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 Table of Contents    
Year : 2020  |  Volume : 62  |  Issue : 5  |  Page : 577-581
Assessment of lithium-related knowledge and attitudes among patients with bipolar disorder on long-term lithium maintenance treatment

Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Click here for correspondence address and email

Date of Submission27-Oct-2019
Date of Decision25-Dec-2019
Date of Acceptance16-Jun-2020
Date of Web Publication10-Oct-2020


Background: Gaps in lithium-related knowledge among bipolar disorder (BD) patients on lithium prophylaxis may pose safety concerns and could adversely influence attitudes to lithium.
Objective: To assess the lithium-related knowledge and attitudes among patients with BD.
Materials and Methods: This was a cross-sectional, observational study assessing euthymic, adult outpatients with BD on lithium prophylaxis (≥1 year) using a semi-structured pro forma, lithium questionnaire for knowledge, lithium attitude questionnaire (LAQ), and medication adherence rating scale (MARS).
Results: Descriptive analysis revealed several deficits in knowledge, including lack of critical safety information or need for periodic blood tests. Lower knowledge group had significantly more negative attitudes. Favorable attitude toward lithium (lower LAQ score) was significantly associated with the number of psychiatric follow-ups in the last year and MARS score.
Conclusion: There were critical deficits in lithium-related knowledge among the patients. Lower lithium knowledge was associated with negative lithium attitudes. Educative interventions should be delivered periodically to regular lithium users.

Keywords: Attitude, bipolar disorder, India, knowledge, lithium

How to cite this article:
Kumar S, Singh S, Mahal P, Vishwakarma A, Deep R. Assessment of lithium-related knowledge and attitudes among patients with bipolar disorder on long-term lithium maintenance treatment. Indian J Psychiatry 2020;62:577-81

How to cite this URL:
Kumar S, Singh S, Mahal P, Vishwakarma A, Deep R. Assessment of lithium-related knowledge and attitudes among patients with bipolar disorder on long-term lithium maintenance treatment. Indian J Psychiatry [serial online] 2020 [cited 2020 Oct 24];62:577-81. Available from:

   Introduction Top

In spite of advent of newer agents, lithium is still preferred in clinical practice for the management of bipolar disorder (BD) and is among the first-line maintenance agents.[1] However, lithium-related knowledge might be “dangerously little” or “limited” even among regular attendees on prescribed prophylactic treatment from specialized clinics.[2],[3] About one-fourth of patients on regular lithium believed that it was being prescribed because they were lithium deficient. Moreover, even adherent patients might still show surprisingly low levels of lithium knowledge,[4],[5] putting them at a greater risk for toxicity. Apart from safety and efficacy concerns, the deficits in knowledge negatively influence the attitudes toward medication.[6],[7]

However, till date, no published work from India has specifically focused on lithium-related attitudes or lithium knowledge. A PubMed-based electronic search (using key terms) supplemented with MedInd and Google Scholar returned only one related paper assessing medication adherence in a BD sample on various medications, wherein drug attitudes were assessed in relation to adherence.[8]

A previous paper[9] from our larger nonfunded project had focused on lithium adherence and its clinical predictors, highlighting that adherence remains far from ideal in an exclusive lithium-maintained cohort with BD.[9] The present paper, also a part of that nonfunded project, primarily focused on providing descriptive account of lithium-related knowledge and attitudes.

   Materials and Methods Top

Study settings and participants

This cross-sectional, observational study was conducted at a tertiary care teaching hospital in North India between April 2018 and January 2019. Institutional ethics committee clearance was obtained before initiation of the study. Written informed consent was taken from all participants.

Adult outpatients with BD diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders-5 criteria,[10] on lithium prophylaxis for at least 1 year or more, and in clinical remission for at least past month or more (as per history and records) were approached for inclusion in the study. Patients with a comorbid major psychiatric disorder other than alcohol/tobacco dependence were excluded. The clinical care of the patients was continued as usual.

Assessment tools

  • A semi-structured pro forma was used to gather relevant sociodemographic and clinical characteristics of the participants. The information was obtained from all available sources of information, including treatment records
  • Lithium questionnaire (LQ) is a semi-structured questionnaire with 13 questions exploring lithium-related knowledge in a Yes/No format and empty spaces next to each item to seek elaboration from the respondent, as required.[4] The maximum LQ score of 13 is possible, with a score of one per item, although it has been primarily employed for descriptive purposes. The theme of questions in LQ broadly represents those explored in the lithium knowledge test (LKT) developed from Peet and Harvey's work,[11] which has a more structured format with seven multiple-choice questions. In the absence of any recent or valid scale to assess for lithium-related knowledge, we have used a questionnaire approach based on Lee et al.,[4] to facilitate comparisons and to provide descriptive information about deficits in lithium-related knowledge
  • Lithium attitude questionnaire (LAQ) comprises 19 self-rated items (Yes/No format) assessing individual attitudes toward prophylactic lithium treatment.[12] It comprises seven subscale scores assessing attitude toward different aspects associated with lithium treatment. LAQ has a possible score range of 0–19, with higher scores indicating greater degree of negative attitudes toward lithium prophylaxis.[12] LAQ was found to be the only valid and reliable tool for the assessment of lithium attitudes[6],[7]
  • Medication adherence rating scale (MARS) is a brief, valid, and reliable instrument,[13] pertaining to adherence behaviors, with higher scores indicative of better adherence.

