Norfolk lithium database
Stephen Bazire
Chief Pharmacist
Norfolk and Waveney Mental Health
NHS Foundation Trust
Hon Prof, School of Pharmacy, UEA
Famous people thought to have
had bipolar disorder
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Adam Ant (musician)
Frank Bruno (sportsman)
Lord Byron (writer)
Winston Churchill (politician)
Kurt Cobain (musician)
Ray Davies (musician)
Charles Dickens (writer)
Ernest Hemingway (writer)
Linda Hamilton (actor,
Terminator)
John Keats (writer)
Otto Klemperer (musician)
Paul Merton (comedian)
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Spike Milligan (writer and
comedian)
Marilyn Monroe (actress)
Florence Nightingale (nurse)
Edgar Allan Poe (writer)
Axl Rose (musician)
Robert Schumann (musician)
Tony Slattery (comedian and
actor)
Robert Louis Stevenson (writer)
Mark Twain (writer)
Vincent van Gogh (artist)
Tennessee Williams (writer)
Virginia Woolf (writer)
Prof. Kay Redfield Jamison
“Lithium moderates
the illness but
therapy teaches
you how to live
with it”
Prof. Kay Jamison 1995
Bipolar spectrum
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Bipolar I (classical manic-depression)
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Bipolar II
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Mania and severe depression or mania alone
Mean age of onset 21, peak 15 - 19 years
0.8% US adults
depression with at least one hypomanic episode
0.5% US adults, slight gender difference (F > M)
May be genetically distinct from Bipolar I
Bipolar III (Pseudounipolar Bipolar Disorder)
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Recurrent depression and mixed states
antidepressants may induce hypomanic switching and/or
mixed states
Bipolar disorder is multidimensional
Mania
Sub-syndromal mania
(hypomania)
Mania
Remission
Subsyndromal
depression
Depression
Acute and maintenance
drug therapy
Licensed and widely used as
mood stabilisers:
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Lithium
Carbamazepine (non-response
to lithium)
Olanzapine (manic episode)
Licensed for mania/hypomania
and relapse prevention
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Valproate semisodium
Antipsychotics
Quetiapine
Olanzapine
Risperidone
Acute and adjunctive
treatments:
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Antipsychotics
Benzodiazepines
Antidepressants
Unlicensed/being investigated:
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Lamotrigine (bipolar depression)
Gabapentin
Topiramate
Other atypicals including risperidone
and clozapine
Calcium-channel blockers
Cannabis
Lithium - the gold standard
Cade JFJ, Lithium salts in the treatment of psychotic
excitement Med J Aust 1949;36:349-52
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Effective in mania
Reduces number of relapse
Reduces severity of relapses
Reduces mortality
Reduces suicide
Reduces incidence of Alzheimer’s Disease
Putative therapeutic plasma range
Plasma levels
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Prophylactic therapy plasma levels 0.40.8mmol/L
Analysis of RCTs by NICE revealed that:
 0.6-1.0mmol/L had lowest relapses
 0.4-0.6mmol/L higher level of relapse
 Generally higher levels needed in acute mania
POMH-UK audit showed monitoring was poor
across the UK
The risks of not monitoring
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102 litigation claims involving
lithium prescribing and monitoring
53 due to inadequate monitoring
 13 deaths (suicides excluded)
 7 cases of renal failure
 6 cases of neurological sequelae
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(MDU November 2003)
Norfolk lithium database project
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Norfolk-PCG/NMHC Clinical Liaison group
2000
Prescribing sub-group
Lithium prescribing and monitoring:
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Initial prescribing and monitoring responsibilities
Variations in therapeutic plasma levels quoted
between N&N and JPH
Inconsistent approach to continuing monitoring
Issuing guidelines doesn’t work
Eagles et al, Acta Psychiatr Scand 2000, 101, 349-53
Lithium monitoring
- Norfolk and not very good
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Lithium guidelines existed but not widely followed
Survey showed poor monitoring against Royal College
of Psychiatrists guidelines (except Coast)
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Norfolk & Norwich Pathology lab one-year survey
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Surgeries showed huge variation
32% of patients had only had one level
less that 30% of patients had adequate monitoring
Shared care responsibility not recognised
Plasma levels quoted
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JPH 0.4-0.8mmol/L, N&N 0-1.0mmol/L
If you want a job done
properly, do it yourself…
Norfolk-wide lithium database was set-up to:
 Maintain register of all people taking lithium
in Norfolk
 Send blood test reminders to all patients
every 3 months
 Send up to three reminders
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third alerting the GP directly
Ensure adequate information, education &
access to specialist advice
Be integral with a full shared-care agreement
Shared care
agreement
showing secondary
and primary care
responsibilities
It is the GP’s
responsibility to act
should a plasma
level by out of
range after
stabilisation
Standard process of Norfolk
lithium database
11 wkly recall letter
& blood form
Yes
Yes
Test?
No
2nd reminder
& blood form
Test?
No
GP ALERT
& Recall 3
Letters sent out each week
Registration
 Welcome and
consent
 4-week consent
 12-week consent
 26-week
* average 2002-2010
7
2
1
0
Blood reminder
letters
 13-week
87
 17-week
17
 GP alert
5
Outcomes
(Lithium database started in 2002)
Tests per
year
n=
1999
2003
2004
2009
1457
1283
1249
1288
3+
46%
79%
77%
81%
2
22%
13%*
16%*
1
32%
8%*
7%*
0
??
0.5%
* Includes new starters and discontinuers
Structure
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Based in Pharmacy at Hellesdon
hospital
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Covers Trust catchment area
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Run by 0.8wte Band 5 plus cover
Norfolk and NE Suffolk
Programme is at the limits of capacity
NPSA Alert December 2009
1. Monitoring according to NICE Guidelines
2. Reliable systems for test results between
labs and prescribers
3. Initiation with appropriate verbal and
written information
4. Blood tests monitored regularly, no repeats
without safety assured
5. Systems to detect interactions
To be implemented by December 2010
Could Norfolk system be
extended?
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Currently no
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Current database uses Access, no further
capacity
Could be considered with web-based
system if rewritten
Post-PHEN/Waltham Abbey
meetings update (1.7.10)
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NWMHFT has allocated funds to commission P1 (software
company in Norwich, maintains current database) to
formulate proposals and options:
Draft Specification and vision
Options include:
1.
2.
3.
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Database programme written that PCTs/Trusts could purchase
and run themselves
NWMHFT runs national data collection from Path Labs, local
PCTs/Trusts access that and send own reminders out
NWMHFT runs everything, with contact person locally
Due to report back to PHEN (Eastern Region Chief
Pharmacists/Prescribing Advisors Network) on 20.7.10
Some issues being considered
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Confidentially
Continuity
Would PCTs or mental health Trusts run this?
Would still need a contact person locally (at least initially) to
roll-out implementation
Accessing and updating changes in GPs
That for each PCT/Trust, there will be patients getting blood
tests done at Path labs in different PCTs
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Makes tracking all patients difficult
e.g. some patients from the edges of Norfolk get bloods done in
Ipswich and Bury St Edmonds
Would make a national/regional data source more efficient
Stephen Bazire 1.7.10