in the study. Data were collected from the electronic medical files. Laboratory values for WBC count, serum creatinine, and TSH levels at baseline within the week before the onset of lithium, and at 1st, 3rd, 6^th, and 12th month of treatment were recorded. Results: A total of 143 patients (82 females, 61 males; 100 BD, 43 non-BD) aged 9-18 were included. Non-BD diagnoses were psychotic and schizoaffective disorders, unipolar depression, attention-deficit/hyperactivity disorder, conduct disorder, severe mood dysregulation syndrome, borderline personality disorder, and autism. Mean age of the participants were 15.90 ± 1.16 years for the bipolar group and 14.88 ± 1.79 years for the nonbipolar group. Patients with BD reported more adverse effects. There was a statistically significant increase in WBC counts and TSH levels at any time point. A statistically significant elevation in serum creatinine was found at 3rd and 12th month of treatment. During the course of lithium treatment, WBC counts exceeded 13,000 in 14 (9.8%) patients, and TSH levels exceeded 5.5 mU/L in 41 patients (28.6%). Twenty-one (14.68%) patients were started on thyroxin replacement. Basal TSH levels and duration of the lithium treatment were higher in the participants with TSH levels exceeding 5.5 mU/L. Lithium maximum dose, lithium blood level, basal TSH level, and duration of treatment were higher in the participants receiving thyroxin replacement. No patients had serum creatinine levels exceeding the normal reference values. Conclusion: Our study suggests that lithium is a generally safe and tolerable agent for children and adolescents with BD and non-BD; however, close monitoring of thyroid functions particularly in patients with a higher basal TSH level and longer duration of lithium use is important.

Long-term use of antidepressants, mood stabilizers, and antipsychotics in pediatric patients with a focus on appropriate deprescribing

It is estimated that 8% to 12% of youth are prescribed psychotropic medications. Those in foster care, juvenile justice systems, residential treatment facilities, and with developmental or intellectual disabilities are more likely to be prescribed high-risk regimens. The use of psychotropic medications in this age group is often off-label and can be associated with significant risk, warranting critical evaluation of their role. Landmark trials, pediatric-specific guidelines, and state-driven initiatives play critical roles in supporting evidence-based use of psychotropic medications in children. Overall, there is a lack of literature describing the long-term use of psychotropic medications in youth—particularly with regard to neurobiological, physical, and social changes that occur throughout development. Deprescribing is an important practice in child and adolescent psychiatry, given concerns for over-prescribing, inappropriate polytherapy, and the importance of reevaluating the role of psychotropic medications as children develop.

Lithium Treatment Over the Lifespan in Bipolar Disorders

Lithium has been the treatment of choice for patients with bipolar disorder (BD) for nearly 70 years. It is recommended by all relevant guidelines as a first-line treatment for maintenance therapy. In this review, we outline the current state of evidence for lithium in the treatment of BD over the lifespan. First, we summarize the evidence on efficacy in general, from relapse prevention to acute anti-manic treatment and its role in treating mood episodes with mixed features and bipolar depression. As patients are often treated for many years and different aspects have to be considered in different phases of life, we discuss the particularities of lithium in the treatment of paediatric BD, in older aged individuals and in pregnant women. Lastly, we discuss the evidence on lithium's proposed suicide-preventive effects, the dangers of rapid discontinuation and lithium's adverse effects, particularly with regard to long-term treatment.

Safety considerations in the psychopharmacology of pediatric bipolar disorder

Introduction: The standard of treatment of pediatric bipolar disorder (BPD) often requires life-long psychopharmacological management. Several pharmacological agents are approved by the US FDA for the treatment of pediatric BPD. However, each medication may cause adverse events (AEs). Provider awareness of AE profiles of common pharmacologic agents would serve to better inform patients and families in evaluating and selecting between treatment options. Areas covered: This review focuses on medications that, in our clinical experience, are commonly prescribed for youth with BPD and were evaluated in prospective clinical trials for the treatment of pediatric BPD. This paper highlights acute and long-term AEs described in these studies. Expert opinion: Most medications increase risk of AEs in youth with BPD. Treatment with lithium may lead to thyrotropin elevations, but generally does not cause significant weight gain. Divalproex may lead to weight gain; however, this finding was not consistent in comparison studies with lithium. Olanzapine, risperidone, quetiapine, and asenapine are associated with metabolic abnormalities and weight gain. Studies of ziprasidone, aripiprazole and lurasidone do not suggest significant metabolic AEs. More studies are needed to assess efficacy and safety of medications in managing pediatric BPD. Special focus on long-term maintenance trials is required to further identify long-term AEs in this population.

