From the Editor
In the past, lithium had a large role – in the treatment of bipolar, yes, and before that, as a general remedy for a variety of conditions. Indeed, lithium could be found in various things, including pop (see the picture of the ad for 7 Up below). But times have changed. Lithium prescriptions are less common, and bipolar management increasingly involves other medications. (And, no, 7 Up doesn’t contain that salt anymore.)
How does lithium compare to these medications for people with bipolar? Dr. Jens Bohlken (of the University of Leipzig) and his co-authors do a retrospective study drawing on a national database from Germany. “When treatment failure was defined as discontinuing medication or the add-on of a mood stabilizer, or antipsychotic, antidepressant, or benzodiazepine, lithium appears to be more successful as monotherapy maintenance treatment than olanzapine, citalopram, quetiapine, valproate, and venlafaxine.” We look at the big study, and mull its implications on this side of the Atlantic.
Can we nudge people to vaccinate? As the world works to get more shots in arms, Dr. Mitesh Patel (of the University of Pennsylvania) argues that behavioural economics will be important. In Nature, he writes that we have a golden opportunity to learn from the vaccine roll-out: “Each institution should report its vaccination efforts and performance, and conduct rapid experiments on how best to encourage people to get their vaccines – especially their second doses.”
Finally, some physicians have commented that being touched by illness has helped them become better doctors. Dr. Chloe Beale, a British psychiatrist, agrees to disagree in a blog for BMJ. “I can’t give the expected, tidy narrative of emerging stronger for having my illness.”
Selection 1: “Bipolar Disorder and Outcomes of Monotherapy with Lithium, Valproate, Quetiapine, Olanzapine, Venlafaxine, and Citalopram”
Jens Bohlken, Steffi Riedel-Heller, Michael Bauer, Karel Kostev
Pharmacopsychiatry, 25 January 2021
Bipolar disorders are characterized by frequent recurrent depressive episodes and usually less frequent manic episodes. Due to the often decades-long course of the disease and the severity of the symptoms, it can lead to limitations in psychosocial and cognitive functions as well as the ability to lead an independent life…
Over the past 3 decades, the spectrum of drugs prescribed to patients with bipolar disorder has changed considerably, both nationally and internationally. Although it continues to be the best documented of all therapies, lithium has lost its primary position as the leading long-term therapy for the disease to other treatments, particularly quetiapine. The decline in lithium prescriptions is accompanied by increased multi-medication. A direct comparison of the drugs used and recommended in long-term therapy in a multicenter randomized study is still a desideratum. The few comparative studies in this area often have methodological weaknesses and are associated with various implementation problems. Therefore, observational studies on large samples of patients in routine care are of particular importance… Most recently, Hayes and colleagues were able to show that lithium monotherapy is superior to other drugs in a large GP-based study of more than 5000 patients from 1995 to 2014. The criterion for the failure of monotherapy was not only the discontinuation of therapy but also the additional administration of other psychotropic drugs because the initial therapy alone was not sufficiently successful…
So begins a paper by Bohlken et al.
Here’s what they did:
- This retrospective study included bipolar disorder patients who had initially started on a monotherapy with lithium, valproate, quetiapine, olanzapine, venlafaxine, or citalopram in 93 private neuropsychiatric practices in Germany, between January 2006 and December 2017.
- The data was drawn from a national database (the Disease Analyzer database).
- “Treatment failure was defined as time to discontinuation of medication or addition of another mood stabilizer, antipsychotic, antidepressant, or benzodiazepine.”
- Statistical analyses were done.
Here’s what they found:
- “The present study included 4990 bipolar disorder patients who received monotherapy with one of the study drugs (1098 lithium, 502 valproate, 927 quetiapine, 927 olanzapine, 574 venlafaxine, 962 citalopram).”
- Demographics. the mean age varied between 48.9 and 50.9 years, while the proportion of women was between 50.3 and 62.9%.
- Therapy failure. “At 24 months after the index date, 23.7% of lithium patients were still on the monotherapy. The proportion of monotherapy after 24 months was lower in patients treated with other drugs, from 15.4% in patients taking quetiapine to 7.9% in those treated with olanzapine…”
- Comparison. “In the multivariate regression model, therapy with each of the 5 drugs (valproate [HR: 1.18], quetiapine [HR: 1.18], olanzapine [HR: 1.66], venlafaxine [HR: 1.14], citalopram [HR: 1.27]) was associated with a higher risk of therapy failure compared to lithium therapy.”
A few thoughts:
- This is a good paper.
- There is much to like here, including the robust sample size (5000).
- To summarize the findings in a Twitter-worthy sentence: lithium bests the other medications.
