Evidence-Based Reviews

Lithium for bipolar disorder: A re-emerging treatment for mood instability

Current Psychiatry. 2014 June;13(6):38-44

References

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A diary of symptoms or clinically relevant matters such as fluid intake or frequency of GI- or neurological-related events will help the clinician monitor the frequency and severity of side effects. The patient and clinician should not be discouraged by emerging side effects in the short term, because they may dissipate or become minimally intrusive.

Several strategies can alleviate immediate GI effects, such as dosing with meals, enteric-coated formulations, multiple dose strategies, and short-term use of antidiarrheal medicine as needed. Side effects that disrupt a patient’s fluid and electrolyte balance (diabetes insipidus) to the point of clouding mental status will require discontinuing the medication until mental status improves, then reconsideration of the treatment regime, which will include managing diabetes insipidus with amiloride. Managing side effects may require consultation with specialty services. Likewise, some patients might experience neurologic side effects, such as profound tremor, that interferes with their ability to function. However, many side effects can be managed symptomatically with practical strategies (eg, a sugar-free lozenge for dry mouth or dysgeusia). Consider lower lithium dosages and serum levels because patients may experience benefits with lower therapeutic levels.

Long-term side effects include decreased renal function, hypothyroidism, persistent tremor, and dermatologic effects of acne and alopecia. Monitor renal and thyroid function annually in stable patients and more frequently when making changes in the treatment plan.

Before discontinuing lithium, consider discussing the medical issues with a specialist who has experience with complications of lithium.

Bottom Line
Lithium is an effective and under used medication for managing bipolar disorder. Initial prejudices and side effects often deter patients and prescribers from proceeding with a therapeutic trial of lithium. Although the mid-range lithium level of 0.6 to 0.8 mEq/L is desirable, many patients will experience significant benefits with lower levels. Initial strategies include the use of low-dose preparations that are unlikely to have uncomfortable side effects.

Related Resources
• Andreasen A, Ellingrod VL. Lithium-induced diabetes insipidus: prevention and management. Current Psychiatry. 2013;12(7):42-45.
• Cipriani A, Hawton K, Stockton S, et al. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. BMJ. 2013;346:f3646. doi: 10.1136/bmj.f3646.

Drug Brand Names
Amiloride • Midamor Lithium • Eskalith, Lithobid

Disclosure
Dr. McInnis reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Lithium for bipolar disorder: A re-emerging treatment for mood instability

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