Electronic health record–observed lithium persistence after within-service initiation in bipolar disorder: an incident-initiator cohort study from a multinational tertiary psychiatric service in the United Arab Emirates
4 affiliations
- 1Al Amal Psychiatric Hospital, Emirates Health Services, Dubai, United Arab Emirates
- 2Department of Psychiatry, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 15551, Al Ain, United Arab Emirates
- 3Department of Psychiatry, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
- 4Department of Psychiatry, Al Ain Hospital, SEHA, Al Ain, United Arab Emirates
Abstract
Background: Lithium is a first-line maintenance treatment for bipolar disorder, but real-world persistence varies widely across health systems, and no incident-initiator cohort analysis of lithium has been reported from any Gulf Cooperation Council bipolar disorder population. We aimed to characterise lithium initiation, observed within-service treatment persistence, and post-discontinuation treatment pathways in a multinational tertiary psychiatric service in the United Arab Emirates.
Methods: A retrospective cohort study at a tertiary psychiatric service in the United Arab Emirates from 2018 to 2025. Among adults with a recorded ICD-10 F31 diagnosis, the incident initiator subset comprised adults whose first recorded lithium-bearing encounter occurred more than 90 days after their first service contact. The primary outcome was observed treatment persistence within the health-system record. A patient was classified as having discontinued lithium when at least 90 days elapsed with no lithium-bearing encounter; a 90-day grace period, reflecting routine dispensing intervals, was then added before the discontinuation date. Secondary outcomes included peri-initiation co-prescription and documented next-line treatment within 180 days of discontinuation. Incident initiation was apparent within the study service only; prior or out-of-network lithium exposure could not be excluded.
Results: Among 135 incident initiators (median age 35 years, 48.1% female, 31.1% Emirati), lithium was initiated a median of 556 days after first service contact, most commonly during inpatient (43.0%) or outpatient (35.6%) encounters. Only 11.9% received lithium as a single recorded psychotropic; 82.2% had a concurrent antipsychotic, most commonly aripiprazole (40.0%). Estimated observed persistence was 25.0% (17.7 to 32.9) at 6 months, 4.6% (1.7 to 9.8) at 12 months, and 0.0% at 24 months. The documented next-line treatment was most commonly an antipsychotic, with individually reported second-generation antipsychotics accounting for approximately three fifths of discontinuers. In exploratory adjusted analyses, no prespecified covariate was statistically associated with observed discontinuation.
Conclusions: Observed health-system-record persistence on lithium in this multinational cohort was very limited and substantially below international benchmarks, consistent with a mixture of true discontinuation, care transfer, out-of-network prescribing, and incomplete within-service medication capture. Strategies maintaining within-service visibility and cross-provider record linkage are warranted.
Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s40345-026-00434-w.
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BibTeX
@article{bokhari2026electronic,
title = {{Electronic health record–observed lithium persistence after within-service initiation in bipolar disorder: an incident-initiator cohort study from a multinational tertiary psychiatric service in the United Arab Emirates}},
author = {Syed Ali Bokhari and Muhanad Elnoor and Mohamed A. Alnor and Syed Fahad Javaid},
journal = {International Journal of Bipolar Disorders},
year = {2026},
month = jul,
doi = {10.1186/s40345-026-00434-w},
url = {https://doi.org/10.1186/s40345-026-00434-w},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Electronic health record–observed lithium persistence after within-service initiation in bipolar disorder: an incident-initiator cohort study from a multinational tertiary psychiatric service in the United Arab Emirates
AU - Syed Ali Bokhari
AU - Muhanad Elnoor
AU - Mohamed A. Alnor
AU - Syed Fahad Javaid
PY - 2026
DA - 2026/07/30
JO - International Journal of Bipolar Disorders
DO - 10.1186/s40345-026-00434-w
UR - https://doi.org/10.1186/s40345-026-00434-w
AB - Background: Lithium is a first-line maintenance treatment for bipolar disorder, but real-world persistence varies widely across health systems, and no incident-initiator cohort analysis of lithium has been reported from any Gulf Cooperation Council bipolar disorder population. We aimed to characterise lithium initiation, observed within-service treatment persistence, and post-discontinuation treatment pathways in a multinational tertiary psychiatric service in the United Arab Emirates. Methods: A retrospective cohort study at a tertiary psychiatric service in the United Arab Emirates from 2018 to 2025. Among adults with a recorded ICD-10 F31 diagnosis, the incident initiator subset comprised adults whose first recorded lithium-bearing encounter occurred more than 90 days after their first service contact. The primary outcome was observed treatment persistence within the health-system record. A patient was classified as having discontinued lithium when at least 90 days elapsed with no lithium-bearing encounter; a 90-day grace period, reflecting routine dispensing intervals, was then added before the discontinuation date. Secondary outcomes included peri-initiation co-prescription and documented next-line treatment within 180 days of discontinuation. Incident initiation was apparent within the study service only; prior or out-of-network lithium exposure could not be excluded. Results: Among 135 incident initiators (median age 35 years, 48.1% female, 31.1% Emirati), lithium was initiated a median of 556 days after first service contact, most commonly during inpatient (43.0%) or outpatient (35.6%) encounters. Only 11.9% received lithium as a single recorded psychotropic; 82.2% had a concurrent antipsychotic, most commonly aripiprazole (40.0%). Estimated observed persistence was 25.0% (17.7 to 32.9) at 6 months, 4.6% (1.7 to 9.8) at 12 months, and 0.0% at 24 months. The documented next-line treatment was most commonly an antipsychotic, with individually reported second-generation antipsychotics accounting for approximately three fifths of discontinuers. In exploratory adjusted analyses, no prespecified covariate was statistically associated with observed discontinuation. Conclusions: Observed health-system-record persistence on lithium in this multinational cohort was very limited and substantially below international benchmarks, consistent with a mixture of true discontinuation, care transfer, out-of-network prescribing, and incomplete within-service medication capture. Strategies maintaining within-service visibility and cross-provider record linkage are warranted. Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s40345-026-00434-w.
SN - 2194-7511
ER -