How does lithium work?

Ah, lithium; it’s been our gold-standard treatment for bipolar disorder for many years, and can work for people who have failed other drug trials. It is also one of the only drugs known to decrease the risk of suicide1. But how does it work?

It’s a bit more complicated to understand than, for example, an SSRI (which, ultimately, increases serotonin in the synapse, through a fairly intelligible mechanism of stopping reuptake). Despite knowing since 1949 that lithium was an effective treatment for bipolar disorder, we still don’t fully understand its mechanism of action.

There are a lot of signalling pathways in the brain.

One of the difficulties in determining this is that lithium goes everywhere in your body. Within the brain, it can cause an absurd number of changes through numerous signalling pathways. Like other drugs, it can cross the brain-blood barrier (an important quality for psychiatric medications, since they target the brain) but, uniquely among psych meds, it can also enter your intracellular space — hiding inside your cells, instead of just floating around in your blood.

It is excreted by the kidneys in urine, although it is also known to be excreted in human sweat and tears2. (I’ve had hyper-salty tears caused by lithium every so often.)

Lithium appears to increase the concentration of some neurotransmitters (potentially serotonin and GABA) while moderating the effects of dopamine and norepinephrine through its effects on voltage-gated channels3. This action causes a broad cascade of effects throughout the entire brain that restores balance in people with bipolar disorder. Lithium can get into any cell in your body, and it goes inside your neurons (brain cells) too. This is how it affects voltage-gated channels and moderates the activity of all neurotransmitters.

Although we usually call it a mood stabilizer, it’s not related to any other drug we put in this class, since it is not an anticonvulsant. Lithium is probably most accurately classified as a neuroprotective drug4, like memantine (a drug typically used for Alzheimer’s disease). There is even some speculation that memantine could augment the effect of lithium, due to its similar mechanism of action, but specific to the NMDA receptors.

A key point to understanding the pharmacodynamics of lithium is that lithium, in the human body, can use the same transporters as sodium. It fits where sodium should go — therefore, it exits cells through active transport systems designed for sodium, but at about half the speed of sodium. The similarity of lithium and sodium explains why lithium is excreted by the kidneys and not metabolized by the liver.

a) lithium salts; b) sodium salts

This is also why activated charcoal will not absorb lithium. Your body sees it as a metallic salt (it has a positive charge), and metals (or charged ions) are not attracted to charcoal. In addition, the similarity of sodium and lithium creates a sort of sodium-lithium ecosystem in your body; if you maintain a steady dose of lithium but drastically reduce your intake of sodium, your lithium levels can rise to toxicity.

References

  1. Kessing, L. V., Søndergård, L., Kvist, K., & Andersen, P. K. (2005). Suicide risk in patients treated with lithium. Archives of General Psychiatry, 62(8), 860–866. https://doi.org/10.1001/archpsyc.62.8.860
  2. Fraunfelder, F. T., Fraunfelder, F. W., & Jefferson, J. W. (1992). The effects of lithium on the human visual system. Cutaneous and Ocular Toxicology, 11(2), 97–169. https://doi.org/10.3109/15569529209042704
  3. Lenox, Robert H., H. C.-G. (2000). Overview of the Mechanism of Action of Lithium in the Brain: Fifty-Year Update. 61.
  4. Gray, J. D., & Mcewen, B. S. (2013). Lithium’s role in neural plasticity and its implications for mood disorders. Acta Psychiatrica Scandinavica, 128(5), 347–361. https://doi.org/10.1111/acps.12139

Happy World Bipolar Day!

I am bipolar type 1. 🎭 That is the most severe form of bipolar disorder. (Bipolar 2 can have very severe depression, but because it doesn’t have severe mania it doesn’t progress along the same course. Something like that.) I’ve been inpatient 18 times, and I’ve been discharged from the ER a few additional times as well.

Interestingly, I don’t have what most people would think of if you said “classic bipolar disorder”. I have mostly dysphoric manias (and sometimes euphoric hypomania), so no grandiose delusions or belief that I can see the flow of energy that connects all things. Just bugs that… may or may not be real. 🐜 But, the dysphoric mania type is actually sliiiiiightly more common than euphoric (feel-good) mania in real-world bipolar 1 people, according to one study1

The main reason my bipolar is unusual is that it is so FAST. My psychiatrist describes it as “brittle” — a medical term often applied to highly unstable diabetes patients, where blood sugar skyrockets but then drops with intervention but then skyrockets again. It follows the same kind of course.

