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Introduction: The perinatal period poses heightened vulnerability to bipolar affective episodes. Lithium serves as first line in the management of bipolar disorder, demonstrating efficacy in stabilizing mood episodes and preventing relapses. Therefore, it also a recommended treatment during the pregnancy period. However, its use presents potential risks for both the mother and the developing fetus. Given the prevalence of bipolar disorder in reproductive-age women, it is crucial to investigate the risks associated with lithium use during pregnancy, along with its subsequent obstetric and neonatal complications. Objectives: This report outlines a case of severe polyhydramnios in a 42-year-old primigravida patient, under long-term lithium and antipsychotic treatment. Additionally, a systematic search for similar case reports was conducted to provide an overview of the existing literature. Methods: The patient's medical history and perinatal medical care are documented in this case report. A systematic literature search on MEDLINE (PubMed) was conducted using Boolean operators. Results: The patient was diagnosed with bipolar disorder type I and had a history of lithium treatment for over 20 years, supplemented later with antipsychotics. During her pregnancy, she experienced a polyuria-polydipsia syndrome and a severe polyhydramnios. She also suffered renal impairment. Together, it is indicative of a nephrogenic diabetes insipidus (NDI), likely induced by prolonged lithium treatment. As the pregnancy progressed, she experienced premature rupture of membranes at 34 weeks and 5 days. The newborn needed medical support and was admitted to the neonatal unit, without further complications. Systematic research showed three published case reports describing nephrogenic diabetes insipidus (NDI) and polyhydramnios associated to lithium treatment. Conclusions: Chronic administration of lithium may contribute to the development of resistance to antidiuretic hormone (ADH), leading to polyuria-polydipsia syndrome and potentially severe obstetric complications. The co-administration of lithium and antipsychotics may exacerbate these effects. Further research is needed to elucidate their combined clinical impacts. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: Lithium nephropathy can occur in long-term lithium-treated bipolar disorder patients. Key risk factors include duration of lithium exposure, cumulative dose, acute intoxication episodes, advanced age, and comorbidities such as hypertension, diabetes mellitus, hyperparathyroidism, and hyperuricemia, along with concurrent use of antipsychotics. The clinical presentation is gradual, with mild proteinuria, often accompanied by arginine vasopressin resistance. Histological studies show a correlation between interstitial fibrosis and cumulative lithium duration. Approximately 15 to 25 per cent of exposed patients may experience a gradual decline in glomerular filtration rate. The outcome after lithium discontinuation varies. Objectives: This case study aims to analyze and document the clinical presentation, diagnosis, and management of lithium nephropathy in a patient with Bipolar Disorder. Methods: We gathered data on the medical history, lab results, and treatment approach for a patient with Bipolar Disorder. Results: The patient, a 50-year-old woman, had been under the care of Psychiatry since 2008 due to a diagnosis of Bipolar Disorder Type I. During this time, she had experienced depressive and manic episodes but had not presented significant symptom decompensation for the past 14 years, successfully managed with lithium at a current dose of 600 mg per day. However, on this occasion, the patient sought hospitalization due to recent behavioural disturbances, including restlessness, disinhibition, abrupt changes in behaviour, pressured speech, sleep problems, agitation, and aggression. The patient also reported an increased sense of polyuria and polydipsia. Evaluation in the emergency department revealed elevated lithium levels of 1.47 mmol/L and hypokalemia, that justified lithium withdrawal. After lithium levels decreased, an estimated glomerular filtration rate remained low. She was diagnosed with lithium nephropathy, an adverse effect of long-term lithium therapy. Treatment with lithium changed to sodium valproate. Treatment with asenapine started and sustained for two months. Over the following two years, the patient experienced four additional hospital admissions in Psychiatry due to manic episodes. Conclusions: Long-term lithium therapy can lead to lithium nephropathy with symptoms such as polyuria, polydipsia, and acute kidney failure. Consistent monitoring of patients receiving lithium is crucial to detect potential adverse effects.This case highlights the challenges in managing bipolar patients, as discontinuing lithium exacerbated symptoms despite switching to sodium valproate for nephropathy prevention. Long-term lithium treatment, while effective for bipolar disorder, poses significant renal risks. We emphasize continuous renal function monitoring and assessing the risk-benefit of lithium treatment while actively researching lithium nephropathy and its impact on glomerular function. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: Lithium is a well-established mood stabilizer used in the management of bipolar disorder, that is generally well-tolerated; however, it is associated with rare but potentially severe neurological side effects. Lithium-induced encephalopathy is characterized by a spectrum of symptoms, ranging from subtle cognitive deficits to severe manifestations such as altered mental status to overt delirium, seizures and coma. Risk factors include advanced age, concomitant medication and underlying renal impairment. This symptoms do not consistentely correlate with lithium concentrations. Objectives: This abstract aims to provide an overview of the clinical characteristics, underlying mechanisms, and management of lithium-induced encephalopathy. Methods: We discuss a case of a 62-years-old woman diagnosed with bipolar disorder under treatment with lithium and olanzapine, without recent changes of posology. She presented to emergency department with subacute and fluctuating neuropsychiatric symptoms, including confusion, disorientation in time and space, complex visual hallucinations, delusional ideas, alteration in memory and logic thinking, dysarthria and dyspraxia. Neuroimaging showed no structural abnormalities, blood tests were normal and serum lithium levels were within the therapeutic range (0.8 mEq/L). Upon discontinuation of lithium, the patient exhibited a gradual resolution of symptoms. We conducted a comprehensive search of medical databases, including PubMed, to identify relevant articles related to lithium encephalopathy published up to September 2023. Results: This case challenges the conventionally established threshold of elevated serum lithium levels in the development of encephalopathy. The underlying pathophysiology is complex and multifactorial, with proposed mechanisms including alterations in neurotransmitter balance, oxidative stress, mitochondrial dysfunction and individual susceptibility to idiosyncratic reactions. Early diagnosis is challenging, necessitating a high clinical suspicion, neuroimaging and exclusion of other etiologies. Management strategies involve discontinuation of lithium, even when serum lithium levels are within the therapeutic range, supportive care, and, in severe cases, hemodialysis to reduce lithium levels rapidly. Conclusions: Clinicians should maintain a high index of suspicion of lithium-induced encephalopathy, especially in patients presenting with neurological symptoms while on lithium treatment. Early recognition and intervention are essential for minimizing morbidity and preventing potentially irreversible neurological damage. Further research is needed to better understand the precise mechanisms underlying it, risk factors and to refine treatment strategies. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: Lithium was the first mood stabilizer and today continues to be a first-line treatment in the treatment of bipolar disorder despite its adverse effects, which make it important to monitor blood levels and control kidney function. Objectives: Presentation of a case of litium withdrawal and relapse in bipolar disorder. Literature review relating to the risk of relapse when lithium treatment is interrupted. Methods: We present a clinical case of a patient who suffers a deterioration in renal function that requires the withdrawal of lithium and who consequently suffers a relapse. We conducted a bibliographic research of articles in Pubmed on this topic. Results: A 49-year-old male, with a history of multiple admissions to UHB since the age of 18 with a diagnosis of bipolar disorder and treatment with lithium. Decompensations towards the manic pole have always been related to interruptions in lithium treatment. On several occasions when the patient was feeling well emotionally, he believed himself to be "cured" and abandoned the treatment, triggering a manic episode, showing verbal aggression, increased self-esteem and delusional ideation of harm. Remission was usually achieved with the reintroduction of lithium and the addition of high-dose quetiapine. Between episodes, constant overvalued ideas of economic scarcity seemed to persist, which were accentuated in the form of delusional ideas of ruin in depressive decompensations. After 7 years of stability, control analysis showed blood litemia of 2.2 mEq/L with deterioration of kidney function and generalized tremor was observed, without improvement after serum therapy. He was admitted for dialysis and lithium was suspended. Treatment with valproate was started and a consultation scheduled in a week to adjust the dose. The patient did not attend that consultation and was admitted three days later to Psychiatry Hospitalization showing a challenging attitude, evident dysphoric mood, accelerated speech, with derailments and echolalia. Delusional ideation of harm with auditory hallucinations. Insomnia and hyporexia. Chronic renal failure persisted. Conclusions: Lithium is a very effective drug but with a narrow therapeutic range that requires adequate monitoring due to the possible consequences of its use at different organs and systems of the body. when lithium is found in the blood at toxic levels with deterioration of kidney function and glomerular filtration fails to recover, lithium treatment should be suspended. Sudden withdrawal of lithium significantly increases the risk of relapse due to rebound effect. More than 50% of patients experience a recurrence within 10 weeks of withdrawal. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: Lithium is considered the gold standard mood stabiliser for bipolar disorder, yet its use during pregnancy remains controversial, demanding careful consideration of potential risks and benefits. Classically, it has been associated with an increased risk in congenital heart defects, however, recent studies point towards a much lower absolute risk than was previously believed. Furthermore, discontinuation of lithium before or during pregnancy poses a high risk of destabilisation and lithium has been shown to reduce the risk of relapse both in pregnancy and in the postpartum period. Hence, treatment planning is of the upmost importance in this patient group and individual risk stratification should be undertaken for patients to make informed decisions about their treatment. Objectives: To describe the case of a patient with bipolar disorder who discontinued lithium treatment while attempting to conceive and subsequently presented with a manic episode and to expand the scientific knowledge on this topic. Methods: Case report and brief literature review. Results: A 41-year-old patient with a diagnosis of bipolar disorder, previously on lithium 900mg/day, was admitted to the emergency department with symptoms suggestive of a manic episode. One month prior, the patient had discontinued treatment with lithium due to her desire to pursue pregnancy and interrupt treatment while trying to conceive. The patient had a history of postpartum psychosis followed by various depressive and manic episodes with psychotic symptoms, leading to a bipolar disorder diagnosis and commencing treatment with lithium. Her consultant psychiatrist had informed her of the individualised risks of interrupting treatment with lithium and had advised to continue treatment alongside frequent follow-up due to the high-risk of relapse. Despite her consultant's recommendation, she decided to interrupt treatment and hence a personalised lithium tapering regime and advice to continue treatment with quetiapine 200mg/day was given. During the ED stay, treatment with olanzapine was introduced which helped to stabilise her symptoms. Lithium levels were subtherapeutic (lithium serum level 0.11 mmol/L). Inpatient psychiatric admission was avoided due to rapid symptom improvement, strong social support in the community and her preference for ambulatory care. Lithium was gradually reintroduced and antipsychotic treatment was adjusted at follow up appointments, which ultimately led to the resolution of symptoms and stabilisation. Conclusions: This case highlights the significance of considering continuing lithium treatment in bipolar disorder during pregnancy planning. Decisions about medication in pregnancy are multifaceted, making appropriate risk stratification imperative in order to inform individualised care plans to minimise the risk of relapse in these patients. