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11/13/24, 8\:19 PM Guide | Lithium counselling

Lithium counselling

Table of contents

Introduction

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.
Con
Clarify the purpose of the consultation\:
“ I’ v e c o m e t o d i s c u s s a m e d i c a t i o n c a l l e d l i t h i u m , w o u l d t h a t b e o k a y ?”
It is important to establish a good rapport and an open line of communication with the patient early in the consultation\:
h a v e a n y q u e s t i o n s a t a n y p o i n t - o r i f s o m e t h i n g i s n o t c l e a r - p l e a s e f e e l f r e e t o i n t e r r u p t a n d a s k m e .
”
“ I f y o u

Ideas, concerns & 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
“ H a v e y o u h e a r d o f l i t h i u m ?”
“ W h a t d o y o u k n o w a b o u t l i t h i u m ?”
“ D o y o u k n o w w h a t l i t h i u m i s u s e d f o r ?"
Concerns
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u a b o u t t a k i n g l i t h i u m ?”
Expectations
“ W h a t w e r e y o u h o p i n g t o g e t f r o m o u r d i s c u s s i o n t o d a y ?”
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , y o u w o u l d l i k e m e t o d i s c u s s t o d a y ?”
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 quick, focused 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.
https\://app.geekymedics.com/osce-guides/counselling/lithium-counselling/ 1/511/13/24, 8\:19 PM Guide | Lithium counselling
Additionally, answer any questions the patient might have about their diagnosis before moving onto how lithium works.
Example
" C o u l d y o u s t a r t b y t e l l i n g m e a b o u t w h a t’ s b e e n go i n g o n i n t h e l e a d u p t o y o u b e i n g p r e s c r i b e d l i t h i u m ?”
“ B e f o r e I s t a r t t a l k i n g a b o u t t h e m e d i c a t i o n , d o y o u h a v e a n y q u e s t i o n s a b o u t w h a t’ s h a p p e n e d s o f a r ?”

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
“ L i t h i u m w o r k s b y c h a n g i n g t h e w a y y o u r b r a i n p r o c e s s e s s i g n a l s t o h e l p s t a b i l i s e y o u r m o o d .
”

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

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
1
Mention that patients on lithium will receive a lithium record book. 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
“ Y o u s h o u l d t a k e y o u r l i t h i u m a t t h e s a m e t i m e e v e r y d a y . T h e t i m e y o u t a k e i t i s u p t o y o u .
”
“ I f y o u m i s s a d o s e , d o n’ t t a k e a d o u b l e d o s e t h e n e x t t i m e . I n s t e a d , t a k e t h e n e x t d o s e a s u s u a l .
”
“ Y o u’ l l b e g i v e n a b o o k t o r e c o r d y o u r b l o o d t e s t r e s u l t s a n d d o s e s i n . t r a v e l l i n g i n c a s e y o u r e q u i r e m e d i c a l a s s i s t a n c e .
”
I t' s i m p o r t a n t t h a t y o u k e e p t h i s b o o k w i t h y o u w h e n
https\://app.geekymedics.com/osce-guides/counselling/lithium-counselling/ 2/511/13/24, 8\:19 PM Guide | Lithium counselling

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
2
In addition, the patient will require six-monthly thyroid function tests, urea and electrolytes and calcium monitoring.
2
Example
“ O n c e y o u’ v e s t a r t e d t a k i n g t h e n e w m e d i c a t i o n , w e’ l l n e e d t o t e s t t h e l e v e l s i n y o u r b l o o d o n c e a w e e k t o m a k e s u r e y o u
a r e o n t h e c o r r e c t d o s e . I t i s i m p o r t a n t t h a t t h e b l o o d t e s t i s 1 2-h o u r s a f t e r y o u r p r e v i o u s d o s e . T h e f r e q u e n c y o f b l o o d
t e s t s w i l l d e c r e a s e a s t h e l e v e l b e c o m e s s t a b l e .
”
“ O n c e s t a b l e , w e w i l l n e e d t o m e a s u r e t h e l e v e l o f l i t h i u m i n y o u r b l o o d o n c e e v e r y 3 m o n t h s .
”
“ A d d i t i o n a l l y , w e’ l l n e e d t o m o n i t o r y o u r k i d n e y a n d t h y r o i d f u n c t i o n t w i c e a y e a r”
" L i t h i u m c a n c a u s e y o u r t h y r o i d t o b e c o m e u n d e r a c t i v e i n s o m e c a s e s , w h i c h i s w h y w e n e e d t o m o n i t o r t h y r o i d f u n c t i o n .
"
" Y o u r k i d n e y s h e l p t o p r e v e n t l i t h i u m f r o m b u i l d i n g u p i n y o u r b o d y , t h e y a r e w o r k i n g e
"
s o w e n e e d t o m o n i t o r y o u r k i d n e y f u n c t i o n t o e n s u r e
“ I t i s l i k e l y t h a t i f t h i s m e d i c a t i o n c o n t r o l s y o u r s y m p t o m s w e l l , y o u’ l l b e t a k i n g i t f o r t h e f o r e s e e a b l e f u t u r e . T h e n e e d f o r
o n g o i n g l i t h i u m t h e r a p y w i l l b e r e v i e w e d b y y o u r p s y c h i a t r i s t o n a r e g u l a r b a s i s .
”

Side e

Lithium can cause a range of side e
There are several common side e
2
Increased thirst
Increased volume and frequency of urination
Tiredness
Weight gain
Fine tremor
Inform the patient that if the above side e
It is also important to explain more concerning side e
Encourage the patient to seek urgent medical attention if they experience any of the following\:
Confusion
Drowsiness
Problems with vision
Loss of appetite
Di
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.
https\://app.geekymedics.com/osce-guides/counselling/lithium-counselling/ 3/511/13/24, 8\:19 PM Guide | Lithium counselling
Mnemonic
Use the mnemonic LITHIUM to remember the side e
Lethargy
Insipidus (diabetes)
Tremor
Hypothyroidism
Insides (gastrointestinal)
Urine (increased)
Metallic taste
Tip\: Non-steroidal anti-in
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
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 o
Dispose of PPE appropriately and wash your hands.
Example
“ J u s t b e f o r e w e
d i s o r d e r a n d t h e n e e d t o t a k e l i t h i u m , a d r u g w h i c h h e l p s t o s t a b i l i s e m o o d .
"
“ T h a n k y o u f o r y o u r t i m e t o d a y . D o e s e v e r y t h i n g w e’ v e d i s c u s s e d m a k e s e n s e ?”
" I' d l i k e t o o
"

Reviewer

https\://app.geekymedics.com/osce-guides/counselling/lithium-counselling/ 4/511/13/24, 8\:19 PM Guide | Lithium counselling
Dr William Davis
Psychiatry Registrar

References

1. MIND. L i t h i u m a n d o t h e r m o o d s t a b i l i s e r s . Published in 2020. Available from\: [LINK]
2. Patient.info. L i t h i u m . Published 2020. Available from\: [LINK]
3. NHS.uk. L i t h i u m Published 2020. Available from\: [LINK]
4. Royal College of Psychiatrists. L i t h i u m i n p r e g n a n c y a n d b r e a s t f e e d i n g . Published 2018. Available from\: [LINK]
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/counselling/lithium-counselling/ 5/5