Poor Lithium- the best most stigmatized drug for mood on the market

Yesterday I had a conversation with a patient about lithium.  Maybe it’s the 20th one I’ve had like this in the last year.  It goes like this.

me “I want to talk to you about a medication that can help your symptoms, but when I mention the name of it, people often have strong reactions to it.  The medication has a long history and a lot of it is bad, but it’s actually because of how we used to use the medication.  Can I tell you about it?”

patient” What is it?”

me: Lithium

patient: “absolutely not, no way”

me: “Can I explain why it got such a bad reputation first, and how it could help you?”

Patient: ok

me:  “About 35 years ago,  when psychiatric medications for disorders were being invented, someone discovered this amazing drug lithium.  We would have really sick patients in the hospital and we would give them this drug, and they would come up to us and say after just a few days ‘Wow, I’ve never felt so good before.  My brain never felt this healthy and normal before’  and we would reply ‘Well you’re not even on a therapeutic dose yet, wait until you are on one.’

And guess what happened next.  We continued to give them more medication because that was the accepted practice at the time and the patients didn’t get better, they sometimes stayed the same but more often, they got sick or they got worse.  So then lithium was off the table as a med we could use.  That happened often enough that lithium made a lot of people sick and over time we quit using it.  We went back to using other drugs with more side effects over time than it had.

But then, about 20 years later, providers who remembered how well it worked in really sick patients got brave and wondered, logically, why didn’t we listen when those patients on small doses said they felt wonderful and normal?  And then those brave providers resumed using lithium again only usually in much lower doses, and got fantastic results.  Lithium is proven in multiple studies to be the best drug on the market for preventing and controlling suicidal thoughts.  Lithium can boost the effectiveness of antidepressants, and is the best mood stabilizer.  It’s very calming and usually very well tolerated in small doses.  Lithium is a generic and cheap, so you won’t see the advertising to make this a more publicly acceptable drug.  So what do you think?

patient: “no, anything but lithium.”

Now of course they don’t all say no, in fact likely 2/3 will say they will try it.  But I’ve had two “nos” in the last week.   When I bring up lithium,  we haven’t gotten to that  discussion before we’ve tried a number of other medications.  It’s nice to get patients feeling better but it’s even better to help them feel well .  They are also frustrated about the medications only making them partially better.  And wellness is about more than just medications and of course we also discuss those factors too.  But a lot of those same patients who reject lithium will willingly accept Abilify, Latuda or Seroquel because they’ve seen those ads in publications and on television.  Those are great medications as well and we use them a lot in psychiatry, but my approach as a nurse practioner is always to start with the safest medications first.  And the risks with lithium (some gastric upset if taken on an empty stomach, and feeling more thirsty are the most common,  and rarely over time some effects on the kidneys and thyroid in high doses) vs the new Atypicals (chance of Neuroleptic Malignant Syndrome, sudden death from cardiac arrest in the Elderly,  higher risk of developing diabetes or elevated cholesterol with long term use, weight gain, elevated hormone prolactin, and others), actually make the side effect profile of lithium a much safer drug.

Mental health is life and death.  Not everyone should run out and request lithium as the magic elixir.  It doesn’t work for everyone.  And if you’re already taking an Atypical medication and doing well,  your provider will monitor your response and will monitor for any worrying issues.  Your safety and health today trump the risks of taking those over time, when you feel you don’t want to live at all , or that you can’t function at all then time exploring all the options is frustrating and could put your life at risk.  Many providers will use those drugs very early in their practices without explaining all the long term risks of taking them.  I prefer to make them the last option and make my medication selections based on safety first, if we have time to explore, and sometimes the condition is so bad or so resistant we don’t have that time.  Still overall, lithium is an amazing drug.  If it hadn’t been for a very close friend of mind taking it for 20 years as an adjunct for her depression, I might never have thought about it again either.  But time and time again, I’ve seen it work and help a lot of people feel better.  It’s worth exploring.

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Poor Lithium- the best most stigmatized drug for mood on the market

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