Lithium Prescribing Research Articles

Lithium Prescribing on an Older Adult Inpatient Ward and Trialling Improvements to Communication on Discharge

Lithium Prescribing on an Older Adult Inpatient Ward and Trialling Improvements to Communication on Discharge

Joint primary and secondary care study of lithium prescribing and monitoring

Lithium is licensed for the treatment and prophylaxis of mania, bipolar disorder, recurrent depression and intentional self‐harming behaviour. Despite its effectiveness, lithium use is complicated by its narrow therapeutic range. In 2009, the National Patient Safety Agency issued a safety alert highlighting the issues and requested NHS organisations ensure reliable systems and monitoring were in place. This article explores how well the guidelines are followed in terms of lithium prescribing and monitoring across primary and secondary care.

Ten-Year Trends in Lithium Prescribing in Alberta, Canada.

Despite lithium's clinical efficacy, it is commonly thought that its use is declining. The objective of this study is to describe the new and prevalent lithium users as well as rates of discontinuation of lithium use over a 10-year period. This study used provincial administrative health data from Alberta, Canada between January 1, 2009 and December 31, 2018. Lithium prescriptions were identified within the Pharmaceutical Information Network database. Total and subgroup specific frequencies of new and prevalent lithium use were determined over the 10-year study period. Lithium discontinuation was also estimated through survival analysis. Between the calendar years of 2009 and 2018, 580,873 lithium prescriptions were dispensed in Alberta to 14,008 patients. The total number of new and prevalent lithium users appears to be decreasing over the 10-year timeframe, although the decline may have stopped or reversed in the latter years of the study period. Prevalent use of lithium was lowest among individuals between the ages of 18-24 years while the highest number of prevalent users were in the 50-64 age group, particularly among females. New lithium use was lowest amongst those 65 years and older. More than 60% (8,636) of patients prescribed lithium, discontinued use during the study timeframe. Lithium users between ages of 18-24 years were at the highest risk of discontinuations. Rather than a general decline in prescribing, trends in lithium use are dependent on age and sex. Further, the period soon after lithium initiation appears to be a key time period in which many lithium trials are abandoned. Detailed studies using primary data collection are needed to confirm and further explore these findings. These population-based results not only confirm a decline in lithium use, but also suggest that this may have stopped or even reversed. Population-based data on discontinuation pinpoint the period soon after initiation as the time when trials are most often discontinued.

The highs and lows of prescribing and monitoring lithium safely

Lithium has an important role in the management of bipolar disorder and treatment‐resistant depression but its narrow therapeutic window means that careful monitoring is needed. This article discusses the investigations, monitoring requirements, drug interactions and complications to be aware of to ensure lithium prescribing is as safe as possible.

Clinical Audit of the Awareness of Safety Guidelines on Lithium Prescribing Within the Acute Hospital- James Cook University Hospital

AimsLithium is a useful drug and is of particular benefit in patients with chronic mood disorders like bipolar affective disorder and recurrent depression. Lithium requires careful monitoring and dose adjustment for safe use due to its narrow therapeutic index and high potential for toxicity. Monitoring must carry on even when mental health patients taking Lithium are admitted to acute hospital. Therefore, the main aim of this clinical audit was to evaluate the level of awareness of the lithium safety guidance amongst medical staff working within the Acute Hospital, James Cook University Hospital. Ideally 100% of staff should have the appropriate knowledge.MethodsQuestionnaire consisted of 6 items which were derived from key points within the Trust guidelines for Lithium. It was designed to highlight the key points in the document and check the level of awareness of the respondents. Respondents were drawn from James Cook University Hospital and South Tees Liaison Psychiatry team. A total of 25 respondents were included in the study.Results96% (24/25) of the respondents were aware that renal and thyroid function should be checked for patients on Lithium. 84% (21/25) were aware of the potential impact of Lithium on Kidney function (eGFR) and 68% (17/25) were aware of signs of Lithium toxicity.60% (15/25) of acute staff were aware about referring patients with deranged Lithium levels to the Liaison Psychiatry team. 40% (10/25) were aware of the drugs that could potentially increase lithium levels like Diuretics, Non-steroidal anti-inflammatory drugs, ACE (angiotensin converting enzyme) inhibitors. Only 24% (6/25) of acute trust staff were aware about checking lithium levels on admission.ConclusionIdeally, a 100% compliance and positive response rate should be achieved as these relate to completion of expected safety checks. Lithium is a potentially high-risk drug with a narrow therapeutic index. Possibility of its acute and chronic side effects, including lithium toxicity, makes it essential to follow safety guidelines on lithium prescribing and hence ensure patient safety.In view of this, the clinical audit results clearly show that there is significant room for improvement to achieve a 100% positive response rate for awareness of safety guidelines on Lithium prescribing.Overall, there were an average of 57% positive responses and 42% negative responses for awareness of various aspects of the safety guidelines for Lithium.A robust action plan which included teaching sessions on creating awareness about lithium monitoring was planned because of this audit.

