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Goodwin's perspective on lithium.

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A good read for those who are interested.

Goodwin's Perspective

Also speaking at the press conference, Frederick Goodwin, M.D., a world authority on BD, said he hoped the new test will help lithium "resume its rightful place as one of the major strategies for treating bipolar disorder, pretty much like it is in the rest of the world."

Many practitioners in the United States, Goodwin explained, view lithium as an historic artifact. They do not know how to use the drug or view it as very difficult to use. Goodwin, director of the Center on Neuroscience, Medical Progress and Society and research professor of psychiatry at George Washington University Medical Center, took the APA and psychiatry residency programs to task for failing to adequately educate psychiatrists in lithium's use.

Because lithium does not make any money for anyone, it is an orphan drug, Goodwin said. He asked press conference attendees how long it had been since they had seen an APA program on lithium.

"It is a disgrace to let young guys and gals get out of psychiatry residency programs without knowing how to use lithium or how to use it well enough," Goodwin added. "If I were on accreditation bodies for residencies, I would not accredit them if they allowed residents to graduate without knowing how to administer one of psychiatry's major drugs."

He revealed that he has been an expert witness for families of suicide victims in two lawsuits. "A couple of doctors took people off lithium because they had been convinced that these alternative drugs were just as good or better [than lithium], and they didn't have to do blood levels, so it was more convenient

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Interesting. I think that some docs get scared of a potential law suit from Lithium toxicity. So they prescribe the latest AAP, which they've been convinced by the pharm rep won't have the potential for "deadly" side effects. (Zyprexa anyone?) I think Lithium really does have to remain in the amorarium. Even low dose-combination therapy can be useful given it's unique neuroprotective effects (Manji et al., 1999).

Two things that struck me from the article:

"Real toxicity is about twice the therapeutic levels of lithium," Goodwin said. "Maintenance levels for bipolar I disorder are in the range of 0.6 mEq/L to 0.8 mEq/L, and for bipolar II [disorder], 0.4 mEq/L to 0.6 mEq/L."


I think that over the long term, higher range doses, while not toxic, often lead to renal ill-health. If you're going by levels, there are a number of studies that indicate that 0.45-0.6 mEq/L might be a decent lower bound for lithium prophylaxis in BPI, not just BPII. (See Coppen et al. 1983. I've seen reference to Abu-Saleh and Coppin (1989) as having the same result, but it's not apparent in the abstract and I can't get the full-text. In the latter, the exception was that older patients fared less well in the lower dose range.) Also, in the Manji article they note that the neuroprotective effects become apparent in rat and human-esque neurons at levels as low as 0.3.

There are specific times, Goodwin said, when he might want to know more about his patients' lithium levels and have the levels monitored frequently. For example, if a patient experiences breakthrough depression, one of the strategies that works well is to increase the lithium levels temporarily.


I think this is a really valid point. Pdocs often rely to much on levels. While checking levels is super important for toxicity, people's individual response is what's important. For me, I probably get as much benefit from 120 mg of Lithium as other people get at 1200. (Granted, the low-dose of Li is just barely holding me. But, I've actually been higher, based on a pdoc going by traditional levels for BPI. I actually got a little worse psychologically and, well, my kidneys revolted.) I also think the extra Lithium PRN aproach is interesting and potentially empowering.

Anyway, just some random thoughts.


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A thought...

This study, so far as I can tell, seems to focus on monotherapy.  For myself, I don't think lith does much for depression; but how would i know?  I'm on Lamictal for that!

Which makes me woner, if those on Tegretol et al had been combo'd with Lamictal, would the suicide event rate have dropped?

While lith is absolutely important in bp treatment in general, I think it should not be fovused on so much that other combo treatments (or treatments with it as part of the combo) should be ignored.

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Late, not sleepy, so rambling.

Here's what I know/have read/have been taught:

0.  Lithium is a good drug.

1.  Lithium (as of 2005) is the **only** drug known to decrease suicide.

1b.  We don't know *why.*

1c.  This is independent of any effect on moods.

1d.  So, in suicidal patients, lithium is first-line.

2.  Therapeutic for bipolar is high, like 0.8 to 1.0.

2b.  Lower levels work just fine if the patient is clinically un-manic.

3.  Lithium is a useful adjunct in "resistant" depression.

4.  Lithium is more useful in bringing highs down than in bringing lows up.

5.  Monitor renal and thyroid function.

5b.  Especially renal.  Dialysis is *not* an acceptable side effect.


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