Blood sugar in brittle diabetes

Usually, I think my cycle (including both mania, which almost always comes first for me, and then depression — most bipolar people have one type of episode almost always come first, but it’s a 50/50 split which one2) is 2 to 4 weeks long. If it’s a lot faster than that it’s considered a mixed episode.

I rarely ever have euthymic (normal mood) periods and I don’t have any asymptomatic periods. (I have persistent problems with memory and executive functioning and other stuff.) 

💊 Currently every day I take: lithium, Thorazine (chlorpromazine), Zyprexa (olanzapine), Valium (diazepam), and Adderall (amphetamine salts). 💊

What causes bipolar disorder?

A lot of research links bipolar disorder to various things:
a) circadian instability, sleep problems ⏰
b) inflammatory processes in the brain 🔥
c) epilepsy 📈 — they have a lot in common, and medications used to treat epilepsy are often used to treat bipolar disorder; I think you can think of bipolar as being similar to some kind of epileptogenic brain activity but on a more macro scale. Similarities to Temporal Lobe Epilepsy include age of onset and genetic cause among other things and they do have a very very high comorbidity rate.
d) genetics 🧬 — 97% of bipolar disorder is explained by genetic variance alone and it is more heritable than autism or schizophrenia (I believe it might be the most heritable psychiatric disorder in DSM-5)

Most people get bipolar disorders in their 20s, but I got it early. I had suicidal depression sometime before the age of 10 and had my first clear hypomanic episode when I was 16. My parents were anti-psychiatry, so I wasn’t in treatment until I went to college and I almost became an emancipated minor because I was still 17 and it was that serious 🙃

Unlike autism, which is a fairly new concept (although autistic people have almost certainly existed for thousands of years) bipolar disorder is a very old idea for a distinct illness that occurs in all cultures that I know of. Other English names for it have been “manic depression” (a term I actually prefer), “manic-depressive psychosis”, “circular insanity” 🔁, all referring to a highly organized and unusually patterned occurrence of severe disturbances in mood.

That’s actually what I study now in my PhD program! I’m looking for patterns in bipolar disorder. I’m very good at patterns 🧩

References

1.  Grant BF, Stinson FS, Hasin DS, et al. Prevalence, correlates, and comorbidity of bipolar I disorder and axis I and II disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2005;66(10):1205-1215. doi:10.4088/JCP.v66n1001

2. Koukopoulos A, Reginaldi D, Tondo L, Visioli C, Baldessarini RJ. Course sequences in bipolar disorder: Depressions preceding or following manias or hypomanias. J Affect Disord. 2013;151(1):105-110. doi:10.1016/j.jad.2013.05.059


Bipolar disorder and media consumption

Recently, on Twitter, I confessed that I had not been able to complete reading NeuroTribes (a very interesting book, and also a lengthy one). The other person insisted that a PhD student should be able to read a book and accused me of lacking academic integrity — basically, that I am lazy and don’t deserve my PhD.

I’m here to say that attitude is inherently ableist. But to give the benefit of the doubt, perhaps most people don’t know that bipolar disorder actually can affect your ability to read. I learned to read early as a child — I was a prolific consumer of text, and I had a college reading level in elementary school (this is called hyperlexia). But after being medicated for bipolar disorder, my ability to sustain focus and momentum while reading a long document has been very limited.

Lithium is probably the biggest offender. It kind of affects how you see words on the page — like a pseudo-dyslexia, the words seem kind of blurry and distorted. It can be impossible to read full books. I can still read journal articles because they generally have a defined structure and an abstract. I can also read poetry, which I enjoy. I recommend seeking out these kinds of texts if reading is something you struggle with.

Most of all, I want you to know that this is common, you are not alone in having an acquired inability to read and you still deserve your career, whatever that may be. It’s not a matter of “intellectual thoroughness”; it’s part of a disability, and it’s more common than you think.

I also find it difficult to watch videos, TV, or movies. The information conveyed through video media covers many modalities — sound (music), speech, visuals, movement (spatial), and the overall plot you’re supposed to be following. Sitting for the length of a movie is hard, but it’s also just hard to follow so many things at once. My brain gets overwhelmed with too much information of different kinds to process (evidence of poor sensory integration, a symptom of autism). But it helps to reduce the overload by using captions (combining speech with visuals, thus reducing the number of information modalities) or watching something animated, which compresses the demands of visual and spatial information greatly.

Have you ever had trouble consuming media?

What strategies have you used?


Anxiety and mania

Recently, The Mighty published an article about the differences between anxiety and hypomania. However, I wanted to complicate the discussion by bringing up something that breaks the juxtaposition of anxiety and mania: primarily anxious mania, which is most likely a mixed episode associated with bipolar type 1.

