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Dr. Bob is Robert Hsiung, MD,
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Posted by jrbecker on March 9, 2006, at 12:18:20
Psychiatr News March 3, 2006
Volume 41, Number 5, page 33
© 2006 American Psychiatric Association
Services
Clinical & Research News
Lithium Often Takes Backseat To Other Bipolar Therapies
Jim Rosack
Despite the evidence base, lithium is still reserved for the sickest patients with bipolar disorder.Patients with bipolar disorder who exhibit suicidal ideation are more likely to be prescribed antidepressants and second-generation antipsychotics (SGA) than lithium, despite lithium's reputation for an antisuicide effect.
Data published in the December 2005 Psychiatric Services by the team running the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) indicates that lithium appears to be "reserved for those patients with more severe illness characteristics." The report provides a snapshot of current medications taken by the first 1,000 patients who entered the STEP-BD study, which was funded by the National Institute of Mental Health (NIMH).
For many years lithium has been thought to exert an antisuicide effect, with some researchers reporting that in patients with bipolar disorder, lithium is associated with up to a six-to eightfold reduction in the risk of suicide attempt or completion compared with placebo. Other researchers reported that suicide completion was 2.7 times more likely to occur in patients with bipolar disorder on divalproex compared with those on lithium.
Yet these earlier studies did not control for other medications taken concomitantly or for severity of illness at baseline relative to prescription choice. In addition, "little is known about the antisuicidal benefits of other new agents for bipolar disorder, particularly the second-generation antipsychotics."
STEP-BD investigators, led by Gary Sachs, M.D., a professor of psychiatry at Massachusetts General Hospital and Harvard University, enrolled nearly 5,000 patients aged 15 and older with bipolar disorder I, II, or NOS, or cyclothymia, at 11 academic research centers across the U.S. The researchers' goal of the current report was to provide "a description of community-based pharmacotherapy treatments relative to suicidal ideation" in the first 1,000 patients to enter the study. The study group was assessed between November 1999 and April 2001 to determine "prevalence of prescriptions for mood stabilizers, second-generation antipsychotics, and antidepressants and the clinical features of patients who received these different classes of medications."
A battery of assessments was administered to each patient, yielding demographic details, past and current signs and symptoms of mental illness, and past and current treatments.
At baseline, 605 of 998 patients were euthymic (61 percent), 58 (6 percent) were manic or hypomanic, 87 (9 percent) were mixed or cycling, and 248 (25 percent) were depressed (two patients did not complete the entire baseline assessment).
Among the 998 patients, 211 (21 percent) exhibited signs of suicidal ideation. Suicidal ideation was significantly more common among persons who were experiencing depressive (49 percent) or mixed episodes (47 percent) than those who were manic or hypomanic (9 percent) or euthymic (7 percent).
Sachs and his coauthors reported that 362 (36 percent) patients were taking lithium at baseline, and 349 (35 percent) were taking divalproex. Of the 270 patients (27 percent) who were taking an antipsychotic, nearly all (264) were taking an SGA. Of those taking an SGA, about two-thirds were also taking either lithium or divalproex.
The number of patients taking an antidepressant was 418 (42 percent); 346 (83 percent) were taking one antidepressant, while 72 (17 percent) were taking at least two antidepressants at the beginning of the study.
Finally, Sachs and his colleagues reported that "rates of suicidal ideation were similar between patients who were taking any lithium and those who were not. Rates of suicidal ideation were also not statistically significantly different between those taking divalproex and those who didn't take divalproex. However, the mean number of prescribed medicines for patients with suicidal thoughts was higher than for those without suicidal thoughts.
"Our findings suggest," Sachs and his colleagues wrote, "that after use of other medications and baseline severity indices were controlled for (such as severity of illness and history of suicide attempts), psychiatrists may be more likely to prescribe lithium for suicidal patients with bipolar disorder."
"Suicidal Ideation and Pharmacotherapy Among STEP-BD Patients" is posted at <http://ps.psychiatryonline.org/cgi/content/full/56/12/1534>;.
