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Monitoring patients on lithium

Published online by Cambridge University Press:  02 January 2018

John M. Eagles*
Affiliation:
Grampian Primary Care NHS Trust, Royal Cornhill Hospital, Aberdeen AB25 2ZH
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Abstract

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Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © Royal College of Psychiatrists, 2002

Sir: I read the recent paper by Nicholson and Fitzmaurice (Psychiatric Bulletin, September 2002, 26, 348-351) with interest. Their literature review preceded the publication of our fairly recent study (Reference Eagles, McCann and MacLeodEagles et al, 2000) that investigated lithium monitoring before and after the distribution of clinical practice guidelines in the north-east of Scotland. From our findings, I would wish to extend, and to mildly contest, some of the points made by Nicholson and Fitzmaurice.

With regard to specific points within the Lothian Guidelines, there are two points. Thyroid dysfunction occurs, commonly, more in women than in men and especially during the first 2 years of lithium treatment (Reference Johnston and EaglesJohnston & Eagles, 1999). It is probably logical, therefore, certainly in the early years of lithium treatment, to monitor thyroid function at 6-monthly intervals. Second, I agree that there is no good evidence on which to base advised serum levels; Nicholson and Fitzmaurice selected 0.6-1.0 mmol/l, while we advise 0.5-1.0 mmol/l. It is important to note that, within this range, some patients may respond only at higher serum levels (Reference Gelenberg, Kane and KellerGelenberg et al, 1989).

As we did in north-east Scotland (Reference Eagles, McCann and MacLeodEagles et al, 2000), Nicholson and Fitzmaurice intend to audit the effect of circulating lithium monitoring guidelines in Lothian. We found that guidelines significantly improved the monitoring of renal and thyroid function. More importantly, however, standards of monitoring were poor before and after guideline distribution, and remained even poorer among patients who were no longer in contact with psychiatric services. We endorsed Cookson's (Reference Cookson1997) conclusion that all patients on lithium should remain in contact with an experienced psychiatrist.

References

Cookson, J. (1997) Lithium: balancing risks and benefits. British Journal of Psychiatry, 171, 120124.Google Scholar
Eagles, J. M., McCann, I., MacLeod, T. N. N., et al (2000) Lithium monitoring before and after the distribution of clinical practice guidelines. Acta Psychiatrica Scandinavica, 101, 349353.Google Scholar
Gelenberg, A. J., Kane, J. M., Keller, M. B., et al (1989) Comparison of standard and low serum levels of lithium for maintenance treatment of bipolar disorder. New England Journal of Medicine, 321, 14891493.CrossRefGoogle ScholarPubMed
Johnston, A. M. & Eagles, J. M. (1999) Lithium-associated clinical hypothyroidism. Prevalence and risk factors. British Journal of Psychiatry, 175, 336339.Google Scholar
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