Psychosis lithium treatment

A thorough discussion of this topic is beyond the scope of this chapter. However, a recent review of controlled studies of mood stabilizers (Keck et al, 2000) provides a reasonable summary. Pooling response data from five studies (from 1954 to 1994) and 124 acute manic patients revealed that 70% of the patients had at least partial improvement with lithium treatment. Response took 2-3 weeks, was superior to antipsychotics in ameliorating affective symptoms, produced an improvement in psychosis, but was less effective in treating psychomotor agitation. DSM-III and earlier criteria were used to diagnose the patients in these trials, so these samples may not be comparable to patients in more modern studies. Table 37.2 summarizes a compilation of clinical... 

Are childhood psychiatric histories of bipolar adolescents associated with family history, psychosis, and response to lithium treatment / Affect Disord 51 153-164. 

Despite this favorable result, lithium was hardly considered as a psychopharmaceutical for many years. There were a variety of reasons for this. Firstly, mania is not a very common psychosis and there is spontaneous remission in many cases. There were thus not so many occasions where lithium treatment was indicated. Secondly, lithium salts were considered to be toxic because for some time they had been given in excessive doses to patients with heart failure and in this way, had led to a number of fatalities (Cade, 1970). Thirdly, a few years after Cade s first publication psychiatrists attention had been claimed by chlorpromazine and the subsequent neuroleptics and antidepressants, thus explaining why lithium almost fell into oblivion. It was onl> in the 1960s that it once more attracted some interest, after the Danish psychiatrist Mogens Schou had shown that lithium salts were not only useful in the manic phase of manic depressive illness but also could prevent depressive episodes in patients suffering from bipolar psychoses. 

Baastrup PC. Lithium-behandling of mani-depressiv psykose en psykoseforebyggende behandlingsmade (Lithium treatment of manic-depressive psychosis a procedure for preventing psychotic relapses). Nordisk Psykiatrisk Tiddskrift 1966 20 441-450. 

Noack CH and Thautner EM (1951) The lithium treatment of maniacal psychosis. Med J Aust 38 219-222. 

Optimize the dose of mood stabilizing medication(s) before adding on lithium, lamotrigine, or antidepressant (e.g., bupropion or an SSRI) if psychotic features are present, add on an antipsychotic ECT used for severe or treatment-resistant depressive episodes or for psychosis or catatonia... 

There are no randomized, double-blind, controlled studies of hospitalized children and adolescents with acute mania. Two systematic, albeit open, studies of lithium in hospitalized, acutely manic adolescents had response rates of 67%-80% in classic manic adolescents, and 33%-40% in manic adolescents with prior ADHD (Strober et al., 1988 1998). In a discontinuation study in which manic adolescents stabilized on lithium were subsequently assigned double-blind to placebo or continuation treatment, the response rate was 53.5%, and the presence of prior ADHD made no difference in outcome (Kafantaris et al., 1998). However, the presence of psychosis decreased the likelihood of lithium response and antipsychotic medication was necessary for stabilization. Naturalistic discontinuation of lithium (because of noncompliance) after stabilization resulted in relapse rates of 90% vs. 37.5% for those remaining on lithium (Strober et al., 1990). A NIMH multisite study is currently examining this issue more systematically. 

Little work has been done on the drug treatment of schizophreniform or brief reactive psychosis. Flirschowitz et al. ( 374) further explored the range of lithium s efficacy by systematically treating patients with schizophrenic or schizophreniform disorders. They found that poor-prognosis schizophrenia rarely responded to lithium. 

Thus, although lithium therapy of sufficient duration may be the treatment of choice in classic milder presentations of mania, the adjunctive antipsychotics (especially the novel agents) may be preferable in conditions such as mania with psychosis and schizoaffective disorder, given their faster onset of effect and broader spectrum of activity (see the section Alternatiye Treat later in this chapter). 

Schou M, Juei-Neiison N, Stromgren E, et ai. The treatment of manic psychosis by the administration of lithium salts. 

Hyperparathyroidism was considered a possible cause of treatment-resistant manic psychosis in a patient taking lithium (663). 

Alcohol should be avoided during furazolidone and metronidazole therapy. Toxic psychosis has been seen in patients under treatment with furazolidone. Metronidazole should be used with caution when coadministering with warfarin, phenytoin, lithium, omeprazole, and phenobarbital. The coadministration of pentamidine with drugs toxic to the kidney should be avoided. 

Trials of lithium in patients with acute psychosis (and not just mania) showed that lithium was inferior for the treatment of severely overactive patients, presumably because of its toxicity, but comparable to neuroleptics for the treatment of less overactive patients, regardless of diagnosis (Braden et al. 1982 Johnstone et al. 1988). A trial conducted in the 1960 comparing opium and chlorpromazine in acute schizophrenic patients showed equivalent improvement over three weeks with both drugs (Abse, Dahlstrom, Tolley 1960). 

It is not clear that so-called antipsychotic drugs are superior to other types of drugs with sedative effects but different mechanisms of action. Lithium, benzodiazepines and opium have been shown to be comparable to neuroleptics in the treatment of psychotic states in some studies. The ability of the neuroleptic drugs to reduce the most characteristic symptoms of psychosis such as hallucinations, delusions and thought disorder have often been interpreted as evidence of their specifically antipsychotic or antischizophrenic action (The National Institute of Mental Health Psychopharmacology Service Center Collaborative Study... 

The program is straightforward in its call to start drugging children in the absence of any scientific basis In the absence of treatment data, treatment of childhood bipolar illness is modeled on that of adults. Even if the child shows no signs of psychosis, the most toxic adult drugs are recommended For non-psychotic children, in descending order, treatment should be tried with lithium, divalproex, atypical antipsychotic, combining any of these approaches, and other anticonvulsants plus atypical antipsychotics or conventional antipsychotic. ... 

A woman stable on lithium for several years developed marked psychosis and parkinsonism within a week of starting to take diltiazem 30 mg three times daily. An acute parkinsonism syndrome developed in a 58-year-old man within 4 days of adding 30 mg of diltiazem three times daily to his treatment with lithium and tiotixene. However, this report has been questioned as the symptoms may have been attributable to an adverse effect of the tiotixene, and, even if the lithium toxicity was genuine, it is thought to have been more likely due to recent increases in the lithium dose, or the patient s diuretic therapy than diltiazem. ... 

In 1949, Cade, in Australia, showed that lithium salts would control the manic phase of manic-depressive psychosis. This was the first effective psychotherapeutic agent of any kind, ante-dating even chlorpromazine. Possibly on account of the remoteness of his country. Cade s discovery was slow in gaining acceptance but is, today, the standard treatment (see further. Section 11.0). 

Lithium is important as the treatment of choice for manic depressive psychosis and this has provoked a wide variety of NMR studies in an endeavour to probe its mode of action. Organolithium compounds are used extensively in synthetic organic chemistry and as industrial catalysts, especially in polymerization reactions. 

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