Lithium (Lithobid)

What lithium is

Lithium, dispensed as lithium carbonate, is sold as a generic and under the brand name Lithobid. It is the original mood-steadying medicine in psychiatry, studied for decades, and its active ingredient is a simple salt of a naturally occurring element rather than a designed molecule. It is used both to treat manic episodes and to steady mood over time. Because the amount that helps and the amount that is too much sit closer together than with most medicines, lithium is used carefully, with regular blood tests that keep it in a safe and helpful range.

What it treats

Your clinician might suggest lithium for one of these, among other possible off-label uses:

• Bipolar disorder, both to calm manic episodes and to help keep mood steadier over the long run
• Depression, sometimes added to another medication when it has not done enough on its own

Lithium is also one of the few medicines with long-standing evidence for lowering the risk of suicide over time, though not every study agrees, which is part of why it is still so widely used. Whether it is a good fit depends on several factors, including your history and your kidney and thyroid health. As with everything in psychiatry, that is decided case by case.

Who should not take lithium. FDA labeling lists one firm exclusion: a known allergy to an ingredient in the tablet or capsule. Beyond that, the label says lithium should not be used when the kidneys are severely impaired, because the kidneys are how lithium leaves the body, and that it should be avoided in people who have, or may have, Brugada syndrome, an inherited heart rhythm condition. Tell your clinician if you have kidney disease, if you have fainted without explanation, or if anyone in your family has Brugada syndrome or died suddenly and unexpectedly before age 45. Milder kidney problems do not rule lithium out, but they change the dose and how closely levels are watched.

How it works

Honestly, no one knows with complete certainty how lithium works, and here that is even more true than usual: despite being used for decades, its exact mechanism is still not fully understood. What research supports is that it acts inside nerve cells in ways that seem to steady the signals involved in mood, and that for many people this translates into fewer and less severe swings over time. The biology is only part of the picture: how much a medication helps, and how it feels, is individual. Two people on the same medication can have very different experiences.

How to take it

There is no single right way to take lithium; it depends on you and your clinician. What matters most with this medicine is steadiness, taking it consistently and keeping your body's fluid and salt balance fairly even, because big changes there can change your lithium level. The plan you and your clinician make together is the one to follow, not a number you read online. A few points matter here:

• Take it the way you and your clinician agreed, and keep your regular lab appointments. The blood tests are how we keep the level in a safe and helpful range.
• Aim for enough fluid to stay well hydrated, and keep it steady day to day. Getting dehydrated pushes your lithium level up, so that is the direction to watch, but drinking far more than you used to is also a change, and the goal is a consistent daily habit rather than a number you set for yourself. Ask what a reasonable amount looks like in your case.
• Keep your salt intake steady too. Your body handles lithium and sodium in similar ways, so cutting back sharply on salt can push your lithium level up. Large swings in either direction are what to avoid, which is why it is worth mentioning a new low-sodium diet, a cleanse, or any big change in how you eat before you start it.
• Tell your clinician when you are sick. Heavy sweating, a fever, or a stomach bug with vomiting or diarrhea can raise your level quickly. Contact your clinician the same day, because the dose may need to be held or lowered until you are well.
• Check before adding over-the-counter pain relievers like ibuprofen or naproxen, and tell your clinician about any new medicine, especially water pills (diuretics) and blood pressure medicines, since some of these can raise your lithium level.
• If you miss a dose, ask your clinician or pharmacist what to do rather than doubling up.
• Try not to stop on your own, and if you do stop, try not to stop abruptly. Stopping lithium suddenly is linked with symptoms returning sooner than they do when it is lowered gradually over several weeks. Deciding you are done with lithium is a fair conversation to have, and it is one worth having before you stop rather than after.

What to expect

This varies from person to person. For mood steadiness, the benefit usually builds over weeks rather than appearing right away, while some side effects, if they happen, show up earlier and often ease as your body settles. Early on, your clinician may check your level more often while the dose is found, then less often once things are steady. If it does not turn out to be the right fit, that is useful information, not a dead end, and there are other options. As always, this is case by case.

Side effects

Not everyone gets side effects, and many that do happen ease as your body settles. The lists below are possibilities, not certainties.

Possible more common side effects:

• A fine trembling of the hands
• Increased thirst and needing to urinate more often
• Nausea or mild stomach upset, especially early on
• Acne, or a flare of acne you have had before
• Weight changes
• Feeling slowed down, or mild fogginess
• A metallic taste, or changes in appetite

If any of these stick around or bother you, they are worth raising. Send a non-urgent message through the patient portal or bring it up at your next visit; often a small change helps.

Acne deserves its own mention, because it is common enough to matter and it is the kind of side effect people tend not to bring up. It is not vanity to care about it. If it shows up, say so, and say how much it bothers you, because that changes what we do about it. Before you start any acne treatment, including one a dermatologist prescribes, check with your clinician first: some of them interact with lithium or affect mood, and that is a conversation worth having in advance rather than after the fact.

Two slower changes are worth knowing about, because they are part of why we monitor: over time lithium can affect the thyroid and the kidneys. That is exactly what the periodic blood tests are watching for, and catching them early is what lets us act on them, and some, like thyroid changes, are straightforward to treat.

