Evaluation of lithium in treatment of psychotic excitement

Edward Trautner (1890-1978), a pioneer of psychopharmacology

This article examines the scientific career of Edward Trautner, who did pioneering research in the 1950s on lithium treatment for psychiatric disorders. Trautner was the first scientist to study the mechanism of action of lithium as a psychiatric medication. His research established that lithium could be used safely and rationally, and anticipated by a decade the large volume of research in the 1960s and 1970s that led to international acceptance of lithium treatment for mood disorders. Trautner was a pioneer of biological psychiatry who considered pharmacology to be a useful therapeutical tool rather than a permanent cure for putative chemical imbalances. His research involved cross-disciplinary collaborations that combined clinical and laboratory research in the disciplines of psychiatry, physiology, biochemistry, teratology, and even oncology. Trautner himself had a multidisciplinary background that included publications in literature and philosophy.

The Syndrome of Irreversible Lithium-Effectuated Neurotoxicity

OBJECTIVES

Persistent sequelae of lithium intoxication gained clinical attention in the 1980s and were named Syndrome of Irreversible Lithium-Effectuated Neurotoxicity (SILENT). The authors review the published cases of SILENT reported in the literature and discuss various clinical manifestations.

METHODS

The authors' inclusion criteria included persistence of sequelae for at least 2 months after the cessation of lithium administration. They conducted a MEDLINE and Pub Med search for journal articles from the year 1965 to 2004. They also cross-referenced available papers.

RESULTS

The authors identified 90 cases of SILENT in peer-reviewed publications. Persistent cerebellar dysfunction was the most commonly reported sequela. Other atypical presentations have also been reported.

CONCLUSION

Although the biologic mechanism remains unclear, the authors hypothesize that the putative cause of SILENT is demyelination caused by lithium at multiple sites in the nervous system, including the cerebellum. Recent advances in the understanding of the molecular basis of lithium-induced neurotoxicity may be able to provide a means of defining a pathway associated with the long-term prophylactic properties of lithium, distinct from its toxicity profile. This identification of differential gene expression patterns that distinguish between therapeutic and toxic actions of lithium may help in the discovery of new drugs for mood stabilization. Clinically and heuristically, it is important to raise the awareness of this syndrome so that clinicians are able to avoid it. A precise definition, operational diagnostic criteria, and a descriptive name will aid in the early identification and prevention of SILENT.

Cade's observation of the antimanic effect of lithium and early Australian research

John Cade had a major influence on the treatment of affective disorders following his report in 1949. His discovery of the efficacy of lithium as an antimanic agent was the result of an inevitable progression from the hypothesis of a metabolic basis for mania to clinical trials. Starting with animal studies, he progressed to patients. Further reports on lithium in the Medical Journal of Australia quickly followed in 1950 and 1951. The present paper reports on these and other Australian studies over the next few years. Lithium has moved in 50 years from a novel status to an internationally recognised major treatment of affective disorders.

Clinical manifestations and management of acute lithium intoxication

Acute lithium intoxication is a frequent complication of chronic lithium therapy for manic depressive disorders. Because of lithium's narrow therapeutic index and widespread use, lithium intoxication remains prevalent in 1994. This review summarizes information on the renal handling of lithium and the physiologic basis for toxicity. Recent reports that describe previously unrecognized side effects of lithium intoxication are discussed. We also present management guidelines based upon our understanding of the renal handling of lithium. In this review we compare the effectiveness of lithium removal by various dialysis methods, including bicarbonate dialysis, peritoneal dialysis and continuous arteriovenous hemofiltration. Hemodialysis remains the cornerstone for the treatment of acute lithium toxicity.

