what teaching needs to be reinforced with lithium therapy?
Ment Health Clin. 2018 January; 8(1): 41–48.
Outcomes of patient education practices to optimize the safe utilise of lithium: A literature review
Monica Zolezzi, BPharm, MSc, ACPR, PhD, 
i Yassin Hassan Eltorki, RPh, MSc,2 Mahmoud Almaamoon, RPh, PharmD,three Mahmoud Fathy, RPh, PharmD,iv and Nabil East. Omar, RPh, PharmD5
Monica Zolezzi
1Banana Professor, College of Chemist's shop, Qatar University, Doha, Qatar; Clinical Pharmacist, Hamad Medical Corporation Mental Health Hospital, Doha, Qatar, aq.ude.uq@izzelozm
Yassin Hassan Eltorki
iiClinical Pharmacist, Hamad Medical Corporation Mental Health Hospital, Doha, Qatar
Mahmoud Almaamoon
3Pharmacist HMC, Pharmacy, Al Wakra Hospital, Doha, Qatar
Mahmoud Fathy
4Pharmacist HMC, Pharmacy, Al Wakra Hospital, Doha, Qatar
Nabil East. Omar
5Clinical Chemist, Hamad Medical Corporation–National Centre for Cancer Care and Enquiry Infirmary, Doha, Qatar
Abstract
Introduction:
Lithium is commonly used to treat various psychiatric disorders and is particularly effective in the maintenance phase of bipolar disorder. Unfortunately, this drug has a narrow therapeutic alphabetize and, if not monitored regularly, can result in toxicity. Therefore, for lithium to exist prescribed safely, clinicians must ensure that patients are well educated on lithium toxicity, its prevention, and symptom recognition. This commodity summarizes studies that investigated lithium education strategies to assistance promote the rubber utilize of lithium.
Methods:
Four electronic databases were searched using central terms and subject headings. Reference lists of relevant papers were also reviewed. The search was limited to literature published in English language, without year limits. Eligible studies examined lithium patient instruction and the affect on patients' knowledge of safe lithium employ.
Results:
Of a total of 517 citations that were retrieved from the electronic database search, 12 were selected for inclusion in this review. Most of the studies included assessed the outcome of lithium educational activity on various aspects of patients' knowledge, including but not limited to, lithium toxicity. Of the studies assessing the correlation between lithium knowledge and lithium levels, most demonstrated a positive correlation betwixt lithium cognition and lithium levels that were more stable and inside the higher end of the recommended therapeutic range.
Conclusions:
Studies evaluating lithium patient education and its upshot on improving the safe use of lithium are express. Nevertheless, this literature review highlights that lithium patient education is disquisitional to promote its safe use.
Keywords: lithium patient education, lithium safety outcomes, lithium toxicity
Introduction
Lithium is used to care for a multifariousness of psychiatric disorders and has demonstrated efficacy in the maintenance stage of bipolar disorder.1,2 Notably, lithium has multiple drug interactions, undergoes significant renal excretion, and has a narrow therapeutic window that, if not adequately monitored, can outcome in toxicity, even at doses considered to be therapeutic.iii Lithium toxicity has been divided into 3 categories: acute, acute-on-chronic, and chronic.4 Studies5,vi have shown that toxicity is more likely to result from chronic, therapeutic administration rather than from acute poisoning or overdose. Chronic and acute-on-chronic intoxication accept been suggested to be triggered by concurrent illness, drug interactions, or gradual aridity, resulting in reduced renal excretion of lithium.4,7 Toxicity associated with lithium maintenance treatment is prevalent; approximately 75% to ninety% of patients have reported signs and symptoms of toxicity at some point during their handling.viii Studies9-xi also suggest that the serious neurologic consequences of toxicity are usually in the context of chronic or astute-on-chronic administration of lithium. Prior to 1975, bloodshed ranged from ix% in patients who presented with toxicity from chronic poisonings to 25% in acute poisonings.10 These results probably overestimated mortality because of the presence of publication bias.xi More than recent data12,13 suggest bloodshed rates of equal to or less than 1%, perchance due to improved lithium therapy monitoring.