Combining schizophrenia and depression polygenic risk scores improves the genetic prediction of lithium response in bipolar disorder patients

Lithium is the gold standard therapy for Bipolar Disorder (BD) but its effectiveness differs widely between individuals. The molecular mechanisms underlying treatment response heterogeneity are not well understood, and personalized treatment in BD remains elusive. Genetic analyses of the lithium treatment response phenotype may generate novel molecular insights into lithium’s therapeutic mechanisms and lead to testable hypotheses to improve BD management and outcomes. We used fixed effect meta-analysis techniques to develop meta-analytic polygenic risk scores (MET-PRS) from combinations of highly correlated psychiatric traits, namely schizophrenia (SCZ), major depression (MD) and bipolar disorder (BD). We compared the effects of cross-disorder MET-PRS and single genetic trait PRS on lithium response. For the PRS analyses, we included clinical data on lithium treatment response and genetic information for n = 2283 BD cases from the International Consortium on Lithium Genetics (ConLi+Gen; www.ConLiGen.org). Higher SCZ and MD PRSs were associated with poorer lithium treatment response whereas BD-PRS had no association with treatment outcome. The combined MET2-PRS comprising of SCZ and MD variants (MET2-PRS) and a model using SCZ and MD-PRS sequentially improved response prediction, compared to single-disorder PRS or to a combined score using all three traits (MET3-PRS). Patients in the highest decile for MET2-PRS loading had 2.5 times higher odds of being classified as poor responders than patients with the lowest decile MET2-PRS scores. An exploratory functional pathway analysis of top MET2-PRS variants was conducted. Findings may inform the development of future testing strategies for personalized lithium prescribing in BD.

402 - An audit of Lithium Prescribing Practices in an Old Age PsychiatryService highlighting renal impairment in this cohort

AbstractAims:To compare Lithium prescribing practices in a Psychiatry of Old Age (POA) Service in the North-West ofIreland among adults aged 65 years and over with best practice guidelines.Methods:Review of the literature informed development of audit standards for Lithium prescribing. These included National Institute for Clinical Excellent (NICE) 2014 guidelines, The British National Formulary(2019) and Maudsley Prescribing Guidelines (2018). Data was collected retrospectively, using an audit-specific data collection tool, from clinical files of POA team caseload, aged 65 years or more and prescribed Lithium over the past year.Results:At the time of audit in February 2020, 18 patients were prescribed lithium, 67% female, average age 74.6 years. Of those prescribed Lithium; 50% (n=9) had depression, 44% (n=8) had bipolar affective disorder (BPAD) and 6% (n=1) schizoaffective disorder.78% (n= 14) of patients met the NICE standard of 3-monthly lithium level. Lithium levels were checkedon average 4.5 times in past year, average lithium level was 0.61mmol/L across the group and 39% (n=7) had lithium level within recommended therapeutic range (0.6-0.8mmol/L).83% of patients (n=15) met the NICE standards of 3 monthly renal tests. Taking into consideration mostrecent blood test results, 100% (n=18) had abnormal renal function.Half (n=9) were initiated on lithium by POA service and of these, 56% (n=5) had documented renal impairment prior to initiation. Of patients on long term lithium at time of referral (n=9), almost half (n=4) had a documented history of lithium toxicity.Conclusions:The results of this audit highlight room for improvement in lithium monitoring of older adults attending POA service. Furthermore, all patients prescribed lithium had impaired renal function. This is an important finding given the associations between those admitted to hospital with COVID-19 and co- morbid kidney disease and increased risk of inpatient death.Our findings highlight the need for three monthly renal function monitoring in elderly prescribed lithiumgiven the additive adverse effects of increasing age and lithium on the kidney. Close working with specialised renal services to provide timely advice on renal management for those with renal impairment prescribed lithium is important to minimise adverse patient outcomes.

