Dr Stuart Adams Consultant Psychiatrist Cheam CMHT

1
Bipolar Disorder and Lithium Prescribing

• Dr Stuart AdamsConsultant PsychiatristCheam CMHT

2
Q1 Indicate whether the following statements are
True or False-

• Valproate should never be prescribed in women of
  child bearing age (T/F)
• Bipolar disorder has a prevalence rate of 1
  (T/F)
• Lithium reduces the risk of suicidal behaviour in
  patients with bipolar disorder (T/F)
• Antidepressants should always be discontinued in
  patients presenting with mania (T/F)

3
Q2 The following are side effects of lithium
treatment-

1. Blurred vision (T/F)
2. Hypothyroidism and hyperparathyroidism (T/F)
3. Increased Gastrointestinal disturbances (T/F)
   (anorexia, vomiting, diarrhoea)
4. Muscle weakness (T/F)
5. Polyuria, polydypsia (T/F)
6. Fine Tremor (T/F)

4
Q3 Which of the drugs listed below have
potential risk of causing lithium toxicity if
given with Lithium-

1. Carbamazepine (T/F)
2. SSRI (T/F)
3. ACE inhibitors (T/F)
4. Antipsychotics (T/F)
5. Antacids without sodium bicarbonate (T/F)

5
Bipolar disorder is complex

• Bipolar disorder is an episodic, potentially
  life-long, disabling disorder that can be
  difficult to diagnose
• Need to improve recognition, reduce sub-optimal
  care and improve long-term outcomes
• There is variation in management of care across
  healthcare settings

6
How to diagnose..

• Bipolar disorder is a cyclical mood disorder
• Abnormally elevated mood or irritability
• alternates with depressed mood
• bipolar I at least one manic or mixed episode
• bipolar II at least one major depressive
  episode and at least one hypomanic episode

7
Presentation Key features
Mania Elevated, expansive or irritable mood With or without psychotic symptoms Marked impairment in functioning
Hypomania Elevated, expansive or irritable mood No psychotic symptoms Less impairment of functioning
Depression Mild, moderate or severe With or without psychotic symptoms
Rapid cycling At least four episodes in 1 year
Mixed states Manic and depressive features present during same episode
8
Incidence and prevalence..

• Annual incidence
• 7 per 100,000
• Estimated lifetime prevalence bipolar I
• 416 per 1000
• Peak onset between 15 and 19 years of age
• Suicide
• bipolar I 17 attempt suicide
• bipolar disorder 0.4 die annually by suicide

9
Co-morbidity is common..

• Anxiety
• 3050
• Substance misuse disorders (drugs and alcohol)
• 3050
• Personality disorders, in particular borderline
  personality disorder (exercise caution when
  diagnosing)

10
Primary care management.

• Refer to confirm diagnosis..
• Consider EIT referral
• Pharmacological management
• Treat the acute phase
• Monitor.

11
Treat the acute phase..

• Consider an antipsychotic if
• manic symptoms are severe
• there is marked behavioural disturbance
• Consider valproate or lithium if
• there has been previous response and good
  compliance with one of these drugs
• Consider lithium if
• symptoms are less severe

12
Initiate long-term pharmacological treatment

• After a manic episode with significant risk and
  adverse consequences
• Bipolar I two or more acute episodes
• Bipolar II evidence of significant functional
  impairment or risk of suicide or frequently
  recurring episodes

13
Choose long-term drugs..

• Base choice of lithium, olanzapine or valproate
  on
• previous response
• risk and precipitants of manic versus depressive
  relapse
• physical risk factors
• patient preference and history of adherence
• cognitive state assessment if appropriate
• Valproate should not be prescribed routinely
  for women of child-bearing potential

14
Support long-term pharmacological treatment

• Ensure prescribing advisers are aware of NICE
  guidance, and what to consider when choosing
  treatment
• Focus on optimising appropriate long-term
  treatment
• Support service user education and empowerment in
  pharmacological treatment and management
  decisions
• Make use of early intervention teams, regional
  mental health trusts and CAMHS teams

15
Use antidepressants with care.

• Acute manic phase
• Stop antidepressants at onset of acute manic
  phase and decide if discontinuation is abrupt or
  gradual based on
• current clinical need
• previous experience of discontinuation/withdrawal
  symptoms
• the risk of discontinuation/withdrawal symptoms

16
Consider need for treatment

• Is long-term antidepressant treatment needed
  after an acute depressive episode?
• No evidence for reduced relapse rates
• May be associated with increased risk of mania

17
Consider psychological therapy

• For those who are stable, individual structured
  psychological therapy should include
• at least 16 sessions over 6 to 9 months
• psychoeducation
• promotion of medication adherence
• monitoring of mood, detection of early warnings
  and prevention strategies
• coping strategies

18
Take possible pregnancy into account

• Valproate should not be used routinely for women
  who may become pregnant. It may
• cause foetal abnormalities
• affect the childs cognitive development
• If prescribed, ensure adequate contraception.
  Explain risks during pregnancy and to the health
  of the unborn child
• An antipsychotic may be used with caution

19
Mitigate drug-related weight gain

• Review medication strategy and consider
• dietary advice and support
• advising regular increased aerobic exercise
• referring to a specialist mental health diet
  clinic or health delivery group
• referring to a dietitian if needed for people
  with complex co-morbidities

20
Review annually

• Over the course of the year an annual review
  should include
• lipid levels, including cholesterol, in
  patients over 40
• plasma glucose levels
• weight
• smoking status and alcohol use
• blood pressure

21
Patient Safety Alert

• Safer Lithium Therapy

22
Indications for using Lithium

• Bipolar Affective disorder Type 1
• Treatment of Unipolar Depression
• Reducing suicidal risk and suicidal behaviour
• Other licensed uses include
• treatment of aggressive or self-mutilating
  behaviour .
• Unlicensed uses include
• the prevention and treatment of steroid induced
  psychosis
• the elevation of the white blood cell count in
  patients prescribed clozapine.