The literature2,8,9,11,14,xv recommending strategies to reduce lithium toxicity and its associated costs is extensive. Individualized prescribing, regular monitoring practices, and clinician's awareness of the associated risk factors, equally well equally patient instruction, accept been recommended. For lithium to be used safely, patients demand to be well aware of the features of lithium toxicity, and clinicians must provide this educational activity early during treatment initiation, as well as in a regular and consistent manner. Patient-reported instruments, such as the Lithium Knowledge Test (LKT) and the Lithium Attitudes Questionnaire (LAQ), accept been used to appraise patients' lithium cognition and compliance attitudes, which are important if therapy with lithium is to be rubber and effective.16,17 The LKT scores are obtained by adding up the responses to a total of twenty questions, whereas the LKT risk scores (LHS) are obtained by adding together the responses to the questions on symptoms of toxicity. Studies18-xx reveal that adequate lithium noesis (as assessed by LKT scores) is associated with shorter duration of treatment, younger age, and positive attitudes toward treatment with lithium. Intensifying patient pedagogy, particularly in older adults, seems to be an important strategy to potentially forbid lithium toxicity with chronic use.15
Many specialized lithium outpatient clinics, inpatient psychiatric services, and reputable Web sites provide information, psychoeducation, and brochures about lithium to patients.16,20,21 Studies15,22,23 have not only assessed patients' lithium knowledge and attitudes, but also correlated these with adherence, mood control, and therapeutic drug levels. This commodity summarizes studies evaluating the relationship between patients' lithium noesis and safer utilization patterns of lithium. Studies assessing the bear on of lithium educational strategies on toxicity-related outcomes are also reported.
Methods
For this review, a computerized search was conducted using PubMed Fundamental, MEDLINE, Embase, and Google Scholar databases, without year limits. In order to identify studies describing lithium patient education and the affect on patients' knowledge on safe utilise of lithium, the following key words were used: lithium instruction, lithium counseling, lithium toxicity, and lithium cognition. The initial screening of commodity titles and abstracts was conducted by one reviewer (M.Z.). Studies were selected for total review based on the following inclusion criteria: articles in English language language that depict a lithium patient pedagogy strategy or studies reporting any form of assessment of patients' knowledge on the safe employ of lithium. Manufactures were excluded if educational strategies were not focused on lithium condom or if the impact of lithium pedagogy was not evaluated. All review manufactures were also excluded. The full texts of all potentially relevant articles were retrieved and every bit distributed among 5 reviewers (M.Z., Y.E.T., M.A., K.F., N.E.H.) to confirm eligibility.
Results
Of the 517 citations identified in the initial electronic database searches, 52 full-text articles were retrieved to undergo a more comprehensive exam based on the inclusion/exclusion criteria. An additional 7 citations were identified through a review of the references of potentially relevant articles, for a total of 59 manufactures to be examined more thoroughly past the reviewers. As shown in the Figure, of the 44 articles that qualified for full review, 12 were included. Information in these 12 articles were independently extracted by the same 5 reviewers using a standardized information drove tool.
Flow diagram of the literature review process
The results of the 12 manufactures included in this review15,16,19,20,24-31 are summarized in Tables 1 and 2. As highlighted in Tabular array 1, eight of the 12 included studies16,20,24-26,29-31 examined the bear upon that educational strategies had on patients' lithium knowledge. Table ii summarizes the studies15,nineteen,27,28 that assessed lithium noesis without a lithium patient education intervention. A total of seven studies15,19,26,27,29-31 reported lithium levels equally toxicity outcomes.
TABLE ane
Studies assessing lithium (Li) noesis after the provision of Li education program
TABLE 2
Studies assessing lithium (Li) cognition without the provision of a Li educational activity programme
As summariazed in Table 1, a variety of educational strategies were described in these studies, including verbal and written advice, visual education via videos, and psychoeducation. The LKT (and the related LHS) was the preferred instrument used to assess patient knowledge almost lithium therapy and its prophylactic profile (in 8 of the 12 included studiesxv,16,19,20,25,27,29,thirty); however, in some studies,20,30,31 modified versions of the LKT were used.
In nigh studies15,19,26,27,29-31 included in this review (7 of 12), researchers investigated the correlations and/or associations of the patients' lithium noesis with lithium blood levels. In half dozen of these 7 studies15,19,26,27,29,30 it was concluded that lithium levels were more often than not more stable and within the therapeutic range in those individuals with higher lithium knowledge scores. However, not all studies reported an clan with decreased incidence of lithium toxicity or improved lithium tolerability.
Discussion
Current literature evaluating the relationship betwixt patients' lithium noesis, use patterns, and patient outcomes is scarce. Despite the availability of several validated questionnaires, such equally the LKT (and related LHS) and LAQ, patients' noesis of and attitudes toward lithium treatment and its associated risks appear to exist rarely evaluated using these tools.
