Janusz Rybakowski: The Faces of Manic-Depressive Illness

Janusz K. Rybakowski’s reply to Donald Klein’s comments


          I would like to thank Donald Klein, who I consider one of the greatest clinical psychopharmacologists, for his comment on my book. To begin with, some words of rectification. Apart from publishing in Polish, PubMed lists 478 scientific articles in English of which I am the author or co-author. As to the book itself, following Donald’s information on Amazon, I checked and was greatly surprised by the price of the book - $471 USD. In recent years, during psychopharmacologic conferences in Europe, the book was displayed by Wisepress and was available for $40 USD. Furthermore, if any INHN member would like the book, I offer to send it free.

          On a serious note, the issue raised by Donald in connection with the book is the underutilization of lithium in the USA. It concurs with the recent article written by the eminent specialist on bipolar disorder, Robert Post (2018), who deplores the fact that lithium is so scarcely used in the USA, even to a greater extent than in European countries. He points to the multiple assets of lithium beyond its antimanic and prophylactic effect, such as antidepressant action, suicide prevention, pro-cognitive and anti-dementia effects, as well as diminishing the frequency of some medical conditions. He argues that the fear of lithium side-effects, such as progressive renal impairment, can be exaggerated and also points out the purposefulness of the early start of the long-term prophylaxis with lithium, e.g., following the first episode of mania.

          In a recent review article, based on my personal 47-year experience with lithium therapy, I challenged the negative perception of lithium by some clinicians. First, I presented the data showing lithium superiority over other mood stabilizers. Secondly, I delineated the lithium-induced side effects which can make a challenge for a more frequent application of this drug and described their proper treatment. Finally, I discussed the benefits of long-term administration of lithium, including the phenomenon of the "excellent lithium responders" (ER), as well as a subject of starting lithium prophylaxis early in the course of the illness (Rybakowski 2018).

          In 2016 we described five patients (two men and three women, aged 64-79 years) with ultra-long-term lithium treatment (40-45 years) and good response to such treatment. Serum lithium levels were reported for them within the range of 0.60-0.65 mmol/l, except for one male, having 0.7-0.8 mmol/l. Both males had impaired renal function. However, no progression has been observed within the last five years. One female suffered from Hashimoto's disease and was treated with levothyroxine. In all patients the cognition and professional activity were at the level of healthy subjects with comparable age and education. Their functioning in family and social roles was good. The beginning of lithium prophylaxis usually had been made within the first three years of the illness. Therefore, we could conclude that in patients with favorable response to lithium, such a longitudinal administration of the drug can produce satisfactory performance in vocational and psychosocial areas and the management of potential adverse effects can be adequate (Permoda-Osip et al. 2016).

          Recently, I also attempted to study the prescription of lithium in my home country, Poland. During 2004-2010 the prescription of lithium in Poland rose by 4% while in 2010-2017, this increase amounted to 16%. However, in the second half of 2017 the prescriptions of lithium for bipolar disorder were surpassed 2.9-fold by valproate, 2.1-fold by quetiapine, 1.9-fold by olanzapine and 1.8-fold by lamotrigine (Rybakowski and Checinska 2018).   

          As a well-known lithium researcher, I was invited to be a keynote speaker during a conference held in Copenhagen on  November 23, 2018, devoted to the 100th birthday of Mogens Schou, the giant of lithium therapy and my personal friend for more than 30 years. My speech made the editorial of the December 2018 issue of Bipolar Disorder (Rybakowski et al. 2018).



Permoda-Osip A, Abramowicz M, Kraszewska A, Suwalska A, Chlopocka-Wozniak M, Rybakowski JK. Kidney, thyroid and other organ functions after 40 years or more of lithium therapy: a case series of five patients. Ther Adv Psychopharmacol 2016; 6: 277-82.

Post RM. The new news about lithium: an underutilized treatment in the United States. Neuropsychopharmacology 2018; 43, 1174-9.

Rybakowski JK. Challenging the negative perception of lithium and optimizing its long-term administration. Front Mol Neurosci 2018; 11: 349.

Rybakowski JK, Checinska K. The use of lithium in Poland in 2004-2017. Pharmacother Psychiatry Neurol 2018; 34: 85-94.

Rybakowski JK, Vinberg M, Kessing LV, Malhi GS, Selo M, Licht RW. Mogens Schou (1918-2005): A scientist, a doctor and a lithium champion. Bipolar Disord 2018; 20: 680-2.


June 13, 2019