BackgroundLithium remains first choice as maintenance treatment for bipolar affective disorder. Yet, about half of all individuals may stop their treatment at some point, despite lithium’s proven benefits concerning the prevention of severe affective episodes and suicide.MethodsRetrospective cohort study in the Swedish region of Norrbotten into the causes of lithium discontinuation. The study was set up to (1) test whether patients with bipolar affective disorder or schizoaffective disorder, treated with lithium maintenance therapy, were more likely to discontinue lithium because of adverse effects than lack of therapeutic effectiveness, (2) explore gender differences, (3) understand the role of diagnosis and (4) identify who, patient or doctor, took the initiative to stop lithium. Review of medical records for all episodes of lithium discontinuation that had occurred between 1997 and 2013 with the intent to stop lithium for good.ResultsOf 873 patients treated with lithium, 54% discontinued lithium, corresponding to 561 episodes of lithium discontinuation. In 62% of episodes, lithium was discontinued due to adverse effects, in 44% due to psychiatric reasons, and in 12% due to physical reasons interfering with lithium treatment. The five single most common adverse effects leading to lithium discontinuation were diarrhoea (13%), tremor (11%), polyuria/polydipsia/diabetes insipidus (9%), creatinine increase (9%) and weight gain (7%). Women were as likely as men to take the initiative to stop lithium, but twice as likely to consult a doctor before taking action (p < 0.01). Patients with type 1 BPAD or SZD were more likely to discontinue lithium than patients with type 2 or unspecified BPAD (p < 0.01). Patients with type 1 BPAD or SZD were more likely to refuse medication (p < 0.01). Conversely, patients with type 2 or unspecified BPAD were three times as likely to discontinue lithium for lack or perceived lack of effectiveness (p < 0.001).ConclusionsStopping lithium treatment is common and occurs mostly due to adverse effects. It is important to discuss potential adverse effects with patients before initiation and continuously during lithium treatment, to reduce the frequency of potentially unnecessary discontinuations.

Background Currently, the evidence for lithium as a maintenance treatment for bipolar disorder type II (BD-II) remains limited. Guidelines commonly extrapolate recommendations for BD-II from available evidence for bipolar disorder type I (BD-I). Comparing the impact of lithium discontinuation is one way of assessing effectiveness in both groups. Aims To compare the impact of lithium discontinuation on hospital admissions and self-harm in patients with BD-I or schizoaffective disorder (SZD) and patients with BD-II or other bipolar disorder. Method Mirror-image study, examining hospital admissions within 2 years before and after lithium discontinuation in both patient groups. This study was part of a retrospective cohort study (LiSIE) into effects and side-effects of lithium for maintenance treatment of bipolar disorder as compared with other mood stabilisers. Results For the whole sample, the mean number of admissions/patient/review period doubled from 0.44 to 0.95 (P<0.001) after lithium discontinuation. The mean number of bed days/patient/review period doubled from 11 to 22 (P = 0.025). This increase in admissions and bed days was exclusively attributable to patients with BD-I/SZD. Not having consulted with a doctor prior to lithium discontinuation or no treatment with an alternative mood stabiliser at the time of lithium discontinuation led to more admissions. Conclusions The higher relapse risk in patients with BD-I/SZD suggests a higher threshold for discontinuing lithium than for patients with BD-II/other bipolar disorder. In patients with BD-II/other bipolar disorder, however, judged on the impact of discontinuation alone, lithium did not appear to prevent more severe depressive episodes requiring hospital admission.

Following publication of the original article [1], the authors reported an error in Fig. 1 and Table 1, concerning the number of female participants. The correct number is 283, instead of 238 that was originally published.

IntroductionEvidence for lithium as a maintenance treatment for bipolar disorder type II remains limited since most treatment-prevention studies focus on bipolar disorder type I or do not distinguish between types of bipolar disorder.ObjectivesTo compare the impact of lithium discontinuation on hospital utilisation in patients with bipolar disorder type I or schizoaffective disorder and patients with bipolar disorder type II or other bipolar disorder.MethodsMirror-image study, examining hospital utilisation within two years before and after lithium discontinuation as part of LiSIE, a retrospective cohort study into effects and side-effects of lithium for the maintenance treatment of bipolar disorder as compared to other mood stabilisers.ResultsFor the whole sample, the number of admissions increased from 86 to 185 admissions after lithium discontinuation, with the mean number of admissions/patient/review period doubling from 0.44 to 0.95 (p < 0.001). The number of bed days increased from 2218 to 4240, with the mean number of bed days/patient/review period doubling from 11 to 22 (p = 0.025). This increase in admissions and bed days was exclusively attributable to patients with bipolar disorder type I or schizoaffective disorder.ConclusionsOur findings suggest that due to a higher relapse risk in patients with bipolar disorder type I or schizoaffective disorder there is a need to apply a higher threshold for discontinuing lithium than for patients with bipolar disorder type II or other bipolar disorder.DisclosureMichael Ott has been a scientific advisory board member of Astra Zeneca Sweden, Ursula Werneke has received funding for educational activities on behalf of Norrbotten Region (Masterclass Psychiatry Programme 2014–2018 and EAPM 2016, Luleå, Sweden): Astra