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Psychiatric News Special Report: Lithium Clinics and High-Risk Populations With Bipolar Disorder · The Medical Mind

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  Welcome back everybody to the July episode of the psychiatric news special report
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  podcast. We have wonderful article today,
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  lithium clinics and high risk populations with bipolar disorder.
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  We are joined by two of the authors.
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  We have Dr. Sarah El Halabi and Dr.
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  Steven Ferrando here with us. I'll let you them both introduce themselves,
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  a little bit of their bio, their background and their blah,
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  blah, blah.
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  Sarah, go ahead. Yeah.
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  Hey everyone, thank you for having me.
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  I did my residency at Westchester Medical Center and then I did my fellowship
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  in CL and Women's Mental Health at Yale.
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  And I am starting a job in the Cleveland Clinic where I'll be doing both
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  CL and Women's Mental Health. And so those are my clinical interests.
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  Outside of that, I immersed in the narrative medicine world and
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  the literary world in general where it brings me a lot of joy.
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  Happy to be here.
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  Hey everyone, I'm Dr. Steve Verando.
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  I'm the chair of psychiatry at Westchester Medical Center Health Network
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  and New York Medical College. I had the pleasure of having Sarah as
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  one of our outstanding residents who also ~ chose
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  a pathway that I've chosen throughout my life as a consult liaison psychiatrist.
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  That's my central identity.
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  ~ And I think in terms of the article we're gonna discuss,
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  ~ we love to embrace complexity.
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  ~ And certainly that's what's at hand here
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  in prescribing lithium in potentially high risk populations.
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  Yeah, I don't know. There's something about the CL psychiatry group with
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  the world where they end up in leadership positions because they know what's going
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  on in the hospital systems, right?
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  They have to interact with all of them.
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  So this is a little something.
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  So I primarily do like a child and adolescent work.
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  So we don't get to play around with lithium as much,
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  but I thought this was an interesting article for many,
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  many reasons. So this...
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  Article is, know, lithium is a first word in the article,
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  but it's not necessarily about like lithium so much.
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  it's more about the complexities that come along with lithium.
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  And then some of the other psychiatric meds,
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  think we'll talk about it in a little bit about that make them unique
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  and a little bit of a challenge and how sometimes as much as like lithium
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  is this very unique psychiatric to psychiatry medication.
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  It's kind of falling out of favor and we're not using it nearly as much
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  as we have in the past. And, you know,
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  think part of the article says that there are residents coming out
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  of training who hardly have ever prescribed it or if at all.
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  it's like, it's kind of a shame,
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  especially for a medication that is so,
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  so, so well established and so unique to the field itself.
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  So Dr. Halabi, do you want to talk about that or a little bit?
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  Yeah, sure. I'm happy to answer that question.
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  So part of how this idea popped in my mind was that I was seeing different patients,
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  some of them were pregnant, but a lot of them were older people on lithium
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  who would come in with all these problems.
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  And I kept thinking, why is that the case?
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  And I casually just asked my co fellows and people around me like,
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  hey, like how common is lithium prescribed?
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  And the answer was not that common.
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  So I
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  thought, why don't we just centralize the prescription of lithium?
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  Because it's seeming to me that it's not as popular as it used to be,
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  especially as the older psychiatrists would just say,
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  yeah, lithium, we're very familiar with that.
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  ~ And that's sort of how this idea was born.
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  I don't think it's a particularly unique idea because lithium,
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  as you said, is a well-established medication,
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  but the idea of putting it in one place and controlling all the variables might be.
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  Yeah, Dr. Friend, do anything to add to that as maybe someone who's
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  a little more seasoned per se.
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  Sure, mean, ~ yeah, there's a lot of elements to this.
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  I mean, I think, you know, on a system level,
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  ~ you know, when you have acute care patients,
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  we're often thinking about using lithium because patients tend
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  to be more treatment refractory.
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  You tend to see more acute manic episodes or refractory depression where you're
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  looking to do augmentation.
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  So we are more inclined in that setting to think about initiating lithium,
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  although it may not be the first choice often like in acute mania,
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  where frankly, I think that ~ the marketing of a lot
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  of the atypical antipsychotics and the perceived ease of use and lack
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  of need for serum level monitoring and toxicity monitoring appear to be less.
