What we’ve said about Lithium

“Lamotrigine. which is the weakest, but also probably the best tolerated. We have lithium, which is the gold standard, the classic. And we have Depakote. Works great. There are some problems with it, especially with both male and female fertility”

“Those are the two medications that have shown to have evidence in reducing suicidality. Lithium for bipolar and clozapine for schizophrenic patients has shown to actually reduce suicidality”

“Where I think it's least appreciated and most valuable is in the middle of this mood spectrum, where sometimes this might be along with modified social rhythm therapy, for example, or Lamotrigine”

“simplified social rhythm therapy is my number one mood stabilizer and then lamotrigine and low-dose lithium”

“Which are the MSAEs? This I thought was where you were going with the Ls. Three Ls and a Q for the mood stabilizers with antidepressant efficacy. I missed trazodone. Lithium, lamotrigine, trazodone, and we have to put quetiapine on there”

“the idealistic bipolar patient, the patient with euphoric mania and then with intermittent episodes of depression. That is considered the idealistic lithium patient. Depakote has some evidence with rapid cycling. It has some evidence with mixed episodes”

“It's lithium. Okay. And... It's latuda, and then it's gabapentin. And why? Because I find latuda to be effective quickly and at low doses. Lithium is most effective long-term”

“if you have any schizophrenia spectrum disorder and you have any hint of mood problems on either pole, add a mood stabilizer. If it's agitation, probably try Depakote first along with impulsivity. That may help. And if it's anything else, lithium, lithium, lithium”

“Lithium-initiated postpartum has the strongest evidence for the prevention of postpartum psychosis. And in postpartum psychosis, highly linked to bipolar disorders”

“lithium has evidence for unipolar depression as an augmenting agent, right? So there's probably some, in my opinion, there's probably some percentage of people that have just a really clear-cut unipolar but severe depression, that there's something in there that's a little bit more bipolar”

“But since learning about that, whenever I've heard a patient has had recurrent mood episodes and I see a lot of the previous medication trials haven't worked, I really make sure that there's been a mood stabilizer trial at some point”

“The best evidence goes to ECT, TMS, TMS. antipsychotics, particularly aripiprazole has the best evidence and the biggest effect size, lithium, thyroid supplement, and the ketamines, esketamine and ketamine. So those would be our top line interventions”

“Starting with 150 milligrams, because that's the smallest dose we can engineer, and going up by 150 milligram steps every four to seven days and nights. Until something good happens, something bad happens, go back down one step, or you get to 600 milligrams daily and then check a level”

“So the first thing that I would say about lithium is that you should try it at And around 450 milligrams nightly on an ER”

“There is not a narrow therapeutic window for lithium. There's a narrow therapeutic window for lithium if we're treating acute mania. Okay, that's the key. That's the key. So when it comes to treating lower acuity conditions or in the long term, you can see clinical improvement, even if it's not perfect, with lower doses of lithium”

“Adjunctive treatment with lithium or for mild bipolar, anything in the 0.4 to 0.7 range is actually fine. You don't have to do the old manic dosing”

“maintenance is considered the 0.6 to 0.8 range. 0.8 to 1.2 is considered acute mania. Now that doesn't mean that you're protecting mania. That means the patient is actively manic. That's when you push up to 0.8 to 1.2”

“the onset of effect of lithium takes at least two weeks most of the time. So that's the problem with the mood stabilizers. I think that's why a lot of people don't use them today, because they want instant gratification as a clinician and a patient. You have to set expectations”

“I will titrate Up to the range of around 750 or even 900 depending on the reported adverse effects even without the first lab draw. But this is because I'm in a low resource clinic where despite my efforts many people will refuse or be unable to get lab draws”

“for lithium levels, treat the patient, not the level. So go off of your actual long-term clinical stability or lack of stability. Look at the sleep patterns carefully”

“We're looking for kidney function, right? We're looking for thyroid function, and we're looking for calcium levels. That's the simplistic way of saying it. Those are the main ones that we're going to see being impacted on labs”

“with low dose lithium we don't need to be monitoring all labs or we don't need to have the same lab monitoring schedule that we have with higher dose lithium. We wouldn't expect the same level of kidney dysfunction”

“if you have a patient that absolutely you know is never going to follow up for labs, lithium probably is not the medication, the correct medication”

“But just know that you don't have to do the ER twice a day. You can dose it all once in the daytime. But you're going to have to time your lithium level draws accordingly, which can be a bit of a challenge”

“The way you're actually supposed to tell if this is really happening or if it's just simple polyuria from lithium, which is, by the way, the most common adverse effect of lithium, is that you're actually supposed to do a 24-hour urine collection study”

