very low lithium dosing for suicide prevention

[hebel]

Currently going through a psychopharm book by Ghaemi, who has a section about lithium with some discussion of the lithium in the drinking water studies most of us have read before.

In the book, he seems to be inferring that its a good idea to prescribe very lose doses of lithium (~30mg of lithium citrate or 120mg of lithium orotate) to people with affective illness (including MDD alone) to prevent suicide, although he doesn't seem to commit to actually advising people do this (maybe a CYA move, idk).

Any of you guys do this?

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[tr]

Yes, I don't think this is a niche practice? Lithium was one of the two augmenting agents in the Star-D. I don't do it much myself but I definitely have seen others augment treatment-resistant and/or suicidal unipolar with low-dose lithium.

The lithium orotate is interesting, I don't know that I've seen anyone prescribe it. It is available OTC and I have had a couple of people come to me who were taking it as a supplement, without physician oversight.

 

[Sushirolls]

I've done 300-600mg as adjunct in more acute SI patients with MDD. Usually hangs around once in remission for 3-9 months, depending on patient's treatment goals.

Less than 150mg I consider naturopath dosing and question the efficacy, reinforced by too many patients coming to me on it and still depressed. But then again, maybe their 'sluggish adrenals' need more supplements, or perhaps the pig thyroid needs to be custom compounded for that extra special cost. No, wait! Lets add the latest supplement with a plant no one knows how to pronounce because that is the key to therapeutic value...

 

[clausewitz2]

I've had a few people come to me taking Li orotate but usually these are the people heavily into nootropics and various research chemicals so there are usually more pressing concerns like figuring out how to taper off Phenibut 3 g BID

 

[romanticscience]

I have not used it this way. However, I do use it in one of my older stable bipolar patients for Alzheimers prophylaxis.

If I remember correctly, he says he starts low dose lithium and VPA for “bipolar spectrum” patients. If they respond, great; if not, he moves to treatment level dosing. He also says he would consider topiramate or neurontin. He has his own criteria for this diagnosis.

 

[Old&InTheWay]

One risk of prescribing any amount of lithium to someone who is not bipolar, is that someone could see them in the ED in the future and assume they are bipolar based on the lithium. I had a very BPD patient who was very chronically suicidal who we discharged on 300mg of lithium (mainly in reaction to her teleological mode of functioning). She showed back up in the ED a few weeks later and the NP who evaluated her decided she was manic, added bipolar to her diagnosis list, got a lithium level, determined she was sub-therapeutic, and increased her dose to 900mg.

 

[clausewitz2]

He has his own criteria for this diagnosis.

As Grand Inquisitor of the Bipolar Crusade, could he do otherwise?

 

[Sushirolls]

We can't stop midlevels or others from not doing their jobs well. I've got patients diagnosed as bipolar that had PTSD, substance use disorders, borderline, etc that I'm pealing back there meds, more often then I'd like.

Educating the patient what and why the meds are for is the best defense.

I can't spend my clinic hours pre-interpreting the chaos of what the ED or even inpatient midlevels are going to do to my patients.

 

[Mad Jack]

I have not used it this way. However, I do use it in one of my older stable bipolar patients for Alzheimers prophylaxis.

If I remember correctly, he says he starts low dose lithium and VPA for “bipolar spectrum” patients. If they respond, great; if not, he moves to treatment level dosing. He also says he would consider topiramate or neurontin. He has his own criteria for this diagnosis.

Topiramate is like, fourth line voodoo, and gabapentin just isn't effective. Some real head-scratchers there

 

[romanticscience]

Topiramate is like, fourth line voodoo, and gabapentin just isn't effective. Some real head-scratchers there

The rational is that although clinical effectiveness is lacking, they have low side effect burden. It’s tricky because your targeting a diagnosis without consensus or controlled study (eg, bipolar spectrum).

 

[psychacad]

The rational is that although clinical effectiveness is lacking, they have low side effect burden. It’s tricky because your targeting a diagnosis without consensus or controlled study (eg, bipolar spectrum).

lol, our field is such a mess. I guess you can't really blame him for making up his own dx when half the DSM is built on "expert consensus opinion" rather than any scientific evidence.

