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Objective: The goal of this survey study was to assess specific aspects of lithium therapy for bipolar disorder, including psychiatrists’ prescribing practices, understanding of therapeutic drug monitoring, and concerns and perspectives regarding lithium therapy. Methods: A 14-item survey was electronically distributed to 225 staff psychiatrists at 8 academic hospitals. Results: The survey was completed by 85 psychiatrists (38% of the 225 psychiatrists to whom the survey was distributed), with between 81 and 85 respondents completing the different items. When asked about the agents with which they initiated therapy, 49 (61%) reported initiating therapy with an atypical antipsychotic and 34 (42%) reported starting with lithium therapy in 50% or more of patients newly diagnosed with bipolar disorder. When prescribing lithium, most of the respondents (n=68, 82%) reported that they used once daily dosing, and 67 respondents (79%) indicated that they ordered lithium blood levels 12 hours postdose. When interpreting lithium levels, 46 respondents (55%) reported “always” changing a clinically stable patient’s lithium dose when the level was above the therapeutic range, compared with 4 (5%) who reported always changing the dose when the level was below the therapeutic range. When asked about their concerns regarding lithium therapy, more than half of the respondents reported that they were especially concerned about toxicity, organ dysfunction, and other adverse effects, as well as therapeutic drug monitoring. Conclusion: Shifts in prescribing practices, inconsistent interpretation of lithium levels, and concerns about safety and therapeutic drug monitoring highlight the need for evidence-informed guidelines reflective of current practice.

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Background: The guiding principle of the Canada Health Act (CHA) is to provide Canadians with “medically necessary care.” We note the historic limitations of the CHA with respect to the full integration of medicines and pharmaceutical health care and point to the priority given to drugs and pharmacy-related care in 2 recent federal reports on health care reform. In The Health of Canadians — The Federal Role (Kirby 2002) and Building on Values: The Future of Health Care in Canada and its related submissions (Romanow 2002), the role of drugs and pharmacy in Canadian health care receives unprecedented emphasis. Methods: To determine whether the emphasis on pharmacare made by Kirby, Romanow, and others is retained in federal-level health reform planning, we conducted a content analysis of major federal party platforms and policies tabled for the spring 2004 election (as well as brief reference to those tabled for the winter 2006 election). Results: Recommended pharmacy-related reforms focus on potential catastrophic costs to individual patients rather than on a consideration of essential medicines as medically necessary for a growing number of Canadians. Furthermore, little consideration is given to the role pharmacists could play in minimizing the potential risks of inappropriate drug use and associated costs. Discussion: We consider the difficulty of reconciling the principles of the CHA and the reality of a piecemeal pharmaceutical health care system. Conclusion: Health reforms are needed that take into consideration the growing importance of drugs in health care and the issue of equity and access to drugs for Canadians.