The use of lithium carbonate in the treatment of mood disorders

The use of lithium ions in the treatment of manic states is discussed. Lithium is possibly the only specific drug treatment presently available for the major psychoses and has met with enthusiasm in England, Scandinavia, Australia and, more recently, in Canada and the United States.

A number of the published papers on the subject are not sufficiently comprehensive to provide guidance for even its empiric use; some lack the necessary controls and design to permit comparisons with other studies.

Some clinicians with wide experience of lithium therapy do not maintain laboratory control of patients by ordering serum lithium determinations but rely entirely on clinical judgement in establishing drug schedules. This is not advised if one has little experience with lithium therapy because of the possible side effects and toxicity.

     

Pseudotumor cerebri secondary to lithium carbonate

Three patients were initially seen with headache, blurred vision, and papilledema while taking lithium carbonate for their respective bipolar affective disorder. A diagnosis of pseudotumor cerebri was made in each case when a thorough evaluation revealed only elevated intracranial pressure. Two of the patients had complete resolution of their symptoms and papilledema after discontinuing use of the drug. Increased intracranial pressure with papilledema persisted in the third patient when she failed to adjust psychiatrically, necessitating continuance of the lithium carbonate therapy. A history of lithium carbonate ingestion should be sought in patients with the syndrome of pseudotumor cerebri. All patients receiving this drug should have a regular funduscopic examination.     

The impact of long-term lithium treatment on renal function in an outpatient population

AIM: This study aims to compare younger and older populations of lithium-treated patients and to examine the impact of long-term lithium treatment on renal function. METHODS: A retrospective, cross-sectional survey of all patients attending a specialist clinic was carried out. Demographic, clinical and biochemical data from the two groups were compared, and stepwise regression was used to investigate an association between duration of lithium treatment and renal function. RESULTS: The findings reveal a positive association between duration of lithium use and mean serum creatinine levels (t=3.369, p=0.001), and so prolonged lithium treatment may be a risk factor for progressive renal impairment. However, under appropriate supervision this may not be of clinical relevance. CONCLUSION: We conclude that lithium can be safely prescribed over a protracted period of time, even in elderly populations, but should be monitored closely under specialist supervision, to ensure early identification and management of adverse effects.     

Forced alkaline diuresis for lithium intoxication

A case of lithium intoxication treated with forced alkaline diuresis is described. Although clearance of lithium from the plasma by this method is less efficient than by haemodialysis it is as effective as peritoneal dialysis, is easier for nursing and medical staff to undertake and carries less risk of complications. In the absence of facilities for haemodialysis forced alkaline diuresis is the treatment of choice for lithium intoxication.     

Lithium neurotoxicity at therapeutic level--a case report

A 30 years old Hindu male presenting with symptoms of lithium toxicity. On investigation, serum lithium level was found to be 0.5 meq/l. Though toxicity at this level of lithium is unusual, still neurotoxicity happened to be the cause of his hospital admission. He was debarred from taking lithium further and carbamazepine was started as mood elevator. He responded favourably.     

Concomitant neuroleptic malignant syndrome and lithium intoxication in a patient with bipolar I disorder: case report

The purpose of this report is to remind clinicians of the risk of the simultaneous occurrence of neuroleptic malignant syndrome (NMS) and lithium intoxication. A 39-year-old female with bipolar I disorder was admitted to our psychiatric ward due to relapse of a manic episode and a suicide attempt in which she had ingested 20 to 30 tablets of lithium (300 mg/tablet) 12 hours before admission. Except for intramuscular injection of 5 mg of haloperidol 30 minutes after admission, the patient received no antipsychotic drugs during her hospitalization. Six hours after admission, she began to show symptoms of NMS. Lithium intoxication was also found. Within a week, her condition had stabilized with no neurological complications or cognitive deficits noted during the following 4 months. Discussed in this case report are the risk factors of NMS found in this patient, drug interactions of lithium and antipsychotic agents as related to NMS, and problems in clinical management.     