Neuropsychiatric manifestations of alkali metal deficiency and excess

The alkali metals from the Group IA of the periodic table (lithium, sodium, potassium, rubidium, cesium and francium) are reviewed. The neuropsychiatric aspects of alkali metal deficiencies and excesses (intoxications) are described. Emphasis was placed on lithium due to its clinical uses. The signs and symptoms of these conditions are characterized by features of an organic brain syndrome with delirium and encephalopathy prevailing. There are no clinically distinctive features that could be reliably used for diagnoses. Sodium and potassium are two essential alkali metals in man. Lithium is used as therapeutic agent in bipolar affective disorders. Rubidium has been investigated for its antidepressant effect in a group of psychiatric disorders. Cesium is under laboratory investigation for its role in carcinogenesis and in depressive illness. Very little is known of francium due to its great instability for experimental study.

Clinical and neuropathological aspects of long-term damage to the central nervous system after lithium medication

A female patient, who died at the age of 61 and had suffered from several manic-depressive psychoses for more than 30 years, developed three phases of intoxication under lithium therapy. There was a 15-year history of electro- and Pentetrazol-induced convulsive therapy prior to lithium medication; neuroleptics were still administered during lithium therapy. The last lithium intoxication, 3 years prior to death was during a low-dosage therapy with normal lithium levels followed by severe lasting impairment: akinesia, rigidity, dysarthria, ataxia, and an organic alteration in character. For the first time, neuropathological findings could be established in such a case: extensive damage to granule and Purkinje cells in the cerebellum; gliosis in the dentate nucleus, the inferior olives, and the nucleus ruber; cytoplasmic inclusions in various nerve cells of the cranial nerve nuclei; cytoplasmic vacuoles, especially in the cells of the supra-optic nucleus. Surprisingly little damage could be found in the substantia nigra and in the neostriatum. The clinical course as well as the pattern and intensity of the brain damage oppose an interpretation as a consequence of preceding convulsive shock therapy.

Acquired transient CNS hypersensitivity to lithium therapy

Organic brain syndrome is reported to occur occasionally in patients who are treated with lithium carbonate alone, or in combination with neuroleptics. Such neurotoxicity is often associated with moderate to low serum lithium levels and is usually reversible upon the cessation of lithium treatment. The authors report on a 57 year old manic-depressive and alcoholic patient who, after four years of lithium treatment, developed symptoms of CNS hypersensitivity which reappeared several times when he was challenged with lithium during a two month period. The possible role of an underlying, subclinical encephalopathy, caused by episodic drinking, is considered.

Reassessing the bipolar-unipolar dichotomy

This paper is a critical review of the literature on the dichotomous classification of affective disorders into unipolar and bipolar types. The majority of genetic studies show significant overlap in the liability to develop two forms of illness, and the majority of lithium studies show a similar clinical responsiveness of both groups to both acute and maintenance treatment. Biological studies comparing the two groups are difficult to interpret as most have compared manics to depressives without controlling for motor activity, excitement, and other state-dependent clinical variables. Viewed in light of our research findings in a recent genetic study of affective states, we believe these data suggest that the separation of affective disorders by polarity may have been premature, and that the search for heterogeneity should now be carried out using alternative strategies.

Dermatologic manifestations of lithium: a review

This paper summarizes the major dermatologic and immunologic complications associated with lithium carbonate ingestion. This drug has demonstrated proven efficacy in the treatment of bipolar affective disorder. This fact, the authors believe, outweights its dermatologic complications, and only exacerbation of psoriasis warrants termination of therapy.

Effect of lithium on cardiovascular performance: report on extended ambulatory monitoring and exercise testing before and during lithium therapy

