Depression lithium prophylaxis

Lithium is used in the prophylaxis and treatment of mania and in the prophylaxis of bipolar disorders and recurrent depression. Lithium should be stopped 24 hours before major surgery but the normal dose can be continued for minor surgery, with careful monitoring of fluids and electrolytes. After major surgery, renal function is reduced and this may compromise clearance of lithium. Lithium is a drug with a narrow therapeutic index and it should be avoided if possible in patients with renal impairment. Renal function should be tested before initiating treatment. If lithium is given to patients with renal impairment, a reduced dose should be used and serum lithium concentrations should be monitored closely. 

Fieve RR, Platman SR, Plutchik RR The use of lithium in affective disorders, I acute endogenous depression. Am J Psychiatry 125 79-83, 1968 Fieve RR, Kumbaraci T, Dunner DL Lithium prophylaxis of depression in bipolar I, bipolar II, and unipolar patients. Am J Psychiatry 133 925-930, 1976 File SE Rapid development of tolerance to the sedative effects of lorazepam and triazolam in rats. Psychopharmacology 73 240-245, 1981... 

An earlier study of 40 unipolar depressed patients by this same group found a cumulative probability of recurrence over 2 years to be 0.08 with lithium and 0.58 without lithium (290). These investigators concluded that the outcome strongly supported the value of lithium prophylaxis in unipolar depression, contrasting this agent s lack of acute efficacy. 

Moncrieff, J. 1995, Lithium revisited. A re-examination of the placebo-controlled trials of lithium prophylaxis in manic-depressive disorder, Br.J.Psychiatry, vol. 167, no. 5, pp. 569-573. 

Muller-Oerlinghausen B. Does effective lithium prophylaxis result in a symptom-free state of manic-depressive illness Some thoughts on the fine-tuning of mood stabilization. Compr Psychiatry 2000 41(2) 26-31(Suppl. 1). 

Schou M. Artistic productivity and lithium prophylaxis in manic-depressive illness. Br J Psychiatry 1979 135 97-103. 

Lithium is not essential for vital functions but has an effect on the nervous system. It has an important use as a medicine for treatment of manic-depressive illness. Two Danish doctors and brothers, Carl and Fritz Lange, reported at the end of the 19 century that lithium might prevent and cure depressions. The observation was forgotten. An Australian scientist, John Cade, found and followed the trail and in 1949 published results showing that lithium salts can, in a miraculous way, help manic people to a normal life. Why. Owing to the chemical similarities between lithium and sodium ions, the former may interfere with and influence the messages of the nerves, conveyed by the latter. For many people lithium prophylaxis has produced a wonderful freedom from fluctuations in the frame of mind with all the disturbances of life they can lead to. 

Treatment of Manic—Depressive Illness. Siace the 1960s, lithium carbonate [10377-37-4] and other lithium salts have represented the standard treatment of mild-to-moderate manic-depressive disorders (175). It is effective ia about 60—80% of all acute manic episodes within one to three weeks of adrninistration. Lithium ions can reduce the frequency of manic or depressive episodes ia bipolar patients providing a mood-stabilising effect. Patients ate maintained on low, stabilising doses of lithium salts indefinitely as a prophylaxis. However, the therapeutic iadex is low, thus requiring monitoring of semm concentration. Adverse effects iaclude tremor, diarrhea, problems with eyes (adaptation to darkness), hypothyroidism, and cardiac problems (bradycardia—tachycardia syndrome). 

Turning to the pharmacotherapy for mania, for decades lithium was the only effective drug treatment. More recently, a number of antiepileptic drugs including carba maze pine, lamotrigine and valproate have been shown to also act as mood stabilisers and are becoming established for the treatment and prophylaxis of both unipolar mania and bipolar manic depressive disorders. 

Belelh D, Lan N, Gee KW Anticonvulsant steroids and the GABA/benzodiazepine receptor-chloride ionophore complex. Neurosci Biobehav Rev 14 315-322, 1990 Bellaire W, Demisch K, Stoll K-D Carbamazepine vs. lithium. Application in the prophylaxis of recurrent affective and schizoaffective psychoses. Muenchener Medizinische Wochenschrift 132 S82-S86, 1990 Belmaker RH Receptors, adenylate cyclase, depression, and lithium. Biol Psychiatry 16 333-350, 1981... 

Dunner DL, Stallone FL, Fieve RR Lithium carbonate and affective disorders, V a double-blind study of prophylaxis of depression in bipolar illness. Arch Gen Psychiatry 33 117-120, 1976... 

Song F, Freemantle N, Sheldon TA Selective serotonin reuptake inhibitors meta-analysis of efficacy and acceptabihty. BMJ 306(6879) 683-687, 1993 Song L, Jope R Chronic lithium treatment impairs phosphatidylinositol hydrolysis in membranes from rat brain regions. J Neurochem 58 2200-2206, 1992 Souza EG, Mander AJ, Goodwin GM The efficacy of lithium in prophylaxis of unipolar depression evidenced from its discontinuation. Br J Psychiatry 157 718-722, 1990... 

In bipolar depressed patients, lithium (with or without concurrent antidepressants) is the maintenance treatment of choice, with divalproex (DVPX) or carbamazepine as potential alternatives (see also Chapter 10, Maintenance/Prophylaxis ). Maintenance lithium has also been shown to prevent relapse in recurrent unipolar depression (Table 7-22). 

