Posted by Scott L. Schofield on March 27, 2000, at 10:42:54
In reply to Re: Li-discontinuation--more, posted by Noa on March 27, 2000, at 7:20:58
Hi Noa.
After reading your reply, I can see why you want to discontinue lithium. I think it was worth a shot at trying to treat your dysthymia. The side effects you experience really suck, and if you are receiving no benefit from it, I can't see any reason to stick with it. I don't think you should forever banish lithium from your medicine chest of artillery, though. That it may have produced a positive response early in treatment may indicate that it may be useful in future combinations. I'm not trying to sell the stuff. I hate it (for me).Depakote?
Lamictal?
How about Parnate + (Wellbutrin or desipramine) + Ritalin?
As far as the discontinuation-induced refractoriness to lithium is concerned, I think my treatment of it in my prior post was well-balanced. The details of Cam's contribution echo that which I had already stated. I am not convinced that discontinuation-induced refractoriness exists as a discreet phenomenon. I have no emotional stake in this. However, one study of a mere 28 people in the absence of life-charting and without correlating the type and course of illness for each case is, for me, far from being a well designed investigation. Why did they not include the rest of their "large, naturalistic follow-up of patients"? I'm sure I could reproduce these results if I were to choose 28 24-year olds who presented with their index episode of mania.
It has been my personal experience that I tend to find what I'm looking for. I am not a well-disciplined Ph.D. who is supposedly trained to approach an issue with impeccable objectivity. I'm getting better, though. If I want to cruise Medline to prove that lithium-discontinuation-induced lithium-refractoriness exists, voila... (see below)
The anecdotal reports are there, a few multiple-case studies are there, and only one contradictory citation showed-up - yours, although I'm sure there are more. What does this prove? Not a whole hell of a lot. No intelligent investigation of this issue exists. I will say that there is enough stuff here to persuade me to consider the possibility. There is certainly enough stuff here to give evidence that it does happen, regardless of how frequently or infrequently. If I were to find myself in a pair of shoes of roughly the same style as my friend was wearing, I would definitely place a weight on the balance scale on the side of caution.
None of this applies to you anyway.
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This is the abstract you cited in its entirety:
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1 : Am J Psychiatry 1998 Jul;155(7):895-8 Related Articles, Books, LinkOut
Lithium discontinuation and subsequent effectiveness.Coryell W, Solomon D, Leon AC, Akiskal HS, Keller MB, Scheftner WA, Mueller T
University of Iowa College of Medicine, Iowa City 52242-1000, USA. william-coryell@uiowa.edu
OBJECTIVE: Several reports have raised concern that the discontinuation of lithium may result in treatment resistance following recurrence of affective disorder. This report explores this possibility. METHOD: The data derive from a large, naturalistic follow-up of patients with major depressive disorder or mania. Twenty-eight of the patients in the study were free of lithium and experiencing an episode of mania or schizoaffective mania diagnosed according to Research Diagnostic Criteria when they entered the study, recovered while taking lithium, later experienced a recurrence while not taking lithium, and then resumed lithium treatment. Survival analyses of time to recovery and, subsequently, time to recurrence, used continued lithium treatment as an additional censoring variable. RESULTS: Patients given lithium recovered no more quickly from their index episode than they did from their first prospectively observed episode. Moreover, lithium prophylaxis appeared no less effective after the first prospectively observed episode than after the index episode. CONCLUSIONS: These findings provide no evidence that lithium discontinuation results in treatment resistance when lithium is resumed.
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1 : Am J Psychiatry 1992 Dec;149(12):1727-9 Related Articles, Books
Lithium-discontinuation-induced refractoriness: preliminary observations.Post RM, Leverich GS, Altshuler L, Mikalauskas K
Biological Psychiatry Branch, National Institute of Mental Health, Bethesda, MD 20892.
The authors used a systematic life-chart methodology to observe four patients with bipolar disorder in whom long periods (6-15 years) of effective lithium prophylaxis were followed by relapses on lithium discontinuation. Once the drug was reinstituted, it was no longer effective. The incidence, predictors, and mechanisms underlying this phenomenon all require further systematic study. The current preliminary observations suggest an additional reason for caution when lithium discontinuation in the well-maintained patient is considered.
