From BALANCE to DSM‐5: taking lithium seriously

Ghaemi, S. Nassir

doi:10.1111/j.1399-5618.2010.00861.x

Cited by 9 publications

(11 citation statements)

References 9 publications

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“…Comparing VPA with Li, Geddes et al (2010) found that VPA monotherapy was less effective than Li monotherapy at preventing relapse episodes (hazard ratio, 0.71; confidence interval:0.051-1.00, P = 0.0472). The BALANCE study also questioned the use of VPA over Li as a first-line and prophylactic antimanic agent (Ghaemi, 2010;Nivoli et al, 2012). Similar to our study, Davis et al (1999) carried out a meta-analysis of 10 double-blind randomized studies comparing relapse rates and found that the difference between the effectiveness of Li and CBZ was nonsignificant: 60% for Li patients and 55% for CBZ.…”

Section: Discussionsupporting

confidence: 58%

Prophylactic efficacy of lithium, valproic acid, and carbamazepine in the maintenance phase of bipolar disorder

Peselow

Clevenger

IsHak

2016

International Clinical Psychopharmacology

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Mood stabilizers are used clinically for the management of bipolar disorder. Prophylactic therapy with mood stabilizers is the primary treatment for preventing depressive and manic relapses in bipolar patients once they are stabilized. In this study, we examined the relative efficacy of the three most commonly used mood-stabilizing agents: lithium (Li), valproic acid (VPA), and carbamazepine (CBZ), in preventing relapse episodes. A total of 225 patients with bipolar disorder were included in the present analysis. Patients taking Li, VPA, or CBZ were followed up for up to 124 months, until suffering a manic, mixed, or depressive episode (relapse), or until the end of the study/study termination (no relapse), whichever came first. The median unadjusted survival time was 36 months for patients taking VPA, 42 months for patients taking CBZ, and 81 months for patients taking Li. These results indicate that patients stayed longer on Li, suggesting that it might have been better tolerated than either CBZ or VPA. χ-Analysis showed that patients taking Li were significantly less likely to experience relapse during the observational period than patients taking either VPA or CBZ (P<0.05). A Cox regression model showed that the hazard of experiencing relapse was significantly predicted by the total number of depressive (P=0.007) and manic symptoms (P=0.02) assessed before the observation period. In addition, after controlling for symptom covariates, the hazard of experiencing relapse was 1.66 times (95% confidence interval 1.03-2.67) or 66% higher for patients taking VPA compared with patients taking Li (P=0.037). Although the hazard of experiencing relapse was higher for patients taking CBZ compared with those taking Li, the risk was not elevated by a significant amount. Notwithstanding the limitations of the naturalistic design of this study, the differences in relapse prevention and survival time observed in these medications show Li fairing relatively better in prophylactic therapy.

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Section: Discussionsupporting

confidence: 58%

Prophylactic efficacy of lithium, valproic acid, and carbamazepine in the maintenance phase of bipolar disorder

Peselow

Clevenger

IsHak

2016

International Clinical Psychopharmacology

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“…74 Other recent studies and analyses confirm and extend these conclusions, and add that none of the atypical antipsychotics, despite some having FDA approval for use in maintenance, has convincing evidence of efficacy for that purpose. 75, 76 Ghaemi 75 and Goodwin and colleagues 76 argue that the flaw in the methodology of all the maintenance studies of SGAs is that they start with preselected acute responders to the SGA being tested for maintenance. This "enriched" population of responders is then randomly assigned to either stay on the SGA or switch (often abruptly) to placebo or an active comparator (e.g., lithium).…”

Section: Continued On Next Pagementioning

confidence: 97%

“…Patient and physician biases against it need to be addressed. 75 Because of its narrow therapeutic index, trough serum concentrations of lithium should be closely monitored. The British National Institute for Health and Clinical Excellence guidelines (2006) recommend that levels be taken seven days after initiation and then seven days after every dose or formulation change and the introduction or discontinuation of interacting medications.…”

Section: Continued On Next Pagementioning

confidence: 99%

The Psychopharmacology Algorithm Project at the Harvard South Shore Program

Mohammad

Osser

2014

Harvard Review of Psychiatry

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This new algorithm for the pharmacotherapy of acute mania was developed by the Psychopharmacology Algorithm Project at the Harvard South Shore Program. The authors conducted a literature search in PubMed and reviewed key studies, other algorithms and guidelines, and their references. Treatments were prioritized considering three main considerations: (1) effectiveness in treating the current episode, (2) preventing potential relapses to depression, and (3) minimizing side effects over the short and long term. The algorithm presupposes that clinicians have made an accurate diagnosis, decided how to manage contributing medical causes (including substance misuse), discontinued antidepressants, and considered the patient's childbearing potential. We propose different algorithms for mixed and nonmixed mania. Patients with mixed mania may be treated first with a second-generation antipsychotic, of which the first choice is quetiapine because of its greater efficacy for depressive symptoms and episodes in bipolar disorder. Valproate and then either lithium or carbamazepine may be added. For nonmixed mania, lithium is the first-line recommendation. A second-generation antipsychotic can be added. Again, quetiapine is favored, but if quetiapine is unacceptable, risperidone is the next choice. Olanzapine is not considered a first-line treatment due to its long-term side effects, but it could be second-line. If the patient, whether mixed or nonmixed, is still refractory to the above medications, then depending on what has already been tried, consider carbamazepine, haloperidol, olanzapine, risperidone, and valproate first tier; aripiprazole, asenapine, and ziprasidone second tier; and clozapine third tier (because of its weaker evidence base and greater side effects). Electroconvulsive therapy may be considered at any point in the algorithm if the patient has a history of positive response or is intolerant of medications.