Putative Mechanisms of Action and Clinical Use of Lithium in Children and Adolescents: A Critical Review

BACKGROUND

Lithium is a first-line treatment for bipolar disorder in adults, but its mechanism of action is still far from clear. Furthermore, evidences of its use in pediatric populations are sparse, not only for bipolar disorders, but also for other possible indications.

OBJECTIVES

To provide a synthesis of published data on the possible mechanisms of action of lithium, as well as on its use in pediatric samples, including pharmacokinetics, efficacy, and safety data.

METHODS

Clinical trials in pediatric samples with at least one standardized measure of efficacy/ effectiveness were included in this review. We considered: i) randomized and open label trials, ii) combination studies iii) augmentation studies iv) case series including at least 5 patients.

RESULTS

Different and non-alternative mechanisms of action can explain the clinical efficacy of lithium. Clinical studies in pediatric samples suggest that lithium is effective in managing manic symptoms/episodes of bipolar disorder, both in the acute phase and as maintenance strategy. Efficacy on depressive symptoms/phases of bipolar disorder is much less clear, while studies do not support its use in unipolar depression and severe mood dysregulation. Conversely, it may be effective on aggression in the context of conduct disorder. Other possible indications, with limited published evidence, are the acute attacks in Kleine-Levin syndrome, behavioral symptoms of X-fragile syndrome, and the management of clozapine- or chemotherapy- induced neutropenia. Generally, lithium resulted relatively safe.

CONCLUSIONS

Lithium seems an effective and well-tolerated medication in pediatric bipolar disorder and aggression, while further evidences are needed for other clinical indications.

Understanding suicide: Focusing on its mechanisms through a lithium lens

BACKGROUND

Current intervention strategies have been slow in reducing suicide rates, particularly in mood disorders. Thus, for intervention and prevention, a new approach is necessary. Investigating the effects of a medication known for its anti-suicidal properties on neurobiological and neurocognitive substrates of suicidal thinking may provide a deeper and more meaningful understanding of suicide.

METHOD

A literature search of recognised databases was conducted to examine the intersection of suicide, mood disorders, and the mechanisms of lithium.

RESULTS

This review synthesises the extant evidence of putative suicide biomarkers and endophenotypes and melds these with known actions of lithium to provide a comprehensive picture of processes underlying suicide. Specifically, the central importance of glycogen synthase kinase-3β (GSK3β) is discussed in detail because it modulates multiple systems that have been repeatedly implicated in suicide, and which lithium also exerts effects on.

LIMITATIONS

Suicide also occurs outside of mood disorders but we limited our discussion to mood because of our focus on lithium and extending our existing model of suicidal thinking and behaviour that is contextualised within mood disorders.

CONCLUSIONS

Focusing on the neurobiological mechanisms underpinning suicidal thinking and behaviours through a lithium lens identifies important targets for assessment and intervention. The use of objective measures is critical and using these within a framework that integrates findings from different perspectives and domains of research is likely to yield replicable and validated markers that can be employed both clinically and for further investigation of this complex phenomenon.

Using Lithium in Children and Adolescents with Bipolar Disorder: Efficacy, Tolerability, and Practical Considerations

Lithium has been an intriguing treatment option in psychiatry for over a century. While seemingly just a simple elemental compound, it has powerful treatment effects for both depression and bipolar disorder. The evidence base for treatment of pediatric bipolar disorder is relatively small, but, in recent years, additional clinical trial data have enabled lithium to re-emerge as a valuable and, in many cases, preferred treatment. Pharmacologically, lithium is complex, with varied effects at both intracellular and extracellular levels. As a treatment for bipolar disorder in pediatrics, lithium is challenging, given its narrow therapeutic window and myriad of potential side effects. However, the efficacy of lithium continues to match that of newer pharmacologic agents, and its tolerability has been shown to be comparable with more commonly prescribed medications. Lithium is still one of few drugs that have been proven to reduce the risk of suicidality, and it may have utility in illnesses beyond affective disorders. Practically, as a primary agent or as an adjunct, lithium continues to claim a rightful place in the treatment armamentarium of child psychiatry. New dosing paradigms have improved tolerability and reduced potential side effects. Recent evidence affirms that lithium is effective for pediatric bipolar disorder in multiple phases of the illness.

