Patients ask me all the time if lithium is still the best medicine for Bipolar Disorder even though it has been around almost 100 years.
The short answer is yes lithium is still the best single medication, but now we have more good medications if a patient doesn’t tolerate lithium and to use in combination with lithium to help it work better.
The long answer is that we now have better options for both treating and preventing mania, but our options for treating Bipolar depression are still somewhat limited after lithium. Lets briefly review how lithium works and what the alternatives are:
Lithium – The Best Medication for Bipolar Disorder
Lithium is the third element on the periodic table and is mined out of the ground as a yellow salt so it is completely natural. Taking lithium is like taking a high dose of a mineral or element like iron or magnesium. Lithium is dissolved in the fluid of the body like an electrolyte so maintaining your hydration level is important to prevent your lithium concentration from getting too high. Lithium is dosed by blood level because it is excreted by the kidneys, but the rate of excretion varies a lot from person to person because everyone’s kidneys are different and your body size doesn’t play much of a role in your lithium dose.
Lithium is moderately effective for treating and preventing mania, but highly effective for treating and preventing depression in Bipolar Disorder and starts working in a few days to a week. The most common side effect is nausea so it is given extended release forms slow the absorption from the gi tract and with food to further limit the risk of nausea. The second most common side effect is increased urination in some people and if the urination is too frequent, lithium has to be discontinued.
There is a long term risk of kidney damage with lithium after being on it for 20 to 30 years so kidney function is carefully monitored in all people on lithium. Lithium can suppress thyroid gland function, but only while patient take lithium so thyroid function is monitored and many people on lithium also take a thyroid supplement. It is common to have your blood drawn for your lithium level a couple of times when your first start and again at least yearly to monitor level, thyroid function and kidney function.
Lamotrigine – The Second Best Medication for Bipolar Disorder
There is only one other medication that treats Bipolar Depression like lithium. Lamotrigine (brand name Lamictal) is a seizure medication that has also been approved by the FDA to treat both mania and depression in Bipolar Disorder. However, its use is limited by the risk of a severe, life-threatening rash that patients can develop, typically when lamotrigine is first started.
Psychiatrists prevent the life threatening rash using a desensitization process similar to allergy shots where lamotrigine is started at very low dose and gradually increased to the target dose over several weeks to a few months. The slow process for starting lamotrigine makes it difficult to use it for any current mood episode.
Lamotrigine is typically added to other medications such as lithium and/or an antipsychotic because of the slow process for starting it. Even when a new patient not on any medication prefers lamotrigine, I still start lithium or an antipsychotic first to stabilize their mood before starting lamotrigine. Then later, when the lamotrigine is working well, I will stop the lithium or antipsychotic initially started.
Antipsychotics – The Third Best Medications for Bipolar Disorder
Antipsychotic are group of medications that block excessive dopamine in the brain. They were originally developed to treat psychotic symptoms (hallucinations, paranoia and delusions) in schizophrenia, but they have also been shown to be extremely effective for treating mania.
More recently, long term studies of antipsychotics have shown that they can also gradually decrease the number of depressive episodes over time. Two antipsychotics even have formal FDA indications for Bipolar Depression even though evidence suggests that all have this ability.
The main limitations for using antipsychotic is the profound weight gain they cause along with increased blood pressure, elevated cholesterol and occasionally diabetes. However, metformin, an old diabetes drug, can block much of the weight gain if it is started with the antipsychotic.
One of the older antipsychotics, perphenazine, has regained popularity because it causes little to no weight gain and the movement side effects are rare if you keep the dose low. Older antipsychotic can cause serious movement side effects including stiffness, hand tremors, painful muscle spasms, restless legs and even facial grimacing and lip smacking.
Combinations of Medications Often Work the Best
In some ways this discussion of which medication is best is not realistic because only patients with mild Bipolar disorder are treated with a single medication. It is far more common to use combinations of medications at moderate doses that complement each other well rather than pushing single medications to high dose increasing the risk of side effects.
It is not unusual for one of my patients to be on lithium, lamotrigine and an antipsychotic. While it seems like a lot of medication, my patients are very stable and some are even successful professionals. My patients also tend to have minimal side effects because I don’t have to push the dose of any medication very high most of the time.
Obviously, this is not complete discussion of the risks or potential side effects of any of the medications mentioned here. Please contact your mental health prescriber for a full discussion of the risks and potential side effects.
Also, please leave your thoughts and questions in the comments below.