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: Bipolar Disorder (BD) is a severely debilitating psychiatric disorder with high rates of morbidity and mortality, and patients with BD have a 10-year reduction in their life expectancy. Bipolar disorder (BD) is frequently associated with type 2 diabetes mellitus (T2DM). BD patients with comorbid T2DM have been shown to have three times higher odds of a chronic course and rapid cycling and are more likely to present worse outcomes to treatment with lithium and/or other mood stabilisers when compared to BD patients without IGM (impaired glucose metabolism). Objectives: The functioning of the hypothalamic-pituitary-adrenal (HPA) axis has been never investigated in BD with respect to the glucose metabolic status. Therefore, we assessed the cortisol awakening response (CAR) in bipolar patients with or without comorbid T2DM. Methods: Twenty euglycemic bipolar patients [12 males and eight females; mean age (±SD): 47.4 ± 14.4 years; mean (±SD) duration of illness: 18.3 ± 12.1 years], 16 BD patients with T2DM [11 males and five females; mean age (±SD): 63.6 ± 12.8 years; mean (±SD) duration of bipolar illness: 17.1 ± 10.8 years; mean (±SD) duration of T2DM: 5.2 ± 5.3 years], 18 healthy subjects [seven males and 11 females; mean age (±SD): 45.0 ± 12.1 years] and 12 non-psychiatric subjects with T2DM [eight males and four females; mean age (±SD): 56.7 ± 11.2 years; mean (±SD) duration of T2DM: 5.2 ± 3.5 years] were recruited. Saliva cortisol was measured at awakening and after 15, 30, and 60 min. Results: With respect to both healthy controls and controls with T2DM, euglycemic and diabetic BD patients exhibited a CAR occurring at significantly lower levels. No significant difference emerged in the CAR between the two groups of bipolar patients. Controls with T2DM had an overall post-awakening cortisol production significantly higher than healthy controls. Conclusions: Our results show that the CAR of patients with BD is reduced in terms of overall cortisol production but normal in terms of cortisolo reactivity independently from the occurrence of comorbid T2DM. The dampened CAR points to a tuning down of the functioning of the HPA axis in both euglycemic and diabetic BD patients, which may be a factor of vulnerability, since a preserved HPA axis functioning is essential to deal with stressors, which may precipitate affective episodes Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: Lithium treatment is a proven method for bipolar disorder management, but its narrow therapeutic range and the risk of severe side effects, including lithium intoxication, pose significant clinical hurdles. Lithium intoxication, a potentially life-threatening complication, can occur during treatment, raising ongoing questions about its clinical factors, risk elements, and best practices for management. Objectives: Our objective is a comparative analysis between patients who have experienced lithium intoxication and those who have not, aiming to identify influencing factors and enhance clinical care. Methods: We collected demographic data, age at lithium treatment initiation, treatment duration, therapeutic adherence, Mental Health consultations, and lithium level monitoring from 14 individuals requiring clinical attention due to lithium intoxication and 14 patients with similar gender, age, and diagnosis with lithium treatment but without intoxication during four years of follow-up. Results: Regarding the results, the age of onset of lithium treatment in patients with lithium intoxication was 30.2 years (SD=8), and the duration of lithium treatment averaged 11.1 years (SD=8.8), which did not significantly differ from the control group with ages of onset at 38.1 years (SD=15.1) and treatment duration of 9.27 years (SD=8.8), respectively. Lithium intoxication patients developed severe complications, including hospitalizations in medical-surgical units, the necessity for dialysis, and death, one fatal case. Although therapeutic adherence to lithium, measured through pharmaceutical dispensation, exceeded 90% and was comparable in both groups, patients affected by lithium intoxication exhibited a significantly higher treatment discontinuation rate (OR 32.5; 95% CI, 3.1 to 337.8) during the follow-up period. Patients who experienced lithium intoxication had an average of psychiatric consultations every 11.2 months (SD=13.4), with 35.7% not attending at least once a year, while the control group had an appointment every 5.31 months (SD=2.7) (p > 0.05). Lastly, despite both groups having a similar frequency of plasma lithium level monitoring, occurring approximately every 5.5 months (SD=2.6) and 7.8 months (SD=4.8), respectively, in 28.5% of those who suffered from lithium intoxication did not undergo any monitoring for periods exceeding 18 months (p < 0.05). Conclusions: Our research highlights the significance of delivering thorough clinical care and continuous monitoring to patients receiving lithium treatment for bipolar disorder. Ensuring effectiveness therapeutic adherence and maintaining strict monitoring of lithium levels are critical factors that significantly enhance treatment safety. Appropriate management has the potential to improve the quality and safety of care for people with bipolar disorder who are dependent on lithium therapy. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: Bipolar disorder (BD) is a chronic and severe psychiatric disorder, characterized by the alternance of episodes of (hypo)-mania and major depression. Lithium (Li) is the first-line treatment for BD but unfortunately response to Li is highly variable: after at least two consecutive years of treatment, only a fraction of patients receiving Li will display significant improvement in the frequency and/or severity of mood recurrences. This interindividual variability of treatment response is difficult to predict, in the bipolar disorder context. This could be determined by genetic factors still misidentified by available genetic studies. In addition, no clinical or biological markers are available to reliably define eligibility criteria for a lithium treatment in bipolar disorder. A consequence is a long process of therapeutic trials (18-24 months) to phenotype Li response, delaying the stabilization. Objectives: To identify objective biomarkers of the prophylactic response to lithium in order to improve patient care and propose therapeutic alternatives to patients who do not respond to lithium. Methods: Using a genome-wide methylomic approach, and then logistic regressions incorporating as covariates the different types of treatments, we were able to identify differentially methylated regions (DMRs) whose methylation difference between responders and non-responders was not impacted by co-prescribed treatments. Then, we used Methylation Specific High-Resolution Melting (MS-HRM), a PCR based method than can be implemented in any medical laboratory at low cost and with minimal equipment, to estimate methylation proportion of 9 DMRs in 61 samples of bipolar patients. Results: In the sample of 61 individuals with BD, the 9 MS-HRM-measured DMRs combined with clinical variables (age, sex, cigarette smoking status, lifetime number of hospitalizations, age at onset of BD, polarity at onset, psychotic symptoms at onset, family history of BD, lifetime alcohol/cannabis misuse, panic disorders, Li prescribed as the first mood stabilizer (vs 2nd or 3rd choice)) correctly classified 83,6% of individuals as good or non-responders (n=61, prophylactic response phenotype defined using the "Alda" scale). Excluding the partial responders, the percentage of correctly classified individuals is as high as 100% (n=43, 18 non responders and 25 responders). The AUC are respectively AUC=0.913 and AUC=1.0. Conclusions: The MS-HMR method allow to identify the response status of individuals with BD with 9 DMR. These DMRs discriminate good from non-responders and can be used in combination with clinical variables. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: The spectrum of neuropsychiatric adverse effects of corticosteroids ranges from unspecific symptoms to structured psychotic or affective episodes. We present the case of a 30-year-old woman admitted to our hospital due to behavioral alterations, coinciding with the initiation of treatment with corticosteroid boluses as part of a chemotherapy regimen for gastric adenocarcinoma. She had a previous diagnose of Addison's disease, undergoing treatment with supplemental corticosteroids. Objectives: 1) To describe the clinical particularities of this case, focusing on the psychopathological aspects and their correlation with the corticoid treatment. 2) To review the available literature regarding the clinical characteristics and management of corticosteroid-induced psychosis, with special interest in patients with adrenal insufficiency that require long term steroid supplementation. Methods: A review of the patient's clinical history and complementary tests were carried out. Likewise, we reviewed the available literature in relation to the clinical presentation of corticosteroid-induced psychosis and its pharmacological management. Results: The patient was admitted to our hospital due to acute behavioural alterations, which temporally coincided with the 4th cycle of FOLFOX chemotherapy and corticosteroid boluses. She presented with incoherent speech, with non sequitur answers and glossolalia, as well as dysphoric affect and purposeless behavior. She presented a favorable clinical course after the initiation of treatment with antipsychotics and temporary suspension of corticosteroid treatment. Manic symptoms are the most common presentation of "corticosteroid-induced psychosis", with the key characteristic being the temporal association with the corticosteroids administration. Although the discontinuation of steroids generally results in a sudden decrease in symptoms, additional treatment with antipsychotics such as haloperidol or olanzapine might be required for a symptomatic control. In patients with adrenal insufficiency, long-term treatment with lithium or anti-seizure treatments are effective strategies in relapse prevention when a higer steroid dose is required. Conclusions: - Corticosteroid-induced psychosis is a well described clinical phenomenon, that usually presents with manic symptoms rather than psychotic experiences. - Progressive discontinuation of corticosteroid treatment usually results in complete cessation of symptoms, but additional psychopharmacological treatment might be required, especially in patients with adrenal insufficiency undergoing long-term corticosteroid treatment. - This case outlines the psychopathological richness in the presentation of corticosteroid-induced psychosis, and illustrates the challenges in the pharmacological management in patients with adrenal insufficiency. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: Lithium is a mood stabilizer often used as a first-line treatment for bipolar disorder. Its narrow therapeutic window and changes in the absorption, distribution, and elimination of the drug following bariatric surgery have important implications regarding patient safety. Objectives: We present a 51-year-old female patient with bipolar disorder and a medical history of morbid obesity, type 2 diabetes mellitus, hypothyroidism, hyperlipidemia, and essential hypertension. She was mentally stable on lithium 1200 mg/day, valproate 500 mg/day, and quetiapine 400 mg/day. She had undergone laparoscopic sleeve gastrectomy. After a month, she showed up to the emergency room (ER) with nausea, vomiting, diarrhea, and fatigue. Gastroenteritis was suspected until the patient started showing neurological symptoms such as delirium, dysarthria, ataxia, chorea, and athetosis. Methods: The patient was monitored and received aggressive intravenous hydration (3000 cc of 0.9% serum isotonic) in the intensive care unit (ICU). She was prescribed intramuscular biperiden injection of 5 mg/ml/day, pheniramine 45.5 mg/2 ml/day, and lorazepam 1 mg/day. Her lithium levels were checked every six hours. She was agitated and disoriented for the first five days despite lithium levels being in the therapeutic range. On day six, her blood lithium levels dropped to 0.399 mmol/L. Her psychiatric examination revealed that she resumed cooperation and orientation, her dysarthria subsided. However, her thought content and attitude were grandiose, and she had a labile affect. We prescribed 5 mg/day of olanzapine routinely and 1 mg/day of lorazepam on a needed basis. The next day, her labile affect became calmer, and her sleep improved so she was discharged from the ICU and admitted to general surgery inpatient service, and olanzapine was titrated to 10 mg per day since she had elevated mood symptoms. Results: After 7 days of intravenous hydration and supportive treatment, her neurological symptoms completely subsided except for a fine tremor, which lasted for another 3 days and then ceased. She was clinically stabilized without further need for intervention. Her lithium level was 0.206 mmol/L before her discharge. Conclusions: We believe it is of utmost importance to build a consensus in guidelines and inform physicians about lithium toxicity and its symptoms after bariatric surgeries. We recommend a careful follow-up of the patient pre-and postoperatively. Preoperative psychiatric intervention includes decreasing the lithium dose gradually and discontinuing it. After the operation, lithium can be started with a much lower dose and may be increased by checking lithium levels every week for at least 6 weeks after the operation until the patient can digest solid food again, and then every 2 weeks for 6 months, and thereafter every month for one year. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: During the perinatal period lithium is proven effective as maintenance therapy and to prevent postpartum psychosis. Pregnancy affects all aspects of kidney physiology altering the pharmacokinetics of lithium. To minimize the risk of both maternal and neonatal complications around delivery, several authors have provided clinical advice on lithium dosing around delivery: decreasing dose by 30-50%, suspend lithium therapy 24-48 hours before scheduled cesarean section or induced delivery or even discontinuing lithium after first signs of labour. Objectives: To evaluate the validity of these recommendations by investigating 1) maternal lithium serum concentrations changes around delivery, 2) the lithium trasplacental passage at delivery and 3) the association between neonatal lithium serum concentration at delivery and neonatal outcomes. Methods: Psychopathologically stable women with a singleton pregnancy (n=66) who used lithium around delivery, were included in this retrospective observational cohort study (HCB/2020/1305). All women were advised to suspend lithium administration at the onset of labour in the event spontaneous deliveries. Study date: demographic, psychiatric, obstetric and neonatal outcomes for each mother-infant pair obtained from the hospital medical records.Lithium serum concentrations were determined by means of an AVL 9180 electrolyte analyzer based on the ion- selective electrode (ISE) measurement principle. Limit of quantification (LoQ) was 0.20 mEq/L. Results: The most common psychiatric diagnosis was a bipolar disorder type I (n=54, 90%). Forty mothers (61%) were on lithium monotherapy. Mean (SD) umbilical cord and intrapartum maternal lithium serum concentration was 0.59 (0.13) mEq/L and 0.55 (0.13) mEq/L respectively. There was a strong positive correlation between umbilical cord and maternal lithium serum concentrations (Pearson correlation coefficient 0.95 (95%IC: 0.91,0.97). In a subsample (N=22) a paired t test indicates that the maternal serum lithium concentrations at delivery were significantly lower (mean difference=0.19 mEq/L, 95%CI=0.13-0.25) than those during obtained the day before delivery hospitalization, after a mean (SD) of 31.29 (±11.92) hours (SD=11.92) have elapsed since the taking the last dose of lithium prior to delivery. Four women (6%) relapsed early postpartum.There were no significant differences between lithium monotherapy (N=18/40) and polytherapy (N=11/26) groups with regard to acute neonatal complications (p>0.05). The only acute neonatal complication associated to umbilical cord lithium serum concentration was hypotonia [0.712 (0.298) vs. 0.534 (0.214) (F=5.065; df=1,60; p=0.028)]. Conclusions: When lithium is used around delivery, maternal and neonatal well-being can be maximized by maintaining maternal serum lithium concentrations at the minimal effective level and discontinuing briefly when presenting to hospital for delivery. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Abstract Introduction Many clinicians are reluctant to use traditional mood-stabilizing agents, especially lithium, in children and adolescents. This review examined the evidence for lithium's safety and efficacy in this population. Methods A systematic review was conducted on the use of lithium in children and adolescents with bipolar disorder (BD). Relevant papers published through June 30th 2018 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library. Results 30 articles met inclusion criteria, including 12 randomized controlled trials (RCTs). Findings from RCTs demonstrate efficacy for acute mania in up to 50% of patients, and evidence of long-term maintenance efficacy. Lithium was generally safe, at least in the short term, with most common side effects being gastrointestinal, polyuria, or headache. Only a minority of patients experienced hypothyroidism. No cases of acute kidney injury or chronic kidney disease were reported. Conclusions Though the available literature is mostly short-term, there is evidence that lithium monotherapy is reasonably safe and effective in children and adolescents, specifically for acute mania and for prevention of mood episodes. [ABSTRACT FROM AUTHOR]