Statistical analysis was done using Statistical Package for the Social Sciences version 23.0 (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp). A two-tailed P < 0.05 was considered statistically significant.

   Results Top

A total of 84 participants with BD were recruited of which five had to be excluded from final analysis due to missing key data. The final study sample comprised of 79 participants.

[Table 1] shows the sociodemographic and clinical profile of the study sample and also describes the lithium attitudes as assessed on LAQ.
Table 1: Sociodemographic, clinical profile and lithium attitudes of the study sample (n=79)

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[Table 2] shows the item-wise responses on the LQ pertaining to lithium knowledge.
Table 2: Participants' responses for lithium-related knowledge (n=79)

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To assess the relationship of lithium-related knowledge to lithium attitudes, the study sample was divided (based on statistical median cutoff of 7 on LQ) into low (LQ <7) and high (LQ ≥7) lithium knowledge groups. The LAQ score was compared across patients with a low versus high lithium knowledge. Those in low knowledge group had a significantly higher mean LAQ score (9.92 ± 4.669) compared to high knowledge (5.90 ± 3.53) group (U = 377.50; P < 0.01), suggestive of more negative attitudes. The MARS score was significantly lower in low knowledge group compared to high knowledge group (5.77 ± 3.02 vs. 7.95 ± 2.20; U = 404.50; P < 0.01).

To assess the relationship of lithium attitudes to various clinical variables, Spearman correlation was used, which revealed a statistically significant negative correlation of LAQ total with the number of visits with psychiatrist in the past year (rs= −0.37; P < 0.01) and MARS score (rs= −0.73; P < 0.01). No significant relationship was observed with age, gender, education, marital status, illness duration and duration of lithium, lithium prescription in the first-degree relative, presence of comorbid medical disorder, or past psychiatric hospitalization.

   Discussion Top

The findings from this paper are relevant for lithium-maintained adult outpatients with BD. The study sample was on long-term lithium (median: 26 months) with a median of four outpatient visits over the last year, a long-standing BD (median: 84 months), with adequate representation from both genders, and largely literate patients.

One of the first observations includes a remarkable proportion with major deficiencies in lithium-related knowledge, including a lack of critical safety information. About two-thirds did not know about specific warning signs of lithium toxicity (68.4%) or any special precautions on lithium (63.3%), and half of them did not report being on lithium to other doctors while seeking consultation (51.9%). This is further complicated by the fact that one in three was unaware of the need for periodic serum level estimations (34.2%).

When compared to few previous international studies, findings were broadly similar. In a highly compliant lithium clinic sample, one-third of knowledge questions on an average were not answered.[3] In another study, 30% did not know why blood was taken, in spite of them undergoing periodic tests.[5] A high hazard score, derived from LKT, was reported.[5]

Interestingly, about one-fifth (22.8%) of the sample could not name their medication (any generic or commercial names of lithium were acceptable). Two previous studies, by Lee et al. and de Souza et al.,[4],[14] asked this exact question, with 20% and 38% unable to name it, respectively. Majority was unaware of the “mood-stabilizing properties” of lithium, believing it to be a sedative, or tranquilizer, etc., Such patients might discontinue it without understanding the implications thereof. An study conducted among Chinese BD outpatients reported a similar pattern and frequency of deficits in lithium knowledge, with some differences, such as 78% knew of mood-stabilizing properties (as opposed to 43% in the present study).[4]

Not surprisingly, the responses on “pregnancy question” had an overwhelming majority (83.5%) favoring to stop lithium during pregnancy. In the elaboration section, however, they could not provide any specific information on teratogenic risks. In clinical practice, stopping of lithium is not always a straightforward decision, with individual case considerations in mind.[1],[15] Finally, one in three (36.7%) did not think that they need to take lithium for several years. Efforts must be made to prevent self-initiated lithium discontinuations in such patients.