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  ~ And so I think there's a certain comfort level with that newer generation
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  of medications, many of which do have indications for,
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  you know, acute mania and even prevention of relapse.
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  But, you know, we know lithium has some unique properties in including,
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  ~ you know,
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  other areas of medicine recognize even some neuro regenerative properties
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  of lithium. So ~
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  You know, I think ~ on a system level,
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  then it's important to set up structures that can help facilitate psychiatrists have
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  to have a comfort level in monitoring these meds
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  and monitoring the potential for toxicities,
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  both short and long term. think that's really what we were kind of seeking
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  to write about is not only that lithium works and it has a lot of uniqueness,
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  but
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  How do you set up systems that create a comfort level ~ for
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  the prescribers to really use this medicine?
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  We were talking a little bit before everybody kind of joined on Dr.
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  Halabi and myself about we had just had a journal club meeting where
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  I work at Inova Healthcare over here in Northern Virginia.
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  And it was about clozapine. A very similar kind of discussion was brought up about,
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  you know, a resident was kind of leading the journal club about clozapine and how,
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  you know, I never prescribed it during my whole training and what
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  is this medication and kind of the fallout of the
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  the REMS changing, the REMS change or the elimination of the REMS,
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  we should say with clozapine in the past year and what's happened with that.
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  And I had just gotten this article in my email,
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  I think earlier in that day or a couple of days ago when I'd read through
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  it and I was like, oh, this seems like a very apt kind of parallel
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  of lithium clozapine, these two again,
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  classically psychiatry medications that have fallen out of favor because I think Dr.
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  Fonda, what you were kind of saying,
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  It's hard to prescribe them. There's a of challenges that come along with them.
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  And for a lot of psychiatrists who may be not in a hospital setting,
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  not in an outpatient setting, there's a lot of work and there's,
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  I don't want to say laziness, but additional hoops that have to kind
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  of go along with prescribing any of those medications,
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  correct?
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  Yeah.
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  Yeah. And I, ~ I do also work some,
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  time in a community clinic where I'm more isolated and doing med management
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  and it is, it's a heavier lift.
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  So we will get patients who are prescribed these higher level monitoring meds like
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  lithium and clozapine and long acting injectables,
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  right? And, and, ~ the patients will come and we're much less equipped.
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  you know, kind of you have to see the patients one by one.
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  So you have to set up a process whereby,
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  you know, you're creating the same standard for every patient and making sure that
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  things don't fall through the cracks.
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  And that is definitely a challenge.
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  ~ So I think the idea of having sort of a,
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  you know, a special day or a special clinic or,
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  you know, wherein you leverage all the,
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  you know, the people who are
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  have the expertise and ~ you have a standardized monitoring protocol
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  ~ so that you're thinking about everything for every patient in the same way,
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  right? ~ It makes it easier.
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  Yeah, I also do kind of want to add to that,
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  that SMI is a big, is a heavy load.
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  It's not something that people manage alone.
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  takes a village. And there is definitely the convenience,
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  whether you're in a psychiatric hospital or a medical one,
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  that there's a team every day,
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  you're there, they're there, they can get a level,
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  everyone's talking to each other versus being one person in a clinic doing
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  all this alone, you're going to have challenges.
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  So who are the people, let's talk about that,
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  guess, who are the people that are making up this village?
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  Who's in these lithium clinics that are proposing?
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  I think the thought was it depends on the group we're talking about.
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  ~ For example, like in older people,
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  Maybe geriatricians, nephrologists,
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  ~ internists. For pregnant women,
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  it would be different. I think it depends on the high-risk population that
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  has the bipolar disorder. And the psychiatrist obviously embedded in each of these.
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  Yeah, and it may be difficult,
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  obviously, from a structural standpoint to have all those people in the same room
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  at the same time, right? So you can leverage other things like you might,
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  for instance, we're setting up here ~ at the medical center,
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  ~ a what we call an advanced psychopharmacology clinic,
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  which subsumes, you know, lithium,
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  clozoril, LAIs.
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  and refractory polypharmacy,
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  ~ refractory patients where polypharmacy is employed and it serves both kind
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  of a consultative functioning and then a monitoring,
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  prescription and monitoring function ~ so that you're applying the same idea
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  to multiple complex drugs.