Safety and efficacy of lithium in children and adolescents: A systematic review in bipolar illness

Introduction:

Many clinicians are reluctant to use traditional mood-stabilizing agents, especially lithium, in children and adolescents. This review examined the evidence for lithium’s safety and efficacy in this population.

Methods:

A systematic review was conducted on the use of lithium in children and adolescents with bipolar disorder (BD). Relevant papers published through June 30th 2018 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.

Results:

30 articles met inclusion criteria, including 12 randomized controlled trials (RCTs). Findings from RCTs demonstrate efficacy for acute mania in up to 50% of patients, and evidence of long-term maintenance efficacy. Lithium was generally safe, at least in the short term, with most common side effects being gastrointestinal, polyuria, or headache. Only a minority of patients experienced hypothyroidism. No cases of acute kidney injury or chronic kidney disease were reported.

Conclusions:

Though the available literature is mostly short-term, there is evidence that lithium monotherapy is reasonably safe and effective in children and adolescents, specifically for acute mania and for prevention of mood episodes.

Urinary reference ranges and exposure profile for lithium among an Italian paediatric population

The aims of the present study were to establish reference values useful in monitoring Lithium (Li) treatment and to trace environmental Li exposure profiles in paediatric age. A cross-sectional study was conducted on a group of healthy Italian children aged 5-11. Data on possible predictors were assessed through a questionnaire, and Li levels in morning and evening urinary samples were determined by ICP-MS technique. The reference intervals for the evening and morning samples were respectively 3.8-51.9μgL^-1 or 5.6-60.6μgg^-1 creatinine and 4.8-71.7μgL^-1 or 4.8-73.2μgg^-1 creatinine. Urinary Li levels showed a significantly inverse correlation with age and a positive correlation with urinary creatinine in both the evening and morning samples. No other studied variables influenced Li urinary excretion. These results, obtained using a readily available matrix as urine, can be useful for both environmental research and Li treatment monitoring.

Challenges and Promises of Pediatric Psychopharmacology

Most prescriptions for psychotropic medications are written by primary care physicians, yet pediatricians, many of whom are teaching residents and medical students about pediatric psychopharmacology, often feel inadequately trained to treat mental health concerns. Over the past several decades, the number, size, and quality of psychopharmacologic studies in youth has greatly increased. Here we review the current evidence for efficacy and safety of each of the major pharmacologic drug classes in youth (psychostimulants, antidepressants, mood stabilizers, and antipsychotics). Psychostimulants have a robust body of literature supporting their evidence as first-line treatment for attention-deficit/hyperactivity disorder. Selective serotonin reuptake inhibitors (SSRIs) have documented efficacy for pediatric depression and multiple different anxiety disorders with childhood onset. Combining cognitive-behavioral therapy with SSRI treatment enhances treatment benefit and minimizes adverse events of medication. Mood stabilizers, including lithium and anticonvulsant medications, have a less robust strength of evidence and come with more problematic side effects. However, they are increasingly prescribed to youth, often to treat irritability, mood lability, and aggression, along with treatment of bipolar disorder. Antipsychotics have long been a mainstay of treatment for childhood-onset schizophrenia, and in recent years, the evidence base for providing antipsychotics to youth with bipolar mania and autistic disorder has grown. Most concerning with antipsychotics are the metabolic side effects, which appear even more problematic in youth than adults. By better understanding the evidence-based psychopharmacologic interventions, academic pediatricians will be able to treat patients and prepare future pediatrician to address the growing mental health care needs of youth.

[Pharmacological treatment of bipolar disorder in children and adolescents]

OBJECTIVE

To review the options for acute and maintenance pharmacological treatment of bipolar disorder in children and adolescents.

METHODS

A comprehensive literature review of randomized clinical trials and open-label studies was conducted.

