# Reasons for discontinuing and restarting lithium multiple times: a case-register study based on the South London and Maudsley NHS Foundation Trust Clinical Record Interactive Search system

## TL;DR

This study explores why patients with bipolar or schizoaffective disorder stop and restart lithium multiple times, finding that psychiatric reasons are more common than physical side effects.

## Contribution

The study provides new insights into the patterns and reasons for repeated lithium discontinuation and reinstatement in psychiatric patients.

## Key findings

- Psychiatric reasons accounted for over 70% of lithium discontinuations across multiple events.
- Relapse into the underlying affective disorder was the primary reason for restarting lithium.
- Adverse physical effects were a minority reason for discontinuation, even increasing slightly with repeated events.

## Abstract

Despite the therapeutic benefits, non-adherence to lithium is common. One recent study showed that most patients discontinue lithium due to adverse effects. Little is known about individuals starting and discontinuing lithium repeatedly.

We aimed to determine reasons for discontinuing and restarting lithium multiple times in patients with bipolar or schizoaffective disorder.

Retrospective cohort study based on psychiatric case records of the SLaM Biomedical Research Centre Case Register (SLaM BRC case register).

Anonymised clinical data were extracted via the Clinical Record Interactive Search (CRIS) application. Patients with at least three events of lithium discontinuation between 2012 and 2022 were included.

Of 2888 eligible patients, 123 patients had discontinued lithium on at least three occasions. Psychiatric reasons, such as suspected lack of insight, feeling subjectively well or disagreeing with diagnosis, were the most common reasons for lithium discontinuations. They accounted for 77.2% of cases in the first event of discontinuation, 73.2% in the second and 72.3% in the third event. Adverse physical effects accounted for 19.5% of cases in the first event of discontinuation, 25.2% in the second and 26.0% in the third event. Relapse into the underlying affective disorder accounted for 83.7% each of reinstatements in the first and second events and 82.1% in the third event.

In our sample, lithium was discontinued due to adverse effects in only a minority of patients. In most cases, the reasons for lithium discontinuation were considered psychiatric. Lithium was mainly restarted due to relapse. This warrants a better understanding of the reasons for repeatedly discontinuing lithium and the best way to promote lithium adherence to prevent a perpetual cycle of remitting when on lithium and relapsing when off lithium.