Lithium Uses and FDA Approvals Lithium remains one of the most effective medications for treatment of bipolar disorder, particularly for preventing manic episodes, treatment and lowering the risk of suicide. It boasts the highest efficacy in preventing suicide, reducing the risk 5-fold in those with recurrent unipolar depression and 6-fold for those with bipolar disorder. FDA-approved for acute mania and long-term bipolar treatment maintenance, it is also used off-label for conditions like depression treatment , treatment of suicidal ideation, dementia treatment, treatment of alcoholism, agitation, headache treatment , neutropenia, SIADH, and promoting longevity. Mechanism of Action It is neuroprotective, stabilizing neurons and promoting brain-derived neurotrophic factor (BDNF). Lithium's therapeutic properties have made it essential for mental well-being, appearing naturally in vegetables and drinking water. It has also been linked to lower suicide rates in areas with higher lithium content in water. Furthermore, research shows it extends lifespan in model organisms like fruit flies and may help delay or prevent Alzheimer’s disease. Lithium in Psychiatry As the gold standard for bipolar disorder treatment, Dr Shariq Qureshi uses lithium is also used to augment treatment-resistant unipolar depression, particularly in older adults. It can be used as an off-label treatment for headaches and cluster migraine treatment. Additionally, it increases white blood cell count, providing treatment options for conditions like neutropenia. Recommended Monitoring and Risks Because of its narrow therapeutic index, lithium treatment requires careful monitoring of blood levels, thyroid-stimulating hormone (TSH), and renal function through a comprehensive metabolic panel (CMP). Lithium is cleared through the kidneys and is not metabolized, avoiding interactions with liver enzymes, though it can interact with medications affecting renal clearance. The key investigations recommended before starting lithium include: - Lithium level monitoring - TSH test (to detect hypothyroidism) - RFT (to assess renal function) - EKG (if cardiac disease is present) - Pregnancy test Hypothyroidism and Renal Monitoring Long-term lithium treatment may lead to hypothyroidism in approximately 15% of patients, making TSH monitoring crucial. But hypothyroid patients can be treated with levothyroxine. Renal function must also be monitored closely due to the risk of nephrogenic diabetes insipidus and overall kidney function decline. If nausea becomes problematic, switching to extended-release lithium or taking the full dose at bedtime can help reduce side effects. Cardiac Considerations At therapeutic doses, lithium is cardioprotective, reducing the risk of myocardial infarction without increasing the risk of stroke, unlike carbamazepine. However, in older patients or those with cardiac risks, an EKG is recommended before starting lithium due to potential arrhythmias. Lithium During Pregnancy Lithium poses a low risk of teratogenic effects like Ebstein’s anomaly when taken during the first trimester of pregnancy. It is safer than alternatives like valproic acid or carbamazepine. However, maintaining therapeutic levels during pregnancy is challenging due to fluctuating lithium concentrations throughout the trimesters. Weekly monitoring of lithium levels is recommended if continued during pregnancy. Drug Interactions and Combination Therapy Lithium can be combined with other mood stabilizers, such as valproic acid, lamotrigine, and second-generation antipsychotics. When used with first-generation antipsychotics, the risk of neuroleptic malignant syndrome (NMS) increases. Lithium may also contribute to serotonin syndrome, so caution is advised when combining it with serotonergic drugs. Dosing and Therapeutic Range Lithium dosing varies by condition. For acute mania, blood levels between 1.0 and 1.4 mmol/L are desired, while maintenance therapy aims for levels between 0.6 and 1.0 mmol/L. For treatment-resistant depression, lower levels between 0.5 and 0.8 mmol/L are effective. Blood levels should always be checked at trough (12 hours after the last dose). Tremor is a common side effect, which can be managed with low-dose propranolol. Hydration and Lifestyle Considerations Dehydration poses a significant risk for lithium toxicity, especially since heavy sweating can reduce lithium levels. Patients are advised to stay adequately hydrated to prevent renal complications. In conclusion, lithium continues to be a cornerstone of psychiatrist treatment, particularly for treatment of bipolar disorder. Its unique properties, including neuroprotection and cardioprotection, make it a versatile option for both acute and long-term management by psychiatrist for bipolar, though careful monitoring is essential to prevent adverse effects.