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“…Time to recurrence is often brief, and early episodes are more likely to represent relapses than recurrences. 67 Therefore, it may not be straightforward to draw conclusions about long-term effects from such studies.…”

Section: What Is a Good Indicator Of Treatment Effectiveness?mentioning

confidence: 99%

Beyond the Guidelines for Bipolar Disorder: Practical Issues in Long-Term Treatment with Lithium

Calkin

Alda

2012

Can J Psychiatry

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Objective: Several treatment guidelines are available for clinicians working with patients with bipolar disorder (BD), but some of the more nuanced aspects of lithium therapy go beyond the scope of such guidelines. Therefore, in this perspective, our objective was to focus on specific practical issues of lithium treatment, including the selection and initiation of long-term treatment, and management and discontinuation (if indicated) of lithium prophylaxis. Method:We conducted a focused review of the relevant literature on the treatment of BD.Results: Consultation requests to a BD specialty service often relate to issues for which there is limited evidence, including when to initiate long-term treatment, whether choice of mood stabilizer is specific, how long to treat acute episodes, whether to switch or add on medication when treatment fails, how long to continue effective treatment, and what medication to use when a lithium-responsive patient must discontinue lithium. Conclusion:Optimal long-term treatment of BD will require more research as well as better alignment of clinical and training programs. W W WObjectif : Plusieurs guides de traitement sont offerts aux cliniciens qui travaillent auprès de patients souffrant du trouble bipolaire (TB), mais certains des aspects plus nuancés de la thérapie par le lithium vont au-delà de la portée de ces guides. Par conséquent, dans cette optique, notre objectif était de mettre l'accent sur des questions pratiques spécifiques du traitement par lithium, notamment la sélection et l'initiation d'un traitement à long terme, et la gestion et l'interruption (si indiqué) d'un traitement préventif par lithium.Méthode : Nous avons mené une revue ciblée de la littérature pertinente sur le traitement du TB.Résultats : Les demandes de consultation à un service spécialisé en TB ont souvent trait aux questions pour lesquelles les données probantes sont limitées, notamment, le moment d'initier un traitement à long terme, si le choix d'un régulateur de l'humeur est spécifique, combien de temps traiter les épisodes aigus, s'il faut changer de médicament ou en ajouter lorsque le traitement échoue, combien de temps continuer un traitement efficace, et quel médicament utiliser quand un patient qui répond bien au lithium doit arrêter le lithium. Conclusion :Le traitement à long terme optimal du TB exigera plus de recherche ainsi qu'une meilleure harmonisation des programmes cliniques et de formation.

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From BALANCE to DSM‐5: taking lithium seriously

Abstract: Ghaemi SN. From BALANCE to DSM‐5: taking lithium seriously. Bipolar Disord 2010: 12: 673–677. © 2010 The Author. Journal compilation © 2010 John Wiley & Sons A/S.

Cited by 9 publications

References 9 publications

Prophylactic efficacy of lithium, valproic acid, and carbamazepine in the maintenance phase of bipolar disorder

Prophylactic efficacy of lithium, valproic acid, and carbamazepine in the maintenance phase of bipolar disorder

The Psychopharmacology Algorithm Project at the Harvard South Shore Program

Beyond the Guidelines for Bipolar Disorder: Practical Issues in Long-Term Treatment with Lithium

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From BALANCE to DSM‐5: taking lithium seriously

Abstract: Ghaemi SN. From BALANCE to DSM‐5: taking lithium seriously. Bipolar Disord 2010: 12: 673–677. © 2010 The Author. Journal compilation © 2010 John Wiley & Sons A/S.

Cited by 9 publications

References 9 publications

Prophylactic efficacy of lithium, valproic acid, and carbamazepine in the maintenance phase of bipolar disorder

Prophylactic efficacy of lithium, valproic acid, and carbamazepine in the maintenance phase of bipolar disorder

The Psychopharmacology Algorithm Project at the Harvard South Shore Program

Beyond the Guidelines for Bipolar Disorder: Practical Issues in Long-Term Treatment with Lithium

Contact Info

Product

Resources

About

Abstract: Ghaemi SN. From BALANCE to DSM‐5: taking lithium seriously. Bipolar Disord 2010: 12: 673–677. © 2010 The Author. Journal compilation © 2010 John Wiley & Sons A/S.