The author describes how her anxiety leaves her “immobilized”. This can actually happen in mania, too — but usually not in hypomania. Hypomania is often very productive. Full mania is no longer productive — it’s frantic, potentially confused, and may be characterized by manic stupor. Emil Kraepelin used this term to describe a flight of ideas and elevated mood (not necessarily happy, but revved-up) combined with psychomotor slowness or immobility. I’ve been in this state, and I experienced it subjectively as intense feelings of anxiety paralyzing my every move. This might also be referred to nowadays as catatonia, and something similar can occur in severe depressive states; however, the catatonia that coincides with mania is likely excited catatonia (characterized by purposeless movements rather than being completely still).

Hypomania isn’t rare, exotic, or exciting to me. It’s just part of my life, and I take advantage of it when it comes around — which it will, no matter what. But, to me, full mania is to be avoided. Anxiety is also a daily part of my life, but the anxiety and paranoia I experience during a manic episode is even more excruciating than it usually is. Juxtaposing them as discrete, separate states can only take you so far in understanding what mania is and how it affects people.


Was Vincent van Gogh autistic?

There’s no doubt in my mind that Van Gogh had bipolar disorder. He had many symptoms related to bipolar disorder: manic episodes, depressive episodes, hallucinations, sleep disturbance, substance abuse, memory problems, nightmares, and anxiety, to name a few from his asylum files.

Yet, additional diagnostic labels could help to clarify his overall presentation. One diagnosis that has been put forward is BPD. It does seem to explain some of the events of his life, for example, his heated interpersonal conflicts and fears of abandonment related to Paul Gauguin. However, a diagnosis of autism has not been seriously considered. This is interesting in light of the heightened prevalence of bipolar disorder in autism — an autistic person is as much as 8.5 times more likely to have bipolar disorder than a non-autistic person (this number assumes no intellectual disability and a diagnosis before age 28).1 Another study found that 7% of autistic people also had bipolar disorder.2

As a child Van Gogh was described by his younger sister as “intensely serious and uncommunicative, and walked around clumsily as if in a daze, with his head hung low”, and went on to say that he was like a stranger both to his siblings and to himself. A servant said he was “an odd, aloof child who had queer manners and seemed more like an old man” than a child.3 These are characteristics often ascribed to some autistic children, even poor motor coordination (dyspraxia).

Vincent was deeply intelligent, thoughtful, and demonstrated what seemed like the capacity to be successful, but as a young man he struggled to find a vocation that could accommodate him. He drifted from an art dealership (where he was fired for arguing with buyers), to a teaching job, to a minister’s assistant for a Methodist church, to a bookshop where he reportedly doodled and translated parts of the Bible into English, French, and German, to religious studies. He failed his entrance exam in theology and his missionary course. Religion was a special interest for Van Gogh. He was endlessly devoted and passionate about the subject, but his odd behavior made him an ineffective preacher, and he was not a good student.

Van Gogh had severe social problems which seem to have started early in his life. People repeatedly thought that he was odd, and they didn’t want to be around him. His peculiarities were off-putting. Children were scared of him. Scholars suggest that he did not understand the concepts of diplomacy or salesmanship, that he lacked insight into the thought processes of others, and lacked the ability to cognitively understand their emotions and motivations.3 He was emotionally dysregulated and prone to agitated or impulsive meltdown behaviors. As his interest in painting became more intense and all-consuming, he neglected maintenance of his body or appearance, appearing even more eccentric.

One of the highlights of Van Gogh’s medical files that has yet to be parsimoniously explained is his chronic stomach issues. In particular, gastrointestinal problems seem to be an important feature of autism4 although bipolar disorder may also be related to stomach problems.

Vincent van Gogh (Dutch, 1853 – 1890 ), Green Wheat Fields, Auvers, 1890, oil on canvas, Collection of Mr. and Mrs. Paul Mellon

Finally, there’s the most obvious trait of Van Gogh’s: his artistic ability. Many people have suggested that Vincent might have had some form of synesthesia. Further, I hypothesize that hue discrimination may, like pitch discrimination, be enhanced in some autistic people.5

A diagnosis of autism didn’t exist in Van Gogh’s time — in fact, wouldn’t exist for over 50 years after his death. Perhaps it’s not so surprising that the autism connection has been overlooked. Vincent van Gogh’s wild, reckless nature combined with intellectual and artistic sensibilities (and lack of mathematical talent) defies narrow stereotypes of autism, yet embodies a certain reality of it: he was thoughtful yet lacked insight, seen as a stranger by the world around him while experiencing the world as fundamentally strange, and possessed incredible gifts yet was understood as deficient. Maybe it’s time to look beyond famous scientists and mathematicians for autistic historical figures.