Introduction Bipolar Disorder (BD) is a severe psychiatric condition characterized by grey matter (GM) volumes reduction. Neurotrophic factors have been suggested to play a role in the neuroprogressive changes during the illness course. In particular peripheral brain-derived neurotrophic factor (BDNF) has been proposed as a potential biomarker related to disease activity and neuroprogression in BD. The aim of our study was to investigate if serum levels of BDNF are associated with GM volumes in BD patients and healthy controls (HC). Methods We studied 36 inpatients affected by a major depressive episode in course of BD type I and 17 HC. Analysis of variance was performed to investigate the effect of diagnosis on GM volumes in the whole brain. Threshold for significance was P < 0.05, Family Wise Error (FWE) corrected for multiple comparisons. All the analyses were controlled for the effect of nuisance covariates known to influence GM volumes, such as age, gender and lithium treatment. Results BD patients showed significantly higher serum BDNF levels compared with HC. Reduced GM volumes in BD patients compared to HC were observed in several brain areas, encompassing the caudate head, superior temporal gyrus, insula, fusiform gyrus, parahippocampal gyrus, and anterior cingulate cortex. The interaction analysis between BDNF levels and diagnosis showed a significant effect in the middle frontal gyrus. HC reported higher BDNF levels associated with higher GM volumes, whereas no association between BDNF and GM volumes was observed in BD. Discussion Our study seems to suggest that although the production of BDNF is increased in BD possibly to prevent and repair neural damage, its effects could be hampered by underlying neuroinflammatory processes interfering with the neurodevelopmental role of BDNF. [ABSTRACT FROM AUTHOR]