- This study draws from German data. It should be noted that bipolar management largely falls to specialists in that country – a model of care somewhat different than in North America. Still, the authors note that several studies have found similar results. They write: “Baldessarini et al. compared lithium with antiepileptic and antipsychotic drugs in the National MarketScan research database and showed that, in a total of 2743 patients, the treatment continuity (survival time) of lithium was significantly longer at 200 days than that of both anticonvulsants at 90 days and antipsychotic drugs at 90 days…”
- Of course, perspective is needed: most patients needed more than one medication, even if that drug was lithium. Two cheers for lithium? The clinical point here: lithium is underappreciated, but needs to be part of a comprehensive medication and non-medication approach to the patient with bipolar.
- On a pivot: on this side of the Atlantic, lithium is badly out of fashion. In a brief report considered in a past Reading, Dr. Scott B. Patten and Jeanne V. A. Williams (both of the University of Calgary) draw on national survey data to consider lithium prescribing in Canada. “The frequency of lithium use is surprisingly low,” they find. For that Reading:
The full paper be found here:
Selection 2: “Test behavioural nudges to boost COVID immunization”
Nature, 9 February 2021
In many nations, public-health agencies are independently scheduling appointments for COVID-19 vaccinations and setting up delivery sites.
And yet, few vaccination rollouts capture information on what methods are used to encourage people to get their shots, and how they are performing. That means that successful approaches won’t spread as quickly as they should, and efforts that perform poorly will remain in place for too long. The COVID-19 pandemic – with its accumulating losses – will last longer. We need to start learning now how best to ‘nudge’ people to receive their vaccinations.
So begins a paper by Dr. Patel.
“Nudges are subtle changes in how choices are offered. They don’t involve mandates or changes to the price of care; they are usually shifts in how a message is framed. Nudges are everywhere, by design or otherwise. The challenge is not whether to introduce them, but to learn how to do so for the greatest benefits. Think of it as user-experience testing that might save lives and livelihoods.”
He forwards three suggestions for their use in vaccinations:
- Messaging should frame vaccination as the default. “Our work on a previous project required clinicians to accept or cancel orders for routine care such as vaccines or tests, and found that this nudge increased influenza vaccination rates by nearly ten percentage points. It increased ordering of cancer screening tests by up to 22 percentage points.”
- The process has to be easy. “Rehab for people who have had heart attacks can reduce their chances of a second heart attack by as much as 30%, but too few enrol… Giving clinicians templated forms and patients lists of nearby rehab centres tailored to their insurance coverage increased referral rates from 15% to 85%.”
- A single approach will not work for everyone. “Nudges can be personalized. For example, health systems could check who has not received an influenza vaccine in the past, which might reveal who is likely to be vaccine hesitant.”
A few thoughts:
- This is a short but interesting paper.
- A past Reading considered the work needed to reach certain populations, such as racialized Canadians. Could nudging be part of the solution?
- Dr. Patel doesn’t consider how to reach those with severe mental illness. Of course, that’s a population that would be particularly important to reach – a recent World Psychiatry paper, for example, found that those with mental illness had a death rate almost double of those without. This paper can be found here:
And the Patel paper can be found here:
Selection 3: “My illness does not make me a better doctor”
thebmjopinion, 28 January 2021
When I became unwell with a mental illness, I was about five years into my job as a consultant psychiatrist. As soon as I decided to take leave from work and seek treatment, I made a point of speaking completely openly about my illness. Colleagues, friends, and family were all made aware of what was going on and I have tried to maintain that candour now I am recovering. Several people have called my actions ‘courageous’; various others have suggested that I would be a better psychiatrist for this new insight I’ve gained into my patients’ experiences. I vehemently disagree with both views.
So begins a blog by Dr. Beale.
She notes the ongoing stigma of mental illness. “While those doctors who led the way in speaking openly about their mental health have rightly been applauded for their honesty, we must be realistic about the limits of clinicians’ lived experience – both as a benefit to practice and as a tool for demolishing stigma.”
“Mental illness is no leveller. It is vastly heterogeneous and I cannot possibly know what it’s like to experience any condition other than my own. Being a doctor with lived experience does not make me good at my job by default or give me a greater level of insight into the very varied lives of my patients, nor does it give me the right to speak for anyone but myself. It certainly doesn’t permit me to make a consultation with a patient about me and my life.”
In terms of the lessons she has learned? “I have gained certain insights. For example, I think I do have more empathy towards people who share my particular diagnosis than I had as a clinician alone. Having been a psychiatric patient, I am much more aware of the power imbalance between clinicians and patients in this specialty. I am more attuned to the roles and needs of families and carers of patients than I used to be. Since receiving treatment I find I am more mindful of the ‘little’ things and how they impact patients, such as administrative errors, cancelled appointments, and communication failures.”
A couple of thoughts:
- This blog is well written.
- The comment about mental illness not being a leveller is particularly important.
The full blog can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.