 

[clausewitz2]

Topiramate is like, fourth line voodoo, and gabapentin just isn't effective. Some real head-scratchers there

When I see topamax in someone's chart who has a bipolar diagnosis, I imagine five possibilities:

1) The prescriber has some very weird ideas about how these things work
2) This person also has migraines/headaches and complains a lot about them
3) This person refuses to touch anything that causes weight gain and/or wants to lose weight
4) This person drinks too much
5) The prescriber does not believe they have bipolar disorder

 

[clausewitz2]

The rational is that although clinical effectiveness is lacking, they have low side effect burden. It’s tricky because your targeting a diagnosis without consensus or controlled study (eg, bipolar spectrum).

Which is super ironic given his fixation on ideas of "Hippocratic" medicine, by which he means treating a "disorder" rather than "symptoms", and his complaints about how modern psychiatry does the opposite. My dude, when you are treating "bipolar spectrum" you are treating a set of symptoms, you have confused the map with the territory.

 

[Merovinge]

Yes, I don't think this is a niche practice? Lithium was one of the two augmenting agents in the Star-D. I don't do it much myself but I definitely have seen others augment treatment-resistant and/or suicidal unipolar with low-dose lithium.

The lithium orotate is interesting, I don't know that I've seen anyone prescribe it. It is available OTC and I have had a couple of people come to me who were taking it as a supplement, without physician oversight.

I use lithium quite frequently in the adolescent population for treatment resistant depression with SI. It's not a panacea but compared to other alternatives, particularly with reasonable parents who lock up the bottle, I think its pretty mainstream and evidence supported.

 

[Mad Jack]

When I see topamax in someone's chart who has a bipolar diagnosis, I imagine five possibilities:

1) The prescriber has some very weird ideas about how these things work
2) This person also has migraines/headaches and complains a lot about them
3) This person refuses to touch anything that causes weight gain and/or wants to lose weight
4) This person drinks too much
5) The prescriber does not believe they have bipolar disorder

Only thing I've been using it for is to attempt to mitigate side effects of atypical antipsychotics, since there's a decent amount of research showing it has some effectiveness in this capacity. We don't have a lot of options in that regard, it's basically just this and metformin, with some slight evidence for melatonin and one other option that escapes me

 

[clausewitz2]

Only thing I've been using it for is to attempt to mitigate side effects of atypical antipsychotics, since there's a decent amount of research showing it has some effectiveness in this capacity. We don't have a lot of options in that regard, it's basically just this and metformin, with some slight evidence for melatonin and one other option that escapes me

There's not bad evidence that it reduces binge-drinking so my alcoholic migraineurs end up with it not infrequently but yes, that is the other major purpose of it in my view. Naltrexone or Naltrexone/bupropion v. zonisamide are the other drugs I'd consider for the purposes of addressing neuroleptic-related weight gain.

 

[tr]

Only thing I've been using it for is to attempt to mitigate side effects of atypical antipsychotics, since there's a decent amount of research showing it has some effectiveness in this capacity. We don't have a lot of options in that regard, it's basically just this and metformin, with some slight evidence for melatonin and one other option that escapes me

Liraglutide? Less risk of inducing hypoglycemia esp in people who are more overweight than frankly diabetic. Some amazing results just came out on semaglutide for weight loss as well, I'm wondering if this might be an option in the future.

 

[Mad Jack]

Liraglutide? Less risk of inducing hypoglycemia esp in people who are more overweight than frankly diabetic. Some amazing results just came out on semaglutide for weight loss as well, I'm wondering if this might be an option in the future.

Difficulty: cost and actually getting it approved by insurance if they only have weight gain but not diabetes. Hopefully we get enough robust data that we can get other agents approved specifiy for weight gain associated with atypicals, but even then insuramce will probably force me to try metformin first because $$$

 

[Stagg737]

Only thing I've been using it for is to attempt to mitigate side effects of atypical antipsychotics, since there's a decent amount of research showing it has some effectiveness in this capacity. We don't have a lot of options in that regard, it's basically just this and metformin, with some slight evidence for melatonin and one other option that escapes me

Augmentation with Abilify has some evidence for mitigating metabolic side effects from other antipsychotics, especially Clozapine.

