Tuesday, August 7, 2012

A Taste of My Own Medicine: Is Lithium the Best Option for Treating Bipolar Mania?

She ran through the store frantically, shoving items she didn't need or wouldn't even use into her cart. See, to her, everything seemed like a great deal and everything was something she'd use. She had taken out some cash in an attempt to set a budget, but it didn't really work for two reasons. First, she had no idea how much money was (or, rather, wasn't) in her checking account to begin with. Secondly, she was already over budget. But it wasn't a problem. She figured she'd just transfer the money from her savings to her checking. Online banking is a beautiful thing, she thought to herself as she pranced up to the register to pay.

She got home and couldn't wait to show her husband what she'd bought. But he couldn't pay attention. He was busy running through their finances. He worked hard 6 days a week to make ends meet in a failing economy. "All you've been doing for the last week is spending money! I can't do this anymore. We have no money! Our checking account is overdrawn. There's no money in savings. I've been pulling from my 401K to make it work around here!"

She became instantly angry. "Fine! If you don't want me to spend money, then why don't you get a new wife?! Maybe she'll be better!" she screamed, whipping her wedding ring down the garbage disposal just before stomping out the door. Again. Probably on her way to spend more money that we don't even have, thought her husband.

She got back home about 3 AM to, obviously, find her husband fast asleep. So she hopped online and began to chat endlessly with her friend on the other end of the country. She even did a little online shopping. Chatting. Shopping. Chatting. Shopping. All through the night. Her husband got up at 7 AM for work, but she didn't even acknowledge him. She was too busy running around like the Tasmanian Devil trying to get the already-clean apartment even cleaner. She had to do something with all the energy she had stored up inside.

This is a small glimpse into the life of a young lady we'll call Sarah. Sarah is bipolar. Actually, to be specific, she has what is referred to as bipolar 1. Bipolar 1 has little to do with how severe it is, but rather which end of the spectrum is the more severe one. In Sarah's case, it is more severe on the manic side. Also having this same diagnosis, I am able to explain from personal experience that mania is not always enjoyable. Those of us who are creative types can sometimes benefit from mania, as it can further encourage creativity. However, the cons far outweigh the pros like severe insomnia, frantic energy, impulsivity (usually sexually or financially-as we saw with Sarah), severe irritability/anger, irrationality, and the fallout: a downswing into depression.

Luckily, there are solutions. Most psychiatrists work with their patients to find what we refer to as medication "cocktails." For those with bipolar 1, the cocktail usually includes one to two mood stabilizers, an anti-psychotic, and an anti-anxiety medication. For me, like most, this is the hardest part of treatment. I have been on dozens of different medications and probably close to 30 cocktails just in the last 3 years.

My current one is the one I credit most of success to-along with most of my physical problems. It includes Thorazine, Lamictal, and the age-old drug that started bipolar treatment: Lithium. While I have had only one issue from the first two drugs, Lithium has caused me a great number of other problems, making me (and hundreds, if not thousands, of other users) question if Lithium is really worth it. It is the most effective drug for people like Sarah and myself who live in constant fear of another manic episode, but how many other problems must we incur before we look for other options? Is Lithium really "worth the price of admission?"

First, let's talk about the benefits of Lithium. In the year I have been on Lithium, I have gotten my spending under control. I have a budget that I stick to, a separate savings account that I have given over to the control of a personal financial advisor, and have even become known around my town as the "discount queen." Also, I have not had one episode of severe insomnia, which is one of the first indicators or symptoms of mania. This is a huge improvement from a 4-year manic streak. I'll take it.

In fact, like I said earlier, I credit some of my success to Lithium because I am level-headed and lucid, and thereby, able to make better decisions that positively affect my life and the lives of those around me. This is actually the case for most people, as 20 to 40 percent of people respond to Lithium alone, eliminating the need for another mood stabilizer (which is very hard to do with any other drug. I know. I've tried. Many times), according to Dr. Gary J. Kennedy, Director of the Division of Geriatric Psychiatry at Montefiore Medical Center (2008). I am grateful to have my life and relationships back. Thanks, Lithium!

However, here's where the problems come in. Since I've been on Lithium, I have had the same side-effects that most people get: sedation, weight gain, hair loss, and hypothyroidism. And if that's not enough, to manage the medication's effectiveness and to watch/manage the above side-effects, blood work is required, generally once a month and up to once every three months, depending on how long some of us see our psychiatrists. And then there's the risk of excess Lithium, which can lead to toxicity and a number of additional issues and is a current area of concern for me. Don't worry, though. I'll tackle these side-effects one paragraph at a time. Here we go!

The first thing anyone on Lithium will notice is a significant drop in energy. This is not necessarily a bad thing because mania produces an excessive frantic, Tazmanian Devil-like energy, so the person must have that significant of a drop at first to come back down to normal. So in the initial stages of using Lithium, this is a good thing.

