Letters to the editor

Eagles et al. (1) have attempted to evaluate, through a useful and informative study, the effectiveness of clinical practice guidelines in influencing the practice of lithium monitoring by primary care physicians and psychiatrists in the United Kingdom. They concluded that standard of lithium monitoring required improvement and locally agreed-upon practice guidelines are useful. However, certain conceptual and practice-related issues related to formulation of guidelines and lithium monitoring merit clarification and discussion. It is well recognized that clinical practice guidelines are beneficial to general physicians and specialists alike (2). However the authors report only a ‘clinically small’ improvement in clinical practice, after distribution of the guidelines for which there could be certain possible explanations. First, although reasonable strategies for development and dissemination of guidelines were employed, the authors do not provide any information in relation to the methods, namely development, dissemination and implementation strategies (3), employed for ensuring their implementation. It could have been helpful if the authors had discussed their guidelines vis-à-vis the general principles governing their formulation. Secondly, it has not been discussed whether the guidelines were actually read or used by the doctors concerned (2). Thirdly, guidelines were circulated in January 1996, whereas assessment of practice records was carried out for the whole of 1996. Efforts (or lack of efforts) made by the authors to keep up the enthusiasm (3) or ensure feedback/ reminders (2) have not been discussed, which brings forth the fact and consideration to be kept in mind that developing, implementing and ensuring effectiveness of any practice guideline is not an easy task (2, 3). Although only a brief description (but with adequate explanations) of the guidelines is provided in the paper, the aspect of measurement/estimation of serum lithium 10–16 hours after the most recent dose merits explanation. This is not in keeping with the literature (4, 5) where time of estimation, based on the pharmacokinetic profile of lithium, is recommended as 12 hours (4) or 1260.5 hours (5). The authors have aptly highlighted and discussed the deficiencies in lithium monitoring observed during the course of the study, and make an assertion that ‘patients in sharedcare arrangements experienced better monitoring across majority of parameters examined. ’. However, monitoring in ‘shared-care’ was not ‘ideal’, as substantiated by percentage values for various parameters in Table 1. Lack of appropriate action in relation to regular serum estimation, monitoring of high levels and case-record marking should raise serious concern over the quality of care so provided. This issue of ‘less than ideal monitoring’ assumes further importance and low implementation of the guidelines could have been discussed, as less stabilized or less educated patients are probably seen more frequently in the psychiatric services/ ‘shared-care’ settings (1). However, in future, a step in the right direction would be to develop practically feasible lithium monitoring guidelines (as recommended by the authors), provide adequate psychoeducation to the patients and ensure regular checks to ensure adequate (if not ideal) lithium surveillance.