Response to letter to the editor: Perspectives, attitude and practice of lithium prescription among psychiatrists in India.

Sir,

Addressing the first critic from the commentary which was regarding the inclusion of the psychiatrists in the study, we have already stated in the methods section that only those whom the principal investigator could contact were circulated with the questionnaire for the purpose of the survey. The generalizability of our results to the entire section of psychiatrists in India was already mentioned as the first and foremost limitation. Even in the discussion section, the findings were presented and compared only based on the responses from the psychiatrists who completed the survey.[1]

Another concern raised in the commentary was about the relatively higher response rate of our survey. Response rate depends on factors such as topic of the survey, time taken for completion of the survey/shorter e-questionnaires, nonmonetary incentives, an offer of survey results, personalized e-questionnaires, using a simple header, textual representation of response categories and giving a deadline/ e-mail subject line. One major reason for the higher response rate for our survey could be the time taken as the number of questions was limited.[2] Sometimes, mere chance factors can predict the variability in the response rate.

We have considered the barriers for lithium prescription such as adverse effect monitoring, difficulty in dose titration, lack of experience, patient's clinical comorbidities, patient's low adherence to serum-level monitoring, and slow action of lithium. Nonconsideration of other adverse effects might be due to the semi-structured nature of the questionnaire rather than using a validated one.[1]

The possibility of giving socially desirable answers was considered as a possible limitation of the online survey and has been already acknowledged. The statement “Furthermore, there might be a discrepancy between the responses given and the actual practice” clearly emphasizes this lacuna.[1] There are differing schools of thought regarding the plasma levels of lithium, accurately reflecting the intracellular levels. Findings by Schreiner et al. suggest the possibility that lithium erythrocyte: plasma ratio is dependent on the plasma lithium concentration.[3] Therapeutic drug monitoring in patients on lithium therapy is necessary and is routinely done as a part of routine monitoring, to look for noncompliance and to identify lithium toxicity. Taking the recent evidence into consideration, a study conducted from North India further confirmed the need for therapeutic drug monitoring in clinical practice.[4] The therapeutic drug monitoring of the drug is also recommended by the clinical practice guidelines.[5]

Ethical clearance was taken for the conduct of the study from the institutional ethics committee, it was somehow missed in the original paper – AIIMSRPR/IEC/2018/214.

Though we have included several ways to reach the participants, our main route of circulating the survey was through email and WhatsApp. It was ensured that there should be no duplication of IP addresses while including the sample.[1]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.