Background Cognitive deficits have been reported during the early stages of bipolar disorder; however, the role of medication on such deficits remains unclear. The aim of this study was to compare the effects of lithium and quetiapine monotherapy on cognitive performance in people following first episode mania. Methods The design was a single-blind, randomised controlled trial on a cohort of 61 participants following first episode mania. Participants received either lithium or quetiapine monotherapy as maintenance treatment over a 12-month follow-up period. The groups were compared on performance outcomes using an extensive cognitive assessment battery conducted at baseline, month 3 and month 12 follow-up time-points. Results There was a significant interaction between group and time in phonemic fluency at the 3-month and 12-month endpoints, reflecting greater improvements in performance in lithium-treated participants relative to quetiapine-treated participants. After controlling for multiple comparisons, there were no other significant interactions between group and time for other measures of cognition. Conclusion Although the effects of lithium and quetiapine treatment were similar for most cognitive domains, the findings imply that early initiation of lithium treatment may benefit the trajectory of cognition, specifically verbal fluency in young people with bipolar disorder. Given that cognition is a major symptomatic domain of bipolar disorder and has substantive effects on general functioning, the ability to influence the trajectory of cognitive change is of considerable clinical importance. [ABSTRACT FROM AUTHOR]

Background Treatment strategies for mental disorders may vary according to illness stage. However no data currently exist to guide treatment in first episode psychotic mania. The aim of this study was to compare the safety and efficacy profile of chlorpromazine and olanzapine, as add-on to lithium, in patients with a first episode of psychotic mania, expecting better safety profile and adherence to olanzapine but similar efficacy for both treatments. Methods Data from 83 patients were collected in an 8-week randomised controlled trial on clinical variables, side effects, vital signs, and weight. Analyses of treatment differences over time were based on intent-to-treat principles. Kaplan-Meier estimated survival curves were used to analyse time-to-event data and mixed effects models repeated measures analysis of variance were used to determine treatment group differences over time on safety and efficacy measures. Results Ethics committee approval to delay informed consent procedure until recovery from the acute episode allowed the inclusion of 83 patients highly representative of those treated in the public sector. Contrary to our hypotheses, safety profile of both medications was similar. A signal for higher rate ( P = . 032) and earlier occurrence ( P = .043) of mania remission was observed in the olanzapine group which did not survive correction for multiple comparisons. Conclusions Olanzapine and chlorpromazine have a similar safety profile in a uniquely representative cohort of patients with first episode psychotic mania. The possibility for a greater impact of olanzapine on manic symptoms leading to earlier remission of the episode needs exploration in a large sample. [ABSTRACT FROM AUTHOR]

Introduction: Management of bipolar disorder (BD) include assessment of non-adherence (Berk et al., 2010). Knowledge about lithium therapy has been shown to improve adherence and reduce the risk of toxicity. Objectives: Better understand patient's knowledge level and attitudes towards lithium; verify the variables which could influence adherence. Methods: At admission BD patients completed the Italian versions of the Lithium Knowledge Test (LKT) and Lithium Attitudes Questionnaire (LAQ): adapted translations of a validated psychiatric survey. Scores were correlated to clinical, demographic, pharmacological variables as well as patient's plasma lithium levels. Results: 16.5% showed good lithium knowledge. Knowledge positive correlated with education level (p < 0,04). 21.7% expressed negative attitudes towards lithium therapy: obstacles to adherence were younger age (for side effects <0,01), earlier onset of illness (doubt efficacy <0,04), and late onset of lithium prophylaxis (with poor concept of illness <0,05). Lithiemia positively correlated with duration of illness (p < 0,02), duration of lithium treatment (p<0,01), good lithium knowledge (p<0,04) and positive attitude towards lithium (p<0.04). Duration of lithium therapy positively correlated with general attitude towards lithium (p<0,02), lithium therapy specifically (p<0,01), and severity of illness insight (p<0,009) Conclusions: A low percentage of patients had a good lithium knowledge. Duration of lithium therapy seems to be a protective factor for adherence; younger patients, earlier age of onset, late addition of lithium to therapy could represent barriers for adherence and topics for psychoeducational individual support. [ABSTRACT FROM AUTHOR]

Introduction: Lithium is a well-known drug and frequently a key factor in the management of acute mania, unipolar and bipolar depression and prophylaxis of bipolar disorders. However, its effect on thyroid function cannot be overlooked, with numerous reports of thyroid abnormalities' onset during tretament with lithium. Objectives: To assess the prevalence, risk factors and management of thyroid disfunction in patients undergoing lithium therapy. Methods: Non-systematic review of the literature from Pubmed database, using the key words: lithium treatment, lithium toxicity, thyroid dysfunction, goitre, hypothyroidism, hyperthyroidism, thyroid autoimmunity. Results: Our assessment has identified female sex, middle age, autoimmune disease or the history of thyroid disease in the family as risk factors for the development of thyroid abnormalities while undergoing lithium therapy (the most common being goiter and hypothyroidism). It is recommended that thyroid function tests and assessment of thyroid size are performed among patients initiating lithium therapy, at baseline and later annually (more frequently among patients presenting risk factors). Conclusions: We find it important to stress that the development of thyroid dysfunction does not typically require discontinuation of lithium. Lithium should not be stopped unless its serum concentration is beyond the therapeutic range. Instead, supplementation with levothyroxine should be started (according to specific indications). Clinicians managing lithium-treated patients must keep thyroid disorders in mind, and screen them clinically and through thyroid function tests during follow-up in order to institute early and appropriate treatment. [ABSTRACT FROM AUTHOR]

Introduction: Lithium has been one of the oldest substances used in psychiatric treatments and remains the first-line treatment for prevention of manic and depressive episodes of bipolar disorder (BD), but it has also a wide spectrum of side-effects. Objectives: The goal is to review efficacy, and clinical use of lithium, such as its side effects, and its benefit-to-risk ratio. Methods: Non-systematic literature review based on scientific databases such as PubMed. Results: The first modern use of lithium was for the treatment of mania. Lithium has also proven useful in major depression, particularly for augmentation of antidepressants, for aggressive behavior and it has a specific antisuicide effect. Lithium's prophylactic and antisuicidal effects are most unique. However, the use of lithium became problematic due to the serious toxicity since lithium also a narrow therapeutic index, with therapeutic levels between 0.6 and 1.5 mEq/L. Conclusions: Awareness of the benefits and risks of lithium is essential for the use of this lifesaving agent. Lithium levels must be carefully monitored and lithium dosage adjusted as necessary. [ABSTRACT FROM AUTHOR]

Introduction: A 47 y.o. female patient was admitted to the female PICU with a manic episode. Upon admission she presented with mood elation, psychosis, pressured speech, lack of sleep and agitation. Objectives: To investigate negative prognostic factors such as the co-morbidity with a personality disorder in patients presenting with severe mania. Methods: The patient was assessed regularly by the psychiatric team consisting of a CT doctor and one General Adult Consultant. Appropriate psychological assessments for mania and laboratory investigations took place. Results: The patient initially scored above 45 in the Young Mania Rating Scale (YMRS), establishing a diagnosis of severe mania. She was treated with Olanzapine titrated up to 20mg OD and augmentation with Lithium treatment. Lithium plasma levels were at 0,6. Due to the treatment resistant manic presentation a second antipsychotic agent was administered and the patient was also treated with Zuclopenthixol depot 400mg every two weeks. Clinical improvement was observed after 16 days from admission. Conclusions: The clinical team wondered about the clinical challenges of the case. According to the literature having a Personality Disorder diagnosis is a negative prognostic factor for patients with mania and this is relevant to this case as well. [ABSTRACT FROM AUTHOR]

Introduction: Treating pregnant women with bipolar disorder is among the most challenging clinical endeavors. Patients and clinicians are faced with difficult choices at every turn, and no approach is without risk. Many primary mood stabilizers have been associated with risk of congenital malformations. In the last 15 years, there has been an increase of antepartum use of atypical antipsychotic drugs, many of which could be viable alternatives to mood stabilizers. Electroconvulsive therapy has been recommended as a safe and efficacious treatment of bipolar depressive and manic episodes in pregnant women. Objectives: This case presents a 24-year-old woman, with COVID-19 infection, that underwent an acute manic episode at her 20-weeks-pregnancy. The goal was to stabilize the patient by the use of electroconvulsive therapy. Methods: The patient was admitted in isolation in the psychiatric ward. Treatment was started with olanzapine 20mg/d and lorazepam 4mg/d. The patient maintained psychotic agitation that required higher dosage, while on the second week of isolation the PCR test was negative. After six weeks of treatment severe manic symptoms continued and electroconvulsive therapy was started. Results: She received 10 electroconvulsive therapy sessions. The patient showed a substantial clinical improvement after the seventh administration. She gave birth at 37 weeks, with no complications during labor (Apgar 9/10). Conclusions: Electroconvulsive therapy has been shown as a suitable option for patients with severe psychiatric disorders in the pregnancy period, either medication resistant illness and psychotic agitation. [ABSTRACT FROM AUTHOR]

Introduction: Bipolar disorder (BD) is a chronic, recurring illness that can lead to serious disruptions in functioning. Objectives: To evaluate functionning in this population and to explore the relationship with socio-demographic and clinical features of BD. Methods: This is a descriptive and analytical cross-sectional study including patients with BD (DSM V) in euthymia, followed on an ambulatory basis to the Mood Disorders Unit of the Psychiatry A Department at Hedi Chaker Hospital University of Sfax between January and April 2019. Patients were considered euthymic if they scored less than 7 on the Young Mania (YMRS) rating scale and less than 8 on the Hamilton Depression scale (HDRS-17). The Short Function Evaluation Test (FAST scale) was used to evaluate functionning. Global functional impairment is defined by a total FAST score>11. Results: We recruited 62 patients with a mean age of 45.65 years (SD=13.3) and a sex ratio of 1.13. 88.7% of patients were followed for BD I and 11.3% for BD II. The mean age of onset was 29.37 years (SD=11.6). The mean numbers of manic and depressive episodes were respectively 3.73 (SD=3.8) and 2.48 (SD=2.9). The mean FAST score was 28.97 (SD=15). Overall impairment was observed in 85.5% of patients. Impaired functionning was significantly more frequent in patients with a history of surgery (p=0.046), in those with a higher number of depressive episodes (p<0.001) and in subjects with partial remission (p=0.01). Conclusions: Thus, the treatment should target not only the improvement of symptoms but also the reduction of the incapacity of patients. [ABSTRACT FROM AUTHOR]

