When is lithium indicated for treatment?

Indications for Lithium Treatment

Lithium is primarily indicated for the treatment of bipolar disorder, specifically for acute manic episodes and as maintenance therapy to prevent recurrence of mood episodes. 1

Primary Indications

• Acute treatment of manic episodes in bipolar I disorder 1
• Maintenance treatment of bipolar disorder to reduce frequency and intensity of mood episodes 1, 2
• Prevention of both manic and depressive episodes in bipolar disorder 3, 4

Specific Clinical Scenarios

Bipolar Mania

• First-line treatment for bipolar mania, along with valproate or carbamazepine 2
• Typically normalizes manic symptoms within 1-3 weeks 1
• Should be offered to individuals with bipolar mania, though treatment should be initiated only in settings where close clinical and laboratory monitoring are available 2

Maintenance Treatment

• Recommended for maintenance treatment of bipolar disorder for at least 2 years after the last episode 2
• Reduces relapse rates compared to valproate in long-term treatment 5
• Continuation beyond 2 years should preferably be decided by a mental health specialist 2

Bipolar Depression

• May be used in combination with antidepressants (preferably SSRIs) for moderate to severe depressive episodes of bipolar disorder 2
• Evidence for lithium monotherapy in acute bipolar depression is conflicting 3

Age Considerations

• FDA-approved for use in patients 12 years and older for both acute mania and maintenance therapy 2
• Can be used safely in children, though risperidone and quetiapine may be superior in some aspects for pediatric patients 5

Monitoring Requirements

• Baseline laboratory assessment should include complete blood cell counts, thyroid function tests, urinalysis, blood urea nitrogen, creatinine, serum calcium levels, and pregnancy test in female adolescents 2
• Regular monitoring of lithium levels, renal and thyroid function every 3-6 months 2
• Therapeutic serum concentration range is 0.6-1.0 mM; levels >1.5 mM may be toxic 6

Important Considerations and Cautions

• Treatment with lithium should be initiated only where personnel and facilities for close clinical and laboratory monitoring are available 2
• Lithium has a narrow therapeutic window, requiring careful monitoring to avoid toxicity 7
• For individuals who do not respond to lithium, alternative options include anticonvulsants like valproate, carbamazepine, or lamotrigine 6
• When discontinuing prophylactic therapy, it should be done gradually with close monitoring for relapse 2
• Lithium withdrawal has been associated with increased risk of relapse, especially within 6 months of discontinuation 2

Efficacy Considerations

• Lithium is the only drug that has demonstrated efficacy in preventing any mood episodes, manic episodes, and depressive episodes in randomized trials not enriched for prior response 4
• It remains the gold standard for bipolar disorder treatment despite the introduction of newer medications 5
• Approximately one-third of patients with bipolar disorder experience complete remission with lithium, another third show improvement, and one-third do not respond 6

Lithium's long-term stabilizing properties in bipolar disorder have been well-documented, and these benefits occur independently of any acute response to the medication 3. When weighing treatment options, the potential risks of lithium should be balanced against its proven efficacy and the fact that serious adverse effects are usually avoidable with proper monitoring 3.