Why lithium should be used in patients with bipolar disorder? A scoping review and an expert opinion paper

ABSTRACT

Introduction

Lithium treatment is considered the gold standard for the long-term management of bipolar disorder and recurrent unipolar depression. It is also extremely effective in other psychiatric conditions characterized by impulsivity and aggression, and for the prevention of suicidal behaviours.

Areas covered

This paper provides a scoping review and an expert commentary regarding the use of lithium in adult patients. Available information about efficacy, tolerability, dosing, and switching is analyzed, and the strategies that may be most useful in real-world clinical settings are highlighted.

Expert opinion

Lithium is effective on different domains of bipolar disorder, including the long-term prevention of recurrences of affective episodes, management of acute mania as well as in the prophylaxis of all affective episodes. Lithium has been defined a ‘forgotten drug,’ since its use in routine clinical practice has been declined over the last 20 or 30 years. Reasons for this trend include lack of adequate training on the management of lithium side effects. Considering its efficacy, use of lithium in ordinary clinical practice should be promoted. Several strategies, such as using slow-release formulations, can be easily implemented in order to minimize lithium side effects and improve its tolerability profile.

KEYWORDS:

• Personalization
• mood stabilizer
• treatment
• efficacy
• tolerability

Acknowledgement

The authors are grateful to the inputs and suggestions provided by Prof. A. Zuddas, who suddenly passed away.

Article highlights

• Lithium is the gold standard for the treatment of subjects with bipolar disorder, and it is also useful in patients with refractory unipolar depression, as well as in a variety of disorders characterized by impulsivity and aggression.

• According to the ISBD/IGSLI Task Force, the standard lithium serum levels should be 0.60‐0.80 mmol/L in adult patients with bipolar disorder. The lithium serum levels should be reduced to 0.40‐0.60 mmol/L in case of good response but poor tolerance, or to increase it to 0.80‐1.00 mmol/L in case of insufficient response and good tolerance.

• Doses above 1.5 mM might lead to toxic effects, while life-threatening effects are seen above 3.5 mM.

• In recent years, patients with bipolar disorder have been mainly treated with antipsychotics, with an increase from 12.4% of outpatient visits for bipolar disorder in the 1997-2000 period to 51.4% in the 2013-2016 period. At same time, the prescription of mood stabilizers and lithium decreased from 62.3% (in the period 1997-2000) to 26.4% in the 2013-2016 period. These trends confirm the to rediscover the efficacy and tollerability of lithium treatment.

• Lithium is one of the single most effective treatments available in psychiatry, with side effects that can be easily managed, also using extended-release formulations.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was supported by Angelini Pharma unconditionally.