Indications and contraindications Lithium

The double-blind controlled studies of lithium in acute mania were positive several decades ago, and in the largest randomized study comparing lithium with placebo in a study primarily designed to evaluate the acute antimanic efficacy of valproate, lithium and valproate appeared to show approximately equal efficacy and both were superior to placebo.(49) However, there appear to be a number of subtypes of illness with consistently higher or lower rates of response. As shown schematically in Fig 3, a useful rule of thumb is that lithium is relatively less effective, with an efficacy rate of around 30 per cent in acute manic syndromes characterized by anxiety and dysphoria/56 comorbid substance abuse/51 comorbid medical conditions/5^ the pattern of illness of depression-mania-well intervals as opposed to mania-depression-well intervals/56 in those with a negative family history of bipolar illness in first-degree relatives, (54) in those with evidence of EEG(55> and neurological dysfunction,(52) and in those with a pattern of rapid cycling(56 or multiple prior episodes/5^ft59,,60 and61)

Fig. 3 Variable lithium response rate based on bipolar subtype

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