Certain lithium compounds, also known as lithium salts, are used as psychiatric medication, primarily for bipolar disorder and for major depressive disorder. Lithium is taken orally (by mouth). Common side effects include increased urination, shakiness of the hands, and increased thirst. Serious side effects include hypothyroidism, diabetes insipidus, and lithium toxicity. Blood level monitoring is recommended to decrease the risk of potential toxicity. If levels become too high, diarrhea, vomiting, poor coordination, sleepiness, and ringing in the ears may occur. Lithium is teratogenic and can cause birth defects at high doses, especially during the first trimester of pregnancy. The use of lithium while breastfeeding is controversial; many international health authorities advise against it, and the long-term outcomes of perinatal lithium exposure have not been studied. The American Academy of Pediatrics lists lithium as contraindicated for pregnancy and lactation. The United States Food and Drug Administration (FDA) categorizes lithium as having positive evidence of risk for pregnancy and possible hazardous risk for lactation. Lithium salts are classified as mood stabilizers. Lithium's mechanism of action is not known. In the nineteenth century, lithium was used in people who had gout, epilepsy, and cancer. Its use in the treatment of mental disorders began with Carl Lange in Denmark and William Alexander Hammond in New York City, who used lithium to treat mania from the 1870s onwards, based on now-discredited theories involving its effect on uric acid. Use of lithium for mental disorders was re-established (on a different theoretical basis) in 1948 by John Cade in Australia. Lithium carbonate is on the World Health Organization's List of Essential Medicines, and is available as a generic medication. In 2023, it was the 187th most commonly prescribed medication in the United States, with more than 2 million prescriptions. It appears to be underused in older people, and in certain countries, for reasons including patients' negative beliefs about lithium.
Medical uses
In 1970, lithium was approved by the United States Food and Drug Administration for the treatment of bipolar disorder, which remains its primary use in the United States. It is sometimes used when other treatments are not effective in a number of other conditions, including major depression, schizophrenia, disorders of impulse control, and some psychiatric disorders in children. Because the FDA has not approved lithium for the treatment of other disorders, such use is off-label. Lithium is unique among medications in that it is proven to prevent suicide in mood disorders such as bipolar disorder and recurrent major depression. The mechanisms of biological action of lithium are only partially understood. For instance, studies of lithium-treated patients with bipolar disorder show that, among many other effects, lithium partially reverses telomere shortening in these patients and also increases mitochondrial function, although how lithium produces these pharmacological effects is not understood. High blood levels of lithium can lead to lithium toxicity.
Bipolar disorder Lithium is primarily used as a maintenance drug in the treatment of bipolar disorder to stabilize mood and prevent manic episodes. It is also effective in the acute treatment of manic episodes. It is effective for mania within the first 7 days of treatment. For acute treatment, although recommended by treatment guidelines for the treatment of depression in bipolar disorder, the evidence that lithium is superior to placebo for acute bipolar depression is low-quality. Atypical antipsychotics are considered more effective for treating acute bipolar depressive episodes. Lithium is effective for the long term prevention of bipolar depressive episodes. Lithium treatment was previously considered to be unsuitable for children, however more recent studies show its effectiveness for treatment of early-onset bipolar disorder in children as young as eight. The required dosage is slightly less than the toxic level (representing a low therapeutic index), requiring close monitoring of blood levels of lithium during treatment. Within the therapeutic range there is a dose-response relationship. A limited amount of evidence suggests lithium carbonate may contribute to the treatment of substance use disorders for some people with bipolar disorder. People with bipolar disorder are at a 3 times higher risk for dementia. Lithium reduces the risk of dementia by 50% among people with bipolar disorder.
Schizophrenic disorders Lithium is recommended for the treatment of schizophrenic disorders only after other antipsychotics have failed; it has limited effectiveness when used alone. The results of different clinical studies of the efficacy of combining lithium with antipsychotic therapy for treating schizophrenic disorders have varied.
Major depressive disorder Lithium is widely prescribed as an adjunct treatment for depression.
Augmentation If therapy with antidepressants (such as selective serotonin reuptake inhibitors [SSRIs]) does not fully treat and discontinue the symptoms of major depressive disorder (MDD) (also known as refractory depression or treatment resistant depression [TRD]) then a second augmentation agent is sometimes added to the therapy. Lithium is one of the few augmentation agents for antidepressants to demonstrate efficacy in treating MDD in multiple randomized controlled trials and it has been prescribed (off-label) for this purpose since the 1980s. A 2019 systematic review found that as an adjunct to antidepressants, lithium was much more effective than placebo. The studies in the review ranged from the 1970s to the 2000s. While SSRIs have been mentioned above as a drug class in which lithium is used to augment, there are other classes in which lithium is added to increase effectiveness. Such classes are antipsychotics (used for bipolar disorder) as well as antiepileptic drugs (used for both psychiatric and epileptic cases). Lamotrigine and topiramate are two specific antiepileptic drugs in which lithium is used to augment.
Monotherapy There are old studies indicating efficacy of lithium for acute depression with lithium having the same efficacy as tricyclic antidepressants. A 2019 systemic review of studies from the 1970s to 2000s found that lithium monotherapy was just as effective as antidepressant monotherapy.
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