RESULTS

Published data from randomized controlled trials show that antipsychotics are significantly more effective than mood stabilizers in the treatment of manic or mixed episodes. Few data are available related to the treatment of depressive episodes. No trials of selective serotonin reuptake inhibitors have been conducted. Only open trials suggest that lithium and lamotrigine may be effective, whereas quetiapine did not demonstrate efficacy relative to placebo in two studies. Studies regarding the effectiveness of antipsychotics and mood stabilizers for the comorbid disorders are also few and inconclusive. Although long-term treatment is a core aspect of the management of children and adolescents with bipolar disorder, there is a lack of consistent efficacy data. If non-controlled trials suggest that lithium, lamotrigine, quetiapine, ziprazidone, and the combination of risperidone and divalproex or lithium may be useful in some conditions, only aripiprazole has shown efficacy relative to placebo for long-term symptom reduction and relapse prevention. Safety data show that the most frequently reported adverse events in children and adolescents treated with mood stabilizers are gastrointestinal and neurological, whereas use of antipsychotics is mainly related to weight gain and sedation. Lastly, while results from studies having evaluated the impact of pharmacological treatment on neuropsychological functioning are inconsistent, some of them nevertheless suggest that treatment with mood stabilizers may be associated with specific impairments.

CONCLUSION

Despite recent developments in identifying effective pharmacological interventions, numerous critical gaps remain.

Lithium in the Acute Treatment of Bipolar I Disorder: A Double-Blind, Placebo-Controlled Study

BACKGROUND

Lithium is a benchmark treatment for bipolar disorder in adults. Definitive studies of lithium in pediatric bipolar I disorder (BP-I) are lacking.

METHODS

This multicenter, randomized, double-blind, placebo-controlled study of pediatric participants (ages 7-17 years) with BP-I/manic or mixed episodes compared lithium (n = 53) versus placebo (n = 28) for up to 8 weeks. The a priori primary efficacy measure was change from baseline to the end of study (week 8/ET) in the Young Mania Rating Scale (YMRS) score, based on last-observation-carried-forward analysis.

RESULTS

The change in YMRS score was significantly larger in lithium-treated participants (5.51 [95% confidence interval: 0.51 to 10.50]) after adjustment for baseline YMRS score, age group, weight group, gender, and study site (P = .03). Overall Clinical Global Impression-Improvement scores favored lithium (n = 25; 47% very much/much improved) compared with placebo (n = 6; 21% very much/much improved) at week 8/ET (P = .03). A statistically significant increase in thyrotropin concentration was seen with lithium (3.0 ± 3.1 mIU/L) compared with placebo (-0.1 ± 0.9 mIU/L; P < .001). There was no statistically significant between-group difference with respect to weight gain.

CONCLUSIONS

Lithium was superior to placebo in reducing manic symptoms in pediatric patients treated for BP-I in this clinical trial. Lithium was generally well tolerated in this patient population and was not associated with weight gain, distinguishing it from other agents commonly used to treat youth with bipolar disorder.

Short-term effects of lithium on white blood cell counts and on levels of serum thyroid-stimulating hormone and creatinine in adolescent inpatients: a retrospective naturalistic study

OBJECTIVE

The purpose of this study was to determine if the known side effects of lithium in adults may be generalized to younger patients with psychiatric disorders.

METHODS

A retrospective naturalistic study design was used. Data were collected from the database of a tertiary pediatric medical center covering the years 1994-2010. Included were patients hospitalized for bipolar and non-bipolar disorders and treated with lithium, alone or in combination with other medications. The electronic medical files were reviewed for changes in thyroid and kidney function and for hematological parameters during the course of treatment.

RESULTS

Sixty-one patients 12.5-20.4 years of age (mean 16.94±1.66) met the study criteria: 33 with bipolar disorder and 28 with a non-bipolar disorder. Mean duration of lithium treatment (mean lithium blood level, 0.73±0.24 mEq/L) was 193.68±254.35 days. Mean levels of thyroid-stimulating hormones (TSH) rose significantly from baseline to last measurement (3.16±2.68 vs. 1.52±0.92 mU/L; paired t=-5.19, df=50, p<0.001); in 25% of patients, TSH levels at the last measurement were above normal (≥4 mU/L). Only one patient developed TSH values >10 mU/L (the threshold considered clinically significant). Positive correlation was found between pre- and posttreatment TSH levels (Pearson's r=0.60; n=51, p<0.05). White blood cell count (WBC) also increased significantly following lithium treatment (7195±2151 vs. 7944±2096 cells/mm(3); t=2.83, df=60, p=0.006). No significant changes were noted in serum creatinine levels. There was no difference in these parameters between patients treated with lithium alone or in combination with other medications.