An audit of lithium prescribing practices in an old age psychiatry service highlighting renal impairment in this cohort

AimsTo compare Lithium prescribing practices in a Psychiatry of Old Age (POA) Service in the North-West of Ireland among adults aged 65 years and over with best practice guidelines.MethodReview of the literature informed development of audit standards for Lithium prescribing. These included National Institute for Clinical Excellent (NICE) 2014 guidelines, The British National Formulary (2019) and Maudsley Prescribing Guidelines (2018). Data were collected retrospectively, using an audit-specific data collection tool, from clinical files of POA team caseload, aged 65 years or more and prescribed Lithium over the past one year.ResultAt the time of the audit in February 2020, 18 patients were prescribed lithium, 67% female, average age 74.6 years. Of those prescribed Lithium; 50% (n = 9) had a depression diagnosis, 44% (n = 8) had bipolar affective disorder (BPAD) and 6% (n = 1) had schizoaffective disorder.78% (n = 14) of patients were on track to meet, or had already met, the NICE standard of 3-monthly serum lithium level. Lithium levels were checked on average 4.5 times in past one year, average lithium level was 0.61mmol/L across the group and 39% (n = 7) had lithium level within recommended therapeutic range (0.6-0.8mmol/L).83% (n = 15) of patients met the NICE standards of 3 monthly renal tests, thyroid function test was performed in 89% (n = 16) and at least one serum calcium level was documented in 63% (n = 15). Taking into consideration most recent blood test results, 100% (n = 18) had abnormal renal function, 78% (n = 7) had abnormal thyroid function and 60% (n = 9) had abnormal serum calcium.Half (n = 9) were initiated on lithium by POA service and of these, 56% (n = 5) had documented renal impairment prior to initiation. Of patients on long term lithium therapy at time of referral (n = 9), almost half (n = 4) had a documented history of lithium toxicity.ConclusionThe results of this audit highlight room for improvement in lithium monitoring of older adults attending POA service. Furthermore, all patients prescribed lithium had impaired renal function, half had abnormal calcium and two fifths had abnormal thyroid function. This is an important finding given the associations between those admitted to hospital with COVID-19 and comorbid kidney disease and increased risk of inpatient death.Our findings highlight the need for three monthly renal function monitoring in older adults prescribed lithium given the additive adverse effects of increasing age and lithium on the kidney. Close working with specialised renal services to provide timely advice on renal management for those with renal impairment prescribed lithium is important to minimise adverse patient outcomes.

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

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.

Lithium exposure in pregnancy found generally safe; risk is higher early

In findings not consistent with guidelines that have discouraged the prescribing of lithium for pregnant women, a systematic review and meta‐analysis has concluded that the risk associated with lithium exposure at any time in pregnancy is relatively low. The researchers suggested that since the risk of malformations is highest with lithium use in the first trimester, dosages early in pregnancy should be adjusted to the lower end of the therapeutic range. Findings were published online Oct. 18 in the American Journal of Psychiatry.

Changes in prescribing for bipolar disorder between 2009 and 2016: national-level data linkage study in Scotland.