 

[Mad Jack]

Augmentation with Abilify has some evidence for mitigating metabolic side effects from other antipsychotics, especially Clozapine.

Probably the next best evidence behind that already listed, but the problem I found was that weight reductions were modest outside of clozapine iirc, and I don't have a single patient on clozapine these days. Used to have a few before I switched practice settings, but almost all of my weight gain compliance issues have been with either aripiprazole or paliperidone lately

 

[whopper]

In the areas where suicide was found to be lower due to lithium in the water we're talking about amounts less than the equivalent of 1 mg a day.

I think it's not a bad idea to consider lithium especially when suicide's on the table for consideration but the data I've seen with populations and lithium don't translate to 30 mg a day. I'm not saying he's wrong. He likely saw much more data than I did.

 

[clausewitz2]

In the areas where suicide was found to be lower due to lithium in the water we're talking about amounts less than the equivalent of 1 mg a day.

I think it's not a bad idea to consider lithium especially when suicide's on the table for consideration but the data I've seen with populations and lithium don't translate to 30 mg a day. I'm not saying he's wrong. He likely saw much more data than I did.

It's not just the ground-water studies. There are a lot of converging strands of evidence suggesting a very significant effect of lithium on rate of suicide completion. First paper I found that attempts to summarize these and it is a bit old (2010) but there are more like it:

Lithium Reduces Pathological Aggression and Suicidality: A Mini-Review

Abstract. From a practical point of view, the well-proven antisuicidal and anti-aggressive effects of lithium are of utmost importance for a rational, safe and economical treatment of patients with affective disorders. Regular lithium long-term treatment reduces the otherwise 2- to 3-fold...

www.karger.com

I talk smack about the bipolar imperialists but they aren't wrong when they talk about lithium saving lives.

 

[calvnandhobbs68]

Only thing I've been using it for is to attempt to mitigate side effects of atypical antipsychotics, since there's a decent amount of research showing it has some effectiveness in this capacity. We don't have a lot of options in that regard, it's basically just this and metformin, with some slight evidence for melatonin and one other option that escapes me

Way better evidence for metformin than topiramate though.

 

[Stagg737]

Probably the next best evidence behind that already listed, but the problem I found was that weight reductions were modest outside of clozapine iirc, and I don't have a single patient on clozapine these days. Used to have a few before I switched practice settings, but almost all of my weight gain compliance issues have been with either aripiprazole or paliperidone lately

Right, was just trying to suggest the other option you were forgetting. Either JAMA or the green book had an article a few months ago about "The three meds that may save lives" in regards to the metabolic side effects of antipsychotics and they were Metformin, Melatonin, and Topiramate. I looked but can't find the article for the life of me.

 

[Mad Jack]

Right, was just trying to suggest the other option you were forgetting. Either JAMA or the green book had an article a few months ago about "The three meds that may save lives" in regards to the metabolic side effects of antipsychotics and they were Metformin, Melatonin, and Topiramate. I looked but can't find the article for the life of me.

Yeah, I read the same article lol. I want to say it was the green book, because I could swear I read it while I was eating breakfast one day and my JAMA subscription is online but my green book comes in the mail

 

[whopper]

Topiramate saving lives? I wonder if it's cause it clouds the person's mind enough for them not to be coherent enough to complete the act!

 

[d2305]

GLP1s work better for weight loss, but they're not free.

 

[Liquid8]

Have used lithium carbonate often to augment AD where SI is a risk, but have to be careful in the more impulsive type. Have never used or seen lithium ororate being used though - didn't think there was much research or naturopathic, but it's been a while since I've looked it up.

A few of our neurologists are using it fairly liberally for migraines; was recently asked to assist in weaning off someone who isn't bipolar for this reason as their GP wants to put them on frusemide.

 

[clausewitz2]

A few of our neurologists are using it fairly liberally for migraines; was recently asked to assist in weaning off someone who isn't bipolar for this reason as their GP wants to put them on frusemide.

In my neck of the woods it's neurologists putting everyone on Depakote for migraines but the principle seems to be the same. Headache pharmacology practices seem very reminiscent of how we tend to use meds in psychiatry, makes me wonder why more psychiatrists don't treat headaches routinely.

