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Long-term clinical effectiveness of lithium maintenance treatment in types I and II bipolar disorders

  • Leonardo Tondo (a1), Ross J. Baldessarini (a2) and Gianfranco Floris (a3)
Abstract
Background

The effectiveness of lithium is being questioned increasingly and requires clarification.

Aims

To assess the effectiveness of lithium treatment in depression and mania, syndromal types I and II, with predominantly mixed or psychotic episodes or rapid cycling, during treatment resumed following discontinuation, and across three decades.

Method

The longitudinal course of 360 patients with bipolar disorder compliant with lithium treatment for at least 1 year and without comorbidity for substance use disorder was reviewed.

Results

Risk of single-episode recurrences, a common index of treatment failure, was similar to that in other reports. Both episode frequency and ‘time ill’ improved more in type II than type I cases. Reduced morbidity during treatment was similar in patients with mixed or psychotic episodes, or rapid cycling, and in less complex cases. Retreatment yielded minor decrements in response, and there was no tendency for lesser responses in more recent years.

Conclusions

Based on overall affective morbidity, long-term lithium treatment in compliant patients without comorbid substance use disorder, though imperfect, remains effective, even in subgroups of supposedly poor prognosis.

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Copyright
Corresponding author
Dr Leonardo Tondo, Centro Lucio Bini, 28 Via Cavalcanti, 09128 Cagliari, Italy. Tel: +39 070 486 624; fax: +39 070 496 354; e-mail: ltondo@aol.com
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Declaration of interest

R. B. has recently served as a consultant or received research support from: Biostream, Janssen, Eli Lilly Protarga and Solvay.

Footnotes
References
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Long-term clinical effectiveness of lithium maintenance treatment in types I and II bipolar disorders

  • Leonardo Tondo (a1), Ross J. Baldessarini (a2) and Gianfranco Floris (a3)
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eLetters

Potentially Harmful and Ignored Side Effect of Lithium Therapy

Kate M. Reeh, Unemployed
25 June 2004

I write, not as a physician, but as a sufferer of a bipolar disorder who has noticed one side effect, which I believe could have possibly fatal

repercussions, that no physician in any article that I have read does not address: the effect of lithium on emotions.

When I am on a strict lithium regimen, the drug cuts me off from feeling any emotions, expressing any feelings when it would be appropriate

and cathartic. That the drug cuts off feelings of sadness and grief; that when I take lithium while taking lithium I lose the ability to cry, feel sadness, just feel what I should appropirately be feeling--even severe emotional pain.

The literature, at best, will say "it enables you to control your emotions". That statement is misleading. Another article states that as a side effect that you may "feel dulled". Neither of these articles mentions the true effect of what lithium is doing: causing complete emotional numbness.

This is not something benign. During my first experience with a strict lithium regimen was unable to cry for two years--I was unable even to grieve the death of my father. I felt literally nothing. Lithium robbed me of feeling grief over somehone whom I watched die a painful death--and loved very very dearly. I was not even able to cry. I heard my mother say to my sister that I "seemed unaffected by it". Is that an appropriate response to loss?

My therapist was worried, I was worried and wondered what had happened to me. Crying has always been cathartic for me (and I would assume for many others). I cry, get my feelings out, and then am able to move past whatever emotional blockage, loss, or painful situation that I face.

Two years, two years of feelings locked inside. Then came an incident that was work related and I literally blew up on the job. I started screaming at a supervisor and co-worker and was unable to stop myself. It was like I had stepped out of my body and was watching anotherperson doing these things. The next day I was fine, but the damage was done. I had lost a good job.

Later, due to money I had available at the time; obtaining a job and insurance and eventually COBRA, I was able to take Lamictal and the emotional numbnessthat lithium had caused disappeared,even when I took a small dose of lithium to aid in fighting depression. When l lost my job andI no longer had access to money and insurance I had to go back on a strict lithium regimen. The symptoms recurred.

While back on the lithium regimen, I fought normal side effects of fatigue, dry mouth, weight gain, and other usual side effects, but I fought an almost debilitating depression that was absent when I was on theLamictal regimen. It took several months, not days or weeks, for the depression to subside. And yes, the emotional dullness returned.

Emotional numbness is not benign. I cannot express adequately in words to you how it feels. I have spoken to others who have had the same experience--this obviously is not a side effect that is experienced by only a few.

This needs to be studied. Patients need to be warned that this may occur. It is being glossed over, ignored, and I wonder if it is even being studied. If this is the situation, the patients taking lithium--which is highly praised by doctors as the "most effective drug in dealing with bipolars disorders", are being done a great dis-service and perhaps even deceived as to what this medication may do to them.

As a Bipolar II sufferer who does a great deal of research regarding her disorder I am finding no mention whatsoever of this particular side effect when I read about this drug. Any good psychiatrist will tell you that suppressed emotions are not healthy and can even cause harm. It is one thing to be told that lithium will help you "control your emotions", it is another thing altogether to be told that you cannot feel them when you need to. That you spend your days in an emotional vaccuum because youexperience an emotional numbness.

I taking Lamictal at the moment on the free meds program. What am I going to do when I am no longer eligible? I won't be eligible for insurance and won't be working full time because after almost three years of unemployment--and losing three jobs in two years--I will not have access to insurance. I have taken Depakote and never will again, is not an option--not after the side effects I experienced, and a tremor that matched anything I experienced on lithium. I am allergic to Tegretol, itcaused a severe rash after three weeks and I never had problems similar tothat with Lamictal. What is going to happen to me?

I cannot go without medication but I do not ever want to experience what lithium put me through again. I have gone through it twice, and dread the thought of having to deal with it again. I don't think I could do it--frankly suicide is more appealing.

That this aspect of lithium is not discussed in articles about this medication causes me great concern. I don't know how to start to a forum of professionals, or anyone to take me seriously regarding the potential harm this drug may cause. Not being able to cry, feel sadness, feel grief, not being able to let painful feelings out so that a patient can bereleased from them I cannot help but feel is a potential danger.

What must I say to convince you that this must be studied, that patients should be advised of this side effect, that any article written about lithium should warn of this side effect. How many people must suffer my experience before someone will take notice?

Respectfully,

Kate M. ReehBipolar II sufferer
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