Lithium Counselling – OSCE Guide

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This guide provides a structured approach to lithium counselling in an OSCE setting.


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Clarify the purpose of the consultation: “I’ve come to discuss a medication called lithium, would that be okay?”

It is important to establish a good rapport and an open line of communication with the patient early in the consultation: “If you have any questions at any point – or if something is not clear – please feel free to interrupt and ask me.”


Patient’s ideas, concerns and expectations

A key component of counselling involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).

Asking about a patient’s ideas, concerns and expectations can allow you to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation. It can sometimes be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided some examples for each of the three areas below. 

Ideas

  • “Have you heard of lithium?”
  • “What do you know about lithium?”
  • “Do you know what lithium is used for?”

Concerns

  • “Is there anything, in particular, that’s worrying you about taking lithium?” 

Expectations

  • “What were you hoping to get from our discussion today?”
  • “Is there anything, in particular, you would like me to discuss today?” 

Tip: Establishing the patient’s ideas, concerns and expectations early in the consultation will enable you to focus on the factors that matter most to the patient. This will increase the quality of the consultation and further build rapport between you and the patient.


Patient history

Although the purpose of this station is to counsel the patient, it is a good idea to gather a quickfocused history early in the consultation.

Lithium is commonly prescribed as a mood stabiliser following a diagnosis of bipolar disorder. Exploring the patient’s symptoms will help you to emphasise how important it is that they take their medication as directed to reduce the risk of future symptom relapse. 

Additionally, answer any questions the patient might have about their diagnosis before moving onto how lithium works.

Example 

“Could you start by telling me about what’s been going on in the lead up to you being prescribed lithium?”

“Before I start talking about the medication, do you have any questions about what’s happened so far?”


What is lithium and how does it work?

Lithium is a mood stabiliser. It is used to treat a variety of mood disorders including:1

  • Bipolar disorder (both mania and hypo-mania)
  • Recurrent depressive episodes which have not responded to anti-depressants 

In an OSCE scenario, it is most likely that lithium has been prescribed for a patient who has been newly diagnosed with bipolar disorder. Although the mechanism of action of lithium is poorly understood, it is thought to act on multiple steps in the cellular signalling pathway, leading to prophylaxis of both mania and depressive episodes.2

Portray this to the patient by keeping it as simple as possible. Using patient-friendly language, explain that lithium alters signals in the brain to help stabilise mood.

Example 

“Lithium works by changing the way your brain processes signals to help stabilise your mood.”


How to take lithium

Lithium is prescribed in both tablet and liquid form. It is likely you’ll be told the form and dosing regimen the patient has been prescribed in the brief.

Inform the patient to swallow the medication with plenty of water.

Patients are often encouraged to take lithium at night, although this isn’t essential. The patient can choose when to take it, but you must encourage them to take the medication at the same time every day.

Inform the patient that they should not stop taking lithium suddenly or change their dose without speaking to their doctor first.

If a patient misses a dose of lithium, inform them not to take a double dose and instead to take their next dose as normal.3

Mention that patients on lithium will receive a lithium record book.1 They should take this book to all of their appointments to help keep track of their blood test results. Encourage the patient to carry this book with them at all times in case of emergency, particularly if going on holiday.

Example 

“You should take your lithium at the same time every day. The time you take it is up to you.”

“If you miss a dose, don’t take a double dose the next time. Instead, take the next dose as usual.”

“You’ll be given a book to record your blood test results and doses in. It’s important that you keep this book with you when travelling in case you require medical assistance.


Monitoring

Lithium may take several weeks or months to begin working. Explain to the patient that it takes several weeks to get the dose of lithium correct. To do this we will need to take a blood sample every week at the beginning of your treatment.

The lithium level must always be measured 12 hours after their previous dose. Once the lithium level is stable the frequency of blood tests will decrease to once a month, and finally once every 3 months.2

In addition, the patient will require six-monthly thyroid function tests, urea and electrolytes and calcium monitoring.2

Example 

“Once you’ve started taking the new medication, we’ll need to test the levels in your blood once a week to make sure you are on the correct dose. It is important that the blood test is 12-hours after your previous dose. The frequency of blood tests will decrease as the level becomes stable.”