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  But that's in a health system like this where
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  you know, we're kind of setting it up so that,
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  yeah, these are complex patients.
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  You come here for this, ~ if it's not viable on
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  a solo outpatient basis to be following,
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  you know, this type of patient.
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  ~ And so then we can bring to bear other specialists either
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  by telehealth or ~ other type of consultation to kind of have one EMR.
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  Right? Because that's important too,
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  because multiple specialists may be involved if you're worried about renal
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  complications, chronic renal complications in a patient on lithium.
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  But you want to keep them on that medication because it's working for them,
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  right, for many years. ~ Then,
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  you know, you need to kind of have all the expertise in one place and
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  be able to access the information in the labs and all of that.
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  I think that's very critical.
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  Yeah, I think that's something,
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  you know, again, we talk about healthcare systems as a lot
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  and how everybody's talking their own language,
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  is in a way as if everyone's on different EMRs,
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  it doesn't work, right, especially if we're looking at a team kind
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  of setting and having that village per se that we had discussed before.
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  So talk to us about, I think,
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  Dr. Alavi, there are three main groups,
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  ~ three main populations that would be best served.
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  the older generations, people who are geriatric patients,
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  pregnant individuals. And then there was one other group,
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  the other group was the renal disease.
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  Yes.
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  Yeah. So go through, guess, if you guys want to tag team,
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  going through these populations about what are some unique challenges and
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  how can we help them out more.
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  I can start by speaking about pregnant folks.
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  some of the challenges that pregnant people face is,
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  well, a, general, ~ how does my illness affect the baby,
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  but also how does the medication affect the baby?
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  And you can see this with a wide range of medications and lithium
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  is not an exception. ~ Unfortunately,
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  in bipolar disorder, the postpartum period is a very high risk period.
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  And so we want people to be stable ASAP.
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  ~ And lithium is a big gun. So ~ having that explained to people ~
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  and having the ~ ideas about lithium being a dangerous drug debunked
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  is very useful because you guarantee the stability of both mom and baby.
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  And I can definitely say that in the MFM clinic I was in that discussion
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  was had many times ~ successfully.
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  So it is possible.
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  Yeah, kind of like before going switching off to here,
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  talk, talk to us about those, you know,
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  just for people who may not remember from like step one and step two,
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  like some of the risks like Epstein's anomaly and everything else that comes along
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  with and how are they overstated almost to
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  I think the issue, and if anyone here knows more,
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  please correct me, of abstinence anomaly is that it is a relative risk
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  and not an absolute risk per se.
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  it's, it's always compared to what is the existing baseline.
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  And given the risk of ~ uncontrolled bipolar disorder and the relative risk
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  of abstinence anomaly, uncontrolled disorder,
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  of bipolar disorder, of trumps.
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  There are some risks with lithium that people need to be aware of,
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  like ~ thyroid issues, renal issues in mom.
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  And we always recommend for the baby to get ~ care by the pediatrician
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  and for the pediatrician to know that the patient is on lithium.
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  ~ And for mom as well, there are some labs that need to be done because
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  as mom goes into the third trimester and then delivers,
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  lithium is a very ~ water dependent molecule,
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  if you want to say that. And so we need to be very aware of the serum levels
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  of lithium and her increasing need of lithium in the third trimester,
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  then to decrease that.
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  when she delivers. So it needs a lot of monitoring,
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  but it's very possible.
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  I would just compliment with what Sarah said in that
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  ~ she's absolutely right. When
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  you have medical complexity
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  and pregnancy certainly ~ has this multi-level consideration
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  here with the mother and the fetus,
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  but it's always important to look at the benefit risk calculation.
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  in light of the fact that something like Epstein's anomaly is,
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  as she said, a relative risk,
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  but an extremely low absolute risk,
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  right? whereas we know that complications of untreated bipolar disorder
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  in the mother can greatly affect the developing fetus
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  and ~ childbirth, you know, et cetera.
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  it's ~
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  it's extremely important to be aware of that and not to be either,
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  you know, I mean, and you have to sort of manage your response to that,
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  right? Because you can't be, you can't overshoot and not prescribe it at all,
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  but you can't be willy-nilly either,
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  right? So, and that's where it gets back to this having a system
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  of monitoring and having a high-risk OB involved
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  and having open communication and things like that so that
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  you can stipulate, hey, this is necessary and we need this type
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  of situation to monitor.
