Lithium Prescribing and Therapeutic Drug Monitoring in Bipolar Disorder: A Survey of Current Practices and Perspectives.

Abstract

The goal of this survey study was to assess specific aspects of lithium therapy for bipolar disorder, including psychiatrists' prescribing practices, understanding of therapeutic drug monitoring, and concerns and perspectives regarding lithium therapy. A 14-item survey was electronically distributed to 225 staff psychiatrists at 8 academic hospitals. The survey was completed by 85 psychiatrists (38% of the 225 psychiatrists to whom the survey was distributed), with between 81 and 85 respondents completing the different items. When asked about the agents with which they initiated therapy, 49 (61%) reported initiating therapy with an atypical antipsychotic and 34 (42%) reported starting with lithium therapy in 50% or more of patients newly diagnosed with bipolar disorder. When prescribing lithium, most of the respondents (n=68, 82%) reported that they used once daily dosing, and 67 respondents (79%) indicated that they ordered lithium blood levels 12 hours postdose. When interpreting lithium levels, 46 respondents (55%) reported "always" changing a clinically stable patient's lithium dose when the level was above the therapeutic range, compared with 4 (5%) who reported always changing the dose when the level was below the therapeutic range. When asked about their concerns regarding lithium therapy, more than half of the respondents reported that they were especially concerned about toxicity, organ dysfunction, and other adverse effects, as well as therapeutic drug monitoring. Shifts in prescribing practices, inconsistent interpretation of lithium levels, and concerns about safety and therapeutic drug monitoring highlight the need for evidence-informed guidelines reflective of current practice.