Lithium (Eskalith)

What lithium is

Lithium is a medication sold under brand names such as Eskalith and Lithobid. It is one of the oldest and most studied medicines in psychiatry, and it is actually a simple mineral salt rather than a manufactured compound. It is used mainly 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, 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.

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 the right amount of fluid, not the most you can manage. Steady beats heavy here. 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, and that is a good moment to check in rather than wait.
• Check before adding over-the-counter pain relievers like ibuprofen or naproxen, and tell your clinician about any new medicines, including 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 these changes are usually manageable when caught early.

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, which needs prompt attention.
• 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

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.

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?