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Lithium in mood disorders; A One-sided Re-appraisal
Lithium- the drug of choice for bipolar patients in developing countries
Lithium in mood disorders-a partial reporting
Atypical antispychotics and decline in the use of Lithium in mania
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Babatunde Adetunji, Fellow in Forensic Psychiatry New York University Medical Center, Manhattan, New York, USA, Oluyemisi Adetunji, BA. MS; Andrew Newton, MD, PhD
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medikhelp{at}yahoo.com Babatunde Adetunji, et al.
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Dear Editor, To the uncritical mind, it appears as if Young and Hammond (1) have made a case for more use of lithium in mood disorders than is currently the trend. They partly based their argument on the metaanalysis by Smith et al. (2). A close perusal of the metaanalysis however revealed that the case made by Young and Hammond for lithium is one sided, unbalanced and may be misleading. Even though the study by Smith et al stated that lithium remains the medication with the strongest evidence base, we believe that its declining use may be due to incontrovertible evidence of adverse effects. For example, in the metaanalysis by Smith et al, when withdrawals for any reason and withdrawals for adverse events were analyzed, there were more withdrawals with lithium as compared to lamotrigine, valproate semisodium and olanzapine. Even in terms of efficacy, the choice of lithium remains arguable. For example, when relapses due to depression were analyzed, Smith et al found that there were more relapses with lithium than with lamotrigine and valproate semisodium. In terms of manic episode, there were more relapses with lithium as compared to olanzapine and in terms of any mood episode; there were more relapses with lithium than valproate semisodium and olanzapine. We do not advocate for any particular medication but we strongly feel that for this type of medication advocacy, authors should attempt to provide a balanced argument rather than a one-sided endeavor. It is also very patronizing to partly ascribe the declining use of lithium to poor training of psychiatrist rather than acknowledge the fact that psychiatrists may actually be basing their choices on individual patient criteria as well as the profile of medications within the wide array of available agents. References 1). Young AH and Hammond MH: Lithium in mood disorders: increasing evidence base, declining use? The British Journal of Psychiatry (2007) 191: 474-476. 2). Smith, L. A., Cornelius, V., Warnock, A., et al (2007) Effectiveness of mood stabilizers and antipsychotics in the maintenance phase of bipolar disorder: a systematic review of randomized controlled trials. Bipolar Disorders, 9, 394-412 |
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Om Prakash, Assistant Professor of Psychiatry National Institute of Mental Health And Neurosciences(NIMHANS), Bangalore, INDIA
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op{at}nimhans.kar.nic.in Om Prakash
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It appears from the article (1) that lithium's use is declining due to advent of newer mood stabilizers. This scenerio may be true for developed countries but still lithium is the most prescribed mood stabilizing agent in developing countries. In routine clinical practice, more than 50% patients with bipolar disorders are receiving lithium due to being avaivable in affordable price. Among other mood stabilizers, sodium valporate is increasing its base while lamotrigine and carbamazepine are still among last preferences among clinicians in developing countries. Surpisingly, lithium is still the drug of choice among physicians(non-psychiatrists) in developing countries. This article definitely gives impetus to clinicians for lithium use. References:1). Young AH and Hammond MH: Lithium in mood disorders: increasing evidence base, declining use? The British Journal of Psychiatry (2007) 191: 474-476. |
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Javed Ahmad Latoo, Specialty Registrar Adult Psychiatry Camden & Islington Mental Health and Social Care Trust, St Pancras Hospital, St Pancras Way, London, Honorary Clinical Assistant Neuropsychiatry,National Hospital for Neurology and Neurosurgery London
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javedlatoo2000{at}yahoo.co.uk Javed Ahmad Latoo, et al.