Introduction: Evidence for lithium as a maintenance treatment for bipolar disorder type II remains limited since most treatmentprevention studies focus on bipolar disorder type I or do not distinguish between types of bipolar disorder. Objectives: To compare the impact of lithium discontinuation on hospital utilisation in patients with bipolar disorder type I or schizoaffective disorder and patients with bipolar disorder type II or other bipolar disorder. Methods: Mirror-image study, examining hospital utilisation within two years before and after lithium discontinuation as part of LiSIE, a retrospective cohort study into effects and side-effects of lithium for the maintenance treatment of bipolar disorder as compared to other mood stabilisers. Results: For the whole sample, the number of admissions increased from 86 to 185 admissions after lithium discontinuation, with the mean number of admissions/patient/review period doubling from 0.44 to 0.95 (p < 0.001). The number of bed days increased from2218 to 4240, with the mean number of bed days/patient/review period doubling from 11 to 22 (p = 0.025). This increase in admissions and bed dayswas exclusively attributable to patientswith bipolar disorder type I or schizoaffective disorder. Conclusions: Our findings suggest that due to a higher relapse risk in patients with bipolar disorder type I or schizoaffective disorder there is a need to apply a higher threshold for discontinuing lithium than for patients with bipolar disorder type II or other bipolar disorder. [ABSTRACT FROM AUTHOR]

Introduction: Lithium has been the mainstay therapy for bipolar disorder (BD) for decades, but there is little consensus regarding its possible effects on kidney function and the rate of change in estimated glomerular flow rate (eGFR) over time. Objectives: To describe patients with BD regarding their renal function and their sociodemographic and clinical characteristics potentially related to eGFR. Methods: This is a cross-sectional study with an initial sample of 95 patients with BD. Multiple linear regression analysis was applied to investigate the association of lithium serum levels and their duration of treatment with eGFR, independent of confounding factors. We excluded patients without data regarding any of the variables from the final model. Results: In the multivariable analysis, the model was composed of eight variables (Figure 1). The mean duration of treatment was 10 years (Figure 2). Serum lithium level was associated with low levels of eGFR (β = -18.06 [-34.70 - -1.42], p = 0.03); among the other variables, only age remained associated with it (β = -0.72 (-1.10 - -0.33), p = <0.01). Conclusions: We replicated the correlation between serum lithium levels and eGFR. Our results contradict the claim that duration of treatment with lithium correlates with lower levels of eGFR, while suggesting serum lithium level could be a possible early marker of lithium nephrotoxicity. [ABSTRACT FROM AUTHOR]

Introduction: The association between lithium and thyroid dysfunction has long been known. Yet it is not known whether lithiumassociated hypothyroidism is reversible, once lithium treatment has been stopped. Objectives: To determine whether lithium-associated hypothyroidismwas reversible in patientswho subsequently discontinued lithium. Methods: Retrospective cohort study in the Swedish region of Norrbotten into the effects and side-effects of lithium treatment and other drugs for relapse prevention (LiSIE). For this particular study, we reviewed medical records between 1997 and 2015 of patients treated with lithium. Results: Of 1340 patients screened, we identified 90 patients with lithium-associated hypothyroidism who subsequently discontinued lithium. Of these, 27% had overt hypothyroidism at the time when thyroid replacement therapy was initiated. The mean delay from lithium start to thyroid replacement therapy start was 2.3 (SD 4.7) years. Fifty percent received thyroid replacement therapy within 10 months of starting lithium. Of 85 patients available for follow up, 35 (41%) stopped thyroid replacement therapy after lithium discontinuation. Six patients reinstated thyroid replacement therapy subsequently. Only one of these had overt hypothyroidism, occurring 13 days after stopping lithium and 11 days after stopping thyroid replacement therapy. Conclusions: Lithium-associated hypothyroidism seems reversible in most patients, once lithium has been discontinued. In such cases, thyroid replacement therapy discontinuation could be attempted much more often than currently done. Based on the limited evidence of our study, we can expect hypothyroidism to recur early after discontinuation of thyroid replacement therapy if at all. [ABSTRACT FROM AUTHOR]

Introduction: In 2016, 39% of adults worldwide were overweight and 13% were obese. The prevalence of obesity is significantly greater in patients with bipolar disorder versus controls, with an odds ratio of 1.65. Since patients with schizophrenia and bipolar disorders are known to be at increased risk for obesity compounded by pharmacotherapy, bariatric surgery may become a more common treatment option for this population. While bariatric surgery has been previously associated with reduced drug oral bioavailability due to changes in gastric pH, surface area, transit time, and volume capacity, we present a case of lithium toxicity occurring three weeks after sleeve gastrectomy. Objectives: To increase awareness regarding the potential for lithium toxicity following bariatric surgery. Methods: Case report. Results:A29-year-old woman with Bipolar I Disorder, Unspecified Anxiety Disorder, and recent sleeve gastrectomy presented to the Emergency Department with altered mentation and lethargy for five days. Total daily doses of her psychotropic medications were: lithium 1050 mg, lurasidone 180 mg, trazodone 300 mg, and as needed lorazepam up to 3 mg. Three days prior to admission her lorazepam was changed from standing to as needed; otherwise her medications had not been changed following surgery. On admission, the patient was found to have a supratherapeutic lithium level (3.67mmol/L) and an elevated creatinine (1.4 mg/dl) and received multiple fluid boluses and required hemodialysis. Conclusions: The pathophysiology of lithiumtoxicity after bariatric surgery, particularly after restrictive procedures, remains unclear. Wesuggest that therapeutic drug monitoring be performed regularly for patients on lithium after bariatric surgery to prevent toxicity. [ABSTRACT FROM AUTHOR]

Introduction: Electroconvulsive therapy (ECT) is indicated for the treatment of both manic and depressive phases of bipolar disorder in some cases: the severity of the symptoms, the necessity of an urgent response or the impossibility of using drugs for the treatment. Objectives: To show the benefits of the application of ECT in patients with comorbidities with a case communication. Methods: We present a 60-year old male patient with a bipolar disorder diagnosis with 41 years of treatment history. Due to a depressive episode, he was admitted to the psychiatric ward. Symptoms consisted of mutism, psychomotor retardation, and refusal of oral intake of food (BMI 14.5) and hydration, attributing the latter with autolytic intentionality. His vital risk was aggravated because of chronic renal failure and nephrogenic diabetes insipidus, both related to the treatment with lithium he had followed for years, requiring an adequate water intake. During his admission symptoms hadn't responded to therapeutical dosages of venlafaxine that hadn't been able to be increased over 150 mg/day due to adverse effects. Analysis ordered by the Nephrology department indicated that he presented SIADH (syndrome of inappropriate anti-diuretic hormone) related to treatment with valproate, as it remitted after stopping the drug. Together with the family judicial authorization for treatment with ECT was requested and granted. Results: We administered up to 12 ECT sessions, with clinical improvement after the 5th-6th session. Conclusions: ECT is a therapeutical option to consider in cases of severe psychiatric disorders in which a pharmacological approach is not enough or is not well tolerated. [ABSTRACT FROM AUTHOR]

Introduction: The evidences of comparative efficacy and tolerability of anticonvulsants in longterm therapy for bipolar disorder (BD) are sparse. Objectives: to compare the longterm efficay and tolerability of valproate (SV), lamotrigine (LAM), topiramate (TPM) in BD. Methods: 90 BD patients (34 men, 56 women, mean age - 40.8±12.7, disease duration at least 2 years (mean - 14.1±9.4), with at least 2 episodes during the past year, were randomized into 3 therapeutic groups (SV, LAM, TPM). Efficacy was separately assessed by the changes in the relapse rate and duration of both depressive and manic episodes. Results: The mean relapse duration decreased for SV by 81.84%, LAM-71.4%, TPM-73.5% (p<0.0001), the frequency - 67.7%, 63.3% and 63.6%, respectively (p<0.0001) (SV vs LAM vs TPM - NS). The TPM group had the highest dropout rate and the shortest period of time for therapy discontinuation. Manic symptoms duration decreased (p<0.0001) in the SV group by 79.0%, LAM - 69.3%, TPM - 63.8%, depressive - 64.4%, 80.2%, 73.9%, respectively. Manic episodes frequency (p<0.0001) - by 60.0%, 41.7%, 54.5%, depressive - 50.0% (p<0.0001), 55.0% (p<0.0001) and 43.8%(p<0.05), respectively. Differences between drugs (Mann-Whitney test) in pairwise comparison to reduce the duration of manic symptoms for SV andTPM (p=0.008), depressive - for VN and LAM (p=0.002), frequency of manic episodes for SV and LAM (p=0.003), depressive - NS. The incidence of side effects: TPM (26.7% of patients) >SV(20.7%) > LAM(12.9%). Conclusions: SV, TPM, LAM have equal efficacy. VN, TPM were better of LAM in controlling manic, LAM - in depressive symptoms. [ABSTRACT FROM AUTHOR]