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Ned Tijdschr Geneeskd 2000 Feb 26;144(9):401-4 Related Articles, Books
[No title available].[Article in Dutch]
Oostervink F, Nolen WA, Hoenderboom AC, Kupka RW
Academisch Ziekenhuis, Utrecht.
[Medline record in process]
Three man, aged 66, 60 and 26 years with bipolar disorder and long periods (20-5 years) of effective lithium prophylaxis had relapses on lithium discontinuation. Once the drug was reinstituted, it was no longer effective. Combinations of lithium with a classical MAO inhibitor or a second mood stabilizer (valproic acid and carbamazepine, respectively) ultimately proved to be successful. The risk of refractoriness should be kept in mind before considering to stop lithium therapy. A better compliance can be achieved by informing patients about the risks of discontinuing lithium, by maintaining a minimal maintenance dose and by adequately coping with possible side effects.
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2 : Am J Psychiatry 1994 Oct;151(10):1522 Related Articles, Books
Refractoriness induced by lithium discontinuation despite adequate serum lithium levels.Bauer M
Publication Types:
Comment
LetterComments:
Comment on: Am J Psychiatry 1992 Dec;149(12):1727-9
Comment on: Am J Psychiatry 1993 Nov;150(11):1756
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Am J Psychiatry 1993 Nov;150(11):1756 Related Articles, Books
Refractoriness induced by lithium discontinuation.Terao T, Terao M
Publication Types:
Comment
LetterComments:
Comment on: Am J Psychiatry 1992 Dec;149(12):1727-9
Comment in: Am J Psychiatry 1994 Oct;151(10):1522
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Nonresponse to reinstituted lithium prophylaxis in previously responsive bipolar patients: prevalence and predictors.Maj M, Pirozzi R, Magliano L
Department of Psychiatry, First Medical School, University of Naples, Italy.
OBJECTIVE: The authors explored the prevalence and predictors of nonresponse to reinstituted lithium prophylaxis in bipolar patients who had relapsed after discontinuation of successful lithium treatment. METHOD: The study was conducted with 54 bipolar patients for whom lithium had been reintroduced after one or more recurrences following discontinuation of successful prophylaxis. They were followed up, through bimonthly personal interviews, for 1 year after recovery from the episode during which lithium treatment had been resumed, or up to the first recurrence with onset after lithium reinstitution. RESULTS: During the follow-up period, 44 patients did not have any affective episodes, whereas 10 had at least one recurrence. The only significant difference between the two patient groups was the longer duration of prediscontinuation lithium treatment for the patients who relapsed. CONCLUSIONS: Nonresponse to reinstituted prophylaxis should be considered among the possible risks of the interruption of effective long-term lithium treatment.
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: Psychol Rep 1994 Apr;74(2):355-61 Related Articles, Books
Lithium maintenance therapy for bipolar I patients: possible refractoriness to reinstitution after discontinuation.Murray JB
Psychology Department, St. John's University, Jamaica, NY 11439.
Publication Types:
Review
Review, tutorial
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94 : Neuropsychobiology 1993;27(3):132-7 Related Articles, Books, LinkOut
New developments in the use of anticonvulsants as mood stabilizers.Post RM, Ketter TA, Pazzaglia PJ, George MS, Marangell L, Denicoff K
Biological Psychiatry Branch, National Institute of Mental Health, Bethesda, MD 20892.
There is increasing recognition that lithium is inadequate in the treatment of up to 50% of bipolar patients. In addition to subgroups that are nonresponsive from the outset, loss of efficacy (tolerance) and discontinuation-induced refractoriness have recently been observed. The anticonvulsants carbamazepine and valproate are effective alternative or adjunctive treatments, but tolerance can also occur during their long-term prophylactic use. New treatment algorithms for this loss of efficacy, including combination therapies, require further systematic study. Preliminary data suggesting that some patients with extremely rapid and chaotic mood fluctuations may respond to the L-type calcium channel blocker nimodipine are presented, and the theoretical implications discussed.
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There are more.
poster:Scott L. Schofield
thread:28042
URL: http://www.dr-bob.org/babble/20000321/msgs/28235.html