Lithium medication is still the most researched and proven treatment for bipolar disorder. So, why does it seem as though lithium is prescribed less and less?

4 (insufficient usage of lithium)

Despite all the misinformation, stigma and stereotypes, it is still the first line treatment for several types of bipolar disorder / manic depression.

5 (lithium use in acute mania and maintenance therapy) The truth is that lithium is cheap, effective, proven, and safe.

There is a lot of mystique around lithium, but in reality it is a natural salt – a simple mineral. It is ironic that so many folks resist taking lithium, insisting they want a “natural” approach. Lithium is actually as natural as it gets – it just happens to be one of the most effective bipolar medications.

Sadly, many people who could benefit from the oldest, best researched, most natural and most proven bipolar treatment are discouraged by a lot of negative half-truths and myths – many propagated online by people who are out to profit from their own products.

Everyone has different treatment needs. Many people do better on other leading bipolar medications such as Depakote or Lamictal.

However despite Depakote, the number one prescribed bipolar drug in the US, a number of studies have shown that lithium is THREE TIMES more effective in preventing suicides.  Lithium use has been shown to be associated with an 87% less likelihood of suicide when compared to placebo.

6 (significantly less suicides with lithium vs. placebo, odds ratio (OR) 0.13)

My message is simple – I know lithium is not for everyone, but all my experience and research has convinced me that everyone should try it first to see. It has the most research, best track record and experts like Kay Redfield Jamison, psychiatric professor at Johns Hopkins and world renowned bipolar author and scholar (and who uses lithium herself), continues to explain lithium is still the gold standard in bipolar care.

However, bipolar treatment regimens should be tailored for the individual by a specialized physician.

My only side effect issue was with weight gain, which can be overcome by eating in a way which minimizes mood swings and avoids physical symptoms of bipolar such as metabolic syndrome, high blood pressure, diabetes, and so forth: The Bipolar Diet

My own lithium experience

Lithium medication saved my life.

Many people whose lives could easily be transformed from bipolar hell resist this cheap and effective treatment, often due to nothing but myths and half-truths. I know because I was one of them!

I should have done my homework. You see, modern lithium treatment involves lower doses and therefore fewer side effects.

In the words of international bipolar expert, Jim Phelps MD, “Lithium is like two different medications: low doses are pretty easy to manage and produce few side effects.  High doses are tricky to manage, require close monitoring to stay safe, and can cause side effects which make people want to consider alternative treatments.”

This is something I learned the hard way. The day I was diagnosed as bipolar my psychiatrist lent me a copy of Kay Redfield Jamison’s autobiography, An Unquiet Mind.

It is a wonderful book and reading it answered a lot of questions for me. But it completely freaked me out about taking the “miracle” salt because Dr. Jamison describes having terrible side effect problems with reading and concentration.

Then I did something really dumb – went on an amateur website about psychotropic medication and read that taking it makes you fat, bald, and stupid. I never did any proper research, and I missed a really important passage in Dr. Jamison’s book about what happened WHEN THE PATIENT SWAPPED TO A LOWER DOSE!

So, I tried Depakote, Geodon, Neurontin, and a whole lot of other things – and guess what – they made me fat, bald and stupid. More to the point, they did NOT stabilize me.

Finally, at the point of last resort I tried it. WOW! Now I am stable, happy and healthy. And I have finally read the part in An Unquiet Mind where Dr. Jamison describes the benefits of being on a low dose. Duh!

Summary of lithium pros and cons

Lithium has the most research and evidence behind it and is particularly known as an anti manic. It is good for preventing suicide, but weak against depression.

Lamictal has evidence showing effectiveness against depression, but is not as effective against mania.

Zyprexa (olanzapine) is very effective, but is so strongly associated with weight gain, diabetes and other serious side effects that it rarely the preferred first choice.

7 (weight gain with zyprexa use)

Why is lithium still the gold standard?

Why is lithium still regarded as the first line treatment for bipolar symptoms?

The main reason is that it treats the broad range of bipolar symptoms more completely than any other medication. It is effective against both mania and depression, and it reduces the risk of suicide.

It also does well in stabilizing mood and slows down the frequency of cycling – which is why it is a good maintenance therapy. Plus, we have the most research on it, it is much cheaper than new medications, and it is arguably the most “natural” medication, being based on a simple and naturally occurring mineral salt.