“Now, you can also see demargination of the white blood cells and a little higher white blood cell count on lithium. That is fine. Don't worry about that. It's non-pathological”

“Ordering labs is not as big a deal. It's not as time intensive as I once imagined. It's not like you need to go on a website and fax things and all these things. You can make a lab requisition form and give it to the patient”

“What are the two major adverse effects in my experience with lithium? It is thirst combined with increased urination. Not the same as diabetes insipidus. That can happen. It's more rare. And then acne”

“if you're dosing it appropriately and at the minimum effective, then you're not going to see much weight gain. But acne, unfortunately, if it happens, there's not really much you can do about it”

“the 20-year actual risk for renal dysfunction when you're not using it at the manic doses is much, much tinier than everyone is aware of”

“So make sure you talk to your patient about hydration, right? Salt intake because taking in too much salt will lower the lithium level and not taking in enough salt will raise the lithium level. Being dehydrated will raise the lithium level and over hydrating will wash out the lithium”

“when it comes to the blood pressure medications, the ones that interfere with lithium, there's actually quite a few. And what I just say is you need to make sure you tell your primary care doctor or whoever prescribes you a blood pressure medication that you're on lithium”

“high levels of lithium guarantee you decline of kidney function. High levels of Depakote do not guarantee any end-organ dysfunction necessarily. You've got to monitor for it, but it's not a guarantee. You're pretty much looking out for a low platelet issue. Hyperammonemia, the liver producing too much ammonia”

“spironolactone, which we know increases lithium levels. So it is an option if you have a very compliant patient that you can check labs, check labs before the dose, the start of the spironolactone, check labs after the start of the spironolactone dose”

“But that said, it's not 1000% contraindicated. And if the patient fully understands the risks, they're well monitored, they've got good family support, you've got a close eye on them, it's not completely contraindicated”

“there is amiloride. Technically, that has been written about and has some small case studies about where you add that with lithium and it reduces the amount of damage that lithium can do to the kidneys and also reduces the polyuria”

“it's only 20% of patients who are taking it, 50% are taking Antidepressants, 60% are taking antipsychotics, 20% are taking lithium. And yet we think that it's one of the best tools that we have”

“Be very careful when you lower lithium though. Among the mood stabilizers, abrupt lowering of lithium or stopping the lithium may be more likely to even induce mania rather than simply unmask it”

“we might actually want to avoid lithium in people with genuine migraines. Not just headaches, migraines. Because it does seem to likely worsen the migraines in a lot of people”

“when you pitch it to a patient as the second you get a side effect, we're going to go back down to the lower dose. Whoa, what a difference that makes”

“I literally say to the patients, like the way I think about it is we don't do labs because this medication is unsafe. It's because we're doing this labs, this medication is extra safe”

“even if you have guaranteed decline in renal function, that is not the same as renal failure, okay? And if you told me that over the next 20 years, I had the choice between 30% worse kidney function and 30% less brain function, I'll tell you this. I'm going to take the better brain function every single time”

“You kind of just counsel patients, try to keep your hydration levels stable. Don't let yourself get too dehydrated”

“I made a little page sheet that I share with the patient. And what I would do the first few times I prescribed lithium, and I still do this with patients that I feel like need to hear it. I share my screen and I walk through the, it's a Google Doc”

“I do think there's enough evidence so far to at least mention that this seems to be something that is a positive effect of lithium in preventing dementia. Especially in bipolar disorders”

“You need to be open to updating your formulation. And like I said, working with the patient and describing what you're seeing and then giving them the options within certain parameters”

“A lot of people can get away with having a lower daily dose of lithium if they're on their 200 of lamotrigine. And then it'll be much more tolerable than trying to do just the lithium, for example”

“is it actually better in the long run than let's say lithium plus lamotrigine? I don't think so. But, you know, they don't study that kind of thing head to head”

“It would have gotten an F in that respect because we have no data in terms of rigorous understanding of it, almost no data at all. But it gets a B because, man, this is really important to understand”

“lithium is one of the only psych meds that regulates the circadian rhythm the genes for bipolar the closest we've come to finding the genes for bipolar is linking them to the clock genes that regulate the circadian rhythm. And we know that lithium normalizes the expression of those clock genes”

“by using this other, this low-dose approach that I just described, it makes it safer for you, for your patients, and gives you the opportunity. It's like exposure therapy for using lithium”

“You give lithium to a bipolar disorder patient, they get better. You give lithium to a patient with schizophrenia and nothing really happens. And so you have to look across validators”