There is good evidence that lithium monitoring and patient education need to be improved. A national audit by the Prescribing Observatory for Mental Health (POMH) with 38 Trusts (N=3,373) in patients who have recently starting lithium, there was a documented baseline measure of renal or thyroid function in 84 and 82 per cent respectively. However, for patients prescribed lithium for a year or more, the NICE standards for monitoring lithium serum levels, and renal and thyroid function were only met in 30, 55 and 50 per cent of cases respectively. 

Important roles for pharmacy teams are:

• Knowing lithium’s interactions and educating patients and carers about these, especially with OTC medicines, including herbal remedies and supplements, and reinforcing the need to seek advice before purchasing
• Knowing the signs of lithium toxicity and educating patients and carers to identify the signs (e.g. upset stomachs)
• Educate patients and carers on how to prevent toxicity, such as adequately hydrating especially if exercising heavily, and advice on safe alcohol consumption
• Checking that their lithium booklets are complete and counselling on any signs of toxicity
• Counselling on the use of medication including standby medication for mania – especially insomnia – or depressive symptoms
• Informing patients about the importance of adherence with medication 
• Giving advice on side effects and how to minimise or treat them 
• Monitoring physical health and providing patients with lifestyle advice on issues such as smoking cessation and weight gain 
• Giving advice on what to do if medication is missed 
• Referring to the GP where necessary.