Tips for using lithium in bipolar disorder

Despite numerous drug treatment innovations, just about all patients with bipolar disorder that I have treated reported improvement after starting a lithium regimen.

In the 1970s, the clinical literature began highlighting numerous drug therapies for different bipolar symptoms. Before then, I had been taught to treat all “manic-depressive” patients with lithium—regardless of whether mood swings, bouts of anger, depression, or mania were the dominant symptoms.

So I experimented. I prescribed lithium to any potential bipolar patient who did not meet DSM criteria for another mental illness. I discovered the following:

1. A family history of any mental illness, especially alcohol abuse and depression, is a strong indicator of bipolar disorder and of potential positive response to lithium.
2. The existence of mood swings, especially without cause, confirms the diagnosis of bipolar disorder when paired with family history.
3. Lithium, 900 mg/d, works fine as acute or maintenance therapy. I would decrease the dosage for smaller people (eg, 600 mg/d for a patient weighing approximately 125 lbs). I would only increase the dosage—to 1,200 mg/d—for patients with severe mania.
4. Gauging lithium blood levels is a waste of time, assuming you have checked for kidney disease. Across 3 decades in practice, the only patient I have ever seen with an abnormally high lithium blood count also suffered renal failure.
5. Side effects I have seen most commonly with lithium are:
   • weight gain in women, in which case another medication should be prescribed
   • tremor, which should warrant a check of the patient’s caffeine intake.

Other side effects (such as diarrhea and GI upset) are usually mild and easy to control by adding other medications.

Despite numerous drug treatment innovations, just about all patients with bipolar disorder that I have treated reported improvement after starting a lithium regimen.

In the 1970s, the clinical literature began highlighting numerous drug therapies for different bipolar symptoms. Before then, I had been taught to treat all “manic-depressive” patients with lithium—regardless of whether mood swings, bouts of anger, depression, or mania were the dominant symptoms.

So I experimented. I prescribed lithium to any potential bipolar patient who did not meet DSM criteria for another mental illness. I discovered the following:

1. A family history of any mental illness, especially alcohol abuse and depression, is a strong indicator of bipolar disorder and of potential positive response to lithium.
2. The existence of mood swings, especially without cause, confirms the diagnosis of bipolar disorder when paired with family history.
3. Lithium, 900 mg/d, works fine as acute or maintenance therapy. I would decrease the dosage for smaller people (eg, 600 mg/d for a patient weighing approximately 125 lbs). I would only increase the dosage—to 1,200 mg/d—for patients with severe mania.
4. Gauging lithium blood levels is a waste of time, assuming you have checked for kidney disease. Across 3 decades in practice, the only patient I have ever seen with an abnormally high lithium blood count also suffered renal failure.
5. Side effects I have seen most commonly with lithium are:
   • weight gain in women, in which case another medication should be prescribed
   • tremor, which should warrant a check of the patient’s caffeine intake.

Other side effects (such as diarrhea and GI upset) are usually mild and easy to control by adding other medications.

Despite numerous drug treatment innovations, just about all patients with bipolar disorder that I have treated reported improvement after starting a lithium regimen.

In the 1970s, the clinical literature began highlighting numerous drug therapies for different bipolar symptoms. Before then, I had been taught to treat all “manic-depressive” patients with lithium—regardless of whether mood swings, bouts of anger, depression, or mania were the dominant symptoms.

So I experimented. I prescribed lithium to any potential bipolar patient who did not meet DSM criteria for another mental illness. I discovered the following:

1. A family history of any mental illness, especially alcohol abuse and depression, is a strong indicator of bipolar disorder and of potential positive response to lithium.
2. The existence of mood swings, especially without cause, confirms the diagnosis of bipolar disorder when paired with family history.
3. Lithium, 900 mg/d, works fine as acute or maintenance therapy. I would decrease the dosage for smaller people (eg, 600 mg/d for a patient weighing approximately 125 lbs). I would only increase the dosage—to 1,200 mg/d—for patients with severe mania.
4. Gauging lithium blood levels is a waste of time, assuming you have checked for kidney disease. Across 3 decades in practice, the only patient I have ever seen with an abnormally high lithium blood count also suffered renal failure.
5. Side effects I have seen most commonly with lithium are:
   • weight gain in women, in which case another medication should be prescribed
   • tremor, which should warrant a check of the patient’s caffeine intake.

Other side effects (such as diarrhea and GI upset) are usually mild and easy to control by adding other medications.