None of the studies included in this review described educational strategies using engineering. This may exist explained past the fact that almost of the studies found on this topic are more than a decade old, when technology applications for this use were not yet widely available to consumers. In add-on, it has been reported that in mental health, these types of treatment innovations tend to be delayed, often related to the stigma that is prevalent in the provision of mental health services.32 In 2015, Hidalgo-Mazzei and colleagues33 described the development and planned validation of a smartphone awarding to monitor signs and symptoms of bipolar disorder, offer customized embedded psychoeducation contents, but validation of this instrument has not however been published. However, this blazon of educational strategy has already been shown to better handling outcomes in other chronic conditions, such equally diabetes and chronic obstructive pulmonary illness.34,35
In ane of the articles reviewed,24 reinforcement of information and the use of more i grade of lithium educational strategy showed a positive correlation with lithium knowledge scores. These results are consistent with like studies of educational strategies in other chronic diseases.36 Additionally, studies14,16,20,27 included in this review indicate that patient didactics strategies improve patients' knowledge of and attitudes toward lithium handling and contribute to patients achieving more than stable lithium levels. Some other report, by Tillery,37 showed improved lithium knowledge among wellness care providers after a lithium therapy educational activity programme was provided past clinical pharmacists. In this report, lithium levels were stable and maintained inside the therapeutic range in the patients beingness cared for by these clinicians. This study was excluded from this review because the lithium therapy educational activity programme was non aimed at patients and it did not appraise patients' lithium cognition. Pharmacist-run lithium clinics have been described in the literature, all of which highlight the important role of pharmacists in mental health, particularly with regard to patient instruction and therapeutic drug monitoring.27,38,39
The studies reviewed have as well elucidated that increasing age appears to accept a negative correlation with lithium knowledge. Some studies15,31 accept also demonstrated a positive correlation between historic period and adventure scores. These results are indicative that older patients may benefit from continuous reinforcement of information regarding lithium toxicity signs and ways to forbid toxicity.2,xv,xix,twenty,28,thirty,31 This was too highlighted for patients with learning disabilities and their care providers, and for those receiving lithium maintenance handling.15,25,31 Future enquiry should accost whether more than noesis does, in fact, foreclose adverse events and whether patient instruction can farther ameliorate knowledge, particularly in elderly patients, where other limitations (eg, cerebral impairment) might hamper educational efforts.xx
Conclusions and Recommendations
Lithium is an important medication for the treatment of serious mental illness. Withal, it is associated with potentially fatal toxicity considering of its narrow therapeutic index, renal elimination, and multiple drug-drug interactions. The nowadays review has identified several cardinal areas for the safe and responsible monitoring of lithium treatment, including:
- • Based on worldwide guidelines, skillful clinical management of patients with bipolar disorder involves an observable educational component for both patients and their relatives.2,40 Patients should receive written information reinforced with verbal advice before the outset dose of lithium is taken.2,21,forty It should be reinforced at the first lithium dispensary date and, when necessary, throughout the grade of their treatment.21 Patients currently on lithium therapy should withal receive this written and verbal advice.2,21,40
- • In social club to make lithium therapy safe, information must convey key letters, including:
-
-
What lithium is and what information technology is used for
-
Assessments needed before starting lithium
-
How to take lithium
-
Blood tests afterward a patient starts taking lithium
-
What side effects lithium can cause
-
What happens if the level of lithium is too loftier
-
What can make the lithium blood levels get too loftier
-
Actions to be taken if lithium toxicity is suspected
-
- • Lithium pedagogy is of detail importance in certain populations, such as the elderly, people with learning disabilities, patients on medications that can interact with lithium or increase the hazard of dehydration, and those receiving lithium maintenance treatment.2,15,25,40 Offering more regularly scheduled lithium pedagogy and refresher courses in these populations is advisable.
- • Educational strategies may all-time interpret into improved knowledge and improved awareness of lithium toxicity by the apply of a variety of interventions, written and verbal, imparted on a more regular ground (eg, at every iii-calendar month follow-up), not but before commencing treatment.2,21,40 Future directions should incorporate technology-based applications that tin can support and sustain the beneficial outcomes imparted by these educational strategies.