“Once stable, we will need to measure the level of lithium in your blood once every 3 months.”

“Additionally, we’ll need to monitor your kidney and thyroid function twice a year”

“Lithium can cause your thyroid to become underactive in some cases, which is why we need to monitor thyroid function.”

“Your kidneys help to prevent lithium from building up in your body, so we need to monitor your kidney function to ensure they are working effectively.”

“It is likely that if this medication controls your symptoms well, you’ll be taking it for the foreseeable future. The need for ongoing lithium therapy will be reviewed by your psychiatrist on a regular basis.”


Side effects

Lithium can cause a range of side effects that the patient needs to be warned about.

There are several common side effects that are usually mild and self-resolving:2

  • Increased thirst
  • Increased volume and frequency of urination
  • Tiredness
  • Weight gain
  • Fine tremor

Inform the patient that if the above side effects don’t improve with time, the patient should book a consultation with their doctor.

It is also important to explain more concerning side effects associated with lithium toxicity which can be life-threatening. 

Encourage the patient to seek urgent medical attention if they experience any of the following:

  • Confusion
  • Drowsiness
  • Problems with vision
  • Loss of appetite
  • Difficulty speaking
  • Seizures
  • Excessive thirst and urination

Explain to the patient that the risk of toxicity is reduced by taking their dose at the same time every day and regularly attending to have their blood tested.

Reassure the patient that lithium has been prescribed for decades and is safe when taken as prescribed with appropriate monitoring in place.

Mnemonic

Use the mnemonic LITHIUM to remember the side effects and complications:

  • Lethargy
  • Insipidus (diabetes)
  • Tremor
  • Hypothyroidism
  • Insides (gastrointestinal)
  • Urine (increased)
  • Metallic taste

Tip: Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen should be avoided when taking lithium as they can increase the serum level of lithium.2


Pregnancy

If the patient is a female of childbearing age (commonly used in lithium counselling OSCEs), it is vital to discuss the risk of taking lithium during pregnancy.

Remember to discuss the risks with the patient using language that is easy to understand.

Although the evidence isn’t clear, it is important to inform the patient of the following risks:2,4

  • Lithium associated birth defects generally occur within the first trimester of pregnancy when the fetal organs are developing
  • Lithium has been shown to increase the risk of fetal heart defects
  • Lithium is able to pass into the baby’s circulation through breastmilk and breastfeeding should therefore be avoided

Advise the patient that they should use a reliable method of contraception such as a subdermal implant or intrauterine system (IUS) to prevent accidental pregnancy whilst taking lithium.

Encourage the patient to speak to their psychiatrist if they begin to consider starting a family so that an appropriate plan can be put in place. This may involve considering alternative treatment options during pregnancy or making an informed decision to continue treatment with an understanding of the associated risks to both mother and baby.4


Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the consultation.

Finally, thank the patient for their time and offer them a leaflet summarising the key information related to lithium therapy.

Dispose of PPE appropriately and wash your hands.

Example 

“Just before we finish, I’d like to summarise what we’ve talked about. We’ve discussed your recent diagnosis of bipolar disorder and the need to take lithium, a drug which helps to stabilise mood.”

“Thank you for your time today. Does everything we’ve discussed make sense?”

“I’d like to offer you a leaflet that summarises everything we’ve talked about today.” 


Reviewer

Dr William Davis

Psychiatry Registrar


Editor

Dr Chris Jefferies


References 

  1. MIND. Lithium and other mood stabilisers. Published in 2020. Available from: [LINK]
  2. Patient.info. Lithium. Published 2020. Available from: [LINK]
  3. NHS.uk. Lithium Published 2020. Available from: [LINK]
  4. Royal College of Psychiatrists. Lithium in pregnancy and breastfeeding. Published 2018. Available from: [LINK]

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