References

1. Selten J-P, Lundberg M, Rai D, Magnusson C. Risks for nonaffective psychotic disorder and bipolar disorder in young people with autism spectrum disorder: A population-based study. JAMA Psychiatry. 2015;72(5):483-489. doi:10.1001/jamapsychiatry.2014.3059

2. Skokauskas N, Frodl T. Overlap between autism spectrum disorder and bipolar affective disorder. Psychopathology. 2015;48(4):209-216. doi:10.1159/000435787

3. Butterfield, B. The Troubled Life of Vincent Van Gogh. Vincent van Gogh website. September 21, 2002. Accessed May 24, 2020.
http://www.geocities.com/Paris/Louvre/9633/VincentVanGogh.htm

4. Adams JB, Johansen LJ, Powell LD, Quig D, Rubin RA. Gastrointestinal flora and gastrointestinal status in children with autism – comparisons to typical children and correlation with autism severity. BMC Gastroenterol. 2011;11. doi:10.1186/1471-230X-11-22

5. Heaton P, Williams K, Cummins O, Happé F. Autism and pitch processing splinter skills: A group and subgroup analysis. Autism. 2008;12(2):203-219. doi:10.1177/1362361307085270


What do mixed episodes feel like?

For me, mixed episodes are the worst part of my bipolar disorder. It’s hard for people without bipolar disorder to comprehend how it could be that you feel mania and depression at the same time. It doesn’t have to be simultaneous, per se — it could just be very quickly alternating — but for me it is, at times, simultaneous.

In actuality, mixed episodes aren’t rare. The most common presentation of bipolar 1 disorder is a combination of depression and mixed episodes (32%), followed by the combination of depression and manic episodes (30%; Grant et al., 2005). Mixed episodes are also common in bipolar 2 disorder (Benazzi et al., 2004) although, understandably, these tend more towards the depression side.

To understand my own mixed episodes, I draw a distinction between physical and mental energy. Mania typically involves high levels of both physical and mental energy: you feel physically great, you never seem to get tired, and your thoughts and ideas might be racing around in your head. In contrast, depression involves low physical and mental energy: you’re tired and sluggish, you might be in pain, and your thoughts feel jammed like a printer that just won’t print.

Your brain on depression.

My own mixed episodes tend to feature low physical energy and high mental energy. I can’t sleep at night because my thoughts keep me awake, but instead of feeling ready to go in the morning, I feel tired and miserable. I may pace around because of all the energy inside my head, but my body aches constantly. I tend to become very preoccupied with suicide. Mixed episodes are the most dangerous time for me.

I also might have hallucinations during mixed episodes, and they’re distinctly unpleasant. One that recurs for me is the bugs. I start out by feeling them crawling on my skin, particularly when I lie down in bed to try and sleep at night. No matter how many times I meticulously check my pillow, I can’t find any bugs, but I know they’re there (and know they’re not there — simultaneously). At times, though, this has progressed further to actually seeing bugs everywhere around my apartment, and not being able to tell which are real and which are imagined (because there probably were some real bugs). I once came to the conclusion that not all of the bugs could be real because there were simply too many different species living in my studio apartment. On another occasion, I heard voices mocking me from inside my dishwasher.

Other times, I acquire some delusional or near-delusional beliefs. I have been absolutely convicted that I had AIDS in one instance, Parkinson’s disease in another. I don’t have either of these diseases, but I couldn’t be dissuaded from my belief, at least in the moment. When I believed I had AIDS, I even started writing goodbye letters.

Though I’ve never departed too far from reality, personally — just wandered a little bit astray. I’ve been underwater, but always close enough to see the light on the surface. Some people experience psychosis in a much more encompassing way. Hallucinations and delusions can be truly terrifying, even life-changing experiences. Mine seem a bit mundane in comparison. No angels, no demons… just bugs.

To my horror, I’ve probably seen most of these at some point.

One could also envision a mixed episode with high physical energy and low mental energy. This might result in a kind of catatonic state, probably an agitated catatonia. This is considered a very dangerous state in its own right because catatonic patients are less than fully conscious of their actions, and if they are very agitated, they could pose a risk to themselves and others around them.

Do you have mixed episodes? How do you understand them?


