Lithium Clinic Research Articles

Audit of Lithium Monitoring in a Mental Health for Older Persons (Dublin North City Central) Service

Abstract Background Lithium is a psychotropic medication used for the treatment of bipolar affective disorder and augmentation for treatment resistant depression. Lithium monitoring is essential due to the narrow therapeutic range of serum lithium and the potential for toxicity. Other medications with similar risk profiles, such as warfarin, have established monitoring programmes. Older adults receiving lithium therapy are at an increased risk of adverse events, given the prevalence of medical co-morbidities and changing pharmacokinetics. The authors of this audit identified the lack of formalized lithium monitoring programme in the Mental Health Service for Older Persons (MHSOP). The aim of this audit to compare monitoring practices in the MHSOP against the current gold standard Irish Medication Safety Network (IMSN) for Prescribing and Monitoring of Lithium Therapy. Methods A survey of all community medical charts identifying patients attending the service receiving lithium therapy was completed. Data collected pertained to diagnosis, treating consultant, lithium dose, if the patient received educational material, compliance with ECG and blood monitoring. Results The MHSOP active case load was 682 patients, 14 patients were prescribed lithium therapy. Cycle 1 of the audit demonstrated poor compliance of lithium monitoring against the gold standard. A lithium pack was inserted in patient files to prompt all clinicians to follow the recommended standardized monitoring of lithium therapy as per the IMSN guidelines. In cycle 2 of the audit there was an improvement in recording blood monitoring across the patient group. Conclusion The audit demonstrated improvement in compliance with international guidelines following the intervention. It was recommended that a formalized Lithium Clinic was a needed resource for the MHSOP. The lithium monitoring pack will continue to be added to clinical files, included in Non-Hospital Consultant (NCHD) induction and multi - disciplinary teaching sessions. It is proposed that the audit be repeated in one year to longitudinally assess compliance.

Are We Monitoring Our Lithium Patients as Well as We Should be? A Two-Cycle Audit Evaluating Lithium Clinic Documentation in a District General Hospital in Wales

Are We Monitoring Our Lithium Patients as Well as We Should be? A Two-Cycle Audit Evaluating Lithium Clinic Documentation in a District General Hospital in Wales

Lithium-Associated Hypothyroidism in a Specialized Lithium Clinic at a Tertiary Care Hospital in Riyadh, Saudi Arabia: A Retrospective Study.

Hypothyroidism is a common side effect of lithium use and is associated with a slower response to treatment and poorer long-term remission in patients with bipolar disorder. No studies have examined the prevalence of lithium-associated hypothyroidism or its associated factors in Saudi Arabia. We aimed to estimate the prevalence of lithium-associated hypothyroidism among psychiatric patients in a specialized lithium clinic at a tertiary care hospital in Saudi Arabia and to examine the possible risk factors for its development. This retrospective observational study included 117 participants. The prevalence of secondary hypothyroidism was 15%. The median duration between the start of lithium therapy and the first abnormal thyroid test result was 341 days. The multiple logistic regression showed that none of the studied variables, namely, sex, current age, age of lithium initiation, continuity on lithium, lithium level (≤0.5 mmol/L or >0.5 mmol/L), and prescription of as-needed medications, was significantly associated with secondary hypothyroidism. Our study also shed light on the possible clinical significance of baseline TSH levels in developing hypothyroidism secondary to lithium. Further multicenter studies with larger sample sizes are warranted to examine the generalizability of these results.