Another main observation is the presence of significantly negative attitudes for lithium, relative to two earlier studies, also using LAQ.[6],[7] The current sample reflects a median score of 6 (interquartile range[IQR] 4–10) on LAQ (score range 0–19), while a similar study from Brazil found a much lower mean score (3.5 ± 3.2).[7] Another study from the United Kingdom (UK) reported a median LAQ score of 2 (IQR 1–5).[6] Similar to that observed in the present study, available studies have consensus that positive lithium attitudes are associated with better adherence[6] and a greater number of visits/contacts with psychiatrists over the last year.[7],[8],[16] The lower knowledge group had a significantly more negative attitude to lithium treatment and poorer adherence, broadly similar to the existing literature.[6],[7]

The authors emphasize the need to place a higher premium on interventions to promote safe and effective use of lithium among regular users. Methods ranging from use of “lithium cards,” audiovisual aids, smartphone apps, structured education, to concordance therapy may be explored.[17],[18] Lithium-related interventions should be delivered as part of an integrative psychoeducation program for BD.[18]

However, some important study limitations include a purposive sample from a single center and limited generalizability. The LQ was a tool to elicit descriptive information, rather than a validated scale. The cross-cultural validity of LAQ and MARS is not tested though MARS has been commonly used in Indian studies.

   Conclusion Top

The sample was found to be deficient in several critical aspects of knowledge and had moderately negative attitude toward lithium prophylaxis. We emphasize the need for structured interventions to promote safe and effective use of lithium among regular users.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Bond DJ, Frey BN, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord 2018;20:97-170.  Back to cited text no. 1
Delany N. How much do patients on lithium know about their medication? Psychiatric Bulletin 1991;15:136-7.  Back to cited text no. 2
Schaub RT, Berghoefer A, Müller-Oerlinghausen B. What do patients in a lithium outpatient clinic know about lithium therapy? J Psychiatry Neurosci 2001;26:319-24.  Back to cited text no. 3
Lee S, Wing YK, Wong KC. Knowledge and compliance towards lithium therapy among Chinese psychiatric patients in Hong Kong. Aust N Z J Psychiatry 1992;26:444-9.  Back to cited text no. 4
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:???.  Back to cited text no. 5
Dharmendra MS, Eagles JM. Factors associated with patients' knowledge of and attitudes towards treatment with lithium. J Affect Disord 2003;75:29-33.  Back to cited text no. 6
Rosa AR, Marco M, Fachel JM, Kapczinski F, Stein AT, Barros HM. Correlation between drug treatment adherence and lithium treatment attitudes and knowledge by bipolar patients. Prog Neuropsychopharmacol Biol Psychiatry 2007;31:217-24.  Back to cited text no. 7
Selvakumar N, Menon V, Kattimani S. A cross-sectional analysis of patterns and predictors of medication adherence in bipolar disorder: Single center experience from South India. Clin Psychopharmacol Neurosci 2018;16:168-75.  Back to cited text no. 8
Singh S, Kumar S, Mahal P, Vishwakarma A, Deep R. Self-reported medication adherence and its correlates in a lithium-maintained cohort with bipolar disorder at a tertiary care centre in India. Asian J Psychiatr 2019;46:34-40.  Back to cited text no. 9
American Psychiatric Association (APA): Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (DSM-5) Arlington, VA: American Psychiatric Association; 2013.  Back to cited text no. 10
Peet M, Harvey NS. Lithium maintenance: 1. A standard education programme for patients. Br J Psychiatry 1991;158:197-200.  Back to cited text no. 11
Harvey NS. The development and descriptive use of the lithium attitudes questionnaire. J Affect Disord 1991;22:211-9.  Back to cited text no. 12
Thompson K, Kulkarni J, Sergejew AA. Reliability and validity of a new medication adherence rating scale (MARS) for the psychoses. Schizophr Res 2000;42:241-7.  Back to cited text no. 13
de Souza C, Vedana KG, Mercedes BP, Miasso AI. Bipolar disorder and medication: Adherence, patients' knowledge and serum monitoring of lithium carbonate. Rev Lat Am Enfermagem 2013;21:624-31.  Back to cited text no. 14
Viguera AC, Whitfield T, Baldessarini RJ, Newport DJ, Stowe Z, Reminick A, et al. Risk of recurrence in women with bipolar disorder during pregnancy: Prospective study of mood stabilizer discontinuation. Am J Psychiatry 2007;164:1817-24.  Back to cited text no. 15
Scott J, Pope M. Nonadherence with mood stabilizers: Prevalence and predictors. J Clin Psychiatry 2002;63:384-90.  Back to cited text no. 16
Scott J, Tacchi MJ. A pilot study of concordance therapy for individuals with bipolar disorders who are non-adherent with lithium prophylaxis. Bipolar Disord 2002;4:386-92.  Back to cited text no. 17
Colom F. The evolution of psychoeducation for bipolar disorder: From lithium clinics to integrative psychoeducation. World Psychiatry 2014;13:90-2.  Back to cited text no. 18

Correspondence Address:
Raman Deep
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/psychiatry.IndianJPsychiatry_339_19

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  [Table 1], [Table 2]