Trillian's Depression Page
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Lithium: Mineral and Drug

Lithium's Side Effects

Most patients do not experience serious side effects when they begin lithium therapy. Initially, the patient may have slight nausea, stomach cramps, diarrhea, thirstiness, muscle weakness, and feelings of being somewhat tired, dazed, or sleepy. A mild hand tremor may emerge as the dose is increased. These effects are normally minimal and usually subside after several days of treatment. But some of the initial side effects may carry over into long-term therapy and others may emerge. Some patients continue to have a slight hand tremor. Many drink more fluids than usual-without always being aware of it--and urinate more frequently, while still others may gain weight. Weight gain often can be controlled with proper diet. Crash diets should be avoided, however, since they may adversely affect lithium levels. Also, to avoid excessive weight gain, excessive amounts of drinks with high sugar content should be avoided.

In patients who have low amounts of thyroid hormone, enlargement of the thyroid gland may develop, but this condition is generally not serious if monitored closely by a physician. It can be successfully treated with supplementary thyroid medication without withdrawing lithium.

Because of physiological changes in kidneys observed in some lithium-treated patients, any past or current kidney disorder or changes in frequency of urination should be reported to the physician. Long-term lithium therapy can also worsen certain skin conditions, especially acne and psoriasis, and may produce edema, or swelling, which is due to accumulation of water in tissues.

Lithium must be taken with care, with attention to taking the proper dose, having regular blood tests, and reporting changes in diet, exercise, and the occurrence of illness. Toxic levels of lithium in the blood can cause vomiting, severe diarrhea, extreme thirst, weight loss, muscle twitching, abnormal muscle movement, slurred speech, blurred vision, dizziness, confusion, stupor, or pulse irregularities. Sudden physical or mental changes should be reported to the doctor immediately. These problems can almost always be avoided when the doctor's instructions are followed carefully.

Periodic Blood Tests

The amount of lithium needed to treat or prevent manic and depressive symptoms effectively differs greatly from one patient to another. The doctor determines how much lithium a patient needs by taking a sample of blood from time to time. The blood is analyzed to determine how much lithium is present. Testing for the lithium blood level is a vital part of treatment with lithium. It aids the doctor in selecting and maintaining the most effective dose. Just as important, lithium blood levels assure the doctor that a patient is not taking a toxic dose--that is, a poisonous dose.

Lithium is an unusual drug because the amount needed to be effective is only slightly less than the amount that is toxic. For that reason, patients must be very careful not to take more lithium than prescribed.

Lithium levels in the blood can change even when the patient takes the same dose every day: The concentration of lithium can increase when a person becomes ill with another medical condition, especially influenza or other illnesses that result in fever or changes in diet and loss of body fluids. Surgery, strenuous exercise, and crash diets are other circumstances that can lead to dangerously increased lithium levels in the blood. The doctor should be informed of illness or changes in eating habits, and a regular blood testing schedule should be set up and followed rigorously.

If a patient stops taking lithium for only one day, the blood level of the drug falls to half that needed for effective therapy. A forgotten dose should not, however, be taken with the regular dose the next day, because it could raise the lithium level too much. Furthermore, the lower lithium level that results from missing one dose is unlikely to jeopardize therapeutic response.

Because the blood level of lithium rises rapidly for a few hours after swallowing a lithium pill and then slowly levels off, having a blood test right after taking the drug can mislead the doctor into thinking that the dose is too high. To gauge the average blood level accurately, it is important to have blood drawn about 12 hours after the last dose of lithium. Otherwise, the results will be misleading and possibly dangerous. Most patients take their nighttime dose of lithium and then come to the doctor's office the next morning to have a blood test before taking their first dose for the day. Some patients are able to take their full daily dose at bedtime and don't have to worry about the morning dose when getting a blood level.

Precautions in Taking Lithium

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Lithium is excreted from the body almost entirely by the kidneys. If, for some reason, the kidneys are unable to get rid of the proper amount of lithium, the drug may accumulate to dangerous levels in the body. The excretion of lithium in the kidneys is closely linked to that of sodium. The less sodium, or salt, in the body, the less lithium is excreted, and the greater chance of lithium buildup to toxic levels. Diuretics cause the kidneys to excrete sodium; as a result, lithium levels rise. The reason that many illnesses can increase lithium levels is that increased sweating, fever, a low salt diet, vomiting, and diarrhea all result in less sodium present in the body, thus producing higher levels.

Lithium should not be taken by patients with severely impaired kidney function. Patients with heart disease and others who have a significant change in sodium in their diet or periodic episodes of heavy sweating should be especially careful to have their lithium blood levels monitored regularly.