Psychiatr Serv 2005 56 1534[Abstract/Free Full Text]
Posted by San Diegan on March 9, 2006, at 12:58:51
In reply to Lithium Often Takes Backseat To Other Bipolar Tx, posted by jrbecker on March 9, 2006, at 12:18:20
Maybe it's because of the constant blood draws required, especially at first? The relatively narro w therapeutic window?
Often it's not just efficacy that's considered, its' se's and stuff like blood testing.
Posted by ed_uk on March 9, 2006, at 13:44:12
In reply to Re: Lithium Often Takes Backseat To Other Bipolar, posted by San Diegan on March 9, 2006, at 12:58:51
I find it disturbing how meds such as Topamax, which have little or no evidence to support their use in bipolar disorder, have gained such popularity in the US. Lithium is one of the most well established treatments for bipolar disorder. It should not be discarded in favour of Topamax etc.
Ed
Posted by linkadge on March 9, 2006, at 15:00:00
In reply to Re: Lithium Often Takes Backseat To Other Bipolar, posted by ed_uk on March 9, 2006, at 13:44:12
Some of the work of Dr. Manji showed that lithium and depakote had some similar biochemical effects, other mood stabalizers did not.
Linkadge
Posted by ed_uk on March 9, 2006, at 15:09:30
In reply to Re: Lithium Often Takes Backseat To Other Bipolar, posted by linkadge on March 9, 2006, at 15:00:00
Hi Link :)
Lithium is old, inexpensive, off patent and has a rather 'scary' reputation. Some PDocs may prefer to prescribe newer shinier meds. I do think it's important to remember lithium's well established efficacy.
The recent trend to refer to ALL the antiepileptics as 'mood stabilisers' should be discouraged IMO. There is little or no evidence that Topamax, Neurontin, Lyrica, Zonegran or Keppra should be considered to be 'mood stabilisers'.
Ed
Posted by ed_uk on March 9, 2006, at 15:16:14
In reply to Re: Lithium Often Takes Backseat To Other Bipolar, posted by linkadge on March 9, 2006, at 15:00:00
In addition, there is no evidence that clonazepam (Klonopin) has any special efficacy in bipolar disorder. Other benzos such as chlordiazepoxide (Librium) could be equally effective meds for anxiety and agitation in bipolar pts.
Ed
Posted by linkadge on March 9, 2006, at 21:03:01
In reply to Re: Lithium Often Takes Backseat To Other Bipolar » linkadge, posted by ed_uk on March 9, 2006, at 15:16:14
Manjii's work revealed that there were certain destinct structural and biochemical abnormalities in bipolar brains. One of the big abnormalities was a grey matter reduction in the subgenual prefronal cortex (I think sg 25) Both lithium and depkakote seemed to share an ability to reverse atrophy in that region. Other mood stabalizers did not.
Lithium reversed grey matter deficits in other brain regions too, in a time dependant manner. Depakote was not as strong in this effect, and other mood stabalizers showed no effect. Lithium and depakote also increased BDNF and BCL-2 in certain key brain regions. BCL-2, being neuroprotective and neurotrophic. Other mood stabaliers did not affect BDNF or BCL-2
The list went on, but I got from his work that lithium and valproate acutally seemed to be working to combat/reverse bipolar progression wheras other drugs did not seem to do much in this regard.
Linkadge
Posted by Emily Elizabeth on March 9, 2006, at 22:54:57
In reply to Lithium Often Takes Backseat To Other Bipolar Tx, posted by jrbecker on March 9, 2006, at 12:18:20
It's not totally what this thread is about, but Lithium has helped my treatment resistant (unipolar) depression soooooo much. I have tried so many different things over the past 3 yrs, but adding Li to my combo finally made the difference. I was a little hesitant to go w/ such a "heavy duty" drug, but I'm glad that I did. So, TRD babblers, think about Li, okay?
Best,
EE
Posted by Phillipa on March 9, 2006, at 23:18:47
In reply to Re: Lithium Often Takes Backseat To Other Bipolar, posted by linkadge on March 9, 2006, at 21:03:01
Lithium is a natural salt I believe too. Fondly, Phillipa
Posted by Toph on March 10, 2006, at 9:59:37
In reply to Lithium Often Takes Backseat To Other Bipolar Tx, posted by jrbecker on March 9, 2006, at 12:18:20
More gratuitous testamony: I haven't had a major manic or depressed episode in over 20 years on lithium. I have no significant side-effects other than transitory diarrhea when dehydrated and virtually unnoticable tremmors. I would only exchange this med for another if I had kidney problems or if they found a cure for BP I.
