From the Guidelines
Discontinuing lithium within the first week of treatment poses a significant risk of relapse, particularly if the patient has a history of manic episodes, as evidenced by studies showing a high relapse rate after lithium discontinuation 1. The primary concern with stopping lithium early is not the risk of withdrawal symptoms, which are more relevant after long-term use, but rather the potential for the underlying condition to worsen. Since lithium takes time to reach its full therapeutic effect, stopping it within the first week means the patient may not have benefited from the treatment.
- Key points to consider:
- The risk of relapse is high after discontinuing lithium, especially within the first few months, with studies indicating that over 80% of patients with a manic episode will have at least one episode of relapse 1.
- The decision to discontinue lithium should be made cautiously, considering the patient's clinical status, the reason for starting lithium, and any side effects they may be experiencing.
- Patients and their families should be educated on the early signs and symptoms of mood episodes so that treatment can be resumed if necessary.
- Any attempts to discontinue prophylactic therapy should be done gradually, while closely monitoring the patient for relapse, as suggested by the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1.
From the Research
Risks of Discontinuing Lithium within the First Week
- The decision to discontinue lithium within the first week of treatment can be associated with significant risks, primarily due to the potential for early recurrence of bipolar illness 2.
- Studies have shown that stopping lithium treatment, especially when done abruptly, can lead to a rebound effect, increasing the risk of manic recurrences in the first weeks after discontinuation 2, 3.
- The pathophysiology of this rebound effect is not fully understood, but it is clear that abrupt discontinuation of lithium poses a higher risk of recurrence compared to gradual discontinuation 3.
- Symptoms such as tremor, polyuria, and general muscular weakness may decrease after lithium withdrawal, but the risk of relapse into manic or depressive episodes is a significant concern 4.
Factors Influencing Discontinuation Risks
- The risk of early recurrence of bipolar illness after lithium discontinuation can be influenced by factors such as the polarity of the disorder (BP-I vs. BP-II), with BP-I patients being less likely to remain in remission 3.
- The method of discontinuation (rapid vs. gradual) also plays a crucial role, with gradual discontinuation over 2 to 4 weeks showing a lower risk of new episodes compared to rapid discontinuation 3.
- Additionally, the timing of discontinuation in relation to the patient's illness onset and history of suicidal behavior can impact the risks associated with stopping lithium treatment 5.
Clinical Implications
- Given the potential risks, it is essential to carefully consider the decision to discontinue lithium, especially within the first week of treatment, and to discuss potential adverse effects and the risks of recurrence with patients before initiation and during treatment 6, 2.
- Gradual discontinuation, when possible, is recommended to minimize the risk of early recurrence and rebound effects 2, 3.
- Close monitoring of patients after lithium discontinuation is crucial, particularly in the first year, due to the increased risk of affective illness recurrence and suicidal behavior 5.