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  Yeah, I think we all have lost count.
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  I think of the number of patients who are,
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  been pregnant, been told by their OB or somebody else,
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  they're like, Hey, you can't be on this medication.
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  You need to get off of it. And then they just stop it cold turkey.
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  And then you have those relapses and in the mania,
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  et cetera, and causes problems to mom and baby,
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  right? It's like that there's so many times that this occurs and it's one of like,
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  again, the greatest
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  I don't want say myth, it's like,
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  you know, there's the nuance that's necessary when we're having these discussions
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  that like there's ways to treat it without kind of necessarily going fully,
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  fully off of it or staying fully,
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  fully on it. And that's important.
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  I just want to hammer that home to everybody.
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  So who wants to talk about, let's say maybe the renal disease folks,
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  this other population.
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  Yeah, I mean, I can I can feel that a bit.
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  So there's a couple of different levels
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  to this is, you know, one of them is this concern about
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  the development of chronic renal disease
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  and renal failure in patients who have been on long term lithium.
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  Right. So I mean, that's an important distinction because patients
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  can over time develop
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  ~ renal insufficiency
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  as measured by BUN creatinine,
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  creatinine clearance, et cetera.
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  ~ But the actual ~ risk
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  of precipitating renal failure and going to dialysis is very,
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  very low. And some of that is related to our
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  vigilance about how to prescribe these meds,
• 18:52
  right? We generally do a pretty good job so that the,
• 18:57
  you know, the over time, the absolute risk of inducing,
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  you know, chronic renal failure and maybe even needing dialysis
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  and transplant is extremely low,
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  right? So we've kind of addressed that.
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  ~ But there is a very, you know,
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  there's a small and measured inherent risk.
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  Right? So that's the one side of does lithium cause renal insufficiency,
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  renal failure? Yes, to a degree,
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  but not as catastrophically as we might be concerned about.
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  Right? So then there's the other side of it is in patients who actually have renal
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  failure or renal insufficiency,
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  even patients on dialysis. First of all,
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  I should mention that renal...
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  that lithium is dialyzable in overdose,
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  right? So that's one of the big advantages of being able
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  to have lithium as a renally excreted molecule
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  and so forth that we can,
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  you know, if a patient unfortunately overdoses,
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  we can dialyze that patient. So that's great.
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  But for the...
• 20:11
  actual dialysis population, there are some patients who are on,
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  you know, lithium. ~ Often they're on lower doses ~ because
• 20:22
  of the clearance issues. But remember,
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  when that patient goes to dialysis,
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  that lithium is going to be cleared,
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  right? So you're removing that lithium from them every time you dialyze.
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  So those patients are then ~ often dosed after their dialysis session.
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  So if they're
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  Monday, Wednesday, Friday, or whatever,
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  you on those days you just dose the lithium after their dialysis.
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  I think it goes to like one of those myths,
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  right? Again, they're like, if I'm having a discussion outpatient and I'll bring
• 20:56
  it up, they'll be like, well, isn't that gonna destroy my kidneys?
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  Am I gonna end up on dialysis from this?
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  And it's like, I think we were saying in the article about like a 1 % chance,
• 21:05
  up to like a 1 % chance of of lithium induced renal failure,
• 21:11
  correct? Something along those lines,
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  so.
• 21:15
  depends on, right, it depends on where you see,
• 21:17
  but yes, it's relatively low now.
• 21:20
  And we all counsel our patients about hydration.
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  And, ~ you know, I try to make my patients a little bit,
• 21:28
  you know, like really focused on that kind of thing,
• 21:31
  especially in the type of weather we have now.
• 21:33
  You know, look, you need to stay hydrated.
• 21:36
  We all do, but especially, you know,
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  and so the patients tend to pick up on that,
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  you know.
• 21:43
  The last population is, know, one of the main reasons I do focus more
• 21:47
  on child adolescent work is the older population,
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  right? They end up on all these meds and all these,
• 21:55
  you know, medical complications that,
• 21:57
  you know, from my brain is a little bit more than I'm like wanting to work with
• 22:01
  and figure out. But talk to us a little about some of the unique challenges
• 22:05
  in older adults with lithium.