Introduction Brain changes in bipolar disorders (BD) may represent inherited risk factors or consequences of the illness (brain plasticity). Neuroanatomical changes, which predispose for BD could aid in early diagnosis, whereas the neuronal sequellae of BD could yield biological outcome measures for prevention and treatment. Methods To separate neuroanatomical changes into those that increase the risk of BD versus those that result from it, we acquired MRI/clinical data from participants at different stages of BD, including: (1) affected and unaffected offspring of bipolar parents ( n = 86); (2) participants with substantial illness burden who had had at least 2 years of current Li treatment ( n = 37) or were Li naive ( n = 19). We also recruited 99 healthy controls matched to the above-mentioned cohorts by age and sex. Results Relative to controls, both the affected and unaffected offpring of bipolar probands showed increased right inferior frontal gyrus (rIFG) volume, but comparable hippocampal volumes and prefrontal N -acetyl aspartate (NAA) levels. Larger rIFG volume was associated with an increased risk of conversion to psychiatric disorders within 4 years following the MRI scanning (hazard ratio = 4.5). In contrast, Li naive patients with substantial illness burden had smaller rIFG, hippocampal volumes and prefrontal NAA levels than controls, who were comparable in these indices to the the Li treated subjects with substantial illness burden. Conclusions Brain structural changes in BD may not be static, but may instead result from an interplay between illness burden and compensatory processes. This illness related brain plasticity may be modulated by lithium treatment. [ABSTRACT FROM AUTHOR]

Introduction There is substantial evidence that even minor perturbation of thyroid function plays a significant role in clinical course and treatment outcome in bipolar mood disorder. Aims and objectives To understand the relationship between thyroid profile and bipolar disorder subtypes and to study the relationship between pre-treatment thyroid profile and response to treatment with lithium along with other predictors of response to treatment with lithium in cases of bipolar mood disorder. Methods This study was conducted in the indoor facilities of LGBRIMH, Tezpur in the year of 2012, after clearance from scientific and review committee and Ethics committee of the institute. Forty-five consecutive indoor patients diagnosed with bipolar mood disorder using DSM-IV TR criteria were selected. On day 1, blood was collected for thyroid profile and BPRS 24 item scale version 4.0 was applied. They were all started on lithium monotherapy, and only lorazepam was used on SOS basis. On day 30, the BPRS was applied again to check the response to treatment. Appropriate statistical analysis was done using SPSS version 16. Results The response to treatment was good with the mean % fall of the BPRS score being 40%, with the maximum fall in the subscale of grandiosity and minimum for depression. Age, illness duration, substance use, family history 2nd or later episodes were negatively correlated with treatment response. Pretreatment T4 level was positively correlated while pre-treatment TSH level was negatively correlated with the treatment response. Conclusion Pre-treatment T4 and TSH level were predictors of treatment response with lithium. [ABSTRACT FROM AUTHOR]

Introduction Lithium is a mood stabilizer used in the treatment of bipolar disorder. Lithium has recently been associated to permanent neurological damage namely persistent cerebelar dysfunction as well as peripheral and central neuropathies. Objectives To present a clinical case of a probable Syndrome of Irreversible Lithium-effectuated Neurotoxicity (SILENT) and a review of the literature concerning this rare syndrome. Aims Increase awareness and knowledge of SILENT. Methods Psychiatric and psychological evaluation of a probable clinical case of SILENT and review of the literature using the key words “lithium neurotoxicity” and “Syndrome of Irreversible Lithium-effectuated Neurotoxicity”. Results A 54-year-old female patient was admitted in our hospital due to involuntary lithium intoxication, with acute renal and cardiovascular failure, neurological, metabolic and electrolytic dysfunction in an acute confusional state and in need of dialysis. The patient clinical picture rapidly improved although, when she achieved normal lithium seric levels, it was observed a worsening of the preexisting confusional state followed by two consecutive generalized tonic-clonic convulsions and a partial convulsion. A short time after, it was recognized the development of a persistent catatonic state. It was detected urinary incontinence and repetitive, monosyllabic, incoherent, short phrased speech featuring echolalia, together with emotional lability and incongruous affect. The patient slightly improved with the introduction of anti-Parkinson's pharmacotherapy. Conclusions This clinical case raises several differential diagnoses due to its psychiatric and neurologic characteristics. We conclude that the most probable diagnosis is SILENT. [ABSTRACT FROM AUTHOR]

The aim of the present study was to investigate whether the use of lithium followed recommended practice in acutely manic adolescent inpatients. This study was a 12-month retrospective review of patients with manic episode admitted to Bakırköy Mazhar Osman Mental Health and Neurological Diseases Education and Research Hospital. Length of stay, medication data, serum levels and adverse effects were recorded for patients who started lithium treatment within average of 7 days of admission ( n = 52). Average length of stay was 23.63 (SD = 17.6). The maximum dose prescribed within 24 h of starting treatment was 721.15 mg (SD = 239.5). The maximum daily dose was reached in an average of 7 days to 1136.5 mg (SD = 336.4). The average time after starting treatment until the first recorded serum level was 5 days. The average serum level reached was 0.5 mEq/L (SD = 0.22), which was raised to 0.6 mEq/L (SD = 0.3) at discharge with an average daily dose of 1038.46 mg (SD = 460). In 8 admissions (15.4%), one adverse effect was recorded that could have been related to lithium treatment but adverse events did not lead to discontinuation of drug. The literature supports that rapidly attained high serum levels are associated with positive outcomes. In this current study, clinicians used a relatively slow dose titration and lower serum levels were obtained suggesting that lithium was not considered as a primary agent for treating mania. Taking advantage of lithium especially for the maintenance treatment of bipolar disorder and tolerability may have driven these findings. [ABSTRACT FROM AUTHOR]

Introduction Lithium is currently a drug of choice for treating persons with bipolar disorder and is widely used in this population. Approximately, 30% of patients taking lithium experience at least one episode of lithium toxicity. Treatment of acute toxicity involves correction of electrolyte abnormalities, volume repletion followed by forced diuresis, and dialysis in severe cases. A case report is described and it is reviewed some alternative treatment options before considering withdrawal of lithium treatment in lithium-induced nephrogenic diabetes insipidus. Case report A 58-year-old woman diagnosed of hypertension and bipolar disorder for 20 years. At first, she was controlled with valproic acid until she suffered a manic episode which required a mood stabilizer switch. She started a treatment with lithium 1200 mg/day and olanzapine to 10 mg/day and was completely recovered. After a year of stabilization, olanzapine was retired and she maintained stabilized with lithium 1000 mg/day during last 17 years. During last 8 months, she suffered polydipsia and polyuria (4 L/day). She was diagnosed of nephrogenic diabetes insipidus. Some measures like liquid restriction, lithium monodose and low sodium diet were carried out, obtaining a partial response. Taking into account, she was stabilised with lithium for many years, it was decided to introduce hydrochlorothiazide 25 mg/day, clinical and analytical resolution of nephrogenic diabetes insipidus was obtained. A year later, she maintains psychopathological stabilization, without any lithium secondary effects. Conclusion Some treatment options for lithium-induced nephrogenic diabetes insipidus could be introducing thiazides, amiloride, indomethacin, desmopressin or carbamazepine, instead of withdrawal lithium. [ABSTRACT FROM AUTHOR]

Introduction Tobacco is a source of mineral elements that can affect human health in various ways, such as lithium, which is used as a psychiatric medication. Lithium salts are used as mood-stabilizing drugs and indicated in the treatment of manic-depressive psychosis. Objective Studying the lithium content in tobacco over the smokers’plasma content and evaluate the potential role of lithium in tobacco addiction. Methods A total of 18 different tobacco products (cigarettes, smokeless and water pipe tobacco) and 125 plasma samples (45 from smokers, 10 from ex-smokers and 70 from non-smokers) were collected to determinate the lithium content. Tobacco samples were digested with nitric acid and lithium concentration was measured by inductively coupled plasma-optical emission. The collected plasma samples were diluted 1/10 with a nitric acid solution and the lithium level was measured by inductively coupled plasma-mass spectrometry. Results The average concentration of lithium in the cigarettes (16.59 ± 0.59 μg/g) was higher compared to those in the smokeless tobacco (8.39 ± 4.44 μg/g) and in the water pipe tobacco (6.13 ± 6.32 μg/g) but with no significant difference ( P = 0.182). For plasma lithium levels, there was no significant difference ( P = 0.186) between smokers and non-smokers (6.20 ± 6.24 vs. 4.98 ± 6.20 μg/g). However, a significant negative correlation was noted between plasma and the lithium content in tobacco products ( r = –0.435; P = 0.04). The lithium plasma level was significantly and negatively correlated with the dependence score ( r = –0.316; P = 0.031). Conclusion The correlation between plasmatic lithium and dependence score in smokers suggests that lithium would be involved in tobacco addiction probably through his regulating action of mood. [ABSTRACT FROM AUTHOR]

Introduction Lithium is among the most effective therapies for bipolar disorder. Lithium treatment may cause hypothyroidism, goiter or to a lesser extent hyperthyroidism, since it can affect several aspects of thyroid functioning. The prevalence of lithium-associated hypothyroidism varies extensively between studies, reaching up to 47%, and affecting more females than males (5:1). Objective Determine the prevalence of thyroid dysfunction in an acute inpatient psychiatric department dedicated to affective disorders and its association with lithium therapy. Aims To review the relation between lithium treatment and thyroid dysfunction. Methods Observational, descriptive and retrospective study with clinical and laboratorial data concerning all inpatient episodes of 2015 in our Psychiatric Department. A non-systematic literature search was performed in PubMed. Results The present study documented a high prevalence of thyroid dysfunction, particularly in women. Most cases were due to either hypothyroidism or subclinical hypothyroidism. Patients treated with lithium were more often under thyroid hormone replacement therapy (levothyroxine). Conclusions The evidence that lithium treatment is associated with hypothyroidism is well established and this condition is easily treatable with levothyroxine. This study highlights the importance of baseline screening of thyroid function and regular long-term monitoring in patients treated with lithium. [ABSTRACT FROM AUTHOR]

