High Lithium Levels: Dead, Alive or Doing Well? a Service Evaluation Looking at Outcomes Over Subsequent 2 Years

Abstract

Aims

Lithium is an effective mood stabiliser in the management of Bipolar affective Disorder. Timing and decision to restart lithium after an episode of toxicity can be challenging. National guidelines offer advice on management of acute toxicity but little information on restarting lithium. Abrupt withdrawal of lithium can provoke relapse. Clinical experience of the authors was that patients who had Lithium stopped following toxicity often relapsed, leading to poor mental health, frequent admissions to acute and psychiatric hospitals and sometimes death. Restarting of lithium in hospital or after discharge was often variable. The aim of the evaluation was to review the outcomes of patients admitted to the University Hospitals Birmingham NHS Foundation Trust (UHB) with a lithium level over 1.2 mmol/L.

Methods

Patients were selected if recorded lithium level was over 1.2mmol/L on admission to UHB. Case note review of electronic patient records was carried out to identify demographic factors of participants alongside medical and psychiatric outcomes over the following 2 years.

Results

84 patients were identified as having lithium levels over 1.2mmol/L. 76% Female. Mean age 61 years (range 20-95 years). 77% of patients had been prescribed lithium for more than 6 years. Mean lithium level was 1.68 mmol/L (range 1.2-3.44 mmol/L). Around 2/3 of patients admitted with lithium above therapeutic range were referred to the liaison psychiatry team. 12% of the patients died during that admission. Just over 2/3 (69%) of those discharged from hospital had been restarted on lithium. When lithium was not restarted during the acute admission, only 13% were restarted in the community within the next 2 months. Two year mortality of patients admitted with elevated lithium levels was 31%. 10% of patients were admitted to a psychiatric hospital within 1 year. The mean number of admissions to the acute hospital (UHB ) within one year was 1.6 (range 0-26).

Conclusion

Admission to hospital with high lithium levels appears to be associated with a number of negative outcomes. These data cannot attribute causality. Conditions predisposing to lithium toxicity such as frailty could contribute to negative outcomes. Given these high mortality figures for this group, discussions on restarting lithium following high levels may need to focus more on the priorities for the patient. Further studies looking at the outcomes of restarting and discontinuing lithium and comparing with those who have not experienced elevated levels would be helpful.