CONCLUSIONS

Lithium treatment in adolescents with bipolar or non-bipolar disorders is associated with a significant increase in blood TSH levels and WBC count. Lithium-treated adolescent inpatients with a high basal TSH level may be at risk of developing pituitary-thyroid axis dysregulation. Therefore, baseline measurement of thyroid functions and serial monitoring throughout treatment are recommended.

Therapeutic benefits of delayed lithium administration in the neonatal rat after cerebral hypoxia-ischemia

Aim

We have previously shown that lithium treatment immediately after hypoxia-ischemia (HI) in neonatal rats affords both short- and long-term neuroprotection. The aim of this study was to evaluate possible therapeutic benefits when lithium treatment was delayed 5 days, a time point when most cell death is over.

Methods

Eight-day-old male rats were subjected to unilateral HI and 2 mmol/kg lithium chloride was injected intraperitoneally 5 days after the insult. Additional lithium injections of 1 mmol/kg were administered at 24 h intervals for the next 14 days. Brain injury was evaluated 12 weeks after HI. Serum cytokine measurements and behavioral analysis were performed before sacrificing the animals.

Results

Brain injury, as indicated by tissue loss, was reduced by 38.7%, from 276.5±27.4 mm³ in the vehicle-treated group to 169.3±25.9 mm³ in the lithium-treated group 12 weeks after HI (p<0.01). Motor hyperactivity and anxiety-like behavior after HI were normalized by lithium treatment. Lithium treatment increased neurogenesis in the dentate gyrus as indicated by doublecortin labeling. Serum cytokine levels, including IL-1α, IL-1β, and IL-6, were still elevated as late as 5 weeks after HI, but lithium treatment normalized these cytokine levels.

Conclusions

Delayed lithium treatment conferred long-term neuroprotection in neonatal rats after HI, and this opens a new avenue for future development of treatment strategies for neonatal brain injury that can be administered after the acute injury phase.

Clinical characteristics associated with lithium use among adolescents with bipolar disorder

OBJECTIVE

Little is known regarding demographic and/or clinical characteristics associated with the use of lithium among adolescents with bipolar disorder (BP) in naturalistic clinical settings. We therefore examined factors associated with lithium among adolescents with BP presenting to a tertiary outpatient clinic.

METHODS

Participants were 100 adolescents 13-19 years of age, with BP-I, BP-II, or BP not otherwise specified (BP-NOS). Diagnoses and lifetime medication exposure were determined using the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime Version (KSADS-PL). Analyses examined for demographic and clinical correlates of lifetime lithium exposure.

RESULTS

Twenty percent of participants reported lifetime lithium use. Participants with, versus those without, lifetime lithium use were significantly older and significantly more likely to have BP-I, lifetime history of psychiatric hospitalization, and psychosis. Lithium-treated participants were significantly more likely to report use of second-generation antipsychotics (SGAs) and antimanic anticonvulsants. In contrast, participants with lithium exposure were significantly less likely to have BP-II, self-injurious behavior, and a family history of depression. Adolescents with lithium exposure had significantly less parent-reported family conflict and mood lability, and significantly less self-reported impulsivity, emotional dysregulation, identity confusion, and interpersonal problems. In multivariable analyses, lithium use was associated with greater lifetime SGA use, lower parent-reported family conflict, and lower adolescent-reported interpersonal problems.

CONCLUSIONS

Lithium was infrequently used among adolescents with BP in this sample. Although constrained by retrospective methodology and a single site, our findings suggest that clinicians may be deferring lithium use until late in treatment. The fact that there are lower rates of lithium use among adolescents with suicidal ideation, impulsivity, mood lability, and family history of depression suggests potential missed opportunities for use of lithium among high-risk adolescents with BP.