- • The knowledge imparted past educational strategies should be regularly tested to ensure they are effective in improving patients' cognition of and attitudes toward treatments. The use of the LKT and LAQ are validated tools that tin can provide an adequate cess of lithium education programs and to ensure that the necessary information has been retained past patients.
- • Pharmacists are valued members of the wellness care team with unique cognition and skills in pharmacokinetic management who are bachelor for consultation in most hospital settings, and who may provide pedagogy to other health care professionals not only in an inpatient psychiatric setting, but also in the community. Pharmacists working in outpatient settings are in a especially skillful position to exist educating on and assessing patients for lithium toxicity. Although educational material alone is unlikely to requite rise to changes in clinical practice, lithium-monitoring standards may exist improved through the involvement of a multidisciplinary squad and a more detailed provider education system.
References
1. Burgess South, Geddes J, Hawton K, Taylor M, Townsend E, Jamison Thou, Goodwin G. . Lithium for maintenance handling of mood disorders. Cochrane Database Syst Rev. 2001. 3: CD003013 DOI: ten.1002/14651858.CD003013. PubMed PMID: 11687035. [PubMed] [Google Scholar]
two. Goodwin GM, Haddad PM, Ferrier IN, Aronson JK, Barnes T, Cipriani A, et al. . Show-based guidelines for treating bipolar disorder: revised third edition recommendations from the British Clan for Psychopharmacology. J Psychopharmacol. 2016; xxx 6: 495- 553. DOI: 10.1177/0269881116636545. PubMed PMID: 26979387. [PMC costless article] [PubMed] [Google Scholar]
3. Hampton LM, Daubresse 1000, Chang HY, Alexander GC, Budnitz DS. . Emergency department visits past adults for psychiatric medication agin events. JAMA Psychiatry. 2014; 71 9: 1006- 14. DOI: x.1001/jamapsychiatry.2014.436. PubMed PMID: 25006837. [PMC costless article] [PubMed] [Google Scholar]
iv. Gitlin M. . Lithium side furnishings and toxicity: prevalence and management strategies. Int J Bipolar Disord. 2016; iv 1: 27 DOI: 10.1186/s40345-016-0068-y. PubMed PMID: 27900734. [PMC free article] [PubMed] [Google Scholar]
5. Waring WS, Laing WJ, Adept AM, Bateman DN. . Pattern of lithium exposure predicts poisoning severity: evaluation of referrals to a regional poisons unit. QJM. 2007; 100 5: 271- 6. DOI: 10.1093/qjmed/hcm017. PubMed PMID: 17412747. [PubMed] [Google Scholar]
half dozen. Dennison U, Clarkson K, O'Mullane J, Cassidy EM. . The incidence and clinical correlates of lithium toxicity: a retrospective review. Ir J Med Sci. 2011; 180 three: 661- 5. DOI: 10.1007/s11845-011-0712-6. PubMed PMID: 21516355. [PubMed] [Google Scholar]
7. Ott Chiliad, Stegmayr B, Salander Renberg E, Werneke U. . Lithium intoxication: incidence, clinical course and renal role--a population-based retrospective cohort study. J Psychopharmacol. 2016; 30 10: 1008- nineteen. DOI: ten.1177/0269881116652577. PubMed PMID: 27307388. [PMC free article] [PubMed] [Google Scholar]
8. Sadock BJ, Sadock VA, Ruiz P, . Kaplan and Sadock'southward comprehensive textbook of psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2012. [Google Scholar]
ix. Oakley PW, Whyte IM, Carter GL. . Lithium toxicity: an iatrogenic trouble in susceptible individuals. Aust N Z J Psychiatry. 2001; 35 half dozen: 833- forty. DOI: 10.1046/j.1440-1614.2001.00963.x. PubMed PMID: 11990895. [PubMed] [Google Scholar]
10. Hansen HE, Amdisen A. . Lithium intoxication: written report of 23 cases and review of 100 cases from the literature. Q J Med. 1978; 47 186: 123- 44. PubMed PMID: 356084. [PubMed] [Google Scholar]
