Why lithium remains the gold standard
Lithium has been used for bipolar disorder since the 1950s and remains the most evidence-based treatment available. It is the only psychiatric medication proven to reduce suicide risk — a finding supported by multiple studies showing 60-70% reductions in completed suicides in bipolar patients maintained on lithium. Despite the availability of newer medications, lithium's evidence base remains unmatched.
How lithium works
Lithium's mechanism is not fully understood. It affects multiple neurotransmitter systems and has neuroprotective properties — research shows it may actually increase gray matter volume in the brain regions affected by bipolar disorder. It is effective for acute mania, acute bipolar depression (to a lesser extent), and long-term maintenance. Its anti-manic effects are typically seen within 1-2 weeks.
Side effects and management
Common side effects — particularly early in treatment — include tremor, increased thirst and urination, weight gain, cognitive dulling, and GI symptoms. Many side effects diminish over time or respond to dose adjustments. The most significant concern is lithium toxicity, which can occur when blood levels rise too high due to dehydration, drug interactions, or dose issues. Symptoms of toxicity include coarse tremor, confusion, and coordination problems — this is a medical emergency.
Regular blood monitoring is required with lithium — typically every 3-6 months once stable. Kidney and thyroid function are monitored because lithium can affect both. Monitoring sounds burdensome but is straightforward and protects you from the most serious risks. Most people on stable lithium therapy experience minimal disruption from monitoring.