The Kleine–Levin syndrome (KLS) is characterized by periodic, sudden-onset episodes of hypersomnia, compulsive hyperphagia, and behavioral–emotional symptoms, lasting from a few days to a few weeks, with complete remission in the intercritical periods. We report on efficacy of lithium treatment in a highly recurring form of the disorder in a 17-year-old male adolescent. The decreasing severity of the disorder paralleled the progressive increase of lithium dosage, up to 0.9 mEq l–1. Implications regarding the pharmacological treatment of this neglected disorder are discussed. [Copyright &y& Elsevier]

Objectives Lithium is a drug which may cause thyroid dysfunction. The most widely known dysfunctions associated with long-term lithium treatment are goiter and hypothyroidism. Lithium associated thyrotoxicosis is however uncommon. This current review explores the common mechanisms of lithium induced hyperthyroidism. Methods A systematic review of database was made using PubMed. The search keywords used were lithium therapy, thyroid side effects, thyroid dysfunction mechanism, hyperthyroidism, thyrotoxicosis. Results Lithium induced hyperthyroidism is uncommon, the incidence rate varying from 0.1% to 1.7%. The mechanisms of lithium associated hyperthyroidism are uncertain. Recent studies have proved that high proportion of investigated patients experienced transient thyrotoxicosis and painless thyroiditis. Different mechanisms have been discussed, including autoimmune inflammation, direct cellular destruction, susceptible individuals with preexisting Grave’s disease, a rebound effect of lithium therapy interruption… The pathogenesis of painless thyroiditis is unclear but different studies suggest a possible direct toxic effect of lithium on the thyroid gland. Lithium stimulates thyroid autoimmunity: lithium treated patients presented more positive antithyroid peroxidase antibodies than not lithium treated patients. This could be explained by an increased activity of B-cell lymphocyte activity and reduced ratios of suppressor to cytotoxic T-cell lymphocyte. Conclusion Long term lithium treated patients should be monitored for the development of thyroid dysfunction. It’s recommended to perform thyroid function test, thyroid antibodies and thyroid ultrasonography with a closer follow-up for lithium-treated patients with thyroid antibodies, or family history of thyroid disease. [ABSTRACT FROM AUTHOR]

Introduction: The aim of the study is to provide information about lithium effectiveness and safety in the treatment of very old patients with mood disorders. Subjects: All patients aged ≥75 years attending our private practice in the past 10 years. Results: We treated 183 subjects aged ≥75 years. 25 were in the lithium group and 138 in the no-lithium group. Bipolar disorder diagnosis and history of previous suicide attempts were more frequent in the Li group. Mean duration of lithium treatment was 31.3 ± 35.0 months. Mean daily dose of lithium was 390 (± 178.5) mg. Treatment with lithium was associated with better Clinical General Impression-Improvement scores than other psychopharmacological treatments. Rates of discontinuation were not significantly different between lithium and other treatments. In no patient, hypothyroidism or renal failure were major clinical problems.T4 treatment (a proxy for hypothyroidism) was prescribed to 8 (32%) of lithium-treated patients. Lithium was withdrawn in 6 (24%) patients. The reasons for the suspension of lithium were: [1)] Unproven effectiveness of the drug for the individual patient. [2)] Occurrence of serious cardiac or renal disease, independent of the use of lithium. [3)] Erratic and unpredictable metabolism of lithium in the very elderly. [4)] Poor compliance (two cases). [5)] Age related spontaneous mitigation of the disease. Discussion: Lithium can be valuable in the treatment of elderly patients, with adequate precautions. Elderly patients require lithium dosages that are 25 to 50% lower than those used in younger individuals. A single bedtime dosing regimen is recommended. [ABSTRACT FROM AUTHOR]

Objective: Women with a history of bipolar disorder or postpartum psychosis are at extremely high risk of relapse postpartum. Although lithium prophylaxis has demonstrated efficacy in reducing postpartum relapse, the timing of prophylaxis remains controversial. Here we evaluate the use of lithium during pregnancy compared to initiation postpartum in women at high risk for postpartum psychosis. Method: In total, 76 pregnant women at high risk for postpartum psychosis were referred to our psychiatric outpatient clinic between 2003 and 2010. Women who were medication-free at the time of initial evaluation were advised to start lithium prophylaxis immediately postpartum. In contrast, women already on maintenance lithium during pregnancy were advised to continue this treatment. Results: All women with a history of psychosis limited to the postpartum period (PP, n=30) remained stable throughout pregnancy despite being medication-free. In contrast, 23.9% of women with a history of bipolar disorder (BD, n=46) relapsed during pregnancy, despite the majority using prophylaxis throughout pregnancy. Postpartum relapse was highest in women with BD who experienced mood episodes during pregnancy (63.6%). Remarkably however, none of the 21 women with PP using postpartum prophylaxis relapsed, compared to 44.4% of PP patients who declined lithium prophylaxis. Conclusions: We recommend initiating prophylactic treatment immediately postpartum in women with a history of psychosis limited to the postpartum period, offering an important clinical advantage by avoiding in utero fetal exposure to prophylactic medication. Additionally, patients with BD require continuous prophylaxis throughout pregnancy and the postpartum period to effectively reduce their peripartum relapse risk. [ABSTRACT FROM AUTHOR]

Introduction: It has been shown that new antipsychotics (NAP) olanzapine or aripiprazole in combination with valproic acid or lithium are safe and improving the efficacy of the treatment of manic episode, and the mood stabilizing therapy in bipolar disorder (BD). NAP have less potent antidopaminergic action, and lover risk of Neuroleptic Malignant Syndrome (NMS) than typical antipsychotics. Case description: 59 years old male, with recent history of cognitive impairment, and long history of BD treated with combination of valproic acid, lithium and olanzapine was admitted to the hospital with acute manic episode. Because of ineffectiveness of the recent treatment there was added aripiprazole (15mg/d) followed by slow reduction of olanzapine. After following 3 weeks the clinical symptoms of lithium intoxication, and the raising blood level of lithium (1,47mmol/l) were observed, although the oral dose of lithium was not changed. The symptoms of intoxication disappeared during 10 days after lithium discontinuation. However, after the next 8 days of the treatment with aripiprazole combined with valproic acid - the NMS symptoms rapidly emerged and were lasting for 12 days Comment: We have found in the literature description of NMS in the patient on aripiprazole combined with lithium, and in the patient with mental retardation treated with aripiprazole added to olanzapine. Our presentation reveals increased risk of toxic interactions between lithium and the new antipsychotic Aripiprazole, as so the possible role of neurobiological deficits as risk factors of NMS. [ABSTRACT FROM AUTHOR]

Introduction: Lithium is a widely used pharmacological agent with efficacy in the management of affective disorders. Lithium has a narrow therapeutic range with a clear propensity to cause toxicity. Optimisation of safe lithium use mandates knowledge of the clinical features of lithium toxicity, drug interactions and other risk factors/clinical situations that may precipitate toxicity. Such knowledge may facilitate reversal or minimisation of risk factors. Aims: Evaluate current levels of safe prescribing and monitoring of lithium with focus on clinical areas aforementioned. Objectives: Ascertain current safety standards of lithium use and subsequently deliver clinical sessions concentrated on knowledge deficits identified in the audit hence maximising safety for our patients. Methods: This audit devised a local standard for safe prescription and monitoring of lithium via consulting the pharmacy department, BNF and NICE guidelines 2006. A random sample (n=50) of medical and nursing staff involved in the care of patients on lithium therapy was obtained. Three four-item multiple choice questions were devised for medical and nursing staff with distinct questions for each discipline focusing on important clinical situations and risk factors in lithium use. The audit was anonymous but details were collected on the healthcare role and level of training. Participants also selected their level of confidence for answering each question on a five item scale. Results: Data processing is underway for this audit however at this preliminary stage important trends indicating opportunities to improve clinical knowledge and practice are identifiable. Conclusions: Conclusions will be made once data processing is complete. [ABSTRACT FROM AUTHOR]

Patients with major depressive episodes require effective treatment to reduce depressive symptoms and improve functional disability. Various alternative treatment strategies have been proposed for non- or partially responsive depressions in unipolar and bipolar disorder. However, achieving an adequate response in patients with MDD continues to be a challenge. Possible treatment strategies for patients with a depressive episode who are non-responsive to an adequate trial of any antidepressant treatment strategy include switching, combination with another antidepressant with a different mechanism of action, or augmentation with a non-antidepressant drug. Augmentation options include lithium, anticonvulsants, and the thyroid hormones, triiodothyronine, T3, and levothyroxine, T4. Add-on lithium as the first-choice augmentation strategy in treating patients with resistant depression is currently the most well-documented augmentation strategy, with more than 30 open-label studies and 10 placebo-controlled studies in the acute treatment of depressive episodes, and has been shown to augment the therapeutic effects of a broad spectrum of antidepressants. More recently, attention has turned to the atypical antipsychotics, e.g. aripiprazole, olanzapine, risperidone and quetiapine. Several controlled studies show favourable outcomes of augmentation treatment with these antipsychotics in unipolar and bipolar depression. [ABSTRACT FROM AUTHOR]

