Tuesday, September 16, 2014

Bipolar Disorder: Lithium-The Cinderella or Aspirin of Psychiatry?


Lithium in Tap Water and Suicide Mortality in Japan.

Abstract: Lithium has been used as a mood-stabilizing drug in people with mood disorders. Previous studies have shown that highest levels of suicide mortality rate in Japan. Lithium levels in the tap water supplies of each municipality were measured using natural levels of lithium in drinking water may protect against suicide. This study evaluated the association between lithium levels in tap water and the suicide standardized mortality ratio (SMR) in 40 municipalities of Aomori prefecture, which has the inductively coupled plasma-mass spectrometry. After adjusting for confounders, a statistical trend toward significance was found for the relationship between lithium levels and the average SMR among females. These findings indicate that natural levels of lithium in drinking water might have a protective effect on the risk of suicide among females. Future research is warranted to confirm this association.

Australian Trilogy:

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"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."

One might ask why there has been such a shift from Lithium.

Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?

Could it be the fact that 
Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.

Some felt it has to do with how little money is to be made from Lithium.



My questions are: Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?


Stephen Fry has disclosed that he attempted suicide last year and only survived the “close run thing” when a colleague found him unconscious after he had taken “huge” quantities of pills and vodka.

Fry suffered a nervous breakdown in 1995 while he was appearing in the West End play Cell Mates and disappeared for several days, coming close to suicide.

In 2006 he made a two-part television documentary called Stephen Fry: The Secret Life of the Manic Depressive, in which he spoke to other celebrities including Carrie Fisher and Tony Slattery about their own problems with the illness. In the programme he also disclosed that he had first attempted suicide aged 17 by taking an overdose.

In 2011 he said of his illness: “The fact that I am lucky enough not to have it so seriously doesn’t mean that I won’t one day kill myself, I may well.”

I hope he is on lithium!  
Unless he is doing a Carrle Fisher!

©Am Ang Zhang 2013

Cade, John Frederick Joseph (1912 - 1980)
Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.

In 1985 the American National Institute of Mental Health estimated that Cade's discovery of the efficacy of lithium in the treatment of manic depression had saved the world at least $US 17.5 billion in medical costs.

And many lives too!

I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here.      It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.

The following is an extract from The Cockroach Catcher:
“Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he overdosed on the Lithium?”

“No. my wife is very careful and she puts it out every morning, and the rest is in her bag.”

Phew, at least I warned them of the danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium but from my experience it was otherwise the best.

“Get him admitted and I shall talk to the doctor there.”

He was in fact delirious by the time they got him into hospital and he was admitted to the local Neurological hospital. He was unconscious for at least ten days but no, his lithium level was within therapeutic range.

He had one of the worst encephalitis     they had seen in recent times and they were surprised he survived.

Then I asked the Neurologist who was new, as my good friend had retired by then, if the lithium had in fact protected him. He said he was glad I asked as he was just reading some article on the neuroprotectiveness of lithium.

Well, you never know. One does get lucky sometimes. What lithium might do to Masud in the years to come would be another matter.

I found that people from the Indian subcontinent were very loyal once they realised they had a good doctor – loyalty taking the form of doing exactly what you told them, like keeping medicine safe; and also insisting that they saw only you, not one of your juniors even if they were from their own country. It must have been hard when I retired.

Some parents question the wisdom of using a toxic drug for a condition where suicide risk is high. My answer can only be that lithium seems inherently able to reduce that desire to kill oneself, more than the other mood stabilizers, as the latest Harvard research shows.
Lithium has its problems – toxic at a high level and useless at a low one, although the last point is debatable as younger people seem to do well at below the lower limit of therapeutic range.
Many doctors no longer have the experience of its use and may lose heart as the patient slowly builds up the level of lithium at the cellular level. The blood level is a safeguard against toxicity and anyone starting on lithium will have to wait at least three to four weeks for its effect to kick in. In fact the effect does not kick in, but just fades in if you get the drift.
Long term problems are mainly those of the thyroid and thyroid functions must be monitored closely more so if there is a family history of thyroid problems. Kidney dysfunction seldom occurs with the Child Psychiatrist’s age group but is a well known long term risk.
Also if there is any condition that causes electrolyte upset, such as diarrhea, vomiting and severe dehydration, the doctor must be alerted to the fact that the patient is on Lithium.
Could Lithium be the Aspirin of Psychiatry? Only time will tell!
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