Understanding the Prevalence of Discontinuation
Lithium has long been a cornerstone treatment for bipolar disorder, praised for its efficacy in stabilizing mood and reducing suicide risk. However, its long-term use is associated with a significant rate of discontinuation. The reasons for stopping are multifactorial, stemming from both the drug's physiological effects and the patient's psychological relationship with their illness and medication. A Swedish cohort study found that over half of the patients treated with lithium discontinued it at some point. A deeper look at the various discontinuation triggers reveals common themes across patient experiences and clinical decision-making.
Adverse Physical Side Effects
Adverse physical effects are the most commonly cited reason for lithium discontinuation, prompting over 60% of cessation episodes in one study. These can be categorized based on their onset and severity.
Short-term and Common Side Effects
Many patients experience immediate or short-term side effects that can be intolerable. The five most frequent adverse effects reported include:
- Diarrhoea: One of the most common gastrointestinal complaints, often leading to early discontinuation.
- Tremor: Fine motor tremors, particularly in the hands, can be socially embarrassing and functionally impairing for patients.
- Polyuria/Polydipsia: Increased thirst and frequent urination are hallmarks of lithium use and can significantly impact a patient's quality of life, sometimes leading to a condition known as nephrogenic diabetes insipidus.
- Weight Gain: A notable percentage of patients discontinue lithium due to weight gain concerns, which can be particularly distressing for women.
- Nausea: This is often reported early in treatment as the body adjusts, and while it may resolve over time, many cannot tolerate the initial discomfort.
Long-term and Serious Health Complications
While some side effects are bothersome, others pose serious long-term health risks that necessitate discontinuation, often initiated by the treating physician.
- Renal Impairment: Long-term lithium use is associated with chronic kidney disease (CKD). Monitoring creatinine levels is essential, and a decline in kidney function is a significant reason for stopping treatment. In some cases, decline may continue even after discontinuation.
- Thyroid Dysfunction: Hypothyroidism is a relatively common and treatable side effect, but severe cases can lead to discontinuation, although typically thyroid hormone replacement is attempted first.
- Hyperparathyroidism: Lithium can cause an increase in parathyroid hormone (PTH) and calcium levels (hypercalcaemia). This adverse effect can lead to problems like kidney stones and requires careful monitoring.
Patient-Driven and Psychiatric Factors
Beyond physical side effects, a significant proportion of discontinuation is driven by patient perception, psychiatric symptoms, or other personal reasons.
Perceived Clinical Stability
Perhaps counterintuitively, a patient's feeling of being well is a leading reason for discontinuing lithium. Patients may mistakenly believe they are cured, leading them to stop the medication without medical guidance. This is particularly common among men. However, this decision significantly increases the risk of relapse and suicide attempts.
Psychological and Cognitive Effects
Lithium can cause adverse psychological and cognitive effects that patients find intolerable, including:
- Emotional Blunting: Some patients report feeling emotionally muted or that their creativity is inhibited, which can be particularly troubling for artists or other creative individuals.
- Cognitive Impairment: Complaints of fatigue, impaired concentration, and poor memory can lead to discontinuation, especially if patients feel it affects their professional or daily lives.
- Non-Adherence: Broader issues of non-adherence are also prevalent, driven by a dislike of medication, a wish not to be reminded of their illness, or a general resistance to treatment.
Comparison of Discontinuation Drivers
Discontinuation can be prompted by different parties for different reasons. The following table compares patient-driven and clinician-recommended factors.
| Factor | Patient-Initiated Discontinuation | Clinician-Recommended Discontinuation |
|---|---|---|
| Motivation | Feeling well, perceived side effects (minor), psychological resistance, inconvenience of daily medication | Severe or progressive medical complications, unmanageable toxicity, high risk of intoxication |
| Common Side Effects | Weight gain, emotional blunting, mild tremor, gastrointestinal issues | Significant renal impairment, thyroid or parathyroid issues |
| Treatment Insight | May reflect lack of insight into the illness or underestimation of the medication's importance | Based on objective medical monitoring and risk/benefit analysis |
Risks and Management of Discontinuation
Dangers of Abrupt Cessation
Regardless of the reason, abrupt lithium discontinuation should be avoided whenever possible. Rapid withdrawal is associated with a significantly higher risk of mood episode recurrence and an alarming increase in suicidal behavior. The rebound effect, where a swift return of symptoms occurs, can be more severe than the original illness.
Recommended Tapering Strategies
To minimize the risks, a slow, gradual tapering process is the recommended approach, typically over a minimum of 15–30 days, or even longer. This allows the body to adjust more gently. During this period, close monitoring for mood changes and potential relapse is critical, often accompanied by the introduction of alternative mood-stabilizing treatments.
The Importance of Shared Decision-Making
For any consideration of lithium discontinuation, shared decision-making between the patient and their healthcare team is essential. The discussion should weigh the proven benefits of lithium against the burdens imposed by side effects or other concerns. Reassuring patients that lithium can often be restarted successfully if needed can be an important part of this conversation.
Conclusion: Navigating Discontinuation Safely
Deciding to stop lithium is a major clinical decision, influenced by a blend of adverse effects, serious medical complications, and patient-driven psychological factors. While medication side effects, both common (tremor, weight gain) and serious (renal impairment), are leading reasons, patient perception and autonomy are also key drivers. Abruptly stopping lithium carries significant risks of mood relapse and increased suicidality, making a medically supervised, gradual taper essential. An open dialogue with a healthcare provider, weighing the individual's risk-benefit ratio, and considering alternative treatments is the safest pathway forward. By understanding the full spectrum of reasons, patients and clinicians can work together to achieve the best possible long-term health outcomes.
For more in-depth clinical discussion, consult The Lithium Handbook on lithium discontinuation.
