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Patients will be included for this indicator if they have:

An issue for Lithium in the last 6 months (After 1st October)

Code for Lithium prescription



665B. Lithium stopped (recorded after last prescription issued)

Accepted blood test declined exception code:

41M.. Blood test declined

Then they need:

The latest code for serum lithium with a numeric value between 0.4 and 1.0 (In the last 4 months)

44W8. Serum lithium level
44W80 Lithium level therapeutic
44W81 Lithium level high - toxic
44W82 Lithium level low
R1053 [D] Lithium, blood level abnormal
44vE. Lithium Level therapeutic


Or the latest code for serum lithium therapeutic (In the last 4 months, which is recorded on the same date as the latest lithium result (v10))

44W80 Lithium level therapeutic
44vE. Lithium Level therapeutic

Mental Health exception reporting codes (Added in the last 12 months)

9h9.. Exception reporting: mental health quality indicators
9h91. Excepted from mental health quality indicators: Patient unsuitable
9h92. Excepted from mental health quality indicators: Informed dissent


Mental health 010.1 Rationale

Lithium monitoring is essential due to the narrow therapeutic range of serum lithium and the potential toxicity from intercurrent illness, declining renal function or co-prescription of drugs, for example thiazide diuretics or non-steroidal anti-inflammatory drugs (NSAIDS), which may reduce lithium excretion.

The National Patient Safety Agency (NPSA) recently conducted a review of the use of oral lithium treatment for bipolar disorder, which demonstrated that wrong or unclear dose or strength, and monitoring were key issues for lithium therapy. A search of all medication incidents related to the use of lithium reported to the National Reporting and Learning System between November 2003 and December 2008 identified a total of 567 incidents. Two of these resulted in 'severe' harm to the patient, although the majority were reported as 'no harm' events.

The NICE clinical guideline on bipolar disorder CG38 states that for patients with bipolar disorder on lithium treatment, prescribers should:

The aim should be to maintain serum lithium levels between 0.6 and 0.8 mmol/litre in patients who are prescribed lithium for the first time. For patients who have relapsed previously while taking lithium or who still have sub-threshold symptoms with functional impairment while receiving lithium, a trial of at least six months with serum lithium levels between 0.8 and 1.0 mmol/litre should be considered. If the range differs locally, NHS England will be required to allow for this.

Where a contractor is prescribing, they are responsible for checking that routine blood tests have been done (not necessarily by the practice) and for following up patients who default.

Mental health 010.2 Reporting and verification

See indicator wording for requirement criteria.

Due to the way repeat prescribing works in general practice, patient on lithium therapy are defined as patients with a prescription of lithium within the preceding six months.


Prepared By Jean Keenan