Benazzi, F. (2007). Bipolar disorder — focus on bipolar II disorder and mixed Benazzi, F., Koukopoulos, A., & Akiskal, H. S. (2004). Toward a validation of a new definition of agitated depression as a bipolar mixed state (mixed depression). European Psychiatry, 19(2), 85–90. https://doi.org/10.1016/j.eurpsy.2003.09.008

Grant, B. F., Stinson, F. S., Hasin, D. S., Dawson, D. A., Chou, S. P., Ruan, W. J., & Huang, B. (2005). Prevalence, correlates, and comorbidity of bipolar I disorder and axis I and II disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 66(10), 1205–1215. https://doi.org/10.4088/JCP.v66n1001


Memory in bipolar disorder

People with bipolar disorder commonly have memory problems. This is actually something I’ve been doing research about as a PhD student at UCLA. Not only that, it’s something I struggle with myself.

There are two main categories of memory problems in bipolar disorder: problems that are associated with a mood episode, and problems that exist outside of mood episodes (during euthymia, or well periods).

During episodes of depression, problems with explicit memory are common. That’s the kind of memory you’re using when you try to recall facts or events — in contrast to implicit memory, which includes emotional learning (conditioning) and procedural learning (like learning how to ride a bicycle). Implicit memory tends to be preserved, but depressed people struggle to explicitly remember things. For example, trying to remember the names of past presidents might become extremely effortful. This is actually the same for unipolar depressives. Controlling for the severity of depression symptoms, bipolar and unipolar depressives are very similar in the area of memory performance (Bearden et al., 2006).

Multiplication tables might be very difficult for a depressed person to recall

Memory impairments are more pervasive in manic episodes. Research has found that during a manic episode, people perform more poorly at tasks requiring episodic memory (the kind of memory you use when you remember a scene you’ve lived through, typically from a first-person perspective), working memory, spatial attention, and problem solving (Sweeney et al., 2000). Many people who have experienced manic episodes have a great deal of difficulty remembering what happened during the episode. It’s possible that mania disrupts the encoding of new memories (King et al., 2013). For some of us, this is a double-edged sword: it’s painful to remember, and yet it’s painful not to remember. Sometimes we’re left trying to piece together what actually happened while simultaneously part of us is trying to move on from it. Even worse, sometimes other people remember better than you do.

Problems with episodic memory aren’t limited to mania, though.

Various studies have shown bipolar people who are euthymic (not currently having a mood episode) to perform poorly at memory-related tasks. Problems with executive functioning frequently come up — these problems can be similar to people with ADHD. But one of the most noteworthy findings is impairment in episodic memory about one’s own life. In particular, it seems like memory for specific events is impaired, but memory for personal facts (like one’s name or birthday) are not affected (Shimizu et al., 2009).

It’s hard for me to remember a lot of things I’ve lived through. Not infrequently I meet people who tell me we’ve met before, but I have no idea who they are. I have friends that I don’t remember how or where we met. Even memories I’d like to keep seem not to stick very well, which is saddening. I forget most of what happens after a year or two. Sometimes the things I do remember are a little strange. According to my psychiatrist, I have an incredible ability to know exactly how many times she’s told me the same story in the past, but I don’t remember the contexts I heard it in.

I feel like my psychiatrist would relate to this

One study (King et al., 2013) found that when they asked bipolar disorder patients to recall memories from their life, they were more likely to recall those memories from a third-person or observer perspective. It makes me wonder why that is. It’s like the people with bipolar disorder can’t remember being in their own head, even if they can “see” what happened in their memory. Something is disconnected between their past and present minds. They specifically can’t remember being themselves.

Bipolar disorder can be so much more than having emotional “ups” and “downs”. For some people bipolar disorder affects us every day and changes how we live life. Many people don’t realize how memory problems can affect us. When I write, I write about the present at least as much as I write about the past, because I know how transient the present really is.

Have you ever experienced something like this?


Bearden, C. E., Glahn, D. C., Monkul, E. S., Barrett, J., Najt, P., Villarreal, V., & Soares, J. C. (2006). Patterns of memory impairment in bipolar disorder and unipolar major depression. Psychiatry Research, 142(2–3), 139–150. https://doi.org/10.1016/j.psychres.2005.08.010

King, M. J., Macdougall, A. G., Ferris, S., Herdman, K. A., Bielak, T., Smith, J. R. V, … Mckinnon, M. C. (2013). Impaired episodic memory for events encoded during mania in patients with bipolar disorder. Psychiatry Research, 205(3), 213–219. https://doi.org/10.1016/j.psychres.2012.08.005

