Expert: Ivan Goldberg, M.D. - 8/5/2010

Question
Dear Dr. Goldberg,
my sister has bipolar 1 & is currently on paliperidone 6 mg & lamictal 100 mg, lorazepam 2 mg.
Now recently, i have studied her file & discovered that at no time, she has been placed on 1200-1800mg of lithium, no have i seen her lithium levels been monitored. Of recent , she has been non-compliant with her meds and i was considering to place her into hospitalisation and have her placed on lithium and made arrangements with her pdoc as well.She has been spending excessively, also shaved her hair off with her razor(like britney spears did!), has no modesty when changing her clothes(leaves door open). Also stalking behavior with her ex-boyfriend.
Now the only hitch i have with lithium(you are a proponent of lithium & also i saw on the oprah show , how people on lithium are quite normal), is the below article that states outcome with lithium at a later stage in illness is not favourable .(she is 39 years old) Do you have any article that does a rebuttal ? or in your experience can we start her on lithium at this late stage without any downside ?
She has been on lithium before but only 400 mg, the pdoc dischareged her from hospital when he saw she became euthymic when administered with Chloropromazine (200 mg), lithium (400mg) , CBZ(400mg), cogentin.
We are in Kenya(East Africa) , lithium is available as 400mg(400 mg t.i.d).
please help with your comments on the article & best way to approach this situation.

Goldberg JF, Ernst CL. Features associated with the delayed initiation of mood stabilizers at illness onset in bipolar disorder. J Clin Psychiatry. 2002;63:985-991.

Answer
Hi . . .Anil,

Lithium treatment without periodic blood tests is often both ineffective and dangerous. You should insist that between 11.5 and 12.5 hours after her last dose of lithium that a test of the amount of lithium in your sisters blood plasma be performed.

I have often initiated lithium treatment to patients in their 40s to 70s and they have had good results/ Most of the writings on this topic support my position. Here is an abstract of a study of lithium use in geniatric patientrs:

Am J Geriatr Pharmacother. 2006 Dec;4(4):347-64.

Treatments for late-life bipolar disorder.
Aziz R, Lorberg B, Tampi RR.

Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.

Abstract
BACKGROUND: Bipolar affective disorder is not uncommon in the elderly; prevalence rates in the United States range from 0.1% to 0.4%. However, it accounts for 10% to 25% of all geriatric patients with mood disorders and 5% of patients admitted to geropsychiatric inpatient units. These patients often present a tremendous treatment challenge to clinicians. They frequently have differing treatment needs compared with their younger counterparts because of substantial medical comorbidity and age-related variations in response to therapy. Unfortunately, the management of geriatric bipolar disorder has been relatively neglected compared with the younger population. There continues to be a scarcity of published, controlled trials in the elderly, and no treatment algorithms specific to bipolar disorder in the elderly have been devised. OBJECTIVE: The goal of this article was to review the current literature on both the pharmacologic and nonpharmacologic management of late-life bipolar disorder. METHODS: English-language articles written on the treatment of bipolar disorder in the elderly were identified. The first step in data collection involved a search for evidence-based clinical practice guidelines in the Cochrane Database of Systematic Reviews (up until the third quarter of 2006). Systematic reviews were then located in the following databases: MEDLINE (1966-September 2006), EMBASE (1980-2006 [week 36]), and PsycINFO (1967-September 2006 [week 1]). Additional use was made of these 3 databases in searching for single randomized controlled trials, meta-analyses, cohort studies, case-control studies, case series, and case reports. "Elderly," used synonymously with "geriatric," was defined as individuals aged > or =60 years. However, to take into account ambiguity in the nomenclature, the key words aged, geriatric, elderly, and older were combined with words indicating pharmacologic treatments such as pharmacotherapy; classes of medications (eg, lithium, antidepressants, antipsychotics, anticonvulsants, benzodiazepines); and names of selected individual medications (eg, lithium, valproic acid, lamotrigine, carbamazepine, oxcarbazepine, topiramate, gabapentin, zonisamide, clozapine, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole). These terms were then combined with the diagnostic terms bipolar disorder, mania, hypomania, depression, or bipolar depression. Finally, the terms ECT and psychotherapy were also queried in combination with indicators for age and diagnosis. A few articles on "older adults," usually defined as individuals aged 50 to 55 years, were also included. They may allow for possible extrapolation of data to the geriatric population. Additionally, several mixed-age studies were included for similar considerations. Case reports and case series were described for their potential heuristic value. RESULTS: Unfortunately, there is a considerable dearth of literature involving evidence-based clinical practice guidelines and even randomized controlled trials in elderly individuals with bipolar disorder. Available options for the treatment of bipolar disorder (including those for mania, hypomania, depression, or maintenance) in the elderly include lithium, antiepileptics, antipsychotics, benzodiazepines, antidepressants, electroconvulsive therapy (ECT), and psychotherapy. CONCLUSIONS: The data for the treatment of late-life bipolar disorder are limited, but the available evidence shows efficacy for some commonly used treatments. Lithium, divalproex sodium, carbamazepine, lamotrigine, atypical antipsychotics, and antidepressants have all been found to be beneficial in the treatment of elderly patients with bipolar disorder. Although there are no specific guidelines for the treatment of these patients, monotherapy followed by combination therapy of the various classes of drugs may help with the resolution of symptoms. ECT and psychotherapy may be useful in the treatment of refractory disease. There is a need for more controlled studies in this age group before definitive treatment strategies can be enumerated.


Best regards . . .

Ivan
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