People with bipolar disorder typically require long-term pharmacological treatment to prevent episodes of depression or mania. However, evidence-based guidelines are often not followed by prescribers and, in some countries, prescribing of lithium is in decline. Polypharmacy is also common in bipolar disorder.AimsTo employ a data linkage approach to describe and evaluate prescribing patterns in bipolar disorder in Scotland between 2009 and 2016. By linking prescribing data to the electronic Scottish Morbidity Records, we identified a cohort of 23 135 patients with bipolar disorder who were prescribed psychotropic medication between 2009 and 2016. We examined trends in proportions of patients prescribed each of six drug categories. Random effects logistic models examined change in prescribing over years of interest. The most common form of treatment was antidepressant monotherapy (24.96%), with only 5.90% of patients receiving lithium monotherapy. Prescribing of antipsychotics and anti-epileptics increased from 2009 to 2016 (antipsychotics: odds ratio 1.16, 95% CI 1.15-1.18; anti-epileptics: odds ratio 1.34, 95% CI 1.32-1.36), whereas prescribing of lithium decreased (odds ratio 0.83, 95% CI 0.82-0.85). Prescribing of valproate decreased from 2009-2016 in women, but increased in men (women: odds ratio 0.93, 95% CI 0.90-0.97; men: odds ratio 1.11, 95% CI 1.04-1.18). Antidepressant monotherapy was the most common form of treatment for bipolar disorder in Scotland and prescribing of lithium has declined between 2009 and 2016. The findings are concerning and represent a gap between treatment guidelines and clinical practice.Declaration of interestNone.

Can an Integrated Science Approach to Precision Medicine Research Improve Lithium Treatment in Bipolar Disorders?

Clinical practice guidelines identify lithium as a first line treatment for mood stabilization and reduction of suicidality in bipolar disorders (BD); however, most individuals show sub-optimal response. Identifying biomarkers for lithium response could enable personalization of treatment and refine criteria for stratification of BD cases into treatment-relevant subgroups. Existing systematic reviews identify potential biomarkers of lithium response, but none directly address the conceptual issues that need to be addressed to enhance translation of research into precision prescribing of lithium. For example, although clinical syndrome subtyping of BD has not led to customized individual treatments, we emphasize the importance of assessing clinical response phenotypes in biomarker research. Also, we highlight the need to give greater consideration to the quality of prospective longitudinal monitoring of illness activity and the differentiation of non-response from partial or non-adherence with medication. It is unlikely that there is a single biomarker for lithium response or tolerability, so this review argues that more research should be directed toward the exploration of biosignatures. Importantly, we emphasize that an integrative science approach may improve the likelihood of discovering the optimal combination of clinical factors and multimodal biomarkers (e.g., blood omics, neuroimaging, and actigraphy derived-markers). This strategy could uncover a valid lithium response phenotype and facilitate development of a composite prediction algorithm. Lastly, this narrative review discusses how these strategies could improve eligibility criteria for lithium treatment in BD, and highlights barriers to translation to clinical practice including the often-overlooked issue of the cost-effectiveness of introducing biomarker tests in psychiatry.

Association of Polygenic Score for Schizophrenia and HLA Antigen and Inflammation Genes With Response to Lithium in Bipolar Affective Disorder

ImportanceLithium is a first-line mood stabilizer for the treatment of bipolar affective disorder (BPAD). However, the efficacy of lithium varies widely, with a nonresponse rate of up to 30%. Biological response markers are lacking. Genetic factors are thought to mediate treatment response to lithium, and there is a previously reported genetic overlap between BPAD and schizophrenia (SCZ).ObjectivesTo test whether a polygenic score for SCZ is associated with treatment response to lithium in BPAD and to explore the potential molecular underpinnings of this association.Design, Setting, and ParticipantsA total of 2586 patients with BPAD who had undergone lithium treatment were genotyped and assessed for long-term response to treatment between 2008 and 2013. Weighted SCZ polygenic scores were computed at different P value thresholds using summary statistics from an international multicenter genome-wide association study (GWAS) of 36 989 individuals with SCZ and genotype data from patients with BPAD from the Consortium on Lithium Genetics. For functional exploration, a cross-trait meta-GWAS and pathway analysis was performed, combining GWAS summary statistics on SCZ and response to treatment with lithium. Data analysis was performed from September 2016 to February 2017.Main Outcomes and MeasuresTreatment response to lithium was defined on both the categorical and continuous scales using the Retrospective Criteria of Long-Term Treatment Response in Research Subjects with Bipolar Disorder score. The effect measures include odds ratios and the proportion of variance explained.ResultsOf the 2586 patients in the study (mean [SD] age, 47.2 [13.9] years), 1478 were women and 1108 were men. The polygenic score for SCZ was inversely associated with lithium treatment response in the categorical outcome, at a threshold P < 5 × 10−2. Patients with BPAD who had a low polygenic load for SCZ responded better to lithium, with odds ratios for lithium response ranging from 3.46 (95% CI, 1.42-8.41) at the first decile to 2.03 (95% CI, 0.86-4.81) at the ninth decile, compared with the patients in the 10th decile of SCZ risk. In the cross-trait meta-GWAS, 15 genetic loci that may have overlapping effects on lithium treatment response and susceptibility to SCZ were identified. Functional pathway and network analysis of these loci point to the HLA antigen complex and inflammatory cytokines.Conclusions and RelevanceThis study provides evidence for a negative association between high genetic loading for SCZ and poor response to lithium in patients with BPAD. These results suggest the potential for translational research aimed at personalized prescribing of lithium.