Audit of Lithium in a Psychiatry of Old Age Service

AimsThe aim of this audit is to compare our prescribing and monitoring practices in the Mental Health Service for the Elderly team (MHSE) in County Monaghan with current NICE guidelines (National Institute for Health and Care Excellence, UK). Lithium is used in the management of Bipolar Affective Disorder (BPAD) and refractory Depression in the elderly and across other patient groups. The elderly population is more vulnerable generally than other patient groups to adverse effects and toxicity from Lithium including at therapeutic doses. This is due to the increased likelihood of having other medical morbidities, interaction with other medications and the higher prevalence of renal impairment.MethodsThe audit duration was from the beginning of April to the end of June 2021. Data were collected for demographic variables and for therapeutic variables such as Lithium dose, serum Lithium level, adverse effects due to Lithium, weight and signs of Lithium toxicity. Re-audit was completed during the month of June 2021.ResultsTen patients attending the MHSE team were prescribed Lithium at the time of the audit and were included in the audit. 60% were females and 40% were males. The mean age was 77.3 years. 50% had a Depressive disorder and 50% had a diagnosis of BPAD. The mean Lithium dose was 310 mg and the mean serum Lithium level was 0.5mmol/L. All 3-monthly Lithium levels were completed. 100% were provided with information booklets, record books and BMI recorded. 60% of six-monthly Lithium levels were completed. 20% of six-monthly bloods were completed but not documented. There were eight patients prescribed Lithium in the re-audit. 62% were females and 38% were males. The mean age was 78.8 years. 75% were diagnosed with refractory Depression and 25% with BPAD. The mean Lithium dose was 337.5 mg and the mean serum Lithium level was 0.6mmol/L. 100% of patients completed their three and six-monthly serum Lithium levels and documentation was complete for 100% of patients.ConclusionWe recommend the establishment of a Lithium Clinic to ensure proper monitoring of this group. This includes clear pathways for patients to have their bloods taken (GP or hospital), pro forma reminder letters for GPs and patients, a recording table for blood results and physical variables in the patient file, alert cards and the provision of written information about Lithium for patients and carers.

Lithium Clinics in Berlin and Dresden: a 50-Year Experience.

Although lithium's serendipitous discovery as a medication for depression dates back more than 200 years, the first scientific evidence that it prevents mania and depression arose only in the 1960s. However, at that time there was a lack of knowledge about how to administer and monitor lithium therapy safely and properly. The lithium clinics in Dresden and Berlin were remarkably similar in their beginnings in the late 1960s regarding patient numbers and scientific expertise without being aware of one another due to the Iron Curtain separating Germany into a western and eastern part until 1990. In what were initially lithium-care programs run independently from one another, the lithium clinics embedded in academic settings in Dresden and Berlin represent a milestone in the history of psychopharmacological treatment of affective disorders in Germany and trailblazers for today's lithium therapy. Nowadays, lithium's clinical applications are unquestioned, such as its use in strategies to prevent mood episodes and suicide, and to treat depression. The extensively documented knowledge of lithium treatment is the fruit of more than 50 years of observing disease courses and of studying side effects and influencing factors of lithium prophylaxis. Its safe and proper administration-in determining the correct indication, baseline and follow-up examinations, recommended dosages, monitoring, or the management of side effects-is well established. Subsequently, both national and international guidelines continue recommending lithium as the gold standard in treating patients with unipolar and bipolar disorders.

Happy 50th Anniversary, Lithium Clinics: The Perspective of a Long-Time User.

Happy 50th Anniversary, Lithium Clinics: The Perspective of a Long-Time User.

Clinical Outcomes of a Pharmaceutical Care Service in Lithium Clinic adjunct to Standard Care Compared with Standard Care Alone in Patients with Bipolar Disorder: 10 years Naturalistic Retrospective Cohort Study

Clinical Outcomes of a Pharmaceutical Care Service in Lithium Clinic adjunct to Standard Care Compared with Standard Care Alone in Patients with Bipolar Disorder: 10 years Naturalistic Retrospective Cohort Study

Patients receiving lithium therapy have a reduced prevalence of neurological and cardiovascular disorders

A variety of evidence from laboratory and animal studies suggests that lithium has neurotrophic and cytoprotective properties, and may ameliorate or prevent some disease states. We investigated whether such a protective effect can be observed in human psychiatric patients receiving lithium therapy. We carried out a retrospective chart review of 1028 adult psychiatric male and female outpatients attending four lithium clinics in metropolitan New York City. Patients were divided into two groups based on lithium usage, and the prevalence of neurological and cardiovascular disorders was compared. The main outcome measures were the occurrence in the two patient groups of a variety of neurological disorders and myocardial infarction. Odds ratios were calculated to assess the risk of having a disorder for patients receiving lithium compared to patients not receiving lithium: for seizures, the odds ratio was 0.097; for amyotrophic lateral sclerosis, the odds ratio was 0.112; for dementia not otherwise specified, the odds ratio was 0.112; and for myocardial infarction, the odds ratio was 0.30. Logistical regression analysis showed that lithium treatment is a significant negative predictive factor in the prevalence of each of these disease states, when age, duration of clinic attendance, and use of anti-psychotic medications are taken into account. Our results show that patients receiving regular lithium treatment have a reduced prevalence of some neurological disorders and myocardial infarctions. One possible explanation of these results is that a protective effect of lithium observed in laboratory and animal studies may also be present in human patients receiving regular lithium therapy.

Renal function during long-term lithium treatment: a cross-sectional and longitudinal study.