23

• Actions
• Patients prescribed lithium are monitored in
  accordance with NICE guidance

NICE specifies lithium blood levels are used to
adjust dosage at least every 3 months and that
thyroid function tests and renal function tests
are undertaken every 6 months.
This level of monitoring is required as
clinically observable side effects may not be
apparent even with toxic levels
24

• Actions
• There are systems in place to ensure that the
  results of blood tests are communicated between
  laboratories and prescribers.

Whether in primary or acute setting, levels must
be available when dosing decisions are taken
25

• Actions
• At the start of lithium therapy and throughout
  their treatment patients receive appropriate
  ongoing verbal and written information and a
  record book to track lithium blood levels and
  relevant clinical tests.

The NPSA with POMH-UK have developed support
material for this action
26
Side effects

• Fine Tremor
• Gastrointestinal disturbances
• Polyuria, polydypsia
• Weight gain oedema

• Hair loss, Acne, Psoriasis precipitated and
  exacerbated
• Hypothyroidism, hyperparathyroidism
• Hyperglycaemia, hypocalcaemia, hypomagnesaemia

27
Toxic effects (Most patients experience toxic
effects with levels above 1.5mmol/L)

• Blurred vision
• Increased Gastrointestinal disturbances
  (anorexia, vomiting, diarrhoea)
• Muscle weakness
• CNS disturbances (drowsiness, lethargy, ataxia,
  coarse tremor, impaired
  co-ordination, dysarthia)

28

• Actions
• Prescribers and pharmacists check that blood test
  are being monitored regularly and that test
  results are safe before issuing or dispensing
  repeat prescriptions.

Standard Operating Procedures (SOPs) will
describe clear processes for both prescribing and
dispensing that must be adhered to if monitoring
falls below safe standards or patient are
unwilling to share information.
29

• Actions
• Systems are in place to identify and deal with
  medicines that might adversely interact with
  lithium therapy.

SOPs, decision support systems, patient
medication records, patient records, inpatient
charts, medication administration records reflect
the need to identify and deal with potential
interacting medicines whether on prescription or
brought over-the-counter
30
Common Drugs that Lithium shows Interaction with
are

• 1. Analgesics Excretion of Lithium is reduced by
  NSAIDS e.g. Ibuprofen, Diclofenac, Indomethacin
• 2. ACE inhibitors by reducing Glomerular
  perfusion pressure increases re absorption of
  lithium and hence, toxicity.
• 3. Diuretics e.g. Frusemide increased toxicity
  with medications that cause sodium depletion.

31
Common Drugs that Lithium shows Interaction with
are

• 4. Anti-epileptics Neurotoxic effect with
  Carbamazepine
• 5. Anti Psychotics Neurotoxic and increased risk
  of extra pyramidal side effects but can be used
  with caution
• 6. Anti Depressants increase lithium toxicity
  with SSRIs, Venlafaxine, and Tricyclics.
• 7. Antacids excretion of lithium is increased by
  sodium bicarbonate

32
The Lithium Booklet

• 24 page booklet with
• details of the patient
• supporting health provider services
• current drug therapy
• Provides information each patient must know and
  understand in order to make lithium therapy safe.

33
The Lithium Alert Card

• Credit card size
• Carried by the patient at all times.
• Informs healthcare professionals that the patient
  is taking a specific brand of lithium and
  provides details of contacts in an emergency.

34
The Lithium Record Book
35
Q1 Indicate whether the following statements are
True or False-

• Valproate should never be prescribed in women of
  child bearing age FALSE
• Bipolar disorder has a prevalence rate of 1TRUE
• Lithium reduces the risk of suicidal behaviour in
  patients with bipolar disorder TRUE
• Antidepressants should always be discontinued in
  patients presenting with mania TRUE

36
Q2 The following are side effects of lithium
treatment-

1. Blurred vision FALSE (toxicity)
2. Hypothyroidism and hyperparathyroidism TRUE
3. Increased Gastrointestinal disturbances FALSE
   (toxicity)
4. Muscle weakness FALSE (toxicity)
5. Polyuria, polydypsia TRUE
6. Fine Tremor TRUE

37
Q3 Which of the drugs listed below have
potential risk of causing lithium toxicity if
given with Lithium-

1. Carbamazepine TRUE
2. SSRI TRUE
3. ACE inhibitors TRUE
4. Antipsychotics TRUE
5. Antacids without sodium bicarbonate FALSE

38
References.

• Quick reference guide a summary
  www.nice.org.uk/CG038quickrefguide
• NPSA lithium Alert http//www.nrls.npsa.nhs.uk/res
  ources/?entryid4565426