The use of lithium
Lithium has been used in psychiatry for more than 75 years. It is the nationally recommended first-line long-term treatment for bipolar disorder and was consistently described to our investigators as the “gold standard”. Yet its use has fallen, with one study finding that lithium prescribing had reduced from 30% in 2001 to around 16% in 2018. Our report draws on a survey of 645 people with bipolar disorder, alongside visits and interviews with staff in mental health trusts and GP practices.
We found that some people were “cycling through” other medications before lithium was raised with them, and some were never offered it at all. A charity told us that “it is never presented as an option in the first place”. Patients also said that when conversations about lithium did take place, they usually began with its risks and side effects rather than its benefits. This could put patients off taking it.
For those who take it, the effect can be profound. One person told us they had not been admitted to hospital in 20 years since starting lithium.
Variation in monitoring
Lithium needs regular monitoring. However, we found psychiatrists setting reminders in their own diaries to follow up patients and relying on paper records, rather than having digital infrastructure to make sure risks are managed effectively. Some patients said they had to book their own tests or remind their GP practice when they were due. One said their practice lost a blood test and removed lithium from their repeat prescription.
Dedicated lithium clinics used to be common but now run in only a small number of trusts, with leadership teams unsure why they had closed. Clinicians contrasted this with clozapine, where clinic-based monitoring makes safe prescribing feel like “teamwork” rather than the responsibility of one prescriber.
Safety recommendations
We are asking NHS England to make sure there is oversight of care for people who take lithium, including monitoring. We are also asking the Royal College of Psychiatrists to publish a national position statement and protocol on the use of lithium, to support clinicians to offer it where appropriate.
Matthew Mansbridge, Senior Safety Investigator said: “For many people with bipolar disorder, lithium is life-changing, but not everyone who could benefit is being offered it. One of the biggest barriers is confidence that people taking lithium will get the regular monitoring they need. Currently, there is no national oversight of this. Our recommendation to NHS England would help change that and give clinicians and patients the confidence to consider lithium as an early treatment option.”
Rosie Phillips, Deputy CEO of Bipolar UK, said: “We’re concerned to see lithium prescribing continuing to decline when we know what a difference it can make to the lives of some people with bipolar. It shouldn’t be treated as a last resort simply because the systems needed to support its safe use aren’t working as they should. We welcome HSSIB’s recommendations to strengthen monitoring and give both clinicians and patients greater confidence to consider lithium earlier, where clinically appropriate.”
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