BackgroundThe effects of lithium treatment on renal function have been previously shown, albeit with discrepancies regarding their relevance. In this study, we examined glomerular filtration rate in patients treated with lithium for up to 33 years.MethodsAll lithium patients registered from 1980 to 2012 at a Lithium Clinic were screened. Estimated glomerular filtration rate (eGFR) was calculated from serum creatinine concentration using the Modification of Diet in Renal Disease Study Group equation. A cross-sectional evaluation of the last available eGFR of 953 patients was carried out using multivariate regression analysis for gender, current age, and duration of lithium treatment. Survival analysis was subsequently applied to calculate the time on lithium needed to enter the eGFR ranges 45 to 59 mL/min/1.73 m2 (G3a) or 30 to 44 mL/min/1.73 m2 (G3b). Finally, 4-year follow-up of eGFR was examined in subgroups of patients who, after reduction to an eGFR lower than 45 mL/min/1.73 m2 either i) continued lithium at the same therapeutic range or ii) discontinued lithium or continued at concentrations below the therapeutic range (0.5 mmol/L).ResultsIn the cross-sectional evaluation, eGFR was found to be lower in women (by 3.47 mL/min/1.73 m2), in older patients (0.73 mL/min/1.73 m2 per year of age), and in patients with longer lithium treatment (0.73 mL/min/1.73 m2 per year). Half of the patients treated for longer than 20 years had an eGFR lower than 60 mL/min/1.73 m2. The median time on lithium taken to enter G3a or G3b was 25 years (95% CI, 23.2–26.9) and 31 years (95% CI, 26.6–35.4), respectively. Progression of renal failure throughout the 4-year follow-up after a reduction to an eGFR lower than 45 mL/min/1.73 m2 did not differ between the subgroup who continued lithium as before and the subgroup who either discontinued lithium or continued at concentrations below the therapeutic range.ConclusionsDuration of lithium treatment is to be added to advancing age as a risk factor for reduced glomerular filtration rate. However, renal dysfunction tends to appear after decades of treatment and to progress slowly and irrespective of lithium continuation.

The evolution of psychoeducation for bipolar disorder: from lithium clinics to integrative psychoeducation

Coping and living with bipolar disorder is complex and sometimes counterintuitive. It demands a number of attitudes and aptitudes that include a huge emotional insight, healthy and regular lifestyle, skills to identify subtle changes and motivation to reach full treatment adherence. Patients' engagement and proactive attitude are a must for a successful therapeutic outcome. This may partly explain the therapeutic impact of psychoeducational programs in this disorder. However, the history of group psychoeducation in bipolar disorder is full of ups and downs. Interestingly enough, worldwide-respected opinion leaders in group therapy were initially not very enthusiastic with the use of such strategy with bipolar patients. I. Yalom, for instance, defined a bipolar patient as “one of the worst calamities that could befall group therapy” 1. Since then, the practice of psychoeducation has been evolving together with the conceptualization of bipolar disorder.

Lurasidone and Bipolar Disorder

Lurasidone and Bipolar Disorder

How a local lithium clinic performs in comparison with national data

How a local lithium clinic performs in comparison with national data

Persistence of cognitive impairment and its negative impact on psychosocial functioning in lithium-treated, euthymic bipolar patients: a 6-year follow-up study

Previous cross-sectional studies report that cognitive impairment is associated with poor psychosocial functioning in euthymic bipolar patients. There is a lack of long-term studies to determine the course of cognitive impairment and its impact on functional outcome. Method A total of 54 subjects were assessed at baseline and 6 years later; 28 had DSM-IV TR bipolar I or II disorder (recruited, at baseline, from a Lithium Clinic Program) and 26 were healthy matched controls. They were all assessed with a cognitive battery tapping into the main cognitive domains (executive function, attention, processing speed, verbal memory and visual memory) twice over a 6-year follow-up period. All patients were euthymic (Hamilton Rating Scale for Depression score lower than 8 and Young mania rating scale score lower than 6) for at least 3 months before both evaluations. At the end of follow-up, psychosocial functioning was also evaluated by means of the Functioning Assessment Short Test. Repeated-measures multivariate analysis of covariance showed that there were main effects of group in the executive domain, in the inhibition domain, in the processing speed domain, and in the verbal memory domain (p<0.04). Among the clinical factors, only longer illness duration was significantly related to slow processing (p=0.01), whereas strong relationships were observed between impoverished cognition along time and poorer psychosocial functioning (p<0.05). Executive functioning, inhibition, processing speed and verbal memory were impaired in euthymic bipolar out-patients. Although cognitive deficits remained stable on average throughout the follow-up, they had enduring negative effects on psychosocial adaptation of patients.