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Dear Editor, It seems as if Young and Hammond (1) have provided the incomplete information while supporting the use of lithium in mood disorders. They might have over emphasized the case for Lithium by not reporting the complete finding of recent systemic reviews (2,3). Some of the important conclusions of Smith et al 2007 not mentioned in Young and Hammond(1) re-appraisal were (a) semi sodium valproate and lamotrigine significantly reduced depressive relapses compared to lithium ,(b) Lithium and olanzapine significantly reduced manic relapses, (c)Lithium significantly reduced manic relapses compared with lamotrigine,(d) olanzapine significantly reduced manic relapses compared to lithium, (e) withdrawals due to an adverse event was approximately twice as likely with Lithium compared to valproate semi sodium and lamotrigine. Some of these conclusions were confirmed by another recent systemic review by Soares-Weise et al 2007 (3). This review also found some evidence for the role of CBT, group psychoeducation and family therapy as adjuncts to pharmacological maintenance treatments. Medications found effective in management of bipolar disorder are known to cause serious side effects particularly lithium and olanzapine. Both can lead to irreversible side effects like renal and thyroid effects with lithium and metabolic effects with olanzapine. There is also a risk of high relapse due to rapid discontinuation of medication particularly in case of lithium which could be a problem in patients with poor compliance stabilized on lithium. Decline in the use of Lithium could be attributed to various reasons including availability of other equally effective drugs, ease of initiating other available medications particularly in outpatient setting and no mandatory requirement to do baseline and regular physical investigation with other medications. It is unfair to blame poor training of doctors for decline in lithium use in bipolar disorder. Lithium is an effective medication but all medications including Lithium should be used on the basis of latest evidence, past response to medication, medical history/profile of patients in view of serious side effects caused by these medication and patient choice. Decleration of interest -NIL Dr Javed Latoo MBBS DPM MRCPsych Specialty Registrar Adult Psychiatry Camden & Islington Mental Health and Social Care Trust Honorary Clinical Assistant Neuropsychiatry National Hospital for Neurology and Neurosurgery References 1). Young AH and Hammond MH: Lithium in mood disorders: increasing evidence base, declining use? The British Journal of Psychiatry (2007) 191: 474-476. 2). Smith, L. A., Cornelius, V., Warnock, A., et al (2007) Effectiveness of mood stabilizers and antipsychotics in the maintenance phase of bipolar disorder: a systematic review of randomized controlled trials. Bipolar Disorders, 9, 394-412 3). Soares-Weiser K, Bravo Vergal Y, Beynon S, Dunn G, Barbieri M, Duffy S,Geddes J, Gilbody S,Palmer S, Woolacott N (2007) A systematic review and economic model of the clinical effectiveness and cost effectiveness of interventions for preventing relapse in people with bipolar disorder. Health Techno Assess 2007 Oct; 11(39):1-226 |
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Prakash S Gangdev, Psychiatrist Mood and Anxiety Disorders Program, RMHC-London, Ontario Canada
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Prakash.Gangdev{at}sjhc.london.on.ca Prakash S Gangdev
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The decline in the use of Lithium as a mood stabilizer (Young & Hammond, 2007)coincides with the the supermarketing of atypical antipsychotics as antimanic agents that can also prevent a recurrence. Unfortunately, confounders in the research on mania have not been adequately identified/addressed.Consider this: most of the atypical antipsychotics were tested as add-on therapies and for generally a short trial period. Manic episodes may be complicated by psychotic symptoms, and psychomotor acceleration is a hall mark of mania. Antipsychotics (atypical and others) may all be effective in lessening physical overactivity and psychotic symptoms. Furthermore, usually, manic episodes have a finite duration. If the next episode was destined to not occur in the next few months, it would be erroneous to conclude that atypical antipsychotics have a prophylactic effect on the basis of a short trial. Add-on psychopathology such as maladaptive coping with stressors, personality traits/disorders and comorbid conditions such as anxiety disorders may all contribute to the mood disturbance with the erroneous impression that the (true) "bipolar episode" is not yet over. In such a scenario too, antipsychotics may be effective. Alternately, psychosis may be misdiagnosed as manic episode and yet be treated with the right medication - antipsychotics. The atypical antipsychotics may have acquired a reputation of being antimanic and mood stabilizers on the basis of these confounders and owing to the uncritical acceptance of the antipsychotics trials and reviews, as well as muddling of the boundaries of manic episode (by disregarding the effects of stressors, personality disorders, comorbid conditions). With the ease of prescribing and a body of "evidence" to support the use of atypical antipsychotics, it is hardly surprising that they are the first-choice agents. The matter may be resolved by first, clearly defining a manic episode, and then treating them with atypical antipsychotics alone and comparing them head to head with lithium. Reference 1)Young AH and Hammond MH: Lithium in mood disorders: increasing evidence base, declining use? The British Journal of Psychiatry (2007) 191: 474-476. |
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