Posted by 4WD on March 10, 2006, at 22:59:56
In reply to I LOVE Lithium!! :), posted by Emily Elizabeth on March 9, 2006, at 22:54:57
> It's not totally what this thread is about, but Lithium has helped my treatment resistant (unipolar) depression soooooo much. I have tried so many different things over the past 3 yrs, but adding Li to my combo finally made the difference. I was a little hesitant to go w/ such a "heavy duty" drug, but I'm glad that I did. So, TRD babblers, think about Li, okay?
>
> Best,
> EE
Hi Emily ElizabethI remembered you were on lithium and was going to search the archives for some of your posts and now here you are right on the main page. I just started lithium last night. 300mg a.m. and 300mg p.m.
About a year and a half ago, I went from straight unipolar depression with some anxiety to what I can only desribe as hell. Horrible fear, terror actually, mixed with deep depression at the same time. It has gotten some better in the last few months but hasn't gone away. I've never had manic episodes just those horrible hyper, jittery scared feelings.
Anyway, Depakote helped but the headaches (and toothache too) were too intense. So now I'm trying lithium. It is the one drug I really know nothing about. I'm scared of it - I always thought of it as "the last resort." What do I need to know about it?
I read that I shouldn't take NSAIDs while on it? Do you? Have you had any troubling side effects? What about increased appetite/weight gain?
Thank you,
Marsha
Posted by Emily Elizabeth on March 11, 2006, at 1:36:05
In reply to Re: I LOVE Lithium!! :) » Emily Elizabeth, posted by 4WD on March 10, 2006, at 22:59:56
I'm scared of it - I always thought of it as "the last resort." What do I need to know about it?
That's sorta how I felt about it too. And now that I've taken it for a while, I don't know why I felt that way. Your pdoc should do some bloodwork. One thing is to get a sense of what your blood level of Li is--whether it is in the therapeutic range or not, also if it is too high. The other thing is that it might supress thyroid functioning, so every few months or so, bloodwork should be done to make sure TSH etc are all still okay.
>
> I read that I shouldn't take NSAIDs while on it? Do you?I've read that, but my pdoc has never mentioned it (and she is rather detail-oriented). I don't usually need any pain-killers though, except for the occasional excedrin. You might want to ask your doc abt it.
Have you had any troubling side effects?
I have some daytime sleepiness, but it is hard to say if that is the Li or not. It isn't so severe that I'd stop the Li even if it is the case.
What about increased appetite/weight gain?
Actually for a few months I had decreased appetite--I'm not sure what that was all about. But in general, I don't think I've gained weight or had a dramatic increase in appetite.
While I was adjusting to the Li I did feel rather "stoned" but that went away after a week or so. I also had a little nausea and tummy rumbling. That also went away.
Some people have cognitive side effects (i.e., can't think). I'm pretty sure that I'm not experiencing that, but I worry whenever I can't think of the right word! LOL!
I currently take 750mg, all at night. 900 was too much, but 600 left too much room for improvement. Good luck with it. I hope that it turns things around for you, as it has for me!
Best,
EE
Posted by Chairman_MAO on March 12, 2006, at 22:15:22
In reply to I LOVE Lithium!! :), posted by Emily Elizabeth on March 9, 2006, at 22:54:57
In case anyone didn't know, lithium was first used for psychic distress in ancient Greece.
There's one drug that the pharmaceutical companies CERTAINLY cannot overcharge for in the name of "R&D"!
Posted by platinumbride on March 13, 2006, at 8:43:24
In reply to Re: I LOVE Lithium!! :) » Emily Elizabeth, posted by Chairman_MAO on March 12, 2006, at 22:15:22
I loved lithium for 4 months. And then it just pooped out!
I am still on it, but have added abilify to the mix. I hope desperately that this combo (along with the other anti-anxiety stuff and anti-akathisia stuff) will not fail me.
Diane
PS: I never gained an ounce on lithium and never had toxicity or any of the other things they say you will have!
This is the end of the thread.
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