Clinical course and need for hospital admission after lithium discontinuation in patients with bipolar disorder type I or II: mirror-image study based on the LiSIE retrospective cohort

Abstract

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.

Suicidal and non-suicidal self-injurious behaviour in patients with bipolar disorder and comorbid attention deficit hyperactivity disorder after initiation of central stimulant treatment: a mirror-image study based on the LiSIE retrospective cohort

“…The reasons for this are not quite clear. A higher occurrence of agitated depression and anxiety may play a role, 26,46 factors that could not be explored further in our study.…”

“…However, as 91% of included patients had a diagnosis of BD-II/other BD, our results are applicable mainly to this group and cannot automatically be extrapolated to patients with BD-I/SZD. 26 As previously pointed out by others, mood stabilisers should be used concomitantly to prevent manic episodes. 14 An incidental finding from our study was that SGA were positively associated with SA/ NSSI events, already before, but even more so after CS initiation.…”

Discontinuing psychotropic drug treatment

“…Most previous research has supported the view that abrupt or rapid discontinuation of long-term lithium maintenance treatment leads to risk of early relapses and recurrences exceeding that expected from the previous course of illness in the same individuals. The new study by Öhlund et al 1 adds findings indicating that discontinuation of lithium, even rapidly, was much less likely to be followed by admission to hospital in those with BD-II or other unspecified types of bipolar disorder than those with BD-I and schizoaffective disorder. Such an outcome is consistent with the generally much lower risk of psychiatric hospital admission in patients with BD-II, although it is not in accord with a previous comparison of patients with BD-I and BD-II based on risk of new illness episodes rather than hospital admission.…”

“…16,19 The impact of abrupt or rapid treatment discontinuation in these studies and that of Öhlund et al 1 was most apparent in initial months, with more similar risk × time rate functions thereafter that paralleled risk × time before treatment. 1 Hospital admission increased non-significantly after stopping lithium abruptly or rapidly in the new study by Öhlund et al, 1 although contrasts were limited by including conditions other than BD-I and late spontaneous recurrences probably unrelated to treatment discontinuation. The preponderance of available evidence supports the view that gradual discontinuation of most psychotropic drugs over at least several weeks is likely to reduce early risks of relapses 6,9,[11][12][13][14][15][16]17 as well as risk or severity of early withdrawal reactions 6,9,17,19,20 and should be considered a preferred clinical practice.…”

“…That earlier relapses or recurrences are a consequence of treatment discontinuation itself is supported by differences in morbidity in patients after discontinuing a treatment versus their spontaneous illness course before starting treatment. 11 Such adverse clinical responses have been reported in association with discontinuing lithium or other treatments in bipolar disorder, 1,[12][13][14] antipsychotics in schizophrenia, 15 and antidepressants in patients with major depression. 16 For selective serotonin reuptake inhibitors these effects may last for periods varying between a few weeks to a year or more.…”