For women in the fertile age range, the possibility of harmful effects on the unborn child may pose problems for continued use of lithium. Children of mothers who received lithium during the first 3 months of pregnancy have been reported in some, but not all, studies to have a slightly increased frequency of malformations of the heart and blood vessels. Even though this risk is low and uncertain, it is strongly recommended that women discontinue lithium during the first 3 months of pregnancy. The decision to stop the medication, however, must be weighed against the possible consequences of an untreated manic or depressive attack, which may result in injury, physiological stress, dehydration and malnutrition, sleep deprivation, or possibly even suicide. Because of the risk of postpartum depression or mania, lithium is sometimes restarted during the final weeks before birth is expected. Women should not breast feed when they are taking lithium, except in rare circumstances when the potential benefits to the mother outweigh possible hazards to the child.

Taking Lithium: How Long?

When fully effective, lithium can control manic-depressive illness for the rest of a person's life. But it is not a cure. Like antihypertensive medications for controlling high blood pressure, lithium should not be discontinued without consulting the physician.

Unfortunately, some patients stop taking their lithium when they find that it diminishes the wonderful sense of well-being they felt when hypomanic; most resume taking their medication when disabling manic episodes return.

Other patients discontinue lithium because they feel they no longer need it. Such reasoning is perfectly understandable. When a person remains well week after week, there is a tendency to forget to take lithium or to deliberately stop taking the medication, believing that the illness has been cured. Lithium's effects, however, last only when patients regularly take the medication. If patients stop taking lithium--no matter if they've been taking it for 5 weeks or 5 years--the chances of having another manic or depressive attack increase. In fact, patients who stop taking the medication are just as likely as patients who have never been treated to fall back into a manic or depressive episode.

This does not mean, though, that all patients must take lithium for a lifetime. After a long period of treatment without a recurrence of mania or depression, the doctor and patient may consider withdrawal of medication under close supervision. That decision will depend upon several factors, including the impact that a subsequent episode may have on the patient's marriage or other significant relationships, career, and general functioning; the likelihood that an emerging recurrence will be detected early enough to prevent a full-blown attack; and the patient's tolerance of lithium.

A Checklist for Patients Taking Lithium

1. Take the medication on a regular basis as prescribed by the doctor. Ask the doctor for instructions on what to do if one or more doses are missed. Unless the doctor advises otherwise, do not catch up on a missed dose by doubling the next dose. This may produce a dangerously high blood level of lithium.
2. Obtain regular blood tests for lithium levels.
3. Have the doctor take blood tests for lithium levels 12 hours after the last dose. Inform the doctor if it has been less than 11 hours or more than 13 hours since the last dose.
4. Inform the doctor if other medications are being taken, since they can change lithium levels.
5. Notify the doctor whenever there is a significant change in weight or diet. It is especially important to tell the doctor if you plan to begin a rapid weight-loss diet, since lithium levels in the body may be drastically affected.
6. Advise the doctor about any changes in frequency of urination, loss of fluids through diarrhea, vomiting, excessive sweating, or physical illness, particularly if there is a fever, because adjustment of dosage or further testing may be required.
7. If planning to become pregnant, advise the doctor.
8. If another doctor is being seen or an operation is planned, be sure to inform that doctor that you are taking lithium.
9. Because it may take time for mood swings to completely controlled by lithium, try not to get discouraged. Continue taking the medicine as prescribed until advised otherwise by the doctor. However, be sure to notify the doctor of recurrence in mania or depression because it may be necessary to increase the dose or to receive additional medication for a time. Psychotherapy can help you to recognize manic or depressive episodes early in their course, as well as help you to express and understand your feelings about having manic depressive illness.
10. Ask the doctor any questions about the treatment program or any procedures that you do not understand. A well-informed patient and family are important factors contributing to a successful treatment outcome. Also, if your psychotherapist is someone other than the doctor prescribing medication, it is important for the two professionals to exchange information about your progress and problems as needed.

If a doctor has prescribed lithium for you or someone close to you, you may wish to know more about the medication: Is it safe? Will it cause discomfort? Most importantly, will it work? Chances are you've been told that lithium may prevent future bouts of your illness. You can benefit from this remarkable effect only if you continue to take the drug exactly as the doctor prescribes. You may have to take it for long periods of time, perhaps indefinitely. That means lithium is as important to you as insulin is to a diabetic or other kinds of daily medications are to people with high blood pressure. Like a diabetic or hypertensive person, you may question whether you need to continue taking the medication day after day, especially if you feel well. But lithium can save your life as surely as those other drugs save theirs. This pamphlet will help you learn more about lithium.

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