Friday, April 13, 2007

Lithium cuts suicide risk in recurrent depression

The overall rate of suicidal acts was 1.48 percent annually among those not given lithium compared with 0.17 percent per year among those treated with lithium -- an 88.5 percent reduction in risk.
For better or worse, current thought among the medical community is that SSRIs are so safe, a monkey could prescribe them. Just above monkeys, of course, are psychiatrists, family docs, and nurse practitioners. Psychologists typically gain the most support for their petitions for prescribing rights on the safety of SSRIs.

But lithium is something altogether scarier, again, for better or worse. Psychiatrists prescribe lithium. Nobody else does. And now there's evidence that, at least in the population defined in this study, the attributable benefit of lithium could be about 8/9 for suicide prevention. So some questions immediately arise (some maybe because I just haven't got around to looking at the original article yet):

1) What patients with depression (since most depression is undoubtedly recurrent depression) would benefit from lithium? I don't know what it feels like to be on lithium, but from Kay Redfield Jamison's An Unquiet Mind, it doesn't sound like the most benign drug. Thus, balancing the way lithium makes patients feel, in addition to all the long term nephrotoxicity and such, with the benefit of less death by suicide will be quite an important endeavor. Will that be an endeavor for psychiatrists, or for the larger mental health practitioner community?

2) Do all of these patients suddenly need psychiatrists to prescribe their lithium, or would non-psychiatrists become more comfortable prescribing lithium, at least as a depression adjuvant, which would likely be a far less complex endeavor than managing bipolar disorder?

3) Does this strengthen or weaken the case for prescribing rights for psychologists? After all, this paper is proposing a change to our current care model that could cause a dramatic increase in the need for more specialized mental health services. Of course, this assumes that the answer to question 2) is that non-psychiatrists would not become more comfortable prescribing lithium adjuvant therapy for depression.

4) And of course, if one mood stabilizer decreases the risk of death by suicide for folks with recurrent depression, what would the others do? Now that some atypical antipsychotics have been approved as mood stabilizers, where do they fit into this picture?

5) Do SSRIs remain relevant to the treatment of recurrent depression? Not to be too cynical, but all but Lexapro are off patent.

On a parallel note, check out The Last Psychiatrist's take on new evidence that adjuvant SSRI therapy adds nothing to patients with bipolar disorder already on a mood stabilizer. Especially relevant to question 5).


Anonymous said...

Was Shawn on lithium?

Also, psychologists should not be able to prescribe medications!

: Joseph j7uy5 said...

Somewhere in the last several months there was a review comparing the cognitive impairment caused by mood stabilizers. I think Trileptal and Lamictal were the best (caused least impairment), then...I don't remember. Lithium was in the middle.

OK, here it is: