Trillian's Depression Page

Lithium: Mineral and Drug

Pure lithium, like sodium, calcium, or potassium, is a naturally occurring mineral. Lithium is found abundantly in certain rocks and the sea and in minute amounts in plant and animal tissues. Lithium also shows up in water, notably in the springs and spas where in earlier times people "took the waters," bathing in and drinking the lithium-rich water for its soothing effects. Whether lithium actually calmed 19th-century ladies and gentlemen has never been documented. What we do know is that, from time to time since antiquity, doctors have noticed that lithium can control overexcitement in some of their patients.

Today, lithium is administered to patients as a lithium salt, usually as lithium carbonate or lithium citrate, which is taken by mouth in capsule, tablet, or syrup form. Pharmaceutical companies often assign a "trade name" to their products. Examples of trade names for lithium are Cibalith, Eskalith, Lithane, and Lithobid. Some companies use only the chemical name, that is, lithium carbonate or lithium citrate.

Modern physicians rely on these various forms of lithium to treat serious mental illness. Properly administered, it is one of the most powerful medications available for mood disorders.

The Development of Lithium Treatment

John Cade, an Australian physician, introduced lithium into psychiatry in 1949 when he reported that lithium carbonate was an effective treatment for manic excitement. Unfortunately, Dr. Cade's discovery coincided with reports of several deaths from the unrestricted use of lithium chloride as a salt substitute for cardiac patients. Four patients died, and several developed toxic reactions. It was not known at that time that lithium can accumulate to dangerous levels in the body or that lithium has to be used with special caution in patients with cardiac disorders.

As a result of these experiences, lithium was virtually neglected in this country until the early 1960s. Research by European psychiatrists, especially Dr. Mogens Schou in Den mark, hastened acceptance of lithium in the United States. Renewed interest in the compound led to numerous clinical trials. These studies showed how lithium could be used safely and effectively to treat psychiatric disorders.

In addition, research--both in animals and humans--showed that lithium influences several functions in the body, including the distribution of sodium and potassium, which regulate impulses along the nerve cells. Lithium can affect the activity of neurotransmitters and biological systems because it . alters the way in which a variety of messages are transmitted after they reach their target. Although scientists have many promising leads, they have yet to explain the biochemical actions of depression.

In 1970, the U.S. Food and Drug Administration (FDA) approved lithium as a treatment for mania. Four years later, the FDA also approved the use of lithium as a preventive, or prophylactic, treatment for manic-depressive illness.

Lithium's Uses

Psychiatrists use lithium in two ways: to treat episodes of mania and depression and to prevent their recurrence. Lithium can often subdue symptoms when a patient is in the midst of a manic episode, and it may also ameliorate the symptoms of a depressive episode. The single most important use for lithium, though, is in preventing new episodes of mania and depression. Lithium is also being used experimentally to treat other disorders.

Manic and Depressive Episodes

Lithium is highly effective in treating acute episodes of mania, especially when symptoms are mild. Patients going through severe manic episodes need to be calmed as quickly as possible, however, and lithium may take 1 to 3 weeks to achieve its full effect. Therefore, physicians most often treat very disturbed patients by first combining lithium with 'a different type of drug, a tranquilizer, such as haloperidol or chlorpromazine. When lithium has had a chance to act, the tranquilizer may be gradually withdrawn. Lithium can normalize the manic disorder without causing the drugged feeling that often occurs with tranquilizers. Also, tranquilizers may produce troublesome side effects that limit their usefulness as a long-term treatment.

Lithium is also effective in treating depressive episodes in some patients with manic-depressive illness. For these patients, some doctors prefer to treat mild to moderate depressive episodes with lithium alone because of the possibility that conventional antidepressant drugs such as imipramine may trigger a hypomanic or manic attack. If the depression is severe, treatment is usually begun with a conventional antidepressant in combination with lithium. That same combination is sometimes used in unipolar depressions that do not respond to anti depressant medications alone.

Lithium's Role in Preventing Manic and Depressive Episodes

As noted, lithium's greatest value is in preventing or reducing the occurrence of future episodes of bipolar disorder. The effectiveness of this lithium prophylaxis or lithium prophylactic treatment has been demonstrated in more than two decades of careful research. In related research, several major studies indicate that lithium can decrease the frequency or severity of new depressive episodes in recurrent unipolar disorder. This suggests that lithium may also have prophylactic value in treating this mood disorder. Conventional antidepressants also have been shown to be effective prophylactic treatments for recurrent unipolar depression.

In prophylactic treatment, lithium is administered after a manic or depressive episode to prevent or dampen future attacks. Some patients respond quickly and have no further episodes. Others respond more slowly and continue to have moderate mood swings even months after therapy is started. These highs or lows usually become progressively less severe with continued lithium treatment; often they disappear. With other patients, lithium may not prevent all future manic and depressive episodes, but may reduce or lessen their severity so that the individual can continue to lead a productive life.

There are patients who are not helped at all by lithium. About one in ten patients with bipolar disorder who takes lithium does not respond to the medication, but continues to have manic-depressive episodes at the same frequency and severity as before. Doctors cannot predict with certainty how lithium will work in any individual case. This can be determined only by actual use of the medication.

When deciding whether a patient should start lithium prophylactic therapy, a psychiatrist or other physician considers the likelihood of a new episode in the near future; the impact that the episode might have on the patient, family, and job; the patient's willingness to commit himself or herself to a long-term treatment program; and the presence of medical conditions that may rule out lithium treatment. Usually, a doctor prescribes lithium prophylactic therapy only after a patient has had two or three well defined episodes requiring treatment. Patients who have had only a single attack, mild attacks, or a long interval between episodes--for example, over 5 years--usually do not. receive prophylactic treatment unless the second episode would be life threatening or highly disruptive to the patient's career or family relations.

Such rules, though, serve as only broad guidelines. Patients must act as the doctor's partner in weighing the circumstances and making the decision. Each patient should understand the reasons for lithium prophylaxis as well as the benefits and risks and be an informed participant in the treatment program.

When lithium fails or when a patient has another medical condition that precludes its use, the doctor may consider an alternative prophylactic drug treatment. First, however, he or she will reevaluate why lithium failed: Was dosage adequate? Did the patient take the medication as prescribed? Does the patient have a problem with thyroid function? Many patients with mood disorders have malfunctioning thyroid glands, a problem that can be successfully treated with a thyroid hormone or related preparations without withdrawing lithium.

For manic-depressive patients, the anticonvulsant drugs carbamazepine (trade name Tegretol) and valproate (trade name Depakote) seem to be the best alternatives to lithium. Sometimes the anticonvulsant drugs are given alone, sometimes in combination with lithium, to prevent or dampen future episodes.

Patients with unipolar disorder who fail on lithium often are given an antidepressant drug alone or in combination with lithium. A severe episode may be treated with electroconvulsive therapy. Information on alternatives to lithium treatment can be found in the literature listed at the end of the pamphlet.

Other Disorders

Lithium may also be useful for treating other mental illnesses. Research psychiatrists have evaluated lithium as a treatment for a variety of psychiatric disorders, including schizophrenia, schizoaffective disorder, alcoholism, premenstrual depression, and periodic aggressive and explosive behavior. Lithium appears to produce the best responses in patients who have mood swings, a tendency to have intermittent bouts of illness, or a family history of mood disorder.

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