1. NICE: mood stabilizers as prophylaxis
   1. 1. After 1 MANIC episode with sig risk and adverse conseq
   2. 2. BIPOLAR I : >=2 acute episodes
   3. 3. BIPLOAR II : sig Fn impair, sig risk of suicide, freq episodes
2. MONITORING
   1. PLASMA LEVELS
      1. 0.6-1.0 mmol/l
      2. children and adolescent req higher level
      3. MONITOR WEEKLY UNTIL LEVEL IS REACHED, 12 hr post dose
   2. BEFORE STARTING
      1. ECG , TFT, RFT, U&E
   3. MONITORING
      1. PLASMA LEVELS q 3/12, U&Es and TFTs q 6/12
3. MOA
   1. Blocks neuronal calcuim channel
   2. GABA pathways
4. INDICATIONS
   1. BIPLOAR DISORDER
      1. -NICE recom as FIRST LINE MOOD STABILIZER
      2. PROPHYLAXIS : reduces both no. and severity of relspses
      3. NNT to prevent relapse of Mania=10, Deprn=14
      4. Protects against ANtideprn induced hypomania
      5. Relapse within 1 yr of starting prophylaxis is highly suggestive of a poor long term response
      6. PATTERN OF ILLNESS THAT PREDICTS GOOD RESPONSE = MANIA-->DEPRN -->EUTHYMIA OR IRREGULAR PATTERN
      7. POOR IF DEPRN -->MANIA --> EUTHYMIA OR RAPID CYCLING
      8. Intermittent treatment worsens natural course
      9. REDUCES MORTALITY FROM SUICIDE (which is otherwise 15%), incidences of self harm are also reduced
   2. DEPRESSION
      1. NICE recom as ANTIDEP AUGMENTATION IN UNIPOLAR DEPRN
      2. Prophylaxis in RECURRENT DEPRN
   3. OTHER INDICATIONS
      1. MANIA - takes a week to achieve response
      2. SCHIZOAFFECTIVE - with antipsychotics
      3. AGGRESSIVE AND SELF MUTITILATING BEHAV
      4. STEROID INDUCED PSYCHOSIS
5. ADR
   1. Initial, mild , transient
      1. GIT upset, FINE hand tremor (Rx PROPRANOLOL), mild thirst and polyuria
   2. LONG TERM
      1. HYPOTHYROIDISM
         1. RX: THYROXINE REPLACEMENT
         2. Higher in middle aged women ~20%
         3. CHeck for Thy AutoAb
         4. NO NEED TO STOP LITHIUM
         5. HYPERPARATHYROIDISM
      2. NEPHROTOXICITY
         1. benign effect in majority
         2. INTERSTITIAL NEPHRITIS
         3. NEPHROGENIC DI - may be irreversible after ~>15 yr Rx
      3. "curbs creativity"
   3. TOXICITY
      1. >1.5
         1. GIT (anorexia, nausea, diarrhoea) / CNS (muscle weakness, drowsiness, ataxia, COARSE TREMOR, muscle twitching
      2. >2
         1. disorientation --seizures -- coma -- death
         2. Rx- osmotic diuresis or forced alkaline diuresis
         3. THIAZIDE OR LOOP DIURETICS
      3. >3
         1. PERITONEAL OR HEMODIALYSIS
6. DRUG INTERACTIONS
   1. DIURETICS
      1. Inc serum level of LITHIUM
      2. THIAZIDES ARE WORST, LOOP are a bit better
   2. NSAIDS
      1. Inc level upto 40%, be careful with prn Rx, toxicity with COX 2 inhibitors
   3. HALOPERIDOL
      1. SEVERE NEUROTOXICITY
   4. CARBAMAZEPINE
      1. Neurotoxic , usually if levels of lithium are too high
   5. SSRIS
      1. CNS toxicity ( rare in clinical experience)
   6. ACE INHIBITORS
      1. Dec excretion of Lithium -->renal failure
      2. BE careful with Angiothesin 2 antagonists - losartan family