11. Baird-Gunning J, Lea-Henry T, Hoegberg LCG, Gosselin South, Roberts DM. . Lithium poisoning. J Intensive Care Med. 2017; 32 4: 249- 63. DOI: 10.1177/0885066616651582. PubMed PMID: 27516079. [PubMed] [Google Scholar]
12. Bailey B, McGuigan M. . Comparing of patients hemodialyzed for lithium poisoning and those for whom dialysis was recommended past PCC but not done: what lesson tin can nosotros larn? Clin Nephrol. 2000; 54 5: 388- 92. PubMed PMID: 11105800. [PubMed] [Google Scholar]
13. Offerman SR, Alsop JA, Lee J, Holmes JF. . Hospitalized lithium overdose cases reported to the California Toxicant Command Organisation. Clin Toxicol (Phila). 2010; 48 5: 443- 8. DOI: x.3109/15563650.2010.482533. PubMed PMID: 20515402. [PubMed] [Google Scholar]
fourteen. Haussmann R, Bauer Chiliad, von Bonin S, Grof P, Lewitzka U. . Treatment of lithium intoxication: facing the need for show. Int J Bipolar Disord. 2015; 3 1: 23 DOI: 10.1186/s40345-015-0040-2. PubMed PMID: 26493348. [PMC free article] [PubMed] [Google Scholar]
fifteen. Enudi W, Lawlor B, O'Connell HP. . A survey of patients' knowledge about lithium therapy in the elderly. Prim Care Companion CNS Disord. 2014; 16 two :pii: PCC.13m01550 DOI: ten.4088/PCC.13m01550. PubMed PMID: 25133060. [PMC free article] [PubMed] [Google Scholar]
16. Peet G, Harvey NS. . Lithium maintenance, 1: a standard education plan for patients. Br J Psychiatry. 1991; 158: 197- 200. PubMed PMID: 1707323. [PubMed] [Google Scholar]
17. Harvey NS. . The development and descriptive use of the Lithium Attitudes Questionnaire. J Bear on Disord. 1991; 22 4: 211- 9. DOI: ten.1016/0165-0327(91)90067-iii. PubMed PMID: 1939930. [PubMed] [Google Scholar]
eighteen. Collins North, Barnes TR, Shingleton-Smith A, Gerrett D, Paton C. . Standards of lithium monitoring in mental health trusts in the UK. BMC Psychiatry. 2010; 10: 80 DOI: 10.1186/1471-244X-10-eighty. PubMed PMID: 20939864. [PMC free article] [PubMed] [Google Scholar]
19. Dharmendra MS, Eagles JM. . Factors associated with patients' noesis of and attitudes towards treatment with lithium. J Bear upon Disord. 2003; 75 ane: 29- 33. PubMed PMID: 12781347. [PubMed] [Google Scholar]
20. Schaub RT, Berghoefer A, Müller-Oerlinghausen B. . What practise patients in a lithium outpatient clinic know about lithium therapy? J Psychiatry Neurosci. 2001; 26 4: 319- 24. PubMed PMID: 11590971. [PMC gratuitous commodity] [PubMed] [Google Scholar]
22. Fifty-fifty C, Thuile J, Kalck-Stern Grand, Criquillion-Doublet Due south, Gorwood P, Rouillon F. . Psychoeducation for patients with bipolar disorder receiving lithium: short and long term impact on locus of control and noesis about lithium. J Affect Disord. 2010; 123 1-3: 299- 302. DOI: x.1016/j.jad.2009.09.008. PubMed PMID: 19815295. [PubMed] [Google Scholar]
23. Colom F, Vieta Due east, Tacchi MJ, Sánchez-Moreno J, J Scott. . Identifying and improving not-adherence in bipolar disorders. Bipolar Disord. 2005; 7 Suppl v: 24- 31. DOI: 10.1111/j.1399-5618.2005.00248.x. PubMed PMID: 16225557. [PubMed] [Google Scholar]
25. Clarke DJ, Pickles KJ. . Lithium handling for people with learning disability: patients' and carers' knowledge of hazards and attitudes to handling. J Intellect Disabil Res. 1994; 38 2: 187- 94. PubMed PMID: 8193454. [PubMed] [Google Scholar]
26. Colom F, Vieta E, Sánchez-Moreno J, Martínez-Arán A, Reinares M, Goikolea JM, et al. . Stabilizing the stabilizer: group psychoeducation enhances the stability of serum lithium levels. Bipolar Disord. 2005; 7 Suppl five: 32- 6. DOI: 10.1111/j.1399-5618.2005.00249.x. PubMed PMID: 16225558. [PubMed] [Google Scholar]