Molecular mechanisms in lithium-associated renal disease: a systematic review.

Lithium is an essential treatment in bipolar disorder and treatment-resistant depression; however, its use has been limited by concerns regarding its renal adverse effects. An improved understanding of potential molecular mechanisms can help develop prevention and treatment strategies for lithium-associated renal disease. We conducted a systematic literature search using MEDLINE, Embase, and PsychINFO including English-language original research articles published prior to November 2015 that specifically investigated lithium's effects on nephrogenic diabetes insipidus (NDI) and chronic kidney disease (CKD), using molecular markers. From a total of 3510 records, 71 pre-clinical studies and two relevant clinical studies were identified. Molecular alterations were reported in calcium signaling, inositol monophosphate, extracellular-regulated, prostaglandin, sodium/solute transport, G-protein-coupled receptors, nitric oxide, vasopressin/aquaporin, and inflammation-related pathways in lithium-associated renal disease. The majority of studies found that these mechanisms were implicated in NDI, while few studies had examined CKD. Future studies will have to focus on (1) validating the present findings in human subjects and (2) examining CKD, which is the most clinically relevant lithium-associated renal effect. This will improve our understanding of lithium's biological effects, as well as inform a personalized medicine approach, which could lead to safer lithium prescribing and less renal adverse events.