Shimizu, M., Kubota, Y., Mason, R., Baba, H., Calabrese, J. R., & Toichi, M. (2009). Selective Deficit of Autobiographical Incident Memory in Subjects with Bipolar Disorder. Psychopathology, 42, 318–324. https://doi.org/10.1159/000232974

Sweeney, J. A., Kmiec, J. A., & Kupfer, D. J. (2000). Neuropsychologic impairments in bipolar and unipolar mood disorders on the CANTAB neurocognitive battery. Biological Psychiatry, 48(7), 674–684. https://doi.org/10.1016/S0006-3223(00)00910-0


Best books for people diagnosed with bipolar disorder

When I was first diagnosed with bipolar disorder, my therapist gave me a book that changed my life. Books can influence how you understand your own bipolar disorder, and yourself in relation to it. I haven’t read every single book out there, but here are a few that I have read.

Welcome to the Jungle by Hilary Smith

Technically, this is a self-help book. It contains a lot of good information, tips, and recommendations. The thing I like about this book in particular is its humorous and lighthearted style. I read the original edition of this book, and I no longer have it because I gave it to someone else, but I still remember some of the bipolar jokes! I recommend this book to anyone who has just been diagnosed with bipolar disorder but doesn’t know much about it, and needs a source of information.

Manic by Terri Cheney

Manic is a memoir. Memoir can be so helpful, in my opinion, because it allows us to have insight into the lives of people who have faced similar struggles as us. This book describes itself as “visceral” — focused on the experience of mania and depression from a very subjective viewpoint. Cheney herself said the focus is “on what bipolar disorder felt like inside my own body”. Paradoxically, it becomes very relatable by just how idiosyncratic it is. I recommend this book to anyone who feels alone in their struggles with bipolar disorder.

An Unquiet Mind by Kay Redfield Jamison

This is the book that changed my life. As a freshman in college, it single-handedly inspired me to pursue a career in research, and specifically bipolar disorder — which is now my career. Jamison is an authority on bipolar disorder, but this book is not a textbook — it’s a memoir. In a display of great vulnerability (at the time, nobody could know if this book would end her career) Jamison tells the story of her life, from childhood to a breakdown shortly after completing graduate school, mania, psychosis, depression, and a serious suicide attempt. Throughout it all, Jamison interjects wisdom and knowledge. This book simultaneously provides both deep information about bipolar disorder and a revealing look into the life of somebody who lives with it. I would recommend it to anyone who with a curious mindset, who wants to know more about the science of bipolar disorder and the culture of academic psychiatry, as well as the personal experience of living with bipolar disorder from the perspective of an expert.

Have you read any good books about bipolar disorder? Feel free to leave a comment!


Should I be afraid to take lithium?

Lithium has a reputation. When I was first prescribed it, I felt a sense of fear and also — somehow — a sense of achievement, like I had won the lottery for crazy. When you hear about lithium, it’s often to stress that it is only for those top shelf mental illnesses; and it is good for that, however, it’s not necessarily true that you’re on the top shelf just because you’re starting lithium. A lot of people take lithium. On some occasions it might be the first medication tried. There are a few things to know about lithium in order to make truly informed choices about what you’re getting into.

It’s highly effective

Lithium is one of the most effective medications for bipolar disorder. Which medication is the best varies by person, and a lot of people have success with anticonvulsants like Lamictal. But for many people, the most effective medication is lithium, and its effectiveness has been well-documented for many years (it was first used in psychiatry in 1949). According to one study, about 30% of people who try lithium witness a complete recovery, while 60% see some improvement.

Unlike some other medications, lithium isn’t just a treatment for symptoms of mania; it actually prevents future mood episodes. Relapses become less frequent and shorter. There is some evidence that lithium has a protective effect in the brain.

Lithium has a decent chance of working for any type of bipolar disorder, but there are some people in particular who are very likely to be lithium responders. Those people tend to have:

  • Fewer hospitalizations prior to starting lithium
  • Later age of onset
  • An episodic course (moods cycle and then resolve for a while, as opposed to chronic cycling)
    • About 44% of people with an episodic course have complete remission on lithium, compared to 15% of people with a non-episodic (chronic) course.
    • In one study, 90% of lithium responders who experienced full recovery had complete remission of mood symptoms in between episodes before starting lithium.
  • Mania occurs before depression (mood cycling starts with mania)
  • Strong family history of bipolar disorder and/or a family history of lithium responsiveness
    • One study found that 35% of patients without a family history of lithium response had a complete recovery (similar to other studies mentioned), but among those with a family history of lithium response, that number jumped up to 67% full recovery.

