Bipolar Disorder Medications: Lithium

Lithium has long been considered the gold standard in the psychiatric community for the treatment of Bipolar Disorder. Though the exact mechanism of how it works in Bipolar Disorder is still unknown, it remains a highly effective mood stabilizer for treating bipolar mania and depression as well as an effective maintenance treatment for patients who have achieved stability. In adults, it has been shown to prevent relapse and decrease the risk of suicide.¹ And further evidence suggests there is a decrease in relapse rate for adolescents who follow a lithium regimen over the long term.² Potential benefits of lithium treatment in adults include antimanic effects, a decrease in the frequency of cycling between moods, and an antidepressant effect. From my clinical perspective, lithium is an excellent mood stabilizer in some bipolar youth. The problem is that we still can't predict which children and adolescents make up this lithium-responsive group.

One downside of lithium is that, like many psychotropic medications, its use requires intermittent blood tests to determine the level of the drug in the blood. Although tests to monitor your child's levels of psychiatric medications are normally done in an outpatient setting and are monitored by your child's physician, it's generally a good idea for parents to familiarize themselves with the results. (Just as it's important to have a sense of your cholesterol levels, it's wise to keep a record of your child's lithium levels to note any trends that may emerge over time.) The blood tests may be done weekly, monthly, or a few times per year, depending on whether the blood level is in the therapeutic range and if the child is responding. The potential upper therapeutic level (the highest safe level at which a medication can help) is close to the toxic level for lithium (that is, the danger level).

If a child's lithium level is too low, there's a good chance that the medication won't work. If the level is too high, it can potentially cause significant problems. Therefore, monitoring lithium levels carefully is important. (Generally, the recommended blood levels of lithium should be between 0.6 mmol/L [millimole per liter] and 1.2 mmol/L.) Lithium levels equal to or above 2 to 3 mmol/L can be highly toxic and result in serious complications. Early in the course of treatment, levels must be measured frequently, perhaps once a week, as the dose is adjusted. Once the patient is doing well and the blood level is stable and not too high, blood testing may be done once a month or two for awhile and then once every three months.

The timing of the testing is also important. It should be done ten to twelve hours after the last dose, at a time when the lithium levels are relatively stable. In some cases, over-the-counter products can alter lithium levels. For example, sodium bicarbonate (found in baking soda and also in antacids) tends to decrease levels of lithium by increasing its excretion. Anti-inflammatory drugs such as ibuprofen (Advil or Motrin) can also raise the levels. What's more, lithium is exchanged for sodium in the body; thus, if a child is losing sodium by vomiting, sweating, or diarrhea, the body holds onto the lithium (instead of sodium), and the levels can rise. It's important that a youngster on lithium drink fluids to replace sodium and fluids lost due to sports activities, sunbathing, or a high fever or during a very hot day in the classroom. If a child is ill and taking in only minimal amounts of food and liquids, it may be necessary to contact the doctor to discuss lowering the lithium dose until the illness is under better control.

If you and your doctor decide lithium is the right choice for your child, you should let school personnel know as well. The excessive thirst and increased urination that lithium often causes makes it necessary for a child to increase his fluid intake. You may want to ask the teacher to allow your youngster to keep a water bottle or a sports drink such as Gatorade, which provides sodium, minerals, and fluids, at his desk.

Lithium, like all medicines, can have a variety of side effects even when the dosage is at acceptable levels (in general, the potential for side effects of lithium increases as blood levels rise). In discussing these side effects, it is not my intent to alarm parents, but I do want to stress that they are certainly something to be mindful of if your child begins lithium treatment. Potential side effects may include hand tremors, gastrointestinal problems such as diarrhea and nausea, excessive thirst, bedwetting, and negative effects on the kidneys or heart. Thyroid problems, especially hypothyroidism (under functioning thyroid gland), are not uncommon side effects. If a child appears to have a very good response to lithium but has thyroid problems, the physician and parent may discuss keeping the child on lithium while adding supplemental thyroid replacement medication to the child's treatment regimen.

Lithium is available in liquid, tablet, and capsule forms. Some are immediate-release preparations, and others are slow-release.

1. L. Tondo, R. J. Baldessarini, R. J. Hennen, et al., Lithium treatment and risk of suicidial behavior in bipolar disorder patients, Journal of Clinical Psychiatry 59(1998): 405.
2. M. Strober, W. Morrell, C. Lampert, et al., Relapse following discontinuation of lithium maintenance therapy in adolescents with bipolar I illness: Anaturalistic study, American Journal of Psychiatry1 47(1990): 457.

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