Countering the declining use of lithium therapy: a call to arms

Abstract

For over half a century, it has been widely known that lithium is the most efficacious treatment for bipolar disorder. Yet, despite this, its prescription has consistently declined over this same period of time. A number of reasons for this apparent disparity between evidence and clinical practice have been proposed, including a lack of confidence amongst clinicians possibly because of an absence of training and lack of familiarity with the molecule. Simultaneously, competition has grown within the pharmacological armamentarium for bipolar disorder with newer treatments promoting an image of being safer and easier to prescribe primarily because of not necessitating plasma monitoring, which understandably is appealing to patients who then exercise their preferences accordingly. However, these somewhat incipient agents are yet to reach the standard lithium has attained in terms of its efficacy in providing prophylaxis against the seemingly inevitable recrudescence of acute episodes that punctuates the course of bipolar disorder. In addition, none of these mimics have the additional benefits of preventing suicide and perhaps providing neuroprotection. Thus, a change in strategy is urgently required, wherein myths regarding the supposed difficulties in prescribing lithium and the gravity of its side-effects are resolutely dispelled. It is this cause to which we have pledged our allegiance and it is to this end that we have penned this article.

Fig. 1

Comparison of effectiveness of mood stabilisers (adapted from Malhi et al. 2018). This schematic utilises a framework (panel a) to illustrate the clinical effectiveness of mood stabilisers, according to their strengths in managing depressive and manic episodes, both acutely and prophylactically. Lithium is effective in treating both manic and depressive episodes, although for depressive episodes in particular, it is most effective when utilised prophylactically rather than acutely. Lamotrigine is only effective in managing depressive episodes, and here again it is best utilised prophylactically rather than acutely. (* = modest efficacy; ** = significant efficacy).

Fig. 2

Clinical profile of lithium responders (adapted from Gershon et al. 2009). Lithium responders have clear-cut mood episodes (Recognisable), an episodic pattern of illness (Recurrence), and have periods that are symptom-free (Remission)