A patient with acute mania after discontinuation of lithium

The abrupt discontinuation of lithium in patients with bipolar disease puts the patient at a high risk for a relapse. Lithium is a drug with a narrow therapeutic index. Intoxications might occur during the treatment. The individual risk-benefit-ratio should be discussed with the patient before starting lithium. Atypical antipsychotics are an alternative to lithium in the treatment of bipolar disease. Several guidelines recommend the use of atypical antipsychotics in a long acting (depot) formulation in bipolar patients (off label use). The long acting (depot) formulations offer the benefit that during a hypomanic or a beginning manic episode, the drug can not easily be discontinued. During the phase of early signs of a beginning manic episode the patients tend not to see the need to take any medication (lack of insight into illness) which leads to non-adherence that puts the patient at a high risk for a manic episode. If lithium is prescribed, special counselling is needed, especially about fluid intake and potential drug interactions (NSAIDS, ACE-inhibitors, diuretics).