Lithium continues to be the preferred method of maintenance monotherapy in older adults with bipolar disorder (OABD), according to a Delphi survey published in Bipolar Disorders. Although the numbers and proportion of OABD are growing, there are limited guidelines for lithium use, despite its potential for toxicity and ineffectiveness.

To determine the status of lithium among preferred options for maintenance treatment of OABD, as well as to provide clinical guidelines for safe and effective use of lithium in this population, researchers used a Delphi survey method. A total of 25 experts in OABD from 9 countries reached a consensus under the guidance of an oversight committee that monitored and analyzed the survey results, creating more focused questions in subsequent versions.

Over the course of 3 iterations of the survey, there was a 100% response rate. Data revealed that lithium was, in fact, the preferred choice for maintenance monotherapy. Serum levels of 0.4 to 0.8 mmol/L for patients aged 60 to 79 years and 0.4 to 0.7 mmol/L for patients aged 80 years and older are recommended. In addition, the researchers provided specific guidelines for routine monitoring of lithium in OABD for laboratory investigation and clinical assessment.

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Investigators note that the first-line therapeutic options to combine with lithium for maintenance in OABD are lamotrigine, quetiapine, and valproate. Second-like options for monotherapy for OABD are lamotrigine, olanzapine, quetiapine, and valproate.

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Researchers conclude that “Laboratories should report the therapeutic range for serum levels of lithium separately for older adults.” The proposed guidelines for OABD may help to mitigate the decline in lithium prescriptions in recent years and provide specific guidance to clinicians on bet practices for effective and safe OABD maintenance treatment. Researchers add that other possible choices for mood stabilizers carry their own risks, and although they recommend lithium, it “is not necessarily the best option for all OABD and clinicians must continue to make individualized choices based on multiple factors.”


Shulman KI, Almeida OP, Herrmann N, et al. Delphi survey of maintenance lithium treatment in older adults with bipolar disorder: An ISBD task force report [published online October 30, 2018]Bipolar Disord. doi: 10.1111/bdi.12714