• 22:08
  We can probably tag team this one.
• 22:10
  As you said, polypharmacy is a problem,
• 22:13
  and especially if part of that polypharmacy is diuretics and NSAIDs.
• 22:19
  And I do believe I remember a case where that patient was on
• 22:24
  two different diuretics and lithium,
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  and the diuretics were prescribed by different people.
• 22:29
  So that's a problem. And older adults often end up on a lot of medications,
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  so there has to be a system of monitoring that keeps them together.
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  Their physiology is also vastly different than,
• 22:41
  well maybe not vastly, but quite different from younger people with
• 22:47
  the changes leading to higher lithium levels or normal lithium levels giving them
• 22:53
  more side effects. So these are things that have to be watched.
• 22:56
  Yeah, and I think it comes to mind a patient that I'm actually treating.
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  on the inpatient service right now treating
• 23:05
  a patient who's 67,
• 23:09
  long-term bipolar disorder admitted in the setting of a manic episode with
• 23:16
  treatment nonadherence. And lithium works for this individual
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  who happens to also be
• 23:25
  diabetic and to have a bit of a creeping creatinine.
• 23:29
  So the patient is very aware that the lithium works for them,
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  but you've got the diabetes, you've got the creeping creatinine,
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  you've got the fact that he happens
• 23:44
  to be hypertensive and needing
• 23:49
  to manage the diabetes and the antihypertensive.
• 23:56
  ~ And patient wants to be on lithium.
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  So we start them, you know, at a lower dose and elevated gradually.
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  And, you know, he's doing well,
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  but this is the type of patient ~ who's older,
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  had accumulating complications of their underlying physical illnesses,
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  responds well to lithium, wants to be on lithium.
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  You really just need to set up.
• 24:22
  ~ and he's, by the way, a hypothyroid.
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  So we had to adjust his high thyroid medication.
• 24:29
  you know, all of these elements that are cumulative over time,
• 24:32
  but his psychiatric illness is devastating and it needs to be treated.
• 24:38
  So you just have to have that system of care that can take care of him.
• 24:44
  One of the questions Dr. Frendel you had mentioned before was
• 24:49
  the systems question and in regards to
• 24:55
  with psychiatry, think from a hospital point of view is not always seen
• 25:00
  as like the great big moneymaker,
• 25:02
  right? And it's the resources that go towards it is not from our point
• 25:07
  of view enough, right? It's never enough,
• 25:10
  right? And something like a lithium clinic,
• 25:13
  a clozapine clinic, anything along those lines,
• 25:16
  psychopharmacology clinic, like you were saying,
• 25:18
  I think is another ask of the system,
• 25:21
  right? How do we...
• 25:24
  How do we justify this? How do we kind of talk about this and say,
• 25:27
  or pitch this in a way? How can we all pitch this to get this going
• 25:31
  for other systems?
• 25:34
  Yeah, mean, we in CL psychiatry are very used
• 25:40
  to talking about indirect benefits,
• 25:43
  right? There's always a need for a consult psychiatrist in the MedSurg hospital,
• 25:49
  but there's never the funds and,
• 25:52
  you know, who's going to pay for it.
• 25:54
  But I think that there is direct and a lot of indirect benefit.
• 26:02
  ~ to having this type of program in a hospital system because inevitably
• 26:09
  we get these complicated patients like the population is aging.
• 26:13
  If you embrace ~ maternal fetal medicine,
• 26:19
  you're dealing with maternal mental health.
• 26:22
  ~ You are dealing with these specialized populations
• 26:28
  who cannot be sufficiently cared for in
• 26:32
  the normal system where it's potentially fractionated,
• 26:36
  right? So if you approach this with intention,
• 26:40
  you solve the problem of the system
• 26:46
  and also the providers who are trying to take care of these,
• 26:49
  the doctors generally who are trying to take care of these patients.
• 26:55
  And in addition to that system level,
• 27:01
  benefit, this can be a referral source for doctors,
• 27:07
  prescribers in the community who are struggling with a certain type
• 27:12
  of patient who has more complex ~ psychopharmacology needs.
• 27:17
  And I think that's what we're trying to emphasize,
• 27:21
  that this is sort of a consultative program.
