What are the indications for lithium (lithium carbonate)?

Indications for Lithium

Lithium is primarily indicated for the treatment of manic episodes in bipolar disorder and as a maintenance treatment to reduce the frequency and intensity of future episodes in patients with bipolar disorder. 1

Primary Indications

• Acute manic episodes in bipolar disorder

  • First-line treatment for moderate to severe manic episodes 1, 2
  • Typically produces normalization of symptoms within 1-3 weeks 1
  • Effective for classic manic symptoms including pressured speech, hyperactivity, reduced sleep needs, grandiosity, and poor judgment 1

• Maintenance therapy in bipolar disorder

  • Reduces frequency of manic episodes 1
  • Diminishes intensity of episodes that do occur 1
  • Shows strongest evidence for prophylaxis of manic episodes compared to other mood stabilizers 3
  • FDA-approved for maintenance treatment 1

Secondary Indications

• Suicide prevention

  • Significantly reduces suicide risk in patients with mood disorders 4
  • Effect appears independent of its mood-stabilizing properties 4
  • Particularly important consideration given the high suicide risk in bipolar disorder (odds ratio 8.66 compared to general population) 4

• Bipolar depression

  • Efficacy for acute bipolar depression remains controversial 2
  • Considered a therapeutic option despite mixed evidence 2
  • Less effective for preventing depressive episodes than manic episodes 2

Special Populations

• Pediatric bipolar disorder

  • FDA-approved for bipolar disorder in youths aged 12 years and older 4
  • Limited evidence from small studies but generally positive results 4
  • Benefits demonstrated for comorbid substance abuse in adolescents 4
  • Lower rates of relapse for adolescents with acute psychotic mania when combined with antipsychotics 4

• Combination therapy

  • Often combined with antipsychotics for patients with psychotic features 5
  • Combinations with mood stabilizers have shown benefit in youth with bipolar disorder 4
  • Antidepressants should only be used in combination with lithium or other mood stabilizers to prevent manic switch 5

Monitoring Requirements

• Baseline assessment before initiating lithium:

  • Complete blood cell count
  • Thyroid function tests
  • Urinalysis
  • Blood urea nitrogen, creatinine, and serum calcium levels
  • Pregnancy test in female adolescents 4

• Ongoing monitoring:

  • Lithium levels every 3-6 months
  • Renal and thyroid function every 3-6 months
  • Regular urinalysis 4
  • Weight and metabolic parameters 5

Important Considerations

• Therapeutic window: Lithium has a narrow therapeutic index requiring careful dosing and monitoring 6

• Discontinuation: Abrupt discontinuation can lead to withdrawal symptoms and rapid relapse; gradual tapering is recommended 5

• Administration options: Single daily dosing may improve compliance and potentially reduce long-term renal damage compared to multiple daily dosing 6

• Maintenance duration: Treatment should continue for at least 2 years after the last episode, with longer treatment often needed 5

• Efficacy limitations: Less effective for rapid cycling patients and for preventing depressive episodes compared to manic episodes 2

Lithium remains a gold standard in bipolar disorder treatment despite the introduction of newer agents, with recent guidelines continuing to recommend it as a first-line mood stabilizer due to its established efficacy in both acute treatment and long-term prophylaxis 2, 7.