Lithium and prevention of cognitive impairment.

To examine the rate of cognitive decline and occurrence of dementia among patients attending a lithium clinic for those aged 65 years and over. Retrospective chart review of the cognitive function of 29 patients receiving maintenance lithium treatment attending the Dublin South East Old Age Psychiatry service, over a nine-year time period. Twenty-nine patients were included in the study (20 female, nine males), with a mean age of 79 years. Two patients had concurrent dementia. Six patients fulfilled ICD10 criteria for mild cognitive disorder and all of these patients also fulfilled revised consensus criteria for mild cognitive impairment amnestic subtype. Sixteen patients were commenced on lithium as an augmentation treatment for recurrent depressive disorder, 12 patients were on treatment for bipolar affective disorder and one patient on treatment for schizoaffective disorder. Patients had been receiving lithium treatment for an average of 109 months with follow-up by the service for a mean duration of 38 months. The initial mean MMSE score of patients at first presentation to the service was 26.9 (SD = 5.6) compared to a mean MMSE score 25.8 (SD = 5.8) (CI of change in MMSE score at 95% level = -2.1 and 0) at follow-up. The mean MMSE of patients with mild cognitive impairment prior at first contact with the service was 26.8 (SD = 3.2) and at follow-up was 26 (SD = 3.2) which was not statistically significantly different (p=0.40) (CI for change in MMSE at 95% level = -3.2 to 1.5). No patient had developed incident dementia during the follow-up period of the study. The results tentatively suggest that lithium may have a protective effect against cognitive decline and a neuroprotective role in patients with concurrent affective disorder and cognitive impairment. Multi-centre prospective studies of cognitive function in patients attending lithium clinics are needed to examine the neuroprotective properties of lithium.

Association between lithium serum level, mood state, and patient‐reported adverse drug reactions during long‐term lithium treatment: a naturalistic follow‐up study

To assess the association between mood state and the prevalence and the severity of lithium adverse drug reactions (ADRs). A 26-year follow-up study was conducted among patients > or =18 years treated at the outpatient lithium clinic of the University Medical Center Groningen, The Netherlands, between November 1973 and December 2000. At each monthly scheduled visit, patients were questioned by a research nurse in a standardized manner about the presence and the severity of nine specific ADRs that frequently occur as a consequence of lithium treatment and that can be identified by the patients themselves. In addition, lithium serum level was measured and mood state was rated at each visit. A total of 186 patients participated and the median duration of follow-up was 5.7 years (interquartile range 2.2-11.8 years). We observed an increased prevalence and severity of ADRs with increased lithium serum level (p < 0.05), also when adjusting for mood state. The prevalence and the severity of ADRs increased with decreasing mood state into the depressive range and decreased with mood state increasing into the manic range (p < 0.05), also when adjusting for lithium serum level. Taking into account the intraindividual dependency of the data resulted in a statistically significant (p < 0.001) association between, respectively, lithium serum level, mood state, and the prevalence and severity of ADRs. Both physicians and researchers need to be aware that lithium serum level and mood state are independently associated with patient reporting and severity scoring of ADRs, which may complicate objective assessment of ADRs.

Trastorno bipolar: ¿qué efecto tiene el cumplimiento terapéutico en el riesgo de conductas suicidas?

Bipolar disorder is associated with high risk for suicidal behavior. Lack of adherence to treatment is one factor that may be partly responsible for this common complication. We searched MEDLINE with the combination of the key words "compliance" or "adherence" with "suicide" and "bipolar", limited to English language papers published between 1990 and July 2008.We evaluate the existent literature studying the influence of treatment adherence on suicidality among these patients. Our findings show a limited number of studies addressing this issue, mostly conducted with patients enrolled in lithium clinics. Results suggest an association between non-adherence and an increased risk of suicidal behavior among bipolar patients. Whether non-adherence leads to increase risk of suicidality due to specific properties of interventions such as lithium treatment or simply is secondary to mood stabilization is still an open question.