 

[hallowmann]

Have used lithium 100-300 mg for augmentation, but never used less than 100 mg, and honestly don't do it often. More often than not I'm taking it off to simplify the regimen.

When I see topamax in someone's chart who has a bipolar diagnosis, I imagine five possibilities:

1) The prescriber has some very weird ideas about how these things work
2) This person also has migraines/headaches and complains a lot about them
3) This person refuses to touch anything that causes weight gain and/or wants to lose weight
4) This person drinks too much
5) The prescriber does not believe they have bipolar disorder

Regularly use topiramate for patients with "bipolar", but really have complex PTSD/PTSD-BPD. I use it as much as a true mood stabilizer about as much as I do gabapentin - which is virtually never, because it doesn't work. Regularly use it in primary care for migraines and weight loss, but once you eliminate the people with hx of nephrolithiasis and the "10-15%" that discontinue due to side effects, which anecdotally feels more like 40-50%, there's not a lot of my patients left on it.

The ones that tolerate it with pretty clear PTSD have great results with it though, so that's the main reason I still give it a shot...

 

[Merovinge]

The ones that tolerate it with pretty clear PTSD have great results with it though, so that's the main reason I still give it a shot...

Is this due to the cognitive dulling side-effect or is there some other benefit I'm missing?

 

[Stagg737]

Topiramate saving lives? I wonder if it's cause it clouds the person's mind enough for them not to be coherent enough to complete the act!

The article was specifically in regards to it counteracting the metabolic side effects of antipsychotics. Though I suppose you could use Dopamax this way as well...

Regularly use topiramate for patients with "bipolar", but really have complex PTSD/PTSD-BPD. I use it as much as a true mood stabilizer about as much as I do gabapentin - which is virtually never, because it doesn't work. Regularly use it in primary care for migraines and weight loss, but once you eliminate the people with hx of nephrolithiasis and the "10-15%" that discontinue due to side effects, which anecdotally feels more like 40-50%, there's not a lot of my patients left on it.

The ones that tolerate it with pretty clear PTSD have great results with it though, so that's the main reason I still give it a shot...

I've also used it once or twice for people with PTSD or agitation who also have severe headaches and iirc it was somewhat helpful for their lability or irritability. Generally keep it in my list of meds to pull out of my *** when nothing else is working though.

 

[hallowmann]

Is this due to the cognitive dulling side-effect or is there some other benefit I'm missing?

Maybe? Honestly the studies for it are small and flawed, but they suggest reduction in hyperarousal states or reexperiencing trauma responses, which certainly could be due to cognitive dulling. The patients I'm using it for are already limited significantly by their PTSD symptoms, so risk is relatively low for them. But like I said, half the people don't like it, but the handful that stay on it that basically couldn't function or calm themselves enough to sleep are actually doing better on it. A lot of those patients couldn't tolerate prazosin, and either don't have the resources for real trauma-based therapy or just aren't ready for it.

 

[whopper]

The article was specifically in regards to it counteracting the metabolic side effects of antipsychotics. Though I suppose you could use Dopamax this way as well...

I've never seen any data showing that Topiramate reduces suicide, but it was brought up above when the discussion was on preventing suicide and the thread topic is lithium and suicide.
Clear teachable moment for teaching students tangential thinking.

 

[Stagg737]

I've never seen any data showing that Topiramate reduces suicide, but it was brought up above when the discussion was on preventing suicide and the thread topic is lithium and suicide.
Clear teachable moment for teaching students tangential thinking.

Eh, it's a bit of a stretch but I guess? Clausewitz brought up alternative reasons to prescribe Topiramate other than bipolar/suicide risk much earlier and MJ commented about it's use to treat antipsychotic-induced metabolic effects. I was just trying to quote the article that supports the metabolic usefulness and lack of suicide, so still peripherally on topic. I'd say that part of the conversation is more like an ADHD thought process than actual tangential thinking, but I guess looking at that line only it would certainly come across that way.

Also, I think this post is a better example of tangential thinking. Going totally off-topic, so I'll stop now, lol.