• 27:24
  It also feeds into things like
• 27:28
  interventional psychiatry interventions,
• 27:30
  Like esketamine, ketamine, ~ neuromodulation therapies,
• 27:35
  so that ~ they can all kind of complement each other.
• 27:39
  And I think that's the approach we're trying ~ to establish
• 27:45
  and kind of become that go-to referral source for those complicated patients where
• 27:52
  maybe the folks in the community need a little extra help.
• 27:57
  Do you feel like with lithium that we're romanticizing it a little bit too much?
• 28:04
  That we've kind of, know, maybe we're,
• 28:07
  you know, I was saying before in the beginning,
• 28:10
  we've fallen out of love with lithium,
• 28:11
  but are we kind of being a bit looking at through rosy tinted glasses?
• 28:16
  do we, with that we need to bring it back.
• 28:21
  Sarah, you wanna comment?
• 28:23
  Yeah, I actually tried to have this same discussion with some older psychiatrists
• 28:27
  and some of them were of the opinion that we are romanticizing lithium,
• 28:31
  that it does have a lot of side effects.
• 28:34
  I don't have a tangible answer to your question,
• 28:38
  but I do think that it will benefit those who it needs to benefit
• 28:41
  and shine completely away from it,
• 28:43
  which is what I feel we're at now,
• 28:44
  is not super helpful. So perhaps the golden mean.
• 28:49
  Yeah, it's something I think we're struggling with because I think we see this,
• 28:54
  you know, the outpatient real life basis is that,
• 28:56
  you know, we're being pushed towards,
• 28:58
  you know, the antipsychotics, the second generations,
• 29:02
  they're just quote unquote easier to use,
• 29:04
  less kind of hassle per se.
• 29:07
  And then, you know, sometimes we have a patient who ends up on lithium,
• 29:11
  whether it's through hospitalization or through something else.
• 29:13
  And it's like, where has this been my whole life?
• 29:16
  You know, this is the thing that's helped them the most.
• 29:18
  it's like, well, it's.
• 29:19
  been around for hundreds of years,
• 29:20
  but you know, we've kind of stopped using it for whatever reason that's there.
• 29:27
  Yeah, think it's one thing I would say is that,
• 29:30
  I don't know, it's always it's kind of human nature to make old things new again.
• 29:35
  And but I think that there really is a role.
• 29:40
  There's clearly a unique role for lithium.
• 29:42
  ~ And it may not be the first line.
• 29:47
  Right. Unless it's a certain category of patient who's hospitalized with mania,
• 29:53
  for instance. I mean, I think it's
• 29:56
  very legitimate to offer lithium as a first line to that patient,
• 30:00
  being mindful of all the monitoring needs and the potential long-term side
• 30:06
  effects. But yeah, I mean,
• 30:11
  think net-net, it's probably still underutilized,
• 30:15
  and ~ probably fewer people are thinking about it ~ than ought.
• 30:23
  gonna be mindful of all of our times,
• 30:25
  ~ but any kind of closing recommendations or thoughts,
• 30:30
  Dr. Halabi or Dr. Ferrando?
• 30:32
  ~ Just the simple notion that wherever there is a problem,
• 30:36
  is a solution.
• 30:38
  Well said.
• 30:39
  All right, and then last kind of question before everybody gets on their way,
• 30:43
  but I was asked about everybody's kind of self care because we all need
• 30:48
  our own self care. So what do you all do for your own self care during these times?
• 30:54
  I'm a big meditator. I meditate and I bake a lot.
• 30:58
  Yeah, I'm a I'll say avid if
• 31:02
  not obsessive runner So I I've been running for many many years.
• 31:07
  ~ It's my meditation and my exercise and my self-care
• 31:13
  Awesome. All right, everybody.
• 31:14
  Well, thank you both. Thank you both for your time.
• 31:17
  ~ in this article, again, lithium clinics and high risk populations with bipolar
• 31:22
  disorder. This is in the July edition of psychiatric news,
• 31:26
  special report. ~ you can find that online psychiatry online.org.
• 31:32
  ~ and also remember to leak, you know,
• 31:35
  give us a like five star rating for the podcast,
• 31:38
  wherever you're listening to subscribe and share with everybody.
• 31:41
  then.
• 31:42
  We will see you in the next month then.
• 31:44
  Thank you so much for your time.