To kick off my series of medication reviews, I have to start with lithium. It has a certain symmetry that is almost beautiful: it saves my life every day by reducing the amplitude of my bipolar symptoms, yet in excess, it almost took my life. I couldn’t get the metallic taste out of my mouth for weeks. Here’s the thing: if you’re bipolar 1, there’s a good chance that it’s the single most effective medication out there. It is for me. That’s why 6 weeks after the overdose in 2018 I was put back on it. At one point, the pharmacy was dispensing it to me weekly.

Lithium is so effective for some people, and not for others — so, researchers talk about “lithium responders” and “nonresponders”. There are certain subgroups of people who tend to be responders. For some reason that is not entirely clear, people who have manias before depression are more likely to be responders than people who have depressions before mania (and most people are consistently one or the other).

Lithium is all-natural. It comes from the earth; it is mined for use in batteries. Discovery of lithium’s mood stabilizing properties in 1949 (though I’ve heard that indigenous Americans once soaked their mentally ill in lithium-rich hot springs) was a happy accident. Yet it has nearly as long been known to cause kidney damage, thyroid damage, diabetes, and more. I have a skin condition called hidradenitis suppurativa that was likely caused by lithium. It causes my inner thighs to develop painful lumps that turn into bleeding lesions, and occasionally develop a secondary infection of the skin and soft tissue.

As terrible as all of that is, I don’t feel I could be living the life I live today without being on lithium. I take 1200mg daily, though the dose is measured by blood level, so one person’s 1200 could be another person’s 1000, or something like that. It has enabled me to recover from the state I was in around 2018, to stay out of the hospital and out of trouble.

Lithium’s mechanism of action is quite complex. It alters the activity of voltage-gated channels throughout the brain. There are no other drugs closely related to lithium, or that share its mechanism of action. Pharmaceutical companies haven’t been able to improve upon it. It remains unique in its treatment of bipolar disorder. One of its more notable clinical features is that it reduces suicidality. It’s ironic to note lithium’s high potential for toxicity.

A common side effect of lithium is tremor. I notice it mostly in my hands; they shake and it’s difficult to eat with a spoon. Interestingly, in toxic situations, the tremor can get much worse. Lithium toxicity also causes profound nausea and vomiting. Toxicity can result from dehydration, or even from travel from a low elevation to a higher elevation. But it’s not just the narrow band between therapeutic and toxic doses that makes lithium deadly — it’s the fact that there is no antidote to lithium toxicity, and lithium doesn’t bind to activated charcoal like most other drugs. Only with hemodialysis can lithium be removed from the body.

What to do if you’ve been prescribed lithium? Drink a lot of water, and wait 1-2 weeks to really feel the difference. Lithium has been absolutely lifesaving for many people. Maybe it will be for you.