Aplastic anemia associated with lithium therapy

A case is reported of fatal aplastic anemia developing in a 50-year-old woman who received lithium carbonate in the generally accepted dosage for a manic-depressive disorder. The serum lithium had been determined at regular intervals and never exceeded what is considered a safe level. Patients for whom lithium is prescribed should have periodic hematologic examinations.     

Lithium carbonate and hypothyroidism.

A case of hypothyroidism as a complication of lithium maintenance therapy is reported. Clinicians should be aware of this condition and patients receiving long-term lithium maintenance therapy should have their thyroid gland function assessed periodically.     

Seasonal variation in plasma levels of lithium in the Indian population: is there a need to modify the dose?

INTRODUCTION: Lithium still remains an important choice in the therapy of manic-depressive psychosis (MDP), and though there are reports of seasonal variation in lithium levels from a few countries, such studies have not been conducted in India. Variability in the lithium level can lead to lack of efficacy or toxicity, making seasonal variation clinically relevant. METHODS: A retrospective case sheet audit was performed for 101 MDP patients for recording plasma lithium level, oral lithium dose, age and gender for one year. The overall average oral lithium dose and level were recorded; the monthly average to which it most closely matched was noted as the control month, and values of other months were compared with this control month by Friedman's test followed by Dunn's test. RESULTS: The mean age of patients was 38.22 (standard deviation 12.07) years, and 72 out of 101 patients were male. The mean lithium dose in November (938.61 +/- 243.40 mg/day), which was the closest to the overall mean dose (938.24 +/- 241.78 mg/day) was taken as the control month, which when compared with other monthly values, did not show any significant difference. The June (0.54 +/- 0.23 meq/L), July (0.55 +/- 0.24 meq/L) and August (0.55 +/- 0.24 meq/L) mean plasma lithium values were significantly high when compared to the October value (0.45 +/- 0.22 meq/L) as control. High-low variability between the plasma lithium values of different months was found to be 25 percent. CONCLUSION: The present study showed a significant high variability of lithium levels in different months of the year, therefore frequent plasma level monitoring and oral lithium dose adjustment to prevent situations of toxicity and lack of efficacy in MDP.     

Intestinal vasculitis and lithium carbonate-associated diarrhoea

A 57-year-old male manic depressive patient is described who presented as an ‘acute abdomen’ whilst receiving treatment with lithium carbonate. Small bowel resection was performed, the histopathology of which revealed local vasculitic changes with thrombosis and subsequent infarction of the ileal wall. The possible aetiological role of lithium in this vasculitis is discussed.     

Lithium iodide cardiac pacemakers: initial clinical experience.

A new long-life cardiac pacemaker pulse generator powered by a lithium iodide fuel cell was introduced in Canada in 1973. The compact, hermetically sealed unit is easily implanted and reliable, has excellent patient acceptance and has an anticipated battery life of almost 14 years. Among 105 patients who received a lithium iodide pacemaker, complications occurred in 18. The lithium iodide pacemaker represents a significant advance in pacemaker generator technology and is recommended for long-term cardiac pacing; the manufacturer guarantees the pulse generator for 6 years.     

Fatal self-poisoning with lithium carbonate.

In a fatal case of self-poisoning with lithium carbonate there was a progressive increase in serum lithium concentration for 48 hours after ingestion of the overdose. It is suggested that the continuous increase in serum lithium concentration reflects prolonged absorption of lithium from relatively insoluble aggregates of lithium carbonate in the gastrointestinal tract. In this case there was an interval of 45 hours between ingestion of the overdose and the onset of central nervous system depression. Simultaneous peritoneal dialysis and hemodialysis were effective in rapidly reducing the serum lithium concentration but there was little concomitant change in the patient's level of consciousness. The terminal event was a respiratory complication of the comatose state.     

Saline infusion and amiloride in the management of lithium toxicity

This paper describes the case of a 74 year old patient who became lithium toxic after 15 years of lithium therapy. We discuss the clinical presentation of the case and some of the possible causes of the sudden development of his toxicity. Although haemodialysis is the treatment of choice for severe lithium toxicity it is not always available. In this paper we propose that the combination of saline diuresis and Amiloride may provide a suitable alternative in the management of lithium toxicity.     

