Lithium in the long-term treatment of bipolar disorders

Abstract

Usefulness of lithium in the prophylaxis of bipolar disorders has been challenged for five major reasons. The authors review the empirical basis of these criticisms and come to the following conclusions. 1. Lithium efficacy is high and beyond reasonable doubt in classic manic-depressive illness. Bipolar patients presenting atypical features show a much poorer response rate to lithium. 2. There is no empirical evidence for a loss of lithium efficacy over time. 3. There is little evidence for discontinuation-induced refractoriness to lithium. 4. Lithium withdrawal phenomena are well established but seem to be rather specific to certain subgroups. Withdrawal phenomena seem to be common in atypical bipolar disorder but rare in fully stabilized classic manic-depressive illness. 5. Other factors limiting lithium efficacy in clinical practice (e. g., non-compliance) are not specific to lithium. In conclusion, prophylactic lithium does have major drawbacks and there is a clear need for more efficacious alternatives in non-classic bipolars. Compared to existing alternatives, lithium currently is to be considered the golden standard. This status might, however, be challenged by major alternative mood-stabilizers that are presently under clinical investigation.

Is the Prophylactic Antidepressant Efficacy of Lithium in Bipolar I Disorder Dependent on Study Design and Lithium Level?

“…Patients with ''classic'' bipolar disorder (episode sequence: mania-depression-euthymia, full interepisodic recovery, few prior episodes, no history of mood-incongruent psychotic features) have been said to respond favorably to lithium. 1 Some, but not all, data also point to a family history of good lithium response as a positive predictor. 7 More recently, research interest has focused on the contribution of study design and lithium level to clinical outcome.…”

“…It has been the mainstay of prophylactic treatment for over 50 years. 1 More recently, the introduction of newer drugs, such as olanzapine or lamotrigine, for maintenance treatment of bipolar disorder has prompted a re-examination of the therapeutic role of lithium.…”

Differenzialdiagnostik und Psychopharmakotherapie bipolarer Störungen

“…Eine ausführliche aktualisierte Aufstellung dieser Prädiktoren für eine Lithium-Response findet sich z. B. bei Kleindienst et al[20]. Ein weiteres Problem ist, dass sich im naturalistischen Langzeitverlauf die scheinbar gute Wirksamkeit von Lithium nicht in dem Ausmaß wie unter Studienbedingungen widerspiegelt, ein Phä-nomen, was sicher genauso auch für alle anderen gegenwärtigen, in Monotherapie eingesetzten Stimmungsstabilisierer gilt.…”

Intoxicación con litio

“…La medicación clásica para prevenir este tipo de riesgo es el litio, pero aun cuando ha sido recomendada por diferentes guías de práctica médica (16), está visión está cambiando con el advenimiento de nuevos fármacos estabilizadores del humor, como la carbamacepina, valproato, lamotrigina, gabapentina, nimodipina y algunos antipsicóticos de nueva generación como la olanzapina (17). El advenimiento de estos fár-macos en el tratamiento del TB ha traído consigo una disminución de su uso en los Estados Unidos en la última década (18).…”