Practice Safety Alerts

Prescribing and monitoring lithium therapy: summary of a safety report from the National Patient Safety Agency

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c6258 (Published 19 November 2010) Cite this as: BMJ 2010;341:c6258
  1. David Gerrett, senior pharmacist, patient safety division1,
  2. Tara Lamont, special adviser, patient safety division1,
  3. Carol Paton, joint clinical lead2, chief pharmacist3,
  4. Thomas R E Barnes, joint clinical lead2, professor of clinical psychiatry4,
  5. Amar Shah, specialist registrar in forensic psychiatry5
  1. 1National Reporting and Learning Service, National Patient Safety Agency, London W1T 5HD, UK
  2. 2Prescribing Observatory for Mental Health, Royal College of Psychiatrists, London E1 8AA
  3. 3Oxleas NHS Foundation Trust, Dartford DA2 7WG, UK
  4. 4Centre for Mental Health, Imperial College, London W6 8RP
  5. 5North London Forensic Service, Barnet, Enfield and Haringey Mental Health Trust, London
  1. Correspondence to: D Gerrett david.gerrett{at}npsa.nhs.uk

Why read this summary?

Lithium is a commonly prescribed drug for treating bipolar disorder and unipolar (refractory) depression. Over 800 000 prescriptions for lithium salts were dispensed in England in 2008.1

Lithium has a narrow therapeutic range and may be affected by changes in renal function and fluid balance (for example, when a person is dehydrated or pregnant).2 Its tolerability profile also provides challenges for prescribing, as adverse effects such as fine tremor may be confused with the coarse tremor seen in toxicity. Lithium treatment increases the risk of clinical hypothyroidism and renal insufficiency (both acute and chronic). Thus tailoring doses for individual patients, with careful monitoring of lithium concentrations, estimated glomerular filtration rate, and thyroid stimulating hormone, is essential.

Treatment is usually started by a psychiatrist, with longer term care and monitoring by a general practitioner, who can be guided by the relevant quality outcome framework (QOF) target for lithium monitoring in the general practitioner contract. The 2006 guidelines from the National Institute for Health and Clinical Excellence (NICE) set out clear standards for lithium monitoring, including measurement of serum lithium concentrations every three months and assessment of thyroid and renal function every six months.3 These guidelines are more stringent than the current quality outcome framework targets for England.

A quality improvement programme showed that mental health trusts often do not have electronic systems that reliably communicate test results between the laboratory and the clinical team or between primary and secondary care.4 It also showed the shortcomings in the monitoring …

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