Lithium Remains a Viable Option for People With Bipolar Disorder

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessLithium Remains a Viable Option for People With Bipolar DisorderVabren WattsVabren WattsSearch for more papers by this authorPublished Online:6 Jul 2015https://doi.org/10.1176/appi.pn.2015.7a15AbstractDespite studies demonstrating the effectiveness of lithium for the treatment of bipolar disorder, its use in clinical practice in the United States is declining, experts say.“Who here has heard of lithium?” asked Michael Ostacher, M.D., an associate professor of psychiatry at Stanford University School of Medicine, during a session at APA’s 2015 annual meeting in May on treating bipolar disorder. Michael Ostacher, M.D., believes that it’s important to continue research on all treatments for bipolar disorder, even treatments that are less utilized such as lithium.David HathcoxOstacher deemed the question—which was followed by a light chuckle from the audience—as relevant because though the drug has been a well-established treatment for bipolar disorder for 45 years, its use, at least in the United States, is declining. “This decline [in lithium prescribing] is understandable,” said Ostacher, who explained to session attendees that the underutilization of the drug may be partly attributed to the marketing surge for other FDA-approved drugs for the treatment of bipolar disorder. According to Ostacher, previous research from insurance databases in the United States suggests antidepressants—initiated at diagnosis and continually used one year after diagnosis—are the most commonly prescribed therapy for bipolar disorder. This research shows that 70 percent of individuals diagnosed with bipolar disorder have been prescribed antidepressants compared with roughly 12 percent who have been prescribed lithium.During his talk, Ostacher presented data from his recent work comparing the effectiveness of lithium with that of other medications in the treatment of bipolar disorder, including the results of BALANCE (Bipolar Affective disorder Lithium/Anticonvulsant Evaluation)—a multisite, randomized, open-labeled comparison study with lithium and the anticonvulsive divalproex. The study, which included 330 adults with bipolar I disorder, showed that the risk of symptom relapse was reduced by 41 percent in patients who took a combined daily dosage of lithium (0.4 mmol) and divalproex (1,250 mg) over a two-year period. The risk of symptom relapse was reduced by 29 percent in patients who took lithium alone and 18 percent in patients who took divalproex alone.“This primarily said that lithium or lithium in combination with divalproex was more effective than divalproex alone,” said Ostacher. “This totally contradicts the way we initiate treatment for bipolar disorder in our patients in the U.S.” Ostacher mentioned that one of the limitations of the study was that most of the sample population was on a monotherapy prior to the study, whereas a significant number of people, particularly in the United States, take multiple medications at once. A study by Andrew Nierenberg, M.D., and colleagues compared the effectiveness of lithium with the antipsychotic quetiapine in 482 patients with bipolar I or bipolar II disorder and at least one comorbid mental health condition. The patients were given a mean dose of 1,008 mg of lithium or a mean dose of 345 mg of quetiapine daily for six months while continuing to take medications for their other mental health conditions. The researchers tracked changes in the severity of bipolar disorder–related symptoms reported by patients—as measured by the scale of Clinical Global Impression for Bipolar Disorder Efficacy Index (CGI-BP EI)—and how frequently providers altered dosages of the medications due to side effects or lack of efficacy, known as necessary clinical adjustments (NCAs). The analysis found both lithium and quetiapine to be equally effective in reducing symptom severity related to bipolar I and II disorder in patients at the study end point. However, the lithium group had significantly fewer NCAs per month than the quetiapine group.After the session, Ostacher told Psychiatric News that “if we learn how to use it properly and safely in patients, lithium can be a mainstay medication for some patients.” He emphasized that it is important for experts in the field to conduct more reliable studies that will provide confident enough results that would increase lithium use in clinical practice. “There are multiple treatment options available to treat bipolar disorder. We just need to have enough information—on all options—to be able to determine which option is best for our patients,” Ostacher concluded. ■ ISSUES NewArchived

Lithium prescribing during pregnancy: a UK primary care database study.

BackgroundWomen taking lithium must decide whether to continue the medication if they conceive or plan to conceive. Little is known about the extent of prescribing of lithium during pregnancy.AimsTo determine: 1) the prevalence of lithium prescribing during pregnancy and 2) to assess whether pregnancy is associated with discontinuation of lithium.MethodFirst, we identified women receiving any lithium prescriptions before and during pregnancy using The Health Improvement Network (THIN) primary care database. Subsequently, we used a Kaplan-Meier plot to compare time to last prescription in women prescribed lithium continuously three months before pregnancy and a comparison group of non-pregnant women. Finally, we described the characteristics of the women prescribed lithium in pregnancy.ResultsVery few women were prescribed lithium during pregnancy; out of 458,761 pregnancies, we identified 47 (0.01%) in which lithium was prescribed after the 6th week of pregnancy (when the pregnancy was likely to be known). In our study of discontinuation, we found pregnant women were more likely to stop lithium than those who were not pregnant. Of the 52 women who were being continuously prescribed lithium three months before pregnancy, only 17 (33%) continued receiving prescriptions beyond the 6th week of pregnancy. However, most of these 17 women continued treatment throughout pregnancy.ConclusionsPregnancy was strongly associated with discontinuation of lithium. Further evidence on the risks of lithium is needed so that women can weight these against the risk of a deterioration in maternal mental health.

Undertaking clinical audit, with reference to a Prescribing Observatory for Mental Health audit of lithium monitoring

Audit is an important tool for quality improvement. The collection of data on clinical performance against evidence-based and clinically relevant standards, which are considered by clinicians to be realistic in routine practice, can usefully prompt reflective practice and the implementation of change. Evidence of participation in clinical audit is required to achieve intended learning outcomes for trainees in psychiatry and revalidation for those who are members of the Royal College of Psychiatrists. This article addresses some of the practical steps involved in conducting an audit project, and, to illustrate key points, draws on lessons learnt from a national, audit-based, quality improvement programme of lithium prescribing and monitoring conducted through the Prescribing Observatory for Mental Health.