Lithium treatment alleviates impaired cognition in a mouse model of fragile X syndrome

Fragile X syndrome (FXS) is caused by suppressed expression of fragile X mental retardation protein (FMRP), which results in intellectual disability accompanied by many variably manifested characteristics, such as hyperactivity, seizures and autistic-like behaviors. Treatment of mice that lack FMRP, Fmr1 knockout (KO) mice, with lithium has been reported to ameliorate locomotor hyperactivity, prevent hypersensitivity to audiogenic seizures, improve passive avoidance behavior and attenuate sociability deficits. To focus on the defining characteristic of FXS, which is cognitive impairment, we tested if lithium treatment ameliorated impairments in four cognitive tasks in Fmr1 KO mice, tested if the response to lithium differed in adolescent and adult mice and tested if therapeutic effects persisted after discontinuation of lithium administration. Fmr1 KO mice displayed impaired cognition in the novel object detection task, temporal ordering for objects task and coordinate and categorical spatial processing tasks. Chronic lithium treatment of adolescent (from 4 to 8 weeks of age) and adult (from 8 to 12 weeks of age) mice abolished cognitive impairments in all four cognitive tasks. Cognitive deficits returned after lithium treatment was discontinued for 4 weeks. These results show that Fmr1 KO mice exhibit severe impairments in these cognitive tasks, that lithium is equally effective in normalizing cognition in these tasks whether it is administered to young or adult mice and that lithium administration must be continued for the cognitive improvements to be sustained. These findings provide further evidence that lithium administration may be beneficial for individuals with FXS.

Post-acute effectiveness of lithium in pediatric bipolar I disorder

OBJECTIVE

This study examined the long-term effectiveness of lithium for the treatment of pediatric bipolar disorder within the context of combination mood stabilizer therapy for refractory mania and pharmacological treatment of comorbid psychiatric conditions.

METHODS

Outpatients, ages 7-17 years, meeting American Psychiatric Association, diagnostic and statistical manual of mental disorders, 4th ed. (DSM-IV) diagnostic criteria for bipolar disorder I (BP-I) (manic or mixed) who demonstrated at least a partial response to 8 weeks of open-label treatment with lithium (phase I) were eligible to receive open-label lithium for an additional 16 weeks (phase II). Up to two adjunctive medications could be prescribed to patients experiencing residual symptoms of mania or comorbid psychiatric conditions, following a standardized algorithm.

RESULTS

Forty-one patients received continued open-label long-term treatment with lithium for a mean of 14.9 (3.0) weeks during phase II. The mean weight-adjusted total daily dose at end of phase II was 27.8 (6.7) mg/kg/day, with an average lithium concentration of 1.0 (0.3) mEq/L. Twenty-five of the 41 patients (60.9%) were prescribed adjunctive psychotropic medications for residual symptoms. The most frequent indications for adjunctive medications were refractory mania (n=13; 31.7%) and attention-deficit/hyperactivity disorder (ADHD) (n=15; 36.6%). At the end of this phase 28 (68.3%) patients met a priori criteria for response (≥50% reduction from phase I baseline in young mania rating scale [YMRS] summary score and a clinical global impressions-improvement [CGI-I] score of 1 or 2), with 22 (53.7%) considered to be in remission (YMRS summary score≤12 and CGI-severity score of 1 or 2). These data suggest that patients who initially responded to lithium maintained mood stabilization during continuation treatment, but partial responders did not experience further improvement during Phase II, despite the opportunity to receive adjunctive medications. The most commonly reported (≥20%) adverse events associated with lithium treatment were vomiting, headache, abdominal pain, and tremor.

CONCLUSIONS

Lithium may be a safe and effective longer-term treatment for patients with pediatric bipolar disorder who respond to acute treatment with lithium. Partial responders to acute lithium did not appear to experience substantial symptom improvement during the continuation phase, despite the possibility that adjunctive medications could be prescribed.

Acute treatment of mania in children and adolescents

PURPOSE OF REVIEW

To examine critically data concerning the efficacy and safety of acute treatments for mania in children and adolescents, in the light of considerable recent emergent evidence.

RECENT FINDINGS

We found consistent evidence favouring the use of second-generation antipsychotics (SGAs), limited evidence favouring the use of combinations of SGA with a mood stabilizer, and no evidence supporting the use of mood stabilizer monotherapy in this context. Various SGA drugs are not clearly separated in terms of efficacy, but do differ in their side-effect profiles. There are insufficient data to comment on the benefit of alternative treatments, psychological treatments and electroconvulsive therapy. The presence of common comorbidities has an inconsistent influence on clinical effectiveness.

SUMMARY

First-line treatment for mania in children and adolescents is a SGA, with combination therapies offering no clear advantage. Gaps in our knowledge remain about expected time to recovery, and when to augment or change treatment when there is lack of effect.