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Lithium – mood stabilizer

for bipolar disorder

Compiled by Linda Stoneman
April 2009

Lithium overview, lithium monitoring and

protocol to help prevent toxicity
Lithium history
• Lithium discovered by Swedish Chemist –
Johan Arfredson in 1817.
• Lithium is element no. 3 in the periodic
table – a soft silvery metal.
• Lithium is used as lithium salts including
lithium carbonate, lithium citrate and
lithium orotate.
Lithium uses and origins
• Used as a mood stabilizer in the treatment
of bipolar disorder.
• Lithium must be used carefully as the
dosages used for the treatment in humans
is only slightly lower than toxic amounts.
• Blood levels should be carefully
monitored. Therapeutic levels range
between 0.4 to 0.8 mmol/l. Toxic range
usually 1.5 mmol/l, but may begin at 1.0.
Lithium uses and origins
• Other forms of lithium include lithium
chloride and lithium bromide, used for
various purposes in manufacturing,
engineering and bomb making!
• The name lithium comes from the Greek
name ‘LITHOS’ meaning stone.
• It was discovered from a mineral
Lithium uses and origins
• Lithium salts are chemical salts of lithium
used primarily in the treatment of bipolar
disorder as a mood stabilizer.

• In the 2nd century it was noted that patients

alternated between excitement and
depression – possibly being the first
documented cases of bipolar disorder.
Lithium uses and origins
• Mood disorders were described by the Ancient
Greeks and Romans as ‘mania’ and
‘melancholia’. In 1686 a connection was made
of the two and was called ‘manico
• Use of lithium salts came from springs and spas
of Northern Italy. People bathed and drank the
waters for soothing effects. The waters were
later found to contain lithium salt.
Lithium uses and origins
• In Modern times use of lithium salts to
treat mania was first proposed by an
Australian doctor in 1949. At this time
other medicines also started to be used for
other mental illnesses.
• In the past, lithium has been used in
popular fizzy drinks including Seven-Up,
known as Lithiated Lemon and Lime Soda.
Lithium uses and origins
• Seven-up contained lithium citrate until
reformulated in 1950!
• One brewery produced lithia beers –
“West Bend”, but was forced to remove
lithium in 1948.
• An early version of Coca-Cola, obtained
from pharmacies – Lithia Coke – a mixture
of Coca-Cola Syrup and lithia waters.
Lithium uses and origins
• The lithia waters were natural occurring
mineral waters, with higher lithium
• The amount of lithium in these drinks was
hundreds of times less than in a minimum
psychiatric dose.
• Lithium comes in many forms and is toxic.
• It should always be monitored by a doctor.
Common drug interactions
• NSAID’s – Non-steroidal anti-inflamatory
drugs – Ibuprofen.
• Angiotensin converting enzyme inhibitors
• Diuretics (thiazides)
• Rarer:- Antibiotics, antipsychotics, SSRI’s
etc. (see BNF for further)
Common side effects of lithium
• Abdominal pain
• Nausea
• Metallic taste in mouth (usually wears off)
• Fine tremor
• Thirst
• Weight gain and oedema

• Is the patient/doctor aware of the difference

between side effects and signs of toxicity?
Signs of toxicity
• Lack of appetite
• Shaking and trembling
• Confusion/drowsiness
• Agitation and restlessness
• Slurred speech and/or blurred vision
• Nausea and vomiting
• Diarrhoea
• Abdominal pain
• Unsteadiness on the feet
• Muscle twitching
• Seizures
• Coma
• Death

• These symptoms can be very similar to that of an episode, and therefore difficult to
differentiate. Agitation and restlessness are common in lithium toxicity, but a blood
test should show if levels of lithium are toxic.
Hydration and toxicity
• It is very important that the body stays fully
hydrated when taking lithium.
• If dehydration occurs the body will
automatically ‘hang on to’ any fluid it has,
but at the same time this means it will
retain more lithium which is normally
excreted by the kidneys in the urine.
This is when toxicity occurs.
Blood Testing
• Routine bloods monitoring should be carried out
every 3/4 months. (Unless complicating factors
or interactions then, monthly testing).
• The doctor or nurse in primary care should be
suitably trained in lithium monitoring.
• The sample should be taken around 12 hours
after the last dose of lithium taken, to give an
accurate level. This is important.
• It’s a good idea to keep a supply of signed
bloods request forms at home for use as
needed. Your GP should be able to supply you
with these.
Questions to ask
if worried about toxicity
• Have you had an infection, cold or diarrhoea
• Have you got a fever or been sweating or
loosing a lot of fluid?
• Is it hot weather or have you been exercising a
• Have you been drinking a lot of coffee and/or
• Have you altered your salt in-take recently?
If at all worried seek advice
• If you are worried about your lithium levels, and maybe
showing some signs of toxicity, or indeed worried about
your general mental/physical health, then seek advice
• Toxicity can occur without apparent increase of serum
level, so treating the patient and not the level is
• See your GP or duty mental health doctor.
• Get your blood tested as quickly as possible, and be
reviewed by secondary care services or A&E the same
• If in doubt and you or your carer are at all worried, go to
your local A&E Department and tell them you think you
may be lithium toxic.
If at all worried seek advice
• Take advice from your doctor whether you
should stop taking lithium – stopping lithium
suddenly can cause a relapse in your condition,
so this is best done supervised, and possibly
with other medications being introduced. Lithium
will be stopped if you are toxic.
• Drink plenty of water if you suspect you are
dehydrated or toxic. Do not drink alcohol or
drinks with caffeine in.
• With the help of a health professional, draw up a
protocol regarding lithium treatment, which will
help in cases of emergency or if worried about
• Establish who will be responsible for monitoring
ie. GP or mental health team, and decide how
often testing should be done.
• Lithium monitoring is ideally carried out using an
agreed protocol. If carried out in primary care,
monitoring should be done by a suitably trained
• At each consult discuss any signs of toxicity.
• The GP should be informed of the target therapeutic
serum level for each individual patient.
• All test results should be communicated to the consultant
• Be aware of your current medications and doses. Stick
to the same brand of lithium.
• If you require any other medication, do you have any
preferences or have you had problems in the past with
certain drugs.
• Have a note of useful telephone numbers ie. GP,
Psychiatrist, Specialist Team and Helpline numbers.
Lithium Treatment Cards
• Carry a lithium treatment card in your
wallet or purse, so people can see you
take lithium. These can be obtained from
pharmacies or the drug manufacturers
themselves. They help you keep track of
regular blood tests and results.
• (Bipolar
Disorder Management).
The End