Treatment Patterns for Schizoaffective Disorder and Schizophrenia Among Medicaid Patients

Treatment Patterns for Schizoaffective Disorder and Schizophrenia Among Medicaid Patients

Treatment Patterns for Schizoaffective Disorder and Schizophrenia Among Medicaid Patients

This study compared background characteristics, pharmacologic treatment, and service use of adults treated for schizoaffective disorder and adults treated for schizophrenia. Medicaid claims data from two states were analyzed with a focus on adults treated for schizoaffective disorder or schizophrenia. Patient groups were compared regarding demographic characteristics, pharmacologic treatment, and health service use during 180 days before and after a claim for either schizophrenia or schizoaffective disorder. A larger proportion of patients were treated for schizophrenia (N=38,760; 70.1%) than for schizoaffective disorder (N=16,570; 29.9%). During the 180 days before the index diagnosis claim, significantly more patients with schizoaffective disorder than those with schizophrenia were treated for depressive disorder (19.6% versus 11.4%, p<.001), bipolar disorder (14.8% versus 5.8%, p<.001), substance use disorder (11.8% versus 9.7%, p<.001), and anxiety disorder (6.9% versus 5.3%, p<.001). After the index claim, a similar proportion of both diagnostic groups were treated with antipsychotic medications (schizoaffective disorder, 87.3%; schizophrenia, 87.0%), although patients with schizoaffective disorder were significantly more likely than patients with schizophrenia to receive antidepressants (61.7% versus 44.0%, p<.001), mood stabilizers (55.2% versus 34.4%, p<.001), and anxiolytics (43.2% versus 35.1%, p<.001). Patients with schizoaffective disorder were also significantly more likely than patients with schizophrenia to receive psychotherapy (23.4% versus 13.0%, p<.001) and inpatient mental health care (9.4% versus 6.2%, p<.001), although the latter was not significant after the analysis controlled for background characteristics. Schizoaffective disorder is commonly diagnosed among Medicaid beneficiaries. These patients often receive complex pharmacologic regimens, and many also receive treatment for mood disorders. Differences in service use patterns between schizoaffective disorder and schizophrenia argue for separate consideration of their health care needs.

Einblicke in die zentrale serotonerge Funktion bei Patienten mit affektiven Störungen

The simple insight in the central serotonergic activity would allow a more specific pharmacotherapy of disorders with serotonergic deficits and could thus serve as a predictive parameter. An antidepressive treatment could be chosen due to the verification or falsification of such a deficit with a serotonergic or noradrenergic substance. In search of predictive parameters we have investigated the loudness dependence of auditory evoked potentials (LDAEP), a parameter that has already been discussed concerning this matter, and serotonin levels in the human blood serum regarding their correlation. Eight outpatients of a lithium clinics were investigated neurophysiologically after blood samples had been taken. A significant negative correlation between LDAEP and serotonin level in the serum was found, a low serotonin level correlates with a high LDAEP. The result of this pilot study justifies further investigations with larger sample sizes. In case of further and stable evidence the use of serotonin levels in the serum as a predicitve parameter is conceivable.

Long-Term Stability of Cognitive Impairment in Bipolar Disorder

To determine the course of cognitive impairment of bipolar disorder with a 2-year longitudinal study and to investigate whether the neuropsychological profile is related to clinical and psychosocial variables in a sample of lithium-treated euthymic bipolar outpatients. Thirty-three bipolar disorder patients (all of whom were diagnosed according to DSM-IV-TR criteria and were treated during 2003 at the Lithium Clinic Program at Santa Maria Hospital, Lleida, Spain) and 33 healthy, matched controls were cognitively assessed twice over a 2-year follow-up period. All patients were receiving the same mood-stabilizer pharmacotherapy (lithium) at the first evaluation, and they were euthymic (Hamilton Rating Scale for Depression score lower than 8 and Young Mania Rating Scale score lower than 6) for at least 3 months before both evaluations. Cognitive assessment was performed by means of a neuropsychological test battery tapping into the main cognitive domains (executive function, attention, processing speed, verbal memory, and visual memory). Repeated-measures multivariate analysis of covariance showed that there were main effects of group in the executive domain (p < .04) and in processing speed (p < .04). Multiple linear regression analysis showed that none of the variables predicted psychosocial functioning (as measured with the Global Assessment of Functioning scale) (R(2) = 0.12, F = 2.08, p = .1). Multilevel logistic regression analysis showed that processing speed appeared to be significant as an indicator of low work activity (Exp[B] = 1.25, 95% CI = 1.005 to 1.547, p = .04). Executive function and processing speed are the cognitive domains affected in euthymic bipolar outpatients, and such deficits are maintained over time. Our results show that executive dysfunction is the main long-term neuropsychological deficit of bipolar disorder. Slower processing seems to be related to worse work adaptation.