Kummerlowe, Megan N.

Introduction: Lithium remains a gold standard treatment for bipolar disorder including during peripartum. Historically, guidelines advised against breastfeeding while taking lithium though recent data suggest it is acceptable for a healthy infant. Lack of awareness of acceptability contributes to decreased patient and clinician comfort and low breastfeeding rates. We report current breastfeeding rates, monitoring practices, and infant outcomes with lithium exposure in breastmilk at our institution. Methods: A retrospective chart review was conducted at a single academic medical center using records from 2013 to 2023. Electronic medical records were queried to identify patients prescribed lithium postpartum. Data were collected on timing of lithium initiation, lithium dose and concentration, breastfeeding status, and infant outcomes. Results: A total of 18 cases of lithium use in the postpartum period were identified. A total of 39% ( n = 7) of patients taking lithium postpartum breastfed. Most patients, 61% ( n = 11), initiated lithium prior to pregnancy, 11% ( n = 2) initiated during pregnancy and 27% ( n = 5) started postpartum. Four infant charts were reviewed with no reports of adverse events. Of these infants, average maternal lithium dose was 750 mg daily, with an average maternal serum lithium concentration of 0.62 mmol/L and average infant serum lithium concentration of 0.16 mmol/L. Conclusion: Our data demonstrate most patients using lithium postpartum have been taking lithium long-term and are not breastfeeding. Lithium exposure in breastmilk appears to be tolerated by healthy infants. There is a need for ongoing research and education on acceptability and infant monitoring recommendations to support patients who would like to breastfeed while on lithium.

Abstract Tactile hallucinations can be highly distressing and lead to psychiatric morbidities and functional impairments. There are no established treatments for tactile hallucinations that occur outside of primary psychotic disorders, and available pharmacologic and nonpharmacologic therapies may have limited effectiveness. We present a case of a 75-year-old female with treatment-refractory tactile hallucinations successfully treated with electroconvulsive therapy (ECT). She endorsed 13 months of distressing tactile hallucinations described as slimly substances on her skin. Symptoms started insidiously, became more severe with time and refractory to multiple antipsychotic medications. She became so severely distressed from the tactile hallucinations that she developed a major depressive episode and became suicidal. Relevant medical history included one prior depressive episode, occipital lobe stroke, restless legs syndrome, and obstructive sleep apnea. She was hospitalized in an inpatient psychogeriatric unit and treated with ECT for 12 sessions over 3.5 weeks. Hallucinations responded well to ECT. Patient experienced some mild memory impairment from treatment. Treatment was optimized with duloxetine titration, addition of mirtazapine and repletion of B6 vitamin. Following the acute course of ECT, she reported an 80 % improvement in tactile hallucinations. Depressive symptoms improved, and suicidal thoughts resolved. She was able to discharge from the hospital and continued with maintenance ECT. Our case illustrates the potential therapeutic role of brain stimulation in the treatment of refractory cases of tactile hallucinations. Further studies are needed to determine effective treatment strategies for treatment-refractory tactile hallucinations to prevent progression to severe psychiatric disturbances and improve quality of life.