Effect of lithium on granulopoiesis in culture.

Lithium carbonate therapy is associated with polymorphonuclear leukocytosis. In vitro studies have shown that lithium ions stimulate formation of granulocytic colonies. In a study undertaken to determine how lithium acts, colony-forming cells uncontaminated by monocytes (which elaborate colony-stimulating factor [CSF] in vitro) were obtained by means of a two-step cell separation procedure. The effects of lithium on colony formation were then studied in (a) cultures stimulated by humoral CSF, (b) cultures in which monocytes were relied upon to synthesize CSF de novo and (c) unstimulated cultures. Lithium enhanced the action of CSF but did not stimulate colony formation in the absence of CSF. In monocyte-stimulated cultures, colony formation increased with lithium concentrations up to 1 mmol/L but this increase paralleled that in CSF-stimulated cultures and therefore was not due to increased CSF production by monocytes. At higher concentrations of lithium, colony formation decreased in the monocyte-stimulated cultures but increased in the CSF-stimulated cultures. A lithium concentration of 4 mmol/L gave the greatest enhancing effect on colony formation in CSF-stimulated cultures and a concentration greater than 1 mmol/L inhibited de novo synthesis of CSF by monocytes.     

喹硫平或丙戊酸镁联合碳酸锂对双相情感障碍躁狂发作患者PANSS、BRMS评分的影响

目的 研究喹硫平或丙戊酸镁联合碳酸锂对双相情感障碍（BD）躁狂发作患者阳性与阴性症状量表（PANSS）、倍克-拉范森躁狂量表（BRMS）评分的影响。方法 选取2018 年4 月至2020 年7 月于我院诊疗的BD 躁狂发作患者118 例作为本研究对象,采用简单随机分组方法分为A 组39 例、B 组38 例和C 组41 例,均给予碳酸锂治疗,B 组和C 组在此基础上分别联合喹硫平和丙戊酸镁治疗,比较三组患者治疗前、治疗1 个月后PANSS、BRMS 评分和认知功能相关指标变化,并记录两组患者不良反应发生情况。结果 治疗前,三组患者PANSS、BRMS评分、言语记忆评分和CPT 评分比较,差异无统计学意义（P>0.05）,治疗1 个月后三组患者PANSS、BRMS 评分均降低,B 组和C 组患者PANSS、BRMS 评分降低幅度高于A 组,差异有统计学意义（P<0.05）,B 组患者言语记忆评分和CPT 评分升高幅度>C 组>A 组,差异有统计学意义（P<0.05）;三组患者不良反应总发生率比较,差异无统计学意义（P>0.05）。结论 喹硫平联合碳酸锂或丙戊酸镁联合碳酸锂治疗BD 躁狂发作患者均可显著改善患者极端情绪程度,且安全性高,但喹硫平联合碳酸锂在改善患者言语记忆和持续操作方面效果优于丙戊酸镁联合碳酸锂治疗。     

The incidence and clinical correlates of lithium toxicity: a retrospective review

Background

Lithium is a commonly prescribed pharmacological treatment for mood disorders. It is associated with a number of side effects and potentially serious toxicity. To date, there is little data from Irish samples on the subject of Lithium toxicity.

Aim

To examine the incidence and clinical correlates of lithium toxicity in Cork, Ireland.

Results

Our study identified 130 cases of biochemical lithium toxicity over 5 years, with an incidence rate of approximately 5.4 cases per 100,000 per year. Mean toxic lithium level was 2.16 mmol/L ±SD 0.87 mmol/L. Of these, 36% cases were reviewed medically in the general hospital at the time of toxicity. A number of issues in relation to lithium toxicity were identified. Neurological symptoms were common, including tremor, confusion, ataxia, drowsiness. However, only 4.2% patients were reviewed by a neurologist while in hospital. Medications that interact with lithium were found in 50% cases, with significant polypharmacy in 15%. The psychiatric services were involved in patient care in 76% cases, and 85% patients presenting with toxicity were reviewed by a psychiatrist. Rates of admission to hospital and haemodialysis were 70 and 11%, respectively.

