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Lithium, usually as the carbonate and occasionally as the citrate salt, is still widely used in American psychiatry, However, the use of valproate for the treatment of mood disorders now surpasses that of lithium. Lithium is approved by the FDA for the treatment of acute mania and as maintenance therapy to prevent or diminish the intensity of "subsequent episodes in those manic-depressive patients with a history of mania." As discussed below, lithium is often used in patients with a variety of recurrent episodic illnesses, with or without prominent affective features. It is also used adjunctively in patients with mood lability, with impulsive or episodic violence or anger, or even with premenstrual dysphoria, alcoholism, borderline personality disorder (BPD), or chronic schizophrenia. Further, it is used as a potentiating agent in a variety of treatment-resistant disorders.

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Table Reference Number

Note. FDA = U.S. Food and Drug Administration; NSAID = nonsteroidal anti-inflammatory drug; SSRI = selective serotonin reuptake inhibitor.

Lithium therapy: overview

Efficacy

Bipolar mania and prophylaxis (FDA indicated)

Depression augmentation

Side effects

Tremor

Polyuria

Polydipsia

Weight gain

Cognitive slowing

Hypothyroidism

Renal function

Dermatological side effects

Memory problems

Safety in overdose

Frequently lethal in blood levels above 3.0 mEq/L and toxic above 1.5 mEq/L. Maintain fluid/electrolyte balance. Gastric lavage; mannitol diuresis vs. hemodialysis for higher blood levels.

Dosage and administration

Start at 300 mg bid or tid and increase total daily dose by up to 300 mg, as needed and tolerated, to blood level of 0.6–1.2 mEq/L for bipolar mania and 0.4–0.8 mEq/L for augmentation.

Discontinuation

Sudden discontinuation associated with risk of relapse. Taper over 3 months for bipolar mania if feasible.

Drug interactions

Antipsychotics: may lithium toxicity

Bupropion: may seizure risk

Carbamazepine: neurotoxicity (rare)

Diuretics: lithium levels

Iodide salts: hypothyroidism

Neuromuscular blockers: respiratory depression

NSAIDs: lithium levels

SSRIs: serotonin syndrome (rare)

Theophylline: lithium levels

Urinary alkalinizers: lithium levels

Verapamil: or lithium levels

Table Reference Number
Table 5–2. Toxicology of mood stabilizers

References

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