Sir,
An article titled “Perspectives, attitude, and practice of lithium prescription among psychiatrists in India” was published by Mandal et al.[1] It is a very interesting attempt by the authors. However, there are a few concerns that we would like to bring to the attention of this scientific forum.
The authors explicitly mention that lithium is the only U. S. Food and Drug Administration (FDA) approved treatment for the maintenance therapy of Bipolar Disorder.[2] This is scientifically misleading, as other psychotropics such as Aripiprazole, Lamotrigine, Olanzapine, Risperidone long-acting preparation (Risperdal Consta), Quetiapine, and Ziprasidone are also have been approved by the FDA specifically for maintenance therapy for Bipolar Disorder.[2,3]
The authors stated that “the majority of psychiatrists who completed the survey were of the opinion that lithium dose titrations should be done both in the acute phase and maintenance phase on a dose-dependent basis rather than the blood level-dependent basis.” One of the most important known evidence is that plasma lithium in humans does not always reflect the intracellular levels.[4] This could explain the possible scientific explanation as to why majority of psychiatrists in the survey opted for a dose-dependent titration rather than the blood level-dependent titration of Lithium to improve the symptoms.
Authors have looked to explore the barriers to lithium prescription such as adverse effects, monitoring, dose titration, experience, clinical comorbidities, the onset of action and adherence, however they missed some other important barriers like the nonavailability of medications and availability of laboratory services to monitor serum lithium and other biochemical parameters while the person is on lithium.
In the survey, authors have asked about the use of lithium over other molecules in both first episodes and multi-episode mania. The question was ambiguous as “others molecules” in the question was not explained clearly, i.e., other molecules can be interpreted as either other mood stabilizers like valproate or an antipsychotic. Furthermore, it was not clear whether the question was about lithium and other molecules being given in the acute phase or maintenance phase of mania and whether mania was associated with or without psychotic symptoms. Choosing a mood stabilizer in bipolar disorder is depends on multiple parameters like the clinical profile of patients and the patient's choice. These were not discussed in the study. Hence, the study finding on psychiatrists with experience of >5 years preferred lithium over other molecules in both first episode and multiple-episode mania than those who had <5 years experience as psychiatrist has to be interpreted with consideration of above limitations.
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REFERENCES
- 1.Mandal S, Mamidipalli SS, Mukherjee B, Hara SK. Perspectives, attitude, and practice of lithium prescription among psychiatrists in India. Indian J Psychiatry. 2019;61:451–6. doi: 10.4103/psychiatry.IndianJPsychiatry_451_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ruegg H, Adler C, Duran LRP, Watson S, DelBello M. Essential Pharmacotherapies for Bipolar Disorder? Curr Treat Options Psych. 2019;6:75. Doi: 10.1007/s40501-018-0162-0. [Google Scholar]
- 3.Food and Drug Administration (FDA) [Last accessed on 2019 Nov 18]. Available from: https://www fda gov/Drugs .
- 4.Lyttkens L, Söderberg, Wetterberg L. Relation between erythrocyte and plasma lithium concentrations as an index in psychiatric disease. Ups J Med Sci. 1976;81:123–8. doi: 10.3109/03009737609179034. [DOI] [PubMed] [Google Scholar]