Correspondence

Case 35-1998: Use of Lithium to Prevent Corticosteroid-Induced Mania

N Engl J Med 1999; 340:1123April 8, 1999

Article

To the Editor:

I was surprised to read that a physician caring for the patient described in Case 35-1998 (Nov. 19 issue)1 administered lithium to prevent corticosteroid-induced manic symptoms. No reference was given for this intervention, and lithium itself can cause central nervous system side effects. Several reviews of the central nervous system side effects of corticosteroids mention the possible value of the prophylactic administration of lithium.2-4 These reviews all cite the same study,5 an interesting report on the effects of lithium in a cohort of patients treated with corticotropin for multiple sclerosis. In this study, lithium-treated patients were compared with a historical control group of patients who had similar medical problems and treatment. The lithium-treated patients had no severe psychiatric symptoms. One definite and one possible case of lithium intoxication occurred. The investigators also noted substantial variation in lithium levels and used a twice-weekly monitoring program to achieve control. Fourteen percent of the historical control patients had psychological side effects severe enough to require termination of corticosteroid therapy or intervention with antipsychotic drugs.

That study, by Falk et al.,5 suggests possible benefits and risks of the lithium intervention. However, the nature of the study, which used historical controls rather than random allocation of patients, limits the value of the observations. The authors were appropriately careful in their recommendations concerning their findings. They comment that lithium “prophylaxis” might be warranted for patients who have previously had adverse effects during treatment with corticosteroids, but they did not recommend routine prophylaxis for any patient group.

Thus, the literature does not appear to support routine lithium therapy “in anticipation of the development of manic symptoms.”1 Patients who become manic during corticosteroid therapy should be treated for mania if corticosteroid therapy must be continued. The use of lithium might be considered for patients who have previously had mood disorders while taking corticosteroids.

William Merrill, M.D.
New Orleans Veterans Affairs Medical Center, New Orleans, LA 70112

5 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 35-1998). N Engl J Med 1998;339:1534-1541
   Full Text | Web of Science | Medline

2. 2

   Brown ES, Suppes T. Mood symptoms during corticosteroid therapy: a review. Harv Rev Psychiatry 1998;5:239-246
   CrossRef | Web of Science | Medline

3. 3

   Long TD, Kathol RG. Critical review of data supporting affective disorder caused by nonpsychotropic medication. Ann Clin Psychiatry 1993;5:259-270
   CrossRef | Medline

4. 4

   Peet M, Peters S. Drug-induced mania. Drug Saf 1995;12:146-153
   CrossRef | Web of Science | Medline

5. 5

   Falk WE, Mahnke MW, Poskanzer DC. Lithium prophylaxis of corticotropin-induced psychosis. JAMA 1979;241:1011-1012
   CrossRef | Web of Science | Medline