Deprescribing Mood Stabilizers

This chapter reviews the literature on lithium withdrawal and provides strategies on how to reduce the risk of relapse through such measures as slow tapers. Combinations of mood stabilizers such as lithium, divalproex, carbamazepine, and lamotrigine are used frequently and recommended even with the approval of several second-generation antipsychotic medications as mood stabilizers. As patients grow older, the potential nephrotoxicity and hepatotoxicity of these medications can become a significant consideration. The question of misdiagnosis of mood instability and off-label use occurring in personality disorders and substance abuse is also addressed. Psychotherapeutic interventions such as psychoeducation, family therapy, and cognitive behavioral therapy that support the treatment of bipolar disorder are described as a part of the deprescribing process and illustrated by case examples.

Criticism of psychiatric treatment

Criticisms of psychiatric treatment often involve comparison to idealized depictions of general medical treatment. Psychiatric treatments are described as not reversing diseases but many treatments in general medicine also do not reverse disease and some have unknown mechanisms. It is stated that psychiatrists prescribe medication to reverse hypothesized mechanisms, but a survey found they usually prescribed a medication in a clinical situation because research had shown it to be effective, even though the mechanism of action was unclear. Antidepressants are said to be ineffective because of a small overall effect averaged over groups of participants but this ignores evidence that some people will derive a significant clinical benefit. Antipsychotics are effective in preventing relapse of psychosis in research studies; for a variety of reasons, withdrawal-induced psychosis is unlikely to explain enough of this advantage to prove the claim that antipsychotics are ineffective. Although lithium research trials are imperfect, including reporting high rates of lithium withdrawal-induced mania, there is still some evidence of benefit in acute mania and of modest benefit in preventing relapse of bipolar disorder in those who can continue lithium for two years or more. Questions comparing psychiatric and general medical treatments were generated.

Patients with Affective Disorders Admitted to Maximum Secure Care (1999-2003)

The State Hospital, Carstairs, is a special secure psychiatric facility for Scotland and Northern Ireland. This study describes the background, illness and offence (where appropriate) characteristics of 25 patients admitted between 1999 and 2003 with a diagnosis of any affective disorder. Patients were, on average, 37 years old and had a lengthy history of psychiatric contact. Patients with an affective disorder were more likely to be admitted under civil proceedings, following a transfer from hospital, as opposed to being admitted under criminal procedure. Sixty per cent were discharged to prison, court or local hospitals within one year of their admission to special secure care. Significant violence during an episode of mania or hypomania (even in the presence of psychotic symptoms) appears rare. Recurrent unipolar depression resistant to first and second line treatments in women, and lithium withdrawal mania in male bipolar patients were the most common clinical problems. Treatments aimed at reducing co-morbid substance misuse, and improving compliance with mood stabilisers, appear important in managing this patient group.