Souza FGM, Goodwin GM. Lithium treatment and prophylaxis in unipolar depression a meta-analysis. Br J Psychiatry 1991 158 666-675. 

Quitkin FM, Kane J, Rifkin A, et al. Lithium and imipramine in the prophylaxis of unipolar and bipolar II depression a prospective, placebo-controlled comparison. Psychopharmacol Bull 1981 17 142-144. 

Souza FGM, Mander AJ, Goodwin GM. The efficacy of lithium in prophylaxis of unipolar depression evidence from its discontinuation. Br J Psychiatry 1990 157 718-722. 

Bipolar patients treated under typical clinical conditions may have a more difficult posthospital course than has been generally appreciated. Mander ( 168), for example, reported on 2745 bipolar patients initially admitted because of an episode of mania or depression, and found that lithium did not reduce the readmission rate within 3 months of discharge. As a result, he proposed that its full prophylactic effect may not occur for 6 to 12 months after the start of treatment, and that it should be reserved for long-term prophylaxis in those who have had a number of severe episodes in a defined period of time. 

Lithium was introduced into modern psychiatric practice in the 1950s and for decades it was the only drug that was thought to have a specific effect on the psychiatric condition known as manic depression. At first it was viewed as a specific treatment for an acute episode of mania and later it was proposed to have prophylactic properties against recurrence of future episodes. It continues to be recommended for the treatment of acute mania, although it is rarely used alone in such circumstances. It is most commonly prescribed for the prophylaxis, or prevention of recurrence, of manic-depressive episodes. 

Several trials of olanzapine for prophylaxis of manic depression have now been conducted, funded by Eli Lilly, and claim to show positive evidence of efficacy. A comparison with lithium demonstrated little difference between the two treatment groups overall, although olanzapine appeared to be better at preventing recurrence of mania (Tohen et al. 2005). The only placebo-controlled trial that has been published showed superiority of olanzapine, but there was evidence of a discontinuation effect. Fifty per cent of the placebo group relapsed within 22 days of randomisation and almost all the excess risk of relapse was confined to the first three months of the study (Tohen et al. 2006). All patients were treated with olanzapine initially and since no gradual discontinuation schedule was mentioned, it appears that it was stopped abruptly at the point of randomisation for patients allocated to placebo. 

Carbamazepine is licenced as an alternative to lithium for prophylaxis of bipolar affective disorder, although clinical trial evidence is actually stronger to support its use in the treatment of acute mania. Carbamazepine appears to be more effective than lithium for rapidly cycling bipolar disorders, i.e. with recurrent swift transitions from mania to depression. It is also effective in combination with lithium. Its mode of action is thought to involve agonism of inhibitory GABA transmission at the GABA-benzodiazepine receptor complex (see also Epilepsy, p. 417). 

Since its introduction several decades ago for the occasional treatment of "psychotic excitement", lithium is still a mainstay in the treatment and prophylaxis of manic-depressive disorders [1]. The biologic basis for the clinical efficacy of lithium is not completely known. Interestingly, the agent relieves both mania and depression, states which appear to be opposites. Its therapeutic range, however, is narrow, and even at the lowest effective dosage, some unwanted side effects may occur [2]. Serum levels above 1.5 mEq/L often result in acute intoxication, which may... 

Lithium is the major drug used to treat the mood disorders of mania and manic-depressive illness. Lithium is the only psychotherapeutic drug that is an effective prophylaxis against disease recurrence. 

Lithium and valproate are the mainstays of treatment for both acute mania and prophylaxis for recurrent manic and depressive episodes. Anticonvulsants such as lamotrigine, carbamazepine, and oxcarbazepine and atypical antipsy-chotics such as aripizrazole, olanzapine, risperidone, queti-... 

I Lithium is also used in the prophylaxis of recurrent unipolar depressive disorder. I Controlled trials suggest response rates of 30-40%, and while the strategy is significantly more efficacious than placebo, the magnitude of effect is small. 

I The evidence base for the efficacy of carbamazepine in treating mania, bipolar depression and in prophylaxis is extremely limited. In recent studies it appears less effective than lithium. 

One in every 1,000 people in the United States currently receives lithium, as Li2C03, for the treatment and prophylaxis of manic-depressive behavior. Doses of 250 mg to 2 g per day are administered in order to maintain a 0.5 to 2.0 mM concentration window, outside of which the drug is either toxic or ineffective. The detailed molecular mechanism by which Li ion brings about its remarkable chemotherapeutic effects is largely unknown, but there are various theories. One theory proposes that lithium binds to inositol phosphates, inhibiting their breakdown to inositol, and so reducing inositol-containing phospholipids. A consequence of this chain of events would be disruption of the neurotransmis-... 

Lamotrigine seems to be more effective than iithium in such cases, especially taking into consideration the proven greater efficacy of iamotrigine in the treatment of bipolar depression.Carhamazepine, an anticonvulsant with known mood-stabilizing capacity, also seems to be superior to lithium in schizoaffective disorder, depressed type, and it may also be used in subsequent prophylaxis. 

Lithium carbonate is used specifically for the prophylaxis or prevention of recurrent mood changes in patients suffering from manic depressive psychoses, the recurrent affective disorders. It is of limited use for other psychiatric states, with the possible exception of pathological aggression, where it does seem to have a role to play. Despite many scares, lithium is a very safe drug in experienced hands. The ability of lithium to reduce or abolish recurrent mood swings has undoubtedly improved immensely the quality of life of many patients and their families and saved the lives of many who would otherwise have been led to suicide. ... 

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