Monitoring lithium therapy: the impact of a quality improvement programme in the UK

The study was designed to test an audit-based quality improvement programme (QIP) addressing lithium prescribing and monitoring in UK mental health services. A baseline clinical audit was conducted against the following standards: (i) measurement of renal and thyroid function before initiating treatment with lithium and (ii) recommended monitoring of serum lithium and renal and thyroid function during maintenance treatment. A re-audit was conducted at 18 months and a supplementary audit at three years. Data were submitted for patients at baseline (n = 3,373), re-audit (n = 3,647), and supplementary audit (n = 5,683), 57% of whom had bipolar disorder. The baseline findings prompted a patient safety alert issued by the National Patient Safety Agency. By supplementary audit, the proportion of patients having four serum lithium tests over the previous year had increased from 30% at baseline to 48%, and the respective proportions that had two tests of renal function from 55% to 70% and thyroid function from 49% to 66%. Elderly patients and those prescribed a drug known to interact with lithium were not more likely to be monitored in line with the audit standards. Between baseline and supplementary audit, the proportion of patients with a diagnosis of bipolar disorder prescribed an antidepressant increased from 36% to 41%. Improvements in biochemical monitoring of lithium treatment were achieved over time with participation in a QIP that included benchmarking of performance against clinical standards and customized change interventions. Nevertheless, gaps remain between the standard and current practice. Antidepressants are frequently prescribed in patients with bipolar disorder despite a paucity of evidence supporting their efficacy.

P-1073 - An examination of current clinical performance with regards to safe lithium prescribing and monitoring in our inpatient unit

Introduction Lithium is a widely used pharmacological agent with efficacy in the management of affective disorders. Lithium has a narrow therapeutic range with a clear propensity to cause toxicity. Optimisation of safe lithium use mandates knowledge of the clinical features of lithium toxicity, drug interactions and other risk factors/clinical situations that may precipitate toxicity. Such knowledge may facilitate reversal or minimisation of risk factors. Aims Evaluate current levels of safe prescribing and monitoring of lithium with focus on clinical areas aforementioned. Objectives Ascertain current safety standards of lithium use and subsequently deliver clinical sessions concentrated on knowledge deficits identified in the audit hence maximising safety for our patients. Methods This audit devised a local standard for safe prescription and monitoring of lithium via consulting the pharmacy department, BNF and NICE guidelines 2006. A random sample (n = 50) of medical and nursing staff involved in the care of patients on lithium therapy was obtained. Three four-item multiple choice questions were devised for medical and nursing staff with distinct questions for each discipline focusing on important clinical situations and risk factors in lithium use. The audit was anonymous but details were collected on the healthcare role and level of training. Participants also selected their level of confidence for answering each question on a five item scale. Results Data processing is underway for this audit however at this preliminary stage important trends indicating opportunities to improve clinical knowledge and practice are identifiable. Conclusions Conclusions will be made once data processing is complete.

The incidence and clinical correlates of lithium toxicity: a retrospective review

Lithium is a commonly prescribed pharmacological treatment for mood disorders. It is associated with a number of side effects and potentially serious toxicity. To date, there is little data from Irish samples on the subject of Lithium toxicity. To examine the incidence and clinical correlates of lithium toxicity in Cork, Ireland. Our study identified 130 cases of biochemical lithium toxicity over 5 years, with an incidence rate of approximately 5.4 cases per 100,000 per year. Mean toxic lithium level was 2.16 mmol/L ±SD 0.87 mmol/L. Of these, 36% cases were reviewed medically in the general hospital at the time of toxicity. A number of issues in relation to lithium toxicity were identified. Neurological symptoms were common, including tremor, confusion, ataxia, drowsiness. However, only 4.2% patients were reviewed by a neurologist while in hospital. Medications that interact with lithium were found in 50% cases, with significant polypharmacy in 15%. The psychiatric services were involved in patient care in 76% cases, and 85% patients presenting with toxicity were reviewed by a psychiatrist. Rates of admission to hospital and haemodialysis were 70 and 11%, respectively. Improvements in the standards of care in relation to lithium prescribing are required.