But prolonged drowsiness is a bad thing. People have been known to sleep through jobs and school, among other events, due to the sedation of Lithium. Even if the person is fully awake, it can affect their speech, making them sound as if they are still asleep. I have personally never had the speech part of the problem, but during the first few months of Lithium treatment, I was always sleeping. The other bad part about the sleep problem is the reverse: oftentimes, if a person doesn't take the night dose of Lithium (or gets off of it), he or she cannot sleep well or at all, without the use of other sleep aids. This is true also if the psychiatrist reduces the patient's Lithium levels. Over all, this is a side effect that is tolerable, as there are feasible ways to work with and around it.

Next, let's dive into the part that, as young women, neither Sarah nor I want to talk about: weight gain. At first, I figured since other medications had already made me gain weight, Lithium would be just as easy to deal with. Wrong. Lithium is a salt-based drug, so adding that much salt, for me it is currently 1350 mg, to the human body is only asking to gain weight. This is a problem for nearly every single person who takes Lithium, just as it is for most drugs of this nature (i.e. Seroquel, Depakote). And the strangest, most frustrating thing about it is that it doesn't matter how much the patient exercises or how healthy he or she was to begin with. Those activities can generally only help a person reduce the amount of weight gained as opposed to preventing it altogether.

However, I am not basing this solely on my experiences. Studies show that about 1 in 10 Lithium patients see this kind of significant weight gain (NHS, 2012). This is a moderately serious side-effect because rapid weight gain can lead to a number of things, one of which I'll touch on in a few paragraphs. This is a side-effect that I have lived with, up to a certain point. But I wouldn't necessarily recommend it for other patients.

Now we come to the one that has personally been the most painful for me, even beyond weight gain. It's hair loss. Having the experience I do in the cosmetology industry, it has been hard for me to watch my own fall out, little by little, with every shampoo. I have literally tried everything, from iron tablets and flax seed to natural hair and special shampoo. Nothing worked until I increased one of the other medications I take. That helped. But it was nothing related to Lithium and it took an additional medication that I otherwise wouldn't have had to take. I am not alone, however. 12 to 19 percent of long term users have some kind of hair loss, which can lead to alopecia in up to 28 percent of users (Mercke, et al, 2000).

This side effect in particular is why many patients on Lithium look for a new drug cocktail. Therefore, I would consider this a major side effect because, although it doesn't affect as many users, the degree to which it affects is large and concerning. This is definitely one of the main side effects to be very aware of. In fact, it's one that, in my opinion, could make or break someone's decision to add Lithium as a part of their treatment.

Finally, I come to the one that has also been a huge part of the reason patients look for new drug treatment: hypothyroidism. Like weight gain, this occurs in about 1 in every 10 patients taking Lithium (NHS, 2012). "What is hypothyroidism," you might ask, "and why is it a problem?" Allow me to answer. First, here's how the American Thyroid Association defines hypothyroidism:

Hypothyroidism is an underactive thyroid gland. Hypothyroidism means that the thyroid gland can't make enough thyroid hormone to keep the body running normally. People are hypothyroid if they have too little thyroid hormone in the blood" (NHS, 2012).

It is a problem because it exacerbates both the last two side-effects (weight gain and hair loss). When the thyroid is underactive, it is not producing enough of the hormones that keep the metabolism running properly, so if weight gain is a problem for the patient, he or she would want to keep an eye on it to assure it is not caused from hypothyroidism as well. The same goes for hair loss.

The treatment for hypothyroidism is to take a thyroid hormone to balance out the levels. So, in turn, Lithium, a drug, has a 10 percent chance of causing a disorder that worsens the already existing side-effects for which the treatment is... another drug. For me, this was the cliché "straw that broke the camel's back." I would be most leery of this side-effect as it encompasses the main two concerns and essentially makes them worse.

Other side-effects of Lithium include: dry mouth, hand tremors, slurred/groggy speech, and acne/skin blemishes.

Lithium is meant to be a treatment for acute mania, bringing manic bipolar patients down to a baseline, somewhat stable mood, depending on what other medications they might be on and how well those meds are working. So the questions remain: Is Lithium the best option? Do the benefits outweigh the costs? My answer is not a simple yes or no.

Here's how it works. I can safely say, based on research, anecdotes of other patients, and my own experiences, that Lithium is the best option for acute mania. This means it works, as stated, to bring manic episodes to baseline. It is one the best option for bringing down mania because the side-effects of short-term use are much easier to deal with over other options (usually Depakote or Seroquel).

However, long-term use is where the problems come in. All of the aforementioned side-effects are the reason. They are too much to ask a patient to deal with and are the reasons Lithium is not recommended by doctors and other research and medical professionals for long-term use. So overall, I recommend that patients use it for long-term maintenance only if, like in my case, it is the absolute (!!!) last option after trying every single other medication.


American Thyroid Association. (2012). Hypothyroidism [Pamphlet].

Kennedy, G. J. (2008, March 6). How does lithium work as a treatment for bipolar disorder, and how does fluid intake affect lithium levels in my body? ABC News, Health.

Kennedy, G. J. (2008, March 6). How effective is lithium in treating various stages of bipolar disorder, and is it good for all cases? ABC News, Health.

Mercke, Y., Sheng, H., Khan, T., & Lippmann, S. (2000, March 12). Hair loss in psychopharmacology. Retrieved August 24, 2012.

NHS Foundation Trust. (2012, July). Lithium citrate. Retrieved August 24, 2012.

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