CLINICAL UPDATE: Major Findings in Bipolar Disorder: “Findings suggest that the combination of lithium and lamotrigine may be particularly advantageous in long-term treatment.”

the following authorities still include lithium bipolar treatment as the first-line medication for bipolar disorder:

1. The American Psychiatric Association’s Guidelines (although these are due for an update and also suggest use of Depakote, Lamictal and Zyprexa in various combinations)

2. Expert Consensus Guidelines

3. The Texas Medication Algorithm Project (TMAP).

Note: All the guidelines differentiate between manic, mixed, and depressive episodes, and acute episodes.  They also take into account the severity of the disease. Lithium is NOT the first-line treatment in all circumstances, especially not for depressive episodes.

Consumer Reports:
If you take lithium, you are much less likely to have a relapse of bipolar disorder. It works as well as valproate, carbamazepine, or lamotrigine for preventing a relapse. But it seems to be better at preventing new symptoms of mania than at preventing new symptoms of depression.”

The downside

Lithium does require more proactive management than other medications. The level in the blood must be kept within a very narrow range. Too little and it is possible to slip back into mania or depression – too much and side effects may become unpleasant or you may even risk death or serious health problems s from lithium toxicity.

How does lithium work?


In 1998, University of Wisconsin researchers found that lithium keeps the quantity of the neurotransmitter glutamate stable and at optimal levels. Dr. Lowell Hokin, a University of Wisconsin professor of pharmacology, theorized that lithium works to control bipolar because of this stabilizing effect on glutamate receptors.


This does not seem to be the whole story of why lithium is effective and it does not explain why other mood stabilizers, that do not target glutamate, can also help.

All we can say for sure is that lithium decreases abnormal activity in the brain by correcting what are probably biochemical imbalances caused by genetics.


Common brands and doses

The common US brands are Eskalith, Eskalith CR and Lithobid. In Canada you will see Carbolith, Duralith and Lithane. Sometimes lithium meds come as simple generics are labelled with chemical names such as lithium carbonate or lithium citrate.

The form may be as a capsule, extended release tablet, or a liquid solution.

Dosing may be 2-3 or 3-4 times per day, depending on how much you need and whether or not you are using the extended release version.

Usually each tablet, capsule, or teaspoon of liquid contains 300 milligrams; but 150, 450, and 600 milligram variations are also available.


Exact doses and dosing schedules will be based on your blood test results, body mass, diet, symptoms, and individual response. The goal is to minimize the dose in order to minimize side effects while also ensuring you maintain a high enough and constant enough level of lithium in your blood to prevent mood swings.

Patty Duke, for example, takes her “little beige pills” twice a day.

Lithium medication FAQ


1. Is lithium addictive?

2. Does lithium cure bipolar?
No. It is an effective treatment, but it is not a cure. Someone who stops taking their lithium medication will probably relapse. .  Think of it as a symptom management tool.

3. Will I ALWAYS have to have blood tests?
Yes. However these become needed far less frequently with time and today there is an innovative new test available that can be administered right there in the doctor’s office.

4. How should lithium be stored?
In a cool, dry, dark place, out of reach of children. Don’t keep your lithium medication in the refrigerator or in the bathroom.

5. Does lithium require a prescription?
Yes! It also requires careful monitoring from an expert clinician who is experienced in looking after patients on lithium medication! This is NOT one of those medications to buy over the Internet!

6. What are some good sources of further information?
A nice easy read that still has plenty of detail is the excellent booklet, by James W. Jefferson & John H. Greist Lithium and Bipolar Disorder: A Guide, Lithium Information Center, Madison Institute of Medicine, 2004, available from Amazon for just $5.95.

Reliable, trustworthy and unbiased information on lithium medication is available in lay terms from two very experienced doctors: Jim Phelps MD and world expert, Dr Manji.

WARNING – Only read the above links from Dr Phelps and Dr Manji if you want some GOOD NEWS for a change!

Lithium medication patient education

Up-to-date, accurate, and complete lithium patient education is proven to significantly enhance outcomes.

Medication compliance, symptom level, weight gain, and quality of life are all on-going challenges for people taking lithium.

Patient education has been demonstrated by research to improve all of these problems.

Lithium medication patient education may focus on any of the following:

1. Taking medication as directed.

2. Understanding risk factors for relapse.

3. Recognizing warning signs for relapse.

4. Managing stress.

5. Identifying supportive strategies.

In fact, education is emerging as one of the most successful psychological and social interventions for bipolar disorder.


As well as improving medication compliance and attitudes to lithium, education has been shown to reduce relapses and improve social and occupational functioning.

Drug companies who provide lithium medication routinely provide lithium medication patient education sheets along with the drugs. You have probably received one of these from your pharmacy.