Yes, you’ll get blood drawn

The dosage of lithium is based on how much lithium is in your blood, not how many milligrams are in the pill. The therapeutic window (the space in between the effective dose and the toxic dose) for lithium is much more narrow than most other drugs, so you’ll have to get blood tests frequently, especially when you’re still trying to figure out what dose is best for you.

If you’re afraid of needles, you will probably overcome that fear.

Because lithium blood levels are the most important factor in dosage, it’s probably pointless to try comparing doses with any bipolar friends. Their minimum and maximum dose is probably different than your minimum and maximum dose, so you’re working with two different scales. The middle of their dose range isn’t the middle of your dose range.

Side effects

No doubt, lithium has side effects. The good news is that if you find a low dose is effective for you, you might experience few or no side effects. If you’re on a high dose, it’s more likely that you’ll experience some side effects. These could include:

  • Hand tremors. This can make your handwriting different, and makes it very hard to put Jello in the fridge.
  • Nausea and vomiting. This tends to happen at quite high doses, and it may be a sign that your dose is too high; however, switching to the extended release version of lithium may help.
    • It’s worth noting that your dose can get too high for a variety of reasons, including dehydration; taking ibuprofren or other NSAIDs (you should probably switch to using acetominophen); or climbing a mountain and reaching a very high altitude. That last one hasn’t happened to me personally.
    • If you do actually vomit, it might be very aggressive vomiting and it always seems to come on suddenly.
  • Brain fog. Attention and memory problems come naturally to bipolar disorder, but lithium makes them worse. You may feel that your brain is just working really slowly, and it’s hard to concentrate or read. (Some people also have visual distortions on lithium that make reading even more difficult. I find it easier to read large print.)

In conclusion

Many people are afraid to take lithium, but some experts argue that it’s actually under-used today due to the public perception of it. So, in my opinion, it’s certainly worth trying. Most people won’t experience too many problems; if you’re on a high dose, you might experience some weird stuff, but to me it’s worth it for reducing my mood symptoms, and all of the weird stuff is manageable if you make some small adjustments to your life.

References

Tighe, S. K., Mahon, P. B., & Potash, J. B. (2011). Predictors of lithium response in bipolar disorder. Therapeutic advances in chronic disease2(3), 209–226. https://doi.org/10.1177/2040622311399173


What’s it like to be in a psychiatric hospital?

I’ve been hospitalized 17 times. At this point, it seems perfectly routine. I pack my carry-on suitcase, grab my Pikachu stuffie, and I’m on my way. I know what to expect. However, whenever I’m in the “psych corner” of the ER, there’s always someone being admitted for the first time, and they’re usually crying. I cried during my first admission, too — my therapist told the police to wait until I stopped to put me in the car. I’d read about the hospital online, but still, I didn’t know what to expect and I was very scared.

So, if you’re ever hospitalized, here’s what to expect.

Limited Choices

Where you can go, what you can do, and even what you can eat are very limited when you’re in the hospital. Psychiatric units vary in size and structure, but it will likely be smaller than you would like. Everyday choices are made manageable for people with acute psychosis or severe mood disturbance, which means there are not very many choices.

Here are some activities which are generally allowed, and which I personally recommend:

  • Reading books. The choices of books on the unit are likely to be very slim, so I recommend bringing your own books. Easy to read books may be for the best, as medications can make reading challenging; I enjoy middle grade and young adult fiction.
  • Talking on the phone with friends and family. There is always a phone. I have been in really outdated units where the phones were actual pay phones that required quarters… but in my experience, this is very rare. Phones are usually made unavailable during groups and meal times.
  • Talking to other patients. The other patients in the hospital are likely to be interesting. Some of them will seem “normal” and some of them won’t; a few may be very agitated or aggressive. Don’t be afraid of them, they don’t mean you harm and if things get out of hand the staff will know what to do. It’s a good opportunity to get to know other people with mental illness, and I’ve had many interactions which I’ve remembered for years.
  • Card games. Sometimes there are board games, which may or may not be in playable condition, but there is almost always a deck of cards. Playing cards is a great way to pass time and interact with other patients at a level that isn’t very demanding. I learned to play Rummy 500 in a psychiatric hospital!
  • Take a shower. It’s easy to forget that you need to shower when everyone is wearing pajamas and look like they’ve been in bed for a year, but showering is something that can affect how the psychiatrists see your level of functioning. It’s also a way to pass time in itself. Sometimes you can bring your own shower products and deodorant, which I do recommend because it will make it seem like you’re doing your whole routine.
  • Go to groups. There will likely be a few groups throughout the day, particularly on weekdays. They are likely to be somewhat simple and plain, which makes it so everyone can participate as much as possible. Going to the groups is probably the single biggest action you can take to expedite your discharge. It’s not the only factor and it won’t make a miracle, but it’s worth a try.
  • Go outside. There will be some kind of small outside area. Sometimes it’s on the roof, sometimes it’s a courtyard or a fenced-in patio. You can usually go outside at designated times during the day, weather permitting.