To assess the effect of long-term lithium therapy on cardiac arrhythmias and cardiovascular performance, extended ambulatory electrocardiographic monitoring was performed in 12 patients, and rest and exercise electrocardiograms in 10 of 12, before and during lithium therapy. Lithium increased the frequency of premature ventricular contractions in three patients, decreased it in one, and produced no change in eight. Three of four patients with atrial arrhythmias showed improvement during lithium therapy. Exercise performance was unchanged. Although 7 of the 12 patients manifested T wave flattening in the resting electrocardiogram, none had S-T segment displacement at rest or on treadmill exercise. Before lithium therapy, arrhythmias on exercise included premature atrial contractions in four patients, ventricular arrhythmias in four (premature ventricular contractions in four, with couplets in two and with ventricular tachycardia in one). During lithium therapy, exercise did not provoke premature atrial contractions or ventricular tachycardia in any of the patients, but three patients had premature ventricular contractions (with couplets in one case). We conclude that lithium at therapeutic levels may precipitate or aggravate ventricular arrhythmias. When administered to patients with heart disease, factors that interfere with renal clearance of lithium (heart failure, salt restriction, long-term diuretic therapy) must be recognized and doses must be adjusted accordingly. Careful follow-up and electrocardiographic monitoring are advisable if lithium is to be used in the presence of ventricular arrhythmias. Cardiovascular performance as assessed by treadmill exercise testing was not affected by long-term lithium therapy.

The cardiovascular effects of lithium in man. A review of the literature

The medical literature since 1900 has been reviewed to determine the nature of lithium's cardiovascular effects. In therapeutic doses, lithium produces reversible T wave flattening and inversion in the electrocardiogram: rarely, it may cause sinus node dysfunction or ventricular arrhythmias. Patients with lithium toxicity almost always present with neurologic signs and symptoms. "Hypotension and cardiovascular collapse," alleged cardiotoxic manifestations of lithium, invariably follow days of coma. Given the possible cardiotoxic effect other psychopharmacologic agents and the hazards of withholding effective therapy in mania, it is concluded that lithium may be used safely in patients with cardiac disease if the dose is adjusted to the rate of lithium excretion and if serum levels of lithium are followed carefully. When used in patients with cardiac arrhythmias, frequent electrocardiographic monitoring is advised.

Lithium neurotoxicity

One of the most alarming and potentially serious complications of Lithium Carbonate therapy is the emergence of central nervous system toxicity. This paper discusses the clinical changes that may occur with illustrative case histories. The role that such factors as serum Lithium levels, sodium balance, organic brain damage, clinical typology, concurrent physical illness and drug interaction play in the genesis of this disorder is discussed. Permanent neurological damage following Lithium poisoning is discussed and guidelines for appropriate use and monitoring of Lithium in psychiatric disorders is outlined.

Acute renal failure and lithium intoxication

A case of acute renal failure is reported in a patient with severe lithium intoxication. Renal biopsy showed damage in the proximal tubules with less marked changes in the glomeruli and interlobular arteries.

Lithium was withdrawn, and after treatment with peritoneal dialysis the patient regained normal renal function.

The accumulation of lithium is known to lead to acute renal failure in the rat and the dog, and this report provides further evidence that it may do so in man.

A controlled study of lithium vs. chlorpromazine in acute schizophrenics

A previous double-blind controlled evaluation of lithium and chlorpromazine in both manic and schizo-affective individuals carried out in this unit (Johnsonet al., 1968) indicated that 85 per cent of the schizo-affectives showed a worsening of thought disorder when treated with lithium carbonate, the majority developing symptoms of an acute brain syndrome. The possibility of experimental design accounting for such treatment outcome must be considered.

The clinical laboratory and electroencephalographic effects of lithium

Eleven patients (six manic, five non-manic) were studied during administration of lithium carbonate. All patients manifested neutrophilia during administration and there was a tendency for elevation in the fasting blood sugar. Serial EEG examinations and lithium determinations were done throughout the study in nine patients. The records of all nine patients showed profound changes in the form of diffuse slowing, widening of the frequency spectrum, potentiation and disorganization of background rhythm. Sensitivity to hyperventilation and paroxysmal bilaterally synchronous delta activity were also noted. Potentiation of an epileptic focus was observed in the EEG of one patient. These findings indicate that the CNS effect of lithium is both cortical and subcortical.