The oldest and best mood stabilizer for depression is lithium carbonate (lithium). Although this medication is primarily used to treat bipolar disorders, lithium can also be effective in alleviating unipolar depressive symptoms. Sometimes, lithium is added on to an antidepressant medication regimen for Major Depression when antidepressants alone are not working out.
What is lithium used for?
There are different ways in which lithium is used.
- To treat mania (high mood with over-activity, racing thoughts and agitation)
Lithium needs to be taken in doses that keep its level in the blood relatively high. Often, other medicines are used initially to treat mania because of the increased risk of side effects with high levels of lithium, and because it takes a number of days to work. Lithium is then introduced a little later to stabilize mood.
- As a mood stabilizer
To help prevent the recurrence of severe swings in mood, after an acute episode of bipolar illness has settled. Lithium may take several weeks, months and probably up to two years to reach its full potential effect as a mood stabilizer. Even if lithium does not completely stop the mood swings, it usually reduces their severity.
- To boost the effect of antidepressants
When antidepressant medications have not worked fully in treating depression, adding lithium can be a very good way of increasing their effectiveness and getting the symptoms to improve.
How does lithium work?
It is not really known how lithium works. Lithium may alter the way that nerve cells respond to some of the chemicals that pass messages between them. However, it is known that it is a very effective medicine.
How often is lithium taken?
Mostly, it is taken as a single dose at night - this is more convenient and reduces the problems with some of the side effects. A few people may find it is better to split the total amount into more than one dose - follow your doctor's advice.
Is lithium addictive?
Lithium is not addictive. But when it is stopped, it should be reduced gradually to minimize the chances of the illness coming back.
Is lithium a safe medicine?
Lithium is safe if used correctly, according you your specialist's or family doctor's instructions.
- Before you are started on lithium, your doctor will need to know your medical history - including any psychiatric illnesses you have had in the past.
- Your doctor will examine you physically and take a blood sample to check your blood count, your kidney function and your thyroid gland.
- Depending on your medical history your doctor may also ask you to collect urine for 24 hours and arrange for you to have an ECG heart tracing done. These tests are simply to make sure that it safe for you to start taking lithium.
The problem with lithium is that a certain level of the drug has to be produced in the blood for it to be effective, but if the level rises too much, unpleasant and potentially serious side effects can occur.
What are the side effects of lithium?
The commonest side effects that people may notice when they start lithium are:
- dry mouth
- a metallic taste
- a slight shakiness
- a feeling of mild weakness
- some bowel looseness (diarrhea).
These usually settle as your body adapts to the medication. After taking lithium for some time, the following may be noticed:
- weight gain.
- passing urine more often and needing to drink more than usual. If this happens, you should tell your doctor.
- swollen ankles due to water retention.
- the thyroid gland may become underactive.
Occasionally, some people feel that they get mild memory problems due to lithium. It is possible that this is due to the mental illness itself, but the lithium may sometimes be responsible.
These problems generally disappear if lithium is reduced or stopped. If they occur, your doctor will be able to advise how they should be handled.
Less commonly, when a person has been taking lithium for some time it can cause the thyroid gland to become underactive. This can lead to symptoms such as:
- a lack of energy
- feeling the cold more
- weight gain
- feeling depressed.
Lithium is also a potentially dangerous drug in that its therapeutic dose (the dose necessary for it to offer antidepressant effects) is uncomfortably close to its toxic dose.
Toxic levels of lithium in the blood can cause slowed or stopped breathing, seizures, coma and even death. Before taking lithium, a person will undergo a battery of laboratory tests including a complete blood count, tests for serum creatinine, electrolytes, and hormones, and a urinalysis. A complete blood count measures the number of red and white blood cells and platelets to ensure that these cells are at normal levels, there are no known infections, and that the body can function normally in case of an injury.
Measuring creatinine in blood serum is a test for kidney function. Since adequate kidney function is essential to clearing lithium from the system, this test is particularly important. Tests for electrolytes, hormones, (thyroid, in particular) and urine components indicate the basic health of an individual and provide baseline levels for comparison during lithium treatment. To avoid lithium toxicity, people must have regular monitoring of their blood levels of lithium to make sure that they remain within an acceptable therapeutic range. Blood lithium levels need to be monitored more frequently during the early stages of treatment, but as treatment stabilizes, monitoring can occur every three to six months.
Pregnancy and Breast Feeding
Lithium crosses the placenta and has been associated with toxicity in the fetus. Children born to women taking lithium during pregnancy have an increased risk of goiter and cardiac anomalies. If possible, lithium should be withheld during the first trimester. Women of childbearing age who may require lithium should be counseled about becoming pregnant.
Lithium is secreted into breast milk. Symptoms of lithium toxicity, including changes in the electrocardiogram, have been seen in some breast-fed infants, whose mothers were taking lithium. If possible, women taking lithium should not breast-feed their infants.
How can I be sure that the lithium level is right?
The body gets rid of lithium through the kidneys in the urine, and it is easy to test the lithium level in the blood.
- After starting lithium, it takes about five days for the lithium to build up to a steady level in the blood. For this reason your doctor will take a blood sample to check the level about five days after you first start to take the lithium. If the level is not quite right, the doctor can easily work out from the blood test what the dose should be.
- Lithium blood tests need to be taken at least 12 hours after the last dose of lithium to make sure the test is reliable.
- Any time a change is made in the dose, the level has to be checked about five days later.
- The lithium level will be checked quite frequently to begin with until it is certain that the level is stable and correct. Once this has been achieved, the frequency of blood tests will be less, but a test should still be carried out about every two to three months.
- Lithium is one of the medicines where it is important to always take the same brand. Even at the same doses, different brands will give different blood levels. If the brand has to be changed, a close eye will have to be kept on the level until it is steady again.
What can I do to avoid high lithium levels developing?
- Make sure that you go for the blood tests whenever they are needed.
- Don't suddenly change the amount of salt in your diet; it is especially important not to suddenly reduce your salt intake.
- Make sure that you drink enough fluids, especially if you are exercising heavily or in hot weather when you will sweat more.
- Remember that alcoholic drinks can make you lose water overall. This is particularly important to bear in mind if you are on holiday abroad: you may feel like drinking more alcohol, and the weather may be hot so you sweat more.
- See a doctor straight away if you get any of the physical illnesses or symptoms listed above. Always tell any doctor or pharmacist that you are taking lithium before you are prescribed, or buy, any new medicines.
How long will I have to take lithium for?
Lithium has a preventative effect when taken in the medium to long term.
- Lithium is mostly taken for at least one to two years to derive full benefit from its use. Many people need to stay on it long-term to prevent the illness relapsing.
- When lithium is stopped, it should be tailed off gradually over a number of weeks or months to avoid a period of mania that can occur if it is stopped suddenly.
How effective is lithium?
Despite the potential difficulties with lithium treatment, it remains the best medication for stabilizing mood in most people. It is the mood-stabilizing drug that has the best-proven results in boosting the effect of antidepressants. Many people find it an effective medicine that helps to control their mood disorder and greatly improve their quality of life.
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