What to bring and what not to bring

Hospitals do vary in their policies and if possible, you can look up their website or call in advance to see what they allow. But this often isn’t possible because when you go to an ER for psychiatric reasons, you could be (and often are) sent to a completely different hospital. Therefore, use your best judgement and pack what you can. I pack a small roller suitcase so that I can fit everything I want.

  • Don’t bring electronics. Cell phones will not be allowed, nor laptops or tablets, or anything that has the ability to take photos, record videos or audio, or access the internet through a browser. However, there are a few exceptions which may be made at some hospitals — UCLA has allowed me to bring old Game Boy consoles, which aren’t capable of anything except playing the inserted cartridge; a basic Kindle e-reader; and an MP3 player with Bluetooth headphones, no wires and nothing with any of the aforementioned capabilities. Bring chargers for your phone and any of these items if you bring them, but be aware you won’t be allowed to charge in your room and staff will supervise your items while charging. (P.S. I’ve heard that electronics are allowed in the UK, so I can only speak for the US.)
  • Bring a light jacket. If you live in a cold climate, you can also bring an outside jacket, but you will want a light jacket for inside the hospital because it’s usually a little bit cold in hospitals. If you bring a hoodie, make sure it does NOT have strings; the same goes for sweatpants and shorts. Strings will probably not be allowed.
  • Bring clothes that make you feel normal. Some people will specifically say to bring comfortable, casual clothing. That is a good idea, but I think the most important thing is to bring clothes that make you feel like yourself, because it’s very easy to feel disrupted when you’re in such a different environment than your usual life. Don’t wear a tuxedo or a $500 designer item, because you’re probably gonna spill cranberry juice on it and you know they wash everything on hot, but wear whatever you want — as long as it doesn’t have strings.
  • Bring slip-on shoes. Some hospitals will not allow you to wear shoes at all. The fancy hospital socks with treads on the bottom are very real, and you’ll get some in the ER. If shoes are allowed on the unit, you’ll have to take the laces out, so bring shoes without laces. Definitely don’t bring boots or anything with a heavy sole, as those will probably not be allowed.
  • Bring books.
  • Bring shower supplies and deodorant. It’s not essential, so if you don’t have space, don’t bring them. But I like them.
  • Bring a comfort item. I always bring my jumbo Pikachu stuffie. Something small would work, but I’m excessive.

Things to be aware of

  • Quiet room. That’s a euphemism, for sure. Most hospitals have one although I think at UCLA they just move you to a different unit if you’re in that place. Basically, this is where they put people who need to calm down. Injectable medications (seems like Zyprexa or Haldol, usually) are often involved, as are restraints. It might actually have padded walls like you see on TV. But if you’re worried about going there, in my experience, you’re probably not going there.
  • Furniture. You won’t notice this until you’ve been in a few hospitals, but they all have a similar physical design with very similar furniture. That’s because they’re designed so you can’t tie anything onto them, if you were to have strings. All safe furniture looks pretty much the same, and it’s very 70s for some reason.
  • Smoking. There are a minority of hospitals that still allow you to smoke cigarettes at designated times. Feel free to bring your preferred kind if you do smoke, but don’t load up; in hospitals I’ve been where smoking is allowed, there are usually house cigarettes available. They are very cheap and seem to be made with cigar tobacco, but trust me, it’s better than nothing.
  • Voluntary status. Not to scare you, but even “voluntary patients” are not 100% free to leave whenever you want. It is better to be admitted voluntarily than involuntarily, but if you do try to leave on a voluntary basis and your treatment team feels strongly that you’re not ready, your status can be changed. At least, mine has been in the past. So it is kind of a catch-22 situation. Some hospitals are more mindful about this than others. It also seems to vary by state.

I hope this overview has been helpful. And if you’re ever hospitalized, don’t worry; it is an adjustment, but most people get used to it very quickly. It’s designed that way. Meals, groups, outside breaks, and pretty much everything will occur at the same time every day. It’s weird how you start to feel hungry for dinner at exactly 5 PM. But it happens quickly!