Introduction: Neuroprotective effects of lithium have been well documented in tissue cultures and animal models. The evidence for lithium related neuroprotection in human subjects is limited and inconsistent, likely due to methodological heterogeneity. Aims: To investigate the effects of lithium on brain chemistry and structure, we recruited bipolar patients selected for substantial illness burden and varied the exposure to lithium by using strict inclusion criteria. Methods: We obtained 1.5T magnetic resonance imaging data from 27 bipolar patients with at least 2 years of ongoing lithium treatment (Li group), 16 subjects with < 3 months lifetime exposure to lithium >2 years ago (non-Li group) and 21 healthy controls. Patient groups had to have at least 10 years of illness and 5 episodes. Results: The non-Li group had significantly lower hippocampal volumes (t=4.68,corrected p<0.05) and prefrontal cortex N-acetyl aspartate (NAA) levels (t=−2.91,corrected p<0.05) than controls, who showed comparable hippocampal volumes and NAA levels to the Li treated subjects. Duration of illness was negatively associated with NAA levels only in the non-Li, but not the Li group. Conclusions: Among patients selected for substantial illness burden, only those with no or minimal lifetime Li exposure had significantly lower prefrontal NAA levels and hippocampal volumes than controls. Patients with at least 2 years of ongoing Li treatment showed no such changes, despite substantial burden of illness. These findings provide indirect support for neuroprotective effects of lithium and negative effects of illness burden on brain chemistry and structure in patients with bipolar disorders. [ABSTRACT FROM AUTHOR]

Introduction: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzyme deficiency worldwide. In this condition acute hemolysis is caused by exposure to an oxidative stressor in the form of an oxidative drug, an infection or aliments. G6PD deficiency can be associated to different psychiatric conditions, but little is known about the risk of acute hemolysis in G6PD deficient patients that are treated with antipsychotics and mood stabilizers. Aims: A clinical description is presented in order to illustrate the possible risk of acute hemolysis with Lithium therapy in a G6PD patient. Methods: A 33 years old male of hispanic origin and a G6PD enzyme deficiency was admitted presenting a first episode of mania. Lithium treatment was initiated. The patient was clinically examined daily. Extensive laboratory evaluation was performed, including complete blood cell count, liver, renal and thyroid function tests, serum electrolytes and glucose levels, urinalysis, lithium blood dosage. Neuroimaging studies were also performed excluding secondary causes of mania. Results: At J7 of lithium therapy the patient presented with jaundice and a blood count revealed a drop in the number of red blood cell (from 3,42 T/L to 2,42 T/L) with an increase of bilirubin (87,2umol/l) which revealed an episode of acute hemolysis. Lithium therapy was discontinued immediately. Red blood cell count continued to drop for another 7 days and returned to normal after 2 weeks of discontinuation of Lihium therapy. Conclusions: Lithium might be a trigger of acute hemolysis in bipolar patients with G6PD deficiency associated. [ABSTRACT FROM AUTHOR]

Introduction: Superiority of asenapine vs placebo, as monotherapy or adjunctive therapy to lithium or valproate, for acute bipolar mania has previously been reported. Objective: Present meta-analyses of asenapine compared with atypical antipsychotics based on placebo-controlled trials. Aim: Further demonstrate the efficacy of asenapine for acute bipolar mania. Methods: The primary endpoint was change from baseline vs placebo on Young Mania Rating Scale (YMRS) total score at treatment week 3. Data for asenapine (5 or 10mg BID) and comparators were obtained from all monotherapy (n=20) or adjunctive treatment trials in patients showing incomplete response to lithium or valproate monotherapy (n=10) published at the time of the analysis. Meta-analyses used a random-effects model described by DerSimonian and Laird (Control Clin Trials 1986;7:177–188). Results: Treatment effects varied substantially across agents and for individual agents across trials. For monotherapy, the change from baseline in YMRS total score with asenapine exceeded placebo by 4.5 points (95% CI, 2.5–6.4; p<0.0001); this was comparable to the treatment effect of all comparators vs placebo (4.9 points; 95% CI, 3.8–6.0). The treatment effect for adjunctive asenapine exceeded placebo by 2.4 points (95% CI, 0.5–4.3); this was also comparable to the overall treatment effect for the combined comparators (2.7 points; 95% CI, 2.0–3.3). Discussion: These meta-analyses demonstrate statistical superiority of asenapine over placebo, as monotherapy or adjunctive therapy, for acute bipolar mania. Further, they reveal that the efficacy of asenapine is similar to that of other atypical antipsychotics used as monotherapy or adjunctive therapy. [ABSTRACT FROM AUTHOR]

Introduction: Allied mental health services play important role in patients’ care in Learning Disabilities as they are more in contact with the patients. Their knowledge about common side effects of medication and relevance of routine blood investigations help Clinicians to provide appropriate care and support. Objective: To ascertain the knowledge of Allied mental health services about common side effects of medication and relevance of routine blood investigations. Methodology: Survey questionnaire was distributed to staff between November 09 and January 10. The questions included about the common side effects of Lithium, Insulin, High dose Antidepressants, High dose Antipsychotics and Anticoagulant Medication. Relevance of Routine Blood Tests and Blood Pressure Monitoring were also asked. Number of questionnaire distributed - 60. Number of Respondents -30. Responses were collected anonymously. Results: Respondent Classification -Registered Nurses- 4, Nursing Assistants- 12, Care Assistants- 10, Associate Practioner- 1, Deputy Charge Nurses- 2, Occupational Therapist -1. Of the Registered Nurses, Associate Practioners, Deputy Charge Nurses the results were 100%. With the Nursing Assistant- 25% (3), Care Assistant- 10% (1) and OT was aware of Routine blood tests and BP. The Nursing Assistants and Care Assistants were aware of one side effect for Lithium, Clozapine, Anticoagulants and Insulin. They were not aware of side effects of High dose Antidepressants & High dose Antipsychotics. The awareness of relevance of Routine Blood Tests and Blood Pressure Monitoring was 80% and 90% respectively. Conclusions: Arrange educational meetings to the Support workers Conduct the survey in a year''s time [Copyright &y& Elsevier]

Introduction: Many authors support the idea that Mood Incongruent Psychosis is a subtype of affective illness, although no clear definition or etiopathogenic basis of the congruent or incongruent subtype has been found. Aims: In this study we intend to evaluate clinical and biological differences between Psychotic Bipolar I patients who have mood congruent or mood incongruent psychotic symptoms. Methods: The study has been carried out in 80 Psychotic Bipolar I Patients before, and after, four weeks of treatment with Olanzapine plus Lithium. We studied the correlation between the plasma concentration, before treatment, of the dopamine metabolite 3,4 Dihydroxyphenylacetic acid (DOPAC) and the clinical response to treatment. Results: The most remarkable result found was that Clinical Improvement after 28 days of treatment correlated positively with the initial concentration of DOPAC, but ONLY in the subgroup of patients with congruent psychotic symptoms. Conclusions: From our results it seems that the Congruence and Incongruence of psychosis in bipolar I patients can provide a basis to objectively divide these patients. Both groups can be distinguished based on the relationship established between their concentration of DOPAC before treatment and their clinical response to the pharmacological treatment. Supported by: Universidad del País Vasco Grant N° EHU 09/21 and Fondo de Investigación Sanitaria and Feder Founds Grant N° 09/01760. [ABSTRACT FROM AUTHOR]

The concept of polypharmacy has generated much argument and this is has now come to a head with specific symposia and now a CINP thematic meeting. Briefly, those in academia, pharmacy and general adult practice tend to frown on this whereas the forensic members rely on it. Steven Stahl has even famously called it “the dirty little secret”. More recently the concept of rational polypharmacy has arisen where the clicinician can justify his prescriptions. All of this depends on treating a named condition eg schizophrenia. Indeed affective disorders are often treated with polypharmacy and many physical conditions are routinely given polypharmacy. If we assume that Kraepelin was wrong about his original assertion that there is a schism and whether other conditions are also not proven like personality disorders, then patients can simply be treated by their symptoms without a diagnosis. There are many advantages to this like the abolition of stigma but more importantly this allows the use of traditional drugs used for other conditions like lithium or anti manic agents to be used as required according to response rather than for specific diagnoses. There are other advantages eg in research and especially genetics. The presentation examines this in detail with some real life examples. [ABSTRACT FROM AUTHOR]

Objectives: Driving is a daily activity for most people in developed countries and is important in maintaining independence. Bipolar patients may have an impaired driving behavior because of the pathology itself, with psychomotor and cognitive disturbances. Additionally, adverse effects of pharmacologic treatment may be detrimental. Methods: 24 remitted bipolar outpatients diagnosed according to ICD-10 criteria were enrolled in the study, receiving either lithium (n=12) or lamotrigine (n=12). Participants were investigated under steady state plasma level conditions. According to the German Guidelines for road and traffic safety data were collected with the Wiener Testsystem (WTS) measuring visual perception, reactivity, stress tolerance, concentration and vigilance. Psychopathologic symptoms were rated with the Montgomery-Asberg Depression Rating Scale (MADRS) and the Young Mania Rating Scale - Clinician rated (YMRS-C). Results: About 40% of patients were without clinically relevant psychomotor disturbances. In 40% of cases mild to moderate impairments could be seen, and 20% of the patients were considered as severely impaired. Data show that patients under lamotrigine had an altogether better test performance than patients treated with lithium. Especially in visual perception and stress tolerance differences were most pronounced. Conclusions: About 20% of remitted bipolar outpatients treated with lithium or lamotrigine must be considered unfit to drive. In 40% of the cases it seems justified to counsel patients individually, taking into account compensational factors. Analysis of our data point to an advantage for bipolar patients treated with lamotrigine when compared with lithium. However causal relationships can not be drawn from our data. [ABSTRACT FROM AUTHOR]