Conclusion

Improvements in the standards of care in relation to lithium prescribing are required.     

Treatment of bipolar disorder

OBJECTIVE: To review the current status of the management of bipolar disorder (manic-depressive illness). DATA SOURCES AND STUDY SELECTION: Controlled clinical trials as well as some recent important open studies are examined. DATA EXTRACTION AND SYNTHESIS: Lithium carbonate remains the mainstay of both the acute and prophylactic treatment of this condition. We highlight specific contentious issues in prophylactic management with lithium, that is, indications for initiating long-term treatment, preferred serum concentrations, timing of the dose, duration of treatment and frequency of laboratory monitoring. In recent years, several alternatives to lithium have been demonstrated as effective in both the acute and prophylactic treatment of patients either unable to tolerate or inadequately responsive to this agent. There is now considerable evidence that carbamazepine is of similar efficacy to lithium and more recent studies suggest that valproate may also be as therapeutic. We outline details of the clinical roles of each of these agents, with guidelines concerning monitoring and adverse effects.     

Lithium toxicity induced by triamterene-hydrochlorothiazide.

Two patients on long-term lithium therapy for manic-depressive psychosis developed serious toxicity within days of being prescribed a combination of triamterene (50 mg) and hydrochlorothiazide (25 mg) for mild symptomless hypertension. Reduced clearance of lithium has been reported to follow its concurrent administration with diuretics that deplete both sodium and potassium. A combination of triamterene with thiazide has not been shown previously to precipitate lithium toxicity.     

Lithium prophylaxis of corticotropin-induced psychosis.

Corticotropin is one of the few accepted treatments for acute exacerbations of multiple sclerosis and retrobulbar neuritis. Psychosis is a serious side effect usually necessitating discontinuation of the drug therapy. Because mood disorders preponderated in most patients previously described with this psychosis, 27 patients were empirically treated with lithium carbonate concurrently with corticotropin. In none of the patients treated with lithium did a psychotic reaction occur, although in a comparable group of 44 patients previously treated identically with corticotropin but without lithium, six (14%) became psychotic.     

Hardness of resin cement cured under different thickness of lithium disilicate-based ceramic

Background  The lithium disilicate-based ceramic is a newly developed all-ceramic material, which is lithium disilicate-based and could be used for fabricating almost all kinds of restorations. The extent of light attenuation by ceramic material was material-dependent. Ceramic materials with different crystal composition or crystalline content would exhibit distinct light-absorbing characteristics. The aim of this study was to analyze the influence of ceramic thickness and light-curing time on the polymerization of a dual-curing resin luting material with a lithium disilicate-based ceramic.

Methods  A lithium disilicate-based ceramic was used in this study. The light attenuation caused by ceramic with different thickness was determined using a spectral radiometer. The commercial dual-cured resin cement was light-cured directly or through ceramic discs with different thickness (1, 2 and 3 mm, respectively) for different times (10, 20, 30, 40, 50 and 60 seconds, respectively). The polymerization efficiency of resin cement was expressed in terms as Vickers hardness (VHN) measured after 24 hours storage. Two-way analysis of variance (ANOVA) and Tukey’s HSD tests were used to determine differences.

Results  Intensity of polymerizing light transmitted through ceramic discs was reduced from 584 mW/cm² to about 216 mW/cm², 80 mW/cm² and 52 mW/cm² at thicknesses of 1 mm, 2 mm and 3 mm, respectively. Resin cement specimens self-cured alone showed significantly lower hardness values. When resin cement was light-cured through ceramic discs with a thickness of 1 mm, 2 mm and 3 mm, no further increasing in hardness values was observed when light-curing time was more than 30 seconds, 40 seconds and 60 seconds, respectively.

Conclusions  Within the limitation of the present study, ceramic thickness and light-curing time had remarkable influence on the polymerization of dual-cured resin cement. When resin cement is light-cured beneath a lithium disilicate ceramic with different thickness, prolonging light-curing time accordingly may still be necessary to insure complete polymerization.