27. Courtney ME, Acomb JA, Lovatt V. . A pharmacy-controlled lithium clinic. Psychiatr Bull. 1995; 19 1: xv- vii. DOI: 10.1192/pb.19.ane.fifteen. [Google Scholar]
28. Delany N. . How much exercise patients on lithium know nigh their medication? Psychiatr Bull. 1991; xv 3: 136- seven. DOI: 10.1192/pb.xv.3.136. [Google Scholar]
29. Doğan South, Sabanciogullari S. . The effects of patient instruction in lithium therapy on quality of life and compliance. Curvation Psychiatr Nurs. 2003; 17 6: 270- 5. PubMed PMID: 14685951. [PubMed] [Google Scholar]
xxx. Rosa AR, Andreazza Ac, Gazalle FK, Sanchez-Moreno J, Santin A, Stein A, et al. . Adaptation and validation of the Portuguese version of the Lithium Knowledge Test (LKT) of bipolar patients treated with lithium: cantankerous-over study. Clin Pract Epidemiol Ment Health. 2006; 2: 34 DOI: 10.1186/1745-0179-2-34. PubMed PMID: 17147815. [PMC free article] [PubMed] [Google Scholar]
31. Rosa AR, Marco Thou, Fachel JMG, Kapczinski F, Stein AT, Barros HMT. . Correlation between drug treatment adherence and lithium handling attitudes and knowledge by bipolar patients. Prog Neuropsychopharmacol Biol Psychiatry. 2007; 31 ane: 217- 24. DOI: 10.1016/j.pnpbp.2006.08.007. PubMed PMID: 16982121. [PubMed] [Google Scholar]
32. Evans-Lacko S, Malcolm Due east, W Grand, Rose D, London J, Rüsch N, et al. . Influence of Time to Alter'south social marketing interventions on stigma in England 2009-2011. Br J Psychiatry Suppl. 2013; 55: s77- 88. DOI: 10.1192/bjp.bp.113.126672. PubMed PMID: 23553699. [PubMed] [Google Scholar]
33. Hidalgo-Mazzei D, Mateu A, Reinares M, Undurraga J, Bonnín Cdel Chiliad, Sánchez-Moreno J, et al. . Self-monitoring and psychoeducation in bipolar patients with a smart-phone application (Uncomplicated) project: design, evolution and studies protocols. BMC Psychiatry. 2015; 15: 52 DOI: 10.1186/s12888-015-0437-half dozen. PubMed PMID: 25884824. [PMC free article] [PubMed] [Google Scholar]
34. Alwashmi M, Hawboldt J, Davis E, Marra C, Risk JM, Abu Ashour W. . The effect of smartphone interventions on patients with chronic obstructive pulmonary disease exacerbations: a systematic review and meta-analysis. JMIR Mhealth Uhealth. 2016; 4 3: e105 DOI: 10.2196/mhealth.5921. PubMed PMID: 27589898. [PMC gratis commodity] [PubMed] [Google Scholar]
35. Chomutare T, Fernandez-Luque L, Årsand E, Hartvigsen G. . Features of mobile diabetes applications: review of the literature and analysis of current applications compared confronting evidence-based guidelines. J Med Internet Res. 2011; 13 3: e65 DOI: 10.2196/jmir.1874. PubMed PMID: 21979293. [PMC free article] [PubMed] [Google Scholar]
36. Cooper H, Booth K, Fear Southward, Gill G. . Chronic disease patient pedagogy: lessons from meta-analyses. Patient Educ Couns. 2001; 44 ii: 107- 17. DOI: x.1016/S0738-3991(00)00182-eight. PubMed PMID: 11479051. [PubMed] [Google Scholar]
37. Tillery EE. . Minimizing negative outcomes associated with potentially harmful lithium levels past means of pharmacist-led educational interventions in an inpatient psychiatric facility. Ment Health Clin [Internet]. 2015; 5 1: 29- 34. DOI: 10.9740/mhc.2015.01.029. [Google Scholar]
38. Greenwood KJ, Drinkwater A. . Pharmacists' experiences using lithium NPSA warning cards. Int J Pharm Pract. 2013; 21 Suppl 1: 41. [Google Scholar]
39. Osher Y, Bersudsky Y, Belmaker RH. . The new lithium dispensary. Neuropsychobiology. 2010; 62 i: 17- 26. DOI: x.1159/000314306. PubMed PMID: 20453531. [PubMed] [Google Scholar]
40. Parker M. . Bipolar disorder: assessment and management. Aust Fam Physician. 2007; 36 iv: 240- 3. PubMed PMID: 17392936. [PubMed] [Google Scholar]
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6007520/
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