Less common, but concerning side effects that could require emergency care:

• Signs that your level may be too high: a coarse or worsening tremor, ongoing vomiting or diarrhea, unsteadiness or trouble walking, slurred speech, confusion, or unusual drowsiness. Lithium has a narrow safe range, and these can be signs of lithium toxicity. Stop taking lithium and contact your clinician right away, or get emergency care if the symptoms are severe.
• Fainting, a seizure, or an irregular or pounding heartbeat
• Signs of an allergic reaction: rash, hives, or swelling of the face, lips, tongue, or throat
• Any new or worsening thoughts of harming yourself, whether or not you think the medication is behind it

For any of these, use the help options at the top of this page: call 911 or go to the nearest emergency department for a medical emergency or severe reaction, or call or text 988 for a mental health crisis.

Pregnancy and breastfeeding

If you are pregnant, thinking about it, or breastfeeding, this is worth going through together rather than settling from a page. What follows is what FDA labeling and the research currently show. Tell your clinician before changing anything, and do not stop suddenly on your own.

Tell us early, because the plan changes

The amount of lithium you need can change during pregnancy, so the blood tests you already know become more frequent and the dose is adjusted along the way. FDA labeling also describes lowering or pausing lithium in the last days before delivery, to reduce the chance of lithium toxicity in you or the baby, and restarting it afterward with close monitoring of your level. These are planned moves rather than signs that something has gone wrong.

What this asks of you is mostly timing: tell your clinician as early as you can if you are pregnant or trying, so the plan is in place rather than being caught up with. If you find out you are pregnant, call rather than stopping on your own.

In pregnancy

FDA labeling states that lithium may cause harm to a developing baby. The main question is the heart. Early reports to birth registries suggested more heart defects after lithium use in the first trimester, especially a rare one called Ebstein's anomaly. Later studies indicate that the increase is likely to be small, and the label describes the data as not enough to settle it. For scale, about 2 to 4 in 100 babies are born with a major birth defect before any particular exposure is considered.

Because of the heart question, the label suggests considering a detailed ultrasound of the baby's heart between 16 and 20 weeks when lithium was taken in the first trimester.

A few other findings come up often enough to name:

• Preterm birth and birth weight. Some studies suggest a higher chance of delivery before 37 weeks. Findings on birth weight are mixed: some studies report heavier babies and low blood sugar after birth, and others find no difference. Lithium has not been linked to low birth weight.
• Your thyroid. Lithium can lead to an enlarged or underactive thyroid during pregnancy, and there are case reports of the same in exposed babies. It is a reason to keep up thyroid blood tests through pregnancy.
• Later learning and behavior. Small studies of children aged 3 to 15 who were exposed to lithium during pregnancy did not find meaningful differences in physical, mental, or behavioral problems compared with children who were not exposed.

Symptoms in the newborn. A baby exposed to lithium late in pregnancy can have signs of lithium toxicity in the first days. These can include floppy muscle tone, unusual sleepiness, trouble feeding, trouble breathing or pauses in breathing, a bluish tinge to the skin, yellowing of the skin (jaundice), and a slow heartbeat. These have mostly been reported when lithium was taken close to delivery, especially when the mother's own lithium level was high, and not every exposed baby has them. The label describes watching and supporting these babies until the lithium clears, which may take up to 14 days. The useful thing you can do is make sure the delivery team knows about the medication ahead of time, so someone is watching for it.

While breastfeeding

Lithium passes into breast milk, and how much reaches the baby varies a lot from one person to the next. The sources do not agree here, and it is better to say so plainly. FDA labeling says breastfeeding is not recommended while taking lithium, and that if you choose to breastfeed, the baby should be watched closely for signs of lithium toxicity. LactMed, the National Institutes of Health lactation database, notes that lithium appears on some lists of medicines to avoid during breastfeeding, but that most sources do not treat that as absolute for healthy babies born at full term, especially babies older than 2 months and when lithium is the only medication. It describes lithium as usable by mothers of full-term babies who are willing and able to monitor them.

What is known: there are numerous reports of babies breastfed during lithium treatment with no signs of toxicity or developmental problems, some for up to a year. The reports of harm cluster around situations where a baby clears lithium poorly: newborns, babies born early, and babies who are dehydrated or sick. The long-term effects are not certain; the limited data show no obvious problems in growth and development.

If you do breastfeed, monitoring is part of it. Both sources describe checking the baby's lithium level and thyroid function, and LactMed adds kidney tests. Sources differ on how often, so that gets set with your baby's clinician. What to watch for in your baby: unusual sleepiness, restlessness, feeding poorly, stiff muscles, a bluish tinge to the skin, or feeling cold. A baby who is sick or not feeding well can become dehydrated, which raises the lithium level, so call the baby's clinician promptly rather than waiting. If your baby is hard to wake, has trouble breathing, or looks blue, get emergency help now.

If you are a man taking lithium

There are reports of lower sperm quality and less sperm movement in men taking lithium, and one of those reports found no effect on the ability to father a pregnancy. A father's use of lithium is not expected to raise risks to a pregnancy.

When to reach out, and where

For routine questions, side effects that can wait, or how things are going, send your clinician a message through the patient portal. These are part of your ongoing care and are answered in the normal course of a few business days, so they are best for things that are not urgent.

If something feels urgent, you do not need to wait for a reply. The help options at the top of this page are the fastest way to get care: 911 or the nearest emergency department for a medical emergency or severe reaction, or 988 any time for a mental health crisis or thoughts of self-harm.

Questions to ask your clinician

• What are you hoping lithium will help with in my case?
• How often will I need blood tests, and what are they checking?
• How much fluid and salt is about right for me, and what would count as a big change?
• What should I do if I get sick with vomiting or diarrhea, or during very hot weather?
• Which other medicines or pain relievers should I check with you about first?
• If I get acne from it, what would we try?
• What is the plan if this one turns out not to be the right fit?
• How will we handle stopping it, if and when we get there, and how gradually?